Effects of Change in Tongue Pressure and Salivary Flow Rate on Swallow Efficiency Following Chemoradiation Treatment for Head and Neck Cancer

Abstract

Purpose Patients treated with chemoradiation for head and neck cancer frequently develop dysphagia. Tissue damage to the oral tongue causing weakness and decreases in saliva production may contribute to dysphagia. Yet, effects of these variables on swallowing-related measures are unclear. The purpose of this study was (1) to determine effects of chemoradiation on tongue pressures, as a surrogate for strength, and salivary flow rates and (2) to elucidate relationships among tongue pressures, saliva production, and swallowing efficiency by bolus type. Methods and Materials 21 patients with head and neck cancer treated with chemoradiation were assessed before and after treatment and matched with 21 healthy control participants who did not receive chemoradiation. Each participant was given a questionnaire to rate dysphagia symptoms. Videofluoroscopic evaluation of swallowing was used to determine swallowing efficiency; the Saxon test measured salivary flow rate; and the Iowa Oral Performance Instrument (IOPI) was used for oral tongue maximum and endurance measures. Results Results revealed significantly lower tongue endurance measures for patients post-treatment as compared to controls (p=.012). Salivary flow rates also were lower compared to pre-treatment (p=.000) and controls (p=.000). Simple linear regression analyses showed that change in salivary flow rate was predictive of change in swallow efficiency measures from pre- to post-treatment for 1mL thin liquid (p=.017), 3mL nectar-thick liquid (p=.026), and 3mL standard barium pudding (p=.011) boluses. Conclusions Based on these findings, it appears that chemoradiation treatment affects tongue endurance and salivary flow rate and these changes may impact swallow efficiency. These factors should be considered when planning treatment for dysphagia.

Objective and subjective hyposalivation after treatment for head and neck cancer: Long‐term outcomes

“…Stimulated saliva production can be assessed by having the patient chew unflavored gum or paraffin for 1 minute, chewing gauze, or exposing the tongue to a solution of 2% citric acid at intervals of 30 seconds. Sialometry studies have examined stimulated and unstimulated saliva flow rates, as well as stimulated saliva weight . Both techniques for measuring stimulated and unstimulated saliva are reliable and validated.…”

“…The Saxon test, which involves chewing gauze for 2 minutes, is a reliable, validated assessment of stimulated saliva production . This test has been found to be a tolerable method for obtaining stimulated saliva production in treated head and neck cancer patients . The Saxon test has been used with patients having undergone primary chemoradiotherapy (CRT), as well as adjuvant CRT, with good patient ability to complete this saliva production task .…”

“…Sialometry studies have examined stimulated and unstimulated saliva flow rates, 10,[12][13][14] as well as stimulated saliva weight. 9,[15][16][17][18][19][20] Both techniques for measuring stimulated and unstimulated saliva are reliable and validated. However, obtaining unstimulated salivary flow can be problematic in the treated head and neck population, as some may experience difficulty with the requisite rinsing of the mouth prior to the exam, as well as repeatedly spitting into a container.…”

“…11 This test has been found to be a tolerable method for obtaining stimulated saliva production in treated head and neck cancer patients. [15][16][17][18][19][20][21] The Saxon test has been used with patients having undergone primary chemoradiotherapy (CRT), as well as adjuvant CRT, with good patient ability to complete this saliva production task. [15][16][17][18][19][20][21] In addition, this test has been performed in conjunction with a battery of other vocal tract assessments, as it can easily be completed during a clinic visit.…”

“…[15][16][17][18][19][20][21] The Saxon test has been used with patients having undergone primary chemoradiotherapy (CRT), as well as adjuvant CRT, with good patient ability to complete this saliva production task. [15][16][17][18][19][20][21] In addition, this test has been performed in conjunction with a battery of other vocal tract assessments, as it can easily be completed during a clinic visit. [15][16][17][18][19][20] Patients' perception of dry mouth has been examined in the primary CRT population, 14,15,[20][21][22][23] 24 patient-rated QOL scale.…”