Endoscopic Management of Postradiation Dysphagia in Head and Neck Cancer Patients: A Systematic Review

Abstract

Objectives: To systematically review the success rate and safety profile of the available endoscopic surgical options for radiation-induced dysphagia in head and neck cancer patients following organ preservation treatment, including upper esophageal sphincter (UES) dilation, cricopharyngeus (CP) myotomy (CPM), and CP intramuscular botulinum toxin (Botox) injection. Methods: A search of MEDLINE, Scopus, Google Scholar, and Cochrane databases was done to identify articles published between January 1980 and December 2017. Pediatric series, foreign language articles, series with Zenker’s diverticulum or following primary surgical treatment including laryngectomy, open UES/CP surgery, or samples with fewer than 5 patients were excluded. Results: An initial search identified 539 articles. All titles and abstracts were reviewed. One hundred and sixteen potentially relevant articles were inspected in more detail, and 14 retrospective studies met eligibility criteria. Dilation group included 10 studies on anterograde and/or retrograde dilation, with an overall 208 patients. Success rate ranged from 42% to 100%. The endoscopic CPM group included 3 studies with a total of 36 patients, and the success rate ranged from 27% to 90%. In the Botox group, 1 one study with 20 patients met our inclusion criteria, with an overall 65% success rate (13/20). Major complications were only reported in the dilation group, which included esophageal perforation and death. Conclusions: The lack of consistency across trials indicates insufficient evidence for guiding clinical practice. This systematic review suggests the need for greater standardization of outcomes and instruments. Future prospective evaluation should use validated patient-rated and clinician-rated assessment tools to optimally measure postoperative swallowing outcomes of head and neck cancer dysphagic patients following organ preservation therapy.

European white paper: oropharyngeal dysphagia in head and neck cancer

“…Despite the lack of high-quality studies, there is some evidence to justify the use of UES myotomy in HNC patients. UES myotomy significantly improved swallowing outcomes of HNC patients with OD following organ preservation therapy [362]. Research by Silver and colleagues also revealed recovery of OD in 90% of their HNC patients following CO2 laser myotomy of a post-(C) RT stenosis at the UES level [368].…”

“…Since 1951, studies have reported several surgical and less-invasive treatments for UES dysfunction. The effectiveness of each treatment in the management of OD, due to various etiologies including HNC and its oncological treatment, is still subject to debate [362][363][364][365]. A malfunctioning UES can be diagnosed as described under previous sections of this paper (see "Videofluoroscopic swallow study" and "Manometry").…”

“…However, these results cannot simply be extrapolated to a HNC patient population and further research with HNC populations is required. Recent systematic reviews confirmed these findings of insufficient evidence to guide clinical practice for HNC patients [362][363][364]. Despite the uncertain evidence, myotomy of the UES, botulinum toxin injection in the UES, and dilatation of the UES or proximal esophagus strictures remain frequently applied surgical modalities in the management of OD in HNC patients following oncological treatment [363,365].…”

“…All muscle fibers are cut using the CO2 laser until the buccopharyngeal fascia is reached. Some surgeons leave the wound open [362], others apply fibrin glue [368] or suture the mucosa over the incised muscle fibers to prevent salivary leakage causing mediastinitis [370]. If endoscopic myotomy cannot be performed due to trismus or pharyngeal strictures an external myotomy can be considered.…”

Cricopharyngeal Achalasia: Management and Associated Outcomes—A Scoping Review

“…CP achalasia, failure of the CP to relax, may be idiopathic or result from gastroesophageal reflux disease, among other etiologies. 4…”