Internal Lymphedema Correlates with Subjective and Objective Measures of Dysphagia in Head and Neck Cancer Patients

Abstract

Background: Tumor/treatment-related internal lymphedema (IL) and/or external lymphedema (EL) are associated with functional deficits and increased symptom burden in head and neck cancer patients (HNCP). Previously, we noted association between EL/IL and patient-reported dysphagia using the Vanderbilt Head and Neck Symptom Survey (VHNSS) version 1.0. Objective: To determine the relationship between IL/EL and subjective and objective measures of swallowing function. Methods: Eighty-one HNCP completed: (1) VHNSS version 2.0, including 13 swallowing/nutrition-related questions grouped into three clusters: swallow solids (ss), swallow liquids (sl), and nutrition(nt); (2) physical assessment of EL using Foldi scale; (3) endoscopic assessment of IL using Patterson scale (n = 56); and (4) modified barium swallow study rated by dysphagia outcome and severity scale (DOSS) and in conjunction with a swallow evaluation by National Outcomes Measurement System (NOMS). Examinations were performed at varied time points to assess lymphedema spectrum, from baseline (n = 15, 18.1%) to 18 months post-therapy (n = 20, 24.1%). Results: VHNSS swallow/nutrition items scores correlated with NOMS/DOSS ratings ( p < 0.001). Highest correlation was with NOMS: ss (-0.73); sl (-0.61); nt (-0.56). VHNSS swallow/nutrition scores correlated with maximum grade of swelling for any single structure on Patterson scale: ss (0.43; p = 0.001); sl (0.38; p = 0.004); nt (0.41; p = 0.002). IL of aryepiglottic/pharyngoepiglottic folds, epiglottis, and pyriform sinus were most strongly correlated with VHNSS and NOMS ratings. NOMS/DOSS ratings correlated with EL (> = -0.34; p < 0.01). No meaningful correlations exist between VHNSS swallow/nutrition items and EL (< -0.15, p > 0.20). Conclusions: IL correlated with subjective and objective measures of swallow dysfunction. Longitudinal analysis of trajectory and impact of IL/EL on dysphagia is ongoing.

Patient perceptions of living with head and neck lymphoedema and the impacts to swallowing, voice and speech function

“…Recent quantitative studies have begun to establish the relationship between the presence of HNL and its impact to swallowing, voice and speech function (Deng, Murphy et al., ; Deng, Ridner, Murphy et al., ; Jackson et al., ; Piso et al., ; Smith et al., ). However, the specific nature of these impacts from a patient perspective has not been previously presented.…”

“…Multiple authors have suggested an association between HNL and increased issues with swallowing (Deng, Murphy et al., ; Deng et al., ; Jackson et al., ; Murphy & Gilbert, ; Murphy & Ridner, ; Murphy et al., ; Piso et al., ; Smith et al., ). Internal HNL has the potential to cause significant thickening and stiffness of the pharyngeal and laryngeal structures; thereby affecting their range of movement and contractibility (Eisbruch et al., ; Jackson et al., ; Murphy et al., ). This may result in prolonged pharyngeal transit time, reduced pharyngeal clearance, and laryngeal penetration and aspiration (Deng, Murphy et al., ; Jackson et al., ).…”

“…Individual, semi‐structured interviews were conducted with each participant. The study authors developed an interview guide containing 10 open‐ended questions, each with an example set of prompting questions, following a review of the literature (Deng, Murphy et al., ; Jackson et al., ; Smith & Lewin, ). Participants were asked to describe the nature and location of their HNL, any treatment they may have accessed for their HNL, and discuss any impact their HNL had on their swallowing, voice and speech function.…”

“…The physiological basis for these chronic side effects has historically been attributed to the effects of definitive radiotherapy and chemo‐radiotherapy, particularly the influence of tissue fibrosis and neuropathy (King, Dunlap, Tennant, & Pitts, ). However, there is now emerging evidence to suggest that the presence of head and neck lymphoedema (HNL) may also contribute to these chronic side effects for some patients (Deng, Murphy et al., ; Jackson et al., ; Smith & Lewin, ).…”

“…Jackson et al. () showed that HNL that occurred at a number of specific internal sites was more likely to result in laryngeal penetration and aspiration, and changes in functional diet status. Whilst, Deng, Murphy et al.…”