**3.2 (Preventive) swallowing protocols**

Over the last years, the prevention of dysphagia has become a major focus point in HNC research. The assumed disadvantages of (prophylactic) feeding tube placement to prevent weight loss and with that effectively immobilizing the swallowing musculature, have led to the so-called 'eat or exercise' principle [10]. This means that oral intake should be maintained as long as possible, and that preventive swallowing rehabilitation programs should keep the swallowing musculature 'active' as much as possible before and during treatment. Studies on preventive rehabilitation in the Netherlands and elsewhere have shown that preventive swallowing protocols (in particular in the short-term) are associated with better post-treatment functional outcomes and quality of life, and are cost-effective, compared to standard care [10, 15–22].

There are several (swallowing) exercises that have proven their value in the treatment of dysphagia. Those exercises are used in standard swallowing protocols, but also within preventive rehabilitation protocols. Most frequently used exercises include a range of motion or resistance exercises (with or without medical devices

such as the TheraBite® device), compensatory techniques (postural changes, diet/ bolus modifications), behavioral swallow exercises such as the (super-)supraglottic swallow [23, 24], the effortful swallow [25], the Mendelsohn maneuver [26], and the Masako (tongue-holding) maneuver [27], and non-swallow exercises such as the Shaker (head-raising) exercise [28]. Also, devices, such as the Swallow Exercise Aid (SEA) have been developed to be able to perform multiple exercises more efficiently. The SEA device allows adaptation to individual subjects' capacity, and thus the application of progressive overload during the training program, and has shown to activate important swallowing structures [29–31]. Nevertheless, in some cases severe, therapy-refractory dysphagia may still exist.

#### **3.3 Surgical procedures**

Surgical treatment of functional impairment may be considered when rehabilitative measures, such as those described above, are insufficient to help ensure safe and efficient oral intake. The primary goals of surgery are to reduce the risk of aspiration, improve bolus transfer, and prevent malnutrition and/or dehydration. What the best surgical technique will depend on the etiology of the dysphagia. If there is less relaxation of the upper esophageal sphincter this can result in a less efficient movement of the bolus into the esophagus. This impaired relaxation can sometimes be remedied by reducing the tonus of the musculature of the pharynx. Cricopharyngeal myotomy, either endoscopically using a CO2 laser or by an open surgical procedure, can be helpful [32, 33]. Myotomy of the cricopharyngeal muscle results in lower resistance of the upper esophageal sphincter. Due to this lower resistance, the bolus can be more easily be transported through the upper esophageal sphincter and enter the esophagus.

Other surgical techniques that can widen the cricopharyngeal muscle are dilatation (in case of fibrosis) or botulinum toxin (botox) injection in case of spasm. Several studies have reported promising results in patients with upper esophageal sphincter dysfunction caused by muscle spasm or hypertonicity [34, 35].

If dysphagia is caused by a serious limitation in laryngeal elevation, an invasive surgical technique called hyolaryngeal suspension can be performed. In this procedure, the hyoid bone is suspended and the thyroid-cricoid complex is fixated to the anterior mandible. This results in a permanent more cranial position of the larynx [36]. This procedure can be very effective in the restore a full oral intake without aspiration. However, it is also reported that previous treatment with (chemo) radiotherapy will negatively influence the outcome [37].

Finally, in some cases, none of the abovementioned treatment options are suitable or effective. If the larynx has severe functional impairments and there is no reasonable likelihood of functional recovery as a 'last refuge', a functional total laryngectomy can be considered. In the case of a total laryngectomy, the airway is surgically separated from the digestive tract by sacrificing the larynx.

Surgery procedures as described above, however, can have serious complication risks. Myotomy (especially open) can cause infections and even pharyngocutaneous fistulas or (retropharyngeal) infection [34, 37]. Besides, studies have shown that the improvement rate is much higher for neurologic dysphagia and idiopathic dysfunction than in patients with swallowing problems due to HNC treatment [32].

#### **4. New treatment option: lipofilling**

Since 2013, the Netherlands Cancer Institute has been using lipofilling as an alternative treatment option. Lipofilling has the advantage of being less radical, less invasive and presenting less of a burden for the patients [38].

*Lipofilling in Post-Treatment Oral Dysfunction in Head and Neck Cancer Patients DOI: http://dx.doi.org/10.5772/intechopen.101824*

Lipofilling is a technique in which autologous fat is transplanted to a site that lacks volume. In 1893, fat was transplanted for the first time with variable success [39]. Since the 1980s with the advent of modern liposuction, the technique of lipofilling has become a standard modality for esthetic as well as reconstructive purposes; however, it is rarely used in HNC patients.

### **4.1** *Physiology of fat grafting*

Of all tissues in the human body, fat possesses the highest percentage of adiposederived stem cells with more than 5.000 of these per gram of fat. Adipose-derived stem cells are present in the mesenchyme, and are a type of multipotent stem cells. This means that these stem cells can differentiate into multiple cell types including osteoblasts, endothelial cells, myocytes, neuronal type cells, adipocytes and chondrocytes [40, 41].

A microscopic view shows that fat consists of a complex matrix of adipocytes mixed with collagen, endothelial cells, adipose-derived stem cells, and fibroblasts. All these adipocytes play an important role in the physiological processes, such as angiogenesis, metabolism, lipid storage and endocrine functions [40]. There is evidence that stem cells may even contribute to the reduction in fibrosis, and the restoration of tissue vascularization and organ function [42, 43].

#### **4.2 Evaluation tools to check patient eligibility**

Lipofilling might be a suitable treatment option for specific patients with chronic dysphagia after HNC treatment. Patients might benefit from lipofilling when part of the etiology of the dysphagia consists of lack of volume, for instance, of the tongue or pharyngeal wall. There are different examination tools to analyze the severity and etiology of dysphagia. Before considering if lipofilling is suitable for a patient, it is recommended to perform objective assessments such as Fiberoptic Endoscopic Evaluation of Swallowing (FEES) or a Video Fluoroscopic Swallow Study (VFSS) and a Magnetic Resonance Imaging (MRI) assessment.

FEES, in which a flexible endoscope is inserted via the nose and the patient is asked to swallow different consistencies, visualizes directly the anatomy and function of the pharyngeal swallowing phase. Also, the sensory and motor components of swallowing can be assessed [44]. On the other hand, VFSS (also known as Modified Barium Swallow) provides information about the oral and oropharyngeal phases of the swallow, including dynamics of the swallowing process. With VFSS, it is possible to analyze the contact between the tongue base and posterior pharyngeal wall and it is more suitable for diagnosing aspiration during swallowing. VFSS is also more informative for detecting problems below the upper esophageal sphincter [45]. Preferably a VFSS is performed, to select eligible patients, but the choice of examination also depends upon clinical presentation, available instruments and clinician's preferences.

To visualize the potential injection sites in the oral cavity and pharynx the most crucial examination of the pre-lipofilling work-up is the Magnetic Resonance Imaging (MRI) [38]. Besides, with the MRI it is possible to evaluate the volume of the tongue and pharyngeal wall. In **Figure 2**, an MRI assessment pre- and post-lipofilling treatment is presented.

In addition to the objective assessments, it might also be helpful to explore patient-reported experiences. The MD Anderson Dysphagia Inventory (MDADI) [46] and the Swallowing Quality of Life questionnaire (SWAL-QOL) [47] are often used in HNC patients to analyze patients' reported swallowing-related quality of life.

**Figure 2.** *MRI assessment pre- and post-lipofilling treatment. On the left side, the loss of tissue in the base of tongue is visible. On the right side, the base of tongue is larger and is filled up with fat.*
