Maxillofacial and Oral Dysphagia

#### **Chapter 4**

## Maxillofacial and Oral Aspects of Dysphagia

*Mohammed Basha*

#### **Abstract**

Oral cavity/mouth is first recipient of food. Food is broken down and prepared for initial phases of digestion. The oral preparatory phase is voluntary. In this phase, food is manipulated by the tongue and teeth. A bolus which is ready to swallow is prepared. Any disruption of oral cavity functions commonly due to oral infections, space infections, facial trauma, congenital-cleft lip and palate, temporo-mandibular joint disorders, salivary gland pathology, oral cancers, radiation therapy, etc., can cause dysphagia. In this chapter, we would explain the maxillofacial and oral aspects of dysphagia along with diagnosis and treatment aspects.

**Keywords:** oral dysphagia, maxillofacial dysphagia, bolus, saliva, tongue, oral infections

#### **1. Introduction**

Facial structures and its functions are very precise and rhythmic, well-orchestrated co-ordination between various structures to achieve multiple goal at the same time. Innumerous central control of voluntary and involuntary function have been studied and documented in many forms of medical literatures. Multiple facial hard and soft tissues, nerves, muscles etc., function in a very unique and well balanced way. The extremely complex process of act of swallowing/deglutition, involves approximately 50 pairs of muscles and nerves that are responsible for preparing and transferring food and liquids from the mouth to the stomach [1]. Due to the close proximity of the pathways of swallowing and respiration, precise coordination between these functions is vital in order to avoid entry of material into the airway [2]. A problem with any of these structures can lead to dysphagia [1].

Patients with pathology in oral cavity often seek treatment for that particular sign and symptoms and there by dysphagia can be easily missed. Even though disorders of swallowing are very common and, when looked for, occur regularly in most branches of surgery. Most common cause of dysphagia is a neurological disturbance [3]. Surgeons/physicians must look for presence of a second pathology affecting their swallow and plan treatment accordingly.

#### **2. Anatomy of oral cavity - selected aspects**

The oral cavity, the pharynx, and the larynx are the three anatomically and functionally separate aero-digestive tract structures which form the swallowing apparatus. Normal deglutition requires precise coordination of these structures [4–7].

A hydrodynamic pump is created with valves by these structures that allow food and liquid to be transferred into the stomach without aspiration [4, 6]. Swallowing comprise of three phases, based on the location of the bolus in the swallowing framework. Oral phase is voluntary and it set off involuntary pharyngeal and esophageal phases [4–6]. Large number of diseases causes symptoms of dysphagia affecting the quality of life of patients [6]. Understanding of the anatomy and physiology of deglutition is required to treat dysphagia.

The oral cavity inlet is guarded by the upper and lower lips. The other units of the mouth are cheeks, maxillary and mandibular teeth, gums and periodontium and periodontal ligaments, hard and soft palate, tongue and floor of mouth. The oral phase of swallowing occurs in the oral region. Masticatory performance is defined as the percentage of particle size distribution of food when chewed for a given number of strokes [8]. This evaluates the quality of chewing. Masticatory performance reflects the capacity to reduce the size of food particles and the number of chews necessary to render food ready for swallowing [9, 10]. Quality of mastication performance is affected by multiple factors like number of teeth in functional occlusion [11–13], biting force [14], dentures [15], Implants and or artificial prosthesis and salivary flow rate – which declines(masticatory performance) with a reduction of salivary secretion [16]. Bolus preparation happens between upper arch (maxillary arch) and lower arch (mandibular arch). Oral cavity transforms into oropharynx posteriorly.

Upper and lower Lips form a sphincter using the orbicularis oris muscle. Intraorally the lips have labial mucosa (mucous membrane), which extends laterally on the inner surface of bilateral cheeks as buccal mucosa. Cheeks contain the buccinator muscles and the buccal fat pads. Palate anteriorly is hard palate formed by fusion the palatine process of both maxillae anteriorly and horizontal plates of palatine bone fused at transverse palatal suture. The soft palate is located posteriorly. Anteriorly, it is continuous with the hard palate and with palatine aponeurosis. The posterior border of the soft palate is free, and has a central process that hangs from midline known as uvula. The soft palate is mobile, and comprised of muscle fibers covered by mucous membrane. The soft palate continues laterally with palatoglossal and palatopharyngeal folds, which joins the tongue and pharynx respectively [17].

#### **3. Oral clinical conditions for dysphagia and treatment aspects**

Patients with pathology in oral cavity often seek treatment for that particular sign and symptoms. Dysphagia can be easily missed. These conditions can be congenital or acquired.

Congenital conditions which are most commonly encountered in our practice are facial clefts; cleft lip and palate. There are always lots of emotions and expectations of parents during treatment. Feeding in the cleft lip and palate setting is the main challenge for the parents, pediatricians, surgeons and nurses. In a study, 97% of parents of cleft infants thought to discuss feeding challenges, 95% thought it was important to have a demonstration of feeding [18]. Poor oral suction, inadequate volume intake, lengthy feeding time, nasal regurgitation, excessive air intake, and coughing or choking are the feeding challenges [10]. The anatomic-structural deformities of cleft infants usually affect the oral phase of the suck-swallow-breathing mechanism. Cleft with syndrome, the risk of poor feeding is 15 times more [19].

The importance of adequate nutrition in cleft patients care is indispensable especially during presurgical and postsurgical period. In cleft palate patients, the ability to secure adequate seal and suction is remarkably reduced [20]. Poor intake abilities and diminished sucking efficiency causes the cleft baby with reduced oral intake, reduced weight gain and inadequate growth [21] (**Figure 1**).

*Maxillofacial and Oral Aspects of Dysphagia DOI: http://dx.doi.org/10.5772/intechopen.89751*

**Figure 1.** *Cleft of the palate pre- and postsurgery.*

Bottles commonly used for feeding infants with cleft deformities include the Cleft Palate Nurser, Mead Johnson LLC, Glenview, IL; Medela Special Needs Feeder, Pigeon Bottle and vented bottles such as the Dr. Brown Bottle [22].

Post-surgery the parent face fresh challenges for feeding. Feeding protocols during post-surgery phase is contentious subject among surgeons. Surgeons recommend 3–5 days of bottle holiday, they recommend syringe feeding. Various studies bespeak that the mechanical effect of feeding have little effect on wound complications or incision breakdown [23–26].

A research conducted by Al Hadadi and colleagues showed that aspiration pneumonia was diagnosed in 15.8% of all Cleft palate babies, which was analogous to a study from Malaysia whose results were 14% [27, 28]. The reason for high incidence of aspiration pneumonia in orofacial cleft is malfunctioning of the palatal muscles and cleft of the palate leading to difficult swallowing and aspiration. It is also been reported that the hyoid bone is abnormal in cleft patients [29].

#### **4. Acquired causes for oral dysphagia**

Oral health is defined as "a state of being free from chronic mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal(gum) disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual's capacity in biting, chewing, smiling, speaking, and psychosocial wellbeing" [30]. According to the World Health Organization dental caries and periodontal diseases have high prevalent rate of nearly 100 and 90% respectively. Aspiration pneumonia in the medically compromised and elderly, and post-operative infections can be prevented by proper oral health and hygiene [31–33].

Loss of tooth will disturb the pattern of pre- swallow and swallowing behaviors. Especially with older individual with loss of multiple teeth find it onerous in chewing and swallowing [34]. Chewing ability directly depends on remaining functional teeth with functional occlusion [11–13].

Oral preparatory stage which is affected the most due to loss of teeth, as loss of tooth diminish chewing ability and causes difficulties in forming the bolus. Bolus size was reported to increase with an increasing number of missing teeth, with larger boluses potentially interfering with optimal swallowing [35]. An ill formed bolus may be difficult to transport smoothly and efficiently into the pharynx, thus leading to additional swallowing abnormalities.

Replacement of loss of teeth by prosthetic teeth/dentures is an effective way to increase the functional masticatory unit. Prosthetic rehabilitation to maintain appropriate mandible position with good occlusion is important in smooth swallowing in older individuals [36].

A study in which relationship between the number of teeth in function, denture use and subjective swallowing problems in a sample size of 5643 individuals aged 40–89 years concluded that individuals with fewer functional teeth or no denture use were likely to have subjective swallowing problems, and suggested that, even if people have few teeth, denture wearing contributes to prevention of swallowing problems [34].

An extensive study conducted in 289 elderly people aged 60 years and older, to evaluate the relationship between the number of teeth, denture wearing, and swallowing by a noninvasive cervical auscultation technique. They concluded that 31.1% had swallowing impairment. About 20% of patients had swallowing impairment in subjects with 20 or more teeth with denture whereas subjects with 20 or more teeth without dentures had swallowing impairment by 26.5%. Swallowing impairment was found in 38.9% in less than 19 teeth without prosthesis. About 57.7% had swallowing impairment with less than nine teeth without dentures. And, 66.7% completely edentulous patients without dentures had difficulty in swallowing, whereas it was to be 28.7% with complete denture prosthesis [37].

Researcher have found that there was higher frequency of entry of secretions, food/liquid, or any foreign material into the laryngeal vestibule above the level of the true vocal folds (laryngeal penetration) in edentulous elderly people who are not wearing any denture prosthesis, but laryngeal penetration was reduced in edentulous elderly people when wearing dentures [38].

The precision fit of dentures has positive effect on the swallowing function. Wearing ill-fitting dentures, particularly in the case of a complete denture, may interfere with achieving sufficient occlusal contact. Insufficient occlusal contact

#### *Maxillofacial and Oral Aspects of Dysphagia DOI: http://dx.doi.org/10.5772/intechopen.89751*

reduces masticatory performance and causes impairment of swallowing activity. In a study which shows ill-fitting dentures increases duration of swallowing in elderly patients using electromyography. Normal swallowing duration form 12 to 70 years age person ranges between 0.80 and 1.60 s. They claimed that in ill-fitting poor prosthesis the swallowing time was 1.84 s and the time was reduced to 1.28 s in wellfitting prosthesis. The quality and fit of prosthesis plays a vital role to improve swallowing ability in elderly individuals [39]. By repairing or relining ill-fitting dentures showed the pharyngeal transit time was shorter when compared to not wearers. Increase of pharyngeal transit time increases the risk of aspiration [40]. A person who has inadequate natural masticatory teeth and are without wearing dentures had a 91% greater risk of dementia than those with adequate natural mastication [41].

Dry mouth or xerostomia is a condition which results in dryness of mouth due to decrease in saliva secretion. It is common in elderly population and has an incidence of 20–60% [42]. Xerostomia affects the oral preparatory and oral phases of swallowing, causes impaired bolus formation and transport [43]. Swallowing disorders in xerostomia can be managed with oral moisturizers, lubricants, and careful use of fluids during eating [44]. It is considered that tooth brushing helps to improve oral hygiene and increased salivary flow rate. Mechanical stimulation of the salivary glands during tooth brushing can promote the discharge of saliva [45]. Tooth brushing may activate impulses to both major and minor salivary tissues following stimulation of oral and pharyngeal regions, causing salivation [46]. In a study by Papas and colleagues showed that tooth brushing increased salivary flow in people with medication-induced dry mouth [46]. Another study stated that elderly people with tooth brushing frequency less than twice per day were more likely to have dry mouth [45].

Hyper salivation may produce swallowing problems caused by aspiration of saliva. It's induced by inflammations of oral cavity, Parkinson's disease, epilepsy, or medicine such as pilocarpine and cholinesterase. Neurological disorders cause excessive pooling of saliva in oral cavity, with unintentional loss of saliva from mouth – drooling of saliva [47]. Drooling impair masticatory function and can cause aspiration.

Infections from the teeth are referred as odontogenic infections; these are very common in dental and maxillofacial practice. These infections can be simple/localized or can become very aggressive involving spaces of neck and deep neck region [48]. Flynn showed that fever, swelling, dysphagia and trismus (**Figure 2**) were the symptoms most commonly observed in patients hospitalized for odontogenic infection [49].

Deep neck space infections can spread along the facial spaces of the head and neck, inducing life-threatening deep space infection associated with a high risk of complications (upper airway obstruction, mediastinitis, thoracic empyema, pericarditis, septic shock) [50–53] (**Figure 3**). Neck spaces communicate with one another, results in spread of infection over larger area. Neck spaces consist of loose connective tissue between the deep cervical fascia (superficial, middle and deep) [54].

Ludwig's angina is an aggressive infection of facial and deep neck spaces, often of dental origin, characterized by a rapid spread of cellulitis in the submandibular and sublingual spaces [55] (**Figure 4**). It was described by Karl Friedrich Wilhelm von Ludwig in 1836 [56]. The origin of Ludwig's angina is odontogenic in 90% of cases, males are more commonly affected than females, and associated teeth are usually mandible molars- second and third molars [57–59]. The dental roots of these teeth usually lie below the mylohyoid ridge, infection from these teeth spread directly into the submaxillary spaces. With all the spaces which are well connected there is continuous spread of infection in sublingual space, pharyngeal and retropharyngeal spaces of neck [60].

**Figure 2.** *Severe trismus in oral and neck infection.*

**Figure 3.** *Thoracotomy for descending oral infection and mediastinitis and empyema.*

**Figure 4.** *A case of submandibular and neck space infection.*

Patients with active or chronic oral/dental infections, poor oral care, medically compromised conditions like uncontrolled diabetes mellitus, malnutrition, drug abuser, AIDS, immunosuppression are highly susceptible for developing space infections. Ludwig's in Children can occur without any predisposing condition [60].

Clinical features have bilateral suprahyoid swelling, hard indurated cardboardlike consistency. It is non-fluctuating and tender on palpation. The mouth is open and the tongue is raised and is in contact with the palate. Patient has dysphagia, drooling of saliva, and breathing/airway obstruction, which are the most salient presenting. Signs and symptoms of the illness depend on the spaces involved, and include pain, fever, malaise, fatigue, swelling, odynophagia, dysphagia, trismus, dysphonia, otalgia, and dyspnea which are due to cellulitis, aided by the awkwardness resulting from the position of the tongue [61]. Redness is usually seen on skin in area front of the neck (**Figure 5**). The diagnosis in patients with Ludwig's angina is based on clinical findings. Panoramic radiography can help to discover the origin of the dental infection, while a cervico-thoracic CT scan with contrast is diagnostic (**Figure 6**). Ludwig's angina is potentially fatal, and its mortality rate can reach up to 50% [60] if not treated timely. Streptococci, Peptostreptococcus species, *Staphylococcus aureus*, and anaerobes are the most commonly cultured organisms from space infections [61]. The odontogenic infections that may cause Ludwig's angina can largely be prevented by timely interventions and periodic dental care.

Ludwig's angina can cause life threatening complications of airway obstruction, which is an acute emergency. Descend of infection into deeper plane can cause mediastinitis, pleural empyema, thrombosis of jugular vein, pericarditis, generalize sepsis and bacteremia, hematogenous dissemination to distant organs, DIC [62, 63].

#### **Figure 5.**

*Deep neck infection with cellulitis.*

**Figure 6.** *CT showing neck abscess with tracheal deviation to opposite side.*

Antibiotics, airway management, surgical drainage remains the key in its management. In life saving conditions, airway protection, emergency surgical drainage of the abscess followed by antibiotics, proper diagnosis and its management is the key to managing deep neck space infections (**Figure 7**).

Flow chart for patients with odontogenic infection attending the emergency department- taken from the work of AlOtaibi and companions [48].

Acute necrotizing ulcerative gingivitis (ANUG), or Vincent's infection, or trench mouth is a disease affecting the oral cavity which was noted in the Greek army by Xenophon. Soldiers suffered sore, ulcerated, and foul-smelling mouths. Similar occurrences were noted among soldiers in World War I who suffered severely from this condition. The disease is commonly found in young middle-aged, which is characterized by painful, hyperemic gingiva with sharply punched-out interdental papillae, gingival bleeding on gentle probing, the presence of a gray necrotic pseudo membrane, and a fetid mouth odor. Increased dysphagia, severe pain, hyper salivation, facial pain and swelling, accompanied by chills and fever. Conservative and supportive treatment measures based on good oral hygiene and aimed at eliminating causative factors usually result in marked improvement of the patient's condition within a relatively short period of time [64].

Viral Infections and its oral manifestations like Herpes simplex infections cause numerous shallow, irregular, necrotic ulcers, with surrounding edema and inflammation, widespread over the inside of both upper and lower lips, on the dorsal and ventral surfaces of the tongue, cheeks and soft and hard palate. Usually, the ulcers are extremely painful to touch. Patient complains of severe pain on eating, chewing and swallowing.

#### *Voice and Swallowing Disorders*

Recurrent aphthous stomatitis (RAS) can be defined as a recurrent oral necrotizing ulceration, the etiology of which remains obscure. Mikulicz and Kummell first described the chronic recurrent nature of this disease. In 1911, Sutton described a more severe form of RAS as periadenitis mucosa necrotica recurrens. At present, the disorder is more simply referred to as mild and severe aphthous or minor and major recurrent aphthous ulcers. In 1937, Behcet described a mucocutaneous-ocular syndrome that now bears his name and is characterized by a triad of symptomsrecurrent oral ulcerations, recurrent genital ulcerations, and ocular inflammation. All these diseases cause oral ulcerations, where in the patients modify their oral intake just to avoid pain. If ulcers on posterior tongue, oropharynx regions, these

**Figure 7.** *Neck infection: pre surgery, with drains, post treatment.*

#### *Maxillofacial and Oral Aspects of Dysphagia DOI: http://dx.doi.org/10.5772/intechopen.89751*

cause severe dysphagia (**Figure 8**). Treatment options include tropical steroids oral pastes, steroids, Vitamin C, immune suppressants based on clinical features, severity and clinicians treatment protocol [65].

Salivary gland pathology also contributes for dysphagia. Most common salivary gland pathology causing symptoms of dysphagia encountered in practice are ranula which occurs in the floor of mouth. Ranula is an extravasation cyst and may develop from extravasation of mucus after trauma to the sublingual gland (**Figure 9**) and rarely submandibular gland or obstruction of salivary ducts [66]. The lesion forms due to extravasation of mucus and subsequent formation of a pseudocyst. It is characteristically large (*>*2 cm) and most reported ranulas are 4–10 cm in size and rarely bigger than 10 cm [67]. When ranula becomes larger, it acquires a blue color

**Figure 8.** *Oral ulcers: pre and post treatment.*

**Figure 9.** *In oral ranula.*

and resemble frog's belly. Big sized ranulas may cause deviation of the tongue with associated difficulties in speech, swallowing and mastication [68]. It commonly occurs in the second and third decades of life and the reported male to female ratio is 1:1.3. The most common factor is that trauma causes direct damage to the duct of the sublingual gland [69]. Treatment option most commonly used is surgical removal of the lesion along with the involved salivary gland.

Bleeding in floor of mouth following trauma causes rapid elevation/enlargement of the tongue secondary to sublingual hematoma can cause life-threatening airway obstruction, necessitating prompt recognition and management of this condition [70]. Etiology of traumatic lingual hematomas include: motor vehicle accidents associated with mandible fractures, assault, child abuse, and seizures. Spontaneous lingual hematomas are usually a result of an inherited coagulopathy or patients on anticoagulant treatment [71–74]. Clinical signs of sublingual or lingual hematoma may include mass like swelling, hematoma, dyspnea, stridor, dysphagia and dysphonia. Tongue enlargement causing upper airway obstruction as it is displaced posterior-superiorly. Securing the airway is the first most important step in the management of these patients. Once airway is secured, hemostasis is focused at based on the primary cause. Treatment options include observation, airway control, steroids, antibiotics, reversal of any coagulopathy, embolization and surgical intervention. Surgical intervention becomes necessary in instances where embolization is unavailable or unsuccessful. This most commonly entails extra-oral ligation of the lingual artery and which requires a detailed understanding of the involved anatomy. Being able to recognize the initial presentation, underlying cause and relevant anatomy of lingual hematomas is critical to the proper management and treatment of this condition [75].

Sublingual hematoma caused by Placement of dental implants in the anterior mandible has been reported. Dental implants placement is a routine procedure done in outpatient departments of dental clinics. Endosseous dental implants placed in canine-premolar region have caused severe bleeding in the loose tissues of the floor of the mouth, the sublingual area and the space between the lingual muscles. Lingual surface of mandible is very vascular. There is rich anastomoses sublingual branch of the lingual artery which anastomoses with the submental artery, a branch of the facial artery, and the incisive arteries, branches of the inferior alveolar artery. Plexus lies very close to the interforaminal lingual cortical plate of the mandible and severe hemorrhage from this region has been reported as a complication of implant

#### *Maxillofacial and Oral Aspects of Dysphagia DOI: http://dx.doi.org/10.5772/intechopen.89751*

placement and other surgical procedures. Many unnamed accessory foramina on the lingual surface of mandible have been reported after anatomical studies by Hofschneider et al., 1999, McDonnel et al., 1994, Loukas et al., 2008. Formation of a hematoma in the floor of the mouth cause tongue getting pushed up, difficulty in swallowing, dysphagia and acute airway obstruction which may require emergent airway protection via intubation or tracheostomy. Accurate preoperative assessment mandible lingual surface with the help of dental CT/cone beam CT and accurate determination of implant length, avoiding lingual perforation, close post-operative follow up is recommended to prevent this complication [76].

Severe Maxillofacial (**Figure 10**), neck injuries and dysphagia are wellestablished complication especially in polytrauma admitted to intensive care unit. Incidence of maxillofacial injuries in polytraumatised patients is relatively high (25.4%) [77]. Approximately 35% are primarily affected by complex midfacial fractures. Every 13th polytrauma patient (7.7%) presents a spinal cord injury with neurologic deficit [78]. The risk for pulmonary aspiration is very high in these

**Figure 10.** *Pan facial fracture.*

patients, which is a leading cause of pneumonia [79], prolong hospitalization and increase mortality rates. High-energy trauma may result in some uncommon types of mandibular fracture, which cause the bony framework to destabilize (flail mandible) (**Figure 11**), and lead to partial or complete occlusion of the oropharyngeal inlet. Bilateral mandible fracture especially involving the parasymphyseal region causing airway obstruction and glossoptosis is known as flail mandible fracture. The mandibular deformity caused by bilateral parasymphyseal fracture usually displacing the fractured mandible posteriorly making the "Andy Gump" face appearance; a face with deficient chin. Airway obstruction can also occur due to loose teeth dislodgement as a result of impact/trauma, foreign bodies such as oral prosthesis, hematomas of the sublingual and nasopharyngeal region [80]. Fractures of parasymphyseal region cause lack of bony continuity which further causes collapse of the genioglossus and intrinsic tongue muscles into the oropharynx. Reestablishment of a patient airway is most important aspect. Emergency reduction of the fracture fragments and temporary stabilization of fracture fragments with the help of bridal wire, anterior traction of tongue with sutures to relieve airway, using oropharyngeal or nasopharyngeal airway, or by endotracheal tube according to the condition and situation of patient. Tracheotomy can always come handy for emergencies in which airway establishment is difficult.

Zachariades reported a rare case of Laryngeal Incompetence Following Facial Trauma. Patient was diagnosed having Le Fort I type of fracture, bilateral fractures of the mandibular condyles, and a comminuted fracture of the symphysis. Patient experienced respiratory difficulty that was alleviated when the mandible was pulled forward. Tracheostomy was done, followed by maxillomandibular fixation. Post

**Figure 11.** *Flail unstable mandible fracture.*

#### *Maxillofacial and Oral Aspects of Dysphagia DOI: http://dx.doi.org/10.5772/intechopen.89751*

operatively nasogastric feeding for 2 days. When the patient was given liquids orally, he would cough; leak was noted around the tracheostomy site. Initial diagnosis of perforation of the esophagus and esophageal-tracheal communication was suspected.

Barium swallow were performed and there was no esophageal-tracheal communication. They diagnosed the condition as laryngeal incompetence. Patient was subsequently sustained on intravenous fluids and Nasogastric feeding. The tracheostomy was kept open throughout the entire period of fixation. When fixation was released after 22 days, they found that laryngeal incompetence had almost completely vanished. The author discusses the reasons for laryngeal incompetence were tracheostomy, general anesthesia administration through tracheostomy, endotracheal cuff, overextension of head during reduction and wiring fractures [81].

A detail prospective evaluation study was conducted by Tiwary and companions on maxilla-facial trauma and associated Styloid process fractures, they found that in 84 patients with road traffic accident causing maxillofacial trauma, 27 patients had styloid process fracture. In maxillofacial fractures: mandible and multiple facial fractures were associated with styloid process deformity. Their results were Styloid process fracture with mandibular fracture was found in 52%. Clinically patients have dysphagia, dull ache in the throat, trismus, foreign body sensation, restricted lateral mandible movement, pain on turning the head to one side, otalgia, tinnitus, and tenderness to palpation of the tonsillar fossa and retromandibular regions. Management includes soft diet, analgesics and muscle relaxants as conservative therapy. Surgical excision of the distal portion of the fractured process is indicated when the patient's symptoms do not subside within a reasonable period of time [82].

Tumors located in the mouth and oropharynx are associated with dysphagia and poor swallowing function, exerting a negative impact on the quality of life of patients who have undergone resective/reconstructive surgery with or without radiotherapy for the treatment of head and neck cancer [83].

Cancer of the lips, oral cavity, oropharynx, hypopharynx, larynx, and esophagus is the fifth most common form of cancer in the world [84, 85].

Dysphagia is a common and debilitating complication of head and neck cancers (HNC), and its treatment places substantial physical and psychosocial burdens on patients [86].

Dysphagia in HNC cripples the quality of life and It can also cause life-threatening complications like aspiration pneumonia [87].

Klingelhöffe and companions in there research have stated that 98% of their patients had a swallowing impairment, and in that 10.2% patients who were unable to swallow. The size of tumor, nodal stage, reconstruction by flap and poor dental status strongly contribute to swallowing impairment. There was an increase in swallowing difficulty in patient with T2 than T1, closure with flap reconstruction over primary closure patients [87].

Chen and companions in their research have claimed that, their patients had difficulty in swallowing dry foods, hard food, and dysphagia was interfering with enjoyment or Quality Of Life (QOL). Patients with tumors of the tongue and buccal cancer had worse functional dysphagia QOL. Buccal cancer also has worse overall dysphagia QOL, functional dysphagia QOL, and physical dysphagia QOL. Emotional dysphagia QOL was associated with poor swallowing ability and depression [88].

Cancers of the tongue are associated with swallowing difficulty in all the phases of swallowing. In a study by Huang and colleagues, they found that there was restriction in tongue movement, with a delay in oral transit time, decreased hyoid bone elevation, aspiration was noted in many, vallecula epiglottica, and residual material in the pyriform sinuses were observed post-surgery. Patient with tongue cancer were associated to have higher incidence of silent aspirations, with

no symptoms, this is dangerous condition that may cause pneumonia and even loss of life [89].

Dysphagia treatment or management for postoperative cancer patients is multistep and complex in nature. There is involvement of Stomatology surgeons, radiation and medical oncologists, dieticians, speech pathologists, and psychologists as a team to address the issues as soon as it is suspected, identified and should be addressed [90].

#### **5. Conclusion**

Oro-pharyngeal dysphagia is always undiagnosed and underestimated as the physician/surgeon focus on the primary disease. Impact of dysphagia should not be underestimated by the surgeon. Swallowing ability and depression are the most important factors associated with dysphagia-specific health-related quality of life. Swallowing rehabilitation programs are recommended to help cope with swallowing rehabilitation and dysphagia. Oral care is of prime importance, we suggest it's important to maintain good oral habits to achieve good systemic health, as mouth is the mirror for good health. Identification of patients who are more likely to have dysphagia, an interdisciplinary preventive interventions during treatment, long-term preventive/curative interventions and aim of minimizing the negative impacts of dysphagia on the nutritional status and quality of life of patients.

#### **Acknowledgements**

I thank to all my teachers, family and friends.

#### **Conflict of interest**

No conflicts of interest.

#### **Author details**

Mohammed Basha Department of Dentistry/OMS, Aster Sanad Hospital, Riyadh, Saudi Arabia

\*Address all correspondence to: dr.salmanbasha@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Maxillofacial and Oral Aspects of Dysphagia DOI: http://dx.doi.org/10.5772/intechopen.89751*

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Section 5

## Radiation-Related Dysphagia

#### **Chapter 5**

## Radiation-Related Dysphagia: From Pathophysiology to Clinical Aspects

*Stefano Ursino, Paola Cocuzza, Stefania Santopadre, Fabiola Paiar and Bruno Fattori*

#### **Abstract**

In Western countries, head and neck cancers (HNCs) account for about 5% of all tumors. Due to tumor locations at the aero-digestive crossroad, patients frequently suffer from swallowing dysfunction caused both by primary cancer (baseline dysphagia) and cancer therapies (treatment-related dysphagia). In this regard, radiation-induced dysphagia represents a real "Achille's heel" which historically occurs in more than 50% of patients and can lead to a malnutritional status and an increased risk of aspiration pneumonia. In fact radiotherapy, by restricting the driving pressure of the bolus through the pharynx and/or limiting the opening of the cricopharyngeal muscle, leads to a post-swallowing pharyngeal residue that may spill into the airway causing ab ingestis pneumonia. On the contrary, an organ preservation strategy should provide both the highest tumor control probability (TCP) and the minimum function impairment with the subsequent maximum therapeutic index gain. In this regard, intensity-modulated RT (IMRT) might reduce the probability of postradiation dysphagia by producing concave dose distributions with better avoidance of several critical structures, such as swallowing organs at risk (SWOARs), which might result in better functional outcomes. Similarly, a prompt swallowing rehabilitation provided before, during, and soon after radiotherapy plays an important role in improving oncologic swallowing outcomes.

**Keywords:** swallowing, dysphagia, intensity and modulated radiotherapy, chemotherapy, aspiration, videofluoroscopy

#### **1. Introduction**

Nowadays, radiotherapy (RT) alone or most frequently combined with chemotherapy (RCT) is considered a valid alternative treatment to surgery for patients affected by head and neck cancers (HNCs) in order to preserve the deglutition organ [1, 2]. Historically, conventional RT has been burdened by severe and potentially "life threatening" toxicity that limited the delivery of high tumor radiation dose and in most cases affected the final treatment result [3–6]. In this regard, radiation-induced dysphagia, as a final multifactorial side effect often requiring enteral nutrition, has always represented a real "Achille's heel" occurring in more than 50% of patients and leading to a malnutritional status, increased risk of aspiration pneumonia, and long-term percutaneous endoscopic gastrostomy (PE) tube placement positioning [7–10].

#### *Voice and Swallowing Disorders*

Moreover, eating together is a defining social activity among family, friends, and colleagues. For most people, the ability to enjoy eating helps to define quality of life (QoL), whereas labored swallowing, prolonged eating times, and the limited range of foods that can be swallowed can lead to disruption of relationships and social isolation [11].

Indeed, in the last decades, an improvement of oncologic outcomes such as local control and overall survival has come from an increasing use of the more aggressive altered fractionation RT schedules and the frequent use of RCT sometimes preceded by induction chemotherapy [1, 12]. Therefore, the common use of high intensified organ preservation strategies has resulted in "potentially" high rates of swallowing dysfunction prompting to consider postradiation dysphagia as the real "barrier to winning the battle of HNC" [13].

#### **2. Basic concepts of oropharyngeal swallowing physiology**

Swallowing is a functional complex process, requiring the involvement and perfect sequential coordination of more than 30 pairs of muscles and 6 cranial nerves (V, VII, IX, X,XII) [14–16].

In this regard, pharynx plays a crucial role as an aero-digestive crossroad region both at its upper (naso and oropharynx) and lower part (hypopharynx and larynx) to ensure the constant and effective protection of the airways from the entrance of the bolus together with the safe passage of the bolus into the upper esophagus. This process implies a very complex anatomical change of the pharyngeal tract from a respiratory to a deglutitory configuration to fastly return to the respiratory one in less than a second [17–19].

This process starts with the passage of the bolus through the palatoglossus sphincter (the beginning of the involuntary deglutition) and ends with the relaxing of the cricopharyngeal muscle and the passive opening of the upper esophageal sphincter that moves the bolus into the lower digestive tract (pharyngeal phase). This phase can be further divided into three different subphases: oropharyngeal, pharyngeal, and pharyngo-esophageal phase.

The oropharyngeal subphase corresponds to the activation of "trigger area" located between the anterior palatine pillars, palatine veil and the base of tongue which is innervated by the IX and X cranial nerves. This subphase is mostly characterized by the uplift of the palatine veil which contacts with the posterior pharyngeal wall to close the nasopharynx avoiding the nasal reflux of the bolus (or regurgitation) and by the contraction of the hyoglossus muscle which causes the tilt of the base of tongue favoring the slip of the bolus into the pharynx [20].

The Pharyngeal phase is characterized by the reinforcement of the nasopharynx sealing for the anterior movement of the posterior pharyngeal wall due to the contraction of superior pharyngeal muscle, by the closure of glottic larynx to protect the lower respiratory tract through the activation of superior laryngeal nerve and by the progression of the bolus to the superior esophageal sphincter.

This is the most crucial phase of deglutition as it corresponds to the crossing and overcoming of the bolus of the aero-digestive crossroad.

The closure of the glottic larynx represents the principle mechanism of inferior airways protection which sequentially starts with the true vocal cords adduction (contraction of inferior and medium tyroarytenoid muscles, lateral cricoarytenoid muscles, and interarytenoid muscles), continues with the false vocal cords adduction (tyroarytenoid muscles contraction), and ends with the epiglottis retroflexion [21]. In this regard, the glottic closure is recognized as the main mechanism to protect inferior airways, the retroflexion of epiglottis being the less important.

#### *Radiation-Related Dysphagia: From Pathophysiology to Clinical Aspects DOI: http://dx.doi.org/10.5772/intechopen.88779*

Specifically, the protection of inferior airways is mostly guaranteed by the early closure of the glottic larynx (due to the true and false vocal cords adduction) together with the combination of the anterior and upper movement of hyolaryngeal complex (due to the contraction of the suprahyoid musculature and inhibition of subhyoid musculature) and the back-forward movement of the base of tongue (due to the contraction of stylo and hyoglossus muscles) that contributes to protect the laryngeal aditus from the spilling of the bolus [17, 22–26].

Indeed, the progression of the bolus through the pharynx is sequentially related to the tongue base retraction and the pharyngeal peristalsis combined with the force of gravity and the downward aspiration of the bolus. Specifically, the tongue base retraction just precedes the pharyngeal peristalsis that is characterized by a craniocaudal stripping wave that propagates toward the hypopharynx and is performed by the sequential contraction of superior, medium, and inferior constrictor muscles. The force of gravity also plays an important role as well as the downward aspiration that is produced in the hypopharynx by the hyolaryngeal complex elevation [19, 27, 28].

#### **Figure 1.**

*Developmental (humans at different ages) changes in PC fiber layers. (A) Low-power photomicrographs of immunocytochemically stained cross sections from adult human MPC, IPC, and CP muscles. Scale bar—1 mm. (B)–(G) High-power photomicrographs of IPC muscles of (B) human newborn, (C) 2-year-old human, (D) adult human, and (E) elderly human, (Scale bar—100 μm). All sections were incubated with monoclonal antibody NOQ7-5-4D specific to slow type I myosin heavy chain (MHC) isoform by avidin-biotin complex method. In all sections, slow type I fibers were stained dark, whereas fast type II fibers were stained light. Slow inner layer (SIL), which contained predominantly slow type I fibers, stained dark, whereas fast outer layer (FOL), which contained primarily fast type II fibers, stained light. Note that layered structure of PCs was identified in 2-year-old human (C) and normal adult humans (A, D), but not in human newborn (B) Also note that PC fiber layers in elderly human (E) were obscured because of fast-to-slow MHC transformation that occurred mainly in FOL of PCs. In addition, fiber type grouping (circled fibers) and fiber atrophy (arrows) were apparent in aged (E) muscle (F). Schematic of human pharynx (posterior view) illustrates arrangement of pharyngeal constrictor (PC), cricopharyngeus (CP), and stylopharyngeus (SP) muscles and tissue sampling sites (enclosed regions) for immunocytochemistry. IPC, inferior PC; MPC, middle PC; SB, skull base; SPC, superior PC; and UE, upper esophagus.*

Lastly, the pharyngo-esophageal phase is characterized by the opening of the superior esophageal sphincter due to both the hyolaryngeal complex elevation and the cricopharyngeal muscle relaxation, the latter produced by the reduction of basal tonic activity of the vagus nerve [29].

Finally, after the passsage of the bolus into the upper esophagus, the superior esophageal sphincter closes, the hyolaryngeal complex lowers down to the baseline position and the glottic larynx opens leading the pharynx to the baseline respiratory conformation.

The neuronal pathways also play a central role in the swallowing process.

Sensory inputs from physicochemical properties of the bolus (taste, pressure, temperature, and nociceptive somatic stimuli) from oropharynx and larynx are transported through cranial nerves V, VII, IX, and X to the central pattern generator within the nucleus tractus solitarius, where they are integrated and organized with information from the cortex. The somatic sensorial input required for proper swallowing is perceived by the lingual branches of the trigeminal and glossopharyngeal nerves, the pharyngeal branches of the glossopharyngeal and vagus nerves, and the laryngeal branch of the vagus nerve. The swallow response is elicited in the brain stem swallowing center, which receives strong modulating inputs from both the oropharynx and the cortex [30].

#### **Figure 2.**

*(A) Schematic of adult human pharynx (posterior view) shows motor innervation of FOL and SIL in PCs. Note that FOL is supplied by Ph-X (left side), whereas SIL is innervated by Ph-IX (right side). After leaving skull through jugular foramen, nerve IX (right side) is subdivided into sensory (cut end) and motor (arrow) divisions. Motor division of Ph-IX gives off three branches—superior (s), middle (m), and inferior (i)—which supply SIL of SPC (dotted lines), stylopharyngeus (SP) muscle, and SIL in MPC, IPC, and CP muscles (dotted lines), respectively. Boxes indicate sampling sites for nerve segment from inferior branch of motor division of Ph-IX (small box) and its innervating muscle tissue (large box). (B, C) Histochemical evidence for motor contribution of IX to SIL in PCs. (B) Karnovsky-Roots AChE-stained cross section of nerve segment sampled from inferior branch of Ph-IX (small box in (E)). Note that this nerve branch contained motor axons (brown staining). Scale bar—100 μm. (C) Whole mount acetylcholinesterase and silver (AChE-Ag)-stained SIL in MPC muscle innervated by nerve terminals (large box in (A)) distal to sampled nerve segment. Note that terminals of this nerve branch innervated motor end plates (MEPs; arrows) on SIL muscle fibers. Scale bar—100 μm. (D) High-power view of AChE-Ag-stained MEPs shows types of MEPs (en plaque or en grappe) and preterminal branching patterns (single or multiple) of axons innervating MEPs. Note that single SIL fiber had multiple en grappe MEPs (left), whereas most FOL fibers (right) had en plaque MEPs with single preterminal axon. Scale bar—20 μm. (E) Schematic illustration of cross section from PC muscle in (A) shows intramuscular distribution patterns of nerve IX innervating SIL and nerve X innervating FOL in muscle.*

#### *Radiation-Related Dysphagia: From Pathophysiology to Clinical Aspects DOI: http://dx.doi.org/10.5772/intechopen.88779*

Besides, the histological and biochemical structure of the pharynx is considered of prior importance for the understanding of radiation-related swallowing damage as well as baseline deglutition impairment in elderly patients. Adult human pharynx is divided in two distinct and separate layers, an inner one (slow inner layer or SIL) that is innervated by the IX cranial nerve and an outer one (fast outer layer or FOL) that is innervated by the X cranial nerve. The first one is composed by a high prevalence of myofibers containing slow-twitch myosin (Type I) characterized by a slow time contraction, high mitochondrial density, and high oxidative capacity, and is mostly responsible for the tone, stiffness of the pharynx, and fine adjustments; whereas the second one is composed by a high prevalence myofibers containing fast-twitch myosin (Type IIb) characterized by a fast contraction, low mitochondrial density, and low oxidative capacity and is mostly responsible for the contraction of the pharynx. Based on the fiber type and response to radical oxygen species, muscles with the highest glycolytic capacity (Type IIB) are most at risk for radiation damage. The immunohystochemical analysis of the pharynx has shown that the ratio between the width of the two layers (SIL/FOL) changes in a craniocaudal direction approximately from 2:1 in the cranial portion to 1:2 in the caudal portion of the pharynx. A physiological transformation process of the fast fibers into slow ones in the outer layer (also known as "fast to slow transformation") has been shown with the aging process reporting an overall 32% and 73% representation of type I fibers in the outer layer of the adult and elderly, respectively [31–33] (**Figures 1** and **2**).

### **3. Pathophysiology of postradiation swallowing impairment**

Generally, based on the above reported mechanisms, anything that restricts the craniocaudal driving pressure, including the back-forward movement of the base of tongue, or impairs the hyolaryngeal complex elevation, or limits the cricopharyngeal muscle and/or superior esophageal sphincter opening, leads to post-swallowing pharyngeal residue that may spill into the airways. Thus, the post-swallowing aspiration is the risky consequence of a severe radiation-related dysphagia with the subsequent life-threatening risk of aspiration pneumonia (**Figure 3**). In this regard, the maintenance of cough reflexes is considered essential to avoid the spillage of the bolus below the vocal cords and prevent silent aspiration [11].

Moreover, a pathophysiological neuromuscular vicious circle can be described regarding postradiation dysphagia mechanism mainly consisting in a selective loss of the more radiosensitive type IIb myofibers together with a damage of peripheral nerves that innervate the swallowing musculature [29, 34, 35]. In the early phase

#### **Figure 3.**

*Example of post-swallowing aspiration in an oropharyngeal cancer patient after RT. (A) Severe pharyngeal residue on Videofluoroscopy, (B) severe pharyngeal residue both on glossoepiglottic folds and pyriform sinuses on fiberoptic endoscopic evaluation of swallowing and (C) aspiration on videofluoroscopy (black arrow).*

(during and immediately after radiotherapy), the neuropathic radiation damage usually arises from the breakdown of epithelium lining of pharyngolaryngeal mucosa, triggering a cascade of inflammatory mediators (i.e., cytokines, neuropeptides, and glutamate signals) that cause significant pain and discomfort and result in persistent sensory deficit [36, 37]. In the late phase (after months from radiotherapy), the replacement of muscular fibers with fibrotic tissue, characterized by loss of vascularity and matrix disorganization that disrupts well-defined compartmentalized structures as well as excessive collagen deposit that entraps nerve trunks or alters the vascular network between or within the nerve tracts, leads to muscular and neurological deficits [38, 39]. Then, the degeneration of muscular fibers probably related to the disuse of swallowing muscles (oral intake strongly declines during and immediately after radiotherapy) contributes to the transformation of fibrosis to atrophy leading to the final fibroatrophic damage [40].

Hyposensitivity and pharyngeal hypo/dysmotility are the clinical consequences of the neuromuscular radiation damage. Therefore, patients usually suffer from reduced sensory inputs (i.e., bolus size and consistencies) that may lead to "intradeglutitory" silent aspiration or impaired bolus movement through the pharynx tube with a consequent "post-swallowing" pharyngeal residue [38].

On the other hand, preclinical data clearly show that with aging, the number of satellite cells for myofiber decreases and those cells that remain exhibit a limited potential of regeneration. Also chronic inflammation and reactive oxygen species, such as those produced after irradiation, have been implicated in this aged effect.

However, endurance exercise has been reported to restore regenerative potential through changes in satellite cell number and function. As a matter of fact, in the study by Schadrach and Wagers [41, 42], the potential benefit of endurance exercise on satellite cells has been proven.

Myofibers of the inferior limb muscles were then isolated from exercised and sedentary mice, both young and old, and used for monitoring satellite cell numbers, and an expansion of the satellite cell pool in the exercised groups was compared with the sedentary one, regardless of the age (young and old).

#### **4. Clinical aspects**

#### **4.1 The role of preventive swallowing exercises**

Preradiation prophylactic swallowing therapy may be beneficial due to the upregulation of antioxidant enzymes and the enhancement of mitochondrial activity to increase the muscle fatigue resistance, as emerged from preclinical experiments [43–47]. In fact, it is crucial for myofibers of swallowing muscles to have efficient antioxidant capabilities to fight radiation-induced ROS that would, otherwise, cause irreversible damages.

Besides, atrophy is a consequence of both alterations of muscle proteins synthesis resulting in loss of muscle mass and the reduction of renewal of stem cells after radiotherapy [48–51].

Again, this knowledge might suggest that the initiation of the prescribed prophylactic swallowing exercises (i.e., before, concomitantly, or immediately following treatment) might improve functional swallowing outcomes [51–54].

Therefore, despite a strong preclinical rationale for the use of prophylactic strength-based exercises as well as to maintain oral intake throughout the entire radiation treatment to prevent or reduce the occurrence of radiation-induced dysphagia, data from the literature have some methodological concerns such as heterogeneity in the prescribed exercise regimen, in the tumor site/stage and the onset of intervention.

*Radiation-Related Dysphagia: From Pathophysiology to Clinical Aspects DOI: http://dx.doi.org/10.5772/intechopen.88779*

However, a recent study by Hutcheson et al. [55] analyzed the independent effect of maintaining oral intake and proactive swallowing therapy in patients who underwent radiotherapy or chemoradiation for pharyngeal cancers. More specifically, the primary independent variables were:



#### **Table 1.**

*Characteristics of swallowing exercises.*

better swallowing functional ability in patients who completed the program of swallowing exercises compared with those who did not.

Rehabilitation swallowing exercises in irradiated patients mainly consist of interventions aimed to reinforce supra-hyoid musculature (Mendelsohn maneuver), airway closure capability (supraglottic and super-supraglottic maneuver), base of tongue retraction (effortful swallow and Masako maneuver), and cricopharyngeus muscle opening (Shaker maneuver). A summary of the swallowing exercises advised in patients undergone to RT is reported in **Table 1**.

#### **4.2 Intensity and modulated radiotherapy (IMRT) as a strategy to reduce swallowing dysfunction**

An organ preservation strategy such as a radiation-based treatment should provide both the highest tumor control probability (TCP) and the minimum function impairment with the subsequent maximum therapeutic index gain [56].

In this regard, in the last few decades, the advancement of new treatment technologies, such as intensity and modulated radiotherapy (IMRT), has shown

#### **Figure 4.**

*Example of SWOARs-sparing IMRT plan for a patient affected by a right tonsillar cancer with omolateral adenopathies (Stage cT3N2b). Dose distributions (Gy) are labeled as percentage isodose line (coral line: 105% isodose; yellow line: 100% isodose; green line: 95% isodose; celestial line: 90% isodose line; cyan line: 85% isodose line; blue line: 80% isodose line). Dark green contour: low-risk target volume (54 Gy); purple contour: intermediate risk target volume (60Gy); dark blue: high risk target volume (66 Gy); brown contour: medium pharyngeal constrictor muscle; red contour: pharyngeal mucosa; orange contour: base of tongue; and yellow contour: oral cavity.*

#### *Radiation-Related Dysphagia: From Pathophysiology to Clinical Aspects DOI: http://dx.doi.org/10.5772/intechopen.88779*

promising results in terms of better oncologic and functional outcomes reducing the dose to the surrounding normal tissues.

Briefly, IMRT is an advanced treatment delivery technique that, exploiting the concomitant movement of multilamellar collimator during X-ray delivery through a computer-guided optimization system, produces concave isodose distributions. As a consequence, a better conformation of high treatment doses to the tumor target volume while significantly reducing the high doses to the nearest healthy tissues through a steep gradient dose is performed.

Studies on swallowing dysfunction using videofluoroscopy after radiation-based treatment revealed abnormalities in most of the previous described pharyngeal swallowing mechanisms. Hutcheson et al. [57], in those patients who referred clinical dysphagia, reported a high rate of minimal or absence of hyolaryngeal elevation and laryngeal vestibule closure, incomplete or absence of pharyngeal contraction, and minimal or no base of tongue retraction. These structures were therefore called "swallowing organs at risk (SWOARs)," and it was recommended that doses to these structures be minimized and studied to gain the potential clinical benefits and to find out the relationship between the absorbed doses to these structures and the risk of aspiration. To this aim, Christianen et al. [58] accurately defined an anatomically CT-image-based guideline for the proper delineation of these structures supposing that a RT-plan optimization to reduce doses to these structures (SWOARs-sparing IMRT) will result in better swallowing functional outcomes. An example of SWOARs-sparing IMRT plan is reported in **Figure 4**.

To date, despite the rationale to use IMRT to reduce posttreatment dysphagia has been well acknowledged, this assumption is still to be confirmed due to the heterogeneity of the current clinical data. Nevertheless, a positive trend seems to emerge by the literature data reporting an overall lower pattern of aspiration after IMRT compared with 3DCRT (2.6–7% versus 7–78%, respectively) and is likely to increase as the radiation oncologist will be more and more encouraged to optimize plans to SWOARs in their clinical practice [59].

To date, the greatest experience on the role of SWOARs-sparing IMRT is from the University of Michigan on 73 patients affected by locally advanced oropharyngeal cancer without the infiltration of posterior pharyngeal wall and without lateral retropharyngeal nodes [60]. In this study, authors reported the safety of dose reduction to these structures in terms of locoregional recurrence rate together with worsening of Patient-Reported Swallowing Scores (HNQOL and UWQOL questionnaires) soon after treatment (at 1 months) followed by a slow and progressive amelioration (between 6 and 12 months) and a subsequent stabilization (after 12 months).

Also, the authors reported worse swallowing scores mostly for solid rather than liquid consistencies, the lack of recovery over time with a mean VF-based SPSS score 4 (meaning necessity of modified diet requiring therapeutic intervention to minimize the risk of aspiration) as well as a pattern of aspiration between 16 and 26% (at 6 and 24 months after therapy).

The dosimetric analysis on the same patient population was subsequently performed by Eisbruch et al. [61] reporting a 50 and 25% risk of VF-based aspiration for doses of 63 and 56 Gy to the pharyngeal constrictor muscles and for doses of 56 and 39 Gy to the supraglottic and glottic larynx.

These findings, despite on a smaller sample size, were confirmed by the University of Pisa mono-institutional prospective experience [62], in which 38 patients affected by naso and oropharynx cancers submitted to SWOARs-IMRT+CT were studied by combining FEES and VFS both at baseline and at 6 and 12 months. An overall moderate/severe dysphagia, based on the amount of pharyngeal residue (P-score) at FEES, accounted for 47 and 37% at 6 and 12 months for solid consistencies. Indeed, a low pattern of post-swallowing aspiration (14 and 10% at 6 and

12 months, respectively) was reported. Differently, videofluoroscopy (VF) findings in this studied population revealed a low pattern of post-swallowing aspiration (14 and 10% at 6 and 12 months after treatment) mostly for solid consistencies.

Interestingly, despite the lack of dosimetric correlation due to the low sample size, higher doses (median doses > 50 Gy) were delivered to the upper SWOARs (such as superior and medium constrictor muscle and base of tongue) and lower doses (median doses < 40 Gy) to the inferior SWOARs.

In this regard, a different radiation-related impairment of upper and lower SWOARs, depending on the primary tumor location (i.e., naso/oropharynx versus larynx/hypopharynx), might justify a variation in the swallowing dysfunction for different consistencies of the bolus suggesting a different involvement of the single SWOARs in the deglutition act.

#### **5. Future directions**

Postradiation swallowing disorders is an ongoing issue that is likely to be further developed in a near future both due to its clinical relevance (mostly in the HPV era with many long-term survivor patients) and to the potential clinical benefit of modern advanced radiotherapy techniques.

At first, based on the previous findings by Pearson et al. [63], other structures to function involved in the hyolaryngeal complex elevation (the supra-hyoid musculature) are likely to be considered in the RT plan optimization process as critical organs.

In this regard, Gawryszuk et al. [64] recently integrated the SWOARs-CT image atlas with the so-called "functional swallowing units (FSUs)" involved in the hyolaryngeal elevation (floor of mouth, posterior digastric/stylohyoid complex and longitudinal pharyngeal muscles), tongue base retraction (hyoglossus and styloglossus muscle complex), and tongue motion (genioglossus and intrinsic tongue muscles) for a RT planning use.

Last but not least, despite being a discussed issue due to the current lack of evidence, the next step is likely to come out from the increasing use of proton therapy. As favorable beam properties of protons allow a higher dose conformity and thus better sparing of normal tissues without jeopardizing target dose coverage, its clinical use is likely to be translated into clinical benefits. Therefore, the SWOARs-sparing Intensity and Modulated Proton Therapy (SWOARs-IMPT) is likely to provide further advantages in terms of swallowing impairment reduction, compared with the standard SWOARs-IMRT (at least in patients with more complex clinical situations) [65].

In the meantime, we are waiting for the results from the British and Italian ongoing prospective clinical trial addressing the role of standard SWOARs-sparing IMRT (ISRCTN25458988 and NCT03448341) [66, 67].

#### **6. Conclusions**

Oropharyngeal dysphagia is the most frequent sequela occurring early and late after a nonsurgical RT-based treatment for HNC often leading to life threatening consequences of a "nonsafe" and/or "inefficacious swallowing act."

As such, an inefficient deglutition can cause malnutrition and dehydration with a consequent immunosuppression, immunodepression, sarcopenia, and hypovolemia-induced state. Concomitantly, an altered oropharyngeal swallowing induces a bacterial colonization in the pharyngeal tract that, in case of nonsafe deglutition causing aspiration, increases the risk to develop clinical aspiration pneumonia.

*Radiation-Related Dysphagia: From Pathophysiology to Clinical Aspects DOI: http://dx.doi.org/10.5772/intechopen.88779*

Therefore, a proper management of radiation-related oropharyngeal dysphagia is a key issue to prevent patients from infectious-related morbidity and mortality that are reported to occur in 7–9% of patients [68].

### **Acknowledgements**

This work was supported by grant from Lega Italiana Tumori Sezione Pisa. We would like to thank Dr. Elvio Russi, Prof. Riccardo Ruffoli, and Dr. Andrea Nacci, as experts of the issue, for their precious cultural contribution.

### **Conflict of interest**

Authors declare no conflict of interest.

### **Author details**

Stefano Ursino1 \*, Paola Cocuzza1 , Stefania Santopadre2 , Fabiola Paiar1 and Bruno Fattori2

1 Department of Radiation Oncology, University Hospital S. Chiara, Pisa, Italy

2 Otorhinolaryngology-Audiology-Phoniatric Unit, University Hospital Cisanello, Pisa, Italy

\*Address all correspondence to: stefano.ursino@med.unipi.it

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Section 6

Salivation by Somatosensory Stimulation

#### **Chapter 6**

## Effect of Salivation by Facial Somatosensory Stimuli of Facial Massage and Vibrotactile Apparatus

*Tsunoda Yumi, Akatuka Sumiko, Fukui Sayaka, Nakayama Enri, Abe Kimiko, Sato Mituyasu, Kimura Masanori, Kato Syunnichiryou, Sakai Maho, Yamaoka Masaru, Watanabe Mao, Ueda Koichirou and Hiraba Hisao*

#### **Abstract**

We studied the effects of salivary promotion of fluid secretion after hand massage, and the apparatus of vibrotactile stimulation (89 Hz frequency, 15 min) in normal humans. Personal massage cannot be performed on handicap and stroke patients, and then giving hand massage to them for 5 min massage gives a tired feeling. So, we focused 3 min stranger massage. Salivary glands can discharge the accumulated saliva by extrusion from the acinus glands' massages as described in the recent Japanese textbook. We think that this method may not produce realistic recovery. Our aim ideas are to relieve stress and increase temperature with lightly touch massage of the skin and for a 1 cycle of 1 s. We recorded RR interval of ECG, total salivation, facial skin temperature, OxyHb of fNIRS on the frontal cortex, and amylase activity for the autonomic changes. In increased 2°C of the facial skin temperature, the hand massage had a need for 3 min and the vibrotactile stimulation for 15 min. Increase from 700 to 1000 ms of RR intervals had a need for 3 min in the hand massage and had 15 min in the vibrotactile stimulation. Although vibrotactile stimulation needs long time of 4–7 years as effective recovery, hand massage may have more effect with a repetition of day after day.

**Keywords:** hand massages, vibrotactile stimulation, facial skin temperature, total salivation, RR intervals of ECG, OxyHb of fNIRS, amylase activity

#### **1. Introduction**

Does somatosensory stimulation in areas of the face and oral cavity promote salivation and recovery of poor salivary glands? We studied the effects of salivary promotion after hand massage and apparatus of vibrotactile stimulation (89 Hz frequency, 9.8 μm amplitude, and 15 min) in normal humans [1]. Namely, we think that the produce of salivation needs effective changes of an autonomic

system for salivation following autonomic activity. Quality of saliva is transmuted by autonomic activity of sympathetic or parasympathetic nerve. In sympathetic activity, viscid saliva functions to allow a food bolus to be easily passed from the mouth into the esophagus. Furthermore, in parasympathetic activity, it is also very important function for the sense of taste and for digestion. In particular, as the poor salivation cannot make the food bolus, dysphasia troubles are induced. On the other hand, poor salivation leads to an increase in dental caries and gingivitis. For ill-fitting dentures of deficits of oral function, massage therapists of the salivation need a rehabilitation method for encouraging salivation and orofacial function [2]. Namely, poor salivations following sickness or advanced aging may be recovered by activation of metabolism of salivary glands. We know that the method of facial traditional massage can induce salivation with increased temperature and blood flow by directly stimulating the salivary glands. However, the descriptions of salivary glands massage from the recent Japanese text will generate salivation by extrusion of accumulated salivary from the acinus glands, and approximately totally 10 pushes form at the anterior to posterior regions of the parotid glands. Furthermore, in the textbook, the submandibular gland is pressed about five times by the thumb to grip the soft parts inside the angle of the mandible, and the sublingual gland is pressed about five times by the thumb from under the chin [3]. The traditional method of saliva massages involved pressing the acinar regions depending on saliva accumulated in that region. However, the principal goal of massages is to maintain one's metabolism. Thus, we think that the real massage must maintain the metabolism of salivary glands at high levels depending on increasing the temperature of facial skin via haptic stimuli, a paratripsis, through the use of the palms of the hand [4]. The real salivary gland massages must be performed to activate the acinar regions. Functional recovery of salivation is encouraged by promotion of the metabolism of the salivary glands, and a rise in metabolism produces with increasing blood circulation in the salivary glands. This increase in circulation also elevates the temperature around the gland which may activate acinus gland cells. Initially, we examined the effect of facial somatosensory stimuli by using of the apparatus of vibrotactile stimuli [1, 5–8]. Secondly, we tried to carry out hand massages, again. So, we will report the effects of salivation in facial vibrotactile stimuli and facial hand massages.

#### **2. Materials and methods**

The Nihon University School of Dentistry provides ethical approval to conduct this pilot clinical study (approval number: 2009-5). All study participants received verbal explanations regarding measurements of hand massages and a vibrotactile apparatus and signed an informed consent. The study participants were again explained about the protection of privacy and personal information and provided the freedom to continue or withdraw their consent.

#### **2.1 The optimum way of hand massage**

We performed facial stranger or personal hand stimuli during 3 and 5 min. After performing the stranger or self-massage procedures for 3 or 5 min, we asked for degree of fatigue. We included 40 healthy subjects (age 26.7 ± 2.4; 25 males, 15 females) and examined well-suited massage time and method depending on first 5 min and then 3 min massage. However, normal subjects were always appealed for feeling of fatigue with an exercise for 5 min. Hand massage for 3 min can be divided *Effect of Salivation by Facial Somatosensory Stimuli of Facial Massage and Vibrotactile… DOI: http://dx.doi.org/10.5772/intechopen.88495*

into stranger and self-massages: own face has been massaged by other person' hand or by own hand. Personal massage is not able to treat patients with handicap and cerebral apoplexy. So, we focused at the exercise for 3 minutes and stranger massage (hand massage), as shown in **Figure 1A**.

After a stranger massage (a light touch and paratripsis massage) of the facial skin, we performed a rotation every second to increase the temperature of the skin and thus boost local blood circulation and improve the metabolism of the parotid glands and around the facial skin (**Figure 1B**).

We performed the resting and stimulating phases during insertion of cotton rolls for each 3 min between 5 and 7 pm under the circadian rhythm. We explored ECG (electrocardiogram), facial skin temperature, total salivations, OxyHb (oxidation hemoglobin) activity of f-NIRS (functional near-infrared spectroscopy) on the frontal cortex and amylase activity between resting and massage phase of the stranger hand massage. We recorded measurement of resting condition for 3 min after each cotton roll was set into the oral cavity, and then after relax of 1 min interval, new cotton roll was fitted into an oral cavity again and we did measurement of stimulating condition for 3 min. The facial skin temperature, RR intervals of ECG and f-NIRS recorded during experiments, and the observational study were measured in each measuring range. Furthermore, we recorded total salivation and saliva amylase activity after each phase of resting, hand massage, and vibrotactile stimulation.

#### **Figure 1.**

*Experimental method. (A) Stranger hand massages performed at 360° roll per 1 s for 3 min. (B-a and -b) 89 Hz and 9.8 μm amplitude vibrotactile stimulation. (C-a) Thermometers on the facial skin, electrodes of electrocardiogram (ECG), and electrical poles of functional near-infrared spectroscopy (fNIRS) in the frontal cortex and the position of electrodes of ECG. (C-b) Photograph of electrical poles of fNIRS and thermistors. (D) The position of cotton rolls into the intraoral cavity. Cotton rolls under the tongue were recorded salivations of the submandibular and lingual glands and cotton rolls on the buccal mucosa of the upper jaw were recorded salivations of the parotid glands.*

#### **2.2 The optimum frequency of vibrotactile apparatus**

Apparatus of 89 Hz frequency and 9.8 μm amplitude vibrotactile stimulation was chosen by data of the previous papers [1, 5–8], as shown in **Figure 1B-a**, -**b**. We tried three vibrotactile stimuli, (89, 114, and 180 Hz, and others all of 9.8 μm amplitude), and the best salivation was 89 Hz frequency in comparison with others, as shown in **Figure 2**. This apparatus was used by poor salivation patients (especially, Sjogrens's syndrome and so on) and about 50% of patients showed the effect [1]. Stranger hand massage had a limit time to do massage for physical fatigue, so we tried the 89 Hz frequency vibrotactile apparatus for long time of facial stimulation. Furthermore, we recorded facial skin temperature, total salivation, RR intervals of ECG, and saliva amylase activity, too.

We explored the facial skin temperature, ECG recording, and fNIRS on the frontal cortex for the comparison with resting for 3 min, stranger massage for 3 min, and vibrotactile apparatus for 15 min.

#### **2.3 Analysis of facial skin temperature**

Facial skin temperature was measured by thermistor-pots (BioResarch Co.) located on the facial skin of parotid glands of both sides with adhesive tape, as shown in **Figure 1C-a**, -**b**. We recorded the temperature through the experiment and analyzed 3 min from start to finish during resting phase, 3 min from start to finish during stranger hand massage, and 15 min from start to finish during the vibrotactile stimulation.

**Figure 2.**

*Total salivation in resting salivation and vibrotactile stimuli (89, 114, and 180 Hz frequency). p < 0.01, t-test.*

*Effect of Salivation by Facial Somatosensory Stimuli of Facial Massage and Vibrotactile… DOI: http://dx.doi.org/10.5772/intechopen.88495*

#### **2.4 Analysis of RR intervals of ECG**

The electrocardiogram (ECG) recording was induced by the standard limb lead. The heart rate was measured by the RR interval rate (time between R and R) and was analyzed by the variance plot and frequency distribution, as shown in **Figure 1C-a**. On the other hand, in the distribution of frequency measured by RR interval rate, we decided a mean RR interval value in order to show almost monomodal peaks [9].

#### **2.5 Analysis of total salivation**

The mouths of each subject were fitted with rolls of cotton placed on both sides of the mouth at the following sites on the duct openings of the parotid glands of the buccal mucosa near the second upper molar teeth, and under the tongue to collect saliva from the sublingual and submandibular glands for a measurement of total salivation, as shown in **Figure 1D**. The total salivations indicate the sum of four cotton rolls (both sides of parotid, and submandibular and sublingual glands), as shown in **Figure 1D**. We measured the resting salivation for 3 min and after a relaxing interval of a minute, we did stranger hand massages salivation for 3 min again. Furthermore, we measured total salivations of the 15 min vibrotactile stimulation after 5 min resting interval of the massage.

#### **2.6 Analysis of an OxyHb of fNIRS on the frontal cortex**

The recording was conducted using a functional near-infrared spectroscopy (fNIRS) OEG16 instrument (SpectraTech, Inc., Shelton, CT, USA) from the frontal cortex. As shown in **Figure 1C-a**, -**b**, the fNIRS probe assembly consisted of six LEDs as light sources, each of which emitted two kind of wavelengths, 770 and 840 nm, and six photodiodes as detectors. The sources and detectors were symmetrically arranged in an area of 3.0–14.0 cm, with the nearest source-detector separation of 2.0 cm, and measurement points were at 16 points on a frontal cortex. During scanning, a velcro band held the probe assembly securely to the forehead of subjects and extended from ear to ear horizontally and from hairline to eyebrows vertically. Each of the LEDs was turned on in sequence, and the diffuse NIR light from each source was acquired through the cortical region at the nearest detector. Thus, 16 source-detector pairs (channels) in total were measured (**Figure 1C**-**a**, -**b**). The sampling rate across all 16 channels was 0.76 Hz. In particular, we showed a 16-channel computerized analysis (as shown in the previous papers [5–7]) and the original waves of four channel recording areas in the central parts. Analysis of amount of OxyHb of fNIRS on the frontal cortex is examined by the program of fNIRS Data Viewer, and we explored channels 4, 7, 10, and 13 of the central part of the frontal cortex. Data recorded by the experiment measured the value of integral of four channels in the center frontal cortex, and we calculated mean value of integral of four waves [5, 6, 10, 11].

#### **2.7 Analysis of salivary amylase activity**

A salivary amylase (α-amylase) activity was measured by salivary amylase monitor (Nipro Co.) provided for chips of salivary amylase monitor. Measurements of saliva amylase activities were recorded after resting, stranger hand massage, and vibrotactile stimulation phases.

#### **3. Results**

We examined the effect of salivation in resting and stimulating stages between the stranger hand massage and vibrotactile apparatus. We focused on a 3 min stranger massage, because a self-massage could not be performed for treating patients with handicap and stroke, and 5 min massage evoked the tired feeling.

#### **3.1 Facial skin temperature**

In 5 min hand massages, facial skin temperature increased about 2–3°C in both hand massages (stranger and personal). On the other hand, in 3 min stimuli, facial skin temperature increased about 1.5–2.0°C. The tendency of increased facial skin temperature in 3 and 5 min stimuli was almost same; namely, the ratio of increased temperature was dependent on stimulus time. On the other hand, in performance of stranger hand massages for 5 min, each operator complained with feeling of fatigue, and sometimes showed overflowing of salivation in the cotton rolls of the oral cavity. From this result, we abandoned this experiment of 5 min stimulation depending on using of five subjects. Furthermore, the 5 min massage procedure elicited the sure fatigue. So, we focused to 3 min stranger hand massage.

In loading, facial skin temperature showed about 33°C in the insert of cotton rolls in an oral cavity, as shown in **Figure 3**. This skin temperature may be stimulated by a foreign substance, because facial skin temperature was decreased up to about 32°C in the resting phase after loading. After a resting phase of 3 min stranger massage stage, facial skin temperature in the stranger massage increased from 32.0 to 34.5°C, as shown in **Figure 3**; namely, stranger massage showed the increase of facial skin temperature from 32.0 to 34.5 in 3 min stimulation.

On the other hand, the apparatus of 89 Hz frequency and 9.8 μm amplitude vibrotactile stimulation was chosen by data of the previous papers [1, 5–8], as shown in **Figure 1**. This vibrotactile stimulation was the best salivation in comparison with others, as shown in **Figure 2**. In the resting phase, facial skin temperature showed about 32°C. Furthermore, the start of 89 Hz vibrotactile stimulation showed about 33°C and after 15 min, it did 34°C; namely, an increase of 1°C spent due to 15 min vibrotactile stimulation, as shown in **Figure 3**.

#### **Figure 3.**

*Changes in temperatures on facial skin before and after 3 min resting phase, 3 min stranger massage, and 15 min vibrotactile stimulation. Black circle is right side and white circle is left side.*

*Effect of Salivation by Facial Somatosensory Stimuli of Facial Massage and Vibrotactile… DOI: http://dx.doi.org/10.5772/intechopen.88495*

#### **3.2 RR interval of ECG and total salivation**

First, we examined the difference between stranger and self-massages of the RR intervals of ECG. However, there were no differences between the RR intervals of ECG of stranger and self-massages. Especially, the RR intervals in 3 min stranger massage had a tendency to decrease (increase of heart rate), and there was a *p* < 0.01 significance (T-test), as shown in **Figure 4A**. Namely, for 3 min of stranger massage, RR intervals increased from about 700 to 1000 ms, and it evoked feeling of sleepy in everybody, as shown in **Figure 4A**. However, a 89 Hz vibrotactile stimulation was spent for 15 min to increase from about 700 to 1000 ms of RR interval, as shown in **Figure 4A**. Especially, immediately after the insert of cotton rolls, RR intervals showed about 700 ms and then after a few min increased up to about 900–1000 ms, as shown in **Figure 4A**. In particular, hand massages are effective to increase temperature and RR intervals. However, no change of total salivation did not show the effect of the autonomic system in 3 min hand massage.

However, hand massages, especially stranger one, will evoke sleepiness by the increased temperature, and metabolism will decrease getting sleepy with the non-increased salivation. Especially, hand massage is needed to countermeasure the effectiveness of fight falling asleep.

On the other hand, total salivation showed about 1.2 ml in resting phase during 3 min, 0.5 ml in stranger massage during 3 min, 1.0 ml in self massage during 3 min, and 3.5 ml in 89 Hz vibrotactile stimulation during 15 min, as shown in **Figure 4B**. Although 3 min hand massages did not show the effect of autonomic activity, 15 min vibrotactile stimulation did it.

#### **Figure 4.**

*RR intervals of ECG (A) and total salivation (B) before and after 3 min hand (stranger and self-massage) massage.*

#### **3.3 Measurement of OxyHb of fNIRS on the frontal cortex**

The increase toward plus direction of OxyHb is associated with neuronal activities, but when we become sleepy, it is decreased toward below zero [12, 13]. On the other hand, the zero level of OxyHb of fNIRS showed parasympathetic activity from our data [5–7]. According to the amount of OxyHb of fNIRS, OxyHb in the stranger massage showed the decrease below zero, as shown in **Figure 5**. The results may be sleepy with decreased OxyHb during the stranger massage. According to analysis of OxyHb activity of fNIRS, during the resting phase and hand stimulation, subjects showed the nonzero number, and during the second half stimulation of 89 Hz vibrotactile apparatus, they showed the zero level. In particular, the below zero level of OxyHb activity coincided with the inducing of sleepy in the stranger massage. We think that the nonzero number is the decreased metabolism with getting sleepy, and the zero level is the parasympathetic activity (2–15 min in 89 Hz vibrotactile stimulation), as shown in **Figure 5** and the previous papers [5–8]; namely, the stranger massage will produce an early excitation (0–2 min) and a late relaxation (3 min), as shown in **Figure 5**.

#### **3.4 Measurement of amylase activity**

In the previous studies [10, 11, 14], measured values with salivary amylase monitor (Nipro Co.) showed the increased value depending on the sympathetic activity; namely, the value of amylase activity measured by salivary amylase monitor is shown as an increase of value following increased sympathetic activity. The results showed that the minimum value was before hand massage (about 15 KIU/L) and then the maximum value was after stranger massage (about 40 KIU/L) and vibrotactile apparatus (about 42 KIU/L), as shown in **Figure 6**. These findings show that subjects (patients) may be excited (decreased RR intervals, as shown in **Figure 4A**) by stranger's hand touching (**Figure 4B**). Furthermore, it may be related to an amount of amylase.

#### **Figure 5.**

*Changes in OxyHb of fNIRS of resting and stranger massage for 3 min, and vibrotactile stimulation of 89 Hz frequency and 9.8 μm amplitude for 15 min. p < 0.01, p < 0.05, t-test.*

*Effect of Salivation by Facial Somatosensory Stimuli of Facial Massage and Vibrotactile… DOI: http://dx.doi.org/10.5772/intechopen.88495*

#### **Figure 6.**

*Changes in amylase activities of loading, resting phase, and hand stranger massage for 3 min, and vibrotactile stimulation of 89 Hz frequency and 9.8 μm amplitude for 15 min.*

#### **4. Discussion**

#### **4.1 Facial skin temperature**

Firstly, although we tried to perform 5 min massage, there were three bad deficits: in 5 min massage, operators complained about being very tired and they cannot handle patients with handicaps and stroke. Furthermore, we performed by the measurement of salivation with the cotton roll method. When we measured the amount salivation of a cotton roll, subjects of 5 min stimulation with heavy salivation often leaked from a cotton roll [8]. So, we focused to 3 min stranger hand massage, and we measured facial skin temperatures after 3 min resting phase and after 3 min stranger hand stimulation phase. In 3 min stranger hand stimulation, facial skin temperature increased about 2.0°C, as shown in **Figure 3**. In particular, in comparison with before and after facial skin temperatures between resting and hand massage, although the resting phase increased as little as possible, the hand massage showed a big increase in temperature. On the other hand, a 89 Hz vibrotactile stimulation was spent for about 15 min to increase temperature (about 1.0°C), as shown in **Figure 3**. The finding showed that the stranger hand massage was especially effective in facial skin temperatures. As shown in **Figure 3**, a 89 Hz vibrotactile stimulation was spent for 15 min for an increase of 1°C [5–8]. However, hand massages are adequate with 2–3 min for an increase of 1°C, as shown in **Figure 3**. Although a 89 Hz vibrotactile stimulation needs long time of 4–7 years as effective recovery, hand massage for 3 min may have more effect with a repetition of day after day, as shown in the previous paper [1]. A 89 Hz vibrotactile stimulation was spent for 15 min time for an increase of 1°C, and this apparatus got effective by using at morning and night. However, as hand massage was necessary for 1–2 min, we may get effect by doing at morning and night; namely, an effective increase in facial skin temperature may be elicited by a good metabolism for recovery [15].

#### **4.2 Effect of autonomic activity**

The effect of autonomic activity can directly be studied by changes in RR intervals of ECG and total salivation. The RR interval and salivation are controlled by an autonomic activation, and the increased RR intervals (decrease of heart rate) and a great deal of serous salivation are parasympathetic activity and the

decreased ones (increase of heart rate) and a little mucus salivation are sympathetic activity [16, 17]. In the experimental room, the RR interval showed about 700 ms in the resting phase between 0 and 1, and after the resting phase of the latter half, it arrived in about 900 ms, as shown in **Figure 4A**. This insert of cotton rolls was activated by sympathetic nerve, and the RR intervals were decreased. Furthermore, in the resting phase of the latter half, it became naturalized, and the RR intervals increased, as shown in **Figure 4A**; namely, it showed the adaptation to the environment in latter resting phase. On the other hand, total salivation was decreased before and after hand massages, as shown in **Figure 4B**. This decrease may be activated by sympathetic nerve. Three minutes hand massages may be a small amount for the effective autonomic activity and an adequate massage times may produce an effective effort of the autonomic nerve. In the 3 min hand stimulation, they showed the increased rate in average values, and they showed significant differences (T-test, *p* < 0.01) in RR intervals. However, in total salivation, the hand massage may not show the effect of the autonomic nerves as 3 min stimulation. Although this finding may be an effective treatment, we thought inadequate recovery of a function for salivation. We reported the increased salivation depending on the 89 Hz vibrotactile stimulation on the facial skin [1, 5–7]. Namely, autonomic changes of stranger massage may be produced by an adequate stimulation time. However, the stranger hand massage did not show the total salivation, and always caused sleepiness after the experiments. We think increased temperature will show a good increased metabolism in stranger massage, but all of subjects are set to sue for sleepiness in the stranger massage. Namely, it is important to get not to sleep for prevention of a decline in metabolism.

#### **4.3 Analysis of OxyHb of fNIRS on the frontal cortex**

We have studied an analysis of OxyHb of fNIRS (a functional near-infrared spectroscopy) on the frontal cortex during vibrotactile stimuli, as shown in the previous papers [1, 5–8]. As a result, we reported that the zero level of the OxyHb of fNIRS showed the parasympathetic activity (**Figure 5**), and total salivation in the vibrotactile stimulation of the 89 Hz frequency and 9.8 μm amplitude were the most effective.

Facial skin temperature increased from 32 to 34°C spend 3 min in the hand massage, and did 15 min in 89 Hz vibrotactile stimulation. Although 3 min stranger massage did not show the effective effect of total salivation, RR intervals increased from 670 to 1000 ms. However, over 3 min massage evoked the fatigue feeling. So, we tried 15 min 89 Hz vibrotactile stimulation. To increase RR intervals, we spent 3 min in the hand massage, but 15 min was spent in the 89 Hz vibrotactile stimulation; namely, an increase of facial skin temperature and RR interval will be effective in the 3 min hand massage.

We measured facial skin temperature and fNIRS on the frontal cortex during 3 min hand stimulation and during 3 and 15 min 89 Hz vibratory stimulation. We reported that the vibrotactile stimuli on the facial skin showed the near zero level of values of OxyHb, DeoxyHb, and TotalHb in fNIRS [1, 5–8]. The OxyHb and DeoxyHb of brain circulation in the frontal cortex were reported to parallel the neuronal activity [2]. The finding is showed by the increased parasympathetic activity [1, 5–8]. On the other hand, the decreased OxyHb (under zero level) showed the decreased neuronal activity with the decreased consumption of oxygen and metabolism, and the drowsy and sleepy conditions were shown by the decreased OxyHb during hand massages [13]. According to OxyHb activities of fNIRS on the frontal cortex, effects between stranger massage and resting condition are almost the same under zero level. Hand stimulation for 3 min may not show the increase of

*Effect of Salivation by Facial Somatosensory Stimuli of Facial Massage and Vibrotactile… DOI: http://dx.doi.org/10.5772/intechopen.88495*

total salivation, except for the increase of facial skin temperatures, RR intervals of ECG and saliva amylase. However, RR interval and salivation were effective effort on 15 min 89 Hz vibrotactile stimulation, as shown in **Figure 4B** and the previous paper [5]. As over 3 min massage produced the fatigue feeling, we thought that repetitious stimuli may change the autonomic system and during hand massage, we tried hard not to get sleepy by talking. However, in the subject, this active feeling was decreased immediately and the subject felt sleepy.

#### **4.4 Changes in an activity of saliva amylase**

A stress is activated by the activation of sympathetic nerve, and an activity of saliva amylase is increased by a self-preservation response of a body; namely, the activity of amylase shows the activity of sympathetic nerve [14]. However, we may relate to amount of amylase because of their mass production after 15 min vibrotactile stimulation, as shown in **Figure 6**. The results showed the increased activation of saliva amylase related to amount of amylase, too. So, the increased saliva amylase was exhibited by about increase 2.5 times in 3 min hand stimulation and 89 Hz vibrotactile stimulation showed three times, as shown in **Figure 6**. This finding shows that subjects may be excited by stranger's hand touching and then decrease of RR intervals (**Figure 4B**). On the other hand, it may be related to increase of amylase activity and amount of saliva in the 89 Hz vibrotactile stimulation, too.

#### **5. Conclusion**

Generally, a massage is an immediate recovery of reducing stress with warm feeling by a light touch. An explanation in Japanese textbook of "salivation glands massage" was caused by extrusion of accumulated salivary from the acinus glands. However, this method of salivation massage was not encouraged by shakeout of poor glands, we thought. Traditional idea of massage shows immediate recovery of reduced stress with warm feeling. Namely, traditional massage on the facial skin shows immediate reaction, and deactivated salivary glands will be a recovery with an improvement of circulating blood by the increased temperature [18]. The increasing temperature by hand stimuli brings forward metabolism in the facial skin and saliva glands, and deactivated saliva glands as a recovery will be a good tendency. We focused on 3 min hand stranger massage, because 5 min massage was provoked by feeling of fatigue, and self-massage could not treat in handicap and stroke patients. However, we were performed by a hand stranger massage for 3 min, because of operator's fatigue over 3 min massage. In the effect of automatic nerve system, the hand stranger massage for 3 min increased RR intervals of ECG, did not increase salivation, and increased the amylase activity. However, the hand stranger massage was the best effectiveness of the increased facial skin temperature. On the other hand, hand massages will evoke sleepiness by the increased temperature, and metabolism will decrease getting sleepy with the non-increased salivation. Furthermore, OxyHb of fNIRS on the frontal cortex showed values below zero during hand stimulation. Values below zero in OxyHb of fNIRS show the sleepiness. This reason may suggest that hand massage is effective not only due to increased temperature and metabolism but also non-increased salivation and heart rates. In particular, during hand massage, we must try not to get sleepy by talking. However, the vibrotactile stimulus apparatus for 15 min showed changes in the RR interval of ECG and salivation. On the other hand, repetitious stimuli may change the autonomic system, but the most suitable time of repetitious intervals is necessary for further experiments. As shown in **Figure 4A-a**, -**b**, a 89 Hz vibrotactile stimulation is spent for 15 min for an increase

#### **Figure 7.**

*Our idea about effects in salivation of facial somatosensory inputs. In summary, we showed our idea of salivation by facial somatosensory stimuli, hand stranger massage, and vibrotactile stimulation. Facial somatosensory sense was excited by oral somatosensory inputs with the 89 Hz vibrotactile stimulation or hand massage. Vibrotactile inputs arrived at the hypothalamus via the trigeminal somatosensory nucleus, and then parasympathetic nerves were activated and produced salivation. So, vibrotactile stimulation will be slowly recovered with the increase of facial skin temperature. Although vibrotactile stimulation spent many time for recovery of glands, hand massage might do a short time for recovery. In particular, the hand stranger massage rapidly increased the produced facial skin temperature and reducing stress. Furthermore, it will recover circulation and metabolism. This massage may be early recovered by a repetitious performing in comparison with a recovery period of the vibrotactile apparatus.*

of 1°C [5–8]. However, hand massages are adequate with 2–3 min for an increase of 1°C, as shown in **Figure 2A** and **B**. Although the 89 Hz vibrotactile stimulation needs long time of 4–7 years for effective recovery, hand massage for 3 min may have more effect with a repetition of day after day. Namely, an effective increase of facial skin temperature may be elicited by a good metabolism for recovery.

In summary, we showed our idea of salivation by facial somatosensory stimuli, hand massage, and vibrotactile stimulation as shown in **Figure 7**. Facial somatosensory sense was excited by oral somatosensory inputs with the 89 Hz vibrotactile stimulation or hand massage. Vibrotactile inputs arrived at the hypothalamus via the trigeminal somatosensory nucleus, and then parasympathetic nerves were activated and produced salivation. So, vibrotactile stimulation will be slowly recovered with the increase of facial skin temperature. Although vibrotactile stimulation spends many time for recovery of glands, hand massage might do a short time for recovery. In particular, the hand massage rapidly increased the produced facial skin temperature and reduced the stress. Furthermore, it will recover circulation and metabolism. This massage may be early recovered by a repetitious performing in comparison with a recovery period of the vibrotactile apparatus.

#### **Acknowledgements**

This work was supported by Sato (2018) and Sogoshigaku (2018) research grant of Nihon University School of Dentistry, by Grants-in-Aid for Scientific Research (21592539) and by a grant from the Ministry of Education, Culture, Sports, Science, and Technology to promote multidisciplinary research projects.

*Effect of Salivation by Facial Somatosensory Stimuli of Facial Massage and Vibrotactile… DOI: http://dx.doi.org/10.5772/intechopen.88495*

#### **Conflict of interest**

None of the authors report any conflict of interest.

#### **Ethical approval**

The Nihon University School of Dentistry provides ethical approval to conduct this pilot clinical study (approval number: 2009-5). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This chapter does not contain any studies with animals performed by any of the authors.

### **Informed consent**

Informed consent was obtained from all individual participants included in the study.

#### **A. Appendices and nomenclatures**

Obey dysphasia rehabilitation society.

#### **Author details**

Tsunoda Yumi1 , Akatuka Sumiko1 , Fukui Sayaka1 , Nakayama Enri2 , Abe Kimiko2 , Sato Mituyasu<sup>2</sup> , Kimura Masanori<sup>2</sup> , Kato Syunnichiryou2 , Sakai Maho2 , Yamaoka Masaru3 , Watanabe Mao2 , Ueda Koichirou2 and Hiraba Hisao2 \*

1 Nihon University Dental Hospital at Surugadai, Chiyoda-Ku, Tokyo, Japan

2 Department of Dysphasia Rehabilitation, Chiyoda-Ku, Tokyo, Japan

3 Department of Physics, Chiyoda-Ku, Tokyo, Japan

\*Address all correspondence to: hiraba60@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

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[2] Ito K. Koukuu kannsou syou (dry mouth). In: Saito E, Mukai Y, editors. Sessyoku Ennge Rehabilitation. Tokyo: Ishiyaku Co.; 2009. pp. 96-98. (in Japanese)

[3] Kakigi Y. Koukuukannsousyou enotaiou. In: Morito M, editor. Koureisha Shika Gaku. Kyoto: Nagasue Syotenn; 2014. pp. 75-78. (in Japanese)

[4] Amelia DA. Chapter 2: Loving touch. In: Baby Massage: Parent-Child Bonding through Touch. New York: Newmarket Press; 1989. pp. 25-40

[5] Hiraba H, Inoue M, Gora K, Sato T, Nishimura S, Yamaoka M, et al. Facial vibrotactile stimulation activates the parasympathetic nervous system: Study of salivary secretion, heart rate, pupillary reflex, and functional nearinfrared spectroscopy activity. BioMed Research International. 2014;**2014**:1-9

[6] Hiraba H, Inoue M, Sato T, Nishimura S, Yamaoka M, Shimano T, et al. Chapter 14: Optimal vibrotactile stimulation activates the parasympathetic nervous system. In: Francisco B-C, editor. Advances in Vibration Engineering and Structural Dynamics. Rijeka, Croatia: IntechOpen; 2012. pp. 335-369. Available from: http://www.intechopen.com

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### Section 7

## Dysphagia Due to Cervical and Facial Tumors

#### **Chapter 7**

## Swallowing Disorders in Cervical Facial Tumors

*Daniela Vrinceanu and Mihai Dumitru*

#### **Abstract**

We review current state of the art protocols on swallowing disorders associated to cervical facial tumors. The clinician needs to translate physiology notions to bedside diagnosis. Facing such a case the ENT surgeon must follow several key steps: thorough history taking, barium transit, endoscopy evaluation of swallowing, high resolution diagnosis imaging. Afterwards surgical treatment plan should take into consideration the need to careful dissection of vascular and nervous structures. Dysphagia may present from initial diagnosis or after surgical resection of the tumor or during radiation and chemotherapy. We discuss the use of various staging scales or questionnaires for assessing quality of life. We illustrate the importance of swallowing disorders management with various cases of tumors at the level of skull base, pharynx, salivary glands, larynx, esophagus, etc. There are various solutions for dysphagia ranging from nasogastric feeding tube placement to percutaneous endoscopic gastrostomy to specially designed exercises. Sometimes the surgeon neglects these disorders and focuses on airway management. However, the rule should be to encourage swallowing as soon as possible after surgery. A good nutritional status is necessary for a positive prognosis in swallowing disorders. Team effort in tertiary oncology units is the key in supporting such complex cases.

**Keywords:** tumors, cervical, facial, swallowing, disorders

#### **1. Introduction**

Pharyngeal dysphagia is defined as a disorder affecting the passage of food from the oral cavity to the stomach. When swallowing associates pain it is described as odynophagia. Tumors at the level of head and neck frequently associate dysphagia and odynophagia [1].

Swallowing disorders represent the first sign of tumor pathology in upper aerial and digestive tract. In 14–18% of the cases the isolated symptom of dysphagia requires a complete screening for primary occult tumors [2].

Surgical removal of cervical and facial tumors hinders swallowing process by removing parts from the pharyngeal muscles or nerves. Even for removal of benign tumors there may be inflicted lesions of cranial nerves responsible with swallowing and lowering the quality of life of the patient mostly because reconstruction achieves structural continuity but not function. Moreover, radiotherapy and chemotherapy lead to oral mucositis hindering correct swallowing [3].

After completing therapy, we can define a residual dysphagia. Unfortunately swallowing disorders become permanent in 40% of cases, diminishes in 39% of the cases and worsens in 20%. In all these cases dysphagia needs further evaluation and require prevention of aspiration and improvement of quality of life [4].

In cervical facial tumors, dysphagia is connected to factors such as: direct extension of the tumor, aggressiveness of the surgical resection, radiotherapy and chemotherapy. Swallowing disorders may represent an element of diagnosis, an indicator of the postsurgical recovery and an important factor the quality of life [5].

#### **2. Clinical physiology of swallowing**

The swallowing process presents three stages: oral, pharyngeal and esophageal. All these stages are marked by activation of specific anatomical and functional connections enabling early diagnostic topography of dysphagia [6].

Oral stage is the only voluntary moment in swallowing. Aliments are submitted to mechanical transformation during mastication and mixture with saliva thus forming the alimentary bolus. Masseter muscles are central in mastication and are innervated by the motor branch of the trigeminal cranial nerve. Consistency of the bolus is also important during swallowing process enabling the correct backward movement towards the pharynx due to the pressure of the tongue on the soft palate. From this point swallowing is becomes uncontrolled and automatic [7].

During pharyngeal stage the bolus stimulates receptors at the level of the anterior region of the pharyngeal tonsils. Impulses from this level reach the brainstem initiating a series of reflex muscular contractions with simultaneous purposes: propulsion of the bolus through digestive tract and protection of superior airways. Therefore, the soft palate is stiffened closing the choana; palatal-pharyngeal arches are medial delineating a sagittal slit through which the bolus passes into the pharynx; epiglottis moves posterior over the laryngeal inlet; vocal cords adduct thus closing and the larynx is displaced anterior and upwards by external muscle groups [8].

All these contractions prevent the entrance of bolus in the larynx and trachea. Upwards movement of the larynx opens the esophageal inlet. Simultaneously the complex of the pharyngeal and superior esophageal sphincters relaxes enabling the passage from hypopharynx to superior esophagus. In the same sequence the entire posterior pharyngeal wall records the contraction of middle and inferior pharyngeal constrictor muscles towards the esophagus. All these processes last only 1–2 seconds [9].

Esophageal stage presents primary peristalsis waves and secondary peristalsis waves transporting the bolus till the stomach. Primary peristalsis continues the pharyngeal contraction and reaches the stomach in 8–10 seconds. Secondary peristalsis waves are generated by esophageal distension. These are initiated by the esophageal plexus and reflexes with afferent vague fibers to the medulla oblongata [10].

All three stages unite the control from cranial nerves IX–XII and trigeminal and facial nerves. Therefore six cranial nerves and more than 25 muscles are responsible for swallowing completion [11].

#### **3. Neurology syndromes affecting cranial nerves**

Syndromes affecting the last four pairs of cranial nerves are frequently encountered in cervical facial tumors mostly when superior jugular lymph nodes enlarge due to metastasis and compress these nerves and posterior cervical sympathetic trunk. Other scenario is regarding the evolution of skull base tumors extending to posterior cranial fossa [12].

*Swallowing Disorders in Cervical Facial Tumors DOI: http://dx.doi.org/10.5772/intechopen.90624*

Vernet syndrome was described in 1916 and implies affliction of cranial nerves IX, X and XI. These jugular foramina syndrome presents with: paralysis of half of the soft palate, paralysis of laryngeal recurrent nerve, paralysis of sternocleidomastoid and trapezius muscles on the same side. As etiology possible is trauma or external tumor compression at the level of the jugular foramina [13].

When a patient with the aforementioned syndrome has further lesion of the XII cranial nerve, we describe the Collet-Sicard syndrome. Hypoglossal paralysis leads to deviation of the protruding tongue towards the affected part and atrophy of the tongue on the same side after 6 months [14].

Involvement of the sympathetic chain leads to Horner syndrome associating enophthalmia, ptosis, myosis, vascular disorders and redness and sweating on the same side of the face [15].

Tapia described as early as 1905 a syndrome affecting nerves X and XII with recurrent laryngeal nerve palsy and tongue palsy on the same side [16].

Causes of these syndromes could be trauma, inflammation or tumor compression. So, facing the case of an isolated neurological syndrome with dysphagia one must take into consideration the possibility of a primary occult or high secondary metastatic cervical tumor [17].

#### **4. Principles of positive diagnosis in swallowing disorders**

From the very beginning the specialist should focus on complete history taking and symptoms accurate recording, pharyngeal clinical exam and swallowing clinical exam [18].

History taking is a key element in diagnosis of swallowing disorders. One should record: pain during swallowing, provocation of cough during swallowing, avoiding food with higher consistency, weight loss, prior history of pneumonia and other neurological diseases. Should be very clear the beginning of dysphagia and associated symptoms such as dysphonia and dyspnea. Very important is the exposure to tobacco smoke and alcohol consumption. Moreover, it is important to record other neurological symptoms as presences of herpes simplex virus lesions, previous trauma or other associated diseases such as diabetes. Another aspect is the swallowing difficulty with solids or liquids, because solid dysphagia points to a possible tumor while dysfunction with liquid aliments is encountered mostly in neurology diseases [19].

Clinical ENT exam should be thorough with an extensive flexible fiber endoscopy for occult tumors at the level of the rhinopharynx, palatine tonsils, tongue base, and pharyngeal-laryngeal junction. Analyze the dental status, use of dental prosthesis, dryness of the mucosa, tongue, lips and soft palate symmetry. Tactile sensibility of lips, tongue and pharynx should be also assessed. Very important is correct palpation of the neck for lymph nodes enlargement and thyroid pathology. There are documented cases in which a large goiter can compress the esophageal inlet and thus lead to dysphagia. A consistent amount of time should be allotted to cranial nerves exam along with a complete neurology consult [20].

Discovering a swallowing disorder requires a controlled passage test with aliments of different textures [21].

#### **5. Objective analysis of swallowing disorders**

There is hardly a consensus regarding optimum evaluation of pharyngeal dysphagia with various strategies at level of diagnosis center or country. ICON 2018 consensus querying five experts from four continents recommends functional endoscopic evaluation swallowing (FEES) and video fluoroscopic swallowing study (VFSS). FEES visualize the pharynx through a trans nasal endoscope and detect rapid movement of solid and liquid aliments with a high risk of aspiration. VFSS may be combined with conventional manometers and enables the correlation between motility and pressure patterns inside the lumen [22].

Also useful is barium transit which facilitates direct dynamic view of the swallowing process and aspiration of the contrast media in the larynx and trachea. Sometimes, the contrast media should be sterile and soluble for preventing aspiration lesions (**Figure 1**). Sometimes even a standard cervical column X-ray can reveal ossification of the anterior vertebral longitudinal ligament leading to Forrestier syndrome [23].

It is recommended the use of and objective evaluation scales such as the one designed by Carnell et al. According to this scale grade 1 is normal performance. Second grade is within functional limits with an abnormal oral stage but a normal diet. Third grade records mild impairment of the pharyngeal stage with a modified diet. Grade 4 requires further therapeutic precautions to minimize aspiration risk. Fifth grade notes the presence of aspiration. Grade 6 will require the use of enteral feeding support. Final grade presents with severe impairment and inadequate transit to esophagus [24].

This objective scale evaluates swallowing for introduction of parenteral nutrition and monitoring the patient evolution. The impact of swallowing dysfunction on quality of life is made through self-evaluating questionnaires. Such tools are: the swallowing questionnaire quality of life (SWAL-QOL) and SWAL-CARE and MD Anderson Dysphagia Inventory (MDADI). SWAL-QOL contains 44 questions reunited in several scores with the purpose of identifying patients with dysphagia. MDADI has only 20 questions with scales for emotional, functional and physical impact of dysphagia [25].

The best management decision takes into consideration both objective and subjective evaluations of swallowing dysfunction.

#### **6. Imaging in swallowing disorders**

Given the history data and clinical exam the next management step should be based on cranial and cervical CT scan or MRI imaging. Imaging enables correct planning of biopsy which is the gold standard in diagnosing tumors at the level of head and neck. A distinct chapter is primitive metastatic lymph nodes which require a thorough imaging screening for detecting the original neoplasm [26].

Up to this point the work-up should follow careful history taking, complete clinical exam, multi-level flexible endoscopy, barium enema with sterile contrast media, head and neck CT scan or MRI, targeted biopsy with pathology exam.

Differential diagnosis of swallowing disorders focuses on tumors if upper aerodigestive tract or a head and neck tumor, neurology syndromes or degenerative neural disease, infectious diseases such as herpes zoster, stroke, cervical vertebra pathology and rare conditions such as dilation of esophageal inlet [27].

### **7. Clinical aspects of dysphagia in cervical and facial tumors**

Malignant tumors of the tongue and mouth floor have an important effect on deglutition. Large resections of the tongue require mounting a nasopharyngeal feeding tube for up to 14 days after surgery. This tube is necessary for preventing resection margins dehiscence and preventing aspiration. During these 2 weeks period the patient performs small exercises in order to develop compensatory mechanisms. Coughing before removal of the tube should require prolongation of its use [28].

Regarding malignant tumors of tongue base, we encounter a low survival with a diminished quality of life (**Figure 2**). Mostly in these cases the only management pathway available is centered on radiotherapy. Gastrostomy is necessary to be maintained up to 6 months and its removal should be attempted only after clinical and imaging confirmation of remission and low probability of bolus aspiration [29].

Nonetheless during palliative oncologic treatment, the nutritional status is very important because symptoms such as oral mucositis may contribute to weight loss and treatment failure.

Parotid gland tumors both benign and malignant greatly influence swallowing through various mechanisms. For example, sectioning the facial nerve will lead to poor preparation of the alimentary bolus during mastication. In many cases this aspect is neglected by the specialist surgeon already troubled by the facial neurologic deficit [30].

#### **Figure 2.**

*Tumor in the left tongue base requiring resection for radical oncology surgery and thus leading to major swallowing dysfunctions.*

Pharyngeal tumors associate swallowing problems from the very beginning. Unilateral pain during swallowing should grow the suspicion of a palatine tonsil tumor. After surgery many of the swallowing deficits are corrected using specially design exercises and head positioning during food intake. Facing a tumor on the posterior of the pharynx the swallowing dysfunction has an early onset but neglected by patients coming from poor economic environments with deficit in healthcare coverage (**Figure 3**). The current treatment possibilities are reduced to radio and chemotherapy after placement of gastrostomy [31].

Tumors at the level of the retro cricoids region present rapid onset of swallowing difficulties with marked weight loss and usually without voice hoarseness (**Figure 4**). Their evolution has a bad prognosis due to the invasion of recurrent laryngeal nerves and development of a Gerhardt syndrome. Often the gastrostomy procedure is preceded by tracheotomy [32].

Esophageal tumors have a clinical debut with swallowing difficulties with a rapid progression. When attempting surgical removal of the tumor the surgeon must take into consideration the reconstructive process with stomach or colon prior to performing gastrostomy. In these cases, the most difficult aspect is the risk of fistula and the cooperation of the patient during exercises in order to prevent aspiration of alimentary bolus [33].

Laryngeal tumors and their extension to the pharynx require total laryngectomy procedures with partial pharyngectomy and preservation during surgery of the middle and inferior constrictor pharyngeal muscles and negotiating between radical oncology and economy of the pharynx mucosa (**Figure 5**) [34].

Reconstruction of the new pharyngeal junction over the placement of a nasogastric tube held in place up to 14 days. Development of a salivary fistula implies the prolonged use of the nasogastric tube and forbidding any swallowing even for saliva in order to expedite healing. Correct food regimen through the probe is important in assuring the nutritional support to scar healing. After removal of the nasogastric tube after total laryngectomy it will be given only half solid aliments able to pass through the new pharyngeal inlet without the use of the muscular fibers removed during surgery. Patients undergoing vocal training also surpass swallowing disorders quicker in the next 3 months [35].

Lymph node metastasis can generate swallowing disorders due to compression over cranial nerves IX–XII (**Figure 6**). Ideally during neck dissections proceed carefully in order to preserve hypoglossal nerve [36].

**Figure 3.** *Carcinoma of the posterior wall of the pharynx with complete dysphagia.*

*Swallowing Disorders in Cervical Facial Tumors DOI: http://dx.doi.org/10.5772/intechopen.90624*

#### **Figure 4.**

*Tumor behind cricoids cartilage with complete obstruction.*

#### **Figure 5.**

*Reconstruction of the pharynx after total laryngectomy with preservation of the constrictor pharyngeal muscles.*

Regarding brachial cysts, lymphangiomas, schwannomas and lipomas their surgical removal implies preservation of neural function. Up to 12% cases with vagus schwannomas present swallowing disorders prior to surgery. After surgery 85% of the cases become dysphonic and even develop Horner syndrome. An extensive informed consent of the patient should be obtained before surgery. Also, the phoniatric treatment should begin as soon as possible after surgery [37].

Carotid body and glomus tumors are benign in nature but difficult to treat. Swallowing disorders are rare before surgery and caused by the contact between the tumor and lateral pharyngeal wall. During surgical dissection sometimes is necessary to section the superior laryngeal nerve with diminished swallowing function for 14 days after surgery. Clinical exam reveals a slight paresis of soft palate and vocal cord on the same side. Steroid therapy and supplementary vitamin B are very useful. Food intake should be in small quantity with anterior neck flexion usually without the need for a nasogastric tube [38].

Parapharyngeal tumors have a latent debut of the symptoms. Frequently these are benign tumors but grow in size and compress adjacent structures. Swallowing

**Figure 6.** *Metastatic lymph node in the skull base with compression of cranial nerves IX–XII and swallowing disorders.*

disorders may be the first signs of this pathology. Masses in front of the styloid process grow towards lateral pharyngeal wall between the superior pole of the palatine tonsil and the Eustachian tube. During clinical exam is noted the protrusion of the pharyngeal wall towards the soft palate and sometimes it may be mistaken for a peritonsillar abscess (**Figure 7**) [39].

Absence of fever and trismus indicates the possibility of a parapharyngeal tumor and requires high resolution CT scan or MRI. During surgery perform careful dissection of the cranial nerves X–XII, the later in close contact with the lateral pharyngeal wall. If this dissection is successful swallowing dysfunctions resolve after local edema retraction in 4 days without further complications [40].

Frequently these tumors are pleiomorphic adenomas of minor salivary glands or derived from the profound lobe of the parotid gland. These tumors evolve behind the styloid process neighboring internal carotid artery, internal jugular vein, cranial nerves IX–XII and cervical sympathetic chain. Swallowing disorders are secondary in these cases and their prognosis depends on the chance of a radical surgical removal and further use of radiation and chemotherapy [41].

Masses from retropharyngeal space are rare. Their approach is transoral if imaging studies tend to support a benign tumor like schwannoma. Swallowing disorders *Swallowing Disorders in Cervical Facial Tumors DOI: http://dx.doi.org/10.5772/intechopen.90624*

#### **Figure 8.**

*Metastasis at the level of the skull base on the right side with origin in the kidney and associating paralysis of the right hypoglossal nerve and right recurrent laryngeal nerve with severe swallowing disorders.*

usually disappear after tumor ablation. Nasogastric tube should be used till complete healing of the incision on the posterior pharyngeal wall [42].

Skull base tumors produce dysphagia and dysphonia through compression of cranial nerves IX–XII leading to the aforementioned neurology syndromes. Frequently such tumors are metastasis from distant primitive tumors, for example renal malignant tumors (**Figure 8**). These primitive origin tumors must be documented carefully and should benefit from maximum oncologic therapy according to specific guidelines. Otherwise tackling the secondary distance metastasis is not recommended because of the poor vital prognosis of the patient [43].

#### **8. Swallowing disorders secondary to oncologic treatment**

During radiation therapy the patient complains of an early onset swallowing difficulty due to oral and pharyngeal mucositis and a latent dysphagia produced by muscular fibrosis. Secondary xerostomia is produced by fibrosis of the salivary glands affected by radiation field and can become permanent [44].

WHO developed a scale for oral mucositis starting from grade 0 without mucositis, first grade with erythema, second grade with ulcers, in grade 3 is necessary to have only a liquid diet and the last stage in which the alimentation is not feasible [45].

#### **9. Treatment principles for swallowing disorders associated to cervical facial tumors**

The management of these swallowing disorders should focus on three stages: before tumor ablation, during treatment modality and after oncologic treatment. Tumor ablation may be achieved through surgery, radiation or chemotherapy. Before this stage the patient must be prepared to withstand treatment aggression through parenteral nutrition. For optimum nutritional status is also recommended the use of a gastrostomy either classic or PEG. The maximum treatment modality comprises surgical ablation with anatomy reconstruction but not always with great functional results. In this stage the use of nasogastric tube is a facile technical solution in order to gain the necessary time for proper pharyngeal sutures healing. At this stage an important aspect the need for an increase uptake in albumin and other proteins to facilitate tissue scaring. The stage after oncologic treatment unfortunately in many cases records the presence of definitive gastrostomy. Palsy of cranial nerves IX–XII will benefit from administering steroids and B vitamins supplements along with phoniatric exercises [46].

There are some practical aspects to analyze starting from the complete informed consent of the patient regarding the functional outcome of cervical facial surgery with targeted oncologic resection. Most often the surgeon is focused on airway complications and tends to neglect the swallowing dysfunctions. There is a shortage of trained specialists for recovery of swallowing disorders. Ideally in every head and neck oncology center there should be a team of specialists focused on early recovery of swallowing and speech dysfunctions [47].

Nutrition after surgery is very important for an optimum physical and psychological recovery of the patient being an important element of the quality of life. The presence or absence of swallowing disorders after surgery is a prognostic factor for the positive evolution of the patient. The evaluation of dysphagia should be part of standard oncology survey. Monitoring the body weight is an indicator of favorable evolution of the patient according to current oncologic nutrition protocols [48].

For recovery after swallowing disorders there are various compensatory strategies: adapting the posture while swallowing with the chin, head rotation or combined movements. For patients with significant tongue resections can be used palatal augmentation or reshaping prosthesis [49].

#### **10. Conclusions**

The ENT specialist encounters swallowing disorders in cervical facial tumors as an early diagnosis element, an aspect of surgical procedures and surgical healing and a residual symptom after radiotherapy or chemotherapy. History taking is a key element in diagnosis and the specialist should record pain during swallowing, provocation of cough during swallowing, avoiding food with higher consistency, weight loss, prior history of pneumonia and other neurological diseases. Should be very clear the beginning of dysphagia and associated symptoms such as dysphonia and dyspnea. Clinical ENT exam should be thorough with an extensive flexible fiber endoscopy for occult tumors at the level of the rhinopharynx, palatine tonsils, tongue base, and pharyngeal-laryngeal junction. A consistent amount of time should be allotted to cranial nerves exam and complete neurology consults.

For objective evaluation of swallowing disorders in cervical facial tumors the barium transit can be very useful because it facilitates direct dynamic view of the swallowing process and aspiration of the contrast media in the larynx and trachea. In some particular cases, the contrast media should be sterile and soluble for preventing aspiration lesions during examination. It is important to have an objective scale to evaluate swallowing for introduction of parenteral nutrition and monitoring the patient evolution. A subjective evaluation of the impact of swallowing dysfunction on quality of life is made through self-evaluating questionnaires which can be very useful in monitoring the evolution, too.

The management of these swallowing disorders should focus on 3 stages: before tumor ablation, during treatment modality and after oncologic treatment such radiation and chemotherapy. For optimum nutritional status is also recommended to use a gastrostomy classic or PEG. The maximum treatment modality comprises surgical ablation with anatomy reconstruction but not always with great functional

#### *Swallowing Disorders in Cervical Facial Tumors DOI: http://dx.doi.org/10.5772/intechopen.90624*

results. In this stage the use of nasogastric tube is a facile technical solution in order to gain the necessary time for proper pharyngeal sutures healing. Also, an important aspect is the need for an increase uptake of albumin and other proteins to facilitate tissue scaring. A good nutritional status is necessary for a positive prognosis in swallowing disorders. Palsy of cranial nerves IX–XII will benefit from administering steroids and B vitamins supplements along with phoniatric exercises. It is important to make a complete informed consent of the patient regarding the functional outcome of cervical facial surgery.

There is a shortage of trained specialists for recovery of swallowing disorders. Ideally in every head and neck oncology center there should be a team of specialists focused on early recovery of post-therapeutically swallowing and speech disorders. Special exercises should begin as soon as possible after surgery with specific alimentary bolus volumes for every case. The swallowing disorders in cervical facial tumors are an important element for monitoring patient evolution, because a patient without dysphagia after therapy has a good local evolution and also an increased quality of life.

### **Author details**

Daniela Vrinceanu1 \* and Mihai Dumitru1,2

1 ENT Department, Emergency University Hospital, Bucharest, Romania

2 Anatomy Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania

\*Address all correspondence to: vrinceanudana@yahoo.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### *Edited by Monjur Ahmed*

The purpose of writing this book is to discuss the updated information on voice and swallowing disorders. The book has been written by international authors and experts in this field. You will find not only clinical aspects but also basic science aspects of voice and swallowing disorders. The chapters include the quantitative analysis of activity patterns of muscles of mastication and deglutition, and salivary secretion after facial massage and vibrotactile stimulation. You will also find the updated management of oropharyngeal dysphagia, dysphagia due to cervical facial tumors, radiation-induced dysphagia, and dysphagia in patients with a stroke. This book can be an important guide to the practicing physicians and surgeons managing voice and swallowing disorders.

Published in London, UK © 2020 IntechOpen © nikolay100 / iStock

Voice and Swallowing Disorders

Voice and Swallowing

Disorders

*Edited by Monjur Ahmed*