Dysphagia Knowledge Hub — 吞嚥困難知識庫

Case Study 5: Radiation-Induced Dysphagia in a Head and Neck Cancer Survivor

Patient Presentation

Mrs. P is a 75-year-old retired seamstress with a history of T2N0 squamous cell carcinoma of the supraglottic larynx, treated with definitive chemoradiation (66 Gy, 33 fractions + concurrent cisplatin) three years ago. She achieved complete clinical response and has been disease-free at last oncology review.

She now presents to the head and neck cancer survivorship clinic with a 6-month history of progressive difficulty swallowing solids, worsening effort required to swallow liquids, and weight loss of 8 kg (from 64 kg to 56 kg). She also reports odynophagia (pain on swallowing) and a sensation of food “getting stuck” just above her sternum. She has had no chest infections.

Current status: BMI 21.5 kg/m² (previously 24.8 kg/m²); MNA-SF 8 (at risk of malnutrition). No recurrence on imaging.

Background: Radiation-Induced Dysphagia

Radiation-induced dysphagia (RID) is a well-recognised late effect of chemoradiation for head and neck cancer (HNC). It is typically progressive, worsening over months to years after treatment completion — in contrast to acute mucositis-related dysphagia which resolves within weeks.

Mechanisms include:

Radiation fibrosis: Progressive fibrosis of the pharyngeal constrictors, cricopharyngeus, and cervical oesophagus — reducing muscle compliance and peristaltic function
Xerostomia: Salivary gland damage reduces saliva production, impairing bolus lubrication
Sensory loss: Radiation damages pharyngeal sensory afferents, increasing silent aspiration risk
Stricture formation: Particularly in the cricopharyngeal and cervical oesophageal region
Lymphoedema: Internal lymphoedema contributes to pharyngeal wall stiffness

Prevalence: 50–75% of HNC patients report significant dysphagia at 1 year post-treatment; 30–40% at 5 years (Hutcheson KA et al., 2012; DOI: 10.1001/archoto.2012.2382).

Assessment

EAT-10: 21 (severe range; high scores on items 1, 2, 3, 4, 6, 7, 8, 10)

Clinical history strongly suggests oesophageal stricture given the “sternal notch” level sensation. Urgent barium swallow and gastroenterology referral arranged.

Barium swallow: Moderate narrowing at C6–T1 level (cricopharyngeal prominence + proximal oesophageal narrowing to approximately 10 mm lumen); mild pharyngeal residue; no aspiration on barium swallow (thin barium).

FEES (performed after gastroenterology review):

Severe pharyngeal residue (bilateral valleculae and piriform sinuses) — not cleared despite multiple dry swallows
Thin liquid (5 mL × 3): aspiration on 2/3 trials — PAS 7 (aspiration, not ejected; reduced cough response suggesting sensory deficit)
IDDSI Level 3 (moderately thick) liquids: penetration only, cleared — PAS 3
IDDSI Level 4 (purée): minimal residue, no aspiration — PAS 1

Management Plan

Gastroenterology: Oesophageal dilation — graded dilation to 15 mm over two sessions. Post-dilation, patient reported immediate improvement in solid-sticking sensation.

Dietary prescription post-dilation:

IDDSI Level 4 (Pureed) initially for 2 weeks post-dilation
Advance to IDDSI Level 5 (Minced & Moist) at Week 3 if tolerating well
IDDSI Level 3 (Moderately Thick) liquids — safer than thin given PAS 7 on FEES
Avoid dry, fibrous foods; all meats must be minced with added sauce

Rehabilitation:

Jaw-opening exercises and Therabite device for trismus prevention (secondary prevention — trismus not yet present but 3 years post-RT is the risk window)
Shaker head-lift exercise (tolerated; no cervical spine contraindication)
Mendelsohn manoeuvre to extend laryngeal elevation
Expiratory Muscle Strength Training (EMST) for cough strength

Nutrition:

Dietitian review: 1600 kcal/day target; high-protein ONS twice daily (oral supplement shake, thickened to Level 3)
Zinc and B12 supplementation (common deficiencies post-chemoradiation)

Xerostomia management:

Artificial saliva spray (Biotène) before and during meals
Maintain hydration with thickened sips throughout meal

6-Month Review

Weight: 58.5 kg (+2.5 kg from nadir)
EAT-10 reduced to 13
FOIS advanced from Level 4 (single consistency, post-dilation) to Level 5 (multiple consistencies with special preparation)
Second dilation performed at 3 months — sustained improvement at 6 months
No aspiration pneumonia
Considers herself “eating reasonably well” — can participate in family meals with her own IDDSI foods

Learning Points

Late-onset dysphagia in HNC survivors requires urgent investigation: Worsening dysphagia years post-radiation is not expected — it warrants both recurrence workup and fibrosis/stricture assessment.
Oesophageal stricture is treatable: Dilation dramatically improves functional outcomes and should be considered early.
Prophylactic exercise during radiation: Evidence supports prophylactic swallowing exercises during chemoradiation to reduce long-term dysphagia severity (Carroll WR et al., 2008; DOI: 10.1001/archoto.2008.44). This patient did not receive them — retrospectively a missed opportunity.
Silent aspiration is common post-radiation: Sensory loss from radiation means clinical signs (cough) underestimate aspiration. FEES is essential.

References

Hutcheson KA, et al. (2012). Late dysphagia after radiotherapy-based treatment of head and neck cancer. Arch Otolaryngol Head Neck Surg, 138(7):682–9. DOI: 10.1001/archoto.2012.2382
Carroll WR, et al. (2008). Pretreatment swallowing exercises improve swallow function after chemoradiation. Arch Otolaryngol Head Neck Surg, 134(2):162–6. DOI: 10.1001/archoto.2008.44
Lewin JS, et al. (2008). Otolaryngology and swallowing rehabilitation. Curr Opin Otolaryngol Head Neck Surg, 16(3):219–24. DOI: 10.1097/MOO.0b013e3282fe96e8