Dysphagia Knowledge Hub — 吞嚥困難知識庫

Head and Neck Cancer: Managing Dysphagia Through Treatment and Recovery

Dysphagia is one of the most disruptive and persistent complications of head and neck cancer (HNC) and its treatment. Whether arising from the tumour itself, surgical resection, radiotherapy, chemotherapy, or a combination, swallowing difficulties affect an estimated 50–75% of HNC patients — and for many, dysfunction persists long after treatment ends. Proactive, multidisciplinary swallowing management across the full treatment trajectory is essential to preserve function, prevent aspiration pneumonia, and support quality of life.

Why Swallowing Is So Vulnerable in HNC

The oral cavity, oropharynx, larynx, and hypopharynx are all directly involved in swallowing, and cancers in these regions — or their treatment — inevitably disrupt the finely coordinated neuromuscular sequence that moves food and liquid safely from mouth to oesophagus.

Tumour effects include structural obstruction, pain on swallowing (odynophagia), reduced tongue mobility, and trismus. Surgical resection may alter anatomy in ways that require significant functional relearning. Radiotherapy causes acute mucositis, oedema, and pain in the short term; and fibrosis, xerostomia (dry mouth), reduced tongue base retraction, and cricopharyngeal dysfunction in the long term. Late radiation-associated dysphagia (LRAD) can emerge or worsen years after treatment completion and is increasingly recognised as a major survivorship issue.

Assessment Across the Treatment Phases

Current guidelines from ASHA and RCSLT recommend that speech-language therapy (SLT) involvement begins before treatment starts. Pre-treatment baseline assessment — including instrumental evaluation with videofluoroscopic swallowing study (VFSS) or fibreoptic endoscopic evaluation of swallowing (FEES) where indicated — documents swallowing function before any intervention and enables personalised goal-setting.

During treatment, swallowing may deteriorate rapidly. Regular clinical monitoring allows timely modification of food and liquid texture using the IDDSI framework, adjustment of compensatory strategies, and early detection of aspiration. Instrumental reassessment should be triggered by clinical signs of aspiration risk or significant functional decline.

After treatment, structured re-evaluation at 3, 6, and 12 months is recommended, with patient-reported outcome measures (e.g., MD Anderson Dysphagia Inventory, MDADI) used alongside clinical and instrumental findings.

Swallowing Rehabilitation Strategies

Evidence supports both prophylactic and active rehabilitation approaches:

Prophylactic exercises — begun before or during radiotherapy to maintain muscle strength, range of motion, and coordination — aim to prevent or mitigate post-treatment decline. The Jaw Opening Against Resistance (JOAR) exercise, Shaker head-lift manoeuvre, effortful swallow, and Mendelsohn manoeuvre all have evidence in this population.

Texture modification using IDDSI levels enables continued safe oral intake when swallowing is impaired. Patients should receive individualised IDDSI prescription rather than blanket restriction — unnecessary restriction of texture can reduce intake and enjoyment, contributing to malnutrition and low morale.

Saliva management is a frequently overlooked component. Xerostomia significantly impairs oral processing and bolus formation. Saliva substitutes, frequent sips of water, and humidity modification can help.

Trismus management through jaw-stretching devices (e.g., TheraBite) reduces the progressive fibrosis that limits mouth opening and impairs mastication.

Nutritional Considerations

Malnutrition is common and independently worsens treatment outcomes and recovery. Dietetic involvement should be concurrent with SLT throughout. Where oral intake is insufficient to meet needs — particularly during acute treatment phases — supplemental or total enteral nutrition via nasogastric tube or gastrostomy (PEG) may be required. The decision to place a prophylactic gastrostomy remains debated; decisions should be individualised and made through shared decision-making.

Supporting Patients and Carers Through the Journey

Living with treatment-related dysphagia is psychologically demanding. Social eating — a cornerstone of relationships and cultural life — is often severely restricted. Patients benefit from:

Family members and carers also need education on meal preparation, recognising signs of aspiration, and what to do if swallowing deteriorates.

Long-Term Surveillance

Late radiation-associated dysphagia underscores the need for long-term follow-up beyond the active treatment period. Patients who appear to have recovered may experience gradual worsening years later as fibrosis progresses. Annual swallowing review, maintenance exercise programmes, and clear pathways for re-referral are recommended for all patients who received radiation to the pharyngeal or laryngeal structures.

Dysphagia management in HNC is a long game. Early, consistent, evidence-based intervention — from diagnosis through survivorship — preserves swallowing function and meaningfully improves quality of life.