Invited Article

Otolaryngology–
Head and Neck Surgery

Expert Consensus Statement: 2023, Vol. 168(4) 571–592

© 2023 American Academy of
Otolaryngology–Head and Neck
Management of Dysphagia in Head Surgery Foundation.
DOI: 10.1002/ohn.302
and Neck Cancer Patients http://otojournal.org

Maggie A. Kuhn, MD, MAS1, M. Boyd Gillespie, MD, MSc2 ,

Stacey L. Ishman, MD, MPH3, Lisa E. Ishii, MD, MHS4,
Rebecca Brody, PhD, RD, CNSC5 , Ezra Cohen, MD,
FRCPSC, FASCO6 , Shumon I. Dhar, MD7 ,
Kate Hutcheson, PhD8 , Gina Jefferson, MD9 ,
Felicia Johnson, MD10, Anais Rameau, MD, MPhil11 ,
David Sher, MD, MPH7 , Heather Starmer, MA, CCC-SLP,
BCS-S12 , Madeleine Strohl, MD13, Karen Ulmer, MS, RN,
CORLN14, Vilija Vaitaitis, MD15, Sultana Begum, MPH16,
Misheelt Batjargal, MD, MHA16, and Nui Dhepyasuwan, MEd16

Abstract warranted to address additional controversies related to

Objective. To develop an expert consensus statement (ECS) dysphagia in HNC patients.
on the management of dysphagia in head and neck cancer
(HNC) patients to address controversies and offer oppor-
1
tunities for quality improvement. Dysphagia in HNC was Department of Otolaryngology-Head and Neck Surgery, University of
California Davis, Sacramento, California, USA
defined as swallowing impairment in patients with cancers of 2
Department of Otolaryngology-Head and Neck Surgery, University of
the nasal cavity, paranasal sinuses, nasopharynx, oral cavity, Tennessee Health Science Center, Memphis, Tennessee, USA
oropharynx, larynx, or hypopharynx. 3
Department of Otolaryngology, Cincinnati Children's Hospital Medical
Center, Cincinnati, Ohio, USA
Methods. Development group members with expertise in 4
Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins
dysphagia followed established guidelines for developing ECS. University Medical Institute, Cockeysville, Maryland, USA
5
A professional search strategist systematically reviewed the Department of Clinical and Preventive Nutrition Sciences, Rutgers
University, West Linn, Oregon, USA
literature, and the best available evidence was used to 6
Moores Cancer Center at UC San Diego Health, La Jolla, California, USA
compose consensus statements targeted at providers mana- 7
UT Southwestern Medical Center, Dallas, Texas, USA
8
ging dysphagia in adult HNC populations. The development Department of Head and Neck Surgery, Division of Surgery, The University
group prioritized topics where there was significant practice of Texas MD Anderson Center, Houston, Texas, USA
9
Department of Otolaryngology-Head & Neck Surgery, Division of Head &
variation and topics that would improve the quality of HNC Neck Surgical Oncology/Microvascular Reconstruction, University of
patient care if consensus were possible. Mississippi Medical Center, Jackson, Mississippi, USA
10
ENT Ozarks, Springdale, Arkansas, USA
Results. The development group identified 60 candidate 11
Department of Otolaryngology-Head and Neck Surgery, Weill Cornell
consensus statements, based on 75 initial proposed Medicine, New York City, New York, USA
12
topics and questions, that focused on addressing the Department of Otolaryngology-Head and Neck Surgery, Stanford
following high yield topics: (1) risk factors, (2) screening, University, Stanford, California, USA
13
Department of Otolaryngology-Head and Neck Surgery, University of
(3) evaluation, (4) prevention, (5) interventions, and (6)
California-San Francisco, San Francisco, California, USA
surveillance. After 2 iterations of the Delphi survey and 14
Milton J Dance, Jr Head and Neck Cancer at GBMC, Baltimore,
the removal of duplicative statements, 48 statements met Maryland, USA
15
the standardized definition for consensus; 12 statements Department of Otolaryngology-Head and Neck Surgery, Louisiana State
were designated as no consensus. University Health Science Center, New Orleans, Charleston, South
Carolina, USA
16
Conclusion. Expert consensus was achieved for 48 state- American Academy of Otolaryngology-Head and Neck Surgery Foundation,
ments pertaining to risk factors, screening, evaluation, Alexandria, Virginia, USA
prevention, intervention, and surveillance for dysphagia
in HNC patients. Clinicians can use these statements to Corresponding Author:
Maggie A. Kuhn, MD, MAS, Department of Otolaryngology–Head and Neck
improve quality of care, inform policy and protocols, Surgery, University of California Davis, 2521 Stockton Boulevard Suite 7200,
and appreciate areas where there is no consensus. Sacramento, CA 95817-2207, USA.
Future research, ideally randomized controlled trials, is Email: [email protected]
 10976817, 2023, 4, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1002/ohn.302 by Venezuela Regional Provision, Wiley Online Library on [02/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
572 Otolaryngology–Head and Neck Surgery 168(4)

Keywords access to timely and evidence‐based swallowing evaluation,

dysphagia, head and neck cancer, laryngeal cancer, nasophar- management, and education for HNC patients and their
yngeal cancer, oral cavity cancer, oropharyngeal cancer, families.11,12 Reasons for disparities in dysphagia care among
radiation, swallowing HNC patients include the predominant focus on cancer
treatment with reduced emphasis on the management of
Received September 8, 2022; accepted February 1, 2023. cancer‐related complications, lack of appropriate resources or
expertise, and conflicting evidence supporting which inter-
ventions are most likely to improve dysphagia‐related
outcomes. As a result, there is substantial practice variation

S
wallowing is a life‐sustaining function that is
in the management of HNC‐related dysphagia, with many
critical for hydration, nutrition, management of
patients referred for dysphagia evaluation months to years
secretions, and consumption of required
after HNC treatment, if they are ever referred at all.12
medications. Swallowing function also contributes to the
Given discrepancies in care and substantial knowledge
quality of life through the enjoyment of food and
gaps, the management of dysphagia in HNC patients was
beverage, the social interaction of mealtime, and the
selected as a topic for expert consensus statement (ECS)
shared cultural experience of the cuisine. Safe and efficient
development by the American Academy of Otolaryngology‐
swallowing is the result of a series of complex and well‐
Head and Neck Surgery Foundation (AAO‐HNSF)
coordinated voluntary and involuntary musculoskeletal
Guidelines Task Force (GTF). The objective of this ECS is
actions which are intricately regulated via mucosal
to formulate areas of consensus among a group of experts in
sensory receptors, cranial nerves, brainstem centers, and
the field to identify potential methods to reduce the burden of
higher cortical controls. Disruption of one or multiple of
dysphagia in HNC patients from the time of diagnosis and
these components may result in the development of
throughout the lifespan. The primary aim was to highlight
swallowing symptoms, or dysphagia.
areas of controversy and identify opportunities to improve
Dysphagia at diagnosis is common in head and neck
the recognition and rehabilitation of swallowing impairment,
cancer (HNC) patients due to tumor involvement of
as well as to reduce the severity and duration of dysphagia
upper aerodigestive tissues important for normal swal-
and its impact on the quality of life in the HNC population.
lowing. Dysphagia is reported at presentation in up to
28% of all HNC patients, and in up to 50% of patients
with pharyngeal cancers.1 Dysphagia is also an acute and Methods
chronic side effect of HNC treatment due to the This ECS was developed according to an a priori
traumatizing effects of surgery, radiation, and che- protocol13 (previously used by AAO‐HNS to successfully
motherapy on the tissues of the upper aerodigestive tract. develop other consensus statements) with the following
Therefore, dysphagia prevalence typically increases from steps: (1) define the subject of the ECS as management of
disease presentation through treatment to long‐term dysphagia in HNC patients, (2) recruit the expert
posttreatment surveillance, ultimately affecting up to development group, (3) vet potential conflicts of interest
45% to 75% of HNC survivors.2,3 With the global among proposed development group members, (4) per-
incidence of HNC increasing by 36% over the past form a systematic literature review, (5) determine the
decade, partly driven by increasing numbers of human scope and population of interest for the ECS, (6) develop
papillomavirus‐associated oropharyngeal cancers in topic questions and consensus for statements for each
younger patients, the prevalence of survivors with4 topic question, (7) develop and implement modified
HNC‐related dysphagia is likewise expected to increase Delphi method surveys, (8) revise the ECS in an iterative
into the foreseeable future.5 fashion based on survey results, and (9) aggregate the
HNC patients with dysphagia are at risk of complica- data for analysis and presentation. The pertinent details
tions including medication noncompliance, malnutrition, of each of these steps will be briefly described.
dehydration, pneumonia, and death.6,7 Aspiration pneu-
monia has been observed in 24% of HNC patients treated
with chemoradiotherapy over a 5‐year period.8 Outcomes ECS Topic Clarification, Scope Refinement, and
from aspiration among HNC patients are poor with Development Group Recruitment
reports of approximately one‐third of those hospitalized The topic of “Prevention and Management of Dysphagia in
dying within 30 days of admission.8 Additionally, HNC Head & Neck Cancer Patients” was proposed for an ECS by
patients with dysphagia have significantly reduced quality the AAO‐HNS Airway and Swallowing Committee. After
of life and higher rates of anxiety and depression as well deliberation, the AAO‐HNSF GTF approved and prioritized
as decisional regret9 about their cancer treatment the suggestion; development group leadership was selected;
compared to those without dysphagia.10 and administrative support was allocated. Development
Despite increasing awareness that modern organ‐ group membership was strategically established to ensure
preservation treatment protocols do not necessarily translate appropriate representation of all relevant stakeholder groups
into function preservation, there continues to be limited and organizations within otolaryngology, head and neck
 10976817, 2023, 4, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1002/ohn.302 by Venezuela Regional Provision, Wiley Online Library on [02/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Kuhn et al. 573

oncology, speech‐language pathology, and nutrition. The formulating the initial statements, which were then evaluated
stakeholders were contacted regarding the consensus through the Delphi survey method.
statement project and the requirements and desired qualifica-
tions for development group membership; each group then
nominated its own representative content expert to Delphi Survey Method Process and Administration
participate. A modified Delphi survey method was utilized to assess
The ECS development group included representa- consensus for the proposed statements,13 with multiple
tives from the American Society for Radiation anonymous surveys completed to minimize bias within the
Oncology; the Society of Otorhinolaryngology and development group and facilitate consensus. Web‐based
Head‐Neck Nurses; the American Broncho‐ software (www.surveymonkey.com) was used to administer
Esophagological Association; the American Head confidential surveys to development group members. A
and Neck Society (AHNS); the American Society of potential topic list of 60 questions and draft statements was
Clinical Oncology; the American Speech‐Language‐ put together by the development group during the first call
Hearing Association; the Dysphagia Research Society; and each development group member was invited to provide
the Academy of Nutrition and Dietetics (AND); 1 draft statement for each of their top 5 ranked topic list
and appropriate committees within the AAO‐HNS, choices. The survey period was divided into 2 Delphi rounds.
including the Head and Neck Surgery and Oncology All answers were deidentified and remained confidential to
Committee, the Airway and Swallowing Committee, development group members; however, names were collected
the Board of Governors, and the Section for Residents by staff to ensure proper follow‐up, if needed.
and Fellows. The methodologists and the representa- Based on the outcomes of the top‐ranked topic list
tive from the AND were the only nonvoting members choices and resulting discussion, the development group
of the development group. All proposed nominees chair and assistant chair developed the first Delphi
for the development group practiced in the United survey, which consisted of 60 statements. Prior to
States. dissemination to the development group, the Delphi
All development group members are in active clinical surveys were reviewed by the methodologist for content
practice, are content experts in dysphagia, and agreed in and clarity. Questions in the survey were answered using a
advance of the appointment to participate in all verbal 9‐point Likert scale, where 1 = strongly disagree, 3 = dis-
discussions (performed via teleconference) and votes. Once agree, 5 = neutral, 7 = agree, and 9 = strongly agree. The
the development group was assembled, the complete surveys were distributed, and responses were aggregated,
disclosure of potential conflicts of interest was reported and distributed back to the development group, discussed via
vetted. Conflicts of interest were managed consistent with the teleconference, and revised if warranted. The purpose of
Council of Medical Specialty Societies Code for Interactions the teleconference was to provide an opportunity to
With Companies,14 which requires that the chair and a clarify any ambiguity, propose revisions, or drop any
majority of the participants do not have a direct conflict with statements recommended by the development group.
the deliberations. The development group chair and assistant Criteria for consensus were established a priori as
chair led the development of the consensus statements and follows1:
the Delphi process with input from 2 methodologists from
AAO‐HNSF leadership and GTF, and with administrative • Consensus: Statements achieving a mean score of
support from an AAO‐HNSF staff liaison. 7.00 or higher and having no more than 1 outlier,
The title of the ECS was adjusted to remove the word defined as any rating of 2 or more Likert points
“prevention” as the development group felt that “prevention” from the mean in either direction.
was fully encompassed in “management.” The target • Near consensus: Statements achieving a mean
audience of the ECS was defined as otolaryngologists, score of 6.50 or higher and having no more than
radiation oncologists, speech‐language pathologists (SLP), 2 outliers.
oncology nurses, registered dietitian nutritionists (RDN), and • No consensus: Statements that did not meet the
medical oncologists who manage dysphagia, in HNC criteria of consensus or near consensus.
populations. The target population was defined as adults
with HNC who are 18 years or older. “Dysphagia” was Two iterations of the Delphi survey were performed.
defined as swallowing impairment. Once the target popula- All group members completed all survey items in the first
tion and scope of practice were determined, the development Delphi survey; in the second iteration, there were 2 items
group used the results of the literature reviews, combined that were only completed by 10 of the 12 voting members
with their expert opinion and stakeholder needs, to propose of the panel. The development group reviewed the results
topics and questions for which knowledge gaps, uncertainty, of all 60 items via teleconference after the first Delphi
or opportunities for quality improvement existed. Topics survey. Twenty‐four statements were revised for improved
were focused on areas with significant practice variation that clarity. Eight items did not reach consensus and were not
would most benefit from consensus from expert clinicians. discussed further. There were 10 statements that reached
These topics and questions were used as the basis for near consensus and were discussed thoroughly. Four of
 10976817, 2023, 4, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1002/ohn.302 by Venezuela Regional Provision, Wiley Online Library on [02/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
574 Otolaryngology–Head and Neck Surgery 168(4)

these statements did not reach consensus and were not pharyn*[tw] OR hypopharyn*[tw] OR laryn*[tw] OR
included in the second survey, while 6 were revised for mandible*[tw] OR SCC[tw] OR UADT[tw]) AND
improved clarity. The second iteration of the survey was (“neoplasms”[mh] OR carcinoma*[tw] OR adenocarci-
used to reassess items for which there was near consensus, noma*[tw] OR cancer[tw] OR cancers[tw] OR cancerous
or for items for which there were suggestions for [tw] OR neoplas*[tw])))
significant alterations in wording that could have affected Literature searches yielded 774 articles, with 330
survey results. All 13 statements included in the second remaining after the titles and abstracts were screened for
iteration reached consensus and no further Delphi surveys relevance. These articles were reviewed by the chair and
were needed. assistant chair and classified per the Oxford Centre for
Evidence‐Based Medicine's 2011 levels of evidence.4
Literature Review Based on the evidence levels, there were 14, level 1
articles; 37, level 2 articles; 62, level 3 articles; 190, level
Two systematic literature reviews were performed by an
4 articles; and 27, level 5 articles.
information specialist, using keywords chosen by the
development group, to identify current evidence regarding
the management of dysphagia. The second review was Results
performed to clarify or expand on topics explored by the A total of 60 statements were generated by the development
group after the first search. The literature searches were group for assessment. After 2 iterations of the Delphi survey
conducted in March 2021 and April 2021 and included all and the removal of duplicate and similar statements, 48
relevant publications since 2000 in English from PubMed, statements met the standardized definition for consensus
EMBASE, Cochrane Database of Systematic Reviews, Web (Tables 1-6) and 12 did not (Table 7). The ECS was
of Science, Agency for Healthcare Research and Quality, categorized into topic areas: (1) risk factors, (2) screening, (3)
ECRI National Guideline Clearinghouse, Canadian Medical evaluation, (4) prevention, (5) interventions, and (6)
Association Infobase, The National Institute for Health and surveillance.
Care Excellence (UK), TRIP Database, National Library of
Guidelines (UK), Scottish Intercollegiate Guidelines Risk Factors for Dysphagia Among HNC Patients
Network, New Zealand Guidelines Group, Australian
One statement was created which pertained to factors
National Health and Medical Research Council, Guidelines
placing HNC patients at greater risk of developing
International Network, Cumulated Index to Nursing and
dysphagia (Table 1). The development group had an
Allied Health Literature, Health Services/Technology
extensive discussion and carefully revised this multipart
Assessment Texts, Proquest Central, Joanna Briggs Institute
statement which reached a consensus.
EBP database, Scopus, Google Scholar, NHS Evidence ENT
and Audiology (UK), and BIOSIS. The search strategy was
completed using the following search terms: Screening for Dysphagia in HNC Patients
(dysphagia[tab] OR (“deglutition disorders”[mh] OR A total of 5 statements concerning appropriate
“deglutition”[mh] OR “energy intake”[mh] OR eating screening for dysphagia among HNC patients were
[mh] OR dysphagia[tw] OR swallow*[tw] OR deglutition developed, and 3 reached a consensus (Table 2). The
[tw] OR eating[tw] OR intake*[tw] OR aspirat*[tw] OR development group focused on critical dysphagia
gastrostomy[tw] OR “g‐tube”[tw]) AND ((“Head and screening practices for HNC patients. The consensus
Neck Neoplasms”[Mesh] OR “Squamous Cell Carcinoma was reached regarding the timing of dysphagia
of Head and Neck”[Mesh]) OR ((squamous[tw] OR head screening for HNC patients: It is best performed prior
[tw] OR neck[tw] OR cervical[tw] OR oral[tw] OR mouth to initiation of cancer therapy. Additionally, the
[tw] OR tongue[tw] OR glottis[tw] OR mucous*[tw] OR development group agreed on the inclusion of nutri-
mucosal[tw] OR nose[tw] OR nasal[tw] OR trachea*[tw] tion screening using validated screening tools and
OR esophag*[tw] OR oesophag*[tw] OR aerodigestive patient‐specific characteristics. However, the recom-
[tw] OR nasopharyn*[tw] OR oropharyn*[tw] OR mended application of patient‐reported questionnaires

Table 1. Risk Factors for Dysphagia Among HNC Patients: Statements That Reached Consensus
Number Statement Mean Outliers

1 1. The presence of any or multiple of the following features predicts an increased risk of developing 8.82 0
dysphagia from treatment for HNC
a. Patient factors (advanced age, pretreatment malnutrition, pretreatment dysphagia, pretreatment
sarcopenia, rural location, alcohol abuse, cranial neuropathies, dementia, feeding tube dependence)
b. Tumor factors (recurrence, advanced T and N stage, hypopharyngeal subsite)
c. Treatment factors (tracheostomy, chemotherapy + XRT, multimodality treatment)
Abbreviations: HNC, head and neck cancer; N, node; T, tumor; XRT, radiation therapy.
 10976817, 2023, 4, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1002/ohn.302 by Venezuela Regional Provision, Wiley Online Library on [02/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Kuhn et al. 575

Table 2. Screening for Dysphagia in HNC Patients: Statements That Reached Consensus
Number Statement Mean Outliers

2 Dysphagia screening for newly diagnosed HNC patients guides preventative and supportive interventions 7.09 1
when performed prior to cancer treatment.
7 A validated clinician nutrition screening tool is useful in assessing nutritional risk in HNC patients. 7.18 0
14 SLP consultation is optimal prior to treatment in HNC patients who are at risk for dysphagia. 8.55 0
Abbreviations: HNC, head and neck cancer; SLP, speech-language pathologists.

Table 3. Evaluation of Dysphagia in HNC Patients: Statements That Reached Consensus

Number Statement Mean Outliers

8 A comprehensive nutritional assessment of HNC patients with dysphagia includes anthropometric 7.91 0
measurements, biochemical measurements, and individualized nutrition requirements.
9 Bedside swallow assessment by an SLP is useful in evaluating swallowing safety following tracheostomy. 7.36 0
10 In HNC patients who fail dysphagia screening, instrumental swallow evaluation provides insight into the nature 7.55 1
of swallowing impairment.
11 Instrumental evaluation procedures (endoscopy or fluoroscopy) are useful swallowing evaluation methods for 8.55 0
HNC patients after radiotherapy.
13 Pretreatment instrumental swallowing evaluation establishes baseline swallowing function and impairment in 8.09 0
HNC patients who report symptoms of dysphagia or who are at risk of developing dysphagia during treatment.
18 FEES affords the benefit of direct visualization of the swallowing mechanism at the point of care for HNC 8.00 0
patients.
19 Videofluoroscopy provides functional imaging of the oral cavity and upper esophagus in HNC patients. 8.00 0
20 Perform swallowing evaluation prior to oral diet initiation in HNC patients with tracheostomy. 7.18 0
21 Videofluoroscopic assessment of swallowing is beneficial following total laryngectomy to evaluate for the 7.27 1
postsurgical leak.
Abbreviations: FEES, flexible endoscopic evaluation of swallowing; HNC, head and neck cancer; SLP, speech-language pathologists.

and symptom‐driven assessments for screening dys- prevention topics agreed upon by the development team
phagia in HNC patients did not reach a consensus. included the involvement of appropriate specialists
(eg, RDN and SLPs) as members of the multidisciplinary
Evaluation of Dysphagia in HNC Patients team (MDT), RDNs, prophylactic swallowing therapy,
feeding tube use, and pain management. Statements
The development group created 9 statements on the
regarding the benefits of contemporary chemoradiation
theme of dysphagia evaluation in HNC patients. All 9
strategies such as intensity‐modulated radiotherapy
statements reached consensus (Table 3). Discussions
(IMRT) were also agreed upon by the development
involved the timing and choice of instrumental evaluation
group. Prevention‐related statements not reaching con-
procedures among HNC patients. The statements support
sensus included the role of prophylactic feeding tubes,
flexible endoscopic evaluation of swallowing (FEES) or
chemotherapy regimens, and HNC patient/caregiver
videofluoroscopic swallow study (VFSS) for positive
education in influencing swallowing outcomes.
dysphagia screening in HNC patients and following
radiotherapy. SLP assessment and instrumental swallow
evaluation are useful before cancer treatment in HNC Interventions for Dysphagia in HNC Patients
patients with dysphagia or those at high dysphagia risk. The development team reviewed 22 statements relating to
Furthermore, consensus statements support evaluation by interventions for dysphagia in HNC patients; of these,
an RDN to improve nutrition outcomes in HNC patients a consensus was reached on 18 (Table 5). Statements
with or at risk for dysphagia. with agreement among the development group covered a
spectrum of interventions. These included diet allocation,
patient/caregiver education, oral care, feeding tube use
Prevention of Dysphagia Among HNC Patients and discontinuation, behavioral swallowing and lymphe-
Fourteen statements relating to the prevention of dema therapy, and surgical procedures. The development
dysphagia among HNC patients were developed. Of group agreed that interventions require the participation
these, 11 reached a consensus. (Table 4). Important of an MDT approach for optimal dysphagia
 10976817, 2023, 4, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1002/ohn.302 by Venezuela Regional Provision, Wiley Online Library on [02/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
576 Otolaryngology–Head and Neck Surgery 168(4)

Table 4. Prevention of Dysphagia Among HNC Patients: Statements That Reached Consensus
Number Statement Mean Outliers

15 Nutritional evaluation and management by an RDN contribute to improved nutritional outcomes of HNC 7.36 0
patients.
24 HNC patients have improved swallowing outcomes if encouraged to continue eating and drinking, guided by a 8.09 0
dysphagia specialist, throughout cancer treatment.
29 Radiation-associated dysphagia can be reduced by contouring and avoiding swallowing organs at risk during 8.27 0
head and neck radiotherapy.
31 A multidisciplinary team with members from head and neck surgery, radiation oncology, medical oncology, 8.45 0
speech-language pathology, nutrition, and nursing is preferred to provide comprehensive care for HNC
patients and minimize dysphagia associated with treatment.
32 Prophylactic swallowing exercises benefit HNC patients undergoing radiation therapy by optimizing functional 7.09 1
status and quality of life.
33 Acute and chronic pain management in HNC patients contributes to improved swallowing and nutritional 7.70 1
outcomes.
34 The use of IMRT is associated with less xerostomia than conventional techniques, which has a positive impact 7.55 0
on swallowing function.
35 HNC patients treated with IMRT have improved swallowing outcomes in comparison to those individuals 8.09 1
treated with less conformal techniques.
36 Dysphagia-optimized IMRT improves patient-reported swallowing outcomes vs standard IMRT. 7.27 0
37 The addition of chemotherapy to HNC treatment regimens is associated with worse swallowing outcomes in 7.45 0
HNC patients.
39 Cricopharyngeal myotomy improves swallowing outcomes in patients undergoing laryngectomy. 7.36 1
Abbreviations: HNC, head and neck cancer; IMRT, intensity-modulated radiation therapy; RDN, registered dietitian nutritionists.

management. Statements not reaching consensus by the factors associated with poorer swallowing outcomes
development group included the optimal use of enteral include advanced tumor stage (T3‐T4) and nodal stage.16,19
nutrition or reactive feeding tubes. Also, statements Hypopharyngeal17,20,21 and oropharyngeal subsites are
concerning the effect of acupuncture and chronic also associated with worse long‐term swallowing out-
lymphedema on swallowing function were not supported comes.19,22‐24 Moreover, treatment‐related factors play a
by group consensus. significant role in posttreatment dysphagia. Surgical de-
tails, including tracheostomy, tumor resection extent,
Surveillance for Dysphagia Among HNC Patients surgical approach, and types of reconstruction alter the
anatomy and function of the swallowing organs contri-
Six statements relating to the surveillance of dysphagia in buting to dysphagia.1 The use of adjuvant radiation is also
HNC patients were developed and all reached a consensus associated with dysphagia and has side effects in both acute
(Table 6). These statements highlighted optimal strategies and late settings.1,20 Factors associated with prolonged
for ongoing monitoring and detection of dysphagia in feeding tube dependence include the dose of radiation to
HNC patients throughout the lifespan. These included the larynx (supraglottic and glottic), pharyngeal constrictor
lifelong assessment by an MDT, individualized dysphagia muscles, the contralateral parotid gland, and the bilateral
care, and evaluation of new‐onset dysphagia in HNC neck as well as the volume of the area treated.16,17,24,25 In
survivors. Both dysphagia‐related patient‐reported out- addition, concomitant treatment with chemotherapy sig-
comes and measures of health are used for surveillance nificantly worsens swallowing outcomes due to the
and inform the frequency of assessment. increased prevalence of oral mucositis among other factors.
Other associated treatment factors impacting dysphagia
Discussion severity include total radiation dose, fractionation regimen,
target volumes, and treatment delivery techniques.1,15
Risk Factors for Dysphagia Among HNC Patients Multimodality therapies such as “triple therapy” which
Several patient‐related factors increase the risk of dys- includes surgery, radiation, and chemotherapy portents a
phagia in HNC patients (Table 1; Statement 1) including greater risk for swallowing dysfunction.17 Patients who
advanced age (greater than 62 years), pretreatment undergo TORS + CRT have demonstrated poorer long‐
swallowing dysfunction, weight loss, performance status, term swallowing outcomes than those who receive surgery
and smoking and/or alcohol abuse.1,15‐18 Tumor‐related or organ‐preservation therapy alone.26
 10976817, 2023, 4, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1002/ohn.302 by Venezuela Regional Provision, Wiley Online Library on [02/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Kuhn et al. 577

Table 5. Interventions for Dysphagia in HNC Patients: Statements That Reached Consensus
Number Statement Mean Outliers

12 The inability to safely maintain adequate oral nutrition is an indication of enteral feeding in HNC patients. 8.36 1
16 Patient and family education about oral care helps decrease the adverse effects of dysphagia associated 7.27 0
with HNC.
23 Oral intake is encouraged in HNC patients judged by a dysphagia specialist to be low risk for the consequences 8.09 0
of aspiration.
25 Identification of appropriate textures and liquids for safe consumption of oral intake is beneficial for HNC 8.18 1
patients with dysphagia.
26 Pretreatment feeding tubes are most appropriate for HNC patients with baseline swallowing impairment and/ 7.18 2
or malnutrition.
30 NPO status is not universally required for aspirating HNC patients. 7.73 0
40 Swallowing therapy is most effective when initiated by the start of HNC treatment. 7.00 1
41 Essential to counseling for HNC patients and caregivers are aspiration precautions and (self) Heimlich. 7.36 0
42 Comprehensive education for HNC patients and their caregivers includes instructions for which medications 7.73 1
may be crushed or administrated via feeding tube.
43 Self-assessment of nutrition and hydration status is an important component of HNC patient and caregiver 7.64 1
education.
44 Consistent, daily oral care (including cleaning the tongue, palate, and teeth) reduces bacterial load and the risk 7.09 1
of developing aspiration pneumonia due to swallowing impairment in HNC patients.
47 HNC patients' ability to maintain weight and hydration via PO diet are key considerations prior to 8.55 1
discontinuation of enteral feeding devices.
48 Devices can be used to augment the intensity of behavioral swallowing therapies in HNC patients. 7.09 0
49 Device-facilitated therapies are more effective when evidence-supported devices are selected based on 7.18 1
dysphagia pathophysiology.
52 Lymphedema therapy contributes to improved swallowing in HNC patients with lymphedema. 7.4 1
53 Pharyngoesophageal dilation is beneficial in HNC survivors who report dysphagia and have identified stenosis. 8.27 0
54 Surgical interventions that curtail intractable aspiration improve the pulmonary health of HNC patients with 7.27 0
refractory aspiration pneumonia.
55 Functional total laryngectomy for intractable aspiration offers improved quality of life for HNC patients when 8.00 0
pulmonary infections persist despite NPO status, in the setting of concurrent tracheostomy dependence and
nonfunctional voice.
Abbreviation: HNC, head and neck cancer; NPO, nil per os; PO, per os.

Table 6. Surveillance of Dysphagia in HNC Patients: Statements That Reached Consensus

Number Statement Mean Outliers

17 New-onset dysphagia in disease-free HNC survivors requires a work-up to exclude disease recurrence or new 8.36 1
primary tumor.
56 Patients with dysphagia after HNC treatment experience improved nutrition status and health outcomes when 8.00 0
followed by a multidisciplinary team.
57 Life-long monitoring for dysphagia signs and symptoms is important for HNC survivors. 8.18 0
58 Obtaining dysphagia-related patient-reported outcomes are an important component of ongoing HNC care. 7.82 1
59 The specific cadence and method of screening for dysphagia in HNC survivors are dictated by individualized 7.00 0
factors (tumor site, cancer stage, treatment history, and prior functional deficits).
60 Dysphagia surveillance in HNC survivors includes measures of health (for instance, nutritional status, weight, 7.55 1
and lung function).
Abbreviation: HNC, head and neck cancer.

Screening for Dysphagia in HNC Patients from a dysphagia prehabilitation program. On this
Assessment of dysphagia risk at the time of HNC basis, there was a strong consensus that SLP consulta-
diagnosis establishes a functional “start point” and may tion is optimal prior to HNC treatment (Table 2;
identify a subset of patients who could most benefit Statement 14). Owing to discordance between
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578 Otolaryngology–Head and Neck Surgery 168(4)

Table 7. Statements That Were Classified as No Consensus

Number Statement Group Mean Outliers

3 Symptom-driven dysphagia evaluation in HNC patients (such as for dehydration, malnutrition, Screening 6.64 1
coughing, or choking) is useful to establish impairments to the swallowing mechanism.
4 Patient-reported questionnaires are good screening tools for dysphagia in head and neck Screening 6.36 2
patients.
5 Comprehensive screening for dysphagia in HNC patients includes clinician-reported outcome Screening 6.45 2
measures.
6 The Patient-Generated Subjective Global Assessment identifies nutrition risks in HNC patients. Screening 5.45 2
22 HNC patient and caregiver education on the signs and symptoms of swallowing impairment Prevention 5.36 1
helps preserve swallowing function.
27 Placement of prophylactic feeding tubes in HNC patients may improve 6-month quality of life. Prevention 4.73 3
28 Feeding through prophylactic feeding tubes extends long-term dependence on enteral feeding in Prevention 6.09 1
HNC patients.
38 Chemotherapy options for curative HNC treatment do not differ in their propensity to impact Prevention 4 1
swallowing function.
45 Enteral nutrition is beneficial when an HNC patient is unable to eat for >7 d or has anticipated Interventions 7.73 2
inadequate intake (<60%) for >10 d.
46 Reactive use of a feeding tube is appropriate in HNC patients with uncontrolled aspiration or Interventions 8.09 2
inability to adequately meet nutritional needs by mouth.
50 Acupuncture mitigates early toxicities of HNC chemoradiation therapy such as pain, Intervention 5.45 0
xerostomia, dysgeusia, and dysphagia.
51 Chronic lymphedema from HNC treatment is associated with enduring fibrosis of swallowing- Interventions 6.82 1
related structures.
Abbreviation: HNC, head and neck cancer.

pretreatment patient perception of swallowing dysfunc- personnel can implement screening tools to identify
tion in comparison to instrumental assessment by VFSS patients at risk for a more thorough evaluation.
or clinician assessment,27 the development group agreed Routine rescreening is critical to assess for changes in
on the benefit of newly diagnosed HNC patients nutrition status based on the clinical setting.36 An
undergoing pretreatment dysphagia assessment by a objective scoring system coupled with patient self‐
clinician including instrumental assessment (Table 2; assessment, such as the Patient‐Generated Subjective
Statement 2). At a minimum, the pretreatment evalua- Global Assessment (PG‐SGA),37 may appropriately
tion serves as a reference for posttreatment evaluation identify those patients in need of nutrition intervention
and management of dysphagia. There is no standardized from an RDN, dysphagia prehabilitation, and even those
screening assessment tool for pre‐HNC treatment who would benefit from a feeding tube prior to HNC
evaluation. The total dysphagia risk score (TDRS) is treatment initiation.
one validated stratification tool that predicts the
development of dysphagia due to curative radiotherapy.
TDRS incorporates T‐classification, neck irradiation,
Evaluation of Dysphagia in HNC Patients
weight loss, primary tumor site, and type of radio- Proactive swallowing referral to an SLP is a best practice
therapy planned (ie, concurrent chemoradiotherapy, standard recommended by the National Comprehensive
accelerated radiotherapy).28 Cancer Network (NCCN) among HNC patients experi-
In addition to dysphagia, HNC patients are at high encing dysphagia or for those whose treatment is likely to
risk for malnutrition.29 While the cause of malnutrition is affect swallowing.38 This practice standard derives from a
typically multifactorial, dysphagia is a frequent contri- body of evidence supporting the utility of pretreatment
butor30 and can profoundly impact the patient during swallowing evaluation to detect not only moderate to
treatment and recovery. Nutrition screening to identify severe dysphagia or aspiration,39 but even mild dysphagia
the risk of malnutrition is an integral part of the initial that is shown to increase the severity and prevalence of
evaluation for HNC patients.29 Early identification of dysphagia after treatment.40 There was strong consensus
nutrition risk can lead to timely and appropriate that pretreatment instrumental swallowing evaluation
interventions, thus improving patient outcomes.31‐34 A establishes baseline swallowing function and impairment
brief, easy‐to‐use screening tool, such as the malnutrition in HNC patients who report symptoms of dysphagia or
screening tool,35 facilitates nutrition risk identification29 who are at risk of developing dysphagia during treatment
(Table 2; Statement 7). RDNs or other trained healthcare (Table 3; Statement 13). As is the case across the
 10976817, 2023, 4, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1002/ohn.302 by Venezuela Regional Provision, Wiley Online Library on [02/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Kuhn et al. 579

continuum of HNC care, instrumental swallow evaluation was strong consensus that bedside swallow assessment by
is optimal to visualize the safety and efficiency of bolus an SLP is useful to evaluate swallowing safety following
clearance through the aerodigestive tract while simulta- tracheostomy (Table 3: Statement 9).
neously examining swallow physiology. Regardless of the Another unique population of HNC patients is those
manner of screening or risk stratification, there was undergoing total laryngectomy (TL) which permanently
strong consensus that in HNC patients who fail dysphagia separates the airway from the digestive tract with inherent
screening, instrumental swallow evaluation provides in- implications on swallowing function. The postsurgical
sight into the nature of swallowing impairment (Table 3; leak is a common barrier to re‐initiation of oral intake,
Statement 10). The utility of instrumental swallow with an incidence reported between 10% to 28%
evaluation in the HNC population is long recognized depending on prior radiation therapy and closure
due to a high prevalence of sensory impairment (ie, technique.54 The optimal method of evaluation and ideal
“silent” aspiration), altered anatomy (eg, edema, recon- timing to initiate oral intake after TL is debated, with
struction), and physiologic impairment in HNC patients published studies largely supporting radiographic assess-
with dysphagia obligating visualization of the aerodiges- ment in the form of a VFSS with barium or water‐soluble
tive tract during swallowing. Psychometrically sound iodinated contrast prior to initiation.55‐58 VFSS also
clinician‐graded ratings of instrumental examinations allows for simultaneous evaluation for other common
may further enhance the clinical yield of these proce- sources of dysphagia in this population (eg, velophar-
dures.41‐45 yngeal insufficiency, stricture, or pseudodiverticulum).59
There was strong consensus that instrumental evalua- As such, there was strong consensus for VFSS following
tion procedures (FEES or VFSS) are useful swallowing TL to evaluate for a postsurgical leak (Table 3;
evaluation methods for HNC patients after radiotherapy Statement 21).
(Table 3; Statement 11). Common physiologic impair- Appreciating the common co‐occurrence of malnutri-
ments include incomplete pharyngeal constriction, tongue tion and dysphagia, there was strong consensus for
base retraction, hyolaryngeal excursion, epiglottic inver- nutrition evaluation by an RDN and the use of validated
sion, and pharyngoesophageal opening46‐48 that can occur nutrition assessment tools to identify malnutrition and
alongside structural changes such as stricture and other nutrition problems as part of a comprehensive
submucosal edema of the laryngopharynx. Sensory nutrition assessment for HNC patients (Table 3;
impairments are also common. Aspiration is often Statement 8).36 The PG‐SGA60 and Subjective Global
“silent” in this population, particularly in long‐term Assessment tools61 generate valid and reliable data when
HNC survivors with profound laryngeal sensory depriva- completed by adult patients with cancer in acute and
tion reported in subpopulations with late radiation‐ ambulatory care settings.62,63 Studies with HNC patients
associated dysphagia.49 The choice of “best” instrumental have used the PG‐SGA to identify malnutrition and direct
evaluation is matched to the clinical context as both nutrition interventions.63‐65 Evaluation of additional
FEES and VFSS offer relative advantages.50,51 There was assessment parameters can address common cancer‐
strong consensus that FEES affords direct visualization of related nutrition issues. Body composition assessment
the swallowing mechanism at the point of care in HNC with dual X‐ray absorptiometry, computed tomography
patients, whereas VFSS provides functional imaging of (CT) scans, or bioimpedance analysis can offer insight
the oral cavity and upper esophagus in HNC patients into the presence of sarcopenia, often masked by over-
(Table 3; Statements 18 and 19). weight or obese weight status and fluid accumulation.29
HNC patients with tracheostomy represent a unique Sarcopenic dysphagia, defined as total body sarcopenia
population who requires specific attention. Tracheostomy that includes the swallowing muscles, makes identifying
alters aerodigestive tract physiology and subglottic muscle wasting critically important in HNC patients.66,67
pressure generation with implications on swallow safety Routine nutrition reassessments will identify ongoing
and efficiency.52 Furthermore, factors that necessitate changes in nutritional status.
tracheostomy in HNC also contribute to oropharyngeal
dysphagia. As such, there was strong consensus to
perform swallowing evaluation prior to oral diet initiation Dysphagia Prevention Among HNC Patients
in HNC patients with tracheostomy (Table 3; Statement There was strong consensus for the preference of an MDT
20). There is substantial debate regarding both screening to curtail the impact of dysphagia among HNC patients
and evaluation of oropharyngeal swallowing after tra- (Table 4; Statement 31). An MDT includes expert HNC
cheostomy. A systematic review of 6 published reports of team members, including those who maintain awareness
the modified Evan's Blue Dye Test in patients with and of dysphagia as a potential complication of HNC and its
without HNC reported inadequate diagnostic accuracy treatment. Studies have examined the impact of an MDT
with highly variable sensitivity to detect aspiration on swallowing using historical comparisons or cross‐
between 38% and 95% and relatively better specificity sectional designs.68 These trials demonstrated improved
between 79% and 100%.53 In absence of best practice swallowing function by integrating speech and swallow
screening data in this population, as an initial step, there therapy programs into the multidisciplinary care of
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580 Otolaryngology–Head and Neck Surgery 168(4)

patients. In the largest study, cohorts were compared they found that even in those patients who had a feeding
before and after the initiation of a proactive swallow tube during treatment, continuing some level of oral
therapy program, the authors found reduced use of intake yielded better swallowing outcomes than patients
feeding tubes and increased oral intake following who were nil per os (NPO).82 Continuing oral intake
proactive swallow therapy.68 The totality of the data during radiation therapy may be challenging for many
would suggest that MDTs which include SLP improve patients due to anticipated treatment toxicities. It is
swallowing outcomes and patient satisfaction, even if the critical for the dysphagia specialist to work closely with
overall effects are numerically modest. Swallowing pre- the MDT to ensure optimal management of treatment
habilitation may minimize the progression of dysphagia toxicities to support a patient's ability to continue per os
from HNC treatment by maintaining muscle mass, intake. For example, the Eat All Through Radiation
strength, range of motion, and coordination. Swallow Therapy program was developed to provide a framework
exercise programs specifically target the oral cavity, for clinician‐supported oral intake targeting swallowing
pharynx, and larynx.69 A variety of potential prehabilita- preservation.83 Consistent with this literature, the devel-
tion schemes have shown improved functional swallowing opment group agreed that HNC patients have improved
including the patient's ability to handle a greater variety swallowing outcomes if encouraged to continue
of food and drink, maintain muscle mass, reduce trismus, eating and drinking, guided by a dysphagia specialist,
improve taste, smell, and salivary function, and decrease throughout cancer treatment (Table 4; Statement 24).
the need for feeding tubes.12,70‐72 Whereas others report Medical nutrition therapy (MNT) incorporating
no significant difference in swallow outcomes and feeding nutrition evaluation and ongoing management, im-
tube use.69 However, there is a lack of consensus on plemented by an RDN throughout HNC treatment, is
exercises prescribed, repetitions per exercise, repetitions a cost‐effective, low‐risk intervention that can improve
per day, timing to initiate prehabilitation, and duration of patient nutrition outcomes (Table 4; Statement 15). 31‐
34
prehabilitation therapy. Dysphagia prehabilitation likely MNT aims to maintain or lessen reductions in
most benefits a specific subset of HNC patients. Future nutritional status, decrease symptom burden, and
multicenter randomized clinical trials are needed to fully minimize the development of malnutrition. Several
define specific exercise programs targeting a particular studies specifically evaluate patients receiving radia-
HNC patient group and the timing and intensity of tion therapy to the head, neck, or gastrointestinal
therapy needed to achieve lasting results. A key to regions and have shown that individualized nutrition
prophylactic swallowing intervention is maintaining interventions and counseling improve nutrition out-
muscular engagement and mobility of the swallowing comes, including calorie and protein intake, 84,85
system during radiation. There is some discrepancy in the reduce deterioration in nutritional status, weight,
literature regarding the value of prophylactic swallowing and fat‐free mass loss, and enhance symptom toler-
therapy during radiation therapy.73,74 Though studies ance, 86 and physical function.85,87 Furthermore,
have varied in their intervention approach with regard to patient‐centered outcomes, including global quality
exercises chosen and dose of exercise,75 most have of life markers declined less and recovered more
demonstrated improvements in multiple domains in- quickly in those receiving RDN‐directed nutrition
cluding quality of life,76 diet level,71 physiologic func- interventions.63,85,88
tion,12,77 maintenance of muscle mass,78 and feeding tube The vast majority of HNC patients experience pain
dependence.79 Many studies that fail to demonstrate the prior to, during, or following treatment, regardless of
benefit of prophylactic exercises suffer challenges with treatment modality.89 The development group agreed that
poor adherence and feasibility rather than poor efficacy of the management of pain is critical to engage in oral intake
the intervention or methodologic barriers. On this basis, and preventing swallowing deterioration (Table 4;
the development group agreed that prophylactic swal- Statement 33). In a randomized controlled trial of
lowing exercises benefit HNC patients undergoing radia- prophylactic swallowing therapy, pain and fear of pain
tion therapy by optimizing functional status and quality were cited as primary contributors to nonadherence.78
of life (Table 4; Statement 32). Given the issues regarding There was consensus that acute and chronic pain
adherence, the MDT must ensure that the treatment management in HNC patients contributes to improved
proposed is feasible and that barriers to adherence are swallowing and nutritional outcomes. Considering pain
addressed in a proactive manner. Clinical models also management in this population, it is important to factor
need to be considered given early evidence that clinician‐ in the potential for both nociceptive and neuropathic
directed therapy appears to be more efficacious than pain. Neuropathic pain is particularly prevalent in
home‐based patient‐directed therapy.80 patients undergoing head and neck radiation90 and is
Maintaining oral intake during HNC treatment is one generally not responsive to narcotic analgesics.91 As an
strategy to limit long‐term dysphagia risk. Langmore example, the prophylactic use of gabapentin has been
et al demonstrated that continued oral intake through associated with lower pain ratings during HNC treat-
the end of HNC treatment were associated with more ment,92 reduced use of feeding tube during treatment,93
favorable diet levels 1‐year posttreatment.81 Furthermore, improved short‐term diet outcomes and swallowing
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Kuhn et al. 581

function,48 and excellent 1‐year posttreatment swallowing on the experimental arm, experienced a statistically
outcomes.94 Benefits have also been noted when gaba- significant improvement in MD Anderson Dysphagia
pentin has been used in the postoperative setting.95 Inventory (MDADI) score 1 year after treatment, thus
The advent of IMRT over the past 2 decades has establishing dysphagia‐avoidance IMRT as the standard‐
remarkably improved swallowing outcomes without of‐care planning approach.114
sacrificing oncologic results. There was strong con- Assessment of the contribution of chemotherapy to
sensus that IMRT techniques are the preferred dysphagia is complex due to many factors including the
standard for reducing xerostomia which may impact timing of chemotherapy (induction, concurrent, adju-
swallowing outcomes (Table 4; Statements 34). In the vant), dose, specific agents, swallowing evaluation meth-
seminal PARSPORT randomized study, Nutting et al odology, and use of other treatment modalities (surgery
showed a clear, statistically significant reduction in the and radiotherapy). Most prospective, randomized studies
patient‐reported dry mouth at every time point from 3 that established the utility of chemotherapy in locally
to 24 months, with the significantly more measured advanced HNC were performed prior to the adaptation of
salivary flow in the contralateral parotid in the IMRT validated swallowing outcome measures. Therefore, data
cohort. A smaller randomized study of IMRT versus to adequately conclude that chemotherapy is associated
conventional radiotherapy in nasopharynx cancer with a difference in swallowing outcome is lacking. The
showed an over twofold reduction in observer‐rated development group agreed that the enhanced toxicity
xerostomia, 96 and importantly, there was significantly associated with chemotherapy during concurrent therapy
less long‐term feeding tube use in the IMRT cohort. 97 with radiation or as a component of trimodal therapy
A third randomized trial of IMRT versus three‐ following surgery is associated with an increased risk of
dimensional‐conformal radiotherapy (ie, using CT‐ acute and chronic dysphagia (Table 4; Statement 37).
based planning but conventional fields) in non‐ There was consensus that concurrent cricopharyngeal
nasopharyngeal HNC confirmed physician‐reported myotomy at the time of TL reduces dysphagia following
xerostomia improvements lasted through 10 years of the surgery (Table 4; Statement 39). In normal swal-
follow‐up. As in the previous randomized studies, lowing, the cricopharyngeus muscle relaxes, thus allowing
there was an apparent improvement in oral intake as a bolus to pass distally into the esophagus. However, in
well, as there was significantly less chronic weight loss many HNC patients, including those undergoing TL, the
in the IMRT cohort. 98 On the basis of this evidence, cricopharyngeus muscle fails to completely relax, which in
there was a strong consensus that IMRT confers addition to inefficient bolus transit, can lead to poor
decreased xerostomia and impacts the preservation of alaryngeal voice outcomes.115,116 Cricopharyngeal
swallowing ability (Table 4; Statement 33). myotomy has been shown to be beneficial in reducing
Likewise, the development group reached an agree- cricopharyngeal muscle spasms and improving tracheoe-
ment that IMRT parotid‐sparing techniques cause lower sophageal speech in patients with tracheoesophageal
rates of dysphagia compared to conventional radio- voice prostheses.117 Patients that have not undergone
therapy (Table 4; Statement 35). Retrospective studies cricopharyngeal myotomy during TL require may require
consistently found that patients treated with IMRT additional adjuvant therapy such as dilation, botulinum
experienced superior swallowing outcomes than those toxin injection, or secondary myotomy.118‐120
individuals treated with conventional radiation therapy
measured by physician‐reported toxicity grade,99 Dysphagia Interventions in HNC Patients
physician‐reported functional score,100 or patient‐
Interventions for dysphagia among HNC patients was the
reported outcome.101 The Italian Head and Neck
topic area yielding the most statements from the
Radiotherapy Study Group summarized these data,
development group owing to significant clinical practice
highlighting the multiple domains of superiority in
variability, lack of abundant high‐quality evidence, and
swallowing outcomes seen with IMRT.102
its importance as an opportunity for care optimization.
Additionally, there was consensus supporting second‐
Statements pertaining to intervention that reached con-
generation IMRT techniques that go beyond parotid
sensus included ones relating to swallowing therapy,
sparing to preserve swallowing organs at risk (Table 4;
feeding tubes, diet allocation, patient and caregiver
Statements 29 and 36). Several landmark dosimetry
education or counseling, oral care, lymphedema therapy,
studies showed that the dose to swallowing structures,
and surgery.
including the pharyngeal constrictors,103‐106 larynx,105,107
floor of mouth,108,109 and esophageal inlet,110‐112 signifi-
cantly influenced dysphagia outcomes. This work culmi- Swallowing Therapy
nated in a phase III randomized trial in which patients Dysphagia management in the HNC population is
with pharyngeal cancer were treated with either standard primarily prevention‐based, so there was a strong
IMRT or dysphagia‐optimized IMRT, which significantly consensus that swallowing therapy is most effective
reduced the dose to the pharyngeal musculature (ie, the when initiated early in HNC treatment (Table 5;
113
superior/middle/inferior constrictors). Patients treated Statement 40). When comparing patients treated
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582 Otolaryngology–Head and Neck Surgery 168(4)

reactively versus proactively, proactively managed co- discontinue enteral feeding (Table 5; Statement 47).
horts demonstrate reduced feeding tube use during Practical recommendations for transitioning from enteral
treatment, shorter duration of feeding use posttreatment, nutrition to an oral diet are provided by the Enteral
maintenance of some oral intake at the conclusion of Nutrition Safe Practices Consensus Recommendations of
treatment, and more favorable swallowing func- the American Society of Parenteral and Enteral
tion.12,77,121,122 The development group recognized that Nutrition.129 A long‐accepted algorithm recommends
a variety of devices designed to augment the intensity of that HNC patients consume 75% of their nutrition
behavioral swallowing hold promise (Table 5; Statement requirements orally for 3 days before enteral nutrition is
48). Many such devices are available and include ceased.130 Incremental decreases in both enteral nutrition
expiratory muscle strength training, electromyography, volume and administered hours help support acceptable
resistive tongue‐strengthening apparatuses, and electrical nutrient intake during the transition. Documentation of
stimulation among others. The widespread use of these intake helps ensure the patient can completely wean from
devices requires supporting evidence from trials that enteral nutrition to an oral diet. Key parameters for
address underlying dysphagia pathophysiology (Table 5; ongoing monitoring are nutrition and hydration status
Statement 49). with weight and oral intake measured weekly. Fostering a
patient‐centered approach to the feeding transition by
Diet Allocation and Feeding Tubes involving the HNC patient and/or caregivers can assist
The development group agreed that nutrition supplemen- with achieving goals, and multidisciplinary collaboration
tation via a feeding tube is appropriate in certain HNC ensures that patients can consistently and safely meet
patients. There was strong consensus supporting enteral their needs through oral nutrition in the context of the
feeding in HNC patients who are unable to safely overall oncology plan.
maintain adequate oral nutrition (Table 5; Statement There was a strong consensus that oral intake is
12). The optimal timing of feeding tube placement encouraged in HNC patients if judged by a dysphagia
(prophylactic vs reactive) is debated due to a lack of specialist to be low risk for consequences of
high‐quality randomized controlled trials.123,124 The aspiration (Table 5; Statement 23). While data demon-
NCCN Clinical Practice Guidelines in Oncology recom- strate an increased risk of development of aspiration
mend pretreatment prophylactic feeding tube placement pneumonia in patients with HNC compared to controls,
for HNC patients undergoing chemoradiation therapy the proportion of HNC survivors developing aspiration
who have severe weight loss, dehydration, dysphagia, or pneumonia remains low when compared to the number of
other conditions impacting safe and adequate oral intake patients with dysphagia.131,132 Furthermore, prolonged
because it may lessen the negative impacts of treatment.88 NPO status has been shown to increase both dysphagia
Pretreatment feeding tube placement is not suggested for severity and risk of death.133,134 Factors associated with
those at lower risk, but thorough monitoring for an elevated risk of developing aspiration pneumonia
nutritional decline is strongly encouraged.88 As such, include age >80 years, hypopharyngeal primary, ad-
there was strong consensus supporting pretreatment vanced tumor stage, and chemoradiation. Additionally,
feeding tubes for HNC patients with baseline malnutri- comorbid conditions like neuromuscular disease and
tion or significant swallowing impairment (Table 5; esophageal disorders may be associated with an elevated
Statement 26). An important added benefit of a prophy- risk of pneumonia.135
lactic feeding tube125 is the reduction in treatment breaks There was strong consensus among the development
for reactive placements, which may lead to an adverse group that the identification of appropriate textures and
oncologic outcome.125 Concerns exist that prophylactic liquids for safe consumption is critical for HNC patients
placement may delay tube removal and return to eating, with dysphagia (Table 5; Statement 25). Determining the
resulting in worse quality‐of‐life and even worse long‐ most appropriate diet by dysphagia specialists often
term dysphagia.126 However, studies generally rebuke this requires instrumental assessment of swallowing phy-
theory, neither finding a significant difference in long‐ siology, safety, and efficiency.43 Although there is limited
term feeding tube dependency nor an increased risk of data on the HNC patient population, the impact of diet
long‐term dysphagia.126‐128 A randomized study of modifications on outcomes has been shown to reduce
prophylactic versus reactive feeding tubes from Sweden pulmonary complications and length of stay in other
showed no difference in any patient‐reported quality‐of‐ dysphagic populations.136 Appropriate diet modification
life or functional endpoints 1 to 8 years following may contribute to less patient fear and anxiety
HNC treatment. Still, additional high‐quality randomized about choking.137 The International Dysphagia Diet
trials are needed to more definitively answer this Standardization Initiative diet levels describe a continuum
question.125 of 8 levels from a thin liquid to regular solids.116 Use of
There was agreement among the expert development these descriptors is suggested to improve communication
group that HNC patients' ability to maintain their weight between clinicians as patients move across levels of care
and hydration via oral diet was essential prior to and facilities.
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Kuhn et al. 583

The development group likewise agreed that NPO There was also a strong consensus that HNC patients
status is not universally required for HNC patients and their caregivers should be instructed to self‐assess
(Table 5; Statement 30). When aspiration is observed nutrition and hydration status throughout treatment and
during a swallowing evaluation, common recommenda- recovery (Table 5; Statement 43). Dysphagia, in combina-
tions include dietary modifications and avoidance of, or tion with other acute toxicities, such as odynophagia,
thickening of liquids. Although the use of free water dysgeusia, and mucositis, can increase the risk for
protocols in HNC patients has not been specifically dehydration and malnutrition, especially during and
studied, these data suggest that in carefully selected immediately after chemoradiation.142 Malnutrition and
patients, it might be done safely under the supervision of a dehydration are associated with adverse outcomes such as
dysphagia specialist and could lead to improvements in lower tolerance for cancer treatment, unplanned treat-
QOL and hydration.138 ment interruptions, poor quality of life, and decreased
survival.143 Although self‐assessment of nutrition and
Education, Counseling, and Oral Care hydration status is not precise, it may be useful in the
HNC patients and their caregivers should be alerted to early identification and intervention of adverse effects.
recognize signs of aspiration, such as choking, throat Measuring hydration status is difficult due to the complex
clearing, or difficulty eating, and report them systems involved in fluid regulation. Although urine color
promptly to their dysphagia specialist. Choking that monitoring may not be an accurate measure of hydration
progresses to airway obstruction is a life‐threatening in clinical situations, it is a useful and readily apparent
event. There was consensus that counseling for HNC tool for patients and caregivers to use in the home
patients and caregivers should include education environment.144
regarding aspiration precautions and the Heimlich The development group reached a consensus on the
maneuver (Table 5; Statement 41). While most are benefit of HNC patient and family education in oral care
familiar with the Heimlich maneuver as performed by to reduce the adverse effects of dysphagia (Table 5;
a rescuer, patients can also be taught to self‐administer Statement 16). There was agreement on consistent daily
whereby gravity and a chair back (or railing) are used oral care to reduce the risk of aspiration pneumonia in
to provide thrust to the abdomen.139 Pavitt and HNC patients with dysphagia (Table 5; Statement 44).
colleagues completed a study comparing the efficacy Effective oral care routine for HNC patients extends
of experimenter‐performed Heimlich compared to self‐ beyond brushing and flossing the teeth. Reduced auto-
performed Heimlich. Their limited study found that debridement of the oral cavity due to a texture‐modified
self‐administered Heimlich over a chair back resulted diet can lead to an overgrowth of bacterial flora. The
in greater peak esophageal pressures than the Heimlich resultant bacterial flora is not typically seen in a healthy
maneuver performed by another individual. Concerns mouth, and usually consists of Gram‐negative bacteria
related to the injury should be considered against the common to phlegm and epithelial residue.145 Mechanical
risk of morbidity and mortality from airway obstruc- debridement of the tongue and palate, in addition to
tion, and those risks must be included in patient brushing and flossing, has been shown to reduce
education. pneumonia risk in HNC patients with dysphagia and
For patient safety and efficacious medication may increase cough reflex.146
delivery, there was consensus that HNC patients and
caregivers be educated on the nuances of medication Lymphedema Therapy
administration via feeding tube and that the expertise Lymphedema is a pathologic accumulation of lymph fluid
of clinical pharmacists should be utilized (Table 5; in the interstitial tissue resulting from an inability of the
Statement 42). HNC patients with dysphagia may be lymphatic system to transport lymph fluid from the tissue
reliant on feeding tubes for nutrition and medication to the central circulatory system.147 Among HNC
administration. Incorrect medication administration patients, external lymphedema manifests as soft tissue
through a feeding tube can lead to reduced drug swelling while internal lymphedema affects the mucosal‐
efficacy, increased risk for toxicity, increased adverse lined structures of the aerodigestive tract. Both internal
effects, and tube obstruction.140 The American Society and external lymphedema is associated with greater
for Parenteral and Enteral Nutrition developed patient perception of dysphagia, laryngeal penetration/
evidence‐based guidelines for safe medication admin- aspiration, and diet modification.148,149 Preliminary stu-
istration. 129 Among medications that cannot be safely dies suggest that manual lymph drainage, combined with
administered via feeding tube are sustained‐release stretching and swallowing exercises, may improve lym-
medications, enteric‐coated medications, and most phedema and dysphagia symptoms in HNC survivors.
proton pump inhibitors. 141 A comprehensive “Do Although prospective studies defining best practices for
Not Crush” list may be found on the Institute for the management of lymphedema and dysphagia related to
Safe Medication Practices website (https://www.ismp. internal lymphedema are lacking,150 there was strong
org/recommendations/do-not-crush). consensus among panel members that lymphedema
 10976817, 2023, 4, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1002/ohn.302 by Venezuela Regional Provision, Wiley Online Library on [02/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
584 Otolaryngology–Head and Neck Surgery 168(4)

therapy contributes to improved swallowing in HNC The development group agreed on the selective use of
patients with lymphedema (Table 5; Statement 52). functional TL for intractable aspiration in HNC patients
Components of lymphedema management include patient with concurrent tracheostomy and nonfunctional voice
education as to the chronic nature of the disease and who continue to aspirate despite NPO status (Table 5;
complete decongestive therapy including manual lym- Statement 55). Elective TL was historically used for the
phatic drainage, compression, exercises and stretching, dysfunctional larynx,166 with support provided by a
and skin care.147 retrospective study in 2012 from MD Anderson which
demonstrated functional TL after previous treatment for
Surgical Interventions HNC decreased the incidence of pneumonia, decreased
dependence on enteral nutrition, and allowed some level
The development group reached a consensus for the use
of oral intake.167 Fifteen of the 23 patients had successful
of pharyngoesophageal dilation in HNC survivors who
voice restoration with tracheoesophageal puncture. Topf
report dysphagia and have identified stenosis (Table 5;
et al found elective TL to be an effective intervention in
Statement 53). Radiotherapy causes tissue ischemia with
preventing aspiration and restoring oral diet, with
fibrosis which may result in luminal stenosis in 5.7% to
acceptable complication rates. Conversely, other aspects
16.7% of irradiated HNC patients.151 Dilation of stenotic
of quality of life may be affected by TL. In 11 patients
segments may be safely performed using a variety of
undergoing TL for dysfunctional larynx at The
dilators (bougies, balloon dilators, olive‐tip dilators) with
Netherlands Cancer Institute, the biggest areas of concern
multiple anesthesia options (general anesthesia, sedation,
were speech difficulty, smell and taste changes, mouth
or local anesthesia for interventions in the office).152
opening, and saliva thickness.168 Roughly half of the
There is a theoretical advantage to balloon dilators, which
patients reported an improvement in swallowing and
apply controlled radial forces on the stenosed segment,
dyspnea with the other half reporting a deterioration of
compared to bougies which apply shearing forces,153,154
their swallowing and dyspnea complaints as compared to
however safety and efficacy outcomes of the T2 techni-
before surgery. Although aspiration is prevented with the
ques are similar in benign strictures based on randomized
elective TL, most patients will still have dysphagia
controlled trials.155‐159 Combined anterograde and retro-
postoperatively. Of note, a majority of patients with
grade dilation or rendezvous procedure may be offered in
elective TL have been reported to require pharyngoeso-
cases of near‐complete or complete stenosis.160 The
phageal segment dilation to improve swallowing func-
overall success in improving dysphagia with dilation in
tion.116 Therefore, patients and their treatment team must
HNC patients has been reported to range between 42%
consider the risks of experiencing the negative conse-
and 100%.115 Esophageal perforation is the most com-
quences of aspiration against the alterations in voice and
monly reported complication, with an estimated rate per
swallowing that come with the various surgical options.
patient at 5.4%.161
There was strong consensus supporting the use of
select surgical interventions to address aspiration and Dysphagia Surveillance Among HNC Patients
improve pulmonary health in HNC patients with Swallowing dysfunction is the most common ongoing
laryngeal dysfunction and aspiration or significant quality‐of‐life complaint experienced by up to 55% of
risk of aspiration (Table 5; Statement 54). For HNC patients treated with multimodality
example, a tracheotomy may be performed to improve therapy.5,169,170 Therefore, the development group agreed
pulmonary clearance that results from substantial, that lifelong monitoring for the signs and symptoms of
chronic aspiration.162 Also, vocal fold medialization, dysphagia is important for HNC survivors (Table 6;
either by injection augmentation or laryngeal frame- Statement 57). Furthermore, strong consensus supported
work surgery, has been shown to be safe and improve improved nutrition outcomes and health status when
voice and swallowing outcomes in those with glottic HNC patients followed by an MDT (Table 6; Statement
insufficiency. 163,164 However, long‐term prevention of 56).171 HNC survivor quality of life concerns are regularly
aspiration has not yet been demonstrated after addressed by comprehensive history and physical exam-
medialization in HNC patients. Glottic and supra- ination. Symptoms and signs of dysphagia include
glottic closure procedures preserving the laryngeal coughing, throat clearing during meals, difficulty
framework have been proposed but wound dehiscence, chewing, nasopharyngeal regurgitation during eating,
voice limitations, and dependence on tracheostomy prolonged meal duration, dietary limitations/avoidances,
have prevented the widespread adoption of these history of pneumonia, weight loss, and aspiration.
techniques. 160 Laryngotracheal separation and tra- However, patients may not report any of these due to
cheoesophageal diversion are reversible procedures altered laryngopharyngeal sensations. Physical examina-
shown to be effective in preventing aspiration, how- tion should assess for trismus, mucosal dryness, tongue
ever postoperative fistulas, poor voice outcomes, and mobility and strength, cranial nerve function, state of
persistent feeding tube dependency are drawbacks to dentition, and oral hygiene. The clinician, aided by both
these strategies. 165 FEES and VFSS, should also evaluate for voice quality,
 10976817, 2023, 4, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1002/ohn.302 by Venezuela Regional Provision, Wiley Online Library on [02/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Kuhn et al. 585

dysarthria, coughing on the swallow, and change in voice treatment should prompt close evaluation for recur-
quality after swallowing.169,172 Retrospective assessment rence or new primary.
of such MDTs has shown excellent patient adherence, a
good collection of clinician/patient outcome tools during
treatment, and favorable nutrition and quality of life Conclusions
outcomes.69,173 Randomized controlled trials are in A development group of otolaryngologists, SLPs, a
progress to evaluate the functional and nutrition out- medical oncologist, a radiation oncologist, a head and
comes of multidisciplinary nutritional rehabilitation for neck nurse, and an RDN developed consensus statements
HNC patients, which will help to standardize nutritional on dysphagia management among HNC patients based
assessment and allocation of resources to this patient on available evidence and expert opinion, utilizing an
population.174 established protocol. Numerous topics related to dys-
The development group reached a consensus that phagia among HNC patients were identified in which
obtaining patient‐reported dysphagia‐related out- there were significant variations in practice and contro-
comes are an important component of ongoing HNC versy, including risk factors, screening, evaluation, pre-
care (Table 6; Statement 58).175,176 Patient‐reported vention, interventions, and surveillance. Statements were
outcome measures (PROMs) have been developed to generated to improve the quality of care provided to
quantify patients' subjective experience with swal- HNC patients. The group members highlighted the
lowing difficulty. Some PROMs like the Eating importance of early identification of HNC patients at
Assessment Tool‐10 have been developed to measure high risk of dysphagia based on clinical characteristics or
dysphagia in the general population. 177 Other PROMs screening outcomes. The involvement of an MDT is
like the MDADI and Swallowing After Total preferred to optimize comprehensive dysphagia care in
Laryngectomy questionnaire were specifically devel- HNC patients. Evaluations by SLP and RDN before,
oped for HNC survivors. 178,179 PROMs can help during, and after HNC treatment guide diet recommen-
identify patients with negative consequences of swal- dations and informs patients suitable for prophylactic and
lowing dysfunction such as malnutrition or aspiration therapeutic interventions. Dysphagia surveillance among
risk, 180,181 and therefore complement conventional HNC patients is lifelong and is facilitated by MDT and
clinical evaluation. A sudden or rapid deterioration PROMs. Further research is needed with a focus on
in PROM scores may be a sign of disease progression functional outcomes of HNC care pathways and pro-
or recurrence and ought to trigger an appropriate spective randomized trials comparing swallowing inter-
workup. 182 The change in PROMs values between pre‐ ventions to better guide and individualize the care of
and posttreatment has been shown to be prognostic for dysphagia among HNC patients.
overall survival among HNC patients and thus
particular attention should be paid to patients with Acknowledgments
persistently depressed scores. 151,183,184 The authors gratefully acknowledge the support of Elizabeth
The NCCN guidelines for follow‐up with respect to Moreton for conducting the literature search and Joe Reyes for
speech and swallowing do not provide a specific cadence his administrative support.
or method for screening for dysphagia. There was strong
consensus that the specific cadence and screening for Author Contributions
dysphagia in HNC survivors must be dictated by the Maggie A. Kuhn, writer, chair; M. Boyd Gillespie, writer,
individualized patient, tumor, and treatment factors assistant chair; Stacey L. Ishman, writer, methodologist; Lisa E.
(Table 6; Statement 59). The development group agreed Ishii, writer, methodologist; Rebecca Brody, writer; Ezra Cohen,
that dysphagia surveillance in HNC patients includes writer; Shumon I. Dhar, writer; Kate Hutcheson, writer; Gina
measures of health such as nutritional status, weight, and Jefferson, writer; Felicia Johnson, writer; Anais Rameau, writer;
lung function (Table 6; Statement 60). The NCCN David Sher, writer, Heather Starmer, writer; Madeleine Strohl,
guidelines recommend that patients with ongoing dys- writer; Karen Ulmer, writer; Vilija Vaitaitis, writer; Sultana
function have regular visits with an SLP until the patient Begum, writer, AAO‐HNSF staff liaison; Misheelt Batjargal,
establishes a stable baseline following the completion of writer, AAO‐HNSF staff liaison; Nui Dhepyasuwan, writer,
AAO‐HNSF staff liaison.
HNC treatment.
The expert group agreed that new‐onset dysphagia
necessitates a workup to exclude recurrence or new Disclosures
primary tumors in HNC survivors who are otherwise Competing interests: Stacey L. Ishman, MD, MPH:
presumed to be disease‐free (Table 6; Statement 17). A clinical trial (Inspire Medical), NIH funding; Ezra
study on patient‐reported pretreatment swallowing Cohen, MD, FRCPSC, FASCO: consulting fee: Bayer,
measures found that HNC patients who reported BioNTech, Eisai, Gilead, Merck, MSD and Regeneron;
pretreatment dysphagia were at greater risk of Kate Hutcheson, PhD: personal fees— Medbridge Inc,
recurrence and death from the disease. 185 Any wor- ATOS Medical and American Speech Language and
sening or new symptoms of dysphagia after HNC Hearing Association; research funding: NIH, Thrive
 10976817, 2023, 4, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1002/ohn.302 by Venezuela Regional Provision, Wiley Online Library on [02/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
586 Otolaryngology–Head and Neck Surgery 168(4)

Foundation, Patience Centered Outcomes Research 10. Nguyen NP, Frank C, Moltz CC, et al. Impact of
Institute, and MD Anderson Institutional Research dysphagia on quality of life after treatment of head‐and‐
Grant Program; Anais Rameau, MD, MPhil: author/ neck cancer. Int J Radiat Oncol Biol Phys.
reviewer; intellectual property rights: founder and 2005;61(3):772‐778.
inventor of MyophonX, a silent speech device; David 11. Paleri V, Roe JW, Strojan P, et al. Strategies to reduce
Sher, MD, MPH: royalty: Uptodate, Treatment of long‐term postchemoradiation dysphagia in patients with
locoregionally advanced (stage III and stage IV) head head and neck cancer: an evidence‐based review. Head
and neck cancer: The larynx and hypopharynx; Heather Neck. 2014;36(3):431‐443.
Starmer, MA CCC‐SLP: Research funding: NCI SBIR 12. Messing BP, Ward EC, Lazarus CL, et al. Prophylactic
funding through Vibrent Health. swallow therapy for patients with head and neck cancer
Funding source: None. undergoing chemoradiotherapy: a randomized trial.
Dysphagia. 2017;32(4):487‐500.
ORCID iD 13. Rosenfeld RM, Nnacheta LC, Corrigan MD. Clinical
M. Boyd Gillespie http://orcid.org/0000-0002-1383-5643 consensus statement development manual. Otolaryngol
Rebecca Brody http://orcid.org/0000-0003-1816-0881 Head Neck Surg. 2015;153(2 suppl):S1‐S14.
Ezra Cohen http://orcid.org/0000-0002-9872-6242 14. Kahn NB, Jr., Lichter AS. The new CMSS code for
Shumon I. Dhar http://orcid.org/0000-0001-9873-8641 interactions with companies managing relationships to
Kate Hutcheson http://orcid.org/0000-0003-3710-5706 minimize conflicts. J Vasc Surg. 2011;54(3 suppl):34S‐40S.
Gina Jefferson http://orcid.org/0000-0001-8332-776X 15. Chen S‐C. Oral dysfunction in patients with head and neck
Anais Rameau http://orcid.org/0000-0003-1543-2634 cancer: a systematic review. J Nurs Res. 2019;27(6):58.
David Sher http://orcid.org/0000-0003-3943-7480 16. Wopken K, Bijl HP, Langendijk JA. Prognostic factors for
Heather Starmer http://orcid.org/0000-0002-1716-9852
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