Functional Problem

Tumors of the head and neck are often treated with surgery followed by radiotherapy with or without chemotherapy. Some tumors are treated with primary chemoradiotherapy.
The addition of multimodality therapy has had a very significant and positive impact on cure rates as well as the preservation of vital organs in the upper aerodigestive tract.  However, chemoradiotherapy can result in significant side effects, including tissue fibrosis which can affect tissues and structures within the oral cavity, pharynx, larynx and esophagus. These structures are important for both speech and swallowing. One region where tissue fibrosis and scarring can occur is within the pharyngo-esophageal (PE) segment. The PE Segment extends from the level of the soft palate to the thoracic esophagus. While the most common portion of the PE segment to be affected by scarring is the transitional zone behind the cricoid, the entire region from the soft palate to the thoracic inlet may be adversely affected by either radiation alone or used in conjunction with chemotherapy.
 
The normal mechanism for an unencumbered swallow involves the opening of the upper esophagus to permit the passage of foods and liquids through the esophagus into the stomach. If this region becomes fibrotic and/or scarred, the entrance into the esophagus can be narrowed to such a degree that no foods or liquids can pass through it. In some instances, the region is narrowed to a degree where the opening will only accommodate the passage of liquids on pureed foods. If some material does not pass into the esophagus, it can remain in the pharynx after the swallow, at which point it can enter the airway/trachea (i.e., aspiration). Aspiration can result in medical problems such as pneumonia.

In addition, individuals undergoing total laryngectomy and voice restoration surgery (i.e., tracheo-esophageal puncture (TEP) procedure) require a working pharyngo-esophageal sphincter in order to communicate, since the PE region vibrates when air is introduced for voice production. Should stenosis or narrowing of this region occur, there may be no ability to produce voice for communication.

In those individuals who have an intact larynx, the stenosis may extend upward to include the pharynx and oropharynx, which may also have a negative impact on voice and resonance, often causing an inability to speak or creating a hypernasal voice.

 

Rehabilitative Solutions

There are various ways to address the problem of PE stenosis. One way to improve functioning is to dilate this region. This is typically accomplished by placing progressively wider rubber bougies through the narrowed region to stretch it. Success with dilation, however, can vary. Some individuals require re-dilation on a regular basis (i.e., once a week or once a month). Others can eat and drink for longer periods. The ability to dilate requires that at least a small passage exists and therefore there is a channel for a bougie to pass. Alternatively, if a complete obstruction is present, that will require a more sophisticated approach involving retrograde and antegrade dilation (rendez vous procedure) provided that the obstructed segment is very short (<2 cm).
    
Some patients are not successfully rehabilitated with dilation and an alternative solution is required. In others, the mere act of dilation may convert a partial stenosis to a complete obstruction. A more long-term solution for those with difficulty eating because of PE stenosis involves reconstructive surgery.  The head and neck reconstructive surgeon can transfer a flap of tissue from another part of the body to reconstruct the PE   segment so that there is a wider passageway for foods and liquids. The narrowed region is opened by augmenting the caliber of the lumen with nonirradiated tissue.   In patients with a complete obstruction, the segment can be bypassed with the transferred tissue to create an extra- anatomic conduit for food and liquids.  Flaps commonly used include radial forearm, lateral arm, jejunum and gastro-omental.

Swallowing is typically assessed before and after treatment for PE stenosis (i.e., dilation or surgery). Examination usually includes a barium swallow test and/or a Modified Barium Swallow procedure, the former conducted by a radiologist and the latter conducted in a collaborative fashion by a radiologist and speech-language pathologist. These radiographic tests identify the degree of narrowing within the PE region, what portion of food and liquid is entering the esophagus, and whether the patient is aspirating. These tests are also helpful for the clinician/physician to make diet recommendations, once the stenotic region has been evaluated. In addition, voice is typically assessed before and after treatment for the PE stenosis. This assessment is typically conducted by the speech-language pathologist. The patient with PE stenosis should consult with a head and neck reconstructive surgeon who will determine the type of treatment, based on radiographic swallow assessment and ability to produce voice.