Swallowing can be impaired for a range of reasons but is particularly a problem for people with head and neck cancers or neurological tumours. People with other cancers (e.g. lung, gastrointestinal), people who are significantly de-conditioned (from being very unwell for a long time), those who are approaching end of life or those with nerve damage to the throat (such as a vocal fold palsy) may also be affected.

Dysphagia may be caused by the cancer itself or its treatments. Surgery to the head and neck will result in altered anatomy which may affect the mouth, including tongue, jaw, lips and palate. Changes to these structures can lead to a varying degree of dysphagia. Radiotherapy to the head and neck will result in a number of side effects such as dry mouth (xerostomia), sore mouth (mucositis), thick, sticky phlegm, nausea, vomiting, pain, reduced mouth opening (trismus), which can also impact on swallowing. Longer term side effects can also occur such as fibrosis, which can result in significant dysphagia.

If un-treated, swallowing problems can lead to poor nutritional status and potentially life-threatening complications such as aspiration pneumonia (a type of lung infection that is due to food and drink from the mouth entering the lungs instead of the stomach).

The primary specialists in assessment and management of swallowing problems are speech and language therapists at a registered and enhanced level, however all health and care professionals have a role in screening for swallowing problems and making appropriate referrals for specialist support as indicated. Nurses and respiratory physiotherapists at a registered and enhanced level have a key role in identifying when someone may have signs of aspiration and dietitians may be involved to assess and maintain nutritional status if someone has problems eating and drinking normally.

Identification of swallowing problems include the following:

• Coughing, clearing the throat, or choking when eating
• Pain on swallowing
• Food sticks abnormally in the throat
• Taking longer to finish a meal
• Avoiding certain foods because they are too difficult to eat
• Unexplained pneumonia, chest infections or fever
• Wet, gurgly voice

Other signs can include:

• Excess saliva in the mouth and/or drooling
• Bringing food back from the throat
• Food or drink coming down the nose

If the patient is an inpatient the patient should be kept nil by mouth, referred to speech and language therapist for an assessment and alternative intravenous fluids considered.

Management of swallowing problems includes:

• Carry out simple swallowing screen followed by diagnostic swallow assessment from a speech & language therapist if indicated
• The 100ml water swallow screen is often used in head and neck cancer but would be replicable in other cancer patients

This can be undertaken face-to-face or remotely by any trained medical professional. It involves a measured 100ml of water and the larynx is palpated by the trained professional to count upward movement to indicate a swallow whilst the time taken to finish the amount after the instruction to the patient to drink this a quickly as you comfortably can is given. Normal swallow rates are anything up to 10 swallows in 10 seconds and watching for signs of coughing, throat clearing or wet voice quality. Obviously, this should be stopped if overt signs of significant coughing or choking which will indicate swallowing difficulty.

Although only water an abnormal score would indicate likely difficulty with solids as well.

Local SLTs tend to get people to observe 4 tests then they are observed to check they have palpating and timing the test correctly.

A simple swallow screen is also carried out in stroke units which could also be appropriate to be used with cancer patients by other professionals this does involve quite a bit of training ½ day then observation of 2 screens and then competency checking with 3 patients of their own by an SLT or a nurse already trained in swallow screening. This includes diet as well as fluids.

Swallowing questionnaires are often used to help patients identify they have swallowing issues to act as a screening toll for referral onto to SLT.

Most usual are:

• Sydney Swallow Questionnaire (SSQ)
• Eating Assessment Tool (EAT10) – often used but any score above 3 is considered abnormal which is quite a low cut off for referral on but is very widely used as a screening tool

Carry out nutritional screening for malnutrition, followed by a dietetic assessment if indicated.

• Ensuring correct positioning
• Ensuring excellent mouth care
• Ensuring correct utensils for eating and drinking

Referral to specialists is needed for the following:

Dietitian:

• carry out a detailed dietary assessment including assessment of current intake, nutritional status, functional capacity, biochemical markers and potential for further problems
• manage oral nutritional supplements both non-prescribable and prescribable
• manage enteral and parenteral nutritional support
• discuss ethical issues/ quality of life and potential feeding routes

Speech and Language Therapy:

• carry out a detailed swallowing assessment, with a full case history, examination of oro-motor system and trials of oral intake
• provide information pre-operatively (prehabilitation) for people who are high risk of swallowing problems postoperatively, e.g. certain surgical procedures for head and neck cancer
• advise on diet modification and swallow manoeuvres to facilitate oral nutrition as appropriate
• provide a prehabilitation dysphagia therapy programme for maintenance of swallow function during cancer treatment
• assess impact of interventions on quality of life