Dysphagia Due to Non-Hodgkin’s Lymphoma after Radiation:

A Case Report of Rehabilitation Management

Annisa Budi Prayuni, Ira Mistivani

Department of Physical Medicine and Rehabilitation, Dr. Cipto Mangunkusumo National General Hospital,

Faculty of Medicine, University of Indonesia, Jakarta, Indonesia

Keywords: Dysphagia, Head and Neck Cancer, Lymphoma, Rehabilitation Management

Abstract: A 63 years old female was consulted to Dysphagia Clinic in Medical Rehabilitation Department six months

after 20 times radiation with total dose 40Gy due to Non-Hodgkin’s Lymphoma (NHL). She complained

about difficulty in swallowing, dry saliva, and inadequate coughing. First Flexible Endoscopic Evaluation of

Swallowing (FEES) indicated that she had oropharyngeal neurogenic dysphagia with risk of post

swallowing aspiration and Functional Oral Intake Scale (FOIS) was 1 with tube dependent without oral

intake. She got 12 times Neuromuscular Electrical Stimulation (NMES) in suprahyoid and infrahyoid

muscle for 60 minutes and biofeedback 2times/week, breathing and oromotor exercises, Mendelsohn

maneuver, Masako and Shaker Exercise. After 2 months of intensive rehabilitation, the second FEES

showed a progression that patient might swallow semi-solid food with repeated swallowing, FOIS was 2

with tube dependent with minimal oral intake and after 5 months continued with oromotor and swallowing

exercises FOIS was 3 with tube supplements with consistent oral intake. QoL was assessed with M.D.

Anderson Dysphagia Questionnaire, result was improving from 53,68 to 70. Comprehensive rehabilitation

management for dysphagia due to HNC after radiation can improve swallowing function, safety oral intake,

and enhance QoL

1 INTRODUCTION

Dysphagia is a common symptom of head and neck

cancer (HNC), including Non-Hodgkin’s

Lymphoma (NHL), as well as representing a

complication of its treatment, chemoradiation. The

use of radiotherapy with or without chemotherapy

for treatment of HNC as a primary treatment

modality has increased significantly over the past

twenty years. Despite preservation of the structures

of the head and neck, swallow function is not

maintained at normal levels after treatment

(Hutscheson, 2012). Aspiration rates among HNC

patients is estimated to be 36%–94% have been

reported in the literature after treatment with primary

chemoradiotherapy while the incidence of silent

aspiration due to a decrease in the cough reflex is

22%–67% (Kweon, 2018).

Fibrosis of the irradiated tissue of the head and

neck results in impaired movement of the oral

tongue, tongue base, pharyngeal constrictors, and

larynx, leading to dysfunction. Due to mucositis,

edema of the soft tissues, copious mucous

production, xerostomia, and tissue swelling, patients

begin to develop acute dysphagia. These

complications begin to show from 4 to 5 weeks after

radiation-based therapy and persist through the first-

year posttreatment and may be present many years

after completion of radiotherapy (Pauloski, 2008;

King, 2016). Later, fibrosis, neuromuscular

dysfunction, muscles atrophy, lymphedema, and

damage to neural structures occur, leading to the late

effects of dysphagia (Hutscheson, 2012; Kweon,

2018).

Radiation-induced dysphagia is responsible for a

change in the type of diet and a prolongation of the

mealtimes, which participate in anorexia,

malnutrition, and decreasing quality of life (QoL)

(Kweon, 2018; Pauloski, 2008).

144

Prayuni, A. and Mistivani, I.

Dysphagia Due to Non-Hodgkin’s Lymphoma after Radiation: A Case Report of Rehabilitation Management.

DOI: 10.5220/0009066201440148

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 144-148

ISBN: 978-989-758-409-1

2 CASE DESCRIPTION

A 63 years old female was consulted to Dysphagia

Clinic in Medical Rehabilitation Department after

six months after 20 times radiation with total dose

40Gy due to NHL. Radiation is carried out in the

neck region according to figure 1. She got

Nasogastric Tube for nutrition intake and

tracheostomy due to history of airway obstruction

cause of tumor enlargement. She complained about

difficulty in swallowing, dry saliva, mucositis and

inadequate coughing. She experienced weight loss

despite being consulted for nutritional intake via

NGT.

First Flexible Endoscopic Evaluation of

Swallowing (FEES) indicated that she had

oropharyngeal neurogenic dysphagia with risk of

post swallowing aspiration. The results showed that

she had delayed of laryngeal elevation, swallowing

reflex was decreasing, retroflexion of epiglottic was

delayed and cough reflex was inadequate. Her

Functional Oral Intake Scale (FOIS) was 1 with tube

dependent without oral intake. She got 12 times

Neuromuscular Electrical Stimulation (NMES) in

suprahyoid and infrahyoid muscle for 60 minutes

and surface EMG (sEMG) biofeedback 2 times a

week, breathing and oromotor exercises,

Mendelsohn maneuver, Masako and Shaker Exercise

(Figure 2 and 3). The exercises were given for home

exercise and evaluated with biofeedback at hospital.

After 2 months of intensive rehabilitation, the

second FEES showed a progression that patient

might swallow semi-solid food with repeated

swallowing, FOIS was 2 with tube dependent with

minimal oral intake. Oromotor exercises that include

ROM exercises, Mendelsohn maneuver, Masako and

Shaker exercises was continues until the 5

month.

Follow-up was done every month. After almost

seven months of rehabilitation, FEES showed an

improving that patient could swallow solid-food and

liquid with repeated swallowing without penetration

and aspiration, also cough reflex was adequate.

FOIS was 3 with tube supplements with consistent

oral intake. Figure 4 shows the progression of the

FOIS results. QoL was assessed with M.D.

Anderson Dysphagia Questionnaire, result was

improving from 53,68 to 70. Now, the patient still in

rehabilitation program to improve her swallowing

with target total oral intake.

Figure 2: Application of Neuromuscular Electrical

Stimulation and Biofeedback therapy of the patient

Figure 1: Patient’s radiation area

Dysphagia Due to Non-Hodgkin’s Lymphoma after Radiation: A Case Report of Rehabilitation Management

145

Figure 3: Oromotor Exercises and Masako Exercises of the patient

Figure 4: Progression of Functional Oral Intake Scale of the Patient

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

146

3 DISCUSSION

Patients with cancer of the head and neck may be

treated with surgery, radiotherapy, chemotherapy, or

a combination. Each treatment modality may have a

negative impact on post-treatment swallowing

function, especially in this case report dysphagia

occurred after treated by radiation. Rehabilitative

management available to reduce or eliminate

swallowing disorder in patients treated for cancer of

the head and neck, which include postures,

maneuvers, exercises, and modalities such as NMES

and sEMG biofeedback to help patient achieve

optimal function, improve swallowing function,

safety oral intake, and enhance QoL (Pauloski,

2008).

In this patient, radiation dose was 40 Gy which

may affect fibrotic in irradiated structures results in

limited mobility of the oral tongue, tongue base,

pharynx and larynx. Besides that, radiation also

damage the salivary glands results in significantly

reduced salivary flow. Patient also felt dry in saliva.

Studies of saliva flow after radiation showed that

reduce the dose with below 24 to 26 Gy made saliva

flow is persevered and will increase toward

pretreatment levels over the first year. Glands

receiving a mean dose higher than the threshold will

produce little saliva with no recovery over time.

Reduced saliva weight does not correlate with

slowed or inefficient swallow. Instead, reduced

saliva weight seems to change the patient’s

perception of swallowing ability and, on that basis,

affects diet choices (Logemann, 2001).

Oromotor exercises that include range of motor

(ROM) exercise, postures, and maneuvers were

given to the patient. The normal range of motion of

the lips, jaw, tongue, and larynx is often disrupted

after treatment for cancer of the head and neck, as a

result of fibrosis induced by radiation. ROM

exercises are designed to improve the movement by

extending the target structure in a desired direction

until a strong stretch is felt. Range of motion

exercises can be used for the lips, jaw, oral tongue,

tongue base, larynx, and hyoid-related musculature

to improve movement. Tongue range of motion

exercises for the oral tongue include extension,

lateralization, elevation, and retraction (Pauloski,

2008).

Mendelsohn maneuver is one of maneuver that

we give to the patient. This maneuver is a voluntary

prolongation of laryngeal excursion at the midpoint

of the swallow, intended to increase the extent and

duration of laryngeal elevation and thereby increase

the duration of cricopharyngeal opening. Since the

first FEES showed that patient had delayed of

laryngeal elevation, we choosed Mendelsohn

maneuver which research has indicated that it is

effective at increasing the extent and duration of

laryngeal elevation as well as duration of

cricopharyngeal opening. Mendelsohn maneuver

may be practiced with or without a bolus as dictated

for safety and as an exercise (Pauloski,2008).

The Masako exercise or tongue-hold exercise is

an oro-pharyngeal exercise rehabilitation technique

to enhance the function of the constrictor pharyngeal

superior. This technique is mainly performed to

strengthen its function of pushing food boluses from

the oral cavity to the pharynx by strengthening the

contact between the tongue base and the laryngo-

pharyngeal wall. Patient holds the tongue forward

between the teeth while swallowing. Its intent is to

improve movement and strength of the posterior

pharyngeal wall during the swallow (Logemann,

2008; Byeon, 2016).

Another exercise that we were given to the

patient is Shaker Exercise. Suprahyoid muscle group

responsible for displacement of the hyolaryngeal

complex and opening of the Upper Esophageal

Spinchter (UES) appears responsive to external

influences, like a simple isometric/isokinetic head

lift exercise. For this exercise, patient was instructed

to raise the head high and forward enough to be able

to see their toes without raising shoulders off the

ground. The rationale for the exercise is to build

strength in the suprahyoid musculature, thus

enhancing hyoid and laryngeal (Pauloski 2008).

sEMG Biofeedback was used to the patient twice

a week for evaluate the exercise. Biofeedback was

used during swallow attempts and oromotor exercise

to assist the patient in maintaining the requested

duration of each swallow attempt and to providing

progressively more challenging targets based on

strength. Electrodes were placed on the on the

submental muscles (mylohyoid, geniohyoid, anterior

belly of digastric, genioglossus) and a third

reference electrode was placed to one side of

zygomaticus. The sEMG signal represents the timing

and force of the muscle contraction and is displayed

graphically on a screen. An ascending threshold

approach was employed in which the patient was

required to progressively increase swallow effort

and strength to obtain a visual feedback (Benfield,

2008; Crary, 2004).

Surface neuromuscular electrical stimulation

(NMES) has recently been proposed as a treatment

option for pharyngeal dysphagia. Surface electrical

stimulation is applied through electrodes placed on

the neck with the goal of promoting increased hyoid

Dysphagia Due to Non-Hodgkin’s Lymphoma after Radiation: A Case Report of Rehabilitation Management

147

or laryngeal elevation. NMES for dysphagia has

become a widely utilized clinical procedure yet is

accompanied by considerable controversy because

of a lack of physiologic rationale and limited

published efficacy data (Pauloski,2008).

Study from Ryu et al evaluated the effect of

NMES in patient suffering from dysphagia

following treatment for head and neck cancer with

procedure 30 minutes of NMES, 5 days a week for 2

weeks combined with traditional swallowing

therapy. This study showed that NMES combined

with traditional swallowing training is superior to

traditional swallowing training alone in patients

suffering from dysphagia following treatment for

head and neck cancer (Ryu, 2009). Meanwhile,

another study from Langmore et al that did a

randomize controlled trial of 170 patients with active

NMES and swallow exercises versus sham NMES

and swallow exercises group showed that after 12

weeks program, NMES did not add benefit to

traditional swallow exercises (Langmore, 2016).

Although the results of existing studies showed

inconsistent results, NMES combined with oromotor

and swallowing exercises seems provide benefits to

the patients with progressing Functional Oral Intake

Scale (FOIS) and increasing the QoL from M.D.

Anderson Dysphagia Questionnaire result. Now, the

patient still in rehabilitation program to improve her

swallowing function with target safety total oral

intake with adequate nutrition. Patient may still need

modification of diet and swallowing maneuver.

In conclusion, comprehensive rehabilitation

management for dysphagia due to HNC after

radiation can improve swallowing function, safety

oral intake, and enhance QoL.

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Medicine and Rehabilitation Association

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