Dysphagia with Head and Neck Cancer: Why We Can’t Wait to Treat

The more I’ve worked with patients undergoing treatment for head and neck cancer, the more I’ve come to love working with this population. But here’s one thing I’ve learned loud and clear—they have to be doing something to preserve swallowing function, and that something needs to start early. Like, before treatment even begins.

Too often, these patients receive a PEG tube before starting chemoradiation (CRT), and once treatment begins, most of them just don’t feel like doing much. And who can blame them? But if we wait until the end of treatment to start swallow therapy, we’re already behind.

Enter: The Research

Back in 2012 at the ASHA Convention, Dr. Michael Crary and Dr. Giselle Carnaby presented a study called Pharyngocise. The results? Not necessarily surprising—but definitely powerful.

📄 Read the full article here.

The Study

Title: “Pharyngocise”: Randomized Controlled Trial of Preventative Exercises to Maintain Muscle Structure and Swallowing Function During Head-and-Neck Chemoradiotherapy
Authors: Carnaby-Mann, Crary, Schmalfuss, & Amdur
Published In: International Journal of Radiation Oncology

This study looked at 58 patients with oropharyngeal head and neck cancer undergoing CRT. None had a history of nonoral feeding prior to the study.

Groups and Protocols

Patients were randomly assigned to one of three groups:

• Usual Care: Typical supervision for feeding and general swallowing precautions from hospital SLPs.
• Sham Treatment: A made-up task called “valchuff” (think puffing out cheeks, lip blowing, mouth opening), done twice daily with 10 reps over four 10-minute cycles.
• Pharyngocise: High-intensity swallowing therapy including falsetto, tongue press, effortful swallow, and jaw resistance using the Therabite system. Sessions were held twice daily for up to 6 weeks during CRT.  Therapy was 2 times daily with the SLP, for a max of 6 weeks (duration of CRT) including 10 reps over 4 cycles each lasting 10 minutes.   Therapy sessions were 45 minutes.

All patients also received clinical and instrumental swallowing evaluations before CRT and were given home exercise programs (interestingly, the sham group had better compliance with the home exercises than the pharyngocise group).

What Did They Find?

Muscle deterioration was measured via MRI, focusing on the genioglossus, mylohyoid, and hyoglossus muscles. Spoiler alert: All groups had muscle loss—but the pharyngocise group showed the most muscle preservation.

Here’s a quick snapshot of the outcomes:

• Swallowing Function: Declined across all groups, but least in the pharyngocise group.
• Diet Maintenance During CRT:
  • Pharyngocise: 42% maintained full oral diet
  • Usual care: 14%
• Tube Feeding:
  • Pharyngocise: 20%
  • Usual care: 30%
• FOIS Scores:
  • Pharyngocise group dropped from median 7 → 5
  • Usual care & sham groups dropped to 4

At 6-week follow-up (Pharyngocise vs. Usual Care):

Outcome	Usual Care	Pharyngocise
Normal Diet	2/14	5/12
Nonoral Feeding	6/14	3/12
Functional Swallowing	2/14	6/12
>10% Weight Loss	6/13	4/14
Salivation Decline	12/13	8/14
Taste Decline	10/12	9/14
Smell Decline	6/11	2/13
Any Complication	7/14	5/12

The Bottom Line

✅ Exercise works.
✅ It helps maintain muscle structure, swallow function, and even quality of life.
❌ Diet modification alone isn’t enough.

Pharyngocise showed the best results—but really, any exercise is better than none. These patients benefit from early and consistent engagement, starting before CRT and continuing during treatment. Post-treatment? They’ll likely need even more intensive rehab.

Outcome Tools for This Population

If you’re assessing and tracking patients with head and neck cancer, here are a few outcome measures you’ll want in your toolbox:

• MASA-C: Mann Assessment of Swallowing Ability – Cancer
• FOIS: Functional Oral Intake Scale
• MDADI: MD Anderson Dysphagia Inventory
• MDASI: MD Anderson Symptom InventoryAre you ready for a deeper dive with even more resources available? Join the Dysphagia Skills Accelerator today. You will get so many great tools with new tools being added all the time! Click here to join now!

  Have you ever wanted a way to create a more standardized protocol for your Clinical Swallow Evaluation?   Do you often forget or leave out parts of the CSE, you know, the parts that are important for your Plan of Care?  You probably need the Clinical Dysphagia Assessment Toolkit if you answered yes.   You can get your copy here.  

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References

Carnaby-Mann, G., Crary, M. A., Schmalfuss, I., & Amdur, R. (2012). “Pharyngocise”: Randomized controlled trial of preventative exercises to maintain muscle structure and swallowing function during head-and-neck chemoradiotherapy. International Journal of Radiation Oncology, Biology, Physics, 83, 210–219. https://doi.org/10.1016/j.ijrobp.2011.11.049

Crary, M. A., Mann, G. D. C., & Groher, M. E. (2005). Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. Archives of Physical Medicine and Rehabilitation, 86(8), 1516–1520.

Schindler, A., et al. (2008). Adaptation and validation of the Italian MD Anderson dysphagia inventory (MDADI). Revue de Laryngologie Otologie Rhinologie, 129(2), 97–100.

Armstrong, T. S., et al. (2006). Validation of the MD Anderson symptom inventory brain tumor module (MDASI-BT). Journal of Neuro-Oncology, 80(1), 27–35.

Wang, X. S., et al. (2010). Validation and application of a module of the MD Anderson Symptom Inventory for gastrointestinal cancer (MDASI-GI). Cancer, 116(8), 2053–2063.

Other Reading on Pharyngocise:

Hutcheson, K. A., Bhayani, M. K., Beadle, B. M., Gold, K. A., Shinn, E. H., Lai, S. Y., & Lewin, J. (2013). Eat and exercise during radiotherapy or chemoradiotherapy for pharyngeal cancers: use it or lose it. JAMA otolaryngology–head & neck surgery, 139(11), 1127-1134.

Charters, E., Davies, S., Sharman, A. R., Milross, C., Findlay, M., & Clark, J. (2024). Keeping Swallowing on Track During Radiation Therapy for Head and Neck Cancer. International Journal of Radiation Oncology* Biology* Physics, 120(1), 29-32.

Perry, A., Lee, S. H., Cotton, S., & Kennedy, C. (2016). Therapeutic exercises for affecting post‐treatment swallowing in people treated for advanced‐stage head and neck cancers. Cochrane Database of Systematic Reviews, (8).

Patel, A., Goswami, G., & Gupta, N. (2021). Rehabilitation strategies and results in patients treated with chemoradiotherapy/radiotherapy for head and neck cancer: Institutional experience. J Otolaryngol ENT Res, 13(3), 70-72.

Wall, L. R., Ward, E. C., Cartmill, B., Hill, A. J., & Porceddu, S. V. (2017). Adherence to a prophylactic swallowing therapy program during (chemo) radiotherapy: impact of service-delivery model and patient factors. Dysphagia, 32(2), 279-292.

Paleri, V., Roe, J. W., Strojan, P., Corry, J., Grégoire, V., Hamoir, M., … & Ferlito, A. (2014). Strategies to reduce long‐term postchemoradiation dysphagia in patients with head and neck cancer: an evidence‐based review. Head & neck, 36(3), 431-443.

Wall, L. R., Ward, E. C., Cartmill, B., Hill, A. J., Isenring, E., Byrnes, J., & Porceddu, S. V. (2020). Prophylactic swallowing therapy for patients with head and neck cancer: a three‐arm randomized parallel‐group trial. Head & neck, 42(5), 873-885.