Search

Objectives We assessed the severity of dysphagia before and after oral cavity cancer surgery.

The effectiveness of the cough reflex in patients who aspirated following radiation for head and neck cancer was evaluated in 89 patients (49 chemoradiation, 33 postoperative radiation, and 7 radiation alone). All patients had modified barium swallow because of dysphagia. The cough reflex was graded as present and effective, ineffective, intermittently effective, or absent. All patients were cancer-free at the time of the swallowing study. The cough reflex was present and effective in 46 patients (52%), ineffective in 17 patients (19%), and absent in 26 patients (29%) on initial investigation. Among the 43 patients who had ineffective or absent cough reflex, their treatment was chemoradiation (26), postoperative radiation (13), and radiation alone (4). In 30 patients who had sequential modified barium swallow, the cough reflex was constantly effective, ineffective, or intermittently effective in 12 (40%), 13 (43%), and 5 (17%) patients, respectively. The cough reflex was frequently ineffective or absent in patients who aspirated following radiation for head and neck cancer. Cough may also be intermittently ineffective to protect the airways following radiation.

Concurrent chemoradiation offers excellent local control and survival for patients with locally advanced head and neck cancer while allowing anatomic organ preservation. Treatment toxicity is significant, however, often resulting in long-term dysphagia and aspiration. We review the prevalence of post-treatment swallowing dysfunction, describe current thinking about its pathogenesis and management, and signal possible directions for future research.Apoptosis from chemoradiation induces abnormal motility of the upper aerodigestive tract, resulting in stasis of the bolus in all phases of the swallow, and resulting in aspiration when the larynx is not protected during swallow. Long-term scarring may result in stenosis of the upper digestive tract. Recent findings suggest the role of transforming growth factor beta 1 in the pathogenesis of normal tissue damage and late scarring induced by radiation. Aspiration is often silent, and therefore a modified barium swallow or videofluoroscopy are required for its diagnosis. Swallowing therapy may improve swallowing efficiency and reduce the aspiration rate, and should be started immediately.Successful management of swallowing dysfunction following chemoradiation is a complex undertaking requiring a team approach. Collaboration among different specialists (physicians, speech pathologist, dietitian, and psychologists) remains the key to a desirable outcome.

Purpose The aim of this study was to assess the survival, pattern of failure, morbidity, and prognostic factors of concurrent chemoradiation for locally advanced oropharyngeal cancer. Materials and methods A retrospective survey of patients who underwent chemotherapy and radiation for locally advanced oropharyngeal carcinoma at the Veteran Affairs North Texas Health Care System, Dallas, Tex. Results Between December 1999 and September 2004, 48 patients with locally advanced oropharyngeal cancer underwent concurrent chemotherapy and radiation. At a median follow-up of 23 months, the 3- and 5-year survival for the whole group were, respectively, 52% and 41%. Seventeen patients (35%) developed recurrences. There were 12 (25%) locoregional failures (6 local failures alone and 6 local and regional failures). Distant metastases developed in 8 patients (5 alone, 3 associated with locoregional failures). Four patients (8%) developed second primaries. No difference was observed in survival between base of tongue and tonsillar carcinoma (P = .32). The 5-year survival for T1-T2 and T3-T4 tumors was, respectively, 84% and 27% (P = .01). No patient with T1-T2 tumors developed distant metastases (P = .04). Forty-five patients (94%) developed toxicity grade 3 to 4 (40 mucositis and 26 hematological). The median weight loss was 18 lb (range, 0–47 lb). Eight patients (16%) developed aspiration pneumonia during and after treatment. Five patients (10%) died of aspiration (2 during and 3 post treatment). Four patients (8%) developed esophageal strictures requiring repeated dilatations post treatment. Two patients had radionecrosis (1 soft tissue and 1 bone) requiring hyperbaric oxygen. Eighteen patients (37%) had prolonged tube feedings (>3 months) after treatments because of severe dysphagia or aspiration. Conclusion Concurrent chemoradiation provided good locoregional control for locally advanced oropharyngeal carcinoma. Patients with small tumors (T1-T2) had excellent survival. The poor prognosis associated with large tumors may be due to the risk of developing distant metastases. Acute and late toxicities remained significant. Aspiration pneumonia and severe dysphagia were the most prevalent complications of the combined modality approach.

Background and purpose We would like to assess the prevalence of aspiration before and following chemoradiation for head and neck cancer. Patients and methods We reviewed retrospectively the Modified Barium Swallow (MBS) in 63 patients who underwent concurrent chemotherapy and radiation for head and neck cancer. MBS was performed prior to treatment to determine the need for immediate gastrostomy tube placement. MBS was repeated following treatment to assess the safety of oral feeding prior to removal of tube feeding. All patients were cancer free at the time of the swallowing study. No patient had surgery. Dysphagia severity was graded on a scale of 1–7. Tube feedings were continued if patients were diagnosed to have severe aspiration (grade 6–7) or continued weight loss. Patients with abnormal swallow (grade 3–7) received swallowing therapy following MBS. Results Before treatment, there were 18 grade 1, 18 grade 2, 9 grade 3, 8 grade 4, 3 grade 5, 3 grade 6, and 4 grade 7. Following chemoradiation, at a median follow-up of 2 months (1–10 months), one patient had grade 1, eight patients had grade 2, nine patients had grade 3, eight patients had grade 4, 13 patients had grade 5, seven patients had grade 6, and 11 patients had grade 7. Six patients died from aspiration pneumonia (one before, three during, and two post-treatment), and did not have the second MBS. Overall, 37/63 (59%) patients developed aspiration, six of them (9%) fatal. If we excluded the 10 patients who had severe aspiration at diagnosis and the six patients who died from pneumonia, the prevalence of severe aspiration was 33% (21/63). Conclusions Aspiration remained a significant morbidity following chemoradiation for head and neck cancer. Its prevalence is underreported in the literature because of its often silent nature. Diagnostic studies such as MBS should be part of future head and neck cancer prospective studies to assess the prevalence of aspiration, and for rehabilitation.

The aim was to assess the influence of treatment, tumor stages and sites on the severity of dysphagia following treatment. Sequential modified barium swallow (MBS) examinations were performed in patients who complained of chronic dysphagia following treatment of their head and neck cancer. Patients were selected if they were cancer free at their last MBS and had 2 or more MBS studies. Dysphagia severity was graded on a scale of 1 to 7. Dysphagia grade was compared between the first and last MBS to assess its evolution. Between 1996 and 2005, 63 patients with chronic dysphagia underwent MBS to assess dysphagia severity for nutritional support. Twenty-one patients (33%) had improvement of their dysphagia. Two of these patients (3%) achieved normalization of the swallowing. Twenty-five patients (40%) had no change of the dysphagia severity. Dysphagia grade increased in 17 patients (27%). Analysis of patient characteristics did not show any significant difference between these three groups of patients. MBS is a useful tool to monitor dysphagia severity and to identify aspiration risk. Stages of disease and treatment modality do not seem to impact on the course of dysphagia.

Our aim was to identify risk factors for aspiration following concurrent chemoradiation for oropharyngeal cancer. 46 patients with locally advanced oropharyngeal carcinoma underwent concurrent chemoradiation at our institution. All patients underwent modified barium swallow to assess dysphagia severity and to determine the need for continued tube feedings after treatment. Dysphagia severity was graded as 1-7. There were 5 Grade 2, 11 Grade 3, 5 Grade 4, 5 Grade 5, 10 Grade 6 and 10 Grade 7 scores. 25 patients (54%) developed aspiration (5 trace, 20 severe). The aspiration rate for T1-T2 and T3-T4 tumours was 31% and 67%, respectively (p = 0.03). There was no statistical difference in the aspiration rate between the base of the tongue and tonsillar carcinoma (p = 0.23). Despite anatomical organ preservation, most patients with locally advanced oropharyngeal carcinoma had moderate to severe dysphagia after chemoradiation. Patients with large tumours had a significant risk of developing aspiration following treatment.

The aim of the study was to assess the aspiration risk following postoperative radiation for head and neck cancer. Thirty-seven patients had Modified Barium Swallow before and following treatment. Dysphagia severity was graded from 1 to 7. Before treatment there were sixteen grade 1, seventeen grade 2, three grade 3 and one grade 5. Following postoperative radiation, two patients had grade 1, eleven patients had grade 2, thirteen patients had grade 3, four patients had grade 4, four patients had grade 5, one patients had grade 6, and two patients had grade 7. Nineteen percent (7/37) of the patients developed aspiration (grade 5-7). Aspiration is life-threatening and may develop for all tumor sites and stages.

Our aim was to assess the influence of age, co-morbidity factors and tumour characteristics on dysphagia severity in the diagnosis of head and neck cancer. Modified barium swallow (MBS) examinations were performed in patients at diagnosis of head and neck cancer. Dysphagia was graded on a scale of 1 to 7 of increasing severity. Between 2000 and 2006, 236 patients with dysphagia underwent MBS at diagnosis of their head and neck cancer. 82 patients were scored as Grade 1, 88 as Grade 2, 29 as Grade 3, 15 as Grade 4, 9 as Grade 5, 5 as Grade 6, and 8 as Grade 7. Grade 3-7 dysphagia occurred in 20% and 31% of patients with T1-T2 and T3-T4 tumours, respectively (p = 0.004). Corresponding values for N0-N1 and N2-N3 tumours were 20% and 39%, respectively (p = 0.002). The percentage of patients with Grade 3-7 dysphagia was 5%, 29%, 33% and 52% for oral cavity, laryngeal, oropharyngeal and hypopharyngeal tumours, respectively, (p = 0.002). Age and co-morbidity factors (e.g. diabetes, hypertension, coronary artery disease, peripheral vascular diseases and arthritis) did not appear to have an impact on swallowing in this limited retrospective study. Patients with locally advanced stages (T3-T4, N2-N3) are at risk of severe dysphagia. Patients with oral cavity tumours appear to be less at risk of dysphagia than those with tumours in different anatomic locations. The role of age and co-morbidity factors should be investigated in future prospective studies.

The aim of the present study was to assess dysphagia severity following postoperative radiation for locally advanced oropharyngeal cancer.Eighteen patients with oropharyngeal carcinoma had undergone postoperative radiation. There were eight base of tongue, eight tonsils, and two soft palate carcinomas. All the patients had undergone modified barium swallow (MBS) to assess the persistence of dysphagia (more than one month) post-treatment. All the patients were cancer-free at the time of the swallowing study. Dysphagia severity was graded as 1-7.At a median follow-up of 12 months, there were three grade 2, four grade 3, two grade 4, five grade 5, two grade 6, and two grade 7. Only three patients (17%) had normal swallow post-treatment. Six patients (33%) had mild to moderate dysphagia (grade 3-4). Nine patients (50%) developed aspiration (grade 5-7). Among the patients who developed aspiration, four (22%) required tube feeding for severe aspiration.Long-term (more than one year) dysphagia following postoperative radiation for oropharyngeal cancer may be symptomatic of permanent damage to the swallowing mechanism. Evaluation of patients who complain of persistence of dysphagia a year or more following treatment should include MBS, because of the increased risk of aspiration.

To assess the risk of developing aspiration during chemoradiation for head and neck cancer.A retrospective review of 114 patients who underwent concurrent chemoradiation for locally advanced head and neck cancer was undertaken. Patients were determined as having aspiration if they had pneumonia on chest-X-ray (CXR) and/or had documented aspiration on the modified barium swallow (MBS) during their treatment.Fifteen patients (13%) developed aspiration during chemoradiation. Twelve patients (10%) had aspiration demonstrated on CXR alone (9 patients) or combined with MBS (3 patients). Three patients (3%) had aspiration on MBS alone. Three of the six patients with aspiration observed on MBS had normal swallowing on their pretreatment MBS. All 15 patients had severe mucositis and neutropenia at the time of the aspiration. Despite broad-spectrum antibiotics and supportive care, six patients (5%) died.Aspiration may develop during chemoradiation for head and neck cancer because of radiation-induced altered swallow.

Summary Background We would like to assess the safety and effectiveness of prophylactic percutaneous endoscopic gastrostomy (PEG) tube feedings during concurrent chemoradiation for head and neck cancer. Methods Patients who underwent chemotherapy and radiation for head and neck malignancies were evaluated for their ability to resume oral feeding following treatment. All patients underwent PEG tube placement prior to the treatment because of the expected mucositis. Gastrostomy tubes were removed following treatment when the patients were able to resume oral feedings without aspiration. Results Between March 1999 and 2006, 104 patients with locally advanced head and neck cancer underwent concurrent chemotherapy and radiation. One patient declined placement of gastrostomy tube. Ninety patients (86%) developed grade 3–4 mucositis during chemoradiation. Five patients died during treatment from aspiration pneumonia and sepsis. One hundred two patients lost weight during treatment. The mean and median weight loss during concurrent therapy was, respectively, 8.5 and 8 kg (1–23.5 kg). Following treatment, tube feedings were continued 1–41 months (mean: 8 months; median: 5 months) because of continued weight loss, chronic dysphagia, or aspiration. At a median follow-up of 19 months (1–62 months), no patient developed serious complications from tube feedings. Conclusion Dysphagia resulting from the severe mucositis produced severe weight loss, despite tube feedings. Gastrostomy tube feedings are safe. Gastrostomy tubes should be placed prophylactically for patients undergoing chemoradiation for head and neck cancer.

The aim of this study was to evaluate the aspiration rate following nonsurgical therapy, i.e. chemoradiation or radiation alone for laryngeal cancer. Modified barium swallow was performed in 43 patients who complained of dysphagia following chemoradiation (n = 22) or radiation alone (n = 21) for laryngeal cancer. Patients were selected if they were cancer free at the time of the swallowing study. Dysphagia severity was graded on a scale of 1–7. Patients were grouped according to the dysphagia severity: no aspiration (grade 1–4), and severe (grade 5–7). Mean and median dysphagia grades were 4.4/5 and 3.5/3 for chemoradiation and radiation, respectively. Aspiration occurred in 12 patients (54%) of the chemoradiation group and 7 (33%) of the radiation alone group (p = 0.13). There was a higher proportion of patients with large tumor (T3–T4) in the chemoradiation group (64%) compared to the radiation group (5%) (p = 0.0001). Aspiration is a significant source of morbidity in patients treated for laryngeal cancer with chemoradiation or radiation alone. Aspiration occurred in both groups. Although the observed difference in aspiration rates did not achieve statistical significance, the higher aspiration rate in the chemoradiation group may be due to a higher proportion of large tumors, to the additional toxic effect of chemotherapy, or to the small number of patients in both groups. Diagnostic studies such as modified barium swallow should be part of future laryngeal cancer prospective studies to assess the prevalence of aspiration as it may be silent.

This study examines the efficacy of swallowing therapy in cancer-free patients who developed aspiration following treatment for locally advanced head and neck cancer. The records of 41 patients who underwent swallowing therapy for aspiration were reviewed. All patients were cancer free at a median follow-up of 25 months (6-150 months). Their treatment were respectively chemoradiation (24), and postoperative radiation (17). All patients had two or more modified barium swallow (MBS). Dysphagia severity was graded from 1 to 7. Dysphagia grade was compared before and following swallowing therapy. Before swallowing therapy, there were 16 grade 5 (trace aspiration), and 25 grade 6-7 (severe aspiration). In the chemoradiation group, there were nine grade 5, five grade 6, and 10 grade 7. Corresponding numbers for the postoperative group were: seven grade 5, seven grade 6, and three grade 7. Following swallowing therapy, there were six grade 3, seven grade 4, 10 grade 5, six grade 6, and 12 grade 7. In the chemoradiation group, there were four grade 3, three grade 4, four grade 5, five grade 6, and eight grade 7. In the postoperative group, there were two grade 3, four grade 4, six grade 5, one grade 6, and four grade 7. Overall, 13 patients (32%) had improvement of their dysphagia severity. Seven of them were in the chemoradiation group (29%), and six (35%) were in the postoperative group. Among 25 patients who presented with grade 6-7 aspiration, only nine (36%) improved to grade 5 or less. Four of them (27%) were in the chemoradiation group, and five (29%) were in the postoperative group. Swallowing therapy is effective to improve dysphagia severity and reduce the need for tube feedings. However, a significant number of patients still suffered from chronic severe aspiration. New strategies must be devised to improve their outcome.

Objective The purpose of the study is to evaluate dysphagia severity following chemoradiation and postoperative radiation for head and neck cancer, and particularly the aspiration risk because of its potential life-threatening consequence. Materials and methods We reviewed retrospectively the modified barium swallow (MBS) results in 110 patients who complained of dysphagia following chemoradiation (57) and postoperative radiation (53) of their head and neck cancer. Patients were selected if they were cancer free at the time of the swallowing study. Dysphagia severity was graded on a scale of 1–7. Patients were grouped according to the dysphagia severity: mild (grades 2–3), moderate (grades 4–5), and severe (grades 6–7). Results Mean and median dysphagia grades were 4.84/5 and 4.12/4 for chemoradiation and postoperative radiation respectively. The mean difference between the two groups is statistically significant ( p = 0.02). Mild dysphagia occurred in 13 patients (22%) of the chemoradiation group and 17 (32%) of the postoperative group. Corresponding number for the moderate group was 25 (43%) and 25 (48%), respectively. Severe dysphagia was significant in the chemoradiation group (34%) compared to the postoperative group (19%). However, the difference was not statistically significant ( p = 0.29). There was a higher proportion of patients with large tumor (T3–T4) in the chemoradiation group who developed severe dysphagia. Conclusion Dysphagia remained a significant morbidity of chemoradiation and postoperative radiation for head and neck cancer. Dysphagia may be more severe in the chemoradiation group because of the higher proportion of patients with large tumor, the high radiation dose, and a high number of oropharyngeal tumors. Aspiration occurred in both groups. Diagnostic studies such as MBS should be part of future head and neck cancer prospective studies to assess the prevalence of aspiration, as it may be silent.

We would like to assess the evolution of chronic dysphagia (1 year or more) following treatment for head and neck cancer. Modified barium swallow (MBS) examinations were performed in cancer-free patients who complained of dysphagia following treatment for head and neck cancer. The severity of the dysphagia was graded on a scale of 1-7. Each patient had at least 2 MBS. Severity of dysphagia was compared between the first and last MBS study to determine whether the swallowing dysfunction had returned to normal. Patients with complaint of dysphagia and normal MBS also underwent a regular barium swallow to assess the structural integrity of the pharynx and esophagus. Between 1996 and 2001, 25 patients with dysphagia underwent repeat MBS following treatment. Swallowing dysfunction did not return to normal in the majority of the patients. At a median time of 26 months following treatment (range 15-82 months), only two patient (8%) had normalization of the swallowing. The severity of dysphagia decreased in eight patients (32%), remained unchanged in 12 patients (48%), and worsened in five patients (20%). Eight patients (32%) still had aspiration problems at 12-83 months following treatment. Six patients (24%) required dilation because of pharyngeal stenosis. Three patients who required dilation had improvement of the dysphagia severity. Chronic dysphagia is a relentless process possibly due to excessive scarring. Patients with chronic dysphagia are at risk of malnutrition, and aspiration. Management of chronic dysphagia requires a team approach with nutritional support, psychological counseling, dilation, and tube feedings when indicated.

The purpose of this investigation was to evaluate chronic dysphagia (lasting 3 or more months) following treatment for head and neck cancer. Since dysphagia is a common sequela post therapy in cancer survivors, it may be helpful for the clinician to be aware of the persistence of dysphagia as well as its usual severity. Modified Barium Swallow (MBS) examinations were performed in cancer-free patients who complained of dysphagia following treatment for head and neck cancer. The severity of the dysphagia was graded on a scale of 1 to 7. Each patient had sequential MBS and underwent swallowing therapy in between. The severity of dysphagia was compared between the first and last MBS study to determine whether the swallowing function had returned to normal.Between 1996 and 2004, 12 patients with dysphagia underwent repeated MBS following treatment. Swallowing function did not return to normal in all patients. At a median time of 29 months following treatment (range 8 to 94 months), the severity of dysphagia decreased in 8 patients (67%), remained unchanged in 3 patients (25%) and worsened in 1 patient (8%). Chronic dysphagia following treatment is unlikely to resolve with time despite rehabilitation therapy. Excessive scarring following treatment may be responsible for the persistence and severity of dysphagia. Physicians should be aware of the long-term effects of dysphagia on patient nutrition and psychological well-being.

Background & Aims: Etodolac is a generic nonsteroidal anti-inflammatory drug (NSAID). Previous in vitro studies have shown that etodolac is a selective inhibitor of cyclooxygenase (COX)-2 with selectivity in between that of other COX-2 inhibitors such as celecoxib and rofecoxib. However, there are no outcomes data assessing clinically significant upper gastrointestinal (CSUGI) events with etodolac. Methods: A historical cohort study was performed at the Dallas Veterans Affairs Medical Center in which 16,286 veteran patients (5596 patient-years) received etodolac or naproxen during a 3-year period without concurrent use of other ulcerogenic drugs other than low-dose aspirin. The primary outcome was the CSUGI event rate of the etodolac and naproxen groups without concomitant low-dose aspirin. Results: The incidence of CSUGI events was .78% and .24% for naproxen and etodolac, respectively. In the NSAID-naive subset, the incidence of CSUGI events was .99% and .24% for naproxen and etodolac, respectively. Compared with naproxen, etodolac was associated with a reduction in upper gastrointestinal events, corresponding to an odds ratio of .39 (95% confidence interval, .20–.76; P = .006). Concomitantly used low-dose aspirin increased event rates with naproxen 2-fold and etodolac 9-fold. Hence, there was no significant difference in gastrointestinal event rates between etodolac and naproxen when low-dose aspirin was taken concomitantly. Conclusions: Etodolac is a generic COX-2 selective inhibitor that reduces CSUGI events compared with the nonselective NSAID naproxen. However, concomitant use of low-dose aspirin negates the gastrointestinal safety advantages of etodolac.

Background To assess the prevalence, severity and morbidity of dysphagia following concurrent chemoradiation for head and neck cancer. Patients and methods Patients who underwent chemotherapy and radiation for head and neck malignancies were evaluated for their ability to resume oral feeding following treatment. Modified barium swallow (MBS) studies were performed if the patients complained of dysphagia or if there was clinical suspicion of aspiration. The severity of dysphagia was graded on a scale of 1–7. If significant abnormalities were found, swallowing studies were repeated until resolution of dysphagia. Results Between March 1999 and May 2002, 55 patients with locally advanced head and neck cancer underwent concurrent chemotherapy and radiation. Aspiration pneumonia was observed in eight patients, three during treatment and five following treatment. Five patients died from pneumonia. Two patients developed respiratory failure requiring intubation as a complication of pneumonia. At a median follow-up of 17 months (range 6–48 months), 25 patients (45%) developed severe dysphagia requiring prolonged tube feedings for more than 3 months (22 patients) or repeated dilatations (three patients). Among 33 patients who underwent MBS following treatment, 12 patients (36%) had silent aspiration (grade 6–7 dysphagia). Thirteen patients (39%) developed grade 4–5 dysphagia which required prolonged enteral nutritional support to supplement their oral intake. Most patients had severe weight loss (0–21 kg) during treatment, likely due in part to mucositis in the orodigestive tube. Conclusions Dysphagia is a common, debilitating and potentially life-threatening sequela of concurrent chemoradiation for head and neck malignancy. Physicians should be aware that the clinical manifestations of aspiration may be unreliable and insidious, because of the depressed cough reflex. Modified and traditional barium swallows should be performed following treatment to assess the safety of oral feeding and the structural integrity of the pharynx and esophagus. Patients with severe dysphagia may benefit from rehabilitation. Tube feeding should be continued for those with aspiration.

Purpose To evaluate the quality of life (QOL) associated with dysphagia after head-and-neck cancer treatment. Methods and materials Of a total population of 104, a retrospective analysis of 73 patients who complained of dysphagia after primary radiotherapy (RT), chemoradiotherapy, and postoperative RT for head-and-neck malignancies were evaluated. All patients underwent a modified barium swallow examination to assess the severity of dysphagia, graded on a scale of 1–7. QOL was evaluated by the University of Washington (UW) and Hospital Anxiety and Depression questionnaires. The QOL scores obtained were compared with those from the 31 patients who were free of dysphagia after treatment. The QOL scores were also graded according to the dysphagia severity. Results The UW and Hospital Anxiety and Depression scores were reduced and elevated, respectively, in the dysphagia group compared with the no dysphagia group ( p = 0.0005). The UW scores were also substantially lower among patients with moderate-to-severe (Grade 4–7) compared with no or mild (Grade 2–3) dysphagia ( p = 0.0005). The corresponding Hospital Anxiety ( p = 0.005) and Depression ( p = 0.0001) scores were also greater for the moderate-to-severe group. The UW QOL subscale scores showed a statistically significant decrease for swallowing ( p = 0.00005), speech ( p = 0.0005), recreation/entertainment ( p = 0.0005), disfigurement ( p = 0.0006), activity ( p = 0.005), eating ( p = 0.002), shoulder disability ( p = 0.006), and pain ( p = 0.004). Conclusion Dysphagia is a significant morbidity of head-and-neck cancer treatment, and the severity of dysphagia correlated with a compromised QOL, anxiety, and depression. Patients with moderate-to-severe dysphagia require a team approach involving nutritional support, physical therapy, speech rehabilitation, pain management, and psychological counseling.

The case of a parapharyngeal adult extracardiac rhabdomyoma (ER) in a 69-year-old man is presented focusing on computed tomographic diagnosis, surgical approach, and pathologic diagnosis. Although a rare neoplasm, adult ER has a propensity for occurring in the head and neck. Systematic computed tomography evaluation with contrast serves to define the extent of the lesion and assist in the differential diagnosis of parapharyngeal masses. In this case, a transcervical extra-pharyngeal approach for excision was utilized with minimal associated morbidity and a rapid return of normal function. Careful pathologic diagnosis is required to distinguish ER from other neoplasms, especially granular cell myoblastoma.

To determine whether routine early endoscopy is beneficial to patients with upper-gastrointestinal-tract bleeding that ceases during hospitalization, we randomly assigned 206 patients to routine endoscopy (100 patients) or no routine endoscopy (106). Patients in the latter group underwent endoscopy only if recurrent bleeding occurred during hospitalization or if x-ray films disclosed gastric ulcer or suggested neoplasia. All patients were initially treated with an empiric antacid regimen. When the two groups were compared (experimental versus control), there were no significant differences in overall hospital deaths (11 versus eight), recurrence of bleeding (33 versus 32), number of transfusions required to treat recurrent bleeding (mean +/- S.E.M., 7.4 +/- 1.2 versus 6.3 +/- 0.7 units), deaths after recurrent bleeding (eight versus five), or duration of hospital stay. During the 12 months after discharge, there were also no significant differences in frequency of readmission to the hospital, incidence of further gastrointestinal bleeding, number of hemorrhage-related deaths, or frequency of gastrointestinal surgery. We conclude that endoscopy should not be a routine procedure in patients with upper-gastrointestinal-tract bleeding that ceases during treatment.

Examples of diverticulitis of the colon associated with fistulae to the left hip, inferior mesenteric vein, and portal vein resulting in the demonstration of intrahepatic abscesses, the vermiform appendix, and the skin are presented with a review of the literature. A case of a fistula to the epidural space is included.

Biliary tract disease is a major cause of acute pancreatitis. However, with traditionally employed Telepaque, radiographic visualization of the gallbladder during acute pancreatitis remains unreliable, even in patients with apparently normal gallbladders. Therefore, oral cholecystography has customarily been deferred for such patients for several weeks. Recently, successful oral cholecystography has been described during the acute episode of pancreatitis, using Bilopaque, a more water-soluble cholecystopaque. The relative intestinal absorption of Telepaque and Bilopaque and the ability of these agents to produce diagnostic oral cholecystograms of fasting patients with acute alcoholic pancreatitis were compared. Forty-five hospitalized patients were studied within 96 hours of admission. Mean peak plasma contrast concentrations for Bilopaque exceeded those for Telepaque. Thirty-one percent of the Bilopaque group achieved diagnostic single-dose oral cholecystograms, compared with to 11% of the Telepaque group (P less than 0.05).

Evaluation of the efficacy and adequacy for double-contrast barium enema (DCBE) of a recently described oral lavage solution incorporating anonabsorbable solute (Golytely®) and its comparison with a traditional method of colon cleansing, is reported. Preparation with Golytely® achieved results equal to those of the traditional, more rigorous method with a saving of time and reduction in patient annoyance and without significant alterations in patients' weights and body fluid status.

The purpose of these studies was to develop a radiologic method for assessing gastric emptying of an indigestible solid in humans and to apply this technique to the evaluation of patients with diabetes mellitus. Thirty healthy subjects ingested 10 solid radiopaque markers (small pieces of nasogastric tubing) together with a standard meal (donuts and 7-Up). Radiographs of the upper abdomen were obtained hourly for up to 6 h until all markers had emptied from the stomach. Although most of the liquid component of the meal, labeled with 111In, emptied during the first hour (as assessed simultaneously by radionuclide scintigraphy), few radiopaque markers emptied from the stomach during the first 2 h after the meal. Most markers emptied during the fourth postprandial hour, and all 10 markers had emptied by 6 h in 45 of 46 experiments. In contrast, not all of the solid radiopaque markers emptied from the stomach by 6 h in 16 of 26 experiments in patients with diabetes mellitus (p less than 0.001 vs. healthy controls). In some experiments, 99mTc-labeled scrambled eggs were added to the meal so that emptying of this digestible solid, assessed by scintigraphy, could be compared with emptying of liquids and solid radiopaque markers. In healthy subjects, the digestible solid emptied more slowly than the liquid (t 1/2 = 154 +/- 11 min vs. 30 +/- 3 min, p less than 0.001), but emptying of digestible solid was significantly faster than the emptying of the indigestible solid radiopaque markers. In diabetics, emptying rates for the digestible solid and liquid were close to normal (t 1/2 = 178 +/- 5 min and 40 +/- 3 min, respectively), whereas indigestible solid markers were retained in the stomach 6 h after the meal in 50% of the patients. Radiopaque markers proved to be a simple method for measuring gastric emptying of indigestible solids in humans. Using this technique, patients with insulin-dependent diabetes mellitus had a high incidence of abnormally slow gastric emptying of indigestible solids; the method may be a more sensitive indicator of gastric motor dysfunction than radionuclide scintigraphy.

Using radiopaque markers, we evaluated gastric emptying in 10 male patients with end-stage renal disease on continuous ambulatory peritoneal dialysis and in 15 normal men. Dialysis patients were studied twice, once without peritoneal dialysate in the abdomen (drained) and once with 2 L of dialysate in the abdomen (full). Each normal man and 9 of 10 dialysis patients, when drained, emptied all 10 markers by 6 h after a test meal. In contrast, 5 of the 10 dialysis patients, when full, had delayed emptying of radiopaque markers. Thus, continuous ambulatory dialysis may delay gastric emptying of indigestible solids.

A case of Zollinger-Ellison syndrome in an elderly man who presented with dysphagia and subsequently developed esophageal stricture is described. This is an infrequent concomitant of the Zollinger-Ellison syndrome, especially as a presenting complaint. The literature on esophageal involvement in the Zollinger-Ellison syndrome is briefly reviewed.

The role of gastroesophageal reflux (GER) and reflux esophagitis in the pathogenesis of gastrointestinal hemorrhage was assessed in 13 male patients with chronic paralysis or neurologic impairment. Nine of the 13 patients initially presented for barium meal examination to evaluate anemia, hematemesis, heme-positive stools, or melena. Six of the 9 had radiographic evidence, confirmed by upper gastrointestinal (GI) endoscopy, of esophagitis with or without stricture without other upper GI tract lesions. Notably absent were antecedent symptoms of GER such as heartburn or dysphagia. Careful examination of the esophagus, although difficult, must be an integral part of the evaluation for anemia and/or gastrointestinal blood loss in paralyzed patients.

A simple, noninvasive radiographic method was used to investigate the influence of food and of marker length on gastric emptying of indigestible solids. Ten healthy human subjects who had fasted for 12 h exhibited more rapid emptying when solid radiopaque markers were ingested with water than they did when markers were ingested with a 400-kcal solid and liquid meal. Mean (+/- SE) emptying of markers that were 10 mm in length averaged 55% +/- 15%, 97% +/- 3%, and 100% 1, 2, and 4 h after ingestion of the markers with water, compared with 4% +/- 2%, 32% +/- 11%, and 64% +/- 12% emptying 1, 2, and 4 h after ingestion of markers with the meal (p less than 0.05). Ingestion of a second and third test meal significantly prolonged gastric emptying of indigestible markers (p less than 0.05). No significant difference in emptying of the 10- and 2-mm markers from the stomach was detected. These experiments indicate that gastric emptying of indigestible solids in humans is strongly influenced by food intake, but not by the particle lengths studied.

We investigated the occurrence of new constipation, diarrhea, nausea, vomiting, visible blood in stool, abdominal pain, black stools, belching, and flatus in 324 outpatients following upper or lower gastrointestinal tract barium procedures. We also evaluated the roles of age, sex, patient mobility, and types of barium enema (single- or double-contrast). At least one new symptom was reported after 51% of all examinations. Constipation was the most frequently reported single symptom after barium meal or small bowel examinations. Fifty percent of all constipation occurred following upper gastrointestinal examinations. Abdominal pain was common in patients of the seventh decade, especially following barium enema. Nausea typically followed barium swallow or upper gastrointestinal series. Belching and passage of flatus were the most frequently reported symptoms after barium enema, both single- and double-contrast. No significant relationship between the frequency of symptoms and patient age, sex, or the type of barium enema was established.

The skin and the upper gastrointestinal tract are frequent sites of malignant tumors. However, cutaneous metastasis from primary gastrointestinal tract lesions remains a relative rarity. Similarly rare is spread of primary skin cancer (nonmelanomatous) to upper gastrointestinal tract. This paper presents an unusual example of primary esophageal carcinoma with synchronous skin and bone metastases and a case of squamous cell carcinoma of the stomach, possibly due to spread from a remote squamous cell carcinoma of the skin.

Two cases of primary carcinoma of the lung with clinically demonstrated colon metastases are presented. Such metastases may present with intermittent or continuous colonic obstruction, lower gastrointestinal tract bleeding, or anemia. The metastases may be synchronous or metachronous with respect to diagnosis of the lung lesion. Potential problems in management are discussed and the literature, relating to colonic metastasis from bronchogenic carcinoma, is reviewed.

Epithelial polyps of the stomach can be divided into 2 types: adenomatous and hyperplastic or regenerative. Imprecisions in terminology and histologic classification of the reported cases make it difficult to establish the true incidence of each type. The size of gastric polyps has been among the criteria for predicting malignant potential of the lesion. We present 4 patients in whom large, sometimes multiple, gastric masses represented benign hyperplastic polyps. The radiographic and pathologic features of these large gastric polyps which were not associated with carcinoma are reviewed.