many patients resume an oral diet, but also experience dysphagia. Swallowing efficiency is frequently affected (Starmer, Tippet, & Webster, 2008) with estimates ranging widely from 17– 70%, depending on the degree of dysphagia measured (Balfe et al., 1982; Maclean, Cotton, & Perry, 2008).
Fistulae may develop at any point after surgical excision, but most frequently occur in the first few weeks. Depending on the location, pharyngo-cutaneous, oro-cutaneous fistuale are more common in patients requiring more extensive resections, especially including pharyngectomy or when surgery is performed as a salvage procedure after failed chemoradiation (Starmer et al., 2008). Post-operative infections also increase the likelihood of developing fistulae. Patients are typically NPO while fistulae are present to reduce any flow through the fistula tract and to promote healing. Once the fistula is closed, diet progresses from liquids to denser consistencies as tolerated.
The most common symptom of a fistula is leakage of saliva or food material from an opening on the neck. This is typically noted after swallowing and may be induced by gently pressing in the surrounding area to express secretions. Fistulae often require surgical management. The role for the speech-language pathologist (SLP) is primarily supportive until healing has occurred and rehabilitation may resume.
Pharyngeal clearance problems may exist after laryngectomy and adversely affect swallowing. This can then result in backflow of material into the pharynx during the swallow. Pharyngeal residue visualized on videofluoroscopy may be a primary sign of reduced pharyngeal pressure (Pauloski et al., 2008). Sullivan and Hartig (2001) discussed that reduced pharyngeal clearance may be due to the loss of both superior and anterior motion previously accomplished by hyolaryngeal elevation and tongue base retraction that are required to assist opening of the UES. Potential causes for pharyngeal stasis include anything that might impair neuromuscular control of the pharyngeal wall or base of tongue musculature, including post- treatment edema and surgical resection impairing range and strength of palatal motion. In some cases, reverse or poorly coordinated peristalsis occurs related to surgical resections requiring a gastric transposition. This may alter propulsive properties and also be responsible for residual material in the pharynx after swallowing. These problems compound the time required to swallow a bolus and complete a meal. Pharyngeal transit times may double, making mealtime more laborious and challenging.
Problems with pharyngeal clearance are evident when patients complain of feeling persistent material in their throats, regurgitate material they were attempting to swallow, and exhibit a wet, gurgly vocal quality. Traditional swallowing exercises aimed at maximizing tongue base retraction via the Masako or tongue-hold maneuver (Fujiu & Logemann, 1996) are indicated when weakness impairs bolus propulsion, given that these have been shown to increase pharyngeal wall movement anteriorly, allowing better tongue base contact for propulsion. Alternating liquids and solids also can help to clear the pooled residual material. In addition, compensatory strategies, like a head rotation or an effortful swallow, are sometimes effective in increasing pharyngeal pressure and promoting improved bolus passage through the pharynx and the esophagus.
Stricture (narrowing) may develop in the pharynx or esophagus and impede bolus passage. This is more commonly seen in the hypopharynx related to tight surgical closures. Prior radiation therapy and post-operative infections also may increase the likelihood of scarring and stricture formation.
A stricture is suspected when patients evidence difficulties with denser consistencies of food along with a globus sensation and pooled materials in the pharynx (Samlan & Webster, 2002). In some cases, a stricture may be so narrow as to allow only the passage of thin liquids. A stricture can usually be seen on videofluoroscopic exam whereby the bolus column segmentally narrows in a consistent area on repeated swallows. Another symptom of