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Radiation Therapy to the Head and Neck: What You Need to Know About Swallowing

This information describes swallowing problems that can be caused by radiation therapy to the head and neck and how to prevent them.

Normal Swallowing

Many muscles and nerves work together to help you swallow (see figure below). When you eat and drink, food and liquids mix with your saliva. Your saliva makes the food soft and moist and chewing breaks the food down further. As you chew, the food and saliva form a ball called a bolus.
The bolus gets pushed to the back of your mouth with your tongue. Then, a reflex takes over and the back of your tongue squeezes back and your larynx (voice box) closes. This sends the bolus down your esophagus (food pipe) and into your stomach.
 

If your tongue is weak or if your larynx doesn’t close all the way, food or liquid will enter your trachea (wind pipe) or lungs (aspiration), which can cause pneumonia.

Effects of Cancer and Treatment on Swallowing

Depending on the size and location of your tumor, the structures that support normal swallowing may not work well. The side effects of treatment can also affect these structures.

Radiation therapy can cause:
 
  • Sores (mucositis) in the mouth and throat
  • Dry mouth
  • Thicker saliva
  • Swelling
  • Pain when swallowing
These symptoms begin about the second week of treatment and may get worse during treatment. Most symptoms will start to improve about 2 weeks after treatment has ended. 
 
Radiation therapy can also cause permanent tissue scarring. The effects of this scarring depend on the area that was treated. Below are some effects of scarring:
 
  • The muscles attached to your jaw may tighten and make it difficult to open your mouth and chew your food. This is called trismus.
  • Your salivary glands may not produce enough saliva. This can make swallowing difficult because your mouth is too dry.
  • The muscles in your tongue and the back of your throat may not be able to move as well. This can make it harder to push the bolus down your throat and open up your esophagus.
  • Your larynx may not lift enough to open your esophagus.
  • Your esophagus may narrow, which can cause food to get stuck in the back of your throat.
Not everyone will have all of these problems. Your treatment will be planned to decrease your chances of developing them. Your healthcare team will also teach you things that you can do to help decrease these problems.
 
Other treatments can also affect swallowing. Surgery can affect the structures in your mouth and throat, which could make swallowing more difficult. Some chemotherapy medications can cause sores in the mouth and throat. This can make swallowing painful.
 

Swallowing Problems

Difficulty swallowing is called dysphagia (dis-fey-juh). Your healthcare team will work with you to help you manage this problem. This team includes your doctors, nurses, a swallowing specialist, and a dietitian.

Painful swallowing

If you have painful swallowing during your treatment, you will be given pain medication to manage it. Take the medication as instructed by your doctor. If it does not help, tell your doctor or nurse. Try to use your swallowing muscles as much as you can. This can help prevent long-term problems with swallowing.
 
Tell your doctor or nurse and swallowing specialist if you have trouble opening your mouth during or after your treatment. They can teach you exercises to help with this.
 

Aspiration

When you are having trouble swallowing, food or liquid can pool in the back of your throat. It can then pass into your airway instead of your esophagus. This is called aspiration. Signs of aspiration include coughing during or after swallowing. Do not try to swallow if you have any of these signs. Call your swallowing specialist immediately. He or she will review the swallowing exercises with you and help figure out why you are having trouble. He or she will also tell you which foods and liquids are safe for you.
 
Aspiration can lead to pneumonia. Call your doctor or nurse immediately if you have any of the following symptoms:
 
  • Shortness of breath
  • Wheezing
  • Painful breathing
  • A productive cough (a cough that produces phlegm or mucus)
  • A temperature of 100.4° F (38° C) or higher
  • Managing Swallowing Problems

Swallowing therapy

You will see a swallowing specialist before and during your treatment. He or she will:
 
  • Explain how treatment can affect your swallowing
  • Teach you exercises to stretch and strengthen the muscles involved in swallowing

Exercises

Do these exercises as soon as you begin treatment. They may help decrease long-term swallowing problems.
 

Swallowing Exercises

  • Tongue hold exercise (Masako exercise)
  1.  Put the tip of your tongue in between your teeth. If you cannot do this, put it against the front of the roof of your mouth. Stick your tongue out as far as you can.
  2. Hold this position with your tongue and swallow. Try not
    to let your tongue tip slip back. Then, relax.
  • Effortful swallow exercise
  1. Swallow normally, but squeeze hard with your throat and tongue muscles.
  2. Then, relax.
  • Mendelsohn swallow maneuver exercise
  1.  Swallow normally; feel your voice box go up and down.
  2. Swallow again. When you feel your voice box go up, squeeze hard and hold it up for 2 seconds. Then, relax.

 

  • Supraglottic swallow exercise
  1. Take in a regular breath and hold it tightly.
  2. While holding your breath, swallow; immediately, cough out the breath. Do not inhale before you cough.
  • Super supraglottic swallow exercise
  1. Take in a regular breath and hold it tightly, bearing down as if you are having a bowel movement.
  2. While holding your breath, swallow; immediately, cough out the breath. Do not inhale before you cough.
  • Shaker exercise
  1. Lay flat on the floor or a bed.
  2. Lift your head as if you are looking at your toes.
  3. Hold your head in this position for 10 seconds. Increase the amount of time until you can hold it for 1 minute. Then, relax.
  4. Lift your head and lay it back down (do not hold it up.) Repeat this movement 30 times.

Do these exercises _____ times a day.

Tongue range of motion (ROM) exercises

  • Tongue protrusion exercise
  1. Stick out your tongue as far as you can until you feel a good stretch.
  2. Hold it there for ________________________. Then, relax.
  • Tongue retraction exercise
  1. Pull your tongue far back in your mouth, as if you are gargling or yawning.
  2. Hold it there for ________________________. Then, relax.
  • Tongue lateralization exercise
  1. Move your tongue as far to the left as you can so you feel a good stretch in your tongue.
  2. Hold it there for ________________________. Then, relax.
  3. Move your tongue to the right as far as you can until you feel a good stretch in your tongue. 
  4. Hold it there for ________________________. Then, relax.
  • Tongue tip exercise
  1. Place the tip of your tongue behind your top teeth or on your gums.
  2. While holding this position, open your mouth as wide as possible for ______________. Then, relax.
  • Back tongue exercise
  1. Say “kuh” with a strong “k” sound; move the back of your tongue as if you were going to say the “k” sound.
  2. Hold this position for__________________. Then, relax.

Do these exercises _____ times a day.

Tongue Strengthening Exercises

You will need a tongue depressor or spoon to do these exercises.

  • Tongue tip strengthening exercise
  1.  Stick out your tongue as far as you can and push it firmly against a tongue depressor or spoon.
  2. Hold this position for__________________. Then, relax.
  • Sides of tongue strengthening exercise
  1. Place the tongue depressor or spoon against the left side of your tongue; push your tongue firmly against the tongue depressor or spoon.
  2. Hold this position for__________________. Then, relax.
  3. Place the tongue depressor or spoon against the right side of your tongue; push your tongue firmly against the tongue depressor or spoon.
  4. Hold this position for__________________. Then, relax.
  • Top of the tongue strengthening exercise
  1. Push down on your tongue with a tongue depressor or spoon. As you are doing this, push up with your tongue.
  2. Hold this position for__________________. Then, relax.

Do these exercises _____ times a day.

Jaw Exercises

Active range of motion and stretching exercises

Sit or stand. Hold your head still while doing these exercises.

 

  1. Open your mouth as wide as you can, until you can feel a good stretch but no pain. Hold this stretch for ______ seconds.

  1. Move your jaw to the left. Hold this stretch for 3 seconds.

  1. Move your jaw to the right. Hold this stretch for 3 seconds.

  1. Move your jaw in a circle. Make 5 circles in each direction.
Do these exercises _____ times a day.
 
Passive stretching exercise
 
  1. Place 1 thumb on your top teeth in the middle of your jaw.
  2. Place the pointer (index) finger of your other hand on your bottom teeth in the middle of your jaw.
  3. Open your mouth with your fingers, but do not bite down or resist. Let your fingers do all of the work.
  4. Hold this stretch for _____ seconds.

Your swallowing specialist may teach you other exercises or strategies to help you continue swallowing throughout your treatment. These will be based on your swallowing evaluations.

Dietary Guidelines

Eating well is an important part of your cancer treatment. If you are having pain or difficulty swallowing, you may not be able to eat enough food. This can make you lose weight and decrease your energy. You also may not be able to drink enough liquid to stay hydrated.
 
The suggestions in this section may help make swallowing easier and more comfortable for you. Your swallowing specialist will recommend the proper food and liquid textures for you. When you try new foods and liquids, they should have the textures recommended by your swallowing specialist.
 
The following foods may irritate your throat or be hard to swallow:
 
  • Very hot or cold foods and liquids
  • Citrus fruits and juices (e.g., orange, lemon, lime, grapefruit, pineapple)
  • Tomatoes
  • Hard, dry, or coarse foods (e.g., toast, crackers, raw vegetables, potato chips, pretzels)
  • Spices (e.g., pepper, chili powder, horseradish, curry powder, hot sauce, nutmeg)
The following foods may be easier to swallow:
 
  • Soft, puréed, or moist foods such as soufflés or casseroles
  • Soft foods such as custards and puddings
  • Lukewarm or room-temperature foods
  • Liquid nutritional supplements, such as:
    • Carnation® Breakfast EssentialsTM
    • Carnation® Instant Breakfast® VHC
    • Scandishake®
    • Ensure®
    • Boost®
    • Glucerna® (if you have diabetes)
These items can be found at your local grocery store, pharmacy, or on the Internet. You can find a list of websites to purchase liquid nutritional supplements in the resource Eating Well During and After Your Cancer Treatment. Ask your nurse to give you the resource.
 
Try the following suggestions if dry mouth or thick saliva is a problem for you:
 
  • Drink 8 to 10 cups of liquids a day. Being well-hydrated will help loosen thick saliva.
  • Keep a bottle of water or other liquid with you when you are away from home. Sip from it frequently throughout the day.
  • Chew sugarless gum or suck on sugarless candy. This can cause more saliva to flow.
  • Add sauces, gravies, or other liquids to your foods.
  • Use a humidifier at home to help loosen thick saliva and secretions.
For more dietary recommendations, ask your nurse or dietitian to give you the following resources:
 
 

Feeding Tube

You may have a feeding tube placed to maintain your weight and ensure you get the nutrition you need. Even if you are using a feeding tube, eat and drink as much as you can. This will decrease the chance that you will have long-term swallowing problems.
 
If you have a feeding tube placed, you nurse will teach you how to use it and give you written instructions. He or she will tell you the kind of formula to use and how much formula to use for each feeding. 
 
At the end of your treatment, your doctor or nurse will tell you how to start taking all of your foods and liquids by mouth. The feeding tube will be removed when you no longer need it.
 
If you have any questions about your feeding tube, contact the office of the doctor who placed it.