1. Aspiration Pneumonia
(in head and neck cancer)
Dr Ajeet Kumar Gandhi
MD (AIIMS), DNB (Gold Medalist),MNAMS
UICCF (MSKCC,USA)
Assistant professor, Radiation oncology
Dr RMLIMS, Lucknow

2. Physiology and anatomy of swallowing

3. Anatomy of swallowing

4. Aspiration
• Inhalation of oropharyngeal or
gastric content to the larynx or
lower respiratory tract
• Not uncommon in healthy
individuals (sleep)
• Protective mechanisms:
– Cough reflex (pharyngeal
sensitivity)
– Active ciliary mechanism
– Immunocompetent status
– Low burden of virulent bacteria
in normal pharyngeal
secretions

5. Aspiration
• Pneumonitis: chemical injury of
sterile contents
• Pneumonia: infectious process
from colonized content
• Altered protective mechanisms
• Altered microbial flora
• Submucosal effects, including
fibrosis, and vascular and nerve
(sensory and motor) injury

6. Long term functional deficits: head
and neck cancers

7. Swallowing dysfunction: Surgery or RT alone
• Surgery Alone
– Extent and site of the tumour
– Extent of surgical resection: Tongue, BOT, Arytenoids
– Type of reconstructive procedure (less role)
• RT alone
– Total radiation dose, fraction size, radiated volume
– Inter-fraction interval, treatment techniques, use of intensity-
modulated RT (IMRT) and tissue–dose compensation
– site and size of the primary tumour
– patient smoking during and after RT
• Surgery plus RT
– Additive effect
– Early and late components

8. Predictors of aspiration
• Primary site: Hypopharyngeal and Laryngeal primary, BOT
• Elderly age
• Baseline swallowing dysfunction
• Stage of disease: advanced T stage
• Habitual alcohol consumption, sleeping pill use, poor oral
hygiene, hypoalbuminemia, coexistence of other malignancies*
• Concurrent chemoradiotherapy
• Bilateral neck irradiation
• Weight loss
• Neck dissection after CTRT
*Kawai et al. BMC Cancer (2017) 17:59

9. Risk Factors for Aspiration
• Altered level of consciousness
* Alcohol
* Drugs
* Hepatic failure
* CVA
* Anesthesia
• Depressed cough or
gag reflex
• Esophageal disorders
* GERD
* Strictures
* Vomiting
• Disruption of glottic closure
* ET tube
* NG tube
* Endocopy/
Brochoscopy
• Neuro/muscular disorders
* Multiple sclerosis
* Parkinsons
* Myasthenia
* Seizures
* Stroke
• Scoliosis/ Kyphosis
• Dry Mouth

10. Incidence of aspiration rate
• Aspiration rate at diagnosis: 17% (10/63); 35-80% (Literature**)
• Aspiration prevalence CTRT: 33% (21/63)
Nguyen NP et al. Radiotherapy and Oncology 80 (2206) 302-306
**Stenson KM. Arch Otolaryngol Head Neck Surg 2000; 126:384-9

11. Aspiration and outcome
• The 1-year and 5-year cumulative incidence of aspiration
pneumonia was 15.8% and 23.8%
• The 30-day mortality rate after hospitalization for aspiration
pneumonia was 32.5%.
• Aspiration pneumonia was associated with a 42% increased risk of
death (hazard ratio, 1.42; P<.001) after controlling for confounders.
Xu B et al. SEER database Cancer 2015

12. Impact of aspiration on outcome
• Silent aspirators: Prolonged feeding tube dependence,
weight loss, reduced intake
• Impaired quality of life and failure of organ
preservation
• Cause of mortality (10-20%): Sepsis and respiratory
failure

13. Aspiration pneumonia: Clinical Symptoms
Symptoms can vary greatly
from asymptomatic to:
• Clearing throat
• Coughing
• Gurgling
• Wheezing
• Abrupt onset of dyspnea
• Chest pain
• Tachycardia
• Tachypnea
• Hypotension
•Fever
• Hypoxemia
• Diffuse crackles or decreased
breath sounds

14. Aspiration pneumonia: Diagnosis
• Symptoms: Wet cough, sputum, and fever.
• Objective findings:
– Coarse crackles in the chest, elevated inflammatory
markers (e.g. white blood cell count or C-reactive
protein), or image findings (e.g. infiltration on a chest X-
ray or consolidation in chest computed tomography)
• Aspiration was suspected clinically (choking or delayed
swallowing) or by endoscopic or video-fluorographic
examinations.
• No evidence of atypical pneumonia: Legionella and
Mycoplasma

15. Swallowing studies
• Video-fluoroscopic/Modified barium swallow
– Analysis of phases of swallowing
– Amount of aspiration and penetration, Laryngeal sensation,
residue/pooling after swallow
– Penetration: Portion of bolus entering laryngeal vestibule to
the level of vocal folds
– Oropharyngeal swallowing efficiency
• Flexible endoscopic evaluation of swallowing safety
(FESS)
• Esophagogram/Manometry/Biplane Fluoroscopy
*Eisbruch A et al. IJROBP 2002

18. Triggers for dysphagia evaluation

19. PAS: Penetration Aspiration Scale

20. Swallowing scales
Grade 1-5: Swallowing therapy
Grade 6-7: Tube feeding

21. Handling aspiration pneumonia
Preventive strategies
• Pre-treatment counselling
– Dietary and postural strategies
– Preventive exercises: Early vs. Late
– Dental prophylaxis
• Encourage enteral feeding as long as appropriate even with NJ
tubes
• Prophylactic PEG vs NJ tube
• Treatment modifications
– Surgical planning
– Radiation beam modulation:
• Reduce unnecessary doses to DARS : DARS sparing IMRT
• Minimize Xerostomia

22. Swallowing exercises

30. Aspiration Pneumonia:
Therapeutic
• Acute phase treatment
• Compensatory meal alterations
– Posture: head back, chin down, head tilt etc.
– Bolus volume and consistency
• Therapy exercises directed to dysfunction of patients
• Swallowing manoeuvres
• Pharyngeal/cervical oesophagus dilatation
• Prosthetics
• Neuromuscular electrical stimulation (NES) has been used as
an adjunct to swallowing therapy

32. Swallow Challenge
• Have the patient brush their
teeth and rinse their mouth
• Have suction equipment available
• Instruct the patient to drink a full
glass of water WITHOUT stopping

33. Take home message
• Aspiration pneumonia is underreported in head and neck
cancers and oncology as such!!
• Patient, tumor characteristics and treatment parameters help
predict patients at high risk of aspiration
• Objective tests: MBS and FESS are useful investigations and
triggers may help in optimizing it`s use
• Swallowing maneuvers and exercises are both preventive and
therapeutic: Need to adapt to patients needs
• DARS optimized IMRT is promising: Needs further follow up

34. Thank you
Patient and care giver awareness is one of the
important keys!!