|Year : 2021 | Volume
| Issue : 2 | Page : 202-205
Radiation-induced dysphagia and life-threatening stridor in nasopharyngeal carcinoma
Santosh Kumar Swain, Smrutipragnya Samal
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
|Date of Submission||25-Sep-2020|
|Date of Decision||31-Oct-2020|
|Date of Acceptance||02-Nov-2020|
|Date of Web Publication||24-Aug-2021|
Prof. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
Source of Support: None, Conflict of Interest: None
Radiotherapy plays an important role in the treatment for head and neck cancer. The radiation to the head and neck region can lead to a rare long-term swallowing and breathing defect by causing stenosis at the pharynx which reduces the quality of life. We are presenting a case of radiation-induced severe pharyngeal stenosis in a 44-year-old female diagnosed with nasopharyngeal carcinoma. Nasopharyngeal carcinoma is a rare variety of the cancer where radiation therapy is the treatment of choice because of its high radiosensitivity. Radiation-induced dysphagia may occur due to structural, mechanical, and neurological deficits. Although radiotherapy has a promising outcome in nasopharyngeal carcinoma, complications around the irradiation areas are inevitable and lead to compromised quality of life. Although there is no effective treatment option available for pharyngeal stenosis, many supportive, restorative, and palliative treatments are available under different clinical situations. Here, we report a case of postradiation-induced pharyngeal stenosis presenting with dysphagia and stridor that underwent treatment with pharyngeal dilation with coblation.
Keywords: Coblation, nasopharyngeal carcinoma, pharyngeal stenosis, radiotherapy
|How to cite this article:|
Swain SK, Samal S. Radiation-induced dysphagia and life-threatening stridor in nasopharyngeal carcinoma. BLDE Univ J Health Sci 2021;6:202-5
Surgical treatment and radiation are important options in the management of the head and neck cancer. Nasopharyngeal carcinoma is an important head and neck cancer arises from the epithelial cells lining of the nasopharynx. The commonly used treatment option in nasopharyngeal carcinoma is radiotherapy. In head and neck cancer, radiotherapy may cause scarring of the upper aerodigestive tract and may lead to dysphagia and breathing difficulty. These occur due to pharyngeal or esophageal stenosis which may happen as late sequelae of treatment in head and neck cancer. These manifestations cause morbidity and life-threatening situation among the cancer-free survivors. Nasopharyngeal carcinoma is a common malignancy in some regions of the world including southern China and Hong Kong. Radiotherapy is the treatment of choice for the patient of nasopharyngeal carcinoma without distant metastatic lesions. There are various late complications of radiation therapy documented during the treatment of the nasopharyngeal carcinoma such as endocrine dysfunction and temporal lobe injury. However, the delayed effect on the pharynx and larynx has not been studied adequately; these parts are usually exposed to radiation during the treatment of the nasopharyngeal carcinoma and other head and neck cancer. Pharyngeal stenosis due to the effect of radiotherapy affects the swallowing in the initial period. However, in severe cases of the pharyngeal stenosis, it leads to dysphagia and breathing difficulty. Here, we are presenting a case of radiation-induced pharyngeal stenosis in a 44-year-old female who came with dysphagia and life-threatening stridor.
| Case Report|| |
A 44-year-old female attended the outpatient department of the otorhinolaryngology with complaints of stridor and dysphagia to solid food for 1 week. She had a history of radiation therapy 8 years back for the treatment of T2N1M0 nasopharyngeal carcinoma. She had a history of dilation of the pharynx and esophagus by gastroenterologists 5 years back for dysphagia. The endoscopic examination of the nasopharynx showed no evidence of disease. However, the endoscopic examination of the hypopharynx and larynx showed stenosis at the level of the hypopharynx with a diameter of 2–3 mm [Figure 1]. The larynx was not visible in fiberoptic nasopharyngolaryngoscopy. X-ray neck anterior–posterior and lateral view of the neck showed normal tracheal airway but stenosis at the hypopharynx and larynx. Computed tomography (CT) scan revealed the stenosis at the hypopharynx [Figure 2]. Stridor was not relieved with use of the corticosteroids, oxygen and nebulization. Hence, we performed emergency tracheostomy under local anesthesia, and the patient relieved from the stridor at the operating. The patient was planned for dilation of the stenotic segment of the pharynx by the coblation technology. The stenotic segment of the pharynx was dilated with help of the coblator by use of the laryngeal wand. The stenotic segment was widened and the Ryle's tube was inserted for purpose of food entry into the gastrointestinal tract. After 1 week, the Ryle's tube was removed and the tracheostomy decannulated. The patient was discharged uneventfully. At follow-up visit after 3 months of surgery, the patient had no complaint of the dysphagia and breathing difficulty with adequate pharyngeal airway [Figure 3].
|Figure 1: Endoscopic picture of the pharynx showing stenosis with compromised airway|
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|Figure 2: Computed tomography scan of the neck showing stenotic segment at the hypopharynx and upper esophageal area|
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|Figure 3: Postoperative follow-up after coblation-assisted dilation (yellow arrow) of the pharyngeal stenosis|
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| Discussion|| |
Nasopharyngeal carcinoma is an uncommon malignant tumor with an incidence of 20/100,000 population in a year in the high-risk region. Radiotherapy is the treatment of choice in nasopharyngeal carcinoma. Dysphagia and stridor are extremely rare and morbid complaint by the patients following radiation therapy in nasopharyngeal carcinoma or any head and neck squamous cell carcinoma. In this present case, the patient had a history of nasopharyngeal carcinoma and completed radiotherapy 8 years back and coming with complaints of dysphagia and stridor. Despite advancement in radiotherapy, there are still side effects and these are mucositis, skin changes, and dysphagia due to changes in the pharynx and esophagus. These manifestations occur during the acute clinical period, the first 6 months after radiotherapy.
The etiology for dysphagia and stridor following radiotherapy to the head and neck area is complex. The etiology may include xerostomia secondary to the radiation-induced damage of the salivary glands, esophagitis, and tracheobronchial aspiration, cause stenosis at the pharynx and esophagus. Head and neck squamous cell cancers are common variety of malignancies in the population. The treatment options in different head and neck squamous cell cancer are surgery and chemoradiation. The radiotherapy and concomitant chemotherapy are widely accepted treatment options for the preservation of the organs. There is considerable shuffling of the treatment modalities by the clinicians for treatment of the head and neck cancer. Some surgeon chooses preoperative radiotherapy, whereas some prefer postoperative radiation. In few cases, full therapeutic doses of radiation are given, although in the reduced dose. However, clinicians should learn about the benefits of combinations of these two treatment modalities. The upper aerodigestive tract of the head and neck region is highly susceptible toward radiation-induced damage and causes stenosis of the pharynx with impairment of the swallowing.
Dysphagia and stridor are rare and late complications following radiotherapy in the cancer of the head and neck region. In this case, the patient of nasopharyngeal carcinoma underwent radiotherapy and developed pharyngeal stenosis after a long time. The etiopathology of dysphagia and compromised airway after radiotherapy are complex which includes xerostomia secondary to radiation-induced injury to the salivary glands, esophagitis, trachea-esophageal aspiration, and recurrence of the lesions or second primary. The application of intensity-modulated radiation therapy greatly minimized the damage to the adjacent part and adjust the maximum to the target tissue. However, the locoregional control of the malignancy at the head and neck region needs aggressive radiation treatment for reducing the tumor cells. These enhance radiation schedules and high doses of the radiation (60–70 Gray), leading to rapid dose accumulation which is less tolerable. The muscles of the pharynx, larynx, and upper esophagus present deep to the submucosal which is overlaid by stratified squamous epithelium and the lamina propria of the mucosal layer. The seromucinous glands and lymphoid aggregates are situated throughout the mucosal layer and so radiation injury to these areas leads to noticeable soft-tissue deformities like stenosis or stricture by altering the contour of the pharynx, larynx, and esophagus.
The diagnosis of the pharyngeal stenosis should be properly evaluated with help of the fiberoptic nasopharyngolaryngoscopy and CT scan of the neck. CT scan will assess the exact site and extent of the stenosis in the pharynx and larynx. The pharyngeal stenosis or stricture can be congenital or acquired, but their treatment is similar. The common treatment option for pharyngeal and esophageal strictures is dilation. The initial step in the management of the pharyngeal stenosis after treatment of malignancy is performing endoscopy and biopsy to rule out any recurrence. In this case, the malignancy was initially diagnosed with nasopharyngeal carcinoma and completely cured by radiotherapy. There was no evidence of recurrence of the malignancy at the pharynx except the stricture or stenosis. The stenosed pharynx or esophagus can be dilated to accommodate to a 48 Fr dilator. In our patient, the dilation was performed by gastroenterologists previously but not successful. The strictures or stenosis commonly develops over period of months and does not show an urgent problem. The safe dilation of the stenotic part requires several endoscopies. The pharyngeal stenosis causing dysphagia requires dilatation or Ryle's tube insertion depending on the severity of the obstruction. The dilatations often provide temporary relief toward dysphagia. There is again a chance of the re-stenosis. Coblation is an important technology useful for dilatation of the pharyngeal stenosis. Coblation technique utilizes bipolar radiofrequency energy which generates a field of ionized sodium molecules which ablates and coagulates soft tissues without any thermal damage. Conductive saline solution is kept in the gap between soft tissue and device tip and converts saline into ionized plasma layer. Once the plasma layer touches the tissue, there are enough breaks the molecular bonds, causing molecular dissociation. This effect of the tissue dissociation occurs at the temperature of about 4°C–70°C, so reduce the thermal damage to the tissue. We used coblation technology for the dilation of the stenotic segment of the pharynx. This case report will surely give the awareness regarding this dreaded complication of radiation-induced dysphagia and stridor.
| Conclusion|| |
Radiotherapy is the treatment of choice in nasopharyngeal carcinoma without distant metastasis. Persistent biological alteration after the radiation therapy to the head and neck region can go undetected for years but eventually lead to functional deficits by causing pharyngeal stenosis. In the early stage of the complications, patients may be asymptomatic, but once the stenosis in the pharynx progress leads to dysphagia and stridor. It reduces the quality of life and enhances the risk of mortality even among cancer-free survivor. Although there is no absolutely effective treatment available, dilatation of the pharynx with help of the coblation is an ideal treatment. Clinicians should be aware about the complications associated with pharyngeal stenosis and its severity along with its treatment options.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Swain SK, Samal S, Mohanty JN, Choudhury J. Nasopharyngeal carcinoma among the pediatric patients in a non-endemic region: Our experience at a tertiary care teaching hospital in eastern India. Egypt Pediatric Assoc Gazette 2020;68:23.
Swain SK, Samal S, Anand N, Mohanty JN. Pediatric nasopharyngeal carcinoma. Int J Health Allied Sci 2019;9:1-6.
Lam KS, Tse VK, Wang C, Yeung RT, Ho JH. Effects of cranial irradiation on hypothalamic-pituitary function- a 5-year longitudinal study in patients with nasopharyngeal carcinoma. Q J Med 1991;78:165-76.
Sun LM, Li CI, Huang EY, Vaughan TL. Survival difference by race in nasopharyngeal carcinoma. Am J Epidemiol 2007;165:271-8.
Strauss M. Long term complication of radiotherapy confronting the head and neck surgeon. Laryngoscope 1983;93:310-13.
Pauloski BR, Rademaker AW, Logemann JA, Lazarus CL, Newman L, Hamner A, et al
. Swallow function and perception of dysphagia in patients with head and neck cancer. Head Neck 2002;24:555-65.
Kuo P, Chen MM, Decker RH, Yarbrough WG, Judson BL. Hypopharyngeal cancer incidence, treatment, and survival: Temporal trends in the United States. Laryngoscope 2014;124:2064-9.
Batth SS, Caudell JJ, Chen AM. Practical considerations in reducing swallowing dysfunction following concurrent chemoradiotherapy with intensity-modulated radiotherapy for head and neck cancer. Head Neck 2014;36:291-8.
Liao W, Zhou H, Fan S, Zheng Y, Zhang B, Zhao Z, et al
. Comparison of significant carotid stenosis for nasopharyngeal carcinoma between intensity-modulated radiotherapy and conventional two-dimensional radiotherapy. Scientific reports 2018;8(1):1-7.
Fenwick JD, Pardo-Montero J, Nahum AE, Malik ZI. Impact of schedule duration on head and neck radiotherapy: Accelerated tumor repopulation versus compensatory mucosal proliferation. Int J Radiat Oncol Biol Phys 2012;82:1021-30.
Peters LJ, Ang KK, Thames HD Jr. Accelerated fractionation in the radiation treatment of head and neck cancer. A critical comparison of different strategies. Acta Oncol 1988;27:185-94.
O'Rourke IC, Tiver K, Bull C, Gebski V, Langlands AO. Swallowing performance after radiation therapy for carcinoma of the esophagus. Cancer 1988;61:2022-26.
Swain SK, Ghosh TK, Munjal S, Mohanty JN. Microscope assisted coblation tonsillectomy among paediatric patients-our experiences at an Indian teaching hospital. Pediatr Pol 2019;94:170-74.
[Figure 1], [Figure 2], [Figure 3]