Publication

Abstract : Introduction: Surgery and radiation are factors which can alter normal functioning of DARS (Dysphagia Aspiration Related Structures), and can lead to disorders of different grades, post treatment. Priorities are being placed on better quality of life with, dysphagia optimized intensity modulated radiation therapy (doIMRT) as advocated by Eisbruch et al [1]. The Case: A 36 year old lady was diagnosed with primary malignancy of tongue, T1N0M0 in September 2010, at a local hospital. She underwent wide local excision of lesion of right lateral border of anterior two thirds of tongue, with modified neck dissection of ipsilateral level 2 and 3 nodal stations. She was on regular follow up there and was disease free till January, 2014, following which she had local recurrence and was referred to our institute for further care. At presentation she was found to have T3 lesion with suspicious level IA node. She underwent total glossectomy, with right marginal mandibulectomy, left selective nodal dissection (Level I to IV), and right level IIA dissection; and ALT free flap reconstruction and tracheostomy. Postoperative histo-pathological staging was recurrent pT3N0M0, Stage III. Surgical margins being positive, she received concurrent chemoradiotherapy to a dose of 60 Gy in 30 fractions to tumour bed, and lymph nodal basins bilaterally and a simultaneous accelerated dose of 66 Gy to positive margin, using 3DCRT (due to financial constraints), and 3-weekly cisplatin. Postoperatively she had dysphagia and her nutritional support was maintained with a PEG tube and continues to be on PEG support. Swallowing Rehabilitation Procedures: Swallowing assessment using FEES (Fibre-optic endoscopic evaluation of swallowing) and video fluoroscopy (VFS) showed poor hyo-laryngeal elevation, leading to aspiration. Oral and pharyngeal phases of swallowing were affected, with pooling in oral cavity and poor mobilization of food bolus to pharyngeal phase. Maneuvers like tilting the head back while swallowing and jet feeding taught to her, had failed to improve her swallowing status. Her case was discussed with experts in swallowing and she is still on swallowing rehabilitation. Discussion : Total glossectomy is a morbid procedure, which by itself deranges oral phase of swallowing, and to a certain extent the pharyngeal phase also. Radical radiation dose could worsen the pharyngeal phase as well. An earlier analysis from our centre [2] had shown that dose exceeding 63 Gy to superior and middle constrictors and 56 Gy to inferior constrictors does compromise swallowing. Radical intent treatment like this poses dilemmas to treating oncology team and also drains personal, social, economical, and emotional resources of patient. Whether a less morbid organ-preserving oncological surgical procedure, with supportive optimized adjuvant radiation with or without brachytherapy could have given the same results, with an improved quality of life need to be looked into.