ORIGINAL ARTICLE Submandibular Gland Transfer for Prevention of Xerostomia After Radiation Therapy Swallowing Outcomes Jana Rieger, PhD; Hadi Seikaly, MD; Naresh Jha, MBBS; Jeffrey Harris, MD; David Williams, MD; Richard Liu, MD; Tim McGaw, DDS; John Wolfaardt, PhD Objective: To assess swallowing outcomes in patients had preservation of 1 submandibular gland (SJP group) with oropharyngeal carcinoma in relation to the Seikaly- and 11 who did not (control group). Jha procedure for submandibular gland transfer (SJP). The SJP has recently been described as beneficial in the Main Outcome Measures: Quantitative and qualita- prevention of xerostomia induced by radiation therapy tive aspects of swallowing were obtained to determine in patients with head and neck cancer. whether patients in the SJP group performed more op- timally than those in the control group. Design: Inception cohort. Results: Baseline and stimulated salivary flow rates were Setting: University-affiliated primary care center. significantly different between groups. Patients in the SJP group were able to move the bolus through the oral cavity Patients: A phase 2 clinical trial was conducted from and into the pharynx faster than those in the control group. February 1, 1999, through February 28, 2002, to evalu- In addition, patients in the SJP group swallowed less often ate SJP in patients with head and neck cancer. During per bolus than patients in the control group. The com- that period, a consecutive sample of 51 patients who un- plete swallowing sequence was twice as long in controls. derwent surgical resection and reconstruction with a ra- dial forearm free flap for oropharyngeal carcinoma were Conclusions: The SJP for submandibular gland trans- referred for functional assessment of swallowing after fer appears to be beneficial in promoting more time- completion of adjuvant radiation therapy. At 6 months efficient swallowing behaviors. This efficiency has im- after surgery, swallowing assessments for 24 patients were plications for the overall well-being and nutritional status available. of patients with head and neck cancer. Intervention: The cohort of 24 patients included 13 who Arch Otolaryngol Head Neck Surg. 2005;131:140-145 EROSTOMIA IS A CONDI- for lubrication, and therefore comfort, of Author Affiliations: tion in which the function the mouth and oral pharynx, but is also Craniofacial Osseointegration of the salivary glands has necessary for modulation of microbial or- and Maxillofacial Prosthetic been altered such that the ganisms in the mouth, remineralization of Rehabilitation Unit, Caritas oral cavity lacks saliva, re- teeth, maintenance of the mucosal im- Health Group (Drs Rieger, Seikaly, and Wolfaardt), Faculty sulting in subjective complaints of dry mune system, and preparation of a bolus X 1 of Rehabilitation Medicine mouth. Xerostomia resulting from can- of food during mastication. When sali- (Dr Rieger), Division of cer treatment has a devastating impact on vary function is compromised, the result- Otolaryngology Head and Neck quality of life. Individuals diagnosed as ing sequelae include oral discomfort, mu- Surgery (Drs Seikaly, Harris, having cancer of the head and neck are cositis, periodontal disease, dental caries, and Liu), Division of General overwhelmed by the notion of treatment loss of teeth, fissures of the tongue, de- Surgery (Dr Williams), and potentially involving surgery, radiation creased taste acuity, inability to wear Department of Dentistry therapy, and chemotherapy. The com- dentures if needed, and difficulty with mas- (Drs McGaw and Wolfaardt), mon experience of the patients is that sur- tication and deglutition.1-9 The develop- University of Alberta; Division viving these therapies is the primary mor- ment of xerostomia in survivors of head of Surgical Oncology (Dr Seikaly) and Department of bid challenge to regaining quality of life. and neck cancer, therefore, is of serious Radiation Oncology (Dr Jha), However, the common clinical experi- consequence to their nutritional status and Cross Cancer Institute, ence is that where xerostomia occurs, this their overall quality of life. Edmonton, Alberta. condition becomes a primary threat to re- Because of the location of primary tu- Financial Disclosure: None. gaining quality of life. Saliva is important mors of the head and neck, the major sali- (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 131, FEB 2005 WWW.ARCHOTO.COM 140 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 vary glands are often in the field of the postoperative ra- poral measures of swallowing events. In contrast, an- diation therapy.1,10,11 For this reason, the potential for other report involving patients with head and neck cancer8 development of xerostomia in this patient population is found that patients with xerostomia took longer to mas- very real. Salivary dysfunction develops immediately when ticate a dry bolus and were left with greater oral and pha- the major salivary glands are in the radiation field, and ryngeal residues than a group of healthy controls. These such dysfunction is permanent with little chance for re- reports appear to provide conflicting information regard- covery.10,12 The prevalence of xerostomia in patients with ing the effect of xerostomia on objective measures of swal- head and neck cancer after radiation therapy, whether lowing function. However, the effect of xerostomia was that therapy is the primary or secondary treatment, has being compared differently, with one set of reports us- been reported to vary from 94% to 100%.13-15 ing salivary weight to understand the effect of xerosto- Treatment for xerostomia can be supportive or pre- mia on swallowing,7,9 and the other report using a group ventive. Supportive care for xerostomia includes the use of healthy controls for comparison with patients with xe- of saliva substitutes and moistening agents. Saliva sub- rostomia.8 Regardless, evidence is emerging that sup- stitutes duplicate the properties of normal saliva and pro- ports what has been largely anecdotal evidence of swal- vide relief for approximately 40% of patients who use lowing problems related to xerostomia. them.16 However, they are costly and provide only tem- From previous salivary flow studies, it has been dem- porary relief.1 Moistening agents include chewing gum, onstrated that the SJP has yielded beneficial results in pre- candy, and sips of water. Again, these provide only tem- venting xerostomia in patients undergoing radiation porary relief of xerostomia. Furthermore, the constant therapy of the head and neck region.10,17-19 The objec- intake of water during the course of a day is associated tives of the present study were to explore the benefits of with polyuria, often resulting in nocturnal wakefulness. the SJP beyond previously reported salivary flow rates.19 The use of candies is associated with increased dental car- Specifically, we compared measures of swallowing out- ies and mucosal damage stemming from pressure against comes obtained via videofluoroscopy after adjuvant ra- the soft tissues of the mouth when sucking on the candy.1 diation therapy between a group of patients who re- One modality of preventive care for xerostomia is the ceived the SJP and a group of controls (ie, patients who Seikaly-Jha procedure for submandibular gland transfer did not receive the SJP owing to oncological reasons). (SJP). One submandibular salivary gland is transferred into the submental space, using retrograde flow through the facial vessels. An incision is made from the mastoid METHODS process to the mentum. A flap is elevated, and the sub- mandibular gland is released from surrounding struc- A phase 2 clinical trial was conducted from February 1, 1999, tures and then repositioned in the submental space un- through February 28, 2002, to evaluate the SJP for subman- der the anterior belly of the digastric muscle. The dibular gland transfer in patients with head and neck cancer. submental and sublingual space is then shielded during The trial was approved by the internal review board and the postoperative radiation therapy, thereby protecting and human ethics committee of the University of Alberta (Edmon- preserving the transferred submandibular and sublin- ton), and informed consent was obtained from each patient. gual salivary glands. If any facial, preglandular, or sub- During that period, 51 patients who underwent surgical resec- tion and reconstruction with a radial forearm free flap for oro- mental nodes are found to be involved with metastatic pharyngeal carcinoma were referred for functional assessment cancer, the gland transfer is abandoned and the gland is of swallowing after completion of adjuvant radiation therapy resected. The surgical procedure is described as requir- (ie, at least 6 months after surgery). Of those patients, 8 died ing no special surgical skills and adds approximately 45 before a post–radiation therapy assessment could occur, 8 were minutes to the total surgical time.10 It is a relatively in- lost to follow-up, 4 did not receive conventional adjuvant post- expensive treatment modality, with recent reports dem- operative radiation therapy (ie, they received intensity- onstrating efficacious results in the prevention of xero- modulated radiation therapy), 4 had a history of previous sur- stomia after radiation therapy.10,17-19 Statistically significant gery or radiation therapy for head and neck cancer, and 3 differences in salivary flow between patients who have