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A) Benign
Swallowing disorders due to benign neoplasms are more common
in infants and children than in adults. Benign neoplasms affecting the oral cavity
and pharynx in children are primarily lymphangiomas and hemangiomas. They may
occupy and disfigure multiple contiguous anatomic structures (e.g., tongue, floor
of mouth, face and neck) and cause not only dysphagia but also airway obstruction.
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Generally,
congenital hemangiomas tend to regress and involute with age; in contrast, lymphangiomas
do not spontaneously regress and, in fact, may grow and become more extensively
infiltrative and obstructive as the child matures. Resection of these latter tumors
is difficult and often carried out in stages, with every attempt made to preserve
the integrity and function of normal structures.
In adults, benign masses
such as lipomas and goiters may, depending on their size and location, cause dysphagia.
Their diagnosis is relatively straightforward, and the decision to excise the
mass is usually based on clinical presentation and symptoms.
Other benign
tumors such as paragangliomas may cause dysphagia by impairing cranial nerve sensory
and motor functions, either by their presence (compression, traction, stretching)
or as a result of their treatment. Some surgeons advocate anticipation and correction
of expected neurologic deficits (e.g., medialization thyroplasty for vocal cord
paralysis) at the time of the tumor resection (37, 38) (37) (105).
B) Malignant
Dysphagia may result from both the malignancy itself
(solid tumor, leukemia, or lymphoma) and/or the treatment of the malignancy (surgery,
radiation, chemotherapy). Malignant neoplasms of the oral cavity or pharynx can
cause dysphagia by virtue of the tumor mass itself, tissue fixation, local inflammation
and pain (39) (106). Any adult with odynophagia (pain during swallowing) persisting
for more than a few weeks deserves a careful examination to rule out malignancy.
The symptoms may be very subtle, often described as a "slight irritation"
or a sensation of "something down there", and may be dismissed as insignificant
unless a reasonable index of suspicion is maintained.
Nonetheless, additional
qualifiers such as unilaterality, referred otalgia, discomfort or irritation worse
with swallowing, or gradual weight loss mandate a thorough inspection and palpation
of all mucosal surfaces within the upper aerodigestive tract to exclude malignancy.
Depending on the location and extent of a malignant tumor, dysphagia and/or odynophagia
may be an early or late symptom of the disease. Primary tumors arising in the
tongue base and supraglottic larynx are often "silent", not causing
any symptoms until enlarged cervical nodes appear.
Patients rarely regain
totally normal swallowing function after surgical resection of oropharyngeal or
laryngeal malignancies. The magnitude of their dysphagia depends on the site of
the primary tumor; extent of the surgical resection, structures involved in the
surgical resection and type of reconstruction performed (40) (107). Defects in
the roof of the mouth or laterally in the oral cavity are more easily compensated
for with prostheses or static tissue flaps than are reconstructive efforts to
replace the dynamic actions of the tongue or pharynx with their complex sensory
and motor functions. Although the ideal goal in post-resection reconstruction
is to duplicate the form and function of the excised tissues, matching their dynamic,
functional and sensate properties is extremely challenging (41) (108).
References
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Neoplastic
