Article

Prophylactic Swallowing Exercises in Patients with Laryngeal

Cancer Who Underwent Total Laryngectomy—A Randomized Trial
Elena Teodora Schipor-Diaconu 1,2 , Raluca Grigore 1,2 , Paula Luiza Bejenaru 2 , Catrinel Beatrice Simion-Antonie 2 ,
Bianca Petra Taher 1,2 , Simona Andreea Rujan 1,2 , Anca Ionela Cirstea 1,3 , Raluca Andreea Iftimie 4
and Ruxandra Ioana Stancalie-Nedelcu 1,2, *

1 Department of Otorhinolaryngology, Ophtalmology, Faculty of Medicine, “Carol Davila” University of

Medicine and Pharmacy, 050474 Bucharest, Romania; elena-teodora.diaconu@drd.umfcd.ro (E.T.S.-D.);
anca-ionela.cirstea@drd.umfcd.ro (A.I.C.)
2 Department of ENT, Head and Neck Surgery, Coltea Clinical Hospital, 030167 Bucharest, Romania
3 Department of ENT, Head and Neck Surgery, Emergency Universitary Hospital Bucharest,
050098 Bucharest, Romania
4 Ophtalmological Emergencies Clinical Hospital, 010464 Bucharest, Romania
* Correspondence: ruxandra-ioana.nedelcu@drd.umfcd.ro; Tel.: +40-734131697

Abstract: Objectives: This study aims to determine the efficacy of prophylactic swallowing exercises
on swallowing function in patients undergoing total laryngectomy for laryngeal cancer. Methods:
The design was a randomized controlled trial set in one tertiary care academic medical center. A
total of 92 patients undergoing total laryngectomy for stages III and IV laryngeal cancer performed
five targeted swallowing exercises for a period of three months after their surgery, starting two
weeks after the surgery. Weekly swallowing therapy sessions were held with the patients in order to
encourage adherence and proper technique. The controls received no preventive exercise and were
referred for swallowing treatment following the surgery, as well as radiation therapy if necessary.
The Functional Oral Intake Scale (FOIS) and the Performance Status Scale for Head and Neck Cancer
Patients (PSS-H&N) were used to measure swallowing function at the baseline, one week following
the surgery, and three, six, nine, and twelve months following the surgery. Results: Right after
Citation: Schipor-Diaconu, E.T.;
Grigore, R.; Bejenaru, P.L.;
the surgery, there were no statistically significant variations between the intervention and control
Simion-Antonie, C.B.; Taher, B.P.; groups in the FOIS scores (p value = 0.64), the Eating in Public subscale scores (p value = 1) and
Rujan, S.A.; Cirstea, A.I.; Iftimie, R.A.; Normalcy of Diet subscale scores (p = 0.33) of the PSS-H&N. The scores were significantly better
Stancalie-Nedelcu, R.I. Prophylactic among the intervention patients at months 3, 6, 9, and 12 for all the scores, with p values smaller than
Swallowing Exercises in Patients with 0.000. Conclusions: Although not immediately following the surgery, the patients who engaged in
Laryngeal Cancer Who Underwent prophylactic swallowing exercises showed improvements in their ability to swallow at 3, 6, 9, and
Total Laryngectomy—A Randomized 12 months following their procedure.
Trial. Curr. Oncol. 2024, 31, 6853–6866.
https://doi.org/10.3390/ Keywords: total laryngectomy; swallowing exercises; swallowing function; quality of life; rehabilitation
curroncol31110506

Received: 1 August 2024

Revised: 22 October 2024
Accepted: 28 October 2024 1. Introduction
Published: 2 November 2024 The incidence and mortality rates of laryngeal cancer have been slightly decreasing
for the past 10 years in European countries [1]. For Romania, laryngeal cancer is the 16th
most common type of cancer, with an incidence of 1804 patients, accounting for 1.7% of
Copyright: © 2024 by the authors.
all cancers [2]. The oncologic control of laryngeal carcinoma is the main objective of its
Licensee MDPI, Basel, Switzerland. treatment. In order to maintain a good quality of life, preserving speech and swallowing
This article is an open access article abilities are secondary but very important objectives. Laryngeal carcinomas can be treated
distributed under the terms and with radiation therapy, chemotherapy, surgery, or a mix of these. Treatment for laryngeal
conditions of the Creative Commons cancer should be determined by the knowledge of an interprofessional team, such as that
Attribution (CC BY) license (https:// found in a multidisciplinary clinic or on a tumor board. The type, location, and function
creativecommons.org/licenses/by/ of the larynx, as well as the patient’s medical and social comorbidities, all influence the
4.0/). course of the treatment. Also, when nonsurgical treatments of laryngeal cancer have

Curr. Oncol. 2024, 31, 6853–6866. https://doi.org/10.3390/curroncol31110506 https://www.mdpi.com/journal/curroncol

 with radiation therapy, chemotherapy, surgery, or a mix of these. Treatment for laryngeal
cancer should be determined by the knowledge of an interprofessional team, such as that
found in a multidisciplinary clinic or on a tumor board. The type, location, and function
of the larynx, as well as the patient s medical and social comorbidities, all influence the
Curr. Oncol. 2024, 31 6854
course of the treatment. Also, when nonsurgical treatments of laryngeal cancer have failed
or recurred, total laryngectomy is the standard of care for surgical salvage; it is also fre-
quently used as the main treatment for advanced-stage laryngeal malignancy [3]. Ad-
failed or recurred, total laryngectomy is the standard of care for surgical salvage; it is
vanced-stage
also frequently (III
usedand IV)main
as the tumors require
treatment formultimodality
advanced-stagetreatment, which may[3].
laryngeal malignancy consist of
Advanced-stage (III and IV) tumors require multimodality treatment, which may consist piece
surgery followed by radiation therapy [4]. In Figure 1, we have a total laryngectomy
with
of a stage
surgery IV squamous
followed by radiation celltherapy
carcinoma (T4a,
[4]. In N2c,
Figure M0).
1, we It can
have be laryngectomy
a total seen that the whole
larynx
piece is resected;
with a stage IVthe tumor involves
squamous the epiglottis
cell carcinoma (T4a, N2c,andM0).
rightItaryepiglottic
can be seen fold, protrudes
that the
whole larynx is resected; the tumor involves the epiglottis and right
through the thyroid cartilage on the right side, and also involves the first tracheal ring. aryepiglottic fold,
protrudes
Consideringthrough
the the thyroid
extent cartilage
of the tumor, on only
the right side,laryngectomy
a total and also involves the first
could tracheal
be performed. The
ring. Considering the extent of the tumor, only a total laryngectomy
structures that are most important for the swallowing function are the epiglottis, the ar-could be performed.
The structures that are most important for the swallowing function are the epiglottis, the
yepiglottic folds, and also the vestibular folds, but in this case, they could not be spared.
aryepiglottic folds, and also the vestibular folds, but in this case, they could not be spared.
Also, the superior laryngeal nerve is important as it innervates the cricothyroid muscle,
Also, the superior laryngeal nerve is important as it innervates the cricothyroid muscle,
thusproviding
thus providing a good
a good swallowing
swallowing function;
function; in thisincase,
this case, it could
it could not be not be spared.
spared. For a good
For a good
swallowing
swallowing function
function afterafter surgery,
surgery, it is important
it is important that the pharyngeal
that the pharyngeal wall is well wall is well pre-
preserved
served so that the suture is made without tension. For all the patients
so that the suture is made without tension. For all the patients in this study, the pharyngeal in this study, the
pharyngeal wall suture
wall suture was tension-free. was tension-free.

Figure1.1.Total
Figure Total laryngectomy
laryngectomy piece
piece withwith a stage
a stage IV tumor.
IV tumor.

Total
Totallaryngectomy
laryngectomy cancan
leadlead
to numerous changes,
to numerous the most
changes, the obvious being the
most obvious lossthe loss
being
of the natural voice, but also the loss of upper airway functions (the moistening, heating,
of the natural voice, but also the loss of upper airway functions (the moistening, heating,
and filtering of air), resulting in pulmonary problems and the loss of olfaction. After the
and filtering of air), resulting in pulmonary problems and the loss of olfaction. After the
surgery, the patient has to adapt to the altered anatomy and its lifelong consequences,
surgery, the patient has to adapt to the altered anatomy and its lifelong consequences,
leading to physical, emotional, psychological, and social changes that affect their average
leading
daily to physical,
functioning emotional,
and quality of lifepsychological,
[5]. and social changes that affect their average
daily functioning and quality of life [5].
The altered physiology and biomechanics of swallowing are another significant effect.
While The
afteraltered physiology
such major and biomechanics
surgery people of swallowing
expect and become accustomed aretoanother significant
some degree of ef-
fect. Whileswallowing
diminished after such major surgery
functioning, studiespeople expect
show that and self-reported
long-term become accustomed
swallowingto some
problems can appear in as much as 72% of patients after TL (total laryngectomy) [5]. The
estimates of the frequency of swallowing problems (dysphagia) after TL usually range
from 17 to 70%. The characteristics most frequently considered distressful by patients
Curr. Oncol. 2024, 31 6855

were having to take longer to be able to swallow, needing liquids to wash down a bolus,
and avoiding particular food consistencies [6]. Dysphagia can also lead to malnutrition in
patients with TL. Malnutrition has long been identified as an important prognostic factor,
associated with a poorer quality of life and reduced survival in patients, as well as being
associated with post-operative complications including the development of pharyngo-
cutaneous fistula, infection, and delayed wound healing [7]. Being so frequent amongst
patients with TL and leading to numerous complications, dysphagia becomes one of
the most important problems which should be addressed in order to maintain a good
quality of life. Swallowing exercises targeted at particular swallowing deficits can be
used to improve the mobility and motility of vital swallowing structures. There were
five intervention swallowing exercises chosen because each has been shown to improve
swallowing function.

2. Materials and Methods

From 1 April 2023 to 1 April 2024, we recruited 96 consecutive patients with stages III
and IV laryngeal cancer. The objective was to compare the mean outcomes of a treatment
group and a control group with the effect size being the expected difference in the means
between the treatment and control groups. The significance level (α), as is common, was
set at 0.05, and the probability of correctly rejecting the null hypothesis when it is false
was set at 0.80. With a total sample size of 96 (48 per group), the effect size that can be
detected with 80% power at a 5% significance level, given a standard deviation of 10 units,
is approximately 5.71 units. As the effect size that we were aiming to detect was larger than
5.71, a sample size of 96 patients (48 per group) was considered sufficient.
We included patients that were diagnosed at our center, but also patients that came
with a diagnosis from other centers. All the patients went through a case analysis performed
by our tumor board. The tumor board analyzed the stage of the tumor, the presence or
absence of distant metastases, and the histopathology of the tumor, and only patients with
laryngeal squamous cell carcinoma stages 3 and 4 who were suitable for surgery (total la-
ryngectomy with selective neck dissection) were included in this study. Patients that could
not be operated on were referred to radiotherapy and/or chemotherapy. Also, patients who
required extensive surgery such as total pharyngo-laryngectomy and/or esophagectomy
were excluded from this study. We also excluded patients who had previously undergone
radiation treatment as this produces changes which can interfere with the quality of swal-
lowing amongst patients. Patients with a history of neurological conditions that might
impair swallowing ability were also excluded. All the patients also had to be mentally and
cognitively capable of following instructions with several steps and comprehending how
to respond to certain questions on a questionnaire. One patient dropped out of this study,
and three developed a pharyngo-cutaneous fistula, so they were excluded from this study.
The remaining sample size was 92 patients. The Coltea Clinical Hospital’s institutional
ethics committee board approved this study on 20 March 2023, and issued the approval
number 5820/abcc. Every patient gave their informed permission. The intervention or
control treatments were randomly assigned to the patients (Chart 1).
The objective of this study was to assess whether prophylactic swallowing exercises
initiated immediately after surgery can lead to an improvement in the swallowing function
in patients undergoing total laryngectomy for laryngeal cancer.
Curr. Oncol. 2024, 31, FOR PEER REVIEW 4
Curr. Oncol. 2024, 31 6856

Processofofenrollment,
Chart1.1.Process
Chart enrollment,allocation,
allocation, follow
follow up
up and
and analysis
analysis of
of the
the sample.
sample.
2.1. Intervention Group
2.1. Intervention Group
Prophylactic swallowing exercises were the intervention; the patients were encour-
agedProphylactic
to begin these swallowing
exercises exercises
two weekswere the intervention;
following the surgerythe andpatients werethem
to continue encour-
for
aged
threetomonths.
begin these exercises two weeks following the surgery and to continue them for
three months.
2.1.1. Effortful Swallow (ES)
2.1.1. Effortful
The goal Swallow (ES) swallow (ES) technique is to push and swallow with enough
of the effortful
force to aid in bolus clearance
The goal of the effortful swallow while (ES)
applying increased
technique pressure
is to push and to the bolus,
swallow withand it is
enough
known for its instantaneous effect [8]. An easy way to perform it
force to aid in bolus clearance while applying increased pressure to the bolus, and it is is to stick the tongue
out and
known forhold it between teeth
its instantaneous while
effect [8].swallowing
An easy way (Figure 2). The
to perform purpose
it is to stickof the
the effortful
tongue out
swallow maneuver is to increase pressure on the bolus by enhancing
and hold it between teeth while swallowing (Figure 2). The purpose of the effortful swal- the contact between
themaneuver
low posterior pharyngeal
is to increase wall and theon
pressure base
theofbolus
the tongue during swallowing.
by enhancing the contact Initially,
betweenthe the
effortful swallow was suggested as a compensatory technique to improve bolus clearance in
posterior pharyngeal wall and the base of the tongue during swallowing. Initially, the
the vallecula by facilitating bolus flow into the pharynx. However, because of its ability to
effortful swallow was suggested as a compensatory technique to improve bolus clearance
modify the physiological elements of swallowing, the ES is also employed as a therapeutic
in the vallecula by facilitating bolus flow into the pharynx. However, because of its ability
or rehabilitative treatment. The effortful swallow has multiple physiological effects, and
to modify the physiological elements of swallowing, the ES is also employed as a thera-
because it is a simple maneuver, it is frequently used in clinical practice. All the sensor
peutic or rehabilitative
locations with both the treatment.
saliva andThe effortful
water trialsswallow
and across hasdifferent
multipleages physiological
showed that effects,
the
and because it is a simple maneuver, it is frequently used in clinical practice.
creation of the tongue-to-palate maximum pressure was larger during the effortful swallow All the sensor
locations
than duringwithnormal
both the saliva andThis
swallowing. water trialsisand
finding across
similar different
across studies ages
[9].showed that the
creation of the tongue-to-palate maximum pressure was larger during the effortful swal-
low than during normal swallowing. This finding is similar across studies [9].
 Curr.
Curr. Oncol.
Oncol. 2024,3131, FOR PEER REVIEW
2024, 5
6857

Figure 2. The effortful swallow maneuver.

2.1.2. Tongue Pull Back (TPB) Exercise

A 2.
Figure
Figure number
2. The of intricate
Theeffortful swallow
effortful sensory–motor
maneuver.
swallow maneuver. processes work together during the pharyngeal
swallow to convey a bolus smoothly and successfully through the pharynx and into the
2.1.2. Tongue
esophagus.Tongue PullBack
Pull
Pharyngeal Back(TPB) (TPB) Exercise contract sequentially, the tongue base retracts, and
Exercise
constrictors
the upperA
A number
number ofofintricate
esophageal intricate sensory–motor
sensory–motor
sphincter (UES)processesprocesses
opens. work thetogether
In work together
swallowing during the pharyngeal
during
process,the pharyngeal
the purpose of
swallow to
swallow to convey
convey aabolus
bolus smoothly
smoothly and and successfully
successfully through
through the pharynx
the pharynx and intoand theinto posterior
the
tongue base retraction is to shift the base of the tongue posteriorly to meet the
esophagus. Pharyngeal
esophagus. Pharyngealconstrictorsconstrictorscontract contractsequentially,
sequentially,the thetongue
tonguebase baseretracts,
retracts,and and the
pharyngeal
the upper
wall, which
esophageal
travels
sphincter
bothopens.
(UES)
superiorly
In the
and anteriorly.
swallowing process,
In order to force the bolus
upper esophageal sphincter (UES) opens. In the swallowing process, thethe purpose
purpose of of
tongue
through
tongue the pharynx
base retraction and
is to into the esophagus during swallowing, the posterior movement
base retraction is to shift theshift
basethe of base
the tongueof the tongue
posteriorly posteriorly
to meettothe meet the posterior
posterior pharyngeal
ofwall,
the tongue
pharyngeal base
wall, and
which superior–anterior
travels both superiorly movement
and
which travels both superiorly and anteriorly. In order to force the bolus of
anteriorly. theIn posterior
order to pharyngeal
force bolus wall
thethrough the work
together
through the
pharynx to
and raise
into pharyngeal
pharynx theand into the
esophagus pressure
esophagus [10].
during swallowing, A deficit
during the in
swallowing, tongue
posterior base retraction
the posterior
movement movement causes resi-
of the tongue
of
due the tongue base and superior–anterior movement of the
base and superior–anterior movement of the posterior pharyngeal wall work together to the
in the pharynx and is prevalent in individuals posterior
with pharyngeal
dysphagia wall
[11]. work
Regarding
together
precise
raise to raise pharyngeal
muscles
pharyngeal involved
pressure in pressure
tongue
[10]. [10].
A deficit base Aindeficit
retraction,
tongue in tongue base retraction
theretraction
base research causes
is ambiguous.
causes residue resi-inWhen
the dis-
due in the pharynx and is prevalent in individuals with dysphagia [11]. Regarding the
cussing
pharynxanatomy,
and is prevalent the majority of sources
in individuals with mention
dysphagiathe [11].intrinsic
Regarding andthe extrinsic lingual mus-
precise muscles
precise muscles involved in tongue base retraction, the research is ambiguous. When dis-
involved
cles. However,in tongue when base retraction,the
describing the research is ambiguous. When discussing anatomy,
cussing anatomy, the majority of sourcestongue mentionbase s propulsive
the intrinsic activity
and extrinsic during
lingual mus- the pharyn-
the
geal majority
swallow, of sources
they mention
typically the
refer intrinsic
to the and
“tongue extrinsic
base” lingual
or muscles.
“posterior However,
tongue” when The
[10,12].
cles. However, when describing the tongue base s propulsive activity during the pharyn-
describing
most the tongue base’s
often recognized muscles propulsive
involved activity during the pharyngeal
in tongue swallow, they typi- [13],
geal swallow, they typically refer to the “tongue base” orbase retraction
“posterior tongue” are the hyoglossus
[10,12]. The
cally refer to the “tongue base” or “posterior tongue” [10,12]. The most often recognized
genioglossus
most often recognized [14,15], muscles
and styloglossus
involved in [13,15]. tongue base Some publications
retraction also list the
are the hyoglossus [13],mylohyoid,
muscles
genioglossus involved
[14,15], inand
tongue base retraction
styloglossus [13,15]. are the
Some hyoglossus
publications [13],
also list genioglossus
the mylohyoid, [14,15],
digastric, and geniohyoid muscles [16]. The classic exercise for strengthening the tongue
and styloglossus
digastric, [13,15]. muscles
Some publications also exercise
list the mylohyoid, digastric, and genio-
base
hyoid theand
is musclestonguegeniohyoid
[16]. retraction,
The classic
[16].
inexercise
which Thethe classic
for patient pulls
strengthening
forback
strengthening
the the tongue
tongue base
theas
is
tongue
fartongue
the is it can go,
base is the tongue retraction, in which the patient pulls back the tongue as far is it can go,
like trying in
retraction, to which
touchthe thepatient
back of theback
pulls tongue the to the as
tongue roof of
is the
farmouth.it canmouth.
go, like Studies
trying tohave
touchshown
like trying to touch the back of the tongue to the roof of the Studies have shown
that
the adding
back of resistance
the tongue toto the
the TPB
roof of exercise
the mouth. can increase
Studies
that adding resistance to the TPB exercise can increase its efficiency [17]. One method de- have its efficiency
shown that [17].
adding One method
resistance de-
scribed
to the TPB
scribed in the literature
exercise
in the literature is is
thethe
can increase finger-resisted
its efficiencyTPB
finger-resisted TPB
One exercise.
[17].exercise. method aUsing
piece ofa in
Using described piece of sterileisgauze
the literature
sterile gauze
tothe finger-resisted
tohold
hold the tongueTPB
the tongue exercise.
between
between thethe Usingfingers,
fingers, athe
piecetheofparticipant
sterilehas
participant gauze to hold
has
to pull to pull
the the tongue
tongue theinto between
tongue
the into the
the
mouth. fingers,
mouth. The the
The thumb
thumb participant
isis
positioned has to
positioned pull
beneath the
beneath thetongue
tongue, into
the tongue, whilethethe
mouth.
whileindex The
theand thumb
middle
index andisfingers
positioned
middle fingers
beneath
arepositioned
are the tongue,
positioned above.
above. while
During
During the
theindex
exercise,
the andparticipants
exercise, middle fingers
participants are
are advisedarepositioned
to open their
advised above.
to lipsDuring
open wide,
their lipsthe wide,
exercise,
allowing theirparticipants
fingers to areenter,
advised
whiletothey open their
pull back lips wide,
their allowing
tongue. Theytheirare toldfingers
to offerto enter,
allowing their fingers to enter, while they pull back their tongue. They are told to offer
some resistance,
while they pull back but not theirso much
tongue. thatTheyit would limitto
are told range
offerofsome
motion or cause them
resistance, but not to lose
so much
some resistance, but not so much that it would limit range of motion or cause them to lose
theirittongue
that wouldhold. limitThey range areoftold not toorforce
motion cause thethem
tongue to back (Figure
lose their 3). hold. They are told
tongue
their
not to tongue
force the hold.tongue They backare(Figure
told not 3).to force the tongue back (Figure 3).

Figure 3. The tongue pull back exercise.

Figure
Figure3.
3. The
The tongue pullback
tongue pull backexercise.
exercise.
 2.1.3. Chin Tuck Against Resistance (CTAR) Exercise
By strengthening the swallowing muscles, the chin tuck against resistance technique
helps in swallowing. It especially targets the suprahyoid muscles. The CTAR exercise in-
volves the patient pulling their chin down toward their upper chest against a resistance
Curr. Oncol. 2024, 31 like a rubber ball or other such object or even the patient s hand (Figure 4). This exercise 6858
is performed while sitting. It is easy to modify CTAR exercises to target different muscles
and enhance muscle coordination during swallowing by varying the resistance level or
position.
2.1.3. ChinItTuck
is critical
Against to choose
Resistance the (CTAR)
right resistance
Exercise level for the patient s physical state and
treatment objectives. The phases of the
By strengthening the swallowing muscles, the CTAR exercise are against
chin tuck as follows:
resistance technique
helps in swallowing. It patient
1. Preparation—the especiallysitstargets the suprahyoid muscles. The CTAR exercise
comfortably.
involves the patient pulling
2. Positioning—in theirthe
our case, chin down places
patient towardtheir
theirhand
upperunder
chest their
against a resistance
chin.
like a rubber ball or other such object or even the patient’s
3. Chin tuck—the patient tucks the chin down toward the chest. hand (Figure 4). This exercise is
performed while sitting. It is easy to modify CTAR exercises to target different
4. Resistance—the patient applies resistance with their hand. Typically, the resistance muscles and
enhance muscle coordination
is kept for 5–10 s. during swallowing by varying the resistance level or position.
It is critical to choose the right resistance level for the patient’s physical state and treatment
5. Rest and repeat—after a brief period of relaxation, the activity is repeated. It is often
objectives. The phases of the CTAR exercise are as follows:
advised to carry out several sets of repetitions each day [18].
1. Preparation—the patient sits comfortably.
Tongue pressure is enhanced by the CTAR exercise, which is beneficial for a healthy
2. Positioning—in our case, the patient places their hand under their chin.
swallowing function. This exercise also helps to build muscle endurance and strength,
3. Chin tuck—the patient tucks the chin down toward the chest.
4.which enhances the patient
Resistance—the overall applies
swallowresistance
function.with
Comparing
their hand.chinTypically,
tuck against resistanceisexer-
the resistance
ciseskept
to traditional
for 5–10 s. therapeutic approaches alone reveals a considerable improvement in the
tongue pressure and overall swallow performance. The correct patterns
5. Rest and repeat—after a brief period of relaxation, the activity is repeated. It is often of muscular activa-
tionadvised
during swallowing
to carry out are reinforced
several through theeach
sets of repetitions repetition
day [18]. of CTAR exercises [19].

Figure4.4.Chin
Figure Chintuck
tuckagainst
against resistance
resistance exercise.
exercise.

Tongue
2.1.4. pressure
The Head is enhanced
Lift (HL) Exerciseby the CTAR exercise, which is beneficial for a healthy
swallowing function. This exercise
Using the knowledge that the pull also of
helps
the to build muscle
thyrohyoid, endurance
mylohyoid, and strength,
geniohyoid, and an-
which enhances the overall swallow function. Comparing chin tuck against resistance
terior belly of the digastric muscles contracting causes the following opening of the upper
exercises to traditional therapeutic approaches alone reveals a considerable improvement
esophageal sphincter, the head lift exercise, also referred to as the Shaker exercise, is defined.
in the tongue pressure and overall swallow performance. The correct patterns of muscular
Enhancing the muscles strength and endurance is the goal, as it will increase the upper
activation during swallowing are reinforced through the repetition of CTAR exercises [19].
esophageal sphincter s opening width. The workout comprises an isometric high-intensity
head-raising
2.1.4. The Head that
Liftincludes three head raises held for 60 s each, with a 60 s rest period be-
(HL) Exercise
tweenUsing the knowledge thatlow-intensity
them and an isokinetic the pull of thesegment consisting
thyrohyoid, of 30 successive
mylohyoid, geniohyoid, head lifts at
and
a steadybelly
anterior paceofwithout holding
the digastric (Figure
muscles 5). The goal
contracting causesof it
theisfollowing
to raise the anteroposterior
opening of the upperdiam-
esophageal sphincter, the head lift exercise, also referred to as the Shaker exercise, is defined. is a
eter and the cross-sectional area of the opening of the upper esophageal sphincter. This
non-invasive
Enhancing theexercise
muscles’designed
strength specifically
and endurancefor people with as
is the goal, dysphagia. It is a the
it will increase substitute
upper for
invasive procedures
esophageal sphincter’slike botulinum
opening width.toxin
The injections or cricopharyngeal
workout comprises myotomies
an isometric [20]. The
high-intensity
HL exercise that
head-raising is anincludes
extremely difficult
three exercise
head raises heldforforphysically
60 s each,fragile
with apersons,
60 s restsuch as the
period
between them and an isokinetic low-intensity segment consisting of 30 successive head lifts
at a steady pace without holding (Figure 5). The goal of it is to raise the anteroposterior
diameter and the cross-sectional area of the opening of the upper esophageal sphincter. This
is a non-invasive exercise designed specifically for people with dysphagia. It is a substitute
for invasive procedures like botulinum toxin injections or cricopharyngeal myotomies [20].
Curr. Oncol. 2024, 31, FOR PEER REVIEW 7
Curr. Oncol. 2024, 31, FOR PEER REVIEW 7
Curr. Oncol. 2024, 31 6859

elderly and stroke patients, even if it is beneficial for improving the swallowing function in
elderly and
dysphagia strokeApatients,
patients. evenfinds
person who if it isitbeneficial
difficult for improving the swallowing function in
The HL exercise is an extremely difficult exercise for to physically
physically change
fragile positions
persons, cannot
such as the
dysphagia
readily patients. A person who finds it difficult to physically change positions cannot
elderlycomplete
and stroke this exercise,
patients, mostly
even if it isbecause
beneficial it requires
for improvingbeingthe
in the supine position.
swallowing function Ad-
in
readily complete
ditionally,
dysphagiait patients.
can wear this exercise,
Adown
personthewho mostly
neck because
s muscles,
finds
ittorequires
particularly
it difficult
being
the
physically
in the supine position.
sternocleidomastoid.
change positions cannot Fre- Ad-
ditionally,
quent
readily it
exposure
completecan wear
to this
musculardown the
exhaustion
exercise, neck s muscles,
can result
mostly because particularly
in transient
it requires being the
pain sternocleidomastoid.
andsupine
in the discomfort. This Fre-
position.
quentcompliance,
lowers exposure
Additionally, tobeing
it can muscular
wear one
down ofexhaustion
theneck’s
the reasons can
whyresult
muscles, patientsin transient
discontinue
particularly pain and
their discomfort.
treatment,
the sternocleidomastoid. so This
lowers compliance,
performing
Frequent this exercise
exposure being
to muscular one
assisted of the happen
should
exhaustion reasons aswhy
can result often patients discontinue
as possible
in transient pain [21]. their treatment,
and discomfort. This so
performing
lowers this exercise
compliance, assisted
being one of theshould
reasonshappen
why patientsas often as possible
discontinue [21].
their treatment, so
performing this exercise assisted should happen as often as possible [21].

Figure 5. The head lift exercise.

Figure 5. The head lift exercise.
Figure 5. The head lift exercise.
2.1.5. Resistive Jaw-Opening (RJO) Exercise
2.1.5. Resistive Jaw-Opening (RJO) Exercise
This
2.1.5. is an exercise
Resistive that strengthens
Jaw-Opening the temporomandibular joint muscles and also ac-
(RJO) Exercise
This is an exercise that strengthens the temporomandibular joint muscles and also
tivates the
activates suprahyoid
the suprahyoid muscle. To
muscle. produce
To resistance,
produce the thumb
resistance, the thumbis placed directlydirectly
is placed beneath
This is an exercise that strengthens the temporomandibular joint muscles and also ac-
the chin,
beneath and then the
the suprahyoid patient
chin, and then presses
the patient upward while opening
pressesresistance,
upward while the mouth.
openingisthe While
mouth.keeping
While the
tivates the muscle. To produce the thumb placed directly beneath
upward
keeping pressure,
the upward the pressure,
patient progressively
the patient seals their mouth
progressively seals while
their resisting
mouth while the upward
resisting
the chin, and then the patient presses upward while opening the mouth. While keeping the
pressing
the upward (Figure 6). The
pressing practice
(Figure 6). entails fully expanding
The practice entails fullythe jaw and the
expanding holding
jaw and it there
holdingfor ten
it
upward
seconds. The pressure,
exercise the
has patient
to be progressively
performed every seals
day, theirtwo
with mouth sets while
of resisting
exercises of fivetherep-
upward
there for ten seconds. The exercise has to be performed every day, with two sets of exercises
pressing
etitions (Figure 6). The practice entails fully expanding the jaw and holding Wada et al.for ten
it there
of five each with aeach
repetitions ten second
with a ten pause between
second pauseevery
between repetition. Furthermore,
every repetition. Furthermore,
seconds.
showed
Wada al.The
etthat the exercise
RJOthat
showed hasRJO
exercise
the to be
enhancedperformed
exercise the upper
enhancedevery theday,
esophageal
upper with two setsopening
sphincter
esophageal of exercises
sphincter inopeningof five rep-
dyspha-
giaetitions
in patients
dysphagia eachafterwith a
four weeks
patients ten second
of use
after four pause
[22]. The
weeks between
of useisometric every
[22]. The repetition.
maximal
isometric tongue Furthermore,
maximal basetongue
pressure Wada
and et al.
base
showed
pressure
tongue that tongue
and
endurance thehave
RJOendurance
exercise
both beenenhanced
have boththe
demonstrated beenupper esophageal
todemonstrated
considerably tosphincter afteropening
considerably
increase thisincreasein dyspha-
workout
[23]. Additionally, it can thicken the mylohyoid and digastric muscles, which is significant and
gia
after patients
this after
workout four
[23]. weeks of
Additionally, use it[22].
can The
thicken isometric
the maximal
mylohyoid and tongue
digastricbase pressure
muscles,
which
tongue
because ismuscle
significant
endurance because
have and
thickness bothmuscle
been thickness forceand
demonstrated
contractile arecontractile
to considerably
closely force are
correlated. closely
increase
In order correlated.
afterto this
induceworkout
In order
[23].
changes into induce
Additionally,
muscle changes
physiology, insuch
it can thicken musclethe
as physiology,
mylohyoid
changes such
in muscle as changes
and thickness
digastric in muscle
muscles,
through whichthickness
resistance istrain-
significant
through
because
ing, resistance
an adequate training,and
muscleresistance
thickness an
andadequate
contractile
prolonged resistance
force are
exercise and prolonged
closely
duration exerciseTo
arecorrelated.
essential. duration
order are
In specifically
to induce
essential.
induce
changes skeletalTo specifically
muscle
in muscle induce
physiologic
physiology, skeletal
changes,
such muscle physiologic
such in
as changes asmuscle
muscular changes,
hypertrophy,
thickness such
through as muscular
the training train-
resistance
hypertrophy, the training should be performed for a minimum of 6 to 8 weeks. The RJO
should
ing, an be adequate
performedresistance
for a minimum of 6 to 8 weeks.
and prolonged exercise The RJO exercise
duration has the benefit
are essential. of
To specifically
exercise has the benefit of being less strenuous than the HL exercise, but it also carries
being less skeletal
induce strenuous than the
muscle HL exercise,
physiologic but it also
changes, suchcarries the risk ofhypertrophy,
as muscular temporomandibular the training
the risk of temporomandibular joint pain and dislocation issues. Consequently, it is not
joint pain
should for and dislocation
be individuals
performedwith issues.
for asevereConsequently,
minimum it is not
of 6 to 8 weeks. advised for individuals with severe
advised temporomandibular jointThe
issues,RJOand exercise has the
it also necessitates benefit of
temporomandibular
being less strenuous joint
thanissues,
the and
HL it also
exercise, necessitates
but it also paying
carries close
the attention
risk of to how
temporomandibularthe
paying close attention to how the temporomandibular joint feels and wears out during the
temporomandibular
joint pain
exercise [21]. joint feels
and dislocation and wears
issues. out duringitthe
Consequently, exercise
is not advised [21].for individuals with severe
temporomandibular joint issues, and it also necessitates paying close attention to how the
temporomandibular joint feels and wears out during the exercise [21].

Figure 6. Jaw opening against resistance.

Figure 6. Jaw opening against resistance.

Figure 6. Jaw opening against resistance.

 Curr.Oncol.
Curr. Oncol.2024,
2024,31
31, FOR PEER REVIEW 8
6860

2.2. Control Group

2.2.
The controls
The controlsreceived
receivednono preventive
preventive exercises
exercises andand werewerereferred for swallowing
referred for swallowing treat-
ment following
treatment following the surgery
the surgery on an on“as an “asneeded”
needed” basis as swallowing
basis as swallowing issues appeared
issues appeared in
patients.
in patients.
Weekly swallowing
Weekly swallowingtherapy therapysessions sessions werewere attended
attended by the patients
by the patientsin order to encour-
in order to en-
age adherence
courage adherenceand properand proper technique.
technique. The standard
The standard of careofwas careusedwasas the as
used control treat-
the control
ment, which
treatment, entailed
which referring
entailed patients
referring who had
patients whodysphagic
had dysphagic symptoms symptomsafter the cancer
after treat-
the cancer
ment was was
treatment finished
finished to a to
heada headand andneckneck speech pathologist
speech pathologist for evaluation
for evaluation and and
treatment
treatmentre-
related
lated toto swallowing.
swallowing. FiveFive intervention
intervention swallowing
swallowing exercises
exercises were wereselected selected
because because
research re-
search has demonstrated
has demonstrated that they thatcanthey can all
all help helpwith
people people with dysphagia
dysphagia improveimprovetheir abilitytheir to ability
swal-
to swallow.
low. They included
They included the resistive
the resistive jaw-openingjaw-opening exercise, exercise,
the head thelift
head lift exercise,
exercise, the chin thetuck
chin
tuck against
against resistance,
resistance, the tongue
the tongue pull backpull back exercise,
exercise, and theandeffortful
the effortful
swallow. swallow. To further
To further pro-
promote adherence
mote adherence to the to swallowing
the swallowing exercise
exercise routineroutine
and to and to document
document the names
the names of those of those
who
who
werewereunableunable to complete
to complete it, theit,patients
the patients were advised
were advised to keeptoakeep dailyaperformance
daily performance diary.
diary.
Written Written instructions
instructions on howon tohow
carrytoout carry
the out the individual
individual swallowing swallowing
exercisesexercises
were given were
to
given to eachTwo
each patient. patient.
distinct Two distinct swallowing-specific
swallowing-specific scales that also scales that also
addressed addressed
some swallowing- some
swallowing-related
related quality of lifequality issues wereof lifeused issues were used
to perform to perform
functional functional
swallowing swallowing
assessments. Theseas-
sessments.
comprised These comprised
the Functional OraltheIntake
Functional Oral Intake
Scale (FOIS) Scale (FOIS)
[24] (Figure 7) and[24] the (Figure
Performance 7) andSta-the
Performance
tus Scale for Head Statusand Scale for Head
Neck Cancerand Neck (PSS-H&N)
patients Cancer patients (PSS-H&N)
[25] (Figure 8). All[25]
the(Figure
research 8).
All the research
participants wereparticipants
evaluated bywere evaluated
a clinician who was by aspecially
cliniciantrained
who was in the specially
use of thesetrained
scalesin
the use of these scales and who was blinded to the
and who was blinded to the intervention assignment one week following the surgery to intervention assignment one week
following
establish athe surgery
baseline andto establish
then at three, a baseline
six, nine,andand thentwelve
at three, six, nine,
months and twelve
following months
the surgery.
following the surgery.
Three distinct subscalesThree makedistinct subscales
up the short, make up the
clinician-rated short, clinician-rated
PSS-H&N: Normalcy ofPSS-H&N: Diet, Un-
Normalcy
derstandabilityof Diet, Understandability
of Speech, and Eating inofPublic. Speech, andsubscale
Every Eating has in Public.
a value Every
between subscale
0 and
has
100;aa value
higherbetween
score denotes 0 anda100; better a higher
function. score
Thedenotes
Eating ina Public
better subscale
function.recordsThe Eating the pa- in
Public
tient s subscale
capacity to records
share the a mealpatient’s capacity
with others in to sharewhich
public, a mealhelpswithto others
address in public,
swallowing-which
helps
relatedtoquality
address of swallowing-related
life problems. The interviewer quality ofslife problems.
ability The interviewer’s
to comprehend the patient ability
s speech to
comprehend the patient’s speech is rated on the Understandability
is rated on the Understandability of Speech subscale. The patient s ability to handle a regular of Speech subscale. The
patient’s ability toby
diet is measured handle a regularof
the Normalcy dietDietis measured
subscale. Ten by thefoodNormalcy
categoriesofare Diet subscale.
ranked Ten
on this
food categories are ranked on this subscale, with easier-to-eat
subscale, with easier-to-eat alternatives at the bottom and more difficult-to-eat options at alternatives at the bottom
and moreThis
the top. difficult-to-eat
scale is sensitive options to at the top. This
functional scale is
variations insensitive
a wide range to functional
of head variations
and neck
in a wide
cancer range of
patients and headhasandbeenneck cancer patients
demonstrated to beand has been
reliable among demonstrated
raters [24]. to The be Under-
reliable
among raters [24]. The Understandability of Speech subscale
standability of Speech subscale of the PSS-H&N was not examined since the ability of speech of the PSS-H&N was not
examined since the ability of speech is lost for these patients
is lost for these patients for variable amounts of time depending on the method chosen for for variable amounts of time
depending on the method
speech rehabilitation. chosen
A 7-point oralfordietary
speechtolerance
rehabilitation.
scale isAcalled
7-point theoral
FOIS.dietary
It variestolerance
from
scale
total reliance on PEG or a nasogastric tube (1) to the tolerance of an unrestricted oral(1)
is called the FOIS. It varies from total reliance on PEG or a nasogastric tube dietto
the tolerance of an unrestricted oral diet (7). It offers crucial
(7). It offers crucial details regarding the kinds of adjustments or restrictions that patients details regarding the kinds
of adjustments
must make to their or restrictions
oral diet and that patients
whether must
they maketube-based
require to their oral diet and whether
nutritional supplements they
require
[25]. tube-based nutritional supplements [25].

Figure 7.
Figure 7. Functional
Functional Oral
Oral Intake
Intake Scale.
Scale.
Curr. Oncol. 2024, 31 6861
Curr. Oncol. 2024, 31, FOR PEER REVIEW 9

Figure 8. Performance Status Scale for Head and Neck Cancer patients.
Figure 8. Performance Status Scale for Head and Neck Cancer patients.
2.3. Statistical Analysis
2.3. Statistical Analysis
We used Excel for analyzing the data and used the t-test: Paired Two Sample for
Means. WeWeused
looked at variations
Excel in the therapy
for analyzing theassignment
data andbased
usedonthe thet-test:
patient Paired
character-
Two Sample for Means.
istics. The PSS-H&N and FOIS scores were treated as continuous variables. Intention-to-
We looked at variations in the therapy assignment based on the
treat analyses were performed to look at the outcomes for both the intervention and con-
patient characteristics. The
PSS-H&N and FOIS scores were treated as continuous variables.
trol patients. We compared the scores and reported the differences in the scores at each Intention-to-treat analyses
were performed
time point following to
the look at (at
baseline the3, outcomes for both
6, 9, and 12 months afterthe intervention
the surgery). and control patients. We
The thresh-
old for significance was chosen at p < 0.05 (two-tailed).
compared the scores and reported the differences in the scores at each time point following
the baseline Analysis
2.4. Descriptive (at 3, 6, 9, and 12 months after the surgery). The threshold for significance was
chosen at p1 <is 0.05
In Table (two-tailed).
described the analysis of the tumor stage, age and BMI of the sample.

TableDescriptive
2.4. 1. Descriptive analysis.
Analysis
Variable Mean In Range Standard Deviation
Table 1 is described the analysisMedian
of the Mode
tumor stage, Variance
age and BMI of the sample.
Tumor stage 3.5 3–4 0.5 4 4 0.25
Age 63.98 52–81 6.71 63 69 63.93
BMI 1. Descriptive analysis.4.63
25.55 Table 16.16–32.89 26.005 23.01 25.97

Variable Mean 3. Results Range Standard Deviation Median Mode Variance

Tumor stage 3.5 3–4 0.5 4 4 0.25
Age 63.98 52–81 6.71 63 69 63.93
BMI 25.55 16.16–32.89 4.63 26.005 23.01 25.97

3. Results
Out of all the patients, ninety-six consented to take part, one patient dropped out, and
three patients developed a pharyngo-cutaneous fistula, so the sample size was 92 patients. The
participants in this study had a mean age of 63.98 years, 80% of whom were male. Regarding
age and sex, there were no appreciable differences between the intervention and control
groups; the p value for age was 0.94 and for sex was 0.64. The BMI was also calculated for all
the patients and there were no significant differences between the control and the intervention
group; the p value was 0.25. For the majority of the patients in the intervention and control
groups, the baseline scores on all the evaluations were identical (Table 1).
Curr. Oncol. 2024, 31 6862

Swallowing Function and Swallowing-Related Quality of Life (QOL)

The swallowing-related QOL and Normalcy of Diet scores as measured by the Eating
in Public and Normalcy of Diet subscales of the PSS-H&N were quite low at the baseline
for the patients in both the intervention and control groups, with a range from 0 to 25
in both groups. There were no statistically significant differences in the Eating in Public
subscale scores between the patients immediately after the surgery (p value = 1); however,
these scores improved after 3, 6, 9, and 12 months for the intervention group. The scores
were significantly better among the intervention patients at months 3 (p value < 0.000),
6 (p value < 0.000), 9 (p value < 0.000), and 12 (p value < 0.000).
Likewise, there were no statistically significant differences in the Normalcy of Diet
subscale of the PSS-H&N scores between the patients from the intervention group and
the control immediately after the surgery (p = 0.33). The range was from 0 to 20 for
both the intervention and control groups at the baseline. The scores improved for the
intervention patients relative to the controls at months 3 (p value < 0.000), 6 (p value < 0.000),
9 (p value < 0.000), and 12 (p value < 0.000).
The oral dietary tolerance (FOIS score) followed a similar pattern among the inter-
vention and control patients. There were no statistically significant differences in the FOIS
scores between the individuals in the intervention group and the control immediately after
the surgery (range from 1 to 3 in both groups, p value = 0.64). However, the patients in the
intervention group have significantly improved FOIS scores at months 3 (p value < 0.000),
6 (p value < 0.000), 9 (p value < 0.000), and 12 (p value < 0.000) (Table 2).

Table 2. Characteristics of the patients.

Characteristic Total Sample Intervention Control p Value

63.98 64.04 63.93
Age, mean, standard deviation (STD) 0.94
(STD 6.71) (STD 6.78) (STD 6.72)
Male sex 74 38 36 0.64
Tumor stage 0.64
3 44 21 23
4 48 25 23
25.55 24.94 26.15
BMI, mean, standard deviation 0.25
(STD 4.63) (STD 4.1) (STD 5.09)
FOIS baseline range 1 to 3 1 to 3 1 to 3 0.64
FOIS score 3 months (range) 1 to 5 2 to 5 1 to 3 <0.000
FOIS score 6 months (range) 1 to 6 4 to 6 1 to 5 <0.000
FOIS score 9 months (range) 2 to 7 5 to 7 2 to 6 <0.000
FOIS score 12 months (range) 3 to 7 6 to 7 3 to 7 <0.000
PSS H&N Eating in Public baseline (range) 0 to 25 0 to 25 0 to 25 1
PSS H&N Eating in Public 3 months (range) 25 to 75 50 to 75 25 to 50 <0.000
PSS H&N Eating in Public 6 months (range) 50 to 100 75 to 100 50 to 75 <0.000
PSS H&N Eating in Public 9 months (range) 50 to 100 75 to 100 50 to 100 <0.000
PSS H&N Eating in Public 12 months (range) 75 to 100 75 to 100 75 to 100 <0.000
PSS H&N Normalcy of Diet baseline (range) 0 to 20 0 to 20 0 to 20 0.33
PSS H&N Normalcy of Diet 3 months (range) 30 to 70 50 to 70 30 to 50 <0.000
PSS H&N Normalcy of Diet 6 months (range) 50 to 100 80 to 100 50 to 70 <0.000
PSS H&N Normalcy of Diet 9 months (range) 60 to 100 90 to 100 60 to 90 <0.000
PSS H&N Normalcy of Diet 12 months (range) 80 to 100 90 to 100 80 to 100 <0.000
Curr. Oncol. 2024, 31 6863

4. Discussion
The patients randomized to perform prophylactic swallowing exercises had functional
swallowing and swallowing-related QOL outcomes that were significantly better than those
of the patients who were referred for swallowing assessment and treatment on an as-needed
basis after completing their treatment, according to this study of patients with laryngeal
cancer undergoing total laryngectomy. This study’s limited sample size could make it
harder to identify differences and result in just a partial reflection of the real variations.
To address this lack of difference more conclusively, greater research on the effects of
preventive swallowing exercises over time may be beneficial. It is yet unclear if the control
patients could catch up to the intervention patients in time and if the control patients with
persistent dysphagic symptoms who received swallowing evaluation and treatment after
the treatment for cancer was concluded were able to improve their swallowing function to
the level observed in the patients who had completed the prophylactic swallowing exercise
intervention. More research involving a larger patient population over a longer period of
time is required.
Through a prospective randomized controlled experiment, we examined the im-
pact of preventive swallowing exercises on swallowing outcomes in patients undergoing
total laryngectomy.
Exercise improves swallowing function; however, the exact process is unclear. Pa-
tients may exhibit edematous tissue and a progressive development of fibrosis. For some
people, fibrosis may manifest years after the end of their cancer treatment. In either case,
fibrosis causes problems with the swallowing structures’ ability to move and coordinate,
which in turn disrupts the effective and efficient bolus transport required for swallowing
function [26]. Exercise may help to reduce some of the parameters associated with fibrosis,
according to a recent study on the impact of exercise on wound healing and inflammation
reduction in mice [27]. Furthermore, by strengthening the nonfibrotic tissue to make up for
the fibrotic structures’ lack of mobility, the training of the swallowing structures may also
aid [28].
Also, these types of exercises improve the muscle tone and strength and altogether the
functionality of the tongue. The anatomy and physiology of the swallowing mechanism
undergo significant changes after a total laryngectomy, and the tongue, which plays a
crucial role in the oral phase of swallowing, needs to adapt. The capacity to adapt is
primarily linked to the tongue’s trophism. The tongue takes on a primary role in controlling
boluses, propelling them forward, and starting the pharyngeal phase of swallowing. The
tongue’s ability to collect and move food from the oral cavity into the oropharynx depends
on a healthy trophism. Exercises enhance tongue strength, coordination, and endurance,
being associated with higher tongue forces at all ages, directly impacting the quality of
swallowing [29].
A 2007 abstract from the Dysphagia Research Society Meeting by Carnaby-Mann et al.
that examined the impact of a behavioral swallowing training program on the preservation
of swallowing-related muscle composition is also worth mentioning. When comparing
patients who received behavioral swallowing treatment during head and neck cancer treat-
ment to controls, they discovered that the former group had a higher degree of swallowing
muscle preservation [30].
Established swallowing exercises were included for the intervention group, and the
combination of exercises was chosen to improve bolus transport, which is widely acknowl-
edged as the main dysphagic consequence that affects patients. We also used two validated
measures of swallowing function that were administered by clinicians. These measures
addressed the swallowing-related quality of life and the issues of being able to eat outside
the home and with others, as well as providing a detailed description of the patients’ oral
tolerance and intake and the need for complete or partial PEG use [31].
However, it is important to note some of this study’s limitations. We did not employ
an analysis of some of the patients’ parameters, such as the anthropometric parameters or
the type of diet or nutritional status of the patients before the surgery, subgroup analyses,
Curr. Oncol. 2024, 31 6864

and a multivariate analysis. Only the BMI is insufficient to characterize the whole status
of the patients, and this could have added to a better understanding of how the exercises
affect certain types of patients, which types benefit more from performing the exercises,
and how we can adapt them to patients that have a lower nutritional status, so a higher
risk of developing malnutrition.
We did not employ video–fluoroscopic assessments, which could have yielded a more
accurate gauge of the exercises’ impact on the swallowing function. Most practicing swal-
lowing clinicians consider video–fluoroscopy, also called a modified barium swallowing
examination, to be the preferred tool because it allows the real-time visualization of bolus
flow in relation to structural movement throughout the upper aerodigestive tract. Addi-
tionally, physicians can watch how different bolus textures, volumes, and compensatory
techniques affect the physiology of swallowing [32]. Even though the examination is clini-
cally useful, doctors need to be aware that a patient’s performance during the examination
might not be totally indicative of how they typically eat and drink. Treatment can be
applied systematically during and after the evaluation in accordance with the physiologic
swallowing problem when the video–fluoroscopy procedure is standardized, interpreted,
and reported by skilled clinicians utilizing standardized and validated metrics [33]. Video–
fluoroscopic swallowing examinations at the same time points could be beneficial for future
research to monitor any changes in swallowing function over time during the course of
swallowing treatment and to assess the progression of the condition [33].
A larger sample size would also have been necessary to address the crucial question
of how much and how often the exercises must be performed in order to produce a
benefit for swallowing. It may have also allowed us to predict which patients would
have benefited more from prophylactic swallowing exercises. Furthermore, as mentioned,
the small sample size might have made it more difficult for us to determine the precise
amount of the variations that were seen and to find statistically significant differences in
the swallowing function.
Even though this study’s outcomes are positive, we still need to be aware of the
substantial toll that undergoing total laryngectomy for the treatment of laryngeal cancer
has on our patients. Although the results of swallowing following treatment are obviously
improved by instituting a strict preventive swallowing regimen, we must remember the
additional burden this places on each patient and continue to be mindful of how much
some patients can or cannot handle.

5. Conclusions
In summary, at three, six, nine, and twelve months following the cancer treatment,
the patients who engaged in prophylactic swallowing exercises demonstrated significantly
improved swallowing outcomes. To build on these results and offer a more robust analysis
of the impact of preventive swallowing exercises on these patients, future research with a
bigger sample size is required.

Author Contributions: E.T.S.-D.—conceptualization, investigation, data curation, writing—original draft

preparation; R.G.—conceptualization, interpretation of data for the work, supervision; P.L.B.—methodology,
design of the work, acquisition of data; C.B.S.-A.—design of the work, software, drafting and critically
reviewing; B.P.T.—formal analysis, acquisition of data, drafting the work; S.A.R.—investigation,
acquisition of data, drafting the work; A.I.C.—interpretation of data, writing—review and editing;
R.A.I.—conceptualization, visualization, writing—review and editing; R.I.S.-N.—acquisition of data,
validation, critically reviewing. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: This study was approved by the institutional ethics committee
board of Coltea Clinical Hospital, number 5820/abcc, on 20th of March 2023.
Informed Consent Statement: Informed consent was obtained from all subjects involved in this study.
Curr. Oncol. 2024, 31 6865

Data Availability Statement: The data presented in this study are available in this article and on
request from the corresponding author.
Conflicts of Interest: The authors declare no conflicts of interest.

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