Nicole Pizzorni, Francesco Mozzanica, Luca Roncoroni, Letizia Scarponi, Antonio Schindler, Department of Biomedical and Clinical Sciences “L. Correspondence to: Antonio Schindler, MD, Department of Biomedical and Clinical Sciences “L.
The swallowing mechanism requires the coordinated movements of several structures of the head and neck region; it is therefore not surprising that diseases of the mouth, pharynx, larynx and cervical spine can lead to dysphagia. The swallowing mechanism requires the coordinated movements of several structures of the head and neck region[1]; it is therefore not surprising that diseases of the mouth, pharynx, larynx and cervical spine can lead to dysphagia, that is the impairment in bolus transit from the mouth to the stomach[2]. Dysphagia can be due to the tumor itself, to its treatment or, more rarely, to associated diseases, such as Parkinson’s or stroke. A large number of surgical procedures are available to treat head and neck cancer, depending on the tumor site, on its extension and on the patient’s age and general conditions. After marginal glossectomy or hemiglossectomy, swallowing impairment is mainly characterized by alterations of oral control and of lingual peristalsis, due to clumsiness in the tongue movement and difficulties in triggering the swallowing reflex.
After surgery of oro-pharyngeal tumors, both oral and pharyngeal phases of swallowing are impaired. After partial laryngectomies, particularly horizontal partial laryngectomies, significant alterations of swallowing are inevitable and compensatory mechanisms, lasting several months, are necessary to restore it[22-24]. After total laryngectomy, swallowing is usually well preserved as the respiratory and digestive tracts are entirely separated. Neck dissection is often necessary in head and neck cancer treatment because of the neck metastasis. Chemo-radiotherapy can be used in the treatment of head and neck cancer with a curative intent, as an adjuvant to surgery or with a palliative intent in order to provide symptomatic relief. Candidiasis: candidiasis is a common opportunistic fungal infection frequently seen in infants and in dental wearers. Tonsillitis and peritonsillar abscess: acute tonsillitis is a common inflammatory process of the tonsillar tissue frequently seen in school-aged children (Figure 4). Acute epiglottitis: this rare condition results from an infection of the epiglottis and surrounding structures that may potentially cause an acute airway obstruction.
Ludwig's angina: this potentially fulminant cellulitis of the mouth flor presents an acute onset and spreads rapidly bilaterally affecting the sublingual, submandibular and parapharyngeal spaces.
Systemic infectious disorders: not infrequently, systemic infectious diseases may determine dysphagia.
Isolated cranial nerve deficits can affect the facial nerve (CN VII), hypoglossal nerve (CN XII), glossopharyngeal nerve (CN IX), vagus nerve (CN X), leading to dysphagia. Dysphagia is common in both UVFP and BVFP as glottis closure, ensured by vocal cord abduction, allows airway closure during bolus passage and effective cough. Swallowing impairment and prognosis depend on paralysis etiology: as VFP recover swallowing is usually restored. Cranial nerve deficits may not only be an isolated deficits but also multiple cranial nerve deficits exist. Bolus transit from the mouth to the esophagus may be impaired because of non-oncological obstructions; these include foreign bodies, hypo-pharyngeal polyps, cervical osteophytes and complications of anterior spine surgery. Foreign body ingestion is particularly common in patients with intellectual disability and occurs mainly in the pediatric population, but it may occur in adults as well[65].
Hypopharyngeal polyps are a very uncommon disease and only few cases of hypopharyngeal polyps have been reported in recent years[67-68]. Cervical osteophytes is a common clinical feature, occurring in up to 30% of the population[70]; only in a small portion of individuals, however, cervical osteophytes impinge sufficiently in the pharynx to induce obstruction. Zenker's Diverticulum (ZD) is an hypopharyngeal pouch herniating in the posterior part of the pharynx in the so called Killian’s dehiscence. Achalasia or cricopharyngeal spasm, cricopharyngeal incoordination or congenital weakness are implicated in the pathogenesis of ZD[79-81].
The treatment for ZD is indicated for all symptomatic patients with or without associated complications and is invariably surgical in nature. Dysphagia due to diseases and disorders of the head and neck area represent a smaller portion of oro-pharyngeal dysphagia compared to neurological diseases; although each disorder per se is relatively rare, the combination of all clinical situation represents an important group of clinical conditions that can not be overlooked. Campisi G, Compilato D, Di Liberto C, Di Fede O, Pizzo G, Falaschini S, Lo Muzio L, Craxi A.
Genden EM, Ferlito A, Silver CE, Jacobson AS, Werner J, Suarez C, Leemans CR, Bradley PJ, Rinaldo A. Genden EM, Ferlito A, Silver CE, Takes RP, Suarez C, Owen RP, Haigentz M Jr, Stoeckli SJ, Shaha AR, Rapidis AD, Rodrigo JP, Rinaldo A. Pauloski BR, Rademarker AW, Logemann JA, Stein D, Beery Q, Newman L, Hanchett C, Tusant S, MacCracken E. McConnel FM, Logemann JA, Rademaker AW, Pauloski BR, Baker SR, Lewin J, Shedd D, Heiser MA, Cardinale S, Collins S, Graner D, Cook BS, Milianti F, Baker T. Lango MN, Egleston B, Ende K, Feignferd S, D’Ambrosio DJ, Cohen RB, Ahmad S, Nicolaou N, Ridge JA.
Merlano M, Benasso M, Corvo R, Rosso R, Vitale V, Blengio F, Numico G, Margarino G, Bonelli L, Santi L. Merlano M, Vitale V, Rosso R, Benasso M, Corvo R, Cavallari M, Sanguinetti G, Bacigalupo A, Badellino F, Margarino G, Brema F, Pastorino G, Marziano G, Grimaldi A, Scasso F, Sperati G, Pallestrini E, Garaventa G, Accomando E, Cordone G, Comella G, Daponta A, Rubagotti A, Bruzzi P, Santi L. Wendt TG, Grabenbauer GG, Rodel CM, Thiel HJ, Aydin H, Rohloff R, Wustrow TP, Iro H, Popella C, Schalhorn A. Forastiere AA, Goepfert H, Maor M, Pajak TF, Weber R, Morrison W, Glisson B, Trotti A, Ridge JA, Chao C, Peters G, Lee DJ, Leaf A, Ensley J, Cooper J. Eisbruch A, Lyden T, Bradford CR, Dawson LA, Haxer MJ, Miller AE, Tekson TN, Chepeha DB, Hogikyan ND, Terrell JE, Wolf GT.
Agarwal J, Palwe V, Dutta D, Gupta T, Laskar SG, Budrukkar A, Murthy V, Chaturvedi P, Pai P, Chaukar D, D’Cruz AK, Kulkarni S, Kulkarni A, Baccher G, Shrivastava SK. Dornfeld K, Simmons JR, Karnell L, Karnell M, Funk G, Yao M, Wacha J, Zimmerman B, Buatti JM.
Caudell JJ, Schaner PE, Meredith RF, Locher JL, Nabell LM, Carroll WR, Magnuson JS, Spencer SA, Bonner JA.
Logemann JA, Pauloski BR, Rademaker AW, Lazarus CL, Mittal B, Gaziano J, Stachowiak L, MacCracken E, Newman LA. Pauloski BR, Rademaker AW, Logemann JA, Lundy D, Bernstein M, McBreen C, Santa D, Campanelli A, Kelchner L, Klaben B, Discekici-Harris M. Fountas KN, Kapsalaki EZ, Nikolakakos LG, Smission HF, Johnston KW, Gregorian AA, Lee, GP, Robinson JS.
Schindler A, Mozzanica F, Alfonsi E, Ginocchio D, Rieder E, Lenglinger J, Schoppmann SF, Scharitzer M, Pokieser P, Kuribayashi S, Kawamura O, Kusano M, Zelenik K. Feeley MA et al, Zeenker’s diverticulum: analysis of surgical complications from diverticulotomy and cricopharyngeal myotomy.
Although each disorder per se is relatively rare, the combination of all clinical situation represents an important group of clinical conditions that can not be overlooked. Their incidence and prevalence vary by geographical area, age, gender and site of the tumor. Signs of dysphagia prior to treatment were reported in up to 59% of the patients, because of the obstruction, of the nerve involvement and of the pain caused by the tumor; in particular, dysphagia occurs more often in pharyngeal tumors than in oropharyngeal or laryngeal malignancies and it worsen significantly with increased tumor stage[13-16]. Over time, patients treated primarily with surgical approach usually develop compensatory strategies and function was observed to improve thanks to the healing process and to the sensory recovery; however, the anatomic modifications consequent to surgery may cause different degrees of swallowing impairment.
When the tongue is sutured into the surgical defects, the patient may experience difficulties in oral control, in lingual peristalsis and in mastication. In particular, tongue propulsion will be reduced, patients may experience nasal regurgitation, the triggering of swallowing reflex may be delayed and the pharyngeal peristalsis may be reduced, leading to oral and pharyngeal residue.
Because of the tumor resection, laryngeal anatomy is severely modified and glottis closure impaired (Figure 1). Nonetheless, oropharyngeal dysphagia may arise due to pharyngeal-esophageal stenosis, which may occur after large resections or as a consequence of adjuvant radiotherapy. Neck dissection may impact on swallowing function as several muscular and nerve structure involved in swallowing may be damaged, leading to a prolonged tube feeding dependence[25-26]. The overall survival rate for locally advanced head and neck cancer increased thanks to the application of concomitant chemo-radiotherapy protocols[27-35]. In particular, xerostomia, often lasting several years, may impair oral functions because of insufficient wetting and decreased bolus lubrication and significantly impact on patients’ perception of dysphagia[42]. For what it concerns the oral phase, the following anatomo-physiological deficits can be found: reduced mouth opening, reduced range of lingual motion, reduced lingual strength, impaired bolus formation and transport through the oral cavity, prolonged oral transit time and increased oral residue. The more common head and neck infctions are: candidiasis of the oral mucosa, acute epiglottitis, Ludwig’s angina, Vincent’s angina, major aphthous ulcer, tonsillitis, peritonsillar abscess, herpes zoster and systemic infectious disorders such as acquired immunodeficiency syndrome and tetanus.

The disease can occur also in patients with chronic oral steroid therapy, patients with diabetes mellitus or cellular immune deficiency states such as cancer or human immunodeficiency virus (HIV) infection.
Both viral and bacterial agents can determine the disease that may lead to inflammatory changes of the mucosal surfaces with secondary pain and dysphagia. The most common pathogen is Haemophilus influenzae type b but also Streptococcus pyogenes, Streptococcus pneumonia, Staphilococcus aureus, Herpes simplex virus, Candida albicans and non-infectious insults, such as thermal damage, may play a role in the genesis of this disease (especially after the introduction of the HIB vaccine)[49].
The progressive swelling of the soft tissues and the elevation and posterior displacement of the tongue against the palate and into the hypopharynx, may result in airway obstruction. The infectious process presents with trismus, risus sardonicus, muscle rigidity, often seen in the nuchal and pharyngeal musculature, dysphagia, odynophagia and spasms. Glottal incompetence results in aspiration or penetration with onset of coughing or choking during liquid intake.
Behavioural treatment of dysphagia is generally indicated to compensate altered swallowing mechanism: head turn or head tilt direct the bolus down the unaffected side of pharynx.
Unilateral palsy of nerves IX, X and IXX is called Collect- Sicard syndrome[62] and is due to diseases affecting the jugular foramen as metastasis to lymphnode, fractures of the occipital bone and internal carotid artery dissection.
The vast majority of the hypopharyngeal and esophageal polyps reported in literature were of giant size (>5 cm), but smaller polyps may be also present (Figure 6). Cervical osteophytes are typical of the aged population and may develop after trauma, even though often occur as a sign of general spinal degeneration, called Forestier diesases or diffuse idiopathic skeletal hyperostosis; in some cases they impact on the larynx causing dyspnea or dysphonia, because of impact on vocal fold movements. In the immediate post-surgical treatment dysphagia may arise as a complication in up to 50% of the population 1 month after surgery[74-75]. This is a triangular area of muscular weakness that plays an important role in the diverticulum development and is located between the oblique fibers of the inferior constrictor and the transverse fibers of the cricopharyngeal muscle below[77]. Even though a wide variety of abnormalities in UES function have been described, the most widely accepted theory is that inadequate UES relaxation causes an high intra-bolus pressure[83-84].
Videofluoroscopy is to be preferred to the static film, mainly because dynamic images are essential in the evaluation of the dysphagia severity through the analysis of aspiration timing and extension. Exceptions to this can be considered morbidly ill patients, patients with small diverticulum, and patients with minimal symptoms. Head and Neck disorders may impair swallowing through different mechanisms; symptoms, dysphagia severity, treatment options and prognosis for this variety of clinical situations vary enormously. Current trends in initial management of oropharyngeal cancer: the declining use of open surgery. Long-term voice and swallowing modifications after supracricoid laryngectomy: objective, subjective, and self-assessment data. Pretreatment organ function in patients with advanced head and neck cancer; clinical outcome measures and patients views.
Surgical variables affecting postoperative swallowing efficiency in oral cancer patients: a pilot study. Impact of neck dissection on long-term feeding tube dependence in patients with head and neck cancer treated with primary radiation or chemoradiation. Five-year update of a ?randomized trial of alternating radiotherapy and chemotherapy compared with radiotherapy alone in treatment of unresectable squamous cell carcinoma of the head and neck. Treatment of advanced squamous-cell carcinoma of the head and neck with alternating chemotherapy and radiotherapy.
Simultaneous radiochemotherapy versus radiotherapy alone in advanced head and neck cancer: A randomized multicenter study.
Chemotherapy added to locoregional treatment for head and neck squamous-cell carcinoma: three meta-analyses of updated individual data. An intergroup phase III ?comparison of standard radiation therapy and two schedules of concurrent chemoradiotherapy in patients with unresectable squamous cell head and neck cancer. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. Long-term swallowing problems after organ preservation therapy with concomitant radiation therapy and intravenous hydroxyurea. Objective assessment of swallowing dysfunction and aspiration after radiation concurrent with chemotherapy for head-and-neck cancer.
Impact of demographics, tumor characteristics, and treatment factors on swallowing after (chemo) radiotherapy for head and neck cancer. Objective assessment of swallowing function after definitive concurrent (chemo)radiotherapy in patients with head and neck cancer.
Radiation doses to structures within and adjacent to the larynx are correlated with long-term diet- and speech- related quality of life. Factors associated with long-term dysphagia after definitive radiotherapy for squamous cell carcinoma of the head and neck.
Xerostomia: 12-month changes in saliva production and its relationship to perception and performance of swallow function, oral intake, and diet after chemoradiation. Swallowing dysfunction—preventative and rehabilitation strategies in patients with head and neck cancers treated with surgery, radiotherapy, and chemotherapy: a critical review. Relation of mucous membrane alterations to oral intake during the first year after treatment for head and neck cancer. Evaluation of bilateral vocal fold dysfunction: paralysis versus fixation, superior versus recurrent, and distal versus proximal to the laryngeal nerves.
Vocal cord medicalization for unilateral paralysis associated with intrathoracic malignancies. Dysphagia and aspiration with unilateral vocal fold immobility: incidence, characterization and response to surgical treatment. A case of Collet-Sicard syndrome associated with traumatic atlas fractures and congenital basilar invagination.
Basal fracture of the skull and lower (Ix, X, XI, XII) cranial nerves palsy: four case reports including two fractures of the occipital condyle. Cervical osteophytes impinging on the pharynx: importance of size and concurrent disorders for development of aspiration. National and regional rates and variation of cervical discectomy with and without anterior fusion, 1990-1999. Risk factors for dysphagia after anterior cervical spine surgery: a two-year prospective cohort study. Structural abnormalities of the cricopharyngeus muscle in patients with pharyngeal (Zenker’s) diverticulum. Association between Zenker diverticulum and gastroesophageal reflux disease: development of a working hypothesis. Timmerman, Department of Family Medicine, Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands. Self-perception of dysphagia is usually high as the impairment often involves the oral phase or is due to pain or obstruction. Self-perception of dysphagia is usually high as the impairment often involves the oral phase or is due to pain or obstruction; this criterion does not apply to dysphagia associated to silent aspiration only which could occur after laryngeal surgery[4]. Amplitude and site of resection are the main factors influencing the severity of dysphagia and the recovery time[17-19]. When the lingual resection exceeds 50% of the tongue, lingual peristalsis and control of bolus in mouth are often severely reduced. Upper esophageal sphincter spasm may also arise leading to difficulty mainly with solid foods (Figure 3).
Swallowing alterations after neck dissection are typically related to recurrent laryngeal nerve injury and suprahyoid muscle resection, causing a lower rest position of the hyoid bone, a decreased hyoid bone elevation and a higher percentage of penetration.
Impairment of pharyngeal stage can be due to: reduced tongue base posterior movement with consequent reduction of tongue-base contact with the posterior pharyngeal wall, defective velopharyngeal closure, reduced pharyngeal contraction, reduced laryngeal elevation, reduced glottis and laryngeal vestibule closure and reduced opening of the upper esophageal sphincter. Approximately 80% of the patients undergoing a radiation treatment experience acute mucositis, both during treatment and in the first weeks after the treatment[45]. Other local infections including tuberculosis, diphtheria and gonorrhoea, that can determine local inflammatory changes responsible of swallowing impairments, are nowadays extremely rare. It is also not uncommon after radiotherapy, use of antibiotics that disrupted the normal oral flora or in patients who have undergone immunocompromising treatments.
Diagnosis of acute tonsillitis is clinical, and it can be difficult to distinguish viral from bacterial infections[47]. Clinical features of acute epiglottitis include stridor, dyspnea, hoarseness, fever, sore throat, odynophagia, dysphagia, drooling, and cervical lymphadenopathy. The majority of cases are related to dental infections (the second and third molars are frequently involved), even if also traumatic events, foreign bodies or spreading from other local infections may be implied[50]. These latters are overlaid on background rigidity, variable in duration, very painful and can be triggered by auditory, visual, tactile and emotional stimuli[53].

The Vagus nerve splits into a sensitivity component (superior laryngeal nerve) which provides sensibility to the epiglottis, false vocal folds and pyriform sinus, and a motor division which controls motor skills of laryngeal (recurrent laryngeal nerve) and contributes to the pharyngeal plexus. Kraus and al(1996) in accord to Hirano and Bless (1993)[58-59] reported aspiration between 40%-53% of patients. Mendelsohn maneuver, laryngeal adduction exercises, supraglottic swallow technique and exercises to improve strength may be also indicated.
Progressive dysphagia and regurgitation of the mass into the mouth are the most common symptoms reported[69].
Dysphagia is usually due to mechanical obstruction and in some cases to impairment in epiglottic inversion (Figure 7); swallowing of solids is generally more compromised than semisolids or liquids[71]. Dysphagia is often due to retropharyngeal edema and decreased pharyngeal wall movement, impaired upper esophageal sphincter opening, incomplete epiglottic deflection and pharyngeal residue after swallow (Figure 8); symptoms are usually more evident with solids than with semisolids or liquids[76]. ZD is frequently related to a focal or systemic myositis, as confirmed by histological analysis, hiatal hernia and gastro-esophageal reflux disease[85]. An invariable association to ZD is cricopharyngeal bar, which consists in an indentation on the posterior hypopharyngeal wall visualized on videofluoroscopy (Figure 9). The treatment could be endoscopic, like the ESD (Endoscopic Staple-assisted Diverticulostomy) and laser diverticulotomy or it could be classically open like diverticulopexy or diverticulectomy with cricopharyngeal myotomy[86-90]. Clinicians involved in the management of oro-pharyngeal dysphagia should be aware of the different diseases of this area and build teams or connections with different medical specialists in order to guarantee the best treatment option for each patient. Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): an update of 93 trials and 17, 346 patients.
This review focus on the most common and important clinical conditions of the head and neck districts associated with dysphagia: head and neck cancer and impairments associated with its treatment, Zenker’s diverticulum, head and neck infections, cervical spine disorders and cranial nerves deficits. The 84-91% of the head and neck cancers are squamous cell carcinoma and they often metastasize to the neck lymph nodes[6].
Aspiration and pharyngeal impairment occur more often in patients with hypopharyngeal and laryngeal cancer; esophageal impairment is more frequent in patients with hypopharyngeal cancer[13,15]. Moreover, laryngeal sensation is often reduced because of superior laryngeal nerve function impairment; laryngeal elevation and upper esophageal sphincter opening may also be reduced and triggering of swallowing reflex can be delayed.
Its incidence varies according to different factors related to the treatment and to the patient, such as total radiation dose, fraction size, radiated volume, interfraction interval, treatment techniques (e.g. Moreover, a sensibility impairment following concomitant chemo-radiotherapy is often reported in literature, leading to a delayed or absent swallowing reflex. The pathogen more often responsible for candida infections is Candida albicans, a commensal micro-organism found to inhabit in the oral cavity in the majority of healthy individuals. Similarly, abscess formation in the perioral structures such as the tonsils, floor of mouth, buccal space, and retropharynx can also lead to inflammatory changes, oedema, and pain associated with severe dysphagia.
The bacterial agents more commonly isolated include: Streptococcus viridans, Staphylococcus epidermidis, Staphylococcus aureus and group A ?-haemolytic Streptococcus. The diagnosis is made by the clinical presentation (depends on the inoculation site, incubation and the time between the first symptom and the start of spasms) and a history of a prior wound. Vagal nerve deficits determines vocal fold paralysis and poor initiation of swallowing reflex. Modified bolus consistence, thickening liquids, slows transit increasing time to allow laryngeal closure. Vocal fold paralysis is often reported and seems to persist even after the dysphagia resolves[63]. The challenge for the dysphagia clinician is to determine whether the osteophytes are the cause of dysphagia or other pathologic processes impair swallow or both condition coexists, as it happens in most of the cases.
Both behavioral and surgical treatment are possible, although there is not enough evidence to know the efficacy of either option. However, the finding of the bar should not be taken as a certain proof that the bar itself causes the patient’s dysphagia. Endoscopic treatment should be preferred to the open ones in case of high-risk elderly patients. Treatment options for head and neck tumors generally have a curative intent and are represented by surgery and chemo-radiotherapy; recently, organ-sparing protocols combining radiotherapy, chemotherapy and surgery are increasingly used[7-9]. On the other hand, a longer oral and pharyngeal transit time and a greater amount of oral and pharyngeal residue are typical of oral and pharyngeal tumors[14]. Therefore, reduced bolus clearance, oral and pharyngeal residue and silent aspiration, typically post-deglutition, mostly characterize dysphagia after concomitant chemo-radiotherapy. Clinical presentation may vary but odynophagia is frequent and contributes to the genesis of the swallowing impairment. Clinical presentation is usually characterized by progressive difficulty of swallowing, odynophagia, dysphonia, trismus, extra-oral swelling and pain.
In addition, lack of appetite, odynophagia (frequently caused by oral, palatal and oesophageal opportunistic infections as esophageal candidiasis) or aphthous ulcers and change in taste may determine poor oral intake[52]. The course of the disease may be rapid in not vaccinated patients and death can occur by generalized muscle spasms and respiratory failure. Vocal fold paralysis can be unilateral or bilateral; in adults with vocal fold palsy most of cases are unilateral[54]. Some studies reveal dysphagia not only related to glottal insufficiency but also resulting in reduced hyolaryngeal movement, epiglottic and supraglottic structures closure and pharyngeal pooling[61]. The surgical treatment by itslef, in particular medialization procedure, does not seem to improve swallowing ability while it is useful to improve cough strength.
Dysphagia is due to both deficit in laryngeal closure and to pharyngeal paralysis with residue in the omolateral pirifom sinus (Figure 5). Although patients may benefit from behavioural treatment, only surgical removal allows resolution of the swallowing symptoms; however, surgical treatment should be limited to symptomatic cases and after exclusion of other mechanism of dysphagia[72]. The classical clinical presentation of ZD normally includes dyspshagia combined with a varying degrees of regurgitation, a symptom which commonly affect 80% of these patients. Indeed, the patient symptoms are often caused by other problems, not infrequently distal to the bar in the esophagus. This kind of therapy for ZD is based on the division of the septum between the diverticulum and esophagus, within which the cricopharyngeus muscle is contained (cricopharyngeal myotomy). Dysphagia and its complications (aspiration pneumonia and malnutrition) are common in patients with head and neck cancer, significantly impacting on quality of life[10-12]. However, oro-pharyngeal deficits persist because of the late toxicity of the pharyngeal-laryngeal mucosa, because of the fibrosis process and because of the neurological impairment. The swallowing impairment is the presenting symptom in more than half of the patients and is largely due to the oral and pharyngeal oedema. The medical treatment is often supportive with the use of sedative agents against the spasms and the removal of the source of infection. There is not information in literature regarding the treatment of dysphagia in Collect Sicard Syndrome because dysphagia often resolves treating the primary causes of cranial neuropathies. In addition to these, aspiration, chronic cough, alithosis and weight loss (in severe cases) can also be considered as common symptoms[78]. Many years after the chemo-radiation treatment, dysphagia may still occur, probably due to soft tissue fibrosis, peripheral neuropathy and sensibility deficits.
Medical and surgical management is focused on maintaining a patent airway and treating the infection. The mortality rate approach 10% and is related to airway compromise (more frequently), pneumonia, mediastinitis, septic shock or empyema[51]. In some cases it may be necessary to administer passive human tetanus immunoglobulin, followed by active immunization with the tetanus vaccine.
Unilateral vocal fold paralysis (UVFP) results in glottal insufficiency, which can determine change in vocal quality, dysphagia and weak cough[55]. When dysphagia persists, tongue resistance exercises[64] and compensatory technique may be useful. The diagnosis of Ludwig’s angina is made clinically, based on the physical findings of fever, neck and submandibular swelling, as well as elevation of the tongue. Imaging techniques and in particular the CT may be useful in order to determine the extent of the infection and the degree of airway compromise. The management of Ludwig's angina consists of airway stabilization and intravenous antibiotics.

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