The clinical application of the 100 mL water swallow test in head and neck cancer Joanne M. Patterson a,⇑ , Anthony Hildreth b , Elaine McColl c , Paul N. Carding d , David Hamilton e , Janet A. Wilson c a Macmillan Speech & Language Therapist, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, UK b Northumbria University, Newcastle Upon Tyne, UK c Institute of Health & Society, Newcastle University, Newcastle Upon Tyne, UK d Speech & Language Therapy, Freeman Hospital, Newcastle Upon Tyne, UK e ENT Department, Sunderland Royal Hospital, UK article info Article history: Received 23 September 2010 Received in revised form 29 November 2010 Accepted 29 November 2010 Available online 12 January 2011 Keywords: Swallowing Assessment Head and neck cancer Chemoradiotherapy Aspiration Radiotherapy summary Water swallow tests have been used as to screen patients with neurological dysphagia who are at risk of aspiration. This study examines the clinical utility of the 100 mL water swallow test (WST) in head and neck cancer, by measuring its sensitivity and specificity for identifying aspiration and for monitoring swallow performance up to one year following (chemo)radiotherapy. Patients referred for (chemo)radiotherapy were assessed on the WST (n = 173) pre-treatment and 3, 6 and 12 months post-treatment. Patients failed the test if they coughed or had a wet voice quality post swallow or were unable to finish the task. A Flexible Endoscopic Evaluation of Swallowing was conducted at the same time points, to test for the presence of aspiration. The WST was timed and the number of swallows required was recorded. Sensitivity of the WST for predicting aspiration was >67%, specificity >46%. There was marked deteri- oration from pre- to 3 months post-treatment for the time taken to drink 100 mL (p = 0.005), but this improved over the first year (p = 0.001). Disease characteristics, patient demographics, radiotherapy dose, or treatment volume were not predictors of this improvement. The 100 mL WST is a quick and simple assessment for identifying patients with aspiration, post (chemo)radiotherapy. This test is a useful adjunct to a clinical examination, helping to highlight patients who require an instrumental assessment such as videofluoroscopy. Furthermore, quantitative measures can be derived from this test, which can be used as a measure of swallow performance over time. Ó 2010 Elsevier Ltd. All rights reserved. Introduction Dysphagia is not only a symptom of head and neck cancer (HNC) but is a common side effect of its treatment. A clinical or bedside swallow assessment is the first step in identifying whether dysphagia is present. Research has shown that the reliability of a clinical assessment can be improved by using a water swallow test (WST). 1 Much of what has been published on WSTs focuses on the identification of aspiration in patients with neurological condi- tions, whereas the HNC dysphagia literature predominantly reports on instrumental tests such as videofluoroscopy. To date there is no validated non-instrumental swallow assessment for the HNC patient population. A simple swallowing test would be clinically useful for initial identification of patients who require a further instrumental examination. Furthermore, evidence suggests a wide variation in the recovery of swallowing in the post- treatment period, in those patients treated with radiotherapy, with some studies reporting an improvement, no change or deteriora- tion. 2–6 Therefore a simple swallow test, using quantitative mea- sures, would be desirable so that clinicians can also monitor performance over time. The 100 mL WST 7 is a timed test, from which measures of swal- low volume (mLs per swallow) and capacity (mLs per second) can be derived. This test has a sensitivity and specificity of 85% and 50% for detecting swallow dysfunction in stroke patients. 8 Its use as a simple assessment for the presence of aspiration in HNC patients has not been reported. In a previous paper we showed that, at diag- nosis, patients with HNC have significantly impaired swallow per- formance on the 100 mL WST, 7 when compared with a non- dysphagic sample. Those with advanced tumours had poorer scores, with a trend for the pharyngeal cancer group to perform worse than other sites. Gender was an important variable in the HNC and non-dysphagic group, with males having greater swallow volume and capacity than females. In this paper, we now look to explore the 100 mL WST’s value as a measure of post-treatment swallowing performance. The aim of this study was to (1) investigate the sensitivity and specificity of 1368-8375/$ - see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.oraloncology.2010.11.020 ⇑ Corresponding author. Tel.: +44 191 5699009. E-mail address: joanne.patterson@ncl.ac.uk (J.M. Patterson). Oral Oncology 47 (2011) 180–184 Contents lists available at ScienceDirect Oral Oncology journal homepage: www.elsevier.com/locate/oraloncology