Challenges in the diagnosis and management of coexisting drop-head syndrome and dysphagia: a case report and review of the literature

Background This paper presents a comprehensive diagnostic method for coexisting dropped head syndrome (DHS) and dysphagia, both associated with long-term complications of neck radiation. The symptoms reported are common after radiotherapy, but their co-occurrence, causal link, and the years since the initial treatments all contribute to the uniqueness of the case presented. A literature review on the topic is also included. Case presentation A 54-year-old White male presented with progressive neck extensor weakness consistent with dropped head syndrome (DHS), associated with dysphagia and voice changes, occurring 17 years after radiotherapy for Hodgkin’s lymphoma. A comprehensive clinical and instrumental evaluation, including a videofluoroscopic swallowing study (VFSS), electromyography (EMG), and magnetic resonance imaging (MRI), revealed mild-to-moderate dysphagia characterized by reduced swallowing efficiency, with residue in the valleculae and pyriform sinuses (> 50% occupancy) and a Penetration-Aspiration Scale score of 1 (no aspiration). The findings were consistent with postural and neuromuscular alterations involving the cervical region. Bolus clearance improved with manual head support. A structured 2-week rehabilitation program was associated with improved quality of life (as reported by improvement in the SWAL-QOL score) and stable nutritional status, though no objective physiological change was documented on the follow-up electromyographic exam. To our knowledge, this is the first work describing the importance of considering delayed-onset swallowing impairment associated with DHS in patients previously treated with radiotherapy for head-and-neck malignancies. Conclusions The co-occurrence of DHS and dysphagia, both related to long-term complications of neck radiation, necessitates a comprehensive diagnostic approach that is currently lacking in the relevant literature. Swallowing assessments and screenings should be standard procedures in the long-term follow-up of tumors affecting the head-and-neck regions. The study underscores the importance of considering neuromuscular pathophysiological and mechanical mechanisms in post-radiotherapy dysphagia.