Head and Neck Cancer

See the Assessment section of the Head and Neck Cancer Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives.

SLPs and audiologists do not diagnose head and neck cancer. The diagnosis is made by the physician based on

  • physical examination;
  • laboratory tests;
  • pathology reports;
  • instrumental examinations such as endoscopy or videofluoroscopy;
  • imaging such as computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI); and
  • histopathology studies such as biopsy.

Assessment of functional impairments in HNC requires a multidisciplinary approach involving medical, surgical, and rehabilitation disciplines. As integral members of the HNC team, the SLP and audiologist provide valuable information to assist in diagnosis of, and treatment planning for, disorders of speech, voice, resonance, swallowing, and cognitive-communication, and for hearing loss and vestibular problems. See ASHA's resource on interprofessional education/interprofessional practice (IPE/IPP).

Ongoing, periodic assessment is often needed following initial SLP and audiologic assessments to monitor changes in function (e.g., radiation-associated dysphagia; cognitive changes secondary to chemotherapy; hearing loss).

When assessing an individual with HNC, clinicians consider factors that help determine the scope of the assessment and the domains assessed, including the following:

  • Timing of the consult (e.g., pre-operative/pre-treatment; immediate postoperative; during recovery; during adjuvant (chemo)radiotherapy; during long-term maintenance; and during follow-up care)
  • Medical complexity and medical/surgical management of the cancer(s)
  • Associated conditions
  • Side effects of treatment

Person- and Family-Centered Care

Person- and family-centered care is a collaborative approach grounded in a mutually beneficial partnership among individuals, families, and clinicians. Each party is equally important in the relationship, and each party must respect the knowledge, skills, and experiences that the other brings to the process. This approach incorporates individual and family preferences and priorities and offers a range of services, including counseling and emotional support, providing information and resources, coordinating services, and teaching specific skills to facilitate communication. See ASHA's resource on person- and family-centered care.

Screening

Screening is completed prior to conducting comprehensive evaluations. Screening does not provide a detailed description of the severity and characteristics of deficits associated with the cancer but, rather, identifies the need for further assessment. Screening may result in recommendations for rescreening, comprehensive assessments, and/or referral for other examinations or services.

Audiologic Screening

Hearing screening and otoscopic inspection for impacted cerumen occur prior to screening for other deficits (e.g., cognition). If the individual wears hearing aids, the hearing aids should be inspected by an audiologist to ensure that they are in working order, and they should be worn by the individual during screening. Hearing screening is within the scope of practice for SLPs.

If the individual fails the hearing screening or if hearing loss is suspected, a referral for a full audiologic evaluation is necessary. In addition to hearing screening, audiologists may also screen for vestibular deficits as indicated. See the assessment section of ASHA's Practice Portal page on Hearing Loss – Beyond Early Childhood.

Speech, Language, Cognitive-Communication, and Swallowing Screening

The Position Statement on Screening for Head and Neck Cancer by the American Head and Neck Society (AHNS) indicates that "Presenting symptoms of these cancers vary by site of origin, but are usually characterized by noticeable alterations in normal functions of speech and swallowing" (AHNS, 2012; para. 1).

It is critical for SLPs to

  • be familiar with the functional changes (e.g., in speech, voice, swallowing) that might signal possible HNC;
  • recognize these changes when delivering speech and language services; and
  • make appropriate referrals as needed.

In addition to recognizing functional changes that might signal possible HNC, SLPs are also aware of, and screen for, deficits following treatment for HNC.

These can include

  • changes secondary to surgery (e.g., speech deficits, changes in swallowing function, changes in voice that affect ability to communicate effectively) and
  • swallowing deficits and cognitive-communication deficits (e.g., working memory deficits) following chemotherapy and/or radiation therapy.

Comprehensive Assessment

Although SLPs and audiologists do not diagnose HNC, in order to guide appropriate assessment, they need a clear understanding of the individual's

  • medical assessment;
  • physical condition;
  • course of medical/surgical/rehabilitative treatment recovery; and
  • the nature/effects of the damage by the malignant lesions.

Consistent with the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2016a; WHO, 2001), comprehensive assessment is conducted to identify and describe

  • impairments in body structure and function, including underlying strengths and weaknesses in communication, swallowing, hearing, and balance;
  • co-morbid deficits or health conditions, such as metastatic tumors;
  • limitations in activity and participation, including functional communication and interpersonal interactions;
  • contextual (environmental and personal) factors that serve as barriers to or facilitators of successful communication and life participation; and
  • the impact of communication, swallowing, and cognitive impairments on quality of life: determining functional limitations relative to the individual's premorbid social roles and abilities and the impact on his or her community.

See ASHA's resource on the International Classification of Functioning, Disability, and Health (ICF) for examples of handouts featuring assessment data consistent with ICF .

The focus of the comprehensive assessment varies depending on the timing of the assessment.

Pre-treatment assessment focuses on

  • obtaining a baseline of communication skills and determining current and future functional needs (e.g., for returning to work);
  • recording the individual's voice for possible later use in speech generating devices;
  • providing education and counseling regarding anticipated changes in communication (including hearing) and swallowing as well as therapy needs; and
  • obtaining a baseline audiogram prior to chemotherapy or radiation to monitor for possible hearing changes related to ototoxicity.

Post-treatment assessment focuses on

  • obtaining a detailed description of the individual's current function and needs, based on the surgical resection or (chemo)radiotherapy treatment;
  • conducting a dynamic assessment that may include trials of compensatory communication systems (e.g., use of esophageal speech, electrolarynx, a speaking valve in individuals with tracheostomy, augmentative and alternative communication [AAC] systems);
  • conducting training trials in the care and use of a tracheoesophageal voice prosthesis; and
  • reassessing hearing and vestibular function.

Assessment may result in

  • Diagnosis of resulting functional deficit in speech, swallowing, voice, resonance, cognition, hearing, or balance
  • Description of the characteristics and severity of the disorder(s)
  • Statement of prognosis and recommendations for intervention that relates to overall communication adequacy, including AAC measures as needed
  • Recommendations for a multitiered system of supports
  • Identification of contextual factors that serve as barriers to or facilitators of successful communication and life participation
  • Recommendations for appropriate means of nutrition (oral vs. non-oral) and specific oral intake and strategies to facilitate safe and efficient eating/drinking
  • Recommendations for audiologic services (e.g., hearing aids, hearing assistive technology, balance therapy)
  • Determination of the impact of speech, language, cognitive-communication, swallowing, hearing, or balance impairments on quality of life and functional limitations relative to premorbid social roles and abilities for the individual and the impact on his or her community

Assessment is conducted in the language(s) used by the person, with sensitivity to cultural and linguistic variables. Accommodations and modifications can be made to testing procedures. Documentation should include descriptions of these accommodations and modifications, and scores from standardized tests should be interpreted and reported with caution. See ASHA's Practice Portal pages on Bilingual Service Delivery, Collaborating With Interpreters, Transliterators, And Translators, and Cultural Competence.

SLP Assessment

The comprehensive assessment of communication and swallowing abilities typically includes the following components (see box below).

Case History

  • Medical history, including exposure to risk factors, tumor staging details, and surgeries and other treatments
  • Medical plan of care—curative versus palliative
  • Current medications and side effects
  • Nutritional status
  • Personal information, including occupation and education
  • Cultural and linguistic background
  • Presence of support by significant other and/or other family member(s)

Self-Reported Areas of Concern

  • Functional communication success
  • Communication difficulties
  • Contexts of concern (e.g., social interactions, work activities)
  • Swallowing difficulties
  • Psychosocial impact of condition on individual and family/caregiver
  • Individual's goals and preferences
  • Report of sensory changes (e.g., hearing changes, dryness or pain in the throat)

Sensory and Motor Status

  • Sensory and motor skills—relevant for determining capacity for nonspeech communication methods, if needed

Oral-Peripheral Examination

  • Structural integrity, including oral mucosa and dentition
  • Functional integrity, including strength, speed, and range of motion of oral musculature
  • Symmetry and movement of structures of the face, oral cavity, head, neck, and respiratory system while at rest and while speaking and swallowing
  • Movement and sensation of oral and facial structures
  • Chemo-sensation (i.e., taste and smell)

Respiration

  • Respiratory pattern (abdominal, thoracic, clavicular)
  • Coordination of respiration with phonation (breath-holding patterns, habitual use of residual air, length of breath groups)
  • Presence of tracheostomy tube, type of tube, size of tube, presence of cuff

Voice and Resonance

  • Auditory-Perceptual Assessment (Subjective)
    • Voice Quality—including roughness, breathiness, strain, pitch, and loudness
    • Phonation—including voice onset/offset and ability to sustain voice during speech
    • Resonance—normal, hyponasal, hypernasal, cul-de-sac
  • Instrumental Assessment
    • Laryngeal Imaging—measures of structure and gross function (using videoendoscopy) and measures of vocal fold vibration during phonation (using videostroboscopy)
    • Acoustic Assessment—objective measures of vocal function related to vocal loudness, pitch, and quality
    • Aerodynamic Assessment—measures of glottal aerodynamic parameters required for phonation
    • Resonance Assessment—including objective measures of nasality using a nasometer

See the assessment section of ASHA's Practice Portal page on Voice Disorders.

Articulation and Speech Intelligibility

  • Identify salient features of the individual's speech that aid in treatment planning.
  • Examine influence of stress and/or fatigue on verbal communication (e.g., influence of physiologic and contextual factors).
  • Assess articulation and speech intelligibility using
    • production of increasingly complex linguistic stimuli—phonemes, syllables, single- and multisyllable words, and sentences—and
    • connected speech in different tasks (speaking and reading) and contexts (social, educational, or vocational).
  • Conduct an assessment for alaryngeal speech, if appropriate.

Swallowing

  • Assessment of diet level, weight change, and current nutritional status to establish baseline prior to medical/surgical management.
  • Instrumental assessment (Pauloski et al., 2000; van der Molen et al., 2009)
    • Pre-treatment instrumental assessment
      • helps determine risk for post-treatment dysphagia—results may influence decisions regarding treatment
    • Flexible endoscopic evaluation of swallowing (FEES) for individuals with HNC
      • offers optimal visualization of the tumor, reconstructed anatomy, and effects on swallowing;
      • allows assessment of palatal function in patients with palatal resections and inspection of secretion management; and
      • helps assess secretion management.
    • Videofluoroscopic swallow study (VFSS) for individuals with HNC
      • helps assess oral phase deficits;
      • provides information about pharyngeal phase, including physiological deficits, the presence of aspiration and residue, and the use of compensatory strategies to eliminate aspiration and improve bolus clearance/reduce residue;
      • provides insight into esophageal aspects of swallowing; and
      • is more appropriate in patients who cannot tolerate the endoscope due to type of cancer.

See the assessment section of ASHA's Practice Portal page on Adult Dysphagia for more details.

Cognitive-Communication

  • Evaluate memory, attention, problem-solving, and executive skills in the context of functional communication.

See the assessment section of ASHA's Practice Portal page on Traumatic Brain Injury in Adults and ASHA's resource on evaluating and treating communication and cognitive disorders.

Assessment for AAC

  • Assess readiness/willingness to use AAC systems
  • Evaluate best-suited AAC system

See the assessment section of ASHA's Practice Portal page on AAC for more details on assessment for AAC.

Identification of Contextual Barriers and Facilitators

  • Facilitators—including ability and willingness to use compensatory techniques and strategies, including AAC systems; family support; and motivation to return to prior level of function
  • Barriers—including reduced confidence in verbal communication; cognitive deficits; and visual and motor impairments

Audiologic Assessment

The comprehensive audiologic assessment typically includes the following components:

  • Case history
  • Otoscopic examination
  • Acoustic immittance testing
  • Pure-tone audiometry—includes ultra-high frequencies (i.e., above 8000 Hz) where changes in hearing typically first occur
  • Bone-conduction measures
  • Speech audiometry
  • Word recognition

Vestibular testing may also be indicated.

For details, see the Assessment sections of ASHA's Practice Portal pages on Hearing Loss – Beyond Early Childhood, Balance System Disorders, and Tinnitus and Hyperacusis

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.