Head and Neck Cancer

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

Treatment for functional deficits associated with HNC addresses the specific needs of the individual and takes into account the treatment stage at which the patient presents. Interventions that enhance activity and participation through modification of contextual factors may be warranted even if the prognosis for improved body structure/function is limited.

Speech-Language Pathologists (SLPs) and audiologists consider a number of factors when formulating realistic and functional treatment plans within the context of the individual's overall medical/surgical treatment. Factors include the individual's age and educational level, social history and present social context, vocational history and current vocational status, and cultural and linguistic background.

Decisions about goals and treatment options are made in partnership with clients, families/caregivers, and other professionals involved in the person's care. Successful intervention often requires collaboration between SLPs, audiologists, and professionals from medical and surgical specialties as well as rehabilitation specialties and others who provide support to individuals with HNC. (See ASHA's resources on interprofessional education/interprofessional practice [IPE/IPP] and person- and family-centered care.)

Treatment should be conducted in the language(s) used by the person with HNC and by either a bilingual clinician or via collaboration with trained interpreters, when necessary (see ASHA's Practice Portal page on Bilingual Service Delivery and Collaborating with Interpreters, Transliterators, and Translators).

It is also important to be sensitive to cultural influences and family expectations regarding treatment decision making, the determination of who makes these decisions, and the value of and adherence to recommended intervention (see ASHA's Practice Portal page on Cultural Competence).

Consistent with the WHO (2001) framework, intervention is designed to

  • capitalize on strengths and address weaknesses related to underlying structures and functions that affect communication;
  • facilitate the individual's activities and participation by helping the person acquire new skills and strategies; and
  • modify contextual factors that serve as barriers and enhance facilitators of successful communication and participation, including development and use of appropriate accommodations.

Depending on assessment results, intervention addresses

  • effective and intelligible communication to support the individual's functional daily communication needs;
  • optimal methods/techniques to maximize swallowing safety and the efficiency of oral intake to minimize the risk of pulmonary complications and nutritional deficits;
  • support for, or return to, safe and efficient oral intake (including incorporating the patient's dietary and lifestyle preferences);
  • audiology services as needed for identified hearing loss or balance problems (e.g., hearing aids, hearing assistive technology, balance therapy); and
  • cognitive and communication demands of relevant social, academic, and/or vocational tasks to facilitate performance of those tasks.

Treatment Considerations

SLP intervention can be preventive (e.g., swallowing treatment in individuals undergoing chemoradiation to minimize swallowing impairment and the impact of fibrosis and to improve functional swallowing outcomes [Carnaby-Mann, Crary, Schmalfuss, & Amdur, 2012; Hutcheson et al., 2013; van der Molen et al., 2011]) or direct (e.g., therapy to address deficits in communication, swallowing, and cognition). A large of part of HNC management also includes educating and counseling the individual and the family.

Several factors influence the nature, scope, and duration of SLP management, including

  • structures affected (e.g., larynx only vs. tongue only);
  • type and extent of medical/surgical management (e.g., timing of postsurgical intervention impacted by healing from surgery);
  • need for reconstruction after surgical ablation of tumors;
  • time of patient presentation (pre-surgical, immediate postoperative, outpatient therapy, and long-term maintenance/follow-up); and
  • impact of pain, nutritional compromise, cognition, and respiratory status.

Treatment Options

Communication

Exercise Training

Postoperatively, exercise-based (resistance) training is targeted at improving strength and range of motion of oral structures to improve articulatory precision, combat the effects of trismus, and improve patient-related quality of life (Lazarus et al., 2013, 2014). Examples include the following:

  • Exercises targeting jaw opening for speech production
  • Tongue strengthening (e.g., active resistance in anterior and lateral directions against an external device/object) and range-of-motion exercises for articulatory precision
Alaryngeal Speech

Alaryngeal speech targets the production of speech using a sound source other than the larynx and may include use of

  • an electrolarynx;
  • esophageal speech; and/or
  • tracheoesophageal speech.

Each of these options has its own benefits and drawbacks. Specific recommendations need to take into account the individual's communication needs, physical and mental status, and personal preference.

Timing of voice restoration depends on the extent of surgical resection and reconstruction, previous radiation, and preference of the surgeon and institution. See ASHA's video resource, Alaryngeal Speech Options After Total Laryngectomy (Messing, 2016).

Comparison of Alaryngeal Speech Options

 

Artificial Larynx

Esophageal Speech

Tracheoesophageal Speech

Mechanism An external mechanical sound is introduced into the vocal tract. Air is introduced into the esophagus and then propelled through the pharyngoesophageal (PE) segment, which vibrates for sound production. A surgical puncture (known as a tracheoesophageal puncture [TEP]) is performed, creating a fistula tract between the trachea and esophagus that is fitted with a one-way prosthesis. This allows for the shunting of tracheal air into the esophagus; the tracheal air is then propelled through the PE segment to produce sound.
Technique Neck-placement electrolarynx is placed flush to the skin on the side of the neck, under the chin, or on the cheek. Sound is conducted into the oropharynx and is articulated normally. An intraoral device introduces sound into the posterior oral cavity via a small tube—the sound is then articulated normally. Intraoral devices are used for individuals who cannot achieve adequate sound conduction via external placement on the skin or in the immediate post-op period. Injection involves using the articulators to increase oropharyngeal air pressure, which, in turn, overrides the sphincter pressure of the PE segment, thereby insufflating the esophagus. Inhalation involves decreasing thoracic air pressure below environmental air pressure by rapidly expanding the thorax so that air insufflates the esophagus. The individual occludes the tracheostoma to direct air through the prosthesis into the esophagus for phonation. Hands-free valves are also available to allow appropriate patients to speak without using digital occlusion of the stoma.
Speech/Voice Quality Speech/voice quality is electronic or mechanical and is monotone, with limited variation of pitch. Voice can be rough; low in intensity/volume; wet in quality (not typically); and low in pitch. Utterance length is short. Speech/voice is similar to esophageal speech but with better utterance length; intelligibility and volume of speech are generally acceptable.
Advantages Rapid learning; earliest alaryngeal option (within 2–3 days post-op); does not interfere with acquisition of other forms of speech; loudness of speech is adequate; low-cost maintenance of device; can be used even when extent of surgery precludes use of the PE segment for phonation (e.g., gastric pull-up). Less conspicuous; hands free; nonmechanical sound; patient is independent of devices; there are no expenses for equipment; no further surgery is required. Air supply for speech is pulmonary; allows for natural phrasing of voice; patient has more acoustically normal speech; voice restoration often occurs within 2 weeks of surgery; this form of alaryngeal speech is the most intelligible and acceptable to listeners.
Disadvantages Dependence on batteries; mechanical sound; loss of hands-free speech; requires ongoing care and maintenance of device; voice quality is "mechanical"; may cause interference with oral movements if oral adapter is used; good manual dexterity is required to operate the device; intelligibility is reduced; voice is difficult for new listeners to understand. Low fundamental frequency (~ 65 Hz); short phrase duration; low acquisition rate; extended learning period; least natural/acceptable to listeners; least fluent option. Tract can be difficult for patient to maintain; requires ongoing cleaning and maintenance of valve; requires good manual dexterity for valve maintenance; can lead to aspiration with valve failure or tract enlargement; may require long-term care by an SLP; some items are high in cost.
Voice

Voice therapy may be indicated for individuals with HNC, secondary to surgical excision or other changes to the glottis (e.g., phonatory function) due to radiation. See ASHA's Practice Portal page on Voice Disorders.

Alternative and Augmentative Communication (AAC)

Both low-tech and high-tech AAC systems have been used with individuals with HNC—typically on a temporary basis in the acute postsurgical phase. However, the use of AAC systems can be a long-term option for individuals who have had extensive surgical resection, those who do not prefer traditional alaryngeal communication options, and those who have not been able to master any alaryngeal speech options.

See ASHA's Practice Portal page on Augmentative and Alternative Communication for further discussion of key issues.

Swallowing

For a complete discussion of the treatment of swallowing disorders, refer to ASHA's Practice Portal page on Adult Dysphagia. Specific considerations for HNC are discussed below.

Therapeutic Exercises

Therapeutic exercises typically focus on improving/maintaining the range of motion and strength of oropharyngeal and laryngeal musculature to maximize swallow safety and efficiency. Examples include laryngeal elevation exercises, Masako (tongue hold) exercise, Shaker (head-lifting) exercise, super-supraglottic swallow, and jaw range of motion, as indicated, as well as lingual isometric exercises. These exercises are typically used in preventative dysphagia treatment for patients undergoing radiation therapy to reduce impairment, maintain function, and assist in recovery.

Compensatory Techniques/Postural Modifications

Postural modifications help redirect movement of the bolus in the oral cavity and pharynx and help modify pharyngeal dimensions in a systematic way to reduce risk of aspiration and/or improve the efficiency of the swallow by facilitating bolus clearance. Examples of postural modifications include the head tilt, head rotation, head back, side lying, and chin tuck.

Swallow Maneuvers

Swallow maneuvers are specific strategies that clinicians use to change the timing or strength of particular movements of swallowing. Examples of swallow maneuvers include the supraglottic and super-supraglottic swallow, effortful swallow, and the Mendelsohn maneuver. Biofeedback (e.g., surface neuromuscular electromyography [sEMG]) has been used in conjunction with swallow maneuvers for some individuals with HNC to provide visual information during the swallowing process to ensure proper production of maneuvers.

Diet Modifications

Diet modifications include changes to the viscosity and texture of the food to allow for safer or more efficient oral intake. Examples include changing the viscosity of liquids or softening, chopping, or pureeing solid foods. Modifications of the taste or temperature may also be used to change the sensory input of the bolus.

Intraoral Palatal Prostheses

Palatal prostheses can be used to normalize pressures and movements in the intraoral cavity by providing physical support for individuals with structural deficits. Palatal prostheses may be used to improve speech, resonance and swallowing following HNC surgery. SLPs work closely with maxillofacial prosthodontists to determine contour of augmentation and may provide speech and swallow retraining after fitting of the prosthesis.

Three types of intraoral prosthesis are typically in used in individuals with variations of oral cancer:

  • palatal lift — aids in velopharyngeal closure by lifting the structurally intact but neurologically impaired soft palate.
  • palatal obturator — provides a barrier between the oral and nasal cavities to compensate for tissue loss in those who undergo hard palate resection; the intent is to prevent nasal air/bolus passage and to improve intra oral pressure.
  • palatal augmentation prosthesis — lowers the palatal vault in those who have had oral cancer resection such as hemi and/or total glossectomy with reconstruction.

Cognition

Cognitive change can be a significant complication in individuals with HNC following chemotherapy or radiation (Gan et al., 2011). For more information about treating cognitive-communication problems, see ASHA's resource on evaluating and treating communication and cognitive disorders.

Audiologic Management

Patients receiving treatment for HNC may experience decreased hearing ability and possible difficulty with balance and tinnitus. The timing of audiologic management is important, as patients often need time to heal and regain strength before they are ready for hearing services.

The management of hearing difficulties, balance, and tinnitus secondary to HNC may include

Counseling

Clinicians typically work directly with the individual who has HNC, but they also play a critical role in counseling his or her family, caregiver(s), and other significant persons about the nature of the disorder and the course of treatment.

The focus of counseling depends on when the consult takes place during the course of disease progression and management.

In the pre-treatment phase, counseling may

  • introduce the role of the audiologist and SLP in management;
  • provide an overview of communication, swallow, cognitive, and hearing changes associated with medical and surgical management;
  • discuss the typical type and timeline of rehabilitation; and
  • discuss the role of caregivers and support systems.

In the post-treatment phase, counseling may focus on

  • rehabilitative treatment needs and options;
  • motivation for participation in treatment;
  • prognosis; and
  • the value of participating in survivor and caregiver support groups.

Palliative Care and End-of-Life Issues in HNC

Palliative care is a team-based approach that focuses on symptom management and improving the quality of life for individuals with advanced disease processes and their families. SLPs are integral members of the palliative care team. They focus on meeting the individual's complex and evolving communication and swallowing needs to maintain optimal quality of life.

The pattern of functional decline in individuals at the end of life varies, depending on a person's diagnosis. SLPs need to understand the process of dying in order to understand the emotional and psychological issues faced by their patients and patients' family members. The wishes of the patient and family are paramount when considering end-of-life issues, and the role of the SLP extends only as far as the patient or family wishes. Patients and caregivers may not agree with clinical recommendations and may feel that these recommendations do not provide the best quality of life for their loved one.

Views of the natural aging process and acceptance of disability vary by culture. Cultural views and preferences may not be consistent with medical approaches typically used in the U.S. health care system, but such views must be recognized and respected. The clinician approaches clinical interactions with cultural humility and demonstrates sensitivity to social and cultural influences when sharing potential treatment recommendations and outcomes. See ASHA's Practice Portal page on Cultural Competence.

See ASHA's resource on end-of-life issues in speech-language pathology. See also ASHA's Practice Portal page on Adult Dysphagia for a discussion of treatment considerations related to swallowing and end-of-life issues.

Service Delivery

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

In addition to determining the type of treatment that is optimal for individuals with HNC, audiologists and SLPs consider other service delivery variables—including format, provider, dosage, timing, and setting—that may affect treatment outcomes.

  • Format: Whether a person is seen for treatment one-on-one (i.e., individual) or as part of a group. The format of service delivery for this population can include in-person and telepractice models.
  • Provider: The person providing treatment (e.g., SLP, trained volunteer, caregiver).
  • Dosage: The frequency, intensity, and duration of service.
  • Timing: The timing of intervention relative to the diagnosis—this includes timing of behavioral intervention in relation to surgical/physical management.
  • Setting: The location of treatment (e.g., inpatient, outpatient, home, community based).

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