The scope of this page is limited to malignant tumors in adults, located in and/or around the nose, paranasal sinuses, oral cavity, pharynx, larynx, and salivary glands. This resource does not discuss benign tumors of the head and neck region, skin cancers involving the head and neck, auditory nerve lesions, brain tumors, or cancer that has metastasized to this region from elsewhere in the body. This resource also does not address thyroid cancer. Thyroid cancer does not fall under the National Cancer Institute’s head and neck cancer (HNC) classification system, although some speech-language pathologists (SLPs) may consider it in this category given their evaluation and treatment approaches.
See the Head and Neck Cancer Evidence Map for summaries of available research on this topic.
HNC includes malignant tumors that most commonly arise from the moist squamous cell mucosa or lining of the head and neck regions. Although curative treatment may be different based on region and severity, some audiology and speech-language pathology interventions will be the same.
HNC is characterized according to the primary site of origin as malignancies of the
The most commonly used model for classifying HNC is the TNM staging model, which classifies the extent of cancer spread (Amin et al., 2017; Lydiatt et al., 2018). The TNM model assigns a numerical status (Stage 0, x, I, II, III, or IV) based on
Lymph node involvement is typically defined as a late-stage (III or IV) malignancy regardless of the size or location of the primary tumor (Amin et al., 2017; Lydiatt et al., 2017, 2018). This rule does not apply to HNC from human papillomavirus (HPV), as HPV-related tumors have their own staging system (Economopoulou et al., 2020).
Tumor staging and location, physiologic impact, and patient/care partner goals often determine the course of cancer treatment. The following factors help determine overall prognosis:
Cancer treatment may involve surgery, radiation therapy, and/or systemic therapy (i.e., chemotherapy, hormone therapy, and/or immunotherapy). Different surgery types (e.g., laser, TransOral Robotic Surgery [TORS], open surgical resection with or without reconstruction) and chemoradiation therapy regimens have different side effects and rehabilitation timelines. Such differences may affect intervention approaches, quality of life, and functional outcomes (Aggarwal et al., 2021; Zebralla et al., 2021).
Incidence of HNC refers to the number of new cases identified in a specified time period.
Prevalence of HNC refers to the number of individuals who are living with head and neck cancer in a given time period.
Globally, it is estimated that HNC accounts for approximately 880,000 to 1.1 million new cases of cancer annually, with approximately 400,000–450,000 deaths a year secondary to HNC (Bray et al., 2018; Mody et al., 2021; World Health Organization [WHO], 2020b). About 3.6% of all cancers are HNC in the United States, with approximately 65,000 Americans developing head and neck malignancies annually (Siegel et al., 2022). There are currently over 14,000 deaths related to HNC each year in the United States alone (Siegel et al., 2022).
Generally, regarding the association of gender assigned at birth to HNC, males are 2–7 times more likely to develop HNC than females, with variability noted depending upon the site of HNC (Dhull et al., 2018; Ferlay et al., 2015; Lorenzoni et al., 2022). In the United States, non-Hispanic White individuals are more likely to develop HNC than are all other races (Surveillance, Epidemiology, and End Results Program [SEER], 2021; U.S. Cancer Statistics Working Group [USCSWG], 2021b). U.S. statistics are reported below by type of HNC.
The incidence of HNC in the United States has been steadily increasing over the last 2 decades (Siegel et al., 2022; USCSWG, 2021b). This is, in part, due to the influence of the human papillomavirus (HPV). Currently, the estimated proportion of oropharyngeal cancers testing positive for HPV within the United States is 68%–70% (Centers for Disease Control and Prevention, 2020; Mashiana et al., 2021). Over 20,000 HPV-associated oropharyngeal squamous cell cancers are diagnosed annually within the United States according to data compiled by the USCSWG (2021a). Guo et al. (2022) found that HPV-associated oropharyngeal cancer rates are falling in young adults but continue to rise in individuals aged 45 years and older.
Presenting signs and symptoms of HNC vary based on location of the primary tumor, lymph node involvement, and subsequent metastases and may include the following:
Functional signs and symptoms can occur due to the disease itself or as a result of cancer treatment. Depending on the location of the malignancy and time of presentation along the continuum of medical and surgical management (i.e., prior to, during, or after treatment), signs and symptoms may include functional impairments in one or more of the following domains.
Reduced overall intelligibility resulting from one or more of the following:
See ASHA’s Practice Portal page on Voice Disorders for more details related to signs and symptoms of dysphonia.
In addition, the presence of a tumor in the palate can impede velar mobility, which can impact resonance. See Classification of Velopharyngeal Dysfunction [PDF] and ASHA’s Practice Portal page on Resonance Disorders.
The nature and severity of swallowing problems in HNC depend on tumor size and location, staging, and treatment protocol (e.g., the type of surgical resection/reconstruction, radiation therapy, systemic therapy, and related side effects).
Changes in structural integrity and changes in use, sensation, strength, range of motion, and/or coordination of head and neck musculature may result in functional swallowing problems, such as
Individuals who are post-laryngectomy may have swallowing problems that are unique to this population. Laryngectomy and reconstructive approaches may result in decreased function of the upper and lower esophageal sphincters or strictures (Raj et al., 2020; Sweeny et al., 2012; Zhang et al., 2018).
See ASHA’s Practice Portal page on Adult Dysphagia for more details related to signs and symptoms of swallowing disorders.
See also ASHA’s Practice Portal pages on Hearing Loss in Adults, Balance System Disorders, and Tinnitus and Hyperacusis.
Side effects of medical (i.e., radiation therapy and systemic therapy) and surgical management can impact function and rehabilitation planning. Many of these side effects (e.g., dysphagia, lymphedema) can occur both during and after treatment, even several years after its conclusion (Aggarwal et al., 2021; Hamilton et al., 2022; Smith, 2019; Starmer et al., 2014; Stubblefield, 2017). Ototoxicity—damage to the hearing and/or organs of balance of the inner ear by drugs or chemicals—can occur during or after chemotherapy treatment for HNC (Breglio et al., 2017). Other side effects include the following:
Related comorbidities that can influence speech, language, and swallowing assessment and treatment include the following:
Currently identified causes of HNC include
Other factors that have been reported to increase the risk for HNC include
SLPs play a central role in the screening, assessment, diagnosis, and treatment of people with HNC. The professional roles and activities in speech-language pathology include clinical and educational services (diagnosis, assessment, planning, and treatment); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).
Appropriate roles for SLPs include the following:
As indicated in the Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so.
Audiologists play a central role in the assessment, diagnosis, and rehabilitation of hearing and vestibular deficits in individuals with HNC. See ASHA’s Scope of Practice in Audiology (ASHA, 2018).
Appropriate roles for audiologists include the following:
As indicated in the Code of Ethics (ASHA, 2023), audiologists who serve this population should be specifically educated and appropriately trained to do so.
Audiologists and SLPs collaborate with many other disciplines in caring for individuals with HNC. Referral to, and collaboration with, members of the oncology care team is important for ensuring quality service for individuals—particularly during the assessment process and treatment planning. A clear understanding of functional effects related to a particular treatment approach is critical as they can impact an individual’s choice of treatment modality and compliance with interventions.
Some medical centers have interprofessional practice HNC teams that follow facility-specific clinical HNC pathways (Brill, 2019; Messing et al., 2019). Team members may include, but are not limited to, surgeons, oncologists (e.g., medical, radiation), pathologists, dietitians, social workers, nurses, psychologists/psychiatrists, dentists/prosthodontists, and physical therapists. Collaboration focuses on using information from a variety of professionals to affect functional outcomes that benefit the patient’s communication, swallowing, and quality of life.
See ASHA’s resources on collaboration and teaming and interprofessional education/interprofessional practice (IPE/IPP).
See the Assessment section of the Head and Neck Cancer Evidence Map for pertinent scientific evidence, expert opinion, and client/care partner perspective.
Assessment of communication and swallowing function in HNC requires a multidisciplinary approach (see the Interprofessional Collaboration section). Audiologists and SLPs do not diagnose HNC. The diagnosis is made by the physician based on
Audiologists and SLPs are valuable members of the post-cancer surveillance team. They should discuss any new or concerning findings posttreatment with HNC physicians.
Audiologists and SLPs consider person- and family-centered care tenets and social determinants of health when providing skilled services and engage the patient in shared decision making (Jovanovic et al., 2022; Nallani et al., 2022).
Screening identifies the need for further assessment rather than providing a detailed description of the severity and characteristics of sequelae associated with HNC.
Audiologic screening includes hearing screening and otoscopic inspection, which should occur prior to screening for other deficits (e.g., cognition) if possible. 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 speech-language pathology.
If the individual fails the hearing screening or if hearing loss is suspected, a referral for a full audiologic evaluation is necessary in a timely manner. In addition to hearing screening, audiologists may also screen for vestibular deficits as indicated. Even if a patient passes a screening, a schedule should be established to rescreen as needed to monitor the presence of late-onset hearing and balance disturbances that may occur as a result of cancer treatment. See the Assessment section of ASHA’s Practice Portal page on Hearing Loss in Adults.
Speech-language pathology screening includes screening for functional changes (i.e., in communication, voice, and swallowing) that might signal HNC. SLPs make referrals as needed and complete a comprehensive assessment as warranted.
SLPs also screen for deficits following treatment for HNC, including
Although audiologists and SLPs do not diagnose HNC, they need a clear understanding of the following to guide appropriate assessment:
Consistent with the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2023; World Health Organization, 2001), a comprehensive assessment is conducted to identify and describe
See ASHA’s resource on the International Classification of Functioning, Disability, and Health (ICF) for examples of handouts featuring assessment data consistent with the ICF framework.
Assessment is conducted in the language(s) used by the person being assessed, 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 Responsiveness.
The focus of comprehensive assessment varies depending on the timing of assessment.
Pretreatment assessment occurs between diagnosis and onset of cancer treatment and may involve
Assessment during and post cancer treatment may involve
Ongoing, periodic assessment is often needed following initial audiologic and speech-language pathology assessments to monitor changes in function (e.g., radiation-associated dysphagia, cognitive changes secondary to systemic therapy, hearing loss).
The comprehensive assessment of communication and swallowing abilities typically includes the following components.
Audiologic assessment typically includes the following components:
Otoacoustic emissions testing is a tool to detect and monitor hearing loss due to ototoxicity. Additional pure-tone audiometric testing for ultrahigh frequencies can be added to the standard clinical audiogram to monitor for ototoxic effects (Dillard et al., 2022). Ongoing monitoring of patients treated with chemotherapy is recommended during treatment, if there are changes to treatment (i.e., changes to medication and/or dosage), and upon completion of treatment. Please see Audiological Monitoring of Patients Receiving Ototoxic Drugs [PDF] for further discussion of monitoring protocols.
A potential barrier for audiologic and vestibular monitoring during and after treatment could be the patient feeling unwell. The patient’s overall physical and mental status as a result of treatment (e.g., malaise, fatigue) can create a potential barrier for audiologic and vestibular monitoring both during and after treatment. Tests such as vestibular assessments may be deemed to be too physically taxing for certain patients. It is up to the discretion of the audiologist and the professional medical team to determine if modifications to the monitoring protocol are necessary when a patient is unable to complete entire assessments.
For details, see the Assessment sections of ASHA’s Practice Portal pages on Hearing Loss in Adults, Balance System Disorders, and Tinnitus and Hyperacusis.
Results of a comprehensive speech-language pathology assessment are critical to many members of the interprofessional practice team to optimize functional outcomes. For example, information about sensorimotor skills, oral structures and functions, articulation, vocal resonance, intelligibility, and cognition can assist with decisions about surgical/reconstructive approaches; alaryngeal speech candidacy; and fabrication of palatal augmentation prostheses, obturators, or lifts. Such information can also alert the team to potential signs of a recurrent disease, which warrants further medical evaluation.
Voice assessment includes examination of perceptual, vibratory, acoustic, and aerodynamic characteristics and their impact on the individual’s quality of life.
See the Assessment sections of ASHA’s Practice Portal pages on Voice Disorders and Resonance Disorders.
See the Assessment sections of ASHA’s Practice Portal pages on Traumatic Brain Injury in Adults, Dementia, and Right Hemisphere Damage and ASHA’s resource on evaluating and treating communication and cognitive disorders.
Dysphagia presentation and assessment in individuals with HNC varies based on tumor site and cancer treatment protocols. For example, individuals who undergo partial or total glossectomy may exhibit significant oropharyngeal dysphagia and aspiration risk. Those who have palatal resections may show signs of nasal regurgitation. Total laryngectomy may prevent aspiration by separating the airway from the digestive tract. However, individuals may still be at risk for post-laryngectomy dysphagia due to fistulae, stenosis, stricture, prosthesis leakage, pharyngoesophageal spasm, or base-of-tongue propulsion deficits. Individuals who receive radiation often present with fibrosis-related late effect dysphagia (Arenaz Búa et al., 2018; Chen et al., 2019; Hasegawa et al., 2021; King et al., 2016; Terlingen et al., 2018).
Swallowing assessment includes a clinical interview and exam, physiologic findings from instrumental assessments, and patient-reported outcome measures.
SLPs may collaborate with dietitians and physicians about nutritional status, particularly regarding alternative feeding. SLPs provide these professionals with information about the benefits and risks of oral intake specific to the individual patient. This ensures that consideration is given to both nutritional goals and functional swallowing goals during and after treatment.
See the Assessment section of ASHA’s Practice Portal page on Adult Dysphagia for more details.
See the Treatment section of the Head and Neck Cancer Evidence Map for pertinent scientific evidence, expert opinion, and client/care partner perspective.
The goal of audiology and speech-language pathology treatment is to minimize the side effects of cancer treatment and improve functional status following medical/surgical interventions. Several individual factors influence the nature, scope, initiation, and duration of audiology and speech-language pathology management, including
Audiology and speech-language pathology management may occur prior to, during, and/or after cancer treatment. Management prior to cancer treatment (e.g., preventive, proactive, or pre-habilitative) includes
Management during cancer treatment (e.g., consultative or direct depending on tolerance) includes
Management after cancer treatment (e.g., direct rehabilitative therapy to address current deficits) includes
Consistent with the World Health Organization (2001) framework, intervention is designed to
Decisions about goals and treatment options are made in partnership with clients, families/care partners, and other professionals involved in the person’s care. A successful intervention often requires collaboration between audiologists, SLPs, and professionals from medical and surgical specialties as well as rehabilitation specialties and others who provide support to individuals with HNC. Please see the Interprofessional Collaboration section for further information.
Audiologists and SLPs consider factors such as the individual’s age and educational level, social history and present social context, vocational history and current vocational status, and cultural and linguistic background. Treatment should be conducted in the language(s) used by the person with HNC either by a bilingual clinician or via collaboration with interpreters, when necessary (see ASHA’s Practice Portal pages on Bilingual Service Delivery and Collaborating With Interpreters, Transliterators, and Translators).
It is also important to be sensitive to cultural influences and family/care partner 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 Responsiveness).
A large part of HNC management includes counseling. Clinicians typically work directly with the individual who has HNC, but they also play a critical role in counseling their family/care partners and other significant persons about the nature of the disorder and the course of treatment. When psychosocial or emotional challenges go beyond the clinician’s scope of practice and competence (e.g., concerns about depression), referral to qualified professionals as primary providers of mental health services (e.g., psychologists and psychiatrists) is critical (Eadie et al., 2018; Henry et al., 2022). The focus of counseling may differ depending on the timing in the course of disease progression and management.
In the pretreatment phase, counseling may
In the posttreatment phase, counseling may focus on
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. Treatment can be provided in person or through telehealth as appropriate. Telehealth may offer unique opportunities for monitoring ototoxicity (Brungart et al., 2017).
The management of hearing difficulties, balance, and tinnitus secondary to HNC may include
Management for patients treated with chemotherapy for HNC may focus on hearing loss identification and mitigation due to the likelihood of ototoxicity. Identification involves serial audiologic assessments for ototoxicity monitoring and to identify changes to hearing, tinnitus, and/or vestibular function in a timely manner. Ongoing periodic audiologic assessment allows audiologists to monitor posttreatment changes (e.g., ototoxicity) and communicate that with the medical team (Bass et al., 2013). Mitigation is intended to reduce the impact of hearing loss on communication when ototoxicity cannot be avoided (Dillard et al., 2022). Treatment (e.g., amplification selection and fitting and/or aural rehabilitation) can occur sooner if hearing loss or tinnitus is identified early in patients with HNC.
Procedures for ototoxicity treatment vary as there is no agreed-upon consensus related to management guidelines (Konrad-Martin et al., 2018). Monitoring procedures may also vary based on the treatment plan for the patient (e.g., medication types, dosage). For further information on ototoxicity, please see ASHA’s Evidence Maps.
Intervention approaches are based on thorough examination of functional deficits and individual needs/tolerance, with input from the patient, care partners, and interprofessional team. SLPs may need clearance from the surgical/medical team before initiating specific treatments.
Surgical resections and reconstructions that affect oral cavity anatomy and physiology often impact speech production and intelligibility. Articulatory compensations may include
Treatment may also involve targeted exercise training before, during, or after surgical and/or medical interventions. 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; Lazarus, Husaini, Hu, et al., 2014). Examples include the following:
SLPs who treat trismus need to be aware of patient risks for osteoradionecrosis from radiation treatment, avoid any interventions that are contraindicated, review medical reports to determine risk of osteoradionecrosis, and contact the patient’s physician when concerns arise.
Multimodal and multidisciplinary treatment for voice and resonance disorders is often effective for individuals with HNC. SLPs may frequently collaborate with otolaryngologists and maxillofacial prosthodontists for augmentation procedures to address glottic and palatal insufficiencies (e.g., vocal cord injections, palatal prostheses).
Voice therapy may be indicated for individuals with HNC following surgical excision of laryngeal tumors or radiation treatments that result in changes to the glottis (e.g., phonatory function), vocal fatigue, and/or muscle tension. Surgery to the tongue and oral cavity may also affect vocal tract resonance and vocal quality. Treatment may include
For individuals who have a tracheostomy, treatment may include
For individuals with resonance disorders, treatment may include
See ASHA’s Practice Portal pages on Voice Disorders, Tracheostomy and Ventilator Dependence, and Resonance Disorders for further information.
Communication rehabilitation following surgical removal of the larynx targets the production of speech and voice using a sound source other than the larynx and most often includes use of
Buccal speech and pharyngeal speech are two other types of alaryngeal speech. Their use as a primary method of communication following laryngectomy is rare in the United States, but they are still used in certain cultures and other parts of the world.
See ASHA’s resource, Communication After Total Laryngectomy, for more detailed information on candidacy considerations and treatment approaches. Also, see ASHA’s video resource, Alaryngeal Speech Options After Total Laryngectomy (Messing, 2016).
Individuals with HNC may use both low- and high-tech AAC systems. This may occur on a temporary basis in the acute postsurgical phase or as a long-term option for individuals who have had extensive surgical resection (e.g., laryngectomy or glossectomy) and choose or require an AAC system as their primary mode of communication or in conjunction with alaryngeal speech.
See ASHA’s Practice Portal page on Augmentative and Alternative Communication for further discussion of key issues.
Cognitive changes can occur in individuals with HNC following chemotherapy or radiation, particularly for nasopharyngeal cancer due to the treatment field (Gan et al., 2011; Voon et al., 2021; Zer et al., 2018). For more information about treating cognitive-communication problems, in the areas of attention, memory, executive function, and language processing, see ASHA’s resource on evaluating and treating communication and cognitive disorders and ASHA’s Practice Portal pages on Traumatic Brain Injury in Adults, Dementia, and Right Hemisphere Damage.
Respiration treatment, often in conjunction with a respiratory therapist, may be part of the treatment plan given the presence of tracheostomy, stoma, and/or reduced breath support in individuals with HNC. Speech-language pathology interventions may include
Multiple factors contribute to dysphagia in HNC, including tumor location, type of cancer treatments, and related comorbidities. Due to these variable factors, individualized clinical management is critical (Starmer & Edwards, 2019). For a general comprehensive discussion of the treatment of swallowing disorders, refer to ASHA’s Practice Portal page on Adult Dysphagia. Specific considerations for HNC are discussed below and take into account the timing and nature of speech-language pathology treatment (e.g., proactive or reactive) related to cancer treatment.
Prior to cancer treatment, exercises are often part of preventative, or prophylactic, dysphagia treatment for patients undergoing radiation therapy. These exercises may reduce impairment, maintain function, and assist in recovery (Govender et al., 2020; Messing et al., 2017). There is no singular established best practice for preventative dysphagia treatment (Kraaijenga et al., 2014; Loewen et al., 2021; Yang et al., 2021). Prophylactic speech-language pathology treatment usually focuses on maintaining oropharyngeal and laryngeal muscle strength and range of motion to maximize swallowing function, efficiency, and endurance for oral intake during and after cancer treatment. Examples include endurance-based oropharyngeal exercises with and without resistance and/or biofeedback, range-of-motion exercises with and without resistance, and respiratory training (e.g., lingual isometrics, laryngeal elevation, Shaker, EMST). Clinicians provide education and counseling regarding the importance of these exercises to increase patient adherence to exercise routines and minimize the need for NPO (“nothing by mouth”) status and feeding tubes long-term (Shinn et al., 2013).
During cancer treatment, exercises may be challenging, particularly during chemoradiation therapy due to xerostomia, lymphedema, and pain associated with eating and swallowing. Clinicians work with patients to complete swallowing exercises as appropriate and maintain maximum oral intake while being mindful of patient comfort and aspiration risk (Hutcheson et al., 2013, 2020).
Following cancer treatment, exercises become more reactive or rehabilitative in nature to restore strength, range of motion, and swallowing skills impacted by surgical/medical interventions. Clinicians often address radiation-associated dysphagia using progressively intense resistive exercises, biofeedback, or systematic dysphagia therapy programs (e.g., Carnaby-Mann & Crary, 2010; Hutcheson et al., 2020). They also provide swallowing intervention related to soft tissue fibrosis, lymphedema, neuropathies, and trismus in conjunction with medical/surgical therapies such as esophageal dilation, fistula repair, vocal fold medialization, and intraoral prosthetics (Chee et al., 2021; Hutcheson et al., 2018; Malandraki & Hutcheson, 2018; Smith, 2019).
At any time in an individual’s cancer treatment protocol, SLPs may assist in developing compensatory strategies such as double swallow, alternating liquids and solids, and taking smaller sips and/or bites. SLPs may also make recommendations for bolus delivery methods (e.g., modified spoons or oral syringe feeding). See the works of Halczy-Kowalik et al. (2015) and Knott and Lewin (2013) for considerations related to total glossectomy.
Postural modifications help redirect movement of the bolus in the oral cavity and pharynx and help modify pharyngeal dimensions to reduce risk of aspiration and/or improve the efficiency of the swallow by facilitating bolus clearance. Examples of postural modifications include head tilt, head rotation, head back, side lying, and chin tuck.
Swallow maneuvers are specific strategies that clinicians use to change the timing or strength of swallowing. Examples of swallow maneuvers often used with HNC include the supraglottic and super-supraglottic swallow, effortful swallow, and the Mendelsohn maneuver. Biofeedback (e.g., surface neuromuscular electromyography [sEMG]) may be used with swallow maneuvers to provide visual information during the swallowing process to ensure proper completion of maneuvers.
SLP collaboration with a dietitian is central to diet modification, particularly in HNC when nutritional status is a key part of healing from cancer treatments. Diet modifications include changes to the viscosity and texture of the food to decrease risk of aspiration, to facilitate efficient oral intake and bolus transfer, and/or to maximize oral intake volume. Examples include changing the thickness of liquids or softening, chopping, or pureeing solid foods (International Dysphagia Diet Standardisation Initiative [IDDSI]). Modifications to taste or temperature may also be used to change the sensory input that the bolus provides.
SLPs recommend the least restrictive oral diet to avoid risk (e.g., aspiration) and minimize painful eating or swallowing that may result from chemoradiation. However, SLPs also consider patient preference and provide education regarding risks if the patient chooses not to follow recommendations. SLPs may also work toward increasing complexity/variety of foods as dysphagia resolves.
Individuals may require intraoral prostheses following oral cavity resections that include the hard and soft palate, jaw, or tongue. SLPs and maxillofacial prosthodontists collaborate to fabricate prostheses that are tailored to the patient’s individual communication and/or swallowing needs.
Prostheses provide physical support for individuals with structural deficits to normalize pressure and movements in the intraoral cavity. Palatal prostheses may be used to improve speech, resonance, and/or swallowing following HNC surgery. SLPs work with maxillofacial prosthodontists to determine contour of augmentation, which is often adjusted over time based upon ongoing evaluation of speech, voice, and swallowing function. SLPs also provide speech and swallow retraining after prosthesis fitting.
Intraoral prostheses commonly used in individuals with HNC include the following:
“False” dentition may be added to intraoral prostheses to assist in swallowing rehabilitation for patients who have lost natural dentition during surgery or in preparation for radiation.
Survivorship in HNC refers to individuals who are living with HNC, those in remission, and those who are currently disease-free. The proportion of individuals living longer after an HNC diagnosis is greater than in the past, partially due to better prognosis and outcomes with current HNC treatments. It is also likely due to an increase in the diagnosis of human papillomavirus–related oropharyngeal cancers, which have a higher survival rate and usually affect younger people (Blair, 2018; Nguyen & Ringash, 2018). These survivors face the unique challenge of dealing with the side effects of treatment (i.e., radiation, systemic therapy, and surgery) for longer periods. Survivorship management focuses on surveillance and screening for recurrences or new cancers, assessment and intervention for long-term and late effects, health promotion, and interprofessional care coordination (Ebersole et al., 2021; Jamal et al., 2017). For audiologists and SLPs, this means maximizing communication and swallowing function for as long as possible. Please see the American Cancer Society Head and Neck Cancer Survivorship Care Guideline for further information.
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/care partners. SLPs are integral members of the palliative care team (Kagan et al., 2020). 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 to understand the emotional and psychological issues faced by their patients and the patients’ family members and care partners. The wishes of the patient and family/care partner are paramount when considering end-of-life issues, and the role of the SLP extends only as far as the patient or family/care partner wishes. Patients and care partners 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 Responsiveness.
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.
See the Service Delivery section of the Head and Neck Cancer Evidence Map for pertinent scientific evidence, expert opinion, and client/care partner perspective.
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.
This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.
Aggarwal, P., Hutcheson, K. A., Garden, A. S., Mott, F. E., Goepfert, R. P., Duvall, A., Fuller, C. D., Lai, S. Y., Gunn, G. B., Sturgis, E. M., Ehab, Y. H., & Shete, S. (2021). Association of risk factors with patient-reported voice and speech symptoms among long-term survivors of oropharyngeal cancer. JAMA Otolaryngology—Head & Neck Surgery, 147(7), 615–623. https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2779628
American Cancer Society. (2016). Key statistics about nasal cavity and paranasal sinus cancers. http://www.cancer.org/cancer/nasalcavityandparanasalsinuscancer/detailedguide/nasal-cavity-and-paranasal-sinuses-cancer-key-statistics
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American Speech-Language-Hearing Association. (2018). Scope of practice in audiology [Scope of practice]. www.asha.org/policy/
American Speech-Language-Hearing Association. (2023). Code of ethics [Ethics]. www.asha.org/policy/
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Arenaz Búa, B., Pendleton, H., Westin, U., & Rydell, R. (2018). Voice and swallowing after total laryngectomy. Acta Oto-Laryngologica, 138(2), 170–174. https://doi.org/10.1080/00016489.2017.1384056
Barbon, C. E. A., Chepeha, D. B., Hope, A. J., Peladeau-Pigeon, M., Waito, A. A., & Steele, C. M. (2020). Mechanisms of impaired swallowing on thin liquids following radiation treatment for oropharyngeal cancer. Journal of Speech, Language, and Hearing Research, 63(9), 2870–2879. https://doi.org/10.1044/2020_JSLHR-19-00220
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Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Head and Neck Cancer page:
In addition, ASHA thanks the members of the ASHA-Special Interest Division 3: Working Group on Voice and Voice Disorders, whose work was foundational to the development of this content. Members of the working group were Julie Barkmeier (Chair), Glenn W. Bunting, Douglas M. Hicks, Michael P. Karnell, Stephen C. McFarlane, Robert E. Stone, Shelley Von Berg, and Thomas L. Watterson. Alex F. Johnson served as monitoring vice president. Amy Knapp and Diane R. Paul served as ex officio members.
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association. (n.d.). Head and neck cancer [Practice portal]. https://www.asha.org/Practice-Portal/Clinical-Topics/Head-and-Neck-Cancer/
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.