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Head and Neck Cancer

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, tumors of the thyroid, skin cancers involving the head and neck, auditory nerve lesions, and brain tumors.


See the Head and Neck Cancers Evidence Map for summaries of available research on this topic.

Head and neck cancer (HNC) includes malignant tumors that most commonly arise from the moist squamous cell mucosa or lining of the head and neck regions. They are characterized according to their primary site of origin as malignancies of the

  • nasal cavity and paranasal sinuses;
  • oral cavity (lip, anterior two-thirds of the tongue, gums, oral mucosa, floor of mouth, hard palate, maxilla, and mandible);
  • pharynx, including the nasopharynx, oropharynx (soft palate, tongue base, tonsils, and adenoids), and hypopharynx;
  • larynx (supraglottic, glottic, and subglottic regions); and
  • salivary glands.

HNC usually originates within one of these primary sites. Occasionally, it is secondary in nature, with the primary site elsewhere in the body.

The most commonly used model for classifying HNC is the TNM staging model—used to define severity of the malignancy (Amin et al., 2017; Greene & Sobin, 2009). The TNM model assigns a numerical status (Stage 0, x, I, II, III, or IV) based on

  • tumor size and/or location (T);
  • degree of lymph node involvement (N); and
  • presence or absence of distant metastasis (M).

With the exception of tumors related to human papillomavirus (HPV), 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).

The following factors help determine overall prognosis:

  • Natural history of the specific tumor based on staging, histology, and other comorbidities
  • Ability to achieve disease control through treatment (surgery, radiation therapy, chemotherapy—alone or in combination)
  • Etiology—for example, HPV-associated oropharyngeal cancers have a better prognosis than HPV-negative oropharyngeal cancers (National Cancer Institute, 2015)
  • Complexity of treatment—for example, in advanced HNC, multimodal treatment (e.g., surgery, radiation therapy, and chemotherapy) is more likely to result in short- and long-term side effects and may result in greater communication, swallowing, and hearing needs (Perkins, Hancock, & Ward, 2014).

Globally, HNC accounts for approximately 550,000 cases annually (Fitzmaurice et al., 2017; Thompson, 2014). In the United States, about 3% of all cancers are HNC, with approximately 63,000 Americans developing head and neck malignancies annually (Jemal, Siegel, Xu, & Ward, 2010; Siegel, Miller, & Jemal, 2017).

Overall, HNC is more commonly seen in men than in women (American Cancer Society, 2017a). U.S. statistics are reported below by type of HNC.

  • Oral cavity/pharynx: The incidence of cancer involving the oral cavity/pharynx is 11.4 per 100,000 persons per year. The estimated number of new cancer cases involving the oral cavity and pharynx is 49,670 for 2017 (American Cancer Society, 2017b).
  • Larynx: The incidence of laryngeal cancer is 3.6 per 100,000 persons per year. The estimated number of new cancer cases involving the larynx is 13,360 for 2017 (American Cancer Society, 2017c).
  • Nasopharynx: The incidence of nasopharyngeal cancer is less than 1 per 100,000 persons per year. The estimated number of new cases in the United States was 3,200 for 2015 (American Cancer Society, 2016c).
  • Nasal cavity/paranasal sinus: Each year, approximately 2,000 people are diagnosed with nasal cavity or paranasal cancer in the United States (American Cancer Society, 2016b).
  • Hypopharynx: The incidence of hypopharyngeal cancer is slightly less than 1 per 100,000 persons (American Cancer Society, 2017a). Each year, approximately 3,000 adults in the United States are diagnosed with hypopharyngeal cancer (American Cancer Society, 2017c).

Overall, the incidence of HNC in the United States has been declining, presumably due to a reduced prevalence of cigarette smoking among adults. However, over the past few decades, there has been a rise in HPV-related oropharyngeal cancers (American Cancer Society, 2016a; Chaturvedi et al., 2011).

The proportion of oropharyngeal cancers testing positive for HPV is now approximately 70% (Centers for Disease Control and Prevention, 2017; Chaturvedi et al., 2011), which is a substantial increase from previous rates (Mehanna et al., 2012).

According to a 2008–2012 U.S. surveillance report (Viens et al., 2016), an estimated 15,738 HPV-associated oropharyngeal squamous cell cancers are diagnosed annually, the majority of which (12,638) were reported in males. An additional population-based surveillance study from 1988 to 2004 (Chaturvedi et al., 2011) reported a 225% increase in oropharyngeal HPV-related cancers (0.8 per 100,000 persons to 2.6 per 100,000 persons).

Presenting Signs and Symptoms

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:

  • Foul mouth odor (halitosis) not explained by hygiene
  • Frequent nosebleeds and/or unusual nasal discharge
  • Generalized symptoms that include loss of appetite, unexplained weight loss with or without dysphagia, fatigue, and fever
  • Loosening of teeth or dentures
  • Lump, bump, or mass in the head or neck area, with or without pain
  • Nasal obstruction or persistent nasal congestion
  • Neuropathic pain at sites distant from the location of the tumors (resulting from invasion of the sensory nerves by the cancer cells; e.g., ear pain [otalgia])
  • Noisy breathing (stridor) and/or breathlessness (dyspnea) due to airway obstruction
  • Nonhealing ulcer in the head and neck region
  • Numbness or weakness of a body part in the head and neck region
  • Persistent cough (sometimes marked by coughing up blood [hemoptysis])
  • Persistent sore throat
  • Painful swallowing (odynophagia)
  • Red or white patches in the mouth
  • Reduced range of motion of the jaw (trismus) or of the tongue affecting speech and swallowing
  • Globus sensation
  • Referred pain in the ear/jaw
  • Sensory changes (e.g., changes in or loss of smell and taste; double vision)

Functional Signs and Symptoms

Depending on the location of the malignancy and time of presentation along the continuum of medical/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 (see box below).

Speech

Reduced overall intelligibility resulting from one or all of the following:

  • Articulation errors (e.g., omissions, substitutions, and distortions of stops, fricatives, and affricates; vowel errors)
  • Imprecise speech (e.g., due to dysarthria from cranial nerve palsies)
  • Distortions of lingual phonemes consistent with lingual resection and/or reconstruction

Voice

  • Dysphonia (e.g., changes in vocal pitch, loudness, and/or quality) resulting from untreated tumors within the larynx or supraglottic larynx, surgical resection of the larynx, and/or radiation
  • Aphonia (i.e., loss of voice) postsurgery (e.g., with tracheostomy tube or total laryngectomy)

See ASHA's Practice Portal page on Voice Disorders for more details related to signs and symptoms of dysphonia.

Resonance

  • Hypernasality (e.g., surgical resection to the soft palate, immobility as a result of radiation sequelae and/or a soft-palate defect)
  • Hyponasality (e.g., due to obstruction in nasal passage)
  • Cul-de-sac resonance (associated with base of tongue lesions)

See Classification of Velopharyngeal Dysfunction.

Swallowing

Severity of swallowing problems in HNC depends on tumor size and location, staging, and treatment protocol (e.g., surgical resection and reconstruction, radiation therapy, chemotherapy).

Total laryngectomy surgery typically does not result in swallowing disorders. However, they occasionally occur due to scar tissue at the tongue base, reduced tongue base posterior motion, stricture or narrowing of the esophagus, and poor bolus clearance through the pharynx if a portion of the tongue base is included in the resection.

Functional signs and symptoms of swallowing problems include the following:

Changes in structural integrity and changes in sensation, strength, range of motion, and coordination of orofacial musculature may result in one or more of the following:

  • Oral phase dysphagia:
    • Increased oral transit time
    • Impaired bolus manipulation
    • Increased oral residue
    • Impaired mastication
    • Premature spillage
    • Anterior bolus loss
  • Pharyngeal phase dysphagia:
    • Delayed triggering of pharyngeal swallow
    • Velar leak resulting in movement of materials into the nasopharynx
    • Impaired tongue base movement
    • Reduced pharyngeal contraction
    • Decreased laryngeal and hyoid elevation and anterior motion
    • Reduced epiglottic closure, resulting in increased risk for aspiration
    • Reduced glottic closure
    • Reduced upper esophageal opening
    • Aspiration
    • Residue in valleculae and pyriform sinuses

See ASHA's Practice Portal page on Adult Dysphagia for more details related to signs and symptoms of swallowing disorders.

Hearing

  • Changes in hearing acuity (e.g., as a result of surgery, radiation, or ototoxicity from chemotherapy)
  • Tinnitus

See, for example, Dell'Aringa et al. (2009).

See also ASHA's Practice Portal pages on Hearing Loss Beyond Early Childhood and Tinnitus and Hyperacusis.

Side Effects of Medical/Surgical Management

Side effects of medical (i.e., radiation therapy and chemotherapy) and surgical management, radiation therapy, and chemotherapy can have an impact on function and treatment planning. These side effects can include

  • pain (related to treatment and/or as a result of residual tumor);
  • dental problems (e.g., surgical removal of teeth or portion of jaw; dental caries; dental pain; and osteoradionecrosis);
  • facial and other structural changes, including damage to auditory pathways and structures;
  • hearing loss due to ototoxicity;
  • head and neck lymphedema;
  • loss of appetite;
  • mouth sores and mucositis;
  • nausea and vomiting;
  • numbness/reduced range of motion in the head, neck, and shoulder areas;
  • odynophagia;
  • pharyngeal/upper esophageal stenosis;
  • reduced/altered sense of taste and smell;
  • swelling of the mouth and/or throat;
  • xerostomia; and
  • trismus.

Related Signs and Symptoms

Related signs and symptoms that can have an effect on speech and language assessment and treatment include the following:

  • Cognitive deficits (e.g., changes in executive function as a consequence of radiation or chemotherapy; withdrawal from alcohol abuse)
  • Psychosocial issues resulting from the diagnosis and impact of medical/surgical management (e.g., changes in lifestyle, family and social roles, and employment)
  • Comorbidities such as cancer-related fatigue, depression, and anxiety

Currently identified causes of HNC include

  • use of tobacco, including smokeless tobacco;
  • excessive alcohol consumption; and
  • viruses such as HPV and Epstein-Barr.

Other factors that have been reported to increase the risk for HNC include

  • prolonged sun exposure (especially in cancers of the lip and in skin cancer of the head and neck region);
  • poor dental and oral hygiene;
  • environmental and occupational inhalants;
  • recreational drug use (e.g., marijuana);
  • poor nutrition;
  • gastroesophageal reflux disease (GERD);
  • weakened immune system from medications or underlying disease; and
  • betel nut chewing.

Roles and Responsibilities of the Speech-Language Pathologist

Speech-language pathologists (SLPs) play a central role in the screening, assessment, diagnosis, and treatment of persons with HNC. The professional roles and activities in speech-language pathology include clinical/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, 2016b).

Appropriate roles for SLPs include the following:

  • Providing prevention information to individuals and groups known to be at risk for HNC as well as to individuals working with those at risk
  • Educating other professionals about the needs of persons with HNC and the role of SLPs in diagnosing and managing associated impairments
  • Conducting a comprehensive, culturally and linguistically appropriate assessment of speech, language, resonance, voice, cognition, and/or feeding/swallowing deficits associated with HNC, and diagnosing these deficits as indicated
  • Referring to other professionals to rule out related conditions and facilitate access to comprehensive services
  • Making decisions about the functional management of communication and swallowing in HNC
  • Developing treatment plans, providing treatment (including palliative care), documenting progress, and determining appropriate discharge criteria
  • Evaluating the impact of deficits on quality of life and directing treatments to improve these areas when possible
  • Counseling before and after medical management (surgery, radiation therapy, chemotherapy) to address needs of persons with HNC and their families specific to communication- and swallowing-related issues and providing education aimed at preventing further complications related to these conditions
  • Remaining informed of research in the area of HNC and helping advance the knowledge base related to the nature and treatment of these conditions
  • Advocating for individuals with HNC and their families at the local, state, and national levels, and providing expert testimony when appropriate
  • Serving as an integral member of an interprofessional team working with individuals with HNC and their families/caregivers (see ASHA's resources on interprofessional education/interprofessional practice [IPE/IPP] and person- and family-centered care)

As indicated in the Code of Ethics (ASHA, 2016a), SLPs who serve this population should be specifically educated and appropriately trained to do so.

Roles and Responsibilities of the Audiologist

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:

  • Educating other professionals about the needs of adults with hearing and vestibular deficits pre- and post-medical/surgical management of HNC and the role of audiologists in diagnosing and managing these deficits
  • Screening for and early detection of hearing loss due to ototoxicity, tinnitus, and vestibular disturbances
  • Conducting a comprehensive and culturally and linguistically sensitive assessment using behavioral, electroacoustic, and/or electrophysiological methods to evaluate hearing, auditory function, vestibular and balance function, and related systems
  • Determining candidacy for amplification, assistive technology, and vestibular rehabilitation, and fitting and maintaining amplification and other sensory devices
  • Developing and implementing an audiologic and/or vestibular rehabilitation management plan, including maintenance of appropriate data and documentation
  • Counseling the individual with HNC and his or her family regarding the psychosocial aspects of hearing loss and other auditory processing dysfunction, modes of communication, and processes to enhance communication competence
  • Performing neurophysiologic intraoperative monitoring to help surgeons minimize or avoid injury to neural structures that are at risk due to the pathology and the proximity of neural structures to the surgical field (see ASHA's resource on neurophysiologic intraoperative monitoring)
  • Advocating for the communication needs of all individuals, including advocating for the rights to and funding of services for those with hearing loss, auditory, and/or vestibular disorders, and providing expert testimony when appropriate
  • Serving as an integral member of an interprofessional team working with individuals with HNC and their families/caregivers (see ASHA's resources on interprofessional education/interprofessional practice [IPE/IPP] and person- and family-centered care)

As indicated in the Code of Ethics (ASHA, 2016a), audiologists who serve this population should be specifically educated and appropriately trained to do so.

Interprofessional Collaboration

SLPs and audiologists collaborate with many other disciplines in caring for individuals with HNC. Referral to, and collaboration with, members of the team are important for ensuring quality service for individuals—particularly during the assessment process and during treatment planning.

The focus of collaboration is on the use of information from a variety of professionals to affect functional outcomes that benefit the patient.

(See the ASHA 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/caregiver perspectives.

Assessment and treatment of impairments in individuals with head and neck cancer may require use of appropriate personal protective equipment.

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

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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Acknowledgements

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:

  • Marilyn F. Dille, PhD, CCC-A
  • James H. Hall, Jr., MA, CCC-A
  • Ann T. Kearney, MA, CCC-SLP
  • Jodi K. Knott, MS, CCC-SLP
  • Cathy L. Lazarus PhD, CCC-SLP
  • Donna S. Lundy, PhD, CCC-SLP
  • E. Tracy Mishler, AuD, CCC-A
  • Heather M. Starmer, MA, CCC-SLP
  • Paula A. Sullivan, MS, CCC-SLP
  • Donna C. Tippett, MPH, MA, CCC-SLP

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Head and Neck Cancer. (Practice Portal). Retrieved month, day, year, from 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.

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