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
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
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:
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.
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 of HNC vary based on location of the primary tumor, lymph node involvement, and subsequent metastases, and may include the following:
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).
Reduced overall intelligibility resulting from one or all of the following:
See ASHA's Practice Portal page on Voice Disorders for more details related to signs and symptoms of dysphonia.
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:
See ASHA's Practice Portal page on Adult Dysphagia for more details related to signs and symptoms of swallowing disorders.
See, for example, Dell'Aringa et al. (2009).
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
Related signs and symptoms that can have an effect on speech and language 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
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:
As indicated in the Code of Ethics (ASHA, 2016a), 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, 2016a), audiologists who serve this population should be specifically educated and appropriately trained to do so.
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
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:
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 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.
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.
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
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
Although SLPs and audiologists do not diagnose HNC, in order to guide appropriate assessment, they need a clear understanding of the individual's
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
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
Post-treatment assessment focuses on
Assessment may result in
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.
The comprehensive assessment of communication and swallowing abilities typically includes the following components (see box below).
Self-Reported Areas of Concern
Sensory and Motor Status
Voice and Resonance
See the assessment section of ASHA's Practice Portal page on Voice Disorders.
Articulation and Speech Intelligibility
See the assessment section of ASHA's Practice Portal page on Adult Dysphagia for more details.
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
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
The comprehensive audiologic assessment typically includes the following components:
Vestibular testing may also be indicated.
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
Depending on assessment results, intervention addresses
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
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:
Alaryngeal speech targets the production of speech using a sound source other than the larynx and may include use of
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
|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 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.
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.
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 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.
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 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 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.
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:
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.
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
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
In the post-treatment phase, counseling may focus on
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.
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.
This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.
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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:
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/.