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Managing Speech and Swallowing Complications Resulting from Head and Neck Cancer

by Jan S. Lewin, PhD

Photo by Cancer Type

Head and neck cancer often results in significant functional changes in speech, voice, and swallowing. These problems can occur as a result of the disease or of the treatment. It is important to have a thorough and real­istic understanding of the functional effects of treatment because the restora­tion of communication and the ability to swallow may be critical to your treatment decision.

Speech and swallowing are highly complex processes that depend on pre­cisely coordinated interactions of the structures of the oral cavity (mouth), pharynx (throat), and larynx (voice box). Any alteration to these structures or movements will result in speech and swallowing changes. Therefore, rehabilitation should begin at the time of cancer diagnosis.

The most common problems experi­enced by people with head and neck cancer include difficulty with tongue movements (especially those that involve the back of the tongue), problems with pharyngeal contraction, and limited motion of the larynx. These three actions are critical to the ability to speak, eat, and drink by mouth.

Your speech and swallowing function should be thoroughly evaluated before and throughout your treatment. Some people report no problems swallowing, while in fact they are silently, without coughing or any other indication, aspirat­ing what they swallow. In other words, food is entering the windpipe, placing the individual at risk for pneumonia. Several tests allow clinicians to deter­mine your ability to safely swallow, including the modified barium swallow study and the flexible endoscopic evalu­ation of swallowing.

As much as possible, you should continue to swallow throughout the course of radiation therapy.

Speech and voice evaluation should include examination of sound production and observation of vocal fold movement. Videostroboscopy is the best clinical assessment for visualization of the larynx and assessment of true vocal fold vibration. It is not a radiologic pro­cedure. It is performed as an office procedure and provides important information regarding the ability of the larynx to function properly to pro­duce sound.

After surgery, speech and swallow­ing are generally most impaired when surgery damages the tongue, specifi­cally the anterior tongue for speech and the tongue base or root of the tongue for swallowing. The degree of impair­ment often depends on the quality, rather than the extent, of reconstruction. Some people who have undergone total glos­sectomy, or removal of the entire tongue, swallow better than those who have undergone partial resections that pre­vent tongue movement. Speech and swallowing therapy is essential for functional recovery.

Effects of radiation therapy can produce both immediate and long-term changes in speech, voice, and swallow­ing that may increase in severity years after the completion of treatment. Effects vary among individuals, but most people will experience some degree of speech and swallowing impairment. People who cannot swallow adequately before treatment are at higher risk for long-term swallowing disability after treatment and may require a permanent feeding tube. The addition of chemo­therapy can make the problems worse because chemotherapy intensifies the effects of the radiation. Currently, inten­sity modulated radiation therapy (IMRT) is being used as a routine treatment to cure head and neck cancer. One of the goals of IMRT is to reduce normal tissue damage, thereby preserving function. New studies are being developed to de­termine the potential benefit of intensity modulated proton beam therapy (IMPT) to cure head and neck cancers while still preserving function.

Most swallowing problems occur because of the scarring or fibrosis that happens after radiation therapy. This can result in problems related to chewing, muscle contraction, and airway protec­tion. As much as possible, you should continue to swallow throughout the course of radiation therapy. Even brief periods of not eating by mouth should be avoided. Changes in posture and various types of exercises are often used to strengthen the muscles involved in swallowing. Exercises that are started early provide the best prevention of long-term swallowing problems after radiation therapy. Research shows that people who adhere to swallowing exercises have the best chance to avoid permanent feeding tubes and continue to eat by mouth.

For some people, particularly those with cancer in the oropharynx and larynx, the use of new laser and robotic surgeries are often able to spare the muscles that are critical to speech and swallowing function. However, even when treatment spares organs, preserva­tion of speech and swallowing cannot be ensured. In other words, just because the organ can be saved does not mean it will work. It is important to discuss realistic expectations for functional recovery after organ-sparing procedures with your doctor because neither speech nor swal­lowing may ever fully return to normal, but good functional results are possible.

The focus of speech and swallowing intervention should be early and preven­tive to maximize restoration following treatment. People who are going to receive treatment for head and neck cancer and are at risk for speech or swallowing prob­lems should see a knowledgeable speech pathologist before treatment begins, to start appro­priate therapy to prevent long-term speech and swallowing deterioration.

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Dr. Jan Lewin is a professor in the Depart­ment of Head and Neck Surgery and chief of the Section of Speech Pathology and Audiology at the University of Texas MD Anderson Cancer Center in Houston, TX.

This article was published in Coping® with Cancer magazine, July/August 2014.