Managing Speech and Swallowing Difficulties Resulting from Head and Neck Cancer
by Jan S. Lewin, PhD
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 but also because 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, 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.
You should be thoroughly evaluated by an experienced speech pathologist to assess speech and swallowing function. 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, their food is entering the windpipe.
Several tests allow clinicians to determine the ability to safely swallow. The modified barium swallow study is a radiologic procedure that assesses the entire process of swallowing and is generally condidered to be the evaluation of choice for swallowing problems. The flexible endoscopic evaluation of swallowing uses a flexible endoscope placed through the nose. It is an excellent examination for people who have larynx cancer because it provides the best view of the vocal folds and aspiration. Both tests are indicated for all people with head and neck cancer who have, or are at risk for, swallowing problems or aspiration.
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.
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 radiation 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 new treatment to cure the cancer. It may have an additional benefit of reducing normal tissue damage, thereby 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 and airway protection. As much as possible, you should try 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.
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. Multidisciplinary evaluation and communication are essential. It is important to discuss realistic expectations for functional recovery after organ-sparing procedures with your doctor because neither speech nor swallowing will ever fully return to normal.
The focus of speech and swallowing intervention should be early and preventative to maximize restoration following treatment. People who are going to receive treatment for head and neck cancer and are at risk for speech and/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 associate professor in the Department of Head and Neck Surgery and director of Speech Pathology and Audiology at the University of Texas M. D. Anderson Cancer Center in Houston, TX.
This article was originally published in Coping® with Cancer magazine, May/June 2009.