Treatment of cancer in the head and neck region usually involves radiation therapy, either administered alone or in combination with surgery and/or chemotherapy. Nasopharyngeal cancer (NPC) is a disease known to respond well to chemotherapy and radiotherapy, especially in the early stages.
Effects of radiation on speech and swallowing function may vary; patients will be affected to some degree with varied presentations over time. Usually these problems are not picked up until several months or years after its onset.
During this period of time the patient is at risk of developing nasal regurgitation, coughing during meals and episodes of aspiration pneumonia, symptoms of which suggest worsening of their swallowing function.
Common complaints by patients with NPC post radiation suggesting presence of speech and swallowing dysfunction:
- Dry mouth (xerostomia)
- Altered taste sensation
- Voice change (i.e. hypernasality, hoarseness)
- Poor speech intelligibility
- Bad breath (halitosis)
- Restricted mouth opening (trismus)
- Tongue tremors (fasciculation)
- Food or liquid coming out from nose
- Food sticking in throat
- Requiring drinks to wash food down
- Coughing and choking while eating/drinking
- Taking longer time to finish a meal
- Avoiding certain foods
Patients with the above complaints should then be referred to a speech therapist who would then assess and manage the speech and swallowing difficulties accordingly. Ideally, the speech therapist should evaluate all patients before, during, and after radiation to determine any changes in the patient’s swallow status and to start appropriate exercises and evidence-based swallowing strategies as needed.
There are two main objective assessment tools used by speech therapists to ascertain a patient’s swallowing status and function. Videofluoroscopy for swallowing (VFS) is recognized as the gold-standard evaluation because it captures the entire oropharnygeal swallow. This allows for identification of specific characteristics of the swallowing disorder, which is necessary to determine appropriate interventions to be used and their effectiveness subsequently verified.
The fibreoptic endoscopic evaluation of swallowing (FEES) is a video-endoscopic tool that is sensitive to detect residues, laryngeal penetration, and aspiration, and avoids radiation exposure. Unlike VFS, it does not show the oral phase.
Common findings of VFS/FEES in patients with NPC post radiation:
- Decreased base of tongue movement to posterior pharyngeal wall resulting in reduced bolus propulsion into pharynx
- Reduced laryngeal elevation and laryngeal vestibule closure resulting in high incidence of laryngeal penetration during swallow
- Reduced epiglottic retroflexion resulting in reduced laryngeal vestibule closure
- Reduced pharyngeal contraction resulting in residue along pharyngeal wall post swallow
- Upper esophageal sphincter dysfunction
- High incidence that penetration and aspiration is silent
Information gathered from VFS and/or FEES will allow the speech therapist to tailor effective speech and swallow rehabilitation exercises specific to the patient. Therapeutic interventions may include:
- Dietary modifications (e.g. fluids to help flush solids, or need for thickened fluids, blended diet) vs. need for alternative feeding via nasogastric tube or PEG.
- Postural strategies (e.g. head positioning)
- Swallowing maneuvers that are evidence-based such as super-supraglottic swallow and the Mendelssohn Maneuver
- Therapeutic exercises that target strength and range of movement for jaw, lips, tongue, larynx, and neck
- Speech tasks working on improving intelligibility
- Referral to ENT for vocal cord medialization, botox, and/or UES dilatation and hearing aids for hearing loss
- Referral to prosthodontist for prosthetics to improve speech intelligibility and facilitate swallowing function (e.g. palatal lifts to manage velopharyngeal incompetence or palatal lowering device)
- Referral to dietician for nutritional advice
It is therefore important to understand the need to diagnose and manage swallowing difficulties, since unrecognized dysphagia may lead to multiple health problems such as repeated admissions for aspiration pneumonia and poor nutritional and hydrational status. Coughing and choking during meals, prolonged eating time, and the limited range of foods that can be swallowed can also lead to social isolation thus affecting the patient’s quality of life. As such the speech therapist together with the patient’s primary physician and other medical professionals play a significant role in maximizing optimum management in patients with NPC post radiation.
Elizabeth Roche
Senior Principal Speech Therapist
Low Ai Wei
Speech Therapist
Singapore General Hospital
