Cancers of the head and neck often lead to communication and swallowing disorders. These disorders are collectively known as dysphagia. Severity of such disorders depends on the type and nature of treatment (radiotherapy, chemotherapy and/ or surgeries), the tumour size and its location.

Oral surgeries (e.g. glossectomies) cause poor oral control of food and liquid bolus and poor oral propulsion, which causes swallowing difficulties. Surgery on pharynx and/or larynx, depending on the site and extent of lesion, can lead to aspiration risks due to impaired airway protection during swallowing. Radiotherapy can cause dysphagia due to soreness in the oral cavity, xerostomia and restricted oral movement and pharyngeal structures.

Assessment and management: role of speech therapy

The speech therapist usually assesses and manages patients who present with the following problems:

	When treatment result in swallowing and/or communication problems (e.g. patient scheduled for hemi-glossectomy or total laryngectomy)
	When patients report changes in communication and/or swallowing abilities (e.g. change in voice quality, slurred speech and problems with eating)
	When patients present with symptoms of pneumonia (e.g. fever and chest infection) or aspiration pneumonia.

Before patients are scheduled for laryngectomy or glossectomy, they need to go for a pre-operative consultation with a speech therapist. During the consultation, the impact of surgery on communication and swallowing, and post surgery rehabilitation will be explained. Family members should also be involved to discuss expectations and concerns on management.

After surgery or when patients present with dysphagia or voice changes, a clinical examination of oro-motor function, speech systems, voice quality, and swallowing, will be conducted. This is followed by videofluoroscopy and/or fiberoptic endoscopic evaluation of swallowing to ascertain the nature and causes of symptoms. Patients with vocal fold dysfunction will be referred to the Voice Clinic where ENT surgeon and speech therapist assess vocal fold function and plan management that may involve surgery and/or voice therapy.

Treatment methods

Depending on patients’ needs, the following procedures may be necessary:

	Develop a communication board or encourage patients to write.
	Teach oesophageal speech or the use of electrolarynx for total laryngectomees.
	Improve and maintain muscle function via oro-motor exercises.
	Voice therapy after vocal fold surgery.

Swallowing disorders:

	Compensatory treatment procedures such as postural techniques (head tilts and chin tuck), adjusting the bolus volumes and consistencies.
	Therapy exercises to improve the range of motion of oral and pharyngeal structures such as Shaker exercise and Pharyngocise.
	Swallow manoeuvres such as supra-glottic swallows, Mendelsohn’s manoeuvre, when used during swallowing, will change selected aspects of neuromuscular control.
	Using Surface Electromyography as an adjunct to treating dysphagia.
	Electrical Stimulation therapy based on neuromuscular electrical stimulation is a promising tool for dysphagia management with evidence on its efficacy for head and neck cancer patients.

(Using cervical auscultation and palpation to assess a patient)

With enough evidence demonstrating significant reduction in the quality of life and increased medical costs for patients, early detection and management by the team including speech therapists is imperative.

 

Radika Vasudeva		Melissa Chua
Head		Speech Therapist, SGH
Speech Therapy, SGH