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Speech and swallowing rehabilitation of the patient with head and neck cancer

Speech and swallowing rehabilitation of the patient with head and neck cancer
Authors:
Jan S Lewin, PhD
Marita S Teng, MD, FACS
Tamar Kotz, MS CCC-SLP
Section Editors:
Bruce E Brockstein, MD
Marvin P Fried, MD, FACS
Deputy Editors:
Sonali Shah, MD
Wenliang Chen, MD, PhD
Literature review current through: Dec 2022. | This topic last updated: Aug 24, 2021.

INTRODUCTION — Patients with head and neck cancer face multiple, often severe psychological and functional problems associated with the diagnosis and treatment of their disease. Rehabilitation and restoration of speech and swallowing are critical to optimize quality of life following treatment. (See "Health-related quality of life in head and neck cancer".)

Functional outcomes depend on multiple factors, including the site of origin and stage of the cancer, treatment modality, extent of resection, type of reconstruction, and quality of rehabilitation. Anatomical preservation does not necessarily translate into preservation of organ function. Even treatments that permit organ preservation, surgical (eg, laser, robotic) or nonsurgical (eg, radiation therapy alone or in combination with chemotherapy), frequently result in severe functional sequelae [1]. (See "Locally advanced squamous cell carcinoma of the head and neck: Approaches combining chemotherapy and radiation therapy".)

The critical components of speech and swallowing rehabilitation for the patient with head and neck cancer will be reviewed here. Alaryngeal speech restoration is discussed separately. (See "Alaryngeal speech rehabilitation".)

THE INTERDISCIPLINARY TEAM — Patients with head and neck cancer have a variety of speech and swallowing problems. Many factors contribute, including:

Loss of anatomic structure and continuity within the upper aerodigestive tract

Altered salivary flow

Altered dentition

Mucositis

Odynophagia and dysphagia

Trismus

Malnutrition and weight loss

Treatment-related edema and fibrosis

Depression

Successful treatment for head and neck cancer and posttreatment rehabilitation are facilitated by a strong interdisciplinary team approach to management. This point cannot be overemphasized. Pretreatment evaluation and planning should involve the entire patient care and rehabilitation team, including at a minimum the surgeon, radiation oncologist, medical oncologist, dentist or maxillofacial prosthodontist, speech pathologist, nurse, dietitian, and social worker. Assistance from other specialists (eg, physical therapist, psychologist, pharmacist) may also be needed during the course of treatment.

The attitude and preferences of the patient and the support of family and friends are essential components of treatment acceptance and compliance. Therefore, the patient and family (or significant other) must be included in the treatment planning process. Ideally, patients should meet with all members of the interdisciplinary team prior to the initiation of their cancer treatment. Recovery and rehabilitation are optimized when there is ongoing dialogue between all members of the interdisciplinary team and consistency in the information that is relayed to the patient.

The need for speech and swallowing therapy is often unexpected by the patient and may be difficult to accept. Even though pretreatment difficulty in swallowing may be present in more than one-half of patients with head and neck cancer, these problems may not be self-perceived [2]. In addition, approximately 40 percent of patients report baseline speech problems, and up to 15 percent of patients have moderate to severe cognitive impairment that may impact the rehabilitation process [3]. Pretreatment counseling should provide realistic expectations for recovery and reinforce the patient's responsibility for active participation in an aggressive rehabilitation program.

Baseline evaluation of speech and swallowing function should be obtained for posttreatment comparison. Baseline examination of swallowing function also provides critical information for the prediction of posttreatment functioning. Patients who cannot swallow adequately before treatment are at greater risk for chronic swallowing impairment after treatment and are at greater risk for long-term feeding tube dependence. In fact, prophylactic swallowing exercises have been shown to be effective in maintaining pharyngeal muscle tone. Specifically, the initiation of swallowing exercises prior to the onset of dysphagic symptoms helps to improve posttreatment swallowing function [4,5]. Ongoing studies are evaluating the efficacy of oral intake, eating and drinking by mouth, as a viable alternative to swallowing exercises (eg, PRO-ACTIVE, NCT03455608).

A routine pretreatment dental evaluation is critical for all patients, regardless of the treatment modality. Rehabilitation of both speech and swallowing may be severely compromised by unplanned dental extractions, especially if appropriate consideration is not given to the stability of a possible intraoral prosthesis. In addition, the patient's dental status, dentate or edentulous, will affect speech and swallowing rehabilitation as well as final functional outcomes. (See "Management of acquired maxillary and hard palate defects" and "Management and prevention of complications during initial treatment of head and neck cancer", section on 'Dental issues'.)

Pretreatment counseling is critical and is designed to reduce the fears and misconceptions of the patient and family while assuring them that rehabilitation will be available both during and after treatment to improve functional status [6]. It permits the patient and the family to assimilate information that is often overwhelming and frightening and gives them an opportunity to ask the questions that concern them.

PHYSIOLOGY — Normal speech and swallowing require precise coordination of a series of rapid, complex neuromuscular actions. Speech production is affected primarily by tumors that involve the tongue, other structures of the oral cavity, or the larynx. In contrast, swallowing can be affected by any cancer within the aerodigestive tract [7]. Any alteration in oropharyngeal or laryngeal structures or their neural innervation that disrupts these neuromuscular patterns will have some effect on both speech and swallowing.

Swallowing includes four discrete phases: the oral preparatory, oral, pharyngeal, and esophageal stages. These four biomechanical events occur in a predictable sequence, and each stage is based on the movement patterns and timely occurrence of neurologic triggers from the previous stage. The oropharyngeal swallow consists of the first three stages only. These events begin at the lips and end at the upper esophageal sphincter. Aspects of voluntary and involuntary control characterize the various swallowing stages. (See "Oropharyngeal dysphagia: Etiology and pathogenesis", section on 'Physiology of swallowing'.)

In general, normal swallowing requires intact anatomy, which can vary widely in size, shape, and symmetry in healthy individuals. These variations often affect swallowing but rarely compromise it. However, such variations may result in impaired swallowing or further decompensation in an otherwise debilitated patient [8].

COMPLICATIONS AFTER RADIATION THERAPY — Radiation therapy (RT) is an important and potentially curative modality for head and neck cancers. It can be used in combination with chemotherapy for organ-preserving approaches, as adjuvant therapy following surgical resection, or for palliation in patients with advanced disease. Regardless of the clinical intent, RT produces tissue changes that often result in long-term alterations in speech and swallowing. (See "Management and prevention of complications during initial treatment of head and neck cancer" and "Management of late complications of head and neck cancer and its treatment".)

In general, RT has a greater impact on swallowing than it does on speech [9,10], and the addition of chemotherapy or use of altered fractionation schemes often exacerbate these effects, particularly during the acute recovery period [7,11]. The functional toxicities of radiation-based treatment can be significant, and dysphagia is commonly cited as a potentially dose-limiting toxicity within the first two years of treatment [12].

The magnitude of the problem often depends on the dose and duration of RT, the extent of the treatment field, and whether chemotherapy was used. The impact of a specific radiation dose also depends on the sensitivity of the structure to damage and how critical the structure is to function. Many patients have been treated with curative doses of RT ranging from 60 Gray (Gy) or more to pharyngeal structures, which can result in chronic or late radiation-associated dysphagia (RAD). [13-15]. Current investigations are ongoing to determine the feasibility of radiation de-escalation without compromising patient survival [16]. (See "Definitive radiation therapy for head and neck cancer: Dose and fractionation considerations" and "Locally advanced squamous cell carcinoma of the head and neck: Approaches combining chemotherapy and radiation therapy".)

Unfortunately, a subset of survivors of head and neck cancer develop persistent or late RAD. Although many patients recover functional swallowing capability, approximately 30 to 40 percent of patients treated with radiation regimens of 66 to 72 Gy go on to develop severe, chronic dysphagia [17].

Late severe dysphagia may be uncommon, but when it occurs, the level of dysfunction is often intense and refractory to standard nonsurgical therapies. In a case series of 29 long-term (≥5 years) head and neck cancer survivors with late dysphagia treated with RT or chemoradiotherapy from a single institution, 86 percent aspirated and developed pneumonia [16]. Sixty-two percent of these patients experienced recurrent pneumonias, and 21 percent ultimately underwent elective total laryngectomy to prevent aspiration. No dysphagic patient achieved durable improvement across all functional measures, despite rehabilitative efforts. Ultimately, 66 percent of cases were gastrostomy dependent due to aspiration or poor nutrition.

Contemporary RT techniques may reduce late severe dysphagia by restricting doses to critical structures, such as the pharyngeal constrictors, larynx, oral cavity, and esophageal inlet [18]. Techniques such as intensity-modulated radiation therapy (IMRT) and intensity-modulated proton therapy (IMPT), which target the tumor with set radiation doses while limiting the dose to adjacent structures, tend to reduce radiation-related morbidity, particularly xerostomia. Although the coverage of disease target volumes should never be sacrificed to spare noncritical avoidance structures, dose-limiting constraints to organs at risk may prove geographically possible in many cases, and avoid long-term swallowing dysfunction [19]. (See "General principles of radiation therapy for head and neck cancer", section on 'Intensity-modulated RT' and "Management of late complications of head and neck cancer and its treatment", section on 'Salivary gland damage and xerostomia'.)

In patients with head and neck cancer, RT-induced changes in swallowing are often characterized by early improvement followed by deterioration. Clinicians should not be misled by the early recovery of swallowing as the acute effects of edema resolve. The adverse impact of radiation may equal or exceed that associated with surgery because radiation-induced fibrosis may increase in severity for years after treatment.

Studies comparing swallowing function in radiated patients at 6 months and 10 years posttreatment show a similar degree of abnormality in the pharyngeal swallow [7,20]. These include reduced tongue base contact to the pharyngeal wall, restricted laryngeal motion, and impaired airway protection with resultant aspiration [21,22]. Other studies have shown prolonged pharyngeal bolus transit time and delayed hyoid bone elevation, which causes the upper esophageal sphincter to open early relative to the arrival of the food bolus [20]. Contributory factors to this reduced swallowing ability include tissue changes, fibrosis, and possible alterations in sensory awareness.

Fibrosis and neuropathy — Dysphagia after RT or chemoradiotherapy is probably the result of both fibrosis and cranial neuropathies that cause neuromuscular dysfunction and impede swallowing physiology [23]. There is evidence for neuropathic contributions to posttreatment dysphagia as a result of the denervation of the suprahyoid musculature following RT [24]. Moreover, data suggest that when dysphagia occurs five or more years after RT, it is usually severe and often refractory to standard swallowing therapies. Such late dysphagia is due to significant impairment to the range of motion of the hyolaryngeal complex resulting from the long-term effects of RT [25]. (See "Management of late complications of head and neck cancer and its treatment", section on 'Lymphedema and fibrosis'.)

In patients treated with RT, palpable, high-grade cervical fibrosis is a common finding that compresses peripheral nerve tracts and likely exacerbates swallowing muscle denervation. Other problems associated with radiation damage that can also contribute to swallowing dysfunction include impaired cervical range of motion, abnormal cervical posture, cervicalgia, and head drop syndrome. Manual therapy is a common treatment for radiation-induced cervical fibrosis. A single-institution, prospective single arm unblinded pilot trial, Manual Therapy for Fibrosis-Related Late Effect Dysphagia (MANTLE), has been proposed to evaluate the effect of manual therapy and muscle mobilization targets on reducing treatment-refractory late radiation associated dysphagia (RAD) in survivors of head and neck cancer [26].

Xerostomia and mucositis — RT alters the volume, consistency, and pH of secreted saliva. Saliva changes from thin secretions with a neutral pH to thick and tenacious with increased acidity. Radiation-induced damage to the salivary glands usually causes permanent xerostomia and is one of the most disturbing adverse effects to patients because there are no good effective long-term management strategies. (See "Management of late complications of head and neck cancer and its treatment", section on 'Salivary gland damage and xerostomia'.)

Acute mucositis is also associated with long-term dysphagia and has been reported to be the dose-limiting toxicity of standard chemoradiotherapy regimens. Patients report thick, ropey secretions that result in gagging and regurgitation and predispose to aspiration. High-grade mucositis resulting from intensive chemoradiotherapy protocols generally occurs early, lasts longer, is more severe, and sometimes leads to fibrosis and organ dysfunction [27].

Gastrostomy tube placement — Prophylactic feeding tube placement continues to be controversial. Some data suggest that patients with marked weight loss should receive a feeding tube before therapy begins. Other studies suggest that excessive use of feeding tubes leads to increased long-term feeding tube dependency [28]. Current evidence suggests that even brief intervals of no oral intake decrease swallowing function and, therefore, should be avoided as much as possible [29]. It is likely that a significant number of patients who get feeding tubes do not need them. In one study of patients with head and neck cancer, 48 percent of patients with prophylactic percutaneous endoscopic gastrostomy (PEG) tubes either never used the PEG tube or used it for fewer than two weeks [30]. Thus, many clinicians prefer to defer placement of a feeding tube until a clinical need is evident.

Still, some data suggest that there is no correlation between posttreatment feeding tube dependency and prophylactic feeding tube placement. In fact, some argue that prophylactic tube placement results in fewer nutrition-related complications or hospitalizations and a higher proportion of treatment cycles completed [31]. (See "The role of parenteral and enteral/oral nutritional support in patients with cancer", section on 'Head and neck cancer'.)

Both eating and exercising during regimens of (chemo)radiation are not only feasible, but they are also critical to avoiding long-term gastrostomy tube dependence and can reduce the duration of gastrostomy tube use by 50 percent. It is speculated that proactive swallowing therapy counteracts the loss of the normal resistive load that occurs when the acute side effects of RT or chemoradiotherapy cause patients to stop eating solid foods [32].

Aspiration — Despite the potentially severe effects of RT, dysphagia and aspiration are underreported and underappreciated consequences of RT and chemoradiotherapy. Although the true extent of this toxicity has not been well documented, it has been estimated that at least 50 percent of long-term head and neck cancer survivors have dysphagia, with aspiration rates up to 84 percent. Silent (insensate) aspiration has been reported in up to 80 percent of patients who aspirate, with the highest rates of silent aspiration occurring more than 12 months after the completion of RT [12,21,33]. (See "Health-related quality of life in head and neck cancer".)

Primary tumor site — The primary site of the head and neck cancer can influence the clinical manifestations of fibrosis and xerostomia:

Oral cavity – In patients receiving RT to the oral cavity, dry mouth may affect mastication through changes in tongue mobility, prolongation of oral transit time, and a delay in the triggering of the swallow reflex [6,34-37]. Oropharyngeal swallowing efficiency may be affected indefinitely after RT [22].

Pharynx – Postradiation edema and fibrosis of the pharyngeal constrictor musculature usually impair pharyngeal motility, resulting in retention of food or residue within the pharynx, and the potential for aspiration.

Patients with tumors of the base of tongue or tonsils are at risk for postradiation pharyngeal dysmotility and incoordination, and difficulty triggering the swallow reflex. Subsequent problems in bolus transit may result in aspiration.

Patients with primary hypopharyngeal tumors have the worst swallowing outcomes after RT [38].

Larynx – When the larynx is in the RT field, problems with airway protection and voice changes may also necessitate intervention [39]. Voice changes may result from the mechanical effects of the tumor, the short-term effects of edema, and the long-term effects of fibrosis. Nevertheless, patients prefer laryngeal phonation after organ preservation as compared with any of the methods used to restore oral communication after laryngectomy. (See "Alaryngeal speech rehabilitation".)

RT to the larynx usually results in problems with the pharyngeal swallow, with aspiration reported in up to 80 percent of patients treated with nonsurgical organ preservation for laryngeal cancer [33]. Radiation-induced fibrosis can reduce the range of motion of the tongue and jaw, diminish pharyngeal wall motion, and restrict laryngeal movements, increasing the potential for aspiration [10]. In one report, almost one-half of nonlaryngectomized head and neck cancer survivors had at least some degree of aspiration, which was associated with weight loss and negative impacts on quality of life [12,21,33].

Treatment — As previously mentioned, exercise protocols to strengthen and maintain range of motion, precision, muscle elasticity, and mobility should be started prior to the initiation of RT. Patients should adhere to these established exercise protocols both during and after RT [4,5]. Some patients may find the long-term use of this exercise regimen to be necessary to counter the long-term adverse effects of radiation. In at least one study, patients who performed swallowing exercises during RT had significantly higher patient-reported swallowing-related quality of life [40]. Given the evidence to date, which supports pretreatment swallowing exercises to improve posttreatment swallowing function, it is critical that patients who will be treated with RT are referred to speech pathologists before their cancer treatment begins [41].

An appropriate swallowing therapy program for patients with dysphagia may include the use of specific swallowing maneuvers, changes in body posture, range of motion or resistance exercises, or techniques to heighten sensory awareness and facilitate bolus transit during swallowing [6,7,34,39,42].

Such exercises can improve pharyngeal mobility during the swallow, resulting in enhanced pharyngeal clearance, airway protection, and decreased or absent aspiration in the majority of cases [7,41,43-45].

Despite the benefit associated with swallowing therapy, data suggest that successful treatment of RAD is time dependent among survivors of head and neck cancer. In one study conducted in survivors of head and neck cancer with dysphagia, improved swallowing outcomes were shown in those who initiated swallowing therapy within one year of RT completion compared with those who initiated therapy more than two years post-RT [46].

Providing adequate pain control is important so that patients are able to adhere to and complete critical swallowing exercise regimens. Patients who receive appropriate pain management during chemoradiotherapy maintain swallowing function during treatment and have favorable posttreatment physiologic swallowing outcomes compared with matched controls. Appropriate pain management has been associated with reports of significantly less pain, reduced gastrostomy tube use and duration, and significantly less penetration and aspiration based on modified barium swallow study examinations [47].

Additionally, voice therapy may be of benefit for patients with posttreatment phonation problems that cause difficulty in communication [48].

Other complications — Other complications from RT that can affect speech and swallowing include trismus, dysgeusia (taste alterations), ageusia (loss of taste), dysosmia (altered sense of smell), and esophagitis. Many of these problems begin within the first two weeks of RT and worsen progressively as treatments proceed.

Another common consequence of RT is lymphedema of the head and neck. This can affect the oral and/or pharyngeal anatomy and result in significant speech and swallowing dysfunction. Loss of the bolus from the mouth (drooling) and difficulty moving food through the oral cavity are consequences of head and neck lymphedema that results in significant swelling of the lips and tongue. In addition, lymphedema of the prevertebral tissue may obstruct bolus transit through the pharynx, resulting in complaints of pharyngeal stasis and potential aspiration.

Early experience has shown that targeted therapy that combines techniques of gentle massage, compression bandaging, skin care, and exercise has been very successful in relieving chronic edema, thus facilitating improved cosmesis and a return of speech and swallowing function [49,50].

The magnitude of these effects varies widely, although most patients experience some impairment in both swallowing and speech production. The tissue soreness and edema associated with RT decreases sensation, interfering with the precision of oropharyngeal mobility. This in turn impairs the timing and coordination of the swallow. Articulatory imprecision and oral incoordination may slur speech and impair intelligibility. Patients frequently report a clumsiness or slowness of speech rather than dysarthria associated with articulation. Fortunately, these problems tend to subside as the mucosal irritation and edema resolve.

POSTSURGICAL COMPLICATIONS — Speech and swallowing rehabilitation is essential after resection of tumors of the head and neck. In general, surgical procedures that result in larger surgical defects produce greater deficits in speech and swallowing. With larger ablative defects, it is often necessary to perform reconstructive procedures that utilize flaps that are adynamic or bulky, and these can be associated with a poorer functional outcome. Primary closure or secondary healing of the defect may best preserve postoperative function in selected smaller oropharyngeal resections [51-54].

Minimally invasive techniques — New endoscopic and minimally invasive surgical techniques, including transoral laser microsurgeries and transoral robotic surgery (TORS), offer new opportunities to provide organ-sparing alternatives with oncologic outcomes similar to radiation-based regimens and conventional open techniques. There is evidence that these approaches improve long-term speech and swallowing function.

Benefits have included faster recovery of swallowing function, lower incidence of aspiration pneumonia, lower rates of tracheostomy and gastrostomy, and shorter hospital stays [55-57]. Patients who have failed definitive radiation therapy (RT) protocols may remain candidates for these minimally invasive surgical options in the salvage setting.

The ability to preserve critical swallowing musculature and physiology that would otherwise be compromised by RT is likely the key benefit to maintaining the range of motion of critical swallowing organs. Data suggest improved rehabilitative and functional outcomes after minimally invasive procedures compared with open surgical outcomes [58]. As an example, a study of 35 consecutive cases of TORS for oropharyngeal squamous cell carcinoma found that all patients were able to return to a full oral diet with acceptable/reasonable to normal swallowing function [59]. In addition, adjuvant treatment was spared in 13 cases (37 percent), thereby deintensifying the overall treatment and eliminating the patient's risk of additional dysphagic symptoms from postoperative RT. In another study that examined swallowing function pre- and post-TORS, all patients were able to tolerate a regular diet after surgery, and only one-half of the patients required adjuvant RT [60].

Oral cavity and oropharyngeal cancers — Surgical resection of cancers of the oral cavity can create complex swallowing disorders that involve both the oral and pharyngeal stages, as well as severe disturbances in speech production. Tongue mobility is the most critical component of swallowing initiation and the subsequent triggering of the pharyngeal stage. The presence of food alone is not an adequate stimulus for triggering of the pharyngeal phase of swallowing.

Speech and swallowing function will be affected by the degree of resection, the type of reconstruction, and the use of postoperative RT [61]. In general, resections that preserve neural innervation combined with reconstructions that allow optimal residual tongue movement, especially of the back and base of tongue, will result in the best speech and swallowing functional outcome.

Surgeries that suture the tongue to the floor of the mouth or buccal mucosa severely impair articulation and the oral stage of the swallowing. Fortunately, such surgeries are rarely performed anymore. The degree of swallowing impairment often depends on the quality of the reconstruction rather than the extent of resection. The shape of the oral tongue reconstruction affects postoperative speech and swallowing outcomes [62]. As an example, slightly protuberant or convex flap shapes result in superior function after total or subtotal glossectomy compared with flat or concave flaps, which provide limited structural contact necessary for articulation and bolus transit. Some patients who have undergone total glossectomy swallow better than patients following composite resection of the tongue, floor of the mouth, and mandible.

Oral surgery that interferes with lip closure, the rotary action of the jaw, facial tone, or tongue movement will affect the oral preparatory stage of swallowing, including taste, sensation, and the enjoyment associated with eating. During this stage, food is masticated and mixed with saliva. Patients can be taught to bypass this stage, although at the expense of the social and sensory enjoyment associated with eating.

Any surgery involving the anterior floor of mouth that inhibits movement of the tip and lateral aspects of the tongue will inhibit chewing and food control, the swallowing reflex, and the pharyngeal initiation of the swallow. Similar deficits may follow resection of tumors of the posterior oral cavity (ie, tonsil or base of tongue). However, resection of these tumors more commonly interferes with the triggering of the swallow reflex, which largely occurs in the region between the anterior faucial arches and the point where the tongue base crosses the rim of the mandible [63]. Such patients will have further difficulty with oropharyngeal propulsion and pharyngeal motility, especially with the addition of postoperative radiation [61]. When large areas of the pharynx must be sacrificed, the patient may not be able to move food through the pharynx at all.

Treatment — While swallowing therapy can improve oral control of the bolus and facilitate the initiation of the swallow reflex, pharyngeal dysmotility is usually permanent [64]. However, the use of specific swallowing maneuvers and postures is often successful in improving pharyngeal transit. (See 'Complications after radiation therapy' above.)

Speech intelligibility can be significantly altered by total, subtotal, or partial glossectomy [65-68]. Speech therapy is effective in improving speech intelligibility, even after major resection [8]. Generally, a palatal augmentation prosthesis will improve speech production and swallowing when 50 percent or more of the oral tongue is removed [69].

Exercise therapy is maximized by adhering to defined principles of strength training and neuroplasticity. Additional measures of biofeedback including surface electromyography or endoscopic monitoring during swallowing therapy can help the patient identify and modify swallowing behaviors.

Conflicting data have been reported with regard to the potential benefit of transcutaneous neuromuscular electrical stimulation (NMES) as a treatment for dysphagia in patients with head and neck cancer. A randomized, sham-controlled clinical trial found that current models of NMES added no benefit to traditional swallowing exercise in head and neck cancer patients with chronic moderate-severe dysphagia after chemoradiation [70]. NMES frequently lowers the hyolaryngeal complex because of more intense levels of stimulation to the superficial hyoid strap muscles as opposed to the deeper laryngeal elevators. Therefore, transcutaneous NMES may provide benefit only to patients who can elevate the larynx against a downward-pull type of resistance while swallowing. Careful examination of NMES during videofluoroscopic examination is important to identify patients who are candidates for this type of swallowing therapy to avoid aspiration or any further potential harm [71].

Laryngeal and hypopharyngeal cancers — The degree of functional deficit following laryngectomy depends on the extent of resection. While it is clear that patients who undergo either partial or total laryngectomy will experience some degree of both voice and swallowing disorders, posttreatment quality of life studies suggest that eating and swallowing seem to be of greater importance to patients than voice and speech production [72]. (See "Health-related quality of life in head and neck cancer".)

The most common problem following laryngeal surgery is the inability to elevate and close the larynx, which is critical for safe and efficient swallowing. During the pharyngeal stage of swallowing, the larynx and hyoid bone elevate and move anteriorly away from the path of the bolus to protect the airway and help open the upper esophageal sphincter, allowing the bolus to pass into the cervical esophagus. As the bolus passes through the sphincter, the larynx descends and the upper esophageal sphincter (the cricopharyngeus muscle) closes in a state of tonic contraction.

To prevent food from entering the trachea during swallowing, three valves (the true vocal folds, the laryngeal inlet, and the epiglottis) close to prevent food from entering the trachea during swallowing, thereby avoiding aspiration. Any surgical procedure that compromises closure of the valves will result in disordered swallowing and aspiration [64].

Myotomy of the cricopharyngeus muscle has been used to improve swallowing disorders resulting from cricopharyngeal dysfunction. However, studies are conflicting, with some showing no benefit [73] while others report a benefit in only a limited number of patients. In most cases, reduced cricopharyngeal opening is due to a reduced laryngeal excursion that myotomy will not improve. Injection of botulinum toxin into the cricopharyngeus muscle is also an option to relax the relative hypertonicity of the muscle in some cases, even after partial or total laryngectomy [74].

In most cases, patients with swallowing disorders related to impairment in cricopharyngeal functioning will benefit from swallowing therapy and exercise programs that focus on improving laryngeal movement [75].

Impaired voice production also follows laryngeal surgery. Depending on the extent of laryngeal surgery, postoperative voice disorders can range from breathiness or hoarseness to complete aphonia. Accompanying abnormalities in voice pitch and intensity may or may not be evident. Management of posttreatment voice disorders may include speech therapy alone or in combination with any one of a variety of surgical procedures designed to optimize voice production [76]. (See "Alaryngeal speech rehabilitation".)

Rehabilitation following laryngopharyngectomy — Partial laryngectomies can be either vertical hemilaryngectomy (VHL), supraglottic laryngectomy, or supracricoid partial laryngectomy, depending on the location of the tumor. (See "Treatment of locoregionally advanced (stage III and IV) head and neck cancer: The larynx and hypopharynx", section on 'Surgery'.)

Patients who undergo VHL usually experience a brief period of swallowing difficulties while the surgically unaffected side gradually compensates for the damaged side. They typically have difficulty swallowing liquids due to reduced laryngeal closure. In most instances, the unaffected side will eventually cross the midline during phonation and approximate the surgically treated side for closure within a few weeks [77].

In contrast, VHL produces moderate to severe impairment in vocal quality that is characterized by varying degrees of hoarseness and loudness. This is the result of the irregular vibration produced by the impaired approximation of the vocal fold and reconstructed hemilarynx. While improvement does occur in most patients, dysphonia does not fully resolve in the majority.

Supraglottic tumors, by the nature of their location, affect laryngeal structures above the glottis and, thus, do not significantly affect the true vocal folds. Resection of supraglottic tumors may be achieved endoscopically or through open horizontal supraglottic laryngectomy. Although voice and speech are usually preserved following supraglottic resection, swallowing is severely affected postoperatively because airway protection has been significantly compromised, and aspiration is common. (See "Treatment of locoregionally advanced (stage III and IV) head and neck cancer: The larynx and hypopharynx".)

Recovery of swallowing function generally requires swallowing therapy using a formal hierarchy of exercises and techniques designed to facilitate and strengthen the contact between tongue base and arytenoids to prevent food or liquid from entering the airway. Although some patients recover faster, a four- to six-week period of time is usually required to rehabilitate swallowing following supraglottic laryngectomy [78]. If adequate tumor resection requires sacrifice of a significant amount of the tongue base, swallowing without aspiration may never be regained, and a total laryngectomy may be necessary. The requirement of a total laryngectomy for functional reasons is particularly common when surgery is being offered in a salvage, postchemoradiation setting.

Supracricoid partial laryngectomy with cricohyoidopexy or cricohyoidoepiglottopexy has been advocated to control selected advanced supraglottic/transglottic tumors classified as T3-T4 (table 1) for which the conventional surgical alternative would have been total or near-total laryngectomy [79,80]. The avoidance of a permanent stoma for respiration and the continuity of laryngeal phonation following surgery are significant advantages of the procedure. For the majority of patients, these advantages greatly outweigh the temporary but generally severe dysphagia during the acute postoperative period, the need for protracted swallowing therapy, and the permanent alterations in vocal quality associated with the procedure [81]. (See "Treatment of locoregionally advanced (stage III and IV) head and neck cancer: The larynx and hypopharynx".)

The focus of postoperative treatment in this population is to achieve complete and timely neoglottic closure to prevent aspiration during swallowing as well as to reestablish a vibratory source for phonation. A model for swallowing rehabilitation after supracricoid partial laryngectomy is available [82].

Rehabilitation following total laryngectomy — In contrast to other laryngeal surgeries, patients who have undergone total laryngectomy do not routinely complain of significant swallowing problems or aspirate because of the discontinuity of the trachea and esophagus. Many patients report slower swallowing that is primarily the result of pharyngeal dysmotility, cricopharyngeal dysfunction, and reduced strength of tongue base movements following resection of the larynx and hyoid bone.

Although data are limited, the incidence of dysphagia is increasing following total laryngectomy [83]. This is likely because the majority of laryngectomies performed today are in a salvage, postchemoradiation setting. As such, many patients present for surgery with a significant preoperative swallowing abnormality, which is not regained postoperatively. However, these abnormalities often go unrecognized since this population is less likely to be evaluated and treated for swallowing difficulties, likely because aspiration does not occur following total laryngectomy.

Other swallowing-related problems have also been reported [84]:

The development of a fold of mucous membrane or scar tissue at the tongue base can potentially impede swallowing. The tissue has a similar appearance to the epiglottis and has been referred to as a "pseudoepiglottis." At rest, the pseudoepiglottis remains flat against the tongue base; however, during swallowing, food can collect in a large pocket that is exposed between the pseudoepiglottis and the tongue base [85].

As a result of hyoid bone resection and other postoperative structural changes, patients may experience difficulty with tongue movements, chewing, and bolus propulsion through the pharynx.

A stricture within the pharynx or esophagus may narrow the passage for food transit, allowing food to collect proximal to the stricture. In a retrospective study of 263 patients after total laryngectomy, 19 percent developed postoperative strictures, and the majority (82 percent) occurred within the first year [86]. Esophageal dilation is effective in improving swallowing function, but there is often a need for serial dilations [87].

A diverticulum in the pharyngoesophageal wall may retain fluid and food, resulting in the complaint of food "sticking" in the cervical esophagus.

In all cases, postoperative complaints of swallowing difficulty after initiating oral feeding are best examined radiographically during videofluoroscopic recording to help rule out structural abnormalities versus disease recurrence. (See "Oropharyngeal dysphagia: Clinical features, diagnosis, and management".)

Speech rehabilitation following total laryngectomy is discussed separately. (See "Alaryngeal speech rehabilitation".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Head and neck cancer".)

SUMMARY AND RECOMMENDATIONS

Patients with head and neck cancer face multiple, often severe psychological and functional problems associated with the diagnosis and treatment of their disease. Following treatment, rehabilitation and restoration of speech and swallowing are critical to optimize quality of life. Thus, all patients who have speech and/or swallowing dysfunction after treatment should be referred to a knowledgeable speech pathologist; those who are at risk for such dysfunction should ideally be referred before cancer treatment begins.

Successful treatment for head and neck cancer and posttreatment rehabilitation are facilitated by a strong interdisciplinary team approach to management. Pretreatment evaluation and planning should involve the entire patient care and rehabilitation team, including at a minimum the surgeon, radiation oncologist, medical oncologist, dentist or maxillofacial prosthodontist, speech pathologist, nurse, dietician, and social worker. (See 'The interdisciplinary team' above.)

Following radiation therapy to the head and neck region, fibrosis, neuropathy, edema, mucositis, and xerostomia are the major sequelae that affect speech and swallowing. The magnitude of the problems depends on the dose, schedule, and treatment field for radiation therapy, and whether or not chemotherapy was also administered. Furthermore, clinical complications are heavily influenced by the primary site of the tumor. (See 'Complications after radiation therapy' above.)

Exercise protocols to strengthen and maintain range of motion, precision, muscle elasticity, and mobility should be started prior to the onset of radiation therapy and continued in the recovery period. Such exercises can improve oropharyngeal physiology during the swallow, resulting in enhanced oral transit, pharyngeal clearance, airway protection, and decreased or absent aspiration in the majority of cases. Late severe dysphagia is uncommon, but when it occurs, it is often refractory to standard nonsurgical rehabilitative efforts. (See 'Treatment' above.)

Speech and swallowing rehabilitation is essential following resection of tumors of the head and neck. In general, surgical procedures that result in larger surgical defects produce greater deficits in speech and swallowing. The specific deficits are based on the primary site of the tumor and the surgical procedure used to eradicate the cancer. An appropriate, effective plan of rehabilitation depends on thorough and accurate evaluation of speech and swallowing dysfunction.

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