Speech-language pathologists should become involved in the treatment of patients with head and neck cancer soon after an appropriate treatment protocol has been decided by a patient and physician, according to Cathy Lazarus, PhD, CCC-SLP, associate professor in the Department of Otolaryngology at the New York University School of Medicine.
"Ideally, the speech-language pathologist becomes involved when the patient has been identified as having head and neck cancer before their treatment, before their surgery, or before their chemotherapy/radiation protocol if they are not going to have surgery," Dr. Lazarus, who also is director of the Hearing and Speech Department at Bellevue Hospital Center, in New York, told ADVANCE.
She first meets with patients for pre-treatment counseling sessions, where she explains the role of the speech-language pathologist and the function of voice, speech and swallow evaluations.
"In addition to letting patients know what our role is, it lets them know what their role is in terms of their rehabilitation so they know that they are going to be playing a big part in their rehab," Dr. Lazarus said.
During counseling, she explains the exercises that will aid voice, speech and swallowing function. Patients scheduled to undergo a total laryngectomy are told of their post-surgical communication options, such as an electrolarynx and a voice prosthesis if they undergo a tracheo-esophageal puncture (TEP).
Patients who will be fitted with a voice prosthesis are told about the voice production therapy exercises they will be assigned after surgery, and those who plan to undergo chemotherapy and radiation will be assigned prophylactic swallow exercises to maintain current function and prevent problems from developing.
During counseling, Dr. Lazarus fields questions from patients regarding their post-treatment potential to regain speech, voice and swallow function. Generally, she tries to keep her responses vague until the outcome of the surgery is known. She tells patients, "We want to get your voice and speech as clear as they're going to sound and get your swallowing to the point that you can take the widest variety of diet safely and efficiently."
A swallow screening and evaluation are performed to determine the patient's current swallow capacities and diet; and an oral-motor exam determines lingual, laryngeal, velar and lip functioning.
"That gives me a baseline," she explained. "It may be totally different after their treatment starts; but that way I know I have a baseline in terms of range of motion, strength and speed."
Actual therapy, treatments and hands-on involvement of the speech-language pathologist vary depending on whether the patient undergoes a chemotherapy/ radiation protocol or a surgical procedure.
Patients who do not undergo surgery are provided with swallow exercises during consultation, she said. "Most of the exercises are designed to maintain pharyngeal function. The resistance exercises help me to see whether the base of the tongue will work better for the pharyngeal phase of the swallow if we strengthen the tongue."
Patients are taught the effortful swallow and the tongue-hold, or Masako, maneuver to increase tongue base strength; the Mendelssohn maneuver to maintain laryngeal flexibility; and the super-supraglottic swallow to maintain supraglottic airway closure.
After chemotherapy and radiation are concluded, patients are encouraged during a follow-up visit to continue their exercises to prevent swallowing problems from developing.
"Swallowing problems may not show up right away," she noted. "They might show up a year, three years or 10 years later. Hopefully, doing these exercises even once daily the rest of their life will help patients prevent swallow problems from happening later on."
About a third of patients who undergo chemotherapy and radiation present with swallowing problems after treatment is completed, Dr. Lazarus reported. "If they have neck disease or neck metastasis and the radiation is going to be treating the neck, they likely will have pharyngeal phase swallowing disorders."
Due to the effects of radiation, tissue fibrosis can persist long after the treatment concludes. The stiffened tissues can cause patients to develop swallowing problems.
Surgical patients, particularly those with oral cancer or partial laryngectomy, require a more intensive treatment strategy. Dr. Lazarus is called in by the physician to see a patient once the surgery site heals sufficiently enough that swallow exercises will not cause damage. She consults with the patient and performs a modified barium swallow to evaluate the current swallow ability. Swallow and speech therapy are provided as needed.
Patients with oral cancer usually require some level of speech and/or swallow therapy, especially if they have had any part of the tongue resected.
"Even if they have had a small amount resected, they get lingual range-of-motion and lingual control exercises," said Dr. Lazarus. "When you take any portion of the tongue, you want to rehabilitate it in terms of the best level of functioning possible."
She often has patients work on manipulating rolled-up gauze or a Twizzler to work on lateral control of a bolus, up-and- back control of a bolus, and sealing the bolus against the palate. Patients perform isometric resistance exercises with a tongue depressor applied in all directions on the tongue to improve lingual strength, and some patients may be assigned compensatory postures and pharyngeal swallow strengthening exercises.
Speech therapy for oral cancer aims to improve the patient's articulatory precision at the conversational level.
"Usually, I start out with single words that start with consonants so they can work on precision of the stop consonants for tongue palate contact," Dr. Lazarus explained. "They then can work on the precision for the fricatives for those consonants and affricates so they get single words and work on those sounds in all vocalic positions."
Patients then begin articulating phrases, followed by paragraphs, monologues and conversation taping.
The speech-language pathologist also needs to collaborate with a dentist in the construction of a palatal augmentation prosthesis for the patient. The device, which attaches to the upper teeth, lowers the palatal valve so remaining tongue tissue has a point of contact for clearer speech.
"It also helps patients feel the bolus of food or liquid so they can propel the bolus into their pharynx," Dr. Lazarus said. To prevent irritation to the mucosa, a patient will not receive the prosthesis until after the surgery and post-operation radiotherapy are complete.
Patients who have had a partial laryngectomy also may present with voice and swallowing problems.
Swallowing problems in partial laryngectomees usually are pharyngeal phase problems rather than oral phase, Dr. Lazarus observed. "They may need some maneuvers and postures when they eat. They may not be able to take anything by mouth, and they're just practicing getting better at doing the maneuvers and not fatiguing with them."
Patients who have had a supraglottic laryngectomy most likely will present with swallowing difficulties because they have lost airway protection. Voluntary airway closure maneuvers, such as the super-supraglottic swallow, sometimes are combined with head postures, such as chin tuck or head rotation.
Hemilaryngectomees are more likely to present with voice problems. Therapy exercises for these patients focus on modifying pitch, breath control, breath phasing and breath support.
Post-op radiotherapy also is a concern with this population, Dr. Lazarus said. "If they're going to be getting post-op radiotherapy, you don't want to give them any exercises that will irritate their vocal cords and irritate the tissues."
Therapy for patients who have undergone a total laryngectomy focuses entirely on voice. Swallowing problems generally are not an issue unless a complication occurs.
Laryngectomees are instructed on the use of the electrolarynx and esophageal voice unless they have had TEP. Patients who have had primary TEP usually are fitted with a voice prosthesis about 10 to 12 days after the surgical procedure. Patients who have had secondary TEP usually are fitted with a voice prosthesis within 48 hours after surgery.
Providing patient instruction on electrolarynx use extends to more than just correct placement of the device. Dr. Lazarus educates patients on the need to maintain a good seal of the electrolarynx to the skin, coordinating their articulation with the on/off button, and making sure the patient over-articulates to achieve the best sound.
Striving for the best sound and peak intelligibility is a main voice therapy goal with laryngectomees, she said. "You want to teach them to hit their tongue against the palate nice and hard to make their consonants audible. If the stop consonants, affricates and even the fricatives can be audible, their intelligibility increases."
After patients who have had TEP are fitted with a voice prosthesis, they are instructed how to get their digital inclusion over their stoma and how to maintain the seal over the stoma to produce voice.
"Clinicians need to work on increasing phonation length and increasing the duration patients can produce when they cover their stoma," Dr. Lazarus said. "I like to work on getting increased pitch range and increasing stress, intonation and processing by giving them exercises to over-exaggerate the highs and lows so they can get a good pitch range."
It is particularly important to follow up with surgical patients, even those who have made excellent progress in voice or swallow therapy, because post-op radiotherapy can negate current therapy successes. Soreness resulting from radiotherapy may prevent swallowing or inhibit voice production in total laryngectomees due to the irritated mucosa.
"Keep in touch with these patients, even if you're technically done with therapy, because their progress and swallow function may deteriorate after the radiotherapy," Dr. Lazarus urged. "You want to keep tabs on these patients, even if it's just a phone call to see how they're doing."
For More Information
? Cathy Lazarus, PhD, e-mail: email@example.com
? New York University Medical Center, online: www.med.nyu.edu
Alyssa Banotai is an Assistant Editor at ADVANCE. She can be reached at firstname.lastname@example.org.