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Medical Speech-Language Pathology | 03.08.16 - 14:10

Disorders of Swallowing and Voice

13 Rehabilitation of the Head and Neck Cancer Patient Donna Graville, Andrew Palmer, and Peter Andersen

13.1 Introduction The term head and neck cancer (HNC) refers to a myriad of malignant diseases of the head and neck, including not only cancers of the upper aerodigestive tract but also cancers of the skin, salivary glands, thyroid gland, nasal cavity, paranasal sinuses, bone, and cartilage, and metastatic tumors from other body sites. However, in general usage it is most commonly used to describe squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, and larynx. This chapter focuses on the treatment and rehabilitation of the aforementioned patients but the principles and techniques described can be easily extrapolated to the treatment of patients with less common tumors of the head and neck. The dominant histology of HNC is squamous cell carcinoma (SCC), which comprises more than 80% of cases in the United States. While the overall incidence of HNC has remained stable over the last several decades, there have been changes in the incidence of cancer in certain sites. Incidence has risen for the oral cavity, oropharynx, and thyroid gland, and fallen for the hypopharynx and larynx. Currently, it is estimated that there will be more than 40,000 new cases of cancer of the oral cavity and pharynx in the U.S. each year.1 The mortality has fallen during the same time frame for cancer at all sites except thyroid cancer, for which the mortality rate has remained stable.2 The rising incidence of thyroid cancer has been ascribed to an increase in diagnosis of previously undetected thyroid cancers but this proposition is not universally accepted.3 SCC of the head and neck has traditionally been associated with the use of tobacco and alcohol. Those who both smoke and drink have a greatly increased risk of developing SCC of the head and neck, which suggests that the two activities act synergistically to promote the development of cancer.4 However, a subset of perhaps 20% of patients lack the typical risk factors for head and neck SCC. Recent discoveries have indicated that infection with high-risk types of human papilloma virus (HPV) is an independent risk factor for the development of SCC of the head and neck, particularly in the tonsil and base of the tongue.5,6 Recent studies have found an increasing incidence of HPV-associated oropharyngeal cancers in white men and women.1 There is good evidence that some patients whose tumor is caused by HPV may have a better prognosis, and in the future the treatment of patients may, in part, be determined by their HPV status, but it is not yet certain whether this is possible and, if possible, what changes will result.7 The diagnosis of HNC represents a tremendous burden to the patient. Both the tumor itself and the treatment needed to address it result in problems affecting numerous domains of human functioning. The head and neck are vital not only for life but also for how we generally interact with society. Treatment can affect not only the ability to eat and speak, but also sight, hearing, sense of smell, and appearance. Generally, treatment choices are based upon what is most likely to maximize survival as well as on the potential loss of function that a treatment option may cause. There is substantial evidence demonstrating that not only does treatment for HNC affect quality of life across

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multiple domains, but also quality of life can be substantially improved by vigorous efforts at rehabilitation.8 Therefore, the provision of rehabilitation services to patients with HNC is crucial. These services allow patients to recover from deficits caused by treatment, and they may allow the use of treatment choices that are more effective at curing the patient’s cancer but would not be considered if adequate rehabilitation services were not available.

13.2 Head and Neck Cancer Symptoms and Presentation HNC can present with a variety of symptoms. The presenting complaint may often differ depending on the location of the tumor. The most common presenting complaint in patients with cancers of the oral cavity is simply a sore that will not heal. Minor trauma to the oral cavity is common. We have all had the experience of inadvertently biting our tongue or cheek. The oral mucosa generally heals quickly; therefore, the presence of a lesion in the mouth that does not heal within 2 weeks should raise concern. Other common complaints include loose or painful teeth, ill-fitting dentures, bleeding from the mouth, ear pain, or a neck mass. Unfortunately, a substantial number of patients will not heed these early signs of cancer and will present with advanced tumors. Cancers of the oral cavity are often easily visible, but tumors that arise in the oropharynx, hypopharynx, or larynx are not and often require specialized equipment for adequate examination (▶ Fig. 13.1, ▶ Fig. 13.2, ▶ Fig. 13.3). The typical presenting complaints of patients with cancers in these areas include neck mass, ear pain, throat pain, hoarseness, hemoptysis, and difficulty swallowing. Since lesions of these areas are not as easily seen as oral cavity cancers, it is more typical for patients to present with advanced disease. The exception to this is cancers of the glottic larynx, which tend to cause severe hoarseness at an early stage.

13.3 Workup and Staging of Head and Neck Cancer The term cancer staging describes the extent or spread of the disease at the time of a patient’s diagnosis. Proper staging is essential in determining the choice of therapy and in assessing prognosis, and this determination is based on the primary tumor’s size and whether it has spread to other areas of the body. The TNM staging system classifies how advanced a patient’s disease is by assigning a value to three different variables: the size and extent of the primary tumor (T), whether the cancer also involves the lymph nodes in that area (N), and whether the cancer has metastasized (i.e., spread to another part of the body [M]). Once the T, N, and M values are known, a stage of I, II, III, or IV can be assigned, with stage I representing early, and stage IV representing advanced disease.1 Generally speaking, higher stages will require more aggressive treatment


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Rehabilitation of the Head and Neck Cancer Patient

Fig. 13.1 Flexible fiberoptic laryngoscopy. (From Cohen JI, Clayman GL. Atlas of Head and Neck Surgery. Philadelphia, PA: Elsevier Saunders; 2011: 9. Used with permission.)

Fig. 13.2 Endoscopic view of the larynx. (From Cohen JI, Clayman GL. Atlas of Head and Neck Surgery. Philadelphia, PA: Elsevier Saunders; 2011: 9. Used with permission.)

and have a poorer prognosis for survival. For example, a small stage I tumor of the tongue or vocal fold without nodal involvement (e.g., T1N0M0) might have a successful cure with only one modality (likely surgery or radiation only), but an advanced stage IV cancer of the tongue or larynx (e.g., T3N2M0) would typically require two or more modalities for a good chance of a successful cure. The diagnosis of SCC of the head and neck requires a biopsy for confirmation. Depending on the location of the tumor and the equipment available, biopsy may be accomplished in the clinic, but certain tumor locations (i.e., the hypopharynx, larynx, and some locations within the oropharynx) may be

Fig. 13.3 Direct laryngoscopy and pharyngoscopy in the operating room. (From Cohen JI, Clayman GL. Atlas of Head and Neck Surgery. Philadelphia, PA: Elsevier Saunders; 2011: 18. Used with permission.)

inaccessible and therefore the biopsy is often performed in the operating room under anesthesia. Biopsy under anesthesia also allows a thorough examination of the remaining portions of the upper aerodigestive tract. This examination serves several purposes, including determining whether the tumor is anatomically suitable for certain surgical procedures and also to rule out the presence of another malignancy in the patient. For HNC, synchronous cancers are discovered about in about 5% of patients.9 The patient needs a thorough medical evaluation, including preexisting comorbidities, and a physical examination. The details of this evaluation are beyond the scope of this chapter

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Disorders of Swallowing and Voice but it needs to include an assessment of the patient’s cardiopulmonary and renal function. The patient’s medical situation may influence the selection of cancer treatment as well as rehabilitative methods. For example, a patient with renal insufficiency may not be a candidate for treatment with chemotherapy and a patient with severe arthritis may not be able to care for and use a tracheoesophageal puncture. Similarly, the patient’s social situation should be investigated. If the patient lives at a distance from the treatment center and lacks the resources for travel, the treatment plan may need to be adjusted. A patient who cannot write will be more severely impacted by loss of voice than one who can write. All of these factors should be considered when selecting the appropriate method of treating and rehabilitating a patient with HNC. Additional studies may be indicated depending on the particular situation. These may include, but are not limited to, computed tomography (CT), magnetic resonance imaging (MRI), ultrasound examination, and positron emission tomography (PET).

13.4 Oncologic Decision Making The choice of how to treat the patient’s cancer is predicated on the site and stage of the cancer, the individual medical and social situation of the patient, and his or her own desires. The head and neck oncologist should be able to discuss with the patient the various options available and the pros and cons of each. Multidisciplinary input from the surgeon, medical oncologist, radiation oncologist, speech-language pathologist, and other medical specialties may be needed, and presentation at a multidisciplinary Tumor Board is encouraged. Treatment decisions should be based not only on which option provides the greatest chance of cure but also on which will result in the fewest functional limitations after treatment. While the morbidity of surgery is obvious to most patients, one should not underestimate the morbidity of the nonoperative modalities of chemotherapy and radiation therapy. It is the experience of the authors that nonoperative management can be just as difficult for the patient as surgical treatment and the patient should be cautioned that nonsurgical options may not be the least morbid option. Treatment of HNC, as with most other cancers, is based on the triad of surgery, chemotherapy, and radiation therapy. While surgery and radiation therapy are sometimes used alone, there is little role for the use of chemotherapy alone except for palliation. When chemotherapy is used in treatment designed to be curative, it is always in conjunction with radiation therapy. In general, early-stage disease can be treated adequately with either surgery or radiation therapy as a single modality, with roughly equivalent oncologic results. Therefore, the choice of treatment is often based upon which treatment is less morbid. For example, a small oral cavity cancer can be treated with equal efficacy with either surgery or radiation therapy, but surgery can be accomplished with a single day of treatment as opposed to as many as 7 weeks of daily treatments. In addition, radiation therapy can be expected to cause permanent xerostomia and potentially severe dental problems, so surgery is often preferable. In contrast, a small cancer of the true vocal fold, while easily treated with partial or total laryngectomy, is often treated with radiation therapy, because the vocal results with radiation are clearly superior.

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Higher-stage tumors (stage III or IV) typically receive multimodality treatment consisting of combinations of surgery, radiation, and chemotherapy. Tumors of the oral cavity are often treated with surgical resection and postoperative radiation or chemoradiation. Extensive tumors, such as those involving the bone of the mandible or maxilla, may have better survival when treated with surgery than with definitive chemoradiation.10 However, there is extensive experience with tumors of the oropharynx, hypopharynx, and larynx, which show excellent rates of disease control and acceptable morbidity with chemoradiation. As a result, there has been a move toward nonsurgical treatment of advanced tumors in those locations.11,12,13 However, it should not be assumed that merely because the larynx is still present within a patient that it is therefore functional. While randomized studies have demonstrated that patients whose larynx is preserved have superior quality of life in regard to voice and equivalent swallowing quality of life to patients who were not able to achieve laryngeal preservation, there are studies that indicate that findings indicative of locally advanced disease, such as vocal fold fixation and destruction of the cartilaginous framework of the larynx, predict a poor functional outcome after chemoradiation.14,15

13.5 Newer Treatment Strategies While the development of chemoradiation strategies for the treatment of advanced HNC has resulted in decreased use of radical surgery for treatment of these tumors, the recognition of the still substantial morbidity of chemoradiation has been the impetus to develop new strategies that may result in similar oncologic outcomes yet lessen the morbidity of treatment compared to radical surgery and chemoradiation. These options primarily are dependent on recent technological advances that allow transoral access to tumors of the pharynx and larynx. Previously these locations could only be reached surgically with extensive resections through the neck or jaw. Transoral laser microsurgery (TLM) is performed with an assortment of endoscopes and recent series report excellent functional and oncologic results.16,17 Another new technique is transoral robotic surgery (TORS), which uses the DaVinci surgical robot to resect tumors of the oral cavity, pharynx, and larynx. Recent series describing functional and oncologic results for patients treated with TORS again report excellent results.18 These new modalities, while becoming more common, are not suitable for all patients. While the published series describe excellent results, the reports lack the scientific weight of the series of studies that led to the adoption of chemoradiation as a dominant strategy in the treatment of patients with advanced HNC. This is largely a result of the lack of randomized clinical trials comparing the newer strategies and therapy with chemoradiation. The procedures discussed above are being done currently by surgeons with extensive experience in determining which patients are suitable for these treatments, and it is possible that, with wider adoption of the techniques, the results will not be comparable to the early reports. Nonetheless, the development of new technologies and other medical developments share a common goal, namely to provide the best chance of cancer cure with the least negative impact on functional status and the individual’s quality of life.


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Rehabilitation of the Head and Neck Cancer Patient

13.6 The Role of the SpeechLanguage Pathologist across the Treatment Course The speech-language pathologist (SLP) may become involved with the HNC patient and his or her family at any point in the continuum of care, from prediagnostic work-up to long-term rehabilitation. The needs of the patient will vary substantially over that time and, consequently, it is essential that the SLP understand the nature and implications of the different phases of treatment and how intervention should best be targeted in order to optimize patient outcomes. In this, the clinician should be guided by the American Speech-Language-Hearing Association’s Code of Ethics, which states that clinicians should practice only in those areas in which they have appropriate education, training, and experience.19 In order to provide optimal care, the SLP must become knowledgeable about (1) the nature of HNC, (2) the different therapeutic modalities for HNC and their impact, (3) the literature regarding optimal rehabilitation methodology and techniques, (4) the nature and use of devices used for management and rehabilitation, (5) the role of various professionals who are involved in the treatment and rehabilitation and how best to coordinate care, and (6) when to refer the patient to a specialist for further work-up or care. In order to be effective, the SLP not only must understand the nature and implications of the treatment itself and how they affect the rehabilitation timeline, but also must be able to tailor the intervention to the specific needs and wishes of the individual, which may also vary substantially from person to person. In 1972, Virginia Sanchez-Salazar and Anne Stark20 described a crisis management approach to the recovery process after total laryngectomy. Their model was based on their combined approaches as a social worker and speech pathologist and has been used effectively in the rehabilitation of those who have undergone laryngectomy21 but it can also be applied to the process that is experienced by many HNC patients in general. The first crisis occurs with the diagnosis of cancer, during which the individual is overwhelmed by catastrophic implications of the diagnosis and fears of the impact of medical treatment, loss of control, and death. The second crisis occurs after recovering from treatment as the full implications of their treatment are felt. If the individual has been hospitalized, discharge is the next crisis, as the patient must leave the protective environment of the hospital, and both the patient and the family may be fearful of whether they can cope. Finally, once the patient has convalesced and friends/family are no longer so attentive, the individual may have to come to terms with the reality of their postoperative status and the fact that they will always be left with some long-term deficits as a result of the cancer treatment. The SLP has a role in all of these phases, and the role varies according to the phase.

13.6.1 Prior to Treatment The time from diagnosis to treatment is often a whirlwind, both emotionally and practically. Nonetheless, wherever possible, meeting with the patient, family members, caregivers, and anyone who will have a significant role in that individual’s care is of critical importance. Frequently, when an individual is first diagnosed with cancer, they may remember nothing from that

initial physician visit other than the diagnosis itself. Furthermore, when the cancer is “treatable” (i.e., is believed to be present locally but not to have metastasized to other parts of the body) there is a medical imperative to treat it before it has a chance to metastasize and, thus, the time from diagnosis to intervention is often extremely short. Consequently, the first meeting with the SLP can be an important time of education, information sharing, and treatment planning for all involved. In this, however, the SLP must be aware of, and sensitive to, the individual’s need for information. Some individuals will want to know all the details of their treatment and its course, while others will want to hear only the most important information in as brief a form as possible and/or to focus only on the most pressing information. Individuals who are about to undergo HNC surgery may retain only a small percentage of what they are told throughout the entire pretreatment period. Thus, information should also be repeated as and when needed and written information should be provided wherever possible for later reference and review, including self-care guidelines and lists of suppliers/resources and support groups. For those who are about to undergo laryngectomy, take-home booklets and materials, such as a copy of Self-Help for the Laryngectomee,22 are an excellent resource. The specific counseling topics for the preoperative session are listed at the end of this chapter (Appendix 13.1), as well as additional resources and readings (Appendix 13.2). For the patient and family, pretreatment meeting with the SLP is often beneficial in that it is a time to review important information, to ask questions, and to plan for the future. It is best to begin by asking the patient/family what they have been told previously and what they understand about the nature of the intervention. This will allow the clinician to gain a sense of the level of their understanding, to correct any misperceptions, and to provide new information as needed. Since most individuals have a relatively rudimentary understanding of the anatomy and physiology of the head and neck, colored pictures and diagrams are often helpful in illustrating the location of the cancer itself and how intervention will affect function. The short-term impact of possible interventions should be discussed, including, where appropriate, the presence of a tracheostomy and a feeding tube. The short- and long-term impact of intervention on voice, speech, breathing, and swallowing should be discussed. Planning for short-term and long-term communication should be discussed, whether low-tech (e.g., communication boards, paper and pen) or high-tech (e.g., speech output devices, TTY, electrolarynx, etc.). If a permanent change in communication is anticipated, showing a video of patients communicating by various methods and/or demonstrating the appropriate device may be helpful. If there is to be a permanent tracheostomy, its implications for breathing as well as for functional activities (e.g., showering/bathing, water sports, etc.) should also be discussed. Some individuals may wish to meet or talk with another patient who has gone through a similar type of procedure; if so, appropriate arrangements for a visit should be made. In addition, information about support groups and resources may also be helpful (Appendix 13.2). Finally, the timeline for rehabilitation should be reviewed. It is also worth noting that many individuals have a limited knowledge of the nature of the cancer diagnosis and its treatment, and so education should be provided about the

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Disorders of Swallowing and Voice rationale for treatment and the importance of follow-up in order to minimize misunderstandings. Often, family members and other caregivers are looking for guidance about how best to prepare for the individual’s future needs. Information can be shared with them about preparing for discharge home in terms of acquiring skills and knowledge during hospitalization and/or at clinic/training visits, important resources and phone numbers, foods and other items to obtain prior to discharge, and ways of facilitating communication with other friends, family members, or coworkers who may ask for updates. It is often helpful for one family member to function as the “go to” person for phone calls to provide updates to wellwishers and those outside the home. In addition, free medical websites, such as CaringBridge.com, allow for the creation of an individual website that invited members can access and post messages to about the individual’s progress without the need for frequent phonecalls. The pretreatment consultation is a time for the clinician to gather important information, in turn. The SLP will want to assess the individual’s baseline level of function prior to cancer treatment in order to plan more effectively for the rehabilitation course. Factors that may affect treatment decisions and the timing/course of therapy include the extent to which the individual has any of the following: baseline impairments in communication or swallowing due previous treatments for HNC or other neurologic diagnoses; medical comorbidities that may affect recovery; a cognitive impairment; a hearing impairment; reduced capacity for communication via writing; limited social support to assist with postdischarge needs; medical insurance coverage for postoperative rehabilitation; and proximity to a medical center that will enable the individual to attend outpatient therapy, if needed. In addition, factors that are specific to the individual patient will need to be accommodated for therapy to be successful. For example, individuals may have different short- and/or long-term goals depending on their vocational needs, recreational interests, or family responsibilities, which the clinician may be unaware of without more open-ended questioning. The pretreatment consultation is also an opportunity for the clinician to build a relationship and rapport with the individual who is about to undergo treatment and their family.

13.6.2 Short-Term Rehabilitation The short-term rehabilitative course is often dominated by numerous practical challenges. During hospitalization, those treated surgically may be dealing with immediate postoperative changes, such as pain, fatigue, confusion, the need for assistance with self-care, reduced mobility, reacting to the changed cosmesis as a result of surgery and, possibly, the implications of having a tracheostomy tube and/or a feeding tube. In many cases, the patient will not be cleared for oral intake and must take nothing by mouth (NPO) until cleared by the surgeon. Thus, the early work of rehabilitation may focus on communication using writing, communication boards, and/or text-to-speech devices, if available, as well as on tasks like oral-motor exercises, secretion management, and advancement to decannulation of the tracheostomy, from cuff deflation trials to tolerance of a Passy-Muir valve and/or capping trials. In such cases, close coordination between the surgical service and rehabilitation

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service is essential for appropriate intervention and optimal outcomes. During this time, the rehabilitation team provides support for the individual and family/caregivers regarding the nature and course of rehabilitation and education about goals for discharge home, if that is appropriate. If not, the patient may need short-term placement at a rehabilitation facility or a skilled nursing facility (SNF) before being independent and medically ready to return home with outpatient follow-up for ongoing rehabilitation needs. This process can be extremely stressful and disruptive for all concerned and, as individuals leave the support and care of the hospital environment, they may doubt their ability to cope and face additional fears about their ability to achieve an acceptable quality of life in the future. Close coordination of team members, including physicians, nurses, rehabilitation staff (PT/OT/SLP), dieticians, and social workers, is critical. In the patient undergoing chemoradiation, the timeline is substantially different and is covered in more detail later in this chapter. In brief, however, the process may begin with hospitalization for a biopsy, for feeding-tube placement extreme cases, for tracheostomy placement, or hospitalization due to other acute medical needs. More frequently, however, the patient’s deficits may be relatively mild at the start of treatment but change over the course of treatment as the treatment effects of chemotherapy and radiation cause progressive difficulty, including issues with pain, fatigue, nausea/vomiting, edema, muscle fibrosis, xerostomia (dry mouth), and taste changes. Treatment can cause or exacerbate dysphonia and dysphagia depending on the turmor site. Thus, the treatment course involves teaching compensatory maneuvers and techniques as needed, managing the side effects of treatment, maintaining function by use of exercise to avoid muscle fibrosis and atrophy, and educating the patient/family about the nature of the treatment course. Once treatment is completed and some of the acute side effects have started to subside, more aggressive rehabilitation of residual deficits should begin.

13.6.3 Long-Term Rehabilitation As the short-term side effects of treatment subside, focus increasingly turns to management of voice, speech, and swallowing deficits. The amount of rehabilitation that is required will vary substantially from patient to patient, depending on the severity of the deficits, the patient’s motivation, and the patient’s goals. Most individuals will be seen in an outpatient setting in which the clinician is responsible for designing a treatment program, which will usually entail a home program of exercises to be performed several times daily. While some individuals may require specialized equipment and/or a prosthetic for optimal function, rehabilitation of the HNC patient otherwise uses the same types of techniques and strategies that are employed generally in the rehabilitation of neurogenic speech and swallowing deficits. The rehabilitation of the HNC patient is, however, qualitatively different and there are a few key principles that should guide treatment: 1. Knowledge about the impact of HNC and its treatment and the particular details of an individual’s treatment course are essential in designing a treatment program. 2. The focus of therapy may change over time, shifting from compensation/management and maintenance before/during


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3.

4.

5.

6.

cancer treatment to aggressive rehabilitation once cancer treatment and its side effects subside. Optimal treatment is usually multidisciplinary, requiring the work of medical and rehabilitative professionals to be coordinated in order to be mutually reinforcing in the accomplishment of common goals. Communication between providers is essential, as is communication with the patient/family about the impact of HNC treatment, the nature and goals of therapeutic techniques, the rationale for their use, a timeline for rehabilitation, and the need for follow-up with providers. Therapeutic exercises should be targeted to the areas affected by treatment and should performed aggressively, several times per day, for optimal outcomes. Additionally, therapy exercises designed to strengthen affected musculature should follow the principles of exercise physiology, in that the exercise must be appropriate for the targeted task/ behavior (specificity), and tasks must be initiated at a moderately challenging level (intensity) over time (duration), and must then be progressively increased to continue making ongoing gains (progressive resistance). With regard to dysphagia therapy, in the early stages of treatment, aspiration is often unavoidable. Nutritional support while teaching the individual how to swallow the safest consistencies in limited amounts may be an essential part of the earliest phase of rehabilitation.

These principles are discussed in greater detail in the sections that follow.

13.6.4 The Importance of Care Coordination and Communication Following the patient’s initial diagnosis, treatment planning begins by presentation of the patient’s case at Tumor Board, a multidisciplinary meeting at which the pathology results and imaging studies are reviewed to determine the appropriate treatment course. At this meeting, a medical oncologist, radiation oncologist, head and neck surgeon, pathologist, and radiologist are usually present, in addition to other specialties that may be involved in coordinating care and treatment, such as a care-coordination nurse or social worker. It has been estimated that more than 20 different medical specialties can be involved with care of the HNC patient and that the coordination of these different services can be “complex and often chaotic.” Because of the number of medical specialties involved in HNC care, communication between health care providers, and between providers and patients, is often inadequate, which can be a source of frustration for all.24,25 For this reason, many institutions rely on a care-coordination nurse or social worker to assist the patient and family with issues of scheduling and coordination. There are also numerous educational resources available both online and in written form (Appendix 13.2).

13.6.5 Rehabilitation after Head and Neck Cancer Surgery The three primary modalities for the treatment of HNC are surgery, radiation therapy, and chemotherapy. These may be

provided either alone or in combination, depending on the type of cancer, its location, and the extent of the cancer’s spread to surrounding tissues, such as adjacent lymph nodes. The goal of any type of cancer treatment is twofold: (1) to eliminate the cancer before it can spread to other surrounding tissues or other parts of the body, wherever possible; and (2) to do so with the least negative impact on the health and quality of life of the individual. In surgical resection, the goal is to remove the tumor itself, leave a healthy margin of tissue that is cancer-free, and then to close or fill the defect in a manner that has the least negative impact on appearance and function, usually speech, swallowing, and/or breathing.

13.6.6 Surgical Intervention Primary Resection For small tumors, surgical intervention can take the form of primary resection, in which, after complete removal, there is sufficient viable soft tissue remaining to simply suture the defect closed. For this type of surgery, as with other surgeries in general, the smaller the lesion, the smaller the resection, and thus the less impact the surgery will have on speech and swallowing outcomes.26,27 In the case of anterior oral cavity resections, which may involve the lip, anterior two-thirds of the tongue, floor of mouth, or cheek, the patient may experience decreases in sensation, range of motion, and speed of motion. These may result in dysarthria and difficulties with oral management of the bolus during eating. For more posterior resections, which may involve the posterior tongue, tonsil, or soft palate, the patient may experience velopharyngeal incompetence, delayed swallow initiation, and decreased tongue-base range of motion. These may result in difficulties with nasal regurgitation, preswallow spillage of the bolus, aspiration, and hypernasality. Rehabilitation for any type of resection with primary closure may begin as soon as the surgeon clears the patient medically, and this is typically in the acute phase, during the postoperative hospitalization. Intervention may include compensatory maneuvers and strategies, range-ofmotion exercises, or aggressive speech and swallow intervention, and it is usually limited only by issues of postoperative pain and swelling.

Minimally Invasive Head and Neck Surgeries Transoral laser microsurgery (TLM) is a minimally invasive procedure that may be used for HNC (▶ Fig. 13.4, ▶ Fig. 13.5). In a transoral approach, the surgeon uses a CO2 laser to target the tumor while limiting damage to uninvolved structures in the surrounding area. This type of surgery can be done on T1–2 tumors of the upper aerodigestive tract. Small oral, tonsillar, laryngeal, and pharyngeal cancers can be removed with TLM. Transoral robot-assisted surgery (TORS) may also be used for treatment of oral cavity and oropharyngeal tumors. The surgery is performed transorally with two robotic arms for surgical instruments controlled by the surgeon at a console and one arm for an endoscopic camera (▶ Fig. 13.6). This minimally invasive procedure has the advantages of being able to visualize and to access the tumor while minimizing involvement of surrounding structures. This type of surgery can be done on T1–2 tumors, typically without postoperative radiation therapy.

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Fig. 13.4 Patient positioning for transoral laser surgery. (From Cohen JI, Clayman GL. Atlas of Head and Neck Surgery. Philadelphia, PA: Elsevier Saunders; 2011: 392. Used with permission.)

deficits will depend on the extent of surgery and structures resected. Diet modification is often necessary due to odynophagia, and compensatory maneuvers are also often indicated. Even though the surgery is minimally invasive, patients who have more extensive surgery or who have more deficits at baseline may still require significant prolonged rehabilitation and require a feeding tube during this time.

Composite Resection

Fig. 13.5 Transoral view of the supraglottic larynx. (From Cohen JI, Clayman GL. Atlas of Head and Neck Surgery. Philadelphia, PA: Elsevier Saunders;2011:392. Used with permission.)

Advanced tumors (T1–3, N1–2b) can also be successfully resected, but postoperative radiation therapy is often necessary. Rehabilitation with the minimally invasive transoral surgeries tends to be site specific and can be initiated soon after surgery. Oral feeding is often resumed the day after surgery. As with other surgeries, the nature and extent of the postoperative

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Often the cancer is not limited to a single anatomical structure, or the tumor size is such that to accomplish regional control, adjacent sites must also be resected, and this is referred to as composite resection. A sizable resection can leave a large defect in the remaining tissue so that there is not enough healthy remaining tissue to close the defect primarily without a significant impact on function or appearance. In these situations, reconstruction is often required using tissue from another area of the body; this may be done with what is called either a local flap or free flap reconstructive procedure. Local flaps involve mobilizing an area of tissue from an area of the body adjacent to the surgical defect and then suturing it into place to close the defect. Some examples of this type of flap include the pectoralis major flap and the latissimus dorsi flap, in which muscle from the chest or back is detached from most of its attachments and moved superiorly to fill in a surgically created defect or to cover an area of exposed tissue. The flap is pedicled, that is, it retains a connection to its original blood supply and is not detached completely from its original location (▶ Fig. 13.7, ▶ Fig. 13.8). In contrast, free flaps are flaps of muscle, skin, and/or bone, and the veins or arteries that supply them are reconnected to the blood supply in a new area of the head or neck. This is a much more technically complex surgical procedure and requires a reconstructive surgeon to complete the procedure. Examples of this type of flap include radial forearm free tissue transfer, anterolateral thigh flaps, rectus abdominis flaps, fibular free flaps, and jejunal flaps. The latter are often used in pharyngeal reconstruction after total laryngopharyngectomy.


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Fig. 13.6 Transoral robotic surgery. (Used with permission from Neil Gross, MD).

Fig. 13.7 Muscle origin for latissimus dorsi flap. (From Cohen JI, Clayman GL. Atlas of Head and Neck Surgery. Philadelphia, PA: Elsevier Saunders; 2011: 580. Used with permission.)

Oral Composite Resection Patients with oral resections requiring free flap reconstruction have deficits that are structure dependent. Their symptoms may include oral stasis, decreased sensation, decreased oral mobility, and oral transit issues, as well as poor oral control. Mastication may be aected due to reduced tongue control, loss of dentition, and trismus. Treatment in the acute phase postoperatively begins with evaluation of ability to communicate either verbally or via nonverbal means. This patient population will most often require a temporary tracheotomy tube and be unable to orally communicate at first. Writing, communication boards, and text-to-speech applications are good temporary communication options initially until functional vocal communication can be achieved. In the acute phase, oral-motor exercises will need to be cleared by the surgical team and are often not recommended until 72 hours after surgery. The evaluation of ability to take food by mouth also must be deferred until the medical team determines that adequate healing has taken place. This evaluation may be done on an inpatient or an outpatient postdischarge basis. Working on secretion

management will aid in moving toward decannulation in those with a tracheotomy. Some individuals will be discharged from the hospital with their tracheostomy and/or feeding tube in place and will require aggressive subsequent rehabilitation to advance to the point where the tube is no longer needed.

Oropharyngeal Composite Resection Oropharyngeal surgery may involve the tongue base, tonsil, soft palate, and pharynx. Deficits after these surgeries will depend on the structures resected, the nerves resected, and the extent of reconstruction. Typical swallowing deficits include reductions in oral control, palatal closure, base of tongue propulsion, pharyngeal wall motion, laryngeal elevation, laryngeal closure, and cricopharyngeal opening.

Rehabilitation of Postoperative Speech and Swallowing Deficits As is the case with most surgeries, rehabilitation of speech and swallowing is usually structure-dependent and treatment will

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Fig. 13.8 Muscle transferred to the head and neck region for reconstruction, while retaining its original origin. (From Cohen JI, Clayman GL. Atlas of Head and Neck Surgery. Philadelphia, PA: Elsevier Saunders; 2011: 584. Used with permission.)

be a combination of accommodation, compensation, and strengthening of the surrounding musculature. Rehabilitation of oral deficits involves range-of-motion and strengthening exercises for the muscles of speech and swallowing. These may involve the lips, jaw, and tongue, and should be targeted to the area of deficit. Oral transit diďŹƒculties as a result of oral surgery will potentially require the modification of food placement, to maximize sensory input or for positioning on the side of strength. Likewise, texture modification may be needed to compensate for lack of dentition, oral control, or mobility. Employing tasks to help increase oral pressure to aid transit, such as using the lips and cheeks to press back a bolus posteriorly, or lifting the chin to aid with posterior transit, are compensations often employed with this population. Treatment for pharyngeal phase deficits will also depend on the nature of the physiologic impairment. Compensatory strategies could involve postural changes when eating, texture modification, and swallowing modifications, such as the supraglottic safety swallow, double swallows, or alternating liquids and solids. Exercise programs should be aggressive and may include the Mendelsohn, Masako, Shaker, and any other exercises targeting the palate, base of tongue, suprahyoid muscles, and pharyngeal walls.

Intraoral Prosthetics In some surgical resections, even with reconstruction, there may be a significant reduction in speech and/or swallowing

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ability due to an inability to approximate the remaining structures for adequate function. This may cause a reduction in the patient’s ability to create pressure either in the oral or velopharyngeal cavity. In some cases, an intraoral prosthetic may be required. Prosthetics are used to decrease the amount of space that the remaining structures must overcome to help them compensate more easily for the missing anatomy, and they can come in many forms. A palatal drop prosthesis is used to lower the roof of the mouth so that the remaining tongue can create oral pressure for oral transit of a bolus and make lingual contact for speech articulation. Velopharyngeal deficits from surgical defects or nerve damage can cause nasal regurgitation and reduced pharyngeal pressure for swallowing. A prosthetic can support the soft palate (a palatal lift) when there is adequate bulk but reduced mobility of the soft palate, or fill in in a surgical defect when there is inadequate soft palate tissue (a palatal obturator), either of which can benefit speech production and swallowing. Prosthetic management requires an evaluation by an SLP and prosthodontist once the patient is medically cleared by the surgeon, all medical treatments are complete, and all posttreatment edema has subsided. This process may be prolonged in the case of surgery followed by radiation treatment. Together, the SLP and prosthodontist determine the type and scope of prosthetic augmentation needed. Once the prosthetic has been fabricated, the SLP can then assess its adequacy and any need for additional revisions and also modify speech and swallowing rehabilitation based on the presence of the new


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Fig. 13.9 Three different kinds of vertical hemilaryngectomy, based on the extent of vocal fold involvement. (From Loré JM, Medina JE. An Atlas of Head and Neck Surgery. 4th ed. Philadelphia, PA: Elsevier Saunders; 2005: 1103. Used with permission.)

device. The process requires multiple visits with both professionals over many months to achieve the best prosthetic fit and appropriate compensation.

Management of Laryngeal Cancer The vegetative function of the larynx is to protect and stabilize the airway when eating, drinking, or bearing down. The secondary function of the larynx is for phonation, creating voice for speech and communication. The various surgical options for managing laryngeal cancer may affect any of these three functions (i.e., breathing, swallowing, and/or phonation), and therefore often require treatment and management by the SLP.

Partial Laryngectomy Vertical Hemilaryngectomy Vertical hemilaryngectomy is resection of half of the larynx, including true vocal fold, arytenoid, and thyroid cartilage (▶ Fig. 13.9). The resected area is then replaced with remaining muscle. A temporary tracheotomy tube is needed until the postoperative swelling subsides. After healing, the voice is hoarse, with decreased loudness. A feeding tube is usually

needed, although it may be only for a short while. Swallowing deficits include penetration and/or aspiration due to decreased airway closure. Rehabilitation involves working on maximizing vocal efficiency and conservation. Swallowing focuses on teaching the patient to protect his airway by supraglottic safety swallow or employing postural strategies on the affected side. Temporary diet modification is also utilized.

Supraglottic Laryngectomy A supraglottic laryngectomy is a resection of part of the larynx above the level of the glottis. Areas resected can include the hyoid bone, the epiglottis, and the ventricular folds (▶ Fig. 13.10). More advanced cancers of the supraglottic area may require additional surgical resection of the valleculae, tongue base, or the arytenoid. The true vocal folds are spared in this surgery, and thus the patient has potential for a fairly normal voice after healing is complete. A temporary tracheotomy tube and feeding tube are usually required. Dysphagia symptoms include poor timing of airway closure, reduced airway closure, and potentially reduced sensation affecting airway protection. If the resection is extended to the tongue base, then swallowing strength and efficiency may also be affected. For the

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Fig. 13.10 Supraglottic laryngectomy as depicted in (a) superior, (b) frontal, and (c) lateral view. (Reproduced with permission from Loré JM, Medina JE. An Atlas of Head and Neck Surgery. 4th ed. Philadelphia, PA: Elsevier Saunders; 2005: 1119.).

tracheotomized patient, rehabilitation initially involves communication, with work toward decannulation. Dysphagia treatment involves compensation with super-supraglottic safety swallow, effortful swallow, and/or Mendelsohn maneuver, in addition to short-term dietary modification. Postural changes may also be beneficial. An exercise program, including adduction exercises to increase glottic closure and base of tongue to arytenoid closure, is helpful in addition to base of tongue exercises, as needed.

Supracricoid Partial Laryngectomy Supracricoid partial laryngectomy (SCPL) is a complex procedure in which most of the laryngeal structures are removed and the remainder is reconstructed to form an area that is able to function effectively for voice, breathing, and swallowing after extensive rehabilitation. For this reason, appropriate patient selection is critical and must be based on disease variables as well as pulmonary status, motivation, and the ability to participate in aggressive rehabilitation for a prolonged period. The surgery involves the removal of the true vocal folds with the preservation of at least one arytenoid and exists in two different variations. In a cricohyoidopexy (CHP), the cricoid cartilage is sewn up (the “pexy”) to the hyoid, so that the base of tongue and epiglottis can facilitate airway closure for voicing and swallowing. In the cricohyoidepiglottopexy (CHEP), a more extensive procedure, the epiglottis is also removed. The sound source for voice is the arytenoid cartilage approximating either the epiglottis or base of tongue. This also serves to provide airway protection for swallowing. This surgery requires a temporary tracheotomy tube and feeding tube. Swallowing difficulties arise typically from decreased airway protection, poor timing for airway closure, and sometimes delayed swallow initiation. Rehabilitation after SCPL requires training the patient to protect the airway by adduction of the arytenoid to the base of the epiglottis or tongue. As with the supraglottic laryngectomy, compensatory swallow strategies

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with preemptive airway closure are taught. Postural changes may be employed, as is initial diet modification. Adduction exercises to improve airway closure are also helpful.

Total Laryngectomy Total laryngectomy (TL) involves the removal of the hyoid bone, thyroid cartilage, strap muscles, epiglottis, cricoid cartilage, and upper two or three tracheal rings (▶ Fig. 13.11, ▶ Fig. 13.12). It requires the permanent, complete diversion of the airway to the neck and creation of a tracheostoma. There is no longer any connection between the lungs and the mouth or nose. In a TL the entire larynx is removed, including the patient’s true vocal folds, and thus the vibratory source for phonation is absent. TL may be performed for advanced laryngeal cancer or, in some cases, in the absence of cancer due to issues with chronic, intractable aspiration. In other cases, the patient may have had radiation therapy or a combination of chemotherapy and radiation therapy for laryngeal cancer, and because the treatment failed to cure the disease, the patient faces a salvage total laryngectomy. This is similar to a TL except that, due to the lack of healthy tissue in the area, free flap reconstruction is often also required to close the resected area. Patients who undergo TL may have initial swallowing difficulties due to postoperative swelling, decrease in pharyngeal driving force, or cricopharyngeal spasm. These can often be ameliorated during the postoperative healing phase with diet modification and base of tongue exercise. Those who undergo TL with free flap reconstruction may have a prolonged period NPO if there are healing issues, such as a fistula. When healed, difficulties may be related to an esophageal stricture or hypopharyngeal stenosis at the site of the anastomosis, requiring periodic intervention such as esophageal dilatation. For those who have undergone reconstruction, the flap itself may be adynamic or, in the case of a jejunal interposition, peristalse in a manner that interferes with


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Fig. 13.11 Before laryngectomy. (Image courtesy of InHealth Technologies. Used with permission.)

swallowing. They may also have more issues with pharyngeal weakness and require base of tongue exercises.

Alaryngeal Speech Rehabilitation Ideally, the process of alaryngeal rehabilitation begins at the preoperative visit. As discussed previously, the patient is assessed and the three methods of alaryngeal speech are reviewed, namely, the artificial larynx, esophageal speech, and the tracheoesophageal voice prosthesis. Many factors must be considered when deciding which option is likely to be the most appropriate for a particular individual, such as the extent of the planned surgery, as well as the patient’s medical status, motivation, preferences, proximity to rehabilitation resources, and medical insurance coverage. Each method of voice restoration has its advantages and disadvantages, but ultimately the goal of any method is functional communication.

Artificial Larynx (AL) The artificial larynx (AL) is a handheld device that may be either pneumatic or battery-operated. An audible vibratory tone is created, and then the tone is transmitted to the mouth and can be articulated into understandable speech. The most common type of AL is battery-operated and thus is referred to as an

electrolarynx (▶ Fig. 13.13, ▶ Fig. 13.14). In most cases, the electrolarynx can be used either with neck placement or (using a mouth adapter) with intra-oral placement. In both cases, the battery supplies the energy to vibrate a diaphragm in the head of the device. The vibrated air is then transferred via either the intra-oral tube or through the tissues in the neck to the oral cavity. This vibration is then articulated with the tongue, teeth, and lips to make speech. Most devices also allow pitch and loudness to be adjusted. In the United States, the AL is probably the most common method of alaryngeal speech.28 Unlike esophageal or tracheoesophageal speech, the patient can begin learning to use the AL during the inpatient stay. Since there is frequently postoperative edema of the neck, an intra-oral type or neck-type AL with oral adapter should be used in the initial phase. The patient must be instructed in (1) use and care of the AL; (2) proper placement of the device to provide optimal sound transmission; (3) coordinating the on/off control with speaking; (4) proper enunciation (over-articulation), rate, and phrasing. The progression of therapy begins with short functional phrases and transitions into conversation. Education of family, care providers, and other medical staff with whom the patient interacts is essential for successful use of the AL. After postoperative swelling has receded, the patient may try the AL device on the neck. This placement requires the user to

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Fig. 13.12 After laryngectomy. (Image courtesy of InHealth Technologies. Used with permission.)

hold the vibratory head up against the neck. The best location for neck placement may require some experimentation to locate, and practice to achieve consistently. Once this is achieved, the focus is again turned to timing of the on/off control, rate, proper articulation and phrasing, and decreasing secondary behaviors (e.g., unnecessary stoma noise) before moving on to more advanced skills, such as intonation and pitch variation. Advantages of using the AL for communication are that it can be used within a few days postoperatively, it has low daily maintenance/costs, it does not require a surgical procedure, and it can achieve good loudness. Disadvantages are that it requires the use of one hand to talk, it may be visually distracting to a listener, and it has an unnatural sound quality. Contraindications to use of an AL include dysarthria, cognitive impairment, reduced manual dexterity, and/or aphasia. Becoming proficient with the device often requires frequent practice and access to an experienced SLP.

Esophageal Speech Esophageal speech (ES) is another method of alaryngeal communication. This method uses the pharyngoesophageal (PE) segment as the vibratory source (▶ Fig. 13.15). ES requires the patient to control air from the oropharynx, pass it into the upper esophagus through the PE segment, and immediately return it, setting the PE segment into vibration. This vibration,

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in turn, is resonated through the vocal tract and then articulated into speech by the lips, teeth, and tongue. The amount of air supplied past the PE segment and expelled has to be constantly replenished to create continuous voicing for conversation. ES cannot be initiated until the patient is eating a regular diet, typically around 2–4 weeks postoperatively. The patient is taught different ways of transiting air into the esophagus,such as injection and inhalation methods. The initial goals of treatment are (1) achieving esophageal vocal quality; (2) reducing the latency of sound production; (3) using good articulatory precision; and (4) developing a good speech rate. More advanced goals involve inflection, stress, and pitch, as well as decreasing the presence of secondary behaviors, such as facial grimacing and stoma noise. Learning ES is often a long process and, even with a skilled therapist, it may take many months for the patient to become proficient. Historically, even with motivation, adequate training, and prolonged practice, the failure rate remains high and is estimated at 40 to 70%.29 Consequently, it is important to have another means of alaryngeal speech available to the patient who is learning ES. Advantages of ES are that it allows a natural-sounding voice, no devices are needed, it is a hands-free method of communication and, once it is learned, there are no maintenance costs. Disadvantages of ES are that the voice is frequently quiet, it is slower than laryngeal


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Fig. 13.13 Speech using an electrolarynx with neck placement. (Image courtesy of InHealth Technologies. Used with permission.)

Fig. 13.14 One example of an electrolarynx with various accessories, including the intra-oral adapter. (Image courtesy of Griffin Labs. Used with permission.)

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Fig. 13.15 Esophageal speech. (Image courtesy of InHealth Technologies. Used with permission.)

speech, it requires a significant investment of time to learn, and it is associated with a high failure rate. Contraindications to ES include hearing impairment, cognitive impairment, dysarthria, surgery involving reconstruction of the pharynx or esophagus, and lack of availability of to a trained ES teacher.

Tracheoesophageal Speech Tracheoesophageal (TE) speech uses a surgically created fistula between the trachea and esophagus. A small, one-way silicone valve is placed within the TE tract to keep the fistula patent and to allow voicing, while preventing aspiration (▶ Fig. 13.16). This valve is known as a tracheoesophageal voice prosthesis, or TEP. TE speech allows pulmonary air to be transmitted via the voice prosthesis into the esophagus where the air puts the PE segment into vibration. As in ES, this vibration is then resonated throughout the vocal tract and shaped into speech by the articulators. The TEP can be placed at the time of total laryngectomy (primary placement) or at a later date once healing is complete and the patient has resumed an oral diet (secondary placement). Additionally, the TEP itself comes in two different styles, one of which is patient-maintained (a non-indwelling device) and one of which must be placed by an ENT or SLP with specialty training (an indwelling device) (▶ Fig. 13.17, ▶ Fig. 13.18). The patient is typically speaking in phrases at the first TEP session. Patients

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can learn to change their own voice prosthesis once healed and the tract is stable. Indwelling devices will need replacement in the clinic roughly every 3 to 6 months.30 Treatment focuses on (1) achieving adequate valving with minimal effort, that is, achieving adequate closure of the stoma so that pulmonary air can be directed through the voice prosthesis; (2) reducing the latency between stoma closure and voice; (3) articulation; (4) phrasing; and (5) rate of speech. The patient must be taught to manage the day-to-day care of the voice prosthesis, indications of when the device needs to be evaluated and/or replaced, and also emergency procedures in case of accidental dislodgement. There are a number of advantages to TE speech. In carefully selected patients, success rates with the TEP are around 90%.31,32 Compared to ES, TE speech is more easily acquired, with significantly less training and practice, and it has a rate and loudness that are closer to laryngeal speech. Compared to the AL, the voice is more natural-sounding. Disadvantages are the daily care and maintenance of the prosthesis, the cost of the device, and potential complications. The TEP must be changed periodically, because when the valve starts to fail, aspiration will occur if the TEP is not replaced in a timely manner. Contraindications to the TEP include esophagectomy or extensive tracheal resection, severe esophageal dysmotility, or gastroparesis. Poor cognition, manual dexterity challenges, and decreased visual acuity make


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Fig. 13.16 Tracheoesophageal speech. (Image courtesy of InHealth Technologies. Used with permission.)

Fig. 13.17 a,b A selection of indwelling and non-indwelling TEP devices. (Images courtesy of InHealth Technologies. Used with permission.)

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Fig. 13.18 a,b A selection of indwelling and non-indwelling TEP devices. (Images courtesy of ATOS Medical. Used with permission.)

Fig. 13.19 An HME cassette. (Image courtesy of ATOS Medical. Used with permission.) Fig. 13.20 An HME cassette worn in place with a peristomal adhesive housing. (Image courtesy of InHealth Technologies. Used with permission.)

care and maintenance of the prosthesis a challenge. Insurance coverage and access to a health care provider trained in voice restoration with the TEP are critical to successful outcomes.33,34

Pulmonary Rehabilitation after Total Laryngectomy Total laryngectomy results in permanent diversion of the airway, with a number of profound implications. Since the mouth and nose are no longer connected to the lungs, the patient loses the benefit of the upper airway. As a result, during inhalation the air is neither filtered nor conditioned with heat and moisture, as previously. The patient also loses the resistance created by breathing out through the mouth and nose, which optimally inflates the lungs during exhalation. All of these have a detrimental impact on the pulmonary health of a laryngectomee, resulting in increased cough, sputum production, and poorer. A

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wide variety of cloth and foam stoma covers are available commercially for the purpose of improving hygiene and cosmetic appearance. Improving pulmonary function, however, is done most effectively by use of a heat-and-moisture exchange system (HME) (▶ Fig. 13.19, ▶ Fig. 13.20). The HME consists of a disposable filter cassette placed in a housing that is attached peristomally or intraluminally within the stoma. Long-term use of the HME has been shown to decrease sputum production, reduce coughing, and improve pulmonary function.35

AAC Communication in the Head and Neck Cancer Patient Addressing the communication of acute-care patients is a focus of the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), which requires that the communication needs of the acute-care patient be taken into account.36 Communication is an essential component of quality patient care and


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Rehabilitation of the Head and Neck Cancer Patient safety. Use of augmentative and alternative communication (AAC) for HNC patients may be beneficial in the early postoperative phase, where the patient often has a tracheotomy and/or surgical resection that prohibits speaking. Having an AAC system postoperatively allows the patient a means to communicate at a uniquely vulnerable time. It is important for the patient to communicate with the nursing staff, physicians, family, and friends. AAC potentially allows for some sense of control at a time when the patient may have very little control over the current situation. Previous research has shown that communication difficulties during hospitalization result in feelings of loss of control, frustration, fear, anxiety, and anger.37 Initially, communication may most easily be facilitated with pen and paper. Additionally, word- or picture-boards may speed communication of basic needs and reduce the burden of writing. Training medical staff and communication partners to ask questions in a yes/no format may also be helpful. Patients who have cognitive impairments, low levels of literacy, impaired vision, poor strength and/or coordination of the upper extremity, and those who are confused are at greatest risk of being unable to communicate their wants and needs or to summon help in case of an emergency. For those with longer-term speech/communication disabilities, and for those in whom functional speech is not an achievable goal, a number of AAC options should be explored. Long-term periods of nonvocal communication typically require the use of text-to-speech applications or software, dedicated speech-generating devices, and the use of telephone communication devices like a TTY. With the advent of email, mobile phones for text messaging, and smart phones, tablets, and laptops that can download software for text-to-speech applications, instant messaging, and videoconferencing, AAC options are more varied, affordable, and readily accessible than ever before.

13.7 Rehabilitation after Nonsurgical Treatment of Head and Neck Cancer 13.7.1 Radiation therapy Radiation therapy (RT) may be used either in isolation or in combination with one or more of the other treatment modalities, either for cancer cure or for palliation (i.e., reducing the symptoms of incurable cancer). For some kinds of carcinoma and especially for small tumors, RT alone may be sufficient to provide an adequate chance of cure. Alternatively, radiation may be provided before surgery in order to shrink the size of a tumor, after surgery in order to eliminate any residual cancer cells that may remain within the surgical area, or in combination with chemotherapy. The use of high-energy radiation from X-rays or gamma rays or other sources can be used to kill fastgrowing cells within a targeted area, which include cancer cells. Most commonly, an individual will receive RT five times per week for 5 to 8 weeks at a local hospital or clinic. Radiation doses for cancer treatment are measured in a unit called a gray (Gy), a measure of the amount of radiation energy absorbed by 1 kg of human tissue, or a centigray (cGy), which is 1/100th of a gray. Different doses of radiation are needed to kill different types of cancer cells and the total dose may be

delivered across a total of 30 or more fractions (i.e., doses). In addition to the cancer cells, however, other fast-growing cells within the field of radiation will also be affected, including the lining of the aerodigestive tract. Common side effects of treatment include xerostomia (dry mouth), taste changes, mucositis (intense inflammation of the mucosa), edema, muscle fibrosis, dental caries, and delayed wound healing. The radiation is commonly delivered using an external beam approach, in which a machine outside the body delivers the radiation to the targeted area. Alternatively, intensity modulated radiation therapy (IMRT) may be used to increase the radiation dose to key areas, while reducing the radiation exposure to specific sensitive areas of surrounding normal tissue. This can reduce the risk of some side effects, such as damage to the salivary glands, although a larger volume of normal tissue overall may be exposed to radiation. Because the dose of radiation is cumulative, many side effects will progressively worsen over the course of treatment, and remain so for some time before they begin gradually to improve. Slow improvements in dry mouth, taste changes, irritation, and edema, for example, may be noted for weeks or months afterward as the body heals from treatment. Other changes, however, do not improve and may actually worsen over time. In particular, radiation causes fibrosis of the tissues in the affected area, leading to reduced strength and range of motion of affected muscle and cartilage, which may also be compounded by nerve damage (neuropathy). These changes do not improve spontaneously over time and are more likely to worsen without targeted exercise and stretching therapy designed to maintain flexibility and to increase the strength of the affected areas. These changes, also, can continue to progress long after the radiation treatment itself is completed. Thus, the clinician may see individuals with progressive dysarthria, dysphagia, and/or dysphonia months, or even years, after their cancer treatment was completed.

13.7.2 Chemotherapy Like radiation, chemotherapy may be used to reduce the risk of any residual cancer cells remaining after treatment, especially if the primary tumor is large and there is a risk of metastasis. Chemotherapy is rarely used in isolation but is most commonly used in combination with other treatment methods. In some cases, however, chemotherapy alone may be used for palliative purposes. Chemotherapy is systemic, that is, it cannot be targeted to a specific area of the body but either is delivered into the bloodstream or is ingested orally and then has a generalized effect throughout the body. Selection among the large number of potential chemotherapeutic agents is based on the type of tumor and its location. Some agents are essentially toxins that attack fast-growing cells, which include both cancer cells and other cells throughout the body, while others act as radiosensitizers to make the tumor more susceptible to RT. As a result, the side effects of chemotherapy may include nausea/ vomiting, reduced appetite, weight loss, hair loss, and suppressed immune function.

13.7.3 Concurrent Chemoradiation In 1991, the Veterans Affairs Laryngeal Study Group published their landmark study, which subsequently changed the

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Disorders of Swallowing and Voice treatment algorithm for advanced laryngeal cancer.13 In the study, patients were randomly assigned to receive either concurrent chemoradiation (CRT) or TL with postoperative RT. Comparable survival rates were found between the two groups and quality of life was slightly better for those treated nonsurgically.38 Since that time, based on this and other studies, individuals with advanced HNC may be offered a choice between concurrent CRT, in which chemotherapy and radiation therapy are provided simultaneously, or surgery followed by RT. There are three rationales for the use of chemotherapy in conjunction with radiation, namely: (1) chemotherapy in conjunction with radiation therapy may provide cure rates similar to those of surgical resection; (2) chemotherapy may act as a radiosensitizer and improve the efficacy of radiation therapy; and (3) chemotherapy acts systemically and may eliminate distant metastases.39 The use of the two modalities together, however, is not without significant side effects, including all of those listed separately in the sections above, but often with greater intensity due to their combination. Further, should the two modalities prove ineffective at cancer control or should HNC recur at a later date, surgery may be the only option in some type of socalled salvage surgery with increased associated risk of postoperative complications.

masseter or pterygoid muscles.43,44 It is associated with a number of complications, including reduced oral intake, difficulty speaking, and poor oral hygiene.43 The use of a Therabite device and tongue blades have both been found to be effective in increasing mouth-opening.44 The impact of CRT on swallowing is similar to that described for RT alone but may be exacerbated by the combination of modalities. In addition to the same voice, speech, and swallowing changes listed above, the toxicity associated with treatment results in more severe side effects. Acute mucositis, an intense, painful, inflammation of mucosal lining of the oral and/or pharyngeal cavities, is associated with prolonged tube-feeding dependency and worse swallowing outcomes. It has been estimated to occur in 24 to 100% of those in CRT trials.45 Studies have shown that rates of feeding-tube dependency are higher for those who receive CRT than RT alone.41 Some of the most common late effects of CRT include dry mouth, thick saliva, dysphagia, altered taste, and pain.41

13.7.4 Functional Impact of Radiation and Chemoradiation

Because of the high rates of eating and swallowing impairments after CRT, there has been significant interest in strategies to reduce the impact of treatment on swallowing function. Techniques to reduce the incidence and severity of xerostomia include the use of IMRT to reduce damage to the salivary glands, cytoprotective medications like Amifostine to reduce the risk of mucosal injury and mucositis, and the use of sialogogues like Salagen to stimulate salivary flow.45 Increasingly, there has also been an interest in designing protocols to be implemented during CRT in order to reduce the short- and long-term functional impact of treatment.42 Based on a review of the literature, Rosenthal et al45 recommend a therapeutic protocol initiated prior to the onset of treatment. Their protocol includes ten recommendations based on previous research to maximize postradiation swallowing recovery, including a program of radiation swallowing exercises for the musculature of the suprahyoid region, larynx, base of tongue, and pharynx. Since then it has been shown that performance of pharyngeal exercise during CRT results in improved dysphagia-related quality of life, laryngeal elevation, and base of tongue retraction, less structural deterioration of the swallowing musculature, improved swallowing function, and reduced tube-feeding rates after treatment.46,47,48,49 Even with the burden of CRT, it has been shown that therapy during treatment is feasible, and that it is also cost-effective in terms of reductions in costs related to tube feeding and hospitalization.49,50 A typical treatment protocol studied consisted of four exercises targeting the oral, pharyngeal, and laryngeal musculature, including the Mendelsohn maneuver, Shaker exercises, tongue hold, and tongue resistance. Exercises were performed for ten repetitions, five times per day, with the exception of the Shaker exercise, which was performed three times daily. In addition, some participants also performed falsetto phonation and a gargling exercise.

There have been numerous studies of the impact of RT on voice, speech, and swallowing. The impact of RT alone will vary significantly, depending on the size and location of the tumor. Characteristic swallowing changes include: (1) increased oral preparatory and transit time, reduced oral sensation, lingual weakness, and/or impaired dentition (2) increased pharyngeal transit time for a bolus, reduced efficiency, laryngeal penetration/aspiration and/or residue due to reduced sensitivity and delayed initiation, reduced base of tongue retraction, reduced hyolaryngeal elevation, reduced pharyngeal wall contraction, and/or impaired airway closure; (3) reduced bolus driving pressure and nasal regurgitation due to impaired soft palate closure; (4) reduced upper esophageal opening and penetration/ aspiration and residue secondary to reduced laryngeal elevation or stricture formation.40,41,42 Further, dysphagia can occur long after RT has been completed secondary to muscle fibrosis, placing the individual at risk for aspiration and impaired nutrition and hydration.40 Voice changes after RT to the larynx include reduced vocal loudness, reduced pitch, hoarseness, breathiness and vocal fatigue secondary to edema, muscle atrophy, mucosal dryness, and fibrosis of the affected tissues; there is some evidence that these are improved by voice therapy.40 Summarizing the findings from a number of separate studies, some of the most common late effects of RT include xerostomia, dysphagia/ difficulty eating, thick saliva, reduced taste, dental problems, pain, and altered appearance.41 Trismus is another well-known complication of HNC treatment and is the result of tonic contractions of the muscles of mastication that lead to reduced mouth opening. Estimates of its prevalence vary widely, but it occurs most frequently in those having RT to the temporomandibular joint and/or the

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13.7.5 Strategies to Reduce the Functional Impact of CRT and to Improve Outcomes


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Rehabilitation of the Head and Neck Cancer Patient

13.8 Prognostic Indicators for Functional Outcomes and Quality of Life after Head and Neck Cancer Treatment The rehabilitation of the HNC patient has been shown to be qualitatively different from that of patients treated for cancer of other sites.51 General health measures do not adequately address the HNC patients’ specific challenges, which consist of alterations in eating and swallowing, in speech and communication, and in appearance.52 Short-term deficits in all three areas and in overall health status have been documented for at least the first year after treatment.51,53 Some patient groups show improvement in disease- and treatment-specific concerns over the course of the first postoperative year.54 Compared to the general population, however, HNC patients have long-term problems that relate to both treatment-related side effects

and disease-specific problems, as well as to other forms of adjustment.55 In recent years there has been a steadily growing consensus among the medical community that it is not sufficient to measure objective variables alone in determining the efficacy of a particular treatment for cancer.56,57,58 Formerly, the two most important criteria for measuring success were mortality rate and life expectancy, but there is now a move to consider qualitative as well as quantitative variables. In order to develop a more global understanding of the outcomes for individuals after cancer treatment, investigators have adapted methods developed for social research. In particular, the concept of quality of life (QOL) has been embraced as a means of gauging the impact of treatment on individuals with cancer. At its simplest, QOL has been defined as representing “the gap between one’s actual functional level and one’s ideal standard,” and there are now many validated tools and instruments for measuring both the functional level and the QOL of the HNC patient (▶ Table 13.1). The importance of considering the patient’s perspective in

Table 13.1 Questionnaires and scales validated for use in HNC patients Clinician-Rated HNC Status Scales The Performance Status Scale (PSS) for Head and Neck Cancer Patients60

The PSS has three functional assessment scales scored from 0 to100 based on clinician interview and patient report in three separate domains: Understandability of speech, Eating in public, and Normalcy of diet.

Laryngectomy Instruments The Harrison-Robillard Shultz Tracheoesophageal Puncture Rating Scale61

A clinician-rated instrument for three parameters of successful TE speech in the selfchange TEP user relating to Use (the degree of use of TE speech); Quality (the ease of production and intelligibility); and Care (the patient’s ability to independently maintain the device).

The Patient Satisfaction Questionnaire (PSQ)62

The PSQ is a 15-item survey designed to measure patient perception and satisfaction with TE speech. Part A relates to emotional response to laryngectomy, level of verbal communication, listener reactions, and comparison to other speech methods. Part B covers four dimensions of TE voice production and how disturbing or acceptable they are to the speaker.

Dysphagia-Specific HNC QOL Instruments The M.D. Anderson Dysphagia Instrument (MDADI)63

The MDADI is a 20-item questionnaire designed to measure the impact of dysphagia on the QOL of HNC patients. Scores can be summarized into a single Global item and Emotional, Functional, and Physical subscale scores.

Quality of Life Instruments for the HNC patient The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire for Head & Neck Cancer64

The EORTC QLQ-H&N35 is a HNC questionnaire module designed to be used to supplement the general cancer measure (EORTC QLQ-C30). It includes 35 items concerning disease- and treatment-related symptoms, social function, and sexuality and can be summarized into several domains, including Pain, Swallowing, Senses, Speech, Social eating, Social contact, Sexuality, and eleven individual items.

The Functional Assessment of Cancer Therapy-Head & Neck Subscale (FACT-HNS)65

The FACT-HNS is an 11-item HNC-specific module designed to supplement the general cancer measure (FACT-G) as a disease-specific instrument. It addresses additional concerns or symptoms related to the treatment of HNC.

The Head and Neck Cancer Inventory (HNCI)66

The HNCI is a comprehensive HNC survey consisting of 30 items that can be summarized into four domain scores: Speech, Eating, Aesthetics, and Social disruption (which includes both social/role functioning and pain/discomfort).

The University of Michigan Head and Neck Quality of Life (HNQOL) instrument67

The HNQOL is a 30-item multidimensional instrument to assess HNC-related functional status and well-being. Four domain scores can be calculated: Eating, Communication, Pain, and Emotion. Additional items relate to employment, satisfaction with treatment, and treatment response.

The Head and Neck Radiotherapy Questionnaire (HNRQ)68

The HNRQ is a 23-item measure of acute morbidity due to radiation therapy in patients with locally advanced HNC.

The University of Washington Quality of Life instrumentRevised (UWQOL-R)69

The UWQOL-R is a 10-item instrument that measures the treatment effects of HNC across ten separate domains.

Abbreviations: HNC, head and neck cancer; QOL, quality of life; TE, tracheoesophageal; TEP, tracheoesophageal voice prosthesis.

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Disorders of Swallowing and Voice rehabilitation is reinforced by one study in which health care professionals ranked impaired communication and selfimage/self-esteem as the two most important factors in QOL after laryngectomy, whereas patients ranked the physical consequences of surgery (e.g., tracheal mucus production) and interference with social activities as the two most important.59 One year after treatment for HNC, health-related scores for physical function are often worse than at baseline while mental health scores, by contrast, are improved.70 Treatment-related factors, including feeding-tube placement, chemotherapy, and radiation treatment, are predictors of poorer QOL at 1 year posttreatment, as are baseline characteristics, such as smoking and depressive symptoms.70 Treatment variables like tumor size and the extent of surgical resection predict the impact on speech and swallowing, the amount of rehabilitation that an individual will need, and the amount of time that this will take.71,72 Earlier onset of therapy and use of biofeedback may be associated with quicker attainment of therapy goals and, in some cases, aggressive rehabilitation during the inpatient stay may avoid the need for a G-tube.72,73,74 In addition, there is some evidence that demographic and health variables also play a part. Recovery after treatment is often slower in the older individual, although there is some debate about whether “chronological age” or “biologic age” (i.e., the presence of other medical problems) is the more important predictor.75 It is clear, however, that the “total rehabilitation” of the HNC patient involves considering the individual as a whole.76

13.9 Looking Ahead: The Future of Head and Neck Cancer Treatment It is becoming increasingly clear that HNC is not a single clinical entity but a collection of diseases united only by their location. As a result, future therapies will likely be more complex and targeted to specific characteristics of each type of disease. This makes the imperative for multidisciplinary management all the more important. Other challenges for the future include the changing nature of the HNC population. From the end of the twentieth century into the twenty-first, we witnessed a demographic change among HNC patients, where the ratio of men to women changed dramatically, reflecting increases in smoking among women decades earlier. Other demographic shifts are continuing. With the aging of the population as a whole, we must answer questions about what therapies are most appropriate for the elderly HNC patient. Conversely, clinicians will also face a new, younger cohort with HPV-associated HNC, for whom the optimal medical treatments are still being defined, as are optimal patterns of care. In this case, the clinician may be faced with younger patients with HNC who will need to complete treatment and rehabilitation as quickly and efficiently as possible to meet the various demands of work, family, and child-rearing. New treatments and new technologies will bring new opportunities and, probably, new complexities as well. Nonetheless, the goal will remain the same, namely the total rehabilitation of the individual after HNC.

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13.10 Case Studies 13.10.1 Case One A 62-year-old man diagnosed with SCC of the larynx underwent adjuvant chemotherapy and radiation therapy. One year later, his cancer recurred, requiring a salvage total laryngectomy and partial pharyngectomy with radial forearm free tissue transfer. Preoperatively the patient was seen by the SLP for counseling and evaluation. Preoperative evaluation revealed a hoarse voice, no dysarthria, and a normal oral motor examination, but dysphagia for solids was reported. Given the patient’s previous cancer treatment, current dysphagia, and need for reconstruction, a primary tracheoesophageal puncture was not advised. Preoperative counseling for TL was completed with the patient and his wife (see Appendix 13.1). The patient was seen on postoperative day 1 to evaluate whether he was communicating functionally. He was writing his needs on a dry erase board and was also given a communication board. The electrolarynx (EL) with an oral adapter was introduced in the hospital on postoperative day 3. Therapy focused on optimal intraoral placement, coordination of the “on” control with speech, and precise articulation. The EL was not functional for communication at this time, however. The patient was discharged with the nasogastric feeding tube in place. He was given an oral-motor exercise program and electrolarynx drill-work for practice. He was also given a shower-shield and was trained in proper stoma care and pulmonary toilet; he was also trained in the use of a suction machine and humidifier. He was followed up as an outpatient 1 week later and cleared for oral intake by his surgeon. As he was able to take liquids functionally, he was cleared for full liquid and pureed diet and the nasogastric tube was removed. The patient followed up for weekly therapy. During these sessions, heat and moisture exchange for pulmonary rehabilitation were discussed, dietary advancement was achieved, and EL training continued. The patient was to otherwise advance his diet to mechanical soft foods 2 weeks later. An HME was placed as soon as his peristomal area was completely healed. By this time, the patient was 80% intelligible with his electrolarynx and was making good progress. The patient was followed up monthly with the surgeon. Six months postoperatively, the patient asked if he could be evaluated for a tracheoesophageal puncture; although he was proficient with the EL, he wanted to have a more natural-sounding voice. An insufflation test was successfully performed by the SLP and the patient met all the criteria for TEP placement. A secondary TEP was placed as an outpatient procedure. The day of placement the patient was taught to speak in short phrases with his TEP and how to clean and care for the device in situ. The patient then followed up weekly for discussion of care, precautions, and management of the device. When the patient was able to speak conversationally with the TEP and was tolerating an HME, hands-free communication was discussed. He is now proficient with this and follows up for care and changing of the voice prosthesis approximately every 3 to 6 months.

13.10.2 Case Two A 58-year-old woman was diagnosed with cancer of the epiglottis. The patient was scheduled for a supraglottic laryngectomy


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Rehabilitation of the Head and Neck Cancer Patient and was introduced to an SLP at her preoperative consult visit, 1 day prior to her scheduled surgery. The patient was extremely fearful that she was going to lose her “voice box” and did not want to breathe through a hole in her neck. The patient was given accurate information about her surgery, the effects of a supraglottic laryngectomy on speech and swallowing, and rehabilitation timelines. A lot of time was spent discussing the need for a temporary tracheotomy and feeding tube. The patient had very specific questions about how she would communicate with her family and friends with the tracheotomy and how she would look. Methods of communication, including use of the patient’s laptop with text-to-speech software, were discussed. The patient was seen in the hospital on postoperative day 1 and was writing with pen and paper. On postoperative day 3, the patient’s tracheotomy tube cuff was deflated. Attempts to talk with digital occlusion of the trach and cuff deflated were unsuccessful and the patient continued to use writing for primary communication, but she began using her text-to-speech program also. At this time, swallowing therapy with the patient’s secretions was started. The patient was instructed in the super-supraglottic safety swallow and practiced frequently with saliva rather than using oral suction. On postoperative day 5, the patient’s tracheotomy tube was downsized and changed to a cuffless trach. The patient was now able to voice with digital occlusion. Her voice was hoarse and remained so for a few weeks as she learned to swallow, but thepatient was greatly relieved at being able to communicate more easily. Prior to discharge on postoperative day 7 the patient was decannulated and was counseled to use digital occlusion over the trach site bandage when speaking for the next few days, until the site had closed. She was using the supraglottic safety swallow with her saliva frequently. The patient was seen as an outpatient on postoperative day 12 and was cleared for oral intake. The swallow instructions were reiterated, and the patient trialed on nectar thick liquids, thin liquids, and slick purees, but frequent cough was noted. Fiberoptic endoscopic evaluation of the swallow (FEES) was used to evaluate the patient’s airway protection. Use of biofeedback during FEES helped train the patient in the appropriate amount of effort needed for airway closure. During FEES, when the patient employed a stronger breath hold during the safety swallow and this was paired with a chin tuck, the penetration and coughing ceased. The patient was put on a slick pureed and thick liquid diet several times a day, was instructed to monitor her pulmonary status and presence of fevers or night sweats and to begin a food diary with type, quantity, and how the eating went. In addition to the eating program, the patient was trained in exercises to improve airway protection and base of tongue strength. The patient was given adduction with breath hold, effortful swallow, and the Masako exercise. She was instructed to do these exercises with ten repetitions five times per day. The patient returned in 1 week, feeling more confident in her ability to take an oral diet. She was trialed with thin liquids, purees, and soft fruit. Thin liquids were still a challenge and super-supraglottic safety swallow and chin tuck still needed to be diligently employed, but the other textures were tolerated with strong breath hold during swallow only. The patient demonstrated she could take a reasonable quantity by mouth during the session, and this was evidenced by her food diary. The nasogastric feeding tube was removed and the patient was placed on a mechanical soft diet, no breads, and thin liquids. Therapy continued every 1 to 2 weeks, with gradual diet advancement, close monitoring of

weight and any respiratory symptoms, and tracking of oral intake. By her follow-up visit 1 month later, the patient was on a regular diet and still needed to “be careful” with water, but the coughing was much reduced. The exercises were to continue for 2 more weeks and then could be discontinued when she was tolerating a regular diet without any significant difficulties.

13.10.3 Case Three The patient was a 68-year-old man with a history of base of tongue SCC, which was treated with chemotherapy and radiation (CRT) 2 years earlier. He had a gastrostomy tube (G-tube) placed prior to his cancer treatment. The patient offered a history of being able to take some foods orally until about halfway through CRT, when he experienced severe mucositis and was unable to eat due to significant pain. He remained G-tubedependent for all hydration and nutrition until a month after his treatment was completed. He was able to resume taking some liquids by mouth and slick purees two or three times per day, but he still used his G-tube for primary nutrition/hydration and for medications until about 6 months ago, when he downgraded his diet and now takes only sips of liquids by mouth and uses his G-tube for all nutrition and hydration. He has not been seen by an SLP. Despite his dysphagia, the patient is robust and physically active. He notes that his socialization has decreased because he cannot participate in social gatherings involving food. A modified barium swallow (MBS) was suggested. The MBS evaluation was explained to the patient, who was nervous about taking much by mouth for fear of choking. The nature and purpose of the MBS were discussed, as were the importance of taking enough barium to see the problem and the reassurance that suction would be available. During the initial swallow of a small bolus of nectar-thick barium, normal oral prep and transit were noted, and swallow initiation was brisk, but there was significant base of tongue weakness and decreased bolus propulsion. Laryngeal elevation was decreased, with penetration during the swallow. There was little transit through the UES. With such a small bolus, it was unclear if a stricture was present. The patient was asked to take a normalsized sip of nectar-thick barium and to swallow effortfully. This revealed not only the pharyngeal weakness but a stricture with near-complete occlusion at the C6 level of the esophagus. The larger bolus back-flowed from this level, penetrated, and was aspirated. The patient coughed immediately, expectorating most of the barium. The patient was taught to employ the supraglottic safety swallow for all subsequent boluses. In the anterior-posterior position, bilateral weakness was noted. The patient had two issues limiting his ability to swallow: (1) a stricture preventing the majority of the bolus from transiting, and (2) significantly decreased base of tongue movement and laryngeal elevation to drive the bolus and protect the airway. The results were discussed directly with the patient, and the need for pharyngeal exercise in combination with an esophageal dilation was discussed. The therapy program designed involved a 4- to 6-week rigorous program of exercises, including the Shaker, Masako, and gargling exercise, followed by an esophageal dilation. The patient was motivated and performed his exercise program. He was seen every 2 weeks to modify the intensity, frequency, and duration of each exercise. The patient underwent an esophageal dilation as an outpatient procedure,

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Disorders of Swallowing and Voice and the surgeon successfully dilated the patient to 45-French. Subsequently, the patient noted effort with swallowing and coughed, but reported no backflow, and he felt that the bolus was transiting more easily. The patient was taught to use a controlled, effortful swallow as a compensatory strategy, which was helpful in decreasing the post-swallow residue and postswallow cough. The patient was put on a therapeutic eating program of a ½ cup of liquid and a ½ cup of slick smooth pureed foods, three to five times per day. The patient was seen for regular follow-up, continuing his exercise program, aspiration precautions, compensatory swallow strategies, and was advanced to a soft, mashable diet. One month after dilation and after approximately 2 months of exercise, another MBS was performed. The patient had improved base of tongue retraction and laryngeal elevation and the stricture remained patent. Once he had been eating by mouth entirely for 3 weeks without weight loss, his PEG was removed. He continued to exercise with vigor for a total of 12 weeks and then a maintenance program was given. The patient has continued to employ the effortful swallow and alternating liquids and solids compensations and has continued to have a dilation every 12 to14 months.

13.11 Study Questions 1. Tumors of the head and neck area are most commonly associated with a) Infections b) Poor diet c) Use of alcohol and tobacco products d) Genetic factors 2. Over the last few decades, the mortality associated with HNC has been a) Increasing b) Decreasing c) Unchanged d) Unpredictable 3. In recent years, there has been a dramatic increase in the incidence of HNC due to a) HPV b) Hepatitis B c) HIV d) Pollution 4. Cancer is usually staged using the ___ staging system: a) MPT b) TNE c) ENT d) TNM 5. The purpose of preoperative consultation with the SLP is a) To obtain information about the patient’s baseline level of function b) To share information about the upcoming surgery and rehabilitation timeline c) To correct misunderstandings about the procedure and its implications d) To build a clinical relationship with the patient and his/ her family e) All of the above 6. The nature and the severity of the deficits caused by HNC surgery will depend a) On the site of surgery

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b) On the extent of surgery c) On the patient’s motivation d) Answers a & b e) None of the above 7. Surgical reconstruction refers to a) Transplanting tissue from a cadaver or family relative b) Closing a surgical defect without using additional tissue c) Taking tissue from another part of the body and using it to fill a surgical defect d) Adding a new office to the surgical suite 8. Supraglottic laryngectomy is a procedure in which ____ is removed: a) The lateral half of the larynx b) The larynx and two tracheal rings c) The larynx above the level of the vocal folds d) The entire larynx except one arytenoid 9. In a total laryngectomy, the airway is diverted to an opening in the neck called a a) Tracheostomy tube b) Tracheostoma c) Tracheoesophageal puncture d) Trochar 10. The three most common methods of alaryngeal speech rehabilitation are a) Esophageal speech, tracheoesophageal speech, and use of the artificial larynx b) Esophageal speech, transnasal speech, and use of the artificial larynx c) Esophageal speech, tracheal speech, and use of a TTY d) Esophageal speech, tracheoesophageal speech, and use of a TTY 11. In 1991, the Veterans Affairs Laryngeal Study Group published a study that showed that a) Advanced laryngeal cancer could be treated with chemoradiation b) Advanced laryngeal cancer could not be treated with chemoradiation c) Laryngectomy did not need to be followed by radiation d) Laryngectomy could be safely performed after radiation 12. The main goal of intensity modulated radiation therapy (IMRT) is to a) Increase the number of radiation doses given to each patient b) Increase the amount of radiation dose to a key area c) Vary the radiation dose randomly over the course of treatment d) Wean the radiation dose more gradually over time 13. After completion of radiation therapy, most side effects tend to a) Get better over time b) Get worse over time c) Remain unchanged d) Fluctuate 14. After completion of radiation therapy, muscle fibrosis/ weakness tends to a) Get better over time b) Get worse over time


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Rehabilitation of the Head and Neck Cancer Patient c) Remain unchanged d) Fluctuate 15. Recent studies have shown that a treatment protocol will reduce dysphagia symptoms after chemoradiation if initiated a) Before treatment b) During treatment c) Shortly after treatment d) In those with mucositis

Appendix 13.2. Useful Resources and Suggestions for Further Reading in HNC Further reading for clinicians: ●

Appendix 13.1. Specific Counseling Topics To Be Covered Before Total Laryngectomy ●

Respiration: ○ Change in breathing pattern, impact of stoma, need for care and maintenance, including short-term use of mister and suction machines. ○ Need for “neck breather” Medicalert-style bracelet or necklace. Swallowing: ○ Impact on swallowing and need for feeding tube during healing period. Communication: ○ Three methods of alaryngeal speech. ○ Impact of short-term period of voicelessness: planning for communication during hospitalization and at home and ways of getting attention. ○ Completion and submission of TTY application, if appropriate. ○ Calling non-emergency number in local phonebook to notify 911 dispatcher of impact of condition (including altered speech/voicelessness and neck-breather status). General: ○ Impact of laryngectomy on daily life, including bathing/ showering, hygiene, and impact on recreation (e.g., water sports) as well as work-related activities. ○ Provision of information related to laryngectomy resources, including support groups and the possibility of visitor and written material for review (e.g., Self-Help for the Laryngectomee). ○ Emergency guidelines and contact information.

Casper JK, Colton RH. Clinical Manual for Laryngectomy and Head/Neck Cancer Rehabilitation. 2nd ed. San Diego, CA: Singular Publishing Group; 1998 Doyle PC, Keith RL. Contemporary Considerations in the Treatment and Rehabilitation of Head and Neck Cancer. Austin, TX: PRO-ED; 2005 Graham MS. The Clinician’s Guide to Alaryngeal Speech Therapy. Boston, MA: Butterworth-Heinemann; 1997 Logemann JA. Evaluation and Treatment of Swallowing Disorders. 2nd ed. Austin, TX: PRO-ED; 1998

Reading materials for patients: ●

Lauder E, Lauder J. Self-Help for the Laryngectomee. San Antonio, TX: Lauder Enterprises; 2011 Keith RL. Looking Forward: A Guidebook for the Laryngectomee. 3rd ed. New York, NY: Thieme Medical Publishers; 1995 Keith RL, Thomas JE. The Handbook for the Laryngectomee. 4th ed. Austin, TX: PRO-ED; 1996 Support for People with Oral and Head and Neck Cancer. We Have Walked in Your Shoes: A Guide to Living with Oral, Head and Neck Cancer. Locust Valley, NY: Support for People with Oral and Head and Neck Cancer; 2007

Organizations & Websites: ● ● ● ●

● ● ● ● ● ● ●

● ●

● ● ● ●

American Cancer Society 250 Williams Street NW, Atlanta, GA 30303 Phone: 1.800.227.2345; Web: www.cancer.org Head and Neck Cancer Alliance (formerly the Yul Brynner Head and Neck Cancer Foundation) PO Box 21688, Charleston, SC 29413 Phone: 1.866.792.4622; Web: www.headandneck.org International Association of Laryngectomees (IAL) 925B Peachtree Street, NE Suite 316, Atlanta, GA 30309 Phone: 1.866.425.3678; Web: www.theial.org National Cancer Institute (NCI) 6116 Executive Boulevard, Suite 300, Bethesda, MD 20892–8322 Phone: 1.800.422.6237; Web: www.cancer.gov Support for People with Oral and Head and Neck Cancer (SPOHNC) PO Box 53, Locust Valley, NY 11560–0053 Phone: 1–800–377–0928; Web: www.spohnc.org WebWhispers Inc., PO Box 453, Gold Hill, OR 97525 Web: www.webwhispers.org

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Medical SLP: Key Considerations

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