Speech and Swallowing Rehab After Head and Neck Cancer

Head and neck cancer treatment sits directly on the muscles you use to eat and talk. Surgery, radiation, or both can change how you swallow, chew, speak, and taste. Rehabilitation is not an optional extra. The National Cancer Institute calls it "a very important part" of care, and lists speech therapy, diet counseling, physical therapy, and stoma care as parts of it.

Speech-language pathologist (SLP). This is the clinician who tests your swallow and treats it. NCI says a speech therapist will "assess how well the patient is swallowing and give the patient swallowing therapy." An SLP also teaches speech exercises. After surgery, one often visits you in the hospital.

Registered dietitian. NCI says a dietitian helps make sure you get the right amount of protein and calories during and after treatment, and builds a nutrition care plan with you and your family.

Dentist or prosthodontist. Your teeth and jaw bone sit inside the radiation field. Dental care becomes a long-term job, not a one-time visit.

Nurses. NCI notes that a nurse or an SLP can help you learn how to swallow again after surgery.

NCI advises a full oral health exam at least one month before cancer treatment begins. The month matters. If a tooth must come out or a filling needs repair, the mouth needs time to heal first. The exam looks for tooth decay, gum disease, mouth sores, dentures that fit poorly, and problems moving the jaw.

Radiation reaches the salivary glands fast. NCI reports salivary changes within one week of starting radiation to the head or neck. After chemotherapy alone, glands usually recover 2 to 3 months after chemo ends. After radiation, recovery is often only partial. Less saliva means faster tooth decay, so fluoride and daily mouth care become permanent habits.

Dysphagia (trouble swallowing) is not diagnosed by guessing. MedlinePlus describes three main tests.

• Bedside swallow screen. A clinician checks the structures in your mouth. Then you swallow water, other liquids, soft foods, and solid foods while they watch.
• Modified barium swallow study. Also called a videofluoroscopic swallow study. You eat and drink food coated in barium. Fluoroscopy, a moving x-ray, tracks "the barium-coated food in real-time as a live video."
• Fiberoptic endoscopic evaluation of swallowing (FEES). A thin, flexible tube with a light and camera goes through your nose to the back of your throat. The team watches you swallow directly.

These tests answer one question: where does the food go? The risk is aspiration, which means food or liquid entering the airway instead of the food pipe. MedlinePlus warns that aspiration can lead to pneumonia. NCI puts it more starkly, saying food or liquid inhaled into the lung can cause pneumonia and respiratory failure.

MedlinePlus lists the signs that should trigger testing: coughing or gagging when you swallow, pain when you swallow, being unable to swallow, and weight loss.

NCI gives clear triggers during treatment for the mouth and throat. Call your doctor or nurse if:

• Pain in your mouth, lips, or throat makes it hard to eat, drink, or sleep.
• Your temperature reaches 100.4 degrees F (38 degrees C) or higher.

NCI counts mouth and throat problems as serious "if they interfere with eating and drinking because they can lead to dehydration and/or malnutrition." A day when you cannot keep fluids down is a reason to call, not a reason to wait.

Fever deserves extra attention if you have also been coughing or choking at meals, because aspiration can lead to pneumonia. Use the phone numbers on your own treatment instructions, including the after-hours line.

Recovery varies more than most people expect. NCI reports that some patients regain normal swallowing "within 3 months after the end of treatment." Others are left with permanent damage. A team manages the problem, and NCI names speech therapists and dietitians as part of it.

Exercises are prescribed for your specific problem. Which muscles, how many repetitions, and which head positions to use all depend on what your swallow study showed. Ask your SLP to write down your exercises, how often to do them, and which food textures are safe for you right now.

Trismus means the jaw will not open fully. NCI links it to oral surgery, to fibrosis (scarring in muscle) after radiation, and to treatment-related stress. The timing is worth knowing. NCI says the stiffness "usually begins around the time the radiation treatments end," and it may keep getting worse. A jaw that felt fine during treatment can tighten weeks later.

NCI lists jaw exercises among the treatments, along with devices, pain medicine, muscle relaxants, and treatment for depression. Report stiffness early. A tight jaw makes eating, brushing, and mouth exams harder.

NCI is specific here: "Almost all patients who receive chemotherapy and head or neck radiation therapy at the same time will need tube feedings within 3 to 4 weeks." NCI also reports better outcomes when tube feedings start at the beginning of treatment, before weight loss sets in.

Enteral nutrition means liquid nutrients delivered through a tube into the stomach or small intestine. Parenteral nutrition goes straight into the blood through a catheter. NCI says it is used when you cannot take food by mouth or use a feeding tube.

If a tube is offered before treatment even starts, that is why. Ask what would have to change for the tube to come out.

NCI's practical advice for a sore mouth and a hard swallow:

• Choose soft, wet foods that are easy to swallow.
• Soften dry foods with gravy, sauce, or other liquids.
• Use a blender for milkshakes, or blend your meals.
• For dry mouth, keep water nearby and sip often. Ice chips, sugar-free hard candy, frozen desserts, and sugar-free gum also help.
• Drink plenty of liquids. NCI notes that a dry mouth raises the risk of tooth decay and mouth infections.
• Ask about pain medicine. NCI mentions lozenges or sprays that numb the mouth and make eating less painful.

MedlinePlus adds that treatment can include changing what you eat and how you sit while eating. Follow the exact textures and positions your SLP set for you.

The larynx, or voice box, holds the vocal cords. NCI says treatment choices for laryngeal cancer weigh "keeping the patient's ability to talk, eat, and breathe as normal as possible."

The operations differ a great deal. NCI says a hemilaryngectomy "saves the voice," and a partial laryngectomy "helps keep the patient's ability to talk." A total laryngectomy removes the whole voice box. In that operation, NCI explains, "a hole is made in the front of the neck to allow the patient to breathe." That opening is a tracheostomy. You breathe through the neck from then on, and the normal voice is gone.

Speech is not gone. NCI says an SLP often visits in the hospital to "plan therapy and teach speech exercises or alternative methods of speaking." Learning to care for a stoma is part of rehabilitation as well. Ask which speaking methods your center offers, and how soon training can start.

NCI states that regular follow-up care is very important after head and neck cancer treatment. Visits may include exams of the mouth, neck, and throat, and of the stoma if one was made. Regular dental exams may also be needed.

Bring eating changes to those visits. Meals that take much longer, food that sticks, a wet or gurgly voice after drinking, and any weight loss are all worth reporting.

• Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ) — National Cancer Institute
• Mouth and Throat Problems During Cancer Treatment — National Cancer Institute
• Head and Neck Cancers — National Cancer Institute
• Laryngeal Cancer Treatment (PDQ), Patient Version — National Cancer Institute
• Dysphagia Tests — MedlinePlus
• Dysphagia (Swallowing Disorders) — MedlinePlus
• Nutrition in Cancer Care (PDQ), Patient Version — National Cancer Institute