As a dysphagia expert, you know how to assess and treat swallowing disorders, including modifying diets. But some diagnoses, like head and neck cancer, can still feel tricky.
What factors should speech therapy consider when modifying diets for patients with HNC? How is it different from other modified diets?
In this post, we dive into these questions so that you can feel more confident when modifying diets for head and neck cancer.
For a step-by-step guide on how to assess and treat dysphagia, check out The Adult Speech Therapy Roadmap!
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Modifying Diets for Head and Neck Cancer: What Factors To Consider?
1. The Goal of Modifying Diets for Head and Neck Cancers
The goal of diet modification for HNC patients is to safely sustain nutrition and hydration while preserving the ability to swallow.
Some patients may need artificial means of nutrition, especially those at severe risk of aspiration and/or with significant weakness, fatigue, pain, or nausea.
2. Aspiration
Head and neck cancer patients have a high incidence of aspiration without reporting symptoms, so safety is a big concern. A FEES or MBSS is highly recommended when working with these patients.
3. Location of the Cancer and Surgery
Diet modification needs vary based on the location of the cancer and of any dissection, resection, or surgery. Complete a bedside swallowing evaluation to determine if and what type of diet modification is needed.
For patients with partial tongue resections, manipulating and clearing a bolus may be difficult. They often benefit from soft textures, such as a minced or pureed diet, with alternating liquid washes.
Some patients with total tongue resection may benefit from a full-liquid diet or a drinkable puree diet.
For patients with laryngeal or tonsil cancers, dysphagia symptoms can vary widely.
Swallowing is also impacted if the cancer or surgery results in loss of sensation or impairment of additional structures (palate, mandible, etc.).
Again, complete a bedside swallowing evaluation and recommend a FEES or MBSS, as appropriate.
4. Disuse Atrophy
The discomfort and other side effects of cancer and cancer treatments often lead to disuse atrophy in HNC patients.
Common reasons for disuse atrophy are pain, dryness, and discomfort.
Manage xerostomia (dry mouth), educate about the importance of maintaining their swallow, set up a home program of swallowing stretches and exercises, and work with the medical team to address pain.
5. Breathing and Swallowing Discoordination
Patients with head and neck cancer may experience breathing and swallowing discoordination, increasing their risk of aspiration.
A study by Martin-Harris et al. trained patients with HNC and dysphagia to first start an exhale, swallow midway through the exhale, then continue the same exhale after the swallow.
These patients showed improved MBSImP component scores in laryngeal vestibular closure, tongue base retraction, and pharyngeal residue. See the article for more details.
6. Effects of Radiation on Swallowing
The side effects of radiation to the head and/or neck can impact the course of your dysphagia treatment, including your diet modification recommendations.
These side effects include xerostomia, pain, swelling, mucositis, trismus, fibrosis, and other changes to the muscles that can decrease range of motion and increase the risk of aspiration.
Range of motion and oral motor exercises have been shown to help with maintaining and regaining movement and oral intake.
7. Effects of Chemotherapy on Swallowing
The side effects of chemotherapy can also impact swallowing and your diet modification recommendations.
Chemotherapy can cause nausea, vomiting, fatigue, weakness, pain during chewing and swallowing, as well as decreased immune system function. Dehydration, weight loss, and malnutrition are also common concerns.
Work closely with nursing, oncology, and a registered dietician to help manage the side effects of radiation and chemotherapy and to maintain adequate nutrition and hydration.
8. Referring Out
Communicate regularly with the patient’s medical team.
This includes nursing, oncology, registered dietician, dentists, and other specialists that may be part of your patient’s healthcare team (lymphedema specialist, acupuncturist, etc.), as appropriate.
How Is Diet Modification with Head and Neck Cancer Different?
1. Safety
Safety when swallowing is a big concern for our head and neck cancer patients, given their higher incidence of aspiration without reporting symptoms and their compromised immune systems.
2. Rapid Changes
When undergoing radiation and chemotherapy, dysphagia symptoms may change quickly. As a result, you’ll often modify the patients’ diets during their cancer treatment.
Know your patient’s cancer treatment schedule to prepare for these changes.
For example, xerostomia often begins within the first or second week of radiation treatment. While mucositis is often seen in the second or third week of radiation.
3. Xerostomia
Diet modifications that can help with xerostomia include sipping water while eating, moist foods, adding sauces and gravies to moisten foods, and cutting foods into smaller pieces to help with chewing.
4. Low Volume
If your patient is unable to eat as much volume as before due to pain, decreased appetite, or fatigue, work with the dietician to recommend calorie and protein-dense foods.
Eating smaller meals more frequently may also help.
5. Trismus
For patients with trismus (reduced range of motion of the jaw) diet modifications may include cutting foods into smaller pieces and softer foods (adding sauces and gravies, lowering the texture).
More Dysphagia Materials
For more guidance on how to assess and treat dysphagia, visit The Adult Speech Therapy Roadmap!
References
- American Speech-Language-Hearing Association. (n.d.). Head and neck cancer [Practice portal]. https://www.asha.org/Practice-Portal/Clinical-Topics/Head-and-Neck-Cancer/. Retrieved May 11, 2023.
- Gaziano J. E. (2002). Evaluation and management of oropharyngeal Dysphagia in head and neck cancer. Cancer control : journal of the Moffitt Cancer Center, 9(5), 400–409. https://doi.org/10.1177/107327480200900505
- Mansolillo, A. (n.d.) The Essentials: Dysphagia and Head and Neck Cancer [Online course] Medbridge. https://www.medbridgeeducation.com/courses/details/essentials-dysphagia-head-neck-cancer-angela-mansolillo
- Martin-Harris, B., et al. (2015). Respiratory-swallow training in patients with head and neck cancer. Archives of physical medicine and rehabilitation, 96(5), 885–893. https://doi.org/10.1016/j.apmr.2014.11.022