Speech Therapy For Head and Neck Cancer: 9 Steps To Get Started

Head and neck cancers (HNC) comprise 3–5% of newly diagnosed cancers in the United States (Suiter & Gosa, 2019). And dysphagia is very common in patients before, during, and after HNC treatment.

Keep scrolling for a guide to dysphagia and speech therapy for head and neck cancer. Whether it’s your first (or 20th!) patient.

Head and Neck Cancer Treatment & Side Effects: What To Expect

If a patient with HNC develops a swallowing disorder will depend on the location and size of the tumor and on the cancer treatment, amongst other factors.

Head and neck cancers are usually treated with surgery, radiation therapy, and/or chemotherapy (Suiter and Goza, 2019). 

Combining two or three treatments (e.g., surgery followed by radiation or concurrent chemoradiation) is a common HNC treatment recommendation, especially for larger tumors (Kraaijenga et al., 2014). While smaller tumors may require a single treatment, such as surgery or radiation therapy.  

Surgery may be minimally invasive, such as a laser procedure. Or may involve surgical removal of parts or all of the tongue, palate, floor of the mouth, mandible, or maxilla. Some patients may have partial or total laryngectomy, resulting in a voice disorder (Suite & Gosa, 2019).

Side effects of radiation treatment include xerostomia (dry mouth), swallow avoidance, tissue fibrosis, pain, trismus (reduced jaw range of motion), mucositis (painful mouth inflammation), and other changes that decrease range of motion and increase the risk of aspiration.

Side effects of chemotherapy include xerostomia, trismus, pain when chewing and swallowing, nausea, changes in taste, suppressed appetite, and a suppressed immune system (Mansolillo, n.d.)

Speech therapy can help with some of the side effects of HNC treatment. Consult with nursing, oncology, and a registered dietician to help manage side effects and to maintain adequate nutrition and hydration.

Speech Therapy For Head And Neck Cancer

How you assess and treat a patient with HNC depends on several factors, including:

• Location and extent of the disease
• The extent of any metastasis to the nodes (tumor nodes metastasis or “TNM”)
• Staging (how big the tumor is, whether it has spread to the lymph nodes or other organs)
• The cancer treatment course and/or other plans for treatment
• Type of surgical resection, if any (or if organs were preserved via radiation, chemo, and/or immunotherapy)
• How the cancer treatment affects the patient’s ability to safely and efficiently eat and drink to maintain hydration and nutrition.

Head and Neck Cancer Dysphagia Assessment

How is a head and neck cancer dysphagia assessment different from other swallowing assessments?

While you’ll complete a comprehensive clinical swallow evaluation, there are a few unique areas when assessing head and neck cancer. We’ll review these below.

1. Chart Review for Head and Neck Cancer

It’s best to do an extensive chart review for patients with HNC. 

Learn the type(s) of cancer treatment they had or plan to have. Review surgical reports of previous and/or acute oropharyngeal surgeries.

Figure out if your patient is meeting their nutrition and hydration needs. Factors like diet level, artificial means of nutrition (i.e. feeding tube), and weight loss can help you determine this.

2. Patient Interview

Complete a thorough patient and caregiver interview. 

Confirm their medical history, including HNC treatments. Ask about their swallowing abilities. Did their swallow get worse over time (due to radiation fibrosis, swallow avoidance, etc?) Or was there an acute onset, like after surgery?

Ask about and prioritize their goals and quality of life when setting swallowing goals.

3. Oral-Mechanism Examination for Head and Neck Cancer

When completing your OME, carefully examine range of motion, mucosa integrity, and surgical resection(s). 

Do you notice any oral mucositis or oral thrush? Do they complain of pain with movement or when swallowing?

Read How To Do An Oral-mechanism Exam for more guidance.

4. Food & Liquid Trials for Head and Neck Cancer

How you do food and liquid trials during the CSE will depend on your patient’s current diet and liquid intake. 

Be sure to review any recent instrumental assessments (VFSS, FEES) for their recommendations.

5. Education & Recommendations for Head and Neck Cancer

Educate and provide handouts and other resources to explain what dysphagia is, why they’re experiencing dysphagia, and your recommendations. See the Dysphagia Pack for premade patient handouts.

Patients with HNC have a high incidence of aspiration without reporting symptoms, so safety is a big concern. An instrumental assessment like FEES or MBSS is highly recommended when working with these patients.

Use the instrumental assessment results to also guide what exercises and compensatory strategies you recommend.  

Communicate regularly with their healthcare team, such as nursing, oncology, and registered dieticians, and make referrals as appropriate.

How to Treat Dysphagia in Head and Neck Cancer

When treating dysphagia in HNC, focus on your patient’s strengths, goals, and on improving their quality of life.

You’ll likely recommend compensatory swallowing strategies and swallowing exercises and stretches. Your treatment focus will change depending on where they are in their treatment journey, from preventative to maintenance and restorative.

1. Compensatory Swallowing Strategies for Head and Neck Cancer:

Most patients with HNC will benefit from compensatory swallowing strategies.

Which ones you recommend depends on their symptoms, the location of their cancer, and the cancer treatment they’ve undergone.

General head and neck cancer compensatory swallowing strategies include:

• Small bites and sips
• Single bite and/or sip at a time
• Alternating bites and sips
• Slow rate
• Smaller, more frequent meals
• Energy conservation strategies

2. Diet Modifications

Most patients with head and neck cancer also benefit from softer, moist diet textures and cut-up food. 

Treat xerostomia (dry mouth) by increasing fluid intake, sipping water while eating, and eating moist cut-up foods. 

Learn more about Modifying Diets For Head And Neck Cancer.

3. Breath-Swallow Coordination

Patients with HNC may demonstrate breath-swallow discoordination, which increases the risk of aspiration (Mansolillo, n.d.) To improve coordination:

• Target a slow rate of eating and drinking
• Take breaks to gain breath control
• Work on a breath-swallow sequence. 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 (2015)

4. Head And Neck Cancer Swallowing Exercises

Range of motion and oral motor exercises help patients with head and neck cancer maintain and regain movement and oral intake and improve swallowing safety (Riffat et al., 2015; Barton et al. 2022). 

Your patient will ideally start preventative swallowing therapy exercises before the cancer treatment. Then work to maintain and restore swallowing during and after cancer treatment.

Dysphagia Exercises Before Cancer Treatment

When possible, start dysphagia treatment at least two weeks before chemotherapy or radiation begins.

The goal of dysphagia exercises before cancer treatment is to maintain muscle strength, range of motion, oral intake, and swallowing function and safety.

Teach the swallowing exercises and stretches and provide a home program and patient education.

Communicate with nursing or oncology to share your plan, learn precautions, and otherwise collaborate.

Dysphagia Exercises During Cancer Treatment

During chemotherapy or radiation, focus on continuing swallowing exercises to improve strength and range of motion and on safely maximizing oral intake.

During this phase, common limitations to swallowing exercises are pain, aspiration risk, xerostomia, and lymphedema (swelling).

Check in with your patient once or twice week to reassess aspiration risk, swallowing, strength, range of motion, and ability to maintain hydration and nutrition by mouth.

Encourage them to continue their swallowing exercises every day and to eat by mouth, as appropriate.

Refer out to specialists as needed, and continue to communicate with nursing or oncology about updates, precautions, and your plan of care.

Dysphagia Exercises After Cancer Treatment

After chemotherapy, radiation, or surgery, the goal of swallowing exercises is to restore strength, range of motion, and any swallowing skills that were impacted by the cancer treatment.

As always, refer out and communicate with the care team as needed. Read Head and Neck Cancer Dysphagia Exercises to learn which exercises to choose from.

More Dysphagia Help

The Adult Speech Therapy Roadmap Course is a practical, step-by-step guide to speech therapy assessment, documentation, and treatment. The Roadmap was made for SLPs who are:

• New grads or CFYs
• Transitioning from pediatrics
• Been practicing for a while, but want the support of a framework
• Coming back after a long break

References

• American Speech-Language Hearing Association. (n.d.). Adult Dysphagia. Retrieved November 10, 2024 from https://www.asha.org/practice-portal/clinical-topics/adult-dysphagia/
• Barbon, C. E. A., Peterson, C. B., Moreno, A. C., Lai, S. Y., Reddy, J. P., Sahli, A., Martino, R., Johnson, F. M., Fuller, C. D., & Hutcheson, K. A. (2022). Adhering to Eat and Exercise Status During Radiotherapy for Oropharyngeal Cancer for Prevention and Mitigation of Radiotherapy-Associated Dysphagia. JAMA otolaryngology– head & neck surgery, 148(10), 956–964. https://doi.org/10.1001/jamaoto.2022.2313
• Brewer, C., Aparo, M. (2021). The Adult Speech Therapy Starter Pack. Harmony Road Design Publishing.
• Kraaijenga, S. , van der Molen, L. , van den Brekel, M. & Hilgers, F. (2014). Current assessment and treatment strategies of dysphagia in head and neck cancer patients. Current Opinion in Supportive and Palliative Care, 8 (2), 152-163. doi: 10.1097/SPC.0000000000000050.
• Mansolillo, A. (n.d.). The Essentials: Dysphagia and Head and Neck Cancer. [Online Course]. Medbridge. Retrieved from: https://www.medbridge.com/educate/courses/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
• Riffat, F. , Gunaratne, D. A. & Palme, C. E. (2015). Swallowing assessment and management pre and post head and neck cancer treatment. Current Opinion in Otolaryngology & Head and Neck Surgery, 23 (6), 440-447. doi: 10.1097/MOO.0000000000000205.
• Suiter, D.M. & Gosa, M.M. (2019). Assessing and treating dysphagia: A lifespan perspective. New York, NY: Thieme. ISBN-9781626232143