April is Head & Neck Cancer (HNC) awareness month. In this post you will learn more about the usual causes of HNC, its signs and symptoms, how it is diagnosed and treated, and why SLPs work with this population.
Head and Neck cancer can affect the mouth, throat, salivary glands, and the sinuses. These areas are lined with squamous cells, so when they develop cancer we call it a squamous cell carcinoma.
Causes
The leading causes of head and neck cancer vary with age. Most people aged 50 or older tend to develop HNC after consistent exposure to alcohol or tobacco. Those below that age tend to have been exposed to the Human Papilloma Virus (HPV). Other common causes are occupational exposure (e.g., formaldehyde, asbestos, nickel, wood dust, etc), infections with the Epstein-Barr or mononucleosis, and exposure to UV rays such as those found in tanning beds.
To reduce your chances of developing Head and Neck Cancer, avoid or quit smoking, limit alcohol, talk to your doctor about being vaccinated against HPV, use condoms and dental dams during oral sex, protect your lips from UV rays with lip balms containing sunscreen, and visit a dentist regularly.
Symptoms and Diagnosis
Common signs and symptoms of HNC are:
a mouth sore or a sore throat that doesn't heal
changes in the voice
pain on the neck, teeth, face, or while chewing
numbness on your face
difficulty breathing
feeling a mass or a lump in your mouth, throat, or neck
Head and Neck Cancer is best treated when caught early. To diagnose it, doctors may request imaging such as CT scans, MRIs and PET scans, endoscopies, biopsies, and barium swallows. The cancer is then treated using chemotherapy, radiotherapy, and/or removed surgically.
Treatment
Patients going through HNC treatment will likely be closely followed by an multidisciplinary team composed of Dietitians, ENTs, Dental Oncologists, Social Workers, Physiotherapists, Nurses, and Speech-Language Pathologists. SLPs are responsible for:
teaching patients how they can be affected by radiotherapy and potential surgeries to the tongue, the jaw, or the larynx
teaching patients exercises to preserve the function of muscles at the base of the tongue and in the throat so they can eat and drink safely after the treatment
explaining the different options for voice replacement in case the patient needs a total laryngectomy
replacing voice prostheses regularly (which requires extra training and supervision)
A common location for HNC is the larynx, which sits right above the airway and contains your vocal cords. Depending on the size of the cancer and on how it responds to chemotherapy and radiotherapy, doctors may recommend a complete removal of the larynx. When that happens, patients no longer have a connection between the nose and the airway -- air goes in and out the body through a hole on the neck (which is called a stoma).
Food can still be ingested through the mouth, but patients may not taste it as much as before the treatment because radiotherapy may affect the cells on the tongue responsible for the sense of taste and because there is no longer a connection between the lungs and the nose -- meaning that there's nothing pulling air into the nose, therefore the smell receptors in the nose don't capture as much information as they used to.
When the larynx is removed, so are the vocal cords. Patients then have different options to replace the voice:
Voice prosthesis
A tracheoesophageal voice prosthesis (TEP) is usually installed in the patient's trachea during the total laryngectomy surgery. The TEP is a one-way valve that sits on the wall between the esophagus (the food pipe) and the trachea (the wind pipe). To speak, patients cover the stoma, which forces air from the lungs into the TEP. The air moves up the esophagus and toward the mouth. It then echoes through the mouth and the nose, which creates an artificial voice. TEPs have to be replaced frequently, and may be partially covered by insurance and by government programs such as Ontario's Assistive Devices Program (ADP). The video below shows and example of a man who speaks through a TEP prosthesis.
Electrolarynx
An electrolarynx is a device that produces a sound frequency. It is placed against the neck, under the jaw, or on the cheek, and as it echoes through the mouth and the nose it creates an artificial voice. They are a viable alternative to people who are not good candidates for voice prostheses, and their cost may be partially covered by insurance and government funds as well. They require less maintenance than a voice prosthesis, they are non-invasive, and depending on the model both the pitch and the volume can be adjusted.
There is certainly a learning curve when it comes to speaking with an electrolarynx, as users need to find the best spot on their neck or against the vocal tract to place the electrolarynx, learn to coordinate the sound produced by the machine with the movements needed for speech, and also learn to to exaggerate speech movements so others can understand them better.
The video below shows an example of what speech sounds like when the voice is produced by an electrolarynx.
Esophageal speech
Esophageal speech is a less common way of communicating, but it may be the preferred way for some. This technique is completely technology-free. The user learns to swallow air into the esophagus and to control its escape through the pharynx. It requires substantial training, but it is masterable. The downside is that people who aren't familiar with it may find it socially unacceptable, as it could sound like a series of burps before it is mastered by the user.
Augmentative and Alternative Communication (AAC)
Patients may also opt for other forms of communication that don't require speaking, such as text-to-speech apps and pictogram-to-speech apps. In a research study published in 2021 (Repova et al., 2021), patients were able to record their voice prior to their laryngectomy; 20% of them used an AAC device that used personalized speech synthesis to turn text into speech. Given the recent developments in Artificial Intelligence, it is not far-fetched to think that we will soon have the ability to use AAC devices that can mimic our own voice.
Dysphagia
Due to the possible locations of HNC and often as a side-effect of radiotherapy, patients tend to experience dysphagia, which is the medical name for difficulty swallowing. Radiation can affect the salivary glands and make the mouth very dry; it can harden the muscle fibers in the neck and make muscles less mobile; it can affect the sensations of the nerves in the neck and slow down swallowing reflexes; it can make the lining of the throat very sensitive, making it painful to eat and drink.
At the very start of treatment, SLPs meet with patients to teach them exercises to keep the tongue and the muscles in the neck strong and mobile. After the treatment, SLPs meet with patients at least once again to perform a videofluoroscopic swallow study (VFSS) (also known and modified barium swallowing study, or MBSS) and assess in real time what food and liquid consistencies are safer for patients to consume.
Dysphagia, reduced immunity, and infrequent oral care are strong contributors to the development of aspiration pneumonia. SLPs provide recommendations, exercises, and strategies to improve the patient's safety and hopefully help them improve their quality of life.
The ability to eat and drink without pain and without the risk of choking or developing pneumonia is not something most of us tend to dwell on. Patients living with HNC or through its aftermath must navigate every meal and meal-centered holiday with these concerns in mind.
Preventing cancer is essential, but it may still develop despite our best efforts. If you think that something is off, seek medical attention. Usually the earlier a cancer is caught, the better the outcome is.
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