Dysphagia in Head and Neck Cancer – the role of the speech pathologist

Professor Liz Ward has been a leading clinician and researcher in dysphagia management and head and neck cancer (HNC) care for over two decades. Professor Ward joins us to discuss the role of the speech pathologist in managing dysphagia in individuals with HNC.
What causes swallowing problems (dysphagia) in HNC cancer patients?
There are two main causes. The first is the cancer itself because if you have a cancer that has formed in your mouth, larynx or pharynx, its physical presence will disrupt the normal pattern of how we use those structures to control foods/fluids to swallow safely, placing the person at greater risk of aspirating the food/fluid.
The second cause is the management of the cancer. Management can involve surgery, nonsurgical techniques such as radiotherapy/ chemotherapy, or a combination of these. Surgical excision and removal of some of the surrounding tissue around a HNC can result in removal of, or damage to, important structures critical to swallowing.
For those patients who require radiotherapy or chemoradiotherapy, the early stages of radiation treatment can cause painful ulceration in the mouth, leading to tender and sore tissues which make eating difficult. Swelling of the oral pharyngeal and laryngeal structures also impacts on how these structures work, leading to unsafe swallowing.
Furthermore other effects such as taste changes and feelings of nausea and fatigue (if chemotherapy is part of treatment), also impact desire/ability to eat and drink. Patients may need to receive non oral feeding to maintain their nutrition during their chemo/radiotherapy. After treatment, many patients are left with persistent swallowing problems which can be worsened by long term negative effects (neurological damage or hardening or swelling of the tissues) caused by the radiation.
Promising new advances in surgery and radiotherapy techniques target tumours more precisely and spare the healthy tissue around it. It is hoped these may help to reduce the side effects of radiotherapy and improve the swallowing outcomes for patients.
What does it mean to have swallowing problems?
The most common impact for most people with HNC is the damage radiation can do to the production of saliva resulting in chronic dry mouth and this can interfere with swallow. For others, surgery on the tongue, floor of the mouth, pharynx and larynx can make it difficult for a patient to control the food in their mouth - to hold it and then make sure that it goes into their oesophagus and not their airway. Swallowing safely, without aspirating, is the challenge for these patients postoperatively.
How is a patient’s diet managed after treatment?
A diet for a person with HNC is different to other patient groups. Each patient needs to be individually assessed. A speech pathologist’s role is to determine the type of food and drink that is easiest to consume based on the remaining structures and the impacts of radiation on that patient.

Once they start their radiotherapy, a speech pathologist will see most patients weekly to assess their pain and swallowing and see what is needed (eg., pain relief) to make it easier to continue eating.
Most patients will require some modification to the texture of their foods during and after treatment. Soft foods and those with more sauce/gravy/moisture content are easier for people with HNC to manage due to the lack of saliva. Some patients, though fewer than in other clinical groups such as post stroke, may also require modified or thickened fluids. Thickened fluids help slow the movement of the fluid in the mouth so the fluid is easier to control. This is useful if someone has had part of their tongue removed for example.
If a patient is too unsafe or unwell to eat orally, a nasogastric or PEG (percutaneous endoscopic gastrostomy) tube may be necessary to ensure their nutritional needs are met while they are receiving their radiotherapy treatment.
Can you describe your role in the management of these patients?
The speech pathologist’s care of a patient begins at the time of diagnosis. A third of all patients will already be having trouble swallowing due to the presence of their tumour.
Prophylactic swallowing therapy begins prior to and during chemoradiotherapy. Patients are encouraged to do daily exercises to strengthen the muscles of the mouth and throat and teach them how to do a ‘safe swallow’. It’s all about not letting those vital muscles weaken and lose their function during the discomfort of radiotherapy. These exercises are modified during and post treatment. Post treatment, speech pathologists continue to work with patients for months or years to help them rehabilitate and optimise their swallow.
Do you work as part of a team?
In Australia we have a multi-disciplinary approach to cancer management that is recognised around the world as being best practice. HNC patients need care from a range of disciplines including specialist nursing, surgical and allied health. As part of that team, speech pathologists work most closely with the dietician to ensure that we are maximising our patient’s nutrition and swallow safety.
Where are the innovations and solutions coming from in this area?
One of the challenges we are facing is to match the needs of the patients in rehabilitation with the services they need. Following HNC treatment, a patient will have extensive appointments booked with their care team. This can mean long hours spent at the hospital. Today, for example, Mr Jones may be coping well with swallowing but he really needs to see his physical therapist. So how can we prioritise him into the service he needs and allow him to spend more time with family?
At the Princess Alexandra (PA) Hospital the “ScreenIT” computerised screening project is underway.1 This project, lead by Dr Benna Cartmill and Laurelie Wall, involves the patient answering a range of questions designed to take one or two minutes. A report is immediately sent to the allied health team who prioritise appointments for this patient. Our research into using ScreenIT shows this is an effective way to identify people who are experiencing difficulties and get them referred into the services they need in a timely manner. At the PA hospital, we are building up to full scale implementation of ScreenIT with the aim of streamlining our services and reducing the burden on patients.
The other challenge for patients is accessing specialist services. Most specialist cancer centres are located in capital cities. For our regional and rural patients - this presents another challenge. Where do they access services when they return home? At the Royal Brisbane and Women’s Hospital we are running a telehealth project lead by speech pathologist Claire Burns.2 With this post discharge ongoing support, patients can return home and, along with their local clinician, link in with the specialist cancer centre in Brisbane. This helps to ensure their local clinician is also well supported to provide rehabilitation locally, and helps to limit the need for frequent long distance trips for the patient.
Liz Ward
Professor Liz Ward is the Professor of the Centre for Functioning and Health Research in Metro South Hospital and Health Service in Queensland, and a Professor in the School of Health and Rehabilitation Sciences at The University of Queensland. Prof Ward’s primary research area is the investigation of speech and swallowing outcomes for patients undergoing Head and Neck Cancer (HNC) management. Prof Ward has been published in over 200 peer reviewed publications. Her textbook, Head and Neck Cancer: Treatment Rehabilitation and Outcomes, Plural Publishing, is used internationally as the training textbook for this area of clinical practice in speech pathology