Q&A: Speech and Swallowing Problems
CancerWise - February 2009
Most people take speaking, swallowing and hearing for granted. But cancer or its treatment may leave patients unable to perform these previously effortless functions, catching them off-guard and unprepared.
Jan Lewin, Ph.D., associate professor in the Department of Head and Neck Surgery at M. D. Anderson, offers these insights about the loss of speaking, swallowing or hearing capabilities.
Why do some cancer patients need speech, hearing or swallowing help?
Cancer and its treatment often affect structures and physiology that enable patients to talk, eat and hear. For example, head and neck cancer may affect the tongue, larynx (voice box) or the nerves that allow those organs to function. Often treatment impairs abilities in the short run that may deteriorate further over time.
Radiation is associated with formation of fibrosis (scarring). Scarring in the larynx may prevent it from moving, causing it to lose the ability to make sound and to protect the airway from aspiration (when food or saliva travels into the lungs). The inability of the larynx to move may cause additional swallowing problems.
Frequently, lung tumors compress the nerve that makes vocal cords work, causing vocal cord paralysis.
Many chemotherapies also are extremely toxic to hearing.
How do patients react when they learn they are at risk for problems?
The most common reaction to speech, swallowing and hearing problems after cancer is surprise. Often patients believe the problems will get better by themselves, which is not always true.
Most people have no idea what the ramifications of their cancer treatments are. Generally physicians are not trained to evaluate and treat speech and swallowing problems. While doctors may mention possible problems, they often don’t go into depth about long-term consequences. Therefore, it is very important that cancer patients with, or who are at risk for, speech and swallowing problems be referred to a knowledgeable speech pathologist before treatment.
What are some of the tests to diagnose speech and swallowing difficulties?
Some of the available tests include:
Laryngeal videostroboscopy: For patients whose cancer or treatment affects the larynx, this technique maximizes visual examination of the larynx and allows the clinician to observe its function.
Modified barium swallow study: This radiographic examination of swallowing follows the process from the time something enters the mouth until it enters the esophagus (tube to the stomach).
Fiberoptic endoscopic examination of swallowing (FEES): A small, flexible endoscope is inserted into the nose, allowing the clinician to see the larynx and surrounding structures during swallowing.
What is a tracheoesophageal (TE) voice?
When cancer occurs in the larynx, the larynx must sometimes be removed; this procedure is called a total laryngectomy. After a total laryngectomy, there is no way to prevent food and water from being aspirated into the lungs. Therefore, the surgeon separates the trachea (breathing tube to the lungs) from the esophagus, leaving the patient unable to breathe through the nose or mouth. A neck stoma, or hole, is created to provide a new opening for air exchange.
Removing the larynx also prevents the ability to produce verbal speech. The most common and natural way to restore the ability to speak is called tracheoesophageal (TE) voice restoration.
A TE voice prosthesis is a small device that is placed between the trachea and the esophagus, creating a new site for sound vibration. It allows patients to speak in a hoarse but understandable voice that is not very different from the voice they had before surgery. Successful TE speech production depends on the patient's motivation and the clinician's experience and familiarity with the method.
How can cancer patients find help?
It’s important to seek out experienced clinicians who are experts in the evaluation and management of treatment of cancer patients. Generally, these clinicians can be found in major medical centers and advanced cancer practices. Community speech pathologists do not usually have this specialized expertise.
Don’t be afraid to ask questions about expertise and experience.
If you can’t afford specialized treatment, at least demand that the clinician who is treating you contact an institution with specialized expertise for guidance and information.
What is your advice for cancer patients?
People need to seek help before treatment begins, particularly if they have head and neck cancers. No matter what type of treatment is recommended (surgery, radiation and/or chemotherapy), one question to their doctor should always be: “How is this going to affect me?” The response should always include referral to knowledgeable specialists, including a speech pathologist or audiologist.