Head & Neck Surgery
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Head and neck cancers and their treatments may impact a patient’s ability to eat and/or communicate. Many patients will benefit from speech and swallowing therapy to either address or prevent problems with communication and swallowing. Our head and neck cancer team includes expert speech-language pathologists (SLP’s) with specialized interest in the management of communication and swallowing disorders associated with head and neck cancer. Our goal is to preserve and optimize function and quality of life for all of our patients.
If you are diagnosed with head and neck cancer, you can expect to meet with a SLP before starting your treatment as well as during and after your treatment. Your comprehensive care plan will include evaluation of your current speech and swallowing function, education about changes you may experience during and after treatment, and a personalized therapy plan.
Speech & Swallowing Rehabilitation
Your Care Team
Our experts have extensive experience evaluating and treating swallowing disorders, sometimes referred to as dysphagia. Our speech-language pathologists use a number of tests to look at swallowing abilities. There are two primary tests we use to assess swallowing, video fluoroscopy and video endoscopy. Video fluoroscopy is a motion X-ray test where you will be given a variety of food consistencies mixed with barium, a white liquid that shows up clearly on an X-ray. The test measures swallowing ability from the mouth to the throat and to the esophagus if necessary. Video endoscopy is done using a small flexible endoscope that is passed through the nose to the throat. This allows us to look at the swallowing area from above. We can then watch as you swallow different foods and liquids to see how they go through the throat. These tests allow us to understand how your swallowing muscles are functioning so that we can customize your treatment plan.
This fluoroscopic video demonstrates a strong and efficient swallow that clears the dark liquid contrast through the throat into the esophagus (food pipe).
This fluoroscopic video demonstrates a swallow that lacks the strength to push the dark liquid contrast through the throat into the esophagus (food pipe). As a result, the contrast is seen to drip into the airway leading to aspiration.
This endoscopic evaluation demonstrates assessment of airway and swallowing following a supracricoid partial laryngectomy. This surgery involves removal of multiple structures of the voice box that typically offer airway protection during swallowing. By using a compensatory swallowing strategy taught by the speech and swallowing therapist, this patient was able to resume a nearly normal diet.
The anatomy of the swallowing system.
At the Stanford Cancer Center we believe in preventative medicine. Research and clinical experience has shown us that swallowing problems can be common after treatment. We also know that therapy during treatment reduces the chance of swallowing problems. Keeping your swallowing muscles strong and active during radiation therapy is the best way to ensure they continue to work for years to come. Strategies to rehabilitate swallowing function after treatment may include exercises that strengthen muscles or improve coordination, changes in posture while swallowing, or special swallowing techniques to make the food and liquid go down easier and safely. In some cases we will suggest specialty-designed utensils or drinking cups. Changes in food consistencies are sometimes suggested for safety or ease of swallowing.
In the first stage of swallowing, the tongue pushes the food and liquid from the front to the back of the mouth. The lips must stay closed to prevent the food and liquid from spilling out of the front of the mouth. The cheek muscles must maintain tone so that the food and liquid does not spill into the space between the gums/teeth and the cheek.
In the next phase of swallowing, the muscles of the upper throat and soft palate come together to prevent food and liquid from going up the nose. As the food and liquid enters the throat, the airway closes up to prevent food and liquid from entering the windpipe and lungs.
Towards the end of the swallow the muscles of the back of the tongue and throat come together to push the food out of the throat and into the food pipe (esophagus). The muscle at the top of the esophagus relaxes to allow the food and liquid through.
Once the food and liquid is fully within the esophagus, the airway opens back up and all muscles return to their resting position. The muscles of the esophagus then strip the food and liquid from the top of the esophagus into the stomach.
What is Dysphagia?
Dysphagia refers to difficulty in swallowing. Some symptoms of dysphagia include a sense of food/liquid getting caught in the mouth or throat, coughing/choking like things are going down the “wrong pipe”, difficulty chewing, and/or longer time needed to eat/drink. Dysphagia can lead to other problems like weight loss or pneumonia from food/liquids entering the lungs. Head and neck cancer and the treatments use to eliminate cancer are known risk factors for dysphagia. The speech language pathologist can provide preventative and rehabilitative intervention for dysphagia.
What is Trismus?
Trismus occurs when a person has difficulty opening their mouth fully. Trismus can lead to difficulty with eating, dental care, and speech. Trismus often gets worse over time if not treated. Surgery and radiation to the head and neck region are known risk factors for trismus. Trismus prevention is an important part of the care provided by the speech language pathology team.
Our speech-language pathologists have extensive experience in rehabilitation of speech and voice after treatment for head and neck cancers. Collaboration with other professionals such as surgeons and maxillofacial prosthedontists allows for individualized care. We understand the importance of maintaining functional communication after treatment. We offer comprehensive speech and voice care for all of our patients.
Our team has particular expertise in speech rehabilitation after removal of the voice box (total laryngectomy). We offer a full range of therapy options for patients who have had their voice box removed, including tracheoesophageal voice prostheses (TEP). Before your surgery you will meet with a speech-language pathologist to discuss the different communication options available after surgery and to decide what option is best for you. We also offer pulmonary and olfactory rehabilitation after laryngectomy to help improve breathing and taste/smell.
For patients with concerns regarding their voice, we offer comprehensive evaluation and treatment. To evaluate the vocal cords, a test called videostroboscopy is used to provide a magnified, slow-motion movie of the voice box during vibration. During the test, a small, angled telescope will be placed into your mouth or a flexible telescope may be placed through your nose. You will be asked to make specific sounds to make your vocal cords vibrate. These movies are recorded and can be reviewed later. Our team has extensive experience working with patients with voice problems and collaborates closely with our Laryngology team when medical or surgical interventions are necessary.
This video demonstrates the vibration of the vocal folds when creating voice. Our speech-language pathologists have expertise in the evaluation and treatment of voice disorders related to cancer and it's treatments.
What is Dysphonia?
Dysphonia is a change in voice. Dysphonia may present as hoarseness, rough voice, weak voice, changed pitch, or strained production of voice. Surgery and radiation to the voice box may lead to dysphonia. Voice treatment can be provided by the speech language pathologist in partnership with the laryngology team.
What is Aphonia?
Aphonia refers to total loss of voice. Aphonia is common after extensive surgery to the voice box or when the nerve to the voice box is damaged. The speech language pathology team can explore strategies and techniques to restore communication for patients with aphonia.
What is Dysarthria?
Dysarthria is a change in the ability to produce clear speech sounds. Though often associated with stroke and other neurological diseases, surgery and radiation to the head and neck can cause problems with the speech muscles and/or the nerves that connect the muscles to the speech centers in the brain. Dysarthria may be characterized by slurred speech, slowed speaking rate, and irregular speech. The speech language pathologist will help to combat dysarthria through speech intervention.
Our speech pathology team can provide intervention for lymphedema of the head and neck region. Lymphedema is a type of swelling that occurs when the lymphatic system is damaged from surgery or radiation therapies. Lymphedema can cause discomfort and reduced movement in the affected areas. This may lead to cosmetic disfigurement but also functional problems with communication and swallowing as well as difficulties with breathing in some cases. Head and neck lymphedema therapy includes two primary treatments, manual lymphatic drainage and compression. Manual lymphatic drainage is a hands-on therapy that works to reestablish a new, more functional lymphatic drainage pattern. Our speech pathology team can train patients and caregivers to complete this treatment at home in between therapy sessions. Compression garments will be customized and fit according to patient need. Early intervention for lymphedema tends to be most successful rather than intervening once fibrosis develops.
What is Lymphedema?
Lymph nodes and vessels of the head and neck.
Lymphedema is chronic swelling in the head and/or neck due to damage to the lymphatic system. This is typically the result of either surgical or radiation changes. The normal drainage pathways are disrupted leading to pooling of protein rich fluid in the neck or face. The treatment for lymphedema includes skin care, manual lymph drainage, and compression therapy.
What Causes Lymphedema?
Place your hands over the sides of the neck. Alternate circling back and down toward the ear, one side at a time.
- The lymphatic system is an important part of your immune system and serves as a sort of waste disposal system, moving fluid, protein, and bacteria to the lymph nodes where the lymph fluid is processed.
- Damage to the lymphatic system can cause lymph fluid to collect in the tissues around the area of injury leading to swelling.
- Lymphedema may occur if the lymph nodes are removed or the lymph vessels are injured.
- This injury can occur during surgery or radiation treatment.
- It is also possible for a tumor to obstruct the normal lymphatic drainage system, resulting in lymphedema.
What Are the Symptoms of Lymphedema?
Symptoms of head and neck lymphedema include:
- Swollen eyes, face, lips, tongue, neck, or chin
- Swelling below the chin often described by patients as a “turkey waddle”
- A tight or heavy feeling in the neck or face
- Difficulty moving your neck or jaw
- Difficulty with swallowing, speaking, or breathing
How Common is Head & Neck Lymphedema?
Head and neck lymphedema may be seen in 50-75% of patients receiving surgery or radiation for head and neck cancer.
Symptoms may range from very mild to quite severe and the impact of lymphedema is often related to the severity of swelling.
How is Lymphedema Treated?
Place two fingers behind your ear and two in front of your ear.
Circle back and down toward the ear.
Lymphedema is typically treated using complete decongestive therapy which includes:
- Manual lymph drainage - A massage like technique which moves lymph fluid from a congested area to a nearby functioning lymphatic drainage pathway.
- Compression - Use of tight fitting specialty garments which prevents fluid from back filling and promotes continued lymph drainage.
- Exercise - Moving the muscles in the region of swelling helps to promote fluid drainage.
- Skin care - Maintaining clean skin is important to prevent infection and breaks in the skin
Lymphedema therapy is most effective when performed daily, therefore home protocols are an important part of lymphedema treatment.
Who Can Help?
Lymphedema therapy may be provided by a specially trained physical therapist, occupational therapist, or speech pathologist. At the Stanford Cancer Center, head and neck lymphedema treatment is provided in our Speech and Swallowing clinic. To schedule a consultation, call 650-498-6000 (Press Option 2, then Option 3) and specify that you are requesting a head and neck lymphedema evaluation.
What If I Don’t Live Near Stanford?
Your lymphedema therapist may train you and your family or caregivers to do a good deal of the treatment at home. We recommend bringing a caregiver who may assist in your home care to your consultation for training.
If you need additional assistance closer to home, we recommend referring to the Lymphedema Association of Northern America as a starting point to locate a therapist.
Not all lymphedema therapists have experience working with the head and neck. We recommend asking the local center about their level of experience.
In addition to providing state of the art clinical care for communication and swallowing, our speech-language pathology team is engaged in clinical research to determine strategies to improve patient outcomes after a diagnosis of head and neck cancer. Our team recognizes the difficulties of going through cancer treatment and has particular interest in developing strategies to help patients make it through their treatment doing the therapies that will provide the best long-term outcomes. We collaborate closely with our surgeons, radiation oncologists, medical oncologists, and other team members to investigate how we can improve the patient experience of head and neck cancer care.
Annual Head & Neck Cancer Patient & Caregiver Education Symposium
Heather Starmer is passionate about providing patients and caregivers with support and education to help them along their cancer journey. In 2017 she established the annual Head & Neck Cancer Patient & Caregiver Education Symposium. This event brings patients and caregivers together experts in the field of head and neck cancer care to discuss important concepts for treatment and survivorship.
Presentations and Slides
Annual Swallowing Disorders Awareness Symposium
Swallowing disorders have the potential to impact the health and well-being of hundreds of thousands of people across the globe. Every other year, Stanford hosts the Swallowing Disorders Awareness Symposium in conjunction with Dysphagia Awareness month. On alternative years, the event is hosted by our colleagues at the University of California at Davis. This event provides learning opportunities for providers who care for patients with swallowing disorders as well as those who live with or love someone with swallowing difficulty.
Presentations and Slides
June 10, 2020
June 20, 2018