HNC includes malignant tumors that most commonly arise from the moist squamous cell mucosa or lining of the head and neck regions. Although curative treatment may be different based on region and severity, some audiology and speech-language pathology interventions will be the same.

HNC is characterized according to the primary site of origin as malignancies of the

• nasal cavity and paranasal sinuses;
• oral cavity (lip, anterior two-thirds of the tongue, gums, oral mucosa, floor of mouth, hard palate, maxilla, and mandible);
• pharynx, including the nasopharynx, oropharynx (soft palate, tongue base, tonsils, and adenoids), and hypopharynx;
• larynx (supraglottic, glottic, and subglottic regions); and
• salivary glands.

The most commonly used model for classifying HNC is the TNM staging model, which classifies the extent of cancer spread (Amin et al., 2017; Lydiatt et al., 2018). The TNM model assigns a numerical status (Stage 0, x, I, II, III, or IV) based on

• tumor size and spread of cancer into nearby tissue (T),
• degree of lymph node involvement (N), and
• presence or absence of distant metastasis (M).

Lymph node involvement is typically defined as a late-stage (III or IV) malignancy regardless of the size or location of the primary tumor (Amin et al., 2017; Lydiatt et al., 2017, 2018). This rule does not apply to HNC from human papillomavirus (HPV), as HPV-related tumors have their own staging system (Economopoulou et al., 2020).

Tumor staging and location, physiologic impact, and patient/care partner goals often determine the course of cancer treatment. The following factors help determine overall prognosis:

• Natural history of the specific tumor based on staging, histology, and other comorbidities.
• Ability to control disease through treatment (surgery, radiation therapy, immunotherapy, chemotherapy—alone or in combination).
• Etiology—for example, HPV-associated oropharyngeal cancers have a better prognosis than HPV-negative oropharyngeal cancers (National Cancer Institute, 2015; You et al., 2019).
• Complexity, timing, and nature of treatment—for example, in advanced HNC, multimodal treatment (e.g., surgery, radiation therapy, chemotherapy, and immunotherapy) and reconstructive or salvage surgeries (surgery following curative-intent treatment failure) are more likely to result in short- and long-term side effects and may result in greater communication, swallowing, respiratory, and hearing needs (Bertolin et al., 2021; Nilsen et al., 2019).

Cancer treatment may involve surgery, radiation therapy, and/or systemic therapy (i.e., chemotherapy, hormone therapy, and/or immunotherapy). Different surgery types (e.g., laser, TransOral Robotic Surgery [TORS], open surgical resection with or without reconstruction) and chemoradiation therapy regimens have different side effects and rehabilitation timelines. Such differences may affect intervention approaches, quality of life, and functional outcomes (Aggarwal et al., 2021; Zebralla et al., 2021).

Incidence of HNC refers to the number of new cases identified in a specified time period.

Prevalence of HNC refers to the number of individuals who are living with head and neck cancer in a given time period.

Globally, it is estimated that HNC accounts for approximately 880,000 to 1.1 million new cases of cancer annually, with approximately 400,000–450,000 deaths a year secondary to HNC (Bray et al., 2018; Mody et al., 2021; World Health Organization [WHO], 2020b). About 3.6% of all cancers are HNC in the United States, with approximately 65,000 Americans developing head and neck malignancies annually (Siegel et al., 2022). There are currently over 14,000 deaths related to HNC each year in the United States alone (Siegel et al., 2022).

Generally, regarding the association of gender assigned at birth to HNC, males are 2–7 times more likely to develop HNC than females, with variability noted depending upon the site of HNC (Dhull et al., 2018; Ferlay et al., 2015; Lorenzoni et al., 2022). In the United States, non-Hispanic White individuals are more likely to develop HNC than are all other races (Surveillance, Epidemiology, and End Results Program [SEER], 2021; U.S. Cancer Statistics Working Group [USCSWG], 2021b). U.S. statistics are reported below by type of HNC.

• Oral cavity/pharynx: The incidence of cancer involving the oral cavity/pharynx was 11.8–12.1 per 100,000 persons per year from 2014 to 2018 (USCSWG, 2021c). The estimated number of new cancer cases involving the oral cavity and pharynx was over 32,000 each year during that same time (USCSWG, 2021b).
• Larynx: The incidence of laryngeal cancer decreased from 3.3 to 2.9 per 100,000 persons per year from 2014 to 2018 (USCSWG, 2021c). During this period, the estimated number of new cancer cases involving the larynx was approximately 8,500 each year (USCSWG, 2021b).
• Nasopharynx: The incidence of nasopharyngeal cancer is less than 1 per 100,000 persons per year (Chang et al., 2021; SEER, 2021). In 2020, approximately 1,900 people were diagnosed with nasopharyngeal cancer in the United States (WHO, 2020a).
• Nasal cavity/paranasal sinus: Each year, approximately 2,000 people are diagnosed with nasal cavity or paranasal cancer in the United States (American Cancer Society, 2016).
• Hypopharynx: The incidence of hypopharyngeal cancer is slightly less than 1 per 100,000 persons (SEER, 2021). Over 2,200 adults in the United States were diagnosed with hypopharyngeal cancer in 2020 (WHO, 2020a).
• Salivary gland: The incidence of salivary gland cancer is approximately 1.3 per 100,000 persons (SEER, 2021). Approximately 53,583 new cases of salivary gland cancer were diagnosed in 2020 (WHO, 2020a).

The incidence of HNC in the United States has been steadily increasing over the last 2 decades (Siegel et al., 2022; USCSWG, 2021b). This is, in part, due to the influence of the human papillomavirus (HPV). Currently, the estimated proportion of oropharyngeal cancers testing positive for HPV within the United States is 68%–70% (Centers for Disease Control and Prevention, 2020; Mashiana et al., 2021). Over 20,000 HPV-associated oropharyngeal squamous cell cancers are diagnosed annually within the United States according to data compiled by the USCSWG (2021a). Guo et al. (2022) found that HPV-associated oropharyngeal cancer rates are falling in young adults but continue to rise in individuals aged 45 years and older.

Presenting Signs and Symptoms (Pre-Cancer Treatment)

Presenting signs and symptoms of HNC vary based on location of the primary tumor, lymph node involvement, and subsequent metastases and may include the following:

• foul mouth odor (halitosis) not explained by hygiene
• frequent nosebleeds and/or unusual nasal discharge
• generalized symptoms that include loss of appetite, unexplained weight loss with or without dysphagia, fatigue, and fever
• globus sensation
• loosening of teeth or dentures
• lump, bump, or mass in the head or neck area, with or without pain
• nasal obstruction or persistent nasal congestion
• neuropathic pain at sites distant from the location of the tumors (resulting from invasion of the sensory nerves by the cancer cells; e.g., ear pain [otalgia])
• noisy breathing (stridor) and/or breathlessness (dyspnea) due to airway obstruction
• nonhealing ulcer in the head and neck region
• numbness or weakness of a body part in the head and neck region
• persistent cough (sometimes marked by coughing up blood [hemoptysis])
• persistent sore throat
• painful swallowing (odynophagia)
• red or white patches in the mouth
• reduced range of motion of the jaw (trismus) or of the tongue affecting speech and swallowing
• referred pain in the ear/jaw
• sensory changes (e.g., changes in or loss of smell and taste, double vision)

Functional Signs and Symptoms (Pre-, During, and/or Post-Cancer Treatment)

Functional signs and symptoms can occur due to the disease itself or as a result of cancer treatment. Depending on the location of the malignancy and time of presentation along the continuum of medical and surgical management (i.e., prior to, during, or after treatment), signs and symptoms may include functional impairments in one or more of the following domains.

Speech

Reduced overall intelligibility resulting from one or more of the following:

• articulation errors (e.g., omissions, substitutions, and distortions due to decreased strength and/or range of motion)
• imprecise speech (e.g., due to tumor bulk, swelling, trismus, cranial nerve palsies)
• distortions of lingual phonemes consistent with (a) reduced mobility, (b) lingual resection, and/or (c) reconstruction

Voice

• dysphonia (e.g., changes in pitch, loudness, and/or quality; ventricular phonation) due to untreated tumors in the larynx or supraglottic larynx, surgical resection, and/or radiation treatment that may cause glottic insufficiency or reduced vibratory capacity
• aphonia (loss of voice) post-surgery (e.g., with a tracheostomy tube or total laryngectomy)

See ASHA’s Practice Portal page on Voice Disorders for more details related to signs and symptoms of dysphonia.

Resonance

• hypernasality (e.g., due to palatal defect, surgical resection of the hard or soft palate, and/or immobility following radiation)
• hyponasality (e.g., due to the changing shape of the vocal tract or a nasal passage obstruction)
• cul-de-sac resonance (e.g., due to base-of-tongue lesions)

In addition, the presence of a tumor in the palate can impede velar mobility, which can impact resonance. See Possible Causes of Hypernasality and/or Nasal Emission and ASHA’s Practice Portal page on Resonance Disorders.

Swallowing

The nature and severity of swallowing problems in HNC depend on tumor size and location, staging, and treatment protocol (e.g., the type of surgical resection/reconstruction, radiation therapy, systemic therapy, and related side effects).

Changes in structural integrity and changes in use, sensation, strength, range of motion, and/or coordination of head and neck musculature may result in functional swallowing problems, such as

• impaired bolus manipulation and base-of-tongue movement,
• nasal regurgitation,
• impaired/absent epiglottic retroflexion,
• reduced glottic closure,
• impaired peristalsis of the cervical esophagus, and
• diminished upper esophageal sphincter opening due to stricture.

Individuals who are post-laryngectomy may have swallowing problems that are unique to this population. Laryngectomy and reconstructive approaches may result in decreased function of the upper and lower esophageal sphincters or strictures (Raj et al., 2020; Sweeny et al., 2012; Zhang et al., 2018).

See ASHA’s Practice Portal page on Adult Dysphagia for more details related to signs and symptoms of swallowing disorders.

Hearing

• hearing loss
• tinnitus
• dizziness/vertigo

See also ASHA’s Practice Portal pages on Hearing Loss in Adults, Balance System Disorders, and Tinnitus and Hyperacusis.

Side Effects of Medical and Surgical Management

Side effects of medical (i.e., radiation therapy and systemic therapy) and surgical management can impact function and rehabilitation planning. Many of these side effects (e.g., dysphagia, lymphedema) can occur both during and after treatment, even several years after its conclusion (Aggarwal et al., 2021; Hamilton et al., 2022; Smith, 2019; Starmer et al., 2014; Stubblefield, 2017). Ototoxicity—damage to the hearing and/or organs of balance of the inner ear by drugs or chemicals—can occur during or after chemotherapy treatment for HNC (Breglio et al., 2017). Other side effects include the following:

• hearing loss, tinnitus, aural fullness, and/or dizziness/vertigo (e.g., as a result of ototoxicity from chemotherapy or radiation; Frisina et al., 2016; Ganesan et al., 2018; Llorens et al., 2018)
• denervation/neuropathy
• dental problems (e.g., surgical removal of the teeth or a portion of the jaw, dental caries, dental pain, and osteoradionecrosis)
• dysphagia
• facial and other structural changes, including damage to auditory pathways and structures
• fistulae
• head and neck lymphedema
• loss of taste and appetite
• mouth sores and mucositis—inflamed mucosal tissue
• nausea and vomiting
• numbness/reduced range of motion in the head, neck, and shoulder areas
• odynophagia
• osteonecrosis
• pain (related to treatment and/or as a result of residual tumor)
• pharyngeal/upper esophageal spasm, stricture, and/or stenosis
• reduced/altered sense of taste and smell
• skin breakdown and infections at wound site
• soft tissue fibrosis and scarring
• swelling of the mouth and/or throat
• trismus—decreased range of motion in the jaw
• xerostomia—decreased salivation leading to “dry mouth”
• central nervous system toxicity (due to chemotherapy)
• cognitive impairment (due to chemotherapy)

Related Comorbidities

Related comorbidities that can influence speech, language, and swallowing assessment and treatment include the following:

• cognitive changes such as cognitive fatigue or changes in attention and/or executive function resulting from radiation, systemic therapy, or substance (e.g., alcohol, nicotine) withdrawal
• psychosocial concerns resulting from the diagnosis and impact of medical/surgical management (e.g., changes in lifestyle, self-image, family and social roles, and employment)
• changes in physical or mental health such as cancer-related fatigue, depression, and anxiety

Currently identified causes of HNC include

• excessive alcohol consumption;
• use of tobacco, including smokeless tobacco; and
• viruses such as human papillomavirus and Epstein-Barr.

Other factors that have been reported to increase the risk for HNC include

• betel nut chewing,
• environmental and occupational inhalants,
• gastroesophageal reflux disease,
• poor dental and oral hygiene,
• poor nutrition,
• prolonged sun exposure (especially in cancers of the lip and in skin cancer of the head and neck region),
• recreational drug use, and
• a weakened immune system from medications or an underlying disease.

Roles and Responsibilities of the Speech-Language Pathologist

SLPs play a central role in the screening, assessment, diagnosis, and treatment of people with HNC. The professional roles and activities in speech-language pathology include clinical and educational services (diagnosis, assessment, planning, and treatment); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).

Appropriate roles for SLPs include the following:

• Providing prevention information to individuals and groups known to be at risk for HNC as well as to individuals working with those at risk.
• Educating other professionals about the needs of people with HNC and the role of SLPs in diagnosing and managing associated impairments.
• Conducting a comprehensive, culturally and linguistically appropriate assessment of speech, language, resonance, voice, cognition, and/or feeding/swallowing deficits associated with HNC as well as diagnosing these deficits as indicated.
• Referring to other professionals to rule out related conditions and facilitate access to comprehensive services.
• Making decisions about the functional management of communication and swallowing in HNC.
• Developing treatment plans, providing treatment (including palliative care), documenting progress, and determining appropriate discharge criteria.
• Evaluating the impact of deficits on quality of life and directing treatments to improve these areas when possible.
• Counseling before, during, and after medical management (surgery, radiation therapy, systemic therapy) to address the needs of persons with HNC and their care partners specific to communication- and swallowing-related issues as well as providing education aimed at preventing further complications related to these conditions.
• Remaining informed of research in the area of HNC and helping advance the knowledge base related to the nature and treatment of these conditions.
• Advocating for individuals with HNC and their care partners at the local, state, and national levels as well as providing expert testimony when appropriate.
• Serving as an integral member of an interprofessional team working with individuals with HNC and their families/care partners (see ASHA’s resources on interprofessional education/interprofessional practice [IPE/IPP] and focusing care on individuals and their care partners).

As indicated in the Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so.

Roles and Responsibilities of the Audiologist

Audiologists play a central role in the assessment, diagnosis, and rehabilitation of hearing and vestibular deficits in individuals with HNC. See ASHA’s Scope of Practice in Audiology (ASHA, 2018).

Appropriate roles for audiologists include the following:

• Educating other professionals about the needs of adults with hearing and vestibular deficits pre- and post-medical/surgical management of HNC and the role of audiologists in diagnosing and managing these deficits.
• Screening for and early detection of hearing loss, tinnitus, or vestibular disturbance due to ototoxicity.
• Conducting a comprehensive—and culturally and linguistically sensitive—assessment using behavioral, electroacoustic, and/or electrophysiological methods to evaluate hearing, auditory function, vestibular and balance function, and related systems.
• Determining candidacy for amplification, assistive listening technology, and vestibular rehabilitation.
• Developing and implementing an audiologic and/or vestibular rehabilitation management plan, including maintenance of appropriate data and documentation.
• Counseling the individual with HNC and their care partners regarding the psychosocial aspects of hearing loss and other auditory processing dysfunction, modes of communication, and processes to enhance communication competence.
• Performing neurophysiologic intraoperative monitoring (if trained/certified to do so) to help surgeons minimize or avoid injury to neural structures that are at risk due to the pathology and the proximity of neural structures to the surgical field (see ASHA’s resource on neurophysiologic intraoperative monitoring).
• Advocating for the communication needs of all individuals, including advocating for the rights to and funding of services for those with hearing loss, auditory, and/or vestibular disorders as well as providing expert testimony when appropriate.
• Serving as an integral member of an interprofessional team working with individuals with HNC and their families/care partners (see ASHA’s resources on interprofessional education/interprofessional practice [IPE/IPP] and focusing care on individuals and their care partners).

As indicated in the Code of Ethics (ASHA, 2023), audiologists who serve this population should be specifically educated and appropriately trained to do so.

Interprofessional Collaboration

Audiologists and SLPs collaborate with many other disciplines in caring for individuals with HNC. Referral to, and collaboration with, members of the oncology care team is important for ensuring quality service for individuals—particularly during the assessment process and treatment planning. A clear understanding of functional effects related to a particular treatment approach is critical as they can impact an individual’s choice of treatment modality and compliance with interventions.

Some medical centers have interprofessional practice HNC teams that follow facility-specific clinical HNC pathways (Brill, 2019; Messing et al., 2019). Team members may include, but are not limited to, surgeons, oncologists (e.g., medical, radiation), pathologists, dietitians, social workers, nurses, psychologists/psychiatrists, dentists/prosthodontists, and physical therapists. Collaboration focuses on using information from a variety of professionals to affect functional outcomes that benefit the patient’s communication, swallowing, and quality of life.

See ASHA’s resources on collaboration and teaming, interprofessional education/interprofessional practice (IPE/IPP), and Interprofessional Practice in Action: Head & Neck Cancer Center.

Assessment of communication and swallowing function in HNC requires a multidisciplinary approach (see the Interprofessional Collaboration section). Audiologists and SLPs do not diagnose HNC. The diagnosis is made by the physician based on

• physical examination;
• laboratory tests;
• pathology reports;
• instrumental examinations such as endoscopy or videofluoroscopy;
• imaging such as computed tomography, positron emission tomography, and magnetic resonance imaging; and
• histopathology studies such as biopsy.

Audiologists and SLPs are valuable members of the post-cancer surveillance team. They should discuss any new or concerning findings posttreatment with HNC physicians.

Audiologists and SLPs consider focusing care on individuals and their care partners tenets and social determinants of health when providing skilled services and engage the patient in shared decision making (Jovanovic et al., 2022; Nallani et al., 2022).

Screening

Screening identifies the need for further assessment rather than providing a detailed description of the severity and characteristics of sequelae associated with HNC.

Audiologic screening includes hearing screening and otoscopic inspection, which should occur prior to screening for other deficits (e.g., cognition) if possible. If the individual wears hearing aids, the hearing aids should be inspected by an audiologist to ensure that they are in working order, and they should be worn by the individual during screening. Hearing screening is within the scope of practice for speech-language pathology.

If the individual fails the hearing screening or if hearing loss is suspected, a referral for a full audiologic evaluation is necessary in a timely manner. In addition to hearing screening, audiologists may also screen for vestibular deficits as indicated. Even if a patient passes a screening, a schedule should be established to rescreen as needed to monitor the presence of late-onset hearing and balance disturbances that may occur as a result of cancer treatment. See the Assessment section of ASHA’s Practice Portal page on Hearing Loss in Adults.

Speech-language pathology screening includes screening for functional changes (i.e., in communication, voice, and swallowing) that might signal HNC. SLPs make referrals as needed and complete a comprehensive assessment as warranted.

SLPs also screen for deficits following treatment for HNC, including

• changes secondary to surgery (e.g., speech deficits, changes in swallowing function, changes in voice that affect the ability to communicate effectively),
• swallowing deficits and cognitive-communication deficits following systemic therapy and/or radiation therapy, and
• new-onset changes following a period of stability post cancer treatment.

Comprehensive Assessment

Although audiologists and SLPs do not diagnose HNC, they need a clear understanding of the following to guide appropriate assessment:

• medical assessments and procedures
• physical conditions
• the course of medical/surgical/rehabilitative treatment recovery
• the structural and functional impacts of cancer

Consistent with the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2023; World Health Organization, 2001), a comprehensive assessment is conducted to identify and describe

• impairments in body structure and function, including underlying strengths and weaknesses in communication, swallowing, hearing, and balance;
• comorbid deficits or health conditions, such as metastatic tumors;
• limitations in activity and participation, including functional communication and interpersonal interactions;
• contextual (environmental and personal) factors that serve as barriers to or facilitators of successful communication and life participation; and
• the impact of communication, swallowing, and cognitive impairments on quality of life—that is, determining functional limitations relative to the individual’s premorbid social roles and abilities and the impact on their community.

See ASHA’s resource on the International Classification of Functioning, Disability, and Health (ICF) for examples of handouts featuring assessment data consistent with the ICF framework.

Assessment is conducted in the language(s) used by the person being assessed, with sensitivity to cultural and linguistic variables. Accommodations and modifications can be made to testing procedures. Documentation should include descriptions of these accommodations and modifications, and scores from standardized tests should be interpreted and reported with caution. See ASHA’s Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology; Collaborating With Interpreters, Transliterators, and Translators; and Cultural Responsiveness.

The focus of comprehensive assessment varies depending on the timing of assessment.

Pretreatment assessment occurs between diagnosis and onset of cancer treatment and may involve

• obtaining a baseline of communication and/or swallowing skills (e.g., via instrumental assessment) for treatment planning and posttreatment comparison and determining current and future functional needs (e.g., for returning to work);
• recording the individual’s voice for possible later use in speech-generating devices;
• providing education and counseling regarding anticipated changes in communication (including hearing) and swallowing as well as therapy needs;
• obtaining a baseline audiologic assessment prior to chemotherapy or radiation to monitor for possible hearing changes related to ototoxicity;
• conducting pre-treatment vestibular assessment; and
• identifying patient goals and quality-of-life outcomes (e.g., patient’s goals for nutritional intake).

Assessment during and post cancer treatment may involve

• obtaining a detailed description of the individual’s current function and needs, based on the surgical resection and/or chemotherapy or radiotherapy treatment;
• evaluating swallowing function;
• assessing all appropriate communication modalities and systems, which may include trials of esophageal speech or use of an electrolarynx, a speaking valve in individuals with a tracheostomy, and/or augmentative and alternative communication (AAC) systems;
• conducting training in the care and use of a tracheoesophageal voice prosthesis;
• reassessing hearing and vestibular function; and
• administering HNC-specific patient-reported outcome measures.

Ongoing, periodic assessment is often needed following initial audiologic and speech-language pathology assessments to monitor changes in function (e.g., radiation-associated dysphagia, cognitive changes secondary to systemic therapy, hearing loss).

The comprehensive assessment of communication and swallowing abilities typically includes the following components.

Case History

• Medical history, including exposure to risk factors, cancer type, tumor staging, disease status, and surgeries and other treatments
• Medical plan of care—curative versus palliative
• Current comorbidities, medications, and side effects (e.g., pain, mucositis)
• Nutritional status
• Demographic information, including occupation and education
• Cultural and linguistic background (see ASHA’s Practice Portal page on Cultural Responsiveness)
• Presence of support systems (e.g., significant other and/or other care partner)
• Individual’s self-report, including the following:
  • Voice changes or other communication difficulties
  • contexts of concern (e.g., social interactions, work activities)
  • swallowing difficulties
  • psychosocial impact of the condition on the individual and family/care partner (e.g., self-image, quality of life)
  • individual goals and preferences
  • sensory changes (e.g., hearing changes, dryness or pain in the throat)
  • functional communication success

Audiologic Assessment

Audiologic assessment typically includes the following components:

• Otoscopic examination
• Acoustic immittance testing
• Otoacoustic emissions (distortion product otoacoustic emissions [DPOAEs] are more sensitive than transient-evoked otoacoustic emissions [TEOAEs] for ototoxic monitoring)
• Pure-tone audiometry (air and bone conduction), including ultrahigh-frequency testing for air conduction (i.e., above 8000 Hz through 16,000–20,000 Hz)
• Speech recognition thresholds
• Word recognition
• Speech-in-noise testing
• Auditory brainstem response (if objective measure is warranted)
• Vestibular testing, which may include the following:
  • computerized dynamic visual acuity test
  • video head impulse test
  • videonystagmography or electronystagmography
  • rotation test
  • computerized dynamic posturography

Otoacoustic emissions testing is a tool to detect and monitor hearing loss due to ototoxicity. Additional pure-tone audiometric testing for ultrahigh frequencies can be added to the standard clinical audiogram to monitor for ototoxic effects (Dillard et al., 2022). Ongoing monitoring of patients treated with chemotherapy is recommended during treatment, if there are changes to treatment (i.e., changes to medication and/or dosage), and upon completion of treatment. Please see Audiological Monitoring of Patients Receiving Ototoxic Drugs [PDF] for further discussion of monitoring protocols.

A potential barrier for audiologic and vestibular monitoring during and after treatment could be the patient feeling unwell. The patient’s overall physical and mental status as a result of treatment (e.g., malaise, fatigue) can create a potential barrier for audiologic and vestibular monitoring both during and after treatment. Tests such as vestibular assessments may be deemed to be too physically taxing for certain patients. It is up to the discretion of the audiologist and the professional medical team to determine if modifications to the monitoring protocol are necessary when a patient is unable to complete entire assessments.

For details, see the Assessment sections of ASHA’s Practice Portal pages on Hearing Loss in Adults, Balance System Disorders, and Tinnitus and Hyperacusis.

Speech-Language Pathology Assessment

Results of a comprehensive speech-language pathology assessment are critical to many members of the interprofessional practice team to optimize functional outcomes. For example, information about sensorimotor skills, oral structures and functions, articulation, vocal resonance, intelligibility, and cognition can assist with decisions about surgical/reconstructive approaches; alaryngeal speech candidacy; and fabrication of palatal augmentation prostheses, obturators, or lifts. Such information can also alert the team to potential signs of a recurrent disease, which warrants further medical evaluation.

• Sensory and motor skills—relevant for determining capacity for different communication methods (e.g., tracheoesophageal voice prosthesis, esophageal speech, electrolarynx, gesture, writing, AAC), if needed
• Oral-peripheral examination, including the following:
  • structural integrity, including oral mucosa and dentition
  • sensation and functional integrity, including strength, speed, and range of motion of oral musculature and jaw as well as signs of trismus (Chee et al., 2021; Lazarus, Husaini, Jacobson, et al., 2014)
  • cranial nerve assessment
  • visible and/or tactile inspection for ulcerations, leukoplakia, and masses
  • symmetry and movement of structures of the face, oral cavity, head, neck, and respiratory system while at rest and while speaking and swallowing
  • signs of lymphedema (Smith, 2019)
  • chemosensory changes (e.g., taste and smell)
• Assessment for communication after total laryngectomy, if applicable
• Assessment for AAC (see the Assessment section of ASHA’s Practice Portal page on Augmentative and Alternative Communication)

Articulation and Speech Intelligibility

• Assess articulation and speech intelligibility at different levels (e.g., word, sentence, and conversational).
• Assess precision and rate via formal and informal/perceptual measures.
• Determine the influence of stress and/or fatigue on speech production (e.g., influence of physiologic and contextual factors).

Voice and Resonance

Voice assessment includes examination of perceptual, vibratory, acoustic, and aerodynamic characteristics and their impact on the individual’s quality of life.

• Auditory-perceptual assessment, which includes assessment of the following:
  • voice quality—roughness, breathiness, strain, pitch, and loudness
  • phonation—voice onset/offset and the ability to sustain voice during speech
  • resonance—normal, hyponasal, hypernasal, or cul-de-sac
• Instrumental assessment, including the following:
  • laryngeal imaging—measures of structure and gross function (using videoendoscopy), vocal fold vibration during phonation (using videostroboscopy), the presence of structural abnormalities/changes, and paralysis
  • acoustic assessment—objective measures of vocal function related to vocal loudness, pitch, and quality
  • aerodynamic assessment—measures of glottal aerodynamic parameters required for phonation
  • resonance assessment—objective measures of airflow/pressure and nasality using a nasometer

See the Assessment sections of ASHA’s Practice Portal pages on Voice Disorders and Resonance Disorders.

Cognitive Communication

• Evaluate memory, attention, problem-solving, and executive skills in the context of functional communication and cancer treatment (e.g., chemotherapy) timelines, as appropriate.
• Determine cognitive abilities for candidacy of treatment approaches and device use (e.g., palatal or voice protheses).

See the Assessment sections of ASHA’s Practice Portal pages on Traumatic Brain Injury in Adults, Dementia, and Right Hemisphere Disorder and ASHA’s resource on evaluating and treating communication and cognitive disorders.

Respiration

• Respiratory patterns (abdominal, thoracic, clavicular)
• Coordination of respiration with phonation (breath-holding patterns, habitual use of residual air, length of breath groups)
• Presence of tracheostomy tube, type of tube, size of tube, presence of cuff, and any supplemental oxygen requirements (see ASHA’s Practice Portal page on Tracheostomy and Ventilator Dependence)
• Patency of stoma and humidification needs following laryngectomy

Swallowing

Dysphagia presentation and assessment in individuals with HNC varies based on tumor site and cancer treatment protocols. For example, individuals who undergo partial or total glossectomy may exhibit significant oropharyngeal dysphagia and aspiration risk. Those who have palatal resections may show signs of nasal regurgitation. Total laryngectomy may prevent aspiration by separating the airway from the digestive tract. However, individuals may still be at risk for post-laryngectomy dysphagia due to fistulae, stenosis, stricture, prosthesis leakage, pharyngoesophageal spasm, or base-of-tongue propulsion deficits. Individuals who receive radiation often present with fibrosis-related late effect dysphagia (Arenaz Búa et al., 2018; Chen et al., 2019; Hasegawa et al., 2021; King et al., 2016; Terlingen et al., 2018).

Swallowing assessment includes a clinical interview and exam, physiologic findings from instrumental assessments, and patient-reported outcome measures.

• Consider swallowing efficiency and tolerance of the current diet level and/or noncompliance with the recommended diet level.
• Conduct an instrumental assessment to obtain a baseline, identify the risk or cause of oropharyngeal dysphagia, evaluate changes in function over time, and determine what interventions are most applicable or contraindicated (Barbon et al., 2020; Curtis et al., 2022; Hutcheson et al., 2022; Starmer et al., 2011, 2021). Instrumental assessment includes the following:
  • Flexible endoscopic evaluation of swallowing (FEES), which
    • offers optimal visualization of the tumor, reconstructed anatomy, and effects on swallowing;
    • allows for an assessment of palatal function in patients with palatal resections; and
    • helps assess secretion management
  • Videofluoroscopic swallowing study (VFSS) for individuals with HNC, which
    • helps assess oral phase deficits and movement of structures;
    • provides quantitative information about the pharyngeal phase, including pathophysiological deficits and related timing measures, the presence of aspiration and extent of residue, and the use of compensatory strategies to eliminate aspiration and improve bolus clearance/reduce residue;
    • provides insight into the esophageal aspects of swallowing; and
    • may be more appropriate for patients who cannot tolerate the endoscope (e.g., due to the type/location of cancer)

SLPs may collaborate with dietitians and physicians about nutritional status, particularly regarding alternative feeding. SLPs provide these professionals with information about the benefits and risks of oral intake specific to the individual patient. This ensures that consideration is given to both nutritional goals and functional swallowing goals during and after treatment.

See the Assessment section of ASHA’s Practice Portal page on Adult Dysphagia for more details.

The goal of audiology and speech-language pathology treatment is to minimize the side effects of cancer treatment and improve functional status following medical/surgical interventions. Several individual factors influence the nature, scope, initiation, and duration of audiology and speech-language pathology management, including

• the time of patient presentation (pre-surgery/radiation, immediately postoperative, outpatient therapy, long-term maintenance/follow-up);
• structures affected (e.g., larynx only vs. tongue only);
• the type and extent of medical/surgical treatment (e.g., timing/dosage of chemoradiation);
• the need for reconstruction (e.g., of the oral cavity or jaw) and functional outcome of reconstruction after tumor resection;
• the impact of pain, mucositis, xerostomia, nutritional compromise, cognitive status, and respiratory status;
• patient and family/care partner desired goals and outcomes; and/or
• access to care.

Audiology and speech-language pathology management may occur prior to, during, and/or after cancer treatment. Management prior to cancer treatment (e.g., preventive, proactive, or pre-habilitative) includes

• education regarding
  • the course and side effects of medical treatment (e.g., xerostomia; trismus; changes in taste, smell, and hearing),
  • the immediate outcomes of surgical treatment, and
  • posttreatment communication/swallowing expectations and options.
• training in swallowing exercises and providing alternative communication systems prior to undergoing surgery, systemic therapy, and/or radiation to avoid or minimize impairment.

Management during cancer treatment (e.g., consultative or direct depending on tolerance) includes

• suggesting diet modifications to compensate for the side effects of treatment;
• training the patient in compensatory strategies (i.e., for communication, swallowing, or voice deficits); and
• introducing alaryngeal speech options and/or augmentative and alternative communication (AAC), when applicable.

Management after cancer treatment (e.g., direct rehabilitative therapy to address current deficits) includes

• working with the patient to trial oral prosthetics or develop alaryngeal speech;
• educating on the long-term effects of medical intervention as they relate to communication and swallowing, including hearing loss, appetite loss, and taste changes; and
• training in speech, voice, and swallowing exercises to mitigate the long-term effects of surgical/medical intervention (e.g., radiation fibrosis).

Consistent with the World Health Organization (2001) framework, intervention is designed to

• capitalize on strengths and address weaknesses related to underlying structures and functions that affect communication and swallowing;
• facilitate the individual’s activities and participation by helping the person acquire new skills and strategies; and
• modify contextual factors that serve as barriers to and enhance facilitators of successful communication and participation, including the development and use of appropriate accommodations.

Decisions about goals and treatment options are made in partnership with clients, families/care partners, and other professionals involved in the person’s care. A successful intervention often requires collaboration between audiologists, SLPs, and professionals from medical and surgical specialties as well as rehabilitation specialties and others who provide support to individuals with HNC. Please see the Interprofessional Collaboration section for further information.

Audiologists and SLPs consider factors such as the individual’s age and educational level, social history and present social context, vocational history and current vocational status, and cultural and linguistic background. Treatment should be conducted in the language(s) used by the person with HNC either by a bilingual clinician or via collaboration with interpreters, when necessary (see ASHA’s Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology and Collaborating With Interpreters, Transliterators, and Translators).

It is also important to be sensitive to cultural influences and family/care partner expectations regarding treatment decision making, the determination of who makes these decisions, and the value of and adherence to recommended intervention (see ASHA’s Practice Portal page on Cultural Responsiveness).

Counseling

A large part of HNC management includes counseling. Clinicians typically work directly with the individual who has HNC, but they also play a critical role in counseling their family/care partners and other significant persons about the nature of the disorder and the course of treatment. When psychosocial or emotional challenges go beyond the clinician’s scope of practice and competence (e.g., concerns about depression), referral to qualified professionals as primary providers of mental health services (e.g., psychologists and psychiatrists) is critical (Eadie et al., 2018; Henry et al., 2022). The focus of counseling may differ depending on the timing in the course of disease progression and management.

In the pretreatment phase, counseling may

• establish a baseline status and relationship with the patient/care partners;
• introduce the role of the audiologist and SLP in management;
• provide an overview of anatomic, communication, swallowing, cognitive, breathing, vestibular, and hearing changes associated with medical and surgical management;
• discuss the timeline of rehabilitation and possible interventions;
• discuss the role of care partners and support systems; and
• identify goals and expectations of posttreatment communication and oral intake (e.g., Is organ preservation the aim? Is eating more important to the patient than speaking or vice versa? Is the target cure or palliative care?).

In the posttreatment phase, counseling may focus on

• adjustment to new communication and swallowing patterns,
• rehabilitative treatment needs and options,
• motivation for participation in treatment,
• prognosis, and
• connection to survivor and care partner support groups or other community resources.

Audiologic Management

Patients receiving treatment for HNC may experience decreased hearing ability and possible difficulty with balance and tinnitus. The timing of audiologic management is important, as patients often need time to heal and regain strength before they are ready for hearing services. Treatment can be provided in person or through telehealth as appropriate. Telehealth may offer unique opportunities for monitoring ototoxicity (Brungart et al., 2017).

The management of hearing difficulties, balance, and tinnitus secondary to HNC may include

• amplification (see ASHA’s Practice Portal page on Hearing Aids for Adults);
• balance therapy (see ASHA’s Practice Portal page on Balance System Disorders);
• cochlear implant (see ASHA’s information for the public on Cochlear Implants); and
• tinnitus management (see ASHA’s Practice Portal page on Tinnitus and Hyperacusis).

Management for patients treated with chemotherapy for HNC may focus on hearing loss identification and mitigation due to the likelihood of ototoxicity. Identification involves serial audiologic assessments for ototoxicity monitoring and to identify changes to hearing, tinnitus, and/or vestibular function in a timely manner. Ongoing periodic audiologic assessment allows audiologists to monitor posttreatment changes (e.g., ototoxicity) and communicate that with the medical team (Bass et al., 2013). Mitigation is intended to reduce the impact of hearing loss on communication when ototoxicity cannot be avoided (Dillard et al., 2022). Treatment (e.g., amplification selection and fitting and/or aural rehabilitation) can occur sooner if hearing loss or tinnitus is identified early in patients with HNC.

Procedures for ototoxicity treatment vary as there is no agreed-upon consensus related to management guidelines (Konrad-Martin et al., 2018). Monitoring procedures may also vary based on the treatment plan for the patient (e.g., medication types, dosage). For further information on ototoxicity, please see ASHA’s Evidence Maps.

Speech-Language Pathology Management

Intervention approaches are based on thorough examination of functional deficits and individual needs/tolerance, with input from the patient, care partners, and interprofessional team. SLPs may need clearance from the surgical/medical team before initiating specific treatments.

Articulation and Speech Intelligibility

Surgical resections and reconstructions that affect oral cavity anatomy and physiology often impact speech production and intelligibility. Articulatory compensations may include

• exaggeration of the remaining labial, lingual, and jaw movements (Hagedorn et al., 2022);
• a decreased rate of speech;
• use of auditory, visual, or tactile feedback; and
• use of adaptive equipment (see the Intraoral/Palatal Prostheses section).

Treatment may also involve targeted exercise training before, during, or after surgical and/or medical interventions. Exercise-based (resistance) training is targeted at improving strength and range of motion of oral structures to improve articulatory precision, combat the effects of trismus, and improve patient-related quality of life (Lazarus et al., 2013; Lazarus, Husaini, Hu, et al., 2014). Examples include the following:

• tongue strengthening (e.g., active resistance in anterior and lateral directions against an external device/object) and range-of-motion exercises for articulatory precision
• exercises targeting jaw opening for speech production (e.g., trismus and/or lymphedema protocols that include passive and active jaw stretching; Chee et al., 2021; Karlsson et al., 2021; McMillan et al., 2022; Smith, 2019)

SLPs who treat trismus need to be aware of patient risks for osteoradionecrosis from radiation treatment, avoid any interventions that are contraindicated, review medical reports to determine risk of osteoradionecrosis, and contact the patient’s physician when concerns arise.

Voice and Resonance

Multimodal and multidisciplinary treatment for voice and resonance disorders is often effective for individuals with HNC. SLPs may frequently collaborate with otolaryngologists and maxillofacial prosthodontists for augmentation procedures to address glottic and palatal insufficiencies (e.g., vocal cord injections, palatal prostheses).

Voice therapy may be indicated for individuals with HNC following surgical excision of laryngeal tumors or radiation treatments that result in changes to the glottis (e.g., phonatory function), vocal fatigue, and/or muscle tension. Surgery to the tongue and oral cavity may also affect vocal tract resonance and vocal quality. Treatment may include

• diaphragmatic breathing and coordination training;
• expiratory muscle strength training (EMST);
• manual techniques targeted to the neck, including laryngeal manipulation and lymphedema therapy (Smith, 2019);
• training in strategies to minimize vocal fatigue;
• techniques to increase vocal cord adduction or address laryngeal hyperadduction (e.g., resonant voice therapy); and
• vocal exercises aimed at loudness and pitch.

For individuals who have a tracheostomy, treatment may include

• increasing tolerance of cuff deflation;
• manual occlusion; and
• donning/doffing and increasing tolerance of speaking valve (e.g., Passy Muir® valve).

For individuals with resonance disorders, treatment may include

• oral resonance and resonant voice therapy,
• trismus therapy to improve oral tract opening and resonance, and
• palatal prosthesis use.

See ASHA’s Practice Portal pages on Voice Disorders, Tracheostomy and Ventilator Dependence, and Resonance Disorders for further information.

Communication After Total Laryngectomy: Alaryngeal Speech and Voice Restoration

Communication rehabilitation following surgical removal of the larynx targets the production of speech and voice using a sound source other than the larynx and most often includes use of

• an electrolarynx,
• esophageal speech, and/or
• tracheoesophageal speech.

Buccal speech and pharyngeal speech are two other types of alaryngeal speech. Their use as a primary method of communication following laryngectomy is rare in the United States, but they are still used in certain cultures and other parts of the world.

See ASHA’s resource, Communication After Total Laryngectomy, for more detailed information on candidacy considerations and treatment approaches. Also, see ASHA’s video resource, Alaryngeal Speech Options After Total Laryngectomy (Messing, 2016).

AAC

Individuals with HNC may use both low- and high-tech AAC systems. This may occur on a temporary basis in the acute postsurgical phase or as a long-term option for individuals who have had extensive surgical resection (e.g., laryngectomy or glossectomy) and choose or require an AAC system as their primary mode of communication or in conjunction with alaryngeal speech.

See ASHA’s Practice Portal page on Augmentative and Alternative Communication for further discussion of key issues.

Cognitive Communication

Cognitive changes can occur in individuals with HNC following chemotherapy or radiation, particularly for nasopharyngeal cancer due to the treatment field (Gan et al., 2011; Voon et al., 2021; Zer et al., 2018). For more information about treating cognitive-communication problems, in the areas of attention, memory, executive function, and language processing, see ASHA’s resource on evaluating and treating communication and cognitive disorders and ASHA’s Practice Portal pages on Traumatic Brain Injury in Adults, Dementia, and Right Hemisphere Disorder.

Respiration

Respiration treatment, often in conjunction with a respiratory therapist, may be part of the treatment plan given the presence of tracheostomy, stoma, and/or reduced breath support in individuals with HNC. Speech-language pathology interventions may include

• EMST and incentive spirometry to improve cough function and airway protection when swallowing (see, e.g., Hutcheson et al., 2018);
• training initiation of inhalation and exhalation in coordination with swallow to improve laryngeal vestibule closure;
• education and training in stoma care and humidification systems (e.g., laryngectomy tubes and covers, stoma buttons, heat and moisture exchangers [HME]); and
• addressing communication and/or swallowing in the presence of a tracheostomy, voice prosthesis, or hands-free speaking valve (see Ward et al., 2023).

Swallowing

Multiple factors contribute to dysphagia in HNC, including tumor location, type of cancer treatments, and related comorbidities. Due to these variable factors, individualized clinical management is critical (Starmer & Edwards, 2019). For a general comprehensive discussion of the treatment of swallowing disorders, refer to ASHA’s Practice Portal page on Adult Dysphagia. Specific considerations for HNC are discussed below and take into account the timing and nature of speech-language pathology treatment (e.g., proactive or reactive) related to cancer treatment.

Swallowing Exercises

Prior to cancer treatment, exercises are often part of preventative, or prophylactic, dysphagia treatment for patients undergoing radiation therapy. These exercises may reduce impairment, maintain function, and assist in recovery (Govender et al., 2020; Messing et al., 2017). There is no singular established best practice for preventative dysphagia treatment (Kraaijenga et al., 2014; Loewen et al., 2021; Yang et al., 2021). Prophylactic speech-language pathology treatment usually focuses on maintaining oropharyngeal and laryngeal muscle strength and range of motion to maximize swallowing function, efficiency, and endurance for oral intake during and after cancer treatment. Examples include endurance-based oropharyngeal exercises with and without resistance and/or biofeedback, range-of-motion exercises with and without resistance, and respiratory training (e.g., lingual isometrics, laryngeal elevation, Shaker, EMST). Clinicians provide education and counseling regarding the importance of these exercises to increase patient adherence to exercise routines and minimize the need for NPO (“nothing by mouth”) status and feeding tubes long-term (Shinn et al., 2013).

During cancer treatment, exercises may be challenging, particularly during chemoradiation therapy due to xerostomia, lymphedema, and pain associated with eating and swallowing. Clinicians work with patients to complete swallowing exercises as appropriate and maintain maximum oral intake while being mindful of patient comfort and aspiration risk (Hutcheson et al., 2013, 2020).

Following cancer treatment, exercises become more reactive or rehabilitative in nature to restore strength, range of motion, and swallowing skills impacted by surgical/medical interventions. Clinicians often address radiation-associated dysphagia using progressively intense resistive exercises, biofeedback, or systematic dysphagia therapy programs (e.g., Carnaby-Mann & Crary, 2010; Hutcheson et al., 2020). They also provide swallowing intervention related to soft tissue fibrosis, lymphedema, neuropathies, and trismus in conjunction with medical/surgical therapies such as esophageal dilation, fistula repair, vocal fold medialization, and intraoral prosthetics (Chee et al., 2021; Hutcheson et al., 2018; Malandraki & Hutcheson, 2018; Smith, 2019).

Compensatory Strategies and Postural Modifications

At any time in an individual’s cancer treatment protocol, SLPs may assist in developing compensatory strategies such as double swallow, alternating liquids and solids, and taking smaller sips and/or bites. SLPs may also make recommendations for bolus delivery methods (e.g., modified spoons or oral syringe feeding). See the works of Halczy-Kowalik et al. (2015) and Knott and Lewin (2013) for considerations related to total glossectomy.

Postural modifications help redirect movement of the bolus in the oral cavity and pharynx and help modify pharyngeal dimensions to reduce risk of aspiration and/or improve the efficiency of the swallow by facilitating bolus clearance. Examples of postural modifications include head tilt, head rotation, head back, side lying, and chin tuck.

Swallow Maneuvers

Swallow maneuvers are specific strategies that clinicians use to change the timing or strength of swallowing. Examples of swallow maneuvers often used with HNC include the supraglottic and super-supraglottic swallow, effortful swallow, and the Mendelsohn maneuver. Biofeedback (e.g., surface neuromuscular electromyography [sEMG]) may be used with swallow maneuvers to provide visual information during the swallowing process to ensure proper completion of maneuvers.

Diet Modifications

SLP collaboration with a dietitian is central to diet modification, particularly in HNC when nutritional status is a key part of healing from cancer treatments. Diet modifications include changes to the viscosity and texture of the food to decrease risk of aspiration, to facilitate efficient oral intake and bolus transfer, and/or to maximize oral intake volume. Examples include changing the thickness of liquids or softening, chopping, or pureeing solid foods (International Dysphagia Diet Standardisation Initiative [IDDSI]). Modifications to taste or temperature may also be used to change the sensory input that the bolus provides.

SLPs recommend the least restrictive oral diet to avoid risk (e.g., aspiration) and minimize painful eating or swallowing that may result from chemoradiation. However, SLPs also consider patient preference and provide education regarding risks if the patient chooses not to follow recommendations. SLPs may also work toward increasing complexity/variety of foods as dysphagia resolves.

Intraoral/Palatal Prostheses

Individuals may require intraoral prostheses following oral cavity resections that include the hard and soft palate, jaw, or tongue. SLPs and maxillofacial prosthodontists collaborate to fabricate prostheses that are tailored to the patient’s individual communication and/or swallowing needs.

Prostheses provide physical support for individuals with structural deficits to normalize pressure and movements in the intraoral cavity. Palatal prostheses may be used to improve speech, resonance, and/or swallowing following HNC surgery. SLPs work with maxillofacial prosthodontists to determine contour of augmentation, which is often adjusted over time based upon ongoing evaluation of speech, voice, and swallowing function. SLPs also provide speech and swallow retraining after prosthesis fitting.

Intraoral prostheses commonly used in individuals with HNC include the following:

• Palatal lift—aids in velopharyngeal closure and improved resonance by lifting the structurally intact but neurologically impaired soft palate.
• Palatal obturator—provides a barrier between the oral and nasal cavities to compensate for tissue loss in those who undergo hard palate resection. The intent is to prevent nasal air/bolus passage and to improve intraoral pressure.
• Palatal augmentation prosthesis—lowers the palatal vault in those who have had oral cancer resection such as hemiglossectomy and/or total glossectomy with reconstruction for improved articulatory contact (Kumar et al., 2019).

“False” dentition may be added to intraoral prostheses to assist in swallowing rehabilitation for patients who have lost natural dentition during surgery or in preparation for radiation.

Survivorship, Palliative Care, and End-of-Life Issues in HNC

Survivorship in HNC refers to individuals who are living with HNC, those in remission, and those who are currently disease-free. The proportion of individuals living longer after an HNC diagnosis is greater than in the past, partially due to better prognosis and outcomes with current HNC treatments. It is also likely due to an increase in the diagnosis of human papillomavirus–related oropharyngeal cancers, which have a higher survival rate and usually affect younger people (Blair, 2018; Nguyen & Ringash, 2018). These survivors face the unique challenge of dealing with the side effects of treatment (i.e., radiation, systemic therapy, and surgery) for longer periods. Survivorship management focuses on surveillance and screening for recurrences or new cancers, assessment and intervention for long-term and late effects, health promotion, and interprofessional care coordination (Ebersole et al., 2021; Jamal et al., 2017). For audiologists and SLPs, this means maximizing communication and swallowing function for as long as possible. Please see the American Cancer Society Head and Neck Cancer Survivorship Care Guideline for further information.

Palliative care is a team-based approach that focuses on symptom management and improving the quality of life for individuals with advanced disease processes and their families/care partners. SLPs are integral members of the palliative care team (Kagan et al., 2020). They focus on meeting the individual’s complex and evolving communication and swallowing needs to maintain optimal quality of life. The pattern of functional decline in individuals at the end of life varies, depending on a person’s diagnosis. SLPs need to understand the process of dying to understand the emotional and psychological issues faced by their patients and the patients’ family members and care partners. The wishes of the patient and family/care partner are paramount when considering end-of-life issues, and the role of the SLP extends only as far as the patient or family/care partner wishes. Patients and care partners may not agree with clinical recommendations and may feel that these recommendations do not provide the best quality of life for their loved one.

Views of the natural aging process and acceptance of disability vary by culture. Cultural views and preferences may not be consistent with medical approaches typically used in the U.S. health care system, but such views must be recognized and respected. The clinician approaches clinical interactions with cultural humility and demonstrates sensitivity to social and cultural influences when sharing potential treatment recommendations and outcomes. See ASHA’s Practice Portal page on Cultural Responsiveness.

See ASHA’s Practice Portal resource on Palliative and End-of-Life Care. See also ASHA’s Practice Portal page on Adult Dysphagia for a discussion of treatment considerations related to swallowing and end-of-life issues.

Service Delivery

See the Service Delivery section of the Head and Neck Cancer Evidence Map for pertinent scientific evidence, expert opinion, and client/care partner perspective.

In addition to determining the type of treatment that is optimal for individuals with HNC, audiologists and SLPs consider other service delivery variables—including format, provider, dosage, timing, and setting—that may affect treatment outcomes.

• Format—whether a person is seen for treatment one-on-one (i.e., individual) or as part of a group. The format of service delivery for this population can include in-person and telepractice models. The availability of telepractice is an important consideration in order to ensure client access to audiologists and SLPs trained and qualified to work with the HNC population. Reduced accessibility to audiologists and SLPs with expertise in HNC may provide a barrier to assessment and treatment for some patients, especially in rural or underserved areas. Please see ASHA’s Practice Portal page on Telepractice for further information.
• Provider—the person providing treatment (e.g., audiologist, SLP, trained volunteer, care partner).
• Dosage—the frequency, intensity, and duration of service.
• Timing—the timing of intervention relative to the diagnosis. This includes timing of behavioral intervention in relation to surgical/physical management.
• Setting—the location of treatment (e.g., inpatient, outpatient, home, community-based, telepractice).

ASHA Resources

• Alaryngeal Speech Options After Laryngectomy [ASHA Case Study Video]
• ASHA Consumer Pages
  • Laryngeal Cancer
  • Oral Cancer
  • Swallowing Problems From Head and Neck Cancer Treatment
• Aerosol Generating Procedures
• Audiologic Management of Individuals Receiving Cochleotoxic Drug Therapy
• Audiological Monitoring of Patients Receiving Ototoxic Drugs
• Possible Causes of Hypernasality and/or Nasal Emission
• Communication After Total Laryngectomy
• Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V)
• Evaluating and Treating Communication and Cognitive Disorders
• Flexible Endoscopic Evaluation of Swallowing (FEES)
• Focusing Care on Individuals and Their Care Partners
• International Classification of Functioning, Disability, and Health (ICF)
• Interprofessional Education/Interprofessional Practice [IPE/IPP] 
• Interprofessional Practice in Action: Head & Neck Cancer Center
• Neurophysiologic Intraoperative Monitoring
• Palliative and End-of-Life Care 
• Social Determinants of Health
• The Value of Prophylactic Speech-Language Pathology (SLP) Services in the Treatment of Head and Neck Cancer [PDF]
• Videofluoroscopic Swallowing Study (VFSS)
• What's New in Ototoxicity Management

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

• Alaryngeal Speech Options After Laryngectomy [Video by B. Messing]
• American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS)
• American Audiology Board of Intraoperative Monitoring
• American Cancer Society
• American Cancer Society Head and Neck Cancer Survivorship Care Guideline
• American Head & Neck Society (AHNS)
• Applying U.S. National Guidelines for Ototoxicity Monitoring in Adult Patients
• Cancer Information and Support Network
• Changes in the 8^th Edition of the American Joint Committee on Cancer (AJCC) Staging of Head and Neck Cancer: Rationale and Implications
• First Steps: A Guide for New Laryngectomees [PDF]
• Head and Neck Cancer Alliance
• Head and Neck Cancer Survivorship Consensus Statement From the American Head and Neck Society [PDF]
• International Association of Laryngectomees
• International Federation of Head and Neck Oncologic Societies
• National Cancer Institute: Head and Neck Cancer—Patient Version
• National Cancer Institute: Head and Neck Cancers
• National Comprehensive Cancer Network: Guidelines for Patients (Head and Neck Cancers)
• Ototoxicity Monitoring Tests
• Precare: Head and Neck Perioperative Animated Patient Education Guides
• Support for People with Oral and Head and Neck Cancer (SPOHNC)
• The Laryngectomee Guide: Expanded Edition
• Vestibular Toxicity: Causes, Evaluation Protocols, Intervention, and Management
• WebWhispers: Throat Cancer and Laryngectomee Support Group

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Acknowledgments

Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Head and Neck Cancer page:

• Marilyn F. Dille, PhD, CCC-A
• Katharine Fernandez, AuD, PhD, CCC-A
• James H. Hall, Jr., MA, CCC-A
• Katrina M. Jensen, MA, CCC-SLP
• Ann T. Kearney, MA, CCC-SLP
• Jodi K. Knott, MS, CCC-SLP
• Cathy L. Lazarus, PhD, CCC-SLP
• Donna S. Lundy, PhD, CCC-SLP
• Tracy Mishler, AuD, CCC-A
• Casey Richardson, MA, CCC-SLP
• Heather M. Starmer, MA, CCC-SLP
• Paula A. Sullivan, MS, CCC-SLP
• Donna C. Tippett, MPH, MA, CCC-SLP

In addition, ASHA thanks the members of the ASHA-Special Interest Division 3: Working Group on Voice and Voice Disorders, whose work was foundational to the development of this content. Members of the working group were Julie Barkmeier (Chair), Glenn W. Bunting, Douglas M. Hicks, Michael P. Karnell, Stephen C. McFarlane, Robert E. Stone, Shelley Von Berg, and Thomas L. Watterson. Alex F. Johnson served as monitoring vice president. Amy Knapp and Diane R. Paul served as ex officio members.

ASHA seeks input from subject matter experts representing differing perspectives and backgrounds. At times a subject matter expert may request to have their name removed from our acknowledgment. We continue to appreciate their work.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Head and neck cancer [Practice portal]. https://www.asha.org/Practice-Portal/Clinical-Topics/Head-and-Neck-Cancer/