Preserving Your Voice and Ability to Swallow During Head and Neck Cancer Treatment

“We can evaluate the kinds of problems that patients are having, provide therapy to help overcome those challenges, and even help prevent some of the problems,” says Heather M. Starmer, PhD, a clinical professor in the department of otolaryngology, head and neck surgery, at Stanford University in Stanford, California, and the director of head and neck speech and swallowing rehabilitation at Stanford Cancer Center. “This is particularly true in the case of radiation therapy, as a lot of it is about being proactive rather than reactive,” she adds.

With better treatments and increased survival in head and neck cancers, there’s been a shift from simply trying to keep patients alive to helping them maintain key facets of their identity, such as their voice, says Dr. Starmer. “It’s about how they see themselves,” she says.

The Role of Speech-Language Pathologists and Swallow Therapists

“Speech pathologists can look at the big picture and provide interventions that are important to that person,” says Starmer.

But even though speech and swallow therapy and rehabilitation are increasingly being integrated into standard care practices, they’re still not offered to every patient. “The hard part is the patients who don’t have these therapies as part of the treatment,” says Dr. Clark. “Patients need to know that it’s okay to ask for it, and to advocate and be proactive about getting this care.”

Some people live in areas where SLPs may be in short supply or are located far away. While not fully integrated yet, telehealth may be a possibility for some of these patients, Clark notes.

Swallowing Exercises

• Effortful Swallow Gather all the saliva in your mouth onto the center of your tongue, and keep your lips tightly closed. Swallow while squeezing your throat as hard as you can, or pretend that you’re swallowing a whole grape.
• Isokinetic (Dynamic) Shaker Lie down on your back on a hard surface, without a pillow or head rest. Keep your shoulders flat and lift your chin toward your chest so that you can see your toes. Then lower your head to the starting position.
• Jaw Thrust Move your lower jaw forward as far as you can so that your lower teeth are in front of your upper teeth. If you’ve had a jaw replacement, use extra caution with this exercise to avoid stressing the jawbone.
• Lollipop Swallowing Place a sugarless lollipop in your mouth and lick it three times. Then with your lips firmly pressed together, swallow as hard as you can.
• Masako Maneuver Stick your tongue out of your mouth between your front teeth and very gently bite down. Then swallow while keeping your tongue in this position.
• Mendelsohn Maneuver Use your middle three fingers and place them on your Adam’s apple. Swallow once to practice, and feel your Adam’s apple move as you swallow. Swallow again, and when it gets to the highest position in the throat, squeeze your throat muscles and hold it as high for as long as your clinician has directed (or as long as you can if you can’t hold it for that long).
• Tongue Range of Motion Stick your tongue out as far as possible and hold it. Then pull it back into your mouth as far as you can. After that, move the tip of your tongue to one corner of your mouth and hold. Then switch to the opposite side and hold. Finally, open your mouth and place your tongue tip behind your top teeth and hold the stretch.
  

Nutritional Strategies to Help With Swallowing Difficulties

“Food may not taste the same, and it may feel like more of a job than anything,” says Clark.

Starmer and Clark offer the following nutritional strategies to help with dysphagia, as well as to optimize calories and protein.

• Puree or grind food to make it easier to swallow. “Smoothies and cream soups are favorites,” says Starmer. “Food that’s soft, moist, and slippery is easiest to swallow.”
• Add sauces to make food more liquid and swallowing easier.
• Avoid spicy and acidic foods as they can be irritating, especially if you have sores.
• Choose full-fat dairy — milk, sour cream, cheese — to consume more calories and fat. “That’s usually not what we tell people from a cardiovascular standpoint as we usually want to avoid saturated fat,” says Starmer. “But in head and neck cancer, the rule is whatever people will eat to get the calories and nutrition. Obviously, if there’s a high cardiac risk then other foods may work better.”
• Boost protein intake with high-protein foods or protein supplements and drinks (talk to your doctor before adding any supplements to your diet).
• Optimize calories and protein by adding nut butters, creams, medium-chain triglycerides (essential fatty acids that are sold as supplements that you can add to drinks or food), avocado, or tofu.
• Thicken liquids as needed to prevent aspiration (accidentally inhaling food, liquid, or stomach acid into your lungs); this can be done with cornstarch, baby cereal, potato flakes, gelatin, or commercial thickeners.

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• Work with a nutritionist to find foods you like to eat that are safe for you.

Preserving or Rebuilding Your Voice

However, there are measures you can take to preserve and restore your voice after undergoing treatment. These include:

• Work with an SLP. Speech therapists can assess your voice and provide individualized exercises, strategies, and techniques, depending on your specific needs. “One simple exercise is to take a cup of water and blow bubbles into the cup using a straw,” says Starmer. “Then hum into the straw, and glide the pitch of your voice from the lowest comfortable note to the highest. This stretches the vocal cords and doing it in water removes tension.”
• Give up smoking. Radiation therapy is more likely to be successful and the side effects more manageable if you don’t smoke during treatment.

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  If you smoke, try to stop prior to beginning treatment. If you need help quitting, organizations like the American Lung Association and the Centers for Disease Control and Prevention have resources.

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• Stay hydrated. “Hydration is critical for the whole body, and especially for the vocal cords,” says Clark. “We want to keep [the vocal cords] nice and lubricated. It minimizes the strain, especially when it has been compromised as with treatment.”
• Limit alcohol and caffeine. This includes coffee, tea, energy drinks, and caffeinated soft drinks, as both alcohol and caffeine are dehydrating.

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   “Alcohol and caffeinated sodas can also be irritating to your throat and vocal cords,” says Starmer.
• Rest your voice. “Avoid yelling or screaming, and also whispering which actually strains your voice,” says Starmer. “Better to use a soft voice and not talk at all when your voice is tired.”
• Use a humidifier. This is especially important at night when you sleep, if you have a dry mouth or thick saliva.

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  Alternatively, heat up plain water and inhale the steam for 5 to 10 minutes each day.

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• Use assistive devices if needed. Depending on your treatment, you may need assistive devices to help you communicate. These can be temporary or permanent. For example, if you had surgery to remove your larynx (voice box), an electronic larynx (electrolarynx) can help you speak. It’s a battery-operated device that produces sound, enabling you to create a voice.

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• Try text-to-speech technology. This technology converts typed or selected text into synthesized speech, and can operate on a range of tools, from dedicated tablets to smartphone apps.

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