methods of head and neck rehabilitation briefly

1. Rehabilitation in Head and
Neck cancer patients
Dr D.Ramu

2. • ”A set of measures that assist individuals, who experience or are likely
to experience disability, to achieve and maintain optimum functioning
in interaction with their environments" WHO Definition

3. PHYSIOLOGY OF SWALLOWING
• Oral preparatory phase
• Bolus is processed by mastication to an appropriate size, shape, and
consistency to pass through the pharynx and esophagus
• Largely voluntary
• Tongue - directing the bolus
• The anterior portion of the tongue lifts up to the hard palate and retracts
posteriorly forcing the bolus into the upper pharynx.
• Elevation of the posterior portion of the tongue by the mylohyoid muscles
elevates the soft palate, thereby sealing the nasopharynx and preventing
nasal regurgitation

4. • Pharyngeal phase
• Bolus is advanced through the pharynx and into the esophagus by pharyngeal
peristalsis
• Approximation of the soft palate to the posterior nasopharyngeal wall, which
seals off the nasopharyngeal inlet and by contraction of the superior
constrictor muscles.
• Larynx and hyoid are pulled upward and forward allowing the bolus to pass
over the larynx without aspiration ]
• Relaxation of the cricopharyngeus muscle, which makes up much of the upper
esophageal sphincter

5. • Esophageal phase
• Peristaltic contractions in the body of the esophagus combined with
simultaneous relaxation of the lower esophageal sphincter propel the bolus
into the stomach

7. Requirements for Speech Production
• Respiration
• Phonation
• Articulation
• Resonance
Image from Zemlin text

8. Phonation
• When air from the lungs is forced through closed vocal cords, the vocal
cords vibrate and phonation occurs
• The pitch of sounds produced in the larynx is dependent upon the tension
of the vocal cords
• Elongation and tension of the cords results in faster vibration = higher
frequency/pitch
• Shortening and relaxation of the cords results in slower vibration = lower
frequency/pitch
• Fundamental frequency of male voice=130 Hz
• Fundamental frequency of female voice=220 Hz
• The loudness of sounds produced in the larynx is dependent upon the
speed of air flowing through the glottis (space between the cords).
• The air speed is greatest when the pressure build-up below the vocal cords
(subglottal pressure) is high

9. Articulation
• Tongue
• Lips
• Teeth
• Alveolar ridge (gums behind upper teeth)
• Soft Palate
• Hard Palate
• Velum/uvula
• The variable action of the tongue on all of the structures listed above results in our ability to
articulate different speech sounds
• A PHONEME is the technical term for a specific sound of speech
• Phonemes are either vowels or consonants

10. Vowels
• Vowel sounds
• There are 5 vowels in the English language (a, e, i, o, u), but there are 12
different vowels sounds (i.e. the letter “i” makes different sounds in the
words “miss” and “mice”)
• The articulation of the different vowel sounds depends on:
• The point of constriction
• The degree of constriction
• The degree of lip-rounding
• The degree of muscle tension
• Vowel sounds make up 38% of our speech
• Refer to Zemlin, pp. 300-303

11. Consonants
• Consonants of English are classified by:
• Place of articulation
• Manner of articulation
• Degree of Voicing
• Consonant sounds make up 62% of our speech
• Refer to Zemlin, pp. 302

12. Classification of Consonants by Place of
Articulation
• Bilabial: both lips come
together (p, b, m, w)
• Labiodental: lower lip and
upper teeth make contact (f, v)
• Dental: the tongue makes
contact with the upper teeth (-
th)
• Alveolar: the tip of the tongue
makes contact with the
alveolar ridge (t, d, s, z, n, l)
• Palatal: the tongue approaches
the palate (j, r, -sh)
• Velar: back of the tongue
contacts the velum (k, g, -ng)
• Glottal: this is really an
unvoiced vowel (h)
Image from: https://notendur.hi.is

13. Classification of Consonants by Manner of
Articulation
• Manner of articulation refers to the degree of constriction as the
consonants begin or end a syllable
• Stops are defined by complete closure of the lips and subsequent release (p,
b)
• Fricatives use an incomplete closure of the lips to create turbulent noise (f, s,
sh)
• Nasals resonate through the nasal cavity (m, n)
• Hint: try making these nasal sounds with your nostrils plugged 
• Glides and Liquids are produced when the tongue approaches a point of
articulation within the mouth but does not come close enough to obstruct or
constrict the flow of air enough to create turbulence (l, r, w)

15. REHABILITATION AFTER RADIATION THERAPY
• Swallowing
• Reduced tongue base contact to the pharyngeal wall, restricted laryngeal motion,
and impaired airway protection with resultant aspiration
• Prolonged pharyngeal bolus transit time and delayed hyoid bone elevation, which
causes the upper esophageal sphincter to open early relative to the arrival of the
food
• Tissue changes, fibrosis, and possible alterations in sensory awareness
• Dysph agia occurs five or more years after RT
• Severe and often refractory to standard swallowing therapies
• Xerostomia and mucositis
• Trismus, dysgeusia (taste alterations), ageusia (loss of taste), dysosmia
(altered sense of smell), and esophagitis

16. • Exercise protocols to strengthen and maintain range of motion,
precision, muscle elasticity, and mobility should be started prior to
the initiation of RT. Patients should adhere to these established
exercise protocols both during and after RT
• Swallowing therapy program for patients with dysphagia may include
the use of specific swallowing maneuvers, changes in body posture,
range of motion or resistance exercises, or techniques to heighten
sensory awareness and facilitate bolus transit during swallowing
• voice therapy may be of benefit for patients with posttreatment
phonation problems that cause difficulty in communication

17. • Trismus is much easier to prevent than it is to correct once it has set
in
• Use fingers to pull the mandible and maxilla in opposite directions as
frequently as possible during the post-treatment phase.
• A stack of wooden tongue depressors may also be used to progressively
widen the interincisoral opening over time. Finally,
• Various devices, e.g. TheraBite®, are available to act as aids that facilitate
active opening of the mouth

19. POSTSURGICAL REHABILITATION
• Oral cavity and oropharyngeal cancers
• swallowing therapy can improve oral control of the bolus and
facilitate the initiation of the swallow reflex, pharyngeal dysmotility is
usually permanent
• use of specific swallowing maneuvers and postures are often
successful in improving pharyngeal transit
• palatal augmentation prosthesis will improve speech production and
swallowing when 50 percent or more of the oral tongue is removed
• Speech therapy is effective in improving speech intelligibility, even
after major resection

20. • Postures to reduce aspiration, e.g. head turn, chin tuck
• Manoeuvres, e.g. supraglottic swallow, Mendelsohn.
• Therapeutic exercises, e.g. thermal tactile stimulation, range of
motion, shaker
• Diet modifications regarding textures and recommendations on oral
or non-oral intake.

22. • Intra-oral prostheses providing palatal lift, obturation and augmentation
can improve speech and swallow function after oral resections
(1) reduction in the size of the oral cavity, thereby improving resonance characteristics;
(2) direction of food into the oesophagus with the aid of a trough carved into the
prosthetic tongue;
(3) protection of the underlying soft tissue;
(4) development of a surface of the residual tongue coming into contact during speech
and swallowing;
(5) improvement in appearance, psycho-social adjustment and phonetics.
• Trismus - Exercises with tongue depressors or a specific device can increase
mouth opening

24. • Mandible opening; open mouth as far as possible. This is good exercise for
stimulation of tongue base.
• Attempt to lick alvelor ridge, left to right, then right to left.
• Attempt to lick lip, left to right , then right to lef.
• Attempt to push non-affected cheek out and hold for count of three.
• With teeth together and lips closed, attempt to push tongue forward and
hold for count of three.
• Repeat #6 but push tongue to roof of mouth for count of three.
• For prevention of saliva pooling, pucker lips and do a strong suck-back and
swallow.
• Any attempted articulation is good stimulation for tongue movement... I
have a list of non-glossal sentences and then move into some that have
glossal movement. i.e. "Why buy ham mom", "May I have more" and
move to, "Head light" "small hotdog"
• If the patient is not a risk for aspiration, any swallowing activity is good
stimulation for tongue movement. Start with a consistency that is easy to
manage such as pudding or honey and move to a thinner consistency.

25. Laryngeal and hypopharyngeal cancers
• The development of a fold of mucous membrane or scar tissue at the
tongue base can potentially impede swallowing.
• Hyoid bone resection and other postoperative structural changes,
patients may experience difficulty with tongue movements, chewing,
and bolus propulsion through the pharynx.
• A stricture within the pharynx or esophagus may narrow the passage
for food transit, allowing food to collect proximal to the stricture.
• A diverticulum in the pharyngoesophageal wall may retain fluid and
food resulting in the complaint of food "sticking" in the cervical
esophagus.

26. • three major approaches used to restore oral communication, and
many patients learn to use all three methods:
• The electrolarynx
• Tracheoesophageal puncture (TEP) with voice prosthesis
• Esophageal speech

27. • ELECTROLARYNX
• Providing immediate postoperative verbal communication with relative ease
• Equal in intelligibility to esophageal speech
• Better discriminated in noise than esophageal speech
• Improved communication in noisy environments
• Mechanical sound quality

28. • TRACHEOESOPHAGEAL PUNCTURE VOICE RESTORATION
• Physiologic-anatomic variations
• Mechanical problems

30. • ESOPHAGEAL SPEECH
• Oral air that is introduced into the esophagus and expelled past the
PE segment is the driving force for speech production
• Does not require the use of any mechanical or prosthetic device
• Length of time required to learn the technique and the reduction in
quality compared with tracheoesophageal puncture

31. • All multidisciplinary teams should have rehabilitation patient
pathways covering all stages of the patient’s journey including
multidisciplinary and pre-treatment clinics
• All head and neck cancer patients should have a pre-treatment
assessment of speech and swallowing.
• A programme of prophylactic exercises and the teaching of
swallowing manoeuvres can reduce impairments, maintain function
and enable a speedier recovery.
• Continued speech and language therapist input is important in
maintaining voice and safe and effective swallow function following
head and neck cancer treatment

32. • Disease recurrence must be ruled out in the management of stricture
and/or stenosis. (R)
• Continuous radial expansion balloons offer a safe, effective dilation
method with advantages over gum elastic bougies
• Site, length and completeness of strictures as well as whether they
are in the presence of the larynx or not, need to be assessed when
establishing the likelihood of surgically improved outcome
• Primary surgical voice restoration should be offered to all patients
undergoing laryngectomy.
• Attention to surgical detail and long-term speech and language
therapist input is required to optimise speech and swallowing after
laryngectomy
• Patients should commence wearing heat and moisture exchange
devices as soon as possible after laryngectomy.