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306 The Voice and Voice Therapy
PREPARING FOR THE PRAXIS
Directions: Please read the case studies and answer the five questions that follow.
Vivienne is a 77-year-old telephone receptionist at a busy state government office. She reports
talking on the phone for at least 30 min out of each hour and talking in person to local citizens
for 15 min out of the hour. Her chief voice complaints are harsh voice quality and poor voice
durability. She saw an otolaryngologist (ENT), who diagnosed presbyphonia.
1. As the voice clinician, you review the ENT report and find that laryngoscopic
examination most typically reveals:
A. Mild bowing of the vocal fold margins
B. A vocal fold polyp
C. Focal adductory dystonias of the true vocal folds
D. A full unilateral vocal fold paralysis
2. Vivienne presents with no systemic diseases, and she is very willing to comply
with your recommendations for increased vocal quality and amplitude. Suggested
intervention techniques would include:
A. A personal amplification system to use with patrons and coworkers at the office
B. Complete voice rest for at least a week
C. A rigorous vocal hygiene program only
D. Exploring techniques to improve respiratory and vocal efficiency
E. Both A and D
Robbie is a 26-year-old college student who is hard of hearing. She communicates orally and
has come to you for counseling in strategies to increase intelligibility.
3. As a voice clinician, you have researched voice and speech behaviors typical of DHH
individuals. Among other behaviors, you expect to observe:
A. Reduced articulatory accuracy
B. Shortened vowel duration
C. Increased speaking rate
D. Monoloudness
Stefanie, a client who is male-to-female transgender, has been referred to you. She has begun
hormone treatment and is seeking direction with respect to voice and pragmatic speech and
language.
4. As a novice clinician practicing gender-affirming intervention, it is important for you
to know that:
A. The transgender voice client is very concerned about their pitch and resonance
B. Individual is superior to group intervention for the TGD population
C. There are many RCT training programs for transgender women
D. Hormone therapy is all that is needed for the transmasculine voice
CHAPTER 8 Therapy for Specific Patient Populations 307
Marti is a female adolescent high school athlete who has been referred to the emergency room
(ER) on several occasions for respiratory distress. A well-informed ER physician makes the
diagnosis of EILO.
5. As the SLP who received the consult for voice therapy with Marti, it is important for
you to know that EILO is effectively managed through:
A. Behavioral intervention
B. Surgery
C. Vocal fold augmentation
D. Asthma intervention
CHAPTER 9
MANAGEMENT AND
THERAPY FOLLOWING
LARYNGEAL CANCER
LEARNING OUTCOMES
After reading this chapter, one should be able to:
●
Define the modes of head and neck cancer treatment.
●
Define tumor, node, metastasis (TNM) staging.
●
Define the inclusions important in preoperative counseling.
●
Define postoperative methods of communication and the advantages and
disadvantages of each.
●
Define the pharyngoesophageal (PE) segment and its role in both esophageal and
tracheoesophageal speech.
309
310 The Voice and Voice Therapy
ead and neck cancer (HNC) can affect the skin, mucous membranes, glandular structures, neurovascular elements, and supportive soft tissues and bones in the head and
H
breathing, speaking, and eating. In this chapter, we review the risk factors and epidemiology of
HNC. We also provide a historical and contemporary review of medical–surgical management.
Case examples demonstrate the interventional approaches taken by the speech-language pathologist (SLP).
neck. As such, HNCs strike at some of the most basic human functions, including
Types of Head and Neck Cancer
Cancers of the head, neck, and oral regions represent a challenging area of focus due to their
varied anatomical locations and the critical functions they impact. Laryngeal and hypopharyngeal
cancer, nasal cavity and paranasal sinus cancer, nasopharyngeal cancer, oral and oropharyngeal
cancer, and salivary gland cancer are conditions that require a deep understanding of both the
anatomy involved and the potential effects on voice and swallowing. These cancers highlight the
crucial role of SLPs in the multidisciplinary approach to cancer care, emphasizing the importance
of early detection, intervention, and patient-centered rehabilitation strategies. Following are brief
descriptions of each of the five major types of HNC:
●
Laryngeal and hypopharyngeal cancer: The larynx, or voice box, is a critical tube-
shaped organ located at the top of the windpipe (trachea), playing a vital role in
breathing, speaking, and swallowing. Adjacent to the larynx is the hypopharynx, often
referred to as the gullet, which constitutes the lower section of the throat encircling
the larynx.
●
Nasal cavity and paranasal sinus cancer: The nasal cavity, situated just behind the
nose, serves as the passage for air en route to the throat. Surrounding the nasal cavity are
the paranasal sinuses, air-filled spaces that enhance the resonance of the voice.
●
Nasopharyngeal cancer: Positioned at the upper part of the throat behind the nose, the
nasopharynx functions as an airway passage and resonator.
●
Oral and oropharyngeal cancer: The oral cavity encompasses the mouth and tongue,
while the oropharynx consists of the middle part of the throat, extending from the
tonsils to the base of the larynx.
●
Salivary gland cancer: Salivary glands produce saliva, a crucial fluid that moistens the
mouth and initiates the digestion of food with its enzyme content.
HNCs strike at some of the most basic human functions, including breathing, speaking, and
eating. The physical, emotional, and communicative issues associated with laryngeal cancer makes
this disease exceptionally significant. For those patients who are diagnosed with laryngeal cancer
and undergo a laryngectomy, anxiety and fear about their preservation of function as well as their
postsurgical quality of life can prove to be exceedingly distressing to them as well as their families.
The study of cancers affecting the larynx, nasal cavity, nasopharynx, oral cavity, and salivary
glands underscores the pivotal role of SLPs in the field of oncology. With a comprehensive understanding of these conditions, students are better prepared to contribute to the diagnosis, treatment
CHAPTER 9 Management and Therapy Following Laryngeal Cancer 3 11
planning, and rehabilitation of patients facing these life-altering diagnoses. The clinical significance
of these cancers extends beyond their immediate health implications, affecting aspects of voice,
speech, and swallowing that are essential for quality of life. SLPs are tasked with the responsibility
of applying their knowledge and skills in a manner that supports not only the physical recovery
of their patients but also their psychological and social well-being, demonstrating the profound
impact of specialized care in the journey toward recovery and rehabilitation.
Risk Factors and Demographic Facts in Head and Neck Cancer
According to the American Cancer Society (2024), HNC accounts for about 4% of all cancers in
the United States. In 2023, an estimated 66,920 people (49,190 men and 17,730 women) were
diagnosed with HNC. Worldwide, an estimated 562,328 people were diagnosed with HNC in
2020. It is estimated that 15,400 deaths (11,210 men and 4,190 women) from HNC will occur
in the United States in 2024. In 2020, an estimated 277,597 people worldwide died from the
disease (Aupérin, 2020).
Laryngeal Cancer
The American Cancer Society estimates that in 2024, approximately 12,650 new cases of laryngeal
cancer will be diagnosed in the United States, with a higher prevalence in men (10,030 cases)
than in women (2,620 cases). Additionally, it is expected that 3,880 individuals will die from this
disease, predominantly affecting men. Laryngeal cancer typically originates in the glottis (60% of
cases), with the supraglottic area accounting for about 35% of occurrences. The majority of those
diagnosed are over 55 years old, with the average age at diagnosis being around 66 years. Notably,
Black men have a higher incidence and mortality rate from laryngeal cancer compared to White
men, and the disease is significantly more common in men than women. Encouragingly, the
incidence and death rates for laryngeal cancer are decreasing by approximately 2% to 3% annually,
largely attributed to the decline in smoking rates. The lifetime risk of developing laryngeal cancer
is estimated at 1 in 200 for men and 1 in 840 for women, though other risk factors also play a
critical role in an individual’s likelihood of developing this cancer.
Primary risk factors for laryngeal cancer include tobacco use and excessive alcohol ingestion;
associated risk factors include being male, being over age 55 years, being Caucasian or African
American, being exposed to occupational inhalants, having poor oral hygiene, having gastroesophageal or laryngopharyngeal reflux, and being infected with human papillomavirus (HPV)]
(American Cancer Society, 2024). The most frequent symptoms of laryngeal cancer include persistent hoarseness, sore throat, dysphagia and/or painful swallowing, impairment in voice quality,
otalgia, and persistent cough. Most patients are unfortunately diagnosed at advanced stages, especially those with supraglottic tumors (Ciolofan et al., 2017), when the therapeutic options have
a remarkably lower favorable impact on prognosis. The 5-year survival rate in treatable patients
approximates 61% and 50% for glottic and supraglottic cancers, respectively (American Cancer
Society, 2024).
Laryngeal cancers, especially those originating on the vocal cords (glottic cancer), often present
early with hoarseness or voice changes, potentially leading to an early diagnosis. Individuals expe-
312 The Voice and Voice Therapy
riencing persistent voice changes, such as hoarseness that does not improve within 2 weeks, are
strongly advised to consult a health care provider promptly. In contrast, cancers not starting on
the vocal cords may only cause hoarseness at later stages or after spreading to the vocal cords, often
remaining undetected until they have advanced to the lymph nodes, manifesting as a growing
neck mass.
Additionally, cancers arising in the supraglottis, subglottis, or hypopharynx typically do not
cause voice changes in their early stages, making them less likely to be discovered until advanced
stages. Symptoms of these cancers can include a persistent sore throat, pain or difficulty swallowing, ear pain, trouble breathing, unexplained weight loss, and a lump or mass in the neck due to
the spread to lymph nodes. While many of these symptoms can be attributed to conditions other
than laryngeal or hypopharyngeal cancer, it is crucial to seek medical evaluation to determine the
underlying cause and receive appropriate treatment, if necessary.
Oral and Pharyngeal Cancers
According to the American Cancer Society (2024), it is projected that in 2024 there will be 58,450
new diagnoses and 12,230 fatalities attributed to cancers of the oral cavity and pharynx. Significantly, the incidence of these cancers demonstrates a nearly threefold higher rate in men compared
to women. Over recent decades, a notable shift in the distribution of oral cavity cancer cases has
been observed, influenced by changes in risk factors such as reduced smoking rates. Consequently,
the occurrence of cancers on the tongue or tonsils has risen sharply, doubling from one-quarter of
cases in the late 1970s to half of all cases between 2016 and 2020. The incidence of these cancers
has shown a steady increase of approximately 1% per year since the mid-2000s, primarily driven
by oropharyngeal cancers linked to strains of the human papillomavirus (HPV 16 and HPV 18).
Risk factors for oral and pharyngeal cancers include tobacco use in any form and alcohol
consumption, with a dramatically elevated risk for heavy users of both substances. HPV infection
in the oral and throat regions, believed to be sexually transmitted, also poses a significant risk. The
Centers for Disease Control and Prevention (CDC) state that 70% of oropharyngeal cancers in the
United States are caused by HPV (https://www.cdc.gov/cancer/hpv/oropharyngeal-cancer.html).
In response to this, the U.S. Food and Drug Administration expanded the indication for the HPV
vaccine in 2020 to include oral cancer prevention, in addition to its initial approval for preventing
cervical cancer. Despite this advancement, vaccination rates remain disappointingly low, with only
63% of adolescents aged 13 to 17 years being up to date with their vaccinations in 2022.
The symptoms of oral cavity and pharyngeal cancers can vary widely, ranging from sores that
bleed easily and do not heal, to persistent red or white patches, to difficulty swallowing or moving
the tongue or jaw. The approach to treating these cancers is largely determined by the stage of the
disease and its HPV status, though other factors are also considered. Surgery, radiation therapy,
and chemotherapy are standard treatments, with the addition of immunotherapy as a newer option
for advanced stages.
The 5-year relative survival rate for these cancers stands at 69%, though this figure masks
significant racial disparities. This discrepancy exists regardless of the HPV status of the tumor,
highlighting an urgent need for equitable health care interventions and support for all patients
diagnosed with cancers of the oral cavity and pharynx.
CHAPTER 9 Management and Therapy Following Laryngeal Cancer 313
Modes of Cancer Treatment
For the SLP, understanding the impact of various cancer treatments on the voice is paramount
for providing effective clinical care. Treatments for HNCs, including radiation therapy, surgery,
and chemotherapy, each come with unique challenges and complications that can significantly
affect a patient’s vocal function. For SLPs, the clinical application of this knowledge is crucial in
designing rehabilitation programs tailored to address the specific needs of individuals recovering
from cancer treatment. This comprehensive understanding aids not only in the assessment and
diagnosis of voice disorders but also in the implementation of therapeutic interventions aimed at
restoring vocal function and, consequently, improving quality of life for patients.
Radiation therapy, surgery, and chemotherapy each have distinct mechanisms of action that can
lead to various vocal complications. The effects range from acute conditions such as mucositis and
edema to long-term consequences like fibrosis and tissue deficit, which can severely impair vocal
quality and function. The clinical implications for SLPs are profound, requiring a nuanced approach
to voice therapy that considers the physical changes to the larynx and vocal folds. Strategies may
include vocal exercises to improve flexibility and strength, voice rest to reduce strain, and techniques
to maximize phonation efficiency. Additionally, SLPs play a critical role in educating patients about
voice conservation strategies and the potential impact of treatment on vocal performance.
Radiation therapy serves as a cornerstone in the treatment of laryngeal cancer, particularly
when there is a chance to preserve the structure and function of the larynx. For early-stage tumors,
particularly those confined to the vocal cords, radiation therapy might suffice as a sole treatment modality (Schonewolf & Shah, 2023). It can eradicate small cancers, negating the need
for surgery and thus preserving the patient’s voice quality. The precision of modern radiation
techniques allows for the concentration of high-energy rays on the tumor with minimal damage
to surrounding healthy tissue. However, like other treatments, radiation therapy is not without its
drawbacks. It may lead to side effects such as mucositis, edema, and potential long-term changes to
the tissue, such as fibrosis, which can affect voice quality and swallowing function (Brook, 2020).
The overall goal of radiation therapy in managing laryngeal cancer is to achieve optimal control
of the disease while maintaining the maximal possible functionality of the larynx, with a keen eye
on the patient’s quality of life.
When surgery is among the treatment options, the extent and location of the tumor dictate
the extent of surgery. If the tumor crosses the midline, then total or near-total (or subtotal)
laryngectomy may be indicated; if the tumor is located on only one side of the larynx, then hemilaryngectomy or other partial laryngectomy may be an option. Surgery can leave a tissue deficit
following tumor removal, and stiffness due to scarring may follow healing. The tissue deficit may
also leave a gap in the glottal area when the folds approximate. This gap may cause air wastage and
a breathy vocal quality and may result in inadequate vocal loudness and short phonation times. In
addition, the gap in tissue and the stiffness of the surrounding tissue may lead to irregular vocal
fold vibration due to impaired mucosal wave motion.
Chemotherapy may be used before or after surgery or radiation therapy. Chemotherapy has
been used with radiation therapy to treat certain types of laryngeal cancers in an attempt to
preserve the larynx. Certain medications may be used in combination with radiation therapy as a
form of radiosensitization, that is, a strategy to render cancer cells more vulnerable to radiation.
314 The Voice and Voice Therapy
While this approach has its benefits, potential side effects from chemotherapy include fatigue,
a weakened immune system, and mucositis, among other conditions (Riva et al., 2022). Many
individuals experience moderate to severe side effects with chemoradiation intervention. In sum,
dryness, inadequate tissue mass, irregular vocal fold edges, and stiffness can all make vibration of
the vocal fold cover extremely difficult or impossible. This will render the voice abnormal in one
or more vocal parameters.
The role of the SLP extends beyond traditional voice therapy to encompass a holistic approach
to rehabilitation for individuals affected by HNCs. By understanding the complexities of how
radiation therapy, surgery, and chemotherapy impact the voice, SLPs can better prepare and support
their patients through the recovery process. Tailoring rehabilitation efforts to address the specific
challenges posed by each treatment modality ensures that patients receive the most effective care
possible. Ultimately, the goal is to enhance vocal function and quality of life, demonstrating the
significant impact that specialized SLP interventions can have on the lives of those recovering from
cancer treatments (Rocke et al., 2020).
Laryngeal Cancer Case Examples
The picture of a larynx in Figure 9–1 shows a lack of tissue mass due to surgery for removal of
laryngeal cancer. There is a gap between the vocal folds even in full adduction. The voice is breathy,
low in loudness, and rough in quality. The breathy quality results from the air wastage through
the glottal gap, while the low loudness level is due to inadequate medial compression required for
FI GUR E 9 1. Lack of tissue mass in right vocal fold after
surgical removal of laryngeal cancer.
CHAPTER 9 Management and Therapy Following Laryngeal Cancer 315
louder voice production. The rough vocal quality is due to two factors: (a) unequal mass between
the right and left vocal folds, and thus an irregular vocal fold vibrator pattern, and (b) an attempt
to compensate for the excessive glottal gap by hyperactivity of the false vocal folds, which weight
the vocal folds unequally. A third factor, for which the effect is difficult to estimate, is the scarring
following surgery. On laryngostroboscopy, the vocal folds appear unevenly stiff, likely due to
scarring that produces adynamic segments in the vocal folds in the area where tissue has been
excised. In voice therapy for this patient, we need first to eliminate the excessive vocal effort, thus
reducing the false fold activity. We began with the voice facilitating approach (VFA) of inhalation
phonation (see Video 9–1), which retracts the false folds (see Chapter 7). We gradually shifted
from inhalation to exhalation phonation using the /i/ vowel because it is produced with the root
of the tongue elevated and out of the hypopharynx. The next step in voice therapy was to use an
upward pitch shift to slightly increase vocal fold tension and gain slightly better approximation
(reducing the glottal gap) of the postsurgical vocal folds. The upward pitch could be only slight
due to some vocal fold scarring. Greater shifts upward produced too much tension of the vocal
folds, and phonation breaks occurred due to stiffness of the vocal fold cover. A shift of 20 to 25 Hz
was desirable in this case. The improved approximation from increased vocal fold tension during
pitch shift increased vocal loudness. Subglottic air pressure was increased slightly as well. This
case demonstrates how the treatment (surgery) for cancer produced dysphonia as a by-product of
treatment for the disease. Voice therapy was based on achieving the necessary vocal adjustments
using VFAs that would alter the effects of postsurgical anatomy and physiology of the larynx and
also counter the inappropriate compensatory behaviors the patient had developed.
Video 9–1. Inhalation phonation is a helpful
voice facilitating approach for any patient
presenting with ventricular dysphonia. This
section of the text applies inhalation phonation to a voice user who presents with uneven
vocal fold edges due to surgery; however,
other patients featured on the video present
with supralaryngeal hyperfunction due to a
number of functional and neurogenic reasons.
Inhalation phonation helps encourage elongation of the true vocal folds and discourages
the medialization of the false vocal folds.
Grand Rounds: Why is inhalation phonation
best facilitated with the phoneme /i/?
The second case addresses voice therapy for stiffness of the vocal fold cover due to fibrotic
changes secondary to radiotherapy. For this case, we instructed the patient to shift his pitch
downward, to take advantage of the greater mucosal wave that occurs in lower pitches, and also to
decrease subglottic air pressure, so the folds were not overdriven. We used this therapy approach in
a patient who had irradiation treatment for superficial bilateral cancer of the vocal fold cover. He
was able to return to teaching with an improved voice and a voice that would last throughout the
teaching day. The pretherapy voice was very weak, extremely breathy, and of very short duration