BRIEF RESEARCH COMMUNICATION |
https://doi.org/10.5005/jp-journals-10023-1258 |
Speech and Swallowing Deficits in Patients with Head and Neck Cancers Following Conventional Radiotherapy: Considerations in a Tertiary Care Setup
1-4,6Department of Otolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
5Department of Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Corresponding Author: Banumathy Nagamani, Department of Otolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh, India, Phone: +91 2147483647, e-mail: banupallav@gmail.com
Received on: 29 December 2023; Accepted on: 18 September 2024; Published on: 15 November 2024
ABSTRACT
Objective: The present study investigates the prevalence of various speech and swallowing deficits in head and neck cancer (HNC) patients following radiotherapy (RT).
Method: A total of 140 patients diagnosed with stage I and II head and neck cancers participated in the present study. To assess the speech, language and communication skills post-RT, a complete speech, and language test battery was administered.
Results: The results of the present study revealed that after completion of radiotherapy, swallowing dysfunction increased to 59% from 15% pre-RT. Postradiotherapy intervention participants presented with various speech disorders, such as slurred speech (13%), voice disorder (26%), stuttering (1%), and trismus (1%).
Conclusion: This is a preliminary study, which will serve as an eye-opener for the specialists in a multidisciplinary set-up to appropriately intervene the patients that will save the structures of swallowing, speech, and voice, thereby offering a better quality of life.
How to cite this article: Nagamani B, Verma H, Mishra R, et al. Speech and Swallowing Deficits in Patients with Head and Neck Cancers Following Conventional Radiotherapy: Considerations in a Tertiary Care Setup. Int J Phonosurg Laryngol 2024;14(2):33-36.
Source of support: Nil
Conflict of interest: None
Keywords: Deglutition disorders, Dysphonia, Radiotherapy, Xerostomia.
INTRODUCTION
The World Health Organization’s (WHO) cancer report1 revealed that approximately 18.1 million individuals were diagnosed with one or the other type of cancer and 9.6 million were reported to have lost their lives due to cancer around the world in 2018. Report from the cancer registry program, in India estimated that 13,92,179 people were diagnosed with cancer in the year 2020.2 Cancer registry report further stated that head and neck cancer (HNC) (i.e., 66.6%) is one of the leading sites of cancer. One of the studies compared the burden of head and neck cancer as a tip of the iceberg situation, as India has a much greater number of HNCs than reflected through the existing literature.3 There are several treatment options available for cancer, that is, surgical intervention, radiation therapy, chemoradiation therapy, chemotherapy, and a combination of surgical and other adjuvant treatments.
Radiotherapy (RT) is the most invariably used definitive treatment modalities for patients with HNC in early stages (stage 0, I, and II) where tumor is localized.4 There are two most commonly used modes of RT, that is, external beam radiotherapy and internal beam radiation (brachytherapy). About 80% of treatments in a typical RT department are carried out with external beam radiotherapy.5-7 In conventional radiation8 therapy techniques radiation beam is typically limited to simple square or rectangular beams due to adjacent tissues and organs often fall into the high-dose treatment region resulting in various side effects. Several studies in the past reported the effect of radiotherapy which includes xerostomia,9,10 loss of taste and smell,11 dental issues,9,10 dysphagia,12,13 dysphonia,14,15 trismus,9,15 chronic sinusitis,9 articulatory disorders,15 and other issues.
A cross-sectional study16 reported speech and swallowing problems in 63.8% and 75.4% of patients, respectively, after treatment for oral and oropharyngeal cancer. Most common abnormal late examination findings were radionecrosis (10%), cranial neuropathy (48%), trismus (38%), and dysphonia/dysarthria (76%).13 These dysphonic changes persist in 50–95% of patients, up to 5 years postradiotherapy which is classically characterized by breathy, strained, and rough voice quality.17,18
Evolving from a conventional RT using simple treatment fields to highly conformal RT techniques, such as intensity-modulated radiotherapy (IMRT), intensity modulated arc therapy (IMAT) aims to improve the outcomes by intensifying the dose to the target structures as well as minimizing the toxicity to surrounding normal tissue and other vital organs.19 Most of the available studies focused on the effect of advanced therapy modalities such as IMRT or a combination of chemoradiation on quality of life or swallowing dysfunction in the west. In India, especially in tertiary care hospitals, conventional radiation therapy is chosen as the treatment modality due to many factors. Conventional RT generally induces permanent changes in the anatomical structures, organ function of the normal tissues leading to various acute and late radiation morbidities such as mucositis, dysphagia, speech disorders, and xerostomia, having a severe impact on the quality of life (QOL). Hence there is a need to investigate the prevalence of different types of speech and swallowing deficits that are being observed in HNC patients post-RT.
AIM OF THE STUDY
The aim of the present study is to investigate the prevalence of various speech and swallowing deficits in HNC patients following radiotherapy.
METHOD
Participants
The current study included 140 patients with an age range of 45–73. Among 140 participants, 118 were males with age range of 45–73 years, and 22 were females with age range of 50–65 years. The majority of the population was diagnosed with oral cavity cancer (102) followed by oropharyngeal (22), nasal (10), and neck cancers (6). Histopathological reports confirmed that 104 patients had carcinomas and 36 subjects had lymphomas. The present study only included stage I (124) and II (16) cancers. All the participants had undergone 20–30 cycles of conventional radiotherapy as a management option. No participants received speech and swallowing therapeutic services before radiotherapy. However, speech therapist did the preoperative counseling related to speech and swallowing outcomes postradiotherapy.
Inclusion and Exclusion Criteria
The present study included patients only with stage I and II cancers. We included only those patients whose primary management was done using conventional radiotherapy. The data were collected before initiating the speech-swallowing rehabilitation postradiotherapy. We excluded the patients who had undergone surgical intervention, chemotherapy, chemoradiotherapy, and IMRT. Participants with recurrence of tumor were also excluded from the present study.
Tool and Questionnaire Used
The mini-mental status examination (MMSE) (Folstein et al. 1975) was used to assess cognitive status of participants as cognitive decline may pose a threat to swallowing assessment.20 To assess the speech, language, and communication skills we administered the complete speech and language test battery. To assess the swallowing functions, dysphagia severity rating scale (Saitoh et al. 1999) was administered and dysphagia proforma was used.21 The western aphasia battery (Kertesz 1982) was used to analyze the language issues,22 the stuttering severity instrument (Riley 1994) was used to assess the fluency, and the grade, roughness, breathiness, asthenia, strain (GRBAS) rating scale (Hirano 1981) was used for the perceptual analysis of voice.23,24 We further performed the acoustic analysis of voice using phonetic and acoustic analysis toolkit (PRAAT) software. The cranial nerve assessment was performed using the guidelines and suprasegmental aspects of language were also screened.
Procedure
Prior to conducting the data analysis, the aim of the study was explained to the participants and informed consent was taken. The complete case history was taken which includes the demographic details, medical history, psychological history, cancer-related history, radiotherapy history, dietary habits, and lifestyle history. The referral was made for those patients who reported with any kind of speech, language, communication, and swallowing issues following their scheduled radiotherapy sessions. We completed the full test battery in three sessions. In the first session, the complete case history was taken, and cognitive screening was executed using MMSE. During the same day, we took the history related to speech, swallowing, language, and communication prior to the radiotherapy intervention from the patients or the caregivers. During the first visit, we administered the western aphasia battery (WAB).
During the second visit, we assessed the voice and swallowing functions. Voice evaluation included the acoustical analysis using stimulus /a/, perceptual analysis using GRBAS, maximum phonation duration, and s/z ratio. Swallowing assessment included the analysis of oral-motor structures and functions, cough strength, feeding history, tracheostomy status, and respiratory status. The swallowing function was also analyzed for different consistencies and textures. On the basis of the swallowing assessment dysphagia severity was assessed using dysphagia rating scale. The articulation and fluency assessment was done during the third session. We administered the stuttering severity instrument third edition (SSI-3) to analyze the fluency issues. To check the articulatory coordination, we used the diadochokinetic (DDK) rate which includes the alternate motion rate (AMR) and sequential motion rate (SMR). During the same session, we further analyze the suprasegmental aspects of language.
Statistical Analysis
Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) 20 version software. We used descriptive statistical analysis which comprised the computation of mean, standard deviation, and percentage scores.
RESULTS
Speech and Swallowing Deficits Pre-Radiotherapy and Post-Radiotherapy
The results revealed that prior to initiation of radiotherapy, only 20 (15%) subjects had reported odynophagia, whereas after completion of conventional radiotherapy treatment the number of dysphagia patients reached 83 (59%). Postradiotherapy intervention participants were presented with various disorders, such as slurred speech (13%), voice disorder (26%), stuttering (1%), and trismus (1%) as shown in Table 1 and Figure 1.
| Disorders | Number of subjects (pre-RT) | Number of subjects (post-RT) |
|---|---|---|
| Dysphagia | Odynophagia: 20 (15%) | 83 (59%) |
| Slurred speech | 0 (0%) | 18 (13%) |
| Voice disorder | 2 (1%) | 36 (26%) |
| Stuttering | 0 (0%) | 1 (1%) |
| Trismus | 0 | 1 (1%) |
Fig. 1: Distribution of various disorders post-RT in comparison to pre-RT
The Severity of Various Communication and Swallowing Disorders Postradiotherapy
As shown in Table 2 and Figure 2, the majority of patients presented with dysphagia symptoms that include 2% of mild severity, 59% of moderate severity, and 39% of severe severity. However, only one patient presented with severe stuttering whereas 72% of the population had moderate voice disorders. On the articulation assessment, 56% of the population had severe slurred speech, and only 11% of patients presented with mild slurred speech.
| Disorders presented by subjects | Severity of disorders | ||
|---|---|---|---|
| Mild | Moderate | Severe | |
| Dysphagia | 15 | 20 | 48 |
| Slurred speech | 02 | 06 | 10 |
| Voice disorder | 04 | 09 | 23 |
| Stuttering | 00 | 00 | 01 |
Fig. 2: Severity of various communication disorders post-RT
DISCUSSION
The present study revealed that dysphagia was the most prevalent disorder, which was observed in 82 (59%) patients. Same was also reported by many studies12,13 that conventional radiotherapy had more adverse effects on swallowing functions. Previous studies9,10 further reported that high doses may worsen swallowing functions and may lead to severe xerostomia. Results further showed that 26% of the participants were presented with voice disorders and similar findings were reported by many studies.14,15 Studies14,15 revealed voice disorders as one of the long-term issues postradiation therapy which includes hoarseness, aphonia, muscle tension dysphonia, etc. A present study indicated that 18 (13%) subjects had poor speech intelligibility and presented with slurred speech. Our results support the study conducted by Cunqueiro et al.,16 which revealed that after 5 years of radiotherapy, 75% of the participants had dysarthria.
In the current study, only one subject reported the presence of trismus whereas a study conducted by Cunqueiro et al.16 reported the presence of trismus in 38% of the study population. Previous studies18-23 reported more number of patients presenting with trismus compared to current studies. This may be due to the presence of differences in the extent and location of the cancer. Complete test battery analysis showed that only one subject presented with a severe degree of stuttering. To the authors’ best knowledge, there is no study reporting the presence of stuttering Post-Radiotherapy. It can be assumed that in this patient stuttering may be developed due to the presence of stress and anxiety related to the cancer, followed by such a tedious intervention modality, compromising the quality of life.
All the subjects underwent conventional radiotherapy. Further case history revealed that they were all given conventional radiotherapy due to certain constraints such as affordability of patients and time duration of treatment taken. This was definitely not a convincing factor considering the long-term consequences of RT in these patients, as the majority of the patients presented with severe dysphagia (48), moderate to severe hoarse voice (23), and severe slurred speech (10). The severity of communication and swallowing disorder post-RT has been shown in Figures 1 and 2. This in turn had a very severe impact on the quality of life of these patients.25-28 The present study is thus a preliminary attempt that revealed a high prevalence of swallowing and speech problems post-RT. These results support the earlier studies reporting the prevalence of speech and swallowing problems following radiotherapy.29 There is evidence of reduced tongue base retraction, reduced tongue strength, delayed laryngeal vestibule closure, sensory change, and tissue fibrosis of surrounding structures. Thus, the consequence of radiotherapy has a deleterious effect on neuromuscular coordination and the mobility of structures such as the remaining tongue, hyoid bone, and larynx.30 All these life-threatening consequences can be avoided if the patients are appropriately counseled regarding the different techniques, namely conventional vs overweighing intensity-modulated radiotherapy, which is very challenging in a tertiary care setup due to excessive caseload in the outpatient departments (OPDs) and time constraints. In the present study, we did not consider effect of the radiotherapy dosage as every patient had diverse severity and location of tumor. This should be focused in the future studies.
CONCLUSION
Deleterious effects of radiotherapy have always been evidenced and reported following conventional radiotherapy by most researchers. As radiotherapy is considered the most important predictive factor relating to both speech and swallowing impairment, all patients need to be counseled regarding all the available radiotherapy techniques [three-dimensional conformal RT (3-DCRT), stereotactic radiation therapy, and IMRT], which can save the surrounding structures of the tumor significantly compared to conventional radiotherapy, consequences of which leads to life-threatening disorders affecting the day-to-day functioning of an individual.
SUMMARY STATEMENT
The fact already known to professionals is that conventional RT will definitely pose problems with respect to speech and swallowing dysfunction. However, professionals in tertiary care setups are still not referring patients for advanced radiotherapy techniques, which are organ-saving, due to the over spilling OPDs and financial constraints. Hence, these findings will be an eye opener for all the tertiary care professionals to work out effective counseling for all the patients with HNCs and appropriately intervene patients with advanced techniques that will save the structures of swallowing, speech, and voice, thereby offering a better quality of life.
ORCID
Himanshu Verma https://orcid.org/0000-0002-0306-4961
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