Commentary (Schuller): Speech and Swallowing Rehabilitation for Head and Neck Cancer Patients

This paper is an excellent overview of speech and swallowing rehabilitation in head and neck cancer patients. Dr. Logemann and co-workers are clearly leaders in this field and, as such, are eminently qualified to summarize the topic. This subject is of great importance, as the effects of head and neck cancer and its treatment can be economically, psychologically, and socially devastating to patients. Quality-of-life issues continue to be critical in this patient population.

The information contained within the paper is comprehensive but somewhat oversimplified. This is because contemporary surgical technology has surpassed the ability to succinctly describe the myriad varieties of procedures in current use by head and neck surgical oncologists. The reader needs to be aware that certain terms, such as hemilaryngectomy and supraglottic laryngectomy, are now used to collectively characterize numerous procedures that are each distinctly different and can potentially have either a beneficial or an adverse impact on patients' ultimate speech and swallowing functions.

For example, the authors state that when a significant part of the tongue base is removed, the patient may never be able to relearn to swallow, requiring conversion of the surgical procedure to a total laryngectomy. In fact, recent reconstructive developments using tissue transfer techniques seem to avoid the necessity of total laryngectomy with resection of the tongue base.

The information presented by the authors on the apparent benefits of range of motion (ROM) exercises is intriguing. However, it is unclear whether patients who did and did not receive instruction in ROM exercises had similar-stage disease, underwent similar antitumor treatments, and had similar comorbid factors, or whether they were ultimately randomized to treatment groups. Although this is a simple statement to make, undertaking a controlled study in patients with head and neck cancer is a difficult task. However, there is no question that all of these factors can adversely affect the ability to effectively rehabilitate the patient.

In addition, head and neck cancer patients tend to be noncompliant,[1-3] and it is difficult to imagine sustaining adherence to an ROM exercise program in this patient population. These comments are made not as a criticism of the data presented in this article, but rather, as a statement of reality that addresses the importance of close communication among health-care professionals involved in treating this complex patient population.

The authors make the strong statement that all head and neck cancer patients "should be evaluated" following treatment. In these times of cost containment, it is critically important that all health-care professionals recognize the importance of focused utilization of consultants and technologies directed by the head and neck surgical oncologist. Once again, that is why this area requires close communication among health-care professionals to coordinate the appropriate utilization of these services.

In my opinion, it is essential that the head and neck surgical oncologist be the leader of this effort because of the surgeon's intimate knowledge of the patient's overall health status and stage of disease, but especially because of his or her knowledge of precisely what was accomplished at the time of surgery in terms of the amount of tissue resected and the reconstructive techniques utilized. The numerous modifications of standardized surgical techniques now available necessitate an interactive communication network. Hopefully, this will maximize the efficiency of other health-care professionals to optimize the results of their efforts. I have personally experienced numerous examples of the inappropriate involvement of speech and swallowing therapists by health-care professionals who were not even knowledgeable about the patient's disease or specific surgical or nonsurgical treatment he or she had received.

In summary, Dr. Logemann and her co-workers should be congratulated on an excellent paper. Head and neck cancer patients will certainly benefit from their continued research addressing critically important rehabilitation issues in this patient population.

References:

1. Laramore GE, Scott CB, Al-Sarraf M, et al: Adjuvant chemotherapy for resectable squamous cell carcinomas of the head and neck: Report on Intergroup study 0032. Int J Radiat Oncol Biol Phys 23:705-713, 1992.

2. Schuller DE: Do otolaryngologist-head and neck surgeons and/or chemotherapy have a role in the treatment of head and neck cancer? Arch Otolaryngol Surg 117:498-501, 1991.

3. Schuller DE, Metch B, Stein DW, et al: Preoperative chemotherapy in advanced resectable head and neck cancer: Final report of the Southwest Oncology Group. Laryngoscope 98:1205-1211, 1988.