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Abstract

Background

Velopharyngeal dysfunction (VPD) in head and neck cancer is frequently clinically reported, affecting both speech and swallowing function. This review sought to identify the tumor subsites and treatment modalities reported in association with VPD and summarize the current reporting methodology of VPD-related speech and swallowing outcomes in patients following head and neck cancer treatment.

Methods

A literature search was conducted through December 2020 using electronic databases and a total of 15 studies were included in review.

Results

Reported VPD was largely secondary to palate resections. Large variability in reporting methodology was noted with heavy reliance on speech-related perceptual measures and swallowing-related patient-reported outcomes over imaging and instrumental evaluations.

Conclusions

This review revealed inconsistencies in evaluating and reporting VPD, which likely translates into inconsistencies in clinical management. Further attention to VPD secondary to other head and neck malignancies would provide a broader perspective on VPD through head and neck cancer treatment.

Keywords

velopharyngeal dysfunction head and neck cancer speech outcomes swallowing outcomes

Introduction

Speech and swallowing disorders are largely prevalent in patients with head and neck cancer.¹ A systemic understanding of the various levels of breakdown is critical to the clinical management of the overall dysfunction. One prevalent deficit that affects both speech and swallowing is velopharyngeal dysfunction (VPD).

The velopharyngeal (VP) port, constructed by the velum and the surrounding pharyngeal walls, is a critical junction for both speech and swallowing tasks. The velum typically remains lowered with the patent nasopharyngeal airway during breathing. In speech, adequate VP closure, through the combined action of superoposterior movement of the velum and anteromedial movement of the pharyngeal walls, allows for sound energy and airflow to be directed through the oral cavity. Depending on the relative contributions of the VP structures, different patterns (coronal, sagittal, and circular) of VP closure have been described in the literature.^2

-6 Deficits in VP closure during speech manifests as hypernasality (i.e., excessive nasal resonance perceived in speech) and/or nasal airflow deviation errors (i.e., nasal air emission). On the swallowing front, VP closure is necessary to restrict entry of food and liquids into the nasal cavities. Closure of the VP port during swallow appears to occur with significantly greater closure force and muscular activity with fast-twitch motor units dominantly fired in comparison with VP closure during speech.^7,8 Functionally, VPD may result in reduced speech intelligibility and dysphagia with social disturbance and consequently reduced social interactions.⁹ The negative impact of VPD on quality of life (QOL), including social/emotional disturbance, is well documented in the literature.¹⁰ In fact, while swallowing dysfunction was rated to be the most reliable predictor of health-related QOL outcomes in patients treated for nasopharyngeal cancer,¹¹ nearly 60% of the patients with nasopharyngeal cancer exhibit VPD.¹²

Head and neck cancers are steadily rising in recent years, partially attributed to the rise in human papillomavirus (HPV)-related tumors.¹³ Treatment effects are often drastic, leading to significant impacts on speech and swallowing function. Based on site and extent of tumor, treatment modalities typically include a combination of surgery, radiation, and chemotherapy.¹⁴ For instance, certain oral cavity tumors are primarily treated with surgical management followed by adjuvant radiotherapy with or without chemotherapy, whereas other tumors of the oropharynx are often treated with primary radiotherapy with or without chemotherapy.

The impact on functional outcomes has been studied widely with various degrees of focus. Nguyen and colleagues¹⁵ specifically studied the impact of dysphagia on QOL in a retrospective analysis of patients treated with definitive single modality radiotherapy, chemoradiotherapy, and surgery followed by adjuvant radiotherapy. Their results showed that patients with documented moderate-to-severe dysphagia had worst outcomes on overall QOL. Swallowing outcomes were immediately followed by speech outcomes, which weighed heavier than other physical and aesthetic dysfunctions. Swallowing function after chemoradiation therapy was investigated by Eisbruch et al.,¹⁶ in which VPD was identified, along with other deficits, such as poor airway protection and swallowing inefficiency at post-therapy. According to Wu et al.,¹⁷ greater than one fourth of patients with nasopharyngeal cancer treated with radiation therapy presented with late-radiation effects (e.g., poor pharyngeal contraction, airway protection, and vocal cord palsy) with greater than 58% of patients demonstrating VPD. Given the critical role of the VP function in both speech and swallowing, more attention and understanding of these deficits are warranted.

Of specific interest to this review are VPD issues in individuals who underwent head and neck cancer treatment. Although VPD is a common clinical manifestation following head and neck cancer treatment, its management has yet to be systematically reviewed. Thus, the purpose of this scoping review was 2-fold: (1) to identify and describe the tumor subsites and treatment modalities reported in association with VPD in the available literature and (2) to summarize the current reporting methods of VPD-related speech and swallowing outcomes in patients following head and neck cancer treatment. Guided by this scoping review, we will propose some guidelines for clinicians to improve appropriate testing of VP function.

Methods

Literature Search

First, inclusion and exclusion criteria were established to guide our literature search. Inclusion criteria was broad, including all peer-reviewed journal publications that investigated VPD and any head and neck cancer site. All available studies until December 2020 were included in the analysis. Lower limits on time were not set due to the anticipation of a small number of studies. Inclusion criteria and exclusion criteria were set based on etiology. Inclusion criteria were set at head and neck cancer and exclusion criteria included studies that investigated VPD as a result of other etiologies (e.g., cleft palate or other neurogenic disorders). Three major databases were utilized in the search process: PubMed, Google Scholar, and ScienceDirect. Additional articles were obtained through other sources, including textbooks and reference lists.

The first level of search included PubMed with the terms “velopharyngeal dysfunction AND head and neck cancer,” which yielded 22 results. Nine articles were selected due to the abstracts specifically reporting on VP function. The search terms, “hypernasality AND head and neck cancer,” yielded 39 results. Three were selected based on the abstract that specifically listed speech, swallowing, and nasality information. On ScienceDirect, the search terms “velopharyngeal dysfunction AND head and neck cancer,” and “hypernasality AND head and neck cancer” yielded 79 and 54 results, respectively; however, 0 were selected due to the articles not specifically addressing VPD and often including other etiologies in the search results. The same search terms on Google Scholar yielded 99 results out of which conference abstracts, presentations and book chapters were excluded and a total of 20 articles that met the inclusion criteria were selected. Following removal of duplicates and articles that were clinical reports and instructional in nature, a total of 15 articles were selected for review.

Data Extraction

Following removal of duplicates, a total of 15 articles met the inclusion and exclusion criteria. As the major goal for this review was to identify gaps in the literature, the scope was kept broad in order to account for all possible measures of functional outcomes. Therefore, case studies and studies with low n-size were also included in this analysis. PRISMA guidelines were used for abstracting data (Figure 1). In order to facilitate data analysis, key information, including study objectives, sample size, study design, tumor subsite, treatment modality, and detailed speech and swallowing outcome measures reported, was extracted and summarized in table form.

Figure 1.

PRISMA flow diagram depicting the flow of study search and selection.

Results

Tumor Subsite and Treatment Modality

A total of 542 patients from 15 studies were included and reviewed with the sample size ranging from 8 to 64 patients per study. Tumor subsites identified in the reviewed studies included the soft palate, hard palate, base of tongue, tonsil, retromolar trigone, and pharynx. Specifically, 5 studies indicated soft palate ± other regions;^12,18

-21 1 study indicated soft palate, hard palate, or both;²² and the remaining 9 studies indicated oral and/or oropharyngeal regions that may include the soft palate.^23

-31

Surgical resection was the primary treatment modality in 14 out of 15 studies, with the exception of Jacobi et al.²³ which involved patients treated with concurrent-Intensity-Modulated Radiation Therapy and chemotherapy (chemo-IMRT) only. Five studies^{19,20,21,26,31} included patients who underwent adjuvant treatments (radiotherapy or chemoradiation therapy) before or after conventional resection and reconstruction surgery. Prosthetic devices, such as an obturator and/or speech prostheses, were utilized following a total or partial soft palate resection ± reconstruction surgery in 2 studies.^12,22 Sinha et al.²⁰ also reported the use of a palatal prosthesis for some patients who continued to exhibit severe dysphagia even after 12 weeks of swallowing therapy; these patients had extensive surgical defects spanning from the entire soft palate and lateral pharyngeal walls to part of the posterior pharyngeal wall and the base of the tongue. One patient in the Bach et al. study,³¹ who had flap dehiscence but was not eligible for a revision surgery, was also fitted with a speech prosthesis. Further details on the study design, tumor subsite, and treatment modality across studies are summarized in Table 1.

Table 1.

A summary table of 15 studies reviewed: source, number of participants, site of cancer lesion, and cancer treatment modality.

Authors, year	N	Tumor Subsite	Cancer Treatment Modality	Study Design
Jacobi et al., 2016	34	Advanced hypopharynx, nasopharynx, or oropharynx	RT	Evidence obtained from at least 1 well-designed RCT
Chung et al., 2011	53	Tonsil and soft palate	Surgery only	Evidence obtained from well-designed controlled trials without randomization
Katoh et al., 2010	62	Oral and oropharynx	Surgery only	Evidence obtained from well-designed controlled trials without randomization
McCombe et al., 2005	8	Soft palate, retromolar trigone, or tonsillar fossa	Surgery only or surgery + RT	Evidence obtained from well-designed controlled trials without randomization
Yoshida et al., 1993	20	Soft palate, anterior, or middle palate	Surgery only	Evidence obtained from well-designed controlled trials without randomization
Sinha et al., 2004	16	Oropharynx including soft palate	Surgery only	Evidence from well-designed case-control or cohort studies
Hamahata et al., 2017	25	Oropharynx including soft palate	Surgery only	Evidence obtained from well-designed controlled trials without randomization
Sims and Moore, 2018	40	Oropharynx	RT	Evidence from well-designed case-control or cohort studies
Rieger et al., 2008	62	Oropharynx	Surgery only	Evidence obtained from well-designed controlled trials without randomization
Pierre et al., 2014	64	Oral and oropharynx	Surgery only	Evidence from well-designed case-control or cohort studies
Bohle et al., 2005	55	Soft palate	Surgery only	Evidence from well-designed case-control or cohort studies
Inoue et al., 2012	12	Oropharynx	Surgery only	Evidence obtained from well-designed controlled trials without randomization
Seikaly et al., 2008	52	Soft palate, pharyngeal walls, or base of tongue	Surgery only	Evidence from well-designed case-control or cohort studies
Kimata et al., 2002	40	Oropharynx	Surgery only	Evidence obtained from well-designed controlled trials without randomization
Bach et al., 2015	9	Tonsil, soft palate, or glossotonsillar sulcus	Surgery only	Evidence from well-designed case-control or cohort studies

Speech Assessment and Outcome Measures

Table 2 summarizes the results of 15 studies with regards to speech and/or swallowing assessment/outcome measures. Fourteen out of 15 articles reported speech outcome measures including parameters related to VP function. Outcome measures to assess speech ranged from speech intelligibility tests, nasalance, aeromechanical measures of VP function, perceptual ratings of nasality, and a variety of patient-reported surveys. Perceptual measures concerning speech intelligibility, articulation, and/or resonance were most commonly employed (12 out of 14 studies).

Table 2.

Summary of results of the 15 studies that reported speech and/or swallowing assessment/outcome measures.

Authors, year	Speech Assessment		Swallowing Assessment
Authors, year	Type	Result Details	Type	Result Details
Yoshida et al., 1993	Perceptual only—speech intelligibility test based on 100 syllables	1) Patients with posterior band of soft palate demonstrated better speech restoration with obturator compared to without obturator. 2) Patients with resection of posterior edge soft palate had comparatively poorer speech intelligibility scores in comparison to patients without resection of posterior edge of soft palate.
Kimata et al., 2002	Perceptual and instrumental—speech intelligibility based on Hirose’s 10-point scoring system, binary hypernasality, blowing test	1) Patients with type III deficit (surgical resection of soft palate that extended beyond midline) had poorer outcomes in speech intelligibility, binary hypernasality, and blowing test compared to type I and II.	Clinical evaluation only—patient-reported questionnaire on nasal regurgitation	1) Patients with type III deficit reported greater nasal regurgitation compared to type I and II.
Jacobi et al., 2016	Instrumental only—acoustic changes (band energy difference as a nasality measure)	1) Patients with higher radiation doses (>55 Gy) to the base of tongue and oral cavity exhibited increased nasality.
Chung et al., 2011	Perceptual and instrumental—Korean urimal test of articulation and phonology, nasometry, flexible nasoendoscopy	1) Patients with greater than ½ of soft palate resection were associated with poorer nasalance, speech intelligibility, and velopharyngeal insufficiency compared to less than ½ of soft palate resection.
Katoh et al., 2010	Perceptual and instrumental—speech intelligibility test based on understanding of 100 Japanese phonemes, flexible endoscopy assessing VP status, Hirose’s 10-point scoring system	1) Patients who underwent palate resection had significantly impaired speech intelligibility scores compared to healthy controls.2) Blowing pressure ratio scores were correlated with speech intelligibility and swallowing ability.	Clinical evaluation only—patient-reported questionnaire (swallowing ability scale), blowing test	1) Patients who underwent palate resection had significantly impaired swallowing scores compared to healthy controls.
McCombe et al., 2005	Perceptual only—visual analog scale ratings, amyotrophic lateral sclerosis severity scale, Frenchay dysarthria assessment	1) Patients with greater degree of soft palate resection despite reconstruction was associated with greater speech dysfunction.	Clinical evaluation and instrumental—visual analog scale ratings, amyotrophic lateral sclerosis severity scale, VFSS and FEES	1) Nasal regurgitation was present in all patients.2) All patients were able to tolerate some form of modified oral diet; no patient was completely feeding tube-dependent.
Sinha et al., 2004	Perceptual only subjectively judged by authors	1) All patients were able to speak intelligibly although 3 patients were hyponasal and 2 hypernasal.	Clinical evaluation and instrumental—diet outcomes, tracheostomy decannulation, VFSS and FEES were considered for persons with dysphagia	1) All patients were eventually able to resume some form of modified oral diet.
Hamahata et al., 2017	Perceptual only—speech intelligibility test based on 100 monosyllabic Japanese words, Hirose’s speech intelligibility assessment, patient reported hypernasality (yes/no)	1) Patients undergoing >2/3 soft palate resection and reconstruction with the port structure method reported more severe hypernasality.2) Comparatively, less impact was with patients undergoing <1/3 soft palate resection with Gehanno method reconstruction.	Clinical evaluation only—patient-reported diet on a 5-point scale, patient-reported swallowing complaints specific to nasal obstruction/nasal secretions/nasal regurgitation and pharyngeal isthmus size based on CT scan	1) Patients with >2/3 soft palate resection and reconstruction with the port structure method reported more severe nasal regurgitation during swallowing.2) minimal nasal regurgitation was reported with the ALT flap reconstruction and Gehanno method reconstruction.
Sims and Moore, 2018	Perceptual only—patient interview to identify VPI (hypernasality)	1) About 25% of patients with T4 oropharynx cancer present with hypernasality.	Clinical evaluation only—patient interview to identify VPI (nasal regurgitation); Functional Outcome Swallowing Scale	1) About 92% of patients with T4 oropharynx cancer are able to return to full oral diet.
Rieger et al., 2008	Perceptual only—nasometry, pressure-flow, computerized assessment of intelligibility of dysarthric speech	1) Patients who underwent obturator placement for hard and soft palate resection reported poorer satisfaction with speech compared to patients with only partial hard palate resection. Authors draw attention to the data set that included many patients who underwent radiation and likely impacted overall scores.
Pierre et al., 2014	Perceptual only—clinician assessment of hypernasality (presence/absence), 4-point scale on speech intelligibility	1) Patients with tumor involvement of the soft palate were more likely associated with hypernasality and reduced speech intelligibility and this was 16% of the sample.	Clinical evaluation and instrumental—Dysphagia Outcome and Severity Scale; FEES	1) Patients with tumor involvement of the soft palate more likely reported VPD.2) Velopharyngeal insufficiency was noted via FEES on 23% of the sample.
Bohle et al., 2005	Perceptual and instrumental—pressure-flow, computerized assessment of intelligibility of dysarthric speech, percent intelligibility from naïve listeners, clinician ratings of voice and resonance qualities on a 5-point likert scale based on passage readings	1) Speech bulb aid was beneficial to significantly improve speech intelligibility scores in patients undergoing hard and soft palate resection.2) Sample size largely favored <50% resection. Most patients were able to achieve >90% intelligibility on sentence intelligibility tasks.
Inoue et al., 2012	Perceptual only—articulation based on story reading and Hirose’s 100 monosyllabic Japanese words	1) Deterioration in articulation precision was noted for patients who underwent forearm flap reconstruction. Relatively better outcomes were noted for patients with rectus abdominis myocutaneous flap especially with larger (>50% soft palate) defects.	Clinical evaluation and instrumental—survey of diet menu, meal time and other complaints, VFSS, blowing test	1) Nasopharyngeal escape was not noted on VFSS for patients who underwent forearm flap reconstruction.2) Blowing test scores were mildly deteriorated in patients who underwent forearm flap reconstruction but most were able to eat modified oral diet.
Seikaly et al., 2008			Instrumental only—VFSS, diet, tube feeding	1) 14% of patients reported nasopharyngeal reflux and 91% returned to full oral diet.
Bach et al., 2015	Perceptual only—Hirose scoring system, patient report of hypernasality, nasal emission on blowing, nose breathing	1) 22% of patients reported hypernasality with reduced intelligibility.	Clinical evaluation only—patient questionnaire survey on 4-point scale and patient report of nasopharyngeal regurgitation	1) 22% of patients reported nasopharyngeal regurgitation.

Speech intelligibility was assessed in various ways across studies. For example, 3 studies employed formal tests for evaluating speech intelligibility: Frenchay Dysarthria Assessment¹⁹ and Computerized Assessment of Intelligibility of Dysarthric Speech.^12,21 Four studies^25,26,30,31 consistently utilized Hirose’s 10-point scoring system as a speech intelligibility measure, which involves a combined scoring of the patient’s speech understandability by family and by others on a 5-point rating scale (5 points, clearly understood; 4 points, occasionally misunderstood; 3 points, understood only when subject is known; 2 points, occasionally understood; 1 points, never understood). Yoshida et al.²² estimated speech intelligibility by having patients produce 100 Japanese syllables and 10 unknown listeners transcribe the sounds; the mean percentage of correct responses from the listeners served as an index of speech intelligibility. A similar approach was used by Katoh et al.,²⁴ in which speech intelligibility was estimated by having 5 speech therapists score the patient’s production of 100 Japanese phonemes. Chung et al.¹⁸ assessed speech intelligibility based on the percentage of consonants correct calculated from a formal articulation/phonology test (Korean Urimal Test of Articulation and Phonology). Inoue et al.²⁷ reported “speech clarity” through analyzing the patient’s articulatory function during a story reading and during the production of 100 monosyllabic Japanese words. While all patients were found to be able to “speak intelligibly,” no detailed information was provided on how speech intelligibility was assessed in the Sinha et al. study.²⁰ Katoh et al.²⁴ and McCombe et al.¹⁹ additionally included patient-reported questionnaire on speech ability/intelligibility/severity in addition to the perceptual speech evaluation.

Seven studies described the patients’ resonance characteristics, although varying in detailed approaches. According to Bohle et al.,¹² a speech-language pathologist rated the patient’s voice and resonance characteristics during a passage reading using a 5-point Likert scale. Two studies^28,30 included a binary rating system (presence vs absence) of hypernasality as part of perceptual evaluations. Sinha et al.²⁰ described some patients exhibiting hypernasality or hyponasality without any details on the resonance assessment approach. Bohle et al.¹² and Hamahata et al.²⁵ included the presence or absence of hypernasality based on patient-reported questionnaires and complaints. Sims and Moore²⁶ listed VP insufficiency (VPI) as one of the long-term complications among patients with head and neck cancer in their retrospective study, and yet, no details were provided on the nature of VPI or its clinical manifestations.

Seven out of 14 studies incorporated instrumental evaluation to assess VP function. Conventional instrumental measures included nasometry,^18,21 pressure-flow technique,^12,21 and nasendoscopy.^18,24 Somewhat unconventional instrumental measures were also reported in the reviewed literature, which included the relative band energy of the formants as an estimate of nasality,²³ soft blowing/blowing ratio to estimate the extent of nasal emission,^24,27,30 and manometry-based oropharyngeal pressure measures.²⁴

Swallowing Assessment and Outcome Measures

Swallowing outcomes were reported in 10 out of 15 studies. Outcome measures utilized for VP deficit in swallowing ranged from patient reports of food or liquid escape into the nasal cavity, diet outcomes questionnaires and surveys, manometry, blowing test, and conventional imaging techniques such as FEES and VFSS.

Eight out of 10 studies utilized patient-reported outcomes that included patient interview,²⁶ Swallowing Ability Scale,²⁴ patient questionnaire survey,^19,27,30,31 Amyotrophic Lateral Sclerosis Scale (ALSS),¹⁹ patient-reported diet outcomes.^20,25 Sims and Moore²⁶ utilized Functional Outcome Swallowing Scale (FOSS) and presence or absence of percutaneous endoscopic gastrostomy (PEG) tube as outcome measures. The ALSS is a patient-reported outcome scale utilized to assess the patient’s view on speech and swallowing changes, originally developed for use with the ALS population and does not have specific questions related to VPD. McCombe et al.¹⁹ incorporated a combination of perceptual (ALSS, visual analog scale) and instrumental (VFSS and FEES) to assess VP function.

Six studies utilized instrumental evaluation of swallowing via VFSS and/or FEES to assess swallowing.^{19,20,24,27
-29} All 6 studies reported some level of VPI ranging from mild to gross nasopharyngeal escape. Katoh et al.²⁴ additionally reported oropharyngeal pressure measures based on manometry.

Discussion

Velopharyngeal function is an important element associated with speech and swallowing outcomes in head and neck cancer. The multiple aspects involved in VP movement make it a challenging area to study especially when multi-modality treatment methods have very different effects on function. The current review revealed a total of 15 studies that included speech outcomes, swallowing outcomes, or both in relation to VP function in head and neck cancer. Revisiting the purpose of this review, VPD is anticipated in patients with an obvious palate resection and/or those who undergo radiotherapy wherein the field of radiation encompasses soft tissue, including the underlying muscles, of the VP region. However, VPD was also reported when treatment sites include neighboring structures such as base of tongue and posterior pharyngeal wall, making it important to include VPD assessment when evaluating patients with tumors of the posterior oral cavity as well. Radiotherapy-related ramifications on VPD, while noted clinically, were not systematically reported. It would seem apparent that VPD would be more prevalent in patients treated for cancers of the nasopharynx, hard and/or soft palate, and lateral pharyngeal wall. However, it is essential to note that certain oropharyngeal tumors (e.g., palatine tonsil) may require surgical resection of the palate to obtain clear margins. Clear resection margins (i.e., complete resection) are associated with improved curative disease free survival in head and neck cancer and influence the decision regarding adjuvant radiotherapy with or without chemotherapy.^32,33 While adding radiation or chemoradiation therapy can offer superior curative outcomes, the consequent connective tissue fibrosis can result in drastic functional changes.³⁴ In fact, adjuvant radiotherapy has been identified as an independent predictor of speech and swallow dysfunction.³⁵ Taken together, it is vital to extend VPD assessment when evaluating patients with head and neck cancer with tumor location beyond the palatal and nasopharyngeal structures and treatment modalities beyond surgical resection.

Reported speech and swallowing outcomes varied across studies, ranging from patient-reported and perceptual outcomes to objective/instrumental assessment, but were largely skewed towards speech-related perceptual measures and swallowing-related patient-reported outcomes. There is value in understanding the use of certain outcome measures. Clinical impressions of perceptual assessments and patient reports are often what guides appropriate referrals in a clinical setting and therefore the use of speech intelligibility tests is worthwhile. However, its value in estimating VP function is limited unless coupled with instrumental measurements. The established standard of care for VP function among patients with cleft palate and craniofacial disorders includes a combination of perceptual resonance and speech intelligibility assessments and instrumental assessment with the use of nasometry and VP imaging.^36,37 Unfortunately, no such standardized clinical protocol evaluating VP function in patients with head and neck cancer was observed in the reviewed studies, rendering it difficult to draw equal comparisons across studies. It is the understanding of pathophysiology that carries the clinician forward towards treatment and management. The paucity in understanding the physiologic underpinning is likely a contributing factor to the lack of clarity among clinicians in evaluating and treating VPD in head and neck cancer.

Additionally, novel evaluation methods add another layer of variability in understanding the deficit. For instance, the efficacy of a “blowing test” was examined in one study,²⁴ where the authors attempted to determine if this clinical test could predict VP function for speech. The blowing test requires the individual to blow air into a cup filled with water to a particular level under 2 conditions: nares closed and nares open. A blowing time ratio is determined by dividing blowing time with open nose condition over closed nose condition. This measure, without any validation in relation to an external criterion procedure (i.e., established instrumental assessments of VP function), was then correlated with a perceptual speech intelligibility test. On the one hand, a nonspeech blowing test provides little insight into the VP function for speech as nonspeech static oral movement is different from the highly coordinated and precise gestures required for speech.^7,38,39 On the other hand, sole reliance of syllable or word intelligibility tests may not translate into overall speech intelligibility of connected speech. Despite the obvious site of resection, the salient feature (VPD) affecting speech intelligibility was not comprehensively evaluated in a large portion of the literature.

Transitioning to swallowing outcomes, the complexity of the musculature involved in achieving VP closure for swallowing as well as changes in oral cavity dynamics with respect to sensory feedback would demand a more comprehensive understanding. However, no study included in this review reported specific information regarding VP function on swallowing with the use of imaging studies such as VFSS or FEES. While most utilized clinical report of nasal regurgitation during meals, the details of cranial nerve assessments, details of surgical changes and bolus trials utilized in clinical swallow evaluation that can illustrate the mechanism of deficits were also limited. The use of VFSS in the assessment of these patients is necessary in order to understand the pathophysiology.

Both Sinha et al.²⁰ and Hamahata et al.²⁵ utilized diet outcomes post-operatively as a measure of swallowing outcome. Patients were merely asked to report on their oral intake and a report of eating a regular diet would be scored as “no difficulty.” Taking a step back from VPD, it is important to realize that subjective report of diet outcomes and patient reports of difficulty swallowing may not accurately portray intact or impaired swallowing physiology. There appears to be lack of correlation between patient reported outcomes in swallowing and the true physiologic swallowing outcomes noted under imaging .^40,41 For example, Arrese et al.⁴⁰ examined the relationship between patient-reported outcomes on the Eating Assessment Tool-10 (EAT-10) and VFSS physiologic findings among patients who underwent head and neck cancer treatment. The findings relayed that these patients often under-reported their deficit. Similarly, Kirsh and colleagues⁴¹ reported reduced patient awareness of compromised swallowing function following chemoradiation.

Despite the variability in assessment of VPD across the various studies, some general conclusions can be drawn from the results relevant to the scope of this paper. Over 2/3^rd of the reviewed studies reported that greater tumor burden along the soft palate with >50% resection and reconstruction are more often correlated with poorer outcomes for both speech and swallowing.^{18,19,21

-28,30} The greater presence of soft palate is associated with improved intelligibility. Studies that assessed functional oral intake outcomes reported a high number of patients who were able to return to oral diet^19,20,26,27 with 4 studies reporting between 14 and 23% of patients reporting or identifying some form of VPI.^28,29,31 With respect to radiation associated VPD, it appears a radiation dose of >55 Gy is associated with increased nasality on careful acoustic analysis.²³

The deficit in the use of standard perceptual and instrumental evaluation of VPD is enlightening and helps clinicians understand barriers in VPD assessment and management for patients undergoing treatment for head and neck cancer. In the grand scheme of the review, the need for physiology-based outcome measures with respect to speech and swallowing functions is apparent. There was and continues to remain a heavy reliance on patient-reported outcomes alone to account for “improvement.” In addition, the variability in measurements and lack of general standard of care in the assessment of VP function make it challenging to compare outcomes across studies. Despite the limited number of studies, it is evident that patients may present with VPD at any stage in cancer treatment (i.e., post-surgery, post-(chemo)radiotherapy, late radiation effects). Identifying the unique impact of surgery, radiation therapy, and combination of both effects through establishing a standard-of-care evaluation methodology for VPD can help in guiding clinical and multi-disciplinary treatment to result in effective measurable gains post-cancer treatment for this patient population.

For future direction and for clinicians seeking to improve evaluation, we recommend a combination of perceptual (e.g., patient-reported outcomes and speech intelligibility) and instrumental evaluations (e.g., pressure-flow testing or nasometry and manometry for speech and swallowing, respectively, along with VP imaging) would be ideal to create a profile of speech/swallowing function for this unique population. At the authors’ institution, a combination of Speech Handicap Index, Assessment of Intelligibility of Dysarthric Speech, and nasometry is utilized to complete a comprehensive assessment of speech for patients with head and neck cancer. VFSS along with the standardized MBSImP rating scale is utilized to assess impact of VPD on swallow function. As is the case with head and neck cancer, for patients who undergo radiotherapy, recent statistics report approximately 5% of all patients treated will present with late radiation effects in 5 years post-treatment and approximately 12% in 12 years.⁴² A salient feature of late radiation effects includes VPD in the setting of multiple cranial nerve neuropathies. Optimizing function for patients undergoing late radiation effects includes a prosthodontic evaluation for devices such as palatal lift. The efficacy of VPD management in patients undergoing late radiation changes is limited due to the limited understanding of changes and methods to manage the overall oropharyngeal anatomic changes. While exercise-based therapies are not well supported for targeting VP function, preliminary work by Hutcheson et al.⁴³ revealed increased soft palate activation following a course of expiratory muscle strength training. An extended scope would be to create a physiologically based profile of VPD across the continuum of head and neck cancer treatment: a profile that includes objective speech and swallowing outcomes post-treatment with attention to location, size of tumor and sets a standard for assessment of VP function.

Footnotes

Author Note

Part of this study was presented at the American Speech-Language-Hearing Association (ASHA) annual convention, Orlando, Florida, November 2019.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Veena Kallambettu

References

Rinkel

Verdonck-de Leeuw

Doornaert

, et al. Prevalence of swallowing and speech problems in daily life after chemoradiation for head and neck cancer based on cut-off scores of the patient-reported outcome measures SWAL-QOL and SHI. Eur Arch Oto-Rhino-Laryngol. 2016;273:1849-1855. doi:10.1007/s00405-015-3680-z

Skolnick

Shprintzen

McCall

Rakoff

. Patterns of velopharyngeal closure in subjects with repaired cleft palate and normal speech: a multi-view videofluoroscopic analysis. Cleft Palate J. 1975;12:369-376.

Witzel

Posnick

. Patterns and location of velopharyngeal valving problems: atypical findings on video nasopharyngoscopy. Cleft Palate J. 1989;26:63-67.

Finkelstein

Talmi

Nachmani

Hauben

Zohar

. On the variability of velopharyngeal valve anatomy and function. Plast Reconstr Surg. 1992;89:631-639.

Croft

Shprintzen

Rakoff

. Patterns of velopharyngeal valving in normal and cleft palate subjects. Laryngoscope. 1981;91:265-271.

Kuehn

Moller

. Speech and language issues in the cleft palate population: the state of the art. Cleft Palate-Craniofacial J. 2000;37:1-35. doi:10.1597/1545-1569_2000_037_0348_saliit_2.3.co_2

Kuehn

Moon

. Levator veli palatini muscle activity in relation to intraoral air pressure variation. J Speech Lang Hear Res. 1994;37:1260-1270.

Nohara

Kotani

Ojima

Sasao

Tachimura

Sakai

. Power spectra analysis of levator veli palatini muscle electromyogram during velopharyngeal closure for swallowing, speech, and blowing. Dysphagia. 2007;22:135-139. doi:10.1007/s00455-006-9066-z

Pusic

Liu

Chen

, et al. A systematic review of patient-reported outcome measures in head and neck cancer surgery. Otolaryngology-Head Neck Surg (Tokyo). 2007;136:525-535. doi:10.1016/j.otohns.2006.12.006

10.

Wehby

Cassell

. The impact of orofacial clefts on quality of life and healthcare use and costs. Oral Dis. 2010;16:3-10. doi:10.1111/j.1601-0825.2009.01588.x

11.

Lovell

Wong

H-B

Loh

K-S

Ngo

RYS

Wilson

. Impact of dysphagia on quality-of-life in nasopharyngeal carcinoma. Head Neck. 2005;27(10):864-872. doi:10.1002/hed.20250

12.

C-H

J-Y

Hsiao

T-Y

Hsu

M-M

. Dysphagia after radiotherapy: endoscopic examination of swallowing in patients with nasopharyngeal carcinoma. Ann Otol Rhinol Laryngol. 2000;109(3):320-325. doi:10.1177/000348940010900315

13.

Bray

Ferlay

Soerjomataram

Siegel

Torre

Jemal

. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA A Cancer J Clin. 2018;68:394-424. doi:10.3322/caac.21492

14.

Marur

Forastiere

. Head and neck cancer: changing epidemiology, diagnosis, and treatment. Mayo Clin Proc. 2008;83(4):489-501. doi:10.4065/83.4.489

15.

Nguyen

Frank

Moltz

, et al. Impact of dysphagia on quality of life after treatment of head-and-neck cancer. Int J Radiat Oncol Biol Phys. 2005;61(3):772-778. doi:10.1016/j.ijrobp.2004.06.017

16.

Eisbruch

Lyden

Bradford

, et al. Objective assessment of swallowing dysfunction and aspiration after radiation concurrent with chemotherapy for head-and-neck cancer. Int J Radiat Oncol Biol Phys. 2002;53(1):23-28. doi:10.1016/S0360-3016(02)02712-8

17.

C-H

J-Y

Hsiao

T-Y

Hsu

M-M

. Dysphagia after radiotherapy: endoscopic examination of swallowing in patients with nasopharyngeal carcinoma. Ann Otol Rhinol Laryngol. 2000;109(3):320-325. doi:10.1177/000348940010900315

18.

Chung

E-J

Lee

D-J

Kang

H-D

Park

M-I

Chung

C-H

Rho

Y-S

. Prospective speech outcome study in patients with soft palate reconstruction in tonsillar cancer. Oral Oncol. 2011;47(10):988-992. doi:10.1016/j.oraloncology.2011.07.022

19.

McCombe

Lyons

Winkler

Morrison

. Speech and swallowing following radial forearm flap reconstruction of major soft palate defects. Br J Plast Surg. 2005;58(3):306-311. doi:10.1016/j.bjps.2004.09.007

20.

Sinha

Young

Hurvitz

Crockett

. Functional outcomes following palatal reconstruction with a folded radial forearm free flap. Ear Nose Throat J. 2004;83(1):45-48. doi:10.1177/014556130408300116

21.

Rieger

Zalmanowitz

SYY

, et al. Speech outcomes after soft palate reconstruction with the soft palate insufficiency repair procedure. Head Neck. 2008;30(11):1439-1444. doi:10.1002/hed.20884

22.

Yoshida

Michi

K-I

Yamashita

Ohno

. A comparison of surgical and prosthetic treatment for speech disorders attributable to surgically acquired soft palate defects. J Oral Maxillofac Surg. 1993;51(4):361-365. doi:10.1016/S0278-2391(10)80345-3

23.

Jacobi

Navran

van der Molen

Heemsbergen

Hilgers

FJM

van den Brekel

MWM

. Radiation dose to the tongue and velopharynx predicts acoustic-articulatory changes after chemo-IMRT treatment for advanced head and neck cancer. Eur Arch Oto-Rhino-Laryngol. 2016;273(2):487-494. doi:10.1007/s00405-015-3526-8

24.

Katoh

Saitoh

Tsuneyuki

, et al. Blowing ratio as an evaluation tool for velopharyngeal function after oral and oropharyngeal cancer resection. Head Neck. 2010;32(8):1012-1018. doi:10.1002/hed.21283

25.

Beppu

Tokumaru

Yamaki

Sakurai

Hamahata

. A comparison of large soft palate defect reconstruction using the new “tunnel structure” and traditional “port structure” methods. J Reconstr Microsurg. 2017;33(1):70-76. doi:10.1055/s-0036-1592296

26.

Sims

Moore

. Primary surgical management with radial forearm free flap reconstruction in T4 oropharyngeal cancer: Complications and functional outcomes. Am J Otolaryngol. 2018;39(2):116-121. doi:10.1016/j.amjoto.2017.12.012

27.

Inoue

Nagata

Yukawa

, et al. Evaluation of postoperative function in patients undergoing reconstruction following resection of superior and lateral oropharyngeal cancer: long-term outcomes of reconstruction with the Gehanno method. Int J Oral Maxillofac Surg. 2012;41(1):9-16. doi:10.1016/j.jiom.2011.10.003

28.

Pierre

Dassonville

Chamorey

, et al. Long-term functional outcomes and quality of life after oncologic surgery and microvascular reconstruction in patients with oral or oropharyngeal cancer. Acta Otolaryngol. 2014;134(10):1086-1093. doi:10.3109/00016489.2014.913809

29.

Seikaly

Rieger

Zalmanowitz

, et al. Functional soft palate reconstruction: a comprehensive surgical approach. Head Neck. 2008;30(12):1615-1623. doi:10.1002/hed.20919

30.

Kimata

Uchiyama

Sakuraba

, et al. Velopharyngeal function after microsurgical reconstruction of lateral and superior oropharyngeal defects. Laryngoscope. 2002;112(6):1037-1042. doi:10.1097/00005537-200206000-00019.

31.

Bach

Wagner

Pigot

Guth

Denoux

Chabolle

. Velopharyngeal function after free thoracodorsal artery perforator flap in lateral and superior oropharyngeal cancer. Eu Arch Oto-Rhino-Laryngol. 2015;272(10):3019-3026. doi:10.1007/s00405-014-3279-9

32.

Eldeeb

Macmillan

Elwell

Hammod

. The effect of the surgical margins on the outcome of patients with head and neck squamous cell carcinoma: single institution experience. Cancer biology & medicine. 2012;9:29-33. doi:10.3969/j.issn.2095-3941.2012.01.005

33.

Hitter

Soriano

Bettega

Karkas

Reyt

Righini

. [Outcome of surgical and adjuvant radiotherapy treatment of T3-T4 squamous cell carcinoma of the floor of the mouth: evaluation of oncological control and treatment related morbidity]. Rev Laryngol Otol Rhinol. 2007;128(3):155-162.

34.

Logemann

Rademaker

Pauloski

, et al. Site of disease and treatment protocol as correlates of swallowing function in patients with head and neck cancer treated with chemoradiation. Head Neck. 2006;28(1):64-73. doi:10.1002/hed.20299

35.

Zuydam

Lowe

Brown

Vaughan

Rogers

. Predictors of speech and swallowing function following primary surgery for oral and oropharyngeal cancer. Clin Otolaryngol. 2005;30(5):428-437. doi: 10.1111/j.1365-2273.2005.01061.x

36.

Baylis

Perry

Wilson

, et al. Team management of velopharyngeal inadequacy: practical suggestions for speech-language pathologists and surgeons. Perspectives of the ASHA Special Interest Groups. 2019;54:850-856. doi:10.1044/2019_pers-sig5-2019-0003

37.

Pannbacker

. Velopharyngeal incompetence. Am J Speech Lang Pathol. 2004;13:195-201. doi:10.1044/1058-0360(2004/020

38.

Moll

. A cinefluorographic study of velopharyngeal function in normal during various activities. Cleft Palate J. 1965;2:112-122.

39.

Shprintzen

McCall

Skolnick

. A new therapeutic technique for the treatment of velopharyngeal incompetence. JSHD (J Speech Hear Disord). 1975;40:69-83.

40.

Arrese

Schieve

Graham

Stephens

Carrau

Plowman

. Relationship between oral intake, patient perceived swallowing impairment, and objective videofluoroscopic measures of swallowing in patients with head and neck cancer. Head Neck. 2019;41(4):1016-1023. doi:10.1002/hed.25542

41.

Kirsh

Naunheim

Holman

Kammer

Varvares

Goldsmith

. Patient‐reported versus physiologic swallowing outcomes in patients with head and neck cancer after chemoradiation. Laryngoscope. 2019;129(9):2059-2064. doi:10.1002/lary.27610

42.

Hutcheson

Holsinger

Kupferman

Lewin

. Functional outcomes after TORS for oropharyngeal cancer: a systematic review. Eur Arch Oto-Rhino-Laryngol. 2015;272(2):463-471. doi:10.1007/s00405-014-2985-7

43.

Hutcheson

Barrow

Plowman

, et al. Expiratory muscle strength training for radiation-associated aspiration after head and neck cancer: a case series. Laryngoscope. 2018;128(5):1044-1051. doi:10.1002/lary.26845

Velopharyngeal Function Post Head and Neck Cancer: A Review

Abstract

Background

Methods

Results

Conclusions

Keywords

Introduction

Methods

Literature Search

Data Extraction

Results

Tumor Subsite and Treatment Modality

Speech Assessment and Outcome Measures

Swallowing Assessment and Outcome Measures

Discussion

Footnotes

Author Note

Declaration of Conflicting Interests

Funding

ORCID iD

References