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Definitive treatment of cancer that arises from the skin of the face and neck or tissues of the nose, mouth, throat, and larynx may result in impairments in cosmesis, oral communication, feeding, and respiration, as well as affect the senses of sight, hearing, taste, and smell. These functional deficits may have major psychological, social, and vocational consequences if not adequately addressed early and managed properly. Surgical excision and reconstruction are frequently followed by radiation, which by itself may produce clinical problems, including skin erythema, blistering and peeling, edema, delayed wound healing, muscle atrophy and fibrosis with reduced mobility, nerve damage with weak muscles and sensory deficits, dry mouth, and bad or lost taste. Sensory deficits and radiation-induced skin changes require careful grooming and hygiene to prevent further skin damage, by using nonirritating soaps and cosmetic products, an electric razor instead of a blade, lukewarm water for washing, loose-fitting garments, and similar measures. Meticulous oral hygiene is essential, and the patient should frequently use diluted mouthwash with 3% hydrogen peroxide but avoid all irritating agents (ie, alcohol, tobacco, and astringent toothpaste) and should limit denture wear. A sense of noxious taste and dry mouth may be reduced by the use of artificial saliva and by increasing fluid intake. Mobilizing exercises for the mouth, jaw, neck, and shoulders should be emphasized to prevent adhesions and contractures.
Cosmetic defects of the face are primarily treated by surgical reconstruction, but different types of maxillofacial prostheses may be custom-made from plastic materials to closely match the facial contours and complexion. Surgical resection of cancer involving the mouth, pharynx, and larynx may result in impaired functions of chewing, swallowing, and speaking in different proportions. Following resection of the tongue and mandible, physical exercise of the residual muscles may improve chewing and swallowing, and special tubes or utensils may help to place the food into the pharynx or esophagus and thus ease the swallowing process. Defects in the palate may be corrected by a prosthetic device, an obturator, placed between the oral and nasal cavities.
Total laryngectomy results in a complete loss of voice and a permanently open tracheostomy.37 Preoperatively, a speech pathologist should meet with the patient to explain ways to communicate postoperatively. Communication is initiated postoperatively by using writing materials, communication boards, or electronic typing gadgets, but as early as possible the patient is instructed in the use of an artificial electrolarynx. Here, a handheld battery-powered “diaphragm” is placed firmly against the neck to transmit sound waves through the tissues into the mouth, where it resonates and may be articulated with relative ease as comprehensible speech. Greater training, however, is required to become proficient in the esophageal speech, which is generated by trapping air in the upper esophagus by the tongue and releasing it suddenly into the pharynx, thus producing a “burplike” low-pitched sound that may be articulated into words. (Other patients may prefer pharyngeal speech, which is produced by capturing air within the mouth or pharynx.) In some cases, a tracheopharyngeal shunt may be surgically reconstructed to restore a more normal voice.38 Because of the open tracheostomy, the laryngectomized patient is unable to strain during lifting, pushing, or defecation, except by manually closing the stoma. The permanent tracheostomy requires not only good local care, but also inhalation of humidified air through a stoma cover made of a piece of gauze that acts as a sieve for dust and other foreign materials.
Certain laryngeal cancers may be treated with partial resection of the larynx, that is, hemilaryngectomy or supraglottic laryngectomy. Hemilaryngectomy removes one vocal cord, while supraglottic resection removes the epiglottis. The former is associated with a voice change that may be improved with voice therapy, whereas the latter is associated with impaired deglutition, which is restored with appropriate therapy. Aspiration pneumonia is a possible complication of laryngeal dysfunction. In paralysis of a vocal cord, autologous cartilaginous transcervical implant can restore phonation and diminish aspiration.
Radical neck dissection may involve the removal of several neck muscles and temporary or permanent damage of the spinal accessory nerve that supplies the sternocleidomastoid and the trapezius muscles. This is likely to result in gross asymmetry of the neck and shoulders, restriction of motion, overstretching of remaining muscles, and persistent pain if not treated early. During the rehabilitation of these patients, it is of primary importance to unload the shoulder immediately postoperatively, to reduce shoulder and neck pain, and to prevent stretch fibrosis of the trapezius and contracture of the unopposed pectoralis muscles, as well as to provide strengthening exercises for the residual muscles in the neck and shoulder girdle to compensate for lost muscles.39 The patient is instructed to maintain good posture, both while sitting and standing, and to pull back the shoulders frequently. Sleeping on the back is preferable, with proper support provided by pillows placed between the scapulae and under the posterior neck. Lying on the affected side is to be avoided, and when lying on the unaffected side, the affected arm should be slightly raised and supported on a pillow. Occasionally, it may be helpful to wear a sling, or even a shoulder orthosis, to compensate for trapezius paralysis. Therapeutic exercises are initially passive but gradually progress to active-assistive and eventually resistive exercises as tolerated by the patient. Strenuous physical activities, such as lifting, carrying, pulling, and pushing, should be avoided initially but may be resumed in the course of time as the physical condition improves.