How do I help my swallowing after tonsillar head & neck cancer treatment?

arkj prgram emst150 head neck rehab wildflower therapy Nov 22, 2022

A 62yo treated with primary tonsillar SCCA T4N0M0 female comes to our clinic 13 weeks post treatment of her head & neck cancer. She is frustrated and exhausted. She has good news her cancer is gone based on her recent PET scan, but she cannot swallow and has a feeding tube in place. We are speech pathologist. The first thing we do is listen to the patient and then begin our assessment.

How do we assess the swallowing? 

A fiber endoscopic swallowing exam. This is look at the structures inside the pharynx to determine the level of swelling a patient is experiencing following their treatment. The swelling is called internal edema. The staging of internal edema in our clinic is labeled: normal, mild, moderate, and profound based on the Revised Patterson Scale. Following treatment nearly all patients have some degree of internal swelling.  We review the images with the patient and level of their swelling inside their throat that is now impacting their swallowing.

What is the clinical patient report?

For this patient she is having trouble with her spit. Many patients are sitting in our office with a trash can, water bottle with large opening or box of Kleenex to remove the spit from their mouth. She is constantly coughing and choking on her own spit. She can't sleep due to the constant spit and choking.  This is considered normal for this stage of healing in their process. But it is frustrating for the patient. She has a hard time swallowing anything. She doesn't want to eat. Nothing tastes good and her mouth is dry. 

How can we help our patient?
The first thing is reassuring the patient what she is experiencing is normal right now and it will improve. Continue to trust the medical team involved and collaborate with this team. We tell our patient with time this will pass but here is what you can do to help this while we wait.

  1. Sit upright or sleep as upright as possible
  2. Try to get something to swallow (ice chips or water) after cleaning the mouth but we must swallow something.
  3. Begin exercises aimed to rehabilitate the muscles of swallowing that have been impacted.

 What exercises can I do to help my swallow?

  1. Use an EMST75 or EMST150. This stands for expiratory muscle strength training. If the patient has a flap do NOT use this device. 
  2. Swallow hard. This is called an effortful swallow. It loads the muscles of your swallowing and tries to increase the amount of work they do with the swallow. Swallow your ice chips hard, swallow your water hard and swallow your spit hard. When you swallow think “I am swallowing a golf ball”.

When do I begin eating again?
That depends on the level of which you are clearing food or bolus through your throat and the recommendation of your speech pathologist. The speech language pathologist should be guiding you on each step of your swallow rehabilitation. In our case study, she stopped swallowing food. She barely took sips of water as she choked each time. So we started with ice chips after finding the structures inside the throat were experiencing moderate edema impacting her ability to swallow. 

What about this swelling on my neck that just showed up?

The lymphatics to your body have been disrupted. If your speech pathologist is not trained in treatment of lymphedema, they need to refer you to a certified lymphedema therapist who has experience in the head & neck.  Lymphedema requires treatment it will not “go away on it’s own”.
What do we do for our treatment plan of lymphedema in this case?

  1. First, our patient will be measured.
  2. Second, she will be encouraged to video us opening the trunk or decongesting the body and waking up her lymph collectors. This is through a sequenced series of “massages” or movements that your therapist will perform.
  3. It should be skin to skin
  4. The therapist will move from the body to the neck in this patient. She does not present with facial edema.
  5. A compression garment and chip pack will be recommended or created.
  6. This patient did not experience facial edema so she is sent home with a Marena over the counter compression garment with a size medium mid neck.
  7. The sizing was measured by taking the middle portion of her neck and measuring it in cm and referring to the package on the Marena that matches her size.
  8. In a perfect world she will return up to 5x week for this treatment, however, sadly the reality it she will return next week due to the 1.5-hour drive to see us at the clinic.
  9. That is why a video is essential!

How long does our patient see us in the clinic?

It varies. The patient may see us for 6-12 months with goals of exercise, tube feeding weaning, management of lymphedema and teaching her the 3-finger rule for monitoring of trismus signs. Each of these cases are recommended a different treatment plan and exercises based on the swallowing study, pain threshold and patient's motivation. 


Deng, Jie, et al. "Factors Associated with External and Internal Lymphedema in Patients with Head and Neck Cancer" International Journal of Radiation Oncology Biology Physics 84 no 3 (November 2012) 319-328.

Deng, Jie & Murphy, Barbara. "Lymphedema self-care in patients with head and neck cancer: a qualitative study" Supportive Care in Cancer 24 (2016) 2961-4970. 

Deng, Jie. Ridner, Shelia.  “Prevalence of Secondary Lymphedema in Patients With Head and Neck Cancer”. Journal of Pain and Symptom Management 43,no 2 (February 2012): 244-252

Deng, Jie et al. "Refinement and Validation of the Head and Neck Lymphedema and Fibrosis Symptom Inventory" International Journal of Radiation Oncology Biology and Physics 109 no 3 (March 2021) 747-755. 

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