This particular Australian patient lives mostly in Vietnam. He chose to travel between Vietnam and St Vincent’s for the treatment of his head and neck cancer He did so knowing that he was committing to a treatment plan lasting months followed by regular cancer surveillance over the next 5 years. His decision was made with the knowledge that the Head and Neck Service at St Vincent’s has a national and international reputation for excellence, seeing over 350 cancer patients annually.
Diagnostic tests confirmed that the patient had HPV+ oropharyngeal cancer of the left palatine tonsil. Assoc Prof Richard Gallagher, who led the acute care team, then performed a robotic radical tonsillectomy. The specific details of the surgery are described in his post on the benefits of Transoral Robotic Surgery (TORS) based on the same case.
Due to cancer detected in our patient's lymph nodes, extra treatment with radiotherapy was recommended and provided. This is a treatment that brings with it inflammatory side-effects most of which typically begin to subside with the end of treatment. Swallowing and speech are initially impacted on by surgery and then by radiotherapy to the lymph nodes which causes swelling of the throat and other acute and subacute side effects.
As the speech pathologist, my intervention commenced in the recovery ward the day after his surgery. I explained why Richard asked me to work with him and described how speech pathology could help improve the speed with which his speech and swallowing functions returned. To date, my team and I have worked with Richard on 34 such cases where TORS was the primary treatment modality. My experience aligns with published research on this approach which shows that in the long-term, TORS is superior to other surgical interventions for preserving the functions of speech and swallowing. This is because it is minimally invasive surgery.
That said, a minimally invasive radical tonsillectomy followed by radiotherapy will put any patient on a challenging journey for many months. For a speech pathologist the main and immediate post-operative challenge is the patient's swallowing function. Most TORS patients require a modified diet initially. The use of thickened fluids in the short term is often very beneficial in facilitating early, comfortable, and safe return to oral intake. The slower movement of these fluids through the mouth and throat gives time for the body to protect the windpipe. Most TORS patients will typically progress through to normal fluids and near normal foods by the time they are ready to leave hospital. Most TORS patients will not require a nasogastric tube due to the minimally invasive nature of this type of surgery. By the time our patient was discharged home, he had graduated to thin fluids and a soft bite-sized diet. Exactly the progress he and the treating multidisciplinary team were hoping for.
Our patient returned to Vietnam about 3 months after his primary treatment knowing that the Australian care team of doctors would monitor him for five years. Normally he would be reviewed every three months for the first 2 years, then every 4 months for the third year and then every six months for the final two years. In our patient’s case there is a little more flexibility because he lives overseas. Speech pathology reviews are not considered compulsory as part of this five year surveillance process, however they are considered important to ensure any residual dysphagia or speech/voice disorders are managed. Likewise, this approach ensures that any new onset difficulties that may relate to mid-long term side effects of radiotherapy and/or recurrence can be addressed proactively. For the described patient, I participated in some of the initial post-operative reviews that Richard performed in his rooms, as well as seeing him individually through my private practice.
Recovery in this case is considered successful. He is cancer free and his speech and swallowing has essentially returned to normal. He is doing exceptionally well and will now receive care from me on an "as needs" basis. I am learning from our patients all the time and in the case of our Australian in Vietnam, commitment to treatment through our St Vincent’s team, belief in the process, and determination to follow the care team's guidance was indeed the recipe for him!
Therese Dodds
Director – Eastern Suburbs Speech Pathology
Director – Speech Pathology St Vincent’s Private Hospital Sydney
*Alias for privacy reasons
