Comparative evaluation of function after surgery for cancer of the alveolobuccal complex

Maxillofacial prosthetic treatment factors affecting oral health-related quality of life after surgery for patients with oral cancer

STATEMENT OF PROBLEM

After oral cancer surgery, tissue defects can cause deformity and limited mobility, complicating many essential functions. For patients with mandibular, tongue, and oral floor defects, evidence regarding the effects of maxillofacial prosthetics on their oral health-related quality of life (OHRQoL) is lacking. Therefore, maxillofacial prosthetic reconstruction has been implemented with no clear treatment goals.

PURPOSE

The purpose of this clinical study was to identify factors affecting the improvement of OHRQoL by using maxillofacial prosthetic treatment after surgery to repair maxillary, mandibular, tongue, and oral floor defects.

MATERIAL AND METHODS

All individuals who agreed to maxillofacial prosthetics after surgery for oral cancer were enrolled. Oral function and OHRQoL were evaluated before maxillofacial prosthesis placement and 1 month after final adjustments. The oral functions evaluated included masticatory function, swallowing function, and articulatory function. The Oral Health Impact Profile (OHIP-J54) was used to evaluate OHRQoL. Factors affecting changes in the OHIP-J54 score for participants' background and oral functions before and after treatment were analyzed through logistic regression analysis (stepwise method).

RESULTS

Participants included 34 men and 16 women with an average age of 72.4 ±8.7 years. "Psychological discomfort" was correlated with the patient's sex and masticatory function. "Physical disability" was related to articulatory function. "Handicap" was related to the swallowing function. "Additional Japanese questions" were related to the patient's sex.

CONCLUSIONS

Participants' sex and their oral functions, including masticatory, swallowing, and articulatory functions, were associated with improved OHRQoL because of maxillofacial prosthetics after surgery for oral cancer.

Surgical considerations in older adults with cancer

PURPOSE

The aging of the population is a real concern for surgical oncologists, who are increasingly being asked to treat patients who would not have been considered for surgery in the past. In many cases, decisions are made with relatively little evidence, most of which was derived from trials in which older age was a limiting factor for recruitment.

METHODS

This review focuses on risk assessment and perioperative management. It describes the relationship between age and outcomes for colon, lung, hepatobiliary, and head and neck cancer, which are predominantly diseases of the elderly and are a major cause of morbidity and mortality.

RESULTS

Effective surgery requires safe performance as well as reasonable postoperative life expectancy and maintenance of quality of life. Treatment decisions for potentially vulnerable elderly patients should take into account data obtained from the evaluation of geriatric syndromes, such as frailty, functional and cognitive limitations, malnutrition, comorbidities, and polypharmacy, as well as social support. Postoperative care should include prevention and treatment of complications seen more frequently in the elderly, including postoperative delirium, functional decline, and the need for institutionalization.

CONCLUSION

Surgery remains the best modality for treatment of solid tumors, and chronologic age alone should not be a determinant for treatment decisions. With adequate perioperative risk stratification, functional assessment, and oncologic prognostication, elderly patients with cancer can do as well in terms of morbidity and mortality as their younger counterparts. If surgery is determined to be the appropriate treatment modality, patients should not be denied this option because of their age.

Tongue function in patients treated for malignancies in tongue and/or floor of mouth; a one year prospective study

Progress in (reconstructive) surgery and radiotherapy tends to improve survival and reduce oral functional deficits. Despite the growing sophistication of cancer treatment, patients still report deterioration in tongue function. Sensory function, mobility, and force of the tongue were determined in 45 patients with a carcinoma of tongue and/or floor of mouth. Measurements were performed before surgery, shortly after surgery, shortly after radiotherapy, 6, and 12 months after surgery. Surgery had a negative impact on tongue sensory function and mobility. Post-surgery radiotherapy did not further deteriorate sensory function, mobility, or force of the tongue. Patients in the surgery-radiotherapy group (SRG) had significantly worse tongue sensory function and mobility than patients in the surgery group (SG), probably caused by more advanced tumour stage and more extensive reconstructions and related scar tissue. The tongue force in patients in both groups significantly increased in the first 6 months after surgery, but this increase disappeared in the next 6 months. The authors conclude that surgery had a significant negative influence on tongue function, especially in the group of patients treated with radiotherapy. No further deterioration of tongue function was observed after post-surgical radiotherapy within the first year after surgery.

Oral function after oncological intervention in the oral cavity: a retrospective study

PURPOSE

To assess self-perceived oral function of patients with oral cavity cancer at different stages of treatment, ie, before oncologic intervention, 5 weeks after intervention, and 5 years after intervention.

PATIENTS AND METHODS

A cohort of 158 patients with malignancy in the oral cavity treated by surgery in 1999 or 2000 was included. From this cohort we interviewed 69 patients by telephone in 2005 and collected data on dental status, disorders of chewing and swallowing, xerostomia, preference of food consistency, tube nutrition, weight loss, and speech for different stages of treatment.

RESULTS

For patients treated in the maxilla region we observed a significant (P < .05) recovery of perceived chewing ability after 5 years to the level experienced before oncologic intervention. Patients treated in the mandible region reported a deteriorated dental state, chewing ability, lip competence, and xerostomia after 5 years. Patients treated in the tongue and mouth-floor region experienced deterioration for dental state, chewing ability, and xerostomia after 5 years compared with the level before the oncologic intervention.

CONCLUSIONS

Our telephone interview on oral function provided supplementary information on how patients experienced their problems with oral function during various phases of oncologic treatment. A retrospective interview may thus help to add information to incomplete retrospective data.

Approximation of muscle remnants improves cosmesis following hemimandibulectomy

Hemimandibulectomy should be avoided whenever possible, as it results in significant deterioration in quality of life. If hemimandibulectomy is unavoidable, attempts should be made to reconstruct the bone and soft tissue defect by free tissue transfer or a pedicled flap such as a pectoralis major myocutaneous flap. Bony reconstruction may become challenging when oncological safety mandates removal of the vertical ramus or the condyle. Elderly patients and those with significant co-morbidity are not suitable for prolonged microvascular surgery. Oral cancer is a disease of impoverished nations, where most health institutions may not have the infrastructure to offer microvascular reconstruction. The pectoralis major myocutaneous flap, the workhorse for reconstruction of such defects, occasionally has limitations in terms of bulk, limited arc of rotation, shoulder dysfunction etc. Therefore, hemimandibulectomy and primary mucosal closure continues to be a common procedure in developing nations. A simple technique is proposed with which to improve cosmesis following hemimandibulectomy, utilising the locally available muscle remnants. In highly selected patients, the remaining muscles can be approximated to prevent the lateral hollow that is a common but unacceptable sequel to hemimandibulectomy.

Factors influencing postoperative speech function of tongue cancer patients following reconstruction with fasciocutaneous/myocutaneous flaps—a multicenter study

This study investigated postoperative speech function in tongue cancer patients following reconstruction with fasciocutaneous/myocutaneous flaps, to clarify the factor(s) influencing outcome. Eighty-one patients, enrolled from 11 Japanese institutions, were classified into three groups by the site of resection: lateral (N=51), anterior (N=17) and combined (N=13). The lateral group was divided into three subgroups and the anterior group into two subgroups by the size of resection. Mandibulectomy had been performed in 43 patients and radiation therapy in 24 patients. Reconstruction was accomplished by radial forearm flap (N=50), rectus abdominis myocutaneous flap (N=18), pectoralis major myocutaneous flap (N=11), latissimus dorsi myocutaneous flap (N=1) or scapula flap (N=1). Speech function was evaluated with two objective tests and three self-reporting questionnaires. The influence of tongue mobility, age at operation and examination, time interval to examination, and type of flap reconstruction on the functional results was also investigated. Better results were obtained with lateral type resections, smaller excisions, greater tongue mobility, younger patients and longer interval to examination. Mandibulectomy and radiation therapy were negative factors. Type of flap reconstruction had no effect on functional outcome. A treatment method with less functional interference should be developed, particularly for patients anticipated to be in poor functional state postoperatively.

Masticatory efficiency before and after surgery in oral cancer patients: comparative study of glossectomy, marginal mandibulectomy and segmental mandibulectomy

This study evaluated the effect of oral cancer surgery on masticatory efficiency. Masticatory efficiency was measured using the ATP absorption method. Eating ability was measured using a questionnaire. Two groups were employed as controls: The "normal occlusion group" consisted of subjects who had a complete set of natural maxillary teeth opposed to mandibular teeth, and the "unilateral occlusion group" consisted of subjects who had lost their molar and premolar teeth on one side of the mandible as a result of caries or periodontal diseases. Three treatment groups, each of 6 patients, were studied: a glossectomy group, a marginal mandibulectomy group and a segmental mandibulectomy group. There were no differences in masticatory efficiency between two control groups. Masticatory efficiencies of the three oral cancer treatment groups were lower than in the unilateral occlusion group, even 12 months after surgery. Masticatory efficiency of the glossectomy group was significantly higher 12 months after surgery compared with pre-surgery. Masticatory and eating abilities of the marginal mandibulectomy group and the segmental mandibulectomy were reduced at 3 and 6 months after surgery. The masticatory efficiency 12 months after surgery was higher in the marginal mandibulectomy group than the segmental mandibulectomy group, although the difference was not statistically significant. The self assessed eating ability 12 months after surgery was significantly higher in the marginal mandibulectomy group than the segmental mandibulectomy group. These results suggest that discontinuation of the mandible may lead patients to eat only foods that do not require a substantial amount of chewing. Hence, the quality of life of patients in the marginal mandibulectomy group was considered to be better than that in the segmental mandibulectomy group.

Clinical function after primary surgery for oral and oropharyngeal cancer: an 11-item examination

The aim of this study was to record clinical function using an 11-item clinical examination and identify the main postoperative functional deficits. Of 132 consecutive patients undergoing surgery for previously untreated disease between January 1995 and June 1997, 130 were recruited in the study. An 11-domain clinical examination was made on the day before operation, and at 6 and 12 months afterwards. This examination assessed lip competence, tongue movement, oral mucosa, dental state, mouth opening, speech, drooling, diet, appearance, oral sensation and shoulder movement. Preoperatively there were deficits in natural dentition, consistency of diet and tongue protrusion. Postoperatively functional scores fell particularly for tongue movements, mouth opening, mucosa, dentition, speech, diet, appearance, lip sensation and tongue sensation. At 1 year, dental status, sensation and oral mucosa were particularly defective. Patients with large tumours, free tissue transfer, or adjuvant radiotherapy had the worst levels of function.A simple clinical examination provides a rapid assessment of function that can be used in conjunction with validated questionnaires to provide a more comprehensive evaluation of outcome.

Health-related quality of life and clinical function after primary surgery for oral cancer

Clinical function and health-related quality of life (HRQoL) are both important outcome parameters following surgery for oral and oropharyngeal cancer. The aim of this project was to explore the relationship between an 11-point clinical examination and HRQoL. Of 132 consecutive patients undergoing surgery for previously untreated disease between January 1995 and June 1997, 130 were recruited into the study. The University of Washington Quality of Life Questionnaire (UW-QoL) was completed by each patient on the day before operation and 6 and 12 months later. On each occasion the first author made an 11-point clinical examination. The main predictors of cumulative UW-QoL scores were tumour size, clinical functional score and type of operation. The trend was for a fall from preoperative levels at 6 months and then for a slight improvement at 1 year. The differential in respect of baseline function was present at all three time points in each patient group. This suggests that functional deficits at presentation persist following treatment.

Speech, deglutition and life quality after intraoral tumour resection. A prospective study

The aim of the present prospective study was to evaluate the functional sequelae and postoperative development of quality of life after intraoral tumour surgery in 40 consecutive patients with a squamous cell carcinoma of the floor of the mouth. Immediate reconstruction of intraoral soft tissues after tumour resection was accomplished by local flaps (cheek and tongue) (n=27) and by revascularized transfer of small bowel grafts (n=5) and myocutaneous/fasciocutaneous flaps (n=8). Mobility of the tongue was assessed by ultrasound. Quality of speech was analysed using the Freiburg speech intelligibility test. Life quality was assessed by the functional living index-cancer preoperatively and six months postoperatively. A significant decrease in both mobility of the tongue and quality of speech was registered. The most substantial effect on quality of speech resulted from decreased movement of the base and the dorsum of the tongue. A significant increase in life quality at the end of the study period occurred only in the group of patients without substantial reduction of intelligibility of speech, while no significant improvement of postoperative life quality of patients with more severe deterioration of speech quality was found.