Quality of life and swallowing outcomes following major glossectomy: A prospective single-center experience

BACKGROUND

There exists a lacuna in the structured reporting of swallowing dysfunction and quality of life (QoL) outcome following major glossectomy.

METHODS

Prospective cohort study to assess the swallowing dysfunction and QoL following STG (subtotal glossectomy) or NTG (near total glossectomy) over a 6-month period using FEES and PAS scale, MDADI, and FACT-HN.

RESULTS

Twenty-four patients were available for analysis. The pre- and post-adjuvant evaluation revealed a statistically significant improvement in the composite MDADI and FACT-HN scores. Subscale analysis of FACT-HN scores revealed maximum deficit in the head and neck cancer-specific score domain followed by functional domain and social well-being domain, with serial improvement noted in the post-adjuvant setting.

CONCLUSION

This study showed serial improvement in terms of swallowing dysfunction although social and functional well-being domains related to QoL continued to reveal major deficits. Better outcomes were seen with preservation of bilateral base of tongue and mandible.

Risk factors for late postoperative bleeding after partial glossectomy for tongue cancer

BACKGROUND

Partial glossectomy is the most common procedure for early-stage tongue cancer. Although late postoperative bleeding occasionally occurs, the associated risk factors have not been adequately identified.

AIMS/OBJECTIVES

We aimed to investigate the rate and risk factors for late postoperative bleeding after transoral partial glossectomy with or without neck dissection for tongue cancer at our institution.

MATERIAL AND METHODS

We analysed 211 patients who had undergone transoral partial glossectomy between January 2016 and January 2023. The potential risk factors associated with late postoperative bleeding were investigated using univariate and multivariate logistic regression analyses.

RESULTS

Of the 211 patients, 40 (19%) showed late postoperative bleeding, with 19 (9%) classified as grade IIIa (Clavien-Dindo classification). Regarding all grades, late postoperative bleeding was significantly higher in patients aged <70 years and in those with polyglycolic acid (PGA) sheets (p = .046 and .030, respectively). For grade ≥ IIIa, late postoperative bleeding was significantly higher in patients with a history of anticoagulant/platelet administration, a mucosal defect covered with fibrin glue and a PGA sheet (p = .045 and .026, respectively).

CONCLUSIONS AND SIGNIFICANCE

The findings of this study suggest that primary closure decreases the frequency of late postoperative bleeding.

Comprehensive review of the timing of surgical management of macroglossia in Beckwith-Wiedemann syndrome

Beckwith-Wiedemann Syndrome (BWS) is a rare genetic disorder that causes developmental defects as well as an elevated risk of malignancies. Macroglossia, or an enlarged tongue, is a common symptom of BWS that may have a negative influence on a person's quality of life. The aim of this systematic review is to look at the present state of knowledge about the repercussions of macroglossia, as well as the influence of the timing of surgical resection, or glossectomy, in the treatment of severe cases of macroglossia (Ref. 35). Keywords: macroglossia, Beckwith-Wiedemann syndrome, glossectomy.

A Novel Risk Model for Predicting Dysphagia after Tongue Reconstruction: A Retrospective Multicenter Study in Japan

BACKGROUND

There is no consensus on the postoperative outcomes of tongue reconstruction. Therefore, the authors developed a novel risk model for predicting dysphagia after tongue reconstruction.

METHODS

This retrospective study was conducted by the Oral Pharyngeal Esophageal Operation and Reconstruction Analytical, or OPERA, group across 31 cancer centers and university hospitals in Japan. A total of 532 patients [390 (73.3%) men and 142 (26.7%) women; median age at surgery, 60 years (range, 15 to 88 years)] who were diagnosed with oral tongue squamous cell carcinoma and underwent tongue reconstruction following glossectomy between 2009 and 2013 were included. Independent risk factors were identified using univariate regression analysis and converted to a binary format for multivariate analysis. An integer value was assigned to each risk factor to calculate a total score capable of quantifying the risk of feeding tube dependence.

RESULTS

Overall, 54 patients (10.2%) required a feeding tube at the time of evaluation. Predictive factors for feeding tube dependence were advanced age, lower American Society of Anesthesiologists physical status, low body mass index, lower serum albumin, comorbid hypertension and diabetes, extended tongue defect, resection beyond the tongue, laryngeal suspension, postoperative radiation therapy, and no functional teeth. In multivariate logistic regression analysis, age greater than or equal to 58.5 years, postoperative radiation therapy, wider tongue defect, and body mass index less than 21.27 kg/m 2 earned 6, 4, 3, and 2 points, respectively, for a maximum total score of 15.

CONCLUSION

The authors' risk model provides a mathematical tool for estimating the individual risk of postoperative feeding tube dependence before tongue reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Matrix for Mucosal Regeneration in Transoral Glossectomy for Squamous Cell Carcinoma: Objective and Subjective Functional Evaluation

BACKGROUND

Numerous options to manage local reconstruction following transoral partial glossectomy are possible. In this work, we present our experience using a matrix for mucosal regeneration, Integra^®, after transoral resections of squamous cell carcinoma of the oral tongue.

METHODS

A retrospective analysis of patients treated for tongue carcinoma and reconstruction with Integra^®, from September 2017 to September 2022. Functional outcomes were evaluated by measuring swallowing and speech abilities, tongue motility, and subjective quality of life.

RESULTS

The series accounts for 13 consecutive patients, staged from Tis to T3, no positive resection margins were found, average defect size was 17.8 cm². The average histologically measured depth of invasion was 4.1 mm (range 2-12 mm), and no recurrences were observed during follow-up. All patients maintained excellent swallowing function, the average number of recognized words by an external listener during a phone call was 70.5 out of 75, the lingual motility test was good (a mean score of 4.5 out of 6 movements correctly executed) and subjective questionnaires results were optimal. Less satisfying functional results were recorded in elderly patients receiving a wider surgical resection.

CONCLUSIONS

This reconstructive technique for allows obtaining optimal healing and functional outcomes in patients with tumors suitable for transoral glossectomy.

The Effects of Palate Features and Glossectomy Surgery on /s/ Production

PURPOSE

The aims of this article were to determine the effects of hard palate morphology and glossectomy surgery on tongue position and shape during /s/ for patients with small tumors. The first expectation was that laminal /s/ would be more prevalent in patients, than apical, due to reduced tongue tip control after surgery. The second was that patients would hold the tongue more anteriorly than controls to compensate for reduced tongue mass.

METHOD

Three-dimensional tongue volumes were calculated from magnetic resonance imaging for the whole tongue and the portion anterior to the first molar during the /s/ in /əsuk/ for 21 controls and 14 patients. These volumes were used to calculate tongue anteriority and cross-sectional shape. Dental casts were used to measure palate perimeter, height, and width of the hard palate.

RESULTS

Palate height correlated with tongue height in controls (p < .05), but not patients. In patients, tongue anteriority correlated negatively with canine width and cross-sectional tongue shape (p < .05). Controls with a high palate favored laminal /s/. Patients preferred laminal /s/ regardless of palate height (p < .01).

CONCLUSIONS

For controls, hard palate height affected tongue height; a higher palate yielded a higher tongue. For patients, hard palate width affected tongue width; a narrower palate yielded a more anterior tongue. Tongue shape was unaffected by any palate features. Preference for /s/ showed an interaction effect between subject and palate height. Controls with high palates preferred a laminal /s/. All patients preferred a laminal /s/; glossectomy surgery may reduce tongue tip control.

Assessing the suitability of medial sural artery perforator flaps in tongue reconstruction - An outcome study

Introduction

Oncological resection of the tongue can be reconstructed using a multitude of free flaps. The medial sural artery perforator (MSAP) flap has been well described in the literature in terms of its anatomy and harvest. However, functional outcome studies of post-reconstruction tongue defects using the MSAP flap have not been reported. This study represents the largest outcome study of patients with tongue reconstructions using MSAP flaps and a comprehensive review of its use.

Materials and methods

From December of 2010 to October of 2015, 579 patients with subtotal glossectomy and free flap reconstructions in Chang Gung Memorial Hospital were retrospectively reviewed. 27 patients were reconstructed with MSAP flap. The pre- and intra-operative factors, as well as flap-related factors were analyzed. Post-operative complications and functional outcomes were evaluated. Donor site assessment were also conducted.

Results

A 96.3% flap survival rate was found with an average total operating time of 6 hours and 18 minutes. 84.6% of patients had primary closure of the donor site with and the remaining either had skin grafts or delayed closure. Donor site closure can be achieved primarily with no functional deficit. Speech intelligibility remained for most patients. 100% of patients resumed normal oral feeding.

Conclusion

The MSAP flap is a small to medium sized flap most suited for subtotal glossectomy defects where optimal outcomes can be achieved in terms of speech clarity and restoration of oral intake.

Cortical Adaptation following Partial Glossectomy with Primary Closure: Implications for Reconstruction of the Oral Tongue

Objectives:

The considerable variability in functional outcomes for speech and swallowing with different reconstruction techniques following partial glossectomy may reflect the ability of patients to adapt to altered tongue structure. The purpose of this study was to determine mechanisms of cortical adaptation in swallowing to partial glossectomy reconstructed with primary closure.

Methods:

Four patients treated with partial glossectomy and primary closure underwent functional magnetic resonance imaging at a mean of 6 months after operation, and the data were compared to those from 8 healthy controls.

Results:

Statistically significant increases in activity occurred predominately in the parietal cortices and the cerebellum. The volume of the resection was most highly correlated with activity in the premotor and parietal cortices and cerebellum.

Conclusions:

The adaptive changes in the cortex following partial glossectomy with primary closure reflect adaptation to the biomechanics of tongue movement during swallowing, and not altered sensation in the tongue.

Speech and swallow rehabilitation following partial glossectomy: a systematic review

PURPOSE

Tongue cancer is known to negatively affect both speech and swallowing function; however this is the first review to report speech-language pathology (SLP) intervention for both functions following partial glossectomy.

METHOD

Using a PRISMA approach, systematic screening of nine databases was undertaken. Original studies reporting SLP rehabilitation for speech and/or swallowing dysfunction with participants following partial glossectomy as primary cancer treatment were included.

RESULT

These studies are discussed in terms of SLP assessment and intervention trends as well as quality according to current research method standards (levels of evidence, Pedro-P, SCED) in order to determine suitability for guiding current clinical practice.

CONCLUSION

Publications were few (n = 7) and mostly of non-experimental design. This review highlights the gap in evidence and questions the rationale of current SLP rehabilitation following partial glossectomy.

Recovery of speech following total glossectomy: an acoustic and perceptual appraisal

This study involved an acoustic and perceptual analysis of the speech produced by a 31-year-old female following total glossectomy. Speech samples were collected on three occasions within the first 3 months following glossectomy. Vowel articulation was examined acoustically as a function of vowel space and the Euclidean distance separating corner vowels. Perceptual analyses involved presentation of the participant's CV productions to 30 healthy adult listeners who made forced-choice identifications of consonant type. Acoustic analysis revealed improvements in vowel space area and an increase in the Euclidean distances. The perceptual results revealed a statistically significant deterioration in consonants over the 3-month period with anterior sounds being perceived more correctly than medial and posterior sounds. The current study highlights the variable nature of speech following glossectomy, with greater improvements in vowel articulation compared to consonant articulation during the earliest stages of surgical recovery.

Analysis of Determinants on Speech Function After Glossectomy

PURPOSE

To determine which of the following factors-type of reconstruction, size of tumor, and site of excision-may influence speech intelligibility after glossectomy.

MATERIALS AND METHODS

The speech intelligibilities of 27 tongue cancer patients who underwent glossectomy within the range of the hemitongue were investigated within 6 months after operation with a speech intelligibility test formed by 100 sensitive Chinese sounds. They were compared according to the following factors: type of reconstruction (forearm flap or adjacent flap); size of tumor (T1, T2, T3); and site of excision (anterior, middle, posterior, or hemi part).

RESULTS

There was no significant difference in speech intelligibility between the forearm flap reconstructed group and adjacent flap reconstructed group (P > .05). There was a significant difference in the result between the T1 and T3 groups (P < .05). The speech intelligibilities of the patients with tumors in anterior tongue or hemitongue were significantly lower than those with tumor in the middle or posterior tongue (P < .05). Patients with preservation of the tip of the tongue or floor of the mouth had higher intelligibilities (P < .05).

CONCLUSION

For the patients after glossectomy within the range of hemitongue, except for the type of reconstruction, the tumor site or excision extent of the tongue followed by the tumor size may be key factors in determining the postoperative articulation intelligibility.

Analysis of formant frequencies in patients with oral or oropharyngeal cancers treated by glossectomy

AIMS

To compare voice quality as defined by formant analysis using a sustained vowel in patients who have undergone a partial glossectomy with a group of normal subjects.

METHODS & PROCEDURES

The design consisted of a single centre, cross-sectional cohort study. The setting was an Adult Tertiary Referral Unit. A total of 26 patients (19 males) who underwent partial glossectomy and 31 normal volunteers (18 males) participated in the study. Group comparisons using the first three formant frequencies (F1, F2 and F3) using linear predictive coding (Laryngograph Ltd, London, UK) were performed. The existence of any significant difference of F1, F2 and F3 between the two groups using the sustained vowel /i/ and the effects of other factors, namely age, first presentation versus recurrence, site (oral cavity, oropharynx), subsite (anterior two-thirds of the tongue, tongue base), stage, radiation, complication, and neck dissection, were analysed.

OUTCOMES & RESULTS

Formant frequencies F1, F2 and F3 were normally distributed. F1 and F2 were significantly different in normal males versus females. F1, F2 and F3 were not different statistically between male and female glossectomees. Comparison of only women showed significant differences between normal subjects and patients in F2 and F3, but none in F1. This was the opposite in men where F1 was significantly different. Age, tumour presentation, site, subsite, radiation and neck dissection showed no significant difference. Postoperative complications significantly affected the F1 formant frequency.

CONCLUSIONS

The study found that the formant values in patients following a partial glossectomy were altered significantly as compared with the normal control subjects. Only gender and complications and not the age, site, subsite, radiation and neck dissection were seen to influence the formant scores.

Speech outcomes in Cantonese patients after glossectomy

BACKGROUND

We sought to determine the major factors affecting speech production of Cantonese-speaking glossectomized patients. Error pattern was analyzed.

METHODS

Forty-one Cantonese-speaking subjects who had undergone glossectomy > or = 6 months previously were recruited. Speech production evaluation included (1) phonetic error analysis in nonsense syllable; (2) speech intelligibility in sentences evaluated by naive listeners; (3) overall speech intelligibility in conversation evaluated by experienced speech therapists.

RESULTS

Patients receiving adjuvant radiotherapy had significantly poorer segmental and connected speech production. Total or subtotal glossectomy also resulted in poor speech outcomes. Patients having free flap reconstruction showed the best speech outcomes. Patients without lymph node metastasis had significantly better speech scores when compared with patients with lymph node metastasis. Initial consonant production had the worst scores, while vowel production was the least affected.

CONCLUSION

Speech outcomes of Cantonese-speaking glossectomized patients depended on the severity of the disease. Initial consonants had the greatest effect on speech intelligibility.

Acoustic analysis of vowels following glossectomy

This study examined the acoustic characteristics of vowels produced by speakers with partial glossectomy. Acoustic variables investigated included first formant (F1) frequency, second formant (F2) frequency, F1 range, F2 range and vowel space area. Data from the speakers with partial glossectomy were compared with age- and gender-matched controls. Results indicated no significant group difference in the mean F1 values and ranges. The speakers with partial glossectomy exhibited significantly lower mean F2 values for the vowel /i/, and restricted F2 ranges, when compared with the control speakers. These data suggest a limited range of lingual movement along the anterior-posterior dimension for vowel production. The significantly smaller vowel space areas for the speakers with glossectomy supported the hypothesis of vowel formant centralization. Two acoustic measures, vowel space area and F2 range, had a positive correlation with vowel intelligibility scores. F2 range could serve as a sensitive correlate of vowel intelligibility for speakers with partial glossectomy.

[The tongue as a receptor and effector after tumor resection in the oral cavity]

PURPOSE

To evaluate functional impairment in the oral cavity after resection of neoplasm.

MATERIAL AND METHODS

71 patients after partial or total glossectomy were examin ed to evaluate tongue mobility, superficial sensation, oral stereognosis and efficiency of deglutition. The extent of tongue resection, reconstruction procedures, tumor localization and the postoperative radiotherapy were taken into consideration.

RESULTS

Excision of up to one-third of the mobile part of the tongue does not impair its function. Although longitudinal excision of half of the tongue with adjacent structures limits its mobility and sensory sensitivity, efficient deglutition is preserved. Despite extensive disturbances in mobility and sensory sensitivity of the tongue after transversal hemiglossectomy with adjacent structures, efficient deglutition is still achievable after rehabilitation. In the case of total glossectomy efficient deglutition also can be achieved after extended rehabilitation. This is also true for tongue reconstructed with a myocutaneous flap.

CONCLUSIONS

Juxtaposition of limitations in sensorymotor functions with disturbances in deglutition after resection of tongue tumor facilitates understanding and prediction of these processes. Evaluation of deglutition efficiency after tongue reconstruction reflects effectiveness of rehabilitation.

[Changes in spirometry and pulsoximetry examinations after the resection of oral cavity structures]

PURPOSE

Surgical treatment of oral cavity neoplasms consists of the resection of tumor surrounded by a healthy tissue margin. The removal of tissues leads to breathing disturbances. Apnea episodes cause a drop in the arterial blood saturation with oxygen. This study was designed to qualitatively and quantitatively evaluate breathing disturbances and dyspnoea after resection of oral cavity structures, throat structures and muscles of the neck.

MATERIAL AND METHODS

For this purpose, spirometry and pulsoximetry were done. Breathing disorders in sleeping patients were also examined. We enrolled 50 persons after surgery and divided them into three groups according to the type of resected structures: lateral part of the mandible; mental part of the mandible; part of the tongue.

CONCLUSIONS

The following conclusions were drawn: 1) Operations in the oral cavity in spite of reconstructions result in breathing disturbances. 2) Spirometry and pulsoximetry are useful for the study of breathing disturbances. 3) Static and dynamic values of key spirometric parameters were reduced in the patients; 4) Deterioration of blood saturation during sleep in patients after operations confirms breathing disorders.

[Pronunciation and swallowing in patients with tongue deficits following resection of oral cavity tumor]

PURPOSE

Anatomical changes due to resection of oral cavity neoplasm result in respiratory, swallowing, pronunciation and mastication disorders of varying extent and intensity. The aim of this study was to assess the quality of pronunciation and efficiency of deglutition in patients operated due to oral cavity neoplasm.

MATERIAL AND METHODS

112 patients (76 males, 36 females, mean age 53 years) after oral tumor excision were examined. Pronunciation quality was evaluated audio-visually using phonemes of contemporary Polish language (according to Roclawski) which were pronounced alone, in syllables and words. Compensatory function was studied as well. Efficiency of deglutition was examined with videofluoroscopy (according to W. J. Dodds). Oral and pharyngeal activities were analyzed and quantified using a 100 - point scale.

RESULTS

Speech and swallowing disorders of varying intensity were observed in every patient. The frequency and quality of abnormal phonation and the presence of characteristic compensatory mechanisms depended on the extent of post-operative deficits and functional efficiency of adjacent structures. There was a statistically significant correlation between the quality of pronunciation and efficiency of deglutition.

[Psychological responses of patients after partial or total glossectomy due to carcinoma of the oral cavity]

The necessity of partial or total glossectomy due to carcinoma of the oral cavity means that the patient suffers from severe and life-threatening disease and the medical team aims at eliminating that threat. The major goal of surgical intervention is to stop the growth of the cancer. However, it can be associated with considerable injury of the ill person. After the operation, the patient goes through the rehabilitation process during which he or she may experience suffering and various limitations resulting from injury. The patient also tries to adjust to the new situation in life. It is the time for the patient when the threat of death is no longer present or at least it has been averted and now the patient must challenge the process of adaptation associated with the loss of the tongue. The rehabilitation undertaken by the patient with the assistance of the medical team has two major goals. The first goal is to restore the function to the greatest possible extent, that is to learn to swallow and speak again. The second aim is psychological and sociological adaptation. In order to bring the patient into the process of acquiring new skills necessary for the realisation of basic life functions, as well as those needed for the fulfilment of substitutive forms of self-realisation and the achievement of satisfaction in life, the medical personnel should aim at understanding psychological and sociological conditions of the patient which may facilitate or impede patient's rehabilitation process and adaptation to illness. The examination and analysis of psychological dimensions characteristic of people struggling with cancer helps in understanding the patient, but first of all in learning individual experiences, problems and ways of coping with disability resulting from the particular form of injury. Research on the quality of life of patients after partial or total glossectomy is mostly concerned with functional aspects of the loss of the tongue and less attention is being paid to the subjective perspective of a patient. Although most patients suffer from significant functional impairments in swallowing, sensation and speech, as well as from difficulties in adaptation resulting from disability, some research shows that good quality of life can be maintained in patients who are highly motivated, have emotional support from their family and friends, maintain close contact with their physician, and have access to a rehabilitation team consisting of specialists of various disciplines.

[The delay of pharyngeal phase initiation vs the course of the deglutition act in patients after partial or total tongue excision due to oral cancer]

PURPOSE

The coordination of the respiratory and alimentary function is indispensable to transport the food from the oral cavity to the stomach without aspiration risk. Disturbances during pharyngeal phase of swallowing, registered after oral tumour excision, are caused by diminishing of the tongue shape, decreasing of gustatory sensitivity and oral stereognosis. The aim of the work is to estimate the influence the oral tissue excision to the pharyngeal phase of deglution.

MATERIAL AND METHODS

videoradiological examination of deglutition by W.J. Dodds - for 95 patients after oral tumour excision, with swallowing disturbances. Duration of oral and pharyngeal activities, degree of realization these activities and aspiration risk were valued.

RESULT

Abnormal mobility of tongue, lack of palato-pharyngeal and glosso-pharyngeal closure, abnormal formation of bolus accompanied to delayed initiation of pharyngeal phase. The delay of pharyngeal phase initiation was the most important for beginning and ending of the larynx closure, oesophagus opening, pharynx emptying. This delay wasn't statistically significant for duration these activities. The retention in oral cavity and in lower throat, additional deglutitions, inter-deglutition and postdeglutition leakage correlated with delay of the pharyngeal phase initiation.

CONCLUSIONS

1. The delay of pharyngeal phase initation after oral tumour excision is caused by oral swallowing disturbances. 2. The delay of pharyngeal phase initiation after oral tumor excision is dependent on the range of surgery and reconstruction. 3. The delay of pharyngeal phase initiation after oral tumour excision is important for beginning and ending of the pharyngeal phase activities, it isn't important for their duration. 4. The deficit of oral sensory stimuli causes desynchronization of the pharyngeal phase activities and diminishes the swallowing efficiency. 5. Improvement of the swallowing efficiency after partial or total tongue excision is possible by oral phase elongation, by monitoring of the swallowing apnea and by multiple deglutitions.

Quantitative three-dimensional ultrasound analysis of tongue protrusion, grooving and symmetry: data from 12 normal speakers and a partial glossectomee

The functional determinants for a good speech outcome after a partial tongue resection and reconstruction are not well established. The purpose of the present study was to assess the protrusion, grooving and symmetry of the tongue during sustained speech sound production using three-dimensional ultrasound. The participants were twelve normal speakers and one partial glossectomee. The three-dimensional ultrasound volumes of nine sustained speech sounds were measured in three sagittal planes. The data were re-plotted as three-dimensional surfaces. We calculated an anteriority index, a concavity index and an asymmetry index. The glossectomee's postoperative surface plots were characterized by asymmetry and convexity of the tongue surface. The anteriority index illustrated that the glossectomee's ability to protrude her tongue was not affected by the operation. The concavity index captured a decrease in midsagittal grooving in the glossectomee's tongue. The asymmetry index demonstrated height differences in the elevation of the right and left side of the tongue. We conclude that three-dimensional ultrasound offers us a practical tool for the detailed and concise assessment of the lingual shape and deformation in patients undergoing glossectomy surgery.

Evaluation of speech intelligibility after a secondary dehiscence operation using an artificial graft in patients with speech disorders after partial glossectomy

The purpose of this study was to evaluate speech intelligibility after a dehiscence operation using artificial grafts for patients with speech disorders after partial glossectomy that were caused by scars resulting from the primary operation. The subjects were six men and three women, who had had a partial glossectomy for tongue cancer followed by direct closure without reconstruction. They were operated on a second time operation to mobilise the residual tongue by dividing the cicatrix. An artificial graft was applied to the wound to maintain the dehiscence. Speech intelligibility was evaluated by a standardised Japanese speech intelligibility test before, and 6 and 12 months after the second operation. The intelligibility scores significantly improved during the first 6 months after the second operation, and continued to improve slightly during the following 6 months. This study suggests that the dehiscence operation using an artificial graft could improve speech in patients after partial glossectomy.

Total glossectomy: is it justified?

BACKGROUND

The treatment of advanced malignancies of the tongue with total glossectomy is controversial.

METHODS

The present study retrospectively reviews 20 patients that had total glossectomy with or without laryngectomy performed at the Princess Alexandra Hospital (Woolloongabba, QLD, Australia) over the past 10 years. The clinicopathologic parameters, perioperative morbidity and mortality were assessed.

RESULTS

The 5 years disease free and disease specific survival rates were 34% and 38%, respectively. Ninety per cent of patients acquired independent oral feeding prior to discharge, while 57% of patients that had laryngeal preservation performed achieved satisfactory vocal rehabilitation.

CONCLUSION

Total glossectomy is an oncologically sound surgical procedure that should only be performed in carefully selected patients with advanced malignancies affecting the tongue.

Evaluation of swallowing function after intraoral soft tissue reconstruction with microvascular free flaps

This study assessed swallowing function after tumour resection and reconstruction utilizing free vascularized flap closures in patients with oral cancer. Swallowing function was evaluated postoperatively in 23 patients (21 men and 2 women) who had undergone reconstruction with either a lateral upper arm free flap (LUFF, n=16) or a radial forearm free flap (RFFF, n=7). Videofluoroscopy was used to assess tongue mobility and abnormalities of swallowing function. All patients who underwent reconstruction with LUFF or RFFF free flaps had decreased tongue mobility, except for the tip of the tongue. Patients who underwent anterior or posterior resection had greater decreases in tongue mobility than those who underwent medial resection. Swallowing impairment was similar in patients with LUFFs and those with RFFFs. Anterior resection of the oral cavity had a significant negative effect on swallowing function. Silent aspiration occurred in five patients. In conclusion the resection site affected swallowing function, but the type of flap did not, in patients with oral carcinoma, who underwent tumour resection with reconstruction

Reinnervated anterolateral thigh flap for tongue reconstruction

BACKGROUND

Total or near-total glossectomy defects are commonly reconstructed with rectus abdominis myocutaneous flaps for coverage. Sensory reinnervation has rarely been performed.

METHODS

Thirteen consecutive total or near-total glossectomy reconstructions were performed in a 12-month period with anterolateral thigh flaps with (n = 8) or without (n = 5) sensory reinnervation to the lingual nerve. Two-point discrimination, Semmes-Weinstein monofilament testing, pain, and temperature testing were performed before and after 12 months of surgery. Speech and swallow functions were assessed with an established grading system.

RESULTS

Innervated flaps had superior sensory recovery to noninnervated flaps in all testing modalities. Postoperative radiotherapy may delay sensory recovery. Swallow function was better in the innervated group. Return of sensation also improves overall patient satisfaction.

CONCLUSIONS

The reinnervated anterolateral thigh flap is a viable option to reconstruct total or near-total glossectomy defects with good speech and swallow functions.

Total glossectomy without laryngectomy as first-line or salvage therapy

OBJECTIVES/HYPOTHESIS

Advanced carcinoma of the tongue can require total glossectomy. Although radiation therapy is of limited efficacy in T3 and T4 tumors involving the base of the tongue, many surgeons are reluctant to suggest highly mutilating surgery.

STUDY DESIGN

Retrospective cohort study.

METHODS

We compared early postoperative complications, hospital stay duration, function, and oncological outcomes in patients who underwent total glossectomy without laryngectomy as first-line or salvage therapy.

RESULTS

Postoperative course and functional outcomes were similar in the two groups. Overall survival was 32% at 3 years and 21% at 5 years. The risk factors for shorter survival were positive margins of resection (P =.002) and tumor spread into the mandible (P =.04). Salvage surgery was not associated with significantly lower survival (P =.09 [NS]).

CONCLUSIONS

Postoperative morbidity and functional outcomes are similar after first-line and salvage total glossectomy without laryngectomy. Local tumor control is the main factor influencing survival.

Speech after partial glossectomy: a comparison between reconstruction and nonreconstruction patients

PURPOSE

This study was undertaken to compare the articulation intelligibility of patients after hemiglossectomy or minor glossectomy within the hemitongue with or without reconstruction.

MATERIALS AND METHODS

The articulation intelligibility of 19 patients who underwent hemiglossetomy or minor glossectomy within the hemitongue was investigated at least 6 months after surgery with an articulation intelligibility test with 40 sensitive Chinese sounds. Patients were divided into group 1 (those undergoing reconstructive surgery after glossectomy) and group 2 (those not undergoing reconstructive surgery after glossectomy). Defects of the tongue (in group 1) were reconstructed immediately with free radial forearm flaps or pedicled flaps after glossectomy and closed primarily without reconstruction in group 2. The articulation intelligibility scores were compared between the 2 groups.

RESULTS

The mean articulation intelligibility score for group 1 was 77.0% (blade portion glossal sounds), 76.3% (mid portion glossal sounds), and 84.7% (rear portion glossal sounds), and those of group 2 were 94.6%, 92.1%, and 95.3%, respectively. The intelligibility of articulation of group 2 was significantly higher than that of group 1 in blade portion glossal sounds (P <.05), mid portion glossal sounds (P <.05), and rear portion glossal sounds (P <.01).

CONCLUSION

The articulation intelligibility was better in patients not receiving grafts than in those receiving grafts. Reconstruction with flaps, which may interfere with the flexibility and mobility of the tongue, may contribute to articulatory impairment. If speech is the outcome of interest, reconstruction may be unnecessary with hemiglossectomy or other partial (minor) glossectomy within the hemitongue.

Neutral zone approach for denture fabrication for a partial glossectomy patient: a clinical report

According to the neutral zone concept, an appropriate denture form can be molded into a physiologic tooth arrangement by using a narrow rim bar occlusion, tissue conditioner, and a direct relining technique for both intaglio and cameo surfaces by using VLC reline resin. Denture stability can be obtained with this "border molding" technique, not only for edentulous patients but also for those with oral deformities.

Prevention of tongue biting with a removable oral device: a clinical report

A method of preventing tongue biting with a removal device has been described in this clinical report. Restraint of the tongue may be necessary to promote healing by preventing repetitive tongue biting or as a preventive measure after a surgery or an injury. Any device that is used to restrain the tongue should be removable to avoid prolonged interference with oral hygiene, swallowing, mastication, and speech. A removable device is desirable for long-term use by comatose or semicomatose patients.

The difference between delayed extubation and tracheostomy in post-operative sleep apnea after glossectomy or laryngectomy

BACKGROUND

Patients with cancer of the tongue or larynx require glossectomies or laryngectomies and subsequent reconstruction. These procedures remove part of the patient's upper airway. In cancer of the tongue, the removed part of the airway is substituted by a flap of their skin. Post-operatively, it is possible that the patients have problems respiring comfortably. In addition to this, long surgical procedures may simply interfere with their circadian rhythm. To elucidate the possible change in their post-operative respiration, we monitored the patient's respiratory pattern with an apnea monitor.

METHODS

We attached an apnea monitor to the patients and recorded their respiratory pattern and arterial oxygen saturation. The patients were monitored for a total of five days: three days prior to the operation, one day before the operation, the day of operation, two days after, and on the fourth day after the operation. The period of monitoring was from 8:00 p.m. to 6:00 a.m. the next morning.

RESULTS

Sixteen patients completed this study. The patients whose tube was extubated after glossectomy showed frequent apnea, low mean oxygen saturation and low comfort score as compared to the patients with tracheostomy after laryngectomy. Because two failed cases of free skin flap were among the former, it is possible that the frequent apnea is a factor of failed free skin graft after glossectomy and laryngectomy.

CONCLUSION

Further studies are required to improve the patient's respiration during their sleep after tracheal extubation in glossectomy.

Early speech results with the Provox prosthesis after laryngectomy

OBJECTIVES

To assess our initial success using the Provox (Atos Medical AB, Horby, Sweden, and Entermad BV, Woerden, the Netherlands) tracheoesophageal speaking valve as the primary prosthesis to rehabilitate patients after total laryngectomy and to compare our success and complication rates with those previously reported.

DESIGN

A retrospective analysis of all the patients who had a Provox prosthesis placed from November 1994 to November 1995.

PATIENTS AND METHODS

Medical charts were reviewed for success or failure of the prosthesis as determined by the quality of speech and the utility of the device. In addition, complications, whether the patient had a pharyngeal myotomy and/or radiation, and the reasons and timing for replacement were assessed. Twenty-one patients had a Provox prosthesis placed either primarily at the time of their total laryngectomy (n = 8), delayed (n = 5), or as a replacement for another type of prosthesis (n = 8). Follow-up ranged from 2 to 17 months.

RESULTS

The initial success rate was 84%, and the long-term success rate was 74%. Of note, 3 patients had substantially improved speech and none were worse when changed from another type of prosthesis. The mean interval to prosthesis change was 166 days. Reasons for failure included infection, radiation fibrosis, manual incoordination, cerebrovascular accident, and combination of total laryngectomy and total glossectomy. The most common complication (in 2 patients) was retraction of the prosthesis into the esophagus that was successfully managed by replacement with a longer device.

CONCLUSION

Our early results confirm the effectiveness, longevity, and safety of the Provox prosthesis for speech rehabilitation following total laryngectomy.

Combined surgery and postoperative radiotherapy for carcinoma of the base of radiotherapy for carcinoma of the base of tongue: analysis of treatment outcome and prognostic value of margin status

BACKGROUND

Choice of treatment for base of tongue carcinoma is controversial, with options including surgery alone, radiotherapy alone, or multimodality treatment. Given the highly aggressive nature of these tumors, it has been our institutional policy to manage this disease with combined partial glossectomy (with attempt to avoid laryngectomy if possible) with planned postoperative radiotherapy (RT). We reported on our institutional experience with this approach.

METHODS

A retrospective review of the charts of 17 patients with primary base of tongue squamous cell carcinoma treated with surgery and postoperative RT was performed. Patients treated with chemotherapy as part of their management were excluded. All patients underwent partial, hemi-, or subtotal glossectomy; 15/17 patients underwent ipsilateral radical or modified radical neck dissection. All patients received comprehensive postoperative RT (median dose 6000 cGy; range 5040-6920 cGy). Stage distribution was as follows: stage I, 2; stage II, 3; stage III, 2; stage IV, 10. Positive margins for invasive carcinoma were found in 9/17 patients. Median follow-up of surviving patients is 46 months; median follow-up for all patients is 31 months.

RESULTS

For the entire group of patients, the actuarial 3-year local-regional control rate was 68%. The actuarial 3-year overall survival rate was 46%. The local-regional control rate was 83% for patients with stage I-III disease versus 50% for stage IV disease. There were no local failures among eight patients with negative margins (local control 100%) compared with an actuarial local control rate of 36% among patients with positive margins (p = .03). Survival, disease-specific survival, and locoregional control were also highly correlated with margin status (p = .003). Late major complications included 5/17 patients requiring permanent G-tubes and/or tracheostomy to prevent aspiration.

CONCLUSIONS

Surgery plus postoperative RT is an intensive treatment for carcinoma of the base of tongue which offers high locoregional control in patients in whom negative margins are achieved. Positive margins indicate a high risk of locoregional and systemic failure, and these patients should be considered for innovative clinical trials after surgery.

Radiofrequency volumetric reduction of the tongue. A porcine pilot study for the treatment of obstructive sleep apnea syndrome

STUDY OBJECTIVE

To investigate, in an animal model, the feasibility of radiofrequency (RF) volumetric tongue reduction for the future purpose of determining its clinical applications in obstructive sleep apnea syndrome (OSAS).

DESIGN

The study was performed in three stages, one in vitro bovine stage and two in vivo porcine stages. The last stage was a prospective investigation with histologic and volumetric analyses to establish outcomes.

SETTING

Laboratory and operating room of veterinary research center.

PARTICIPANTS

A homogeneous population of porcine animal models, including seven in stage 2 and 12 in stage 3.

INTERVENTION

RF energy was delivered by a custom-fabricated needle electrode and RF generator to the tongue tissue of both the in vitro and in vivo models.

MEASUREMENTS AND RESULTS

Microultransonic crystals were used to measure three-dimensional changes (volumetric reduction). Lesion size correlated well with increasing RF energy delivery (Sperman correlation coefficient of 0.986; p = 0.0003). Histologic assessments done serially over time (1 h through 3 weeks) showed a well-circumscribed lesion with a normal healing progression and no peripheral damage to nerves. Volumetric analysis documented a very mild initial edematous response that promptly tapered at 24 h. At 10 days after RF, a 26.3% volume reduction was documented at the treatment site (circumscribed by the microultrasonic crystals).

CONCLUSION

RF, in a porcine animal model, can safely reduce tongue volume in a precise and controlled manner. Further studies will validate the use of RF in the treatment of OSAS.

Analysis of the articulation after glossectomy

Rehabilitation of the oral cancer patient should aim to achieve not only morphological restoration but also post-operative functions. However, there are few reports describing quantitative evaluation of the latter. The authors have attempted quantitative evaluation of post-operative articulatory function after glossectomy, and report the evaluation of it by speech intelligibility, electropalatography (EPG), and acoustical analysis. Subjects were five directly sutured patients and five patients reconstructed with forearm flap, all after glossectomy. The target syllable was /ta/ from among speech intelligibility test samples. The speech intelligibility and acoustical analysis were investigated pre-operation, and 1,6 and 12 months post-operation. EPG data were collected by DP-01(RION) at 6 months post-operation. Acoustical analyses were carried out by consonant frequency characteristics and formant variance from consonant to vowel transitions. As a result, subjects reconstructed with a forearm flap showed higher restorative tendency than directly sutured subjects. Articulatory characteristics expected from acoustical analysis were more in agreement with the results of EPG than with the results of the speech intelligibility test. From the results, it was suggested that the acoustical analysis used for this research could reveal changes in articulatory movement and will be useful for quantitatively evaluating post-operative articulatory functions.

Prosthetic management for edentulous glossectomy patients

The prosthetic treatment of edentulous glossectomy patients is very difficult. The tongue defect results in oral dysfunction and affects the stability of the mandibular denture. The appropriate denture form and occlusion can be established by using the modified functional impression technique. Through the use of x-ray television and an image-processing system in clinical experiments, it was shown that a wide buccolingual table, an occlusal table height matched to that of the tongue body, and close adherence of the tongue and the lingual flange are effective means of preventing food from dropping to the oral floor, keeping the food on the occlusal table, and crushing the food.

Partial glossectomy for the treatment of anterior open bite. A case report

A 24-year-old Afro-Caribbean with a pronounced anterior open bite and bimaxillary protrusion was successfully treated to a stable result with a partial glossectomy and fixed appliance therapy. Although transient sialorrhea and paraesthesia were experienced post-operatively, speech and function showed some improvement 2 years after treatment.

[Total/near-total glossectomy for advanced carcinoma of the tongue]

Poor survival rates and the limited palliation afforded by radiotherapy alone, together with progress made in reconstructive surgery in restoring mucosal continuity after large resections, make total glossectomy reasonably indicated for treatment of advanced carcinoma of the tongue. The Authors reviewed 19 cases (17 males, 2 females, mean age 58.4 years) of total and near total glossectomy without laryngectomy treated at National Cancer Institute "Regina Elena" of Rome from 1990 to 1993 in order to evaluate oncological and functional results. All patients were reconstructed immediately, 16 with a pectoralis major flap, 2 with a nasolabial flap and 1 with a radial forearm free flap and were available for follow-up from 6 to 45 months (mean 29 months). There was no operative mortality and no patient needed total laryngectomy for aspiration. The rate of local recurrencies was 52.6%, most of them (75%) in patients who had undergone total/near total glossectomy for recurrence. Survival rate was 61.5% after 1 year and 20% after 2 years. 94% of patients resumed swallowing and independent oral alimentation (48% of them without any dysphagia); 84%; of the patients were decannulated and 48% produced easily intellegible speech. Data from our experience let us conclude that, in the light of the acceptable functional results obtained with reconstructive flaps, total glossectomy should be considered as the primary treatment modality in advanced carcinoma of the tongue (including T2 > 3 cm exceeding midline), and should not be reserved only for salvaging hopeless situations.

[Amyloid disease and extreme macroglossia. Apropos of a case]

A case of extreme macroglossia was observed in a patient with amyloid disease and dysglobulinaemia. A medial diamond-shaped glossectomy was required to reduce the size of the tongue. The details of the surgical and anaesthetic procedure are presented. This type of surgery, greatly appreciated by the patient, can only be undertaken after careful preparation. The reported cases are rare and the indication for surgery is difficult due to the unpredictable nature of the local and general clinical course of the disease.

Dysphagia following head and neck cancer surgery

Surgical resection of head and neck cancer results in predictable patterns of dysphagia and aspiration due to disruption of the anatomic structures of swallowing. Common procedures undertaken in the treatment of head and neck cancer include tracheostomy, glossectomy, mandibulectomy, surgery on the palate, total and partial laryngectomy, reconstruction of the pharynx and cervical esophagus, and surgery of the skull base. An overview is presented of normal swallowing physiology, as well as swallowing perturbations that are frequently encountered in postoperative head and neck cancer patients.

Prolonged QT syndrome: perioperative management

Intraoperative cardiac arrhythmias related to prolonged QT syndrome are uncommon. We describe a 26-year-old woman in whom ventricular fibrillation occurred during the final minutes of a partial glossectomy and right supraomohyoid selective neck dissection and discuss the role that this specific operation may have had in the development of the intraoperative event. In addition, we review the perioperative management of patients with prolonged QT syndrome.

Advanced carcinoma of the tongue: total glossectomy without total laryngectomy. Review of 80 cases

Opinions are divided over the validity of total glossectomy without associated total laryngectomy for advanced carcinoma of the tongue. This retrospective study evaluates the oncologic and functional results obtained in 80 patients who underwent total glossectomy as a primary procedure or as salvage surgery. Satisfactory swallowing ability was obtained in 41 patients, and speech was understandable in 49 patients. The survival rate at 1 year was 65%, with early recurrence of the disease, which was especially frequent in patients with prior radiotherapy, being the major cause of death. The study confirms the poor prognosis of cases with mandibular involvement, and the fact that partial laryngectomy, when required, impairs functional results. In the light of the authors' experience, total glossectomy without total laryngectomy should only be undertaken in motivated and well-supported patients able to accomplish the difficult rehabilitation process.

Articulatory function in glossectomized patients with immediate reconstruction using a free jejunum flap

Postoperative articulation in 18 glossectomized patients was investigated. The subjects were: 5 cases of tongue tumour, 7 cases of tumour of the anterior part of the floor of the mouth and 6 cases of tumour of the lateral part. A new modification of the Freiburger test for speech audiometry was used as test material. Then the articulatory function was assessed according to an overall score based on 180 monosyllables, the manner of production of 171 initial consonants and the place of production of 85 glossal sounds. The cases of tumour of the tongue and the lateral part of the floor of the mouth had excellent scores in all classes of sounds, which were compatible with the normative data. The subjects of tumour of the anterior part of the floor of the mouth had low overall scores, low scores for plosive and affricative sounds, and very low scores for sounds produced with the rear of the tongue. The relation between the site or amount of resection and subsequent articulation was significantly poor in all categories of sounds for the cases of anterior tumour, particularly in the movement of the posterior portion of the tongue even though it was not involved in the operation. In all groups there was a weak negative relation between the amount of resection and postoperative articulation. In reviewing the literature, reconstruction with a free jejunum flap was considered to lead to better articulation than reconstruction by other techniques. The need to assess postoperative function objectively was stressed, to compare the postoperative functions and to determine the indications for the reconstructive technique.

Rehabilitation of swallowing and communication following glossectomy

Patients who have had surgical removal of part or all of the tongue are left with varying degrees of swallowing and speech deficiencies. The extent of resection, mobility of the residual tongue segment, and adequacy of the remaining structures determine the amount and type of deficiency. While communicative impairment and dysphagia commonly are seen in a rehabilitation setting, the problems of the glossectomy patient often are unique. This article reviews the anatomy and physiology of the oral and pharyngeal musculature, discusses the speech and swallowing of the glossectomy patient, and presents nursing considerations for successful rehabilitation.

Light-cured interim palatal augmentation prosthesis. A clinical report

The interim palatal augmentation prosthesis produced a significant improvement in function within a short period of time. With the visible light-curing system, modifications of the prosthesis were made quickly and easily. The methods described enable the treatment team to immediately assess the results of prosthesis modifications.

Improvement of speech intelligibility by a secondary operation to mobilize the tongue after glossectomy

To prove the hypothesis that speech after glossectomy would be improved more by increasing the mobility of the remaining tongue rather than by increasing its volume, the speech intelligibility of 4 glossectomy patients was investigated before and after a secondary operation in which a split skin graft was used to mobilize the residual tongue. In each case, the postoperative speech intelligibility scores were higher than preoperative ones (case 1:83.6 to 97.2%, case 2: 76.6 to 82.5%, case 3: 51.5 to 58.5%, case 4: 30.2 to 49.3%). Sounds produced with the rear portion of the tongue were improved in 3 cases, and plosive and affricative sounds were remarkably improved in all cases. These results were considered to be due to the increased mobility, especially the mid and rear portions of the tongue.

Speech production following partial glossectomy

Changes in the dimensions and patterns of articulation used by three speakers to compensate for different amounts of tongue tissue excised during partial glossectomy were investigated. Place of articulation was shifted to parts of the vocal tract congruent with the speakers' surgically altered lingual morphology. Certain metrical properties of the articulatory gestures, such as width of the sibilant groove, were maintained. Intelligibility data indicated that perceptually acceptable substitute sounds could be produced by such transposed gestures.

Postglossectomy deglutitory and articulatory rehabilitation with palatal augmentation prostheses

For patients who may have significantly impaired deglutitory and articulatory functions after glossectomy, an important aspect of the rehabilitative management in our institution is the use of palatal augmentation prostheses. The aim is to reduce the free space between the roof and floor of the oral cavity to permit stronger lingual propulsion during oral deglutition and better linguopalatal contact during articulation. We evaluated ten patients who received this device after glossectomy during the past two years. Modified barium swallows and voice recordings were performed when possible with and without the use of the palatal augmentation prosthesis. Articulatory and deglutitory functions were evaluated on a scaled score ranging from 0 to 10 points. The scores of the patients' average immediate improvements were 4.5 points (range, 2 to 7) for articulation and 3.5 points (range, 2 to 7) for deglutition; the scores of average long-term improvements were 3.4 points (range, 2 to 7) and 2.2 points (range, 6 to 8), respectively. Patients using the palatal augmentation prosthesis experienced significant improvement in both functions. We believe that this device contributes greatly to rehabilitative therapy for patients who have undergone extirpative surgery for tumors of the oral cavity.