Effects of palatal augmentation prosthesis in oropharyngeal dysphagia in Chilean patients with tongue cancer: Cases report

ABSTRACT: Therapy of malignant neoplasms of the tongue or oropharynx may cause dysphagia. Dysphagia in patients has negative significant social and psychological consequences. The six cases reports describe the effect of palatal augmentation prosthesis (PAP) on the management of dysphagia in patients with oral-pharyngeal cancer and as consequence of its treatment. The study also assesses PAP's effects on the quality of life of such patients.

Hemiglossectomy tongue reconstruction: Modeling of elevation, protrusion, and functional outcome using receiver operator characteristic curve.

BACKGROUND: The purpose of this study was to model >12 month speech and the oral phase of swallowing outcomes with the reconstructive metrics of tongue elevation and protrusion in patients reconstructed with the rectangle tongue template for a hemiglossectomy defect. METHODS: We conducted a study using 40 surviving patients (23 men, 17 women) treated between 2000 and 2012. Statistically significant correlations of elevation and protrusion with functional outcomes were modeled with receiver operator characteristic (ROC) curves to understand the performance and reliability of the rectangle tongue reconstruction. RESULTS: Tongue elevation (1.8-1.9 cm) reliably produces best outcomes in nutritional mode, range of liquids, and ≥4/6 for range of solids. Greater tongue elevation (2.1-2.2 cm) reliably produces best outcomes for eating and speaking in public and understandability of speech. Tongue protrusion (0.8-1.0 cm) reliably produces best scores across all assessed outcomes except ≥4/6 for range of solids and ≥4/5 understandability of speech. CONCLUSION: ROC curves are useful for assessing reliability and relating reconstructive objectives to functional outcomes. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1066-1073, 2016.

The Use Of Anterolateral Thigh Flap (ALTF) For Functional Tongue Reconstruction With Postoperative Quality Of Live Evaluation.

UNLABELLED: The use of microsurgery for oral reconstruction of cancer patients, has become standard treatment in restoring oral function. The free anterolateral thigh flap is one of the most preferred options in reconstruction after total, subtotal or hemiresection of the tonque due to squamous cell cancer. The aim of the study was to present the reconstructive method using anterolateral thigh free flap with evaluation of quality of live. MATERIAL AND METHODS: Clinical material includes 46 consecutive patients with tongue cancer, who underwent complex surgical treatment between 2009 and 2011. There were 36 males and 10 females and the M: F ratio was 3.6: 1. All of them were reconstructed using the anterolateral thigh free flap. The quality of life was evaluated 6 months after completing the treatment, based on postoperative functional and aesthetic status. RESULTS: The overall flap survival rate was 96%. Surgical complications were observed in 8 patients (17%). Donor site was closed primarly in 42 cases and in remaining 4 skin graft was required. In all 46 cases understandable speech and return to unrestricted diet mastication and swallowing were achieved. The mean follow-up period after treatment was 32 months. Analysis of aesthetic effects evaluated in 23 cases and shows generally very good results. According to average transformed scores the QOL can be characterized as excellent for >90, very good for 76-90, good for 51-75, moderate for 25-50 and bad for <25 points. CONCLUSIONS: Anterolateral thigh flap, with its versatility in design, long pedicle with a suitable vessel diameter, low donor site morbidity, and very good aesthetic effects, could be the ideal flap for functional tongue reconstruction.

Total glossectomy with laryngeal preservation and free flap reconstruction: objective functional outcomes and systematic review of the literature.

OBJECTIVE: Advanced tongue cancer is a devastating diagnosis with potential for significant morbidity after treatment. This is especially true for patients undergoing total glossectomy with laryngeal preservation (TGLP), free flap reconstruction and adjuvant radiotherapy. The goals of this study were to: 1) determine long-term objective functional and quality of life outcomes, 2) investigate the influence of rehabilitation on functional recovery and 3) determine swallowing ability in patients with TGLP. STUDY DESIGN: Prospective cohort study and systematic review of the literature. METHODS: Functional outcomes data were collected from 2000-2010. Outcomes were measured pre- and 12 months post-surgery and included: gastrostomy-tube (G-Tube) rates, swallowing transit times on video fluoroscopic swallowing studies, speech intelligibility and EORTC-H&N 35 quality of life scores. A systematic review of the literature was conducted to determine comprehensive long term G-Tube rates. RESULTS: Twelve patients were included and eight were still living at 12 months post-surgery. Fifty percent of patients in this study and 24% with systematic review used G-Tubes at 1 year post-surgery. Patients who could swallow did not aspirate, but more than doubled swallowing transit times. Spoken sentence intelligibility averaged 66% and mean quality of life scores improved 8.9 points 12 months post-surgery. Patients who attended >80% of swallowing and speech rehabilitation sessions demonstrated superior swallowing and speech functional outcomes. CONCLUSIONS: Although a potentially morbid treatment, TGLP and free flap reconstruction can provide good swallowing and speech outcomes as well as meaningful long-term quality of life. Regular attendance of rehabilitation sessions is imperative to optimize functional outcomes.

Anterolateral thigh flap harvested from paralytic lower extremity in a patient with late polio sequel.

Free flap reconstruction is the treatment of choice after extensive head and neck tumour resection. When treating a patient with a previous disability, such as lower extremity paralysis secondary to poliomyelitis, it is important to offer the best reconstruction whilst preserving healthy extremities. We report the case of a 51-year-old man with a squamous cell carcinoma (SCC) of the right tongue and a left lower extremity paralysis secondary to an acute poliomyelitis during childhood in which reconstruction was successfully achieved with a left anterolateral thigh (ALT) free flap.

The deep inferior epigastric artery perforator (DIEAP) flap for total glossectomy reconstruction.

PURPOSE: Total or subtotal glossectomy following the resection of intraoral tumors causes significant morbidity. However, which reconstructive technique is the most successful remains controversial. PATIENTS AND METHODS: After approval by the Ethics Committee, charts were reviewed retrospectively for patients treated at the Oral and Maxillofacial Surgery Department, University Hospital La Paz (Madrid, Spain), during a 3-year period (2005-2008). All were reconstructed with a deep inferior epigastric artery perforator (DIEAP) flap after total glossectomy. Data collected included affiliation data, extent of extirpation, type of reconstruction, and surgical outcome, including donor-site morbidity, complications, and functional results. RESULTS: Seven patients (5 men, 71.4%; 2 women, 28.6%) with primary squamous cell carcinoma of the tongue underwent total glossectomy and simultaneous microsurgical reconstruction with a DIEAP flap. In all cases, the flap was harvested with a fusiform shape oriented craniocaudally and limited to zone 1. The average size of the flap was 16.7 × 7.2 cm. Functional outcome related to swallowing was poor; 57.1% of the patients required a permanent gastrostomy. Speech was considered intelligible in 85.7% of cases by 2 independent observers. The surgical outcome was uneventful in most of the cases, with only 1 case of local dehiscence at the mouth floor. None of the cases developed abdominal wall dehiscence or an abdominal hernia at mid- or long-term follow-up. CONCLUSIONS: The DIEAP flap is a reliable alternative for tongue reconstruction. It provides a large volume of soft tissue for transfer and is predictable and stable over time with low donor-site morbidity.

[Tongue reconstruction with a bilateral infrahyoid flap innervated by Ansa Cervicalis after total glossectomy]. / Le lambeau infrahyoïdien bilatéral innervé par l'Ansa Cervicalis pour la reconstruction des glossectomies totales.

INTRODUCTION: Reconstruction after total glossectomy remains a functional challenge. It must provide a large volume to ensure adequate phonation and swallowing. We present the larynx sparing bilateral infrahyoid flap reconstruction procedure after total glossectomy. PATIENTS AND METHOD: Three patients managed for an epidermoid carcinoma of the tongue, classified T4N0, underwent total glossectomy. The tongue was reconstructed with a bilateral infrahyoid flap pedicled on two superior thyroid arteries and innervated by Ansa Cervicalis. RESULTS: Oral food intake was resumed after 8 to 20 days. No false route was observed. The muscular flap mobility was clinically satisfactory. It was assessed by EMG in one case. Esophageal transit confirmed the absence of stasis and false route for one patient. DISCUSSION: This short series proves the feasibility of bilateral innervated and pedicled infrahyoid flap procedure. It is an alternative to volumetric and functional reconstruction after total glossectomy. The indications are rare and restricted to patients without IIa nodal region invasion. Our results are still limited and need to be confirmed by a larger series and by a more systematic assessment.

A longitudinal acoustic study of the effects of the radial forearm free flap reconstruction on sibilants produced by tongue cancer patients.

Acoustic properties of 980 tokens of sibilants /s, z, ƒ/ produced by 17 Canadian English-speaking female and male tongue cancer patients were studied. The patients had undergone tongue resection and tongue reconstruction with a radial forearm free flap (RFFF). The spectral moments (mean, skewness) and frication duration were analysed in connected speech samples produced before the tongue resection, and 1, 6 and 12 months after the surgery. The effects of radiation therapy (RT) and inclusion of the floor of the mouth (FOM) were also studied. Acoustic changes were observed only on alveolar sibilants /s, z/ such that speech was found to improve towards normal over the 1-year period. The reduction of acoustic distinction between /s, z/ and /ƒ/ was short term. A history of RT and involvement of the FOM had no differing effects on outcomes compared with non-RT or non-FOM. Variability between individuals was found, accentuating the speaker-specific abilities for adaptation, compensation and relearning after oral reconstruction.

Microvascular free tissue transfer for tongue reconstruction after hemiglossectomy: a functional assessment of radial forearm versus anterolateral thigh flap.

PURPOSE: The purpose of this study was to evaluate tongue function and donor site morbidity in patients with oral cancer surgically treated and reconstructed with radial or anterolateral thigh free flaps. PATIENTS AND METHODS: Twenty patients underwent primary reconstruction after hemiglossectomy between January 2002 and June 2004. Ten patients were reconstructed using a free forearm flap and the remaining with an anterolateral thigh flap. Eight patients on each group underwent postoperative radiotherapy (average, 60 Gy). All of them were followed postoperatively to determine after 6 months their functional outcome as it related to speech, deglutition, tongue mobility, and donor site morbidity. The intelligibility, deglutition, and tongue mobility were each scored on a scale ranging from 1 to 7 by an independent investigator. Data were analyzed by the 2-tail Mann-Whitney U test. RESULTS: No differences in mean speech intelligibility, tongue mobility, or deglutition mean scores were seen between radial forearm flap and anterolateral thigh flap (P > .05). In all anterolateral thigh flap-treated cases, the donor site was closed directly and no complications were seen. However, in all forearm flaps donor site closure was carried out with skin grafts and dorsal forearm splinting was applied for 1 week postoperatively. In 4 cases a partial skin graft failure was observed and donor sites healed for second intention. CONCLUSION: Anterolateral thigh flap, with its versatility in design, long pedicle with a suitable vessel diameter, and low donor site morbidity, could be the ideal flap for hemiglossectomy defect reconstruction.

Effects of a palatal augmentation prosthesis on lingual function in postoperative patients with oral cancer: coronal section analysis by ultrasonography.

A palatal augmentation prosthesis (PAP) is used in postoperative patients with oral cancer as an intraoral appliance. The purpose of this study was to use ultrasound imaging to evaluate the effects of a PAP on lingual movement dynamics when postoperative patients with oral cancer swallowed food while wearing a PAP and to elucidate the effectiveness of the PAP. The subjects were seven patients with tongue cancer. They wore a PAP as an intraoral device to compensate for postoperative dysfunction after surgery for tongue cancer. The measurements were made by using ultrasonography. Ultrasound images of the lingual movement dynamics of the center of the tongue (central grooving of the tongue in a coronal plane, passing through the distal surfaces of both the left and right lower second premolars) during swallowing were obtained in M mode. The mean duration of lingual-palatal contact was 805.4 +/- 306.0 ms in patients without a PAP and 621.8 +/- 364.9 ms in those with a PAP. The duration decreased significantly in patients wearing a PAP (P = 0.03). The mean total duration of lingual movement was 1612.2 +/- 478.3 ms in patients without a PAP and 1245.6 +/- 272.5 ms in those with a PAP. The mean total duration decreased significantly in patients with a PAP (P = 0.03). The study results indicated that wearing an intraoral appliance may effectively help lingual movement on swallowing in postoperative patients with oral cancer.

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.

[The tongue as a receptor and effector after tumor resection in the oral cavity]. / Jezyk jako receptor i efektor po wycieciu nowotworu jamy ustnej.

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.

[Psychological responses of patients after partial or total glossectomy due to carcinoma of the oral cavity]. / Psychologiczne reakcje chorych po czésciowym lub calkowitym wycieciu jezyka z powodu nowotworu jamy ustnej.

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]. / Opóznienie inicjacji gardlowej fazy polykania a przebieg aktu polykania u chorych po czesciowym lub calkowitym wycieciu jezyka z powodu nowotworu.

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.

Long-term performance of indwelling tracheoesophageal speaking valves in Chinese patients undergoing laryngectomy.

OBJECTIVES: To assess the use of indwelling tracheoesophageal speaking valves in Chinese patients undergoing laryngectomy, to identify the clinicopathologic factors for favorable outcome, and to evaluate the factors that determine prosthesis lifetime. DESIGN: Retrospective review. SETTING: Tertiary care institution. PATIENTS: Sixty consecutive patients with total laryngectomy were included. All had indwelling tracheoesophageal speaking valves for voice restoration. INTERVENTION: Anterograde replacement of voice prosthesis in case of failure of functional speech production or leakage of saliva. MAIN OUTCOME MEASURES: Incidence of successful tracheoesophageal speech rehabilitation for daily communication, influence of different clinicopathologic factors on the outcome, and prosthesis lifetime and its relationship to different clinicopathologic factors. RESULTS: The success rate of speech rehabilitation was 78%. Age younger than 60 years was the only clinicopathologic factor associated with successful speech rehabilitation (P = .04, Fisher exact test). The median device lifetime was 8.2 months. Both age of 60 years or older and the use of subsequent prosthetic valves were identified as risk factors for valve failure on univariate analysis (n = 192; log-rank test; P = .02 and P = .03, respectively), with age of 60 years or older as the only risk factor that reduced the device lifetime in the Cox proportional hazards model (P = .03; relative hazard ratio, 1.5; 95% confidence interval, 1.1-2.4). CONCLUSIONS: Our success rate in using indwelling tracheoesophageal speaking valves was comparable to that reported in the Western literature. The median device lifetime of 8.2 months was satisfactory. Patient age was found to be a significant predictor of successful tracheoesophageal speech rehabilitation, with age of 60 years or more adversely affecting device lifetime.

Prosthetic intervention in the era of microvascular reconstruction of the mandible--a retrospective analysis of functional outcome.

PURPOSE: The purpose of this retrospective study was to compare the functional outcomes of patients who had mandibular resection and reconstruction with and without prosthetic intervention, and to identify predictive factors that may have an impact on functional outcomes. MATERIALS AND METHODS: Two hundred twenty head and neck cancer patients who had undergone mandibular resection and reconstruction with at least 6 months of postoperative convalescence formed the basis of this retrospective review. Patients who did not receive prosthetic intervention formed group I (n = 142); those who received prosthetic intervention formed group II (n = 78). Functional outcomes were measured using four individual assessments (nutritional status, swallowing, masticatory performance, and speech) and one that combined the information from these assessments, the global measure of functional outcome (GMFO). Statistical analyses were used to compare the baseline characteristics and functional outcome between groups I and II and to analyze independent predictors for GMFO. RESULTS: Of the 220 patients reviewed, 78 (35%) had prosthetic intervention; group II patients had better individual functional outcome measures and GMFO. Use of a prosthesis remained associated with GMFO after controlling for other significant predictors; other independent predictors were xerostomia, number of remaining mandibular teeth, number of tooth-to-tooth contacts, type of reconstruction, flap interference, and tongue defect. Patients who had fewer mandibular teeth and received a smaller prosthesis had better overall outcome than patients who received a larger prosthesis. CONCLUSION: Patients who had prosthetic intervention after mandibular reconstruction had significantly better functional outcomes than patients who did not receive prosthetic intervention, even after adjusting for confounding variables.

Survival of a free flap after arterial disconnection at six days.

We know of no definition of how long it takes for a free flap to develop its own independent blood supply from its recipient bed. In this case report, we describe survival of a free flap after loss of the arterial anastomosis at 6 days.