Reconstruction of the tongue with reinnervated rectus abdominis musculoperitoneal flaps after hemiglossectomy

Reconstruction of the tongue after glossectomy is a primary objective in the process of improving the life quality of patients suffering from tongue cancer. We developed a new method of surgical reconstruction of the tongue after hemiglossectomy, with reinnervated rectus abdominis musculoperitoneal flaps. The rectus abdominis musculoperitoneal flap consisted of the rectus muscle, posterior rectus sheath, peritoneum, the 10th, 11th and 12th intercostal nerves, and the deep inferior epigastric artery and veins. Five patients underwent immediate reconstruction of the tongue with rectus abdominis musculoperitoneal flaps after hemiglossectomy. The intercostal nerves were anastomosed to the descending branch of the hypoglossal nerve. All transplanted flaps survived. The peritoneum was replaced by squamous epithelium eight weeks after surgery. During the follow-up period, the contour and function of the reconstructed tongues was satisfactory. Our experience indicates that reconstruction of the tongue with rectus abdominis musculoperitoneal flaps after hemiglossectomy is a suitable, cosmetically acceptable method.     

Fasciocutaneous flap reconstruction of the tongue and floor of mouth: outcomes and techniques

OBJECTIVES: To quantify functional and other outcomes after major resection and fasciocutaneous free-flap reconstruction of the tongue and floor of mouth, and to describe reconstructive technique. DESIGN: A hypothesis-generating, retrospective cohort study of 43 patients who underwent, at minimum, a hemiglossectomy and resection of the floor of the mouth for oral cancer followed by fasciocutaneous free-flap reconstruction. SETTING: A tertiary academic medical center in the midwestern United States. MAIN OUTCOME MEASURES: Speech intelligibility, swallowing, interval to decannulation, length of stay, free-flap success rates, patient survival, and complications. RESULTS: Thirty patients underwent oral tongue reconstructions, and 13, tongue base reconstructions. Median intelligibility scores were greater among patients in the tongue base group (98% intelligibility) than in the oral-tongue group (76% intelligibility) (P<.001). Of the 38 patients undergoing swallowing evaluation, 32 (85%) were able to feed entirely by mouth, most with mild to moderate dysphagia. All patients underwent decannulation (mean interval, 13.7 days). The mean length of hospital stay was 11 days, and free flaps in 42 patients (98%) survived. Twenty-eight patients (65%) were still alive by the end of the study, yielding a mean survival time of 27.4 months. Seven patients (16%) had severe medical and 3 (7%) had major surgical complications. CONCLUSION: The folding techniques used in this study for reconstruction of the tongue with fasciocutaneous free flaps were associated with recovery of adequate speech and swallowing in most patients.     

Functional outcomes after hemiglossectomy and reconstruction with a bilobed radial forearm free flap

OBJECTIVE: This study examines prospectively the functional outcomes of a cohort of patients who had undergone hemiglossectomy and reconstruction with a bilobed radial forearm free flap (RFFF) for oral tongue squamous cell carcinoma. METHODS: Speech and swallowing data were compiled for patients treated for oral tongue cancer with hemiglossectomy and and reconstruction with a bilobed RFFF. The three evaluation periods were preoperative, postoperatively, and postradiation therapy. RESULTS: Eleven patients were included in the study. A significant difference between preoperative and postoperative single-word intelligibility scores was observed. There was no significant difference across any of the evaluation times for sentence intelligibility. Swallowing analysis revealed fewer instances of laryngeal penetration with liquids postoperatively. No significant differences were found in laryngeal penetration with either the pudding or cookie consistencies across any of the evaluation times. There was no incidence of aspiration at any of the evaluation times. There were no significant differences in the number of problems with the oral or oral preparatory phases across any of the evaluation times. The neurotization status of the RFFF had no significant effect on any of the observed speech or swallowing parameters. CONCLUSIONS: The bilobed RFFF provides functional speech and excellent swallowing outcomes in the reconstruction of hemiglossectomy defects.     

Articulatory evaluation after mesopharyngeal reconstruction with the radial forearm flap]

Soft palate and tonsil (mesopharynx) play an important role on articulation and swallowing. We must take care not to restrict these physiological function when we reconstruct the mesopharyngeal defect after cancer ablation. In order not to restrict the postoperative function of mesopharynx, we take it the more important to preserve the function of the residual tissue rather than to rebuild the lost function. We took notice of pliable nature of the radial forearm flap and tried to reconstruct mesopharyngeal defect in five cases with this flap. We analyzed articulatory function and velopharyngeal closure in these cases, postoperatively. Articulatory function was assessed on the results of intelligibility test with 100 Japanese monosyllables. In four cases out of five, about 70% of syllables were accurately heard. According to the Hirose's standard of speech function after the operation of oral and/or oropharyngeal cancer, those four cases were evaluated also to be excellent. Whether the resection was done beyond the uvula or not, proved not to have anything to do with the postoperative speech intelligibility. Although speech intelligibility once went down immediately after the operation, it improved around six months later. The improvement might be due to the following facts; The forearm flap was cicatrized postoperatively, disturbing the mobility. After the softening of the cicatrix began, the flap gradually recovered flexibility, which enabled surrounding structure to move more smoothly. Articulatory dysfunction was characterized as plosives tend to be misunderstood as nasals or affricates. Concerning nasality, the velopharyngeal closure was examined by fiberscope. Perfect closure was seen in two cases, near-perfect in two cases, and insufficient in one case.(ABSTRACT TRUNCATED AT 250 WORDS)     

舌骨下肌肌皮瓣和桡侧前臂皮瓣修复半舌缺损术后患者生活质量的比较

目的　比较桡侧前臂皮瓣（radial forearm flap,RFF）和舌骨下肌肌皮瓣（infrahyoid myocutaneous flap,IHMCF）成功修复半舌缺损术后患者的生活质量,探讨半舌缺损修复方法的选择。方法　采用非随机对照研究。2005年6月～2012年6月我科共行标准半舌切除+半舌缺损修复术且皮瓣完全存活病例24例,均为舌侧缘鳞状细胞癌,未累及舌根,其中T2 19例,T3 5例,根据供区不同分为RFF组（n=10）和IHMCF组（n=14）;对比两组病例术后1年患者生活质量,采用EORTC-QLQ30及FACT-H&N35量表进行评价。结果　EORTC-QLQ30量表各领域得分的差异无统计学意义,FACT-H&N35量表中进食（P =0.005）、语言（P =0.008）、牙齿（P =0.014）、咳嗽（P =0.009）4个领域IHMCF组得分高于RFF组。结论　RFF和IHMCF修复半舌缺损术后总体生活质量相近,而口腔功能则以IHMCF组患者为优;在保证手术成功率的前提下,IHMCF在半舌缺损修复中是RFF良好的替代方法。     

Analysis of the relations between the shape of the reconstructed tongue and postoperative functions after subtotal or total glossectomy

OBJECTIVES/HYPOTHESIS: For reconstruction after subtotal or total glossectomy, both preserving the larynx and maintaining postoperative swallowing and speech functions can greatly improve quality of life; however, postoperative functional results are often unstable. Our experiences suggest that insufficient flap volume in the oral area and postoperative prolapse of the preserved larynx affect postoperative function. The objective was to investigate the relations of the shape of the reconstructed tongue to postoperative swallowing and speech functions. STUDY DESIGN: The shape of the reconstructed tongue was classified on the basis of magnetic resonance and intraoral inspection as protuberant, semi-protuberant, flat, or depressed. Speech intelligibility was evaluated, and body weight, which might affect the shape of the transferred flap, was measured before and after surgery. METHODS: Thirty patients who had undergone subtotal or total glossectomy and subsequent reconstruction were reviewed. RESULTS: We found that speech intelligibility (P <.001), food (P <.01), and deglutition (P <.003) scores were significantly lower in patients with flat or depressed tongues than in patients with semi-protuberant or protuberant tongues. Weight loss after surgery was significantly greater in patients with depressed tongues than in other patients (P <.013). Our results indicate that postoperative function is related to the shape of the reconstructed tongue. CONCLUSIONS: We suggest that 1) wider and thicker flaps, such as rectus abdominis musculocutaneous flaps, be used; 2) flaps be designed to be approximately 30% wider than the defect; 3) laryngeal suspension be used to prevent prolapse of the transferred flap; and 4) careful general management and sufficient nutrition are important in the early postoperative period.     

Progressive functional improvement in hemiglossectomy defects reconstructed with radial forearm free flap at 6-months

Objective

The purposes of the study was to evaluate for the functional improvement of outcomes of patients undergoing surgical management for tongue cancer at varying periods after surgery.

A technique of tongue reconstruction following near-total glossectomy

Total glossectomy is the most crippling of all oral cavity resections. Speech problems are unavoidable and post-operative aspiration is often severe. Two patients are presented who have had tongue reconstructions following near-total glossectomies. In each case a quilted, split-skin grafted pectoralis major muscle flap was used. The speech and swallowing results of these two patients are compared with two patients who underwent a hemiglossectomy and total glossectomy respectively without tongue reconstruction. Only if the suprahyoid and extrinsic tongue muscles are preserved can an active oral phase of swallowing and usable speech be regained by tongue reconstruction.     

Prophylactic fasciotomy of the anterolateral thigh donor site in head and neck reconstruction

IntroductionThe free anterolateral thigh (ALT) flap is a versatile reconstructive option for head and neck defects. Donor site complications are rare but severe; with wound dehiscence, need for secondary closure, and compartment syndrome reported.ObjectivesWe propose prophylactic thigh fasciotomy as a surgical technique to facilitate primary closure while preventing donor site complications during ALT flap harvest.MethodsWe examined donor site wound characteristics, recipient site wound characteristics, and clinical outcomes for 24 consecutive ALT flaps performed for head and neck reconstruction from 2016 to 2018. All ALT donor sites underwent prophylactic fasciotomy.ResultsThere were no incidents of thigh compartment syndrome or wound dehiscence of donor site; one patient underwent primary donor site skin grafting.ConclusionProphylactic thigh fasciotomy allows mobilization of soft tissue to facilitate primary tension-free closure of the ALT donor site even for free flaps with a large skin component, while reducing the possibility of compartment syndrome.     

Sensate radial forearm free flaps in tongue reconstruction.

BACKGROUND: Successful rehabilitation after ablative surgery requires not only the reconstruction of 3-dimensional form but also the restoration of physiologic function. OBJECTIVE: To assess sensory recovery of reinnervated radial forearm flaps used for tongue reconstruction. PATIENTS AND METHODS: Seventeen patients, who underwent reconstruction of glossectomy defects with reinnervated radial forearm free flaps, formed the study group. Recovery of sensation was measured by both subjective and detailed objective tests 8 months after surgery. Sensory function of the flap was compared with that of the normal residual tongue or the adjacent oral mucosa and the contralateral forearm donor site. RESULTS: All patients involved in this study had tongue defects of hemiglossectomy or greater and adjacent floor of the mouth. Sensory recovery was observed in all of the 17 patients within 8 months. Detailed sensory testing showed that median static 2-point discrimination, moving 2-point discrimination, and pressure sensitivity (1.2 cm, 0.8 cm, and 3.7 psi, respectively) were subjectively greater in the innervated forearm flaps than in the contralateral forearm donor site (2.3 cm, 1.7 cm, and 4.6 psi, respectively) (P= .064) and similar to those of the normal tongue (0.9 cm, 0.5 cm, and 3.6 psi). CONCLUSIONS: In all modalities examined, sensate free flaps proved superior in sensory fidelity to the native forearm donor site and closely approached that of the normal tongue. Microsurgical reinnervation of flaps should be considered in tongue reconstruction.     

Evaluation of speech intelligibility in short-reverberant sound fields

Objective

The purpose of this study was to explore the differences in speech intelligibility in short-reverberant sound fields using deteriorated monosyllables. Generated using digital signal processing, deteriorated monosyllables can lack the redundancy of words, and thus may emphasize differences in sound fields in terms of speech clarity.

Methods

Ten participants without any hearing disorders identified 100 monosyllables convolved with eight impulse responses measured in different short-reverberant sound fields (speech transmission index >0.6 and reverberation time <1 s), and we compared speech recognition scores between normal and deteriorated monosyllables. Deterioration was produced using low-pass filtering (cut off frequency = 1600 Hz).

Results

Speech recognition scores associated with the deteriorated monosyllables were lower than those for the normal monosyllables. In addition, scores were more varied among the different sound fields, although this result was not significant according to an analysis of variance. In contrast, the variation among sound fields was significant for the normal monosyllables. When comparing the intelligibility scores to the acoustic parameters calculated from eight impulse responses, the speech recognition scores were the highest when the reverberant/direct sound energy ratio (R/D) was balanced.

Conclusions

Although our deterioration procedure obscured differences in intelligibility score among the different sound fields, we have established that the R/D is a useful parameter for evaluating speech intelligibility in short-reverberant sound fields.     

Functional outcomes after primary oropharyngeal cancer resection and reconstruction with the radial forearm free flap

OBJECTIVE: To report prospectively collected aeromechanical, acoustical, and perceptual speech outcomes, as well as preliminary swallowing data, in patients having reconstruction with radial forearm free flaps after primary resection for oropharyngeal cancer. STUDY DESIGN: Prospective cohort study. METHODS: Acoustical, aeromechanical, and perceptual speech data and swallowing data were gathered at three evaluation times (preoperatively and before and after radiation therapy) for patients treated for oropharyngeal cancer by means of primary resection and reconstruction with a radial forearm free flap. Degree of involvement of the soft palate and base of tongue, along with reconstructive techniques, were entered as between-group factors in the analysis. RESULTS: There were no significant differences in speech intelligibility between the patient groups based on the degree of palate and tongue resected. However, patients with resections of half or more than half of the soft palate had significantly higher nasalance values and larger velopharyngeal orifice areas than individuals who had less than half of the soft palate resected. Significant within-subject differences were revealed across evaluation times for the dependent variables nasalance, velopharyngeal orifice area, and word intelligibility. Ninety-four percent of the patients were able to resume a normal or soft diet. There was a 6% incidence of aspiration in 128 swallows that were analyzed. The amount of base of tongue resected did not significantly affect any of the speech or swallowing parameters. CONCLUSIONS: Radial forearm free flaps are a good reconstructive option after oropharyngeal cancer extirpation. Our acoustic and aeromechanical results indicated that issues related to quality of the speech signal require further study for resections of half or more than half of the soft palate.     

Vibratory segment function after free flap reconstruction of the pharyngoesophagus

Reconstructive options following total laryngo-pharyngectomy include thin, pliable free tissue segments, approximating the natural thickness of the pharyngeal wall. The authors have investigated outcomes in the following clinical series, emphasizing speech and swallowing. Twelve cancer patients underwent laryngopharyngectomy with or without glossectomy. Eight jejunal, 1 radial forearm, and 3 innervated latissimus dorsi flaps were used for vibratory segment (VS) reconstruction, and all 12 patients underwent tracheoesophageal puncture (TEP). Eleven patients achieved intelligible speech, with a median intelligibility of 93%. The vibrating segments showed fluttering of the free flap tissue when studied by videopharyngography. Vocal quality was lower pitched and softer than “conventional” TEP speech. All patients achieved oral intake as their primary mode of nutrition. Free flaps are a successful option for VS reconstruction in patients undergoing laryngopharyngectomy or glossopharyngolaryngectomy, obviating the need for written or electrolarynx communication.     

Speech intelligibility after glossectomy and speech rehabilitation.

BACKGROUND: Oral tumor resections cause articulation deficiencies, depending on the site, extent of resection, type of reconstruction, and tongue stump mobility. OBJECTIVES: To evaluate the speech intelligibility of patients undergoing total, subtotal, or partial glossectomy, before and after speech therapy. PATIENTS AND METHODS: Twenty-seven patients (24 men and 3 women), aged 34 to 77 years (mean age, 56.5 years), underwent glossectomy. Tumor stages were T1 in 3 patients, T2 in 4, T3 in 8, T4 in 11, and TX in 1; node stages, N0 in 15 patients, N1 in 5, N2a-c in 6, and N3 in 1. No patient had metastases (M0). Patients were divided into 3 groups by extent of tongue resection, ie, total (group 1; n = 6), subtotal (group 2; n = 9), and partial (group 3; n = 12). Different phonological tasks were recorded and analyzed by 3 experienced judges, including sustained 7 oral vowels, vowel in a syllable, and the sequence vowel-consonant-vowel (VCV). The intelligibility of spontaneous speech (sequence story) was scored from 1 to 4 in consensus. All patients underwent a therapeutic program to activate articulatory adaptations, compensations, and maximization of the remaining structures for 3 to 6 months. The tasks were recorded after speech therapy. To compare mean changes, analyses of variance and Wilcoxon tests were used. RESULTS: Patients of groups 1 and 2 significantly improved their speech intelligibility (P<.05). Group 1 improved vowels, VCV, and spontaneous speech; group 2, syllable, VCV, and spontaneous speech. Group 3 demonstrated better intelligibility in the pretherapy phase, but the improvement after therapy was not significant. CONCLUSIONS: Speech therapy was effective in improving speech intelligibility of patients undergoing glossectomy, even after major resection. Different pretherapy ability between groups was seen, with improvement of speech intelligibility in groups 1 and 2. The improvement of speech intelligibility in group 3 was not statistically significant, possibly because of the small and heterogeneous sample.     

Enhancing surgical outcomes: The effects of speech therapy on a school-aged girl with Moebius Syndrome

PurposeMoebius Syndrome is a rare congenital neurological condition often characterized by multiple cranial nerve involvement. This case study presents an eight-year old girl with Moebius Syndrome (MC) who received 30 sessions of speech therapy. This occurred after presenting to clinic 11 months after left facial reanimation with gracilis thigh muscle transfer surgery. On examination, only flickers of left facial movement were observed. There was no movement on the right side of the face. As a consequence of the minimal movement, MC presented with drooling and unintelligible speech. The purpose of speech therapy was three fold: minimise the pooling of saliva, improve the placement of the articulators so that articulation of speech sounds would be more accurate, and gain advances in overall intelligibility.MethodsTherapy focussed on speech, facial movement and saliva management using a combination of speech drills, evidence-based articulation therapies, facial exercises with surface electromyography biofeedback, self-awareness training and compensatory saliva management strategies.ResultsAfter a course of 30 one-hour speech therapy sessions, substantial improvements were seen in speech sound accuracy, overall intelligibility, facial movement and saliva control.ConclusionsThe combination of surgery and speech therapy led to functional gains that surgery alone did not achieve. The impact of speech therapy on surgical outcomes in individuals with Moebius syndrome deserves further investigation.     

股前外侧皮瓣修复口腔颌面组织缺损

目的总结游离股前外侧皮瓣在修复口腔肿瘤切除术后组织缺损的经验和教训。方法2004年12月-2005年12月应用吻合血管的游离股前外侧皮瓣修复舌鳞癌17例,口颊鳞癌6例和其他恶性肿瘤切除术后的口腔颌面部组织缺损8例,皮瓣(4～8)cm×(6—23)cm。术中同时气管切开4例。结果皮瓣完全成活者30例,成活率96．8％。3例术后12 h～4 d出现静脉血管危象,其中1例静脉血管危象和1例静脉血栓均抢救成功,皮瓣完全成活;另1例术后因皮瓣淤血时间较长,最后皮瓣坏死约25％。30例患者无瘤生存,1例术后8个月死于颈部淋巴结复发未控。结论股前外侧皮瓣厚薄适中,是修复口腔组织缺损的良好材料。皮瓣大小应与受区缺损大小相当,避免皮瓣挤压。肿瘤手术必须在保证安全切缘的同时,尽可能保留牙齿等重要的口腔功能结构;缝合皮瓣应防止扭曲血管蒂,避免静脉受压。修复软硬腭时加行气管切开比较安全。     

Reconstruction of hypopharyngeal defects with anterolateral thigh free flap: A single-center retrospective analysis

IntroductionReconstruction of expanded hypopharyngeal defects following laryngo-hypopharyngectomy for surgical treatment of primary is still a challenge for head and neck surgeons. Tradiotionally, jejunal or radial forearm flaps are the common reconstructive choice. Recently, the anterolateral thigh (ALT) free flap has served for pharyngoesophageal reconstruction. The goal of this work is to describe a retrospective analysis about a five-year single-center experience in the reconstruction of post-operative hypopharyngeal defects with ALT free flap.MethodsA single-center retrospective study was performed, including patients treated for patients who underwent tumor surgery involving hypopharynx with ALT free flap reconstruction from 2015 to 2020. Exclusion criteria were paediatric (0–18 years) patients, and the absence of follow-up.ResultsThe study included 23 adult patients. The mean size of the flap was 90 cm² (range 60–130 cm²). The mean time required to harvest the antero-lateral tight flap was 70 min (range 35–120 min). The median age was 46.3 years (SD 15.81, range: 19–84 years), with a gender female prevalence (F = 48, M = 33). Mean follow-up was 77.7 months (min 4–max 361, SD 72.46). One patient (4.4 %) showed a hypopharyngeal stenosis.ConclusionALT free flap represents a successful and versatile reconstructive option for hypopharyngeal defects extended to oropharynx and/or larynx following total laryngectomy with circumferential or partial hypopharyngectomy, regardless of the functional and aesthetic results, with minimal donor-site complication.     

Mandibular rescue: Application of the ALT fascia free flap to arrest osteoradionecrosis of the mandible

ObjectivesTo evaluate the use of the anterolateral thigh fascia free flap for use in neovascularization of mandibular bone in moderate osteoradionecrosis (ORN). All patients had ORN secondary to prior radiation therapy that was not severe enough to warrant segmental resection and reconstruction.Study designCase series.SettingTertiary medical center.MethodsIRB approval was obtained, and a retrospective chart review performed of all mandibular rescue procedures performed from 2011 to 2014. Patients with a minimum of two years of follow-up were included in the study.ResultsAll surgeries were performed by the senior surgeon (MF). Eight patients underwent the mandibular rescue procedure with resolution of pain and return to oral feeding in all patients, and no evidence of ORN progression on follow-up imaging. A total of 9 ALT free flaps were performed (one patient had 2 surgeries). Gender was distributed evenly (4 female/4 male). The average age was 66 (58-78), average length of hospitalization was 2.8 days (1–7), and average follow-up was 46.5 months (25–63).ConclusionsThe mandibular rescue procedure is a novel technique using the ALT fascia lata free flap to provide coverage and nutrient blood flow to mandible devascularized secondary to radiation therapy. The flap provides the advantages of low morbidity, ease of harvest, two-team approach to ablation and reconstruction, and quick recovery resulting in ‘short-stay’ free flap surgery. Although conclusions must be tempered in this small case series, our early clinical experience shows the ALT fascia lata flap holds promise in halting the destructive progression of ORN that is not yet advanced enough to require a segmental resection and reconstruction.     

顶舌法联合刮舌法对舌系带过短患儿术后舌尖音训练效果的分析

目的：探讨顶舌法联合刮舌法对舌系带过短患儿术后舌尖音训练效果的影响。方法采用随机对照研究设计,将50例舌系带过短术后仅有舌尖音发音障碍的患儿（4～8岁）随机分为实验组25例,对照组25例。实验组在常规语音训练的基础上配合顶舌刮舌法训练,对照组采用常规语音训练,分别测试两组患儿在语音治疗前和治疗3个疗程后的语音清晰度,比较两组结果。结果实验组及对照组患儿治疗前的语音清晰度分别约为37．91％、37．69％,治疗后分别为87．69％、72．99％,两组患儿治疗前语音清晰度差异无统计学意义（t＝0．726,P ＞0．05）,治疗后两组患儿语音清晰度均较治疗前明显提高,差异有统计学意义（P ＜0．001）,且实验组患儿语音清晰度显著高于对照组。结论顶舌法联合刮舌法可以促进舌系带过短患儿术后仅有舌尖音发音障碍患儿语音清晰度的提高。     

Intelligibility of bone-conducted ultrasonic speech

Ultrasound can be perceived through bone conduction by the profoundly deaf as well as by normal-hearing subjects. Moreover, speech signals modulated onto ultrasound can be detected through bone conduction. This study explored how well listeners can understand ultrasonic speech and the confusion patterns to evaluate and improve bone-conducted ultrasonic hearing. The intelligibility of Japanese words classified by familiarity and Japanese monosyllables with bone-conducted ultrasound was investigated. Results showed that the intelligibility of familiar words was higher than that of unfamiliar words. Further, the results of a monosyllable intelligibility test with bone-conducted ultrasound and those of a test with air-conducted sound showed a similar pattern of speech recognition with regard to the errors made. The relationship between speech intelligibility and sound level showed that the increase in the intelligibility of bone-conducted ultrasonic speech did not exceed the increase in the intelligibility of air-conducted speech as the sound level rose.