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.     

Modified supraglottic laryngectomy and resection of lesions of the base of tongue

Extensive malignant tumors involving the base of tongue and adjacent pharyngeal walls usually require surgical resection combined with radiation therapy and sometimes chemotherapy. Often it is elected to perform a concomitant laryngectomy to prevent chronic aspiration, but not because of tumor extension to the larynx. A new technique allowing preservation of glottic function is described. This involved preservation of the false vocal folds and their surgical closure. The interarytenoid mucosa is preserved. This provides a fistula with a sphincteric function in the interarytenoid area. A permanent tracheostoma is created. This procedure has been used in the treatment of eight patients from April of 1979 to April of 1982. One patient died of sepsis in the early postoperative period. Of the seven evaluable patients, only one experienced significant aspiration postoperatively. All patients achieved adequate phonntion. Four patients developed good speech. The remaining three patients have some speech, but are limited in their articulation because of resection of a significant portion of the oral tongue. Three patients are alive and have developed a recurrence. Two patients are alive with recurrent disease and two patients died of their disease. This procedure appears to allow adequate surgical resection of extensive oropharyngeal neoplasms with preservation of the laryngeal functions of phonation and protection of the lower tracheal-bronchial tree.     

Articulation testing versus conversational speech sampling.

Detailed speech analyses were performed on data from 61 speech-delayed children assessed by both a standard articulation test and a conversational speech sample. Statistically significant differences between the articulation accuracy profiles obtained from the two sampling modes were observed at all linguistic levels examined, including overall accuracy, phonological processes, individual phonemes, manner features, error-type, word position, and allophones. Established sounds were often produced more accurately in conversational speech, whereas emerging sounds were often produced more accurately in response to articulation test stimuli. Error patterns involving word-to-word transitions were available only in the context of continuous speech. A pass-fail analysis indicated that the average subject would receive similar clinical decisions from articulation testing and conversational speech sampling on an average of 71% of consonant sounds. Analyses of demographic, language, and speech variables did not yield any subject characteristics that were significantly associated with concordance rates in the two sampling modes. Discussion considers sources of variance for differences between sampling modes, including processes associated with both the speaker and the transcriber. In comparison to the validity of conversational speech samples for integrated speech, language, and prosodic analyses, articulation tests appear to yield neither typical nor optimal measures of speech performance.     

Surgical variables affecting postoperative swallowing efficiency in oral cancer patients: A pilot study

This study examined the correlation between swallow function at 3 months postoperatively and surgical variables including volume resected, flap volume, ratio of flap volume to volume resected, percentage of oral tongue, tongue base, and anterior and lateral floor of mouth resected, and whether or not the mandible was preserved in 30 surgically treated oral cancer patients. Swallows of measured amounts of liquid and paste (pudding) materials were examined videofluoroscopically. Nine measures of swallow function were completed for each swallow. A factor analysis of all swallow variables was done for liquid and for paste consistencies to determine whether one measure was statistically representative of all swallow measures. This analysis indicated that oral pharyngeal swallow efficiency (OPSE) represented all measures for both liquid and paste consistencies. Then the correlation between OPSE and surgical variables was defined. Only percentage of oral tongue and percentage of tongue base resected were significantly negatively correlated with OPSE. That is, OPSE decreased for both liquid and paste as percentage of oral tongue or percentage of tongue base resected increased. Results are discussed in terms of diet choices and surgical management.     

Hearing and speech assessment of cleft palate patients after palatal closure. Long-term results

OBJECTIVE: The goal of this study was the development of a clinical methodology to assess speech and hearing impairment 5 years after the primary surgical repair of the cleft and, further, to determine the relative importance and long-term consequences of each cleft type and age to the velopharyngeal and eustachian tube function in patients who did not undergo pharyngeal flap surgery following primary palatoplasty. MATERIALS AND METHODS: We evaluated with a certain assessment protocol hearing and speech abilities of 42 patients between 5 and 15 years of age: 9 with CP (cleft of the soft and hard palate), 19 with unilateral cleft lip and palate (UCLP), 14 with bilateral cleft lip and palate (BCLP), surgically treated by a team of surgeons using two different surgical techniques between 18 and 24 months of age. ACCORDING TO OUR RESULTS WE WERE ABLE TO EVALUATE: (a) the impact of hearing impairment to the development of speech in these patients. (b) The relation of hypernasality with compansatory articulation. (c) The influence of cleft type, by means of extent of the cleft palatal musculature, to speech integrity. RESULTS: Sixty-nine percent of our patients presented with mild and moderate hearing loss. Hypernasality was observed in 40.5%, compensatory articulation in 28.5% of our patients. CONCLUSIONS: Our findings indicated: (a) a simultaneous appearance of speech and hearing impairment at the same age for each cleft type post-surgically in our patients; (b) that the muscular and vomer complex rather than the anatomic extent of the cleft is a significant factor for speech outcome after surgical repair; and (c) that hypernasality is exacerbated by compensatory articulation.     

Visual training and correction of articulation disorders by use of dynamic palatography: serial observation in a case of cleft palate

The dynamic palatograph is an electrical apparatus that generates a visual display of constantly changing palatolingual contact as a function of time, using an artificial palatal plate with affixed electrodes. This paper describes a technique of speech therapy incorporating dynamic palatography for a cleft palate patient. The patient, a 6-year-old Japanese girl with a repaired unilateral cleft lip and palate, had been judged to demonstrate articulation disorders involving contact of the tongue with the hard palate or alveolus following surgical improvement of velopharyngeal function. Prior to therapy the tongue tended to contact the hard palate more posteriorly than normal. After therapy with the dynamic palatograph, palatolingual contact was normal in comparison with average speakers. Our findings suggest that the facility of constant visual indication of tongue posture to the clinician and patient during corrective speech therapy using dynamic palatography may expedite results with cleft palate patients in the speech clinic when implemented in a carefully structured treatment plan.     

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)     

Effective rehabilitation after partial glossectomy

Objective  The surgical treatment of cancer of tongue results in speech deficits. Speech disorders in the glossectomised patients fall into, categories of impaired articulation, reduced speech intelligibility, altered oral & nasal resonance, impaired voice quality & reductions in global speech proficiency. Since speech is a social tool, its most significant measurements start with the degree to which it can be understood. Methods  This study was conducted at Tata Memorial Hospital, Mumbai, India, An incidental sample of 25 patients was selected for this study. Different questionnaires specially devised for this study were used to assess patients’ speech & deglutition post-operatively. The data was collected 3 months after surgery of these patients. Results  Studies have indicated that larger the segment of the tongue, the greater is the distortion of speech & difficulty in deglutition. All functions associated with the interaction of the tongue with the related anatomy of the head & neck were severely impaired following glossectomy. The rehabilitation plan for partial glossectomy patients depended upon the assessment of their post-operative articulation level, education, job, age, family & motivation.     

Tongue reconstruction: Concepts and practice

Total or subtotal tongue resection results in the potential for severe speech and swallowing disruption and life-threatening aspiration. This report documents the development of a new design for latissimus dorsi flaps used in tongue reconstruction. In order to create a contractile muscle sling which will raise the neotongue toward the palate for speech and swallowing, the flap is harvested with muscle fibers oriented transverse to its long, skin component axis. The flap is then transferred to the oral and oropharyngeal defect and sutured at the level of the mandibular angle to the remaining muscles of mastication. Conventional microvascular anastomosis for free flaps is followed by end-to-end reanastomosis of the hypoglossal nerve stump to the nerve to latissimus dorsi. The skin component is set into the floor of mouth with a curved wedge resected anteriorly, raising a mound to assist with articulation. Fourteen such reconstructions have been performed on patients undergoing glossectomy for cancer. If not invaded by cancer, the glottic larynx was preserved, and the decannulation rate was 80% at a median postoperative interval of 3.2 weeks. Seventy percent of patients achieved oral intake with pureed food or better, and upward motion of the flap was documented by video swallowing studies. Articulation was particularly good. This innervated latissimus dorsi flap design therefore is a viable method for rehabilitation after total or subtotal glossectomy.     

Surgical impact and speech outcome at 2.5 years after one- or two-stage cleft palate closure

ObjectiveIn the ongoing discussion about timing of palate closure, it is said that early closure is favorable for speech development, but can interfere with maxillary growth. On the other hand, beneficial results on both after one-stage palate closure have also been presented. The assumption that one-stage palate closure leads to less surgical impact on the child probably contributed to the choice for this procedure in most cleft centers. However, no previous research has verified this assumption. The aim of the present study is to compare surgical impact and speech outcome at 2.5 years of age between children who underwent either one- or early two-stage palate closure.MethodsPatients underwent either one-stage palate closure between 2007 and 2010 at a median age of 10.8 months (group 1, n = 24) or early two-stage closure before 2007 at median ages of 10.4 and 18.2 months, respectively (group 2, n = 24). Surgical impact was compared between the two groups by means of duration of surgery, length of hospital stay and number of post-operative complications. Speech outcome was compared by means of resonance problems, nasal air emission, articulation and intelligibility, all assessed at a median age of 2.5 years.ResultsThe one-stage closure group showed significantly shorter duration of surgery and length of hospital stay (p < 0.001 and p = 0.001, respectively) and significantly better articulation (p = 0.029) than the early two-stage closure group.ConclusionOne-stage palate closure is preferable over early two-stage palate closure with regard to surgical impact and speech development. More extensive, prospective studies, in which maxillary growth is taken into account, should be conducted.     

Radiation dose to the tongue and velopharynx predicts acoustic-articulatory changes after chemo-IMRT treatment for advanced head and neck cancer

The aim of this study was to investigate to what extent changes in speech after C-IMRT treatment are related to mean doses to the tongue and velopharynx (VP). In 34 patients with advanced hypopharyngeal, nasopharyngeal, or oropharyngeal cancer, changes in speech from pretreatment to 10 weeks and 1 year posttreatment were correlated with mean doses to the base of tongue (BOT), oral cavity (OC) and tonsillar fossa/soft palate (VP). Differences in anteroposterior tongue position, dorsoventral degree of tongue to palate or pharynx constriction, grooving, strength, nasality, and laryngeal rise, were assessed by acoustic changes in three speech sounds that depend on a (post-) alveolar closure or narrowing (/t/, /s/, /z/), three with a tongue to palate/pharyngeal narrowing (/l/, /r/, /u/), and in vowel /a/ at comfortable and highest pitch. Acoustically assessed changes in tongue positioning, shape, velopharyngeal constriction, and laryngeal elevation were significantly related to mean doses to the tongue and velopharynx. The mean dose to BOT predicted changes in anteroposterior tongue positioning from pre- to 10-weeks posttreatment. From pretreatment to 1-year, mean doses to BOT, OC, and VP were related to changes in grooving, strength, laryngeal height, nasality, palatalization, and degree of pharyngeal constriction. Changes in speech are related to mean doses to the base of tongue and velopharynx. The outcome indicates that strength, motility, and the balance between agonist and antagonist muscle forces change significantly after radiotherapy.     

Functional outcomes following palatal reconstruction with a folded radial forearm free flap

Defects of the soft palate often occur after extirpative procedures are performed to treat oropharyngeal cancers. These defects usually result in velopharyngeal insufficiency and an alteration in speech and deglutition. Palatal prostheses have been used to circumvent this problem in the past. Recently, however, folded radial forearmfreeflaps have been introduced for reconstruction of the soft palate to eliminate velopharyngeal insufficiency and the need for a prosthesis. We conducted a study to evaluate pharyngeal and palatal functions following reconstruction of soft-palate defects with radial forearm free flaps in 16 patients who had undergone resection of the soft palate for squamous cell carcinoma. Nine patients had partial soft-palate defects and 7 had total defects. All patients had lateral pharyngeal-wall defects. In addition, 14 patients had defects of the base of the tongue. Patients were followed for 3 to 40 months. Outcome measures were determined according to several parameters, including postoperative complications, resumption of diet, intelligibility of speech, and decannulation. All patients were evaluated by a speech pathologist and an otolaryngologist with a bedside swallowing evaluation and flexible nasopharyngoscopy. Twelve patients underwent videofluoroscopic studies. There was no incidence of flap failure. One patient developed a transient salivary fistula, which resolved with conservative management. Four patients without dysphagia resumed oral intake 2 weeks after surgery. The 12 patients with dysphagia underwent swallowing therapy. Ten of them responded and were able to resume oral intake, while the other 2 required a palatal prosthesis. Overall, 10 patients resumed a normal diet and 4 tolerated a soft diet within 6 weeks. The 2 patients who required a palatal prosthesis were able to take purees. All patients were decannulated, and all were able to speak intelligibly. Speech was hypernasal in 2 patients and hyponasal in 3. We conclude that the folded radial forearm free flap procedure is a useful alternative for reconstruction of palatal and pharyngeal defects. It is safe and effective, and it results in excellent functional outcomes.     

Swallowing function following extensive resection of oral or oropharyngeal cancer with laryngeal suspension and cricopharyngeal myotomy

OBJECTIVE: To investigate factors that influence postoperative swallowing function in patients who underwent tongue and oropharynx resection. METHODS: Sixty-two subjects who had undergone extensive resection of oral or oropharyngeal cancer between 1993 and 2005 participated in this study. All surgical procedures involved excision of the bilateral suprahyoid muscles or of >or=50% of the tongue base. Laryngeal suspension and cricopharyngeal myotomy were performed on all subjects. A multivariate analysis of the effects of extensive tongue and oropharynx resection on swallowing function was performed. RESULTS: A total of 53 (85.5%) of the 62 subjects achieved independent oral intake and no longer required tube feeding. Six months after surgery, better eating capabilities had been attained by younger patients as compared with older patients; patients with less extensive tongue base resections; patients who had not undergone radiotherapy; and patients reconstructed with free flaps rather than pedicled flaps. CONCLUSIONS: Age was found to be the most important factor in determining whether a patient could achieve independent oral intake after extensive oral or oropharyngeal resection. The main factors in determining the quality of diet attained by the patient were found to be age, the percentage of tongue base resection, and the method of postoperative reconstruction.     

Reconstruction of large defects of the oral mucosa with free, revascularized jejunum transplants

The resection of oropharyngeal cancer often creates large mucosal defects which may impair chewing, swallowing or speech function severely. Therefore, proper reconstruction is crucial for the patient. In five cases with cancer of the floor of the mouth, the tongue, the cheek and the soft palate respectively, a successful reconstruction was achieved by means of a free revascularized jejunal graft. Tumour resection and preparation of the jejunal graft are performed synchronously by two surgical teams. After suturing the graft into the oropharyngeal defect its mesenteric vessels are usually anastomosed to the facial artery and the external jugular vein. Results showed that the jejunal graft is a most adequate substitute for oropharyngeal defects and superior to skin flaps. In a sixth patient the graft was lost because of an arterial thrombosis. This failure was not life threatening, but led to a poor functional result. Postoperative radiation therapy was tolerated by the transplanted jejunal mucosa in spite of a marked inflammatory reaction.     

扁桃体癌手术及修复方法的选择

目的 探讨扁桃体癌手术切除入路与组织缺损的几种修复方法及疗效.方法 采用颈前舌骨入路及下颔骨正中裂开外旋入路切除19例扁桃体癌,分别应用舌瓣、颞肌筋膜瓣及胸大肌肌皮瓣修复缺损.结果 1例胸大肌肌皮瓣术后出现皮肤部分坏死,3例颞肌筋膜瓣修复者术后张口轻度受限,其余患者术后呼吸、吞咽、咀嚼和语音功能恢复良好.结论 在选择合适的手术入路彻底切除肿瘤的前题下,熟练地掌握多种修复方法,择优采用,是恢复良好口咽功能,提高患者术后生活质量的重要保证.     

Using visible speech to train perception and production of speech for individuals with hearing loss.

The main goal of this study was to implement a computer-animated talking head, Baldi, as a language tutor for speech perception and production for individuals with hearing loss. Baldi can speak slowly; illustrate articulation by making the skin transparent to reveal the tongue, teeth, and palate; and show supplementary articulatory features, such as vibration of the neck to show voicing and turbulent airflow to show frication. Seven students with hearing loss between the ages of 8 and 13 were trained for 6 hours across 21 weeks on 8 categories of segments (4 voiced vs. voiceless distinctions, 3 consonant cluster distinctions, and 1 fricative vs. affricate distinction). Training included practice at the segment and the word level. Perception and production improved for each of the 7 children. Speech production also generalized to new words not included in the training lessons. Finally, speech production deteriorated somewhat after 6 weeks without training, indicating that the training method rather than some other experience was responsible for the improvement that was found.     

Early and later vocalization skills in children with and without cleft palate

OBJECTIVE: The purpose of this study was to describe the early vocalization skills in children with cleft lip and palate (CLP) at 6 and 12 months of age and compare these early vocalization measures to later speech and vocabulary development at 30 months of age. METHODS: The participants in the study included 13 children without cleft lip or palate (NCLP) who were typically developing and 13 children with CLP matched for age, gender and socioeconomic status. Standardized measures of cognition, language, hearing, and prelinguistic vocalization measures were administered at 6 and 12 months and speech production, and vocabulary measures were collected at 30 months of age. RESULTS: Group differences were observed in both receptive and expressive language development at 12 and 30 months of age. Group differences were observed in the frequency of babbling and Mean Babbling Level at 12 months and speech sound accuracy and vocabulary production at 30 months of age. Significant correlation coefficients were observed between babbling frequency at 6 months and consonant inventory size, vocabulary at 30 months for the children with clefts and PCC-R for noncleft children. CONCLUSIONS: This study documented that young children with clefts have persistent vocalization and vocabulary deficits well beyond palate closure. Measures of babbling frequency, Mean Babbling Level and consonant inventories provide clinically effective means of identifying these early deficits. Additionally, these measures may provide a tool for monitoring the effects of early intervention programs that promote facilitation of sound and vocabulary development.     

Vowel category dependence of the relationship between palate height, tongue height, and oral area.

This article evaluates intertalker variance of oral area, logarithm of the oral area, tongue height, and formant frequencies as a function of vowel category. The data consist of coronal magnetic resonance imaging (MRI) sequences and acoustic recordings of 5 talkers, each producing 11 different vowels. Tongue height (left, right, and midsagittal), palate height, and oral area were measured in 3 coronal sections anterior to the oropharyngeal bend and were subjected to multivariate analysis of variance, variance ratio analysis, and regression analysis. The primary finding of this article is that oral area (between palate and tongue) showed less intertalker variance during production of vowels with an oral place of articulation (palatal and velar vowels) than during production of vowels with a uvular or pharyngeal place of articulation. Although oral area variance is place dependent, percentage variance (log area variance) is not place dependent. Midsagittal tongue height in the molar region was positively correlated with palate height during production of palatal vowels, but not during production of nonpalatal vowels. Taken together, these results suggest that small oral areas are characterized by relatively talker-independent vowel targets and that meeting these talker-independent targets is important enough that each talker adjusts his or her own tongue height to compensate for talker-dependent differences in constriction anatomy. Computer simulation results are presented to demonstrate that these results may be explained by an acoustic control strategy: When talkers with very different anatomical characteristics try to match talker-independent formant targets, the resulting area variances are minimized near the primary vocal tract constriction.