Quality of life after free-flap reconstruction in patients with oral and pharyngeal cancer

BACKGROUND: Our aim was to investigate quality of life and outcome after microvascular free-flap reconstruction after oncologic surgery. METHODS: Forty-four patients with a large carcinoma in the oral cavity, oral pharynx, or hypopharynx underwent free-flap surgery with or without radiotherapy. Patients completed the University of Washington Quality-of-Life Questionnaire preoperatively and four times during the 12 postoperative months. Survival rates and complications were analyzed. RESULTS: Postoperative composite quality-of-life scores were significantly lower than before treatment with no significant overall improvement during the follow-up. The scores for disfigurement, chewing, speech, and shoulder function remained significantly below the preoperative level throughout the follow-up. Sociodemographic factors predicted quality of life. Heavy drinking and unemployment caused a 2.4-fold and a 4.4-fold increase in risk of death, respectively. The rates for overall survival, tumor recurrence, flap success, and surgical complications were consistent with previous literature. CONCLUSION: Sociodemographic variables affect quality of life and patient survival in patients with oral cancer treated with microvascular free-flap reconstruction.     

Extensive ameloblastoma of the jaws: surgical management and immediate reconstruction using microvascular flaps.

OBJECTIVE: Ameloblastoma is a rare histological benign but locally aggressive tumor with a marked tendency for recurrence. Especially larger, aggressive lesions require a more radical surgical approach resulting in large jaw defects. The purpose of this study is to analyze the long-term functional and esthetic results after immediate reconstruction of large jaw defects using microvascular flaps. STUDY DESIGN: A review of 7 cases of giant ameloblastoma (2 in the maxillary and 5 in the mandibular region) is presented. The lesions were between 4 and 8 cm in diameter. All patients were treated by a radical surgical protocol. All cases were immediately reconstructed using microvascular grafts from either the scapula or the iliac crest bone. Dental implants were inserted in all patients after removal of the osteosynthesis material. RESULTS: All patients were prosthetically rehabilitated. All implants survived throughout the observation time. The esthetic and functional outcomes were satisfying in all patients. No case of recurrence of the tumor could be observed so far. CONCLUSION: According to our opinion, immediate reconstruction is the treatment of choice after radical surgical excision of ameloblastoma. This 1-step procedure decreases the number of surgeries and allows earlier prosthetic rehabilitation.     

Functional results with advanced hypopharyngeal carcinoma treated with circular near-total pharyngolaryngectomy and jejunal free-flap repair

BACKGROUND: Patients treated by a circular pharyngolaryngectomy for advanced hypopharyngeal carcinoma have a poor prognosis and disappointing speech restoration. METHODS: Three carefully selected patients underwent a near-total laryngectomy circular pharyngectomy with jejunal free flap repair and dynamic tracheopharyngeal shunt for treatment of advanced hypopharyngeal carcinoma. They received induction chemotherapy and postoperative radiotherapy. We assessed the functional outcome. RESULTS: There was no major local complication. One year after the end of radiotherapy, all patients were able to eat solid diets. Two patients were able to speak immediately after the end of the treatment. After speech re-education, a high-quality tracheopharyngeal voice was restored in all three patients. Performance Status Scale for Head and Neck Cancer Patients (PSSHN) showed a mean score equal to 81/100 at 1 year. CONCLUSIONS: In selected patients, near-total laryngectomy circular pharyngectomy with tracheopharyngeal shunt and jejunal free-flap repair offers good voice rehabilitation without impairing swallowing function.     

Radial forearm free flap for soft palate reconstruction

Defects of the soft palate resulting from head and neck oncologic surgery traditionally have been rehabilitated using a prosthetic obturator. In general, the results of soft palate obturation have been satisfactory, with most patients achieving velopharyngeal competence during speech and swallowing. However, soft palate obturators have several disadvantages. Device stability and retention are impaired in patients who are edentulous. In addition, prosthetic obturators cover large areas of sensate mucosa in the hard palate, maxillary alveolus, and oropharynx, contributing significantly to the loss of sensory feedback from the oral cavity and oropharynx. Considerable evidence suggests that sensory impairment within the oral cavity and pharynx results in impaired mastication, deglutition, and articulation. A minority of patients find palatal obturators to be unsatisfactory, secondary to either inconvenience or device discomfort.     

Speech Outcome after Cleft Palate Surgery with the G teborg Regimen Including Delayed Hard Palate Closure

The regimen for treatment of children with cleft lip and palate in Göteborg, Sweden, until 1996 included early soft palate repair at 6-8 months of age and delayed closure of the hard palate at about 8 years of age to improve maxillary growth. The aims of this report were to describe the treatment concept and to present speech data of 59 children treated by this method. The speech of 38 children with unilateral and 21 with bilateral cleft lip and palate was evaluated perceptually from standardised tape recordings of repeated sentences and spontaneous speech at five ages from 3 to 16 years of age. All patients were not evaluated at each age level. The results showed a low prevalence of hypernasality after hard palate closure and pharyngeal flap surgery in only five children (8%), indicating a primary velopharyngeal insufficiency in less than 10% of the children. Only three children with bilateral clefts had glottal articulation when at pre-school age and no child with a unilateral cleft did. These results were interpreted as an indication of velopharyngeal competence (VPC) in most of the children. In addition, the speech problem found in these children consisted of retracted oral articulation of alveo-dental pressure plosives, which is almost always an indicator of VPC. However, we do consider that retracted oral articulation is a problem and to improve our results further we have decided to modify the technique for soft palate closure slightly and place the vomer flap further anteriorly to encourage narrowing of the cleft in the hard palate, and to close the hard palate at 3 years of age.     

Surgical Treatment Of Cleft Palate

Abstract

During the period 1958–1985, 230 patients with cleft palate were operated on in the Department of Plastic Surgery, University of Göteborg, Sweden. A modified push-back technique according to Wardill and Kilner was used. The children were operated on at a mean age of 13 months. They were divided into two groups, the first in which the cleft affected the velum only (n = 121) and the other in which it also affected the hard palate (n=109). Postoperative dehiscences and fistulas occurred in 19 (8%) patients, of which 16 (15%) belonged to the group in which the cleft affected the hard palate. Only three (2%) of the 121 patients with a cleft in the soft palate only developed dehiscences. The total number of patients who had to be reoperated on because of dehiscences were 10 (4%) and palatopharyngeal flaps had to be performed in 25 patients (11%) because of speech problems.     

Efficacy of speech aid prostheses for acquired defects of the soft palate and velopharyngeal inadequacy--clinical assessments and cephalometric analysis: a Memorial Sloan-Kettering Study

BACKGROUND: Restoration of speech after surgical resection for oropharyngeal cancer traditionally includes maxillofacial prosthetic intervention. Relatively few publications with objective speech outcomes exist. The purpose of this study was to evaluate speech outcome relative to the size of the surgical defect, the type of speech prosthesis, and the height and position of the speech bulb in relation to the posterior pharyngeal wall in the nasopharynx. METHODS: Fifty-five patients treated at the Memorial Sloan-Kettering Cancer Center Dental Service who underwent ablative cancer therapy were evaluated. All patients were 4 months or longer after surgery and were using a speech aid or obturator prosthesis at the time of the study. Speech samples for percent intelligibility and perceptual evaluation were collected and analyzed, in addition to aeromechanical measurements of palatopharyngeal function. Lateral cephalograms were taken while wearing the prosthesis using a radiopaque marker placed on the posterior aspect of the prosthesis for evaluating the height and position of the prosthesis obturator-speech bulb component. RESULTS: After adjustment for the differences between listeners, findings revealed that as the percentage of resection of palate or tongue increased, the intelligibility of speech decreased. Aeromechanical assessment of speech was the only outcome measure sensitive to the type of speech prosthesis. The position of the speech bulb component, as well as the angle measured, was correlated with the percent intelligibility. The amount of the prosthesis physically contacting the posterior pharyngeal wall was not significantly associated with any of the functional outcome measures. CONCLUSIONS: Speech aid and obturator prostheses contribute to a higher percentage of intelligible speech. A difference in intelligibility exists in relationship to the position of the prosthesis and the anterior tubercle of the atlas vertebrae (C1), both statistically and clinically. The position for optimal speech could not be specifically located mathematically (ie, 3 mm or 3 degrees inferior to the anterior tubercle of the atlas vertebrae) from the analysis. Subjective ratings of the efficacy of the obturator-speech bulbs by the clinicians did not correspond to the percent intelligibility. A strong statistical and clinical correlation exists supporting the efficacy of speech bulb-obturator intervention after velopharyngeal insufficiency for improved intelligibility of both words and sentences.     

Solitary metastatic melanoma of the soft palate

Melanoma of the oral mucosa is frequently situated in the area of the hard palate but extremely rarely in the soft palate. Even metastatic tumors are very rare in this location, and surgery at this stage is seldom indicated. Two patients with solitary metastatic melanoma of the soft palate are described. In both, a subtotal excision of the soft palate was performed, completed by reconstruction with pharyngeal flaps and island flaps from the hard palate. Both patients are alive and free from recurrence 12 years and 4 years after the primary diagnosis of melanoma and 2 years and 18 months after the palatal reconstruction. One patient has normal speech with no nasality; the other patient has very slight hypernasality but no other problems.     

Optimal timing of cleft palate closure. Speech, facial growth, and hearing considerations

We have presented an updated overview of the controversy surrounding the timing of cleft palate closure based upon the goals of cleft palate surgery: attainment of normal speech, maxillofacial growth, and hearing. From a critical analysis of the conflicting literature in these areas, we have developed our own philosophy of the cleft palate closure over the past decade that incorporates these three primary goals in the multidisciplinary care of the cleft palate patient. We feel that only through an objective, long-term, goal-oriented, prospective study of our patients will we be able to obtain realistic data in this controversial area. To date, there are no long-term, prospective, double-blind studies available in the area of cleft palate surgery. In the interim, we must objectively assess our results and, above all, adhere to the primary principle of medicine of doing no harm in the multidisciplinary management of the cleft palate patient.     

Speech after repair of isolated cleft palate and cleft lip and palate.

The speech of children with isolated cleft palate (CP) repaired by one surgeon has been compared with the speech of children with some form of unilateral cleft lip and palate (CLP) repaired by the same surgeon. All palate repairs included an intravelar veloplasty. We identified 57 children (5--12 years old) with cleft palates repaired in infancy, of which three patients with other medical problems were excluded. Of the 54 patients, 44 (81%) attended for review (27 CP, 17 CLP). Video recordings were analysed by two speech and language therapists, using the Cleft Audit Protocol for Speech. The CP patients had no evidence of permanent fistulas. Final speech outcomes were similar for CP and CLP patients. Intelligibility was normal in 10 (37%) CP and nine (53%) CLP patients. Mild consistent hypernasality was present in five (18.5%) CP and four (23.5%) CLP patients. No patients had moderate or severe hypernasality or nasal emission. Mild consistent hyponasality was present in five (18.5%) CP and five (29%) CLP patients. Moderate consistent hyponasality was present in one (4%) CP patient. Dysphonia was present in eight (30%) CP and seven (41%) CLP patients. Cleft-type characteristics were noted in 11 (41%) CP and nine (53%) CLP patients. No CLP patients but 10 (37%) CP patients had required a pharyngoplasty (P=0.004, Fisher's exact test). Possible reasons for this (age, cleft type, surgeon and surgery) are discussed.     

Microvascular free-tissue transfer for head and neck reconstruction in Jehovah's Witness patients

BACKGROUND: Jehovah's Witnesses' religious convictions disallow blood transfusion. Major surgery in these patients is therefore problematic. The objective of this study is to describe our experience with microvascular reconstruction of complex head and neck defects in Jehovah's Witness patients. METHODS: This was a retrospective review of all Jehovah's Witnesses' patients undergoing head and neck free-flap reconstruction at a tertiary academic referral center from 1997 to 2006. RESULTS: Five Jehovah's Witnesses patients underwent a total of 7 free-flap reconstructions (6 radial, 1 rectus). Four flaps were immediate: 1 osteocutaneous radial forearm, 2 fasciocutaneous radial forearm, and 1 rectus abdominus myocutaneous. One fasciocutaneous radial forearm flap was staged. Two patients were planned secondary reconstructions, both facsciocutaneous radial forearm. Iron supplements and/or erythropoietin were administered perioperatively in 6 of the 7 microvascular reconstructions. Selective external carotid embolization was performed preoperatively in 1 patient. Hematocrit levels were 36% to 46% preoperatively and 30% to 41% postoperatively. Immediate postoperative hematocrit decline was 5.2% (3.0% to 6.0%). No transfusions or blood products were administered. CONCLUSIONS: Our case series supports the feasibility of head and neck free-flap reconstruction in these challenging patients.     

A compendium of intraoral flaps

Intraoral flaps are an excellent source of tissue for reconstruction after resection of small malignant tumors of the oral cavity, pharynx, and hypopharynx. The principal donor sites used are the tongue, buccal mucosa, and palate. Intraoral flaps enable rapid rehabilitation of deglutition and speech with minimal morbidity. They provide easily transferred, well-vascularized tissue from sites adjacent to the operative defects. These flaps permit closure without tension and obviate the need for more distant tissue transfers. Their use does not compromise the oncologic resection.     

Tongue reconstruction with free radial forearm flap after hemiglossectomy: a functional assessment

Thirty-three patients with squamous cell carcinoma of the anteriolateral part of the tongue underwent a 50 percent resection of the tongue. The surgical defect was reconstructed with a microvascular radial forearm flap. All the flaps were especially designed to have a narrow waist, shaped like an omega in cross-section, thus allowing for a free tongue tip, and avoiding suturing the edge of the flap to the soft palate and tongue base. Sixteen patients were evaluated for swallowing and speech function at least 6 months following reconstruction. With this technique, the majority of the patients had nearly normal deglutition, although their speech was still unsatisfactory. However, the speech function in this series was better than that in other reported series.     

The Children's Hospital of Philadelphia modification of the Furlow double-opposing z-palatoplasty: long-term speech and growth results

Of the 261 nonsyndromic patients we studied, over 90% had minimal or absent hypernasality, almost 86% had inconsistent or no nasal emission, and 95% had no articulation errors related to velar function. The patients with a Pittsburgh score indicating an incompetent velopharyngeal mechanism comprised only about 6% of the group. Ninety-four percent had a socially functional speech quality. Secondary surgery was done in 6.5% of patients and was done or was recommended in about 8% of patients. Patients with isolated cleft palate seemed to do less well, although their outcomes were not statistically different from those with complete unilateral and bilateral clefts. Relaxing incisions have kept our fistula rate to an acceptably low rate of 6.8%. No major soft palate dehiscences or hard palate flap losses have occurred. The speech outcomes we are achieving are improved over our historical results and compared with published reports using nondouble reversing z-palatoplasty techniques. Similar outcomes with the Furlow repair have been confirmed. Maxillary growth, occlusion, and the need for orthognathic surgery do not seem to be influenced by the CHOP modification of the Furlow double-opposing z-palatoplasty. These modifications facilitate a tension free-closure and a low fistula rate.     

Unrepaired Clefts in the Hard Palate: Speech Deficits At the Ages of 5 and 7 Years and Their Relationship to Size of the Cleft

The purpose of the study was to investigate the relationship between the size of oronasal openings in the hard palate and speech deficits. Audiotape recordings and plaster casts were taken according to standard procedures at 5 and 7 years of age from 22 consecutive children born with complete unilateral cleft lip and palate treated at Sahlgrenska University Hospital, Göteborg, Sweden. The soft palate had been repaired before the age of 12 months, whereas the cleft in the hard palate was left unrepaired, to be closed later. Perceptual judgements of nine speech variables at 5 and 7 years of age were correlated with measures of the area of the residual cleft in the hard palate. "Retracted oral articulation" (to velar place) found in nine of the 22 children correlated significantly with the area of the cleft at the age of 5 years but not later. The establishment of this particular speech error seems to be related to the size of an oronasal opening.     

Unrepaired clefts in the hard palate: speech deficits at the ages of 5 and 7 years and their relationship to size of the cleft.

The purpose of the study was to investigate the relationship between the size of oronasal openings in the hard palate and speech deficits. Audiotape recordings and plaster casts were taken according to standard procedures at 5 and 7 years of age from 22 consecutive children born with complete unilateral cleft lip and palate treated at Sahlgrenska University Hospital, G?teborg, Sweden. The soft palate had been repaired before the age of 12 months, whereas the cleft in the hard palate was left unrepaired, to be closed later. Perceptual judgements of nine speech variables at 5 and 7 years of age were correlated with measures of the area of the residual cleft in the hard palate. "Retracted oral articulation" (to velar place) found in nine of the 22 children correlated significantly with the area of the cleft at the age of 5 years but not later. The establishment of this particular speech error seems to be related to the size of an oronasal opening.     

Speech development in patients with unilateral cleft lip and palate treated with different delays in closure of the hard palate after early velar repair: a longitudinal perspective.

We wanted to find out if different timing of delayed repair of the hard palate in a two-stage procedure had an impact on the speech of 26 patients with unilateral cleft lip and palate (UCLP). The soft palate was closed at the age of 7 months and the hard palate between 38 and 89 months of age. Speech audio recordings at the age of 3 years (baseline, before any repair of the hard palate) and at the ages of 5, 7, and 10 years (the latter obtained at least one year after closure) were analysed. We used standardised speech assessments at routine follow-up and assessment by one external listener. The prevalence of speech errors caused by the cleft was similar to those described in previous reports from our centre in which hard palate repair was delayed. Unexpectedly, the results showed no difference in speech production related to timing of hard palate repair, except for nasal air leakage at the age of 7 years.     

Results of rehabilitation after double-sided prosthetic provision of lower limbs]

FORMULATION OF THE QUESTION: As a problem stood the question what effect the progress in orthopedic technology during the last years had on the rehabilitation results of the persons affected and how etiology and distribution of age and sex have changed. METHOD: We post-examined 50 patients during home visits who had had double-sided amputations of lower limbs and were provided from 1985 to 1993 were examined at home. RESULTS: Etiologically it concerns 25 patients with chronic arterial circulatory disturbances, 10 with trauma, 7 with congenital damages and 8 with consequences of other amputation causes. The rehabilitation results are to be evaluated with good. It could be proved that also elder double-sided amputees can be prosthetically rehabilitated if at least one knee joint could be maintained. The physiotherapeutic post-care was recognized as the weak point of rehabilitation, it has to be improved especially for the elder persons affected. CONCLUSION: The elder double-sided amputee can be enabled to a safe walk on prostheses only by optimum rehabilitation management with quick prosthetic provision and early starting intensive physiotherapeutic post-care which should go on for a much longer time than the stay in hospital.     

Individualized Treatment for the Mandibular Segmental Defect: A Case Report

Ameloblastomas are slowly growing, locally invasive tumors with high recurrence rate and more common in the mandible, if not treated they can grow to enormous size. Radical resection is the only predictable form of treatment for ameloblastomas. However, mandibular resection can lead to dysfunctions in appearance, speech, mastication, and deglutition, which severely impair the patients’ quality of life. The reconstruction of extensive bone defects in the maxillofacial area is still challenging. To meet the demands of functional reconstruction, minimizing the negative influence of mandibular malformation, and disability on patients, the individualized systematic treatment plans highlight denture prosthodontics and require much consideration of multidisciplinary cooperation, with such related fields as maxillofacial surgery, oral implantology, prosthodontics, and radiology taken into account. In this report, we will present a case of reconstructing the mandibular segmental defect after the resection of a rarely giant ameloblastoma. In the case, we took the restoration of the missing teeth and the rehabilitation of the masticatory function as well as restoring bony continuities and facial appearance into consideration, communicated well with prosthodontists and implantologists before surgery, making the individualized systematic treatment plan more effective and efficient.     

转染γ-干扰素的口腔黏膜细胞片修复裸露硬腭对上颌骨腭突生长发育的影响

目的 探讨转染γ-干扰素的口腔黏膜细胞片修复裸露硬腭,对预防上颌骨腭突生长受限的作用,以便最大限度的减少腭裂术后上颌骨腭突继发畸形的发生.方法 3周龄雌性SD大鼠80只,左侧硬腭裸露后,随机分成裸露面自行修复(Ⅰ)组、羊膜修复(Ⅱ)组、羊膜负载的口腔黏膜干细胞片修复(Ⅲ)组、羊膜负载的转染γ-干扰素基因的口腔黏膜干细胞片修复(Ⅳ)组等4种不同的处理方法组,每组20只.术后9周测量硬腭左右侧宽度,并采用SPSS 11.0统计软件对数据进行处理,分析不同处理方法对硬腭宽度的影响.结果 Ⅰ、Ⅱ、Ⅲ、Ⅳ组硬腭非对称率均数分别为(68.64±9.03)%、(58.53±7.40)%、(53.12±4.92)%、(52.25±4.61)%,Ⅰ组与Ⅱ、Ⅲ、Ⅳ组间比较有差异均有统计学意义(P＜0.05),Ⅱ组与Ⅲ、Ⅳ组间比较差异有统计学意义(P＜0.05),而Ⅲ组与Ⅳ组间比较差异无统计学意义(P＞0.05).结论 羊膜与组织工程化的口腔黏膜修复裸露硬腭的方法对预防上颌骨的继发畸形有积极的意义,组织工程化的口腔黏膜法优于单纯应用羊膜进行修复组,转染γ-干扰素的组织工程化口腔黏膜优于未转染组.