|Year : 2019 | Volume
| Issue : 1 | Page : 26-31
Functional outcomes of oral tongue reconstruction: A subjective analysis
Ramandeep Kaur, Vibhu Ranjan Sahni, Satyapal Choudhary, Anubha Bharthuar, Shamit Chopra
Department of Head and Neck Surgery, Patel Hospital, Jalandhar, Punjab, India
|Date of Web Publication||26-Jul-2019|
Patel Hospital, Civil Lines, Jalandhar - 144 001, Punjab
Source of Support: None, Conflict of Interest: None
Background: Squamous cell carcinoma (SCC) of the oral tongue is an aggressive disease and mandates upfront surgery, appropriate reconstruction, and adjuvant therapy as indicated. Contemporary tongue reconstruction has been largely aided by free flaps, making it possible to tailor the flap precisely to the defect. Aims and Objectives: We aimed to assess functional outcomes of our post glossectomy patients subsequent to reconstruction and aimed to identify the flap types associated with the highest satisfaction rates. Methodology: We retrospectively evaluated a cohort of 145 patients with SCC of the oral tongue, who underwent glossectomy at our institution between March 2011 and July 2017. These patients had been reconstructed as per our volume-aided institutional algorithm with primary closure, radial forearm-free flap (RFFF), pectoralis major myocutaneous flap (PMMF), or anterolateral thigh-free flap. Appropriate analysis on surviving and functionally evaluable patients was done through a trilingual confidential IRB-validated phone administered questionnaire. Results: The subjective outcomes were most satisfactory for patients reconstructed with RFFF, which per our institutional algorithm forms the flap of choice for oral tongue volume restoration to the extent of 30%–50%; and also for primary closure, our preferred method for 0%–30% volume restoration. Subjective satisfaction with respect to speech and swallowing was the lowest when the PMMF was utilized for reconstruction. Notably, PMMF was only utilized for tongue reconstruction in severely comorbid patients. Conclusions: Oral tongue reconstruction should aim at restoration of mobility, structural support, restoration of bulk, and obviation of tracheotomy, among other aims. Primary closure for smaller defects and a skin-lined free flap for larger defects appear to be associated with high rates of subjective satisfaction across all parameters.
Keywords: Functional outcomes, glossectomy, tongue reconstruction
|How to cite this article:|
Kaur R, Sahni VR, Choudhary S, Bharthuar A, Chopra S. Functional outcomes of oral tongue reconstruction: A subjective analysis. J Head Neck Physicians Surg 2019;7:26-31
|How to cite this URL:|
Kaur R, Sahni VR, Choudhary S, Bharthuar A, Chopra S. Functional outcomes of oral tongue reconstruction: A subjective analysis. J Head Neck Physicians Surg [serial online] 2019 [cited 2020 Aug 8];7:26-31. Available from: http://www.jhnps.org/text.asp?2019/7/1/26/263515
| Introduction|| |
Squamous cell carcinoma (SCC) of the oral tongue is an aggressive disease and constitutes 22%–39% of oral cavity cancers. It mandates upfront surgery, the appropriate reconstruction, and adjuvant therapy as indicated. Approximately 40% of all SCC patients referred for treatment require resection of the tongue to varying degrees. Immediate reconstruction should be performed after complete excision of the tumor. Quality of life studies have shown that speech, chewing, and swallowing are the most important factors in patients undergoing head and neck surgery. Contemporary tongue reconstruction has been largely aided by free flaps, making it possible to tailor the flap precisely to the defect. Skin-lined free flaps, such as radial forearm and anterolateral thigh flaps, are commonly used to reconstruct oral anatomy following tongue cancer extirpation surgery.
However, data are low quality and conflicting in terms of being able to provide an accurate representation of true functional status postreconstruction, especially in patients with <50% oral glossectomy. We aimed to assess the functional outcomes of our postglossectomy patients subsequent to reconstruction and aimed to identify the flap types associated with the highest indices of satisfaction.
| Materials and Methods|| |
The study was conducted in the Department of Head and Neck Surgery at Patel Hospital, Jalandhar, Punjab, India. The patients with SCC of the oral tongue who underwent surgery from March 2011 to July 2017 were retrospectively reviewed. The epicenter of the tumor was the lateral border of the oral tongue in the majority of cases. These patients had been reconstructed as per our volume-aided institutional algorithm with primary closure (0%–30%), radial forearm-free flap (RFFF-30%–50%), pectoralis major myocutaneous flap (PMMF-30%–100%), or anterolateral thigh-free flap (ALTFF-50%–100%). The decision between ALTFF, RFFF, and PMMF was taken based on our volume-aided algorithm and by surgical risk assessment through application of the NSQIP of the American College of Surgeons (ACS). The patients who had concomitant involvement of oropharynx and who underwent mandibulectomy, pharyngectomy, or mandibulotomy were excluded from the analysis. We also excluded patients who had a prior history of irradiation to the head and neck region, a prior surgical history of other upper aerodigestive tract cancers, or a tongue cancer recurrence prior to functional evaluation.
Appropriate analysis on surviving and functionally evaluable patients was done through a trilingual confidential IRB-validated phone administered questionnaire, administered at 6 months after treatment completion. The subjective outcomes included information on relevant functional parameters such as speech, swallowing, and mastication. The questionnaire included the following questions:
- Any deficiency in verbal communication (speech)
- Any difficulty in assimilating food (food mixing ability/masticatory efficiency)
- Any difficulty in bolus transit (swallowing)
- Difficulty in tongue-palate contact (speech and swallowing)
- Difficulty in tongue-cheek contact (speech and swallowing)
- Perceived postoperative cosmesis/appearance of the oral tongue.
The responses were graded as always (A), occasionally (O), rarely (R), and never (N).
Patients were given scores between 6 and 24; 6 being minimum indicating worse functional outcome and 24 being the best functional outcome. Cumulative scores were calculated for each patient, and median scores were compared between reconstructive modalities to be able to yield the rates of subjective satisfaction. Statistical analysis was performed using Chi-square analysis. T-test was used to evaluate the various variables with respect to final outcomes. Statistical significance was considered for values of P < 0.05.
| Results|| |
One hundred and forty-five glossectomies were retrospectively evaluated. These patients had their surgeries performed at our institution between March 2011 and July 2017. Twenty-three patients were excluded from the study who had concomitant mandibulectomy, mandibulotomy, or pharyngectomy. The questionnaire could be completely administered and answered by 63 patients. The mean age was 58.4 years (range: 44–77). Of 63 patients, 54 were male which constituted 86% of our patients, and 9 (14%) were female, as stated in [Figure 1].
All cases were SCC on final histology. Twenty-four (38%) patients were staged as T1, 25 patients staged as T2 (39%), 13 patients were staged as T3 (21%), and 1 patient staged as T4 disease [Figure 2]. In N classification, 45 patients had N0 disease, 5 patients had N1 disease, and 13 patients had N2 disease. Of 63 patients, 28 (44%) patients had primary closure, 26 (41%) patients were reconstructed with RFFF, 7 (11%) patients had PMMF reconstruction, and 2 (3%) patients were reconstructed with ALTFF [Figure 3]. Of 63 patients, 37 patients had adjuvant radiation and 13 patients had chemotherapy.
On comparison of mean subjective scores between primary closure and RFFF, there was no significant difference. Comparison of scores [Table 1] between the patients who underwent reconstruction with RFFF and PMMF yielded higher subjective satisfaction for the former, with the difference attaining statistical significance (P = 0.003). Furthermore, a comparison of scores between primary closure and PMMF showed that the former was associated with higher satisfaction scores (P = 0.0001). Subjective satisfaction with respect to speech and swallowing was the lowest when the PMMF was utilized for reconstruction. Notably, the PMMF was only utilized for tongue reconstruction in patients with severe atherosclerotic disease, or the ones deemed high risk on the application of the ACS NSQIP risk assessment tool.
| Discussion|| |
Functional impairments after tongue resections could be caused by deficient remaining muscle structure, loss of bulk, damage to the hypoglossal nerve, postoperative fibrosis, and scarring. Therefore, restoration of natural tongue bulk, shape, mobility, and sensation, if possible, is the main principles of tongue reconstruction to maintain tongue mobility and restore articulation, speech, mastication, and swallowing. To achieve these goals, choosing the appropriate reconstruction method is essential. Several techniques, including primary closure, secondary intention, skin graft, and locoregional or free flap reconstruction, can be applied for reconstruction of the tongue. A sufficient tongue volume is necessary to move a bolus of food into the hypopharynx through palate contact, and several affricates and plosives require contact or approach of the tongue to the palate or alveolar ridge for proper pronunciation.
When the tongue defect is small, primary closure or secondary intention is mainly used for reconstruction, but they are not able to restore tongue volume. It is demonstrated that the resected volume of the tongue was inversely correlated with functional outcomes. Therefore, if there is a large defect after tongue resection, locoregional pedicled, or free flaps are necessary to restore the volume of the tongue.
There are various techniques described in available to reconstruct the tongue defects. Hara et al. describe that the transfer of skin-lined free flaps is the optimal method for oral cavity reconstruction. Owing to the key role of the tongue in oral function, enough functional recovery is anticipated following tongue reconstruction.
However, there is no consensus on the ideal reconstructive method according to the extent of glossectomy, especially in cases of partial glossectomy <50%. Most of the studies have compared one or two reconstruction techniques, but in the present study, we compared the different types of reconstruction for tongue defects.
In our study, functional scores had no significant correlation with respect to gender, age, and adjuvant treatment. There has been a conflict in the past regarding the effect of radiation and chemotherapy on speech and swallowing outcomes in tongue cancer, but Dwivedi et al. found no statistically significant differences in mean MDADI subscale scores between the surgery, surgery-RT, and surgery-CRT groups of patients with oral or oropharyngeal cancer. Fujiki et al. compared the effects of radiotherapy after long-term reconstruction. They observed that radiotherapy deteriorated the swallowing outcomes immediately after radiotherapy, but oral intake improved within 6 months, which explains the timing of administration of the questionnaire, anticipating the recovery of short-term effects of radiation therapy in the majority of our patients.
There is no consensus on the ideal reconstructive method according to the extent of glossectomy, especially in cases of partial or hemiglossectomy. A long-term follow-up study of 63 patients by Lee et al. with partial glossectomy of the tongue showed good speech and swallowing function without flap reconstruction. In our study, for the oral tongue volume defect of 0-30%, primary closure was universally utilized. All of these tumors were T1/2 staged and epicentered on the lateral oral tongue. Subjective satisfaction for all studied parameters in these patients was high with a mean score of 22 of a maximum of 24, further indicating that flap reconstruction might only be needed for this defect in case of a different location, for example, tongue tip, which might aid speech articulation; and involvement of concomitant structures, for example, mandibular periosteum or floor of the mouth, to prevent bone exposure and/or tethering of tongue remnant.
A prospective multicenter study by McConnel et al. also reported that speech and swallowing function was better following a primary closure compared to a free flap reconstruction for a partial glossectomy. However, Hara et al. reported that consonant intelligibility was better in the flap reconstruction group than in the primary closure group. In our study, the difference between primary closure and flap reconstruction was not statistically significant. However, since the above two modalities were utilized per algorithm for different groups of patients, it is difficult to conclude preferential utilization of one modality versus the other for a <30% glossectomy defect.
Hsiao et al. however reported that speech outcomes were better with primary closure; however, swallowing function was better with flap reconstruction after hemiglossectomy. That study has several limitations; it included only a limited number of patients, and a significant proportion of patients underwent mandibulotomy, which could adversely influence speech and swallowing outcomes. Regarding postoperative swallowing function, the tongue is essential for propelling a food bolus toward the pharynx, and the shape and bulk of the reconstructed tongue are closely related to postoperative swallowing outcomes. This was supported by our study, where despite the increasing volume of the defect, RFFF patients achieved a nearly similar (21 of a maximum of 24) and high subjective satisfaction score. This modality had been universally applied per algorithm for the 30%–50% glossectomy defect.
For the >50% glossectomy defect, it is notable that Joo et al. has demonstrated that the resected volume of the tongue inversely correlates with functional outcomes. Early stage cancers were thus found to have better functional scores as compared to T3/T4 cancers. Notably, the number of patients undergoing ALTFF in the study is low precluding any meaningful conclusions for this subset. This could be attributable to multiple factors including modest survival of T3/4 tongue cancers, utilization of mandibulotomy (exclusion criterion) in many patients to necessitate complete tumor extirpation and/or watertight flap inset, and medical factors precluding microvascular reconstruction. It is however notable that mean subjective satisfaction scores with respect to speech and swallowing were the lowest (15 of a maximum of 24) when the PMMF was utilized for reconstruction. Notably, the PMMF was only utilized for tongue reconstruction in severely comorbid patients.
Allowing for the heterogeneity of the study subgroups, on comparisons between primary closure and PMMF, and between RFFF and PMMF; both demonstrated superiority of functional outcomes of the non-PMMF modalities with statistical significance.
The present study does have limitations. The nonrandomized, retrospective study design could lead to selection bias. The modalities utilized for reconstruction were largely specific to a particular defect, thus causing potential heterogeneity. In addition, the number of study subjects in each subgroup is small, limiting the statistical power. Further analysis with a larger number of cases is necessary to verify the results of this study.
| Conclusions|| |
Oral tongue reconstruction should aim at the restoration of mobility, structural support, restoration of bulk, and obviation of tracheotomy, among other aims. Primary closure for smaller defects and a skin-lined free flap for larger defects appear to be associated with high rates of subjective satisfaction across all parameters. The use of pedicled flaps should be restricted to circumstances which obviate microvascular reconstruction. A defect-specific and resection volume-aided reconstruction algorithm for tongue defects could prove helpful in reconstructive decision-making.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
This material has never been published and is not currently under evaluation in any other peer reviewed publication.
The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
| References|| |
Garzino-Demo P, Dell'Acqua A, Dalmasso P, Fasolis M, La Terra Maggiore GM, Ramieri G, et al.
Clinicopathological parameters and outcome of 245 patients operated for oral squamous cell carcinoma. J Craniomaxillofac Surg 2006;34:344-50.
Hsiao HT, Leu YS, Chang SH, Lee JT. Swallowing function in patients who underwent hemiglossectomy: Comparison of primary closure and free radial forearm flap reconstruction with videofluoroscopy. Ann Plast Surg 2003;50:450-5.
Joo YH, Hwang SH, Park JO, Cho KJ, Kim MS. Functional outcome after partial glossectomy with reconstruction using radial forearm free flap. Auris Nasus Larynx 2013;40:303-7.
Mascarella MA, Richardson K, Mlynarek A, Forest VI, Hier M, Sadeghi N, et al
. Evaluation of a preoperative adverse event risk index for patients undergoing head and neck cancer surgery. JAMA Otolaryngol Head Neck Surg 2019. doi: 10.1001/jamaoto.2018.4513.
Tarsitano A, Vietti MV, Cipriani R, Marchetti C. Functional results of microvascular reconstruction after hemiglossectomy: Free anterolateral thigh flap versus free forearm flap. Acta Otorhinolaryngol Ital 2013;33:374-9.
Shin YS, Koh YW, Kim SH, Jeong JH, Ahn S, Hong HJ, et al.
Radiotherapy deteriorates postoperative functional outcome after partial glossectomy with free flap reconstruction. J Oral Maxillofac Surg 2012;70:216-20.
Hara I, Gellrich NC, Düker J, Schön R, Nilius M, Fakler O, et al.
Evaluation of swallowing function after intraoral soft tissue reconstruction with microvascular free flaps. Int J Oral Maxillofac Surg 2003;32:593-9.
Lam L, Samman N. Speech and swallowing following tongue cancer surgery and free flap reconstruction – A systematic review. Oral Oncol 2013;49:507-24.
Dwivedi RC, Chisholm EJ, Khan AS, Harris NJ, Bhide SA, St. Rose S, et al.
An exploratory study of the influence of clinico-demographic variables on swallowing and swallowing-related quality of life in a cohort of oral and oropharyngeal cancer patients treated with primary surgery. Eur Arch Otorhinolaryngol 2012;269:1233-9.
Fujiki M, Miyamoto S, Zenda S, Sakuraba M. Longitudinal and long-term effects of radiotherapy on swallowing function after tongue reconstruction. J Laryngol Otol 2016;130:865-72.
Lee DY, Ryu YJ, Hah JH, Kwon TK, Sung MW, Kim KH. Long-term subjective tongue function after partial glossectomy. J Oral Rehabil 2014;41:754-8.
McConnel FM, Pauloski BR, Logemann JA, Rademaker AW, Colangelo L, Shedd D, et al.
Functional results of primary closure vs. flaps in oropharyngeal reconstruction: A prospective study of speech and swallowing. Arch Otolaryngol Head Neck Surg 1998;124:625-30.
[Figure 1], [Figure 2], [Figure 3]