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Clinical Paper
Reconstructive Surgery
fasciocutaneous/myocutaneous
flaps
Y. Matsui, T. Shirota, Y. Yamashita, K. Ohno: Analyses of speech intelligibility in
patients after glossectomy and reconstruction with fasciocutaneous/myocutaneous
flaps. Int. J. Oral Maxillofac. Surg. 2009; 38: 339–345. # 2009 Published by Elsevier
Ltd on behalf of International Association of Oral and Maxillofacial Surgeons.
Abstract. This study analyzed the results of speech intelligibility tests in patients with
tongue cancer who had undergone resection with the aim of making surgical
recommendations for flap design and inset, to improve speech function. A total of
126 patients, enrolled from 13 Japanese institutions, were classified into 3 groups
according to the resected site: lateral, anterior, and combined. The lateral group was
further divided into 3 subgroups and the anterior group into 2 subgroups according
to the size of resection. The speech intelligibility score was analyzed based on
articulatory site and mode: 5 articulatory sites (linguodentoalveolar, linguopalatal,
linguovelar, and their intermediates); and 7 articulatory modes (plosives, fricatives,
affricatives, grids, nasals, vowels and semivowels). Low speech intelligibility
scores were recorded at sites where flaps contribute directly to the pronunciation in
the lateral and combined groups and at the anterior part of the reconstructed tongue
Keywords: speech function; reconstruction; tu-
in the anterior group. Plosives and glides displayed low values in general. A radial mor surgery; tongue.
forearm flap had higher function in the lateral group than other flaps. The type of
flap had no effect in the anterior and combined groups. Surgical techniques and flap Accepted for publication 16 January 2009
selection to improve functional status in each type of resection are discussed. Available online 24 February 2009
Postoperative quality of life is increas- cer often causes postoperative speech plex anatomy and function of the ton-
ingly emphasized in the evaluation impairment, as the tongue is a primary gue2,3,6,9,10,14.
of outcomes for patients who have active articulator. Recent progress in In a previous multicenter study7, the
undergone surgical ablation of oral reconstructive surgery has offered new authors investigated the postoperative
cancer11–13. The resection of tongue can- therapeutic options suitable for the com- speech function of tongue cancer patients
0901-5027/040339 + 07 $36.00/0 # 2009 Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons.
340 Matsui et al.
following reconstruction with fasciocuta- Subjects were classified into 3 main in 3 each. In group A1, reconstruction
neous/myocutaneous flaps and reported anatomical groups according to the involved an RFF in 3 patients, a PMMCF
factors that influenced the functional resected site: lateral (n = 95); anterior in 1, and a RAMCF in 1. In group A2,
outcome of speech. Better results were (n = 13); and combined (n = 18). The lat- surgeons used an RFF in 4 patients, and an
obtained for lateral resections, smaller eral group was further classified into 3 RAMCF and a PMMCF in 2 each. In
excisions, greater tongue mobility, youn- subgroups according to the size of resec- group C, flaps used were an RAMCF in
ger patients, and where there was a longer tion: partial excisions of the anterior two- 9 patients, an RFF in 6, a PMMCF and an
interval to examination. Mandibulectomy thirds of the lateral border of the tongue ALTF in 1 each.
and radiotherapy were associated with (group L1; n = 38); half resections of the Patients displayed no significant differ-
poorer outcomes, while type of flap anterior two-thirds of the lateral border of ences in mandibulectomy, irradiation, age
reconstruction had no effect on functio- the tongue (group L2; n = 35); and com- or time interval between subgroups.
nal outcomes including overall speech plete hemiglossectomies (group L3;
intelligibility. That study also revealed n = 22). All patients in the lateral sub-
Methods for evaluation
that postoperative functional level varies groups underwent resection of the floor
widely among patients who have under- of the mouth to some extent, but resection A speech intelligibility test (SIT)8,9 was
gone the same type and size of resection. never exceeded the midline. The anterior used for evaluation of postoperative
This could be attributable to the surgical group all displayed some excision of the speech function. This is a monosyllable
intervention, such as size of the trans- bilateral floor of the mouth with resection test standardized by the Japanese Hearing
planted flap, and the suturing technique of the tongue. This group was subdivided and Speech Association and the Japanese
used between the remaining stump and according to depth of resection into: resec- Society of Logopedics and Phonatrics.
flap. tion of the anterior floor of the mouth no Japanese pronunciation uses 5 vowels.
The total intelligibility score can objec- deeper than one-third of the full thickness A consonant is usually followed by a
tively evaluate overall postoperative of the midline up to the mylohyoid muscle vowel or semivowel to make a syllable,
speech function. Speech intelligibility plane (group A1; n = 5); and resection of which is the smallest vocal unit in Japa-
tests for syllables can also analyze sources the anterior floor of the mouth deeper than nese. The SIT was conducted in Japanese.
of speech disorders and provide informa- one-third and up to two-thirds of the full Each subject was instructed to pronounce
tion for better speech function through thickness of the midline (group A2; n = 8). 100 listed syllables, and pronunciations
analyses based on articulatory mode and Patients who underwent subtotal hemi- were recorded. Ten untrained volunteers
site, regardless of the languages pro- glossectomy and/or resection of the ante- with normal hearing, who did not know
nounced8. Analyses of various articulatory rior floor of the mouth deeper than two- the patient, then listened to the tape and
sites and modes have seldom been thirds of the full thickness of the midline transcribed the sounds as Japanese sylla-
addressed in the maxillofacial literature. were categorized as the combined group bles that they believed they had heard.
The present study aimed to identify (group C; n = 18). None of the 126 Intelligibility score was expressed as the
surgical recommendations for flap design patients had undergone resection of the percentage of correct responses for all
and inset, to improve speech function in soft palate or tonsillar region. listeners7. Duration between surgical
tongue cancer patients receiving each type A total of 64 patients had received treatment and completion of the examina-
and size of resection, by analyzing the radiotherapy, 53 preoperatively and 9 tion ranged from 6 to 177 months (mean
results of speech intelligibility tests based postoperatively. Mean irradiated dose (standard deviation (SD)), 35.3 29.9
on articulatory mode and site. was 38.5 Gy (range, 18–95 Gy). Mandi- months; mode, 6 months; median, 28
bulectomy had been performed in 60 months).
patients, with marginal mandibulectomy Seventy-nine of the 100 test syllables
Patients and methods in 49 patients and segmental mandibulect- were categorized as glossal sounds accord-
omy in 11 patients. After segmental ing to palatolingual contact during articu-
Subjects
osteotomy, the mandible had been recon- lation by a normal speaker. These were
A total of 126 patients (43 women, 83 structed with a titanium plate at ablative clasified into 5 subgroups based on articu-
men; mean age at examination, 58.5 surgery in all except 1 patient, who under- latory site (linguodentoalveolar (LDA), lin-
years; range, 16–83 years) were enrolled went simultaneous reconstruction with a guopalatal (LP), linguovelar (LV) and
in the present study. Most subjects had scapula flap. Of these 10 patients who intermediates LDA-LP and LP-LV). The
been included in the previous study, but received reconstruction with a titanium articulatory mode of glossal sounds
some were excluded owing to insufficient plate, 7 subsequently underwent mandib- comprised 7 groups (plosives, fricatives,
data and new subjects were included in ular reconstruction, using bone harvested affricatives, grids, nasals, vowels and semi-
this study. These patients had undergone from the ilium in 4 and the scapula in 3. In vowels). As well as overall score, intellig-
reconstructive surgery with fasciocuta- group L1, all except 1 patient underwent ibility was analyzed based on articulatory
neous/myocutaneous flaps after ablative reconstruction with a free radial forearm sites and mode (Table 1; Fig. 1).
surgery for proven malignant tumor of the flap (RFF). In the remaining patient, a The influence of the type of flap recon-
tongue and/or floor of the mouth at 13 vascularized pectoralis major myocuta- struction on speech intelligibility was sta-
Japanese institutions. General informa- neous flap (PMMCF) was used. In group tistically analyzed by comparing scores for
tion about participants was collected by L2, the most popular flap type was RFF, articulatory sites and manners for glossal
the responsible surgeon, under a standard although some patients underwent recon- sounds between two kinds of flaps, as fol-
protocol including: age; T stage; extent struction with a free rectus abdominis lows: in subgroup L2, RFF vs. RAMCF; in
of resection; radiotherapy; and type of myocutaneous flap (RAMCF). In group subgroup L3, RFF vs. PMMCF, RFF vs.
flap reconstruction. Staging was T1 in 6 L3, reconstruction involved an RFF in RAMCF, and PMMCF vs. RAMCF; in
patients, T2 in 74 patients, T3 in 27 10 patients, a PMMCF in 6, and an ante- subgroup A2, RFF vs. PMMCF; and in
patients and T4 in 19 patients. rolateral thigh flap (ALTF) and RAMCF group C, RFF vs. RAMCF.
Speech intelligibility after glossectomy 341
Table 1. Classification of Japanese glossal sounds LP had the lowest (20 21%) among the
LDA(23) Plosives (6) t & d (a,e,o) articulatory sites.
Fricatives (4) s (a,o,e,v)
Affricatives (5) tsv, dz(a,o,e,v)
Glides (4) l(a,o,e,v) Score based on articulatory mode
Nasal (4) n(a,o,e,v)
LDA-LP (4) Glides (4) l(ja,jo,jv,i) LDA
LP (36) Plosives (8) p & b(ja,jo,jv,i)
Fricatives (8) R & (a,o,v,i) In L groups, plosives exhibited the lowest
Affricatives (8) tR & dz(a,o,v,i) values (mean, 60–65%), followed by glides
Nasals (8) m(a,o,v,i), D(a,o,v,i) (mean, 66–69%). Significant differences
Vowel (1) i existed between plosives and other phona-
LP-LV (8) Plosives (8) k & g(ja,jo,jv,i) tions, excluding glides. Fricatives scored
LV (8) Plosives (8) k & g (a,o,e,v) the highest values (mean, 84–85%), with
Total (79) significant differences between all other
phonations in each group, except nasal in
Statistical analyses (Fig. 4). There were no significant differ- L3 (Fig. 5). No significant differences could
ences between A1 and A2, although A1 be found in the same phonation in each set
Statistical analyses were performed using
showed higher values than A2 in most of the 3 groups.
Stat View 5.0 J software (SAS Institute,
articulatory sites. In Group C, LDA had Plosives (33% and 49%) and glides
Cary, NC, USA). A paired t-test was
the highest value (39 24%) and LDA- (46% and 47%) in both A subgroups
utilized to analyze the effects of articula-
tory sites for glossal sounds in each sub-
group. An independent samples t-test was
used to compare results within groups L
and A with regard to articulation site for
glossal sounds and modes. An indepen-
dent samples t-test was also used for ana-
lyses on the influence of the type of flap
reconstruction on speech intelligibility.
Values of P < 0.05 were considered
statistically significant.
Results
Overall score
As in the previous study7, group L1 had
the highest score (69 25%) and group C
had the lowest (37 32%). Lateral sub- Fig. 1. Portions of the tongue dorsum related to lingography (adapted from Michi et al.8).
groups scored higher than both A sub-
groups and group C. Wider resection
resulted in lower intelligibility scores
within groups L and A.
Discussion
Mobility of the residual tongue, particu-
larly of the tip, has been emphasized for
better function after glossectomy8. LDAs
of all L subgroups showed the highest
intelligibility scores in analyses of articu-
latory site and no significant differences
existed between any sets of the 3 L sub-
groups. The reconstruction of the anterior
portion now in use can be assumed to be
functionally sufficient for patients who
Fig. 4. Results of glossal sounds based on articulatory sites (A1 group). LV had the highest underwent resection for lateral-type
values and superiority of LDA over other sites was not as clear. A significant difference between malignant tumor. The low scores for plo-
LDA and another site was only identified for LDA-LP. LDA (LDA-LP: dt = 2.66, P < 0.05), sives and glides of LDA indicate that
LDA-LP (LP(cons): dt = 2.91, P < 0.05), LP(v/sv); (LV: dt = (2.37, P < 0.05), LP-LV (LV: movement of the reconstructed tongue
dt = 2.66, P < 0.05). (Paired t-test). remains insufficient for pronunciation dur-
ing which tight contact to and quick
release from the dentoalveoli by the ton-
showed lower values than in L groups. A1 significantly higher in the L1 group gue are required. The low scores for LDA-
and A2 showed no significant differences, (58 27%) than in the L2 (39 25%) LP, LP-LV and LV are attributed to the
although A2 displayed lower values than and L3 (42 31%) groups. fact that only plosives or glides are pro-
A1 in all modes. A1 showed higher values than A2, nounced in these sites. More efforts to give
In group C, plosives were the lowest, at except for semivowels. mobility of the reconstructed tongue are
<20%, and fricatives were the highest, In group C, vowels (56 44%) and needed for better speech function.
at >50%. semivowels (42 35%) displa yed The study on the type of flap revealed
higher scores than consonants (mean, that RFF was statistically superior to
20–31%). Plosives of LP (20 21%) PMMCF and RAMCF in some arti-
LP
showed almost the same score as those culatory sites of plosives. No clear ten-
As a result of LDA, plosives were lower of LDA (19 27%). Fricatives of LP dency was evident between PMMCF and
than almost all other phonations in the (31 21%) were lower than those of RAMCF, although statistical differences
3 L subgroups (Fig. 6). Plosives scored LDA (56 32%). existed in some aspects. These results
Speech intelligibility after glossectomy 343
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