Abstract
The purpose of the study was to assess and compare the quality of speech and swallowing between three reconstruction options (primary closure—group A, secondary intention healing—group B and flap reconstruction—group C), in small to moderate sized onco-surgical defects of oral tongue. 47 patients fulfilled the eligibility criteria during the study period, of which, 15 belonged to group A, 16 belonged to group B, 16 were in group C. Speech and swallowing assessment was done using Speech Intelligibility Assessment score and MD Anderson Dysphagia Inventory, respectively. The above tests were administered pre-operatively, 1 month and 6 months post-operativey in all the study participants. The average scores of speech intelligibility at 1 month were 66.13% (±19.96), 70.04% (±12.28) and 37.31% (±11.29) for groups A, B and C respectively. Similarly, average long term scores for speech intelligibility in these three groups were 72.7% (±17.72), 83.3% (±12.78) and 52.8% (±11.74) respectively. With regards to swallowing the composite scores at 1 month were 73.67 (±13.69), 68.31 (±16.06) and 41.81 (±5.44), and at 6 months were 83.2 (±10.24), 79.31 (±12.29) and 57.88 (±7.37), respectively for groups A, B and C. All the differences were statistically significant (p < 0.05). Healing by secondary intention offered the best functional outcome in terms of speech intelligibility, and primary closure offered best swallowing outcomes in operated cases of oral tongue. This trial has been registered with the Clinical Trials Registry—India in December 2018 (CTRI Reg. No: CTRI/2018/12/016803).
Keywords: Squamous cell carcinoma, Tongue cancer, Oral cavity, Reconstruction, Free-flap, Radial forearm free flap
Introduction
Oral cancers constitute a major part of human papilloma virus negative head and neck squamous cell carcinoma, particularly in developing nations known for smoking and smokeless tobacco abuse [1]. In these cases, resection of the carcinomatous lesion with adequate margins all around is the cornerstone of treatment, with or without neck dissection, and with or without adjuvant radiotherapy [2, 3]. Following ablative surgery, functional ability of the residual tongue is often compromised, for which, the resected portion of the tongue should be reconstructed at the same setting [3, 4]. Restoration of tongue bulk and mobility is critical for articulation during speech and for the oral phase of swallowing [3]. Traditionally, smaller defects of the tongue are either closed primarily or allowed to heal by secondary intention, and larger defects are reconstructed with flaps or free tissue transfer [5, 6]. However, there is no universal agreement with regards to the suitability of reconstruction method, and the choice in similar sized-defects may vary from case to case. Moreover, the functional outcomes differ between various reconstruction methods, and literature in this regard is marred with controversies with a never-ending quest for the ideal reconstruction option [7–9].
Although various options are available for reconstructing the surgical defect as per its size, choosing an appropriate flap that provides optimal restoration of tongue functionality is still challenging [4]. Several studies have tried to answer this question, but have only done either unilateral evaluation of a reconstructive option or bilateral comparison between any two reconstruction methods [10–12]. The current study analyses the functional outcomes of three major reconstruction options exercised after partial glossectomy or hemiglossectomy. Contrary to most of the previous works, this study also evaluates the functional performance of secondary intention healing with respect to other popular options like free flap or pedicled flap. The primary objective of the study was to assess and compare the quality of speech and swallowing between primary closure, secondary healing and flap reconstruction of small to medium sized onco-surgical defects of oral tongue.
Materials and Methods
Study Design and Setting
This is a prospective, comparative study, conducted in the Department of Otolaryngology and Head and Neck Surgery, in collaboration with the Department of Speech & Hearing, of a tertiary care hospital. The study was cleared by the Institutional Ethical Committee in November 2018 (IEC Project No: 553-2018) and by the Clinical Trials Registry—India in December 2018 (CTRI Reg. No: CTRI/2018/12/016803), and the study itself was carried out between January 2019 and August 2020.
Study Participants
The subjects consisted of biopsy proven, treatment-naïve cases of tongue carcinoma, undergoing surgical treatment in the form of either partial glossectomy or hemiglossectomy with or without neck dissection during the study period. Patients with lesion involving the mandible, skin or base of tongue were excluded from the study. Also, those with prior history of malignancy in the upper aero-digestive tract, and who had pre-existing neurological problems like stroke, Parkinson`s disease or similar disorders that could affect the patient`s speech or swallowing were not included.
Study Groups
In each study participant, the reconstruction method after surgical resection of the tongue cancer was decided by taking into consideration disease factors like the stage of the loco-regional disease, and patient factors like fitness to undergo microvascular surgery. For the present study, the patients were assigned into one of the three broad groups based on the method of reconstruction used. Cases that had primary closure of tongue defect were considered as Group-A, those who had secondary intention healing of the surgical wound were taken as Group-B, and cases that received a flap for tongue reconstruction were included under Group-C. All patients of group A underwent single layered closure of the tongue defect with absorbable sutures and those in Group B underwent KTP laser assisted excision of the tongue malignancy following which the defect was allowed to heal by secondary intention. The patients in Group C had the surgical defect reconstructed either by an axial flap like nasolabial flap, submental flap, and pectoralis major myocutaneous flap, or a free flap like radial forearm free flap and anterolateral thigh flap.
Assessment of Speech and Swallowing
After taking an informed written consent, each of the included patients were assessed a few days prior to the surgery (not earlier than a week), during which the quality of speech and swallowing functions were assessed by a team of investigators which included the first author and a group of Speech-Language Pathologists (SLP). The percentage speech intelligibility was used for analyzing the quality of speech, and the MD Anderson Dysphagia Inventory (MDADI) was used for swallowing. For assessing speech intelligibility, a standard pre-determined passage in the patient`s native language was provided, and the patient was instructed to read the entire paragraph as loudly and clearly as possible. This piece of speech was recorded and was subsequently analyzed by the three SPLs who were blinded for surgical intervention. The percentage of intelligible words was thereby calculated by these three SLPs independently and the average of these three scores was taken for defining the pre-treatment quality of speech. For swallowing related outcomes, the MDADI was used to assess the dysphagia-associated change in quality of life, validated for use in patients with head and neck cancer [13]. In this patient-based questionnaire, 20 questions covering various aspects of swallowing function including global, functional, emotional and physical domains are rated by the patient on a scale of 1 to 5, 1 being completely agree and 5 being completely disagree. Final scoring was obtained as a Global Score (GS) ranging from 1 to 5, and a Composite Score (CS) ranging from 20 to 100. Apart from the immediate pre-operative period, these two tests were administered to all the participants at one-month (short-term follow up) and at six-month (long-term follow up) post-operative periods.
Data Analysis
The collected data was analysed using the SPSS software version 23.0 (SPSS, Inc, an IBM Company, Chicago, Illinois). Average of speech intelligibility scores and MDADI swallowing scores were calculated in each of the 3 groups, and the differences in the average scores between the respective groups were analysed using Kruskal Wallis and ANOVA tests. A p value less than .05 was considered for defining statistically significant difference.
Results
Characteristics of Study Participants
Of the 62 patients operated during the study period, a total of 47 patients fulfilled the eligibility criteria and were included. The mean age of the study population was 49.8 ranging from 22 to 69 years. Thirty-five of the recruited patients were men (74.47%) and 12 were women (25.53%). Most of the included patients had malignant lesion in the lateral border of tongue (n=46), and the rest had lesion involving the dorsum of tongue (n=1). These tumours were staged as per the American Joint Committee on Cancer`s VIII edition of staging manual. Accordingly, majority had T2 disease (n=23), followed by T3 (n=16) and T1 (n=8). Amongst these 47 cases, the tongue defect was closed primarily in 15, left for healing by secondary intention in 16, and reconstructed with the help of a flap in 16 cases. Out of the 16 patients who underwent flap reconstruction, 4 had received free flaps (3 radial forearm and 1 anterolateral thigh), and the remaining had local/regional flaps (10 pectoralis major mycocutaneous flap, 1 nasolabial flap, and 1 submental flap). The detailed clinical characteristics and the functional assessment scores of the entire study cohort has been summarised in a table, available as supplementary material ("Appendix I").
Primary Outcome
Average speech intelligibility scores at pre-operative, 1-month post-operative and 6-month post-operative periods have been tabulated for each of the reconstruction methods in Table 1. The average preoperative scores were comparable between the groups, which reduced drastically after the surgical resection of tongue in all groups; however, to a lesser extent with secondary intention than with primary closure or flap reconstruction. Group-B had better average-speech scores than the other two, both at short-term as well as long-term follow up periods, and the difference was statistically significant.
Table 1.
Average speech intelligibility scores with respect to type of reconstruction. (SD-Standard deviation)
With respect to swallowing function, as depicted in Table 2, Group-A had better MDADI Composite scores than the other two groups in both short-term as well as long-term follow up periods, while Group-B fared better in the Global scores. The average change in scores with respect to the baseline also showed a similar trend however, the long term average global scores comparison was not found to be statistically significant. Group C was found to have the worst functional scores among the three, in both short term as well as long term follow up, and with regards to both speech and swallowing functions.
Table 2.
Depicts the average MDADI Global and Composite swallowing scores and the change from baseline pre-operative scores in each of the reconstruction categories
Subgroup Analyses
This study also analyzed the long-term outcomes of various reconstruction methods as per the T stage of the disease, the results of which has been depicted in Table 3. It was observed that, for T1 lesions, primary closure provided the best long term speech as well as swallowing scores, followed by secondary intention, although the statistical significance was seen only for the difference in speech scores. Among the T2 lesions, secondary intention group was found to have the best speech scores where as the primary closure group had the best swallowing scores, and both were statistically significant. In the T3 category, flap reconstruction group had the best speech outcome and primary closure had the best swallowing scores, however, only the latter was statistically significant.
Table 3.
Comparison of long term functional outcomes between various clinical parameters. FR: Flap Reconstruction; PC: Primary Closure; SI: Secondary Intention: CT-RT: Adjuvant chemoradiation: RT: Adjuvant radiation therapy alone
| Parameter | Categories | Speech Intelligibility Scores at 6 months | MDADI Composite swallowing scores at 6 months |
|---|---|---|---|
| Functional outcomes as per T—stage | |||
| T1 (n = 8) | Group A (n = 2) | 93 | 96 |
| Group B (n = 5) | 89.52 | 82.6 | |
| Group C (n = 1) | 50 | 67 | |
| P value | 0.0064 | 0.365 | |
| T2 (n = 23) | Group A (n = 10) | 76.5 | 83.7 |
| Group B (n = 10) | 84.1 | 78.8 | |
| Group C (n = 3) | 45 | 61.33 | |
| P value | 0.000012 | 0.00985 | |
| T3 (n = 16) | Group A (n = 3) | 46.66 | 73 |
| Group B (n = 1) | 45 | 68 | |
| Group C (n = 12) | 55 | 56.25 | |
| P value | 0.5 | 0.00134 | |
| Functional outcomes as per the adjuvant treatment | |||
| Adjuvant Treatment given | CT-RT (n = 12) | 63.72 | 61.42 |
| None (n = 16) | 79.44 | 84.06 | |
| RT (n = 19) | 64.95 | 71.63 | |
| P value | 0.0334 | 0.000087 | |
| Functional outcomes as per the tip involvement | |||
| Tip involved and resected | Yes (n = 23) | 58 | 66.61 |
| No(n = 24) | 80.65 | 79.62 | |
| P value | 0.000007 | 0.0021 |
Lastly, a post-hoc analysis was done to evaluate the impact of adjuvant therapy and the tip of tongue involvement on the functional ability of operated cases of tongue malignancy. As shown in Table 3, patients who did not receive any adjuvant treatment had better short-term as well as long-term speech and swallowing scores, and the patients whose tip of the tongue was preserved had better speech and swallowing outcomes compared to those who did not.
Discussion
Extirpative surgery of tongue malignancy is well known for its mutilating effect, thereby severely affecting vital functions such as speech, swallowing, breathing etc. [4] Functional rehabilitation following surgery is increasingly being given prime importance due to its impact on overall quality of life for the patient [3, 4]. However, there are only a few studies in literature that have attempted to quantify and evaluate functional outcomes of primary closure and secondary intention healing in tongue cancers. Also, apart from comparing the functional ability of various reconstruction methods at long-term and short-term follow up periods, we have also measured the change in speech and swallowing scores from their respective preoperative status for each of the reconstruction methods.
The results of our study suggest that the secondary intention healing provides the best long-term outcome with respect to speech, followed by the primary closure of surgical wound. Superior speech performance of these methods over reconstruction by flap could be attributed to better mobility of the residual tongue tissue in the former groups compared to the flaps that hinder mobility of tongue. In other words, the bulkiness and drag of the pectoralis major myocutaneous flap and other local flaps may negatively influence the speech intelligibility of these patients. Similar results of compromised speech scores with flaps relative to other methods of reconstruction or no reconstruction have also been reported by the other authors [6, 11, 14, 15]. Interestingly, other functional studies that have included only free flaps have reported better post-operative speech performance. [7, 8, 10, 16, 17].
Even for swallowing, the recipients of flaps had relatively poorer scores, both at short term and long term follow up durations. In the literature, the results are divided about this. While the results of few studies were in line with ours, others have reported better performance in flap-reconstructed patients [6, 18–20]. Interestingly, Yong Bae Ji et al. found no statistically significant difference in swallowing scores by Functional Outcome of Swallowing Scale between the flap-reconstructed defects and those allowed to heal by secondary intention on long term follow up [15]. Nevertheless, studies analysing the functional performance of pectoralis major myocutaneous flap for tongue reconstruction have consistently reported lower scores both for swallowing and speech functions [11, 19]. While reconstruction by flaps could provide adequate mass necessary to initiate swallowing, the lack of coordinated movement due to the absence of nerve supply or the supply by antagonising nerve fibres may contribute to swallowing difficulties. Similar restriction of mobility and flexibility of flap-reconstructed tongue could also be the reason for poorer speech scores [14]. On the other hand, preservation of the nerve supply and synchronised contraction of the residual tongue without any drag may help in achieving better swallowing scores and speech scores, as in the case with primary closure or secondary intention healing [12]. With regard to temporal variations, the performance of both speech and swallowing improved considerably with time in all three groups compared to the scores at short-term follow up, suggesting that the patients would learn to use the residual tongue optimally over a period of time.
Apart from the actual reconstruction option, the functional impairment of the tongue following surgery could also depend on several other factors, including the volume and mobility of the residual tongue [9, 17, 18, 21]. In order to account for variability in the volume of residual tongue in the study cohort, the sub-group analysis was carried out to access the functional outcome by different reconstruction methods in three independent sub-groups of tongue defects, categorised as per the T stage. Accordingly, in smaller tongue lesions, the primary closure offered the best functional outcome, as also reported by others [6]. With relatively larger lesions (T2 or T3 disease) the results were inconclusive and the type of reconstruction is personalised to various patient and disease factors. A notable result of this sub-group analysis was that despite having poor swallowing scores, the flap-reconstructed patients in T3 category had relatively better speech intelligibility scores than other methods. Finally, the post-hoc analysis of the surgical cohort in this study confirmed the existing notions that adjuvant treatment and the excision of the tip of tongue do reduce the quality of life by affecting speech and swallowing. [4, 12, 16, 20]. Nevertheless, a larger study population, uniform distribution of reconstruction methods across the T-stage, and longer follow up would have allowed for more conclusive results. Also, the inference about the functional performance of flaps may be affected by the inclusion of multiple flaps in Group-C. Lastly, other known factors that could affect functional outcomes such as age, gender and co-morbidities were not considered in this study. Overall, though further studies that overcome the above-mentioned caveats are necessary to validate the findings, the present study contributes significantly to the existing literature on reconstruction options in tongue defects.
To conclude, primary closure of surgical defects and healing by secondary intention provide better short term and long term functional outcomes in small to moderate sized defects of tongue.Healing by secondary intention offers best outcomes in terms of speech intelligibility and primary closure offers best swallowing outcomes in oral tongue malignancy. For larger defects flap reconstruction provides better speech outcomes whereas swallowing function still seems to be poorer in these patients.
Appendix I
| Case number | Age | Sex | Diagnosis | T Stage | Tip Involvement | Pre-existing pathology/ comorbidities | Biopsy | Imaging | SURGERY | ||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| PC | SI | FR | Flap used | ND | |||||||||
| 1 | 22 | F | Ca left lateral border tongue | T2 | – | – | WDSCC | MRI | 1 | B/L MRND | |||
| 2 | 46 | M | Ca left lateral border tongue | T3 | + | OSMF + | PDSCC | MRI | 1 | RFFF | B/L SOND | ||
| 3 | 46 | M | Ca left lateral border tongue | T1 | – | – | MDSCC | MRI | 1 | LEFT SOND | |||
| 4 | 38 | M | Ca right lateral border tongue | T2 | – | – | MDSCC | CECT | 1 | RIGHT SOND | |||
| 5 | 60 | M | Ca right lateral border tongue | T1 | – | – | MDSCC | MRI | 1 | RIGHT SOND | |||
| 6 | 49 | M | Ca left lateral border tongue | T2 | – | – | WDSCC | MRI | 1 | LEFT MRND | |||
| 7 | 62 | M | Ca left lateral border tongue | T2 | + | – | WDSCC | CECT | 1 | B/L SOND | |||
| 8 | 47 | M | Ca right lateral border tongue | T3 | + | – | WDSCC | CECT | 1 | RIGHT MRND + LEFT SOND | |||
| 9 | 43 | M | Ca left lateral border tongue | T2 | – | – | MDSCC | MRI | 1 | LEFT SOND | |||
| 10 | 45 | F | Ca dorsum of tongue | T1 | – | – | Low grade mucoepidermoidCa | CECT | 1 | ||||
| 11 | 37 | F | Ca right lateral border tongue | T2 | – | – | MDSCC | MRI | 1 | RIGHT SOND | |||
| 12 | 45 | M | Ca right lateral border tongue | T3 | + | – | MDSCC | CECT | 1 | B/L MRND | |||
| 13 | 60 | F | Ca left lateral border tongue | T2 | + | – | MDSCC | MRI | 1 | LEFT SOND | |||
| 14 | 48 | F | Ca left lateral border tongue | T3 | + | OSMF + | MDSCC | 1 | Nasolabial flap | LEFT SOND | |||
| 15 | 37 | M | Ca left lateral border tongue | T3 | – | – | WDSCC | MRI | 1 | PMMC | B/L MRND | ||
| 16 | 50 | M | Ca right lateral border tongue | T1 | – | OSMF + | MDSCC | MRI | 1 | RIGHT SOND | |||
| 17 | 33 | M | Ca right lateral border tongue | T2 | – | – | MDSCC | MRI | 1 | RIGHT MRND + L SOHND | |||
| 18 | 55 | M | Ca right lateral border tongue | T2 | + | – | WDSCC | MRI | 1 | RIGHT SOND | |||
| 19 | 46 | M | Ca right lateral border tongue | T2 | – | – | WDSCC | MRI | RIGHT SOND | ||||
| 20 | 51 | M | Ca right lateral border tongue | T3 | + | – | WDSCC | MRI | 1 | PMMC | B/L MRND | ||
| 21 | 56 | F | Ca left lateral border tongue | T3 | + | – | MDSCC | MRI | 1 | PMMC | B/L MRND | ||
| 22 | 41 | F | Ca left lateral border tongue | T3 | + | – | WDSCC | MRI | 1 | PMMC | B/L MRND | ||
| 23 | 41 | M | Ca right lateral border tongue | T2 | – | – | WDSCC | MRI | 1 | B/L SOND | |||
| 24 | 60 | F | Ca right lateral border tongue | T2 | + | – | MDSCC | MRI | 1 | PMMC | B/L MRND | ||
| 25 | 47 | M | Ca left lateral border tongue | T3 | + | – | MDSCC | MRI | 1 | PMMC | B/L MRND | ||
| 26 | 63 | M | Ca right lateral border tongue | T2 | + | – | MDSCC | MRI | 1 | RIGHT SOND | |||
| 27 | 61 | M | Ca right lateral border tongue | T2 | + | OSMF + | MDSCC | MRI | 1 | PMMC | B/L MRND | ||
| 28 | 46 | M | Ca right lateral border tongue | T2 | + | – | MDSCC | MRI | 1 | RIGHT SOND | |||
| 29 | 47 | M | Ca right lateral border tongue | T2 | – | – | PDSCC | MRI | 1 | B/L MRND | |||
| 30 | 37 | M | Ca right lateral border tongue | T3 | + | – | MDSCC | MRI | 1 | PMMC | B/L MRND | ||
| 31 | 68 | M | Ca right lateral border tongue | T3 | + | – | MDSCC | MRI | 1 | Free fibular Flap | B/L MRND | ||
| 32 | 36 | M | Ca right lateral border tongue | T2 | – | – | MDSCC | MRI | 1 | RIGHT MRND | |||
| 33 | 56 | F | Ca left lateral border tongue | T2 | – | – | MDSCC | MRI | 1 | LEFT SOND | |||
| 34 | 38 | M | Ca left lateral border tongue | T1 | – | – | MDSCC | MRI | 1 | LEFT SOND | |||
| 35 | 63 | F | Ca right lateral border tongue | T2 | – | WDSCC | MRI | 1 | RIGHT SOND | ||||
| 36 | 65 | M | Ca left lateral border tongue | T3 | + | – | MDSCC | MRI | 1 | LEFT MRND | |||
| 37 | 53 | M | Ca right lateral border tongue | T3 | + | MDSCC | MRI | 1 | B/L SOND | ||||
| 38 | 68 | F | Ca right lateral border tongue | T2 | – | – | MDSCC | MRI | 1 | B/L MRND | |||
| 39 | 48 | M | Ca left lateral border tongue | T1 | – | – | WDSCC | MRI | 1 | LEFT SOND | |||
| 40 | 56 | M | Ca right lateral border tongue | T3 | + | – | PDSCC | MRI | 1 | PMMC | B/L MRND | ||
| 41 | 62 | F | Ca right lateral border tongue | T2 | + | – | MDSCC | MRI | 1 | RIGHT SOND | |||
| 42 | 38 | M | Ca left lateral border tongue | T3 | + | – | MDSCC | CECT | 1 | PMMC | B/L SOND | ||
| 43 | 64 | M | Ca right lateral border tongue | T1 | – | – | WDSCC | CECT | 1 | – | |||
| 44 | 45 | M | Ca left lateral border tongue | T2 | – | – | MDSCC | MRI | 1 | LEFT MRND | |||
| 45 | 69 | M | Ca left lateral border tongue | T1 | – | – | Verrucous Carcinoma | MRI | 1 | Submental flap | – | ||
| 46 | 57 | M | Ca right lateral border tongue | T2 | + | OSMF + | MDSCC | MRI | 1 | ALT | RIGHT SOND | ||
| 47 | 36 | M | Ca right lateral border tongue | T3 | – | – | MDSCC | MRI | 1 | RFFF | RIGHT MRND |
| Case number | Age | Sex | Diagnosis | Post-op period | Adjuvant | MDADI | Speech Intelligibility Score | ||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Pre-op | 1 m | 6 m | Pre-op | 1 m | 6 m | ||||||
| 1 | 22 | F | Ca left lateral border tongue | – | CT-RT | G:5 C:100 | G:4 C:60 | G:5 C:89 | %:100 Scale:1 | %:70 Scale:2 | %:63 Scale:3 |
| 2 | 46 | M | Ca left lateral border tongue | – | CT-RT | G:5 C:100 | G:3 C:50 | G:4 C:59 | %:100 Scale:1 | %:70 Scale:2 | %:77 Scale:2 |
| 3 | 46 | M | Ca left lateral border tongue | – | CT-RT | G:5 C:100 | G:4 C:40 | G:4 C:65 | %:100 Scale:1 | %:80 Scale:2 | %:87.6 Scale: 2 |
| 4 | 38 | M | Ca right lateral border tongue | – | RT | G:5 C:100 | G:3 C:60 | G:4 C:65 | %:100 Scale:1 | %:85 Scale:2 | %:85 Scale:2 |
| 5 | 60 | M | Ca right lateral border tongue | – | CT-RT | G:5 C:92 | G:4 C:42 | G:4 C:64 | %: 100 Scale:1 | %:92 Scale:1 | %:100 Scale:1 |
| 6 | 49 | M | Ca left lateral border tongue | – | – | G:5 C:90 | G:3 C:60 | G:4 C:62 | %:95 Score:1 | %:70 Score:2 | %:80 Score:2 |
| 7 | 62 | M | Ca left lateral border tongue | RT | G:5 C:100 | G:4 C:52 | G:4 C:64 | %:100 Score: 1 | %:95 Score:1 | %: 97 Score: 1 | |
| 8 | 47 | M | Ca right lateral border tongue | – | RT | G:5 C:100 | G: 3 C:48 | G:4 C:80 | %: 97 Score:1 | %:21 Score: 6 | %:35 Score:5 |
| 9 | 43 | M | Ca left lateral border tongue | – | CT-RT | G:5 C:100 | G: 3 C:65 | G:4 C:76 | %:100 Score:1 | %:90 Score:1 | %: 92 Score:1 |
| 10 | 45 | F | Ca dorsum of tongue | Secondary haemorrage | – | G:5 C:100 | G:4 C:67 | G:5 C:100 | %:100 Score:1 | %:87.6 Score:2 | %:90 Score:1 |
| 11 | 37 | F | Ca right lateral border tongue | – | G:5 C:92 | G:4 C:67 | G:4 C:80 | %:100 Score:0 | %:75 Score:2 | %:80 Score:2 | |
| 12 | 45 | M | Ca right lateral border tongue | Neck wound gaping | RT | G:4 C:92 | G:3 C:52 | G:3 C:68 | %:91 Score:1 | %:45 Score:4 | %:45 Score:4 |
| 13 | 60 | F | Ca left lateral border tongue | – | RT | G:5 C:100 | G:4 C:70 | G:4 C:81 | %:100 Score:1 | %:70 Score:2 | %:72 Score:2 |
| 14 | 48 | F | Ca left lateral border tongue | – | RT | G:4 C:90 | G:2 C:35 | G:4 C:60 | %:100 Score:1 | %:42 Score:4 | %:58 Score:3 |
| 15 | 37 | M | Ca left lateral border tongue | RT | G:5 C:100 | G:2 C:42 | G:3 C:53 | %:100 Score:1 | %:30 Score:6 | %:70 Score:2 | |
| 16 | 50 | M | Ca right lateral border tongue | – | – | G:5 C:100 | G:5 C:100 | G:5 C:100 | %:100 Score:1 | %:96 Score:1 | %:96 Score:1 |
| 17 | 33 | M | Ca right lateral border tongue | – | RT | G:5 C:95 | G: 3 C:80 | G: 3 C:85 | %:96 Score:1 | %:58 Score:3 | %:65 Score:3 |
| 18 | 55 | M | Ca right lateral border tongue | – | RT | G:5 C:100 | G:4 C:72 | G:4 C:89 | %:100 Score:1 | %72 Score:2 | %:70 Score:2 |
| 19 | 46 | M | Ca right lateral border tongue | – | – | G:5 C:100 | G:4 C:76 | G:4 C:80 | %:100 Score:1 | %:65 Score:3 | %:70 Score:2 |
| 20 | 51 | M | Ca right lateral border tongue | – | CT-RT | G:4 C:90 | G:3 C:47 | G:3 C:60 | %:90 Score:1 | %:50 Score:4 | %:60 Score:3 |
| 21 | 56 | F | Ca left lateral border tongue | – | RT | G:4 C:87 | G:2 C:48 | G:3 C:52 | %:80 Score:2 | %:30 Score:6 | %:45 Score:4 |
| 22 | 41 | F | Ca left lateral border tongue | – | CT-RT | G:4 C:80 | G:2 C:36 | G:3 C:45 | %:90 Score:1 | %:30 Score:6 | %:45 Score:4 |
| 23 | 41 | M | Ca right lateral border tongue | – | – | G:5 C:100 | G:3 C:76 | G:4 C:78 | %:90 Score:1 | %:65 Score:3 | %:70 Score:2 |
| 24 | 60 | F | Ca right lateral border tongue | – | CT-RT | G:3 C:51 | G:2 C:40 | G:3 C:52 | %:80 Score:2 | %:30 Score:6 | %:50 Score:3 |
| 25 | 47 | M | Ca left lateral border tongue | – | RT | G:4 C:85 | G:2 C:40 | G:3 C:61 | %:90 Score:1 | %:30 Score:6 | %:60 Score:3 |
| 26 | 63 | M | Ca right lateral border tongue | – | – | G:5 C:100 | G:4 C:87 | G:4 C:88 | %:100 Score:1 | %:85 Score:2 | %:90 Score:1 |
| 27 | 61 | M | Ca right lateral border tongue | – | CT-RT | G:4 C:80 | G:3 C:43 | G:3 C:56 | %:80 Score:2 | %:30 Score:6 | %:40 Score:5 |
| 28 | 46 | M | Ca right lateral border tongue | RT | G:5 C:100 | G:3 C:85 | G:4 C: 89 | %:100 Score:1 | %: 70 Score:2 | %: 75 Score:2 | |
| 29 | 47 | M | Ca right lateral border tongue | RT | G:5 C:100 | G:4 C:90 | G:4 C:80 | %:95 Score:1 | %: 85 Score:2 | %:90 Score:1 | |
| 30 | 37 | M | Ca right lateral border tongue | – | RT | G:4 C:90 | G:3 C:51 | G:3 C:60 | %:90 Score:1 | %:40 Score:5 | %:50 Score:3 |
| 31 | 68 | M | Ca right lateral border tongue | CT-RT | G:4 C:92 | G:3 C:40 | G:3 C:52 | %:90 Score:1 | %:30 Score:6 | %:40 Score:5 | |
| 32 | 36 | M | Ca right lateral border tongue | – | G:5 C:100 | G:4 C:84 | G:4 C:90 | %:100 Score:1 | %:70 Score:2 | %:75 Score:3 | |
| 33 | 56 | F | Ca left lateral border tongue | Secondary haemorrage | – | G:5 C:100 | G:3 C:84 | G:4 C:92 | %:100 Score:1 | %:80 Score:2 | %:80 Score:2 |
| 34 | 38 | M | Ca left lateral border tongue | – | – | G:5 C:100 | G:4 C:90 | G:4 C:95 | %:100 Score:1 | %:85 Score:2 | %:90 Score:1 |
| 35 | 63 | F | Ca right lateral border tongue | – | – | G:5 C:100 | G:4 C:80 | G: 4 C:90 | %:100 Score:1 | %:85 Score:2 | %:90 Score:1 |
| 36 | 65 | M | Ca left lateral border tongue | – | – | G:4 C:85 | G:3 C:60 | G:3 C:72 | %:90 Score:1 | %:50 Score:4 | %:60 Score:3 |
| 37 | 53 | M | Ca right lateral border tongue | – | RT | G:4 C:80 | G:2 C:60 | G:3 C:67 | %:90 Score:1 | %:30 Score:6 | %:45 Score:4 |
| 38 | 68 | F | Ca right lateral border tongue | – | – | G:5 C:90 | G:3 C:68 | G:4 G:70 | %:100 Score:1 | %:70 Score:2 | %:80 Score:2 |
| 39 | 48 | M | Ca left lateral border tongue | – | – | G:5 C:97 | G:4 C:82 | G:4 C:89 | %:100 Score:1 | %:70 Score:2 | %:80 Score:2 |
| 40 | 56 | M | Ca right lateral border tongue | – | CT-RT | G:4 C:81 | G:2 C:42 | G:3 C:54 | %:90 Score:1 | %:30 Score:6 | %:40 Score:5 |
| 41 | 62 | F | Ca right lateral border tongue | – | RT | G:5 C:100 | G:4 C:85 | G:4 C:93 | %:100 Score:1 | %:80 Score:2 | %:90 Score:1 |
| 42 | 38 | M | Ca left lateral border tongue | – | RT | G:4 C:90 | G:2 C:38 | G:3 C:54 | %:90 Score:1 | %:35 Score:6 | %:45 Score:4 |
| 43 | 64 | M | Ca right lateral border tongue | – | – | G:5 C:100 | G:4 C:78 | G:4 C:92 | %:100 Score:1 | %:80 Score:2 | %:90 Score:1 |
| 44 | 45 | M | Ca left lateral border tongue | – | RT | G:5 C:95 | G:3 C:78 | G:4 C:84 | %:100 Score:1 | %:80 Score:2 | %:92 Score:1 |
| 45 | 69 | M | Ca left lateral border tongue | – | – | G:5 C:100 | G:3 C:46 | G:4 C:67 | %:100 Score:1 | %:40 Score:5 | %:50 Score:3 |
| 46 | 57 | M | Ca right lateral border tongue | – | RT | G:4 C:89 | G:2 C:32 | G:3 C:76 | %:90 Score:1 | %:30 Score:6 | %:45 Score:4 |
| 47 | 36 | M | Ca right lateral border tongue | – | CT-RT | G:4 C:90 | G:2 C:39 | G:3 C:65 | %:90 Score:1 | %:50 Score:4 | %:70 Score:2 |
Authors' Contributions
All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Dr Aditi Ravindra and Dr K Devaraja. The first draft of the manuscript was written by Dr Aditi Ravindra and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding
None.
Availability of Data and Material (Data Transparency)
Comply with field standards.
Code Availability (Software Application or Custom Code)
Comply with field standards.
Declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethics Approval
The study was approved by the Instituional Ethics Committee of Manipal Academy of Higher Education (IEC Project No: 553–2018) and the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.
Consent to Participate
All study participants were explained in a language that they best understand about the nature of the study and gave their whole-hearted, written consent for participation.
Consent for Publication
All study participants were informed that the data obtained from this study would be sent for publication as a journal article while maintaining anonymity and they gave written consent for the same.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
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Data Availability Statement
Comply with field standards.
Comply with field standards.