Assessment of Speech and Deglutition in Patients with Carcinoma Tongue Post Radial Forearm Free Flap Cover

Abstract

Over the past 30 years, the introduction of reconstructive techniques incorporating microvascular free tissue transfer has transformed the quality of life of patients undergoing head and neck surgery.The free forearm flap was first described for head and neck reconstruction by Yang in 1981 when he used this flap to reconstruct a neck defect secondary to a burn scar contracture.In this retrospective cohort study, we have evaluated patients who underwent reconstruction of hemiglossectomy defect with radial forearm free flap for malignancy of tongue, from year 2018 to 2020, with reference to deglutition and speech.As per the data obtained, 41.7% and 50% of the patients had achieved excellently intelligible speech and moderately intelligible speech respectively whereas only 8.3% had poorly intelligible speech. On evaluation of post operative swallowing, 83.4% of the patients had excellent swallowing score and the remaining 16.6% had moderate and poor swallowing score.Hence, reconstruction of hemiglossectomy defects with radial forearm free flap is an excellent method to restore the functional outcomes in speech and deglutition.

Introduction

Carcinoma of the oral tongue is the most common presentation of squamous carcinoma in the oral cavity and resection is the cornerstone of treatment.

Rehabilitation of the speech and swallowing capacity of these patients be an emotionally and technically challenging endeavor [1].

Surgical resection of larger oral tongue tumors can result in a significant functional impairment in terms of speech and deglutition.Lingual contact with the palate, teeth, and lip is subsequently decreased and results in impaired capacity for articulation.

Posterior propulsion of a food bolus and liquids is also likely to be affected. The use of thin pliable fasciocutaneous free flaps such as a radial forearm free flap, also known as ‘Chinese’ flap can provide intraoral bulk and preserve existing mobility of the remaining native tongue [2–4]. The thin, pliable radial forearm free flap (RFFF) has shown its superiority in tongue reconstruction, especially for hemiglossectomy defects, because maximizing mobility of the residual tongue is the most critical factor for postoperative function [5].

The forearm flap was popularized for head and neck reconstruction by Soutar et al.in 1983 [6].

Soutar described the first large series of forearm flaps for oral reconstruction, as well as the osseocutaneous forearm flap that incorporated the radius for mandibular reconstruction [7].

Numerous authors have published series of forearm flaps demonstrating its utility and versatility in head and neck reconstruction. The forearm flap has a number of unique advantages for head and neck reconstruction. Its surgical anatomy is remarkably consistent, making it a relatively easy flap for surgeons to learn and harvest reliably. The skin on the distal third of the arm is extremely thin, making it an ideal flap for intraoral reconstruction [8].

In our hospital, radial forearm free flaps are used as the first choice for reconstruction after hemiglossectomies.The purpose of our study was to assess the functional status of the patients in terms of deglutition and speech, who have undergone hemiglossectomy and radial forearm free flap cover for the carcinoma tongue.

Study period :1st January 2018 to 31st December 2020

Method of collecting data: Records of patients who underwent reconstruction of hemiglossectomy defect with radial forearm free flap were collected. The cases were investigated consecutively, and their medical records were reviewed. Patients who fit into the inclusion criteria were asked to follow up, with minimum duration of time post surgery for follow up being 6 months. Well formulated medical questionnaire were presented to them for the subjective assessment of speech and deglutition. Simple oral cavity examination was conducted in the outpatient department using a tongue depressor for the assessment of the flap.

Study design : Ambispective descriptive study

Inclusion criteria: All the patients who were diagnosed as having tongue malignancies and underwent hemiglossectomy, followed immediately by reconstructive surgery using a radial forearm free flap, in the age group of 30–70 yrs.

Exclusion criteria: Resection of tongue base, flap necrosis, malignancy involving other structures.

Assessment of oral functions:

Functional assessments were conducted after a minimum duration of 6 months post hemiglossectomy with radial forearm free flap cover.

Speech intelligibility was evaluated using Hirose’s 10 point scoring system(range, 2– 10 points). [9, 10].

A double evaluation was performed by family members and by individuals unrelated to the patient. Speech intelligibility was classified as follows: excellent (8 to 10points), moderate (5 to 7 points), and poor intelligible speech (4 to 2 points) (Table 1).

Table 1.

Hirose’s scoring system for speech ability

Factor	A, by family members		B, by individuals unrelated to the patient
(1) Clearly understood	5 points		5 points
(2) Occasionally misunderstood	4 points		4 points
(3) Understood only when subject is known	3 points		3 points
(4) Occasionally understood	2 points		2 points
(5) Never understood	1 point		1 point
Scoring of A and B for speech
intelligibility 8 to 10 points 5 to 7 points 4 points or fewer	Excellently intelligible speech Moderately intelligible speech Poorly intelligible speech

Swallowing function was examined using the a simple modified swallowing ability scale [11] based on dysphagia score and MTF score; a simple and practical assessment tool consisting of method of intake, time of intake, and food. The dietary patterns, amount of time it takes to eat a meal, and choking on food during meals.

were numerically scored (11 to 3 points) and categorized as excellent (9 to 11 points), moderate (6 to 8 points), or poor (3 to 5 points) (Table 2).

Table 2.

Evaluation of post operative swallowing function

Factor
(1)Food score	Normal diet Minced Pureed Fluid Tube feeding		5 points 4points 3 points 2 points 1 point
(2)Time score for daily meal	Less than 20 min About 30 min More than 40 min		3 points 2 points 1 point
(3)choking on food upon swallowing	Never Sometimes Always		3 points 2 points 1 point
Scoring for factors 1,2 and 3 9 to 11 points 6 to 8 points 5 points or fewer		Excellent Moderate Poor

Statistical analysis: Statistical analysis was done by frequency and percentage(%).

Results

Out of 28 cases of carcinoma tongue patients who underwent hemiglossectomy with radial forearm free flap reconstruction,taken from the medical records, 24 patients( 22 men and 2 women) were included in our study, while 4 were excluded as these patients were deceased. Patient’s mean age was 47 years (range: 35–63 years). All cases were primary operative cases and preoperative radiotherapy was not provided. Further, partial glossectomy cases were not included.

Assessment of speech function: On evaluation of speech post operatively, of 24 patients, 10(41.7%) patients had achieved excellently intelligible speech, 12(50%) patients had maintained moderately intelligible speech, 2(8.3%) had poorly intelligible speech.

Assessment of swallowing function: On evaluation of post operative swallowing, 20(83.4%) patients had excellent swallowing score, while 2(8.3%) had moderate swallowing score and the remaining 2(8.3%) had poor swallowing score.

Discussion

Oral cavity component of the tongue has a very important role in speech articulation, mastication and the oral phase of deglutition.Patients undergoing hemiglossectomy are expected to have a variable impact on their baseline speech and swallowing function during recovery. Adequate mobility of the remaining oral tongue component is critical in that contact with the palate enhances articulation and facilitates the oral phase of swallowing [12].

The tongue plays a central role in articulation by modifying the shape of the oral cavity, causing a change in fundamental resonance characteristics. The complicated arrangements of muscles and the high degree of innervation of this organ facilitate the production of various vowel and consonant sounds that are important for intelligible speech [13].

The microsurgeon’s ability to transfer autologous tissues comprised of bone, functioning muscle, skin or composites has dramatically improved functional outcomes for all head and neck reconstructive procedures, whether oncologic, congenital or traumatic.

The free radial forearm flap is a workhorse flap in tongue reconstruction. Its lack of extra bulk, long vascular pedicle, good calibre of the vessels, pliability and minimal donor site morbidity are among its main advantages; the flap harvest is relatively easy and good calibre of the vessels is suitable for anastomosis with a high success rate. The free radial forearm flap, therefore, offers the best choice for reconstruction of tongue following oncosurgical resection.

Study by Dassonville et al. (2007) which included 213 patients who underwent microvascular head and neck reconstruction between 2000 and 2004 including 146 radial forearm free flaps were assessed in terms of success rate and complications, The pretreatment factors influencing these results,functional and aesthetic outcomes, which showed overall free flap success rate of 93.4%. An unrestricted oral diet and an intelligible speech were recovered by respectively 76 and 88% of the patients. Study concluded that microvascular free flaps represent an essential and reliable technique for head neck reconstruction and allow satisfactory functional results [14].

Study by Khariwala et al. (2007) which included 191 consecutive reconstructions for varied defects of head and neck cancer showed no flap failures. The percent of patients who were able to swallow and maintain an exclusively oral diet postoperatively was 78.5%. Only 16.8% were unable to have an oral diet (NPO) and dependent on a gastrictube (G-tube) for feeding. The type of flap used and the size of defect had minimal effects on swallowing outcomes. The most difficult subsites to reconstruct were tongue defects, which strongly correlated with poor swallowing outcomes. The other factor being preoperative radiation treatment. These results highlighted the utility of free flaps in recreating the precise anatomy required to maintain swallowing function [15].

A study by Bosec et al. (2009) with total of 132 patients showed the 5-year loco regional control and overall survival rates as 68% and 52%, respectively. Advanced age, high co morbidity index, elevated overall stage and tumoral involvement of the inner part of the cheek were correlated with a lower overall survival rate. A good functional result was obtained for oral diet, speech, mouth opening and aesthetic outcome in 87%, 80%, 86% and 88% of the patients, respectively. High co morbidity index, large flap surface, radiotherapy and tumoral involvement of the mobile tongue were significant predictors of poorer functional or aesthetic outcomes [16] (Figs. 1, 2, 3, 4, 5).

Fig. 1.

Hemiglossectomy

Fig. 2.

Harvested left radial forearm free flap

Fig. 3.

Anastomosed radial forearm free flap with neck vessels

Fig. 4.

Post operative 6 months follow up Radial forearm free flap

Fig. 5.

Post operative 6 months follow up- Donor site

A study by Li et al. (2013) showed that using either radial forearm free flaps or free anterolateral thigh perforator flaps for reconstruction of head and neck defects after cancer resection significantly influences a patient's quality of life [17].

In a study conducted by Nguyen et al (2018) speech and swallowing function was assessed in 28 patients at 1-month after surgery and for 25 of the patients at

6-months after surgery. At 6-months, the speech intelligibility scores (mean + SD) demonstrated a statistically significant improvement when compared to the 1-month assessment scores rising from 72.3 ± 0.2 to 77.7 # 8.9. The mean swallowing function score also demonstrated a statistically significant improvement at 6-month increasing from 6.1 to 6.8 [18].

In a study by Sakakibara et al. (2019), 75.8% of the patients evaluated achieved excellent speech functionality and 78.8% achieved excellent swallowing functionality, accounting for most the majority of the cases,which suggested that if reconstruction is performed properly, patients are likely to live lead their daily lives in conditions similar to their preoperative conditions. The study concluded that for the sake of speech and swallowing functionality, use of forearm free flaps with a size 30% to 80% larger than the resection site might be a better option when performing reconstructions following hemiglossectomy [19].

Conclusion

Our findings from the study conclude that radial forearm free flap is a fairly good reconstructive option in carcinoma tongue patients undergoing hemiglossectomy. There has been a good functional improvement in terms of deglutition and speech in these patients. Hence,this reconstruction option can be considered to bring the post operative function of tongue to near normal to a significant extent.

Funding

There is no funding received for the study.

Declarations

Conflicts of interest

There are no conflicts of interest to declare.

Ethical Approval

All examinations performed in this study involving human participants were in accordance with the ethical standards of the institution.

Informed Consent

Informed consent was obtained from all individual participants included in the study.