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Swallowing and speech after radical total glossectomy with tongue prosthesis
Swallowing and speechafter radical total glossectomy with tongue prosthesis L. J. de Souza, U.S., P.R.C.X., P.R.C.S.E., F.C.P.S.,” nnd 0. J. Martins, B.D.X., L.D.X., R.G.S.(Ed.), P.D.S., D.Orth., R.C.S.(Eng.),** Bombay, India TATA
MEMORIAL
HOSPITAL
AND
BOMBAY
HOSPITAL
Radical total glossectomy is now accepted as a useful procedure for the management of advanced cancer of the tongue. This article records our study of speech and swallowing without the tongue. An artificial tongue prosthesis has been developed and found to greatly improve these functions after total glossectomy. The special operative factors to be considered in order to permit a smooth and rapid rehabilitation regarding speech and swallowing have been stressed.
R
adical total glossectomy is currently accepted as a useful means of managing selected cases of advanced cancer of the tongue. Several years ago, when this procedure was first used at the Tata Memorial Hospital in Bombay, there was skepticism as to whether speech and swallowing would be possible after this operation. Even though it was possible to remove the entire disease en bloc by this method, the question was whether the patient would become a useless surgical cripple. This article reviews our work to demonstrate the process of swallowing and speech after total glossectomy in thirty cases and show how these patients can be further helped with the use of an artificial tongue prosthesis. OPERATION
A radical total glossectomy consists of the removal of the entire tongue in continuity with bilateral en bloc suprahyoid neck dissection. The incision that we use is a transverse suprahyoid incision, and the body of the hyoid is resected also. Details of the surgical technique have been described by Kothary and COworker+ elsewhere and are not described here. After removal of the specimen from below, the floor of the mouth is reconstructed with the use of a lining *Assistant Surgeon, Department of Surgery, Tata Memorial “*Consulting Orthodontic Surgeon, Bombay Hospital.
356
Hospital.
Xwallowitig
volume 39 Number 3
Pig. 1. The artificial
tongue prosthesis.
and speech after total glossectomy
Note the retaining
clasps and the posterior
357
eleva-
tion.
of either omentum or amniotic membrane. This acts as a scaffolding for granulations and the growth of the mucosal lining from the sides. The incision is closed in three layers (platysma, subcutaneous fat, and skin). A temporary gastrostomy and tracheostomy are made and maintained until the incision has healed and the patient is able to swallow comfortably. For good, rapid rehabilitation of swallowing and speech postoperatively, it is important to observe the following rules during the operation: (1) Do not damage the nerve supply to the circumoral musculature, especially the mandibular branch of the facial nerve. (2) Do not damage the nerve supply to the constrictor muscles of the pharynx, especially the pharyngeal branch of the vagus. (3) Do not damage the nerve supply to the larygneal musculature. (4) Avoid removal of the epiglottis if possible. (5) Keep intact the mandibular arch and a few good teeth for fitting of the artificial tongue prosthesis. (6) Cut the lower fibers of the masseter muscle inserted at the angle of the mandible; this compensates to some extent for the loss of depressors of the mandible and thus helps prevent difficulty in opening the mouth wide postoperatively. ARTIFICIAL
TONGUE
PROSTHESIS
Approximately 3 to 4 weeks postoperatively, when the incisional wound has healed well and granulations have lined the floor of the mouth, an alginate impression is taken of the upper and lower teeth. A simple dental plate is then constructed, with a few clasps to aid retention. The plate forms a base for the artificial tongue. A hollowed-out area is then prepared, keeping an undercut all the way around so that the soft dental liner, which one uses to line dentures, is mixed and poured into the hollowed-out area. The plate is then inserted into the mouth when the liner is soft so that it will gently flow onto the palate to get its impression with the jaws closed. After this has been allowed to set, it is removed from the mouth and trimmed. The color of the material is very much like that of the normal tongue and gives it an even more realistic ap-
358
Oral surg. March, 1975
de Sown and Matins
Pig. 8. The oral cavity after radical total glossectomy. Fig. 3. The artificial tongue prosthesis fitted onto the lower alveolus.
pearance. An elevation is made in the posterior part of the artificial tongue which just touches the palate on closure of the jaws and helps in speech (Fig. 1). It is important to note that the plate does not rest at all on the floor of the mouth, but retention is obtained from the teeth and alveolus (Figs. 2 and 3). Therefore, a few good teeth should be retained if at all possible. SWALLOWING
WITH
THE ARTIFICIAL
TONGUE
The process of swallowing without the tongue has been studied by us” with the help of cineradiographic procedures. The normal process of swallowing consists of three main phases : oral, pharyngeal, and esophageal. The tongue normally plays the most important part in the oral phase, propelling the masticated food material from the oral cavity to the oropharynx. As soon as the bolus touches the posterior pharyngeal wall, the pharyngeal phase starts, and the pharyngeal tube rises upward to receive the bolus like a magnet. This phase is accentuated after total glossectomy, hence the importance of preserving the function of the constrictor muscles intact. Food is prevented from entering the larynx mainly by the closure of the laryngeal additus. It is important, therefore, not to damage the laryngeal musculature in any way. The esophageal phase of swallowing remains intact postoperatively. The artificial tongue is immobile and cannot replace the propulsive movement of the tongue. The food is placed as far back as possible near the molar teeth, and after mastication it is decanted into the pharynx by tilting the head backward. Liquids are ingested in the manner of brick drinkers, with the head tilted a little backward. The artificial tongue, however, helps to reduce the space in the floor of the mouth created by removal of the natural tongue. Less food material collects here, and decanting is facilitated with the artificial tongue. Barium studies show the residue on the floor of the mouth to be much less with the use of the artificial tongue prosthesis (Figs. 4 and 5). The masticated food
Swallowing
Volume 39 Number 3
and speech after total glossectomy
359
Fig. 4. Barium swallow to show residue in the floor of the mouth without the artificial tongue.
Fig. 5. With the artificial in the floor of the mouth.
tongue there is a marked decrease in the collection of material
is also channeled via the alveolingual grooves the sides of the epiglottis into the oropharynx. SPEECH WITH
THE ARTIFICIAL
on either
side, to be decanted
by
TONGUE
The larynx, which is responsible for the production of sound, remains intact and functional after radical total glossectomy. These sounds are then articulated into speech by the tongue and the circumoral musculature in a normal person. The vowels “a,” “e,” ‘5,” ‘lo,” and “u” are mainly formed by the lips, with minimal shape and position change in the tongue. Hence, it is very important to maintain the function of the circumoral musculature intact. The tongue is more important for the formation of consonants. This it does by change of shape and contact with the teeth and palate. The tongue is the most mobile organ in the body, and no artificial tongue
360
de Soua
a,&
Nartins
Oral Surg. March, 1975
prosthesis can ever attain its mobility. However, a fixed tongue prosthesis can help in certain ways to improve the formation of consonants. Certain consonants like “t,” “d,” etc., require contact of the tongue with the palate. Although the artificial tongue is fixed, by closure of the jaws it can be made to touch the palate, with marked improvement in the formation of these consonants. Again, consonants like “c,” “s,” etc., require a jet of air to be forced in between the tongue and the palate. Here, also, the artificial tongue can be elevated by closing the jaws to form the cleft between the tongue and the palate through which the jet of air can be forced out to form the consonant. The marked improvement in speech can be seen on speech spectrographs made with and without the artificial tongue prosthesis. In fact, unintelligible speech without the tongue is converted to reasonably understandable speech with the artificial tongue. CONCLUSIONS
The present use of radical total glossectomy in the management of advanced cancer of the tongue in no way leaves the patient a surgical cripple. The functions of speech and deglutition are possible without the tongue but can be further improved toward normalcy with the use of an artificial tongue prosthesis. The success of the operation and the prosthesis can bc judged by the statement of a glossectomized patient: “Before the operation, I had a fixed tongue with a lot of disease and severe pain. I also had difficulty in swallowing and speech. After the operation, I also have a fixed tongue, but without disease and pain, and my speech and swallowing, if anything, are better than before.” Above all, it is a unique example of close cooperation between the surgeon, the orthodontist, and the speech pathologist, pooling their experience for the maximum benefit of the patient. Our grateful thanks are due to Dr. P. M. Kothary, M.S., D.L.O.(Loncl.), Consultant E. N. T. Surgeon, Tata Memorial Hospital, and to Dr. P. R. Desia, M.S., F.R.C.H., F.A.C.S., Superintendent, Tata Memorial Hospital, for their constant help and guidance in this work. We are also grateful to Mr. H. K. Oza, M.A. (New York), O.T.R. (New York), for his help in Speech Pathology. REFERENCES
1. Kothary, P. M., Paymaster, J. C., and Potdar, G. G.: Radical Total Glossectomy, Br. J. Surg. 61: 209-212, 1974. 2. Kothary, P. M., and de Souza, L. J.: Swallowing Without the Tongue, The Bombay Hosp. Journal 15: 58-60, 1973. Reprint requests to: Dr. L. J. de Sousa Department of Surgery Tata Memorial Hospital Pare1 Bombay-12, India
MEMORIAL
HOSPITAL
AND
BOMBAY
HOSPITAL
Radical total glossectomy is now accepted as a useful procedure for the management of advanced cancer of the tongue. This article records our study of speech and swallowing without the tongue. An artificial tongue prosthesis has been developed and found to greatly improve these functions after total glossectomy. The special operative factors to be considered in order to permit a smooth and rapid rehabilitation regarding speech and swallowing have been stressed.
R
adical total glossectomy is currently accepted as a useful means of managing selected cases of advanced cancer of the tongue. Several years ago, when this procedure was first used at the Tata Memorial Hospital in Bombay, there was skepticism as to whether speech and swallowing would be possible after this operation. Even though it was possible to remove the entire disease en bloc by this method, the question was whether the patient would become a useless surgical cripple. This article reviews our work to demonstrate the process of swallowing and speech after total glossectomy in thirty cases and show how these patients can be further helped with the use of an artificial tongue prosthesis. OPERATION
A radical total glossectomy consists of the removal of the entire tongue in continuity with bilateral en bloc suprahyoid neck dissection. The incision that we use is a transverse suprahyoid incision, and the body of the hyoid is resected also. Details of the surgical technique have been described by Kothary and COworker+ elsewhere and are not described here. After removal of the specimen from below, the floor of the mouth is reconstructed with the use of a lining *Assistant Surgeon, Department of Surgery, Tata Memorial “*Consulting Orthodontic Surgeon, Bombay Hospital.
356
Hospital.
Xwallowitig
volume 39 Number 3
Pig. 1. The artificial
tongue prosthesis.
and speech after total glossectomy
Note the retaining
clasps and the posterior
357
eleva-
tion.
of either omentum or amniotic membrane. This acts as a scaffolding for granulations and the growth of the mucosal lining from the sides. The incision is closed in three layers (platysma, subcutaneous fat, and skin). A temporary gastrostomy and tracheostomy are made and maintained until the incision has healed and the patient is able to swallow comfortably. For good, rapid rehabilitation of swallowing and speech postoperatively, it is important to observe the following rules during the operation: (1) Do not damage the nerve supply to the circumoral musculature, especially the mandibular branch of the facial nerve. (2) Do not damage the nerve supply to the constrictor muscles of the pharynx, especially the pharyngeal branch of the vagus. (3) Do not damage the nerve supply to the larygneal musculature. (4) Avoid removal of the epiglottis if possible. (5) Keep intact the mandibular arch and a few good teeth for fitting of the artificial tongue prosthesis. (6) Cut the lower fibers of the masseter muscle inserted at the angle of the mandible; this compensates to some extent for the loss of depressors of the mandible and thus helps prevent difficulty in opening the mouth wide postoperatively. ARTIFICIAL
TONGUE
PROSTHESIS
Approximately 3 to 4 weeks postoperatively, when the incisional wound has healed well and granulations have lined the floor of the mouth, an alginate impression is taken of the upper and lower teeth. A simple dental plate is then constructed, with a few clasps to aid retention. The plate forms a base for the artificial tongue. A hollowed-out area is then prepared, keeping an undercut all the way around so that the soft dental liner, which one uses to line dentures, is mixed and poured into the hollowed-out area. The plate is then inserted into the mouth when the liner is soft so that it will gently flow onto the palate to get its impression with the jaws closed. After this has been allowed to set, it is removed from the mouth and trimmed. The color of the material is very much like that of the normal tongue and gives it an even more realistic ap-
358
Oral surg. March, 1975
de Sown and Matins
Pig. 8. The oral cavity after radical total glossectomy. Fig. 3. The artificial tongue prosthesis fitted onto the lower alveolus.
pearance. An elevation is made in the posterior part of the artificial tongue which just touches the palate on closure of the jaws and helps in speech (Fig. 1). It is important to note that the plate does not rest at all on the floor of the mouth, but retention is obtained from the teeth and alveolus (Figs. 2 and 3). Therefore, a few good teeth should be retained if at all possible. SWALLOWING
WITH
THE ARTIFICIAL
TONGUE
The process of swallowing without the tongue has been studied by us” with the help of cineradiographic procedures. The normal process of swallowing consists of three main phases : oral, pharyngeal, and esophageal. The tongue normally plays the most important part in the oral phase, propelling the masticated food material from the oral cavity to the oropharynx. As soon as the bolus touches the posterior pharyngeal wall, the pharyngeal phase starts, and the pharyngeal tube rises upward to receive the bolus like a magnet. This phase is accentuated after total glossectomy, hence the importance of preserving the function of the constrictor muscles intact. Food is prevented from entering the larynx mainly by the closure of the laryngeal additus. It is important, therefore, not to damage the laryngeal musculature in any way. The esophageal phase of swallowing remains intact postoperatively. The artificial tongue is immobile and cannot replace the propulsive movement of the tongue. The food is placed as far back as possible near the molar teeth, and after mastication it is decanted into the pharynx by tilting the head backward. Liquids are ingested in the manner of brick drinkers, with the head tilted a little backward. The artificial tongue, however, helps to reduce the space in the floor of the mouth created by removal of the natural tongue. Less food material collects here, and decanting is facilitated with the artificial tongue. Barium studies show the residue on the floor of the mouth to be much less with the use of the artificial tongue prosthesis (Figs. 4 and 5). The masticated food
Swallowing
Volume 39 Number 3
and speech after total glossectomy
359
Fig. 4. Barium swallow to show residue in the floor of the mouth without the artificial tongue.
Fig. 5. With the artificial in the floor of the mouth.
tongue there is a marked decrease in the collection of material
is also channeled via the alveolingual grooves the sides of the epiglottis into the oropharynx. SPEECH WITH
THE ARTIFICIAL
on either
side, to be decanted
by
TONGUE
The larynx, which is responsible for the production of sound, remains intact and functional after radical total glossectomy. These sounds are then articulated into speech by the tongue and the circumoral musculature in a normal person. The vowels “a,” “e,” ‘5,” ‘lo,” and “u” are mainly formed by the lips, with minimal shape and position change in the tongue. Hence, it is very important to maintain the function of the circumoral musculature intact. The tongue is more important for the formation of consonants. This it does by change of shape and contact with the teeth and palate. The tongue is the most mobile organ in the body, and no artificial tongue
360
de Soua
a,&
Nartins
Oral Surg. March, 1975
prosthesis can ever attain its mobility. However, a fixed tongue prosthesis can help in certain ways to improve the formation of consonants. Certain consonants like “t,” “d,” etc., require contact of the tongue with the palate. Although the artificial tongue is fixed, by closure of the jaws it can be made to touch the palate, with marked improvement in the formation of these consonants. Again, consonants like “c,” “s,” etc., require a jet of air to be forced in between the tongue and the palate. Here, also, the artificial tongue can be elevated by closing the jaws to form the cleft between the tongue and the palate through which the jet of air can be forced out to form the consonant. The marked improvement in speech can be seen on speech spectrographs made with and without the artificial tongue prosthesis. In fact, unintelligible speech without the tongue is converted to reasonably understandable speech with the artificial tongue. CONCLUSIONS
The present use of radical total glossectomy in the management of advanced cancer of the tongue in no way leaves the patient a surgical cripple. The functions of speech and deglutition are possible without the tongue but can be further improved toward normalcy with the use of an artificial tongue prosthesis. The success of the operation and the prosthesis can bc judged by the statement of a glossectomized patient: “Before the operation, I had a fixed tongue with a lot of disease and severe pain. I also had difficulty in swallowing and speech. After the operation, I also have a fixed tongue, but without disease and pain, and my speech and swallowing, if anything, are better than before.” Above all, it is a unique example of close cooperation between the surgeon, the orthodontist, and the speech pathologist, pooling their experience for the maximum benefit of the patient. Our grateful thanks are due to Dr. P. M. Kothary, M.S., D.L.O.(Loncl.), Consultant E. N. T. Surgeon, Tata Memorial Hospital, and to Dr. P. R. Desia, M.S., F.R.C.H., F.A.C.S., Superintendent, Tata Memorial Hospital, for their constant help and guidance in this work. We are also grateful to Mr. H. K. Oza, M.A. (New York), O.T.R. (New York), for his help in Speech Pathology. REFERENCES
1. Kothary, P. M., Paymaster, J. C., and Potdar, G. G.: Radical Total Glossectomy, Br. J. Surg. 61: 209-212, 1974. 2. Kothary, P. M., and de Souza, L. J.: Swallowing Without the Tongue, The Bombay Hosp. Journal 15: 58-60, 1973. Reprint requests to: Dr. L. J. de Sousa Department of Surgery Tata Memorial Hospital Pare1 Bombay-12, India