An analysis of morbidity following major head and neck surgery with particular reference to mouth function

j. max.-fac. Surg. 10 (1982) J. max.-fac. Surg. 10 (1982) 129-134 © 1982 Georg Thieme Verlag Stuttgart • New York

An Analysis of Morbidity Following Major Head and Neck Surgery with Particular Reference to Mouth Function

129

Summary Fifty patients who underwent major surgery for head and neck cancer, together with other modalities of treatment, were assessed with regard to social adaptation, appearance and in particular mouth function. The results of the assessment are analysed and discussed in the paper below.

Key-Words Surgery of malignancies - Social adaptation - Appearance - M o u t h function.

Eugene David Vaughan Head and Neck Unit (Head: Mr. H. J. Shaw, MA, FRCS.). Royal Marsden Hospital, London, England

Introduction Despite many advances in surgical practice and other methods of treatment in head and neck cancer advanced malignant disease of this area continues to have a poor prognosis. The primary aim of surgery in cancer of the head and neck is cure of the patient; function and aesthetics are also important but of secondary consideration. Significantly long term morbidity studies on the effects of surgery and/or surgery combined with other methods of treatment are comparatively rare and the purpose of this paper is to quantify answers to the problem of social and occupational rehabilitation and in particular the extent to which the masticatory and speech apparatus adapts. Methods and Materials Fifty patients who have survived major head and neck surgery for varying periods of time were selected; a questionnaire was constructed and divided into two parts (Table 1 A and B.) The patients were assessed according to the headings as indicated in the questionnaire. The patient reactions to surgery were graded on a numerical basis: 1. Indicated a poor result. 2. Indicated a satisfactory result, and 3. Indicated a very good result. This numerical system is a modification of the Visick grading system used in assessing the results of peptic ulcer surgery (Visick 1948). The author assessed the patients under the headings as indicated. The patients were again scored using a numerical system. 1. Indicated a poor result. 2. Indicated an adequate or satisfactory result. 3. Indicated a very good result.

Results There were twenty cases of tongue carcinoma five of which received some form of chemotherapy. Three cases having Price Hill Schedule A Chemotherapy Regime (Vincristine

Bleomycin Methotrexate - 5 Fluorouracil and Corticosteroids and then Folinic Acid Rescue). Two cases had V.B.M Chemotherapy Regime (Vincristine Bleomycin Methotrexate and Folinic Acid Rescue). Fourteen cases received Radiotherapy - generally to a curative dose of 6000 R or more - two cases had a dose of 4200 R prior to surgery - five cases had in addition radio active Iridium Wire Implantation. All cases had surgery of varying magnitude - in one case surgery was the only modality of treatment. Table 2 shows the details of the treatment received in the individual cases and scores achieved (numerical and percentage) when examined according to Table 1. Nine cases of carcinoma of the lower alveolus were analysed - three cases receiving chemotherapy (two received Price Hill schedule A and one VBM). Five cases received radiotherapy - two receiving 4000 R prior to surgery. A full composite resection was carried out in seven cases three cases having primary closure. Two cases had marginal mandibular resections. Table 3 shows the detailed analysis of these cases together with the individual scores. Table 4 shows the analysis of seven cases of carcinoma of the floor of the mouth. Two cases had chemotherapy - one involving high dose methotrexate. Five cases had curative doses of radiotheraphy prior to surgery. Four cases had composite resections without flap repair. Table 5 considers carcinoma affecting the maxilla and maxillary antrum. There were six cases in this group - two of the cases did not lend themselves to staging according to the U.I.C.C. classifications. One case was verrucous carcinoma. T w o cases had chemotherapy. Four cases had curative radiotherapy - prior to surgery. All cases had prosthetic replacement following sugery. In the present series there were five malignant salivary t u m o u r s - three cases of the minor salivary glands and one of the parotid and submandibular gland respectively. Both adenoid cystic carcinomas had radiotherapy prior to surgery. None of these cases had chemotherapy. Table 6 shows the detailed analysis. As can be seen from Tables 2 A, 3 A, 4 A, 5 A, 6 A, 7 A 42 % Deemed themselves to be poor results. 32 % Felt reasonably satisfied. 26 % Considered the results to be excellent. Examining Tables 2 B, 3 B, 4 B, 5 B, 6 B, 7 B 40 % Were considered poor results. 40 % Were reasonable results. 20 % Were excellent results.

130

J. max.-fac. Surg. 10 (1982)

Table 1

Patients reactions and investigators assessment

Name

Age

E.D. Vaughan

Diagnosis

Staging

A. Patients' response to treatment 1. Appearance- Poor ( ) Satisfactory ( ) Very good ( ) 2. Depression-Severe( )Mild( ) N o n e ( ) 3. Occupation- Unemployed ( ) Change of employment ( ) No change ( ) 4. Social life- Permanently affected ( ) Temporary alteration ( ) No change ( ) 5. Diet-Liquid( )semiSolid( )Solid( ) 6. Weight-losing( )Static( )Gaining( ) 7. Mastication - V e r y poor ( )Impaired( 8. T a s t e - A b s e n t (

)Verygood(

)

) Diminished (~) Unaffected ( )

9. Smell-Absent ( ) Diminished ( ) Unaffected ( ) 10. P a i n - S e v e r e ( )Mild( ) N o n e ( ) It. Numbness-Severe( )Mild( ) N o n e ( ) 12. SativaryLeak-Severe( )Mild( ) N o n e ( ) 13. Speech - Severe defect ( )Milddefect(

)Nodefect(

)

Histology

Treatment

Chemotherapy Radiotherapy Surgery

B. Objective examination

1. Appearance- Poor ( ) Satisfactory ( ) good ( ) 2. Lip s e a l - P o o r ( )Satisfactory( ) G o o d ( ) 3. N u m b n e s s - S e v e r e ( )Mild( ) N o n e ( ) 4. Taste-Absent ( ) Diminished ( ) Normal(

)

5. Oral H y g i e n e - P o o r (

)Fair( ) G o o d ( ) 6. Dentition- F/F or modification ( ) P/P or modification ( ) Natural ( ) 7, Occlusion- Severe derangement ( ) Mild derangement ( ) Class 1 ( ) 8. Mandibular movements (vertical) Severe limitation ( ) Mod eratelimitation( ) None( ) 9. Mandibular movements (lateral) Severe restriction ( ) Mod erate restriction ( ) None ( ) )Fair( )Normal( ) 10. S p e e c h - P o o r ( 11. Swallowing- Poor ( ) Some disturbance ( ) None ) 12. Temporomandibular joint- Severe dysfunction ( ) Moderate dysfunction( ) None( ) 13. Barium swallow- Gross abnormality ( ) Mild abnormality ( ) None ( )

14. Swallow - Severe difficulty ( )Milddifficulty( )Nodifficulty( ) 15. Pain or clicking in temporomandibular joints - Severe ( ) Mild ( ) None ( )

Discussion

The time period which elapsed following surgery before the patients were examined - varied - ranging from fifteen years to one year. As far as one could ascertain, adaptation to their disability was not dependant so much on time elapsed following treatment, but the psychological state of the patient. This point is illustrated very forcefully in considering patient No. 7 Table 3 - where mouth function and speech were very good in spite of the fact he had a composite resection and primary closure. Distant pedicle flap reconstruction was used in many of the cases and where appropriate lost tissue was replaced by a prosthesis - it was not obvious from this series that flap reconstruction or prosthetic replacement materially contributed to improved mouth function. As will be seen later 70 % of the patients had severe mandibular deviation and the problems of constructing dentures which would enable mastication to take place were extremely difficult. It is interesting to note that none of the patients examined who underwent mandibulectomy had a bone graft inserted, this treatment policy may have been influenced by the notorious difficulty of getting a graft to take in an irradiated bed. As can be seen from the results above, there would appear to be a reasonable correlation between what the patient felt and what the clinician found - however in considering the more detailed Analysis certain disappointing features become obvious.

Depression Acute depression is the most common psychological symptom of the post surgical cancer patient (Cantor and Curtis 1971 a) David and Barritt (1977), report severe reactive depression in all of their patients. In this series 72 % of the patients said that the time of interview, they were not depressed or only mildly depressed by the consequences of their operation. 38 % had recourse to drug therapy because of the effects of surgery. David and Barritt (1977) feel that psychotherapy by a psychiatrist is the best line of treatment in these cases.

Occupation West (1977) found in analysing 152 cases with head and neck cancer those patients who did not work before surgery rarely worked afterwards. Of those who were working before surgery approximately 50 % returned to work. This figure is in broad agreement with the present series in that 52 % die not work, 20 % had to change the nature of their occupation and 28 % were again working in their original occupation. In the case of those who did not work, or had to change their occupation several factors influenced their decision, the most important being appearance, speech problems, age, physical demands of their original occupation.

Social Adaptation In the area of social intercourse, 66 % of the present series were extremely introverted and although one has to accept the respondents answers at face value, the possibility of

Analysis of Morbidity Following Major Head and Neck Surgery Table

2 Analysis of Tongue Carcinoma

Staging

Treatment

Table

Score A Max: 45

J. max.-fac. Surg. 10 (1982) 2

i 31

Continuation

Staging

1. T1 NO MO Surgery- Partial Glossectomy-41 later Subtotal GIossectomy. 91%

34 87 %

24 62 %

2. T1 NO MO Surgery- Hemiglossectomy.

39 100%

16. T2 N1 M0 DXT4200R. Surgery- L. 31 Hemiglossectomy L. Block Dis- 62 % section of Neck. 17. T3 N1 MO DXT 6500R CXT VBM X 3. 27 Surgery- R. Hemiglossectomy 60 % R, Block Dissection Forehead Flap Repair.

23 60 %

18. T3 N2 MO DXT 6500R. Surgery- L. Com- 24 posite Resection R. Supra Hyoid 53 % Neck Dissection - Delto Pectoral and Forehead Flap Repair.

17 44 %

19. T3 N2 MO DXT 6500R and Iridium Wires. 20 Surgery-Total Glossectomy R. 44,4 % Block Dissection L. Supra Hyoid Block Dissection Forehead Flap Repair.

18 46 %

20. T3 N2 MO Surgery- L. Hemiglossectomy 22 L. Sided Commando R. Block 40 % Dissection.

18 46 %

45 100%

Treatment

Score A Max: 45

B 39

B 39

3. T2 NO MO DXT 6O00R - CXT PHA X 2. 27 Surgery- R. Hemiglossectomy 60 % L. Sided Commando.

22 56 %

4. T2 NO MO DXT6000R and Iridium Wires. 28 Surgery- Partial Glossectomy 62 % Bilateral Supra Hyoid Neck Dissection.

29 74 %

5. T3 NO MO DXT 600OR, Surgery-Total Glossectomy R, Block Dissection L. Supra Hyoid Block Forehead Flap Repair.

23 51%

16 41%

6. T3 N0 MO DXT 6600R CXT V.B.M, X 2, 25 Surgery- R. Hemiglossectomy 56 % R. Supra Hyoid Neck Dissection,

22 56 %

7. T3 N1 MO Surgery- L. Hemiglossectomy 27 and Partial Excision of Floor of 60 % Mouth - Primary Repair.

28 72 %

8. T3 NO MO DXT 7000R. Surgery- L. Sided 23 Commando and L. Hemiglos- 51% sectomy.

24 62 %

Staging

9. T2 N1 MO DXT6500R and Iridium Wires. 29 Surgery- Partial Glossectomy 64.4 % R. Sided Commando and L, Supra Hyoid Neck Dissection.

27 69 %

1. T1 NO MO

Surgery- Marginal Mandibular 43 Resection. 96 %

37 95 %

2, 1-2 NO MO

Surgery- Marginal Mandibular 42 Resection - Later L. Block Dis- 93 % section.

31 79 %

3. T2 N1 MO

DXT 6500R. Surgery- R. Sided 37 Commando and Primary CIo82 %

25 64 %

Table 3

t0. T2 N1 MO Surgery- R. Partial Glossectomy R. Block Dissection L. Supra Hyoid Neck Dissection.

24 53 %

33 ' 84 %

11.T2N1MODXT7511RandlridiumWires. Surgery- L. Partial Glossectomy L. Marginal Mandibular Resection L. Neck Dissection.

36 80 %

31 79 %

!2. T2N1 MO DXT6000R CXT PHA X 2. 20 Surgery- R. Hemiglossectomy 44 % R, Block Dissection - Forehead Flap Reconstruction.

18 46 %

13. T2 N1 MO DXT 4200R. Surgery- L. 34 Hemiglossectomy L. Block Dis- 76 % section of Neck.

26 67 %

14. T2 N1 MO DXT 6000R and Iridium Wire 24 Implantation. Surgery- L. 53 % Hemiglossectomy L. Sided Commando. R. Sided Block Dissection.

20 51%

15. T2 N1MO CXT PHA X 2, Surgery- L, Hemiglossectomy L. Cornmando - Delto Pectoral Flap Repair.

21 54 %

26 58 %

inadvertent misrepresentation cannot be discounted. However, if return to work is considered as a criterion of adaptation, (70 % did not return to work or had to change their occupation) it is apparent in this series that adaptation to their deformity is distressingly low. It is interesting to

Analysis of Lower Alveolar Carcinoma Treatment

Score A

B

sure,

4. T2 N1 MO

Surgery- R. Sided Commando 35 - Primary Closure. 78 %

26 67 %

5, T3 N1 MO

CXT PHA X 2. Surgery- R. Sided Commando Forehead Flap repair.

18 40 %

16 41%

6. T3 N 1 MO

DXT 6500R CXT PHA X 2. Surgery- L. Commando and Forehead Flap Repair.

23 51%

19 49 %

7. T3 N1 MO

DXT 6000R. Surgery- R. Sided 37 Commando and Primary CIo82 % sure.

31 79 %

8. T4 N1 MO

DXT4000R. Surgery- L. Sided 25 Commando and Palatal Excision 56 % - Forehead Flap Repair.

21 54 %

9. T4 N2 MO

DXT 4000R. CXT VBM X 4 and 15 High Dose Methotrexate. 33 % Surgery - L. Sided Commando - Delto Pectoral Flap Repair.

13 33 %

note that there was considerable disparity between the respondents and the clinicians assessments with regard to appearance, (Table 8 and 9) 56 % of the patients thought their appearance very poor, while the observer felt that only a third merited that description. This finding demonstrates

132 Table

J. max.-fac. Surg. 10 (1982) 4

E.D. Vaughan Table 6

Analysis of Carcinoma of Floor of Mouth

Staging

Treatment

Score A

B

1. T2 NO MO

DXT 6000R. S u r g e r y - R. Com- 27 mando and Forehead Flap 60 % Repair.

18 46 %

2, T2 NO MO

DXT 6000R. S u r g e r y - R. Com- 27 mando and Forehead Flap 60 % Repair.

19 49 %

3. T2 NO MO

DXT 600OR, Surgery - L. Partial 37 Glossectomy L. Sided Corn82 % mando and Primary Repair.

30 76 %

4. T2 N1 MO

CXT VBM X 2. Surgery - R. Hemiglossectomy R. Commando and Primary Repair.

20 44 %

22 56 %

5. T3 N1 MO

DXT 6000R. Surgery - R. Hemiglossectomy R. Sided C o m m a n d o - Primary Repair.

23 51%

20 51%

6. T3 N2 MO

DXT 6600R. Surgery - R. 18 Hemiglossectomy R, Sided 40 % Commando L. Block Dissection - Primary Repair.

15 51%

7. T4 N2 MO

CXT High Dose Methotrexate. 19 S u r g e r y - R. Sided Commando 42 % Subtotal Glossectomy L Supra Hyoid Dissection Forehead Flap Repair.

18 46 %

Table 5

Diagnosis and Staging

Treatment

Hard palate and Alveolus T4 NO MO

S u r g e r y - L. Subtotal Maxillec- 22 tomy R. Total Maxillectomy 49 % Prosthetic Replacement.

15 38 %

Hard palate and S u r g e r y - R. and L. Partial Maxil-29 Alveolus lectomy 64 % T4 NO MO Prosthetic Replacement, (Verrucous Car.)

24 62 %

Ca of Maxilla T4 NO MO Antrum and Alveolus

DXT6600R CXT Methotrexate 22 and Nitrogen Mustard. Surgery-49 % Total Maxillectomy - Orbital Exenteration Prosthetic Replacement.

20 51 2%

Ca of Upper Alveolus T4 N1 MO

DXT 700OR. Surgery - R. Partial 30 Maxillectomy R. Block Dissec- 67 % tion of Neck Prosthetic Replacement.

24 62 %

Ca of Maxillary Antrum

DXT 6300R. CXT PHA X 2. 36 Surgery- Subtotal Maxillectomy80 % Prosthetic Replacement.

31 79 %

Ca of Maxillary Antrum

DXT 70OOR. Surgery - Total 26 Maxillectomy and Orbital Exent- 57.7 % eration Prosthetic Replacement.

27 69 %

B

Score A

B 16 41%

2. Adenoid Cystic DXT 6000R, Surgery - Local 32 Ca R. Retromolar Resection Marginal Mandibular 7 1 % Fossa Resection R. Block Dissection Forehead Flap Repair.

25 64 %

3. Muco Epider- S u r g e r y - R. and L. Subtotal mold Ca of Hard- Maxillectomy. Prosthetic palate Replacement.

30 80 %

23 51%

4. Muco Epider- Surgery-Total Parotidectomy L,38 mold Ca of Parotid Sided Block Dissection, Partial 84 Mandibutectomy Post Auricular Flap.

24 87 %

5. Adeno Ca R. Submandibular Gland

20 51%

7

Surgery - R. Composite Resec- 22 tion - Sub Total Glossectomy- 49 % L. Supra Hyoid Neck Dissection DP and Flap Repair.

Analysis of the remaining Cases

Diagnosis and Staging

Diagnosis and Staging

Treatment

1. Adenoid Cystic DXT 7000R. Surgery-Total 17 Ca of R. Maxilla Maxillectomy and Orbital Exent- 38 % eration - Prosthetic Replacement.

Table

Analysis of Carcinoma of Maxilla and Maxillary Antrum Score A

Analysis of Malignant Salivary Tumours

Score A

B

1. Osteo Sarcoma DXT 7000R. Surgery - Partial L. Maxilla Maxillectomy

38 84 %

27 69 %

2. Fibro Sarcoma S u r g e r y - L. Hemimandibulecof Mandible tomy and Local Excision.

39 87 %

27 69 %

Surgery-Subtotal Mandibulec- 24 t o m y - O s s e o - Myo Cutaneous 53 % Flap (failed) Delto pectoral Flap Repair.

23 60 %

3. Massive Ameloblastoma

Treatment

Salivary Control: Salivary drooling is a very common sequel to head and neck cancer surgery, particularly oropharyngeal cancer, the contributory factors of importance are: 1. Restricted tongue movement. 2. Loss of labial buccal and lingual sulci. 3. Scarring of the orbicularis oris. 4. Excision marking of the lower lip. 5. Paralysis of the mandibular branch of the seventh nerve. 6. Loss of sensory awareness. (34 % of the present series complain of severe sensory dysfunction.) All the above factors lead to impairment of control of salivary secretions. 68 % had an incompetent oral sphincter but only 46 % of the patients examined found it a major problem. Taste

that the observer is much more lenient in what is considered acceptable aesthetically (given the nature of his background).

32 % of the patients complained of taste being severely affected. The incidence is highest in those who had radioactive needle implantation, external beam therapy and finally surgery, particularly of the tongue.

Analysis of Morbidity Following Major Head and Neck Surgery Table 8 S h o w s the detailed Analysis of the Patients Reaction to Treatment 1 - Poor result 2 - Satisfactory result 3 - Very good result

Table 9

J. max.-fac. Surg. 10 (1982) A n a l y s i s of O b j e c t i v e A s s e s s m e n t

1 - Poor result 2 - Satisfactory result 3 - V e r y g o o d result No. of c a s e s in No. of c a s e s in each category, each category. Numerical s c o r e % of total s c o r e

No. of cases in No. of cases in each category, each category, Numerical s c o r e % s c o r e 1. A p p e a r a n c e

(1) . . . . . . . (2) . . . . . . . (3)

.......

28 14

8

56 28 16

1. A p p e a r a n c e

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

17 24 9

34 48 18

2. Lip Seal

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

34 15 f

68 30 2

2. D e p r e s s i o n

(1) . . . . . . . (2) . . . . . . .

19 11

(3) .......

2o

38 22 50

3. Occupation

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

26 10 14

52 20 28

3. N u m b n e s s

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

14 33 3

28 66 6

1. Social Life

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

33 6 11

66 12

4. Taste

22

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

14 17 1g

28 34 38

5. Diet

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . . .

33 11 6

66 22 12

5. Oral H y g i e n e ( f ) . . . . . . . (2) . . . . . . . (3) . . . . . . .

18 23 9

36 46 18

6. Weight

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

28 12 10

56 24 20

6. Dentition

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

36 10 4

72 20 8

7. Mastication

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

39 8 3

78 16 6

7. O c c l u s i o n

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

35 8 7

70 16 14

8. Taste

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

16 20 14

32 40 28

8. M a n d i b u l a r Movements (vertical)

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

26 14 10

52 28 20

g. Smell

(1) . . . . . . . (2) . . . . . . .

6 14

(3)

30

12 28 60

9. M a n d i b u l a r Movements (lateral)

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

35 8 7

70 16 14

.......

10. Pain

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

5 17 28

10 34 56

10. S p e e c h

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

22 18 10

44 36 20

11. S e n s o r y Disturbance

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

17 32 f

34 64 2

11. S w a l l o w i n g

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

11 15 24

22 30 48

12. Salivary Leak

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

23 14 13

46 28 26

12. T e m p o r o mandibular Joint

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

5 16 29

10 32 58

13. S p e e c h

(1) . . . . . . . (2) . . . . . . . . . (3) . . . . . . . . .

23 17 10

46 34 20

13. Barium Swallow

(1) . . . . . . . (2) . . . . . . . (3) . . . . . . .

4 12 34

8 24 68

14. S w a l l o w

(1) . . . . . . . (2) . . . . . . .

13 17

(3)

20

26 34 40

4 20 26

8 40 52

.......

15. T e m p o r o (1) . . . . . . . mandibular joint (2) . . . . . . . dysfunction (3) . . . . . . .

Nutrition and Mastication Marchetta (1976) points out that if one compares preoperative diets with post-operative diets in cases undergoing surgery for head and neck cancer, particularly oropharyngeal cancer, there is frequently little difference. This has not been confirmed in the present series: 66 % were

13 3

confined to a purely liquid diet, while no case pre-operatively was on a liquid diet, 5 1 % were significantly below their normal weight and were unable to increase it, 92 % of the patients in the present series were either totally or partially edentulous 78 % of all patients experienced severe difficulties in mastication; 70 % had severe disruption of the occlusion. Cantor and Curtis (1971 a) described mastication as a learned volitional and automatic process, which can often re-adjust following surgical insult. However, the figures quoted above would indicate that the level of readjustment is generally poor. This may be explained in part by unilateral disruption of the temporo-mandibular joint,

134

J. max.-fac. Surg. 10 (1982)

scar formation and the unopposed action of the muscles of the floor of the mouth. Unopposed muscular pull is particularly important. In the current series, 7 0 % had severe mandibular deviation and nearly 32 % had severe restriction of mouth opening (only 6 % indicated mastication was normal or near normal). It is felt that the disturbance in the masticatory apparatus is a major factor in the psychosocial disruption that these patients suffered. Marchetta (1976) maintains that if the small submental muscles are only partially removed, or left intact, little or no alteration of function is noted. Swallowing Post-operatively, swallowing may be temporarily or permanently impaired. However, since swallowing is a primary function, it is not easily disrupted and ability to swallow will, in general, return. Deglutition may be performed with a minimal amount of muscle and even with loss of the mandible and hyoid bone. With an intact larynx voluntary closure of the glottis may be learnt, and combined with the gulp action effectively bypasses the oro and upper pharyngeal phases. The involuntary component of swallowing then takes over. These theoretical concepts have been confirmed by the barium swallow studies taken of the patients in the present series in that 90 % had virtually normal swallows in the oesophageal phase. 26 % of the patients, however, experienced considerable difficulty in the voluntary component of swallowing. Speech Normal speech is a learned process, and therefore dependent on vision, hearing, intelligence, motivation and imitation. A high degree of central nervous system development is essential to co-ordinate the complex neuromuscular patterns associated with speech production. Kantner and West (1941) described the components of speech as respiration, phonation, resonance, articulation and neurological integration. The function of speech is easily altered by disturbance of any of these speech components. In this series impairment of the articulation mechanism and resonating chambers were the most common disabling factors. The tongue is the organ of articulation and consequently reduction on tongue size or restriction of mobility leads to distortion of consonants; while vowel sounds are generally unaffected. The principal consonants affected are D, G, T and K. Disturbances of the lip sphincter mechanism adversely affect V and F. The resonation chambers most affected are the pharynx and the oral cavity (Cantor and Curtis (1971 b). The combination of an immobile tongue and a reduced misshapen oral cavity leads to severe distortion of speech. The patients speech in the current series, was examined and 4 4 % of the cases had very poor results; 4 6 % of the patients felt that their speech was severely affected. Temporomandibular Joint 92 % of the patients had no complaints concerning the temporomandibular joint, only 1 0 % had any signs of disturbed joint function and these were mainly crepitus or tenderness of the joints. Considering the extent of surgery in many of these cases it would appear from the above

E. D. Vaughhan: Analysis of Morbidity series that occlusal disharmony is only a very minor factor in the generation of the temporomandibular joint dysfunction syndrome. Conclusion

It would appear from the information gained in the above paper that there are serious problems in social adaptation and mouth function, following major head and neck surgery. Failure to return to work is one of the major problems and there are many reasons for this. The appearance of patients following curative surgery is sometimes less than ideal patients on occasions refuse further operations which might improve appearance, tissues which have been brought in to repair defects do not have the same functional or cosmetic characteristics of the tissues they replace, leading to social isolation and unwillingness to face society - the therapeutic team must understand this and give maximum support. On a broader basis the Social Services must have an understanding of the problems and be prepared to offer support. The families of these patients have a vital part to play particularly in rehabilitating these patients psychologically. In particular employers should be willing to employ these people. Speech defects are often considerable - again tending to isolate these patients from the Community and from those at their place of employment - rendering patients unwilling to take their place in society. Consequently speech therapy must be an integral part of the rehabilitation. Inability to masticate and as a consequence under-nutrition leads to weight loss and easy fatigability - rendering the patient less capable of maintaining a normal work out-put. A Nutritionist should be an integral part of the therapeutic team and liquidisers provided to those who experience difficulty in mastication. Finally a maxillo-facial prosthodontist is an absolute necessity for these cases. References

Cantor, R., T. A. Curtis: Prosthetic Management of Edentulous Mandibulectomy Patients. Part I - Anatomic Physiological and Psychological Consequences. J. Prosthetic Dent. 25 (1971 a) 446 Cantor, R., T. A. Curtis: Prosthetic Management of Edentulous Mandibulectomy Patients. Part III Clinical Evaluation. J. Prosthetic Dent. 25 (1971 b) 670 David, D. J., J. P. Barritt: Psycho Social Aspects of Head and Neck Cancer Surgery. Aust. N. Z. Surg. 47 (1977) 584 Kantner, C. F., R. West: Phonetics. Harper & Brothers, New York 1941 Marchetta, J. C.: Function and Appearance following Surgeryfor Intra Oral Cancer. Clin. Hast. Surg. 3 (1976) 471 Visick, A. H.: Measured radical gastrectomy. Lancet 1 (1948) 5-8 West, D. W.: Social Adaptation Patterns among Cancer Patients with Facial Disfigurements Resulting from Surgery. Arch. of Physiological Medical Rehabilitation 58 (1977) 473

Acknowledgements I am most grateful to Mr. H. J. Shaw M A . FRCS. and Mr. P. Clifford M.D. FRCS., Head and Neck Unit, The Royal Marsden Hospital for permission to examine their patients. E. D. Vaughan, FRCS, FDS, RCS Maxillo Facial Unit Walton Hospital Rice Lane Liverpool L 9 IAE England