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Functional recovery of swallowing, speech, and taste in an oral cancer patient with subtotal glossectomy
282
RECOVERY OF MAXILLARY THIRD MOLAR FROM INFRATEMPORAL
5. Dinsworth AR, Byrd DL, Allen JW: Zygomatic complex fracture with an avulsed tooth causing malocclusion: report of case. J Oral Surg 32: 131, 1974 6. Kruger GO: Textbook of Oral and Maxillofacial Surgery, 6th ed. St Louis, CV Mosby, 1985, p 101
J Oral
Maxlllofac
SPACE
7. Laskin D: Oral and Maxillofacial Surgery, vol 2. St Louis. CV Mosby, 1985, pp 79-80 8. Winkler T. von Wowern N. Bittmann S: Retrieval of an upper third molar from the infratemporal space. J Oral Surg 30:730-733. 1970: 35:130. 1977
surg
45.282-285.1987
Functional Recovery of Swallowing, Speech, and Taste in an Oral Cancer Patient with Sub total Glossec tomy MASAHIRO URADE, DDS, PHD, TOMOKAZU IGARASHI, DDS, MASAKAZU SUGI, DDS, PHD, TOKUZO MATSUYA, DDS, PHD, AND TOMIKO FUKUDA, BA*
Partial or hemiglossectomy is frequently performed as a surgical treatment for carcinomas of the tongue, floor of the mouth and gingiva. Lack of the lingual tissue can cause a restriction of tongue movement and taste impairment, depending upon the site and size of excision. In recent years, the use of various cutaneous and myocutaneous flaps (such as the deltopectoral flap and the pectoralis major flap) has enabled wide excision of advanced primary tumors in the head and neck region,lm3 and widened the criteria for the resectability of tumors that were previously considered inoperable. Consequently the rate of local recurrence of tumors has significantly decreased. With an increased cure rate, these flaps serve to reconstruct the excised defects and also help in minimizing morphologic and functional disturbances and supporting the function of the residual tissues. We present a case of a patient with advanced oral cancer reconstructed with a deltopectoral flap who recovered the functions of swallowing, speech, and taste after subtotal glossectomy. Report of a Case A 60-year-old
woman was referred to our clinic on July 22, 1981, complaining of the presence of a wide erythroReceived from the First Department of Oral and Maxillofacial Surgery, Osaka University Faculty of Dentistry, and *Center for Stomatognathic Dysfunction, Osaka University Dental Hospital, Osaka, Japan. Address correspondence and reprint requests to Dr. Urade: The First Department of Oral and Maxillofacial Surgery, Osaka University Faculty of Dentistry, l-8, Yamadaoka, Suita, Osaka 565, Japan. 0278-2391187 $0.00 + .25
plakic lesion on the inferior surface of the tongue and the floor of the mouth for the past three years. The lesion
was diagnosed histologically, by biopsy, as a moderately differentiated squamous cell carcinoma, and clinically classified as a T,N,M, lesion. Combined therapy consisting of Co-60 irradiation (total 30 Gy) and peplomycin (total 80 mg) was used. However, a recurrence of the tumor was recognized on the right side of the tongue, lower premolar gingiva and floor of the mouth eight months after this treatment. Radiographic examination revealed neither tumor invasion of the mandibular bone nor lung metastasis. The patient was admitted to hospital on July 3, 1982, and was treated by subtotal glossectomy, marginal mandibulectomy between the right and left third molar regions, and bilateral upper neck dissections followed by reconstruction with a deltopectoral flap (Fig. IA-C). As shown in Figure IA, the genioglossus, geniohyoid and mylohyoid muscles, and the anterior parts of styloglossus and hyoglossus muscles together with a large part of the intrinsic lingual muscles were excised. The hypoglossal and lingual nerves were partially impaired bilaterally. Following surgery, however, the patient was able to swallow and three weeks after operation she was able to take liquid foods, although there was some spillage. At three months postoperation, her speech was still too unclear to be understood, and she was unable to distinguish between different tastes. When examined using a reagent for testing taste (Taste Disc,@ Sanwa Chemical Co. Ltd., Nagoya, Japan) which contains five serial dilutions, the posterior (points c and d) but not the anterior (points a and b) portion of the remaining tongue was capable of distinguishing bitter, sweet, salty, and sour tastes (Fig. 2, Table 1). The patient’s speech intelligibility and ability to taste gradually improved after about one year postoperation. At three years postoperation, the deltopectoral flap had flattened and softened (Fig. l&-E’), and the remaining tongue had a smooth, functional movement as revealed by lateral videofluoroscopy. The spillage of liquid foods from her mouth was no longer observed. Her speech had
283
URADE ET AL.
Excision
FIGURE 1. A,B, diagrams of operation; C, excised specimen; and D-F, appearance three years postoperation.
become clearer and the overall intelligibility scores were 52.2% in 67 Japanese monosyllables and 24.1% in 67 disyllables (Table 2). Most of the meaning of her speech was comprehensible. Interestingly, her sense of taste had also remarkably improved and she was able to distinguish the four basic tastes in numbers 2 or 3 dilutions of the Taste Disc in all parts of the remaining tongue except the right anterior (Fig. 2a, Table l), indicating an almost normal range.
Discussion Numerous tive aspects
studies
of the surgical
and rehabilita-
of glossectomy have been reported. Accumulated evidence suggests that swallowing and intelligible speech are developed during the postoperative rehabilitation in patients with partial
284
RECOVERY OF SWALLOWING.
and even with nearly total glossectomy.4-6 Sessions has noted that even a small amount of residual tongue, which would appear to be useless, allows for the return of these functions.2 In our case, subtotal glossectomy was performed because of the advanced carcinoma. The form of excision used in this case is not common and most of the mobile and taste-sensitive portions of the tongue were lost. Nevertheless, the patient was able to swallow just after the operation. This suggests that the remaining posterior half and medial third of the tongue with the remaining parts of hyoglossus, styloglossus and digastric muscles, and reconstruction of the defect with a deltopectoral flap, sustained a swallowing movement. However, she could not speak at all and could hardly distinguish differences in taste, except for bitter taste, in the residual tongue at three months postoperation. Since the posterior third of the tongue is innervated by the glossopharyngeal nerve, and this is the most sensitive portion for bitter taste, it is reasonable that this function remained. Her speech intelligibility was markedly recovered with no special training and her speech at three years postoperation was comprehensible. It is well-known that vowels /i, 01 and consonants lk, g, rl are most seriously affected in the glossectomized patients, although the acoustic characteristics of all speech sounds may be influenced by the degree of resection. Furthermore, the mode of articulation between English and Japanese is different.4.7-‘0 In addition, vowels lo, i/, plosives ikl, igl, lpl, and lb/, flapped /r/ and nasal sound /m/ were severely confused, and plosive /t/, nasal /n/, fricative /s/ and affricative /dz/ were slightly distorted. Since Haberman noted that alveolar sounds /t/, id/. and /I/, as well as /n/, were generally produced by substituting the lower lip for the tongue in some manner, and fricatives /s/ and /z/ were sometimes accom-
FIGURE 2. Areas of examination for taste in the remaining tongue. Sensitivity of taste at points (a-d) was measured by using Taste Disc@ as described in Table 1.
SPEECH, AND TASTE AFTER SUBTOTAL GLOSSECTOMY
Table 1. Improvement of the Sense of Taste in the Remaining Tongue After Subtotal Glossectomy Time after Operation
3 months
Positions examined a b C
d
3 years
a b C
d
Basic Tastes Sweet
Salty
Sour
lhtter
NS NS #5 #5
NS NS #5 #5
NS NS #5 #5
NS NS #4 #4
NS #? #3 #3
NS #3 #2 #2
NS #2 (dit? #2 #2
NS #3 #2 #3
Taste Disc@ (Sanwa Chemical Co. Ltd., Nagoya, Japan) including four basic tastes composed of five dilutions (#I week-#5 strong): sweet, 0.3, 2.5, 10, 20. and 80% solution of sugar; salty. 0.3, 1.25, 5, 10. and 20% solution of sodium chloride; sour. 0.02. 0.2, 2, 4. and 8% solution of tartaric acid; bitter, 0.001, 0.02, 0.1. 0.5. and 4% solution of quinine chloride. a-d; positions examined in the remaining tongue (See Fig. 2). NS, no sense. dif, recognized sour taste as salty-sweet one.
plished by vigorously blowing air between the incisors with slight protrusion of lower lip, the above findings may indicate that the impaired mobility of the paretic lower lip rather than the lack of lingual tissue greatly affected her articulation in Japanese. When the patient was examined by lateral videofluoroscopy, compensatory movement of the pharyngeal wall and soft palate was not observed, as reported previously,11,12 but it was noticed that the patient made the plosive /t/ by using the upper anterior teeth and the inside of the lower lip skillfully. A further factor affecting articulation is the adequate retention of the position and mobility of residual tongue. Although it is considered that the use of a deltopectoral flap or a pectoralis major myocutaneous flap enables such a condition to be acquired, opinion is still divided on the effect on speech intelligibility.13,14 At least, consideration should be given to the size and position of the flaps to be inserted, and not prevent mobility of the remaining tongue. In our case, the reconstruction of the tongue with a deltopectoral flap appeared to work effectively for swallowing and articulation by retaining the residual tongue in an adequate position. Few reports exist on taste after glossectomy, presumably because there is little long-term problem.15 This may be a result of partial preservation of taste-sensitive portions of the tongue despite partial or hemiglossectomy. Literature concerning taste after total glossectomy is scant. Although most of the taste-sensitive portion of the tongue was ex-
285
URADE ET AL.
Table 2. Intelligibility Scores of the Patient Three Years After Subtotal Glossectomy Intelligibility Scores Monosyllables
Overall Vowels Consonants
52.2% 84.0% 50.0%
Disyllables
Overall
24.1%
The intelligibility test was performed by using 67 Japanese monosyllabic and disyllabic words. Scores are expressed as mean percentages of correct response on each test for five normal listeners with no special training.
cised (Fig. l), our patient had almost completely recovered her ability to taste three years postoperation. With the method of taste testing employed, the three measuring points were: 1) a point innervated by the chorda tympani located on the margin of the tongue 2 cm lateral to the tip; 2) a point innervated by the glossopharyngeal nerve located in circumvallatae papillae 1 cm lateral to the midline; and 3) a point innervated by the greater petrosal nerve located in the soft palate 1 cm lateral to the midline. Although points c) and d) (indicated in Fig. 2) were located within the region innervated by the glossopharyngeal nerve, it was observed from the control study that in the points equivalent to a) and b), normal volunteers tasted something but were unable to distinguish the tastes. This finding may imply that the sense of taste in point b) was more sensitive in our patient than in normal counterparts, whereas point a) was still denervated in our case. Elevated taste sensitivity in a point innervated by the greater petrosal nerve was not observed in our patient.
References I. Effron MZ, Johnson JT, Myers EN, et al: Advanced
2.
3. 4. 5. 6. 7.
8.
9.
10.
11.
12.
13.
14.
15.
carcinoma of the tongue. Management by total glossectomy without laryngectomy. Arch Otolaryngol 107:694, 1981 Sessions DG: Surgical resection and reconstruction for cancer of the base of the tongue. Otolaryngol Clin North Am 16:309, 1983 Krespi UP, Sission GA: Reconstruction after total or subtotal glossectomy. Am J Surg 146:488, 1983 Haberman MA: Rehabilitation of patients following glossectomy. Arch Otolaryngol 67: 182, 1958 Brodnitz FS: Speech after glossectomy. Curr Probl Phoniatr Logoped 1:68, 1960 Duguay MJ: Speech after glossectomy. NY J Med 64: 1836, 1964 Massengill R, Maxwell S, Pickrell K: An analysis of articulation following partial and total glossectomy. J Speech Hear Disord 35:170, 1970 Skelly M, Spector DJ, Donaldson RC. et al: Compensatory physiologic phonetics for the glossectomee. J Speech Hear Disord 36: 101, 1971 La Riviere C, Seilo MT, Dimmick KC: Report on the speech intelligibility of a glossectomee: Perceptual and acoustic observations. Folia Phoniatr 27:201, 1975 Ohkubo H, Maeda T, Kamimura M, et al: Articulatory function following treatments for carcinoma of the tongue. Jpn J Logop Phoniatr 26:236, 1985 Massengill R, Maxwell S. Pickrell K: A swallowing characteristic noted in a glossectomy patient. Plast Reconstr Surg 45:89. 1970 Morrish L: Compensatory vowel articulation of the glossectomee: acoustic and videofiuoroscopic evidence. Br J Disord Commun 19:125. 1984 Ohira A, Yoshimasu H, Oyama T: Articulation functions in patients with 2/3 or 415 glossectomy combined with reconstruction using myocutaneous flap. Jpn J Logop Phoniatr 26:215, 1985 Kumakura I: A study of speech intelligibility after glossectomy-analysis of 60 tongue cancer cases. Jpn J Logop Phoniatr 26:224, 1985 Pruszewicz A, Kruk-Zagajewska A: Phoniatric disturbances in patients after partial tongue resection for malignant neoplasms. Folia Phoniatr 36:84, 1984
RECOVERY OF MAXILLARY THIRD MOLAR FROM INFRATEMPORAL
5. Dinsworth AR, Byrd DL, Allen JW: Zygomatic complex fracture with an avulsed tooth causing malocclusion: report of case. J Oral Surg 32: 131, 1974 6. Kruger GO: Textbook of Oral and Maxillofacial Surgery, 6th ed. St Louis, CV Mosby, 1985, p 101
J Oral
Maxlllofac
SPACE
7. Laskin D: Oral and Maxillofacial Surgery, vol 2. St Louis. CV Mosby, 1985, pp 79-80 8. Winkler T. von Wowern N. Bittmann S: Retrieval of an upper third molar from the infratemporal space. J Oral Surg 30:730-733. 1970: 35:130. 1977
surg
45.282-285.1987
Functional Recovery of Swallowing, Speech, and Taste in an Oral Cancer Patient with Sub total Glossec tomy MASAHIRO URADE, DDS, PHD, TOMOKAZU IGARASHI, DDS, MASAKAZU SUGI, DDS, PHD, TOKUZO MATSUYA, DDS, PHD, AND TOMIKO FUKUDA, BA*
Partial or hemiglossectomy is frequently performed as a surgical treatment for carcinomas of the tongue, floor of the mouth and gingiva. Lack of the lingual tissue can cause a restriction of tongue movement and taste impairment, depending upon the site and size of excision. In recent years, the use of various cutaneous and myocutaneous flaps (such as the deltopectoral flap and the pectoralis major flap) has enabled wide excision of advanced primary tumors in the head and neck region,lm3 and widened the criteria for the resectability of tumors that were previously considered inoperable. Consequently the rate of local recurrence of tumors has significantly decreased. With an increased cure rate, these flaps serve to reconstruct the excised defects and also help in minimizing morphologic and functional disturbances and supporting the function of the residual tissues. We present a case of a patient with advanced oral cancer reconstructed with a deltopectoral flap who recovered the functions of swallowing, speech, and taste after subtotal glossectomy. Report of a Case A 60-year-old
woman was referred to our clinic on July 22, 1981, complaining of the presence of a wide erythroReceived from the First Department of Oral and Maxillofacial Surgery, Osaka University Faculty of Dentistry, and *Center for Stomatognathic Dysfunction, Osaka University Dental Hospital, Osaka, Japan. Address correspondence and reprint requests to Dr. Urade: The First Department of Oral and Maxillofacial Surgery, Osaka University Faculty of Dentistry, l-8, Yamadaoka, Suita, Osaka 565, Japan. 0278-2391187 $0.00 + .25
plakic lesion on the inferior surface of the tongue and the floor of the mouth for the past three years. The lesion
was diagnosed histologically, by biopsy, as a moderately differentiated squamous cell carcinoma, and clinically classified as a T,N,M, lesion. Combined therapy consisting of Co-60 irradiation (total 30 Gy) and peplomycin (total 80 mg) was used. However, a recurrence of the tumor was recognized on the right side of the tongue, lower premolar gingiva and floor of the mouth eight months after this treatment. Radiographic examination revealed neither tumor invasion of the mandibular bone nor lung metastasis. The patient was admitted to hospital on July 3, 1982, and was treated by subtotal glossectomy, marginal mandibulectomy between the right and left third molar regions, and bilateral upper neck dissections followed by reconstruction with a deltopectoral flap (Fig. IA-C). As shown in Figure IA, the genioglossus, geniohyoid and mylohyoid muscles, and the anterior parts of styloglossus and hyoglossus muscles together with a large part of the intrinsic lingual muscles were excised. The hypoglossal and lingual nerves were partially impaired bilaterally. Following surgery, however, the patient was able to swallow and three weeks after operation she was able to take liquid foods, although there was some spillage. At three months postoperation, her speech was still too unclear to be understood, and she was unable to distinguish between different tastes. When examined using a reagent for testing taste (Taste Disc,@ Sanwa Chemical Co. Ltd., Nagoya, Japan) which contains five serial dilutions, the posterior (points c and d) but not the anterior (points a and b) portion of the remaining tongue was capable of distinguishing bitter, sweet, salty, and sour tastes (Fig. 2, Table 1). The patient’s speech intelligibility and ability to taste gradually improved after about one year postoperation. At three years postoperation, the deltopectoral flap had flattened and softened (Fig. l&-E’), and the remaining tongue had a smooth, functional movement as revealed by lateral videofluoroscopy. The spillage of liquid foods from her mouth was no longer observed. Her speech had
283
URADE ET AL.
Excision
FIGURE 1. A,B, diagrams of operation; C, excised specimen; and D-F, appearance three years postoperation.
become clearer and the overall intelligibility scores were 52.2% in 67 Japanese monosyllables and 24.1% in 67 disyllables (Table 2). Most of the meaning of her speech was comprehensible. Interestingly, her sense of taste had also remarkably improved and she was able to distinguish the four basic tastes in numbers 2 or 3 dilutions of the Taste Disc in all parts of the remaining tongue except the right anterior (Fig. 2a, Table l), indicating an almost normal range.
Discussion Numerous tive aspects
studies
of the surgical
and rehabilita-
of glossectomy have been reported. Accumulated evidence suggests that swallowing and intelligible speech are developed during the postoperative rehabilitation in patients with partial
284
RECOVERY OF SWALLOWING.
and even with nearly total glossectomy.4-6 Sessions has noted that even a small amount of residual tongue, which would appear to be useless, allows for the return of these functions.2 In our case, subtotal glossectomy was performed because of the advanced carcinoma. The form of excision used in this case is not common and most of the mobile and taste-sensitive portions of the tongue were lost. Nevertheless, the patient was able to swallow just after the operation. This suggests that the remaining posterior half and medial third of the tongue with the remaining parts of hyoglossus, styloglossus and digastric muscles, and reconstruction of the defect with a deltopectoral flap, sustained a swallowing movement. However, she could not speak at all and could hardly distinguish differences in taste, except for bitter taste, in the residual tongue at three months postoperation. Since the posterior third of the tongue is innervated by the glossopharyngeal nerve, and this is the most sensitive portion for bitter taste, it is reasonable that this function remained. Her speech intelligibility was markedly recovered with no special training and her speech at three years postoperation was comprehensible. It is well-known that vowels /i, 01 and consonants lk, g, rl are most seriously affected in the glossectomized patients, although the acoustic characteristics of all speech sounds may be influenced by the degree of resection. Furthermore, the mode of articulation between English and Japanese is different.4.7-‘0 In addition, vowels lo, i/, plosives ikl, igl, lpl, and lb/, flapped /r/ and nasal sound /m/ were severely confused, and plosive /t/, nasal /n/, fricative /s/ and affricative /dz/ were slightly distorted. Since Haberman noted that alveolar sounds /t/, id/. and /I/, as well as /n/, were generally produced by substituting the lower lip for the tongue in some manner, and fricatives /s/ and /z/ were sometimes accom-
FIGURE 2. Areas of examination for taste in the remaining tongue. Sensitivity of taste at points (a-d) was measured by using Taste Disc@ as described in Table 1.
SPEECH, AND TASTE AFTER SUBTOTAL GLOSSECTOMY
Table 1. Improvement of the Sense of Taste in the Remaining Tongue After Subtotal Glossectomy Time after Operation
3 months
Positions examined a b C
d
3 years
a b C
d
Basic Tastes Sweet
Salty
Sour
lhtter
NS NS #5 #5
NS NS #5 #5
NS NS #5 #5
NS NS #4 #4
NS #? #3 #3
NS #3 #2 #2
NS #2 (dit? #2 #2
NS #3 #2 #3
Taste Disc@ (Sanwa Chemical Co. Ltd., Nagoya, Japan) including four basic tastes composed of five dilutions (#I week-#5 strong): sweet, 0.3, 2.5, 10, 20. and 80% solution of sugar; salty. 0.3, 1.25, 5, 10. and 20% solution of sodium chloride; sour. 0.02. 0.2, 2, 4. and 8% solution of tartaric acid; bitter, 0.001, 0.02, 0.1. 0.5. and 4% solution of quinine chloride. a-d; positions examined in the remaining tongue (See Fig. 2). NS, no sense. dif, recognized sour taste as salty-sweet one.
plished by vigorously blowing air between the incisors with slight protrusion of lower lip, the above findings may indicate that the impaired mobility of the paretic lower lip rather than the lack of lingual tissue greatly affected her articulation in Japanese. When the patient was examined by lateral videofluoroscopy, compensatory movement of the pharyngeal wall and soft palate was not observed, as reported previously,11,12 but it was noticed that the patient made the plosive /t/ by using the upper anterior teeth and the inside of the lower lip skillfully. A further factor affecting articulation is the adequate retention of the position and mobility of residual tongue. Although it is considered that the use of a deltopectoral flap or a pectoralis major myocutaneous flap enables such a condition to be acquired, opinion is still divided on the effect on speech intelligibility.13,14 At least, consideration should be given to the size and position of the flaps to be inserted, and not prevent mobility of the remaining tongue. In our case, the reconstruction of the tongue with a deltopectoral flap appeared to work effectively for swallowing and articulation by retaining the residual tongue in an adequate position. Few reports exist on taste after glossectomy, presumably because there is little long-term problem.15 This may be a result of partial preservation of taste-sensitive portions of the tongue despite partial or hemiglossectomy. Literature concerning taste after total glossectomy is scant. Although most of the taste-sensitive portion of the tongue was ex-
285
URADE ET AL.
Table 2. Intelligibility Scores of the Patient Three Years After Subtotal Glossectomy Intelligibility Scores Monosyllables
Overall Vowels Consonants
52.2% 84.0% 50.0%
Disyllables
Overall
24.1%
The intelligibility test was performed by using 67 Japanese monosyllabic and disyllabic words. Scores are expressed as mean percentages of correct response on each test for five normal listeners with no special training.
cised (Fig. l), our patient had almost completely recovered her ability to taste three years postoperation. With the method of taste testing employed, the three measuring points were: 1) a point innervated by the chorda tympani located on the margin of the tongue 2 cm lateral to the tip; 2) a point innervated by the glossopharyngeal nerve located in circumvallatae papillae 1 cm lateral to the midline; and 3) a point innervated by the greater petrosal nerve located in the soft palate 1 cm lateral to the midline. Although points c) and d) (indicated in Fig. 2) were located within the region innervated by the glossopharyngeal nerve, it was observed from the control study that in the points equivalent to a) and b), normal volunteers tasted something but were unable to distinguish the tastes. This finding may imply that the sense of taste in point b) was more sensitive in our patient than in normal counterparts, whereas point a) was still denervated in our case. Elevated taste sensitivity in a point innervated by the greater petrosal nerve was not observed in our patient.
References I. Effron MZ, Johnson JT, Myers EN, et al: Advanced
2.
3. 4. 5. 6. 7.
8.
9.
10.
11.
12.
13.
14.
15.
carcinoma of the tongue. Management by total glossectomy without laryngectomy. Arch Otolaryngol 107:694, 1981 Sessions DG: Surgical resection and reconstruction for cancer of the base of the tongue. Otolaryngol Clin North Am 16:309, 1983 Krespi UP, Sission GA: Reconstruction after total or subtotal glossectomy. Am J Surg 146:488, 1983 Haberman MA: Rehabilitation of patients following glossectomy. Arch Otolaryngol 67: 182, 1958 Brodnitz FS: Speech after glossectomy. Curr Probl Phoniatr Logoped 1:68, 1960 Duguay MJ: Speech after glossectomy. NY J Med 64: 1836, 1964 Massengill R, Maxwell S, Pickrell K: An analysis of articulation following partial and total glossectomy. J Speech Hear Disord 35:170, 1970 Skelly M, Spector DJ, Donaldson RC. et al: Compensatory physiologic phonetics for the glossectomee. J Speech Hear Disord 36: 101, 1971 La Riviere C, Seilo MT, Dimmick KC: Report on the speech intelligibility of a glossectomee: Perceptual and acoustic observations. Folia Phoniatr 27:201, 1975 Ohkubo H, Maeda T, Kamimura M, et al: Articulatory function following treatments for carcinoma of the tongue. Jpn J Logop Phoniatr 26:236, 1985 Massengill R, Maxwell S. Pickrell K: A swallowing characteristic noted in a glossectomy patient. Plast Reconstr Surg 45:89. 1970 Morrish L: Compensatory vowel articulation of the glossectomee: acoustic and videofiuoroscopic evidence. Br J Disord Commun 19:125. 1984 Ohira A, Yoshimasu H, Oyama T: Articulation functions in patients with 2/3 or 415 glossectomy combined with reconstruction using myocutaneous flap. Jpn J Logop Phoniatr 26:215, 1985 Kumakura I: A study of speech intelligibility after glossectomy-analysis of 60 tongue cancer cases. Jpn J Logop Phoniatr 26:224, 1985 Pruszewicz A, Kruk-Zagajewska A: Phoniatric disturbances in patients after partial tongue resection for malignant neoplasms. Folia Phoniatr 36:84, 1984