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Glossectomy is performed in order to reduce the size of the tongue. There are four types:--median anterior glossectomy, the most classical being median lozenge glossectomy;--central glossectomy which does not touch the peripheral border of the tongue;--glossectomy combining these two methods;--marginal glossectomy which may be segmental or extended to involve the whole of the perimeter of the tongue.
A knowledge of normal articulation is needed before the prosthodontist can assess the compensatory articulation used by glossectomy patients. The amount and portion of tongue resected is directly correlated with speech intelligibility. The loss of the tip of the tongue is more critical to intelligibility than a hemiglossectomy. Partial glossectomy speakers can often use the residual tongue stump to perform adaptive movements that approximate normal movements and should be treated as an articulation problem. The compensatory articulation used by the total glossectomy patient was reviewed. The prosthodontic management of patients with partial tongue resection often includes lowering the palatal vault, while the management of the total glossectomy patient usually requires a mandibular tongue prosthesis. These prostheses can be refined with the use of multiview videofluoroscopy, videotaping, and spectrographic analysis.
In our experience of 171 glossectomies for recurrence, salvage partial glossectomy yields 50% of local control. Myo-cutaneous flap allows wide total glossectomy without total laryngectomy. This procedure may improve the local control. Of 25 patients treated by this technique, 2 deceased before the 45th post-operative day, 15 swallow correctly and 11 have a good speech. The survival rate is 10/21 at 6 months, 7/16 at 12 and 6/13 at 18. A local failure was observed in 7 and 6 have a second primary in the upper respiratory and digestive tract. Total glossectomy without total laryngectomy is only indicated for patients with bulky tumor, without spread of the vallecula and with no palpable cervical node.
Total glossectomy is the most crippling of all oral cavity resections. Speech problems are unavoidable and post-operative aspiration is often severe. Two patients are presented who have had tongue reconstructions following near-total glossectomies. In each case a quilted, split-skin grafted pectoralis major muscle flap was used. The speech and swallowing results of these two patients are compared with two patients who underwent a hemiglossectomy and total glossectomy respectively without tongue reconstruction. Only if the suprahyoid and extrinsic tongue muscles are preserved can an active oral phase of swallowing and usable speech be regained by tongue reconstruction.
Multiple site specific procedures have been proposed to treat obstructive sleep apnea syndrome (OSAS). Midline glossectomy (MLG) is a procedure that directly enlarges the hypopharyngeal airspace using the carbon dioxide laser. The initial experience of 12 patients is presented. Midline glossectomy as the sole procedure was performed on 11 patients who had failed uvulopalatopharyngoplasty (UPPP) and who were felt to have significant hypopharyngeal collapse on physical examination and Müller's maneuver. One patient with primary hypopharyngeal narrowing underwent MLG. Five (42%) were considered responders with Respiratory Disturbance Index (RDI) decreasing from 60.6 per hour to 14.5 per hour. In seven nonresponders, there was no significant change in the RDI (62.6 events per hour to 48.4 events per hour). Cephalometric analysis showed that responders tended to be more retrognathic (sella-nasion-supramentale (S-N-B = 74.4 degrees)) than nonresponders (S-N-B = 79.3 degrees). Responders were significantly less obese (body mass index (BMI = 30.6)) than nonresponders (BMI = 37.9). There were five minor complications including minor bleeding (n = 3), prolonged odynophagia (n = 1), and minor change in taste (n = 1). There were no major complications, and no persistent difficulties with speech or swallowing. These results demonstrate that direct surgical modification of the tongue base and associated structures can significantly impact obstructive apnea. Midline glossectomy or similar procedures may be useful in a subset of patients with OSAS.
Opinions are divided over the validity of total glossectomy without associated total laryngectomy for advanced carcinoma of the tongue. This retrospective study evaluates the oncologic and functional results obtained in 80 patients who underwent total glossectomy as a primary procedure or as salvage surgery. Satisfactory swallowing ability was obtained in 41 patients, and speech was understandable in 49 patients. The survival rate at 1 year was 65%, with early recurrence of the disease, which was especially frequent in patients with prior radiotherapy, being the major cause of death. The study confirms the poor prognosis of cases with mandibular involvement, and the fact that partial laryngectomy, when required, impairs functional results. In the light of the authors' experience, total glossectomy without total laryngectomy should only be undertaken in motivated and well-supported patients able to accomplish the difficult rehabilitation process.
Locally advanced tongue cancer is a devastating disease for which there are limited therapeutic options that will result in a high rate of cure while preserving function. To determine the oncologic effectiveness of total or near total glossectomy with laryngeal preservation and the possibility of speech and swallowing rehabilitation following treatment, we reviewed our experience with 27 patients treated between 1982 and 1989. Twenty-four patients were eligible for 2-year follow-up and their disease-specific survival was 51%. Swallowing was achieved initially in 18 patients (67%), while 12 had successful long-term deglutition (44%). Oral communication was accomplished in 25 patients (92%). Significant aspiration occurred in three patients and was severe enough to require interval laryngectomy in two patients. The role of laryngeal suspension, palatal augmentation prosthesis, and videofluoroscopy as rehabilitation adjuncts for the total glossectomy patient are described.
To determine the type and extent of speech impairment to be expected following partial glossectomy, pre- and postoperative speech evaluations were performed on 10 patients undergoing surgery for carcinomas of the mobile tongue less than 3 cm in size. In addition, audiotapes of standardized speech samples were made at each evaluation. Preoperative speech evaluation revealed normal rates of verbal diadochokinesis without distortion in all 10 patients. Phonologic analysis was also normal in 9 of these patients. Postoperative evaluation revealed normal rates of verbal diadochokinesis in 6 patients and mild lingual distortion in 4. At 3 weeks postoperatively 1 patient had sibilant distortion and 1 patient overall slurring of speech. Evaluation of both of these patients at 6 months revealed that speech had returned to normal. Blinded comparison of the pre- and postoperative audiotapes revealed no change in 8 patients. In 2 patients the early postoperative tape was thought to "sound different" but the final postoperative tapes in all patients were judged to be normal. This study demonstrates that partial glossectomy for early carcinomas of the tongue can be performed with minimal, if any, permanent speech impairment.
Patients who have had surgical removal of part or all of the tongue are left with varying degrees of swallowing and speech deficiencies. The extent of resection, mobility of the residual tongue segment, and adequacy of the remaining structures determine the amount and type of deficiency. While communicative impairment and dysphagia commonly are seen in a rehabilitation setting, the problems of the glossectomy patient often are unique. This article reviews the anatomy and physiology of the oral and pharyngeal musculature, discusses the speech and swallowing of the glossectomy patient, and presents nursing considerations for successful rehabilitation.
Total glossectomy is a procedure based on sound oncologic principles, and its usefulness may not be fully appreciated. Given the dimensions of the tongue and the need to obtain a wide margin of resection, this procedure may be indicated in selected T3 lesions and recurrences after irradiation. The procedure offers excellent palliation of pain, and form and function may be preserved by rim mandibulectomy when indicated. New reconstructive techniques allow for speedier recovery. Aspiration need not be a complication of total glossectomy if care is taken to preserve the superior laryngeal nerve. Speech rehabilitation plays an important role in returning these patients to their normal environment. Overall 1 and 3 year disease-free survival rates have been encouraging.
The efficacy of total glossectomy for advanced carcinoma of the tongue remains controversial. A retrospective chart review was undertaken to evaluate the oncologic and functional results in 17 consecutive patients who underwent this procedure. There were two patients with stage III disease, eight with stage IV disease, and seven with recurrent disease. The larynx was preserved in seven patients. One patient required a secondary laryngectomy. All patients were reconstructed immediately, 11 with a pectoralis major myocutaneous flap and 6 with free-tissue transfer. The operative mortality was 6 percent; the morbidity was 59 percent. At last follow-up, 53 percent of the patients were alive without disease, with a mean disease-free survival period of 36 months. Ninety-three percent of the patients regained swallowing and independent oral alimentation; 80 percent of those with laryngeal preservation regained intelligible speech. We have concluded that total glossectomy should be considered as a primary modality for advanced carcinoma of the tongue and not solely reserved for salvage in hopeless situations. With or without laryngectomy, excellent survival and functional results can be obtained.
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.
When cancer of the tongue reaches a large size (T3, T4) it is almost impossible to treat it successfully with radiotherapy. The only therapeutic possibility in such cases is, therefore, total glossectomy. This may be effected without laryngectomy and with immediate reconstruction using musculo-cutaneous flaps. Such an operation allows total removal of the tumour and is followed by an acceptable though impaired functional result. Eight cases subjected to total glossectomy without laryngectomy are presented and aspects of ablative and reconstructive surgery are discussed. A report is made of postoperative complications and of functional rehabilitation: mastication is certainly impaired. However, swallowing is regained rapidly and phonation, although altered, is still comprehensible. An acceptable quality of life and good possibilities for a return to a working life result.
To prove the hypothesis that speech after glossectomy would be improved more by increasing the mobility of the remaining tongue rather than by increasing its volume, the speech intelligibility of 4 glossectomy patients was investigated before and after a secondary operation in which a split skin graft was used to mobilize the residual tongue. In each case, the postoperative speech intelligibility scores were higher than preoperative ones (case 1:83.6 to 97.2%, case 2: 76.6 to 82.5%, case 3: 51.5 to 58.5%, case 4: 30.2 to 49.3%). Sounds produced with the rear portion of the tongue were improved in 3 cases, and plosive and affricative sounds were remarkably improved in all cases. These results were considered to be due to the increased mobility, especially the mid and rear portions of the tongue.
Patients with carcinoma of the tongue including the base of the tongue who underwent total glossectomy in a period of just over ten years since January 1979 have been reviewed. Total glossectomy may be indicated as salvage surgery or as a primary procedure. The larynx may be preserved or may have to be sacrificed depending upon the site of the lesion. When the larynx is preserved the use of laryngeal suspension facilitates early rehabilitation and preserves the quality of life to a large extent. Cricopharyngeal myotomy seems unnecessary.
Twenty-three children with Down's syndrome, aged between 3.7 and 17.5 years, underwent partial glossectomy for improvement of cosmetic appearance. Improved speech was also expected. Preoperative and postoperative audiotaped samples of spoken words and connected speech on a standardized articulation test were rated by three lay and three expert listeners on a five-point intelligibility scale. Five subjects were eliminated from both tasks and another four from connected-speech testing because of inability to complete the experimental tasks. Statistical analyses of ratings for words in 18 subjects and connected speech in 14 of them revealed no significant difference in acoustic speech intelligibility preoperatively and postoperatively. The findings suggest that a wedge-excision partial glossectomy in children with Down's syndrome does not result in significant improvement in acoustic speech intelligibility; in some patients, however, there may be an aesthetic improvement during speech.
The loss of motor and sensory function of the tongue following ablative surgery has a devastating effect on oral function. At the present time, there is no way to restore lost tongue musculature following partial glossectomy. The use of sensate cutaneous flaps has been shown to restore sensory feedback to reconstructed areas of the oral cavity. No single composite flap supplies a sensate soft-tissue component together with an osseous component of sufficient bone stock for functional mastication. In this article, the combination of the radial forearm free flap with the iliac crest osteocutaneous or osteomyocutaneous free flap is reported. The radial forearm free flap was used to resurface the resected portion of the tongue to provide maximum mobility and sensation. The lingual nerve was the recipient nerve for anastomosis to the antebrachial cutaneous nerves in all but one case. The iliac bone was used to reconstruct the mandible, with the iliac skin paddle or the internal oblique muscle used to reconstruct the neoridge. This combination of flaps was used in 10 patients. There was one flap failure due to vascular kinking from "piggybacking" the iliac crest to the distal end of the radial forearm flap. As a result, the use of two separate sets of recipient vessels is now advocated. Although a single composite free flap offers an excellent form of oromandibular reconstruction in most cases, it has been shown that oral function deteriorates when large areas of anesthesia are present in the oral cavity. We believe that this combination of two free flaps offers an opportunity for superior function in select patients with significant glossectomy and/or large mucosal defects.
Rehabilitation of the glossectomy patient is one of the most difficult and challenging problems for the prosthodontist and speech pathologist. The tongue plays an important role in articulation, control of secretions, formation of a bolus, propulsion of the bolus toward the pharynx, clearing the palate, and initiation of the swallow reflex. This paper presents speech and prosthodontic considerations for a patient who underwent a glossectomy and had the additional problem of reduced oral opening.