The Functional & Quality of Life Outcomes of Total Glossectomy with Laryngeal Preservation

Analysis of reconstructed oropharynx shape after total glossolaryngectomy reconstruction using a free rectus abdominis musculocutaneous flap

Introduction

Restoring oral intake through oropharyngeal reconstruction is vital for patients undergoing total glossolaryngectomy. Despite its importance, research in this area is limited, leaving clinicians with few guidelines. The debate regarding the optimal shape of the reconstructed oropharynx highlights the need for further research.

Methods

This retrospective study analysed data from 16 consecutive patients who underwent primary reconstruction with a free rectus abdominis musculocutaneous flap after total glossolaryngectomy at the University of the Ryukyus Hospital between April 2015 and March 2022. Parameters assessed included reconstructed oropharynx shape (flat or funnel-shaped), demographics, flap characteristics, post-operative course and oral intake outcomes.

Results

Among the 16 patients, 10 had flat oropharynx, whereas 6 had a funnel-shaped oropharynx. At 6 months post-surgery, 13 patients resumed oral feeding, whereas 3 did not. Significant differences were observed between the groups in preoperative body mass index (21.1 kg/m² vs 17.8 kg/m², Welch's t-test, p=0.035) and days until the first oral intake (34.2 days vs 19.2 days, Welch's t-test, p=0.01). However, no significant differences were found in the form of oral intake at 6 months after surgery (Fisher's exact test, p=0.518).

Conclusion

This study suggests that the shape of the reconstructed oropharynx (flat or funnel-shaped) does not significantly impact long-term post-operative oral intake. These findings provide valuable insights into oropharyngeal reconstruction outcomes after total glossolaryngectomy and offer guidance for future research in this area. Nevertheless, further studies are warranted to elucidate the clinical implications of these findings and address any limitations of this study, particularly those regarding sample size constraints.

Advanced mandibular reconstruction with fibular free flap and alloplastic TMJ prosthesis with digital planning

INTRODUCTION

Resection of the mandible and temporomandibular joint (TMJ) without formal reconstruction is a devastating condition that negatively affects all aspects of the patient's life. We have approached the reconstruction of mandibular defects that include the condyle with simultaneous reconstruction with a vascularized free fibular flap (FFF) using Surgical Design and Simulation (SDS) and alloplastic TMJ prosthesis. The objective of this study is to report the functional and quality of life (QOL) outcomes in a cohort of patients that had undergone our reconstructive protocol.

METHODS

This was a prospective case series of adult patients that underwent mandibular reconstruction with FFF and alloplastic TMJ prosthesis at the our center. Pre-operative and post-operative maximum inter-incisal opening (MIO) measurements were collected, and patients completed a QOL questionnaire (EORTC QLQ-H&N35) during those perioperative visits.

RESULTS

Six patients were included in the study. The median patient age was 53 years. Heat map analysis of the QOL questionnaire revealed that patients reported a positive clinically significant change in the domains of pain, teeth, mouth opening, dry mouth, sticky saliva, and senses (relative change of 2.0, 3.3, 3.3, 2.0, 2.0, and 1.0 respectively). There were no negative clinically significant changes. There was a median perioperative MIO increase of 15.0 mm, and this was statistically significant (p  =  0.027).

CONCLUSIONS

This study highlights the complexities involved in mandibular reconstruction with involvement of the TMJ. Based on our findings, patients can obtain an acceptable QOL and good function following simultaneous reconstruction with FFF employing SDS and an alloplastic TMJ prosthesis.

Delayed in diagnosis of upper aerodigestive tract cancers: A comprehensive review of medical malpractice cases

BACKGROUND

Factors that prompt litigation and influence outcomes for malpractice cases involving cancers of the upper aerodigestive tract are incompletely described.

METHODS

Westlaw, a national legal database, was searched for medical malpractice claims related to upper aerodigestive tract cancer for all years available.

RESULTS

Of the 122 cases meeting inclusion criteria, 106 (86.9%) involved allegations of failure to diagnose or delay in diagnosis. Tongue, larynx, and nasopharynx cancers were more frequently litigated than would be expected based on their incidence (tongue, 38.7% of aerodigestive tract litigation vs. 26.9% of aerodigestive tract cancers; larynx, 33.0% vs. 22.3%; nasopharynx, 10.4% vs. 4.6%). Payouts were made in over half of diagnosis failure lawsuits (56.6%), which carried an average award of $2840690 [IQR 850219-2537509].

CONCLUSIONS

An awareness of litigation on cancers of the upper aerodigestive tract holds the potential to improve patient care and help otolaryngologists avoid potential risks for litigation.

Functional outcomes and complications of total glossectomy with laryngeal preservation and flap reconstruction: A systematic review and meta-analysis

OBJECTIVE

To analyze the functional outcomes and complications of total glossectomy with laryngeal preservation and reconstruction with free or pedicled flaps.

METHODS

A search was conducted using Pubmed/MEDLINE, Cochrane Library, Scopus, and Google Scholar databases. A single arm meta-analysis was performed for feeding tube dependence (FTD), tracheostomy dependence (TD), and speech intelligibility (SI) rates. Peri-operative sequels and complications were evaluated as secondary outcomes.

RESULTS

A total number of 642 patients (median age: 54.2 years; 95% CI 52.1-58) were included. Functional assessment was performed after a median of 12 months (n = 623/642; 95% CI 10.6-12). Overall, the cumulative FTD rate was 22.9% (n = 188/627; 95% CI 10.2-38.7), the TD rate was 7.3% (n = 95/549; 95% CI 1.9-15.8), and the SI was 91.1% (n = 314/409; 95% CI 80.7%-97.8). The cumulative complication rate was 33.1% (n = 592/642). Eighteen patients (n = 18/592; 3.0%) experienced a major fistula, while aspiration pneumonia occurred in 17 cases (n = 17/592; 2.8%).

CONCLUSIONS

Total glossectomy with laryngeal preservation and pedicled/free flaps reconstruction may guarantee good functional results and an acceptable quality of life. Further prospective studies are advised to define clinical guidelines about proper patients' and flaps' selection.

Swallowing analysis in hemi-tongue reconstruction using motor-innervated free flaps: A cine-magnetic resonance imaging study

BACKGROUND

This study aimed to explore the outcomes of motor-innervated free flaps in hemi-tongue reconstruction by assessing the tongue mobility through midsagittal images from cine-magnetic resonance imaging.

METHODS

In this retrospective study, 47 patients who underwent tongue reconstruction following hemi-glossectomy and 10 control subjects without any surgical history were included. Patients were classified into two groups: the motor and no-motor innervation group. Various spatial parameters related to tongue mobility that were acquired from midsagittal sections were compared during consecutive swallowing phases.

RESULTS

Overall, the motor group showed improved functional swallowing scale compared with the no-motor group. In case of tongue base resection, the motor group showed improved mobility of the tongue base during pharyngeal phase, whereas the no-motor group showed increased laryngeal elevation for compensatory movement.

CONCLUSION

The tongue reconstruction with motor-innervated free flaps may facilitate swallowing capacity in patients with a hemi-tongue defect combined with tongue base resection.

Advances in oral tongue reconstruction: a reconstructive paradigm and review of functional outcomes

PURPOSE OF REVIEW

Glossectomy remains a common treatment of oral tongue malignancies, which has a range of functional impacts depending on the extent of resection. This review aims to categorize and provide context for the approach to reconstructing these defects using recent evidence.

RECENT FINDINGS

The reconstruction method of choice should be tailored to the size and location of the glossectomy defect with special consideration to replace tongue volume and preserve mobility. There has been an increasing focus on patient-reported outcomes in oral tongue reconstruction. For defects beyond one-third of the tongue, free tissue reconstruction, and more recently, the submental artery island flap yield excellent results. Advances in reconstruction of larger defects have included preoperative soft tissue planning and assessment of outcomes in total glossectomy patients with laryngeal preservation.

SUMMARY

Depending on the defect, the appropriate reconstruction may range from healing by secondary intention to large volume free tissue transfer. In general, functional outcomes diminish with increasing size and complexity of the defect regardless of the reconstructive technique.

Results of sequential swallowing assessments in patients undergoing upfront surgery for oral tongue squamous cell carcinoma

BACKGROUND

The swallowing outcomes in patients undergoing glossectomy have been inconsistently reported in the literature owing to variable follow up times, different tools for assessment and lack of single institution large scale studies. The aim of our study was to assess the patterns of swallowing outcomes over time and identify factors affecting nasogastric tube dependency at 1-year post-surgery.

MATERIALS AND METHODS

This was a retrospective study of treatment naïve patients with oral tongue carcinoma who underwent surgery and attended the speech and swallow clinic between January 2016 and December 2019 at our institute were included in the study. The findings of swallowing assessment by a speech language pathologist at three time points were recorded.

RESULTS

A total of 606 patients were found eligible for the study. The median age of the patients was 50 years with the 211 (34.8%) patients having T3/T4 disease. The swallowing outcomes in terms of tube dependence and the spectrum of diet tolerance seem to improve over time with an increasing number of patients switching over to a solid diet by 1 year. A higher defect class (HR = 24.43 [3.48-171.27]) and presence of co-morbidities (HR = 4.17 [1.59-10.92]) were associated with sustained feeding tube dependency status at 1 year. A nomogram was developed based on these findings.

CONCLUSION

The swallowing outcomes in terms of tube dependence and the spectrum of diet tolerance seem to improve over time. A higher defect class and presence of co-morbidities were associated with NGT dependency at 1 year.