"As surgeons, we are most concerned about removing all of the cancer, but we also want to preserve the person's quality of life," says lead author Bruce H. Haughey, M.D., associate professor of otolaryngology. "This work strives to improve both."
About 30,000 Americans develop cancers of the mouth each year. Most are caused by tobacco and alcohol use, and the tongue is the site most often affected.
The tongue is a complex and specialized organ that performs many critical functions, says Haughey, who also is a clinical investigator with the Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and the School of Medicine. It is essential for speech and word enunciation, and it positions food in the mouth for chewing before sweeping it back to the throat for swallowing. The tongue's most important function, however, is to protect the airway from swallowed food and liquids. Loss of tissue from the tongue can allow food or liquids to be aspirated into the lungs, where it can cause serious and sometimes fatal pneumonias.
Psychological support is essential for these patients, Haughey says. "We try to describe before surgery how their life will change, but until people 'walk in these shoes,' they don't realize what impact it will have on their function, even with the most elaborate instruction."
Loss of tissue in the tongue can profoundly affect a person's life. The inability to enunciate words prevents people from communicating with family and friends or using the phone, and has lead to job loss. An inability to safely swallow food requires that a person eat by means of a stomach tube, which is not only inconvenient but inhibits socializing, especially over food and drink.
"These things are on our hearts and minds as we do these surgeries," Haughey says.
The study involved 43 patients, average age 58, who had half or more of the tongue removed and who received tongue reconstruction at the time of surgery. The surgeons reconstructed the forward portion of the tongue in 30 of the patients and the base of the tongue in 13 of them.
Replacement tongues were constructed using folding techniques developed by Haughey and his co-authors to provide the optimum shape, size and mobility for speech and swallowing. In most cases, replacement tongues were fashioned from tissue taken from the forearm or thigh.
Swallowing ability was assessed on a validated scale. Of 38 patients tested for swallowing ability, 85 percent were able to swallow with mild to moderate difficulty, enabling them to meet their nutritional requirements by mouth alone. In other studies using alternate tongue reconstruction methods, 50 percent to 62 percent of patients were able to eat regular or soft diets.
Supervised by an independent speech pathologist, patients were asked to speak 50 words into a tape recorder to measure speech intelligibility. The recordings were played back to five individuals with no experience interpreting the speech of head and neck cancer patients. The scores of the five listeners were averaged and the percentage intelligibility of pronunciation was determined for each patient. These were averaged for an overall score.
Patients receiving tongue-base replacement had an overall intelligibility score of 98 percent, while those receiving forward (anterior)-tongue replacement had an overall score of 76 percent. Other studies report intelligibility at 78 and 40-50 percent respectively.
"This study is just a step along the way," says Haughey, "but we hope it will help more patients with oral cancer recover the ability to swallow and speak. The way forward from here involves more complicated approaches such as tongue transplantation which, from our preliminary investigations, appear technically successful."
Haughey BH, Taylor SM, Spector JG, Fuller D. Outcomes and techniques of fasciocutaneous flap reconstruction of the tongue and floor of mouth. Archives of Otolaryngology, 128, 1388-1395, Dec. 2002.
This research was supported by a grant from the Shirley Phelan Head and Neck Cancer Research Fund.
The full-time and volunteer faculty of Washington University School of Medicine are the physicians and surgeons of Barnes-Jewish and St. Louis Children's hospitals. The School of Medicine is one of the leading medical research, teaching and patient-care institutions in the nation. Through its affiliations with Barnes-Jewish and St. Louis Children's hospitals, the School of Medicine is linked to BJC HealthCare.
Journal
Archives of Otolaryngology - Head and Neck Surgery