Year : 2013 | Volume
: 1 | Issue : 2 | Page : 148--151
Speech characteristics and swallowing functions post-segmental mandibulectomy
Priyanka V Naik, Thomas Zacharia, Jensy G Kuniyil, Shwetha
Department of Speech and Hearing, Father Muller College of Speech and Hearing, FMCI, Mangalore, Karnataka, India
Department of Speech and Hearing, School of Allied Health Sciences, Manipal University, Manipal, Karnataka
Objective: To describe the speech and swallowing characteristics following segmental mandibulectomy and coronoidectomy to release trismus. Materials and Methods: A detailed speech and swallowing function assessment was carried out using various formal and informal tests following the surgeries. Result: After the initial assessment, the patient had severe impairment with the movement of articulators, and distortion was observed for labio dentals, lingual sounds, and vowels. Speech intelligibility, diadokokinetic rate, maximum phonation duration were reduced, and also patient had severe voice problem and swallowing problems. Following the assessment post-coronoidectomy, patient had articulatory errors such as distortion, omission, and substitution for majority of sounds secondary to reduced articulatory movements. Swallowing and voice characteristics have improved slightly, and the voice parameters were near normal. Conclusion: Segmental mandibulectomy can have several effects on an individual«SQ»s daily living as it affects speech, which becomes a major hindrance for communication. Also, due to the swallowing difficulties, there may be health issues. Hence, the affected individuals should be evaluated by a speech language pathologist to define the exact nature of changes in communication (including speech and voice), and swallowing that also helps to plan a comprehensive management strategy that includes speech therapy and surgical recommendation, which will have good prognosis in speech and swallow characteristics to give a good quality of life.
|How to cite this article:|
Naik PV, Zacharia T, Kuniyil JG, Shwetha. Speech characteristics and swallowing functions post-segmental mandibulectomy.Arch Med Health Sci 2013;1:148-151
|How to cite this URL:|
Naik PV, Zacharia T, Kuniyil JG, Shwetha. Speech characteristics and swallowing functions post-segmental mandibulectomy. Arch Med Health Sci [serial online] 2013 [cited 2020 Mar 30 ];1:148-151
Available from: http://www.amhsjournal.org/text.asp?2013/1/2/148/123030
The treatment goals in the management of cancer of the oral cavity are the eradication of the cancer and the restoration of form and function. Recent improvements in pre-operative treatment and reconstruction methods have led to improvements in the quality of life of patients with oral cancer. Squamous cell carcinoma in the oral cavity and oropharynx often abuts or invades the mandible. In 1951, Ward and Robben  advocated segmental mandibulectomy for tumors that involved and are very close to bone for adequate cancer resection. The assumption of the authors was based on the understanding that cancers of the tongue and floor of mouth drained through lymphatic channels in the periosteum into the mandible. However, segmental mandibulectomy produced severe functional and cosmetic defects.
Segmental mandibulectomy describes removal of a segment of mandible and thereby interrupting its continuity. Segmental mandibulectomy may be performed in the setting of a composite resection, that is, resection of a segment of mandible in continuity with a cancer of the oral cavity or oropharynx or a primary cancer of the alveolar ridge. Excision of bone, as commonly performed today, was reported by Slaughter and colleagues and then Ward and Robben half a century ago, and the fundamental concepts of extirpation have not changed in the interval. An exception is that uninvolved mandible is no longer removed to provide adequate exposure to remove the cancer. Unless the bone is involved, an osteotomy is now carried out by retraction of the bone fragments, which provides adequate exposure to remove the cancer without removing the bone.
The post-operative functional outcomes of mandibulectomy may involve deficits depending on the type of mandibulectomy and can involve deficits in speech that prominently includes articulation problems due to decreased range of movement, malocclusion of the jaw, trismus and swallowing difficulty, and voice problems due to side-effects associated with surgery and radiation therapy. Speech pathologists are traditionally the professionals who assess, diagnose, and manage voice, speech and swallowing in patients with head and neck cancer. The main focus of speech and swallowing assessment and rehabilitation is to first improve the function by direct therapy and second, to introduce compensatory strategies or maneuvers, when improvement in function cannot or does not occur. 
Speech outcomes after the surgery can be assessed by the use of indicators of speech production such as oral function and articulation tests, aerodynamic and acoustical analysis, speech perception with respect to intelligibility and acceptability, and self-reported speech adequacy in everyday life situations, which can be done using questionnaires 3]
A patient aged 43-years-old came to the department with a history of deviant speech characteristics and swallowing functions post-surgery of segmental mandibulectomy undergone due to carcinoma of floor of mouth, which was caused due to chewing betel nut leaves with lime since 25 years.
Histopathological reports suggested features of well differentiated squamous cell carcinoma. Contrast-Enhanced Computed Tomography revealed multiple enlarged cervical lymph nodes in the left sub-mandibular level 11 and few in level V. The patient was then diagnosed as having carcinoma of the left alveolus T2NOMX.
The patient underwent Medial Radical Neck Dissection (MRND), left segmental mandibulectomy and reconstruction with fibula osteocutaneous free flap under general anesthesia and hematoma drainage tracheostomy under general anesthesia. The patient had complication in phonatory system, severe sub-mucous fibrosis, and trismus with mouth opening less than 1 centimeter post-surgery. Phonatory system complications could not be assessed due to trismus, and then, the patient again underwent a surgery to release the trismus that included the procedures of right coronoidectomy, bilateral buccal release, tongue flap for left and naso-labial flap for right cheek done under general anesthesia.
Speech and swallow evaluation
A detailed assessment of articulatory subsystem included Oral Peripheral Mechanism Examination (OPME), Photo Articulation Test (PAT), Diadokokinetic Rate (DDK), and intelligibility rating using Ali Yavur Jung National Institute of Hearing Handicapped (AYJNIHH) intelligibility rating scale. An assessment of phonatory subsystem that included a voice proforma involving a detailed history, aerodynamic analysis, perceptual voice analysis using GRBAS rating scale, and acoustic analysis using Dr. Speech software was carried out. Also, assessment of the swallowing function was carried out using Swallowing Ability and Function Evaluation (SAFE). A detailed articulatory and swallow assessment was again carried out post-trismus release surgery using the same test protocols.
On evaluation of the articulatory subsystem, the following results were obtained. On OPME, lips drooping on the left side with restricted movements, jaw deviated to right side, and trismus was observed, missing lower left molars, premolars and incisors, tongue slightly deviated to right side at rest, droops to left side on protrusion. Soft palate could not be viewed due to trismus, and hard palate was observed to be normal. The range of motion and speed were reduced for lips, tongue, and jaw. Reduced intraoral breath pressure observed. PAT revealed distortion of bilabial, labiodentals, lingual sounds, and vowels. DDK rate was significantly reduced. The speech intelligibility was rated as 4 on AYJNIHH intelligibility rating scale. On assessment of phonatory subsystem, the aerodynamic analysis revealed maximum phonation duration of 6 seconds; however, S/Z ratio could not be assessed. On GRBAS rating scale, a rating of 3 for grade, rough, breathy and rating of 2 for asthenic and strained were obtained. The values obtained from acoustic analysis using the Dr. Speech software were, Fo = 130 Hz, Jitter = 2.26%, Shimmer = 7.62%, HNR = 9.06, NNE = 8.40, Fo tremor = 14.54, Amplitude tremor = 5.24, and the voice quality estimates revealed severe hoarse voice. On swallowing evaluation, SAFE revealed moderate impairment on subscale 1, severe impairment on subscale 2 with tolerance of thin liquid consistencies, and subscale 3 was within normal limits with thin liquid consistencies. The patient was then diagnosed as "Hoarse voice and reduced speech intelligibility with oral dysphagia secondary to segmental mandibulectomy." After an intensive therapy for a period of 4-5 months, there was a significant improvement in the voice characteristics both subjectively and objectively.
Following the initial assessments, the following results were obtained in the assessment carried out post-trismus release surgery. In the assessment of articulatory system, ON OPME, lips were asymmetric with lip seal absent on left side and lip seal present on right side. The jaw was slightly deviated on the right side at rest and during speech. The tongue posteriorly on the left side was sutured to the floor of mouth, at rest was slightly deviated to the right side and deviated on the left side on movements like protrusion and vertical movements, retraction of the tongue was unable to be done. The left lower molars, premolars, and incisors were removed and no alignment of upper and lower teeth. The soft palate was slightly depressed on the left side but was elevating on phonation, and nasal air emission was not observed. Hard palate was observed to be normal. Intra-oral breath pressure was not able to be maintained due to poor lip seal. Movements of the all active articulators were reduced in range of motion and speed. On PAT distortion of sounds such as /b/, /d/, /k/, /tƒ/, /d ℑ/, and clusters such as /bl/, /br/, /dr/, /kl/, /kr/, /kw/, /gl/, /gr/, /sp/, /st/, /sk/, /sm/, /sn/, /sw/, /mp/, /ntƒ/, /nd ℑ/, /fth/, /lfth/, /ps/, and /ts/ were observed. Omission of sound /g/ and clusters such as /skr/ and /skw/ were observed. Substitution of sound /f/ by /p/ and cluster /fl/ and /fr/ by /pl/ and /pr/, respectively, were observed. DDK rate was noted as 2.2 syllables/second for Alternating Motion Rate and 2 syllables/second for Sequential Motion Rate. The intelligibility was rated as 3 on AYJNIHH intelligibility rating scale. On swallowing evaluation, SAFE revealed moderate impairment on subscale 1, severe impairment on subscale 2 with tolerance of puree consistencies, and subscale 3 was within normal limits with puree consistencies. The patient was then diagnosed as "Reduced speech intelligibility with oral dysphagia."
The present study focuses on the speech characteristics mainly the articulatory subsystem, phonatory subsystem, and swallowing functions observed in an individual with segmental mandibulectomy and recommended coronoidectomy for trismus release. Trismus is the inability to open the jaw, which occurs after the surgery by soft tissue scarring or changes in the muscle around the jaw and is a well-known complication of head and neck cancer treatment with a prevalence rate of 5% to 38%.  Physical therapy is one of the initial treatment option for trismus patients, and since most of the patients fail to achieve adequate mouth opening even after therapy, coronoidectomy is the second surgical option, and studies found out that it is more effective at improving trismus refractory to physical therapy in head and neck cancer patients.  The post-operative functional outcomes will depend mainly on the type of mandibulectomy done. Although voice is not directly affected by mandibulectomy, some patients may exhibit voice problems as a complication of the surgery. Therefore, it has been outlined in the results, the effects of segmental mandibulectomy on speech and swallowing. The patient underwent several months of voice therapy, after which there was a marked improvement in the phonatory subsystem with aerodynamic, perceptual, and acoustic analysis revealing normal values. However, there was no much improvement observed in articulation and swallowing functions due to the trismus that inhibited the movements of articulators for speech and swallowing. Therefore, a surgery was recommended for the release of the trismus that was rarely observed in literature. Recent studies have found out that most patients who undergo treatment for oral and oropharyngeal cancer tend to get swallowing difficulty and found not getting resolved in a follow up after 1 year.  Following the surgery, there were differentiating characteristics observed in speech and swallowing that is outlined in the results. The patient again underwent articulation and dysphagia therapy for 2 months, following which there was improvement in articulatory subsystem that resulted in a rating of 2 on AYJNIHH intelligibility rating scale in speech, and swallowing function was improved to tolerance of ground consistencies under subscale 2 and 3. A study conducted to assess the functional outcome of patients post-mandibulectomy and maxillectomy reveals that, with respect to speech, the patient had articulator imprecision after the surgical excision of both maxilla and mandible due to improper removal of dental, alveolar, and palatal contacts, deviation and improper closure of lips, and misarticulation of bilabials, labiodentals, fricatives, palatal sounds, and affricatives were also seen.  The anatomical defect of the back of the tongue on the left side was the only inhibiting factor that blocked a near-normal improvement and for this reason, a third surgery was recommended that would release the sutured tongue with the floor of the mouth that could give a better function of swallowing and better improved speech intelligibility.
Authors would like to thank the participant and his family for their cooperation. The authors also wish to express their deepest gratitude to the management officials, Father Muller Charitable Institution for permitting to conduct the study and also authors express sincere thanks to the principal Mr. Akhilesh PM, all the staffs and friends, and especially Dr. Rohan Ghatty, Ms. Janet Jason Varghese, and Ms. Niloofer Binth Nizar for their valuable support and information for the paper.
|1||Ward GE, Robben JO. A composite operation for radical neck dissection and removal of cancer of the mouth. Cancer 1951;4:98-109.|
|2||Perry A, Frowen J. Speech and swallowing function in head and neck cancer patients:- What do we know? Cancer Forum-2006;30.|
|3||Pepijn A, et al. Speech outcome after surgical treatment for oral and oropharyngeal cancer. A longitudinal assessment of patients reconstructed by a micro vascular flap. J Head Neck 2005;27:785-93.|
|4||Dijkstra PU, Kalk WW, Roodenburg JL. Trismus in head and neck oncology: A systematic review. Oral Oncol 2004;40:879-89.|
|5||Bharany AD, Izzard M, Wood AJ, Futran AJ. Coronoidectomy for the treatment of trismus in head and neck patients. Laryngoscope 2007;117:1952-6.|
|6||Borggreven PA, Verdonck-de Leeuw I, Rinkel RN, Langendijk JA, Roos JC, David EF et al. Swallowing after major surgery of the oral cavity or oropharynx: A prospective and longitudinal assessment of patients treated by micro vascular soft tissue reconstruction. J Head Neck 2007;29:638-47.|
|7||Premalatha S, Tara S. Functional outcomes of speech following combined maxillectomy and mandibulectomy- A case study. Am Head Neck Soc 2012:22-4.|