Rehabilitation of Swallowing and Communication Following Glossectomy Gary R. LaEilance, PhD; Karen Kraus, RN; Karen F. Steckol, PhD Patients who have had surgical removal of part or all of the tongue are lefi 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.

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ancer of the oral cavity accounts for 3% of all carcinomas in the United States (American Cancer Society, 1990). Lingual tumors represent about 20% of all oral cancers, making them the most frequently occurring cancer in this anatomic region (American Cancer Society, 1990). Glossectomy,surgicalremoval of part or all of the tongue, is the primary treatment for lingual tumors (Christensen, Hutton, Hasegawa, & Fletcher, 1983; Davis, Lazarus, Logemann, & Hurst, 1987). A significant number of glossectomy patients also must undergo palatectomy, maxillectomy, mandibulectomy, and/or resection of the floor of the mouth to control the cancer. Normal speech and swallowingrequire synchronizedmovements of the same anatomical structures: the lips, tongue, mandible, palate, pharynx, and larynx (Logemann, 1989). During speech, air from the lungs is shaped into sounds by altering the position of these structures. Movements of these structures during deglutition propel the bolus through the mouth and into the esophagus and stomach. The tongue plays a primary role in both speech and swallowing. Resection of part or all of the tongue likely will result in decreased speech intelligibility and dysphagia, conditions that are potentially life-threatening.Patients must be able to clearly present their needs and desires. An inability to communicate can impede medical care and may result in fear, frustration, and isolation. Dysphagia may lead to weight loss, poor nutrition, or aspiration pneumonia. The routine patient assessment must include an evaluation of the possible existence of either of these conditions. The role of the rehabilitation nurse as a member of the dysphagia interdisciplinaryteam has been well documented in the literature (DiIorio & Price, 1990; Emick-Herring &Wood, 1990; Mochizuki, Beck, Brigolin, Dobry, & Ellenberg, 1990; Price & DiIorio, 1990). The nurse’s role in the treatment of ~

Address correspondence to Gary R . LaBIance, PhD, Department of Otolaryngology Head-Neck Surgery, Saint Louis University Medical Center, 3660 Vista Avenue, Suite 312, St. Louis, MO 631-10.

speech impairment following glossectomy, however, has received less attention. Rehabilitation of the glossectomy patient is best accomplished through team management. The team involves an otolaryngologist, nurse, occupational therapist, and speechlanguage pathologist, working together to achieve improved swallowing and communication for the patient. The nurse has a fundamental role in rehabilitation of glossectomy patients. Knowledge of anatomy and physiology, nutrition, deglutition, and dysphagia, coupled with the need to communicatedirectly with the patient, make the rehabilitation nurse a vital member of this team. The purposes of this article are to review head-neck anatomy and physiology as they relate to swallowing and speech production, discuss the specific swallowingand speech complications of the glossectomy patient, and present nursing considerations for intervention. Swallowing before and after glossectomy Normal anatomy and physiology: The process of swallowing has been described by numerous authors, including Logemann (1983), Kahrilas (1989), Donahue (1990), DiIorio and Price (1990), and Emick-Herring and Wood (1990). It begins with the oral preparationphase. This involves placement of the food in the mouth, lip closure to prevent drooling, formation of a bolus, and positioning of the bolus between the anterior tongue and the palate. The oral preparation phase is accomplished via rotary and lateral movements of the tongue and mandible, lip closure, and depression of the velum. The second step in the swallow is the oral stage, which involves the formation of a longitudinal groove along the midline of the tongue. Through a squeezing-likeaction of the tongue against the hard palate, the bolus moves back in this channel. The swallowing reflex is triggered when the bolus passes the anterior faucial arches. During the pharyngeal phase, the third step of the swallow process, the bolus moves through the oropharynx and into the esophagus. This phase begins with the triggering of the swallowing reflex and involves closure of the velopharyngeal port (to prevent reflux of food into the nose) and transport of the

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bolus backwards over the posterior tongue and into the pharynx. The last step in the swallow is the esophageal phase, which begins at the point where the bolus enters the esophagus. The larynx is elevated and the glottis is closed. The upper esophageal sphincter opens to allow the bolus to pass. Pressure on the bolus from the peristaltic wave begun in the pharynx drives the food into the esophagus. Disorders of swallowing after glossectomy: Glossectomy

Table 1. Speech Sounds and Place of Articulation ____

Description

Place of Articulation

Speech Sounds

Bilabial

Both lips

b, P, m,w

Labiodental

Lips &teeth

f,

Lingual-dental

Tongue tip &teeth

th

Lingual-alveolar Tongue tip & ridge behind teeth

v

t, d, s,z,n, I

r, sh, zh, ch, j

Lingual-palatal

Tongue blade & palate

Velar

Tongue dorsum &velum k, g, ng

Glottal

Vocal folds

h

patients may have difficulty in all phases of swallowing.These problems can take the form of difficultyin masticating,forming and retaining a bolus, or transporting the bolus. Most frequently, these problems are due to reduced tissue and glossal mobility, which results in an inability to lateralize, elevate, and furrow the tongue, as well as a marked disturbance of the peristaltic wave due to reduction in anterior-posterior tongue movement. When the resection is limited to less than 50% of the tongue, the patient will experience minimal dysphagia (Conley, 1960). These patients initially may have problems triggering the swallowing reflex or may experience a motor awkwardness of the tongue. Tongue range-of-motion exercises usually will improve motor control, and the dysphagia should subside within2to4weeks aftertheoperation(Conley,1960;Logemann, 1983; Summers, 1974). When the resection includes 50% or more of the tongue, swallowing most probably will be impaired. Limited residual tissue and decreased mobility will reduce lingual peristalsis and control of the bolus. Tongue range-of-motion exercises often are indicated to obtain maximum movement from the remaining part of the tongue. Tilting the head forward during mastication will reduce spillage into the buccal gutters. At the start of the swallow, the head c p be tilted backward to allow gravity to carry the bolus into the pharynx. Oral transportof the

bolus also may be assisted by an intra-oralmaxillary prosthesis (Logemann, 1983). If the resection is limited to the tongue, the pharyngeal and esophageal phases of the swallow likely will be normal. Postoperative complications are highly correlated with size and position of the primary tumor, invasion of adjacent structures, and status of the regional lymph nodes. Aspiration is more likely in cases that involve resection of the mandible, palate, or floor of the mouth (Frazell & Lucas, 1962). These patients also may experience difficulty in forming and maintaining a bolus, delayed oral transit times, and problematic mastication due to an inability to move the food (Conley, 1960; Logemann & Bytell, 1979). If the dysphagia persists, the physician may perform an epiglottic or aryepiglottic flap or a laryngectomy(Gillis &Leonard, 1983;Rodriguez, Perry, Soo, & Shaw, 1987). Swallowingtherapy should begin after an assessment of oral functioning and a videofluoroscopic examination. Good movement of the oral structures is essential for the rehabilitation of swallowing and speech following glossectomy. The treatment program should include exercises designed to strengthenresidual musculature, increase range of motion, and develop compensatory strategies. As mentioned previously, the same muscles and similar function are required for speech and swallowing. Because they do require the same muscle movements, it is beneficial to look at speech before beginning treatment. Speech disorders following glossectomy The tongue is the primary structure in speech sound production, responsible for a majority of the vowels and consonants used in the English language (see Table 1). It assumes three basic positions to produce most consonants: tongue-tip elevation (t, d, n, 1,s, z, sh, ch, and zh), tongue-tip protrusion (th), and posterior-tongueelevation (k, g, and ng). Vowels are produced by varying the anterior-posterior and superior-inferior placements of the tongue. Thus, lingual mobility is essential in maintaining intelligible speech. The loss of lingual tissue often results in changes in speech sound production. The residual segment is unable to make the appropriate contacts in a precise, rapid manner, resulting in sounddistortions.Alterations in lingual size and shape also will result in changes in vocal tract resonance: lower pitch and reduced pitch range, guttural voice quality, disturbances in nasality,andexcessiveoraVpharyngealnoises(Gillis&Leonard, 1983; Skelly, Spector, Donaldson, Brodeur, & Paletta, 1971). Speech intelligibility following glossectomy is correlated with the amountof intact tissue (Hufnagle,Pullon, & Hufnagle, 1978; Massengill, Maxwell, & Pickrell, 1970). Rentschler and Mann (1980) showed that the more extensive the surgical resection of the tongue, the more severely intelligibility is impaired. However, it has been demonstratedthat somepatients still can produce intelligible speech despite absence of all or substantialparts of the tongue (Georgian,Logemann,&Fisher, 1982; LaRiviere, Seilo, & Dimmick, 1975; Luchsinger & Arnold, 1965). Vol. 16, No. Srnehabilitation Nursing/Sep-Oct 1991/267

Glossectomy Rehabilitation

The factors affecting postglossectomy speech are (a) the amount of tissue lost and its location (e.g., excision of the right or left half of the tongue appears to require fewer speech adaptations than excision of the entire tip) (Massengill et al., 1970); (b) flexibility of the residual tongue, especially in the middle and rear portions (Michi, Imai, Yamashita, & Suzuki, 1989; Pruszewica & hk-Zagajewska, 1984; Skelly et al., 1971;Urade,Igarashi, Sugi, Matsuya, &Fukuda, 1987); (c) the extent to which the other structures required for speech remain intact, including the lips and teeth and the muscles of the palate, pharynx, andlarynx; and (d) the type of soft-tissue reconstruction that has been done. Suturing the tongue to the buccal mucosa may produce significant limitations of the mobility of the remaining tongue. Skin grafts used between the buccal mucosa and the residual tongue may decrease the amount of scar formation and increase mobility. Cutaneous or musculocutaneous flaps may restore the bulk that has been resected and, thereby, result in maximum potential for tongue movement and improved intelligibility.

Rehabilitation after glossectomy Swallowing therapy: Oromotor exercises are necessary to develop muscle control for swallowingand are begun when the wound has healed, usually 10 to 14 days after surgery (Logemann, 1983). The exercises should include the lips, tongue remnant, jaw, and palate. Tongue and jaw range-ofmotion exercises are particularly important if the patient will undergo postoperative radiotherapy. Radiation treatment will cause increased fibrosis, the effects of which can be minimized with early and continued oromotor exercises. Some patients may demonstrate incomplete lip closure and decreased labial strength. Specific exercises to improve these conditions include stretching the lips widely during production of an /ee/ and puckering the lips as if kissing. Each of these movements should be held about 1 second and then released. Tongue range-of-motion exercises are designed to increase lateralization and elevation in an attempt to improve oral transit. With the mouth opened as wide as possible, the patient should elevate the tongue-tip, elevate the tongue-back, move the tongue laterally, and extend the tongue out of the mouth. In each position the tongue should be moved to its limit, and the position should be held for approximately 1 second and then released. This entire series should be repeated 8 to 10 times in each of the 10 to 15 daily practice sessions. Tongue strength may be increased through resistance exercises such as pushing the tongue against a tongue blade. With the tongue extended, the patient should attempt elevation, lateralization, and forward thrust movements. Pressure should be held against the tongue blade for about 1 second in each position and then released. Coordinationof tonguemovements may be improved through manipulation of objects such as a licorice whip placed in the mouth. The patient should grasp the licorice between the tongue and palate and move it in the mouth from side to side and' front to back. When this is accomplished with moderate success, the motion should be replaced with a circular movement

from the middle of the mouth to the teeth and back again, as if chewing. With continued success, the licorice can be replaced with a piece of 0-shaped candy tied to a string and then with a cloth soaked in juice. In each case, the nurse should hold one end to prevent choking. These items will provide a very small amount of liquid to swallow (Ford, Grotz, Pomerantz, Bruno, & Flannery, 1974). Once the patient has demonstrated the ability to manipulate material in the mouth, exercises should focus on holding and moving a bolus. A 1/3-teaspoonpaste-consistencybolus should be placed in the mouth and moved with the tongue. The patient should attempt to minimize the amount of material allowed to spread to the buccal gutters. When the exercise is completed, the bolus should be expectorated. The size and consistency of the bolus should be varied with continued success. Increasing the use of the buccal musculature and inclining the floor of the mouthmay improvebolus control (Kothary & DeSouza, 1973). The patient also may need to practice a backward propulsion of the bolus. This may be accomplished by instructing the patient to squeeze juice from a long thin cloth placed in the mouth. The patient should attempt anterior to posterior glossalpalatal contact. The amount of juice placed in the cloth should vary according to the patient's ability to swallow. These exercises are designed to increase the strength and range of motion of the structures of the oral and pharyngeal cavities.Well-sequencedmovement of these structuresis crucial to therestorationof swallowing.Improvedstrengthand mobility also will result in improved speech intelligibility. Strategies to improve speech and communication: The patient should be encouraged to speak as soon as the wound has healed and pain has subsided. Exercises should be given to strengthen the intact structures and develop compensatory movementsof the lips, palate, mandible, and remaining tongue for improved intelligibility.Speechtherapy for the glossectomy patient should focus on speech sound production, vocal parameters, and the psychosocial aspects of communication (Cardinale, 1983; Skelly, Donaldson, Fust, & Townsend, 1972). Speech articulation is the prime target for treatment. The patient should be given techniques to maximize residual articulatoryabilities while developingconsistentand appropriate compensatory strategies. This may be accomplished by developing a consistently slow rate of speech; use of a deliberate syllable-by-syllable attack on words; speech sound exaggeration, especially the middle and final sounds in words; and improving prosody through prolonged syllable duration, increased use of meaningful pauses, improved syllable stress, and variations in loudness. Sounds articulated with the lips (/p/ and /b/), teeth (/f/ and /v/), and palate (/ch/ and /rig/) should be attempted first. Drill should focus first on sounds in isolation, then move into words, phrases, sentences, and monologues. Dworkin (1982),Leonard and Gillis (1982),and Skelly et al. (197 1) reported specific compensatory strategies to improve intelligibility. These strategies included the following: 1. Production of the lingual-dentalsound /th/through valving of the lower lip and upper central incisors or upper lip.

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Sounds produced in this manner resemble the phonemes /f/ and /v/. 2. Production of the lingual-alveolarsounds/t/ and /d/through valving of the lower lip and central incisors or alveolar ridge. Because these articulator adjustmentsresemble those used for the lingual-dental sounds, focus should be placed on the aerodynamicsof implosion, as is needed for the /t/ or /d/, rather than the friction required for the /th/. 3. Substituting the bilabial /m/ for the /n/. A momentary velar constriction followed by a quick uvular relaxation with the lips concurrently adducted also may produce a compensated /n/ that is discernible from /m/by degree of labial occlusion and by a shift in nasal resonance. 4.Producing lingual-palatal sound compensations for /s/ and /z/ by the steady propulsion of air through a lax bilabial valve. The central dentition will aid in airstream turbulence and the sibilant acoustic characteristics of /s/ and /z/. 5. Achieving /g/and /k/ through pharyngeal constriction. 6. Achieving /I/and /r/ by a combination of pharyngeal, uvular, and buccal movements. 7. Accomplishing vowel sounds by maximizing lip and mandible gestures and durational variables and by attending to fundamental frequency and intensity variables. Modification of pitch, loudness, and voice quality also should be an integral part of the rehabilitation program. Treatmentshould focus on recognition and use of an appropriate loudnessfor conversation;elevation of the usually low habitual pitch; and increasing pitch range and variability through drill on inflectional patterns that contrast rising inflections with falling and level inflections (Skelly et al., 1972). The patient should be encouraged to maintain good eye contact, so that the listener can take advantage of facial expression and articulator placement; increase use of gestures to improve understanding of communicative intent; and increase use of written communication to facilitate social interactions and reinforce the sense of linguistic competence until intelligibility is regained (Gillis & Leonard, 1983; Pettygrove, 1985). The patient will need frequent and consistent reinforcement to incorporate these compensatory strategies into everyday communication. The nurse and speech-language pathologist, working as a team, can provide this reinforcement. The ability to use these strategies will improve speech intelligibility and, thereby, decrease feelings of frustration and isolation. In addition, the patient will be able to convey information that is vital to continued care.

Prosthetics in glossectomy rehabilitation Prosthetic devices are used in rehabilitation of glossectomy patients when compensatory strategies have had less than adequate success.The prosthesisreduces the space between the palate and the floor of the mouth. The appliances are designed to facilitate constriction of the anterior oral cavity along the alveolar ridge and closure of the posterior oral cavity against the hard palate. By occupying space in the oral cavity, the prosthetic mass also will improve resonance characteristics. While the prosthesis cannot replace the intricately mobile

structure of the tongue, it often results in improved speech intelligibility and swallowing (Gillis et al., 1983; Robbins, Bowman, & Jacob, 1987).

Conclusion Cancers of the oral cavity often result in swallowing difficulty and diminished speech intelligibility. The patient must learn to use residual potential and to develop new strategies to compensatefor lost abilities. The rehabilitationnurse, working with an occupational therapist and speech-language pathologist, can assist the patient in this process. The oromotor exercises presented in this article are designed to improve strength and range of motion of the oral and pharyngeal structures.The ability to swallow and speak clearly is contingent upon adequate strength and movement. Members of the rehabilitation team must help the patient develop conscious and consistent monitoring of speech and swallowingbehaviors, compensatory strategies, and increased awareness of obstacles that interfere with functioning. In addition, the team must provide support and encouragementto minimize feelings of frustration, fear, and isolation. All three authors are afJiated with Saint Louis University in St. Louis: Gary LaBlance as an associate professor in the

departments of communication disorders and otolaryngology head-necksurgery, Karen Kraus as a clinical supervisor in the department of otolaryngology head-neck surgery, and Karen F. Steckol as professor and chair of the department of communication disorders.

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Skelly, M., Donaldson, R.C., Fust, R., & Townsend, D. (1972). Changes in phonatory aspects ofglossectomee intelligibilitythrough vocal parameter manipulation. Journal of Speech and Hearing Disorders, 37(3), 379-389. Skelly, M., Spector, D., Donaldson, R., Brodeur, A., & Paletta, F. (1971). Compensatory physiologicphoneticsfortheglossectomee. Journal of Speech and Hearing Disorders, 36(1), 101-1 14. Summers, G.W. (1974). Physiologic problems following ablative surgery of the head and neck. Otolaryngology Clinics of North America, 7(2), 217-250. Urade, M., Igarashi, T., Sugi, M., Matsuya, T., & Fukuda, T. (1987). Functional recovery of swallowing, speech, and taste in an oral cancer patient with subtotal glossectomy. Journa/ of Oral and Maillofacial Surgery, 45(3),282-285.

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Rehabilitation of swallowing and communication following glossectomy.

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...
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