Speechconsiderations in oral surgery Part II. Speech characteristics oral malignancies

of patients

following

surgery

for

Jon Hufnagle, Ph.D.,* Peter Pullon, D.D.S., MS., M.Ed.,** and Katy Hufnagle, MS.,*** Normal, Ill., St. Louis, MO., and Peoria, Ill. ILLINOIS MEDICINE,

STATE AND

UNIVERSITY, METHODIST

WASHINGTON MEDICAL

CENTER

UNIVERSITY

SCHOOL

OF DENTAL

OF ILLINOIS

The characteristics of speech following ablative surgery for oral malignancies are presented. The speech following cheilotomy, maxillectomy, mandibulectomy, nasopharyngeal excavation, and glossectomy is described. Emphasis is placed on glossectomy because of the prevalence of this surgery and the nature of the research being done in this area. Finally, a discussion of research needs involving the oral surgeon, dentist, and speech pathologist is presented.

C ommon causes of speech disorders by tissue destruction are trauma, tumor growth, wasting diseases, and surgical removal. This article will focus most on the latter. The sites of tissue loss which directly affect speech are those critical points in the mouth and pharynx that either destroy or impair the function of the articulatory valves, referred to in Part I, or create abnormal openings in the tube, thereby altering tube resonance characteristics and impairing its ability to modulate sound or regulate air flow (Fig. 1). Damage to the valves may result from cheilotomy, facial excisions, removal of nasal structure, maxillectomy, mandibulectomy, glossectomy, and nasopharyngeal excavation. The surgical ablation of tissue and its effects on valve function for speech will be considered individually, with reference to the primary valve mechanism, in the discussion which follows. Emphasis will be placed on the speech of the glossectomee because of the greater, although still limited, availability of information in the literature. *Assistant Professor, Department of Speech Pathology and Audiology, Illinois State University. **Professor and Chairman, Department of Pathology, Washington University School of Dental Medicine. ***Director, Speech Pathology Services, Department of Audiology and Speech Pathology, Methodist Medical Center of Illinois.

354

0030.4220/78/0346-0354$00.80/O

0

1978 The C. V. Mosby Co.

I. 2. 3. 4. 5. 6. 7.

Labial Dental Alveolar Palatal Velar Lingual Glottal

Fig. 1. Valves involved in production of speechsounds.

Iml,lpl,lbl InWtl,ldling lkl,lgl Ifl,lvl vowel oo IWI Fig. 2. Lip positions for various speechsounds.

SURGERY THAT INVOLVES THE UP

The lips are involved in articulation of the consontantsIpl, lbl, /ml, Iwl, lfl, and Ivl and may contribute qualitatively to the production of /sl, /z/, It/, ldl, and lrl. They also probably contribute in a secondaryway to possibly aid in the production of the rounded vowels lul, lol, /a/, Id, laul, and lad.' Adequacy of lip function for speechis thus related to the ability of the lips to round, spread, constrict, close, and open rapidly (Fig. 2). Robinson and Niiraner? have stated that the lower lip is more important for speech than the upper lip because of its greater potential for movement. Because of tissue adaptability and associatedactivity of other organs, such as the tongue, somepatients are able to make compensatoryadjustmentsfor speech, even in the presenceof a severe lip deformity. Bloomer and Hawk’ give an example of the functional effects of a shortened and relatively immobilized upper lip due to the removal of external and associatedinternal nasal structures for treatment of carcinoma. There was little loss of speechintelligibility from lip deficiency; however, the patient was forced to substitute labiodental approximations for all bilabial consonants.The bilabial consonantswere generally identifiable when embeddedin a linguistic context. Consonantscreated by action of the tongue and structures other than the lips were not affected.

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&fnagle,

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Oral Surg. September, 1978

Fig. 3. Area of involvement associated with labiodental, linguodental, and linguopalatal sound production.

Bloomer goes on to mention that it was difficult to state how much or in what ways vowel qualities were changed by the patient’s facial deformities. Most of the vowels seemed to be identifiable but were obviously abnormal. The patient’s nasal resonance was also altered, but the changes were difficult to describe acoustically. A facial prosthesis designed for the patient was an attempt at providing cosmetic aid and at protecting the patient from the weather, but was otherwise nonfunctional. SURGERY OF THE FACIOBUCCAL

AREA

Faciobuccal tissue removals affecting speech will be considered by site in reference to the hard and soft palate: those above the palate and those exposing the oral cavity. Supramaxillary

excisions

Several instances of tissue excisions creating openings in the face above the palate have been reported. 3, 4 The effects on speech intelligibility and vocal resonance in such cases are believed to be relatively minor as long as the maxilla is intact and the palatopharyngeal valve functions satisfactorily. Maxillectomy

Removal of any part of the maxilla, if it is not restored surgically or prosthetically, creates serious problems for the speaker (Fig. 3). Labiodental, linguodental, and linguopalatal contacts account for seventeen of the twenty-five consonants used in American speech (Table I). Without effective maxillary-lingual approximation for these consonants, speech becomes unintelligible. A study of six maxillectomy patients has been reported by Kipfmueller and Lang.” The patients, who ranged in age from 24 to 59 years and had individually variant degrees and sites of tissue loss, were provided with prostheses immediately after surgery. Three patients were edentulous and three had sufficient maxillary dentition to provide abutment support for a prosthesis. Approximately 10 days postoperatively (or as soon as impression procedures could be tolerated), the prostheses were modified by the addition of bulbs

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Table

Speech considerations in oral surgery

357

1. English consonant chart and vowel diagram Place of articulation

Manner of articulation Plosive Fricative

Bilabial P (Pipe) b (baby) hw (what) w (watt)

Labiodental

f (fat) v (vat)

Linqual dental

Linqual alveolar

e (thin) d (than)

t (toe) d (dad) s (sack) z tz@4

Affricate Nasals Glide Vowels

m (man)

n (no) I (lake) Front i (eat) I (it) e (ate) E (bed) = tat) a (bath)

SW (further) a (above) A (above)

Linqual palatal

Linqual velar

Glottal

k (cat) g (goat) h (hat)

S tsh@ 3 W-we) tJ-(church) d3 Wke) 0 (sing) r (rat) j (yet) Back ” ww IJ (book) 0 (omit) 3 (jaw) D (watch) a (father)

ing the Fairbanks Rhyme Test.6 The fifty-word recordings of each patient were scoredby thirty untrained listeners, thereby yielding 1,500 informational items on each of the subjects. The results indicated that, whereasspeechintelligibility was markedly impaired without prosthetic treatment, installation of a prosthesis improved speechintelligibility in all instances. Test-retestscoresover time ranging from 2 to 11 months showed that speech intelligibility tended to improve after the patients becameaccustomedto the prosthesis. However, only two attained presurgical levels of intelligibility. Bloomer and Hawk’ made a recording of one of the patients unable to reach presurgical intelligibility. The patient’s resonancedemonstratedhypernasality while the appliance was worn. This was the same resonancecharacteristic that distinguished his nonobturatedspeech.The authors statedthat examination of the patient revealeddeficient palatopharyngeal valve function, probably due to denervation and scarring of the soft palate. Therefore, not all of the speechdefectswere due to the maxillectomy but reflected palatal dysfunction as well. SURGERY OF THE SOFT PALATE

Removal of posterior portions of the maxilla may affect palatopharyngealvalve function (1) by destroying the points of attachment for the palate on one or both sides, (2) through coincident denervation of palatal muscles, and (3) from relative shrinkageand immobilization of the palate through formation of scar tissueassociatedwith the maxillectomy.’ The acoustical outcome of a defective palatopharyngeal valve is hypernasality, usually accompaniedby nasal emissions. Palatal carcinoma is one of the causesfor removal of all or a portion of the soft palate.

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Oral Surg. September. 1978

Bradley7 reports, although without documentation, that the restoration of missing structures with functional prostheses usually results in normal speech, and that speech training is rarely required. This may be true in many cases if the articulatory pattern has not changed to compensate for the palatopharyngeal insufficiency and if the voicing pattern has not changed for the same reason. An additional concern might be hyponasal resonance due to overocclusion of the velopharyngeal area. Wise and Bake? describe a procedure using a tongue flap for palatal repair for the treatment of velar tissue loss. They provide no information about the nature or severity of the speech disorder or the functional results of this method of treatment for the speech of patients who have sustained this procedure. It is presumed that the flap is nonfunctional except insofar as it provides tissue coverage. Clinical experience leads us to believe that a posterior palatal prosthesis might be a preferable method of treatment in such a case. PHARYNGEAL

EXCAVATION

Surgical deepening of the pharynx in connection with removal of a retropharyngeal tumor may impair palatopharyngeal valve closure and thus result in hypemasality and nasal emissions. Diagnosis of a speech disorder in such patients should employ methods applicable to those used in the study of cleft palate. Some patients have been observed to respond successfully to pharyngeal flap surgery, if tissue is available, and some have been able to use a palatal lift appliance with excellent results. GLOSSECTOMY

Instances of persons developing reasonably intelligible speech following removal of part or all of the tongue cast serious doubts upon the notion that the tongue is indispensable and that without it speech would be virtually impossible. Although the reports dealing with speech after glossectomy generally conclude that it is possible to achieve adequate intelligibility after a brief recovery period, the amount of quantitative information concerning this matter is scant. Furthermore, many of the observations made have been with only one patient.gs lo Kalfuss” was one of the first to report systematically on the speech of the glossectomee. She reported on twenty-two patients subsequent to surgery for carcinoma. Articulation and intelligibility in an experimental group and a control group were investigated. Kalfuss also investigated articulation and intelligibility as they related to site and extent of surgery (four groups were developed). Significant differences in articulation and intelligibility were found between the experimental group and the control group. Analysis of the results of speech intelligibility tests comparing the four groups showed that Group IV (most surgically involved) differed significantly from the other groups. The results between groups in articulation showed that Group IV differed significantly from Group I (least surgically involved) only. Information about the speech of all of the patients indicated that, as a group, their articulation of twelve phonemes was impaired. All of the impaired phonemes except the lv/ phoneme normally require linguoalveolar or linguopalatal contacts (Table I). Massengill, Magwell, and Pickrell l2 demonstrated that postoperative speech intelligibility levels decreased with the removal of increased portions of the tongue. Skell~‘~ demonstrated that intelligibility for partial glossectomees was better than for total glossectomees.

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Table II. Objectivesof Skelly’s therapyprogramfollowing glossectomy 1. Improveexcursion andcontrolof availablearticulators. Increase, by drill, the intelligibilityof vowels, lingualand nonlingual consonants, and various

2.

consonant-vowelcombinations. 3. Explore the potential compensationsthat could be made for each lingual phoneme and generalize successfulcompensationsdeveloped with one patient to other patients. 4. Isolate the compensationsof each lingual phoneme most of intelligibility increases. 5. Integrate the compensationsinto each patient’s therapy program.

Table III. Intelligibility improvement following therapy developed by Skelly Therapy

Partial glossectomy Total glossectomy (excluding six with dysphagia)

Pre-therapy intelligibility range

6%-24% O%- 8%

Post-therapy intelligibility range

24%-46% 18%-42%

LaRiviere, Seilo, and Dimmick14 reported the intelligibility of a 32-year-old woman who underwent a radical glossectomyand a partial pharyngectomy. Judgmentswere made on five different tasks for intelligibility: two stressing initial consonants, one stressing final consonants, one for vowels, and one for over-all sentence intelligibility. Intelligibility was impaired, but the task seemedto dictate to what degree. Tasks stressing sentences, initial consonants, and vowels resulted in 88 percent, 66 percent, and 45 percent intelligibility, respectively. Restoration of speechafter the loss of a substantial part of the tongue is one of the oldest recorded examples of speechrehabilitation. However, not until recently has there been any systematicattempt to study the compensatorybehaviors used by some glossectomized persons that allow for acceptableacoustic impressions and intelligible speech. Skelly,13 after initial research on speaker intelligibility, developed an exploratory therapeutic program for the rehabilitation of the glossectomizedpatient (Table II). After a 12-month program, intelligibility testing on monosyllable words showed an intelligibility increase for the partial glossectomy and total glossectomy groups (Table III). From Skelly’s rather extensive investigation, which included cinefluorographic examinations and spectrographic studies, the following observations were made: 1. The six glossectomeeswith dysphagia made no progress from their initial intelligibility score of 0. 2. The partial glossectomeesimproved in a shorter time and fewer sessionsthan the total group. 3. The partial glossectomeesmade marked use of the residual lingual stump. 4. The type and extent of tongue section and flexibility of the residual tongue stump are important determining factors related to eventual speechclarity. 5. Intelligibility is increasedin total glossectomy patients by manipulation of vocal parametersas well as by application of articulatory compensations(lengthening vowel duration, reducing vocal intensity, using meaningful pauses,elevating low habitual pitch, etc.).

360 Hufnagle, Pullon, and Hufnagle

OralSurg. September, I978

6. Development of consistency in substitution appears to be related both to early intelligibility and also to compensatory progress. In addition to the previously mentioned clinical methods of glossectomee rehabilitation, Moore,‘” a prosthodontist, developed a mandibular tongue prosthesis for a glossectomy patient to improve his chewing, swallowing, and speech behaviors. The patient was reported to have swallowed effectively immediately upon placement of the prosthesis. Resonance and voice quality improved, as did intelligibility of speech. The patient did need some speech therapy to enhance articulatory movements. Cinefluorographic filming was used to analyze the patient’s chewing, swallowing, and articulatory patterns, but Moore did not mention any specific observations other than the patient’s ability to quickly regain speech and swallowing habits. He.states that, with a prosthesis, recovery time for speech, swallowing, and chewing can be reduced. As emphasized by a number of authors,“, 13*” success with speech as well as chewing and swallowing is needed as soon as possible after surgery. A prosthetic tongue as described by Moore’” may be one approach to fulfill this need. However, the surgeon, prosthodontist, and speech pathologist must carefully weigh the advantages and disadvantages of prescribing a prosthetic tongue for individual glossectomy patients. Research for indications and contraindications is needed. Reconstructive surgery has also been performed to restore lost functions of the tongue due to total glossectomy. Washio r6 discussed the use of a pterygoid muscle sling in conjunction with a forehead flap to reconstruct the oral floor in an attempt to develop pseudoglossal function after total glossectomy. Results indicated that the surgery proved to assist the deglutition process because of the high convex oral floor. Deglutition was the only process observed, and it is unfortunate that an evaluation of speech was not obtained presurgically and postsurgically. It would have been beneficial to note if the sling improved articulation patterns and intelligibility. In conclusion, a review of the literature seems to indicate that the tongue is a necessary articulator for speech intelligibility. However, because of the heterogeneity of the population in question, any definitive statement about degree of involvement is tentative. The literature contains only one or two in-depth investigations related to speech rehabilitation. Some questions still to be answered are: I. What type of resonance changes occur in glossectomy patients, and to what extent do these changes affect intelligibility? The moderately and severely affected glossectomee can often be identified acoustically by his peculiar resonance patterns. Since there has been such a great change in the resonating cavity, there would certainly be a change in the resonant properties of the cavity. What this change is should be defined. 2. Does the glossectomy patient evidence a different phonatory pattern? Skelly13 has pointed out that changing acoustical parameters can improve intelligibility. More intense investigation in this area is needed. For example, for base-of-tongue excisions, will a change in anatomic contacts produce a change in function? When the base of the tongue is no longer bulging into the epiglottic region, will the reduction in pressure, etc. produce a characteristic change in phonation? 3. Is there a change in stress, intonation, and inflection following a glossectomy?

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Speech considerations inoralsurgery361

An investigation into the connectedspeechpatterns of the glossectomeeis neededto define and characterizethe speechof this group. Possiblechangesfrom normal in stress, intonation, and inflection need to be defined. If these changesexist, a definition of their effect upon the proficiency of the speechoutput is indicated. Finally, it is well known that the laryngectomee has a number of alternative procedures available to him to restore his communicative abilities, including the artificial larynx, esophagealspeech, and prosthetic devices for those persons who are unable or unwilling to learn effective esophagealspeech. It is hoped that, with increased applied research in the areasof oral reconstructive surgery and prosthodontics, the glossectomy patient, as well as the other patients presentedin this article, will be offered the same alternatives. Portions of this article were presented in an oral oncology course at Washington University School of Dental Medicine. I thank Dr. Samir El-Mofty, Department of Pathology, for extending the invitation. REFERENCES

I. Bloomer, H., and Hawk, A.: ASHA Reports No. 8: Orofacial Anomalies: Clinical and ResearchImplication, Washington, D. C., 1973, American Speech and Hearing Association, pp. 42-61. 2. Robinson, J., and Niiranen, V. J.: Maxillofacial Prosthetics(Proceedingsof an InterprofessionalConference), Public Health Service Publication No. 1950, 1966. 3. Bloomer, H.: Observation on palatopharyngeal movements in speech and deglutition, J. Speech Hear. Disord. 18: 230-246, 1953. 4. Bloomer, H., Dingman, R., and Kemper, J.: PalatopharyngealAction in Speechand Deglutition, Motion picture distributed by Audio-Visual Education Center, University of Michigan, 1952. 5. Kipfmueller, L., and Lang, B.: Presurgical Maxillary Prosthesis:An Analysis of SpeechIntelligibility, J. Prosthet. Dent. 28: 620-625, 1972. 6. Fairbanks, Cl.: Test of PhonemicDifferentiation: The Rhyme Test, J. Acoust. Sot. Am. 30: 596-600, 1958. 7. Bradley, D. P.: Cleft Lip and Palate, ed. I, Boston, 1971, Little, Brown and Co., pp. 658669. 8. Wise, R. A., and Baker, H. W.: Surgery of the Head and Neck, ed. 3, Chicago, 1968,Year Book Medical Publishers, pp. l47- 163. 9. Duguay, M. G.: SpeechAfter Glossectomy, N.Y. State J. Med. 64: 1836-1838, 1964. IO. Goldstein, M. A.: Speech Without a Tongue, I. Speech Hear. Disord. 5: 65-69, 1940. 11. Kalfuss, A. H.: Analysis of the Speechof the Glossectomee,Dissertation, Wayne State University, 1968. 12. Massengill, R., Magwell, S., and Pickrell, K.: An Analysis of Articulation Following Partial and Total Glossectomy, J. SpeechHear. Disord. 35: 170-173, 1970. ; 13. Skelly, M.: GlossectomeeSpeechRehabilitation, ed. I, Springfield, 1973, Charles C Thomas, Publisher, pp. 65-97. 14. LaRiviere, C., Seilo, M., and Dimmick, K.: The Pretherapy Speechintelligibility of a Glossectomee,J. Comm. Dis. 7: 357-364, 1974. 15. Moore, D. J.: Glossectomy Rehabilitation by Mandibular Tongue Prosthesis, J. Prosthet. Dent. 28: 429-433, 1972. 16. Washio, H. W.: Use of a Pterygoid Muscle Sling to Provide Glossomimic Function After Total Glossectomy, Plast. Reconstr. Surg. 51: 497-500, 1973. Reprint requests to:

Dr. Jon Hufnagle Department of SpeechPathology and Audiology Illinois State University Normal. Ill. 61761