Accepted 4 April 2008 Published online 21 August 2008 in Wiley InterScience ( DOI: /hed.20884

Transcription

1 ORIGINAL ARTICLE SPEECH OUTCOMES AFTER SOFT PALATE RECONSTRUCTION WITH THE SOFT PALATE INSUFFICIENCY REPAIR PROCEDURE Jana M. Rieger, PhD, 1,2 Jana G. Zalmanowitz, BA, 1 Shirley Y. Y. Li, PhD, 1 Judith Lam Tang, MSc, 1,2 David Williams, MD, FRCSC, 3 Jeffrey Harris, MD, FRCSC, 3,4 Hadi Seikaly, MD, FRCSC 1,3,4 1 Institute for Reconstructive Sciences in Medicine, Edmonton, Alberta, Canada. jana.rieger@ualberta.ca 2 Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada 3 Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada 4 Division of Otolaryngology Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada Accepted 4 April 2008 Published online 21 August 2008 in Wiley InterScience ( DOI: /hed Abstract: Background. Measurement of functional outcomes related to different methods of soft palate reconstruction is necessary to determine efficacy of surgical intervention after resection for oropharyngeal cancer. Methods. Speech data were collected across 4 evaluation times for 4 groups of patients (2 groups consisted of patients with half the soft palate resected followed by conventional reconstruction; 2 groups consisted of patients with half or more of the soft palate resected followed by reconstruction with an adhesion or the soft palate insufficiency repair (SPIR). Results. Sixty-two patients were included. Speech was preserved when conventional reconstructive procedures were used to close smaller defects. For larger defects, reconstruction with an adhesion resulted in poorer speech outcomes than the SPIR. The SPIR group achieved normal speech results at all points of evaluation. Conclusions. The results demonstrate that the SPIR is emerging as an efficacious surgical technique for reconstruction of larger soft palate defects. VC 2008 Wiley Periodicals, Inc. Head Neck 30: , 2008 Keywords: speech; oropharynx; head and neck cancer; soft palate reconstruction; radial forearm free flap; resonance; nasalance; velopharyngeal orifice area; functional outcomes Correspondence to: J. M. Rieger Grant sponsor: Alberta Heritage Foundation for Medical Research. VC 2008 Wiley Periodicals, Inc. With cure and survival being at the forefront of treatment planning for patients with head and neck cancer, the goal of maintaining function has become increasingly important. This is especially salient in the treatment of oropharyngeal cancer given that, physiologically, the oropharynx plays important roles in respiration, deglutition, and speech. Specifically, dysfunction of the soft palate has a negative impact on speech, resulting in reduced intelligibility, hypernasality, and nasal air emission. The assessment of speech function after surgical reconstruction of the soft palate has been based on informal observation 1 5 and intelligibility assessments Although these studies provide useful information on intelligibility of speech, they do not report on acoustic and aeromechanical data related to the speech signal, which provide extra insight into the function of the soft palate during speech. 12 A previous study completed by Seikaly and colleagues 13 revealed that palatal reconstruction yielded close-to-pretreatment levels of intelligibility for most patients. However, Functional Outcomes after Soft Palate Repair HEAD & NECK DOI /hed November

2 acoustical and aeromechanical measures of speech were abnormal in patients with larger resections, indicating that the quality (ie, resonance) of the speech signal was abnormal. Abnormal quality of the speech signal negatively impacts listeners judgments about personal characteristics of such patients. 14 Thus, the surgical challenge is to reconstruct the palatopharyngeal sphincter in such a way that not only normal intelligibility is established, but also normal acoustic and aeromechanic regulation of speech. There is acknowledgement that type and technique of flap inset make a difference in functional outcome. 2,8 In 2003, our team reported on 18 patients who underwent oropharyngeal reconstruction between January 1998 and March 2001, and identified that there was a subgroup of patients (ie, those with ½ the soft palate resected) for whom palatal reconstruction was not entirely successful. 13 Since that time, reconstructive procedures were altered in response to those findings. The intent of the present study is to report prospectively collected acoustic, aeromechanical, and perceptual outcomes in patients with larger defects of the soft palate who underwent oropharyngeal reconstruction since our last report. MATERIALS AND METHODS Subjects. Seventy-eight consecutive patients treated for oropharyngeal cancer by primary resection and reconstructive surgery between May 2001 and June 2006 were followed in a prospective manner through our interdisciplinary Head and Neck Surgery Functional Assessment Clinic. Patients received postoperative radiation therapy (RT) at 1 institution when indicated. No patient received speech therapy or prosthetic intervention during the time of follow-up. Resection and Reconstruction. All patients had involvement of the soft palate, lateral pharyngeal wall, base of tongue, or some combination thereof. Patients were excluded from the study if resection included any of the oral cavity or oral tongue. A lip split and presymphyseal mandibulotomy allowed for access to the oropharynx for resection and reconstruction. When microvascular free flap transfer was planned, all patients underwent reconstruction with a radial forearm free flap (RFFF). Four groups of primary surgical reconstructive procedures were undertaken. The choice of surgical procedure used for any particular patient was based on professional judgment of the head and neck reconstruction team. Factors that influenced the choice of surgical procedure included extent of soft palate defect, evidence from previous functional outcome reports, 13 and clinical update reports of functional outcomes in our patient population. The method of surgical procedure for soft palate reconstruction was stratified into 4 groups as follows: 1. ½ full thickness defect with soft palate insufficiency repair (SPIR): RFFF is folded on itself and then inset into the defect re-creating the anatomic relations of the soft palate, resulting in a large adynamic neo-pharyngeal isthmus. The SPIR modification includes incising the dermis along the free edge of the folded RFFF. Incisions are made on the lateral and posterior pharyngeal walls and small subdermal and submucosal flaps are elevated on either side of these incisions. These flaps are then sutured to the free edge of the folded RFFF in a series of steps, resulting in a 2 layer closure of the nasopharyngeal defect and leaving only a small nasopharyngeal port on 1 side ½ full thickness defect with adhesion: RFFF is folded on itself and sutured to the nasal and oral surfaces. A 1-cm adhesion to the mucosa of the posterior pharyngeal wall is then fashioned. 3. ¼ to ½ full thickness defect: The superior constrictor and overlying mucosa are elevated and attached to the remaining posterior aspect of the soft palate in a tension-free closure, followed by draping of a RFFF over the exposed superior constrictor muscle and suturing to the surrounding mucosa. 4. ¼ or less partial thickness defect: RFFF is used to close the defect in the oral surface of the soft palate. Data Collection. Informed consent was obtained from each patient as part of routine clinical procedure, prior to treatment. Ethical approval to report patient outcomes was obtained from the Health Research Ethics Board at the University of Alberta. Relevant patient and tumor information was collected prospectively. The location and extent of tissue resected, including the percentage of base of tongue and soft palate resected, were made at the time of surgery and noted in surgical reports. Speech outcome assessments were conducted by 2 speech language pathologists at 1 medical facility, according to a standard clinical 1440 Functional Outcomes after Soft Palate Repair HEAD & NECK DOI /hed November 2008

3 protocol. The assessments occurred at 4 points in time: preoperatively (preoperative), approximately 1 month postoperatively before the initiation of RT (early postoperative), approximately 6 to 9 months postoperatively allowing for the completion of RT in those patients who required such (mid postoperative), and finally at approximately 1 to 1.5 years postoperatively (final postoperative). Acoustical, aeromechanical, and perceptual assessments of speech were collected via the Nasometer (model 6200, KayPentax, Pine Brook, NJ), the PERCI-SARS (Microtronics Corporation, 1999), and the Computerized Assessment of Intelligibility of Dysarthric Speech (CAIDS) (Pro- Ed, Austin, Texas), respectively. The Nasometer was utilized to measure resonance balance, the PERCI-SARS was used to estimate the area of the velopharyngeal orifice during speech, and the C-AIDS was used to assess intelligibility. The reader is referred to previous descriptions of the use of these tools for assessing speech Statistical Analysis. Descriptive statistics were produced for each group of patients at each point in time. In addition, a repeated-measures multivariate analysis of covariance (MANCOVA) was used to analyze any changes in the speech outcome measures in the SPIR group across the 4 evaluation times. There were 3 dependent variables included in the speech outcomes: nasalance (%); velopharyngeal orifice (VPO) opening during production of the word papa (mm 2 ); and sentence intelligibility scores (%). Because resection of the base of tongue occurred together with resection of the soft palate and potentially could influence the intelligibility results, the degree of base of tongue resected was entered into the MAN- COVA as a covariate with 5 levels (0%,25%,50%, 75%, and 100%). Statistical analyses were performed using SPSS (V. 14) and an alpha level of.05 was used in the study. Table 1. Patient characteristics in the present study (N 5 62). Characteristics Frequency Age, y* 56.7 (33 82) Sex Male 48 Female 14 Postoperative RT (no.) Yes 58 No 4 Surgical Group ½ full thickness defect with SPIR 10 ½ full thickness defect with adhesion 10 ¼ or less partial thickness defect 22 ¼ to ½ full thickness defect 20 T classification T1 3 T2 18 T3 34 T4 5 Unknown 2 % soft palate resected % base of tongue resected *Mean (range). RESULTS Of the 78 patients who were referred to our clinic for functional assessments, 16 were excluded from this study because of the involvement of structures of the oral cavity such as the anterior portion of the tongue. Therefore, 62 patients participated in the present study, and their characteristics are summarized in Table 1. The average age in the patient group was 56.7 years. The group comprised 48 (77%) males and 14 (23%) females. Ninety-four percent of the patients received postoperative RT. Approximately 48% of the patients had less than half of the soft palate resected, while the remaining 52% had half or more resected. With respect to base of tongue resection, approximately 71% had less than half of the base of tongue resected; the remaining 29% had larger resections of the base of tongue. Actual times of speech data collection varied around the 4 reference time points due to issues that included patient health, patient location, and response to scheduled appointments such that the average time that patients were seen preoperatively was 18 days before surgery (ranging from 1 to 43 days), 45 days after surgery for the early postoperative visit (ranging from 21 to 122 days), 184 days postoperatively for the mid postoperative visit (ranging from 117 to 241 days), and 398 days postoperatively for the final postoperative visit (ranging from 276 to 605 days). Speech data were available at the preoperative time for 58 patients, at the early postoperative time for 52 patients, at the mid postoperative time for 49 patients, and at the final postoperative time for 45 Functional Outcomes after Soft Palate Repair HEAD & NECK DOI /hed November

4 patients. Missing data points were due to either patient attrition (ie, death, moving to a location away from the primary treatment center, or refusal to participate), or missed appointments. In addition, 4 (ie, 3 from surgical group 3; 1 from surgical group 4) of the 62 patients had not reached their final postoperative assessment time at the time of data analysis for this study. Descriptive statistics for the 3 speech outcome measures across 4 evaluation times for the 2 patient groups that had defects encompassing half of the soft palate are presented in Table 2. All speech outcomes fall within normal clinical limits for both groups across all 4 assessment times. Descriptive statistics for the 3 speech outcome measures across 4 evaluation times for the 2 patient groups that had defects half of the soft palate are presented in Table 3. The results for these groups revealed that mean postsurgical nasalance scores in the group of patients who had reconstruction with an adhesion extended 2 standard deviations above the upper limit of normal reference data. This was not seen in the patients who underwent reconstruction with a SPIR. Mean nasalance data in the group of patients who underwent reconstruction with a SPIR fell within 1 standard deviation of the upper limit of normal reference data. Velopharyngeal orifice area was within normal limits at all points except for at the final postoperative assessment in patients who had an adhesion. Sentence intelligibility results were within normal limits for both groups with larger palatal reconstructions. The repeated-measures MANCOVA did not reveal any significant differences in speech outcome measures across the 4 evaluation times in the group of patients reconstructed with a SPIR. DISCUSSION The present study evaluated prospectively collected perceptual, acoustical, and aeromechanical speech outcomes at 4 points in treatment for patients diagnosed and treated for oropharyngeal carcinoma. The results from the perceptual measure reveal that a patient s connected speech intelligibility after surgery can consistently achieve preoperative levels. On the other hand, the acoustic (nasalance score) and aeromechanical measures (velopharyngeal orifice area) suggest that certain methods of reconstruction of the soft palate may not completely restore the palatopharyngeal system to a preoperative level of function for speech in some individuals. The Table 2. Functional outcomes for patients with half the soft palate resected. Nasalance (%) VPO/(mm 2 ) Sentence intelligibility (%) Time ¼ partial thickness defect X(n) 12.9 (19) 13.3 (14) 14.5 (18) 16.8 (19) 0.4 (20) 1.8 (14) 1.0 (18) 1.1 (16) 99.4 (19) 96.7 (14) 96.6 (18) 96.1 (16) ¼ to ½ full thickness defect X(n) 15.1 (18) 20.0 (17) 15.9 (16) 14.3 (13) 0.3 (17) 4.7 (16) 3.1 (16) 2.5 (11) 98.1 (18) 92.1 (15) 88.6 (17) 92.4 (12) Normal mean range 17,21, % (Average SD 5 4.8) mm 2 >90% Abbreviation: VPO; velopharyngeal orifice. X(n) indicates mean values (number of patients completing the assessment) for that time period Functional Outcomes after Soft Palate Repair HEAD & NECK DOI /hed November 2008

5 Table 3. Functional outcomes for patients with half the soft palate resected. Nasalance (%) VPO/(mm 2 ) Sentence intelligibility (%) Time SPIR X(n) 12.1 (9) 18.6 (10) 17.3 (8) 18.5 (6) 0.9 (10) 2.8 (10) 2.1 (8) 1.4 (7) 99.6 (9) 93.8 (9) 98.7 (7) 93.2 (6) Adhesion X(n) 15.3 (10) 26.5 (9) 28.5 (5) 33.9 (8) 0.6 (10) 1.8 (9) 4.8 (5) 10.3 (8) 99.5 (10) 96.0 (9) 96.8 (5) 98.3 (7) Normal mean range 17,21, % (Average SD 5 4.8) mm 2 >90% Abbreviation: VPO; velopharyngeal orifice. X(n) indicates mean values (number of patients completing the assessment) for that time period. acoustic and aeromechanical results appear to be dependent on the extent of resection and the type of surgical reconstruction performed. For individuals with smaller resections (ie, less than half of the soft palate) and therefore less extensive reconstructions, the acoustic and aeromechanical results were within normal limits. These findings confirm results from an earlier publication. 13 However, for individuals who had resection of the soft palate that was more extensive (ie, than half of the soft palate), the acoustic and aeromechanical data revealed differences between surgical reconstructive techniques. An overview of the clinical significance of the findings of this research is important in understanding the efficacy of the different surgical techniques for reconstruction of the soft palate. Clinically, nasalance scores that fall in the high 20s or above are likely indicative of mild to moderate oral nasal distortion that will be perceived by a listener. 19,20 Normative reference data for nasalance values in individuals between the ages of 45 to 64 from Western Canada reveal a mean of 12.8% (SD 5 5.1). 21 Preoperatively, the mean nasalance values across all surgery groups in the present study fell within 61 SD of the mean, well below the suggested level at which listeners would detect a notable oral nasal balance distortion. In the postoperative stages, the mean nasalance scores were elevated to a clinically significant level in only 1 surgical group those who had ½ full thickness defects with an adhesion. Similar clinically significant issues exist for the aeromechanical results. Normal VPO area values range between 0 and 5 mm Velopharyngeal orifice areas between 10 and 20 mm 2 and above have been shown to lead to judgments of hypernasal speech during non-nasal consonant production. 22,23 During non-nasal consonant production in the present study, the only group that showed signs of abnormal VPO areas postoperatively was that in which individuals were reconstructed with a flap and adhesion. The acoustic and aeromechanical speech results not only point to the challenge of reconstructing larger defects of the soft palate, but also demonstrate the efficacy of the SPIR reconstruction for such defects. Patients who underwent reconstruction with the SPIR technique had normal mean group values for nasalance and VPO at all measurement points in time. With respect to intelligibility, all mean values fell within a clinically acceptable range for all groups across all assessment times. The lowest group mean score across the 4 evaluation times Functional Outcomes after Soft Palate Repair HEAD & NECK DOI /hed November

6 was 88.6% intelligibility of connected speech at the mid post-operative evaluation time for the ¼ to ½ full thickness defect group. This value improved to 92.4% for that group at the final assessment time. These results are substantial in that they point to the importance of using other measures than simply intelligibility to rate the success of speech outcomes when the velopharyngeal system is in question. If instrumental assessment of the acoustic nature of speech is not available then, at the least, researchers should strive to report impressions using standardized perceptual evaluations of resonance. One acknowledged weakness of this study relates to how patients were grouped. Although speech outcome measures were collected prospectively, categorization into surgical groups was based on professional judgment rather than random assignment or specific algorithms for treatment. Related to this was the fact that group numbers for the statistical analyses of the SPIR technique were small. Finally, as with many studies that consider this patient population, there were missing data at each measurement point in time. CONCLUSION Reconstruction of resections that encompass half or more than half of the soft palate has proven to be more challenging than reconstruction of smaller defects. The challenge to the reconstructive surgeon is to restore function so that not only intelligibility of speech, but also quality of the speech signal is reinstated. Initially, reconstructions of larger defects of the soft palate at our institution were performed with an adhesion between the folded edges of the microvascular free flap. This method of reconstruction was abandoned when functional outcomes data did not support its efficacy. 13 Therefore, adhesions were abandoned and the SPIR was conceived.thespirisnowprovingtobeanefficacious surgical treatment for restoration of acoustic, aeromechanical, and perceptual aspects of speech function in individuals facing larger resections of the soft palate. REFERENCES 1. Zohar Y, Buler N, Shvilli Y, Sabo R. Reconstruction of the soft palate by uvulopalatal flap. Laryngoscope 1998; 108(1 Part 1): Gillespie MB, Eisele DW. The uvulopalatal flap for reconstruction of the soft palate. Laryngoscope 2000;110: Zeitels SM, Kim J. Soft-palate reconstruction with a SCARF superior-constrictor advancement-rotation flap. Laryngoscope 1998;108(8 Part 1): Moore BA, Magdy E, Netterville JL, Burkey BB. Palatal reconstruction with the palatal island flap. Laryngoscope 2003;113: Sinha UK, Young P, Hurvitz K, Crockett DM. 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