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1 ORIGINAL ARTICLE BLOWING RATIO AS AN EVALUATION TOOL FOR VELOPHARYNGEAL FUNCTION AFTER ORAL AND OROPHARYNGEAL CANCER RESECTION Chieri Katoh, 1 Miki Saitoh, MD, 1 Miki Tsuneyuki, 1 Hitoshi Tanimoto, MD, 1 Kazunobu Hashikawa, MD, 2 Shinya Tahara, MD, 2 Naoki Otsuki, MD, 1 Ken-ichi Nibu, MD 1 1 Department of Otolaryngology-Head and Neck Surgery, Kobe University Graduate School of Medicine, Kobe, Japan. nibu@med.kobe-u.ac.jp 2 Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan Accepted 28 August 2009 Published online 1 December 2009 in Wiley InterScience ( DOI: /hed Abstract: Background. Our objective was to evaluate the value of the blowing test to measure the speech and swallowing function after resection of oral or oropharyngeal cancer. Methods. Speech and swallowing functions of the patients after surgical resection of oral or oropharyngeal cancer were assessed by a speech intelligibility test, blowing time, questionnaires, and oropharyngeal pressures. Blowing time (pressure) ratio was determined by dividing blowing time (pressure) with open nose by blowing time (pressure) with closed nose. Results. Blowing time ratio had significant correlation with blowing pressure ratio (p ¼.014), score of speech intelligibility test (p ¼.0014), questionnaire for aspiration (p ¼.029), nasopharyngeal backflow (CC ¼ 0.676, p ¼.032), amount of food to swallow (p ¼.037), and oropharyngeal pressure during swallowing (p ¼.024). Conclusion. The present results demonstrated the value of blowing time ratio as a simple objective tool for speech and swallowing ability related to velopharyngeal function after resection of oral and oropharyngeal cancers. VC 2009 Wiley Periodicals, Inc. Head Neck 32: , 2010 Correspondence to: K.-i. Nibu This work was presented at Collegium Oto-Rhino-Laryngologicum Amicitiae Sacrum 2008, on August 26, 2008 in Berlin, Germany. VC 2009 Wiley Periodicals, Inc. Keywords: blowing; ratio; velopharyngeal; oral cancer; oropharyngeal cancer; swallowing; speech Despite recent advances in reconstructive surgery, 1 speech and swallowing dysfunction due to velopharyngeal inadequacy still remains a serious issue after resection of oral and oropharyngeal cancers. Thus, it is very important to precisely evaluate the velopharyngeal function in the patients who had surgical resection of oral or oropharyngeal cancer, to plan a rehabilitation program for individual patients 2 and to develop more sophisticated surgical techniques for these cancers. 3,4 To date, various measures have been proposed to assess velopharyngeal function, such as stainless mirror, video-endoscopy, 5 fluoroscopy, 6 speech production measures, 7 sound analyzer, 8 electromyogram, 9 and questionnaires. 10,11 However, all of these have some drawbacks, such as being subjective (not objective), being qualitative (not quantitative), being time-consuming, or 1012 Blowing Ratio for Velopharyngeal Function HEAD & NECK DOI /hed August 2010

requiring special equipment. The blowing test has been used as a simple tool to evaluate velopharyngeal function of the patients with cleft palates in Japan.

2 requiring special equipment. The blowing test has been used as a simple tool to evaluate velopharyngeal function of the patients with cleft palates in Japan. 12 In this test, patients are asked to blow into a plastic drinking straw placed in a transparent glass filled with water. Therapeutic effects of rehabilitation or surgical treatment for individual patients are commonly determined by comparing the pretreatment and posttreatment duration of blowing. The respiratory driving pressure can be directory proportionally by determining the precise depth to which the distal end of the straw is submerged when pressure delivered to the straw is just able to create a bubble that will rise to the surface of the water. 13 In this study, to explore the value of a blowing test as a simple objective tool to measure the velopharyngeal function of patients with oral and oropharyngeal cancers, we evaluated speech and swallowing functions related to velopharyngeal pressures using a blowing test and various tools, including speech intelligibility test, oropharyngeal pressure, and questionnaires. Correlation between the results of a blowing test and those of other measures were statistically analyzed. PATIENTS AND METHODS Speech, swallowing, and blowing function of the patients who had surgical treatment for oral or oropharyngeal cancer at Kobe University Hospital between 2001 and 2007 were assessed by various methods. For the speech intelligibility test, patients were asked to pronounce 100 Japanese phonemes. Recorded voices were evaluated independently by 5 professional speech therapists. 14 Velopharyngeal function was examined using endoscopy in all cases. In the blowing test, after several times for practice, patients were asked to softly blow air through a drinking straw placed in bottled water with and without pinching their nostrils. The distal end of the straw was placed exactly 5 cm below the surface of the water (Figure 1). Duration of blowing at each session (blowing time) was recorded and blowing time ratio was obtained by dividing blowing time with open nose by blowing time with closed nose. Oropharyngeal pressures during pronouncing /ki/, /ke/, /ka/, /ko/, /ku/, /ni/, /ne/, /na/, /no/, and /nu/, swallowing a small amount of water and blowing were also measured using a 4 channel manometer (POLYGRAF ID, Medtronic, Minneapolis, MN) in the patients with oropharyngeal cancer (Figure 2). All pressures were measured with and without pinching their nostrils. Pressure ratio for the respective procedure was obtained by dividing oropharyngeal pressure with open nose by oropharyngeal pressure with closed nose. Patients were also asked to answer questionnaires related to speech (Hirose s 10-point scoring system for Speech Ability, Table 1) 15 and swallowing (Swallowing Ability Scale, 16 Table 2). Correlations between blowing time ratio and scores of other measures were statistically analyzed using Pearson s correlation coefficient test. All the procedures in this study were approved by Kobe University Ethical Committee and were FIGURE 1. Blowing test. After several times for practice, patients were asked to softly blow air into the drinking straw placed in a bottle of water as long as they can, first in a normal condition, and then while pinching their nose. The tip of the drinking straw (diameter: 6 mm; length: 240 mm) was placed exactly 5 cm below the surface of the water. Blowing Ratio for Velopharyngeal Function HEAD & NECK DOI /hed August

3 FIGURE 2. Oropharyngeal pressure. Oropharyngeal pressures while pronouncing /ki/, /ke/, /ka/, /ko/, /ku/, /ni/, /ne/, /na/, /no/, /nu/, swallowing a small amount of water and blowing were measured using 4 channel manometer (POLYGRAF ID, Medtronic, Minneapolis, MN) in the patients with oropharyngeal cancer. All pressures were measured with and without pinching nostrils. Pressure ratio for respective procedure was obtained by dividing oropharyngeal pressure with open nose by oropharyngeal pressure with closed nose. performed with written informed consent from the patients. In total, 62 patients participated in this study. Forty-four patients were men and 18 patients were women. Average age was 66.4 years old, ranging from 35 to 83 years. Forty-five patients had oral cancers and 17 patients had oropharyngeal cancers (Table 3). All the patients had the speech intelligibility test, blowing test, and answered questionnaires. No patient had difficulty in sealing their lips, which may influence directing pressures. Oropharyngeal pressures during pronouncing, swallowing, and blowing were measured in 10 patients with oropharyngeal cancer. Ten healthy volunteers participated in this study as normal controls. The average age of the volunteers was 35.1 years old, ranging from 26 to 53 years. Four were men and 6 were women. RESULTS Table 1. Hirose s scoring system for speech ability. Factor A, by family B, by others 1. Clearly understood 5 points 5 points 2. Occasionally 4 points 4 points misunderstood 3. Understood only when 3 points 3 points subject is known 4. Occasionally understood 2 points 2 points 5. Never understood 1 point 1 point Scoring (A þ B) Intelligibility 8 10 points Excellently intelligible speech 5 7 points Moderately intelligible speech 4 points Poorly intelligible speech Blowing Time Ratio. The scores of the speech intelligibility test of the patients ranged from 18 to 98, with an average of The scores of Hirose s 10-point Scoring System for Speech Ability ranged from 5 to 10, with an average of 8.7. Blowing times with closed nose and with open nose of the patients ranged from 3 to 61 and from 0.5 to 57, with an average of 19.9 and 16.9, respectively. Since the blowing time ranged widely, we decided to use blowing time ratio instead of raw value of blowing time for further analyses. Blowing time ratios of the patients ranged widely from 0.03 to 1.25, with an average of 0.82, while blowing time ratios of the volunteers fell within a narrow range from 0.79 to 1.3, with an average of 0.94 (Figure 3A). Significant difference was observed in the blowing time ratio between patients with oral cancer and patients with oropharyngeal cancer (p ¼.015), but not between volunteers and patients with oral cancer (p ¼.453; Figure 3B). Table 2. Swallowing Ability Scale (deglutition score). 1. Does a part of food remain in the mouth after swallowing? (residue) 2. Do you have a limitation on amount of food to swallow? (feeding) 3. Does a part of food go down into your throat before you begin to swallow? (holding) 4. Does a part of food flow into your nose? (reflex) 5. Do you choke on food you are trying to swallow? (aspiration) 1014 Blowing Ratio for Velopharyngeal Function HEAD & NECK DOI /hed August 2010

4 Table 3. Distribution of the patients according to the primary sites. Primary site Subsite No. of patients Oral Cavity Tongue 37 Buccal mucosa 3 Oral floor 2 Retromolar trigone 2 Gingiva 1 Oropharynx Lateral wall 11 Soft palate 4 Base of tongue 1 Posterior wall 1 Significant correlation was observed between the overall scores of the speech intelligibility test and blowing time ratio (0.398; p ¼.0003). Particularly, the blowing test had strong correlation with the scores of the speech intelligibility test of plosive sounds (/p/, /t/, /k/), but not with those of the nasal sounds (/m/, /n/; Table 4). Similarly, marginal significance was observed between the blowing time ratio and Hirose s 10-point Scoring System for Speech Ability (Table 4). Oropharyngeal Pressure. Oropharyngeal pressures during swallowing ranged from 0 to 81, with an average of The blowing pressures also ranged widely, as was the case with blowing times. Oropharyngeal pressure during blowing with nose closed and with nose open ranged from 7 to 79 (average 24.3) and from 0 to 67 (average 16), respectively. Blowing pressure ratio ranged from 0.15 to 1.53, with an average of As might be expected, strong correlation was observed between the blowing time ratio and blowing pressure ratio (correlation coefficient 0.743; p ¼.014; Figure 4). Average oropharyngeal pressure ratio during pronouncing /k/ and /n/ were 0.64 (ranging from ) and 0.21 (ranging from 0 1.0), respectively. As for /k/, significant correlation was observed between the oropharyngeal pressure ratio during pronouncing and score of the FIGURE 3. Blowing time ratio of control and patients. (A) Blowing time ratios of control and patients. Blowing time ratio was obtained by dividing blowing time with open nose by blowing time with closed nose. Blowing time ratios of the patients ranged widely from 0.03 to 1.25, with an average 0.82, while blowing time ratios of the control group fell within a narrow range with an average of 0.94, ranging from 0.79 to 1.3. (B) Blowing time ratios of control and patients with oral cancer and patients with oropharyngeal cancer. Significant difference was observed in the blowing time ratio between patients with oral cancer and patients with oropharyngeal cancer (p ¼.015), but not between control and patients with oral cancer (p ¼.453). OC, patients with oral cancer; OPC, patients with oropharyngeal cancer. [Color figure can be viewed in the online issue, which is available at Blowing Ratio for Velopharyngeal Function HEAD & NECK DOI /hed August

5 Table 4. Blowing time ratio and speech ability. Speech intelligibility test Monosyllable Correlation coefficient p value Plosive sounds /p/ /t/ /k/ Nasal sounds /m/ /n/ Overall 100 syllables Hirose s Scoring System speech articulation test (correlation coefficient 0.787, p ¼.036), but not in the case with /n/ (correlation coefficient 0.558; p ¼.193). FIGURE 4. Correlation between blowing time ratio and blowing pressure ratio. Oropharyngeal pressure during blowing with closed nose and with open nose ranged from 7 to 79 (average 24.3) and from 0 to 67 (average 16), respectively. Blowing pressure ratio ranged from 0.15 to 1.53, with an average of Strong correlation was observed between the blowing time ratio and blowing pressure ratio (correlation coefficient 0.743; p ¼.014). Swallowing Function and Blowing Test. Finally, we examined the value of the blowing test on swallowing function. As shown in Table 5, blowing time ratio had strong correlations with feeding (limited amount to swallow), reflex (nasopharyngeal backflow), and aspiration. Blowing pressure ratio also had a significant correlation with feeding. Oropharyngeal pressure showed strong significant correlations with feeding, reflex, and aspiration (Table 5). In addition, there was a significant correlation between blowing time ratio and oropharyngeal pressure during swallowing (correlation coefficient 0.506; p ¼.024; Figure 5). DISCUSSION In this study, we examined the value of the blowing test as a simple tool for postoperative speech and swallowing function, especially related to velopharyngeal inadequacy after surgical resection for oral or oropharyngeal cancer. In a clinical setting, blowing time has been usually used in order to record the velopharyngeal function of the patients with a cleft palate. 12 However, blowing time differs greatly from individual to individual due to physical condition or individual variation, as shown in this study. For this reason, we failed to find any significant correlation when we used raw values of blowing time for analyses. To solve this problem, in this study we decided to apply the idea of blowing ratio, the ratio of blowing time with open nostrils to that with closed nostrils, which was first proposed by Ainoda et al 17 as a simple clinical measure of velopharyngeal function in the cleft palate. As we expected, blowing time ratios of normal volunteers converged to around 1.0. Both blowing time ratios and blowing pressure ratios of the patients fell within 0 to 2. In addition, we found that blowing time ratio had strong significant correlation with blowing pressure ratio. Table 5. Blowing ratio and swallowing function. Questions Blowing time ratio Blowing pressure ratio Oropharyngeal pressure during swallowing water C.C. p value C.C. p value C.C. p value Question 1. (residue) Question 2. (feeding) Question 3. (holding) Question 4. (reflex) Question 5. (aspiration) Abbreviations: CC, correlation coefficient. See Table 2 for questions 1 to Blowing Ratio for Velopharyngeal Function HEAD & NECK DOI /hed August 2010

6 FIGURE 5. Correlation between blowing time ratio and oropharyngeal pressure during swallowing. Significant correlation was observed between blowing time ratio and oropharyngeal pressure during swallowing (correlation coefficient 0.506; p ¼.024). In addition, statistical analysis did not show significant difference in the blowing time ratio between the volunteers and those of patients with oral cancer. On the other hand, a significant difference was observed in the blowing time ratio between patients with oropharyngeal cancer and patients with oral cancer. These suggest that, in general, blowing time ratios were not affected by the surgical procedures in the oral cavity. Although some patients with oral cancer had partial resection of oropharynx due to tumor extension, which led to poor oropharyngeal function and low scores of blowing time ratio as shown in Figure 3B. These findings further suggest that the blowing ratio corrects the individual variation of the blowing test and does quantitatively reflect the velopharyngeal function during blowing. For speech ability, the blowing time ratio had significant correlation with the scores of the speech articulation test and Hirose s 10-point scoring system. Especially, the blowing time ratio had a strong correlation with scores of pronouncing plosive sounds which require adequate velopharyngeal function. Also, strong correlation was observed between the scores of speech articulation test of K and oropharyngeal pressure ratio during pronouncing k. These findings further indicate that the blowing time ratio quantitatively reflects the velopharyngeal function for speech. The velopharynx closes during swallowing and pneumatic activities such as speech and blowing. There has been criticism that velopharyngeal closure for blowing and speech should be distinguished from that for swallowing, 18 since the power frequency of electromyogram signals during swallowing is significantly greater than those of blowing and speech. 9 In fact, in accordance with their findings, oropharyngeal pressures during swallowing were significantly higher than those of blowing and speech in the present study. Nevertheless, we found a strong correlation between blowing time ratio and oropharyngeal pressures during swallowing. Blowing time ratio also had strong correlation with the questionnaire for swallowing functions, limited amount to swallow, nasopharyngeal backflow, and aspiration. These findings suggest another value of blowing time ratio as a tool to measure velopharyngeal function for swallowing. In conclusion, present results demonstrated the validity of the blowing test as a simple objective tool for velopharyngeal function for swallowing and speech of the patients with oral and oropharyngeal cancers. From another point of view, findings in the present study remind us that the velopharyngeal dysfunction has great responsibility for speech and swallowing after oral and oropharyngeal cancer resection. We believe that widespread use of this measure at clinical practice for head and neck cancers will provide further benefits for patients who need surgical treatment for oral and/or oropharyngeal cancers. Acknowledgment. Ken-ichi Nibu is the principal investigator of this study and independent of any commercial funder. Ken-ichi Nibu had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. REFERENCES 1. Kimata Y, Sakuraba M, Namba Y, Hayashi R, Ebihara S. Functional reconstruction with free flaps following ablation of oropharyngeal cancer. Int J Clin Oncol 2005; 10: Jäghagen EL, Bodin I, Isberg A. Pharyngeal swallowing dysfunction following treatment for oral and pharyngeal cancer association with diminished intraoral sensation and discrimination ability. Head Neck 2008;30: Kimata Y, Sakuraba M, Hishinuma S, et al. Analysis of the relations between the shape of the reconstructed tongue and postoperative functions after subtotal or total glossectomy. Laryngoscope 2003;113: Hashikawa K, Tahara S, Terashi H, et al. Positive narrowing pharyngoplasty with forearm flap for functional restoration after extensive soft palate resection. Plast Reconstr Surg 2005;115: Honjo I, Mitoma T, Ushiro K, Kawano M. Evaluation of velopharyngeal closure by CT scan and endoscopy. Plast Reconstr Surg 1984;74: Kato H, Miyazaki T, Sakai M, et al. Videofluoroscopic evaluation in oropharyngeal swallowing after radical Blowing Ratio for Velopharyngeal Function HEAD & NECK DOI /hed August

7 esophagectomy with lymphadenectomy for esophageal cancer. Anticancer Res 2007;27: Pinto JH, da Silva Dalben G, Pegoraro-Krook MI. Speech intelligibility of patients with cleft lip and palate after placement of speech prosthesis. Cleft Palate Craniofac J 2007;44: Ainoda N, Okazaki K. Results of systematic speech sound monitoring in children with cleft palate. Folia Phoniatr Logop 1996;48: Nohara K, Kotani Y, Ojima M, Sasao Y, Tachimura T, Sakai T. Power spectra analysis of levator veli palatini muscle electromyogram during velopharyngeal closure for swallowing, speech, and blowing. Dysphagia 2007; 22: Suarez-Cunqueiro MM, Schramm A, Schoen R, et al. Speech and swallowing impairment after treatment for oral and oropharyngeal cancer. Arch Otolaryngol Head Neck Surg 2008;134: Thomas L, Jones TM, Tandon S, Katre C, Lowe D, Rogers SN. An evaluation of the University of Washington Quality of Life swallowing domain following oropharyngeal cancer. Eur Arch Otorhinolaryngol 2008;265 Suppl 1:S Hoshikawa H, Goto R, Karaki M, Miyabe K, Mori N. Clinical analysis of velopharyngeal incompetence in patients with folded pharyngeal flap. [Article in Japanese] Nippon Jibiinkoka Gakkai Kaiho 2003;106: Hixon TJ, Hawley JL, Wilson KJ. An around-the-house device for the clinical determination of respiratory driving pressure: a note on making simple even simpler. J Speech Hear Disord 1982;47: Kuroda H, Inoue K, Amatsu M. Evaluation of speech function after mesopharyngeal reconstruction with radial forearm flap. Kobe J Med Sci 2000;46: Ikema Y, Tsukuda K, Mochimatsu I, et al. Articulatory function in patients receiveing glossectomy followed by reconstruction with a recto-abdominal myocutanous free flap. [Article in Japanese] Nippon Jibiinkoka Gakkai Kaiho 1996;99: Fujimoto Y, Matsuura H, Kawabata K, Takahashi K, Tayama N. Assessment of Swallowing Ability Scale for oral and oropharyngeal cancer patients. [Article in Japanese] Nippon Jibiinkoka Gakkai Kaiho 1997;100: Ainoda N, Suzuki S. Blowing ratio as a diagnostic measure of velopharyngeal function in the cleft palate patietns. Jpn J Logoped Phoniatr 1978;19: Shprintzen RJ, Lencione RM, McCall GN, Skolnick ML. A three dimensional cinefluoroscopic analysis of velopharyngeal closure during speech and nonspeech activities in normals. Cleft Palate J 1974;11: Blowing Ratio for Velopharyngeal Function HEAD & NECK DOI /hed August 2010

Accepted 4 April 2008 Published online 21 August 2008 in Wiley InterScience (www.interscience.wiley.com). DOI: /hed.20884

Accepted 4 April 2008 Published online 21 August 2008 in Wiley InterScience (www.interscience.wiley.com). DOI: /hed.20884 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