Evaluation and management of glossectomy

KUNNAMPALLIL GEJO JOHN BASLP, MASLP

Oromotor exercise

The inability to eat or to drink is not an acceptable way of living

Buset and Cremer

1992.

The speech therapist perspective

Swallowing - vegetative basic biological function of life -a necessity for survival Speech - an overlaid function - necessary for social communication The organs serving the two function is the oral cavity associated with respiratory and laryngeal systems

Swallowing rehabilitation a recent development !

Understanding swallowing physiology Evaluation of disability in objective terms Viz OPSE video fluoroscopy mod. Ba swallow Swallowing Rx Speech pathologists domain Preventing/pre-empting of Aspiration.. Learning from Quality of life perspectives .

Disability- post resection An appraisal

Impact swallowing
Bolus

preparation Bolus propulsion Bolus residue Inadequate nutrition

Aspiration

Oropharynx oral cavity

Base of tongue Tonsils Vallecula Mobile tongue

Swallowing physiology
Four Impt phases

Voluntary phase oral preparatory phase oral phase Involuntary phase pharyngeal phase esophageal phase

Oral & Pharyngeal Phases- Scope for Intervention

Swallowing process
Pharyngeal phase
Food
Tongue movement Bolus passing through esophageal area

Lateral tongue lesion

Posteior tongue lesion

Oral cancer surgical resection

Structural

deviation Functional deficits

Constant

flow of saliva Facial altered counter Impaired speech Mastication affected Interrupted airway temporarily

Surgically related Dysphagia

Dependent upon 1. Which anatomic structures are removed 2. Extent of tissue removed 3. Presence of nerve damage 4. Type of reconstruction (flap/repair/sutures)

Effect of glossectomy on swallowing

Reduced oral control with delayed oral transit times Sensory loss resulting in unwarned of position of food in mouth Reduction in lip closure leading to loss of material from the mouth Reduction in range , flexibility and strength of tongue movements

Difficulty in transferring food from the front to back of oral cavity Loss of bolus into pharynx prior to trigger of the swallow, leading to aspiration Reduced or absent chewing action resulting in long term fluid diet Nasal regurgitation or leakage, if the soft palate has been affected Lack of velopharyngeal seal resulting in insufficient intraoral pressure to assist in propelling the bolus into pharynx

 Incoordination

of swallow due to swelling and reduced sensation in pharynx Damage to cranial nerve 9, 10, 12. 11th nerve Failure of the larynx to elevate fully

Speech Therapist roleSwallowing disorder

To maximize residual function

To offer alternative feeding options

When should dysphagia management begin?

Assessment and management should be done when healing is complete without postoperative complications

SWALLOWING REHABILITATION WHEN?

Healed Wound & no e/o Fistula Preferably before RT ( Incorporate Amifostine) Continue until mucositis makes it painful( after 20GY) Maintain Nutrition all the time ( PEG ) Recommence after 4-6 weeks after Last fraction RT Continue for 6-8 months to prevent fibrosis & minimise sequel Enhance Salivary flow with Sialogogues, Pilocarpine ,

Swallowing assessment informal

Observe how the person handles secretion Examination of the structure & function of the oral structures Cough reflex Sign of aspiration Nutritional status of the patient Interest of the patient for swallowing Rx

Swallowing assessment vidiofluroscopic analysis

Modified

barium swallow Consistency of materialliquid/paste/cookie Swallow measures----- OPSE Indicates the efficiency of swallowing for all the three food materials

Treatment timing
Before radiotherapy During radiotherapy After radiotherapy Little and often practice daily Regular follow up

Deglutitory disorders TONGUE

Mild ---- < 30% resection with tongue mobility Severe --- >50% tongue resection Impairs - lingual peristalsis, antr-postr bolus movts & pharyngeal phase Increased oral phase Drooling of saliva Reduced/absent chewing action resulting in long term fluid diet

Deglutitory disorders LIPS

Minimal oral phase - reduction in lip closure - loss of material from mouth

Deglutitory disorder MANDIBLE

Severe

if combined with glossectomy Oral preparatory, oral& pharyngeal phase Difficulty in chewing Drooling

How to start management?

Explanation

effect Altered swallowing physiology Food consistency for swallowing Amount of material

of surgery and its

Reconstructed tongue after major surgery

Total glossectomy

Lower jaw cancer operated

Partial glossectomy

Postoperative view

Treatment of tongue cancer

Transoral excision

Commandoprocedure

Accumulation of saliva in the anterior part of the oral cavity

Reconstructed area

No ligual /oral tongue to lateral food

Glossectomy with lip splitting approach

Tongue flap A type of reconstruction of the defect

How to start ?
Baseline

data Medical history extent and site of resection Type of reconstruction Oral cavity structural and functional deficits

Dysphagia management
Start after decannulation Oromotor exercise Compensatory methods postural changes change in food consistency Directional maneuvers supraglottic swallow super supraglottic swallow

Dysphagia program
Information

giving about altered swallowing physiology Positive, supportive and realistic assurance Constant family support Assessment of respiratory problem Decannulation of tracheostoma

Range of motion exercises

Start early-as soon as adequate healing Ensure adequate pain control Short frequent practice sessions throughout the day-5-10 min 10 times a day Evaluate progress regularly Potential to improve for up to 3 months

Oromotor exercises tongue

Compensatory methods-5 T
Temperature Taste Total Time Texture

Swallowing therapy

Compensatory method of feeding

Feeding aids
Helps in bolus placement, manipulation &transport in oral cavity 1. Long handled feeding spoon 2. Straw 3. Sippy cup 4. Cup with cut out for nose 5. Asepto syringe & catheter

Swallowing therapy session

Hints & tips on feeding

Pick times when patient is most alert Ensure as upright and comp. position Allow plenty of time to eat and ensure a relaxed environment with no distractions is maintained Encourage patient to place food in non operated side and tilt head to this side Avoid mixed consistencies of food and drink Pay attention to food presentation

Oral hygiene
Encourage

patient to clear mouth after each swallow Carry put oral hygiene after each meal

Each morning

When awake

what will I eat today how will I prepare it how long will it take me to eat will I have to speak to anyone will others understand my speech how long to continue like this

Physicians efforts are to bring back an individual from death

whereas
The rehabilitation professionals efforts are to take him\her towards meaningful life