Optimizing Outcomes following Total and Subtotal Tongue Reconstruction: A Systematic Review of the Contemporary Literature

Abstract

More than 45,000 Americans are diagnosed with oropharyngeal cancer annually and multimodal treatment often requires wide excision, lymphadenectomy, chemotherapy, and radiation. Total and subtotal lingual resection severely impairs speech, swallow, and quality of life (QoL). This study investigates functional outcomes and QoL following subtotal and total tongue resection with free tissue transfer reconstruction. A systematic review of the English language literature was performed using PubMed, Ovid, Embase, and Cochrane databases based on predetermined inclusion/exclusion criteria. Included studies were reviewed for surgical technique, adjuvant treatment, surgical and functional outcomes, and QoL. From an initial search yield of 1,467 articles, 22 studies were included for final analysis. Speech intelligibility was correlated with the volume and degree of protuberance of the neotongue. Adjuvant therapy (radiation) and large tumor size were associated with worse speech and swallow recovery. At 1 year follow-up, despite 14 to 20% rates of silent aspiration, 82 to 97% of patients resumed oral feeding. Neurotized flaps have been demonstrated to improve flap sensation but have not yet demonstrated any significant impact on speech or swallow recovery. Finally, many patients continue to experience pain after surgery, but patient motivation, family support with physician, and speech therapist follow-up are associated with improved QoL scores. Tongue reconstruction is dictated by the amount of soft tissue resection. Taking into consideration the most common factors involved after tongue resection and reconstruction, further studies should focus on more objective measurements to offer solutions and maximize final outcomes.

Free-Flap Reconstruction of the Tongue

“…In general, patients with high motivation, good family support, and regular follow-up with both a physician and a speechlanguage pathologist develop better speech quality, swallowing ability, and overall quality-of-life after free-flap reconstruction of the tongue. 19,20 Speech and swallow therapy are also important in the preoperative setting. 20 In the search for the ideal reconstructive flap after glossectomy, multiple studies have evaluated speech, swallow, and quality-of-life outcomes.…”

“…18 Studies have demonstrated that, in large part, neotongues demonstrate no autologous motion but rather move based on movements of surrounding muscles of the pharynx. 19 Yoleri and Mavioğlu reported a case of tongue reconstruction using the gracilis muscle and obturator nerve, a flap often employed for facial reanimation. In their report, the neotongue regained some autologous movement; however, the patient unfortunately passed away before long-term evaluation could be completed.…”

“…Lam and Samman, and Manrique et al performed systematic reviews of patients undergoing free-flap reconstruction after glossectomy. 2,19 They report that patients undergoing anterior tongue resection with free-flap reconstruction had an average preoperative single word intelligibility of 90% across all studies. Intelligibility dropped to 69% at 1 month postoperatively, but it recovered to 79% at 6 months.…”

“…Also, not surprisingly, a positive relationship has been reported between tongue mobility and both subjective and objective speech evaluations. 19 Multiple studies have found that larger tumors (T3 or T4), resections including the tongue tip, and postoperative RT significantly negatively affect speech. 2,19,22 Furthermore, studies have repeatedly demonstrated that patients who have floor-of-mouth resections have poorer postoperative speech.…”

“…19 Multiple studies have found that larger tumors (T3 or T4), resections including the tongue tip, and postoperative RT significantly negatively affect speech. 2,19,22 Furthermore, studies have repeatedly demonstrated that patients who have floor-of-mouth resections have poorer postoperative speech. 19 Studies vary greatly on the type of free tissue used for reconstruction.…”