Sulcus preservation to improve functional outcomes in compartmental tongue resection: A technique and case series

Bhanu Prakash Bylapudi; Akshay Kudpaje; Prasanna Hegde; Shalini Thakur; Vishal US Rao; Carsten E Palme

doi:10.4103/jhnps.jhnps_40_21

ORIGINAL ARTICLE

Year : 2021 | Volume : 9 | Issue : 2 | Page : 114-118

Sulcus preservation to improve functional outcomes in compartmental tongue resection: A technique and case series

Bhanu Prakash Bylapudi¹, Akshay Kudpaje¹, Prasanna Hegde¹, Shalini Thakur¹, Vishal US Rao¹, Carsten E Palme²
¹ Department of Head and Neck Surgical Oncology and Robotic Surgery, Health Care Global (HCG) Cancer Centre, Bengaluru, Karnataka, India
² Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia. Department of Head and Neck Surgery, Chris O' Brien Life House, Sydney, New South Wales, Australia

Date of Submission	03-Aug-2021
Date of Acceptance	18-Aug-2021
Date of Web Publication	17-Dec-2021

Correspondence Address:
Prof. Carsten E Palme
Faculty of Medicine, University of Sydney, Sydney, New South Wales
Australia

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jhnps.jhnps_40_21

Abstract

The primary aim of surgery in tongue cancers is tumor ablation with clear margins. Apart from tumor clearance, it is equally important to incorporate a technique that can improve the functional outcomes. It is a well-known fact that compartmental surgery has evolved as a propitious approach for early tongue and floor of mouth cancers. To overcome the functional deficits, we propose a technique of tongue reconstruction in cases where attached and reflected gingiva could be preserved when the tumor is not involving the floor of the mouth. We present a case series of three patients with our initial functional results in which this modified approach was performed. The parachute technique of flap inset maintained adequate sulcus. Regular sessions of speech and swallowing assessments were done and functional outcomes in these patients were assessed and compared with three other patients who underwent compartmental resection of tongue followed by interdental flap inset. Incorporation of a simple sulcus preservation technique by parachuting the remnant natural attached gingival mucosa after compartmental resection showed superior functional outcomes. It was also observed that the overall efficiency of chewing and clearance of food from oral cavity was better with this proposed technique as the lateral gutter was well maintained. The results of this study could help clinicians to provide a better functional outcome to the patients by this technique.

Keywords: Compartmental resection, functional outcome, parachute, sulcus preservation, tongue cancer

How to cite this article:
Bylapudi BP, Kudpaje A, Hegde P, Thakur S, Rao VU, Palme CE. Sulcus preservation to improve functional outcomes in compartmental tongue resection: A technique and case series. J Head Neck Physicians Surg 2021;9:114-8

How to cite this URL:
Bylapudi BP, Kudpaje A, Hegde P, Thakur S, Rao VU, Palme CE. Sulcus preservation to improve functional outcomes in compartmental tongue resection: A technique and case series. J Head Neck Physicians Surg [serial online] 2021 [cited 2023 Jun 4];9:114-8. Available from: https://www.jhnps.org/text.asp?2021/9/2/114/332718

Introduction

The primary aim of cancer surgery is tumor ablation with clear margins. Apart from tumor clearance, it is equally important to incorporate a technique that can improve the functional outcomes. Speech and swallowing functions are vital to attain optimal quality of life in patients undergoing tongue surgery.

In tongue cancers, the current preferred primary modality of treatment is wide local excision with neck dissection and soft-tissue reconstruction. The oncological outcomes following this approach have not shown any significant improvement. Hence, certain groups have postulated the concept of compartmental resection with the intent to achieve better local control and survival. There is a debate in the literature on wide local excision versus compartmental resection. It is a well-known fact that compartmental surgery has evolved as a propitious approach for the early tongue and floor of mouth cancers.^[1],[2] The criticism of compartmental surgery is that it is more radical and hence affects reconstruction and functional outcomes including swallowing. The long-term results from the units practicing compartmental surgery have superior oncological and acceptable functional outcomes. This led to modifications and classifications of compartmental tongue resection in the past few years. Invariably, even in patients undergoing wide local excision, the majority would need a flap to reconstitute volume and facilitate healing.

The current discussion is on a modification of compartmental resection in early tongue cancers and its reconstruction that would ameliorate the functional outcomes. To overcome the functional deficits, we propose a technique of reconstruction in cases where attached and reflected gingiva could be preserved when the tumor is not involving the floor of the mouth. We present a case series of early tongue cancers (T2No) with our initial functional results in which this modified approach was performed.

Surgical Technique

Anatomically, the tongue is unique with four pairs of muscles separated by a median raphe. Unlike other sites in the head and neck, like vocal cord or buccal mucosa, there are no anatomical fascial barriers in the tongue. The tongue being an anatomical site separated by a fascial compartment, i.e., midline raphe,^[3] all the patients underwent compartmental surgery. After doing the neck dissection, the tumor is approached “from the bottom up:” from the neck to the tumor. As described by Calabrese et al., the main objective of a compartmental surgery is to detach, when involved, the muscles (mylohyoid, stylohyoid, geniohyoid, and genioglossus) from their insertions and origin.^[1] The principles of an oncological resection are followed to remove the primary lesion with a 1.5–2-cm circumferential macroscopic margin.^[4] During the primary resection, whenever possible, a cuff of mucosa on the lingual side is preserved so that it will help in securing the flap and retaining the normal sulcus to attain optimal speech and swallowing outcomes. The reconstruction of the tongue defects in all these early tongue cancer patients was done with a radial forearm free flap. The technique of adhering the flap to the tongue defect is done according to the reconstructive surgery guidelines. However, it is the fixation of the flap on the lateral side that was hypothesized to improve the functional outcomes. The parachute technique was performed to facilitate easy insertion of soft-tissue free flap and retain the natural sulcus in the current case series with the aim to improve the functional outcomes.

The parachute technique begins by passing the unlocked suture through the cuff of preserved lingual mucosa over the alveolus in a round circle [Figure 1]. After that, clamp both the long and short ends of the unlocked suture with mosquito clamps. At the end, the long ends should be tied to the corresponding points of the transferred flap. In an orderly fashion, the adjoining clamps should be separated into left and right for securing the sutures. The inset of the forearm free flap is done and the pedicle is gently passed to the neck region for anastomosis. Gradually, one after another, the long ends of the sutures were passed through the lateral flap edge at the corresponding point [Figure 2]. In addition, using colored sutures will be helpful in better identification of the alternate sutures. Secure all the unlocked suture ends to the respective points of the free edge of the flap and the lingual mucosa. After that, the sutures are locked in and pulled down to allow the flap to parachute down into the lingual sulcus along the sutures. In this way, an edge-to-edge approximation of the flap and mucosa is achieved by maintaining enough sulcus depth. Since these sutures are placed under proper exposure, there is no risk of accidental damage to the flap pedicle during inset.

Figure 1: Clamped ends of the unlocked sutures passed through the cuff of the lingual mucosa

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Figure 2: Suture ends secured to the respective points of the free edge of the flap and the lingual mucosa

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Case Series and Functional Outcome Assessment

We present a case series of three early tongue cancer patients who were diagnosed with squamous cell carcinoma of the tongue (T2No) and underwent a compartmental tongue resection for the tumor removal. In all the three patients, the floor of mouth mucosa and the attached gingiva were not involved and were preserved during the resection. The reconstruction of the tongue defect was done by the described sulcus preservation technique with a radial forearm free flap.

Functional outcomes of tongue reconstruction after the surgery have been evaluated subjectively and objectively in numerous studies.^[5] All the three patients were assessed by a dedicated speech and swallowing specialist in the preoperative and postoperative setting. Regular sessions of speech and swallowing assessments were done and functional outcomes in these three patients were assessed and compared with three other similar staged tongue cancer patients who underwent compartmental resection of tongue followed by the regular interdental flap inset.

Functional outcome measures and methodology

Patient-reported outcome measures are considered to be the gold standard in measuring outcomes of any health-care system. It has shown a direct correlation to the overall quality of life of the individual. Function-specific indices are used to monitor the outcomes in combination with clinical, subjective, and objective measures.

Functional Oral Intake Scale (FOIS)^[6] and Eating Assessment Tool-10^[7] were used for measuring the swallowing outcome. An oral efficiency scale was developed for the purpose of this study, i.e., Chewing and Clearance Scale (C2 Scale) (range: 0%–100% – indicated by % of solid chewed or cleared from the oral cavity) to measure the oral residue postswallow of 1 standard Parle-G biscuit (International Dysphagia Diet Standardization Initiative Level-7). In the proposed scale, chewing scores indicate the efficacy of mastication of the standard solid and clearance score indicates the residue left behind in the oral cavity post swallow. Chewing efficiency was graded by examining the oral cavity after the patient indicated the completion of chewing. Subsequently, the patients were asked to swallow the chewed solid and the oral cavity was again reviewed to assess the oral residue.

Speech outcomes were measured based on the Speech Intelligibility Rating Scale,^[8] Percentage of Consonants Correct (PCC), and Relative Distortion Index (RDI). Performance Status Scale (PSS) is a cumulative score of speech as well as swallowing.

In the current case series, three patients underwent the proposed sulcus preservation flap inset technique. We compared the functional outcome in these patients with three other similar staged early tongue cancer patients who underwent compartmental resection followed by interdental flap inset.

Functional Outcome Assessment Results

The patients with sulcus preserved had wider consistencies of food as indicated by the higher FOIS score [Table 1] and [Table 2]. Individuals who underwent the sulcus preservation technique reported better outcomes in terms of eating in contrast to the individuals who underwent interdental flap inset. It was also observed that overall efficiency of chewing and clearance of food from oral cavity was better with the proposed technique as the lateral gutter is well maintained by preserving the sulcus.

Table 1: Functional outcomes of the patients who underwent sulcus preservation technique of flap inset

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Table 2: Functional outcomes of the patients who underwent regular interdental flap inset

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In patients with the sulcus preserved, there were fewer consonant errors as indicated by the greater PCC scores. In addition, the distortion among the articulatory errors was predominantly higher in the sulcus preservation group, as indicated by higher RDI, which translates to improved articulatory accuracy. Speech intelligibility was also better in patients who underwent flap inset through parachute technique. Furthermore, the PSS showed better status for sulcus-preserved cases.

Overall, the parachuting technique benefited in preserving the sulcus and all the patients showed a superior outcome in terms of speech, swallowing, and oral hygiene [Figure 3].

Figure 3: Patient during follow-up. Figure showing preserved sulcus depth

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Discussion

Tongue is a muscular structure having intrinsic and extrinsic muscles, but these are not enclosed with a tough fascia. The anatomical compartment is the one where the fascia layers act as a barrier to primary tumor invasion, thus tumor spread follows the orientation of muscle fibers, parenchyma, and soft tissues, including nerves and vessels. In consideration of the one half of the tongue constituted by a group of extrinsic muscles which is separated by midline raphe, it is considered a “compartment.” The success of a compartmental surgery is due to the radical and complete removal of the entire anatomical unit. The current study focused on achieving a superior functional outcome following a compartmental resection in tongue cancers not involving the floor of the mouth.

In general, oral cavity cancers need a streamlined reconstruction to reconstitute the volume. Tongue reconstruction is yet one of the most challenging in head-and-neck reconstruction following cancer surgery.^[9] To ameliorate the speech, swallowing, and quality of life, the tongue reconstruction is still in a process of constant refinement by the surgeons. It is also reported by some authors that patients may adopt individual abilities to compensate for altered conditions after tongue reconstruction.^[10],[11]

A superior tongue reconstruction necessitates more than satisfactory wound healing and flap survival. Increasingly, functional rehabilitation is considered a crucial outcome following reconstructive surgery.^[12],[13]

The hypothesis of this technique is that a simple parachuting technique of flap fixation will improve the functional outcomes in terms of speech and swallowing. All the patients in the current case series underwent the described technique, and the patients showed a superior functional outcome.

The use of free flaps in tongue reconstruction aided in restoring the functional outcome. Free radial forearm flap is the most widely accepted flap for tongue reconstruction due to its stable vascular anatomy.^[14] Each hemi-tongue is considered as a compartment, and a single muscle (extrinsic) or a group of muscles (intrinsic) within it are considered subcompartments.

The main basis of this technique is, the attached and reflected gingiva is preserved when the tumor is not involving the floor of the mouth. This does not compromise the rationale of compartmental resection as it is a completely different anatomical layer. In a standard compartmental resection as described by Calbrese, the sulcus is obliterated because of the interdental suturing. In the current proposed technique, parachuting of multiple sutures is done to preserve the sulcus depth.

The proposed technique is found beneficial in situations where the floor of mouth mucosa and the attached gingiva can be preserved, as it follows the radicality of the Calabrese compartmental resection technique without compromising the ablation of the tongue muscles and improves the tongue mobility as well as the swallowing and speech outcomes.

It is a known fact that, when the resection of the tumor is limited to either the oral tongue or the base of tongue, a good functional outcome can be obtained with immediate free flap reconstruction.^[15] The current proposed technique of sulcus preservation reported improved outcomes in patients who underwent compartmental tongue resection.

Furthermore, the mobility of the reconstructed tongue helps in maintaining oral hygiene. According to the described technique, the lateral gutter is maintained by securing the flap to the lingual mucosa which in turn helps in maintaining the oral hygiene. Furthermore, the proposed sulcus preservation flap inset technique facilitates tongue movements which in turn ameliorate oral hygiene [Figure 4].

Figure 4: Patient during follow-up. Figure showing maintained tongue movements

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The adynamic nature of the free flap will impede the symmetry and mobility of the remaining tongue, thus accentuating the speech impairment.^[5],[16] Mobility of the reconstructed tongue, especially the elevation of the tip of the tongue, plays an important role in the speech outcome.^[17] In the current case series, patients who underwent flap inset via parachute technique showed superior tongue tip movement which in turn improved speech outcomes.

Calabrese et al. proposed that muscles lose function even if only partially cut, so complete removal of extrinsic muscles from their bony insertions cannot worsen the functional defect compared to partial removal.^[2] The results in the current case series support the proposal by Calabrese et al. and also in turn the parachuting technique of reconstruction ameliorated the functional outcome.

The clinical assessment of all the patients in the current case series is done by a combination of objective and subjective assessment tools of speech and swallowing. In all the patients, superior functional outcomes were recorded and it supports the hypothesis of sulcus preservation benefitting the functional outcome.

As demonstrated in the present case series, preservation of sulcus translates to a better range of motion of the tongue both horizontally and vertically. Vertical movements of the tongue tip, body, and back of the tongue are crucial for speech production in terms of both for vowels as well as for consonant production. Although vowel space areas are seen to be major factors for perception of speech, consonants play a major role. An increased number of consonant errors negatively reflect in speech intelligibility.

Similarly, for swallowing, both horizontal and vertical movements play an equivalent role in the oral preparatory and oral propulsion phase aiding in chewing and pushing the bolus posteriorly for swallowing. Better movement leads to better control of food over a variety of consistencies with better chewing and clearance of bolus.

Conclusion

Reconstruction of the tongue to restore its functionality after resection has been greatly advanced by the widespread use of free flap techniques. Incorporation of a simple sulcus preservation technique by parachuting the tongue flap after a compartmental resection showed superior functional outcomes. The results of this study could help clinicians to provide a better functional outcome to the patients by the proposed sulcus preservation technique.

Disclosure

This material has never been published and is not currently under evaluation in any other peer-reviewed publication.

Ethical approval

The permission was taken from the institutional ethics committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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