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Speech Intelligibility After Glossectomy and Speech Rehabilitation
Cristina L. B. Furia, SLP, MSc;
Luiz P. Kowalski, MD, PhD;
Maria R. D. O. Latorre, PhD;
Elisabete C. Angelis, SLP, PhD;
Nívia M. S. Martins, SLP;
Ana P. B. Barros, SLP;
Karina C. B. Ribeiro, DDS, MSc
Arch Otolaryngol Head Neck Surg. 2001;127:877-883.
ABSTRACT
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Background Oral tumor resections cause articulation deficiencies, depending on
the site, extent of resection, type of reconstruction, and tongue stump mobility.
Objectives To evaluate the speech intelligibility of patients undergoing total,
subtotal, or partial glossectomy, before and after speech therapy.
Patients and Methods Twenty-seven patients (24 men and 3 women), aged 34 to 77 years (mean
age, 56.5 years), underwent glossectomy. Tumor stages were T1 in 3 patients,
T2 in 4, T3 in 8, T4 in 11, and TX in 1; node stages, N0 in 15 patients, N1
in 5, N2a-c in 6, and N3 in 1. No patient had metastases (M0). Patients were
divided into 3 groups by extent of tongue resection, ie, total (group 1; n
= 6), subtotal (group 2; n = 9), and partial (group 3; n = 12). Different
phonological tasks were recorded and analyzed by 3 experienced judges, including
sustained 7 oral vowels, vowel in a syllable, and the sequence vowel-consonant-vowel
(VCV). The intelligibility of spontaneous speech (sequence story) was scored
from 1 to 4 in consensus. All patients underwent a therapeutic program to
activate articulatory adaptations, compensations, and maximization of the
remaining structures for 3 to 6 months. The tasks were recorded after speech
therapy. To compare mean changes, analyses of variance and Wilcoxon tests
were used.
Results Patients of groups 1 and 2 significantly improved their speech intelligibility
(P<.05). Group 1 improved vowels, VCV, and spontaneous speech;
group 2, syllable, VCV, and spontaneous speech. Group 3 demonstrated better
intelligibility in the pretherapy phase, but the improvement after therapy
was not significant.
Conclusions Speech therapy was effective in improving speech intelligibility of
patients undergoing glossectomy, even after major resection. Different pretherapy
ability between groups was seen, with improvement of speech intelligibility
in groups 1 and 2. The improvement of speech intelligibility in group 3 was
not statistically significant, possibly because of the small and heterogeneous
sample.
INTRODUCTION
THE PREVALENCE of oral cancer in Brazil is high and dependent on the
geographic area; among countries with an incidence of malignant tumors, it
was ranked eighth in 1999. According to the INCa-Ministério da Saúde
(Ministry of Health), there were 7950 new cases, 5850 (7.5/100 000) for
men and 2100 (2.6/100 000) for women.1
Most tumors occur in the tongue (17.8%-52%).2-3
The primary treatment of tongue cancer includes surgery and/or radiotherapy.
The extent of tongue resections (glossectomy) depends on the location and
extent of the tumor. Surgical reconstruction ranges from primary closure,
reconstruction with local flaps (mucous membrane and tongue), skin graft,
distant flaps (eg, myocutaneous and osteomyocutaneous flaps), and microvascular
free tissue transfer.4-7
The degree, extent, and location of the resection determine resulting
impairment.8 In cases with a possibility of
preserving part of the tongue with volume and mobility, the chances of rehabilitation
are usually acceptable. Among the main effects of surgery are difficulties
in chewing and swallowing of saliva and food, followed by speech alterations.
As for speech, the tongue is one of the most important articulators during
the production of vowel and many consonant sounds. The vowels of a language
are identified according to the position of the tongue in the vocal tract;
therefore, vowels may be altered as a result of resection of this articulator.8
Subjective and objective measures have been described for evaluating
swallowing and speech sequelae in patients undergoing glossectomy. These include
perceptive analysis of speech intelligibility or vocal quality by trained
and untrained listeners and objective evaluation such as palatometry, electropalatometry,
videofluoroscopy, and acoustic and spectrographic analyses.9-18
The intelligibility of speech shows the general skill of the individual in
effectively producing and using articulatory standards in such a way that
the interlocutor can understand the different situations in communication.
Some authors describe articulatory adaptation and compensation for maximizing
the intelligibility of the speech.9, 17, 19-21
In international literature, a few authors demonstrated the importance of
speech therapy after glossectomy.9, 22-23
The aim of this report is to evaluate the intelligibility of the speech
of patients at the beginning and at the end of the therapy, after partial,
subtotal, and total glossectomy.
PATIENTS AND METHODS
The sample was composed of 27 patients (24 men and 3 women) aged 34
to 79 years (median age, 56.5 years), who were treated at the Departments
of Head and Neck Surgery and Otorhinolaryngology and of Speech, Voice, and
Swallowing Rehabilitation at the Centro de Tratamento e Pesquisa Hospital
do Câncer A. C. Camargo, São Paulo, Brazil, from June 18, 1997,
through November 22, 1999. The tumor stages were: T1 in 3 patients, T2 in
4, T3 in 8, T4 in 11, and TX in 1. Node stages were N0 in 15 patients, N1
in 5, N2a-c in 6, and N3 in 1. Metastatis stage was M0 in all 27 patients.24 Tumor histological findings included squamous cell
carcinoma in 26 patients and adenoid cyst carcinoma in 1 patient. Tongue resection
(glossectomy) was associated with the site and extension of the lesion. Resection
for T1, T2, and some T3 tumors was classified as partial glossectomy or hemiglossectomy
(group 3, n = 12 [10 with floor of mouth]); resections including all of the
tongue but preserving the base, as subtotal glossectomy (group 2, n = 9 [all
including floor of mouth]); and larger resections, as total glossectomy (group
1, n = 6 [4 with floor of mouth]). Pectoralis major myocutaneous flap for
reconstruction was used in 15 patients; microsurgical transplant, in 3; tongue
flap, in 6; and primary closure, in 3. All but 2 patients underwent radiation
therapy (preoperative in 3 and postoperative in 22) (Table 1). The postoperative radiation therapy started from 6 to
10 weeks after the procedure (median, 8 weeks). The first recording and the
speech rehabilitation program started from 2 to 8 weeks postoperatively (median,
5 weeks). Eighteen patients started the rehabilitation program simultaneously
with postoperative radiotherapy, and 4 patients started after irradiation
therapy.
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Table 1. Patient Groups According to Treatment
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By the time they started speech therapy, 4 patients were maintained
with a nasogastric feeding tube, 10 were using mixed feeding (oral and nasogastric),
and the remaining 13 patients were receiving only oral feeding (for groups
1 and 2, liquid, thick liquid, and paste; for group 3, all consistencies).
All patients underwent speech, voice, and swallowing therapy for 3 to 6 months.
All patients speak Portuguese and were able to read the speech samples
and to sign the informed consent. The perceptual evaluation of speech protocol
is often used in the clinical routine of the speech pathologist and includes
how the speakers use their voice and speech in relation to vocal quality,
pitch, loudness, articulation, and speech rate and intelligibility. The perceptual
evaluation of speech focuses on the criteria of the intelligibility of the
vowel, isolated or in a standard sentence25;
the vowel-consonant-vowel articulatory sequence (VCV); and spontaneous speech.
The recording protocol consisted of the following:
- Sustained 7-vowel oral emission consisting of /a/, /ê/, /é/, /i /, /ó/, /ô/, and /u/;
- Standard sentence with 7 oral vowels within a consonant/vowel
syllabic context, with the voiceless plosive phoneme /p/ within the standard sentence "Digo /p . . .
/ para ele";
- VCV articulatory sentence using apa, ata, aka,
aba, ada, aga, ama, ana, anha, afa, assa, axa, ava, aza, aja, ala, alha, ara,
and arra (19 consonants), also within the standard sentence "Digo /.../ para
ele"; and
- Spontaneous speech, ie, story in sequence of its
visual presentation on cards.
The speech samples were recorded with 5-second gaps between the emissions,
inside rooms with acoustic treatment and with the patient standing up. The
emissions were captured by a professional unidirectional microphone (Lesson,
Manaus, Brazil) kept 15 cm from the patient's mouth and recorded using a digital
recorder (model MDS 303; Sony, Tokyo, Japan) and a mini-disk (Sony). The recording
order was random to avoid vocal fatigue at the end of the emission, and mainly
to avoid the predictability of the usual sequence of the presentation.
In the pretherapy phase, patients underwent evaluation according to
tongue mobility, the presence of lingual-palatal contact, and the presence
of teeth and/or prostheses. In group 3 patients, anteroposterior tongue movement
was observed in 11 patients, tip-of-tongue elevation in 7, midtongue elevation
in 7, and back-tongue elevation in 8. Four patients had no tongue contact
with the palate. Lingual-palatal contact was observed on the left side of
the tongue in 2 patients, right side of the tongue in 3, tip-of-tongue in
2, midtongue in 4, and back-tongue in 7. We observed 22 toothless patients,
2 with complete dentition, and 3 with partial prostheses (Table 2).
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Table 2. Glossectomy Groups and Characterization of Tongue Mobility,
Lingual/Palatal Contact, and Presence of Teeth and Prostheses
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For all patients, 16 therapy sessions were proposed. The average number
of sessions were 10 for group 1, 12 for group 2, and 10 for group 3.
The speech sample was analyzed by 3 speech therapists (E.C.A., N.M.S.M.,
and A.P.B.B.) experienced in the treatment of patients undergoing oral cavity
resection. The evaluation board was oriented to register individually what
they heard between the alternatives. The recordings of the speech activities
of each patient before and after speech therapy were presented randomly, so
that the listeners did not know what part of the therapeutic process the patients
were in.
Each listener gave a score for each speech task, ie, for vowel from
0 to 7, for syllable from 0 to 7, and for VCV from 0 to 19, according to the
number of understandable answers. The total score was the sum of the listener's
score for vowel from 0 to 21, for syllable from 0 to 21, and for VCV from
0 to 57.
In the story in sequence, speech intelligibility was evaluated by the
listeners, the final score was established after a discussion carried by the
group, and a consensus score was then concluded, based on the following criteria
(adapted from McConnel et al26):
- Intelligible indicates
clear, with no difficulty whatever understanding the speech;
- Partially intelligible,
some difficulty understanding part of the sentence, but no loss in understanding
the story;
- Intelligible with attention,
much difficulty understanding part of the sentence, with loss in comprehension
of the story; and
- Unintelligible, impossible
to understand the sentence and all of the story.
The therapeutic program aimed at maximizing the residual tongue tissue
movements, developing adaptation and articulatory compensations, and modifying
negative compensations. The therapy was planned and followed these steps:
differentiation of isolated vowels and vowels with bilabial phonemes; phonemic
review to maximize adaptation and compensatory movements (articulatory contacts
and/or mobility of remaining structures) to reduce distortion and substitute
articulation; modification of suprasegmentary functions pause (distinctive
value), duration, intensity, and intonation (ascendent and descendent curves,
high and low pitch); reduction of speech rate (words per minute); pneumophonic-articulatory
coordination; speech and saliva coordination; overarticulation exercises;
yawning and chewing; and support of auditory feedback.
To compare the mean total score for vowel, syllable, and VCV, a 2-factor
analysis of variance was used, with surgery as the independent factor and
time (before or after the speech therapy) as repeated measure. The Tukey multiple
comparison procedure (Honestly Significant Difference Tukey test) was used.
The Wilcoxon test was used to compare the mean score for spontaneous speech
analysis (story in sequence) with a score of 1 to 4. The differences were
considered significant at P<.05. The mean () and confidence interval (CI) were represented by Figure 1, Figure 2, and Figure 3. The following formula was used to determine CIs:
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Figure 1. Mean scores of intelligibility
of vowel before and after speech therapy. Error bars represent 95% confidence
intervals. Testing protocol is described in the "Patients and Methods" section.
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Figure 2. Mean scores of intelligibility
of syllable before and after speech therapy. Error bars represent 95% confidence
intervals. Testing protocol is described in the "Patients and Methods" section.
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Figure 3. Mean scores of intelligibility
of vowel-consonant-vowel sequence (VCV) before and after speech therapy. Error
bars represent 95% confidence intervals. Testing protocol is described in
the "Patients and Methods" section.
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RESULTS
The results obtained after judgment by 3 trained listeners were described
according to the speech tasks among the 3 groups of patients before and after
speech therapy.
The improvement in the mean intelligibility of vowel (vowel understanding)
was significant only in group 1. Before therapy, the mean score was 11.83;
after, it was 15.83 (P = .048). Speech impairment
after major glossectomy was severe, and the patients benefited from speech
therapy, but for the others, the results were not significant (Table 3).
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Table 3. Mean of Intelligibility Before and After Speech Therapy
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The improvement of mean intelligibility of vowel in a syllable (vowel-in-syllable
understanding) was significant for group 2. Before therapy, the mean score
was 14.44; after therapy, it was 18.77 (P = .04).
Speech impairment to syllable was moderate to severe in the pretherapy phase
in groups 1 and 2, and the mean intelligibility scores were 12.66 and 14.44,
respectively. Speech was improved in both groups, but it was significant just
for group 2. For group 3, there was no significant difference (Table 3).
The improvement of mean intelligibility for VCV was significant for
groups 1 and 2. Before and after therapy, the mean intelligibility scores
for group 1 were 20.00 and 29.50, respectively (P
= .04); for group 2, they were 26.22 and 36.66, respectively (P = .003). For group 3, there was no significant difference (Table 3).
The results for spontaneous speech, using a score of 1 to 4, demonstrated
improvement of mean perceptual score for groups 1 (3.33 to 2.50; P = .06), 2 (2.78 to 1.65; P = .01), and 3
(1.42 to 1.25, P = .16) for nearly intelligible speech.
The improvement was significant only for groups 1 and 2 (Table 4).
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Table 4. Perceptual Score for Spontaneous Speech Intelligibility Before
and After Speech Therapy*
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The clinical rehabilitation improved speech and swallowing of the patients.
By the end of the rehabilitation program (average length of therapy, 3 months),
25 patients were receiving only oral feeding. Two patients continued to receive
nasogastric feeding. One of these was patient 1 in group 1, aged 75 years,
who eventually underwent a gastrostomy. The other, patient 13 in group 2,
had an aggressive cervical recurrence and was unable to swallow.
COMMENT
Oral cancer and its treatment—surgery, radiation therapy, and/or
chemotherapy—affect the stomatognathic and respiratory systems and can
result in voice, speech, and swallowing impairment.27-28
Restoration of communication skills to maximal efficiency has been a priority
for the speech pathologist. Restoration of speech intelligibility depended,
of course, on the restoration of the tract's structure and function. Surgery
and prosthesis were the possible approaches to this task.
Several studies have reported on the intelligibility characteristics
of patients undergoing partial and total glossectomy. Unfortunately, many
studies have described only 1 or 2 patients.12, 14, 20, 28
In our study, 27 patients had mild to severe impairment of speech intelligibility
before therapy. The sample was heterogeneous according to the extent of surgery
(total or partial resection of the tongue and floor of mouth), reconstruction,
radiation therapy, tongue mobility, and lingual-palatal contact and the presence
of teeth and prostheses. All patients continued the rehabilitation during
the radiation therapy to maximize the mobility of the remaining structures.
During the study, pectoralis major myocutaneous flap was our first choice
for reconstruction after major resections. At that time, routine free flaps
were not available in our institution. The 3 patients who underwent this kind
of reconstruction were young, communicative, actively working patients. The
patients improved their speech, independent of the type of reconstruction.
The small sample size does not permit assessment of the effect of this variable
on the speech intelligibility results.
The objectives and techniques during speech therapy were based on the
literature, according to Skelly et al9, 29
and Gillis and Leonard.30 According to Moll
et al,31 speech characteristics should be defined,
taking into consideration the listener's perception, on all the segmental
and suprasegmental variables of speech. Perceptual analysis reflected the
acceptability of the functional and social role of communication.
The patients might be unable to shape the vocal tract for the vowel
sound in the usual manner. Vowels are sounds produced with laryngeal vibration
and an open vocal tract that is shaped to produce particular patterns of resonance.8 Before therapy, group 1 demonstrated unintelligible
emission, vocalic confusion, and accumulated saliva in the mouth. The lips
and mandibular movements were maximized, and suprasegmental factors were emphasized.
The results were significant (median improvement, 11.83 to 15.83). Group 2
had a stump tongue to help vocal tract modifications before therapy, and the
mean values of intelligibility were better than those of group 1 (median,
15.88). Group 2 patients improved intelligibility through the therapeutic
exercises (median improvement, 15.88 to 17.00), but it was not significant,
probably because of the small sample size and better speech in pretherapy.
The phonological tasks were inserted in standard sentences to extend
the linguistic clues for the speaker and the interlocutor. The emission of
the vowel inserted in the syllable was coarticulated with the phoneme /p/, because of the integrity of the structures involved
in their emission (bilabial). (When emitting the phoneme /p/, there is obstruction of the aerial current by the lips and the
abrupt release.) The result was significant in group 2, because some facilitators
could be described, such as the presence of teeth or prosthesis, improving
the direction and pressure of the airflow to produce bilabial phonemes. The
justification was not applicable for group 1 (not significant), probably because
of the reduced vertical intraoral shape and air pressure to produce this phoneme,
which maximized articulatory imprecision.
The anterior large flap in the oral cavity results in a better oral
phase of swallowing and speech (anterior phonemes), according to Conley and
Sachs32 and Robertson et al.33
In patient 2 (group 1), we observed a pectoralis major myocutaneous flap contacting
the hard palate, thereby improving the speech.
In VCV, we observed the vocal tract constricted (constriction and occlusion)
by high air pressure, and this sequence was coarticulated with the vowel /a/ and produced into a connected speech (standard sentence).
The central vowel had been related to the vowel that caused the least confusion
of intelligibility to the listeners.13 The
tongue was an important articulator for 14 phonemes (anterior-dental, alveolar
and palatal, and posterior-velar). Therapeutic training consisted of constricting
the vocal tract in a similar manner, by holding the teeth or lips together,
lips and gum together, or lips, buccinator, and gum or teeth together to produce
anterior phonemes, and by moving other structures (palatal, pharyngeal, and
laryngeal) to produce posterior phonemes. Leonard et al13
reported that anterior resections alter consonant production because of constriction
and occlusion of the vocal tract, and that posterior resections alter vowel
production.
It was important to add modifications of airflow and air pressure like
those of original sound, and then to produce an acoustic signal that a listener
perceives as the phoneme. The suprasegmentary factors (duration, pause, intonation,
and speech rate) helped the emission and influenced the listener's perception.
Articulatory adaptations and compensations with the remaining structures in
isolation, or together, were described in the literature, ie, lips, buccinators,
mandible, palate, uvula, pharynx, and larynx, for restoration of speech intelligibility
of patients undergoing glossectomy.11, 19-22
An improvement of intelligibility (significant difference) was observed for
groups 1 and 2 (major resections). This is in disagreement with the findings
of Leonard et al,13 who reported worse speech
in patients undergoing subtotal compared with total glossectomy because of
the resections of adjacent structures. The speech results of patients undergoing
glossectomy differ between studies, as do the methods used for analysis. Most
studies involved small samples undergoing evaluation.
Group 3 had a tongue stump and learned to use their residual tongue
mass to its maximum potential. Even with 50% loss of tongue mass, vowel and
consonant articulation was very good. We observed tongue mobility and lingual-palatal
contact, thereby reducing the substitution and articulatory distortions during
therapeutic program. The auditory feedback, again, was important to produce
nearly normal sounds. This group had mild impairment and we observed improvement
of intelligibility, but it was not significant. Heller et al34
described normal speech after 6 or 8 months of speech therapy in patients
undergoing partial glossectomy.
In connected speech, the listener hears contextual cues afforded by
other intact speech sounds. In connected speech, other cues (eg, intonation,
pause, reduced speech rate, saliva control, and air pressure) could also be
imposed on a phrase or sentence and could influence the listener's perception.
It was more a functional task that checked overall intelligibility and demanded
a quick ability to produce many kinds of sounds. The spontaneous speech was
considered intelligible with attention for group 1, and no patients were considered
unintelligible. These were significant improvements after major surgery (total
and subtotal). The speech of group 3 patients was considered nearly intelligible.
Some data reported better results in connected speech or sentence emission
than in monosyllables in patients undergoing glossectomy.10-11
Similar data described improvement of speech intelligibility for patients
undergoing partial glossectomy (6%-24%) and after the therapy (24%-46%). For
patients undergoing total glossectomy, speech intelligibility ranged from
0% to 8% at admission and from 18% to 42% after therapy.12
The role of the speech pathologist is to determine the way the patients
can be rehabilitated by using available structures. The patients can learn
to achieve new speech sound targets that approximate the acoustic characteristics
of the original so closely that the listener will perceive them as the original.
The following 3 strategies were valuable during speech therapy: the reduction
of speech rate, temporal modifications (pause and duration) of emission, and
auditory feedback to maintain acoustic characteristics of sound, in concordance
with previously published data.9, 11, 14
CONCLUSIONS
Different abilities between groups before therapy were seen, ie, the
improvement of intelligibility of speech in groups 1 and 2 was statistically
significant, and the improvement of speech intelligibility in group 3 was
not, possibly because of the small sample. Speech therapy effectively improved
speech intelligibility of patients undergoing glossectomy, even those undergoing
a major resection. The major goal of speech rehabilitation is the functional
use of oral communication.
AUTHOR INFORMATION
Accepted for publication March 15, 2001.
Presented in part at the annual meeting of the American Head and Neck
Society, Fifth International Conference on Head and Neck Cancer, San Francisco,
Calif, July 29 to August 2, 2000.
Corresponding author and reprints: Luiz P. Kowalski, MD, PhD, Centro
de Tratamento e Pesquisa Hospital do Câncer A. C. Camargo, Rua Professor
Antônio Prudente, 211 Liberdade, 01509-010 São Paulo, Brazil
(e-mail: lp_kowalski{at}uol.com.br).
From the Departments of Voice, Speech, and Swallowing Rehabilitation
(Drs Furia and Angelis and Mss Martins and Barros), Head and Neck Surgery
and Otorhinolaryngology (Dr Kowalski), and Cancer Registration and Statistics
(Drs Latorre and Ribeiro), Centro de Tratamento e Pesquisa Hospital do Câncer
A. C. Camargo, São Paulo, Brazil.
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