Rehabilitation

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The rehabilitation of function after oral surgery is a critical element in effective oral cancer surgery. After major oral resections the patients need rehabilitation of speech, swallowing, dentition and mastication as well as cosmesis. This process is best accomplished in a multidisciplinary environment which include the head and neck surgeons, plastic surgeons, speech and language therapists, nurses, dentists, prosthodontists and oral and maxillofacial surgeons.

Perhaps the most important element of rehabilitation is optimizing the patient's resection and reconstruction at the time of surgery. While the oncologic soundness of the tumor resection must not be compromised for functional reasons, neither should excessive resection of uninvolved soft tissue, nerve or bone be performed. Whenever oncologi-cally possible, preservation of the hypoglossal, lingual and mental nerves should be attempted. Gentle handling of tissues, hemostasis, and obliteration of dead space are general principles of surgery which should be adhered to. This, in combination with antiseptic preparation of the oral cavity preoperatively and the use of perioperative antibiotics, may reduce inflammation and improve healing and reduce scar tissue formation, which will tend to maximize postoperative function.

Reconstruction of oral defects after ablative surgery is critical for oral rehabilitation. Perhaps the most important advance in head and neck surgery in the last 15 years has been the safe and effective use of free tissue transfer for reconstruction. Free tissue transfer techniques now allow the excellent reconstruction of the mandible, skin, and mucosa of the oral cavity. Bone flaps from the fibula, iliac crest and scapula are available to the reconstructive surgeon. Soft tissue from the radial forearm, lateral arm, trapezius, rectus abdominis and other sites provide vascularized, nonirradiated soft tissue for reconstructive purposes. It is clear that the appropriate use of these reconstructive tissues has dramatically improved the functional outcome of oral cancer patients. They should be employed whenever necessary. Adequate reconstruction of the mandibular arch, and soft tissues of the tongue and floor of mouth will significantly increase the likelihood of acceptable speech and swallowing after major oral cavity cancer surgery.

Rehabilitation of swallowing after oral cavity surgery is important. Swallowing can be divided into the preparation phase, the oral phase and the pharyn-geal phase. Oral cavity surgery impacts most on the preparatory phase and the oral phase. The preparatory phase of swallowing begins with lubrication of the food bolus by saliva. This is impaired when pre- or postoperative radiation therapy is employed. Significant xerostomia results in the majority of irradiated patients. The xerostomia significantly limits the types and consistencies of food that can be swallowed. Most patients with oral cavity radiation require frequent sips of water to maintain moisture and liquid to wash down the food at mealtimes. One experimental strategy to try to limit xerostomia is to use a salivary gland protectant such as Salagen (pilocarpine hydrochlonde) during radiation. The benefit of Sala-gen™ is not yet proven and it is contraindicated in the presence of coronary artery disease. Amifostine is approved for the prevention of radiation-induced xerostomia. It is not widely used. A number of preparations are marketed for xerostomia but are not superior to water for the majority of patients.

Mastication is critical to an effective preparatory phase of swallowing. Certainly the quality and quantity of the teeth are important for mastication. Mas tication requires intact sensation of the dentition, gingiva, tongue and buccal mucosa, and intact motor function of the hypoglossal nerve for tongue musculature, the facial nerve for oral competence and the third division of the trigeminal nerve for buccinator function. This combination of sensory and motor functions allows the food to be kept in the plane of the molars without biting the soft tissues.

Continuity of the mandibular arch provides great advantage for mastication. However, a patient with a segmental defect of the body of the mandible can frequently masticate some foods satisfactorily. Occasionally a guide plane prosthesis is helpful to maximize occlusion of the teeth in a patient with a lateral mandible defect. These guide plane prosthe-ses help overcome the deviation of the mandible to the resected side from the unopposed action of the intact contralateral pterygoids. An unreconstructed defect of the anterior mandible is uncommon today. This defect will prohibit mastication of solids and patients will tolerate no more than a pureed diet. The combination of poor mastication, swallowing, speech and articulation, cosmetic defect and oral incompetence makes the anterior mandibular arch defect something to be avoided in almost every circumstance. The oral preparatory phase of swallowing can also be inhibited by trismus, which is common after surgery and/or irradiation of the posterior oral cavity and oropharynx.

The oral phase of swallowing consists of preparation of the food bolus followed by presentation to the oropharynx, where the swallowing reflex is initiated during the oropharyngeal phase. The oral phase is volitional. Preparation of the bolus is accomplished by the tongue, cheek, teeth and palate. After mastication and lubrication, the bolus is then propelled to the oropharynx by elevation of the tongue against the hard palate. When the bolus is sensed in the oropharynx the reflexive portion of the oropha-ryngeal phase of swallowing is initiated. Tongue elevation can be restricted due to either loss of tissue volume or motor function after surgery. Patients with near total glossectomy can be sometimes well rehabilitated with a palatal drop prosthesis, which lowers the level of the hard palate so that the residual tongue tissue can articulate with it to propel the bolus posteriorly (Figure 5-21).

Figure 5-21. A, Patient with poor tongue mobility with a palatal drop prosthesis in place. B, Palatal drop prosthesis.

The oral prosthodontist plays a critical role in the rehabilitation of swallowing after oral cancer treatment. The proper number and quality of teeth and their alignment can be restored by maxillary and/or gingival dentures. After resection of the maxilla or hard palate, a dental obturator to cover the oro-antral and oronasal fistulae is necessary for swallowing without nasal regurgitation (Figure 5-22). Patients with large maxillary defects can attain excellent functional results with an obturator. For defects of the soft palate, dysphagia due to nasal regurgitation, hyponasal speech and difficulty with articulation of speech sounds, an obturator with a nasopharyngeal bulb is effective in minimizing nasal regurgitation and improving hyponasal speech. The bulb is properly positioned in the nasopharynx articulating with the posterior pharyngeal wall at the prominence of the body of C2, allowing the remainder of the soft palate to seal off the nasopharynx during swallowing (Figure 5-23).

Osseointegrated implants are an important advance in oral rehabilitation. If adequate bone stock exists, titanium posts can be placed in a multi-

staged process and the ingrowth of healthy bone into and around the implants results in a very secure foundation for oral prostheses.58 Osseointegrative implants can be placed in fibula free flap reconstructions of the mandible after the healing and removal of the fibula fixation hardware (Figure 5-24). Osseointegrative implants should be avoided in the atrophic edentulous mandible especially after

Figure 5-22. A, Maxillectomy defect with split-thickness skin graft. B, Prosthesis in place. C, Prosthesis.

radiation. Osseointegration can also be utilized effectively for external fixation of cosmetic prostheses after extended surgery for oral cavity cancer, which includes soft tissues of the face. It is important for the patient's rehabilitation that they have an acceptable cosmetic appearance in public.

Many patients benefit from evaluation and therapy by certified speech and swallowing therapists.

They can often recommend exercises for the articulation of speech and can help both the patient and prosthodontist to optimize prostheses and to recommend alternative methods of phoneme formation.59 Patients with significant resections of the lips, maxilla, tongue and palate will often benefit from speech therapy.

Speech and swallowing therapists can also help improve swallowing in patients who have undergone oral surgery.60 A modified barium swallow under flu-oroscopic observation by a radiologist and a speech therapist may be helpful diagnostically.61 From this study, abnormalities of mastication, bolus preparation and bolus presentation of the oropharynx can be observed and studied frequently from this data. Strategies for improved function can be devised and taught to the patient and exercises implemented. Accompanying abnormalities of the pharyngeal phase of swallowing can also be diagnosed. Based on

Pharyngeal Flap Surgery
Figure 5-23 A, Soft palate defect after surgical resection and free flap reconstruction of the lateral pharyngeal wall. B, Prosthesis in place. C, The nasopharyngeal bulb prosthesis.

Figure 5-24. A, Panorex of osseointegrated implants in the anterior and right lateral aspects of a fibula free flap reconstruction of the mandible. B, The prosthesis in place.

the clinical findings and the modified barium swallow, therapists can also suggest optimal consistencies, and temperatures of food that can be best managed.

Consultation with a trained nutritionist with experience in treating head and neck cancer patients is essential to provide patients with information and suggestions regarding optimal foods to maintain a balanced nutrition within the patient's consistency restrictions. Patients with impaired oral function risk nutritional deficiency unless an appropriately varied diet is maintained. Many patients benefit from prepared commercial supplements, which are formulated specifically as a balanced diet. Some patients may subsist on liquid dietary supplements alone, while the majority benefit from regular foods as tolerated with additional dietary supplements as needed. Nearly any everyday food can be pureed with liquid in a blender and drunk. Patients should be weighed frequently in the postoperative period to monitor for weight loss. Supplemental tube feeding may be necessary while the patient is relearning swallowing.

Members of the rehabilitation team must educate the oral cancer patient regarding oral hygiene. Teeth brushing and fluoride treatments should be done at least twice daily. The patient should perform these fluoride treatments at home regularly using molded dental trays. Patients with post-radiation xerostomia require frequent sips of water, and may benefit from sialagogues such as lozenges or chewing gum; however it is critical that these be sugar free as the risk of caries is dramatically increased after radiation treatment. All patients with impaired oral function should be instructed to cleanse the oral cavity after eating. This may involve simple rinsing with water or saline solution or irrigation with a hanging bag and warm saline solution. Reconstruction flaps with skin lining the oral cavity may require frequent brushing to eliminate accumulated skin debris and sometimes trimming of the hair growing on the skin flaps is necessary for patient comfort and to decrease the adherence of food. Reconstructive flaps that have been irradiated no longer grow hair. Mouth washes, which contain alcohol, should be avoided as they dry the tissues and cause burning and discomfort. Normal saline or saline with bicarbonate of soda is preferred. Successful oral rehabilitation after oral cancer surgery requires a dedicated team of specialists working together. Each can contribute significantly toward the rehabilitation of speech, swallowing and appearance of the oral cancer patient.

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