Keywords
tongue reconstruction - free flap - postoperative complications - obturator
Introduction
Squamous cell carcinoma (SCC) of the tongue is the most prevalent malignant neoplasm
within the oral cavity in developing countries.[1] The intricate motor activity and sensory feedback controlled by the highly specialized
tissues of the tongue render it a considerably challenging structure to reconstruct
by the head and neck surgeons.[2] Total glossectomy defects, resulting from postoncologic resection of the tongue,
are commonly reconstructed with locoregional or free flaps.[3]
[4] Untoward outcomes following microsurgical reconstruction of the tongue such as inadequate
neo-tongue volume, strictures or tethering of the tongue, flap loss, infection, and
orocutaneous fistula (OCF) can affect oral feeding, speech, and overall quality of
life.[5]
[6] Additionally, these complications can delay the initiation of adjuvant therapy,
hamper oral feeding, and increase treatment costs, length of hospital stay, and risk
of carotid blowout.[7] The management of a fistula in the floor of the mouth primarily involves local wound
care, irrigation, and debridement procedures to ensure that the wound is clean prior
to secondary reconstruction.[8] In the cases with evidence of pus discharge, culture-directed antibiotic treatment
is also indicated.[6]
[8] However, in the setting of recent radiation therapy, the tissues are poorly vascularized
and fibrotic, the mobility of soft tissue may be restricted, and delayed healing decreases
the likelihood of a successful secondary reconstruction.[9] Frequently, prosthetic appliances have been used in the management of these complications
to create a barrier and seal the oral cavity from the external environment.[8]
To the best of our knowledge, this is the only case series that describes prosthetic
management of flap-related complications following glossectomy in three patients treated
for locally advanced tongue cancer. This unique approach offers an alternative for
optimizing postoperative function and outcomes, particularly in the cases where immediate
secondary reconstruction is not feasible.
Case Series
We present a case series of three patients who developed flap-related complications
following glossectomy for the treatment of locally advanced tongue cancer ([Table 1]). Two patients underwent total glossectomy, bilateral selective neck dissection,
reconstruction using free anterolateral thigh flap, and tracheostomy. Patients 1 and
2 also received adjuvant radiation therapy. The third patient underwent right partial
glossectomy, right neck dissection reconstruction using free radial forearm flap,
and tracheostomy. Patients 1 and 2 developed an intraoral fistula tract located in
the anterior region of the floor of the mouth, with no purulent discharge, 2 and 5
months postradiation therapy, respectively ([Figs. 1a] and [2a]). Patient 3 developed discoloration and gaping in the anterior margin of the flap
inset with purulent discharge necessitating exploration and use of pectoralis major
myocutaneous flap for correction of the OCF. However, it did not resolve the issue
and a second procedure using pectoralis major myocutaneous flap was performed for
correction of the OCF that ultimately did not heal ([Fig. 3a]). None of the patients had any extraoral communication or exposed bone as shown
in the preoperative photographs ([Figs. 1a], [2a], and [3a]).
Table 1
Summary of patient characteristics and surgical interventions (n = 3)
|
Sl no.
|
Age/sex
|
Primary diagnosis
|
Surgical intervention
|
Adjuvant radiotherapy
|
|
Case 1
|
44 y/male
|
Carcinoma of the tongue
pT4apN2a
|
Total glossectomy, bilateral neck dissection, reconstruction using free anterolateral
thigh flap, and tracheostomy
|
EBRT to bilateral face and neck to a dose of 56.25 Gy, 25 fractions at 2.25 Gy per
fraction
|
|
Case 2
|
59 y/male
|
Carcinoma of the left lateral border of the tongue pT3pN0cM0
|
Total glossectomy, bilateral selective neck dissection, reconstruction using free
anterolateral thigh flap, and tracheostomy
|
EBRT to B/L face neck to a dose of 60 Gy, 30 fractions while respecting normal tissue
tolerance
|
|
Case 3
|
67 y/female
|
Carcinoma of the right lateral border of the tongue T4aN3b
|
Right partial glossectomy, right neck dissection reconstruction using free radial
forearm flap (FRAFF), and tracheostomy
|
No adjuvant radiotherapy received at the time of OCF presentation
|
Abbreviation: EBRT, external beam radiotherapy; OCF, orocutaneous fistula.
Fig. 1 Case 1. (a) Preoperative photograph. (b) Postoperative mandibular obturator in situ. (c) Mandibular obturator prosthesis (acrylic plate and bulb relined with a soft liner).
Fig. 2 Case 2. (a) Preoperative photograph. (b) Postoperative mandibular obturator in situ. (c) Mandibular obturator prosthesis (acrylic plate relined with a soft liner).
Fig. 3 Case 3. (a) Preoperative photograph. (b) Postoperative mandibular obturator in situ. (c) Mandibular obturator prosthesis (acrylic plate relined with a soft liner).
Owing to recent history of radiotherapy in patients 1 and 2 as well as occurrence
of flap failure in patient 3, the primary treating oncologists did not recommend further
secondary reconstruction for the management of the fistula. Hence, prosthetic treatment
was sought instead. We planned an acrylic-based mandibular obturator prosthesis lined
with a soft liner for all three cases to address the problem of accumulation of food
debris, saliva pooling, and malodor. Lower arch impressions were recorded in a maxillary
tray, master casts made, and cold cure acrylic resin base retained using continuous
wire clasp, and C-clasps were fabricated for each patient. A try-in was done to evaluate the fit ([Figs. 1b], [2b], and [3b]). Consequently, a low fusing compound was added to intaglio surface to accurately
capture the extent of the defect. Finally, each prosthesis was processed in a heat
cure acrylic resin. The prostheses were lined with a soft liner chair-side and delivered
to the patients ([Figs. 1c], [2c], and [3c]). The patients and caregivers were provided with detailed instructions regarding
the use and maintenance of the prostheses. After a comprehensive assessment conducted
by the speech and swallowing therapist, the patients were gradually introduced to
an appropriate oral diet. Regular follow-up appointments were scheduled at 1 week,
1 month, and every 3 months for 1 year. The acrylic-based mandibular obturator prostheses
were well tolerated by all three patients and helped reduce salivary incontinence,
improve deglutition and articulation, enabled return to oral feeding.
Discussion
Managing the development of flap-related complications can be challenging, and the
formation of a fistula subsequent to free flap reconstruction for the tongue is significantly
correlated with factors such as cachexia, advanced tumor stage (T4), complete resection
of the floor of the mouth, and surgical site infection.[7]
[9] To prevent fistula formation, a reliable and suitably sized skin paddle, along with
multilayer mattress sutures that distribute tension are imperative to minimize tear
of the suture line, dehiscence, and fistula.[3]
[4] Fistulas and infections frequently coexist, creating a harmful pattern where one
issue can trigger the other.[6]
[7] Prompt and effective treatment of infections is crucial to minimize the development
of a fistula.[9] The appropriate management approach for flap-related complications can be determined
based on their presentation. Typically, patients may require adequate debridement,
flap inset adjustment, and wound repair.[10]
[11] If a significant portion of the flap is debrided, and the wound cannot be closed,
a second free flap or regional flap should be planned, taking into consideration the
prognosis, tissue quality, and fistula size.[6]
[10]
In the cases where a fistula presents immediately following radiotherapy, it is crucial
to manage the wound less aggressively with adequate wound care to prevent infection
and minimize fibrosis.[6] At this stage, it is essential to provide reassurance to the patient who may be
experiencing pain and discomfort due to the wound condition. In the event of a fistula
occurring weeks later after radiotherapy, it is preferable to wait until the tissue
settles and inflammation subsides before deciding on the appropriate reconstructive
course and options.[6]
[10]
Khoo and Ooi[11] in their systematic review of current practices of management of postreconstructive
head and neck salivary fistulas recommend that fistulas that are diagnosed early after
oncological surgery be treated with a trial of conservative management for fistulas
that demonstrate good wound healing potential. They described conservative management
options that included conventional wound care and negative pressure wound therapy
(NPWT). NPWT works by creating a vacuum seal, effectively eliminates the dead space,
and prevents salivary leaks around the fistula. Prosthetic appliances are designed
to replace missing structure and restore function, aesthetics, and quality of life
for individuals with oral defects or conditions. Typically, employing a prosthodontic
appliance can aid in promoting wound healing by prevention of contamination and bacterial
growth, prevention of potential disruption of the healing tissues, stimulating the
growth of granulation tissue, and improving oral function, including swallowing and
speech.[8]
[11] This approach is particularly valuable in the cases where a secondary flap surgery
to repair a fistula carries the risks of infection, donor site morbidity, flap failure,
or the development of another fistula or recurrence of the original fistula.
Ultimately, the quality of tissue, size of the fistula, time elapsed since radiotherapy,
surgeon's preference, and patient's general condition determine the course of action.[7] In certain circumstances, it may be more effective to employ a prosthodontic appliance
for patient rehabilitation until sufficient tissue healing has taken place and the
effects of radiotherapy have diminished. The prosthetic management reported in this
case series was unique and successfully overcame the therapeutic challenges in managing
flap-related complications for patients who were not ideal candidates for additional
invasive surgical interventions.
Conclusion
The use of an acrylic-based mandibular obturator prostheses in our case series, similar
to a maxillary obturator, applied gentle pressure, eliminated dead space, avoided
additional surgical morbidity, and allowed early return to normal oral functions,
particularly in the cases where immediate secondary reconstruction was not feasible.
Prosthesis care was simple and easy to perform by all the patients. To achieve rehabilitation
goals, open collaboration between ablative surgeons, reconstructive surgeons, radiation
oncologists, and maxillofacial prosthodontists is of utmost importance. Such an alliance
will help advance toward the most effective rehabilitation approach for the patient.
