|Year : 2011 | Volume
| Issue : 3 | Page : 238--240
Speech and swallowing outcomes in buccal mucosa carcinoma
Sunila John, Rashida M Hassuji, B Rajashekhar
Department of Speech and Hearing, MCOAHS, Manipal University, Manipal, Karnataka, India
Department of Speech and Hearing, MCOAHS, Manipal University, Manipal, Karnataka
Buccal carcinoma is one of the most common malignant neoplasms among all oral cancers in India. Understanding the role of speech language pathologists (SLPs) in the domains of evaluation and management strategies of this condition is limited, especially in the Indian context. This is a case report of a young adult with recurrent squamous cell carcinoma of the buccal mucosa with no deleterious habits usually associated with buccal mucosa carcinoma. Following composite resection, pectoralis major myocutaneous flap reconstruction, he developed severe oral dysphagia and demonstrated unintelligible speech. This case report focuses on the issues of swallowing and speech deficits in buccal mucosa carcinoma that need to be addressed by SLPs, and the outcomes of speech and swallowing rehabilitation and prognostic issues.
|How to cite this article:|
John S, Hassuji RM, Rajashekhar B. Speech and swallowing outcomes in buccal mucosa carcinoma.Indian J Palliat Care 2011;17:238-240
|How to cite this URL:|
John S, Hassuji RM, Rajashekhar B. Speech and swallowing outcomes in buccal mucosa carcinoma. Indian J Palliat Care [serial online] 2011 [cited 2019 Sep 20 ];17:238-240
Available from: http://www.jpalliativecare.com/text.asp?2011/17/3/238/92344
Buccal mucosa, the membrane lining of the inner surface of the cheeks is one of the most common sites of oral cancer. It accounts for 37% and 22% of all oral cancers in India among older and younger age groups, respectively.  The higher rate of this condition in Asia is believed to be due to the widespread practice of using betel nuts, tobacco, alcohol coupled with poor oral hygiene, poor diet, and viral infections.  Theexisting literature on buccal mucosa carcinoma addresses the treatment aspects specific to elderly patients.  Our understanding on speech and swallowing outcomes is limited in young adults and warrants reporting.
A young male of 35 years came with the complaint of the presence of a nonhealing ulcer on the left cheek with referred otalgia for the past 4 months. He had developed a similar ulcer in the same buccal region 3 years back for which he underwent surgery in another hospital. He did not present any history of smoking, alcohol, or any other deleterious habits associated with buccal mucosa carcinoma. Biopsy of the ulcer revealed an ill-defined enhancing tissue (9 mm) in the left buccal space and it was diagnosed as recurrent squamous cell carcinoma, stage 4, of the left buccal mucosa. The patient underwent composite resection, pectoralis major myocutaneous flap reconstruction, following which he developed severe feeding difficulty and loss of speech clarity.
A physical examination of the oropharyngeal mechanism was done using tongue depressor, gloves, oral swab, and pen torch on a series of oral movements. Difficulty was observed with the functional movements associated with cheek and lips involving lip retraction, puckering, protrusion, lip coordination during alternate movements of smile, and pucker and cheek coordination during puffing out and sucking in cheeks. However, tongue and soft palate movements, strength of the oral reflex during gag, laryngeal elevation, approximation and strength during coughing, and throat clearing were within normal functioning limits.
Detailed clinical swallow evaluation using different consistencies (regular solid, chapatti; mechanically altered, boiled rice; pureed, mashed banana; regular liquid, water; nectar, juice; and thick liquid, honey) was done to observe the oral and pharyngeal level of swallowing. His ability to transport bolus, approximate lips and maintain closure, and rate of mastication were affected resulting in an increased number of swallows per bolus and pocketing of food on lateral sulci. However, being aware of pocketing, the patient was able to subsequently clear the material. The pharyngeal level transit time and laryngeal elevation were within normal limits. Across consistencies, lateral spillage, stasis, normal taste and temperature perception, and frequent attempts to clear throat were observed. There was aspiration on all consistencies except for pureed, nectar, and thick liquid.
His speech was evaluated by an experienced speech language pathologist (SLP) across the domains of respiration, voice, resonance, prosody, articulation, and intelligibility. His speech was characterized by articulation deficits (imprecise consonants, irregular articulatory breakdown, distorted vowels, and consonant substitution) affected intelligibility (greater difficulty at conversation and word level as compared to in isolation) and prosodic deviations (short rushes of speech). Overall, his voice, and functions of respiration and resonance were adequate.
After evaluation, an impression of oral dysphagia with a mild speech intelligibility deficit was drawn. Swallowing and speech rehabilitation was carried out for 12 days (15 sessions of 30-min duration) with focused counseling on the altered swallowing maneuver. To improve swallowing, direct (range of motion exercises) and compensatory techniques (postural adjustments with the head tilt toward the normal side, diet alterations, and food presentation strategies) were employed. Speech intelligibility was improved by working on the identification of target sounds, discrimination among similar sounds, self-evaluation of intelligibility and behavioral modifications involving consistency in substitution and modification of rate. Post-therapeutically, he was able to decrease his speech rate, and articulate precisely at isolation and word levels but required prompts during conversation. Furthermore, he was able to be fed orally using swallowing maneuvers for different food consistencies.
Patients with buccal mucosa carcinoma often face multiple functional problems encompassing speech and swallowing subsequent to surgical treatment.  These functional problems occur as a result of alterations within the oral cavity. Since both swallowing and speech functions rely on an appropriate coordination of a series of rapid and complex neuromuscular actions, any anatomical variation can have a compromising effect. Although current head and neck cancer treatment protocols attempt to maintain the functions, treatments developed specifically for organ preservation  frequently result in functional sequelae. These cancer treatment modules can affect communication and swallowing that warrants the continuation of taking the help of the SLP as a team member.
Squamous cell carcinoma of buccal mucosa is reported to be having a relatively higher prevalence, and worse survival and recurrence rates as compared to carcinomas of other oral structures with greater chances of tumor and lymphatic invasion.  The present case had recurrent squamous cell carcinoma of buccal mucosa (stage 4) with a 9-mm tumor invading into the buccal region. Even though the literature reports of a high incidence of speech and swallowing functions not improving with time,  the current case improved owing to multiple reasons. The tumor was in the cheek region and did not metastasize to other parts of the oral cavity; tongue movements were within limits allowing him to transfer the bolus toward the intact side. In addition, he also performed range of motion exercises on a regular basis which is presumed to be contributing to greater improvement in speech and swallowing functions. 
The difficulty encountered in speech and swallowing in the current case study was not a result of carcinoma per se but a result of complications following carcinoma surgery. Surgery is the preferred treatment for advanced buccal carcinoma cases and cannot be compromised. The reconstruction procedure tries to prevent contractures in the buccal region that could interfere with the function of the oral cavity. It's known that the buccal region is important in speech and the oral preparatory phase of swallowing and for preventing food spillage into the lateral sulci or extraorally which could be restricted by cancer treatment. Rehabilitation based on the evaluation of oral mechanism examination, clinical swallow examination using different consistencies, and performance of various speech subsystems needs to be considered in such conditions in order to reduce the complications of speech and swallowing.
To conclude, buccal mucosa carcinoma is one of the most common cancers, increasing at a rapid rate in India. The afflicted, subsequent to surgical intervention, end up with variable deficits including that of swallowing and speech. Here comes the role of an SLP as an important team member in the rehabilitation of such cases and enhancing their quality of life. Most of the SLPs who are not aware of their role in this condition need to be sensitized and trained in the therapeutic aspects concerning speech and swallowing rehabilitation.
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