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Original Article |

Risk Factors Predicting Aspiration After Free Flap Reconstruction of Oral Cavity and Oropharyngeal Defects FREE

Jesse E. Smith, MD; Jeffrey D. Suh, MD; Andrew Erman, MA; Vishad Nabili, MD; Dinesh K. Chhetri, MD; Keith E. Blackwell, MD
[+] Author Affiliations

Author Affiliations: Division of Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles.


Arch Otolaryngol Head Neck Surg. 2008;134(11):1205-1208. doi:10.1001/archotol.134.11.1205.
Text Size: A A A
Published online

Objective  To determine risk factors predicting early postoperative aspiration in patients after microvascular free flap reconstruction of oral cavity and oropharyngeal defects.

Design  Retrospective analysis.

Setting  Academic tertiary care referral medical center.

Patients  The study included 100 patients who underwent resection of oral cavity or oropharyngeal tumors with immediate free flap reconstruction of the defect.

Main Outcome Measures  Dysphagia severity was assessed by modified barium swallow study performed within 90 days after surgery to determine the presence or absence of tracheal aspiration. Aspiration risk factors analyzed included age; sex; tumor T and N stage; comorbidity level (American Society of Anesthesiologists classification); preoperative swallowing function; history of tobacco use; surgical approach used for tumor resection; defect classification; type of free flap; history of radiation therapy, surgery, and/or chemotherapy; and surgical defect classification.

Results  The following risk factors were significant predictors of postoperative aspiration on univariate analysis: prior radiation therapy (P < .001), tongue base resection classification (P = .001), tumor N stage (P < .001), hypoglossal nerve sacrifice (P = .004), and presence of a mandibular osteotomy (P = .01). On multivariate analysis, only a history of radiation therapy (P = .002) and tongue base resection (P = .008) remained statistically significant predictors of aspiration.

Conclusion  Patients with resection of more than half of the tongue base and patients with a history of radiation therapy are at high risk of having early postoperative aspiration after free flap reconstruction.

Normal oropharyngeal swallowing requires coordinated actions from structures of the oral cavity, pharynx, larynx, and upper esophagus. Food or liquid boluses must pass though into the esophagus without refluxing into the nasopharynx or penetrating the laryngeal airway. Some or all of these structures and their functions can be temporarily or permanently altered from the surgical management of tumors of the oral cavity and oropharynx.

During surgical resection of tumors of the oral cavity and oropharynx, head and neck surgeons are often faced with the challenge of achieving complete resection margins while preserving a functional swallowing mechanism to avoid postoperative dysphagia and aspiration. Factors considered to influence postoperative swallowing function after surgery in the oral cavity or oropharynx include resections of the mobile and base of tongue,1,2 age younger than 60 years,3 type of reconstruction performed,4,5 and history of radiation therapy.6 The resulting dysphagia and aspiration risk can lead to prolonged limitations in diet and reduced oral intake, which may necessitate alternate routes of alimentation by nasogastric or gastrostomy tubes.

The purpose of this study was to evaluate risk factors that may lead to early postoperative aspiration in patients undergoing oral cavity or oropharyngeal tumor resection with immediate free flap reconstruction of the surgical defect. We suggest that surgical teams can better formulate perioperative feeding strategies, such as gastrostomy tube placement and aggressive swallow rehabilitation, in patients who are at high risk for aspiration.

A retrospective review was performed in 100 patients with oral cavity or oropharyngeal tumors who underwent resection and free flap reconstruction between 1996 and 2006 at the David Geffen School of Medicine at the University of California, Los Angeles. This study was approved by the UCLA Office for the Protection of Research Subjects. There were 40 women and 60 men, with a mean age of 60 years (age range, 30-88 years). The surgical defects were due to resection of squamous cell carcinoma (n = 97), ameloblastoma (n = 1), and osteoradionecrosis of the mandible (n = 2). Flap donor sites included the fibula (n = 49), radial forearm (n = 43), latissimus dorsi (n = 4), rectus abdominus (n = 3), and latissimus dorsi serratus anterior rib (n = 1).

Swallowing assessment was done by a modified barium swallow study (MBSS) in all patients. The MBSS was performed between 8 and 87 days (median, 35 days) after surgery. A single speech pathologist (A.E.) performed and analyzed all MBSSs to assess dysphagia severity using standard protocols. Each subject was given small boluses of liquid, puree, and a solid to assess the ability to swallow various food consistencies. Fluoroscopic imaging covered the field from the lips to the cervical vertebrae in the anterior to posterior direction and the soft palate to the midesophagus in the superior to inferior direction. The subject's swallowing efficiency during the oral preparation phase, the oral phase, and the pharyngeal phase was recorded. The presence or absence of tracheal aspiration was the main outcome measure analyzed in this series.

Risk factors analyzed for aspiration included age; sex; comorbidity level according to the American Society of Anesthesiology classification; preoperative swallowing function; tumor T stage; tumor N stage; history of radiation therapy, chemotherapy, or surgery; type of free flap, surgical approach used for tumor resection (ie, mandibular osteotomy, transoral, transhyoid, or lateral pharyngeal); and surgical defect classification. The presence or absence of preoperative dysphagia was determined by a review of the intake history and the review of systems from the patient's chart. Specific information regarding the presence or absence of dysphagia as a presenting symptom was available in only 78 of the 100 patients. A detailed description of the surgical defects was made by the senior author (K.E.B.) in the operative report of each patient according to the method described by Urken et al.7 Defect subsites that were analyzed included the mandible, lips, floor of the mouth, buccal mucosa, hard palate, oral tongue, tongue base, soft palate, and lateral and posterior pharyngeal walls. Also, the effects of hypoglossal, inferior alveolar, and lingual nerve sacrifice were analyzed.

Statistical analysis was performed using SPSS statistical software (SPSS for Windows 15.0.0; SPSS Inc, Chicago, Illinois). Univariate statistical analysis was performed using the Pearson χ2 test. As univariate analysis cannot control for interrelationships between measured variables and outcomes, multivariate analysis was performed using logistical regression on those factors showing statistical significance on univariate analysis. Statistical significance was set at a level of P < .05.

The donor defect subsites are summarized in the following tabulation:

Most patients had defects that involved the floor of the mouth (n = 81), mandible (n = 58), tongue base (n = 52), and mobile tongue (n = 47). The types of nerves sacrificed during resection are summarized below:

Fifty-one patients had a history of radiation therapy; 27 had a history of head and neck surgery; and 26 had a history of chemotherapy.

On univariate analysis, aspiration was significantly associated with the following risk factors: tongue base resection classification (P = .001), sacrifice of the hypoglossal nerve (P = .004), history of radiation therapy (P < .001), N stage (P < .001), and use of a mandibular osteotomy for exposure (P = .01) (Table 1 and Table 2). Dysphagia as a presenting symptom approached statistical significance on univariate analysis (P = .07). On multivariate analysis, aspiration was significantly correlated with the following factors: a history of radiation therapy (P = .002) and tongue base resection classification (P = .008).

Table Graphic Jump LocationTable 1. Results of Univariate Statistical Analysis
Table Graphic Jump LocationTable 2. Results of Univariate Statistical Analysis

The incidence of aspiration according to radiation therapy status and tongue base resection classification is summarized in Table 3. This analysis shows that in patients without a history of radiation therapy, resection of up to half of the base of the tongue resulted in a 22% incidence of aspiration, while resection of more than half of the base of the tongue was associated with a 75% incidence of aspiration. In patients with a history of radiation therapy, the incidence of aspiration exceeded 50% regardless of the percentage of tongue base resection.

Cancers of the upper aerodigestive tract constitute nearly 4% of all malignant neoplasms. In the head and neck region, oral cavity and oropharynx tumors together account for approximately 52.8% of all malignant neoplasms.8 Surgery with and without radiation therapy remains the current standard of care in the treatment of the majority of oral cancers.9 Microvascular flap reconstruction has proved to be very reliable for repairing defects in the oral cavity and the oropharynx as a direct result of the low incidence of free flap failure, the high incidence of primary wound healing,10,11 and the ability to obtain acceptable results in restoring bony and soft tissue contour.12 However, even with the best means of treatment and reconstruction available, significant dysphagia is reported to affect 12% to 69% of patients with head and neck cancer 6 to 9 months after treatment.13 Severe dysphagia can lead to malnutrition, aspiration pneumonia, and even death.14,15

Enteral feeding is therefore required in many patients after treatment of oral cavity and oropharyngeal cancer. Citing a low incidence of morbidity, some studies have advocated prophylactic gastrostomy tubes in patients undergoing treatment for head and neck cancer.14,16,17 However, enteral feeding is not without its disadvantages. Other studies have shown that enteral feeding may be counterproductive when it is not needed. Gillespie et al18 reported that patients who had been without oral intake for more than 2 weeks had worse swallowing outcomes, possibly owing to swallowing deconditioning, atrophy of pharyngeal musculature, or increased pharyngeal fibrosis. Cheng et al19 demonstrated that patients with head and neck cancer who receive enteral feedings have a substantially decreased quality of life.

According to these studies, it would be advantageous to avoid enteral feedings in patients who are able to swallow safely. The difficulty lies in predicting which patients would benefit from gastrostomy tube placement after free flap reconstruction of oral cavity and oropharyngeal defects. The present series showed a statistically significant relationship between the incidence of perioperative aspiration and the risk factors of tongue base resection classification (P = .008) and a history of radiation therapy (P = .002) after multivariate analysis.

The increased dysphagia and aspiration that follow extensive tongue base resection are probably the result of reduction of the bolus driving pressure that propels the food bolus toward the esophagus. Pauloski et al1 found that the total volume and percentage of tongue base resected were associated with postoperative swallowing dysfunction in 144 patients treated for oral and oropharyngeal cancer 3 months after surgery. McConnel et al20 found that as the percentage of tongue base resected increased, the efficiency of oropharyngeal swallowing decreased. Similarly, Nicoletti et al21 found that cases involving smaller resections had better functional outcomes. In their study, swallowing was affected most by the resection of the base of the tongue and the retromolar trigone.

Many reconstructive techniques are used to repair tongue defects. Small defects of the tongue can usually be closed primarily without significant functional loss and with minimal dysphagia. However, prior studies have shown that when more than 50% of the tongue base is resected, free flap reconstruction may provide the best swallowing outcomes.22,23 Hsiao et al5 compared patients who had tongue defects that were closed primarily with patients with similar defects that were reconstructed with radial forearm free flaps. Their findings showed that the patients who had tongue defects closed primarily had impaired swallowing compared with those whose defects were reconstructed with microvascular free flaps.

The present series also demonstrates that a history of radiation therapy is a significant predictor of postoperative aspiration. The detrimental effects of radiation therapy on swallowing function are well documented in the literature. Radiotherapy results in long-term swallowing dysfunction due to reduced tongue base movement, reduced laryngeal elevation, reduced salivary flow, edema, and fibrosis.6,24 Zuydam et al25 found that radiotherapy exacerbated swallowing dysfunction in patients with more than 25% of the tongue base resected. Their findings also indicate that swallow therapy was effective in treating select patients with postoperative dysphagia and aspiration.

It is important to consider the shortcomings of our analysis. We chose to analyze the presence of aspiration on MBSSs as the main outcome measure as it is an objective finding that indicates an increased risk for aspiration pneumonia. However, not all patients with aspiration on MBSSs will develop aspiration pneumonia while taking oral nutrition. Other factors such as pulmonary reserve and the presence of a protective cough reflex should be considered when making dietary recommendations in patients with aspiration noted on MBSSs. Furthermore, our analysis fails to account for the potential impacts of additional postoperative treatments (eg, radiation therapy and chemotherapy) on deglutition, and these impacts need to be anticipated and considered when recommendations for oral vs enteral nutrition are being made. Finally, our analysis is limited to swallowing function within 90 days of surgery and may not be an indication of long-term functional outcomes. While Pauloski et al1 noted similar swallowing performance when patients were assessed at 3 months and at 12 months after surgery, other studies have documented progressive improvement in head and neck–specific quality of life over a period of at least 12 months after the completion of treatment.26

In conclusion, early swallowing in patients undergoing oral cavity and oropharyngeal resection with free flap reconstruction is significantly affected by a history of radiation therapy and surgical extirpation of more than 50% of the tongue base. Patients with either of these factors are much more likely to have difficulty with aspiration during the first 3 months of the postoperative period. We recommend that patients with these risk factors should be considered likely candidates for perioperative gastrostomy tube placement.

Correspondence: Keith E. Blackwell, MD, Division of Head and Neck Surgery, 62-132 CHS, UCLA Medical Center, Los Angeles, CA 90095-1624 (kblackwe@ucla.edu).

Submitted for Publication: August 11, 2007; final revision received November 19, 2007; accepted November 27, 2007.

Author Contributions: Dr Suh had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Smith, Nabili, Chhetri, and Blackwell. Acquisition of data: Smith, Suh, Erman, and Blackwell. Analysis and interpretation of data: Smith, Suh, and Blackwell. Drafting of the manuscript: Smith, Suh, Nabili, Chhetri, and Blackwell. Critical revision of the manuscript for important intellectual content: Smith, Suh, Erman, Nabili, Chhetri, and Blackwell. Statistical analysis: Suh. Administrative, technical, and material support: Smith. Study supervision: Smith and Blackwell.

Financial Disclosure: None reported.

Pauloski  BRRademaker  AWLogemann  JA  et al.  Surgical variables affecting swallowing in patients treated for oral/oropharyngeal cancer. Head Neck 2004;26 (7) 625- 636
PubMed Link to Article
Wagner  JDColeman  JJWeisberger  E  et al.  Predictive factors for functional recovery after free tissue transfer oromandibular reconstruction. Am J Surg 1998;176 (5) 430- 435
PubMed Link to Article
Fujimoto  YHasegawa  YYamada  HAndo  ANakashima  T Swallowing function following extensive resection of oral or oropharyngeal cancer with laryngeal suspension and cricopharyngeal myotomy. Laryngoscope 2007;117 (8) 1343- 1348
PubMed Link to Article
McConnel  FMPauloski  BRLogemann  JA  et al.  Functional results of primary closure vs flaps in oropharyngeal reconstruction. Arch Otolaryngol Head Neck Surg 1998;124 (6) 625- 630
PubMed Link to Article
Hsiao  HTLeu  YSChang  SHLee  JT Swallowing function in patients who underwent hemiglossectomy: comparison of primary closure and free radial forearm flap reconstruction with videofluoroscopy. Ann Plast Surg 2003;50 (5) 450- 455
PubMed Link to Article
Pauloski  BRRademaker  AWLogemann  JAColangelo  LA Speech and swallowing in irradiated and nonirradiated postsurgical oral cancer patients. Otolaryngol Head Neck Surg 1998;118 (5) 616- 624
PubMed
Urken  MLWeinberg  HVickery  CBuchbinder  DLawson  WBiller  HF Oromandibular reconstruction using microvascular composite free flaps: report of 71 cases and a new classification scheme for bony, soft-tissue, and neurologic defects. Arch Otolaryngol Head Neck Surg 1991;117 (7) 733- 744
PubMed Link to Article
Muir  CWeiland  L Upper aerodigestive tract cancers. Cancer 1995;75 (1) ((suppl)) 147- 153
PubMed Link to Article
Funk  GFKarnell  LHRobinson  RAZhen  WKTrask  DKHoffman  HT Presentation, treatment, and outcome of oral cavity cancer: a National Cancer Data Base report. Head Neck 2002;24 (2) 165- 180
PubMed Link to Article
Suh  JDAbemayor  EASercarz  JSCalcaterra  TCRawnsley  JDBlackwell  KE Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction. Arch Otolaryngol Head Neck Surg 2004;130 (8) 962- 966
PubMed Link to Article
Abemayor  EBlackwell  KE Reconstruction of soft tissue defects in the oral cavity and oropharynx. Arch Otolaryngol Head Neck Surg 2000;126 (7) 909- 912
PubMed Link to Article
Roumanas  EDGarrett  NBlackwell  KE  et al.  Masticatory and swallowing threshold performances with conventional and implant-supported prostheses after mandibular fibula free-flap reconstruction. J Prosthet Dent 2006;96 (4) 289- 297
PubMed Link to Article
Nguyen  NPMoltz  CCFrank  C  et al.  Evolution of chronic dysphagia following treatment for head and neck cancer. Oral Oncol 2006;42 (4) 374- 380
PubMed Link to Article
Mekhail  TMAdelstein  DJRybicki  LALarto  MASaxton  JPLavertu  P Enteral nutrition during the treatment of head and neck carcinoma: is a percutaneous endoscopic gastrostomy tube preferable to a nasogastric tube? Cancer 2001;91 (9) 1785- 1790
PubMed Link to Article
Eisbruch  ALyden  TBradford  CR  et al.  Objective assessment of swallowing dysfunction and aspiration after radiation concurrent with chemotherapy for head-and-neck cancer. Int J Radiat Oncol Biol Phys 2002;53 (1) 23- 28
PubMed Link to Article
Lee  JHMachtay  MUnger  LD  et al.  Prophylactic gastrostomy tubes in patients undergoing intensive irradiation for cancer of the head and neck. Arch Otolaryngol Head Neck Surg 1998;124 (8) 871- 875
PubMed Link to Article
Scolapio  JSSpangler  PRRomano  MM McLaughlin  MPSalassa  JR Prophylactic placement of gastrostomy feeding tubes before radiotherapy in patients with head and neck cancer: is it worthwhile? J Clin Gastroenterol 2001;33 (3) 215- 217
PubMed Link to Article
Gillespie  MBBrodsky  MBDay  TALee  FSMartin-Harris  B Swallowing-related quality of life after head and neck cancer treatment. Laryngoscope 2004;114 (8) 1362- 1367
PubMed Link to Article
Cheng  SSTerrell  JEBradford  CR  et al.  Variables associated with feeding tube placement in head and neck cancer. Arch Otolaryngol Head Neck Surg 2006;132 (6) 655- 661
PubMed Link to Article
McConnel  FMLogemann  JARademaker  AW  et al.  Surgical variables affecting postoperative swallowing efficiency in oral cancer patients: a pilot study. Laryngoscope 1994;104 (1, pt 1) 87- 90
PubMed Link to Article
Nicoletti  GSoutar  DSJackson  MSWrench  AARobertson  G Chewing and swallowing after surgical treatment for oral cancer: functional evaluation in 196 selected cases. Plast Reconstr Surg 2004;114 (2) 329- 338
PubMed Link to Article
Haughey  BHTaylor  SMFuller  D Fasciocutaneous flap reconstruction of the tongue and floor of mouth: outcomes and techniques. Arch Otolaryngol Head Neck Surg 2002;128 (12) 1388- 1395
PubMed Link to Article
Hsiao  HTLeu  YSLin  CC Primary closure versus radial forearm flap reconstruction after hemiglossectomy: functional assessment of swallowing and speech. Ann Plast Surg 2002;49 (6) 612- 616
PubMed Link to Article
Nguyen  NPSmith  HJSallah  S Evaluation and management of swallowing dysfunction following chemoradiation for head and neck cancer. Curr Opin Otolaryngol Head Neck Surg 2007;15 (2) 130- 133
PubMed Link to Article
Zuydam  ACRogers  SNBrown  JSVaughan  EDMagennis  P Swallowing rehabilitation after oro-pharyngeal resection for squamous cell carcinoma. Br J Oral Maxillofac Surg 2000;38 (5) 513- 518
PubMed Link to Article
Netscher  DTMeade  RAGoodman  CMAlford  ELStewart  MG Quality of life and disease-specific functional status following microvascular reconstruction for advanced (T3 and T4) oropharyngeal cancers. Plast Reconstr Surg 2000;105 (5) 1628- 1634
PubMed Link to Article

Figures

References

Pauloski  BRRademaker  AWLogemann  JA  et al.  Surgical variables affecting swallowing in patients treated for oral/oropharyngeal cancer. Head Neck 2004;26 (7) 625- 636
PubMed Link to Article
Wagner  JDColeman  JJWeisberger  E  et al.  Predictive factors for functional recovery after free tissue transfer oromandibular reconstruction. Am J Surg 1998;176 (5) 430- 435
PubMed Link to Article
Fujimoto  YHasegawa  YYamada  HAndo  ANakashima  T Swallowing function following extensive resection of oral or oropharyngeal cancer with laryngeal suspension and cricopharyngeal myotomy. Laryngoscope 2007;117 (8) 1343- 1348
PubMed Link to Article
McConnel  FMPauloski  BRLogemann  JA  et al.  Functional results of primary closure vs flaps in oropharyngeal reconstruction. Arch Otolaryngol Head Neck Surg 1998;124 (6) 625- 630
PubMed Link to Article
Hsiao  HTLeu  YSChang  SHLee  JT Swallowing function in patients who underwent hemiglossectomy: comparison of primary closure and free radial forearm flap reconstruction with videofluoroscopy. Ann Plast Surg 2003;50 (5) 450- 455
PubMed Link to Article
Pauloski  BRRademaker  AWLogemann  JAColangelo  LA Speech and swallowing in irradiated and nonirradiated postsurgical oral cancer patients. Otolaryngol Head Neck Surg 1998;118 (5) 616- 624
PubMed
Urken  MLWeinberg  HVickery  CBuchbinder  DLawson  WBiller  HF Oromandibular reconstruction using microvascular composite free flaps: report of 71 cases and a new classification scheme for bony, soft-tissue, and neurologic defects. Arch Otolaryngol Head Neck Surg 1991;117 (7) 733- 744
PubMed Link to Article
Muir  CWeiland  L Upper aerodigestive tract cancers. Cancer 1995;75 (1) ((suppl)) 147- 153
PubMed Link to Article
Funk  GFKarnell  LHRobinson  RAZhen  WKTrask  DKHoffman  HT Presentation, treatment, and outcome of oral cavity cancer: a National Cancer Data Base report. Head Neck 2002;24 (2) 165- 180
PubMed Link to Article
Suh  JDAbemayor  EASercarz  JSCalcaterra  TCRawnsley  JDBlackwell  KE Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction. Arch Otolaryngol Head Neck Surg 2004;130 (8) 962- 966
PubMed Link to Article
Abemayor  EBlackwell  KE Reconstruction of soft tissue defects in the oral cavity and oropharynx. Arch Otolaryngol Head Neck Surg 2000;126 (7) 909- 912
PubMed Link to Article
Roumanas  EDGarrett  NBlackwell  KE  et al.  Masticatory and swallowing threshold performances with conventional and implant-supported prostheses after mandibular fibula free-flap reconstruction. J Prosthet Dent 2006;96 (4) 289- 297
PubMed Link to Article
Nguyen  NPMoltz  CCFrank  C  et al.  Evolution of chronic dysphagia following treatment for head and neck cancer. Oral Oncol 2006;42 (4) 374- 380
PubMed Link to Article
Mekhail  TMAdelstein  DJRybicki  LALarto  MASaxton  JPLavertu  P Enteral nutrition during the treatment of head and neck carcinoma: is a percutaneous endoscopic gastrostomy tube preferable to a nasogastric tube? Cancer 2001;91 (9) 1785- 1790
PubMed Link to Article
Eisbruch  ALyden  TBradford  CR  et al.  Objective assessment of swallowing dysfunction and aspiration after radiation concurrent with chemotherapy for head-and-neck cancer. Int J Radiat Oncol Biol Phys 2002;53 (1) 23- 28
PubMed Link to Article
Lee  JHMachtay  MUnger  LD  et al.  Prophylactic gastrostomy tubes in patients undergoing intensive irradiation for cancer of the head and neck. Arch Otolaryngol Head Neck Surg 1998;124 (8) 871- 875
PubMed Link to Article
Scolapio  JSSpangler  PRRomano  MM McLaughlin  MPSalassa  JR Prophylactic placement of gastrostomy feeding tubes before radiotherapy in patients with head and neck cancer: is it worthwhile? J Clin Gastroenterol 2001;33 (3) 215- 217
PubMed Link to Article
Gillespie  MBBrodsky  MBDay  TALee  FSMartin-Harris  B Swallowing-related quality of life after head and neck cancer treatment. Laryngoscope 2004;114 (8) 1362- 1367
PubMed Link to Article
Cheng  SSTerrell  JEBradford  CR  et al.  Variables associated with feeding tube placement in head and neck cancer. Arch Otolaryngol Head Neck Surg 2006;132 (6) 655- 661
PubMed Link to Article
McConnel  FMLogemann  JARademaker  AW  et al.  Surgical variables affecting postoperative swallowing efficiency in oral cancer patients: a pilot study. Laryngoscope 1994;104 (1, pt 1) 87- 90
PubMed Link to Article
Nicoletti  GSoutar  DSJackson  MSWrench  AARobertson  G Chewing and swallowing after surgical treatment for oral cancer: functional evaluation in 196 selected cases. Plast Reconstr Surg 2004;114 (2) 329- 338
PubMed Link to Article
Haughey  BHTaylor  SMFuller  D Fasciocutaneous flap reconstruction of the tongue and floor of mouth: outcomes and techniques. Arch Otolaryngol Head Neck Surg 2002;128 (12) 1388- 1395
PubMed Link to Article
Hsiao  HTLeu  YSLin  CC Primary closure versus radial forearm flap reconstruction after hemiglossectomy: functional assessment of swallowing and speech. Ann Plast Surg 2002;49 (6) 612- 616
PubMed Link to Article
Nguyen  NPSmith  HJSallah  S Evaluation and management of swallowing dysfunction following chemoradiation for head and neck cancer. Curr Opin Otolaryngol Head Neck Surg 2007;15 (2) 130- 133
PubMed Link to Article
Zuydam  ACRogers  SNBrown  JSVaughan  EDMagennis  P Swallowing rehabilitation after oro-pharyngeal resection for squamous cell carcinoma. Br J Oral Maxillofac Surg 2000;38 (5) 513- 518
PubMed Link to Article
Netscher  DTMeade  RAGoodman  CMAlford  ELStewart  MG Quality of life and disease-specific functional status following microvascular reconstruction for advanced (T3 and T4) oropharyngeal cancers. Plast Reconstr Surg 2000;105 (5) 1628- 1634
PubMed Link to Article

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