Functional results of primary closure vs flaps in oropharyngeal reconstruction: a prospective study of speech and swallowing

BACKGROUND: The preservation of speech and swallowing function is the primary goal when reconstructing soft tissue defects in the oral cavity or oropharynx. The type of reconstructive procedure used should be based on outcome data examining speech and swallowing function; yet, there is a paucity of such information.

OBJECTIVES: To present the results of a multi-institutional prospective study of speech and swallowing function before and after soft tissue reconstruction of the oral cavity and oropharynx, and to compare 3 methods of reconstruction with respect to speech and swallowing function: primary closure, distal myocutaneous flap, and microvascular free flap.

DESIGN: Prospective case-comparison study.

SETTING: Four leading head and neck cancer institutions.

PATIENTS: The patients were selected from a database of 284 patients treated at the different institutions. The patients were matched for the location of the oral cavity or oropharyngeal defect and the percentage of oral tongue and tongue base resection. Those patients who had previous speech and swallowing deficits and patients in whom postoperative fistulas or wound infections developed were excluded from the study.

METHODS: The patients underwent speech and swallowing evaluation preoperatively and 3 months after healing. This evaluation included videofluoroscopic studies of swallowing and tests of speech intelligibility and sentence articulation. Videofluoroscopy provided measures of swallowing efficiency and bolus movement. Liquid and paste consistencies were used in evaluating swallowing function.

MAIN OUTCOME MEASURE: The functional results of the reconstruction.

RESULTS: Patients who had primary closure were more efficient at swallowing liquids, had less pharyngeal residue, a longer oral transit time with paste, and higher conversational intelligibility than patients who underwent reconstruction with a distal flap. Compared with patients who underwent reconstruction with a free flap, those who had primary closure had more efficient swallowing of liquids, less pharyngeal residue, and shorter pharyngeal delay times with paste. No difference in the speech and swallowing function existed between patients treated with distal myocutaneous flaps and those treated with microvascular free flaps.

CONCLUSION: Contrary to the current theory of oral and oropharyngeal reconstruction, we found that the use of primary closure resulted in equal or better function than the use of flap reconstruction in patients with a comparable locus of resection and percentage of oral tongue and tongue base resection.