Biomechanics of the tongue during swallowing after total laryngectomy: an integrative review

Anjos, Larissa Mendonça dos; Ferreira, Thiago Emerson dos Santos; Pernambuco, Leandro

Larissa Mendonça dos Anjos

Programa Associado de Pós-graduação em Fonoaudiologia, Universidade Federal da Paraíba – UFPB - João Pessoa (PB), Brasil.

http://orcid.org/0000-0002-5881-9794

Thiago Emerson dos Santos Ferreira

Curso de Fonoaudiologia, Universidade Federal da Paraíba – UFPB, João Pessoa (PB), Brasil.

http://orcid.org/0000-0001-8183-3730

Leandro Pernambuco

Programa Associado de Pós-graduação em Fonoaudiologia, Universidade Federal da Paraíba – UFPB - João Pessoa (PB), Brasil.

Departamento de Fonoaudiologia, Universidade Federal da Paraíba – UFPB, João Pessoa (PB), Brasil.

http://orcid.org/0000-0001-6246-9769

Conflict of interest:

nothing to declare.

Correspondence address:
Leandro Pernambuco Departamento de Fonoaudiologia Cidade Universitária, João Pessoa (PB), Brasil, CEP 58051-900. E-mail: leandroape@globo.com

Authors’ contributions

LMA contributed to collection, data analysis, writing, and final review of the article; TESF contributed to data collection and analysis; LP contributed to design, supervision, data analysis, writing, and final review of the article.

Figures (1)
Tables (6)

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Figure 1
Flowchart of the selection of studies

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Base de dados Descritores Pubmed/Medline (((((laryngectomies[MeSH Terms]) OR (laryngectomy[MeSH Terms])) OR (“total laryngectomy”[Title/Abstract])) OR (laryngectomized[Title/Abstract])) AND (((((((deglutition[MeSH Terms]) OR (deglutition disorders[MeSH Terms])) OR (swallowing[MeSH Terms])) OR (swallowing disorders[MeSH Terms])) OR (deglutition[Title/Abstract])) OR (swallowing[Title/Abstract])) OR (dysphagia[Title/Abstract]))) AND (Tongue[Title/Abstract]) EMBASE ('total laryngectomy'/exp OR 'laryngectomy'/exp) AND ('dysphagia'/exp OR 'swallowing'/exp) AND 'tongue'/exp LILACS ((“Total laryngectomy” OR laryngectomized) (Dysphagia OR Swallowing OR Deglutition OR “Deglutition Disorders”) Tongue) SciELO ((“Total laryngectomy” OR laryngectomized) (Dysphagia OR Swallowing OR Deglutition OR “Deglutition Disorders”) Tongue)

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Chart 1
Inclusion and exclusion criteria

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Chart 2
Analysis matrix of studies that investigated the biomechanics of the tongue during swallowing after total laryngectomy

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Table 1
Classification of methodological quality of studies according to criteria of The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Analytical Cross Sectional Studies

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Table 2
Classification of methodological quality of studies according to criteria of The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Reports

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Database Descriptors Pubmed/Medline (((((laryngectomies[MeSH Terms]) OR (laryngectomy[MeSH Terms])) OR (“total laryngectomy”[Title/Abstract])) OR (laryngectomized[Title/Abstract])) AND (((((((deglutition[MeSH Terms]) OR (deglutition disorders[MeSH Terms])) OR (swallowing[MeSH Terms])) OR (swallowing disorders[MeSH Terms])) OR (deglutition[Title/Abstract])) OR (swallowing[Title/Abstract])) OR (dysphagia[Title/Abstract]))) AND (Tongue[Title/Abstract]) EMBASE ('total laryngectomy'/exp OR 'laryngectomy'/exp) AND ('dysphagia'/exp OR 'swallowing'/exp) AND 'tongue'/exp LILACS ((“Total laryngectomy” OR laryngectomized) (Dysphagia OR Swallowing OR Deglutition OR “DeglutitionDisorders”) Tongue) SciELO ((“Total laryngectomy” OR laryngectomized) (Dysphagia OR Swallowing OR Deglutition OR “DeglutitionDisorders”) Tongue)

	Inclusion Criteria	Exclusion Criteria
Population	Individuals undergoing total laryngectomy	Individuals undergoing other head and neck surgeries or with associated neurological conditions
Intervention	Total Laryngectomy	Total laryngectomy in individuals with associated neurological conditions
Results	Characteristics of the biomechanics of the tongue during swallowing after surgery	Studies that investigated swallowing after total laryngectomy, but did not mention tongue outcomes, or that studied the biomechanics of the tongue after total laryngectomy, but only in other functions
Type of study	Original articles, including randomized or non-randomized clinical trials, cohort, case control, cross-sectional studies, case series, and case studies	Experimental studies or those on cadavers, literature reviews, editorials, opinion articles, and annals of scientific events

Author, year, location	Objective	Sample	Type of study	Instrument or exam	Main outcomes related to the biomechanics of the tongue
McConnel, Mendelsohn, Logemann, 1986; United States⁽⁹9 McConnel FM, Mendelsohn MS, Logemann JA. Examination of swallowing after total laryngectomy using manofluorography. Head Neck Surg. 1986;9(1):3-12. http://dx.doi.org/10.1002/hed.2890090103. PMid:3623931. http://dx.doi.org/10.1002/hed.2890090103... ⁾	To analyze the role of different anatomical components of the swallowing process in TL patients with and without tongue impairment.	Group 1 (G1): nine TL without tongue impairment (eight men and one woman);	Transversal	Manofluorography (manometry + videofluoroscopy); questionnaire on swallowing and speech; physical exam.	G1: voluntary control of the food bolus in the oral cavity with minimal residues; greater amplitudes of base pressure gauge waves of the tongue than those of the G2, and non-laryngectomized patients; two patients complaining of dysphagia.
		Group 2 (G2): five TL with tongue impairment due to associated partial/total glossectomy or hypoglossal nerve injury (four men and one woman)			G2: difficulties in containing the food bolus in the oral cavity, presence of residues, and multiple swallows for cleaning; more difficulties in those who underwent glossectomy than in those with hypoglossal nerve damage; low amplitudes of base pressure gauge waves of the tongue than those of G1 and non-laryngectomized patients; head extension as a compensatory strategy; difficulties in initiating the pharyngeal phase of swallowing; all patients complaining of dysphagia.
		There is no information about the participants' age.
McConnel, 1988; United States⁽¹⁴14 McConnel FM. Analysis of pressure generation and bolus transit during pharyngeal swallowing. Laryngoscope. 1988;98(1):71-8. http://dx.doi.org/10.1288/00005537-198801000-00015. PMid:3336265. http://dx.doi.org/10.1288/00005537-19880... ⁾	To investigate the mechanisms of generation of pharyngeal pressure and its relationship with the transit of the bolus in normal individuals who underwent surgery.	Group 1 (G1): 36 not TL (median age: 32 years)	Transversal	Manofluorography (manometry + videofluoroscopy); questionnaire on swallowing and speech; physical exam.	The amplitudes of manometric waves of tongue pressure of G2 are greater than those of G1 and G3; however, those of G3 are lower than those of G1.
		Group 2 (G2): 15 TL without tongue impairment			The motor force of the tongue (pressure produced by the tongue base directly on the bolus) is greater in G2 than in G1.
		Group 3 (G3): five TL with tongue impairment			In TL, although there is an increase in the motor strength of the tongue, there is a decrease in the pharyngeal pressure gradient, especially in the hypopharynx, in addition to a decrease in the time and speed of pharyngeal transit.
		Median age of G2 + G3: 54 years
		Total sample: 33 men and 23 women
Hamlet et al., 1992 United States⁽²⁰20 Hamlet SL, Patterson RL, Fleming SM, Jones LA. Sounds of swallowing following total laryngectomy. Dysphagia. 1992;7(3):160-5. http://dx.doi.org/10.1007/BF02493450. PMid:1499359. http://dx.doi.org/10.1007/BF02493450... ⁾	To identify which acoustic dimensions of swallowing sounds distinguish TL patients from non-TL patients and suggest a causal interpretation.	EG: 13 TL (13 men and one woman). Ages between 41 and 71 years.	Transversal	Videofluoroscopy + accelerometer, simultaneously.	The time between the end of the tongue propulsion gesture and the abrupt spectral change expected shortly thereafter was shorter in the EG than in the CG in swallowing both liquid and pasty substances.
		CG: 17 non-TL (14 men and three women). Ages between 36 and 68 years.	Transversal	Videofluoroscopy + accelerometer, simultaneously.
Lazarus et al., 2002; United States⁽²¹21 Lazarus CL, Logemann JA, Shi G, Kahrilas P, Pelzer H, Kleinjan K. Does Laryngectomy Improve Swallowing After Chemoradiotherapy? A case study. Arch Otolaryngol Head Neck Surg. 2002;128(1):54-7. http://dx.doi.org/10.1001/archotol.128.1.54. PMid:11784255. http://dx.doi.org/10.1001/archotol.128.1... ⁾	To assess swallowing, oral tongue pressure, and tongue base pressure towards the pharynx in an TL patient to improve dysphagia resulting from chemoradiotherapy for the treatment of a tumor in the hypopharynx.	Case: 72 years old, male.	Case report	Videofluoroscopy of swallowing + concomitant manometry.	Incomplete contact and reduced pressure between the base of the tongue and the posterior pharyngeal wall;
		Control: a non-TL individual matched for age and gender.		Iowa Oral Performance Instrument (IOPI) to assess tongue pressure and resistance.	Higher maximum isometric pressure of the tongue in this case, but within normal limits for healthy elderly people;
					Tongue resistance time was shorter in this case, but in both cases, it was lower than the normal limits for healthy elderly people;
					Oral tongue pressure during dry swallowing with no significant difference, but both with lower than expected values;
					Increased pressure of the oral tongue during swallowing, with effort in both.
Maclean et al. 2011; Australia⁽¹⁵15 Maclean J, Szczesniak M, Cotton S, Cook I, Perry A. Impact of a laryngectomy and surgical closure technique on swallow biomechanics and dysphagia severity. Otolaryngol Head Neck Surg. 2011;144(1):21-8. http://dx.doi.org/10.1177/0194599810390906. PMid:21493382. http://dx.doi.org/10.1177/01945998103909... ⁾	To determine whether TL changes the pharyngeal pressure and whether such changes, if they occur, correlate with the surgical technique(s) or severity of dysphagia.	24 TL (19 men and five women).	Transversal	Videomanometry; questionnaire with swallowing scale of the Australian Therapy Outcome Measures (Aus-TOMs).	There was no significant difference between TL with and without swallowing complaints regarding the maximum peak pressure of the tongue base.
		Ages between 46 and 82 years.	Transversal
Morandi et al., 2014; Brazil⁽⁷7 Morandi JC, Capobianco DM, Arakawa-Sugueno L, Ferraz AR, Cernea CR, Andrade CRF, et al. Análise videofluoroscópica da deglutição após laringectomia total. Rev Bras Cir Cabeça Pescoço. 2014;43(3):116-9.⁾	To describe the results of videofluoroscopic analysis of swallowing in TL.	22 videofluoroscopy exams of TL patients who underwent bilateral neck dissection with primary closure (n = 20), pectoral muscle flap (n = 1), and jejunum microsurgical flap (n = 1), followed by radiotherapy.	Transversal	Videofluoroscopy of swallowing.	Reduced movement of posteriorization of the tongue base: 48%;
			Transversal	Videofluoroscopy of swallowing.	Stasis on the base of the tongue: 76%.

	McConnel, Mendelsohn, Logemann, 1986⁹	McConnel, 1988¹⁴	Hamlet et al., 1992²⁰	Maclean et al. (2011); Australia¹⁵	Morandi et al., 2014⁷
1) Were the criteria for inclusion in the sample clearly defined?	N	N	N	Y	Y
2) Were the study subjects and the setting described in detail?	N	N	N	Y	N
3) Was the exposure measured in a valid and reliable way?	N	Y	Y	Y	Y
4) Were objective, standard criteria used for measurement of the condition?	Y	Y	Y	Y	Y
5) Were confounding factors identified?	N	N	N	Y	N
6) Were strategies to deal with confounding factors stated?	N	N	N	U	N
7) Were the outcomes measured in a valid and reliable way?	Y	Y	Y	Y	Y
8) Was appropriate statistical analysis used?	N	N	Y	Y	N
Adequate/Total	2/8	3/8	4/8	7/8	4/8

	Lazarus et al., 2002²¹
1) Were patient’s demographic characteristics clearly described?	N
2) Was the patient's history clearly described and presented in a timeline?	Y
3) Was the current clinical condition of the patient on presentation clearly described?	Y
4) Were diagnostic tests or assessment methods and the results clearly described?	Y
5) Was the intervention(s) or treatment procedure(s) clearly described?	N
6) Was the post-intervention clinical condition clearly described?	Y
7) Were adverse events (harms) or unanticipated events identified and described?	Y
8) Does the case report provide takeaway lessons?	Y
Adequate/Total	6/8

[1] Conflict of interest:

nothing to declare.

Brasil

Brasil

Biomechanics of the tongue during swallowing after total laryngectomy: an integrative review

ABSTRACT

Purpose

Research strategy

Selection criteria

Data analysis

Results

Conclusion