The Use of Facial-Flex® as an Adjunct to Speech Therapy in Recovery from Extensive Oral Cavity Carcinoma
By Joseph R. Spiegel, M.D., Judith N. Creed, M.A., CCC-SLP
L.R. is a 74-year-old white female who was diagnosed with a T2NO (stage II) squamous cell carcinoma of the right side of the oral cavity in January 1997. In February 1997, she underwent initial surgical treatment by right marginal mandibulectomy and right supraomohyoid neck dissection. Microscopic metastases were discovered in the neck (stage III) and radiation therapy was completed between the sixth and thirteenth postoperative weeks. She developed recurrent cancer at the primary site that was diagnosed in December 1997; on January 8, 1998, she underwent right hemimandibulectomy and repair with a right fibula osteocutaneous microvascular free flap. She recovered from surgery without complication and, to date, she has been followed without evidence of recurrent cancer.
After initial recovery from the last extensive surgical procedure, L.R. had persistent complaints of difficulty with mouth opening, pain with jaw motion during eating and poor articulation. Her speech difficulty was due to restricted jaw motion, scarring of the right side of the tongue, paresis of the right hypoglossal nerve and paresis of the right marginal mandibular branch of the facial nerve. She also suffered from severe oropharyngeal dysphagia secondary to these lesions and her nutrition was provided primarily by a gastrostomy tube in the postoperative period. After radiation therapy, physical therapy was instituted with gentle jaw exercises and moist heat. Over 8 weeks, L.R. noted only minimal improvement in her articulation. With ongoing swallowing therapy she had progressed to a diet of pureed foods, but she could not tolerate liquids.
Five months postoperatively, L.R. was provided a Facial-Flex and prescribed an 8-week course of dynamic resistance oral exercise. After 4 weeks, she had progressed to twice-daily exercises with 8-ounce bands. At this point, the protocol was suspended because of persistent pain along the right jaw line. No change in the pain was noted and 3 weeks later the protocol was continued. Over the next 4 weeks of the protocol, L.R. used a once-daily exercise program with 4-ounce bands.
Throughout L.R.’s postoperative course she was under the care of certified speech-language pathologists for both speech therapy for her articulation difficulties and swallowing therapy for oropharyngeal dysphagia. After completing 3 weeks of the first interval of Facial-Flex use, the patient, her family members, and the treating speech pathologists noted improvement in motion of the right oral commissure and improvement in articulation. As she completed the second interval of Facial-Flex exercise, L.R. noted significant improvement in articulation and in her swallowing ability. Over this time she regained her capacity to handle a thin liquid diet and her gastrostomy tube was removed. L.R. continues to use Facial-Flex in a once-daily exercise program as she notes progressive improvement in her jaw pain, mandibular motion and articulation. Close follow-up continues and long term reports of L.R.’s progress will be provided.
This interim report describes a patient with state III carcinoma of the oral cavity requiring extensive surgical resection, complex reconstruction and radiation therapy whose rehabilitation was assisted with an exercise program based on Facial-Flex. The patient found the device easy to use despite the deformities of her oral and facial structures and there were no complications. The patient has had improvement in speech articulation, oral-motor swallowing function and facial motion. Both the patient and the treating therapists noted these results. This preliminary report supports the use of the Facial-Flex as an adjunct to physical therapy and speech therapy in a patient undergoing the complex rehabilitative demands in recovery from extensive oral cavity carcinoma.