Intelligibility alterations in an oral cancer patient following primary sumerv and two reconstructions: A case study y surgery and Marlene Carno Jacobson BA (Sp & Η Therapy) (Witwatersrand) Department of Speech Therapy and Audiology, Hillbrow Hospital, Johannesburg ABSTRACT Intelligibility and perceptual characteristics were examined in η hili„»„„i 7 ι ,vu and mandibulectomy with primary closure and twosubseauent recon^n^-t °Sa'S^e ^ Pat'ent following glossectomy a twelve-month period were instigated, using ΤΖ ύιΖΖΙ s adm^ Ζ USm^Steomyoc^eous flaps. Changes across and fiberoptic investigations. Hndfngs e m p h ^ L Τ ^ ^ ^ ^ Γ Γ ΓΤ' ^ ™ Xe^graphy, bility, relationships between articulators and the positioning ofvocaltrUrt ^ ^ t o for preservation of articulator mo- terious to speech and a more influential rt 'ophic changes dele- OPSOMMING sluit. Veranderinge in die ν ^ Ζ Γ ; ^ οΖΐΖαΖ ^ T ^ T ^ ^ ^ ^ ™ge- staanbaarheidstoetse (moedertaal luisteraars) latZifZ !• W f a l f m a a n d e P™ode ondersoek. Daar is van ver- "" d<*?omumen,K m„ vemmmgs die tmhus vakaL· l » * « % ' <««<·» mikula- The role of the South African speech therapist in the manage- ment of the surgically,' treated cancer patient has been almost exclusively limited to the laryngectomee despite the com- parable incidence of glossectomy and other shared features such as difficulties with communication. Among Sowetan Blacks, the ratio of larynx to tongue lesions is in the order of ι τ a proportion closely corresponding to that noted in the United States of America.20 The primary objective of oral ablative surgery is curative «ence excision of extensive tumours of the floor of the mouth a i r ? ' " ' ^ b C f ° r C e d t 0 i n c l u d e r e s e c t i ° n of unaffected Ξ Γ S t m T K S s u c h a s mandible, tonsil and anterior gue as well as associated cervical lymph nodes. Without ^mediate^reconstruction, this may result in the typical "Andy amdeof C S S ) d e f 0 m i i t y " w h i c h i s Λ ε m o s t extreme ex- tifiabL ^ e r e Τ " 1 C r i p p l m g " 2 2 S u c h a c a i * is readily iden- deelnHH» d S p e e c h ' disordered masticatory and cosmetic Η Γ a n i S m S ' d r ° 0 l i n 8 ' d e n t a l malocclusion and t̂ n of l n t T I t y ' "ThC q U 3 l i t y °f h f e 3 Α ε Γ SUCCeS5ftl1 abla" cure rates. ° f ' ^ h e a d a n d n e c k i s n o t r e f l e c t e d * * m^'inofhead'and'n ° f t h e t u m o u r ' 1 1 « e s within the do- adapt form a " d n e c k reconstructive techniques to restore and The t i m i ^ 0 f Qr ^ " C t l ° n t 0 o r a l Peripheral mechanism, g of oral cavity reconstructive surgery has been con- D , e S u i d - A f * k ° a n s e T y < l s k r i f v i r K ® SASHA 1983 tommumkasieafwykings, Vol 30. 1983 troversial, but currently the compelling advantages of im- mediate rather than delayed reconstruction are being em- phasised. The introduction of composite osteomyocutaneous and myocutaneous flaps (pedicled grafts containing a donor blood vessel and the associated skin, underlying muscle and sometimes bone) has stirred a new wave of enthusiasm for reconstructive suigery. For the patient, the quality of life following radical surgery is largely a measure of adequate reconstruction17 "and the only thing that tends to tide the affected individual over the twilight zone is the hope that some day in the not too distant future his somatic deformity will be corrected."3 Published studies to date focus on speech following primary surgery only, i.e. without reconstruction.1· » One study explores the effects of a prosthetic tongue on intelligibility and food management.13 At present, the focus of surgical reconstruction appears to highlight the anatomical parameters of tissue survival its form, bulk and contour, with a comparatively diluted em- phasis on functional integrity. It seems that the effects of various reconstructive procedures, remain largely unexplored. s y The present study was designed to elucidate the surgically- induced changes in articulator mobility, perceptual R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 16 characteristics and composite speech intelligibility in an oral cancer patient who underwent an initial resection with primary closure, followed by two reconstructions, using osteomyocutaneous flaps. Whereas current surgical practice tends to resect and reconstruct within a single lengthy opera- tion, the subject of this study underwent staged management and thereby afforded a unique opportunity for investigation. METHODOLOGY SUBJECT T.N. was a fifty-six year-old Black bilingual Zulu/Xhosa- speaking illiterate male who underwent a suprahyoid block dissection (commando procedure) for a well-differentiated squamous carcinoma of the anterior floor of the mouth, in April, 1981. He was a heavy smoker and took alcohol fre- quently. The histopathology report described a 5 χ 1 cm le- sion of the floor of the mouth anterior to the tongue, involving the base of the tongue and the gingiva. The cortex of the man- dible had been invaded but no infiltration of the bone was observed. (a) Marlene Carno Jacobson PRIMARY SURGERY Surgical excision included the resection of both mandibular rami from angle to angle, transection of the anterior half of the tongue, and removal of the floor of the mouth. Primary closure was achieved by attaching the remnant of the tongue bilaterally and anteriorly to the buccal mucosa. The geniohyoid, mylohyoid, and hyoglossus muscles were divided. The Hypoglossal nerve (XII) was preserved, but the mandibular branches of the Trigeminal nerve (V) were obligatorily severed, causing a loss of sensation in the lower lip. Details of the original lesion and primary surgery are il- lustrated in Figure 1. In September, 1981, the patient was admitted to the Hillbrow Hospital, Johannesburg, for reconstructive surgery. It was at this point that the writer first came into contact with him. SECONDARY SURGERY At this stage and three subsequent stages, the patient's speech was assessed using the procedures to be discussed shortly. geniohyoid* mylohyoid* Figure 1 Anatomical details of site-of-lesion and primary surgery (a) Lateral view of site and extent of tumour. (b) Muscles (*) divided during tumour excision. (c) Frontal view of area of excision. (d) Lateral view of area of mandibular excision. (d) The South African Journal of Communication Disorders, Vbl. 30, 1983 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) Intelligibility Alterations in an Oral Cancer Patient These four stages co-incide with the pre- and post-recon- struction periods associated with each reconstruction. The first reconstruction, in October, 1981, employed a right pectoralis major (chest) osteomyocutaneous flap and the second, in June, 1982, a spine of scapula-trapezius (shoulder) osteomyocutaneous flap. The reason for the repeated attempt at reconstruction was the fact that resorption of the first graft occurred, leaving only a healthy skin island in the floor of mouth area. Throughout the period subsequent to primary surgery (April 1981, to August, 1982), T.N. experienced severe drooling ow- ing to poor oral closure and dysphagia. Thus, vegetative func- tioning was poor at all Four stages with only the swallowing of liquids and purged foods being possible. PROCEDURES In order to explore and capture the speech changes com- prehensively, a battery incorporating both subjective (1) and objective (2 and 3) procedures was utilised. 1. Speech intelligibility assessment: To obtain an index of in- telligibility, an intelligibility task was constructed for ad- ministration to native speakers who were naive listeners 2. Xeroradiographic studies: To obtain anatomical and physiological data regarding articulatory mobility and the variability of vocal tract dimensions. Xeroradiography pro- vides excellent soft tissue definition; numerous soft tissue densities are presented in a single image, and the com- ponents of the speech production mechanism are easily identifiable by speech pathologists without radiographic training.7 3. Fiberoptic examination: To examine altered anatomical features. (It should be noted that sound spectrography was used in order to derive an objective acoustic representation of auditory parameters. Data yielded by spectrographic measures are the subject of a further paper and will therefore not be discussed at present.) DATA COLLECTION INTELLIGIBILITY DATA 1· Preliminary Speech Materials At each of the four stages, the subject was required to im- itate the model provided by a fluent Zulu speaker, of eighty- two Ngum words, extracted from an article by Lanham'° e c 0 r a L l n f ° ™ i Z U 1 U W ° r d l i s t " T h e s e i m i t a t i < ™ were record ° n u U h C r 4 2 0 0 R e p o r t S t e r e ° IC reel-to-reel tape treated en C a r e f t " V U m o n i t o r i n g w * h i n a soun£ treated environment. 2- Intelligibility Test Construction f o u r * « » w e r e c o n - were selected ΐ " * * ^ ° r i g i n a l e i S h t r t W 0 ^ m s stance of eacj '̂̂ f" t T™ * Γ ^ * l e a S t i n " presented in a f p h o n e m e s · ' n 2 3 The word list is of thTsfcdy ^ A T n d l X · 1 0 ^ ^ s p e c t i v e nature been n c o ^ t e d * * p h o n e m e s h a d n o t therefore the fiiwl r " ^ ° r i g i n a l S p e e c h « - H * and dick; S c e d c L t ( / " / Γ Γ ^ ' ™ ^ /nhl/, /ndl) and /Id/ a " d / g X / ) ; a n d t h e affricates tional framework o f " 5 o f principles of tradi- meworks of articulation such as "the syllable"'6 17 "word initial, medial and final positions"6 was rejected due to the difficult segmentation of multisyllabic words and the common characteristic of vowels in initial and final position in Zulu lexical items. Therefore taiget phonemes were not localised to specific positions within words. It was also impossible to regulate retrospectively, factors such as word length, semantic complexity or conversational familiarity. 3. Tape Construction: Four tapes were constructed by copying each imitated word three times consecutively from a Revox High Fidelity reel-to-reel recorder onto a Uher 4200 Report Stereo IC reel-to-reel recorder. No interval was scheduled between the three identical imitations. The inter- stimulus interval between successive test items was five seconds. The four thirty-item sequences were varied and randomised using random numbers to avoid a "list- learning effect".18 4. Judges: Three judges were chosen, the selection criteria being that they were native speakers of Zulu, had hearing within normal limits, and normal speech discrimination ability at conversational level (55dB HL) and 75dB HL us- ing C.I.D. W.22 P.B. word lists. They had had no previous contact with the patient, nor knowledge of the nature of his speech pathology. The same judges were employed for all four tapes in order to maintain "listener-level stability" 18 5. Playback Conditions: Testing was conducted individually the judges being seated in a sound-treated room approx- imately 1,6 metres in the midline from a pair of Bang and Olaufcen speakers, through which the experimental tapes were presented. The sequence of tape presentation varied for each judge to counteract a possible familiarisation effect which could bias the findings by exaggerating the average intelligibility of the tape played last. After listening to the thrice-presented production of a particular word each judge was required to imitate the subject's production and then to guess the word that he was saying. The judges' responses were recorded on a Sony Stereo Cassette Corder TC with VU meter monitoring for later transcription and analysis. ANATOMICAL AND PHYSIOLOGICAL DATA: 1. Xeroradiography was repeated at each stage with lateral views taken of the articulators in a rest position and dur- ing the sustained production of five Zulu cardinal vowels. 2. Fiberoptic examinations were performed prior to and following the second reconstruction, using a standard Olympus VF 4a Vocal Cords Fiberscope with a camera attachment. Die Suid-Afrikaanse Ttdskrif • r Tydsknf vir Kommunikasieafwykings, Vol. 30. 1983 DATA ANALYSIS INTELLIGIBILITY TEST At each of the four stages, the number of words correctly recognised by each of the judges was scored and totalled A mean percentage intelligibility was derived for each tape The number of refusals was also computed. The judges' stimulus imitations were broadly transcribed. Vowel and consonant analyses of these were conducted, using broad distinctive features in order to highlight perceptual confusions and basic trends in the data. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 18 Marlene Carno Jacobson 40 30 20 10 28,9 PRE- REC. I 25,6 POST- REC. I k.14,4. PRE- REC. II 23,3 POST- REC. II Figure 2 Percentage of words correctly recognised at each stage. 40 30 20 10 10,0 L PRE- REC. I 28,9 POST- REC. I PRE- REC. II POST- REC. II Figure 3 Percentage of words "refused" at each stage. + 1 0 - - 1 0 +2,0 POST- REC. II Figure 4 Percentage of correct words minus percentage of refusals at each stage. ANATOMICAL AND PHYSIOLOGICAL ASPECTS For each stage, superimposed tracings were done of the vocal tract configurations for the five vowels and the rest position, using the cervical spine as a constant axis. In this way, changes in vocal tract dimensions were illustrated. RESULTS A. OVERALL SPEECH INTELLIGIBILITY 1. Single word intelligibility was greatest prior to any reconstructive procedure, that is, with contracted primary closure alone. This was a most surprising finding and con- trary to expectation, as it suggested that reconstruction was functionally unconstructive and possibly destructive to speech (Fig. 2). 2. It may appear that the stage at which speech was almost as intelligible as pre-reconstruction speech was following the first reconstruction. However, notice the large number of refusals at this point (Fig. 3). 3. In order to magnify the differences between the various stages, the number of correctly guessed words was balanc- ed with the number of refusals by subtracting the latter from the former. Following this operation, it became ap- parent that the patient was considerably more intelligible prior to any reconstruction (Fig. 4). \ 4. Following the second reconstruction, speech was more in- telligible than following the first, but still markedly inferior in comparison to pre-construction intelligibility (Fig. 4). 5. Note the deterioration in intelligibility occurring following the first reconstruction and prior to the second when graft resorption occurred (See Fig. 4). This feature is further elucidated by the xerographic findings. ' Β (PHYSIOLOGICAL ASPECTS) (See Fig 5) AND C (ANATOMICAL ASPECTS) (See Fig. 6) 1. If the tracings from each stage are compared, it is evident that prior to the first reconstruction, there was remarkable flexibility in the sizes of the oral and pharyngeal cavities with different vowel productions. (See Fig. 5a.) 2. Following the first reconstruction and prior to the second reconstruction, the "floor of the mouth" displays an in- The South African Journal of Communication Disorders, Vol. 30, 1983 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) Intelligibility Alterations in an Oral Cancer Patient 19 Pre-Reconstruction I Post-Reconstruction I Pre-Reconstruction II Post-Reconstruction II Figure 5 Tracings of /a/ and /i/ xerographs at four stages. Die Suid-Afrikaans 6 ^^fvir Kommunikasieafwykings, Vol. 30, 1983 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 20 Marlene Carno Jacobson The South African Journal of Communication Disorders, Vl. 30, 1983 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) Intelligibility Alterations in an Oral Cancer Patient variant gently rising convex formation, and the new ap- pearance of a bump in the anterior oropharyngeal area can be observed. This was assumed to be a portion of the osteomyocutaneous flap. (See Fig. 6b.) The constancy of the dimensions of the oral and pharyngeal cavities can be observed. (Fig. 5b.) 3. Prior to the second reconstruction, the relative rigidity of the vocal tract can again be noted from the tracings. (Fig 5c.) In particular, there is clearly narrowing of the pharynx compared to Pre-Reconstruction I. Comparison of the /u/ xerographs of Post-Reconstruction I and Pre- Reconstruction II, reveals slight shrinkage of the pharyngeal "bump" and the reduction in size of the gentle hump anteriorly when the graft had resorbed and atrophied. 4. Fiberoptic examination at this point, prior to Reconstruc- tion II, revealed that the pharyngeal "bump" appeared to be the remnant of the tongue which had been sutured posteriorly in the erection of the island flap in the floor of the mouth area. In addition, this resulted in an extremely narrow airway. It would be expected that such a narrow communication between the pharyngeal and oral cavities would seriously affect the radiation of acoustic energy from the pharynx. 5. It was therefore recommended to the suigeons undertaking the second reconstruction that the constriction in the pharynx be reduced and that the tongue remnant be reposi- tioned anteriorly. This was performed unilaterally, as was evident from Post-Reconstruction II fiberoptic examina- tion. Following this, it seemed that there was greater variability in the anterior floor of mouth height as seen on the tracings (Fig. 5d), although this feature is not well- illustrated on the /u/ xerograph following the second reconstruction, as the unilateral change is not captured Hence the second reconstruction restored more open com- munication between the oral and pharyngeal cavities allowing for radiation of sound out of the pharynx anterior- ly through the vocal tract. Support for the notion of the significance to speech of the pharyngeal constriction and its subsequent reduction, is provided by the word in- 9 0 80 7 0 60 SO 7 4 , 7 7 7 , 4 PRE- REC. POST- REC. I PRE- REC. II ' POST- REC. II 21 telligibility results, where recognition of the subject's ut- terances varied in relation to the degree of constriction i e the greater the constriction, the lower the intelligibility while the partially constricted pharynx resulted in improv- ed intelligibility. D. VOWEL INTELLIGIBILITY The intelligibility of vowels was assessed by extracting the judges' imitations of vowels from their imitations of the stimulus words. Hence, vowel intelligibility was not examined in isolation, but, rather, in the context of words. 1. The effect of the first reconstruction was to reduce in- telligibility, which deteriorated even further with atrophy of the graft. 2. Vowels were most intelligible following the second reconstruction, fractionally better than prior to any reconstruction (See Fig. 13). This result further substan- tiates the view that better radiation of acoustic energy was possible when the pharyngeal constriction was reduced 3. The most intelligible vowel at all four stages was /a/ possibly because the constriction was correctly positioned (i.e. back of the oral cavity) and of appropriate magnitude (See Fig. 8.) 4. The back-rounded vowels /u/ and /o/ became more in- telligible when the maxilla and replaced mandible were in better alignment, i.e. reconstruction was positive for the in- telligibility of these phonemes. (See Fig. 8.) 5. Following the first reconstruction, /e/ deteriorated dramatically; possibly both the degree and position of con- striction were totally inappropriate for its production 1 0 0 9 0 80 7 0 60 5 0 - 4 0 3 0 20 10 10Q· /a/ PRE- REC. I POST- REC. I PRE- REC. I POST- REC. II Figure 7 Percentage of intelligible vowels at each stage. D l e Swd-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 30, 1983 Figure 8 Percentage of individual vowel intelligibility at each stage. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 22 When the degree of constriction was reduced and sound allowed to radiate out of the phary nx, the previous level of intelligibility was restored. 6. The predominance of /a/ substitutions for the mid-vowels /e/ and /o/, was perhaps due to the position and degree of constriction, and the difficulty with explicit lip-rounding (because of absent sensation in the lower lip and poor maxilla-mandible alignment). 7. It appeared that when anterior constriction with the tongue remnant was possible (i.e. when the oral cavity was con- tracted, prior to any reconstruction), front vowels /i/ and /e/ were most intelligible while when there was the fixed posterior constriction due to the repositioned tongue rem- nant, the back vowels, /u/ and /o/, became most intelligi- ble. (See Fig. 13.) In other words, vowel intelligibility cor- responded closely with the structure of the oral cavity. Prior to any reconstruction, it seems that the vocal tract had some flexibility but limited ability to constrict at any point, so that it had the appearance of a single tube resonator, displaying free communication between the pharyngeal and oral cavities. The effect of the first reconstruction was to introduce an ex- treme constriction, positionally invariant, with marginal com- munication between the two cavities. The second reconstruction served to maintain an area of con- striction even if it was positionally invariant and allowed for sufficient communication between the two cavities for radia- tion of acoustic energy throughout the vocal tract. These ap- pear to be the critical factors in vowel intelligibility for this patient. Marlene Carno Jacobson E. CONSONANTS Generally, the trends in consonant perception were consistent throughout all four stages, but perception became more predictable and stereotyped, showing reduced variability dur- ing the intermediary two stages, i.e. a limited range of con- sonants was being perceived. (See Table 1.) 1. During the interim two stages, fewer consonants requiring an oral articulation were perceived i.e. most consonants were perceived as / ' / and /h/ (glottal). When viewed in conjunction with the word intelligibility results, inaccuracy of consonants produced in the oral cavity seems preferable to glottal substitutes. 2. The judges attempted to simulate the muffled auditory im- pression of the voice by velarising, nasalising and pharyngealising i.e. by effecting a thoroughly atypical balance among the resonators, for the phonetics of the language. DISCUSSION The present study indicates that speech intelligibility was greatest prior to any reconstructive procedures. This level of intelligibility (28,9%) corresponds fairly closely to the range of partial glossectomy pre-therapy speech intelligibility scores reported by Skelly et al., 1 8 which ranged from 6-24%. It is interesting that these authors used a similar test paradigm to that employed in the present study - they attempted to sample all the phonemes of the language, selected phonetically balanced word lists as stimulus items and administered pre- Table 1 Patterns of Consonant Perception CLASS GROUP COMMON PERCEPT EXAMPLE Plain voiceless /?/ /, t/ /?/ STOPS Other voiceless Modification /tV /h/ STOPS Voiced Continuant (usually fricative) Id/ /z/ Anterior Features of manner and voicing retained It/ /?/ Posterior Features of place and voicing retained /k/ Ixl FRICATIVES Voiceless /h/ /f/ /h/ Voiced Often correct (? effect of additional feature of voicing) Voiceless glottal /hi various; not always correct, possibly because such a common substitute /hi /{/ Voiced glottal IfJ always correct All Substitutes retain features of manner eg. (-(-continuant) best preserved Continuants NASALS anterior nasals: /m/,/n/ liquids and approximants /m/ /w/ Posterior nasal: usually correct - articulator contact virtually possible LIQUIDS AND GLIDES All Usually correct or in-class substitions or glide/liquid /l/ /y/ /w/ /y/ AFRICATES Voiceless Ityl m Voiced fricative /d3/ /z/ The South African Journal of Communication Disorders, Vl. 30, R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) Intelligibility Alterations in an Oral Cancer Patient recorded stimuli within an open response format. In contrast, other studies;5 "·12 have employed either multiple or forced choice paradigms (closed response formats) or utterances ranging in length and compexity, from nonsense syllables to sentences.11·12·20 The stimulus presentation employed in this study diverges from a representation of real verbal interaction, thereby undermining the patient's "functional intelligibility" because words were produced without any syntactic context and without the complementary visual modality, which allows for an integrated signal.15 Nonetheless, for the present purpose, this method was useful in describing the relationship between structure and function. In addition, some words e.g. "cija" did not have an initial vowel to provide acoustic cues in the form of formant transition. It also emerged that approximately five of the test words (asterisked in the word list) were not familiar to all the judges, and hence ought to be altered in future tests. Further, being presented in an imperfect form, therefore almost certainly inaccessible to passive vocabulary, these items may be regarded as "dead weight",4 as they are not discriminating items. However a source of useful information to the judges was the fact that Nguni languages use tones phonemically. These tonemes are likely to have provided helpful suprasegmental cues to words, evident in the way the judges always reproduced the tone contours of the stimuli correctly. Bloomer and Hawk1 mention that III is the least intelligible vowel phoneme for the glossectomee; however, in this case combined glossectomy-mandibulectomy with mandibular retraction and inability to produce lip-rounding, appears to af- fect back vowels more dramatically, rendering these even less intelligible than anterior vowels. The nature of the maxilla- mandible relationship is as important to consonants as to vowels. If alignment is accurate and bilabial approximation achieved, the subject could be expected to produce good bilabial consonants - Ipl, lb/, /m/, /w/, - which may enhance intelligibility considerably. It is therefore critical for reconstructive surgery to strive to meet the goal of adequate maxillary-mandibular, occlusion. Furthermore, for the glossectomee with an additional mandibulectomy, mandibular replacement would seem to be a crucial procedure to vowel and consonant intelligibility and one that is more than elective".17 ; The distinctive predominance of the glottis as a compensatory articulatory site for a glossectomy-mandibulectomy patient is emphasised in this study, particularly in the case of stops and ncatives. The tendency of the judges to perceive most con- ' a s , h a v i n 8 a "fricative manner of production", and a glottal place of articulation", best describes the compen- satory phenomena associated with this subject. These are not «ea a s compensatory characteristics in the literature although men ion is made of the compensatory use of mandibular, buc- cal, labial and palatal movements.18 However, the glottis as the site of compensatory articulation t i r e X T 1 8 1 " 8 3 S t h e l a r y n x w a s t h e o n l y PO^t along the en- D r o ^ t r a C t W h e r e c o m P l e t e closure could be effected. Ap- r e s X a ; i 0 n Τ , a c h i e v e d * the lingua-velar junction and th" " P intelligibility of the velar stops Ik/ and /g/, 23 The trend that glides, liquids and nasals were clearer prior to reconstructive attempts, may have been due to better pre surgical ability to constrict the oral cavity. Although the dissected muscles, namely, geniohyoid, mylohyoid and hyoglossus had probably atrophied following anterior tongue transection, the possibility of styloglossus having been intoct is not unlikely. Support for this notion is provided by the observation that high-back vowels and velar consonants were generally recognisable prior to any reconstruction The presence of residual tongue stump mobility prior to reconstructive efforts, is implied. La Riviere et al." propose that some spontaneous improve- ment of glossectomee speech occurs with time. This may be true for primary closure but not necessarily for surgical reconstruction using flaps which have the potential to resorb In this case, partial contraction was a reality and altered the vocal tract dimensions considerably, with critical articulatory and auditory effects. The findings of this study underline the need for the speech therapist's involvement in the management of the oral cancer patient. The speech therapist may be active from the very ear- ly stages of pre-operative counselling, post-surgical com- munication and swallowing facilitation. He/she may later im- p ement a communication board or gestural system, and could ultimately focus on "communication" (perhaps utilising augmentative methods to supplement the auditory signal) rather than "speech". This is a somewhat predictable conclusion. What this paper demonstrates most powerfully, however, is that speech may be a sensitive and valid criterion of the efficacy of surgical reconstruction. For too long, the role of the speech pathologist in tins area has resided in dealing with a surgical fait accompli and with the use of treatment strategies such as "vocal parameter manipulation"1' and "compensatory physiologic phonetics".18 The present writer suggests that there is a need > tor the speech therapist to enter the treatment arena at a point where he/she can be instrumental in determining and planning the structural springboard" for therapy and assist in the crea tion of optimal prognostic potential. With a sound knowledge of speech anatomy and articulatory phonetics, the speech therapists s intervention may serve as the bridge between anatomical structure and functional integrity. "The management of head and neck cancer presents a unique opportunity for the co-operative efforts of multiple disciplines in order to achieve both maximum cure rates and maximum rehabilitation."21 Die Suid-Afril· jnKoanse Tydskrif vir Kommunikasieafwykings, Vol. 30, 1983 ACKNOWLEDGEMENTS The writer wishes to thank Prof. A. Traill, Associate Pro- fessor, Department of Linguistics, University of the Witwa- tersrand, Johannesburg, for his assistance, guidance and time in conducting investigative procedures, constructing the in- telligibility tapes and interpreting the data. The writer also wishes to thank Dr. Claire Penn, Lecturer, Department of Speech Pathology and Audiology, University of the Witwa- tersrand, for her helpful comments in the writing of this article. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) 24 REFERENCES. 1. Bloomer, A. H. and Hawk, A. M. (1973): Speech Con- siderations: Speech Disorders Associated with Ablative Surgery of the Face, Mouth and Pharynx - Ablative Ap- proaches to Learning. In Orofacial Anomalies: Clinical and Research Implications. A.S.H.A. Reports & Publica- tion of the American Speech and Hearing Association, Washington. 2. Bradley, P. J., Hoover, L. A. and Stell, P. M. (1980): Ar- ticulation after Surgery to the Tongue. Folia Phoniatr. 32 334-341. ' ' 3. Crikelair, G. (1967): History of Reconstructive Surgery in Head and Neck Cancer. In Cancer of the Head and Neck. Conley, J. (Ed.). Butterworthy Inc., Tennesee. 4. Egan, J. P. (1948): Articulation Testing Methods. Laryngoscope 58, 955-991. 5. Georgian, R. Α., Logemann, J. A. and Fisher, Η. B. (1982): Compensatory Articulation Patterns of a Surgical- ly Treated Oral Cancer Patient. J. Speech Hear. Disord 47, 154-159. 6. Hall Powers, M. (1971): Functional Disorders of Articula- tion - Symptomatology and Etiology. Chapter 33 in Handbook of Speech Pathology and Audiology. Travis, L. E. (Ed.). Prentice-Hall, New Jersey. 7. Holonger, P. H., Lutterbeck, E. F. and Bulger, R. (1972): Xeroradiography of the Larynx. Arch. Otolaryngol 81 806-808. 8. Isaacson, C. (1982): Pathology of a Black African Popula- tion. Springer-Verlag, Berlin, Heidelberg, New York. 9. Khumalo, S. J. M. Zulu Tonology (1981): Unpublished Dissertation. Submitted for the Degree of Master of Arts, University of the Witwatersrand, Johannesburg. 10. Lanham, L. W. (1969): Generative Phonology and the Analysis of Nguni Consonants. Lingua 24, 155-162. 11. La Riviere, C., Seilo, Μ. T. and Dimmick, K. C. (1974): The Pretherapy Speech Intelligibility of a Glossectomee. J. Commun. Disord. 7, 357-364. 12. La Riviere, C., Seilo, Μ. T. and Dimmick, K. C. (1975): Report on the Speech Intelligibility of a Glossectomee Folia Phoniatr. 27, 201-214. 13. Leonard, R. and Gillis, R. (1982): Effects of a Prosthetic Tongue on Vowel Intelligibility and Food Management in a Patient with Total Glossectomy. J. Speech Hear. Disord 47, 25-30. 14. Massengill, R., Maxwell, S. and Pickrell, K. (1970): An Analysis of Articulation Following Partial and Total Glossectomy. J. Speech Hear. Disord. 35, 170-173 15. McCormick, B. (1979): Audio-visual Discrimination of Speech. Clin. Otolaryngol. 4, 355-362. 16. McDonald, Ε. T. (1964): Articulation Testing and Treat- ment: A Sensory Motor Approach. Stanwix House Pittsburgh. 17. Myers, Ε. N. (1972): Reconstruction of the Oral Cavity. Otolaryngolgic Clinics of North America, 5, 413-433. Marlene Carno Jacobson 18. Skelly, M., Spector, D. J., Donaldson, R. C., Brodeur, A. and Paletta, F. X. (1971): Compensatory Physiologic Phonetics for the Glossectomee. J. Speech Hear. Disord 36, 101-114. 19. Skelly, M., Donaldson, R. C., Fust, R. S. and Townsend, D. L. (1972): Changes in Phonatory Aspects of Glossec- tomee Speech through Vocal Parameter Manipulation. J. Speech Hear. Disord., 379-389. 20. Skelly, M. Glossectomee Speech Rehabilitation. (1973): Charles C. Thomas, Springfield, Illinois. 21. Southwick, H. W. (1973): Cancer of the Tongue. Surgical Clinics of North America 53, 147-158. 22. Summers, G. W. (1974): Physiologic Problems Following Ablative Surgery of the Head and Neck. Otolaryngologic Clinics of North America 7, 217-250. 23. Ziervogel, D., Louw, J. A. and Taljaard, P. C. (1981): A Handbook of the Zulu Language. Third Edition. J. L. Van Schaik, Pretoria. APPENDIX NGUNI SPEECH INTELLIGIBILITY WORD LIST 1. umunwe (finger) 2. inqawe (a pipe) 3. ivovo (strainer) 4. ithanga (pumpkin) 5. itiye (tea) 6. incwadi (book) 7. inyoni (bird) 8. uzipho (finger-nail) 9. isichaka (poor fellow, servant) 10. ihashi (horse) 11. idada (duck) 12. ugogo (grandmother) 13. umhume (cave) * 14. isipoliyane (female hysteria or a type of brain disease) 15. kaka (to excrete faeces or to surround) 16. khipha (take) 17. tshela (tell) * 18. ukubhubha (to die) * 19. ububovu (pus) 20. isifo (sickness) 21· rola (to roll or to pay out) j - Xhosa 22. hlola (inspect) | 23. dlala (play) 24. xhosa (chase away) 25. cija (sharpen) 26. qangqa (explain) 27. inxele (left side) 28. iqhude (a cock) 29. ingcawe (type of assegai) * 30. ingxoko (grain store) *: Words not familiar to all three judges. / The South African Journal of Communication Disorders, Vl. 30, 1983 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2) GSI 28 Auto Tymp The GSI 28 AUTO TYMP provides testing capability for tympanometry, ipsilateral and contralateral acoustic reflex estmg and screening audiometry. Selection of test sequence s as simple as pressing a button! The Auto Tymp is hghtwe.ght and compact so it can be easily moved from one more DortahT? 0 p t i 0 n a , C a r r y i n 9 c a s e i s avai.aSe if more portability is required. The Needier Westdene Organisation (Pty) Limited In association with / In medewerking met HEARING AND ACOUSTIC INSTRUMENTS (PTY) LTD LEWIS'S HEARING CENTRE (PTY) LTD ENGINEERED ACOUSTIC PRODUCTS NOISE CONTROL e k s s , Die Suid-Afrikaanse TydskHf • „ n J n r Kommunikasieafwykings, Vol. 30, 1983 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2)