Let’s talk total glossectomy for a minute. I’ve actually worked with multiple partial glossectomies in my career and recently have had 2 total glossectomy patients.
It seems like a pretty difficult task, right? Getting someone to eat and drink again with no tongue.
Taking the tongue out of the equation of swallowing makes the entire process very difficult, but not impossible.
I was looking at an article recently, wanting to make sure that I’m doing right by my patient, but also limited to access to most articles.
Son, et al
An article looked at 133 patients from 2007-2012. There was a study of swallowing ability before and after surgery.
The study found risk factors for aspiration with tongue cancer including:
Gender (higher incidence in males)
Extensive tumor resection
Higher node stage
Extensive lymph node dissection
Patients in this study were a mean age of 53.5 with 85 men and 48 women.
Patients with tongue cancer had a higher incidence of:
inadequate tongue control
delayed oral transit time
pyriform sinus residue
inadequate laryngeal elevation
Of the patients:
82 wide resection
23 partial glossectomy
5 total glossectomy
70 underwent radiation
57 underwent chemotherapy
74 VFSS before surgery
87 VFSS after surgery
Of the patients that had VFSS before and after surgery, after surgery, there was a higher incidence of:
lip movement abnormality
oral transit time
pharyngeal phase differences with aspiration/penetration in 8 patients before surgery and in 26 patients after surgery
4 patients with nasal regurgitation after surgery
vallecular residue in 6 patients before surgery and 39 after surgery
pyriform sinus residue in 3 patients before surgery and 16 after surgery
inadequate laryngeal elevation in 1 patient before surgery and 12 patients after surgery
Furia, et al
I read an article recently about Videofluoroscopic Evaluation after Glossectomy (cited below). The study was small, only 15 patients, 5 with partial glossectomy, 2 with subtotal glossectomy and 8 with total glossectomy.
Those patients with partial glossectomy had difficulty with bolus formation, anterior/posterior propulsion and increased oral time particularly with thicker substances.
All patients had increased oral transit time and oral/pharyngeal/esophageal stasis.
2 patients had moderate aspiration, 2/10 had persistent asymptomatic aspiration.
Compensatory strategies that were effective for patients was a head back posture, Supraglottic Swallow, Mendelsohn Maneuver and subsequent swallows following initial swallow of the bolus. After VFSS, 8 patients had a functional swallow and 2 patients had moderate aspiraiton with residue.
I think the biggest take away with our patients with glossectomy, no matter the degree is to not give up on them. These patients deserve a chance at eating and drinking, even if only small amounts.
Don’t be that SLP that completes the VFSS or FEES with no compensatory strategies, no assistance with anterior/posterior propulsion and only 1-2 trials. There is evidence to support that these patients may not have a normal swallow, but may have a functional swallow.
Push for prosthesis for your patients. These can be functional for your patient’s speech and swallowing. There are multiple studies regarding prosthetics for your patient listed below. A flap can help to fill the floor of the mouth and give your patient a stronger chance of a functional swallow.
Furia, C. L. B., Carrara-de Angelis, E., Martins, N. M. S., Barros, A. P. B., Carneiro, B., & Kowalski, L. P. (2000). Video fluoroscopic evaluation after glossectomy. Archives of Otolaryngology–Head & Neck Surgery, 126(3), 378-383.
Son, Y. R., Choi, K. H., & Kim, T. G. (2015). Dysphagia in tongue cancer patients. Annals of rehabilitation medicine, 39(2), 210.
Davis, J. W., Lazarus, C., Logemann, J., & Hurst, P. S. (1987). Effect of a maxillary glossectomy prosthesis on articulation and swallowing. Journal of Prosthetic Dentistry, 57(6), 715-719.
Donaldson, R. C., Skelly, M., & Paletta, F. X. (1968). Total glossectomy for cancer. The American Journal of Surgery, 116(4), 585-590.
Hirano, M., Matsuoka, H., Kuroiwa, Y., Sato, K., Tanaka, S., & Yoshida, T. (1992). Dysphagia following various degrees of surgical resection for oral cancer. Annals of Otology, Rhinology & Laryngology, 101(2), 138-141.
Kothary, P. M., & DeSouza, L. J. (1973). Swallowing without tongue. Bombay Hosp J, 15, 58-60.
Frazell, E. L., & Lucas Jr, J. C. (1962). Cancer of the tongue. Report of the management of 1,554 patients. Cancer, 15(6), 1085-1099.
For so long, we have focused on lingual strength and range-of-motion.
Instruments for Measurement
The Iowa Oral Performance Instrument (IOPI) and the Tongue Press have all been developed to give us visual and numeric strength measurements of the tongue.
We finally have a measurement scale for lingual range of motion.
C.L. Lazarus, H. Husaini, A.S. Jacobson, J.K. Mojica, D. Buchbinder, K. Okay, M.L. Urken. Development of a New Lingual Range-of-Motion Assessment Scale, Normative Data in Surgically Treated Oral Cancer Patients. Dysphagia (2014) 29:489-499.
This study compared results in treated surgical patients vs. healthy patients. 36 patients s/p oral tongue surgery with significantly decreased tongue range-of-motion and 31 healthy individuals.
The scale was validated by correlating range-of-motion with performance status, oral outcomes and patient-related Quality of Life.
The scale was made to define lingual deficits. This is a tool that can be used for baseline and post surgery tongue range-of-motion and to track changes over time with recovery and therapy.
Saliva flow was measured using the Saxon test where the patient was asked to chew a sterile 4×4 piece of gauze for 2 minutes then spit the gauze in a cup. The gauze was weighed before and after mastication.
The Performance Status Scale was used to determine diet type, speech intelligibility, impact of surgery on ability to eat socially.
I’ve had the opportunity recently to sample some different pureed foods. Ok, so I wasn’t exactly jumping for joy with the thought of trying different pureeds, or pureed food at all, but I figured it couldn’t hurt. Besides, if I’m going to feed patients this food or recommend it for my patients, I should know the best pureed foods to recommend.
This is what I’ve always seen with a pureed diet:
A lot of food that I can make an educated guess as to what it is, I’m just not really sure what it is.
With food molds becoming more readily available, your pureed food can actually look like this:
Blossom Foods has pureed foods available, however I’ve never seen or tried their food.
Thick-It has had foods available for some time. I’ve looked at these foods and could never stomach trying them. I think most of us know Thick-It though for the thickeners they produce.
The Thick-It website states their purees are:
Ideal for Caregivers & Healthcare Providers with Dysphagia Patients
Thick-It® Purees were designed to be convenient for people with dysphagia and their caregivers who may not have the time, resources or patience to blend their own pureed foods. At a ready-to-eat consistency, Thick-It® Purees can be swallowed safely and easily, and may reduce the risk of aspiration pneumonia, a potentially life-threatening complication of dysphagia. Patients can receive the proper nutritional benefits while enjoying a wide variety of food options. A complete list of nutrition information is available, including our list of gluten-free products and allergen information.
Thick-It® Purees are Ideal for Any Time of Day
Our purees come in 15 varieties and are perfect for breakfast, lunch, dinner and snacks.
Entrees: Beef in Barbecue Sauce, Beef Lasagna, Beef Stew, Chicken a la King, Salisbury Steak, and Seasoned Chicken Patty
Breakfast: Maple Cinnamon French Toast, Omelet with Sausage and Cheddar Cheese
Sides: Carrot & Pea, Seasoned Green Bean, Sweet Corn, Seasoned Spinach and Seasoned Broccoli
Dessert: Caramel Flavored Apple Pie and Mixed Fruit and Berry
Features and Benefits
Convenient, just open, heat and serve
Can be easily shaped for appealing plate presentation
Consistent texture and reliable nutrition
Great for Emergency stock
5 to 8 servings per can
Once opened, remaining portions can be stored immediately in an air-tight container for 5 – 7 days in the refrigerator or placed in the freezer for up to one year. For quality assurance, unopened products should be consumed within two years of being manufactured, which is determined by the number on the bottom of the can. For assistance with reading the Julian code, please visit our frequently asked questions.
Thick-It® Purees may be covered by Medicaid providers and insurance companies. Contact your or your loved one’s insurance provider to see if they will cover the Thick-It® Purees, as some may cover the expenses associated with swallowing disorders. Visit our frequently asked questions page to learn more about HCPCS codes, which are used for billing insurance purposes.
Today, I received several samples of Thick-it. Pasta, frozen meats, vegetables and fruits in molded trays and several cans of food. The box was huge and heavy with a large thermo container for the frozen foods with dry ice, which my kids thought was the coolest thing when my husband dumped it in the sink in the bathroom.
I opened the first can of Thick It food, which was Berry Fruit Puree. It was actually good, tasting like flavored applesauce. My 8 year-old, very picky daughter loved it.
The frozen pureeds in the molds took close to an hour and a half for the meats to cook in the oven, a little less for the fruits and vegetables. I tried the berry, peaches, corn, green beans, chicken, turkey, ham and roast pork. These are made to look like the actual foods after cooking and turning over and dumping on the plate. The corn was good. The peaches and berries were ok, but very gel textured. The meat, I couldn’t eat. It was very fake tasting and just over-powering and gritty. The green beans were bland. The only foods that kept that shape of the molds were the corn and meats.
My husband stated the meats tasted very gritty and the ham was a very fake, smoky taste that he didn’t much like. He liked the corn and the taste of the fruits, but not the gel texture of the fruits. The chicken and turkey he thought were bland but not as bad tasting as the ham and the green beans did not taste like green beans at all.
I couldn’t eat the canned foods. Not only did it look like something I would feed my dogs, it smelled the same. I took a small bite and food was either very bland or tasted nothing like what it was supposed to taste.
My husband, didn’t mind the canned pureed corn and green beans, just thought they were a little flavorless, but the canned lasagna and seasoned chicken tasted nothing like they were supposed to taste.
I commend Thick-It though on a good effort. It seems they’re on the right track, just some of the food needs some work.
I did have the opportunity to not only meet, but sample Pure-A foods at ASHA 12 in Atlanta, GA. I tried the taco and cheesecake at that time. It was actually not bad. The cheesecake was very good. The taco looked like pureed food, but tasted surprisingly like a taco.
The Pure-a website offers a list of advantages of their products:
PURE A ADVANTAGES
Pure-a meal components have many advantages over frozen options. Below is a brief list of the many benefits Pure-a offers vs frozen.
Pure-a items can make both pureed meals and shakes (Nectar/ Honey Like Consistencies). Just follow the simple directions, in addition, you can make ice cream from Pure-a desserts.
Pureed products use flavorful, dried ingredients. Dried ingredients are used in many of your favorite foods to help boost flavor. They offer great taste, color and aroma while maintaining nutrition. In addition, our products are made wth all natural flavors. Pure-a can afford to use better ingredients because of the shipping savings realized by not shipping water.
Pure-a products are less expensive. Compare the delivered cost of Pure-a products vs frozen products. Because frozen shipping is so expensive, you can save almost $2.00 per unit on a 3 oz protein item by using Pure-a vs frozen options.
Pure-a products are safe, the drying process sterilizes the food, making it safe to eat even if it is not prepared properly. Many frozen items must be heated to 165 degrees in order to be sterilized and safe to eat. In addition, frozen items can thaw during shipping if not handled properly.
Pure-a products are shelf stable, which allows for inexpensive shipping and storage. The savings from shipping can be over $1.00 per 3 oz serving. In addition, you can store Pure-a items in your pantry and do not need to buy and run an expensive second freezer.
Pure-a products are easy to prepare. All you need to do is pour the powder into a bowl, add water, whisk and let sit for 1 minute. No need to use a microwave, oven or steamer which frozen products require.
Pure-a products are better for the environment. Pure-a products do not require significant packaging such as dry ice or gel packs to keep the product frozen.
I sampled several of the Pure-A foods when I received samples for a patient. Grilled asparagus, fiesta taco, cheesecake, baked mac and cheese. Pure-A comes in a small pouch and is shipped in powder form. The box you receive for a variety of packets is small. It is mixed with hot boiling water/liquid and cold water for most of the desserts.
The Pure-A food was actually fairly good. It tasted like a taco or cheesecake filling. It is a little gritty, but I can get used to that given the exceptional taste. The vegetables were not bland and the dessert was enjoyable. The only downside for Pure-A is the smaller selection of food. I am very excited to see the new foods the Pure-A company develops as they continue to grow.
**UPDATE** Today, I received 14 samples of Pure-a in the mail. I tried all of them. The food continues to be very good. The only foods I really didn’t like were the spaghetti, sweet and sour chicken and the asparagus. Other than that, the food was really good and I could tell what it was supposed to be.
My husband wasn’t able to sample the Pure-a, however a pediatric patient really liked the foods and his caregiver was excited at the small size of the packaging and the ease of the preparation. She also stated the food was actually pretty good.
Thick It offers 6 different entrees (Beef in Barbecue Sauce, Beef Lasagna, Beef Stew, Chicken a la King, Salisbury Steak, and Seasoned Chicken Patty), 2 breakfast items (Maple Cinnamon French Toast, Omelet with Sausage and Cheddar Cheese), 5 side items ( Carrot & Pea, Seasoned Green Bean, Sweet Corn, Seasoned Spinach and Seasoned Broccoli) and 2 desserts (Caramel Flavored Apple Pie and Mixed Fruit and Berry). Pure-A offers 9 entrees (Turkey/Mashed Potatoes & Gravy, BBQ Beef and Southern Corn Bread, Italian Spaghetti with Fennel, Fiesta Beef Taco and Corn Tortilla, Sweet and Sour Chicken, Roast Beef/Mashed Potatoes and Gravy, Baked Mac and Cheese, Chicken Parmesan, Teriyaki Beef Bowl), 7 sides (Sauted Spinach and Mushrooms, Fully Loaded Baked Potato, Autumn Harvest Sweet Potato, Creole Corn and Tomatoes, Grilled Asparagus, Green Bean and Tomato Salad, Almond Seasoned Green Beans) and 5 desserts (New York Style Cheesecake, Blueberry Cobbler, Strawberry Shortcake, Georgia Peach Cobbler, Banana Cream Pie).
Both companies also offer samples, so that you or your patients can try these products prior to purchasing large amounts.
The cost comparison from Pure-a states costs as follows:
Save almost $2.00 per unit vs frozen options with Pure-a!
Pure-a meal components offer restaurant quality flavor and aroma at a lower delivered price than frozen options. Because Pure-a meal components are shelf stable, they do not require frozen shipping allowing Pure-a to use better, all natural flavors. In addition to saving on your purchase, you will not need to take up valuable frozen storage space or run an expensive second freezer.
See for yourself how much you can save with Pure-a. Below is an example showing the price for 24 units of Roasted Turkey. Pure-a allows you to save almost $2.00 per unit vs some frozen options.
Frozen Option #1
Frozen Option #2
Price per unit
Price for 24 units
Delivered Price per unit
One concern with both Thick-It and Pure-a is this. My husband and I have recently completely revamped the way we eat. We have stopped eating salt, high fructose corn syrup, corn starch, wheat, basically we eat very fresh food. I would love to see both companies strive to create an alternative for those health-conscious people that don’t want preservatives, salt or gluten, however want a quick and easy fix for pureed. That might not be possible with the packaging, but would be a great advantage for any company!
I highly recommend that you request samples to try this for yourself.
I will still say, if any of you reading this are my SLP someday, please don’t put me on a pureed diet. However, I think I could actually eat some of the pre-made from Thick-It and all from Pure-a.