ORIGINAL ARTICLE

Quality of Life of Patients With Recurrent

Nasopharyngeal Carcinoma Treated With
Nasopharyngectomy Using the Maxillary
Swing Approach
Raymond W.-M. Ng, MMedSc, FRCSE; William I. Wei, MS, FRCS, FRCSE
Objective: To investigate factors affecting the quality
of life (QOL) of patients with recurrent nasopharyngeal
carcinoma who underwent a nasopharyngectomy using
the maxillary swing approach.
Design: Cross-sectional study using self-administered
questionnaire data and medical chart review.
Setting: Tertiary cancer referral center.
Patients: Patients with recurrent nasopharyngeal carcinoma who underwent a nasopharyngectomy using the
maxillary swing approach between January 1998 and December 2003, had a minimal follow-up of 3 months, and
completed the questionnaire.
Interventions: We measured QOL using the validated

traditional Chinese version of the European Organization for Research and Treatment of Cancer core questionnaire and head and neck module.
Main Outcome Measures: Descriptive analysis of the

results and comparison of scores for each QOL domain,

stratified by presence of postoperative trismus, presence of postoperative palatal fistula, sex, age (45 years
and 45 years), duration of treatment (1 year and 1
year), and disease status at follow-up, were performed
using nonparametric tests.

Results: Of the 50 eligible patients, 41 (32 men and 9

women; mean [SD] age, 51.5 [10.4] years) participated
in the study. The meanSD global QOL scale score of
the participants was 68.724.2. Social functioning score
was the lowest (64.625.9) of the 5 functioning scales.
Fatigue and financial difficulties were the most common general concerns. Dryness of mouth, sticky saliva,
and limited mouth opening were the most common head
and neck problems. Women were found to have significantly lower QOL scores in the fatigue (P = .03), diarrhea (P = .03), and emotional functioning (P = .05) domains than men. The presence of severe trismus after the
maxillary swing approach was significantly associated with
a low QOL score in the mouth opening (P=.001), sticky
saliva (P=.006), mouth dryness (P =.02), and social eating (P =.05) domains. However, the presence of palatal
fistula, age, duration of treatment, and disease status at
follow-up did not result in any significant differences on
the QOL scores.
Conclusions: The QOL of patients treated with nasopharyngectomy using the maxillary swing approach to
treat recurrent nasopharyngeal carcinoma was good. Female sex and the presence of postoperative trismus were
factors significantly related to some of the QOL domain
differences after surgery.

Arch Otolaryngol Head Neck Surg. 2006;132:309-316

Author Affiliations: Division of

Head and Neck Surgery,
Department of Surgery,
University of Hong Kong
Medical Centre, Queen Mary
Hospital, Hong Kong, China.

ASOPHARYNGEAL CARCInoma (NPC) has a high

prevalence among the
population of Southeast
Asian countries.1 The primary treatment is external beam radiotherapy. Salvage therapy is considered
when the tumor persists or recurs after radiotherapy. However, further irradiation
is associated with a higher incidence of
complications, and the treatment result is
not satisfactory.2-4 Surgical resection offers an alternate treatment option.
Nasopharyngectomy using the maxillary swing approach is a relatively new operation for resection of recurrent NPC after previous radiotherapy.5 Published data6-8
suggest that surgical salvage using this

(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 132, MAR 2006
309

method has a higher rate of local tumor control than reirradiation in selected groups of
patients. However, postoperative morbidities, including development of postoperative palatal fistula and worsening of trismus, can affect normal speech, eating, and
swallowing functions, thus delaying the return of recovering patients into society.
When we compare a new treatment for
cancer with an older method to determine
which of the 2 treatments is better, we need
not only to look at how much longer people
survive with each treatment but also to determine how well they have survived during that time. The quality-of-life (QOL)
measurement allows us to assess and put
realistic numbers on a persons functioning in the domains of living.
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Table 1. Sociodemographic Characteristics

of All Participants
Variable

Patients, No. (%)

Sex
Men
Women
Marital status
Unmarried
Married
Divorced
Widowed
Education level
No formal education
Primary level
Secondary level
University
Employment status
Full-time
Part-time
Retired
Unemployed
Housewife
Smoking habit
Nonsmoker
Social smoker
Ex-smoker
Drinking habit
Nondrinker
Social drinker
Ex-drinker
Medical illness
No medical illness
Hypertension
Hypothyroidism
Hypopituitarism
Diabetes mellitus

32 (78)
9 (22)
2 (5)
34 (83)
3 (7)
2 (5)
3 (7)
14 (34)
21 (51)
3 (7)
13 (32)
1 (2)
14 (34)
11 (27)
2 (5)
28 (68)
5 (12)
8 (20)
32 (78)
3 (7)
6 (15)
34 (83)
4 (10)
1 (2)
1 (2)
1 (2)

To our knowledge, there have been only a few studies9-12 in the literature on QOL issues of patients with NPC
after radiotherapy and no reports concerning patients with
NPC who underwent nasopharyngectomy. The aim of the
present study is to investigate factors affecting the QOL
of this group of patients.
METHODS

STUDY DESIGN
We conducted a cross-sectional study using a self-reported,
health-related QOL questionnaire to evaluate the QOL of patients with NPC who underwent nasopharyngectomy for recurrent NPC after radiotherapy.

PATIENTS
We reviewed the records of patients who underwent nasopharyngectomy performed at the Head and Neck Division of the Department of Surgery, University of Hong Kong Medical Centre
at Queen Mary Hospital, Hong Kong, China, from January 1998
to December 2003. Inclusion criteria of subjects were that the
patient had undergone a nasopharyngectomy using the maxillary swing approach to treat recurrent NPC and that at least
3 months had passed since surgery. Patients who had undergone a nasopharyngectomy for other reasons, patients with di-

agnoses of other types of malignancies, or patients unable to

complete the questionnaire because of illiteracy were excluded from this study. Eligible subjects were contacted by telephone and invited to participate in the study. At the same time,
their mailing addresses were verified. The questionnaires, the
consent form, and a stamped return envelope were mailed to
those patients who agreed to participate in this study.
Clinical data, including age, sex, smoking and drinking habits, medical history, type of resection, side of surgery, and length
of follow-up period, were obtained from patients records. The
presence of a postoperative palatal fistula was documented in
the record. Moreover, the distance between the upper and lower
incisors (interincisor distance) was measured routinely during each follow-up. A value of less than 25 mm was clinically
defined as severe trismus.

QUESTIONNAIRE
The QOL instrument was developed and translated by the European Organization for Research and Treatment of Cancer
(EORTC).13-15 The questionnaire has 2 parts. The core questionnaire (Quality-of-Life Questionnaire [QLQ]-C30) applies
to all patients with cancers, and the disease-specific questionnaire (QLQ-H&N35) is designed for patients with cancer of
the head and neck region. The raw scores obtained from the
EORTC questionnaires were converted to scores ranging from
0 to 100 using linear transformation according to the scoring
procedures.16 For this study, we used the traditional Chinese
version of questionnaires, which had been validated as useful
in assessing the QOL of Chinese cancer patients.17,18
The QLQ-C30 includes 30 questions comprising both multiitem scales and single-item measures. The 5 functional scales are
physical functioning, role functioning, emotional functioning,
cognitive functioning, and social functioning. The 3 symptom
scales are fatigue, nausea and vomiting, and pain. There is a global
QOL scale. The 6 single-item measures are dyspnea, insomnia,
appetite loss, constipation, diarrhea, and financial difficulties. A
high score for a scale represents a higher response level. Thus, a
high score for a functional scale represents a high or healthy level
of functioning, a high score for the global QOL scale represents
a high QOL, but a high score for a symptom scale or item represents a high level of symptoms (problems).
The QLQ-H&N35 comprises 35 questions incorporating
7 multi-item scales and 11 single items. The multi-item scales
are pain, swallowing, senses, speech, social eating, social contact, and sexuality. The single items are teeth, opening mouth,
dry mouth, sticky saliva, coughing, felt ill, pain killers, nutritional supplements, feeding tube, weight loss, and weight gain.
For all items and scales, high scores indicate more problems.
There are no function scales in which high scores would mean
better functioning.

STATISTICAL ANALYSIS
The transformed raw scores were analyzed with respect to the
scales and items of the EORTC questionnaires. Possible significant factors affecting the QOL measurement were tested. They
included presence of severe trismus (interincisor distance of 25
mm), presence of a postoperative fistula, sex, age (45 years vs
45 years), duration of treatment (1 year vs 1 year), and disease status at follow-up (no recurrence vs recurrence).
We used SPSS statistical software (version 12.0; SPSS Inc,
Chicago, Ill) in the analyses. Univariate analysis of the median
scores between the 6 factors was performed using the MannWhitney U test and covariables adjusted using the multiple regression model. The level of significance was set at 5% in all
the comparisons, and all statistical testing was 2-sided.

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Table 2. Cancer- and Treatment-Related Variables

of All Participants
Variable

Table 3. Descriptive Statistics of the EORTC QLQ-C30

and QLQ-H&N35 Scales

Patients, No. (%)

Type of resection
MS approach
MS neck dissection
Side of surgery
Right
Left
Resectability
Curative
Palliative
Adjuvant treatment
None
RT
CT
RT CT
Duration of treatment
1 y
1 y
Disease status
Alive, no disease
Alive, with disease
Palatal fistula
No
Yes
Wearing obturator
No
Yes
Severe trismus*
No
Yes

EORTC Scale
37 (90)
4 (10)
19 (46)
22 (54)
32 (78)
9 (22)
32 (78)
6 (15)
1 (2)
2 (5)
17 (42)
24 (59)
37 (90)
4 (10)
33 (81)
8 (20)
35 (85)
6 (15)
12 (29)
29 (71)

Abbreviations: CT, chemotherapy; MS, maxillary swing; RT, radiation

therapy.
*Severity of trismus was assessed by measuring the height between the
upper and lower incisors. A value of less than 25 mm was clinically defined
as severe trismus.

The study complied with the latest version of the Declaration of Helsinki (52nd World Medical Association General Assembly; Edinburgh, Scotland; October 2000) and was approved by the ethics committee of the institutional review board
of the University of Hong Kong. We obtained permission to
use the QOL questionnaires from the EORTC.
RESULTS

SAMPLE CHARACTERISTICS
There were 61 nasopharyngectomies performed in the study
period. Seven patients underwent operations for reasons
other than NPC, and 4 patients refused to participate. Of
the 50 patients, 41 (80%) returned questionnaires.
The sociodemographic characteristics of the participants are shown in Table 1. Their ages ranged from 31
to 75 years (mean [SD] age, 51.5[10.4] years). There were
more men than women. Most of the patients were married and had received formal education; however, only
a third of them were employed. Use of cigarettes or alcohol was not common. Recurrent NPC was the sole illness in over 80% of patients.
Table 2 lists the cancer-related and treatmentrelated variables of the participants. In addition to un-

QLQ-C30
Global health system
Physical functioning
Role functioning
Emotion functioning
Cognitive functioning
Social functioning
Fatigue
Nausea and vomiting
Pain
Dyspnea
Insomnia
Appetite loss
Constipation
Diarrhea
Financial difficulties
QLQ-H&N35
Pain
Swallowing
Senses
Speech
Social eating
Social contact
Sexuality
Teeth
Opening mouth
Dry mouth
Sticky saliva
Coughing
Felt ill
Pain killers
Nutritional supplements
Feeding tube
Weight loss
Weight gain

Score,
Median (Range)

Score,
Mean (SD)

66.7 (25-100)
86.7 (27-100)
83.3 (0-100)
75.0 (17-100)
83.3 (50-100)
66.7 (0-100)
33.3 (0-89)
0 (0-67)
16.7 (0-67)
0 (0-67)
33.3 (0-100)
0 (0-67)
0 (0-67)
0 (0-33)
33.3 (0-100)

68.7 (24.2)
82.3 (17.2)
84.6 (20.9)
73.0 (21.7)
76.8 (15.8)
64.6 (25.9)
33.6 (18.0)
7.3 (14.5)
22.1 (18.3)
15.0 (19.9)
23.6 (22.7)
11.4 (19.2)
18.7 (21.1)
7.3 (14.0)
30.9 (35.3)

25.0 (0-92)
16.7 (0-92)
33.3 (0-83)
22.2 (0-100)
16.7 (0-100)
6.7 (0-87)
33.3 (0-100)
33.3 (0-100)
33.3 (0-100)
66.7 (0-100)
33.3 (0-100)
33.3 (0-67)
0 (0-100)
0 (0-100)
0 (0-100)
0 (0-100)
0 (0-100)
0 (0-100)

25.6 (20.0)
23.4 (20.0)
34.1 (24.7)
28.7 (27.2)
25.4 (27.6)
17.8 (20.6)
31.6 (33.1)
31.7 (28.8)
39.0 (34.9)
61.0 (29.7)
55.3 (32.2)
21.1 (20.8)
15.8 (22.6)
31.7 (47.1)
22.0 (41.9)
4.9 (21.8)
22.0 (41.9)
31.7 (47.1)

Abbreviations: EORTC, European Organization for Research and Treatment

of Cancer; QLQ-C30, Quality-of-Life Questionnairecore questionnaire;
QLQ-H&N35, Quality-of-Life Questionnairehead and neck module.

dergoing nasopharyngectomies, 4 patients underwent

radical neck dissection for treatment of concomitant metastatic neck lymph node metastasis. Thirty-two patients
had curative resection. Patients with palliative resection
were referred to other health care practitioners for adjuvant treatments. Seventeen patients underwent surgery within 1 year. During the study period, over 90%
of patients did not show evidence of tumor recurrence.
Eight patients (20%) developed postoperative fistulas, and
29 (71%) had severe trismus.
PSYCHOMETRIC ANALYSIS
The reliability of the questionnaire in this study was calculated using the Cronbach coefficient. Alpha coefficients of a magnitude of 0.70 or greater were sought as
evidence of adequate scale reliability for use at the level
of group comparison. The internal reliability coefficients of the QLQ-C30 and QLQ-H&N35 instruments
were 0.88 and 0.79, respectively.

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Table 4. Association Between Postoperative Severe Trismus, Presence of Palatal Fistula, Sex, Age, Duration of Treatment,
and Disease Status at Follow-up and the EORTC QLQ-C30 Scale
Severe Trismus
Symptom
Global
Physical functioning
Role functioning
Emotional functioning
Cognitive functioning
Social functioning
Fatigue
Nausea and vomiting
Pain
Dyspnea
insomnia
Appetite loss
Constipation
Diarrhea
Financial difficulties

Palatal Fistula

Absent
(n = 12)

Present
(n = 29)

Absent
(n = 33)

Present
(n = 8)

Men
(n = 32)

Women
(n = 9)

75.7
86.7
88.9
77.8
77.8
72.2
25.0
1.4
20.8
12.1
22.2
5.6
16.7
2.8
27.8

65.8
80.5
82.8
71.0
76.4
61.5
37.2
9.8
22.6
16.1
24.1
13.8
19.5
9.2
32.2

66.2
80.0
83.3
72.5
77.8
63.1
35.0
8.6
24.0
16.2
25.3
13.1
20.2
8.1
34.3

79.2
91.7
89.6
75.0
72.9
70.8
27.8
2.1
14.6
9.5
16.7
4.2
12.5
4.2
16.7

71.9
85.0
88.0
76.6
78.6
68.8
30.2
4.2
21.4
12.9
22.9
8.3
16.7
4.2
30.2

57.4
72.6
72.2
60.2*
70.4
50.0
45.7
18.5
25.0
22.2
25.9
22.2
25.9
18.5
33.3

Age
Symptom
Global
Physical functioning
Role functioning
Emotional functioning
Cognitive functioning
Social functioning
Fatigue
Nausea and vomiting
Pain
Dyspnea
insomnia
Appetite loss
Constipation
Diarrhea
Financial difficulties

Sex

Duration of Treatment

Disease Status at Follow-up

45 y
(n = 14)

45 y
(n = 27)

1 y
(n = 17)

1 y
(n = 8)

No Recurrence
(n = 37)

Recurrence
(n = 4)

68.5
83.8
82.1
74.4
76.2
60.7
32.5
14.3
22.6
19.0
23.8
14.3
19.0
14.3
28.6

68.8
81.5
85.8
72.2
77.2
66.7
34.2
3.7
21.8
12.8
23.5
9.9
18.5
3.7
32.1

70.1
87.8
83.3
76.5
76.5
63.7
33.3
9.8
21.6
13.7
27.5
7.8
17.6
7.8
27.5

67.7
78.3
85.4
70.5
77.1
65.3
33.8
5.6
22.5
15.9
20.8
13.9
19.4
6.9
33.3

70.7
83.4
86.5
73.0
76.1
66.2
31.8
7.2
21.6
14.8
23.4
9.9
18.0
7.2
29.7

50.0
71.7
66.7
72.9
83.3
50.0
50.0
8.3
27.8
16.7
25.0
25.0
25.0
8.3
41.7

Abbreviation: EORTC QLQ-C30, European Organization for Research and Treatment of Cancer Quality-of-Life Questionnairecore questionnaire.
*P = .05.
P = .03.

QOL RESULTS
The transformed scores of the QLQ-C30 and QLQH&N35 for all the participants are shown in Table 3.
The meanSD global QOL scale score was 68.724.2.
Among the 5 functioning scales, social functioning had
the lowest scores (64.625.9). Fatigue (33.618.0) and
financial difficulties (30.9 35.3) were common concerns of our participants. Dryness of mouth (61.029.7),
sticky saliva (55.3 32.2), and mouth opening
(39.034.9) were frequent head and neck complaints.
With regard to the QLQ-C30 assessments (Table 4),
we found no significant differences in terms of presence
of severe trismus or postoperative palatal fistula, age,
treatment duration, and disease status at follow-up.
However, women had significantly lower scores than
men on certain QOL domains, including fatigue
(P = .03), diarrhea (P = .03), and emotional functioning
(P=.05).

When analysis was performed with the same factors

using the QLQ-H&N35 measurements (Table 5), age,
duration of treatment, and disease status at follow-up were
not statistically significant. Weight loss (P=.04) was worse
when a postoperative fistula was present. Mouth opening (P = .01), sticky saliva (P = .006), mouth dryness
(P=.02), and social eating (P=.05) were poorer when postoperative severe trismus was present.
COMMENT

Nasopharyngeal carcinoma is a common cancer among

the people of Southeast Asian countries.1 The primary
treatment for NPC is external beam radiotherapy to the
primary tumor in the nasopharynx, paranasopharyngeal tissue, and lymph nodes in the neck.19,20 Local failure in the nasopharynx occurs in 10% to 30% of patients. Depending on the extent of recurrent disease,

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Table 5. Association Between Postoperative Severe Trismus, Presence of Palatal Fistula, Sex, Age, Duration of Treatment,
and Disease Status at Follow-up and the EORTC QLQ-H&N35 Scale
Severe Trismus

Palatal Fistula

Sex

Head and Neck Module

Absent
(n = 12)

Present
(n = 29)

Absent
(n = 33)

Present
(n = 8)

Men
(n = 32)

Women
(n = 9)

Pain
Swallowing
Sense
Speech
Social eating
Social contact
Sexuality
Teeth
Opening mouth
Dry mouth
Sticky saliva
Coughing
Felt ill
Pain killers
Nutritional supplements
Feeding tube
Weight loss
Weight gain

15.3
14.6
27.8
17.6
10.4
7.8
24.2
22.2
8.3
41.7
33.3
16.7
11.1
33.3
25.0
0.0
16.7
33.3

29.9
27.0
36.8
33.3
31.6*
22.0
34.6
35.6
51.7
69.0
64.4
23.0
17.9
31.0
20.7
6.9
24.1
31.0

24.7
21.7
33.3
28.6
25.3
16.9
29.4
32.3
41.4
61.6
57.6
23.2
14.6
30.3
27.3
6.1
15.2
30.3

29.2
30.2
37.5
29.2
26.0
21.7
39.6
29.2
29.2
58.3
45.8
12.5
20.8
37.5
0.0
0.0
50.0
37.5

23.2
20.3
33.3
25.7
21.9
14.9
31.7
31.3
31.3
56.3
52.1
17.7
15.1
40.6
25.0
3.1
21.9
28.1

34.3
34.3
37.0
39.5
38.0
28.1
31.0
33.3
66.7
77.8
66.7
33.3
18.5
0.0
11.1
11.1
22.2
44.4

Age

Duration of Treatment

Disease Status at Follow-up

Head and Neck Module

45 y
(n = 14)

45 y
(n = 29)

1 y
(n = 17)

1 y
(n = 24)

No Recurrence
(n = 37)

Recurrence
(n = 4)

Pain
Swallowing
Sense
Speech
Social eating
Social contact
Sexuality
Teeth
Opening mouth
Dry mouth
Sticky saliva
Coughing
Felt ill
Pain killers
Nutritional supplements
Feeding tube
Weight loss
Weight gain

31.0
22.0
40.5
31.7
30.4
21.4
23.1
28.6
50.0
64.3
54.8
28.6
28.6
14.3
14.3
7.1
28.6
50.0

22.8
24.1
30.9
27.2
22.8
16.0
36.0
33.3
33.3
59.3
55.6
17.3
9.0
40.7
25.9
3.7
18.5
22.2

31.4
19.1
34.3
31.4
26.0
19.6
40.2
35.3
45.1
66.7
52.9
25.5
18.8
23.5
23.5
0.0
23.5
35.3

21.5
26.4
34.0
26.9
25.0
16.6
24.6
29.2
34.7
56.9
56.9
18.1
13.9
37.5
20.8
8.3
20.8
29.2

25.5
23.4
34.7
27.9
24.1
16.7
31.9
30.6
36.9
61.3
55.9
21.6
16.7
29.7
24.3
5.4
21.6
3501

27.1
22.9
29.2
36.1
37.5
28.3
27.8
41.7
58.3
58.3
50.0
16.7
8.3
50.0
0.0
0.0
25.0
0.0

Abbreviation: EORTC QLQ-H&N35, European Organization for Research and Treatment of Cancer Quality-of-Life Questionnairehead and neck module.
*P = .50.
P = .001.
P = .02.
P = .006.
P = .04.

further treatment can be either external irradiation,

brachytherapy, or salvage surgery.21,22
However, reirradiation using brachytherapy or external radiotherapy had been associated with significant morbidity, including radiation-induced temporal lobe encephalopathy and further worsening of preexisting
radiation-induced complications. The local control of tumors is poor.2-4
The maxillary swing approach described by Wei et al5
allows wide exposure of the central skull base region when
the maxillary antrum and the hard palate are retracted lat-

erally. This allows adequate resection of the recurrent tumor and involved paranasopharyngeal tissue (Figure).
With this approach, the local control of recurrent tumors
in the nasopharynx approached the rate of 60% at 5 years,
and the 5-year actuarial survival rate for the curative groups
was 55%.8,23,24 However, postoperative severe trismus and
development of palatal fistula are common problems that
disturb normal speech, eating, and swallowing functions. In addition to the concurrent adverse effects of irradiation, these comorbidities have significantly affected
the QOL of this group of patients.

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Figure. The maxillary swing

approach (right side of patient).
A, Outline of the skin incision.
B, The right maxilla was swung
out to adequately expose the
recurrent nasopharyngeal
carcinoma (black arrow), which
is located at the central base of
the skull.

Currently, psychosocial research on patients with NPC

is limited. To our knowledge, the present study is the first
of this kind to evaluate the QOL of patients who had undergone a nasopharyngectomy for treatment of recurrent NPC after primary radiotherapy. However, several
limitations should be discussed. First, this is a retrospective study, and the small sample represents a carefully
selected group of patients with recurrent NPC that was
amenable to surgery. Comparison with other treatment
modalities was difficult, and perhaps the patients pretreatment QOL status will be much more suitable as an
internal control.
Second, the cross-sectional nature of the study means
that the cause and effect could not be determined. Some
of the physical changes may have already been present before surgery; for example, trismus was common to patients who had had previous irradiation. A prospective longitudinal study and monitoring of serial QOL changes before
and after treatment will provide stronger evidence.
Although the response rate of 80% was acceptable for
questionnaire study, it is important to determine the exact reasons why some (4) patients refused to participate
and some (9) did not respond. There was selection bias
from the responders who tended to be healthier and happier, and thus they had better QOL scores.
Finally, because of the intrinsic property of any QOL
study, our results, especially for the single-item measures, likely lack both specificity and robustness. This
issue can be addressed in future studies by using additional questionnaires or validated questionnaires to specifically evaluate the problem (eg, using the Brief Pain
Inventory25 for evaluation of cancer-related pain and the
Fatigue Symptoms Inventory26 for assessment of cancerrelated fatigue).
Our participants reflected the typical characteristics of
patients with NPC; that is, it affects a younger population
than other head and neck cancers; it is usually not associated with smoking or alcohol abuse; and the patients have
a lower incidence of associated comorbidity. From the
transformed data, we found that most of the scores for the
QOL domains were good and the global QOL scale score
was approaching 70. Financial difficulties and fatigue were
the most common general concerns. Married middleaged men formed the largest group in this study, and tra-

ditionally they are the income earners in their families.

However, many of these patients had unstable incomes as
a result of unemployment and their disease, which caused
a considerable decrease in family income. Fang et al9 found
that financial resources were important variables in determining a patients ability to cope with cancer and treatment complications. Those patients who had a higher economic status and stable employment tended to enjoy a
better QOL. Another study, by Ramsey et al,27 showed that
lower income status of cancer survivors was associated with
worse outcomes for reported pain, ambulation, and social and emotional status.
Fatigue is a common complaint among patients with
cancer. It is very rapid in onset, intense in severity, and
constitutes an overwhelming energy drain. Many studies28,29 show that untreated cancer-related fatigue can lead
to various social, psychological, and cognitive distresses. A further exploration of this problem would be
worthwhile.
Owing to financial constraints, cancer-related fatigue, and irradiation-induced oral symptoms, this vulnerable subgroup of patients with cancer was predisposed to difficulties in social and interpersonal
adjustments, which might explain why their lowest scores
were for social functioning. Although many patients reduce such activities as eating in restaurants, visiting with
friends and relatives, and participating in social functions, others resign themselves to a solitary, reclusive life.
Hammerlid et al30 similarly found that social functioning and role functioning were worse after completion of
treatment among patients with NPC and that the 3 major concerns were difficulty in enjoying meals, feeling ill,
and dryness of mouth.
Among our patients, the most frequent complaints of
physical symptoms were dryness of the mouth, sticky saliva, and limited mouth opening, which are common morbidities after irradiation to the head and neck region. In
addition, surgery will add extra damage to the irradiated nearby oropharyngeal structures, such as the pterygoid muscles. More tissue fibrosis will result during healing, which explains the high incidence of postoperative
trismus.
In our study, the presence of postoperative trismus was
significantly associated with difficult social eating. It dras-

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tically limited the patients choice of food and the type

of precious nutrients available to them. Most patients were
limited to food pastes or purees and other easily masticated food because they had difficulty eating crunchy or
chewy types of food. The normal eating, swallowing, and
speech functions are greatly affected as a consequence
of deglutition problems, xerostomia, sticky saliva, trismus, and decreased pharyngeal mobility.31-33 An active
treatment to alleviate the symptoms of trismus is worth
considering at an early postoperative phrase when fibrosis has not yet been established. Traditionally, radiationinduced trismus is treated with mobilization exercises using mechanical appliances to reduce the severity of
fibrosis34; hyperbaric oxygen35; oral medications, such as
pentoxifylline36; and surgical release of the fibrotic tissue to ease symptoms.37 Combining the procedures of
masticatory muscle myotomy and corornoidotomy38 was
adopted for severe cases.
The rate of palatal fistulas in our patients was 24%,
which is similar to the rates found in the literature.6,8,20
The fistula causes an abnormal change between the oral
cavity and the nasal cavity, thus disturbing the normal
swallowing and speech functions. The likely reason that
the QOL was not affected was that many fistulas were
small in size, and the patient could wear an obturator dental plate to compensate for poor oronasal function. However, an incorrectly fitted obturator can cause many problems, include poor hygiene, pain, and sometimes
ulceration of the mucosal edge. Furthermore, surgical repair is needed for any large palatal fistula.
A patients sex has long been viewed as a particularly
important variable in the psychosocial adaptation to head
and neck cancer. In this study, women were identified
as having significantly lower scores on emotional functioning, fatigue, appetite loss, nausea and vomiting, and
diarrhea. In fact, women are believed to experience greater
psychosocial difficulties because in most cultures they
value facial attractiveness more highly than men do. Moreover, women were found to be frequent users of emotionfocused coping strategies, which is associated with greater
mood disturbance, avoidance, self-blame, and psychological impairment.39
In conclusion, our study shows that the QOL was good
for patients with recurrent NPC treated with nasopharyngectomy using the maxillary swing approach. Although several domains of the QOL assessment instruments were important, some of them, such as dry mouth
and sticky saliva, are inherent to previous radiotherapy;
other domains, such as financial difficulties and low social functioning, may be related to inequality of resources distributed in society.
Our results suggest that psychosocial support should
be provided to female patients because they experience
more significant symptoms after surgery than their male
counterparts. What is more relevant to clinicians is that
this study has identified the significant adverse effects of
postoperative trismus on various aspects of the QOL domain. It is worthwhile to alleviate the degree of trismus
at an early stage of the rehabilitation period when trismus is still reversible. Surgical release should be considered as a treatment for those patients who have severe,
established trismus.

Submitted for Publication: June 7, 2005; final revision

received July 27, 2005; accepted September 7, 2005.
Correspondence: Raymond W.-M. Ng, MMedSc, FRCSE,
Division of Head and Neck Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen
Mary Hospital, 102 Pokfulam Rd, Hong Kong SAR, China
(ngwmr@hkucc.hku.hk).
Financial Disclosure: None.
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