Journal of Plastic, Reconstructive & Aesthetic Surgery (2006) 59, 743–746

The functional intraoral Glasgow scale (FIGS) in

retromolar trigone cancer patients*
Stephen J. Goldiea,*, Mary S. Jacksonb, David S. Soutarb,
John Shaw-Dunna
a
Department of Human Anatomy, University of Glasgow, University Avenue, Glasgow G12 8QQ,
Scotland, UK
b
Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Glasgow G4 0SF, Scotland, UK

Received 30 May 2005; accepted 1 November 2005

KEYWORDS
Retromolar trigone;
Functional intraoral
Glasgow scale (FIGS);
Global oral disability
Summary Background: Surgical incisions in the retromolar trigone (RMT) cause
injury to underlying structures. The functional intraoral Glasgow scale (FIGS) is used
to determine the ability of patients to speak, chew and swallow. FIGS could be used
to investigate whether there is a correlation between clinical tumour stage and the
function of the oral cavity following surgery in the RMT.
Materials and methods: FIGS scores for 58 patients speech, chewing and swallowing
collected pre-operatively, then at 3 and 20 weeks post-operatively, were used to
calculate a total ‘Global Oral Disability’ value and compared with the clinical tumour
size using the TMN staging method.
Results: Patients with RMT cancer who undergo surgical resection can expect a
degree of functional impairment which is proportional to the clinical tumour size.
Discussion: FIGS is a simple and reproducible way of assessing a patient’s functional
impairment following surgery in the RMT, especially when using the new global oral
disability value.
q 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All
rights reserved.

A study of surgical incisions in the retromolar
trigone (RMT) by Goldie et al.,1 showed that injury
was likely to the lingual nerve, submandibular duct,
palatoglossus and medial pterygoid muscles. It was
assumed that this damage would impair normal
function of the oral cavity. The functional intraoral
*
Presented in part at the BAHNO Meeting, 9th May 2003.
* Corresponding author. Tel.: C44 141 427 2018.
E-mail address: stephen_goldie@hotmail.com (S.J. Goldie).
S0007-1226/$ - see front matter q 2006 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2005.11.023
Glasgow scale (FIGS) has been used by staff at
Canniesburn Hospital Plastic Surgery Unit over a
number of years to determine the ability of patients
to speak, chew and swallow before and after
surgery. It was thought that this scale could be
used objectively to determine whether the assump-
tions made by Goldie et al., were in fact true,
and to ascertain whether there is a statistically
significant correlation between clinical tumour
stage and the resulting effect on function of the
744
Table 1 The functional intraoral Glasgow scale (FIGS)
FIGS score
Can chew Can swallow
Any food, no difficulty 5 Any food, no difficulty
Solid food, with difficulty 4 Solid food, with difficulty
Semisolid food, no difficulty 3 Semisolid food only
Semisolid with difficulty 2 Liquids only
Cannot chew at all 1 Cannot swallow at all
oral cavity following surgery in the retromolar
trigone.
Materials and methods
To test this hypothesis the speech and language
therapy case notes of 58 patients who had been
diagnosed with cancer of the retromolar trigone
between 1991 and 1999 were reviewed. Ages
ranged between 37 and 90 years, with the
average being 63 years old. Fifteen patients
were excluded from the study for reasons
including: lack of data; they had been treated
by radiotherapy only; they had died soon after
operation; or had not complied with follow-up.
The remaining 43 had their individual FIGS scores
for speech, chewing and swallowing collected
pre-operatively, then at 3 and 20 weeks post-
operatively then used to calculate a total FIGS
score for global oral disability. This was then
compared with the clinical tumour size that had
been recorded in the surgical notes for each
patient using the TMN tumour staging method.
Minitab, the statistical analysis computer pro-
gram, was used to draw scatter plots and carry
out regression analysis to look for a correlation
between the two recorded values. The statistical
significance of the correlations was tested by
one-way analysis of variance (ANOVA).
FIGS is a simple point scale used to assess a
patient’s ability to speak, chew and swallow
(Table 1). Each of these functions is scored
independently on a scale of 1–5, five being no
disability and one meaning the patient has an
inability to speak, chew, or swallow. In this study,
for the first time, it was decided to add the three
individual scores together to give an overall value
for global oral disability similar to the way the
Glasgow coma scale is used. Therefore, the
maximum total score possible is 15 and minimum
score is 3.
S.J. Goldie et al.
Speech is
5 Clearly understood always 5
4 Requires repetition sometimes 4
3 Requires repetition many times 3
2 Understood by relatives only 2
1 Unintelligible 1
Results
Pre-operative assessment
The graph in Fig. 1 shows the correlation between
the patient’s tumour size and FIGS score pre-
operatively. The best fitting straight line appears
to show a relationship between the two variables,
however, as the p value was greater than 0.05,
there is not a significant correlation between these
two measurements at this stage, i.e. before surgical
intervention.
3 Weeks results
The graph in Fig. 2 shows the correlation
between the patient’s tumour size and FIGS
Score 3 weeks post-operatively. The regression
analysis shows a negative correlation between
the two values, i.e. as tumour size increases so
too does the degree of functional impairment.
The r value or gradient of the line was calculated
as K0.2. The p value was calculated as less than
0.05 making the findings statistically significant.
The maximum and minimum FIGS measurements
were 14 and 3, respectively, at 3 weeks post-
surgery. The median global oral disability value
was 9.
Figure 1 Pre-operative assessment.
The functional intraoral Glasgow scale (FIGS) in retromolar trigone cancer patients
Figure 2 Three weeks results.
20 Weeks results
The graph in Fig. 3 shows the correlation between
the patient’s tumour size and FIGS score 20 weeks
post-operatively. The regression analysis shows a
negative correlation between the two values, i.e.
as tumour size increases so to does the degree of
functional impairment, as was the case at 3 weeks.
The r value or gradient of the line was calculated as
K0.4. The p value was calculated as less than 0.05
making the findings statistically significant. Inter-
estingly, however, the maximum and minimum FIGS
measurements rose to 15 and 6, respectively, at 20
weeks post-surgery. The median global oral dis-
ability value was 12, which is also an increase from
the figure at 3 weeks.
Combined results
In Fig. 4, the three sets are plotted together on the
one graph, allowing comparison of how the strength
of the correlation differs over the time frame, i.e.
the gradient or r value of the three lines. In fact,
there was only minimal change in gradient. There is
also an appreciable change in the position of the
best fitting regression line, with 20 weeks appearing
higher on the graph than 3 weeks, but still lower
than the pre-operative levels.
Figure 3 Twenty weeks results.
745
Figure 4 Combined results.
Discussion
Patients with retromolar trigone cancer who
undergo surgical resection can expect a degree of
functional impairment which is inversely related to
the clinical tumour size. This was shown to be the
case at 3 and 20 weeks post-operatively. At 20
weeks following surgery, patients will still have
some residual disability in speech, chewing and
swallowing, however, there should be an improve-
ment from their experiences at 3 weeks post-
surgery. This data suggests that although the
relationship between tumour size and functional
deficit remains between 3 and 20 weeks, there is a
small, but significant improvement as patients
recover. The increase in gradient between 3 and
20 weeks shows that patients with T1 tumours
improve the most, whereas, larger tumours will
leave a greater residual functional deficit.
Freelander et al., 2 attempted to assess
functional implications of surgery for oral cancer
using the general health questionnaire (GHQ), the
hospital anxiety and depression (HAD) scale and a
subjective measurement of the patients embarrass-
ment when talking and eating/drinking. They
showed that 25% of patients were embarrassed
when eating or drinking and many were unhappy
with their appearance after surgery. However, they
did not look at actual oral function or compare
tumour size with the degree of morbidity. Their
study looked at tumours in various areas of the oral
cavity and so it is difficult to compare their findings
too closely to this current investigation.
T stage and functional outcomes were studied by
Colangelo et al.,3 however, they were only con-
cerned with conversational speech understandibil-
ity and oropharnygeal swallow ability. The methods
for assessing these outcomes were fairly intensive
and of little use as a routine screening tool,
746
however, they did detect a decrease in the
functions measured as T stage increased. Again
their study was not concentrated on tumours of one
particular origin.
Oropharyngeal swallow ability was the only
outcome measure by McConnel et al.,4 which they
compared with tumour volume. In their limited
cohort of 30 patients they could only show a
negative correlation between tumour volume and
reduced oropharyngeal swallow ability when the
tumour arose from the tongue or tongue base. They
also admit that their method for measuring volume
was crude and likely to be inaccurate. Stachler
et al.,5 looked at how patients swallowed food of
different viscosities. They found that anterior
resections (floor of mouth and anterior tongue)
did better than posterior resections (base of
tongue, tonsil, and oropharynx). They did not
investigate how tumour size affected this outcome.
Pauloski et al.,6 used a similar method to
calculate tumour volume as McConnel et al.,4 and
then compared this with speech and swallowing
post-operatively. Our findings contradict theirs as
they did not detect an improvement in function
over 12 months
A paper by Findlay et al.,7 is perhaps an early
attempt at formulating the FIGS. They compared
the ability of patients to swallow food of varying
consistencies with tumour stage. There findings
support the more recent study in part as they found
that patients with T1 tumours were more likely to
return to a diet of solid food compared to those
with larger tumours. Their findings cannot be
compared directly as they included multiple tumour
sites and the current investigation looked at global
oral dysfunction as opposed to just swallowing.
No other study appears to have focused on
cancers of one area of the mouth and to have
compared all three functions: speech, chew and
S.J. Goldie et al.
swallow. This is the first study to use the global oral
disability score to give an overall view of function.
FIGS is a relatively simple and reproducible way
of assessing a patient’s functional impairment
following surgery in the retromolar trigone,
especially when using the new method of combining
the three individual scores to give one global oral
disability value. As predicted by Goldie et al.,1
surgery in the retromolar trigone will have a
progressively more negative impact on oral function
as T stage increases. There is a statistically
significant correlation between clinical tumour
stage and the resulting effect on function of the
oral cavity and oropharynx following surgery in the
retromolar trigone.
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