Glossectomy - Hemi

Considerations

• • Anatomy

  • YouTube (2:41) - Oral floor dissection (cadaver)

    • Tongue muscles (8)

      • Intrinsic muscles (4) - paired 

        • Superior longitudinal, inferior longitudinal, verticalis, transversus 

      • Extrinsic (4)

        • Genioglossus, hyoglossus, styloglossus, palatoglossus 

      • Innervation

        • Hypoglossal nerve innervates all except palatoglossus (CN 10)

    • Artery

      • Lingual - main supply

      • Ascending palatine, tonsillar branch of the facial a. 

    • Veins - Ranine 

  • Definition

    • Extirpation of 1/3 to 1/2 of the tongue 

  • Indications

    • T3 and T4 oral tongue cancers not crossing midline 

  • Contraindications 

  • Staging 

  • eMedicine - TNM Classification for Oral Cavity Cancers

  • Approach

    • Transoral

      • Likely possible for select T3 lesions in patients with normal jaw opening and/or those with limited dentition 

    • Mandibulotomy 

  • Margins - 1 cm clinical margin is considered standard  

  • 2011: The impact of frozen sections on final surgical margins in squamous cell carcinoma of the oral cavity and lips: a retrospective analysis over an 11 years period

  • 2014: Surgical Margins and Its Evaluation in Oral Cancer: A Review

  • 2016: Surgical margins for the extirpation of oral cancer

  • Neck dissection

    • If dissecting the N0 neck

      • Remove levels 1-4 

      • Include the prevascular and postvascular lymph nodes associated with the facial artery and vein adjacent to the mandible as these are a common site of metastasis from both the lateral tongue and the floor of the mouth 

  • 2007: Elective neck dissection in oral carcinoma: a critical review of the evidence

  • 2011: Incidence of oral cancer occult metastasis and survival of T1-T2N0 oral cancer patients

  • 2014: Elective Neck Dissection in patients with stage T1-T2N0 carcinoma of the anterior tongue

  • 2014: Is there a role for neck dissection in T1 oral tongue squamous cell carcinoma? The UCLA experience

    • Factors to consider 

    • 2011: Muscle Invasion in Oral Tongue Squamous Cell Carcinoma as a Predictor of Nodal Status and Local Recurrence: Just as Effective as Depth of Invasion?

    • 2012: Prognostic significance of invasion depth in oral tongue squamous cell carcinoma

    • 2013: Pattern of Lymphatic Metastasis in Relation to the Depth of Tumor in Oral Tongue Cancers: A Clinico Pathological Correlation

    • 2015: Tumor budding correlates with occult cervical lymph node metastasis and poor prognosis in clinical early-stage tongue squamous cell carcinoma

  • Tracheostomy

    • May be needed for T3-4 lesions and lesions that require skin graft / flap reconstruction

    • May incorporate incision into neck dissection incision  

  • Reconstruction - defects > 1/3 of the tongue require some form of tissue reconstruction 

    • Regional flaps 

      • Pectoralis major

      • Latissimus dorsi

      • Trapezius

      • Sternocleidomastoid

    • Free flaps

    • 2008: Rectangle tongue template for reconstruction of the hemiglossectomy defect

    • 2012: Fasciocutaneous flap reconstruction of the tongue and floor of mouth: outcomes and techniques

      • Radial forearm

      • 2004: Functional outcomes after hemiglossectomy and reconstruction with a bilobed radial forearm free flap

      • 2008: Microvascular free tissue transfer for tongue reconstruction after hemiglossectomy: a functional assessment of radial forearm versus anterolateral thigh flap

      • Lateral arm

      • Anterolateral thigh

      • Fibula 

      • Latissimus dorsi

      • Rectus abdominus

      • Iliac crest

Preparation

• • Positioning

    • Supine

    • Shoulder roll, if neck dissection / tracheostomy planned 

  • Preparation and drape 

    • After performing the oral component, sterilize and drape the neck, if neck dissection / tracheostomy planned 

    • Drape the thigh, if skin graft is possible 

    • Drape the arm, if RFFF is planned

  • Local anesthesia

    • Infiltrate only if needed, otherwise, can omit to avoid tongue distortion 

  • Intubation

    • Nasotracheal intubation if possible

  • Equipment 

    • Oral cavity tray

    • Head and neck tray 

    • Lip protector 

Procedure

• • Inspect and palpate the oral cavity

    • Assess

      • Tongue mobility 

      • Mandible involvement 

      • Floor of mouth involvement

      • Midline and contralateral tongue involvement 

    • Estimate the tumor depth

    • Visualize your approach and margins 

  • Perform triple endoscopy

  • Place a Jennings mouth gag or dental bite block

  • Retract the buccal mucosa for adequate exposure using Minnesota retractors or right-angled retractors

  • Optional: Place a 2-0 silk suture 1 cm behind the tip of the tongue in the paramedian position

    • Additional sutures may be used to provide sequential retraction as the resection is performed

    • Exerted traction anteriorly and on the opposite side of the tumor

  • Mark 1 cm plus margins on the mucosa

  • Optional: Place 2-0 silk suture at the anterior margin for orientation 

  • Incision

    • Begin at the tip in the midline

    • Carry posteriorly in the midline raphe to avoid bleeding 

    • Complete posterior and lateral incisions to finish the extirpation 

  • Excise the tumor using electrocautery or dissection with electrocautery ligation 

    • The mucosa may be incised using the knife or needle tip Bovie 

    • Work toward the deep margin with constant palpation to maintain a 1 cm cuff of deep tissue 

  • Dissect and ligate lingual artery branches 

    • Branches may be suture ligated, if possible

      • 3-0 Chromic or Silk may be used 

    • At times, a figure of eight may need to be placed into the muscle 

  • Obtain frozen section margins 

    • Perform these using Metz scissors or the knife either from the resection bed or specimen itself

    • Communicate directly with the pathologist

  • Obtain hemostasis

  • Irrigate

  • Await report on frozen sections  

  • Perform additional surgery, including neck dissection and reconstruction 

    • Resterilize, redrape, regown and glove

Sample operative report

Post-op

Pearls & Pitfalls

High-Yield

Links

• YouTube (9:48) - Hemiglossectomy - 1/4

• eMedicine - Cancers of the Oral Mucosa

• eMedicine - Glossectomy

• UTMB Grand Rounds - Tongue Anatomy and Glossectomy: 101

• OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY - PARTIAL GLOSSECTOMY FOR TONGUE CANCER