Glossectomy - Partial

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)

    • Sensory innervation 

      • Lingual nerve nerve

      • Chorda tympani nerve

      • Glossopharyngeal nerve

    • Artery

      • Lingual - main supply

      • Ascending palatine, tonsillar branch of the facial a. 

    • Veins - Ranine 

  • Indications

    • T1 and T2 oral tongue cancers 

  • Contraindications 

  • Staging 

  • eMedicine - TNM Classification for Oral Cavity Cancers

  • Approach

    • Transoral

      • Likely possible for T1-2 lesions in patients with normal jaw opening and/or those with limited dentition 

    • Mandibulotomy - see HNSpreferences "Mandibulotomy (approach)" page

  • 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

  • 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 - see HNSpreferences "Tracheostomy" page

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

    • May incorporate incision into neck dissection incision  

  • Primary closure

  • Reconstruction

    • STSG (vs allograft) with bolster 

    • Facial artery myomucosal (FAMM) flap

    • 2013: Buccinator-based myomucosal flaps in intraoral reconstruction: A review and new classification

    • Open Access Atlas - Buccinator Myomucosal Flap

    • Radial forearm free flap (RFFF) - see HNSpreferences "Radial forearm free flap - Fasciocutaneous" page

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 

  • Local anesthesia

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

  • Intubation

    • Nasotracheal intubation if possible

  • Equipment 

Procedure

• • Inspect and palpate the oral cavity

    • Assess

      • Tongue mobility 

      • 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 midline

    • 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

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

  • 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 

  • Primary closure

    • Initial incisions may be extended to become elliptical or wedge-shaped, depending on the lesion

      • Lateral lesions may benefit from a wedge resection in order to avoid elongating and narrowing the tongue if a longitudinally oriented ellipse is performed 

    • When closing a wedge resection, a single prong skin hook may be placed at the incision apex to help align segments 

    • Approximate deep dead space

      • 3-0 Chromic may be used 

    • Approximate muscosa and more superficial muscle using vertical mattress sutures

      • 3-0 Chromic may be used 

  • Other options 

    • STSG with bolster 

    • Alloderm 

  • Perform additional surgery, as needed

    • Resterilize, redrape, regown and glove 

Sample operative report

Post-op

Pearls & Pitfalls

High-Yield

Links

• 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