TITLE: Glo= ssectomy
SOURCE: Grand Rounds Presentation,
The Univer= sity of Texas Medical Branch (UTMB Health), Department of Otolaryngology
DATE: November 30, 2011
RESIDENT PHYSICIAN: Leo Martinez, MD
FACULTY PHYSICIAN: Vicente Resto, MD, PhD; Susa= n D. McCammon, MD
DISCUSSANT: Vicente Resto, MD, PhD
SERIES EDITOR: Francis B. Quinn, Jr., MD
ARCHIVIST: Melinda Stoner Qui= nn, MSICS

"This material was prepared by resident physicians in partial fulfillment of educational requirements established f= or the Postgraduate Training Program of the UTMB Department of Otolaryngology/= Head and Neck Surgery and was not intended for clinical use in its present form.= It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to= its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and sho= uld not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." =

Embryology

During the fourth week of life, the tongue appears as a mesenchyme swelling on the floor of the primitive pharynx that is called th= e turberculum impar. The anterior two thirds of the ton= gue form from the first pharyngeal arches, which are lateral to the tuberculum impar. This forms the sulcus of the tongue. The posterior 1= /3 of the tongue is from the hypobrachial eminence of the copula. This forms the third and fourth po= uch.

Tongue defined

The tongue is used for speech, taste, swallowing, manipulation of food, and cleaning of the oral cavity. It is lined with stratified squamo= us epithelium. The tongue develo= ps keratinization when it is repeated pressure placed on it.= There are five taste senses, bitter, sweet, salty, umami, and sour.<= span style=3D'mso-spacerun:yes'> However, they are not located in a tongue taste map as widely believed.

The sulcus terminalis divi= des the tongue into anterior and posterior regions. The tongue ends at the termination= of the base, which is at the vallecula. The foremen cecum is the area in w= hich the thyroid descends.

Muscles of the tongue

There are eight muscles of the tongue, with four extri= nsic and four intrinsic.
The four intrinsic muscles are:

·         Narrows Superior longus=    - tongue at midline by going across the tongue- - runs length of the tongue - moves tongue up and down

·         Inferior longus-= lines the side of the tongue - moves tip up and down

·         Verticalis- Runs= up and down along the middle of the tongue- flattens and depresses tongue

·         Transversus- Divides and lengthens

The four extrinsic muscles are

·         Genioglossus- fr= om the mandible- Protrudes the tongue

·         Hyoglossus- from= the hyoid bone- depress the tongue

·         Styloglossus- fr= om the styloid process- elevates and retracts

·         Palatoglossus- f= rom the palatine aponeurosis- elevates and retracts=

Artery and nerves

The main artery of the tongue is the lingual artery, w= hich branches from the external carotid artery.= Other contributors include ascending palatine and tonsillar branch of the facial artery. = These cause an extensive submucosal plexus which crea= tes the plush blood supply of the tongue. The lingual branch from V2 creates sensation of for the anterior 2/3 of the tongue. The chorda tympani from VII provid= es the taste for anterior 2/3. The l= ingual branch of CN IX does both taste and sensation of the posterior 1/3. The Superior laryngeal nerve from = X, does the sensation of tongue root.

History

The history of tongue disease was first described by t= he Egyptians around 1550 BC. They tried various concoction to treat tongue lesions. In 600-300 BC, Sushrua from ancient India described = macroglossia and a procedure for rupturing of a tongu= e csyt. D= uring the dark ages, Albucasis, a healer, described different oral and tongue lesions, but the only surgical procedure he descr= ibed was draining of a ranula. Other early surgical interventions included tongue bleeding and mauling of the tongue to cause contracture for macroglossia. Several case repo= rts included excising the portion of tongue that protruded from the mouth, ligations of lingual and external carotid artery, and using an ecraseur, which is a chain like snare.

Glossectomy Procedure

A partial glossectomy is 1= /3 or less of the tongue, while a hemiglossectomy is 1/3 to ½ of the tongue, a near total is ½ to ¾ of the tongue, while ¾ or greater is a total glossectomy   The treatment consists of planning. First, involvement = of floor of mouth, mandible, or other surrounding landmarks, size, and presenc= e of lymph node disease must be determined.&nbs= p; Oral cancers can be treated with radiation, but due to potential side effects and ease of surgery, surgical options remain the primary option. With T1/T2 lesions, a transoral partial glossectomy remains a good option. As lon= g as good articulation and swallowing function remain. However, as always, early stage ca= ncers may be associated with nodal disease, and therefore aggressive treatment wi= th elective neck dissection is warranted. T3/T4 cancers can still be treated surgically. A hemiglossectomy or total glossectomy may work. A good strategy for surgical intervention is best described by Obrien and associates

= Initial surgery for primary cancer

·         Preservation of mandible when possible

·         Selective Neck dissections for level 1-4 negative neck, and modified radical neck for clinically positive neck

·         Tracheostomy for advanc= d cancer

Speech therapy should be considered after treatment. <= /p>

Postoperative radiation is often indicated
for the following:

<= span style=3D'mso-list:Ignore'>——<= span style=3D'font:7.0pt "Times New Roman"'> Positive surgical margins

—<= span style=3D'font:7.0pt "Times New Roman"'> Poor differentiation

—<= span style=3D'font:7.0pt "Times New Roman"'> Perineural invasion

—<= span style=3D'font:7.0pt "Times New Roman"'> Involvement of multiple nodes

—<= span style=3D'font:7.0pt "Times New Roman"'> Extracapsular spread of nodal disease.

This applies to all carcinomas of the tongue, but can = be used with any other primary cancers involving the oral cavity. Primary clos= ure of the defect or skin graft can be used for partial gl= ossectomies. Again, a selective neck dissection= s is needed for N0/N1, and modified radical neck for N2 or greater. Patients sho= uld be examined for tongue motility and otalgia preoperative. An evaluation f= or alcohol use is critical to workup withdraw and malnutrition. Otalgia suggests perineural or deep invasion. Deviated tongues with protrusion s= uggest deep infiltration of muscle. =

The lesions should be described as exophytic or endophytic. Sparana et al has suggested that the tumor size is a factor of survivorship. Tumors of ≥ 4mm in thickness= have been show to have 59% chance of neck metastasis= . Tumors of ≥3-4mm have been s= hown to have worse regional recurrence and survivorship. Therefore, the bimanual palpation = of the tumor is essential. Surface measurement should be performed to help with the staging as well. Indirect laryngoscopy should be performed.   Dental evalu= ation with workup of any periodontal disease.&nb= sp; Full mouth extraction should be done before any xRT.

Surgical techniques
Patients should undergo either nasal intubation or tracheostomy placement. A mou= th gag or block should be used to open the mouth.= A silk suture can be used at the tip of the tongue to provide retrac= tion of the tongue. At least a 1 cm margin should be taken around the lesion with frozen margins as well. Hemiglossecto= my uses the same principles, except the incision is at the midline raphe. The more extensive the resection, = the less likely a primary closure will work, as this will cause significant restriction of the tongue. Ho= wever, skin grafts became a good choice with the hemiglossect= omy. With T3/T4 lesions, management is = much more complex. These may infil= trate the floor or involve the mandible. The tongue base is much more difficult to manage. A laryngectomy= is indicated if the lesion extends to the hyoid region. With the advanced stage patients, = the preoperative planning is key. A CT scan will help plan out the course. Surgical approach depends on size, location, invasion, and need for = neck dissection.

The main types of approached for advance disease are t= he

·         transoral,

·         midline mandibulectomy<= /span> or mandibulotomy, and

·         neck approaches.

The transoral is better fo= r small lesion of less than 1.5 mm, but can be used for advance cases. Often combined with other approaches. Limited but simpl= e.

A mandibular release of the tongue is used with midlin= e mandibulectomy. = ; The lip is incised in the midline with a curved incision around the = chin pad. The incision of the floo= r of mouth is made and the mandibular periostium is elevated. Posteriorly, the to= ngue is released across the vallecula. With the median labio-mandibular glossectomy, the lip split is midline with the incision of the tongue being midline. This provides better access to midline lesions. Using the apron flap, the hyoid bo= ne can be identified, and division of the strap muscles made. With the lateral pharyngotomy approach, a good exposure can be achieved.= First, a lateral neck dissection is typically carried out. Then, the hyoid bone is identified= , and resection at the greater cornu is achieved. And retraction of the superior laryngeal, hypoglossal and lingual nerves can be done.

Reconstruction

Small defect of 1/3 tongue volume can be closed primarily. If resection of &f= rac12; of the tongue occurs, then contracture will occur with primary closure. Also, decrease in lingual contact = with the palate, lip and teeth can result. This will lead to impaired articulation and propulsion of food. Ther= efore, these defects need reconstruction of some sort. Local vs. regional flaps are typic= ally used. Again, the goal is to a= chieve mastication, speech, and achieve aesthetic results. Local flaps have limited tissue, inferior results, and not helpful at all tongue defects.   Regional flaps, however, hav= e well vascularized tissue, need only single state reconstruction, and harvest is = not too hard. But, their limited = reach and bulkiness are difficult to overcome.&n= bsp; Concern for tip necrosis as well.

Types of regional flaps are

·         pectoralis major= ,

·         latissimus dorsi,

·         trapezius, and

·         SCM.

Micorovascular flaps can o= vercome the limitations of regional flaps. They can come from the forearm, thigh, latissim= us dorsi, rectus abd, = and iliac crest. The preferred me= thod of reconstruction of near total glossectomy is = free flaps. They also provide dono= r site match to meet the requirements of the defect.

Complications from flap failure reach 0-15%. Aspiration events from free flaps = are 5%, which is similar to 3% with primary closures.

Survival rates for 5 years are 82% for stage I/II dise= ase and 49 for stage III or more. However, if salvage surgery is done, the five-year survival is 15-35= %

Key indicator cases

The key indicator cases for otolaryngology residents h= ave changed from needed to have total laryngectomy to performing gloss= ectomy procedures. The ICD-9 definition of glossectomy is when a significant portion of the tongue is removed, the procedure should be reported as a glossectomy codes. These codes vary according to 1) the amount of tongue that = is removed, 2) whether a neck dissection was performed, 3) whether a resection= of the floor of the mouth was also performed and 4) whether the mandible was resected.

The new key indicators are:

·         Glossectomy; les= s than one-half tongue: 41120

·         Glossectomy; hemiglossectomy: 41130

·         Glossectomy; par= tial, with unilateral radical neck dissection: 41135

· Glossectomy; com= plete or total, with or without tracheostomy, without radical neck dissection: 41140

· Glossectomy; com= plete or total, with or without tracheostomy, with unilateral radical neck dissection: 41145

· Excision of lesion of tongue with closure; posterior one-third: 41113

· Excision of lesion of tongue with closure; w= ith local tongue flap: 41114

· Excision of malignant tumor of mandible: = 21044

· Excision of malignant tumor of mandible; rad= ical resection: 21045

· Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulect= omy (e.g., locally aggressive or destructive lesion(s)): 21047

· Glossectomy; com= posite procedure with resection floor of mouth and mandibular resection, without radical neck dissection: 41150

· Glossectomy; composite procedure with resection floor= of mouth, with suprahyoid neck dissection: 4115= 3

· Glossectomy; com= posite procedure with resection floor of mouth, mandibular resection, and radical = neck dissection (Commando type): 4115

With these cases not being added as key:

· 411= 00 - biopsy of tongue; anterior two-thir= ds <= /span>

· 411= 05 - posterior one-third.

· 411= 10 - excision of lesion of tongue without closure 

· 411= 12 - excision of lesion of tongu= e with closure; anterior two-thirds (BUT POSTERIOR 1/3 IS CODABLE) <= /span>

· 411= 15 - excision of lingual frenum (frenectomy).

Conclusion

Tongue anatomy knowledge is essential for surgical purposes. There are a variety= of surgical treatment options available. Workup is key for any surgical intervention. Reconstruction is challenging for = these tongue defects.

DISCUSSION:
Dr. Resto's remarks on Dr. Martinez's Grand Rounds presen= tation on Glossectomy November 30, 2011

That was a nice presentation. I have several comments, which are in the line of giving you a little bit more background regarding some comments you highlighted. Others are thing= s that I'd like you to update and correct a number of things in your presentation.=

Firstly, when you think of managing oral cavity lesions, I'll say that you really ha= ve to think, in my mind, of separate resection from reconstruction. They have completely different goa= ls, and you cannot bog yourself down in the whole reconstructive reconsideration and sacrifice the management of a tumor.&n= bsp;

In the oral cavity, the biggest key is margin control. The tongue musculature is complex = and highly retractable, just like any other muscle is and you have to be very certain and very deliberate as is to where you're going to introduce your c= uts to incorporate your margins of tissue because it is notoriously difficult to come back after you have excised something and then say "Oh, I have a close margin" and then go back and take another piece. It doesn't behave physically the s= ame as many other tissues in the head and neck do. The pearl that I trained with was = that you designed your margins aro= und as you purposely measured them and I was taught to put some sutures to mark the margins and make sure that your cuts actually come around outside the sutur= es that you placed. That is critically important.

Now, as to how much margin, you know, this is a high priced real estate area so = you clearly don't want to sacrifice your oncologic treatment especially in the ones that you're= going to be able to manage with a simple glossectomy = since that's in theory a very curable case, a very curable lesion, where you potentially can leave your patient with some excellent functional results afterwards.

So, there's no doubt that one centimeter is well accepted. Two centimeters in my opinion is t= oo aggressive . Simply stated, w= hen you take two centimeters around the whole tumor you already have a total of four centimeters on each side of normal tissue and the problem of that is t= hat the patient is not going to be able to talk or swallow as well as he otherw= ise would. So there needs to be a= way in as to how much margin you handle and I think that most people would agree that one centimeter is the target. The key is to do a good one centimeter margin with good control arou= nd that lesion and not only is it challenging on its side, but remember that there's always a deep margin to control as well, and there's no better way = of doing that than just simply using your fingers and palpating. There's simply inherent variabilit= y and that is the reason why a lot of these tumors have a relatively higher rate = of recurrence locally than in other sites.&nb= sp; In my opinion, this has to do with technical shortcomings more than anything else. I'm not sure t= hat the biologies are necessarily different.

Depth of invasion: So the rationale for depth of invasion is simply trying to avoid a neck dissection in an early lesion. It is really about cosmetic, about operative time, and about healing morbidity because it adds nothing to your management if you're willing to go in and do a diagnostic staging neck dissection . What you're real= ly trying to achieve is can we stratify patients that have T1 tumors that do n= ot need a neck dissection versus those that do in order to try to avoid occult neck disease. And that = gets to the idea that not all T1 lesions are made equally though by size criteria they are and you do have a significant number that have delayed metastatic disease and those are correlated with finding microscopic disease on a stain setting diagnostic neck dissection. But it is a big cut in the neck, another wound to manage and the threshold has been found to be four millimeters. The problem with that is that it's really logistics. Are you goi= ng to trust a frozen section cut to tell you how deep the invasion is? Most people would say "No." So then you h= ave to be willing to use an algorithm by which you'll do a partial glossectomy and have the patient counseled that if the depth of invasion is greater tha= n x, y, or z, then you're going to come back and do an interval diagnostic neck dissection. Not everybody lik= es to do that for simple logistic scheduling reasons and the patients, psychologically, say, "What are you talking about? Are you going to do two operations= ? Why can't we do this all in one?" And lastly, = the fact that when you go in and assess your resection, not uncommonly you'll f= ind that what you thought was going to be a great margin isn't such a great mar= gin after all and you'll end up considering radiation therapy. In which case, if you're going to = do radiation, you going to do radiation. But that's the lesson behind depth of invasion, useful in some cases, but I don't think as useful as some hope it would be.

Healing: So you talked about primary closure a lot. Is there any difference in closing= a defect primarily than letting it granulate? So it turns out that from a healing perspective and a functional outcome perspective there really isn't a heck = of a lot of difference between one and the other. The only reason that you'll really= try to close it primarily is because your pain management is going to be a lot easier. It'll heal faster; it= 'll have a lot less exposed surface and basically it's just symptomatic control with the patient. This is imp= ortant because not only do you need to know that you can leave it open and in fact you didn't discuss this but in robotic approaches most of the healin= g is done by secondary intention. = So it is absolutely a well accepted way to handle som= ething if that's what you need to do.

The second is practical. You talk= ed about how everybody advocates a mattress suture in the closure, well, that's simply because the tongue is a tremendously strong muscle and if you put anything less than that you're just going to rip him open. So back to the issue. When you see him back in the offic= e for follow up and your entire closure is busted open, what do you do? You try to re-close it? The answer is "NO." You basically allow it to heal by secondary intention, very acceptable- you're not going to have any kind of = an inferior result especially when you're focused on the mobile tongue area.

Some other releases: I 'd like you to be a little bit t= ighter about terminology; precision = is important. Otomies are access procedures. If tis= sues are excised, then this is an ectomy. So there's not a lateral pharyngectomy – that would be excision of phary= ngeal tissue . It's a lateral pharyngotomy. So there's a lot of fixing to do in the presentation.

Lingual release: You described something which may = be how it is described in a textbook, but I would disagree with it. If you do a mandibular split appro= ach for access then in my opinion you do that to minimize the amount of lingual release that you need to do. = If you do both of them at once you're simply cutting for the sake of cutting and you're just making a bigger wound. &n= bsp; You actually can deliver most of tongue lesions inclusive of many to= ngue base lesions strictly with a lingual release and delivering the tongue down= through the neck and it avoids the morbidity and the complication of a mandibular s= plit such as occlusion issues and all the other stuff. Now, the important technical consideration there is that most folks release from the mandible down to the floor of the mouth. The probl= em with that is that you can never sew that shut. You have to take the attached ging= iva off of the mandible and posteriorly from the teeth simply because there is a much stronger character to the tissues and the periost= eum associated with it and then you re-suture&= nbsp; using circumdental stitches. The second thing is that most people come in and do their U-cut around what mandible they can visualize w= hen in reality when you pull tissue down into the neck you end up ripping so you have to introduce cuts to control your tear. I you do not introduce them, your = tear will naturally go deep into the pharynx making it a lot harder to close wit= h an intact mandible. So you= want to purposely extend those cuts up into the tonsillar pillar area so when the rip happens, it tends to happen superiorly where you can still close it transorally. Now, if you're going to split the mandible, you're simply going to release whatever you have to release. Clearly you're going to have to re= lease one side if you're going to swing things open and in that case you may or m= ay not release it from the gingiva, the most superior aspect of the gingiva, b= ut that's kind of a judgment call. You clearly are not going to release the floor of the mouth from the other side= . You're going to try to keep that together so it's simply going to be faster to heal.

Reconstruction: In my opinion, it's a little bit of a misnomer. We really can't reconstruct tongue. To really reconstruct tongue we'd = have to introduce functional muscle into the residual muscle to have full functi= on restored. Really, what reconstruction tries to achieve is firstly, wound healing, above anything a= nd what tissue you choose to use has to first satisfy your ability heal the wo= und. If you have a through and through = defect which goes into the neck, you perform the neck dissection with primary clos= ure which is okay if you have enough tissue, otherwise granulation, and that's = not an option. If you do a lot of= mattressing from the bottom the Pittsburg group has t= aken skin grafting to its finest art and so you can never say "never" = with a skin graft. It's certainly = very challenging and failure rates are higher once you have a through and through defect, and of course, failure implies a fistula. Since the amount of tissue becomes important, I don't think there's ever a role for a tongue flap, and this is= of historical importance only, in my opinion.= It's simply robbing Peter to pay Paul. But there are a number of lo= cal flaps, with skingrafting whenever you have a su= itable wound. Sometimes granulation = is the right choice, except in any defect which includes the floor of the mouth, because you want to prevent healing with contracture, which will secondarily impair tongue function

You had a nice list of flaps. I w= ould only the submental flap. It has a nice range of= uses in some folk's hands, and it does have some limitations mostly because it's rare that you're going to have a defect a kind of reconstruction where you haven't done any neck dissection, and because of the vascular supply to that flap when you haven't done a neck dissection in that area, it's often place= d at risk. But if you're cog= nizant up front that that's what you want to do and you have the right case with t= he right N0 neck the like and it's still useful and you can swing it in very nicely, based off the submental branch of the facial artery and br= ings some muscle with it and some skin and you can flip it up under and it works= the same was as any regional flap would. Otherwise the list is rather good.&= nbsp;

Lastly, there is an emerging field of minimally invasive approaches to the oropharynx. There's not a who= le lot of things you can do through = the mouth to the oropharynx. The challenge comes with the posterior aspect of the base of the tongue, where = your angle changes. The two major = innovations in this have been in transoral laser work with laryngoscopic exposure techniques whe= re you use a l mirror back there and you use a laser technique for resection, and mainly for its hemostatic ability. <= /span>

The second one of course is the robotic approach and that does have a really significant advantage in that you now have a substantial degree of freedom = in orientation and visualization and that now you can you can truly approach t= he lesion en face from a posterior direction.= And why both of these are incredibly favorable is that it is not uncommon for the approach to a abase of tongue lesion is more morbid than t= he resection of the lesion itself. If you know how you're going to get back there if you're going to do a suprahyoid release or if you're going to do a lateral= pharyngotomy you're likely to need to do a neck disse= ction prior just to get tissue out of the way. Big wound already whether th= ere's any disease there. Same with a mandible split. Big wound, a = lot of healing. It clearly has a rol= e in early isolated lesions and in terms of vascular support of those tissues it could change the way you think about the whole deal. When you do these large open appro= aches you take down a lot of the anastomotic connections, a lot of the vascular supply to these areas, so you have to have a good understanding of what form the axial supply to all of these places which is why you must know where th= ose linguals are, lest you take both linguals and cause the tongue to necrose. When you do a superficial approach= , like laser, you have retained intact the collateral supply to these areas and it turns out that the patients are a lot more tolerant to the extraction of ti= ssue inclusive sometimes of taking both of those lingual arteries, which breaks = with your traditional teaching. Th= ey tell you that taking both linguals amounts to a= total glossectomy but that notion is being challenged= as we develop these minimally invasive approaches to tongue lesions. Obviously the morbidity is much improved, and the morbidity has been much more related to the approaches than to the resection. The drawback is that we wonder whi= ch are the right lesions to go after with the newer approaches and we're trying to define what the upper limits are. We still have not come up with much better approaches for managing occult neck disease beyond the performance of a diagnostic neck dissection,= so once again you find yourself with what remains a somewhat algorithm as to when do I use adju= vant therapy, when do I use neck dissection and= if you are doing a therapeutic neck dissection at what point is it m= ore of a hoopla to go in and do a transoral resecti= on and then come back and do an open neck approach .I think that cases will fall on both sides. You should includ= e here something about transoral laser resection in your presentati= on, just to indicate recognition of the fact that these are important developme= nts, going forward.

References

<= span style=3D'mso-list:Ignore'>—<= span style=3D'mso-list:Ignore'>—<= span style=3D'mso-list:Ignore'>—<= span style=3D'mso-list:Ignore'>—<= span style=3D'mso-list:Ignore'>—<= span style=3D'mso-list:Ignore'>—<= span style=3D'mso-list:Ignore'>—<= span style=3D'mso-list:Ignore'>—<= span style=3D'mso-list:Ignore'>—<= span style=3D'mso-list:Ignore'>—<= span style=3D'mso-list:Ignore'>—<= span style=3D'mso-list:Ignore'>— G, et al: Elective neck dissection and survival in patients with squamous cell carcinoma of the oral cavity and oropharynx. Laryngoscope 2004;&n= bsp;114:2228-2234.

<= span style=3D'mso-list:Ignore'>—Comprehensive treatment strategy for oral and oropharyngeal c= ancer. Am J Surg 1992; 164:582-586.

<= span style=3D'mso-list:Ignore'>—

Embryology

Tongue defined

Muscles of the tongue

The four extrinsic muscles are

Artery and nerves

History

Glossectomy Procedure

= Initial surgery for primary cancer

Reconstruction

Key indicator cases

Conclusion

DISCUSSION: Dr. Resto's remarks on Dr. Martinez's Grand Rounds presen= tation on Glossectomy November 30, 2011

DISCUSSION:
Dr. Resto's remarks on Dr. Martinez's Grand Rounds presen= tation on Glossectomy November 30, 2011