|Year : 2020 | Volume
| Issue : 1 | Page : 3-7
Total glossectomy: Technique review
Viswanath Neelakantan, Girish S Shetkar, Vikram D Kekatpure
Department of Head and Neck Oncology, Cytecare Cancer Hospitals, Bengaluru, Karnataka, India
|Date of Submission||02-Jun-2020|
|Date of Decision||02-Jun-2020|
|Date of Acceptance||03-Jun-2020|
|Date of Web Publication||18-Jun-2020|
Vikram D Kekatpure
Cytecare Cancer Hospital, Yelahanka, Bengaluru - 560 064, Karnataka
Source of Support: None, Conflict of Interest: None
Advanced cancers of oral tongue and recurrent/residual tumors arising from base of tongue may require total glossectomy for curative intent treatment. This procedure is considered morbid due to possibility of life threatening aspiration. This review discusses the technical nuances to reduce functional morbidity. The pull through resection technique allows a compartmental resection of these tumors with adequate margin control without a need for mandibulotomy. Selection of appropriate flap to replace bulk and laryngeal suspension are essential components of reconstruction. With application of these technical advances and adequate post-operative swallow therapy, patients undergoing total glossectomy have acceptable functional outcome.
Keywords: Compartmental resection, microvascular reconstruction, total glossectomy
|How to cite this article:|
Neelakantan V, Shetkar GS, Kekatpure VD. Total glossectomy: Technique review. J Head Neck Physicians Surg 2020;8:3-7
| Introduction|| |
Standard of care treatment for oral cavity cancers requires surgical resection followed by adjuvant treatment as required. While for oropharyngeal cancers, a nonsurgical modality (radiation or chemoradiation) is preferred as an organ preservation modality. Advanced oral cavity lesions, particularly of the tongue and the floor of the mouth (FOM), and oropharyngeal cancers are associated with several morbidities such as pain, speech, and swallowing difficulty and breathing difficulty. For patients with locally advanced lesion involving oral tongue or recurrent lesions of base of tongue, total glossectomy provides an option of free margin resection and curative intent treatment. Total glossectomy as a procedure was generally condemned due to perceived functional morbidity and poor oncological outcomes. Total glossectomy for tongue cancers was first described by Kremer in 1951. With limited availability of reconstructive options, aspiration and feeding tube dependence was dreaded complications. In 1979, the pectoralis major musculocutaneous flap was introduced for head-and neck reconstructions, especially after total glossectomy. Recent advances in reconstruction armamentarium with the introduction of microsurgical flaps have enabled significant improvements in reconstruction techniques for complex defects with improvement in functional outcome. Still, functional rehabilitation of total glossectomy patients remains a challenge. The aim of this review is to provide an overview of total glossectomy with laryngeal preservation, its indications, evaluation, surgical technique, and functional and oncological outcomes.
| Anatomy, Functions, and Role of the Tongue|| |
Human tongue is a complex muscular organ made up mainly of skeletal muscle tissue and is defined as dynamic hydrostat. These muscles contract and relax in tandem providing substance with the oral cavity and induce motion. This aids in speech and swallowing (oral and pharyngeal phases of swallowing) and has a major role in normal breathing process. The tongue comprises four intrinsic (transversalis, verticalis, superior, and inferior longitudinal) and four extrinsic (genioglossus, hyoglossus, styloglossus, and palatoglossus) groups of muscles, the former group contained totally within the tongue substance, and the latter attached to a point outside the body of tongue and inserted into it. The function of the intrinsic muscles is to alter the shape of the tongue, whereas the extrinsic helps to move the tongue in various directions. The interweaving patterns of the fibers of the different muscle groups of the tongue give its high maneuverability and strength. The tongue merges anteriorly and laterally with the FOM, a horseshoe-shaped area that is confined peripherally by the inner aspect (lingual surface) of the mandible. Posterolaterally, the tonsillolingual sulcus separates the tongue from the tonsil fossa. Posteriorly, the vallecula separates the base of the tongue from the lingual surface of the epiglottis. On the undersurface, the tongue is supported by geniohyoid and the mylohyoid muscles; the mylohyoid muscle serves as the diaphragm of the mouth and separates the tongue and FOM from the submental and submandibular triangles of the neck. McConnel et al. proposed a concept of two-pump system consisting of a propulsion pump and a hypopharyngeal suction pump. The propulsive force is generated by the tongue which pushes the bolus toward the laryngeal introitus. The hypopharyngeal suction force was the negative pressure generated at the level of the cricopharyngeus during laryngeal elevation.
The management of advanced carcinomas of the tongue requires a consideration of the entire anatomic subunit comprising the tongue, mandible, FOM with mylohyoid diaphragm, suprahyoid muscles, and the hyoid-laryngeal complex along with the intervening neurovascular structures. This compartment concept is applicable to both the resection of the tumor and subsequent reconstruction. From the surgical standpoint, resection of these tumors needs the removal of the entire compartment for oncologic clearance. Following total glossectomy, besides articulation, both oral and pharyngeal phases of swallowing are grossly affected, and with the absence of laryngeal elevation during swallowing, patients are at increased risk of aspiration. These anatomical and physiological considerations form the basis of functional reconstruction following total glossectomy.
| Indications for Total Glossectomy|| |
Total glossectomy with laryngeal preservation was considered for patients presenting under these five categories,
- Large primary tumors (T3 or T4) of the tongue and tongue base without the involvement of the vallecula and the preepiglottic space
- Recurrent or residual tumors of the tongue, base of the tongue following radiotherapy or chemoradiotherapy
- Nonsquamous tumors arising or extending to the base of the tongue
- Primary, second, or third primary tumors of the tongue/tongue base.
| Preoperative Assessment/evaluation|| |
- Clinical assessment: To assess the extent of induration with palpation and also involvement of the mandible and/or FOM and tongue base
- Panendoscopy: Assess the involvement of the posterior one-third of the tongue/vallecula/tonsillar area, and tonsillolingual sulcus
- Computed tomography (CT) scan/magnetic resonance imaging (MRI): To assess the extent radiologically and to determine resectability. In majority of the situations, it is difficult to assess clinically due to pain, tenderness, or trismus. MRI provides better information on tissue extension within the tongue and may demonstrate perineural invasion [Figure 1]b and [Figure 2]b
- Physical fitness, pulmonary reserve, and cognitive function
- Whether total laryngectomy is required when tumor extends to the preepiglottic space and/or epiglottis or when patients are unlikely to tolerate a degree of aspiration
- Mandible: Tumor may extend across the FOM to involve the periosteum/invade the inner cortex or involve medullary bone. MRI is superior for assessing medullary bone involvement. The extent of resection (marginal or hemimandibulectomy) is planned accordingly
- Plan for temporary tracheostomy, for possible airway compromise related to bulky flap, immediate postoperative edema and loss of adequate laryngeal suspension following the division of the mylohyoid, geniohyoid, and digastric muscles
- Type of reconstruction: Assessment for microvascularized free flap or regional flap depending on the body habitus/ medical status of the patient
- Anesthesia: Fiber-optic guided nasotracheal intubation/or preoperative tracheostomy in case of difficult intubation
- Intraoperative evaluation for reassessing the extent of primary tumor, especially for the posterior and lateral extension.
|Figure 1: Total glossectomy – diagrammatic representation. (a) Primary tumor – tongue – clinical view. (b) Primary tumor – tongue – coronal view. (c) Flap raising – inferior view. (d) Intraoral – flap reflection. (e) Incision marking – intra- and extraoral. (f) Flap inset, laryngeal suspension|
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|Figure 2: Total glossectomy – clinical representation. (a) Primary tumor – tongue – clinical view. (b) CECT – tongue – coronal view. (c) Neck – pull through. (d) Total glossectomy defect. (e) Flap inset and laryngeal suspension. (f) Postoperative follow-up at 4 months|
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| Total Glossectomy-Technique|| |
Total glossectomy encompasses a compartmental removal of the entire oral (anterior two-third) and base (posterior one-third) of the tongue musculature along with intervening neurovascular bundles.
Good surgical access is essential to attain adequate resection margins, hemostasis, and reconstruction. A combined transcervical and transoral approach is usually preferred [Figure 1]a and [Figure 1]c and [Figure 2]a and [Figure 2]c. Other approaches include lip split combined with mandibulotomy or segmental mandibulectomy if required for tumor clearance.
Transcervical markings for the incision placed and subplatysmal flap raised. Adequate exposure is obtained from the angle to the opposite side angle of the mandible. The inferior border of the mandible is identified, and the periosteum is incised along the entire inferior border. Anterior bellies of the digastric muscles and the mylohyoid are separated. Soft tissues on the medial aspect of the mandible are then stripped in a subperiosteal plane. Mylohoid muscle is separated from its attachment along mylohyoid line. Geniohyoid muscle is freed from the inferior mental spine. Depending on the extent of the tumor, the decision regarding marginal/segmental mandibulectomy is decided. Then, transoral incision is placed with adequate margins with respect to the tumor, usually over the gingival mucosa along the alveolar ridge. After adequate mucosal cuts and release along the tonsillar pillars, the tongue is delivered into the neck [Figure 1]d and [Figure 1]e and [Figure 2]c and [Figure 2]d. This permits visualization and assessment of the posterior extent of the lesion (vallecula, the base of the tongue, and supraglottic area).
- Mandibular resection: either a marginal or segmental mandibulectomy is performed depending on the involvement/tumor extent clinically or radiologically
- With total laryngectomy: If the posterior extent of the lesion involves epiglottis and preepiglottic fat/infiltrating hyoid
- Supraglottic laryngectomy: Total glossectomy with supraglottic resection has been described by a few authors for limited laryngeal involvement.
| Principles of Glossectomy Reconstruction|| |
- Prevention of aspiration
- Oral-neck separation
- Restore tongue volume
- Restore propulsive swallowing force
- Laryngeal suspension
- Restore clarity of speech.
Selection of reconstructive options
A variety of flaps have been described for the reconstruction of total glossectomy defects which include both locoregional and free flaps. Rectus abdominis, anterolateral thigh, gracilis and latissimus dorsi are commonly used free flap, while pectoralis major myocutaneous flap, latissimus dorsi are among the frequently used regional flaps. Recent trends favor free flaps for superior swallowing and speech outcomes. Furthermore, an individualized decision regarding the flap should be based on the body habitus to determine the adequate bulk. Loss of flap volume and the downward traction of the pedicle are a few to mention with the suboptimal outcomes associated with regional flap stated in most series; however, a study by Tiwari et al. has reported good functional outcomes with regional flaps.
Volume or bulk of restoration
The most critical part in reconstruction of total glossectomy defects is the bulk of the flap [Figure 2]f. It aids in propelling the food into the oropharynx and also to reduce resonance to produce intelligible speech. Kimata et al. in their series of 30 glossectomy defects categorized neotongue shapes as protuberant, semi-protuberant, and flat or recessed and showed statistical significance with respect to shapes (protuberant, semi–protuberant, and flat or recessed) neotongue with respect to speech and food scores. Furthermore, the flap bulk helps to divert the saliva and food into the lateral gutters minimizing aspiration during swallowing. Taking the loss of volume over a period of time to consideration, it is wise to reconstruct 30% in excess to the actual defect size to compensate the periodic loss.
Suspension of the larynx projects it upward and frontward into an anatomical position required for swallowing, and methods such as epiglottopexy, surgical closure of the glottis, and laryngotracheal separation have also been mentioned in literature to prevent aspiration but not routinely practiced. The technique is usually to suspend over the anterior mandibular arch, and in case of anterior arch resection, suspending it from angle or condyle is also an option [Figure 1]f and [Figure 2]e. Calcaterra and Godde advocated laryngeal suspension in patients undergoing supraglottic laryngectomy and found decreased incidence of aspiration and also facilitated deglutition by effectively diverting food into lateral gutters. Weber et al. in their series also found no aspiration in 12 patients with laryngeal suspension in comparison with 15 patients without laryngeal suspension.
Motor and sensory innervation of flap
Theoretically, it has been postulated that providing a sensate reconstruction enables detecting the presence of food in the oral cavity which can be moved during mastication and then aids in deglutition. There is a lack of data to compare benefits of motor innervation of flaps. Reanimation of the muscle containing flaps may contribute to the prevention of muscle atrophy rather than functional movement. However, the benefit of muscle innervation to overall functional outcome remains investigational.
Speech and swallow therapy
A key point in rehabilitation is a postoperative speech and swallow therapy to improve the functional outcome following total glossectomy with laryngeal preservation. A study by Dziegielewski et al. reported superior speech and functional outcomes in patients who attended more than 80% of swallowing and speech rehabilitation sessions.
| Measuring Functional Outcomes|| |
Functional outcomes of the reconstructed tongue depend mainly on the volume of the flap replaced. This, in turn, affects swallowing function [Table 1] and speech intelligibility [Table 2], as it has a positive correlation. It is important to analyze and correlate between function including swallowing and speech intelligibility and volume of the neotongue [Table 3].
| Conclusion|| |
Total glossectomy is a procedure required for advanced tumors of oral tongue, recurrent/residual, or nonsquamous tumors of the base of the tongue. Life-threatening aspiration and swallowing difficulties are dreaded complications. However, with appropriate selection of flaps and techniques like laryngeal suspension, this procedure has acceptable functional outcomes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
This material has never been published and is not currently under evaluation in any other peer reviewed publication.
The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]