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246
Site of planned
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A. Tahim and Z. Sadiq
For curative management, evidence suggests that for
lesions of the posterior tongue or tongue base, treatment
using radiotherapy is as effective as surgical management,
with improved post-treatment functional outcomes [6]. For
anterior tongue lesions, however, particularly those smaller
than 4cm, surgical excision remains the treatment of choice
for the primary lesion, with an overall 5-year survival rate of
73% for early disease with no evidence of cervical spread
[5].
26.3 Surgical Technique
Interestingly, the transoral approach has been used in the
management of tongue lesions since the fth century AD,
when hot cautery was used in several described tongue excisions. The middle ages saw the use of various snare-like
devices, which progressively tightened around the tongue,
allowing its excision. Marchetti described the rst glossectomy in 1664 [7], and it was not until extra-oral approaches
were developed some 200years later that oral access changed
[8]. Since then, the rise in the complexity of tongue cancer
surgery has mimicked that of head and neck surgery in general, with the development of general anaesthesia, asepsis,
and the expansion of surgical technology and
understanding.
At present, transoral partial glossectomy can be performed using the traditional surgical scalpel, carbon dioxide
(CO2) laser, monopolar electrocautery, the ultrasonic scalpel,
or indeed a combination. Consideration should be given to
visualization, protection, and careful retraction of neighboring tissues. Neck extension, using an appropriately sized
shoulder bolster and a suitable head support, can signicantly help access. Cheek retractors, tongue depressors, and
photographic retractors may allow better visualization while
protecting the cheeks, tongue, and lips. Mouth block or gags
will maintain full mouth opening. Appropriately planned
dental extractions may also aid visualization and access. It is
often useful to place a tongue suture to aid retraction or
manipulation of the tongue (Fig.26.4). Care should be taken,
however, especially when marking the lesion and the margins, to avoid distorting the lesion by over-retraction. Indeed,
marking the lesion with the tongue in a relaxed state is advisable where possible.
molar dental
extractions
Left lateral
ongue suture
Fig. 26.4 A left-sided lateral tongue tumour. Note the extracted posterior molars and the tongue suture placed to assist retraction, visualization,
and access
tongue tumour
molar dental
extractions
Floor of mouth
n
y
26 Transoral Partial Glossectomy
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1 cm excision
margin
Tumour margi
247
Transected ends
of the lingual arter
Gentle retraction
using skin hooks
Fold into
the floor of the
mouth
Fig. 26.5 A left-sided lateral tongue tumour marked in situ, with a
further 1cm excision margin
The lesion can then be examined under anaesthesia, prior
to the administration of any local anaesthetic, to minimize
the risk of local distortion. Its size on palpation can be correlated with preoperative staging imaging. Having marked
the lesion, a further 1cm resection margin can be delineated,
accounting for mobile mucosa and the various curved,
non- linear surfaces of the tongue and the oor of the mouth
(Fig.26.5).
Local anaesthetic can be delivered at this time to aid
haemostasis prior to resection. Otherwise, standard lingual
blocks are useful for postoperative pain management. Prior
to beginning the resection, the resection perimeter can be
formally marked using a surgical instrument such as monopolar diathermy. This will avoid the risk of blurring of the
inked marked margin, which may occur during the resection. The resection itself can be performed in an anterograde or retrograde fashion, but suitable retraction and
tissue tension is imperative (Fig. 26.6). It should begin
supercially at the peripheral resection margin, extending
centrally and deep to create the classic “boat hull-shaped”
resection specimen, with a three-dimensional 1cm margin
around the lesion.
Maintaining appropriate tension to allow effective cutting
of tongue tissue can be difcult owing to access, so gentle
traction using skin hooks (see Fig. 26.6) or appropriately
placed silk sutures can be helpful; direct handling of the
specimen should be minimized. During the resection, it is
important to maintain haemostasis using cautery, clips, or
Underlying tongue
muscle fibres
Fig. 26.6 Retrograde dissection of the tongue lesion during transoral
partial glossectomy
Partial glossectomy
surgical site after
removal of specimen
with clipped lingual
artery at the tumour bed
Fig. 26.7 Partial glossectomy surgical site after removal of specimen
with clipped lingual artery at the tumour bed
ties as appropriate. In particular, the lingual artery should be
identied and securely ligated, if necessary (Fig.26.7).
Care should be taken to ensure that the histopathologist
has relevant information to orientate the specimen for appropriate analysis. This can be achieved prior to, or immediately
after, completely detaching the specimen, by orientating the
lesion using non- resorbable, clearly visible sutures
(Fig.26.8). Intraoperative photography may also be a useful
orientation aid for the pathologist.
248
sutures
sutures
-
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Anterior
marking
Interior
marking
A. Tahim and Z. Sadiq
Secured in place
with resorbable
sutures
Surgical site with
overlying cellulose
based haemostatic
sheet
Fig. 26.9 Surgical site with overlying cellulose-based haemostatic
sheet, secured in place with resorbable sutures
sized defects may heal better via secondary intention; a
recent case series suggests signicantly better function in
tongue mobility, articulation, and speech intelligibility [9].
As adjuncts, antiseptic packs can be sutured over the defect
during the early postoperative period. Another suitable
option is the use of absorbable, cellulose-based haemostatic
agents, tissue engineered resorbable sheets, or viscous haemostatic agents (Fig.26.9).
Fig. 26.8 Relationship between the transoral partial glossectomy site
and the oncological specimen in the correct orientation, with appropriately placed marking sutures
Given the tongue’s impressive vascularity, it is important
to maintain haemostasis intraoperatively. Vasoconstrictive
local anaesthetic, hypotension, and the effective use of bipolar diathermy are useful tools. After removal of the tumour,
however, close liaison with the anaesthetic team is required
to return blood pressure to the preoperative normal level.
Lowering the patient’s head to below the level of the heart
and performance of a Valsalva manoeuvre are extremely
valuable in identifying and preventing potential sources of
postoperative bleeds.
Closure of partial glossectomy defects requires systematic thought. Of course, the signicance of the defect will
vary depending on its size and location, but particular attention should be paid to the risk of reduced tongue mobility
due to adhesion to the oor of the mouth. It is reasonable to
close small defects primarily, but larger defects that involve
the oor of the mouth and display communication into the
neck will require local or free ap reconstruction. Moderately-
26.3.1 Variations inOperative Technique
The traditional surgeon’s steel scalpel remains a popular
instrument, although meticulous bipolar diathermy is
required to maintain intra-operative haemostasis. Although
newer techniques have looked to address the problems
related to haemostasis, a key benet of the cold scalpel is its
almost negligible effect on resection margins [10].
The harmonic scalpel is a device now commonly used in
these procedures. It employs an ultrasonic frequency to generate mechanical energy through vibrations, at a frequency
of 55,000Hz. These then break down the hydrogen bonds in
tissue protein, resulting in a coagulum that seals off blood
vessels. Its benets include the combination of both sectioning and haemostasis in parallel. The time taken for resection
using the harmonic scalpel has been shown to be less than for
standard methods. Postoperative pain is also reduced, a difference often attributed to the lower temperature generated
by the ultrasonic device, compared with traditional cautery.
The ultrasonic device is also kinder to the resection margins,
with a suggested necrosis zone of approximately 0.8 mm,
26 Transoral Partial Glossectomy
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249
compared with 6–8 mm for monopolar cautery [11].
Operative bleeding is often minimal, although signicant
postoperative bleeds arising from the lingual artery have
been noted in up to 10% of cases. For this reason, intraoperative identication and ligation of this vessel has been advocated [12].
Carbon dioxide lasers have been used to carry out transoral partial glossectomy procedures for almost 40 years
[13]. Their use is supported in the existing literature, and outcomes have been comparable with other modalities [14, 15].
A variety of lasers are available with an array of settings;
typical protocols for its use in partial glossectomy procedures set it to 10–12 watts, on a continuous mode. The
benets of its use intraorally have included decreased postoperative pain, reduced bleeding, and good functional outcomes [16]. Animal studies have suggested good wound
healing, particularly when leaving the tongue to heal by secondary intention [17]. It also appears to demonstrate acceptable levels of thermal degradation in surrounding tissues [18,
19], with current dogma supporting a 1-mm safety border to
ensure no damage to histopathological specimens [20]. A
number of laser safety precautions should be taken during
the procedure itself, including appropriate eye protection,
use of non-reective instruments, and protection with damp
gauze. Dental surfaces should be carefully avoided during
the procedure.
Transoral robotic surgery (TORS) techniques are becoming increasingly useful tools in the surgical management of
head and neck disease, including tongue cancer. They have
been shown to be cost-effective and decrease the length of
hospital stay in patients with mild to moderate disease affecting the posterior tongue, but the same benets were not seen
in patients undergoing partial glossectomy of the anterior
tongue with TORS [21].
26.5 Functional Recovery
The tongue has several sensory and motor functions. It is
involved in taste, speech, and articulation, along with manipulation, positioning, and swallowing of food and saliva.
Unsurprisingly, any alteration to it will affect these elements
either directly, through tissue bulk removal, or indirectly by
the effects of postoperative wound healing and scarring.
Therefore, functional recovery after a partial glossectomy
procedure is complex, with swallowing, speech, and salivary
changes being cited as important aspects of the recovery process [22]. A recent retrospective study of patients undergoing
long-term follow-up reported a return to baseline swallowing
and articulation scores, based on standard quality-of-life
indices. These improvements, thought to be due to mechanical recovery of tongue mobility and a gradual subjective
adjustment leading to higher satisfaction scores, were gradual and often were not fully apparent until 12months after
the procedure (Fig.26.10) [23].
Other evidence shows that after these tumour resections,
complex tongue motion adaptations occur to preserve the
acoustic integrity of speech [24]. Specic postoperative rehabilitation has been shown to help preserve function [25]. Such
regimens include range-of-motion exercises (such as elevating
the tongue tip and dorsum towards the palate, lateral tongue
movement, and tongue base motion towards the posterior pharyngeal wall), along with control and strengthening exercises,
26.4 Postoperative Care
The key immediate postoperative complication is bleeding,
so a short period of inpatient observation is advisable.
Postoperative pain can also be signicant, and a wellthought- out postoperative analgesic regimen is sensible.
Similarly, use of the tongue (particularly swallowing) may
cause substantial discomfort, so it is not unreasonable to
employ a nasogastric feeding regimen in the early postoperative period, during which a measured approach to rebuilding
oral intake can be taken, in conjunction with a close liaison
with specialist allied health teams such as dieticians and
speech and language therapists.
Fig. 26.10 A healed surgical site 18 months after transoral partial
glossectomy of a left lateral tongue squamous cell carcinoma (A).
Healing through secondary intention was facilitated through the use of
a cellulose- based haemostatic sheet, resulting in good postoperative
functional recovery
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A. Tahim and Z. Sadiq
jaw-opening exercise, and recorded reading and conversation
training sessions. Other studies have made use of functional
MRI to suggest that in addition to mechanical recovery, there
are adaptive changes in cortical recruitment following partial
glossectomy, which modify and maintain appropriate tongue
motor tasks [26]. Encouragingly, overall quality of life after
these procedures has been reported favourably [22].
26.6 Conclusion
Transoral partial glossectomy offers a curative treatment
modality for tongue malignancies, with acceptable functional outcomes. As in any resective surgery, patient positioning, access to the surgical site, and margin control are
key. Advances in healthcare technology have made tongue
tissue removal safer, but the risk of intraoperative and postoperative bleeding must always be respected. Postsurgical
scarring and its latent effects are unpredictable, but attention
to surgical detail and early rehabilitation may improve
outcome.
References
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11. Harold KL, Pollinger H, Matthews BD, Kercher KW, Sing RF,
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and large-sized arteries. Surg Endosc. 2003;17:1228–30.
12. Pons Y, Gauthier J, Clément P, Conessa C.Ultrasonic partial glossectomy. Head Neck Oncologia. 2009;1:21.
100 cases. J Laryngol Otol. 1985;99:887–9.
14. Jerjes W, Hamdoon Z, Hopper C. CO2 lasers in the management
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C. Prospective evaluation of outcome after transoral CO2 laser
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Med Oral Pathol Oral Radiol Endod. 2011;112:180–7.
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T, etal. Harmonic scalpel versus exible CO2 laser for tongue
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Nutting CM, etal. Quality of life outcome measures following partial glossectomy: assessment using the UW-QOL scale. J Cancer
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Neuroradiology. 2010;52:1185–91.
Floor oftheMouth Cancer
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AlaistarFry andLeoVassiliou
27
27.1 Introduction
The most common oor of mouth malignancy is squamous
cell carcinoma (90%). Other forms of cancer that may arise
in the oor of the mouth could be salivary gland malignancies or, more rarely, mesenchymal tumours such sarcomas,
haematological malignancies, or metastatic tumours.
Staging of oor of mouth carcinomas follows the princi-
ples of TNM staging in the oral cavity.
Primary oor of mouth cancer is generally treated with
primary surgery (with or without reconstruction). The use of
adjuvant radiotherapy or chemoradiotherapy depends on the
staging tumour characteristics and marginal status. The
5-year survival rate in the United States is approximately
63%. The oor of the mouth is an anatomically and functionally important area, and resections of tumours involving the
oor of the mouth have signicant impact on speech, mastication, swallowing, and cosmesis.
27.2 Floor ofMouth Surgical Anatomy
The anterior border of the oor of the mouth is the U-shaped
lingual cortex of the anterior mandible. The oor of the
mouth posteriorly extends to the palatoglossal fold (anterior
dorsal pillar). Lingually, the oor of the mouth is continuous
to the ventral surface of the tongue. Inferiorly, the border
includes the paired mylohyoid muscle arising from the mylohyoid line and inserting to the anterior surface of the hyoid
bone, uniting in the midline raphe and forming the diaphragm that constitutes the oor of the oral cavity.
Medially, above the level of the mylohyoid muscle, the
oor of the mouth is oored by the paired genioglossus
muscle (arising from the superior mental spine and forming
the majority of the body of the tongue) and geniohyoid
muscle (arising from the inferior mental spine and attached
to the anterior surface of the body of the hyoid bone)
(Fig.27.1). Both of these muscles, together with styloglossus and palatoglossus, are the four extrinsic tongue
muscles.
On inspection, the oor of the mouth is covered by delicate oral mucosa. Visible structures include the sublingual
salivary glands and submandibular duct orices (Warthin’s
ducts); in the midline are seen the lingual frenulum and
numerous sublingual veins (Fig.27.2).
Other important structures include the lingual and hypoglossal nerves (Figs.27.3 and 27.4). The anterior blood supply to the region of the oor derives from the lingual artery
and the mylohyoid and submental branches of the facial
artery.
A. Fry
Department of Otolaryngology and Head and Neck Surgery, Guy’s
and St Thomas’ NHS Foundation Trust, London, UK
e-mail: alistair.fry@gstt.nhs.uk; alaistar.fry@gstt.nhs.uk
L. Vassiliou (*)
Department of Oral Maxillofacial Surgery, Royal Blackburn
Hospital, East Lancashire Hospitals Trust (ELHT), Blackburn, UK
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_27
251
252
Artic with temporal
Pt
Temporalis
Pt
line
sublingual gland
oideus
Submandib
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Fig. 27.1 Attachments of
mylohyoid, geniohyoid,
genioglossus, and digastric
muscles to the inner aspect of
the mandible
A. Fry and L. Vassiliou
erygoideus
externus
Fig. 27.2 Visible structures
in the oor of the mouth
Ramus
Mandibular
foramen
erygoideus
internus
Mylo-hyoid
groove
Mylo-
hyoideus
Mylohyoid
Fossa for
submaxillary
gland
Fossa for
Genioglossus
Neutal
spins
Geniohy
Digastricus
Rannie
veins
Frenulum
Puncta of
submandibular
ducts
ular
ducts
ular
ular
e
27 Floor oftheMouth Cancer
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Fig. 27.3 Structures in the
oor of the mouth
253
Lingual
nerve
Sublingual
gland
Submandib
duct
Submandib
gland
Mylohyoid
muscle
Geniohyoid
muscle
Fig. 27.4 Structures in the
oor of the mouth
27.3 Surgical Objectives forFloor ofMouth
Cancer Resection
Planning for surgical resection in the oor of the mouth
requires consideration of a number of important objectives:
• Clear resection margins, to optimise speech and swallow-
ing function and cosmesis
Submandibular
duct
Lingual nerve
Sublingual gland
Submandibular
gland
Mylohyoid muscl
• Sufcient tongue mobility and avoidance of tethering
• Avoidance of pooling of secretions
• Avoidance of submandibular gland duct obstruction
• Preservation of lingual and hypoglossal nerves, if
possible
• Avoidance of oral cervical or oral cutaneous stulae
• Maintenance of mandibular continuity; dental
rehabilitation
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27.4 Types ofFloor ofMouth Resection
Surgery of the oor of the mouth can be classied on the
basis of the extent of resection (depending on tumour pathology and staging) and the structures involved. A range of
reconstructive options are available to restore anatomy and
function.
27.4.1 Laser CO2 Ablation or Excision
For histologically proven mild dysplasia without clinically
suspicious features (Fig. 27.5), laser CO2 ablation can be
implemented. This destructive technique affects only the
supercial layers of the oor of the mouth mucosa and does
not require any grafting or reconstruction.
For a biopsy-proven histologically moderate grade of
dysplasia and selective cases of high-grade dysplasia, laser
excision is recommended, as the specimen requires pathological assessment to rule out the presence of invasive carcinoma. In such cases, the defect may be left to heal under
secondary intention (with or without packing), although surgeons may opt to reline the defect with a split-thickness skin
graft to avoid scar contraction and subsequent tethering.
A. Fry and L. Vassiliou
Fig. 27.6 Carcinoma in situ or early invasive carcinoma
27.4.2 Wide Local Excision
For cases of carcinoma in situ or early invasive carcinoma with
a depth of invasion up to 2mm (Fig.27.6), wide local excision
is advocated. The excision should aim for at least 1cm macroscopic margin peripheral to the lesion, incorporating the
attached mandibular alveolar gingiva (mandibular lingual
periosteum) and part of the lingual mucosa, if necessary.
The treatment of the neck in such cases is usually observant. If clinical, radiological, or cytological evidence of neck
nodule involvement is found, then this operation should be
Fig. 27.5 Mild premalignant dysplasia
Fig. 27.7 Defects of the oor of the mouth following wide local exci-
sion can be left to granulate under secondary intention
paired with appropriate neck lymphadenectomy (neck dissection) and microvascular ap reconstruction. If there is no
clinical, radiological, or cytological evidence of cervical
metastasis, sentinel node biopsy (SNB) could be appropriate
to obtain staging information about the neck nodal status.
The specimen should incorporate the sublingual gland, or
both sublingual glands. The anatomical bed of the excision
should be the mylohyoid and genioglossus muscles. The
submandibular gland ducts should be identied, and their
proximal end should be transpositioned posteriorly to allow
salivary drainage and avoid obstruction.
The defects of the oor of the mouth following wide local
excision can be left to granulate under secondary intention
(Fig. 27.7) using haemostatic or antibiotic-impregnated
packs, or the defect can be relined with a split-thickness skin
graft (STSG) . Primary closure is not advisable, as it may
cause tethering and distortion of the tongue position and
mobility. If a STSG is used, an antiseptic-impregnated gauze
is placed over the skin graft and tied down with suspension
sutures, which are left in place for approximately 1week.
27 Floor oftheMouth Cancer
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Local aps such as the buccinators ap or facial artery
musculo-mucosal (FAMM) ap can be utilised. A nasolabial
ap also can be used to reconstruct lateral and anterior
defects of the oor of the mouth. These local axial pattern
aps require division after a minimum of 3weeks.
27.4.3 Resection ofFloor ofMouth Cancers
For T1 cancers with a depth of invasion of at least 4mm,
cancers with a higher T stage, or tumours with evident cervical nodal involvement, oor of mouth resection with concomitant neck dissection is performed. For lateralised oor
of mouth cancers with no evidence of crossing over the midline (Fig.27.8), a unilateral neck dissection with inclusion of
level 1A can be performed. When a tumour in the anterior
oor of the mouth crosses the midline, bilateral dissection is
advocated.
A temporary tracheostomy is advisable for oor of mouth
resections, as any postoperative bleeding may cause formation of a haematoma and airway obstruction. In most cases,
reconstruction is performed with a microvascular free tissue
transfer—most often a radial forearm free ap, which delivers the appropriate contour and tissue pliability and texture
to achieve adequate anatomical and functional reconstruction (Fig.27.9). The pectoralis major vertical ap can be utilised in selective cases when the patient is not t for
microvascular reconstruction, or in cases of ap failure.
255
Fig. 27.9 Reconstruction performed with a microvascular free tissue
transfer, a radial forearm free ap
27.4.4 Extended Floor ofMouth Resection
withInvolvement ofAdjacent
Anatomical Subsites
Cancers of the oor of the mouth may extend to the neighbouring mandibular alveolus or invade the substance of the
Fig. 27.8 Lateralised cancer of the oor of the mouth
Fig. 27.10 Cancer of the oor of the mouth
tongue (Fig.27.10). A temporary tracheostomy is imperative
for these cases.
When the tumour invades the substance of the tongue, a
partial glossectomy, often including the tip of the tongue,
should be performed. For extensive oor of mouth tumours
that invade the tongue’s intrinsic muscles, a visor approach
and delivery of the tumour and block with a neck dissection
specimen through the neck can be performed. This pullthrough manoeuvre is achieved by dividing the anterior bellies of the digastric, mylohyoid, geniohyoid, and genioglossus
muscles and delivering the tumour through and below the
mandible into the neck.
If the tumour is adherent to the lingual gingivae and there
is no radiological evidence of mandibular bone marrow
involvement, a mandibular ramus resection can be performed
in continuity with the tumour.
Mandibular rim resection is indicated for tumour adjacent
to the cortical bone with no evidence of invasion beyond the
supercial lingual cortex, or for tumour adjacent to the dentition without evidence of periodontal ligament involvement.
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