Partial Glossectomy
Lara Preece
When dealing with tongue cancer, you may undergo a primary surgical treatment called a glossectomy, which is the removal of all or part of the tongue. A glossectomy is typically performed for the treatment of malignant and pre-malignant tongue lesions. How extensive and complicated the surgery is depends on the location of the tumors on the tongue and the extent of the lesions.
If you have been diagnosed with tongue cancer or any other type of head and neck cancer and are interested in a second opinion on your diagnosis and treatment plan, call us or chat online with a member of our team.
A partial glossectomy removes a portion of the tongue. This is a common procedure for tongue cancer, especially for early-stage disease. After removing the cancerous portion of the tongue, the surgeon removes some surrounding tissue, in order to capture cancer cells that may have been missed.
Typically, the malignancy is located in the front two-thirds of the tongue, which often allows the surgery to be performed through the mouth. Sometimes, a tumor may be in a harder-to-reach area, requiring the surgeon to make an incision in the neck or jaw in order to excise the cancer.
Reconstructive surgery may be needed as part of the procedure, depending on the complexity of the procedure and the amount of tongue removed. When more than half the tongue is removed, the surgery is referred to as a subtotal glossectomy.
Special attention needs to be given to oral hygiene, to reduce the possibility of infection following surgery. The patient may also be placed on a liquid or soft-food diet to prevent damage to the structure of the mouth during recovery, and extensive speech therapy may be recommended to help them recover some of their ability to speak.
Two major causes of tongue cancer are tobacco and alcohol use. These behaviors should be stopped once the patient is diagnosed, especially since patients who continue smoking and drinking during and after treatment increase their likelihood of a cancer recurrence.
Glossectomy is a term used to describe a variety of procedures resulting in the surgical extirpation of part, or all, of the tongue. Glossectomy is most commonly performed for the treatment of malignant and premalignant lesions of the oral tongue. This activity reviews approaches to performing glossectomy and highlights the role of the interprofessional team in evaluating and treating patients who undergo glossectomy.
Objectives:
- Identify the indications for a glossectomy.Describe the equipment, personnel, preparation, and techniques for performing a glossectomy.Outline the appropriate evaluation of potential complications of glossectomy and their clinical significance.Summarize the importance of improving care coordination among the interprofessional team to enhance the delivery of care for patients undergoing a glossectomy procedure.
Glossectomy is a term used to describe a family of surgical procedures resulting in resection of the tongue. While there are many classifications, glossectomy is commonly classified by the laterality (left, right, or midline) and the proportion of tongue removed. These include partial glossectomy (less than one-half), hemiglossectomy (half of the tongue), subtotal glossectomy (more than half but less than a total glossectomy), and total glossectomy (whole tongue excision). Glossectomy is most commonly performed for the treatment of malignant and pre-malignant tongue lesions. It can also be performed for macroglossia and obstructive sleep apnea. While the focus of this article is on surgical approaches for the treatment of oral tongue malignancy, the principles discussed can be applied to all glossectomy indications.[1][2]
The tongue is a muscular organ in the mouth that plays a central role in aiding mastication (chewing), deglutition (swallowing), gustation (taste), speech, and articulation. It is a midline structure with mirrored muscle architecture, innervation, and blood supply. The tongue is split into mirrored halves by an avascular midline raphe. Histologically, the mucosa of the tongue is lined with keratinized and nonkeratinized stratified squamous epithelium. It also contains special sensory mucosa for taste perception.
The surface topography of the tongue includes the tip, lateral surface, ventral tongue, dorsal tongue, and tongue base. The tip of the tongue describes the most anterior part of the tongue. The lateral edge of the tongue separates the ventral surface from the dorsal surface of the tongue. The ventral tongue is the undersurface of the tongue, while the dorsal tongue is the superior surface. The base of the tongue is the posterior one-third of the tongue; it includes the tongue tissue posterior to the circumvallate papilla extending to the vallecula (the latter being the region between the base of the tongue and the epiglottis).
The tongue can also be described in thirds. The tip of the tongue is the anterior one-third of the tongue. The posterior one-third of the tongue is the tongue base. The middle third is between the tip and the tongue base. The anterior two-thirds of the tongue is considered part of the oral cavity, while the tongue base at the posterior one-third is considered to be part of the oropharynx.
There are eight paired muscles of the tongue. Muscles of the tongue are classified as intrinsic or extrinsic. The intrinsic muscles do not have insertions or origins external to the tongue; they are confined to the body of the tongue. Their actions shape the tongue but do not change tongue position. They are named for the directions in which they run: superior and inferior longitudinal muscles, transverse muscles, and vertical muscles. Four extrinsic muscles originate outside the tongue and insert into the body of the tongue. These muscles alter tongue position and include the genioglossus, styloglossus, hyoglossus, and palatoglossus muscles.[3]
Motor innervation to the tongue is from the hypoglossal nerve (cranial nerve 12). The nerve originates from the hypoglossal nucleus and exits the skull base through the hypoglossal canal. Once in the neck, it crosses anterior to the internal and external carotid arteries and can be seen deep to the posterior belly of the digastric muscle. It can often be found inferior to the digastric muscle as it proceeds anteriorly, putting it at risk for injury during dissection of neck levels 1B and 2A. The nerve proceeds superomedially deep to the mylohyoid muscle to innervate the intrinsic and extrinsic tongue muscles.
Sensory and special sensory (taste) inputs from the tongue are based on the thirds of the tongue. The sensory function of the anterior two-thirds of the tongue is supplied by the lingual nerve, which comes off the mandibular branch of the trigeminal (V3) nerve. Sensation to the posterior one-third of the tongue is provided by the glossopharyngeal nerve (9). Taste from the anterior two-thirds of the tongue travels along the chorda tympani, which travels early in its course with the lingual nerve (V3) and later in its course with the facial nerve (7). Taste in the posterior one-third of the tongue is from the vagus nerve (10).
Arterial supply to the tongue comes from branches of the external carotid artery, primarily through the lingual artery and the tonsillar branch of the facial artery. Venous drainage is through tributaries to the lingual vein.[4]
Lymphatic drainage from the oral tongue is primarily to levels 1 through 3 of the neck. This includes the submental (level 1a) and submandibular (level 1b) lymph node basins, as well as the upper jugular chain neck lymphatics (levels 2 and 3). Lymphatic drainage from the tongue base is primarily to levels 2 through 4.[5][6] Understanding lymphatics is important in locoregional control of tongue cancers. Neck dissection should always be considered when treating squamous cell carcinoma of the tongue, due to the risk of cervical lymph node metastases, even in the clinically negative (cN0) neck. Clinically N0 necks have been observed to harbor occult metastases at a rate of 20%.[7] Tumor thickness is also associated with cervical lymph node metastases.[8][9][10] Consequently, the nodal disease burden is a predictor of increased mortality, and elective neck dissection has been shown to offer a survival advantage with higher disease-free survival over therapeutic neck dissection.[11][12] Occasionally, lower lymph nodes in levels 3 and 4 can harbor metastases without level 1 or 2 disease and can be thought of as an indication of aggressive management.[13] Neck dissection is therefore strongly recommended as it provides more accurate nodal staging and can also be therapeutic for decreasing tumor burden.
Glossectomy is commonly performed for the extirpation of malignant and precancerous (or "potentially malignant") oral cavity lesions. Other indications include excisional or incisional biopsy of tongue lesions of undetermined etiology, benign neoplasms of the tongue, obstructive sleep apnea, and macroglossia.
There are multiple approaches to performing a glossectomy. Three approaches to glossectomy discussed in this article include (1) transoral glossectomy, (2) glossectomy via lip-split mandibulotomy, and (3) glossectomy via transcervical pull-through.
Choosing the appropriate approach depends on several factors, including the size, depth, and location of the ablation. The TNM system is used for staging head and neck cancers. TNM is scored based on attributes of the tumor (T), cervical lymph node involvement (N), and distant metastasis (M). The Tumor (T) stage is scored as follows:
In general, smaller and shallower, Tis, T1, and T2 tumors lend themselves well to transoral resection alone. Larger tumors or tumors with significant depth, such as large T2 to T4a, are better addressed by either transcervical pull-through or lip-split mandibulotomy because of the improved access. T4b disease is unresectable, and surgery is usually contraindicated.
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