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Partial Glossectomy for Tongue Cancer

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Partial Glossectomy for Tongue Cancer CC-BY-NC 3.0 PARTIAL GLOSSECTOMY FOR TONGUE CANCER Johan Fagan Cancers of the tongue are generally treated of the tongue and FOM has with primary surgical resection. Adjuvant a covering of delicate oral mucosa through irradiation is indicated inter alia for ad- which the thin walled sublingual/ranine vanced tumours, tumours with perineural veins are visible. The frenulum is a mucosal invasion (PNI) or uncertain/close margins. fold that extends along the midline between the openings of the submandibular ducts Resecting tongue cancer without con towards the tip of the tongue (Figure 2). sidering subsequent oral function may severely cripple a patient in terms of speech, mastication, oral transport and swallowing. Resecting the anterior arch of the mandible Ranine veins beyond the midline without reconstructing Frenulum bone and with loss of the anterior attach- Puncta of submandibular ducts ments of the suprahyoid muscles (digastric, geniohyoid, mylohyoid, genioglossus) leads Submandibular duct to an Andy Gump deformity with loss of Figure 2: Anterior tongue and FOM oral competence, drooling, and a very poor cosmetic out-come (Figure 1). Posterolaterally the tonsillolingual sulcus separates the tongue from the tonsil fossa. Posteriorly the vallecula separates the base of tongue from the lingual surface of the ep- iglottis. The mucous membrane covering the tongue and FOM varies in thickness and quality; this has relevance in terms of ob- taining surgical margins and retaining tongue mobility. The undersurface of the tongue has a thin, smooth, pliable mucous membrane. The mucous membrane cover- ing the anterior 2/3rds of the dorsum is thin Fig- and quite smooth and adherent to the ure 1: Andy Gump deformity tongue muscle compared to the mucosa covering the base of tongue (BOT) behind Surgical Anatomy foramen caecum and sulcus terminalis which is rough, thick and fixed to the un- The tongue merges anteriorly and laterally derlying muscle and contains a number of with the floor of mouth (FOM), a horse- lymphoid follicles (lingual tonsil). With shoe-shaped area that is confined peripher- BOT tumours it is therefore difficult to de- ally by the inner aspect (lingual surface) of termine the edge of a tumour making frozen the mandible. Anteriorly the undersurface http://openbooks.uct.ac.za/ENTatlas 34-1 Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery section especially useful to assess resection Vasculature margins. The tongue is a very vascular organ. The ar- The tongue comprises eight muscles. Four terial supply is derived from the paired lin- extrinsic muscles (genioglossus, hyoglos- gual arteries and its branches (ranine ar- sus, styloglossus, palatoglossus) control the tery, dorsalis linguae, and sublingual ar- position of the tongue and are attached to teries) (Figures 6, 7); and the mylohyoid and bone (Figure 3, 4); four intrinsic muscles submental arteries. Additional blood sup- modulate the shape of the tongue, and are ply to the tongue emanates from the tonsil- not attached to bone. Below the tongue are lar branch of the facial artery and the as- the geniohyoid and the mylo-hoid muscles; cending pharyngeal artery. the mylohyoid muscle serves as the dia- phragm of the mouth and separates the tongue and FOM from the submental and submandibular triangles of the neck (Fig- ures 3, 4, 5). Figure 5: Geniohyoid and mylohyoid Figure 3: Extrinsic tongue muscles (palatoglossus not shown) Genioglossus Figure 6: XIIn accompanied by ranine veins Vallecula Geniohyoid Mylohyoid Hyoid Figure 4: Midline sagittal view of tongue http://openbooks.uct.ac.za/ENTatlas 34-2 Johan Fagan when the surgeon elevates the submandib- ular gland from the lateral surface of the Tonsillar artery mylohyoid (Figures 8, 9). It branches off the inferior alveolar artery just before it enters the mandibular foramen, crosses the mylo- hyoid, and disappears anteriorly behind the digastric. It has connections with the sub- Ranine artery mental artery and via a defect in the mylo- Sublingual artery hyoid with the sublingual artery in the Lingual artery FOM. Figure 7: Lingual artery Dorsalis linguae artery Venous drainage is via lingual and ranine The lingual artery originates from the ex- veins. The lingual veins originate on the ternal carotid between the superior thyroid dorsum, sides, and undersurface of the and facial arteries and courses obliquely for- tongue and accompany the lingual artery wards and medial to the greater cornu of the and joins the internal jugular vein. The ra- hyoid (Figures 6, 7). It then loops downward nine veins originate below the tip of the and anteriorly and passes medial to hypo- tongue and are visible on its ventral surface; glossal nerve (XIIn) and the stylohyoid they accompany the XIIn as venae comitan- muscle. It then courses directly anteriorly tes and either join the lingual vein or pass and deep to the hyoglossus and finally as- lateral to hyoglossus to join the common fa- cends submuco-sally on the undersurface of cial vein (Figures 2, 6). the tongue as far as its tip as the ranine ar- tery (profunda linguae); it lies to either side of the genioglossus, and is accompanied by the lingual nerve. Two or three small dor- Submental artery sales linguæ arteries arise beneath the hyo- Mylohyoid muscle glossus and ascend to the posterior part of Mylohyoid artery the dorsum of the tongue and also supply Facial artery the mucous membrane of the posterior Figure 8: Fa- FOM, and oropharynx (Figure 7). The sub- cial artery emerges from behind posterior belly of di- lingual artery branches from the lingual ar- gastric (removed), and gives rise to a few branches in- cluding submental artery tery at the anterior edge of the hyoglossus and runs forward between the genioglossus and mylohyoid and supplies the sublingual salivary gland and mucous membrane of the FOM and gingiva (Figure 7). A branch of the sublingual artery pierces the mylohy- oid muscle and anastomoses with the sub- mental branch of the facial artery in Level 1b of the neck. The submental branch of the facial artery courses along the inferior, in- Figure 9: Mylohyoid artery is a branch of the inferior alveolar artery ner margin of the mandible (Figure 8). The mylohyoid artery and vein are encountered http://openbooks.uct.ac.za/ENTatlas 34-3 Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery Innervation ures 10, 11), oral component of submandib- ular salivary glands (Figures 10, 11), and the Other than palatoglossus which is innerve- lingual and XIIns. The paired sublingual ted by the Xn, all intrinsic and extrinsic salivary glands are located beneath the mu- muscles are innervated by the XIIn. The cosa of the anterior floor of mouth, anterior IXn provides somatic afferent and taste sen- to the subman-dibular ducts and above the sation to the posterior 1/3 of the tongue. mylohyoid and geniohyoid muscles (Fig- The lingual nerve provides general somatic ures 10, 11). The submandibular duct is lo- sensation to the anterior 2/3 of the mouth cated immediately deep to the mucosa of and FOM; taste is provided by the chorda the anterior and lateral FOM, and opens tympani branch of the VIIn via the lingual into the oral cavity to either side of the fren- nerve. The lingual nerve crosses deep to the ulum (Figures 2, 10, 11). submandibular duct in the lateral floor of mouth (Figures 10, 11). In the anterior FOM The mandible borders the FOM, and may it is located posterior to the duct (Figure 11). have to be divided for access (mandibu-lot- omy), or resected if involved by tumour (al- veolectomy / marginal mandibulectomy / Lingual nerve segmental mandibulectomy / hemimandi- Sublingual gland bulectomy). Important surgical features are Submandibular duct the position of the mental foramina through Submandibular gland which the mental nerves exit to innervate Mylohyoid muscle the lower lip; the mylohyoid line to which Geniohyoid muscle the mylohyoid muscles attach, the attach- Figure 10: Su- perior view of FOM, sub-mandibular gland and duct, ment of the genioglossus, and when plan- lingual nerve and mylohyoid and geniohyoid muscles ning marginal mandibulectomy, the height of the body of the mandible and the depths of the dental roots (Figures 12a, b). Lingual nerve Submandibular duct Sublingual gland Submandibular gland Mylohyoid muscle Figure 11: In- traoral view of left sublingual gland with ducts of Rivi- nus, submandi-bular gland and duct, lingual nerve and mylohyoid muscles Structures surrounding the tongue Figure 12a: Attachments of muscles to outer aspect of The following structures are located be- mandible and location of mental foramen tween the mucosa and the mylohyoid mus- cles: paired geniohyoid muscles in the mid- line (Figure 4); sublingual salivary glands (Figures 10, 11), submandibular ducts (Fig- http://openbooks.uct.ac.za/ENTatlas 34-4 Johan Fagan o Avoid obstruction of subman- dibular ducts o Attempt to preserve lingual and XII nerves o Maintain mandibular continu- ity and strength o Maintain dental occlusion o Restore dentition Figure 12b: Attachments of mylohyoid, geniohyoid, The author advocates elective neck dissec- genioglossus and digastric muscles to inner aspect of tion (END) Levels I-IV for squamous cell mandible carcinoma of the oral tongue that is >4mm thick and/or >T2 stage; a useful rule of In older, edentulous patients the mandible thumb is that a tumour which is clinically resorbs and the mental foramen and infe- palpable is likely to have a tumour thickness rior alveolar nerve may be very close to its that warrants END. BOT cancers and tu- superior surface (Figure 13). Marginal man- mours of the anterior FOM that approach dibulectomy may also not be possible in the midline require bilateral END. such a resorbed mandible due to the lack of residual bone. The remainder of this chapter will focus on the surgery of cancer of the oral tongue.
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