Glossectomy

Anatomy and Physiology

Muscles and Divisions of the Tongue

The tongue is a muscular organ located in the mouth, central to various functions such as mastication (chewing), deglutition (swallowing), gustation (taste), speech, and articulation. The tongue is a midline structure with a symmetrical muscle arrangement, innervation, and blood supply and is divided into 2 mirrored halves by an avascular midline raphe, which may also contain adipose tissue and lymphatics.[5] Histologically, the tongue's surface is lined with keratinized and nonkeratinized stratified squamous epithelium, along with specialized sensory mucosa for taste perception.

The topography of the tongue encompasses the tip, lateral surfaces, ventral surface, dorsal surface, and base. The tip represents the most anterior part. The lateral edges separate the ventral surface from the dorsal surface. The ventral surface is the underside of the tongue, which opposes the floor of the mouth, while the dorsal surface is the upper surface. The base of the tongue comprises the posterior one-third, including tissue located behind the circumvallate papillae and extending to the vallecula, which is situated between the base of the tongue and the epiglottis. This region is embryologically distinct from the anterior two-thirds of the tongue.[6]

The tongue can also be segmented into thirds. The tip constitutes the anterior one-third, while the posterior one-third refers to the tongue base. The middle third lies between the tip and the base. The anterior two-thirds is part of the oral cavity, whereas the posterior one-third, known as the tongue base, belongs to the oropharynx.

Anatomically, the tongue is composed of 8 paired muscles, which are classified as intrinsic or extrinsic. The intrinsic muscles are entirely contained within the tongue and primarily adjust its shape without changing its position. They are named based on the direction of their fibers: superior and inferior longitudinal muscles, transverse muscles, and vertical muscles. The extrinsic muscles include the genioglossus, styloglossus, hyoglossus, and palatoglossus, which originate outside the tongue and insert into its body, allowing them to alter its position.[7]

Tongue Innervation

The hypoglossal nerve (cranial nerve XII) provides motor innervation of the tongue. This nerve arises from the hypoglossal nucleus and exits the skull through the hypoglossal canal. Upon reaching the neck, it crosses anterior to the internal and external carotid arteries and is typically located deep to the posterior belly of the digastric muscle. It can often be found below the digastric muscle as it moves anteriorly, making it susceptible to injury during dissection of neck levels 1B and 2A. The nerve then proceeds superomedially, deep to the mylohyoid muscle, to innervate both the intrinsic and extrinsic muscles of the tongue.

The sensory and special sensory (taste) functions of the tongue are determined by its sections. Sensation in the anterior two-thirds is supplied by the lingual nerve, a branch of the mandibular branch of the trigeminal nerve (cranial nerve V, division 3). The glossopharyngeal nerve (cranial nerve IX) provides sensation to the posterior one-third. Taste perception in the anterior two-thirds travels via the chorda tympani, which initially runs with the lingual nerve and later joins the facial nerve (cranial nerve VII). In contrast, taste sensations from the posterior one-third are mediated by the vagus nerve (cranial nerve X).

Arterial Supply and Lymphatic Drainage of the Tongue

The arterial supply to the tongue derives from branches of the external carotid artery, primarily through the lingual artery and the tonsillar branch of the facial artery. Venous drainage occurs through tributaries to the lingual vein.[8]

Lymphatic drainage of the oral tongue primarily leads to levels 1 through 3 of the neck, which includes the submental (level 1a) and submandibular (level 1b) lymph node basins, as well as the upper jugular chain lymphatics (levels 2 and 3). Conversely, lymphatic drainage from the tongue base primarily flows to levels 2 through 4.[9][10] Understanding the lymphatic system is crucial for the locoregional management of tongue cancers. Neck dissection should be considered in the treatment of squamous cell carcinoma of the tongue due to the risk of cervical lymph node metastases, even in clinically negative necks, which can harbor hidden metastases at a rate of 20%.[11] Additionally, tumor thickness is correlated with cervical lymph node metastases.[12][13][14]

As a result, the burden of nodal disease is a predictor of increased mortality. Elective neck dissection has been shown to provide a survival advantage and higher disease-free survival rates compared to therapeutic neck dissection.[15][16] Occasionally, lower lymph nodes in levels 3 and 4 can harbor metastases even when levels 1 or 2 do not show disease, indicating a need for more aggressive management.[17] Therefore, neck dissection is strongly recommended as it offers a more accurate evaluation of lymph node status.

Indications

Glossectomy is a surgical procedure commonly performed to remove malignant and precancerous lesions in the oral cavity. Other indications for glossectomy include excisional or incisional biopsy of tongue lesions of uncertain origin, benign tumors of the tongue, obstructive sleep apnea, and macroglossia.[18][19] Multiple approaches may be used to perform a glossectomy, including transoral glossectomy, glossectomy via lip-split mandibulotomy, and glossectomy via transcervical pull-through.

Glossectomy Approaches

Conceptually, transoral glossectomy, the removal of tongue tissue through the mouth, is the simplest of the 3 approaches, as this technique entails the fewest procedural steps and is considered the easiest option in appropriate cases. However, this method has limited access and exposure, which can be a critical drawback since most glossectomies are performed for cancer. Adequate access and exposure are vital for achieving a microscopically margin-negative resection.

The lip-split mandibulotomy, while providing the widest exposure, is the most time-consuming and has a higher risk of complications. This technique involves performing a sagittal osteotomy to open the mandible, allowing for inferior displacement of the tongue and enabling transoral-transcervical access to the posterior tongue and pharynx. Mandibular reconstruction is required after the ablation is completed.

Glossectomy via transcervical pull-through is another technique that releases the tongue into the neck through the floor of the mouth by opening the sublingual and submental compartments. This method allows for inferior displacement of the tongue and improved visualization of the posterior tongue. Although the exposure is less than that of the lip-split mandibulotomy due to the intact mandible, it does not require mandibular reconstruction since a sagittal osteotomy is not performed.[20]

Technique-Specific Indications

The choice of approach depends on several factors, including the size, depth, and location of the lesion. The TNM system is used to stage head and neck cancers, scoring based on the characteristics of the tumor (T), cervical lymph node involvement (N), and distant metastasis (M). The staging for tumors of the oral tongue is as follows:

• Tis: Carcinoma in situ
• T1: Tumor is ≤2 cm with a depth of invasion (DOI) ≤5 mm
• T2: Tumor is ≤2 cm with DOI >5 mm, or tumor is 2 to 4 cm with DOI ≤10 mm
• T3: Tumor is >4 cm or DOI > 10 mm
• T4: Advanced local disease and invasion into surrounding structures
• T4a: Invasion of nearby structures (eg, the mandible, maxilla, or skin of the face)
• T4b: Very advanced disease, characterized by involvement of the pterygoid plates, skull base, or carotid artery encasement [21]

Smaller and shallower tumors (Tis, T1, and T2) are generally suitable for transoral resection. Larger tumors or those with significant depth (large T2 to T4a) may be better addressed using either transcervical pull-through or lip-split mandibulotomy due to enhanced access. Surgery is usually not an option for T4b disease because it is considered unresectable.

The tumor's location is also vital in determining the optimal surgical approach. Ablations positioned more anteriorly are more amenable to transoral resection, while the involvement of the posterior tongue complicates exposure. For instance, a larger T3 tumor at the tongue tip or anterior half may be suitable for a transoral approach alone. Conversely, a shallow, 3 cm T2 tumor in the posterior middle-third of the tongue that extends onto the base may require assistance from a transcervical pull-through.

Other surgical factors must be considered for more extensive tongue resections. Neck dissection is always considered in glossectomy due to the high likelihood of cervical lymph node metastases.[22] If the floor of the mouth is also resected, combined with a submandibular triangle (IB) nodal dissection, reconstruction may be necessary to restore the floor and separate the neck from the oral cavity to prevent a fistula.[23] Reconstruction may also be indicated to restore form and function if a significant amount of tongue is removed. Both reconstruction and neck dissection require transcervical approaches. Performing an extended procedure might be beneficial if the neck is to be opened, as this allows for better access to potential tumor extensions into the mandible or other deep neck compartments, eg, the sublingual and submental spaces.

Severe trismus is an obstacle to transoral glossectomy. Even with the administration of paralytics, if the jaw cannot be opened, lip-split mandibulotomy or transcervical pull-through may be indicated. Transcervical pull-through requires transoral mucosal cuts that might not be possible in severe trismus cases. In patients with prior head and neck radiation, lip-split mandibulotomy carries the risk of osteoradionecrosis. If feasible, cervical pull-through may be favored over mandibulotomy due to the theoretical risk of osteoradionecrosis.

The most effective approach facilitates a microscopically margin-negative resection. The optimal approach may not always be the fastest one; it may be the approach that requires the most additional steps for exposure with the highest risks of complication. Weighing the risks and benefits of each approach will help determine the most effective approach.

Contraindications

Other than medical comorbidities that may preclude the patient from undergoing surgery, the principal contraindication is an unresectable disease in the case of malignancies. This includes the presence of distant metastatic disease, extensive or total carotid artery encasement, skull base extension, and invasion into the paraspinal musculature.

Equipment

Equipment used to optimize exposure is critical to achieving an oncologic resection and includes the following:

• Adequate lighting is essential in the oral cavity; a headlight is recommended.
• Mouth gags, bite blocks, and lip retractors facilitate freeing the surgeon's and assistants' hands.
• Mouth gags can be used with a bite block or cheek and lip retractor.
• Traction sutures (eg, 2-0 or 3-0 silk) or locking fine-tipped forceps can help deliver the tongue out of the mouth for additional exposure.

For mucosal and muscle cuts, electrocautery can provide hemostasis. However, excessive cautery can affect margin interpretation. Cold dissection can be done with bipolar cautery for hemostasis. The carbon dioxide laser offers the advantage over cautery in limiting collateral tissue damage and preserving margin interpretation, but it provides limited hemostasis by itself.[24] If mandibulotomy or mandibulectomy is planned, bone-cutting instruments and a mandibular plating set will be needed to reconstruct the jaw after completing the glossectomy.[25]

Personnel

Essential personnel for this procedure include the primary surgeon, 1 or 2 surgical assistants, a circulating/operating room nurse, a surgical technologist, and an anesthesiologist. The primary surgeon should also discuss airway management with the anesthesiologist before starting the procedure.

Preparation

Preparation begins with the preoperative assessment of the tumor and the formulation of a perioperative airway plan. This starts with a thorough history and physical exam.

Clinical History

At the initial clinical consultation, a comprehensive clinical history should be gathered. The surgeon should review any previous oncologic treatments, including the status of other cancers, prior surgeries, chemotherapy, and any history of radiation to the head and neck. Clinicians should ask about other head and neck procedures, eg, previous neck surgeries, vascular surgeries, trauma reconstructions, and airway procedures.

Additionally, conditions that might impact wound healing should be assessed. These include a history of head and neck radiation, malnutrition, hypothyroidism, chronic steroid use, autoimmune conditions, and smoking. If free tissue transfer is being considered, an evaluation for peripheral vascular disease is essential. Furthermore, identifying any airway-related issues, including a history of difficult intubations, subglottic stenosis, past intubations, and any history of tracheostomy, is vital as these factors will influence the airway management plan.

Clinical Examination

A physical examination should be conducted during the preoperative consultation to evaluate transoral exposure, along with a visual inspection and palpation of the tumor. The assessment of transoral exposure involves asking the patient to open their mouth and measuring the inter-dental distance. Clinicians should also assess the status of the patient's dentition, and a formal dental evaluation may be necessary.[26] Patients with good mouth opening and a favorable tumor location may be suitable candidates for transoral resection. Conversely, if the patient experiences severe trismus, a transoral approach may not be feasible, and these patients will usually require a lip-split mandibulotomy. Edentulous patients can be advantageous for glossectomy since there is better exposure, no risk of damaging teeth, and the flap inset can be performed without the need for circum-dental sutures—even in patients who otherwise may have poor dentition and periodontal hygiene.

The tumor should be visually inspected to accurately determine the size, location, depth, and anticipated mucosal margins. The surgeon must predict nearby structures that need to be recruited into the composite specimen for microscopically cancer-negative margins, including the floor of the mouth, contralateral tongue, the base of the tongue, pharynx, soft palate, retromolar trigone, maxilla, buccal mucosa, hyoid bone, mandible, and even the larynx. Manually palpating the tongue is equally important to assess the submucosal extent of the tumor and to evaluate for fixation to surrounding structures. Superficial ulcers may appear as a T1 or T2 tumor; however, palpation may reveal a T3 tumor with submucosal extension crossing the midline or involving the deep intrinsic tongue musculature.[27] This finding may alter the approach from a transoral partial glossectomy to a mandibulotomy, with subtotal glossectomy requiring more extensive soft tissue reconstruction.

Palpation of tumors located in the middle third of the tongue is critical, as oncologic resection may require removal of the tongue base, retromolar trigone, or soft palate to achieve adequate margins. Additionally, palpation is vital in cases where the tumor extends into the floor of the mouth since it may suggest mandibular invasion that requires marginal mandibulectomy or even segmental mandibulectomy with osseous reconstruction.[28] Patients experiencing severe pain may be challenging to examine in the office setting. Therefore, since in-office assessments may be complicated by patient discomfort, conducting a thorough physical examination under anesthesia at the beginning of the procedure is essential.

Preoperative Tumor and Airway Assessment

Preoperative flexible laryngoscopy and imaging are powerful adjuncts in evaluating tumor extension and the airway. If flexible laryngoscopy and imaging demonstrate tumor extension into the pharynx or larynx, the transoral approach alone will be insufficient. Assessment of airway landmarks with flexible laryngoscopy may predict potential intubation difficulties and help formulate a plan to secure the airway safely.

In early-stage oral tongue cancer cases, securing the airway is usually not problematic. Patients can often be nasally intubated, which allows the endotracheal tube to avoid obstructing the surgical field. However, for patients with more advanced-stage cancer, there may be signs that indicate a difficult airway, such as trismus, tongue fixation, or mass obstruction of the airway. If the laryngeal landmarks are partially or fully visible, video-assisted laryngoscopy or awake fiberoptic intubation (either nasal or oral) can be advantageous based on the surgical plan. An awake tracheostomy may be necessary to secure the airway when the laryngeal landmarks are obscured, and there is significant laryngeal obstruction. Having an airway management plan is critical when preparing for a glossectomy. Many patients undergoing tongue reconstruction will likely require a temporary tracheostomy due to expected postoperative swelling of the reconstructive flap.[29][30]

Patients with severe trismus pose challenges for preoperative examination and require a more sophisticated airway management plan. In instances where suitable airway landmarks are visible, and the anesthetist is comfortable with the technique, awake nasal fiberoptic intubation may be advisable. Alternatively, awake tracheostomy might be preferred if the airway landmarks are obscured or if both the surgeon and anesthetist believe it is the safest option.

Once the airway is secured, an examination under anesthesia should be conducted. During this examination, a thorough transoral exposure, visual assessment, and tumor palpation should be performed, as the planned glossectomy approach may need to be adjusted based on the findings, particularly if there has been tumor progression since the last evaluation. Patients who were challenging to assess in the office due to trismus or severe pain may present differently during surgery when under anesthesia. Additionally, direct laryngoscopy can be conducted at the beginning of the procedure to evaluate the extent of the tumor in the tongue base, vallecula, or larynx.

Patient Preparation and Draping

The patient is prepped and draped based on the overall planned surgery. Transoral glossectomy without neck dissection is often considered a "clean-contaminated" operation. If a neck dissection and reconstruction are to be performed, the patient can be prepped and draped once for a "sterile" procedure, whether or not contamination by a connection between the oral cavity and the neck is anticipated. If a transoral glossectomy is performed with a neck dissection without connecting to the neck, some may perform the glossectomy in a nonsterile fashion first. After the primary tumor is resected with negative margins, the patient may then be sterilely prepped and draped for neck dissection. The administration and choice of perioperative antibiotics are at the surgeon's discretion.[31]

Technique or Treatment

Transoral Glossectomy Approach

Transoral glossectomy is the least complex technique among those discussed and can achieve excellent oncologic clearance with the lowest risk of morbidity in appropriately selected patients. However, it offers limited exposure to the posterior tongue. This approach is most suitable for T1 and T2 tumors and anterior or superficial lesions. The more anterior the resection, the more feasible it is to use the transoral method alone. If exposure is inadequate for effective cancer removal, converting from a transoral approach to a lip-split mandibulotomy or cervical pull-through may be necessary.

Self-retaining retractors and mouth gags are essential to achieve transoral exposure, freeing the surgeon's and assistants' hands. Various mouth gags, including the Molt, Fergusson, and Jennings gags, can be utilized. A bite block may also be employed to keep the mouth open. Mouth gags can be used with cheek or lip retractors to increase illumination in the operative field and protect the cheeks and buccal mucosa. Using traction on the tongue aids in resection by improving retraction. This can be done by placing traction sutures or using fine-point, ratcheting (locking) forceps on the tongue. Handling the tongue with nonlocking, toothed forceps can be challenging due to its bulk and fluidity.

Mucosal and muscle incisions can be made with cautery, laser, or cold instruments. Monopolar cautery is effective in controlling bleeding. Excessive cautery can interfere with margin analysis for malignant and premalignant lesions despite the tongue's high vascularity. For patients where monopolar cautery is contraindicated, such as those with cochlear implants or defibrillators, a combination of cold steel and bipolar cautery may be employed. The carbon dioxide laser can also be beneficial due to its minimal collateral tissue damage, aiding in margin interpretation.

The surgical technique relies on both visual and tactile feedback. Manually handling the specimen helps assess tumor depth and increases the chances of achieving a negative deep muscle margin. After obtaining exposure and traction, incisions for the mucosal margins—typically 1 to 2 cm—are made down to the muscle. Since the anterior margins are easier to assess, these incisions are generally made first. If feasible, making the posterior cuts early may be advantageous, as blood from the front of the mouth can obscure visibility for posterior incisions.

Adding a second traction suture on the specimen provides an additional vector for counter-traction. With the specimen in hand, muscular incisions incorporate normal tissue into the deep margin. Careful hemostasis and ensuring adequate margins are crucial during muscular dissection. Ventral margins may extend onto the floor of the mouth, and contents from the sublingual compartment may need to be included in the specimen for a cancer-free deep margin. As the specimen is excised, its mobility generally improves. Applying forward traction on both the tongue and the specimen can facilitate posterior mucosal cuts, which should maintain at least 1 cm margins when dealing with malignancies. The dissection of the deep tongue muscle can be connected to the posterior mucosal cuts to achieve an en bloc specimen. Mucosal and deep muscle margins are sent for intraoperative margin analysis. Depending on the extent of tongue removal, the tongue may be closed primarily, allowed to heal by secondary intention, or reconstructed.

Lip-Split Mandibulotomy Glossectomy Approach

The lip-split mandibulotomy combines the transoral glossectomy technique with a sagittal mandibular osteotomy. While the transoral glossectomy can be thought of as a "bird's eye" view of the tumor, the mandibulotomy provides a more "head-on" view of the depth of the tumor. This approach provides excellent access to the sublingual and submental compartments and the suprahyoid tongue musculature. Additionally, lip-split mandibulotomy also allows inferior displacement of the tongue for a wide view of the posterior tongue and pharynx. Though this approach offers the best overall tongue exposure, it requires additional steps that increase the risk of complications.

The technique necessitates transcervical mandibular exposure and a trans-facial lip-split. As neck dissection is usually performed with this procedure, the neck dissection incision can be extended superiorly from the midline to the lip. A mucosal lip incision is made approximately 1 cm anterior to the gingiva to provide a cuff of tissue sufficient for closure. This incision is extended along the mucosal lip in the sagittal plane, either through a median mandibulotomy (between the central incisors) or a paramedian mandibulotomy (between the lateral incisor and the canine). The incision continues anteriorly toward the cutaneous lip, passing through the vermillion border. During this process, the labial artery is typically encountered and may be clipped or cauterized. The incision can be extended along the midline through the chin, along the semicircular contour of the chin subunit, or as a compound Z-type incision across the midline, with the latter producing the best aesthetic outcomes.[32] Muscular cuts are then made through the orbicularis oris, mentalis, and the lip depressors onto the periosteum of the mandible.

Gingival cuts are made at this point in the procedure. Management of the central incisors is at the surgeon's discretion. If not extracted, the roots are at risk of exposure or being dislodged from their periodontal ligament during the sagittal osteotomy. A 15-blade is best for making the gingival cuts between the central incisors as it preserves the most mucosa and does not transmit unintended heat damage that could occur with monopolar cautery. Especially in radiated tissue, monopolar cautery use at this step frequently ablates the gingival tissue, leaving a tissue gap and increasing the risk of a salivary fistula.

The flaps over the mandible are then elevated in the subperiosteal plane to expose the bone. Subperiosteal dissection need only provide enough exposure to place a fixation plate across the osteotomy. In prior head and neck radiation cases, a conservative periosteal elevation is best to reduce the risk of jaw osteonecrosis. If exposure beyond the canines is needed, care should be taken to avoid damage to the mental nerve as it exits the mental foramen.

At this point, our preference is to place a reconstruction plate on the inferior border of the mandible while it is in continuity. The plate is contoured, and the drill holes and screws are placed. The plate is then removed, oriented, and stored with the screws until the mandible needs to be fixated.

Sagittal osteotomy is then performed, which is typically done in a stair-step fashion to facilitate stability.[33] The mandible segments are retracted laterally in an open-book fashion, and the mylohyoid muscle between the mandibular segments can be appreciated. A tumor involving the mylohyoid muscle should be excised to a negative margin. Myotomy of the mylohyoid completely releases the mandible segments from one another, further improving exposure. The oncologic advantages of this approach are apparent at this step of the procedure, primarily consisting of the ability to appreciate the depth of the tumor and a tremendous transoral/transcervical exposure. The glossectomy can be performed by pulling the tongue anteriorly out of the mouth and the specimen inferiorly into the neck to view the posterior cuts. The margins should be sent for intraoperative frozen section analysis. The specimen can be reviewed with the pathologist to enhance communication with the surgeon.

Another consideration is that tumors extending along the floor of the mouth may be adherent to the mandible. The physical exam may demonstrate fixation to the mandible, and imaging may demonstrate cortical erosion or marrow signal asymmetry. Instead of a midline mandibulotomy, segmental mandibulectomy of the involved bone by transcervical approach is another technique for completing the primary resection. Subplatysmal flaps are elevated beyond the mandible. The marginal mandibular branch of the facial nerve is identified and safely retracted out of the field. The soft tissue over planned osteotomies is ablated down to the cortical bone. Bone cuts are made, and the released bone can be retracted to provide additional exposure and an additional traction vector for combined transoral/transcervical resection of the primary.

Glossectomies warranting mandibulotomy/mandibulectomy will usually require soft tissue and mandibular reconstruction. Soft tissue is reconstructed with either a locoregional flap or free tissue transfer. Resected bone is reconstructed with a free bone graft or vascularized osseous free tissue transfer. Reduction and internal fixation can be made with mandibular plates or lag screws. The mucosal closure should be done in such a way as to reduce the risk of a postoperative fistula. The lip-split incision requires closure of the gingiva and the mucosal lip. We generally use chromic or synthetic, absorbable sutures on the mucosa. The muscle layers of the chin and neck are reapproximated. Layered closure of the muscles and skin is performed.

Transcervical Pull-Through Glossectomy Approach

Though mandibulotomy provides excellent exposure, the added steps of the lip-split, osteotomy, and mandibular fixation compound risks of postoperative complications. Head and neck cancer patients with hypothyroidism, diabetes, or previous radiation experience an increased risk of fistula, wound dehiscence, and delayed wound healing. Mandibular osteoradionecrosis is another risk in previously irradiated head and neck patients.

Glossectomy via transcervical pull-through is an alternative resection technique to transoral glossectomy and lip-split mandibulotomy. This approach is a combined transoral/transcervical technique whereby the tongue, floor of the mouth, and the sublingual compartment are released through the submental and submandibular compartments into the neck. Compared to transoral glossectomy alone, this technique provides better exposure for a posterior resection. Transoral glossectomy can be converted to a pull-through without adding a significant time to the procedure. The exposure is not as wide as the lip-split mandibulotomy. However, transcervical pull-through does not require a mandibular osteotomy, thus avoiding the added procedure time for mandibular reconstruction and its associated complications. Flap inset requires thoughtful and disciplined closure to reduce the risk of a postoperative fistula.

The transcervical and transoral portions of the procedure can proceed in any order. A need to proceed back and forth between both approaches is often present. The transcervical approach is provided by the neck dissection. Subplatysmal flaps are elevated. After cervical lymph node dissection of the submandibular triangle is completed, the muscular floor of the neck is assessed for tumor extension or the need to extend the procedure into a lip-split mandibulotomy. Assuming that the disease is limited to the tongue, the procedure can be completed as described.

Anterior transoral glossectomy is performed, as much as can be done oncologically before the pull-through is required to facilitate the posterior resection. Mucosal cuts are made on the anterior tongue along the dorsal and ventral surfaces. The procedure requires the release of the floor of the mouth, so mucosal cuts are extended along the floor of the mouth. For tumors that involve the floor of the mouth, margins may extend to the gingivoalveolar mucosa. If that is the case, the lingual mucosa of the alveolus can be incised, and the entire periosteum elevated off of the lingual cortex of the mandible to encompass the entire floor of the mouth between the tongue tumor and the mandible. Tooth extraction, alveoloplasty, circum-dental inset sutures, or inset to the gingivobuccal mucosa may assist reconstruction. The placement of a traction suture on the specimen facilitates the pull-through. Once the tumor specimen is separated from the tongue remnant anteriorly and the anterior floor-of-mouth cuts are made, attention is switched to the transcervical approach.

The mylohyoid and anterior digastric muscles are released from the mandible. Depending on the extent of the tumor, these muscles can be either transected or resected. If these muscles are involved with a tumor, they should be removed and either included in the composite resection, which is preferred, or sent as a separate margin. The mylohyoid can be released at the mylohyoid line, at its mid-portion, or in the midline. The sublingual compartment is entered and then joined to the floor of mouth cuts, which may include an excision of the sublingual gland. The traction suture on the specimen is pulled into the neck, which provides a view of the posterior resection. The specimen is then removed, and margin analysis is performed. If the margins are negative, reconstruction and closure can be completed. If the surgeon has to employ this approach, soft tissue reconstruction of the defect is generally needed. A combined transcervical/transoral inset method is generally recommended to facilitate wound closure.

Complications

The risks for glossectomy include those pertinent to most surgical head and neck procedures, including pain, bleeding, infection, sequelae of healing, damage to nearby structures, and the need for possible future procedures. Risks of general anesthesia, including cardiopulmonary events, stroke, and death, though remote, must also be considered and discussed with the patient. Furthermore, discussing procedure-specific speech and swallowing function risks is essential in counseling patients.

Dysarthria and Dysphagia

Dysarthria and difficulties with speech or swallowing to varying degrees are almost guaranteed with every glossectomy. The long-term functional outcomes may also vary.[34] Dysarthria and dysphagia are secondary to the loss of intrinsic and extrinsic muscles that shape and position the tongue. Even with shallow partial glossectomy, patients may experience some degree of dysarthria secondary to postoperative changes to their tongue. In general, oral (ie, anterior two-thirds of the tongue) resections lead to more dysarthria than dysphagia, while tongue base (posterior one-third) resections lead to much more pronounced dysphagia and less dysarthria. Total and subtotal glossectomy frequently leads to extreme difficulties with both, regardless of reconstruction, and can lead to oral crippling and gastrostomy dependence.[35] Flaps used to reconstruct the tongue do not have volitional movement; therefore, postoperative tongue function is influenced by residual tongue musculature and the bulk of the reconstructive flap.[36] Rehabilitation and speech therapy are essential in optimizing functional outcomes after postglossectomy.[37]

Changes in speech and swallowing may also be secondary to the sequelae of healing. In cases of primary closure, tongue tethering can occur, limiting freedom of movement. Even in cases of secondary intention, tongue tethering can occur from unanticipated annealing of open surfaces to one another.

Altered Tongue Sensation and Taste

An altered sensation of the tongue is another inevitable complication. Patients may experience neuropathic or phantom sensations from the soft tissue resection. Sensory changes can also be secondary to lingual nerve trauma during glossectomy or neck dissection. In cases with more significant tongue resection, sensory changes are more secondary to loss of sensory input and the sacrifice of the lingual nerve. In reconstructive cases with regional flaps or free tissue transfer, the reconstructive substrate is commonly nonsensate, and if the tissue used contains muscle, the muscle cannot be used in any meaningful way to restore motor function. Some institutions perform reinnervated free flap reconstructions, which provide sensation but no taste.[38] In cases where the tongue base is resected and reconstructed, the altered sensation combined with the loss of functional tongue muscle can result in aspiration, making the patient dependent on tube feeds.[39]

Patients commonly ask about altered taste. A myth regarding the tongue having a taste-specific topography is prevalent. All 5 taste senses are represented throughout the tongue. Higher acuity taste is facilitated by olfaction via retrograde airflow to the nasal cavity, which should be unaffected by glossectomy.

Salivary Fistula

Salivary fistula is another complication in which the oral cavity is continuous with the deep neck space. This complication tends to occur between the floor of the mouth and the submandibular triangle. The loss of the submandibular gland and the vascularized fascia creates a direct communication between the oral cavity and the neck through the floor of the mouth. It can also happen at the site of the sagittal-split osteotomy. In the setting of primary surgery, these wounds tend to heal or can be assisted with some local tissue rearrangement. However, salvage surgery after radiation is prevalent and leaves the operative bed with altered vascularity and impaired healing.[40] Vascularized tissue transfers have become the standard and significantly decrease the risk of fistula, even in the setting of prior radiation.

Additional Surgical Complications

Another risk with surgery is positive margins and recurrences in patients with malignancies. Positive margins can make wound closure impossible, as the reconstruction might not heal the cancer on the inset margins. In that scenario, the risk of salivary fistula and chronic, nonhealing wounds is almost certain. Persistent cancer should always be on the differential in a chronic, nonhealing wound.

Patients undergoing lip-split mandibulotomy face increased risks specific to the osteotomy, including osteoradionecrosis of the mandible, malocclusion, and hardware complications. Osteoradionecrosis is a radiation injury resulting in devitalized bone. If the patient develops osteoradionecrosis, they may require secondary resection and reconstruction.

Even if surgery results in a microscopically-negative margin resection and the wound heals, surveillance could still be complicated. In cases of transoral glossectomy without reconstruction, scar tissue from primary and secondary closure may make it difficult to survey for local recurrences, which may result in future procedures coupled with anxiety for the patient and uncertainty for the oncologists surveilling the patient. In cases with trismus from prior radiation where surgery worsens their trismus, surveillance will be difficult. In such cases, the clinical impression may rely on the sum of imaging, fiberoptic endoscopy, and clinical history.

Clinical Significance

Surgery is the recommended primary treatment for oral tongue cancer. If there are no contraindications to surgery, the National Comprehensive Cancer Network (NCCN) guidelines favor surgery over radiation for oral cavity cancers. Understanding the limitations and advantages of the various approaches to glossectomy can help facilitate resection and appropriate counseling of patients on the expected perioperative and postoperative course.

Enhancing Healthcare Team Outcomes

Effective glossectomy management demands skills, strategy, and responsibilities from a range of healthcare professionals working in a coordinated, patient-centered approach. Physicians, advanced practitioners, nurses, pharmacists, and other health professionals collaborate to optimize patient outcomes and safety through each phase of care. Preoperative assessment by otolaryngologists is complemented by imaging, fiberoptic exams, and consultations with cardiology, pulmonology, and anesthesia to evaluate and manage comorbidities, as well as the involvement of an interprofessional tumor board to guide treatment planning.

Intraoperatively, streamlined communication among surgeons, anesthesiologists, pathologists, and nurses is essential for achieving margin-negative resections and preparing for reconstruction. Postoperative care comprises multiple healthcare team members, including nurses who monitor wound and flap viability, pharmacists who aid in adequate pain control, and dietitians who guide nutrition in conjunction with speech-language pathologists who provide speech and swallowing rehabilitation. This interprofessional strategy ensures seamless care transitions, maximizes functional recovery and supports early reintegration into patients' daily lives.