Overview of Glossectomy

A glossectomy is a type of surgery that involves removing part or all of the tongue. This procedure is usually broken down into categories based on which side of the tongue is removed (left, right, or middle) and how much of the tongue is removed. Here’s a quick look at these categories:

  • Partial glossectomy: This involves removing less than half of the tongue.
  • Hemiglossectomy: This involves removing half of the tongue.
  • Subtotal glossectomy: This involves removing more than half the tongue, but not the whole tongue.
  • Total glossectomy: This involves completely removing the tongue.

While this procedure is most often done to treat severe or advancing conditions on the tongue such as cancerous or pre-cancerous growths, it may also be used to treat oversized tongues (macroglossia), sleep apnea caused by obstruction, and benign tumors that are blocking areas in the mouth. There are various ways to perform a glossectomy that can be used based on the specific reason for the procedure.

Anatomy and Physiology of Glossectomy

The tongue is a powerful muscle located inside the mouth. It helps with everyday tasks like chewing food, swallowing, tasting, speaking, and articulating words. The tongue can be divided into two identical halves. Its outer surface is lined with special tissues that enable us to taste different flavors.

The tongue consists of various parts; the tip is the forward-most part, the lateral surfaces are its sides, and the bottom part of the tongue, which is towards the mouth floor, is called the ventral surface. On the opposite side is the dorsal surface or upper surface of the tongue. The base forms the back one-third of the tongue and extends to a space between the tongue’s base and a part known as the epiglottis. This region is unique compared to the front two-thirds of the tongue.

The tongue is divided into the front one-third (tip), middle, and back one-third (base). The front two-thirds part of the tongue is inside the oral cavity while the back one-third, also known as the tongue base, resides in the oropharynx (part of the throat at the back of the mouth).

There are eight main muscles in the tongue arranged into two groups. The intrinsic muscles, wholly inside the tongue, primarily help change the shape of the tongue but don’t alter its position. They have various names based on their direction. The extrinsic muscles start outside the tongue, letting it change its position.

The hypoglossal nerve (one of the nerves in the brain) gives the tongue its motor function. This nerve can sometimes be prone to injury during specific medical procedures on the neck. The different segments of the tongue have varied sensory and taste functions assigned by various nerves. The front two-thirds of the tongue get sensation and taste from nerves that arise from the jaw region and facial nerve while the back one-third gets signals from the glossopharyngeal and vagus nerve (both are cranial nerves, which emerge directly from the brain).

The tongue’s blood supply mainly comes from the lingual artery and tonsillar branch of the facial artery, which are branches of the main artery on the outside of the neck. Veins in the lingual vein mainly carry away the deoxygenated blood.

The lymphatic system, responsible for fighting infections, drains different sections of the tongue into different regions of the neck. The base of the tongue mainly drains into the middle part of the neck, while the oral part of the tongue drains into the lower neck’s lymph nodes. This knowledge is beneficial for treating tongue cancers especially as it can spread to the cervical (neck) lymph nodes. Even if the disease is not initially present in the neck, the presence of cancer cells can often be concealed. Surgical removal of lymph nodes has been shown to increase survival rates in such conditions.

Why do People Need Glossectomy

Glossectomy is a surgery often done to remove cancerous or precancerous growths, or lesions, in the mouth. Other reasons for the surgery might be to biopsy tongue lesions, remove benign (noncancerous) tongue tumors, treat obstructive sleep apnea, or handle macroglossia (an abnormally large tongue). There are a few ways to do this surgery.

The simplest way is a transoral glossectomy, which means the surgeon removes part of the tongue through the mouth. This method has the least amount of steps and is the easiest in the right cases. But it is limited because the surgeon can’t access and see all parts of the oral cavity. That is crucial when the surgery is done for cancer.

The lip-split mandibulotomy approach, on the other hand, offers the best access and visibility. This method is when the surgeon makes a cut into the mandible (jawbone) to move the tongue and provide access to the back part of the tongue and throat. But, it’s a longer procedure with a higher risk of complications. After the removal, the surgeon must reconstruct the mandible.

The third way is glossectomy via transcervical pull-through. This method involves creating openings in the floor of the mouth, allowing for the tongue to move down and improve visualization. The visibility is less than the lip-split mandibulotomy as the mandible stays intact, but it does not require reconstruction.

Which of these methods the surgeon chooses depends on several factors including the size, depth, and location of the lesion. They use the TNM system to stage head and neck cancers, scoring based on the characteristics of the tumor (T), involvement of the cervical lymph node (N), and distant metastasis (M), which means the cancer spreading to far parts of the body. Their scoring system for tumors of the oral tongue is as follows:

  • Tis: Carcinoma in situ, which means “cancer in place” or very early stage cancer.
  • T1: Tumor is 2 cm or smaller with a depth of invasion (DOI) of 5 mm or less.
  • T2: Tumor is 2 cm or smaller with DOI greater than 5 mm, or a tumor is between 2 to 4 cm with DOI of 10 mm or less.
  • T3: Tumor is larger than 4 cm or DOI greater than 10 mm.
  • T4: Advanced local disease and invasion into surrounding structures.
    • T4a: Invasion of nearby structures, like the jawbone or skin of the face.
    • T4b: Very advanced disease, involving the pterygoid plates, skull base, or carotid artery (the major blood vessels in the neck that supply blood to the brain, neck, and face).

Smaller and shallower tumors (Tis, T1, and T2) are commonly suited for removal through the mouth. Larger tumors or those with notable depth (large T2 to T4a) may be handled better using either the transcervical pull-through or the lip-split mandibulotomy assistance for better access. Surgery is generally not an option for T4b disease because it is considered unresectable, meaning it cannot be safely or fully removed.

The location of the tumor is also important in determining the best surgical method. For instance, a large T3 tumor at the tip or the front half of the tongue may be suitable for a transoral approach alone. Similarly, a shallow, 3 cm T2 tumor in the middle back-third of the tongue may require assistance from a transcervical pull-through method.

There are additional factors to consider for extensive tongue resections. Because there’s a high likelihood of the cancer spreading to the cervical lymph nodes, neck dissection is always considered. If the floor of the mouth is also removed, with a nodal dissection (which means removing the lymph nodes), reconstruction may be necessary to restore the floor and prevent a complication known as a fistula (an abnormal connection between two body parts).

Finding the most effective approach is not just about choosing the fastest one; it may require more exposure steps and have a higher complication risk. The ultimate goal is to achieve a microscopically margin-negative resection, which means that no cancer cells are seen at the edges of the removed tissue. The best approach may vary from case to case, so the doctor will weigh the risks and benefits of each method to determine the most effective one.

When a Person Should Avoid Glossectomy

Aside from serious health conditions that may prevent a patient from having surgery, the main reason a doctor might decide against surgery is if the disease is too advanced to be completely removed. This is often seen in cases of cancer. Factors that might make a disease “unresectable” or unable to be removed include the spread of the disease to distant parts of the body (metastatic disease), the disease encasing or surrounding the entire carotid artery (a major blood vessel in the neck), the disease extending into the base of the skull, and the disease invading the muscles alongside the spine.

Equipment used for Glossectomy

When performing a surgery to help treat cancer (an “oncologic resection”), doctors use certain equipment to make sure they can clearly see everything they need:

To light up the inside of the mouth, they use something like a headlight.

They also use mouth gags, bite blocks, and lip retractors. These tools help keep the mouth open without the doctor and their assistants having to hold it open with their hands. Mouth gags can be combined with a bite block or tools to pull back the cheeks and lips.

If they need to fully expose the tongue for the surgery, they might use sutures (thick, strong thread) or a type of forceps (a tool that looks a bit like a pair of tweezers) to gently pull the tongue out of the mouth.

Electrocautery, a tool that uses electricity to stop bleeding, is often used when cutting through the lining and muscles of the mouth. But too much electrocautery can make it harder to tell healthy tissue from cancerous tissue. Another way to stop bleeding, called cold dissection, uses a slightly different tool and method to do the same thing.

Carbon dioxide lasers can be used to limit any unnecessary damage to the tissue surrounding the surgery area and help the doctor more precisely identify cancerous tissue. However, this tool doesn’t stop bleeding as well by itself.

Further, if the surgery involves cutting (mandibulotomy) or removing (mandibulectomy) part of the jaw, other instruments will be needed. A mandibular plating set, a particular type of bone-cutting instruments, is necessary to reshape the jaw once the tongue surgery (glossectomy) is finished.

Who is needed to perform Glossectomy?

For this medical procedure, several important team members are needed. These include the main surgeon who performs the operation, one or two surgical assistants who help the surgeon, a nurse who helps in the operating room, a surgical technologist who ensures all the surgical instruments are available and in place, and an anesthesiologist who is responsible for your anesthesia — the medicine that helps you sleep and not feel pain during the procedure. The main surgeon also needs to talk about how to handle your breathing (airway management) with the anesthesiologist before the operation.

Preparing for Glossectomy

Before a surgeon operates on a tumor, they must first assess the condition of the tumor and plan how they will manage the patient’s airway during surgery. This plan comes together after some tests and investigations.

When you have your first meeting with the doctor, they will ask about your medical history, including any cancer treatments you have had, such as surgery, chemotherapy, or radiation. If you have had operations on your head or neck or previous airway procedures like a tracheostomy, it is essential for the doctor to know. Additionally, any lifestyle or health conditions that might affect how your body heals after surgery, such as smoking, chronic use of steroids, malnutrition, or autoimmune conditions, are also considered.

In the physical examination, the doctor will ask you to open your mouth as wide as you can, to determine how easily they can access the tumor. This assessment is especially important. A simple visual inspection of the tumor along with feeling it with hands aids in understanding the size, type, and depth of the tumor, and helps to determine the right surgical approach for you.

Additionally, if the tumor is on your tongue, the doctor will manually examine it to assess how deeply it has grown into the surrounding tissues. Sometimes, what appears like a small tumor on the surface can extend significantly below the skin. In such cases, the treatment protocol might need to be adjusted.

Then, an examination under anesthesia is necessary, especially in cases where the patient is in intense pain. This procedure helps the doctor get a thorough understanding of the tumor’s exact location, size, and relation to nearby structures.

Also, the doctor will inspect your airways using medical tools to get a clear picture of the tumor’s spread and whether a straightforward approach to surgery is possible. The observations gathered during this step help in devising a safe and viable airway plan.

Depending on the severity and situation of the tumor, ensuring a clear airway can sometimes be challenging. For example, in some instances, temporary tracheostomy, which involves creating an alternate air passage for breathing, might be needed soon after the surgery due to expected swelling.

In cases where patients experience severe troubles opening their mouth and hence pose a challenge for thorough examination, a different approach to intubation, the process of inserting a tube through the mouth or nose to maintain an open airway, might be required.

After the airway safety plan is made and intubation is successful, another examination under anesthesia is done just before the surgery, especially if there has been some time since the last examination, in which the tumor could have grown or spread further.

Lastly, they will prepare you for surgery. The precautions taken to keep the surgery area clean depend on the specific surgery planned. Antibiotics might be given to lower the risk of infection, depending on what your surgeon thinks is best.

How is Glossectomy performed

Transoral Glossectomy Approach

The transoral glossectomy is a less complex technique used to remove part of the tongue, mainly used if there are small cancerous tumors (T1 and T2) or surface growths at the front of the tongue. This procedure doesn’t always provide good visibility to the back part of the tongue. If the surgeon is unable to get a clear view or reach the back of the tongue, they may need to switch to a different approach, such as lip-split mandibulotomy.

In this method, certain tools like mouth gags and retractors are used to keep the mouth open so the surgeon can see clearly and do the operation effectively. The tongue is stabilized in place with a special technique like fine-point, ratcheting forceps or traction sutures.

The surgeon makes cuts in the tongue using either an electrocautery device (a tool that uses electricity to cut tissue and seal blood vessels), a laser, or cold steel tools. The procedure requires both visual and tactile feedback. This means the surgeon uses their sight and touch to guide their tools accurately, to ensure they achieve clear margins (make sure no cancer cells are left behind).

During the surgery, incisions are made in the tongue down to the muscle. Since it is easier to identify the front edges of the tumor, these incisions are usually made first. Once the tumor is removed, depending on how much of the tongue has been taken out, it can be stitched up, left to heal on its own, or reconstructed.

Lip-Split Mandibulotomy Glossectomy Approach

The lip-split mandibulotomy method combines the transoral glossectomy with a cut in the lower jawbone. While the transoral glossectomy offers a top-down view of the tumor, the mandibulotomy provides a more direct view. This procedure allows the surgeon to see and access the under-surface of the tongue and throat, but is a more complex method with a greater risk of complications.

In this procedure, an incision is made from the middle of the neck to the lip. The surgeon cuts through the layer of the lip and the jawbone. This part of the surgery allows the tongue to be moved downwards, providing a broad view of the posterior tongue and throat.

The surgeon will then make a cut in the gum line, taking special care if there are any teeth in the way. The flaps over the lower jaw are then lifted to expose the bone. A fixation plate is temporarily placed on the jawbone to ensure its shape is maintained after the incision is made.

Once this is done, the surgeon then cuts the jawbone to improve the tumor’s visibility and makes further incisions on the tongue, just like in the transoral glossectomy. These cuts are then reviewed and sent for further examination to ensure the whole tumor has been removed.

While the procedure is more complex and involves more risks, it provides an excellent view of the tumor and surrounding tissues, increasing the chances of complete tumor removal.

Possible Complications of Glossectomy

If you’re going to have a glossectomy, which is a surgery to remove part of or all of your tongue, there are a few risks and complications you should be aware of. These include the risks generally associated with surgical procedures and anaesthesia, such as pain, bleeding, infection, healing issues, damage to nearby areas in your mouth or neck, and the possibility of needing more surgeries later. Although the chances are slim, there can also be heart and lung complications, stroke, or even death as a result of the anaesthesia. It is extremely vital that your doctor discusses these risks with you, along with specific risks to your speech and swallowing abilities, when preparing you for the surgery.

Glossectomy usually leads to issues with speaking and swallowing, medically known as dysarthria and dysphagia. This is due to the loss of certain tongue muscles that help shape and position the tongue. The extent of these challenges can vary, and sometimes even a shallow surgery can affect your speaking abilities to an extent. If the front part of your tongue is removed, it could affect your speech more than your swallowing, and vice versa if the base of your tongue is removed. In more severe cases where a large part or the whole of your tongue needs to be removed, it can result with extreme difficulties with both speech and swallowing.

Other than speech and swallowing difficulties, you might also experience changes to your sense of taste and sensation in your tongue after the surgery. Some patients may experience unusual or “phantom” sensations, which could be due to nerve damage or changes to nerve function during the operation. In cases where a large part of your tongue is removed, you may find yourself mostly reliant on tube feeding.

Another possible complication is a condition known as a salivary fistula. This is where a passageway is formed between your oral cavity and the deeper parts of your neck. It can usually be triggered in areas like the mouth floor and underneath the jawbone. This condition is often manageable, but healing might be slow or complicated in patients who have previously had radiation therapy in the area.

Other surgery-related risks include challenges with wound healing, likely chances of the cancer recurring if present, issues with jaw alignment, problems with certain surgical hardware, bone damage due to radiation, and difficulties for your doctor to monitor your situation after surgery due to scarring or other issues that obstruct their view. So, it’s important to talk about all these potential challenges with your doctor before you decide to go ahead with the surgery.

What Else Should I Know About Glossectomy?

Oral tongue cancer, a type of oral cavity cancer, is best treated with surgery. This is the recommended route by the National Comprehensive Cancer Network (NCCN), preferring it over radiation therapies when there aren’t any factors that would prevent surgery. To determine the best course of treatment, it’s important to consider the pros and cons of different surgical methods. By doing so, medical professionals can prepare for the surgery more effectively and provide patients with a clear understanding of what to expect both during and after the procedure.

Frequently asked questions

1. What type of glossectomy procedure will be performed in my case? 2. What are the potential risks and complications associated with this surgery? 3. How will my breathing be managed during and after the surgery? 4. Will I require reconstruction after the glossectomy? If so, what are the options for reconstruction? 5. What is the expected recovery time and what can I do to aid in my recovery process?

Glossectomy, which is the surgical removal of all or part of the tongue, can have significant effects on a person. It can impact their ability to chew, swallow, taste, speak, and articulate words. The tongue plays a crucial role in these everyday tasks, so the removal of all or part of it can result in difficulties in these areas. Additionally, glossectomy can also affect the lymphatic system and increase the risk of cancer spreading to the cervical lymph nodes.

Based on the provided text, it does not specifically mention glossectomy as a treatment option or reason for surgery. Therefore, it is not possible to determine why someone would need a glossectomy based on the given information.

A person should not get a Glossectomy if their disease is too advanced to be completely removed, such as if the disease has spread to distant parts of the body, encased or surrounded the carotid artery, extended into the base of the skull, or invaded the muscles alongside the spine.

The text does not provide specific information about the recovery time for glossectomy.

To prepare for a glossectomy, the patient should first provide their medical history to the doctor, including any previous surgeries or treatments. The doctor will then conduct a physical examination to assess the size and depth of the tumor. Depending on the severity of the tumor, additional examinations under anesthesia may be necessary. Antibiotics may also be given to lower the risk of infection.

The complications of Glossectomy include risks associated with surgery and anesthesia, such as pain, bleeding, infection, healing issues, and damage to nearby areas. There is also a possibility of heart and lung complications, stroke, or even death as a result of anesthesia. Glossectomy can lead to difficulties with speaking and swallowing, changes to the sense of taste and sensation in the tongue, and reliance on tube feeding. Another possible complication is a salivary fistula, where a passageway is formed between the oral cavity and deeper parts of the neck. Other risks include challenges with wound healing, cancer recurrence, jaw alignment issues, problems with surgical hardware, bone damage due to radiation, and difficulties for doctors to monitor the situation after surgery.

The text does not provide specific symptoms that would require Glossectomy. However, Glossectomy is often done to remove cancerous or precancerous growths, lesions, or tumors in the mouth, to biopsy tongue lesions, treat obstructive sleep apnea, or handle macroglossia (an abnormally large tongue). The choice of Glossectomy depends on factors such as the size, depth, and location of the lesion.

Based on the provided information, there is no specific mention of the safety of glossectomy in pregnancy. It is important to consult with a healthcare professional to assess the risks and benefits of any surgical procedure during pregnancy.

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