Tongue

By : Mahmoud Fathy

Mahmoud Mo'ness

Supervised by : Prof. Dr. Mohammed Hegazy

Embryology:

Anterior 2/3 --> from first pharyngeal arch

Posterior 1/3 --> from third pharyngeal arch

Muscle of tongue --> from occipital myotomes

Gross anatomy:

It is divided into:

a) Anterior 2/3 : oral part.

b) Posterior 1/3 : pharyngeal part.

The 2 portions are separated by V shaped sulcus terminalis at the apex of which lies the foramen caecum.

A) Oral part:

It has the following features:

1)Tip & 2 lateral margins.

2) Lower surface which presents the frenulum in the middle line

3) Upper surface which presents a shallow median groove & is covered with various types of lingual papillae: Filliform- Fungiform & Circumvallate

B) pharyngeal part :

• It is the back of the tongue

• forms the anterior wall of the oropharynx

• Contains the submucous lymphoid follicles which are called lingual tonsils

Muscles of the tongue:

I. Extrinsic muscles: They change the shape & position of the tongue

1)Stylo-glossus

2)Hyo-glossus

3)Geno-glossus

4)Palato-glossus

II. Intrinsic muscles: (They change the shape of the tongue only)

1)Superior & inferior longitudinal muscles

2)Transverse& vertical muscles.

Blood supply:-

Arterial supply :

lingual artery which is a branch of ext. carotid

Venous drainage : Lingual vein (internal jugular vein)

Nerve supply:

1) Common sensation:

Anterior 2/3 : lingual nerve

Posterior 1/3 : glossopharyngeal nerve (IX).

2) Taste sensation:

Anterior 2/3 : chorda tympani of facial n(Vii).

Posterior 1/3 : glossopharyngeal nerve

3) Motor:

Hypoglossal nerve supplies all the tongue ms. except the palato-glossus which is supplied by a branch of vagus through the pharyngeal plexus

Lymphatic drainage:

From anterior 2/3:

1 - From the side:

Ipsilateral submandibular LN then to upper deep cervical LNs

2 - From tip:

Submental LNs then to bilateral upper deep cervical LNs

3 - From central part:

Bilateral submandibular LNs then to bilateral upper deep cervical LNs

From posterior 1/3:Bilateral upper deep cervical LNs

CANCER TONGUE

Etiology:

Predisposing factors: Chronic irritation:

Sepsis

Spirits

Syphlis

Smoking

Spices

Sharp edge of a tooth.

Precancerous lesions:

1. Leukoplakia

2. Dental ulcer

3. Chronic superficial glossitis

4. Benign tumor e.g. Papilloma.

5. Plummer Vinson syndrome

Pathology:

Site:

1. Side of the anterior 2/3 --> 25% each (commonest site).

2. Tip of tongue--> 10%

3. Dorsum of tongue--> 10%

4. Posterior 1/3--> 20%

5. Under surface of tongue--> 5%

6.At the junction of the tonsils --> 5%

N/E:

a) Exophytic:

1. Malignant ulcer: commonest type

2. Malignant nodule or Cauliflower mass

B)Endophytic:

1. Diffuse infiltrating type --> Woody tongue

2. Malignant fissure: Longitudinal & indurated

M/E:

1. Squamous cell carcinoma (commonest) 90%

2. Basal cell carcinoma.

3. Adenocarcinoma (minor salivary tumors).

4. Anaplastic carcinoma (carcinosarcoma) in posterior 1/3

Spread:

(1) Direct:

(a) Intrinsic: to rest of tongue.

(b) Extrinsic:

a) Cancer anterior 2/3: floor of mouth, gums and mandible.

b) Cancer posterior 1/3: tonsil, epiglottis and soft palate.

(2) Lymphatic: (rapid & early & very common)

(3) Blood: Rare occurs only in cancer posterior1/3.

Complications: 1) Fungation and ulceration. 2) Cachexia & loss of weight 3)Distant metastases.4)Infection leads to foul odour and edema. 5) Dysarthria & dysphagia.

6)Hemorrhage:

due to erosion of lingual artery or internal carotid in cancer posterior 1/3

7)respiratory complications:a. Asphyxia due to LN compressing air passages & inhalation of sloughed

tissue b. Aspiration bronchopneumonia.

Clinical picture: Type of patients: old male (> 50 years)

Symptoms & signs:

(1) Rapidly growing ulcer having the following criteria:

a)Number: single or multiple b)size: variable

c)shape: rounded,oval(plateau) or irregular

d)edge: Raised(as center of lesion ulcerates to create peripheral borders)

Everted edges ( rapid growth with less fibrosis)

e)floor: necrotic F)base:indurated

g)marigin:dilated capillary h)discharge: blood or pus

(2) Pain: early due to infection, late due to infiltration of lingual nerve.

May be local in tongue or referred to the ear through chorda tympani via auriculo-temporal nerve.

(3) Profuse salivation: due to pain and inability to swallow

(4) Ankyglolossia; inability to protrude tongue with deviation to the affected side due to infiltration of muscles of the tongue and floor of mouth.

(5) Complications.

Investigations:

1) for diagnosis: biopsy--> punch,incision and excision biopsy

2)for assessment of resectablity: xray to exclude infiltration of mandible

3)for staging: us&ct neck for detectionbof cervical L.N

4) Lyrangioscopy: extent of lesion especially in tumors of posterior 1/3

Operable

(A) of the primary lesion

1) Surgery

2) Irradiation

Inoperable

(B) of Lymph nodes

1. Operable: Radical procedures:

A) of the primary

1. Surgery:

Indications

1. Early cases < 2 cm.

2. Late cases infiltrating bone.

3. Radiocurrent ulcers

4. Radioresistent ulcers

5. Cancer on top of syphilis(endarteries obliterans)

Operations

I. Carcinoma of anterior 2/3 of tongue :

A. V shaped excision (with 2 cm safety margin) -->for tumors of the tip.

B.Partial glossectomy--> for tumors on lateral side.

C. Hemiglossectomy-->for tumors on lateral side.

D. Total Glossectomy --> for tumors crossing midline.

E. COMMANDO operation:

for tumors infiltrating mandible & floor of mouth (Glossectomy with Combined Mandibulectomy And Neck Dissection Operation)

Includes:

1)Part of the tongue

2) Floor of the mouth

3)hemi mandibulectomy

4)Total block dissection on the same side

5) Reconstruction of the mandible: by either

B) titanium mesh: filled with bone graft

A) bone graft:1 Non-vascularized: from Rib- iliac crest -

radius -clavicle

2 Vascularized: - Pedicled osteomyocutaneous flaps: e.g.

Pectoralis major with 4th ribClavicle with sternomastoid muscle

-Free microvascular flap:Free radial flap Free fibular flapFree iliac crest flap

2. Carcinoma of the posterior 1/3:

Total glossectomy--> through median mandibulotomy.

Repair of the tongue :

1)Small defect: primary suture

2) Large defect: advanced from mucosa of the floor of the mouth

3) Very large: deltopectoral myocutanous flap

2 ) Irradiation:

Indication:

1. Early lesion < 2 cm as an alternative to surgery (optional).

2. Tumors of posterior 1/3.

3. Recurrence after surgery.

4. Inoperable cases.

5. Unfit patient.

It can be performed by :

a) Interstitial irradiation:

Caesium needles or Iridium wire for lesions in the anterior 2/3 with No L.N

b) External radiation: (4000-4500 rad)

Used for lesions in the posterior 1/3 or palpable LN.

3} Combined radiotherapy & surgery:

For large tumors (preoperative irradiation then surgery)

(B) of lymph nodes:

No palpable glandsـ 1

If tumor < 2 cm: Irradiation

if tumor > 2 cm: Total block dissection --> as occult nodal involvement occurs in 50%

:Palpable L.Nـ 2

Total block dissection

(II) Inoperable cases:

criteria

a) General:

Unfit patient, presence of distant metastases.

b) local:

Unresectable tumor due to infiltration of vital structures.

1)Palliative radiotherapy.

2)Palliative chemotherapy.

3)Symptomatic treatment:

a. Control of pain: analgesic, morphia

b. Control of oral sepsis: antibiotics, oral washes.

c. Control of hemorrhage: ligation of external carotid artery

d. Control of respiratory obstruction: tracheostomy.

Palliative procedures:

Prognosis:

Posterior 1/3 tumors :

carry bad prognosis due to:

a. Not discovered early.

b. Anaplastic

c. Excessive lymphatic infiltration.

d. Prevertebral and retropharyngeal LNs spread (not accessible for surgery).

Copyright @ All data are from Mansoura faculty of medicine General surgery book

All data are from Mansoura faculty of medicine General surgery book