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Functional aspects of cancer of the base of the tongue
Functional
Aspects of Cancer of the
Base if the Tongue* I. RAPPAPORT,M.D., J. SHRAMEK,M.D., AND S. BRUMMETT,M.D., Orange, California
therefore endeavored to evaluate and possibly draw some guidelines in various operations on the base of the tongue. We will only dwell on the laryngeal factors of speech, as it is influenced by swallowing. During the first stage of deglutition the food is moved by the action of the muscles of the cheeks and tongue into a position on the dorsum of the tongue. The tongue then propels the bolus posteriorly by pressing against the palate progressively from the anterior teeth backwards down into the oral pharynx. At this time the tensor veli palatini and the levator veli palatini muscles contract, stiffening the soft palate and closing the nasopharynx. Return to the mouth is prevented by position of the tongue against the roof of the mouth. Concomitantly the pressure is decreasing in the laryngeal pharynx and upper esophagus. The cricopharyngeal muscle relaxes and at the same time the laryngeal structures and hyoid mechanism move forward and upward with the anterior esophageal wall. The posterior pharyngeal and esophageal walls are fairly stationary. When the bolus reaches the base of the tongue, it is accelerated by a rapid downward and backward movement of the tongue as the larynx moves up. We believe that the epiglottis does not divert the oncoming bolus to one or the other side, as is stated often in the literature. It does, however, assume a horizontal position due to the backward and downward movement of the tongue. The false cords at this time approximate below the tent formed by the arytenoids and aryepiglottic folds.
From th Department of Surgery, University of California College of Medicine, Irvine, California, and St. John’s Hospital, Santa Monica, California.
base of the tongue can be detined emT bryologically as being posterior to the foraHE
men cecum and originally coated by entoderm that previously covered the ventral areas of the second and third and, to a lesser extent, the fourth visceral arches Its primary nerve supply, except for a small area in the valleculae that arise from the fourth arch (vagus innervated), is the ninth (glossopharyngeal) nerve. The anterior two thirds of the tongue is primarily of stomodeal ectoderm origin and its nerve supply is primarily the fifth (trigeminal) for sensation and the seventh (chorda tympani) for taste. The anterior boundary is the lingual V formed by the circumvallate papillae; laterally the borders are the glossopharyngeal sulcus which lies between the base of the tongue and the lateral wall of the pharynx. The posterior margin can be defined as the anterior wall of the glossoepiglottic fossae or valleculae. The lymphatics of the base of the tongue pass through the lateral pharyngeal wall and drain into the subdigastric nodes [I]. Due to the poor results we had obtained previously we have turned to surgery with either preoperative radiation therapy or infusion chemotherapy. Although firm statements cannot be made at this time, we believe that this approach holds more promise. To evaluate our results with surgery, we have had to scrutinize the amount of postoperative functional restoration obtained. The oral cavity is involved with deglutition and speech; we have
TECHNIC Even under the best of circumstances it is
* Presented at the Thirteenth Annual Meeting of the Society of Head and Neck Surgeons, New York, New York, April 17-19, 1967. Vol. 114. ‘October 1967
489
Rappaport, Shramek, and Brummett
490
difficult to obtain 1 to 2 cm. margins in the combined head and neck operation. Therefore in lesions of the base of the tongue we find it necessary at times to evaluate, examine, and document the lesion using a general anesthetic. After the evaluation, and if a conservative procedure is indicated (Fig. 1) (subtotal glossectomy, with or without partial laryngectomy and partial pharyngectomy), we then proceed to plan the skin flaps. This will vary with the circumstances prior to surgery, such as irradiation therapy. One should not be restricted to the use of any “standard incision,” but should have the patient prepared for immediate flaps from the forehead or chest. If large movements of tissue are not necessary, we will utilize two transverse incisions on the patient who has received heavy irradiation. The neck dissection is carried from the clavicle to the hyoid bone. (Fig. 2, 3, and 4.) The mesial and distal ends of the mandible are cut (usually subcondylar) and the tongue is excised en bloc with the neck contents. This entails a partial hyoidectomy and (depending on the case) epiglottectomy and partial laryngectomy and/or pharyngectomy. We have been able to minimize postoperative fistulas even after irradiation by careful attention to the blood supply of the flaps. A tube pharyngostomy with a 14F soft rubber catheter in the dependent pharynx and a feeding gastrostomy are usually required. The feeding gastrostomy markedly reduces the discomfort and the stimulus for salivation. The pharyngostomy directs the pooled saliva to the outside until the tissue has a chance to recover and suture lines heal. Most of the time the pharyngostomy will close spontaneously. Suction catheter drainage is not sufficient for the first two days. It is essential for good flap healing that the head and operative area be stabilized with a form of modified pressure dressing. COMMENTS
The conclusions we have drawn from studying our patients postoperatively with cinefluoroscopy are as follows. In order not to have difficulty with the first phase of deglutition, it is important to have an intact mandibular branch of the facial nerve since the cheeks and lips help position the bolus of food initially. An intact anterior third of the tongue on the operated side and a functioning hypoglossal nerve on the con-
tralateral side with approximately one third of the base of the tongue will also aid in propelling thebolus and is most important in effecting good speech. With a good portion of the base of tongue gone, the propulsion of food in the hypopharynx becomes awkward, and so the bolus is usually propelled down the surgical defect on the side which has been operated upon. (Fig. 5.) If the pyriform sinus is obliterated, there is a funneling of the food toward the larynx and there may be pooling in the laryngeal aditus. This is probably due to the compromised function of the arytenoid and will cause excessive coughing ; thus, a longer period of time will be necessary before the patient can adequately swallow. Although normally the epiglottis has no function, if it is removed with the base of tongue, pooling in the laryngeal introitus is profound and the patient will have difficulty in talking and breathing, especially when eating. The approximation of the arytenoids and false cords is usually sufficient to prevent pneumonitis. Removal of the epiglottis alone has not caused any unusual problem, since the downward and backward movement of the tongue as the larynx moves upward and forward is sufficient to propel the food into the esophagus. The slight pooling in the laryngeal introitus is minimal and in our patients has not shown evidence of spill into the trachea. It is our impression that attempts at saving the mandible by rewiring the fragments can result in significant creation of dead space. It is essential, according to our studies, that this space be as small as possible in order to facilitate proper balance of the tongue, soft palate, and posterior hypopharynx. This is important in deglutition and speech. The question arises as to the function of the superior laryngeal nerve, which has an internal and external branch. We make no attempt to save these nerves; if they are involved in the dissection, they are removed with the specimen. To date we have not had any untoward effects, such as poor to absent sensation of one side of the larynx which would necessitate removal of the larynx. Also it is apparent that the epiglottis has no practical function in the swallowing mechanism. Rather, the protection of the larynx is afforded by the anterior and medial movement of the arytenoid cartilages which in turn approximate the aryepiglottic folds to close off the laryngeal American Journal of Surgery
Cancer of Tongue
FIG. 1. Outline of area to be resected with guide sutures in place.
491
5. The bolus outlined by the barium funneled down the resected side.
FIG.
is being
3
2
4
FIG . 2. Dissection
carried from clavicle showing resection of hyoid bone and transection
FIG
. 3. Cross section showing the position of the hyoid bone to the lines of resection.
FIG
. 4. Another view demonstrating the tissue that is removed as a block.
VOl . 114. October 1967
of the jugular vein.
Rappaport,
492
Shramek,
aditus except for a small area anteriorly, which is protected by closure of the false cords. In this process the aryepiglottic folds become tense and elevated and form the medial wall of the funnel into the esophagus. The pyriform sinus at this time is effaced. The base of tongue effectively deflects the bolus past the laryngeal introitus. For some unknown reason the laryngeal aditus after tracheotomy becomes fairly insensitive to pooling of saliva. It is only when the saliva enters the trachea that attempts are made to expel it. SUMMARY
It is our impression that surgery can be of use in the control of cancer of the base of the
and Brummett
tongue after thorough evaluation of the patient by both surgeon and radiotherapist. Good results can be obtained if an attempt is made to reconstruct functional anatomy and physiology. Acknowledgment: We wish to thank Dr. Thomas E. Have1 of St. John’s Hospital, Santa Monica, California for his support of our endeavors in the field of radiology. REFERENCES 1. ROUVIERE, H. Anatomy
of the Human Lymphatic System, p. 56. Translated by M. J. Tobias. Michigan, 1938. Edwards Bros., Inc.
American Journal
of Surgery
Aspects of Cancer of the
Base if the Tongue* I. RAPPAPORT,M.D., J. SHRAMEK,M.D., AND S. BRUMMETT,M.D., Orange, California
therefore endeavored to evaluate and possibly draw some guidelines in various operations on the base of the tongue. We will only dwell on the laryngeal factors of speech, as it is influenced by swallowing. During the first stage of deglutition the food is moved by the action of the muscles of the cheeks and tongue into a position on the dorsum of the tongue. The tongue then propels the bolus posteriorly by pressing against the palate progressively from the anterior teeth backwards down into the oral pharynx. At this time the tensor veli palatini and the levator veli palatini muscles contract, stiffening the soft palate and closing the nasopharynx. Return to the mouth is prevented by position of the tongue against the roof of the mouth. Concomitantly the pressure is decreasing in the laryngeal pharynx and upper esophagus. The cricopharyngeal muscle relaxes and at the same time the laryngeal structures and hyoid mechanism move forward and upward with the anterior esophageal wall. The posterior pharyngeal and esophageal walls are fairly stationary. When the bolus reaches the base of the tongue, it is accelerated by a rapid downward and backward movement of the tongue as the larynx moves up. We believe that the epiglottis does not divert the oncoming bolus to one or the other side, as is stated often in the literature. It does, however, assume a horizontal position due to the backward and downward movement of the tongue. The false cords at this time approximate below the tent formed by the arytenoids and aryepiglottic folds.
From th Department of Surgery, University of California College of Medicine, Irvine, California, and St. John’s Hospital, Santa Monica, California.
base of the tongue can be detined emT bryologically as being posterior to the foraHE
men cecum and originally coated by entoderm that previously covered the ventral areas of the second and third and, to a lesser extent, the fourth visceral arches Its primary nerve supply, except for a small area in the valleculae that arise from the fourth arch (vagus innervated), is the ninth (glossopharyngeal) nerve. The anterior two thirds of the tongue is primarily of stomodeal ectoderm origin and its nerve supply is primarily the fifth (trigeminal) for sensation and the seventh (chorda tympani) for taste. The anterior boundary is the lingual V formed by the circumvallate papillae; laterally the borders are the glossopharyngeal sulcus which lies between the base of the tongue and the lateral wall of the pharynx. The posterior margin can be defined as the anterior wall of the glossoepiglottic fossae or valleculae. The lymphatics of the base of the tongue pass through the lateral pharyngeal wall and drain into the subdigastric nodes [I]. Due to the poor results we had obtained previously we have turned to surgery with either preoperative radiation therapy or infusion chemotherapy. Although firm statements cannot be made at this time, we believe that this approach holds more promise. To evaluate our results with surgery, we have had to scrutinize the amount of postoperative functional restoration obtained. The oral cavity is involved with deglutition and speech; we have
TECHNIC Even under the best of circumstances it is
* Presented at the Thirteenth Annual Meeting of the Society of Head and Neck Surgeons, New York, New York, April 17-19, 1967. Vol. 114. ‘October 1967
489
Rappaport, Shramek, and Brummett
490
difficult to obtain 1 to 2 cm. margins in the combined head and neck operation. Therefore in lesions of the base of the tongue we find it necessary at times to evaluate, examine, and document the lesion using a general anesthetic. After the evaluation, and if a conservative procedure is indicated (Fig. 1) (subtotal glossectomy, with or without partial laryngectomy and partial pharyngectomy), we then proceed to plan the skin flaps. This will vary with the circumstances prior to surgery, such as irradiation therapy. One should not be restricted to the use of any “standard incision,” but should have the patient prepared for immediate flaps from the forehead or chest. If large movements of tissue are not necessary, we will utilize two transverse incisions on the patient who has received heavy irradiation. The neck dissection is carried from the clavicle to the hyoid bone. (Fig. 2, 3, and 4.) The mesial and distal ends of the mandible are cut (usually subcondylar) and the tongue is excised en bloc with the neck contents. This entails a partial hyoidectomy and (depending on the case) epiglottectomy and partial laryngectomy and/or pharyngectomy. We have been able to minimize postoperative fistulas even after irradiation by careful attention to the blood supply of the flaps. A tube pharyngostomy with a 14F soft rubber catheter in the dependent pharynx and a feeding gastrostomy are usually required. The feeding gastrostomy markedly reduces the discomfort and the stimulus for salivation. The pharyngostomy directs the pooled saliva to the outside until the tissue has a chance to recover and suture lines heal. Most of the time the pharyngostomy will close spontaneously. Suction catheter drainage is not sufficient for the first two days. It is essential for good flap healing that the head and operative area be stabilized with a form of modified pressure dressing. COMMENTS
The conclusions we have drawn from studying our patients postoperatively with cinefluoroscopy are as follows. In order not to have difficulty with the first phase of deglutition, it is important to have an intact mandibular branch of the facial nerve since the cheeks and lips help position the bolus of food initially. An intact anterior third of the tongue on the operated side and a functioning hypoglossal nerve on the con-
tralateral side with approximately one third of the base of the tongue will also aid in propelling thebolus and is most important in effecting good speech. With a good portion of the base of tongue gone, the propulsion of food in the hypopharynx becomes awkward, and so the bolus is usually propelled down the surgical defect on the side which has been operated upon. (Fig. 5.) If the pyriform sinus is obliterated, there is a funneling of the food toward the larynx and there may be pooling in the laryngeal aditus. This is probably due to the compromised function of the arytenoid and will cause excessive coughing ; thus, a longer period of time will be necessary before the patient can adequately swallow. Although normally the epiglottis has no function, if it is removed with the base of tongue, pooling in the laryngeal introitus is profound and the patient will have difficulty in talking and breathing, especially when eating. The approximation of the arytenoids and false cords is usually sufficient to prevent pneumonitis. Removal of the epiglottis alone has not caused any unusual problem, since the downward and backward movement of the tongue as the larynx moves upward and forward is sufficient to propel the food into the esophagus. The slight pooling in the laryngeal introitus is minimal and in our patients has not shown evidence of spill into the trachea. It is our impression that attempts at saving the mandible by rewiring the fragments can result in significant creation of dead space. It is essential, according to our studies, that this space be as small as possible in order to facilitate proper balance of the tongue, soft palate, and posterior hypopharynx. This is important in deglutition and speech. The question arises as to the function of the superior laryngeal nerve, which has an internal and external branch. We make no attempt to save these nerves; if they are involved in the dissection, they are removed with the specimen. To date we have not had any untoward effects, such as poor to absent sensation of one side of the larynx which would necessitate removal of the larynx. Also it is apparent that the epiglottis has no practical function in the swallowing mechanism. Rather, the protection of the larynx is afforded by the anterior and medial movement of the arytenoid cartilages which in turn approximate the aryepiglottic folds to close off the laryngeal American Journal of Surgery
Cancer of Tongue
FIG. 1. Outline of area to be resected with guide sutures in place.
491
5. The bolus outlined by the barium funneled down the resected side.
FIG.
is being
3
2
4
FIG . 2. Dissection
carried from clavicle showing resection of hyoid bone and transection
FIG
. 3. Cross section showing the position of the hyoid bone to the lines of resection.
FIG
. 4. Another view demonstrating the tissue that is removed as a block.
VOl . 114. October 1967
of the jugular vein.
Rappaport,
492
Shramek,
aditus except for a small area anteriorly, which is protected by closure of the false cords. In this process the aryepiglottic folds become tense and elevated and form the medial wall of the funnel into the esophagus. The pyriform sinus at this time is effaced. The base of tongue effectively deflects the bolus past the laryngeal introitus. For some unknown reason the laryngeal aditus after tracheotomy becomes fairly insensitive to pooling of saliva. It is only when the saliva enters the trachea that attempts are made to expel it. SUMMARY
It is our impression that surgery can be of use in the control of cancer of the base of the
and Brummett
tongue after thorough evaluation of the patient by both surgeon and radiotherapist. Good results can be obtained if an attempt is made to reconstruct functional anatomy and physiology. Acknowledgment: We wish to thank Dr. Thomas E. Have1 of St. John’s Hospital, Santa Monica, California for his support of our endeavors in the field of radiology. REFERENCES 1. ROUVIERE, H. Anatomy
of the Human Lymphatic System, p. 56. Translated by M. J. Tobias. Michigan, 1938. Edwards Bros., Inc.
American Journal
of Surgery