Tongue Surgery Research Articles

Tongue imaging during drug-induced sleep ultrasound in obstructive sleep apnea patients

ObjectivesThe aims of this study are to examine the changes of tongue thickness and distance of two lingual arteries through drug-induced sleep ultrasound, and explore the relationship between sonographic measurements and clinical data. Materials and MethodsA total of 26 confirmed obstructive sleep apnea patients were recruited in this one-year study. All patients received ultrasound examination twice (wakefulness and drug-induced sleep) in sleep center under level 1 polysomnographic monitor. Drug-induced sleep was performed by administration of one Stilnox (Zolpidem, 2 mg/tablet) and ultrasound procedure commenced once stage 2 sleep shown in polysomnography. Ultrasound imaging was implemented via submental approach with transducer position at the sagittal midline of the submental area (sagittal view) to measure thickness of the tongue. Transducer was then moved at a transverse midpoint between the inferior border of the mandible and the hyoid bone (transverse view) to measure the distance between 2 lingual arteries. ResultsThe distance between 2 lingual arteries elongated significantly (p < .001) and thickness of tongue muscle became thinner during drug-induced sleep. The distance between 2 lingual arteries (sleep) had positive correlation with apnea/hypopnea index (AHI, r = 0.51, p = .008) and body mass index (BMI, r = 0.46, p = .018). ConclusionDrug-induced sleep ultrasound is feasible to measure changes of tongue in OSA patients. Ultrasound imaging showed that tongue muscle became thinner in conjunction with significant widening in distance between two lingual arteries during hypnotic-induced sleep and that was positively correlated with AHI and BMI. Drug-induced sleep ultrasound may be helpful to enhance safety in tongue surgery for OSA patients.

Compartmental Surgery for Oral Tongue Cancer: Objective and Subjective Functional Evaluation.

To assess functional outcomes in patients treated by compartmental tongue surgery (CTS) and reconstruction for advanced oral tongue/floor-of-mouth cancer. Retrospective case series. A retrospective cohort of patients (n = 48) treated by CTS and free flap reconstruction was prospectively evaluated concerning postoperative functional outcomes at different time points (6 months and 1 year). Swallowing was studied by videonasal endoscopic evaluation (VEES) and videofluoroscopy (VFS), testing various food consistencies and grading the results with the Donzelli scale. Speech articulation, lingual strength, and endurance were studied by phone call and Iowa Oral Performance Instrument (IOPI). Subjective tests (EORTC H&N35 and UWQOL) were administered. After 1 year, VEES showed a Donzelli scale of 67% level 1, 23% level 2, and 10% level 3. Vallecular pouch was present in 81% of patients. VFS showed levels 1, 2, and 3 in 42%, 25%, and 33%, respectively, with liquids (L); 48%, 19%, and 33%, with semi-liquids (SL); and 54%, 33%, and 13%, with semi-solids (SS). Vallecular pouch residue was present in 69% with L, 73% with SL, and 87% with SS. The mean number of words recognized at phone call was 56 of 75 (range, 27-74). IOPI showed a mean tongue strength of 19.2 kPa (range, 0-40), and a mean endurance of 16.2 seconds (range, 0-60). CTS does not significantly affect speech. Sub-clinical food aspiration and vallecular pouch are present in a significant proportion of patients, especially when adjuvant treatments are administered. Residual tongue strength is not affected when proper reconstruction is performed. 4 Laryngoscope, 131:E176-E183, 2021.

An interactive surgical simulation tool to assess the consequences of a partial glossectomy on a biomechanical model of the tongue

Oral cancer surgery has a negative influence on the quality of life (QOL). As a result of the complex physiology involved in oral functions, estimation of surgical effects on functionality remains difficult. We present a user-friendly biomechanical simulation of tongue surgery, including closure with suturing and scar formation, followed by an automated adaptation of a finite element (FE) model to the shape of the tongue. Different configurations of our FE model were evaluated and compared to a well-established FE model. We showed that the post-operative impairment as predicted by our model was qualitatively comparable to a patient case for five different tongue maneuvers.

The role of the T-N tract in advanced stage tongue cancer.

We investigated the role of the soft tissue tract between the primary tumor and the neck lymph nodes, the "T-N tract," in patients with tongue squamous cell carcinoma at an advanced stage. We performed a compartmental tongue surgery in 233 patients. Cumulative incidence of relapses and overall survival curves were compared by T-N tract involvement. Multivariate Cox proportional hazards models were used to assess the independent role of T-N tract. At 4 years of follow-up, patients with disease in the T-N tract experienced a significantly more distant recurrence (40%) than did patients without T-N tract involvement (22%; P = .02). Multivariate Cox models indicate a significant almost triple risk of distant metastases (hazard ratio [HR], 2.70; 95% CI, 1.01-7.19; P = .05) and double risk of death (HR, 2.09; 95%CI, 1.13-3.85; P = .02) in patients with "T-N tract involvement." Our data show that the T-N tract plays an important role in prognosis and survival in patients with tongue cancer.

Anatomic Landmarks in Transoral Oropharyngeal Surgery.

Minimally invasive transoral surgery for oropharyngeal cancer is a challenge for head and neck surgeons because of the inside-out anatomic presentation and the confined workspace. This study was performed to describe the main neurovascular and muscular landmarks in a transoral approach. The authors propose an anatomic stratification for this surgery. Lateral wall of the oropharynx and base of the tongue of 15 formalin-fixed heads (30 sides) and 5 fresh cadaveric heads (10 sides) sagittal sectioned were dissected from the inside outwards. Dissection of 7 fresh cadaveric heads via an endoscopic transoral approach was also performed. The lateral oropharyngeal wall was divided into 3 layers from medial to lateral, based in the styloid muscle diaphragm. The first layer, medial to styloid muscles, includes the tonsillar vascularization and the lingual branch of the glossopharyngeal nerve. The second layer, lateral to constrictor muscles, includes the pharyngeal venous plexus, the glossopharyngeal nerve, and the lingual artery. The third layer, lateral to styloid diaphragm, includes the parapharyngeal and submandibular spaces, the carotid vessels and lingual, vagus, glossopharyngeal and hypoglossal nerves. The base of the tongue was divided into central and lateral parts, which contain the lingual artery and lingual branches of the glossopharyngeal nerve. The main landmarks to find the neurovascular structures in each layer are described. The authors propose an anatomic division, which helps to plan oropharynx and base of the tongue surgery. This anatomic stratification is useful to surgeons when performing a reconstruction of the oropharynx with a transoral approach.

Complications and Pain in Obstructive Sleep Apnoea – Comparing Single and Multilevel Surgery

This study aimed to investigate differences in the complication rate and postoperative pain score between single and multilevel surgery performed on patients with obstructive sleep apnoea. A retrospective analysis was performed on patients with obstructive sleep apnoea who underwent surgery in a tertiary referral centre over 3 years. Patients who underwent single-level nasal, palatal or tongue surgery were compared with patients who underwent concurrent multilevel surgery of 2 or 3 levels. Complications and the postoperative Visual Analogue Scale pain score were recorded and the outcomes between single and multilevel groups were compared. The overall complication rate for patients was 12.6%, 6.7% if only patients requiring intervention were considered. The adjusted odds ratio (OR) for complication rate for patients undergoing multilevel surgery and single-level surgery was 2.76. It was statistically significant (P=0.053) after adjusting for confounders. There was more pain in patients who underwent multilevel surgery than in the single-level surgery group. Concurrent multilevel surgery is a feasible option in patients with multilevel obstruction, especially if they are undergoing palate and tongue surgery, nose and palate surgery or nose and tongue surgery. There may be more complications, though it is not statistically significant. Further studies are required to investigate the differences between single-level nasal surgery and 3-level multilevel surgery. More patients undergoing multilevel surgery than single-level surgery experienced pain. Multilevel surgery patients should have their analgesia reviewed regularly and titrated accordingly.

Erratum to: Compartmental tongue resection with submental island flap reconstruction for large carcinoma of the oral tongue.

Tongue resection is a surgical challenge because of its adverse effects on language articulation, swallowing, respiration, the eventual quality of life, and poor prognosis of advanced disease. To date, the currently accepted standard treatment has been based on excision of the primary lesion with a 1.5–2-cm circumferential macroscopic margin. Compartmental tongue surgery (CTS) is a surgical technique that removes an anatomo-functional compartment containing the primary tumor. This is a prospective study that was carried out from June 2012 to January 2015 for patients with carcinoma affecting oral tongue. We enrolled all cases with ≥T2 tongue cancer with or without infiltration of floor of the mouth. Patients underwent compartmental tongue resection with reconstruction using island submental flap. Pharyngeal tear occurred in two cases that were repaired by simple suture. Bleeding occurred in two cases with control of the affected vessels. Loco-regional recurrence was detected only in two cases that underwent CTS, while 18 patients who underwent traditional tongue resection had local recurrence. CTS via pull through technique with submental island flap reconstruction for large tongue cancer has been evolved to improve oncologic resections, obtaining a better local control of disease and increased survival rate with concomitant successful functional and esthetic outcomes especially in elderly patients with serious comorbidities.

Establishing a danger zone: An anatomic study of the lingual artery in base of tongue surgery.

To contrast the changes in measurement of the hypoglossal/lingual artery neurovascular bundle (HLNVB) to constant surface landmarks in the base of tongue (BOT) during surgically simulated retraction versus resting anatomic position, and to identify a safe zone for BOT robotic surgery to avoid injury to the HLNVB. Human cadaver study. Five fresh-frozen head and neck complexes were obtained, and seven HLNVBs were dissected. A microcaliper was used to measure the distance from the HLNVB to constant surface landmarks in resting and surgically simulated positions using a Feyh-Kastenbauer retractor. Measurements from foramen cecum to palatoglossus muscle (P < 0.042) was significantly different when comparing anatomical to surgically simulated positions. Importantly, the location of the lingual artery in reference to the surface landmarks measured was dramatically altered with tongue retraction. With retraction, the branches of the dorsal lingual artery were not encountered posterior to a horizontal line between midway circumvallate papilla (mCVP). Measurements of the HLNVB to surface landmarks in the BOT differs significantly between resting and a surgically simulated tongue position. The dorsal branch of the lingual artery seems more superficial in the BOT than previously described. A safe zone may exist posterior to an imaginary horizontal line between mCVP; however, further studies are needed to confirm this. NA Laryngoscope, 127:110-115, 2017.

Tongue reduction for OSAHS: TORSs vs coblations, technologies vs techniques, apples vs oranges

Coblation tongue surgery and Trans-oral robotic surgery (TORS) proved to be the most published therapeutical options for the treatment of patients affected by obstructive sleep apneas (OSAHS). A systematic review of the literature and an analysis of the data are presented. The mean rates of failure were 34.4 and 38.5%, respectively in TORS and Coblation groups. Complications occurred in 21.3% of the patients treated with TORS and in 8.4% of the patients treated with Coblation surgery. TORS seems to give slightly better results, allowing a wider surgical view and a measurable, more consistent removal of lingual tissue. However, the higher rate of minor complication and the significant costs of TORS must also be considered. Moreover, both technologies may be applied to a wide range of surgical techniques, each of them with different effectiveness.

Do the turbinates play an important role in obstructive sleep apnea syndrome? – Our experience

Abstract BACKGROUND. Nasal obstruction may trigger obstructive sleep apnea syndrome (OSAS) and it is considered to be a cofactor in its pathophysiology. However, the relation between cause and effect still remains a matter of debate. MATERIAL AND METHODS. 18 patients diagnosed with chronic hypertrophic rhinitis and obstructive sleep apnea syndrome were included in the present study. All patients underwent nasal surgery as the single treatment for their sleep breathing disorders. Rhinomanometric (total nasal airflow, logReff, logVR) and polygraphic parameters (apnea-hypopnea index - AHI, snore flags index – SFI) were evaluated pre- and 2 months postoperatively. RESULTS. There was a statistically significant difference between the values of the preoperative and postoperative total nasal airflow (p-value&lt;0.0001). In case of AHI, there was a decrease in its value from 31.56 preoperatively to 30.03 postoperatively, but the difference was not statistically significant (p=0.937). The SFI, on the other hand, presented a significant decrease (p=0.05), from a mean value of 93.15 preoperatively to 56.02 after the surgery. The correlation of the total nasal airflow with AHI and SFI, revealed that nasal surgery had an important impact upon snoring characteristics (r=0.24) and less upon OSAS severity (r=0.21). CONCLUSION. The nasal cavity obstruction contributes less to OSAS, but still represents a disorder that needs to be corrected in case of such patients. Turbinates reduction surgery may be applied in the treatment of OSAS and combined with palate and/or tongue surgery.

Taste and speech following surgical tongue reduction in children with Beckwith-Wiedemann syndrome.

Beckwith-Wiedemann syndrome (BWS) is an overgrowth disorder in which macroglossia is one of the main signs. We investigated the long-term outcome of tongue surgery reduction (TRS) on taste and speech in patients with BWS who were more than 5 years of age and had undergone surgical anterior wedge resection of the tongue. A questionnaire was used to assess medical history and to determine some aspects of speech, taste, psychological well-being, and degree of satisfaction with regard to TRS and tongue mobility. Speech sound error pattern and degree of intelligibility were measured by a speech therapist, and taste was assessed using a validated test. The degree of both intelligibility and satisfaction with the surgery was high. There were some speech errors; especially the interdental 's', addental 't', and addental 'd' were more noticed. We conclude that anterior wedge resection is an effective technique to treat macroglossia in children with BWS, and that it has no long-term consequences for intelligibility and taste perception and only limited consequences for speech.

Tongue Tie/Ankyloglossia

A 4 years old male child visited our Emergency Room (ER) with his parents with the tongue tie. He didn’t complain of any significant physical disability except difficulty in pronouncing particular words. Mother said that breast feeding was painful. However now they want a surgery for the same. The child underwent tongue surgery and it has been cured which is shown in the Figure.

A new surgical strategy for treatment of tongue squamous cell carcinoma based on anatomic study with preliminary clinical evaluation.

This study characterized the infiltration of primary tumors along the intrinsic and extrinsic muscles of the tongue in oral tongue squamous cell carcinoma (OTSCC), to create a new surgical strategy that is suitable for most stages. A preliminary evaluation of this novel surgical approach was also conducted. An anatomic study of macroscopic specimens from 10 human cadavers and 100 OTSCC patients was conducted. The anatomic characteristics of the primary tumors and the origin and distribution of fibers of the intrinsic and extrinsic tongue muscles were observed and measured. After initial treatment with curative intent, the 100 patients were regularly followed-up with clinical examination and imaging. Based on the anatomic characteristics of the primary tumors and tongue muscles, a new surgical approach was developed, and was described as muscle anatomy tongue surgery (MATS). MATS proved suitable for almost all stages of OTSCC. According to the morphology of the invasive tumor front, the 100 cases were divided into four types. The rate of 2-year local disease control was 98%, locoregional control 86%, disease-free survival 85%, and overall survival 89%. Tongue functions were perfectly recovered in more than 60% of the patients. Application of the principles of MATS to the treatment of OTSCC proved suitable for almost all stages of the disease. MATS is a novel surgical technique that may improve outcomes in tongue cancer surgery.

Development of a new lingual range-of-motion assessment scale: normative data in surgically treated oral cancer patients.

Surgical resection in oral cancer patients can result in altered speech, swallowing, and patient perception of quality of life (QOL). Oral surgery can result in reduced lingual range of motion (ROM). However, few studies have quantified the degree of lingual restriction after surgery. This pilot study describes a new measurement system to define tongue ROM in surgically treated tongue cancer patients. This measurement system was validated by comparing results in these treated surgical patients versus healthy individuals. This scale was further validated by correlating ROM with performance status, oral outcomes, and patient-rated QOL. Thirty-six patients who underwent oral tongue surgery and 31 healthy individuals were included. Tongue ROM was assessed using a novel ROM assessment system. This novel system was examined in these patients versus healthy subjects. This measurement tool was further validated by correlating tongue ROM in treated patients with performance status, oral outcomes, and patient-rated QOL. Tongue ROM was found to be significantly lower in the surgically treated patients than in the healthy individuals (p=0.0001). Tongue ROM correlated with performance status, oral outcomes, and all QOL measures. This new tongue ROM measurement system defined tongue deficits in surgically treated oral cancer patients. This tool was validated by comparing results to those in healthy individuals, as well as by correlating tongue ROM to performance status, oral outcomes, and QOL. This measurement tool can be used to define baseline and postsurgery tongue ROM in oral cancer patients, as well as track change over time with recovery and therapy. Future studies should examine use of this measurement tool with other populations demonstrating tongue deficits.

Coblation-assisted Lewis and MacKay operation (CobLAMO): new technique for tongue reduction in sleep apnoea surgery

Obstructive sleep apnoea is a common condition that is unfortunately associated with a high rate of patient non-compliance regarding device use. Newer surgical interventions have focused on procedures at the palate level, using variants of palatoplasty and transpalatal advancement. However, the extent of tongue reduction surgery required remains controversial. The authors propose an in-between variant that combines midline glossectomy resection (with minimal mucosal sacrifice) and lateral coblation tongue channelling. Four patients underwent a coblation-assisted Lewis and MacKay operation, which is a new technique for tongue reduction. This involved a midline glossectomy combined with lateral coblation channelling of the tongue, alone or as part of major airway reconstruction. Demographic, polysomnographic and quality of life questionnaire data were collected prospectively and analysed. No significant complications were noted in the four patients. (Results of the post-surgical outcomes are presented in another paper.) The coblation-assisted Lewis and MacKay operation reduced the potential complications of aggressive tongue surgery. The contours of the tongue were maintained, but significant reduction was still achieved.

Current Concepts and Pitfalls in the Management of Obstructive Sleep Apnea

Program Description: There are many different ways and surgical techniques available to treat OSA, causing a lot of confusion and disparity in managing these OSA patients. There is a need to standardize diagnosis, treatment, and prognosis. Concepts will be discussed and pitfalls will be highlighted. This miniseminar will address these latest current concepts in airway evaluation, clinical diagnosis, polysomnographic diagnosis, and various surgical management (from nose, palate, and tongue surgery). The miniseminar will also highlight the pitfalls that should be avoided in the management of OSA. Educational Objectives: 1) Recognize the basic concepts of airway evaluation and diagnosis and surgical management of OSA. 2) Confidently diagnose, evaluate, and treat patients with OSA.

Three-dimensional vocal tract modeling of fricatives /s/ and /sh/ for post-glossectomy speakers

Production of fricatives involves a narrow supraglottal constriction along the vocal tract. Air flows through the constriction, and generates turbulent noise source(s) by impinging on some obstacles downstream. In post-glossectomy speakers, the production of /s/ and /sh/ is often problematic. It is mainly caused by the tongue surgery, which changes tongue properties such as volume, motility, and symmetry, preventing the tongue from creating proper constrictions. The purpose of this study was to gain some insights on how the vocal tracts of abnormal /s/ and /sh/ are shaped and what are their corresponding acoustic consequences. Based on cine magnetic resonance images, we built 3-D vocal tract models for /s/ and /sh/ from two post-glossectomy speakers (one with abnormal /s/ and the other with abnormal /sh/). Due to the missing part of the tongue, the reconstructed vocal tracts are asymmetric with either an air-flow bypass or a side branch formed near the constrictions. Two coupled physics submodels are included in the 3-D FEM acoustic simulation: incompressible potential flow for the mean air flow and aeroacoustics for the distributed noise sources. The resulting acoustic spectra and acoustic roles of air flow bypass or side branch will be discussed. [This study was supported by NIH R01CA133015.]

OP168: Compartmental tongue surgery: A 10 years story

Analyzing the cancer invasion pattern into the tongue we observed that the front of invasion follow the muscle fibers, horizontally into the intrinsic muscles and changing to a vertical direction when the extrinsic muscles are reached. The median tongue septum separating the genioglossus was almost never breached; when controlateral invasion occurred, it was via invasion of the intrinsic muscles above genioglossus. Other observed paths of tumour spread were: the fibrous and fatty tissue between genioglossus and hyoglossus muscles, the soft tissue between the hyoglossus muscle, the connective tissue of the floor of the mouth and the sublingual adipose tissue. We identify an anatomical (and functional) area into the tongue that can be at risk of being involved by cancer. We called this area tongue compartment and developed a rational surgical approach to tongue cancer resection: the compartmental surgery (CTS). This technique provides the complete removal of the involved muscle and sublingual tissues as to remove the path of disease spread and sites of potential residual foci. We perform CTS on 198 patients with primary untreated advanced tongue cancer from August 1999 to December 2009. After surgery, patients were followed in an outpatients up to 10 years. Their data of survival and functional recover were collected in a database and then statistically analyzed. 20 patients (10%) had local recurrences after 10 months (2–75 months). 18 patients (9%), had lymph node recurrences after 7 months (2–16 months); 24 patients (12%) had distant metastases after 13 months (1–87 months). Overall 5-yrs OS was 70.6% and 5-yrs DFS was 65.7%. The markedly improved outcomes in CTS patients, compared to those treated by standard surgery, suggest that CTS could be an anatomic approach to the surgical management of tongue cancer and provides better oncologic outcomes.

Analysis of the dynamic relationships between the lingual artery and lingual markers in patients with obstructive sleep apnea

To determine the relationships between the lingual artery and the lingual markers in tongue resting and extended positions in patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) for the clinical application of functional tongue surgery. Computed tomography angiography (CTA) of the lingual artery was performed on 30 OSAHS patients using a 16-slice spiral CT scanner. The anatomical relationships between the lingual artery and the lingual markers were analyzed with the tongue in resting and extended positions using the CTA images. The course of the lingual artery resembled the configuration of the Big Dipper constellation when the tongue was in a resting position. When the tongue was in a full-extended position, the majority of the lingual artery moved forward and upward with the hyoid and formed a "√" fashion. The positions of the tip of the greater horn of the hyoid changed with the tongue positions. While the relationship between the main lingual artery and the tip of the greater horn of the hyoid, as well as the distances between bilateral lingual arteries, remained constant in both tongue positions. In conditions of dynamic tongue movement, the tip of the great horn of the hyoid and the lingual midline are constant anatomical markers to indicate the course of the lingual artery.

Exploration of the relationship between sleep position and isolated tongue base or multilevel surgery in obstructive sleep apnea

This study aimed to elucidate the role of sleep position as a confounding factor on apnea hypopnea index (AHI) and surgical success in isolated tongue base or multilevel surgery. This study was conducted using retrospective analysis of patients who underwent hyoid suspension because of obstructive sleep apnea (OSA), in the St. Lucas Andreas Hospital, Amsterdam, The Netherlands, from 2004 to 2011. Concurrent surgical treatment was documented. Sleep positions and corresponding AHIs before and after surgery were compared. A total of 130 patients were included. 94 patients underwent surgery of base of tongue and palate (either uvulopalatopharyngoplasty or Z-palatoplasty), of whom 72 underwent concurrent radiofrequent thermotherapy of the base of tongue. 36 patients underwent base of tongue surgery alone, of whom 22 underwent concurrent radiofrequent thermotherapy of the base of tongue. 65 patients either had a successful reduction in AHI or in AI. Isolated tongue base or multilevel surgery was as successful on the supine AHI as it was on the AHI in other sleeping positions. Surgery was not more successful in the group with position-dependent patients as compared with the non-position-dependent patients (P = 0.615). Successful and non-successful surgical results could not be explained by variations in percentages of supine sleep position. Sleep position is not a confounding factor on surgical outcomes in tongue base surgery. The results of isolated base of tongue or multilevel surgery in position-dependent OSA patients leave room for improvement, possibly through positional therapy.