Operative Techniques in Otolaryngology (2004) 15, 234-238
Cancer of the Tongue
Anthony Po-Wing Yuen, FHKAM (ORL)
From the Department of Surgery, Division of Otorhinolaryngology, The University of Hong Kong, Hong Kong,
SAR, China.
It is common practice to treat stage I-II carcinomas with
surgery alone and stage III-IV carcinomas with combined
surgery and radiotherapy. Over 90% of treatment failures
are caused by local or regional lymph node recurrences.1-3
Good results largely rely on a surgical management protocol
based on sound principles.
Carcinoma of the tongue has a high propensity for me-
tastasis to regional lymph nodes even in its early stage.
Subclinical nodal metastasis for T1 and T2 oral tongue
carcinoma was found to be 36% in a study of whole organ
serial sectioning of elective neck dissection specimens of
the clinically N0 neck.4 Although preoperative radiological
screening, including computed tomography, magnetic reso-
nance imaging, or ultrasound guided aspiration cytology, is
currently our routine protocol for evaluation, these radio-
logical screening methods are useful but not adequate for
detecting micrometastasis. Elective neck dissection has
been shown to improve survival by reducing lymph node-
related mortality5
Among all the tumor parameters and predictive models
being evaluated, tumor thickness has been shown to be the
most useful at predicting subclinical nodal metastasis, local
recurrence, and survival.6 Management of the N0 neck in
early-stage cancer of the oral tongue is based on tumor thick-
ness. Patients with tumors up to 3 mm thick have 8% subclin-
ical nodal metastasis, 0% local recurrence, and 100% 5-year
actuarial disease-free survival; elective neck dissection is not
indicated. Patients with tumors that are 4 to 9 mm thick have
44% subclinical nodal metastasis, 7% local recurrence, and
76% 5-year actuarial disease-free survival; these patients will
require close postoperative follow-up surveillance with ultra-
sound. For those patients for whom follow-up visits are not
feasible or who are unreliable for close follow-up surveillance
protocol, elective neck dissection is advisable. Patients with
tumors that are at least 10 mm thick have 53% subclinical
nodal metastasis, 24% local recurrence, and 66% 5-year actu-
arial disease-free survival. These patients will be treated as
advanced-stage carcinoma, with a high risk of both local and
regional recurrence. Postoperative radiotherapy covering both
Address reprint requests and correspondence: Anthony Po-Wing
Yuen, FHKAM (ORL), Department of Surgery, The University of Hong
Kong Medical Center, Queen Mary Hospital, 102 Pokfulam Road, Hong
Kong, SAR, China.
1043-1810/$ -see front matter © 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.otot.2004.04.002
the neck and oral cavity is advised, and elective neck dissection
is unnecessary.
Management of cancer of the oral tongue is still contro-
versial in many aspects and will change over time with
better understanding of the cancer and with advances in
technology. The current management protocol in the De-
partment of Surgery of the University of Hong Kong, Queen
Mary Hospital, is summarized below:
Stage I-II oral tongue carcinoma:
● Tumor thickness up to 3 mm: partial glossectomy alone
● Tumor thickness 4 to 9 mm: partial glossectomy ! elec-
tive ipsilateral level I-V functional neck dissection
● Tumor thickness !1 cm: partial glossectomy " postop-
erative radiotherapy of oral cavity and neck
Stage III-IV oral tongue carcinoma:
Partial glossectomy
● radical (or modified radical) neck dissection of N" neck
● ipsilateral selective level I-III neck dissection for N0 neck
if free flap is used for reconstruction
● ipsilateral modified neck dissection for N0 neck if pec-
toralis major myocutaneous flap is used for reconstruction
● postoperative radiotherapy of oral cavity and neck
Postoperative radiotherapy is also indicated in stage I-II
carcinoma after pathologic evaluation of surgical spec-
imens with the following findings:
1. positive resection margin
2. perineural spread
3. extracapsular spread of subclinical nodal metastasis
4. multiple subclinical nodal metastasis
Carcinoma of the base of the tongue:
● Stage I-II: radiotherapy
● Stage III-IV: concomitant regional or systemic chemo-
therapy " radiotherapy
Advanced inoperable carcinoma of the tongue:
● without distant metastasis: concomitant regional or sys-
temic chemotherapy " radiotherapy
● with distant metastasis: palliative symptomatic man-
agement
Yuen Cancer of the Tongue
Figure 1 Magnetic resonance imaging in the coronal plane
clearly shows the tumor on the left side of tongue (arrow).
Preoperative evaluation
Clinical examination and palpation of the tumor, flexible
endoscopy and biopsy, ultrasound screening of the neck !
guided needle aspiration for cytology are routinely per-
formed for all patients. Magnetic resonance imagine is also
useful preoperatively to screen the N0 neck and to evaluate
the 3-dimensional extent of infiltration of the primary tumor
and to document tumor thickness.7 A positron emission
tomography– computed tomography scan is advisable only
for those patients who can afford to pay the fee themselves.
Glossectomy techniques
It is important to ensure adequate surgical resection of the
tumor rather than rely on adjuvant radiotherapy for residual
cancer or subsequent surgical salvage for recurrence. His-
tologic examination of resection margins by frozen section
at operation is always recommended. Unfortunately, frozen
section often does not detect the subclinical local residual
tumor. Both accurate assessment of tumor size and adequate
resection are essential. The preoperative magnetic reso-
nance images can assist the planning of surgical resection in
3-dimensional planes (Figure 1). After the patient is anes-
thetized with nasotracheal intubation, the tumor should be
carefully palpated for the extent of induration. Intra-oral
ultrasound with a right-angle probe of at least 7.5 MHz will
help to evaluate the depth of infiltration (Figure 2). The
border of the tumor is marked by blue dye on the mucosa.
Because 95% of tumors have local spread within 1.2 cm
from the tumor border, a clear histological resection margin
can be achieved at a #95% confidence level with a 1.5- to
2-cm surgical margin of resection from the border of the
tumor.8 A surgical resection margin of 1.5 cm is recom-
mended for small ($4 cm in largest diameter) or thin
tumors ($1 cm) and should be increased to 2 cm for a large
or thick tumor. The mucosal resection margin should be
carefully measured with a ruler and outlined by harmonic
235
Figure 2 Intra-oral ultrasound image of tongue cancer. The
tumor thickness can be measured accurately and is shown to be
13.6 mm thick in this illustrated case.
scalpel (ultrasonic dissecting hook) or diathermy pen (Fig-
ure 3).
Transoral resection and primary closure is adequate for
small tumors. The mucosa is cut open with the monopolar
diathermy or harmonic scalpel. The dissection into the
tongue muscle and salivary glands in the floor of mouth is
performed with a harmonic scalpel and/or ultrasonic coag-
ulating shear scissors (Olympus ultrasonic endosurgery in-
struments, Tokyo, Japan). The harmonic scalpel and ultra-
sonic coagulating shear scissors have the advantage of
excellent hemostasis of vessel size up to 6 mm, which is
adequate for the lingual artery and vein. Partial glossectomy
with the ultrasonic dissecting instrument is bloodless and
fast. Ultrasonic dissection has minimal tissue damage and
wound healing is much better than with either diathermy or
CO2 laser. If the ultrasonic surgical instrument is not avail-
able, the monopolar diathermy pen can be used as an alter-
native. The border of the tumor should be palpated with the
finger repeatedly during dissection, and particular attention
should be given to the deep margin to ensure that the correct
resection margin is achieved (Figure 4). The lingual artery
and vein can be safely coagulated with the ultrasonic coag-
ulating dissecting forceps at the tongue base area without
the necessity of suture or ligation. When diathermy is used
for dissection, the lingual vessels are ligated with 3-0 Vicryl
suture.
With a large tumor that requires reconstruction, neck
dissection should be completed before the glossectomy. The
Figure 3 The border of the tumor has been outlined and the
resection plan of a 1.5-cm margin is also marked on the mucosa by
diathermy.
236 Operative Techniques in Otolaryngology, Vol 15, No 4, December 2004
Figure 4 The tongue is pulled out by suture to improve exposure
of dissection. The finger is used to palpate the deep border of the
tumor and guides the plane of dissection. The ultrasonic coagulat-
ing scissors is used to grasp and cut the muscles with excellent
hemostasis.
floor of mouth is cut by monopolar diathermy so that the
entire tongue can be delivered into the neck for further
resection (Figure 5).
The glossectomy specimen should be cut open with a
cruciate incision to inspect the clearance for resection. Tis-
sue from the patient’s resection margin should be sampled
for frozen section. The tumor size, including the length,
width, and thickness, should be documented. The glossec-
tomy specimen size is also measured to plan the flap size.
Reconstruction techniques
The reconstruction method depends on the extent of resec-
tion. Primary closure is adequate for partial glossectomy of
Figure 5 The whole tongue is pulled down into the neck for
resection with the ultrasonic coagulating scissors of a large tumor.
A 2-cm resection margin is outlined. ND, neck dissection speci-
men.
Figure 6 Deep matrix sutures are used to approximate the deep
surface to secure hemostasis and to obliterate the cavity starting
from back to front.
up to half of the tongue without too much tension on the
wound. Postoperative swallowing and speech functions are
usually satisfactory. A few deep sutures with 3-0 Vicryl are
used to approximate the deep raw surface to reduce the
tension on the wound and to obliterate the cavity to prevent
hematoma formation (Figure 6). The mucosa can be closed
with interrupted sutures of 3-0 Vicryl, taking at least 5 mm
of tissue from the edge to prevent cutting through the tissue
with the sutures (Figure 7).
When more than half of the tongue is removed, primary
closure will compromise the lingual function. Both mucosal
resurfacing and replacement of tongue volume with a suit-
able flap are necessary. Pectoralis major myocutaneous flap
is a simple and reliable choice for reconstruction of the
tongue. Pectoralis major myocutaneous flap, however, has
the disadvantage of too much muscle bulk for small-to-
moderate soft tissue volume deficit. There is also too much
volume deficit in the long term because of postoperative
denervation muscle atrophy. Partial necrosis of the skin
island of the pectoralis major myocutaneous flap is common
if it is based on the pectoral branch of the thoraco-acromial
artery alone. The double arterial supply is advised as routine
to include both the pectoral artery and the lateral thoracic
artery in the pectoralis major myocutaneous flap to improve
the blood supply to the skin island. Free flap is the preferred
method of reconstruction because of its advantages of more
choice of tissues to suit the defect, more reliable skin island,
and less donor site morbidity.
The free radial forearm cutaneous flap is a suitable
choice when a very thin flap is needed for resurfacing the
tongue without the necessity of soft tissue replacement.
However, moderate soft tissue volume replacement is re-
quired to improve swallowing function when the deficit
Figure 7 Primary closure with interrupted sutures after partial
glossectomy of small tumor.
Yuen Cancer of the Tongue 237

Figure 8 The anterolateral thigh flap is used for reconstruction.

A line is drawn between the anterior superior iliac crest and
supero-lateral border of patella of right thigh. A midline circle with
a 3-cm radius is drawn to show the possible sites of perforators.
The perforator is found by Doppler to be 2 cm distal to the circle
in this illustrated case. A flap size of 10 % 16 cm is outlined.

cannot be closed primarily. The free anterolateral thigh

fasciocutaneous flap is recommended for reconstruction of
the partial glossectomy defect in which moderate soft tissue
volume replacement is required. When a total or near total
glossectomy has been performed, a large amount of soft
tissue replacement is necessary; the free anterolateral thigh Figure 10 The skin island is sutured to the wound edge starting
vastus lateralis myocutaneous flap is recommended. The from the base of the tongue. The skin island is adjusted continu-
rectus abdominus myocutaneous flap based on the deep ously during insetting of the flap to fit the surface area required.
inferior epigastric artery is an alternative choice for recon-
struction.
The technique of free anterolateral thigh vastus lateralis cle and the overlying skin island. The donor vessels are
myocutaneous flap is further elaborated in a real patient who identified in the avascular plane between the vastus lateralis
has had a total glossectomy (Figure 5). The cutaneous per- muscle and rectus femoris muscle. The motor nerve supply
forators are identified with a Doppler along the line joining to the vastus lateralis muscle is adjacent to the supplying
the anterior superior iliac spine and superolateral edge of vessels and is also harvested. The vastus lateralis muscle is
patella (Figure 8). Most of the perforators are within a circle cut with diathermy after identification of all sensory and
with a 3 cm radius at the midline. Both thighs are examined motor nerves and donor vessels (Figure 9). The anterolateral
by Doppler; the side with better perforator location, larger thigh myocutaneous flap with the sensory and motor nerves
size perforator, and multiple perforators is chosen. In this is delivered to the neck for reconstruction.
illustrated case, the perforator is 2 cm distal to the midline
circle of the right thigh. For total glossectomy, a 10 cm
(width) % 13 cm (length) flap is usually adequate. In case
two teams are planned to reduce operative time, the flap can
be harvested before the completion of resection. In this
situation, the flap should be designed slightly larger to allow
for subsequent further resection of tissue. Excess skin can
be de-epithelialized and dermal tissue can be preserved for
soft tissue replacement. The sensory supply of the skin
island is also harvested as sensate flap reconstruction. The
anterior branch of the lateral cutaneous nerve of the thigh is
identified and harvested in the subcutaneous layer proximal
to the skin island. The descending branch of the lateral
circumflex femoral artery supplies the vastus lateralis mus-

Figure 11 The vastus lateralis muscle is attached to the mandi-

Figure 9 The free vastus lateralis myocutaneous flap is har-
vested with the vessels (a, artery; v, vein) and sensory and motor
nerves.
ble and hyoid bone by 3-0 nylon sutures. The donor artery is joined
to the left facial artery. The donor vein is joined to the vein along
the left hypoglossal nerve. The motor nerve of vastus lateralis
muscle is joined to the left hypoglossal nerve stump. The lateral
cutaneous nerve of thigh is joined to the left lingual nerve.
238 Operative Techniques in Otolaryngology, Vol 15, No 4, December 2004
Five holes are drilled in the mandible for later attachment
of the vastus lateralis muscle. The skin island is then sutured
to the glossectomy wound edge by 3-0 Vicryl (Figure 10).
The size and shape of the skin island required are adjusted
continuously during the inset of flap, and the excess skin
island is de-epithelialized to fit the surface area required.
After complete closure of the skin island, the vastus lateralis
muscle is attached to the mandible and hyoid bone by using
3-0 nylon sutures (Figure 11). The donor vessels are anas-
tomosed to the suitable recipient vessels in the neck under
the microscope with 9(0) nylon sutures. The motor nerve is
joined to the hypoglossal nerve stump, and the lateral cuta-
neous nerve of the thigh is joined to the lingual nerve stump
(Figure 11). The flap should have adequate soft tissue vol-
ume replacement to bulge into the palate in the oral cavity
when the mouth is closed to ensure adequate bulk for
swallowing (Figure 12).
Postoperative management
A temporary tracheostomy is necessary only for patients
with flap reconstruction. Oral feeding is started the next day
for patients with primary closure. Nasogastric tube feeding
for 1 week is necessary for the patient who requires flap
reconstruction. A speech therapist is helpful in training the
patient to take an oral diet.
After reviewing the surgical specimens by the patholo-
gist, postoperative radiotherapy will be given to those pa-
tients who are pathologic stage III-IV, have tumor thickness
of 1 cm or more, show perineural spread, or have positive
resection margin. Those pT1-2 patients who had elective
functional neck dissection for N0 neck and pathologic sin-
gle-node metastasis without extracapsular spread can be
observed without adjuvant radiotherapy, provided there is
no other indication for radiotherapy.
Patients who develop recurrences do so within 3 years of
operation. Patients are scheduled for follow-up monthly in
the first year, every 2 months in the second year, and every
3 months in the third year. For those N0 neck patients
without elective neck dissection, ultrasound screening of the
neck is performed every 3 months for 3 years.
Conclusions
Management of cancer of the tongue can be improved with
better understanding of the behavior of the cancer and the
Figure 12 The flap is bulging upwards to touch the palate on
closure of the mouth, indicating adequate soft tissue reconstruction
of tongue.
problems in our treatment strategy. With good management
protocol, functional outcome and long-term survival will be
improved.
References
1. Yuen APW, Wei WI, Wong YM, et al: Comprehensive analysis of
results of surgical treatment of oral tongue carcinoma in Hong Kong.
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locoregional recurrence of carcinoma of tongue after radiotherapy fail-
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3. Yuen APW, Wei WI, Wong SHW, et al: Local recurrence of carcinoma
of tongue: patient prognosis. Ear Nose Throat J 77:181-184, 1998
4. Yuen APW, Lam KY, Chan CLA, et al: Clinicopathological analysis of
elective neck dissection for N0 neck of early oral tongue carcinoma.
Am J Surg 177:90-92, 1999
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