Embryology, Anatomy including muscles, arterial supply ,venous and lymphatic drainage; Histology, Carcinoma tongue, Developmental anomalies, Surgical aspect, Tongue Flaps, Clinical considerations have been discussed

1. TONGUE
PRESENTED BY:
Dr MINERVA SINGH
PG 1st YEAR (2018)
MODERATOR: Dr ALOK BHATNAGAR
DEPT. OF ORAL & MAXILLOFACIAL SURGERY
SURGERY
15/06/2018

2. INTRODUCTION
Muscular organ situated in the floor of the mouth
Anchored to Hyoid bone, Mandible, Styloid process & Soft
Palate
Comprises of skeletal muscle (voluntary)
Separated into two halves by median fibrous septum
FUNCTIONS:
• Taste
• Speech
• Mastication
• Deglutition

3. Tip
EXTERNAL FEATURES

4. PAPILLAE

5. Ventrum

6. EMBRYOLOGY
• EPITHELIUM
a. Anterior two-third: FIRST BRANCHIAL ARCH
b. Posterior one third: THIRD BRANCHIAL ARCH
c. Posterior most part: FOURTH BRANCHIAL ARCH

7. 2ND arch is buried by the overgrowth of 3RD arch

8. •Musclesdevelop from occipital myotomes
•Connective tissue develops from the local mesenchyme

9. MUSCLES
EXTRINSIC MUSCLES
1. Genioglossus
2. Hyoglossus
3. Styloglossus
4. Palatoglossus
INTRINSIC MUSCLES
1. Superior longitudinal
2. Inferior longitudinal
3. Transverse
4. Vertical

10. EXTRINSIC MUSCLES

11. MUSCLE ORIGIN INSERTION ACTION
PALATOGLOSSUS Oral surface of palatine
aponeurosis
Descends in the
palatoglossal arch to the
side of the tongue at the
junction of oral &
pharyngeal parts
Pulls up the root of tongue,
approximates the
palatoglossal arches and
thus closes the
oropharyngeal isthmus
HYOGLOSSUS Whole length of greater
cornua and lateral part of
hyoid bone
Side of tongue between
styloglossus and inferior
longitudinal muscle of
tongue
Depresses tongue, makes
dorsum convex, retracts the
protruded tongue
STYLOGLOSSUS Tip and part of anterior
surface of styloid process
Into the side of tongue Pulls tongue upwards and
backwards
GENIOGLOSSUS
(life saving muscle)
Upper genial tubercle of
mandible
Upper fibers into the tip of
tongue
Middle fibers into the
dorsum
Lower fibers into the hyoid
bone
Retracts the tongue
Depresses the tongue
Pulls the posterior part of
tongue forwards and
protrude the tongue
forwards

12. INTRINSIC MUSCLES
CORONAL SECTION SAGGITAL SECTION

13. MUSCLE ORIGIN ACTION
SUPERIOR LONGITUDINAL MUSCLE • Thin layer of muscle inferior to
dorsal mucosa
• Fibers run anterolateral from
epiglottis and median lingual
septum
• Shortens tongue
• Makes dorsum concave
INFERIOR LONGITUDINAL MUSCLE • Thin layer of muscle superior to
genioglossus and hyoglossus
• Fibers anteriorly from root to the
apex of the tongue
• Shortens tongue
• Makes dorsum convex
TRANSVERSE MUSCLE Fibers run laterally from lingual
septum to lateral part of tongue
• Narrows tongue
• Elongates tongue
VERTICAL MUSCLE In the anterior tongue fibers run
inferiorly from dorsum of tongue to
ventral surface
• Shortens tongue
• Makes dorsum convex
(pulls apex down)

14. ARTERIAL SUPPLY

15. The root of tongue is also supplied by the
TONSILLAR BRANCH of FACIAL ARTERY and
ASCENDING PHARYNGEAL BRANCH of
EXTERNAL CAROTID ARTERY.

16. VENOUS DRAINAGE

17. NERVE SUPPLY

18. LYMPHATIC DRAINAGE
/Jugulodigastric
nodes
/
Jugulo-omohyoid nodes

19. HISTOLOGY

21. SALIVARY GLANDS OF TONGUE
GLANDS OF BLANDIN & NUHN
GLANDS OF VON EBNER
GLANDS OF WEBER

22. • GLANDS OF BLANDIN-NUHN
 Seromucus glands found on the under surface of the apex tongue,
covered by a bundle of muscular fibers derived from Styloglossus
and Inferior Longitudinal muscles.
 12-25 mm in length, 8m in width
 Each opens by 3-4 ducts on undersurface of tip of tongue
• GLANDS OF VON EBNER
Serous glands found in moats of circumvallate & foliate
papillae
Secrete lingual lipase, the secretion flushes the moats to
enable the taste buds to respond rapidly to changing stimuli

23. • GLANDS OF WEBER
 Lie along the lateral border of tongue
 Purely mucous
 Open into the crypts of lingual tonsils on the
posterior dorsum of tongue
 Abscess formed due to accumulation of pus and fluid
in this gland is known as PERITONSILLAR ABSCESS

24. DEVELOPMENTAL ANOMALIES
ANKYLOGLOSSIA
FISSURED TONGUE
MACROGLOSSIA
MICROGLOSSIA / HYPOGLOSSIA
CLEFT / BIFID TONGUE
MEDIAN RHOMBOID GLOSSITIS
LINGUAL THYROID

25.  ANKYLOGLOSSIA / TONGUE TIE
 Caused by an unusually short, thick lingual frenulum, a membrane connecting the
underside of the tongue to the floor of the mouth.
 Varies in degree of severity from mild cases characterized by mucous
membrane bands to complete ankyloglossia whereby the tongue is tethered to the
floor of the mouth.
 MILD FORM – Does not influence development, tooth position or phonation
 MODERATE FORM – Exhibits midline mandibular diastema
 SEVERE FORM – Complete attachment of tongue to the floor of the mouth or
alveolar gingiva
MILD MODERATE SEVERE

26.  FISSURED TONGUE
 Also known as lingua plicata or plicated or scrotal or furrowed tongue
 benign condition characterized by deep grooves (fissures) on the dorsum
of the tongue.
 The condition is usually painless. Some individuals may complain of an associated burning
sensation
 The clinical appearance is considerably varied in both the orientation, number, depth and
length of the fissure pattern. There are usually multiple grooves/furrows 2–6 mm in depth
present
 Fissured tongue is seen in Melkersson-Rosenthal syndrome, Down syndrome, psoriasis,
and Cowden's syndrome.

27.  MACROGLOSSIA
 Macroglossia is the medical term for an unusually large tongue.
 Severe enlargement of the tongue can cause cosmetic and functional
difficulties in speaking, eating, swallowing and sleeping.
 Most common causes are
vascular malformations (e.g. lymphangioma or hemangioma) and
muscular hypertrophy (e.g. Beckwith–Wiedemann
syndrome or hemihyperplasia) and Down syndrome.

28.  MICROGLOSSIA
 Microglossia is another rare congenital anomaly in which only a tiny or rudimentary tongue
is present
 Although microglassia may develop as isolated cases but in most of the cases they occur in
association with other anomalies like oromandibular limb hypogenesis syndrome or
hypoglossia- hypodactylia syndrome etc.
 For obvious reasons patients with microglossia often have severe speech difficulties as well
as difficulty in taking food.
 As size of the tongue often determines the growth and size of the mandibular arch in case of
microglossia the length of the mandibular arch will be smaller due to the smaller size of
tongue
 Aglossia is an extremely rare congenital defect characterized complete absence of the
tongue.

29.  CLEFT / BIFID TONGUE
 Children with bifid tongue have a split running along the length of their tongue.
 Cleft occurs because the body fails to completely develop in order to join the two
sides of the tongue together.
 The cause is usually unknown but sometimes exposure to certain viruses or drugs
during pregnancy may cause cleft tongue.
 The biggest problem with cleft tongue is difficulty eating

30.  MEDIAN RHOMBOID GLOSSITIS
 Depapillated ovoid or rhomboid, slightly raised area anterior to circumvallate
papillae
 Occurs due to failure of tuberculum impar to retract
 Related to chronic fungal infections

31.  LINGUAL THYROID
 Lingual thyroid originates from failure of the thyroid gland to descend from the
foramen caecum (tongue) to its normal pre-laryngeal site.
 The ectopic gland located at the base of the tongue is often asymptomatic but may
cause local symptoms such as dysphagia, dysphonia with stomatolalia, upper
airway obstruction and hemorrhage, often with hypothyroidism.
 Treatment could be conservative with substitutive hormone treatment in patients
with mild symptoms, while surgery is recommended in cases with airway
obstruction.

32. CARCINOMA OF TONGUE
In India, oral cancers represent 40% of all the cancers
and carcinoma tongue represents 22% of all the oral
cancers.

33. More common in men of middle age
Lateral border is commonly involved
Metastasis to neck nodes is common
>40% cases show metastasis, >20% cases show bilateral metastasis
Overall survival rates range from 50%-65%
ETIOLOGY
 Tobacco
 Alcohol
 Tobacco and alcohol synergism
 Chewing betel, pan and areca
 Syphilitic glossitis
 Constant chronic trauma due to dental cause – sharp teeth,
ill fitting dentures, sharp crown & bridges etc.
 Poor oral hygiene
 HPV

35. CLINICAL FEATURES
The tumor may begin as a superficially indurated, non-healing
ulcer with slightly raised borders and may proceed either to
develop a fungating, exophytic mass or to infiltrate the deep
layers of the tongue, producing fixation and induration without
much surface change.
Dysphagia, Odynophagia, Mass/Node in neck, Referred pain to
ear, Hemoptysis

36. SPREAD
Local infiltration – tongue musculature, epiglottis, pre-epiglottic
space, tonsils, faucial pillars, hypopharynx
Lymphatic spread – To ipsilateral sub mental, submandibular,
jugulodigastric and middle deep cervical group
• Lesions near to midline and posterior tongue metastasize to deep
cervical (jugulo-omohyoid/jugulodigastric) lymph nodes bilaterally
• Once in deep jugular chain, tumor spreads in downward direction
towards mediastinal nodes.
Haematogenous spread – To Lungs, Liver and Bones
(Base of skull or the spine), Brain

38. TREATMENT MODALITIES
SURGERY, RADIOTHERAPY, CHEMOTHERAPY – as a single
modality or combination
SURGERY
Limited role due to inherent morbidity of a near total or total
gossectomy
Partial glossectomy is performed for lateralized tumors with
minimal cervical lymphadenopathy
Bilateral cervical lymph node dissection is always done when
tumor is deeper than 3mm due to high propensity for occult
microscopic nodal involvement

40. 1. PARTIAL GLOSSECTOMY
It is indicated when the lesion is <2cm and confined to the
lateral border
The wide excision should include at least 2cm of tissue
surrounding the tumor
Flap reconstruction not required, wound heals either by
primary or secondary intension

41. 2. HEMIGLOSSECTOMY
Refers to removal of around 50% of tongue, indicated in radio-
residual tumor, radio-recurrent tumor or when radio facilities are
not available
Reconstruction can be done using PMMC flap, free radial
fasciocutaneous flap, anterolateral thigh flap etc. can be done
Reconstruction by ALT flap

42. 3. TOTAL GLOSSECTOMY
Removal of very extensive growths involving the entire tongue
Lesion is initially given radiotherapy to reduce the size and then
removed surgically
Carries significant mortality and morbidity
Results in severe dysfunction with swallowing and resultant
aspiration (food and liquids falling into the lungs). A total
glossectomy is performed along with a total laryngectomy in
order to prevent aspiration and pneumonia.
A total glossectomy will require a major reconstructive surgery.

43. 4. COMMANDO’s OPERATION
 (COMbined MAndibulectomy and Neck Dissection Operation)
 Indicated when Ca tongue is fixed to mandible with infiltration of the
floor of the mouth
 Hemiglossectomy with hemimandibulectomy, removal of floor of the
mouth and radical neck dissection

44. TONGUE FLAPS
 Excellent donor site because of its abundant vascularity and low morbidity
 Eiselsberg was first to use pedicle flaps in 1901
 Cadenet described rich sub mucous vascular plexus found in tongue, allowing elevation
of flaps as thin as 3mm
 Tongue flaps are loco regional
 BLOOD SUPPLY – LINGUAL ARTERY
 ADVANTAGES –
• excellent blood supply
• low morbidity
• can be used in irradiated patients
 Tongue flaps are used to cover defects in cheek, floor of the mouth, palate, alveolus,
oroantral fistulas and vermillion & lip construction

45. CLASSIFICATION
 Flaps from dorsum of tongue – Posteriorly based
Anteriorly based
Transverse based
 Flaps from lingual tip – Perimeter flap (unpedicled or
pedicled)
Dorsoventrally disposed flap
 Flaps from ventral surface of tongue
 Flaps from lateral surface of tongue

46.  POSTERIORLY BASED DORSAL TONGUE FLAP
-- Also known as SLIDING POSTERIOR TONGUE FLAP
--Myomucosal flap is created by releasing the tongue from the hyoid bone and
maintaining dorsolingual branch of lingual artery
--To allow complete mobilization the entire ipsilateral base is freed from vertical
septum
INDICATIONS
• Repair of oronasal fistula
• Repair of oroantral fistula
• Lip reconstructions
• Buccal mucosa reconstructions
• Reconstruction of hypo pharynx

47.  ANTERIORLY BASED DORSAL TONGUE FLAP
-- To repair defects in the anterior cheek, lip, anterior floor of the mouth, palate,

48.  TRANSVERSE BASED DORSAL TONGUE FLAP
-- To repair anterior floor of the mouth and lower lip
 PERIMETER FLAP
-- Unpedicled or bipedicled
-- For repair of vermillion border of either lip
-- Upper and lower lip reconstruction
 DORSOVENTRALLY DISPOSED FLAP
--Flap reflected ventrally on an anterior base: used for
lining in lower lip reconstruction
--Flap reflected dorsally on a posterior base: used for
lining in upper lip reconstruction

49.  FLAPS FROM VENTRAL SURFACE OF TONGUE
-- Cover defect on anterior floor of mouth
 LATERAL TONGUE FLAT
--Cover defect on buccal mucosa, lateral palate,
alveolus, lip
--Incisions are made on ventral and dorsal surface
of tongue in a ‘v’ shaped pattern, this allows primary
closure of wound
--Pedicel is severed on 14th day

50. • Palatal defects following congenital anomalies, traumatic
injuries, benign and malignant pathologies frequently require
reconstruction.
• Reconstruction of these defects is challenging and complex
due to the amount of tissue left for primary closure after
excision, compromised vasculature as on repaired cleft palate
and limited pedicled flaps around the lesion.
• Tongue flap though doesn’t fulfil all the ideal requirements of a
flap, however because of its flexibility, good blood supply and
position it can be considered as the best among other flaps for
reconstruction of oral and palatal defects.
REPAIRING PALATAL FISTULA USING TONGUE
FLAP
REF: Versatility of Tongue Flaps for Closure of Palatal Defects- Case
Report
http://www.jcdr.net
Journal of clinical and diagnostic research

51. REPAIRING PALATAL DEFECT
USING TONGUE FLAP

52. REPAIRING PALATAL FISTULA USING TONGUE FLAP

53. CLINICAL CONSIDERATIONS
1. INJURY TO HYPOGLOSSAL NERVE
 Paralysis, atrophy of the affected side of tongue
 Tongue deviates to paralyzed side during protrusion due to action of
unaffected genioglossus
 Causes-
- Trauma like fractured mandible
- Infranuclear lesion – gradual atrophy & muscular twitching
- Supranuclear lesion – paralysis without palsy (tongue is stiff, small
and moves sluggishly)

54. 2. PARALYSIS OF GENIOGLOSSUS MUSCLE
 Tongue tends to fall backward, obstructing airway and presenting the risk of
asphyxiation
 Causes –
- unconscious patients as under GA
- Patients with grand mal epilepsy
- parasymphyseal mandibular fracture

55. 3. GLOSSITIS
 Glossitis is usually a part of generalized ulceration of oral
cavity or stomatitis
 In certain anemia, like pernicious and iron deficiency anemia,
the tongue becomes smooth due to atrophy of filiform
 The presence of a rich network of lymphatics & loose
connective tissue is responsible for enormous swelling in
acute glossitis

56. 4. The undersurface of tongue is a good site for
observation of jaundice
5. Referred pain is felt in the ear in diseases of
posterior part of tongue as 9th nerve is common
supply to both the regions
6. Injury to any part of taste pathway – abnormality in
taste appreciation

57. REFERENCES
 BD Chaurasia’s Human Anatomy, Regional and Applied Dissection and Clinical –
Fifth Edition, Volume 3, HEAD & NECK, BRAIN
 Inderbir Singh, GP Pal; Human Embryology – Eighth Edition
 Neelima Anil Malik, Textbook of Oral and Maxillofacial Surgery – Third edition
 Shafer’s Textbook of Oral pathology – Seventh edition
 Manipal Manual of Surgery – Third edition
 Lingual thyroid causing dysphagia and dyspnea. Case reports and review of the
literature - A Toso, F Colombani,1 G Averono, P Aluffi, and F Pia
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2816370/
 http://www.aboutcancer.com/base_tongue.htm
 https://headandneckcancerguide.org/adults/cancer-diagnosis-treatments/surgery-
and-rehabilitation/cancer-removal-surgeries/glossectomy/