Tongue Anatomy & Tongue Carinoma

1. Tongue
By :
Mahmoud Fathy
Mahmoud Mo'ness
Supervised by :
Prof. Dr. Mohammed Hegazy

2. Embryology:
Anterior 2/3 --> from first pharyngeal arch
Posterior 1/3 --> from third pharyngeal arch
Muscle of tongue --> from occipital myotomes

3. 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.

4. 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

5. 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

6. 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.

7. Blood supply:-
Arterial supply :
lingual artery which is a branch of ext. carotid
Venous drainage : Lingual vein (internal jugular vein)

8. 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

9. 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

10. CANCER TONGUE

11. Etiology:
Predisposing factors:
Chronic irritation:
Sepsis
Spirits
Syphlis
Smoking
Spices
Sharp edge of a tooth.

12. Precancerous lesions:
1. Leukoplakia
2. Dental ulcer
3. Chronic superficial glossitis
4. Benign tumor e.g. Papilloma.
5. Plummer Vinson syndrome

13. 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%

14. 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

15. 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

16. 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.

17. 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.

18. 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

19. (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.

21. 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

23. Operable
(A) of the primary lesion
1) Surgery
2) Irradiation
Inoperable
(B) of Lymph nodes

24. 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)

25. 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.

26. 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

27. 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 rib
Clavicle with sternomastoid muscle
-Free microvascular flap:
Free radial flap
Free fibular flap
Free iliac crest flap

28. 2. Carcinoma of the posterior 1/3:
Total glossectomy--> through median mandibulotomy.

29. 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

30. 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.

31. 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.

32. 3} Combined radiotherapy & surgery:
For large tumors (preoperative irradiation then surgery)

33. (B) of lymph nodes:
1 ‫ـ‬No palpable glands
If tumor < 2 cm: Irradiation
if tumor > 2 cm: Total block dissection --> as occult nodal involvement
occurs in 50%
2 ‫ـ‬Palpable L.N:
Total block dissection

34. (II) Inoperable cases:
criteria
a) General:
Unfit patient, presence of distant metastases.
b) local:
Unresectable tumor due to infiltration of vital structures.

35. 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:

36. 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

37. All data are from Mansoura faculty of medicine General surgery book