Phẫu Thuật Tai Mũi Họng Và Phẫu Thuật Đầu Cổ

Chapter 26
Surgery of the Soft Palate
201
Figure 26-3. This temporary prosthesis demonstrates the clasps
used for fi xation in a patient with stable dentition. The posterior
extension serves to replace tissue that was surgically removed. When
the patient has healed and wound contracture is deemed complete,
a fi nal prosthesis is fabricated.
Figure 26-4. This squamous cell carcinoma of the soft palate has
extended anteriorly almost to the junction with the hard palate. A
temporary prosthesis may be required.
Figure 26-5. The Dingman mouth retractor affords good exposure
of the soft palate.
Figure 26-6. In resecting tumors involving the soft palate, the
surgeon must take care to achieve margins in both the oropharynx
and the nasopharynx.
mined by direct inspection, palpation, and correlation
with imaging studies. Resection is undertaken either
with a knife or with an electrocautery unit (Fig. 26-6).
Control of margins is ensured by frozen section, and
the ensuing defect is closed primarily by approximating
the mucosa on the nasal side of the defect to the mucosa
on the oral side (Fig. 26-7). Minor salivary gland tumors
may occasionally be excised with preservation of enough
mucosa to allow primary closure. The high frequency
of malignant disease encountered in these tumors dic-
tates that the lesion be removed with an adequate cuff
of normal tissue. Careful evaluation plus an understand-
ing of the three-dimensional structure of the tumor is
required to ensure complete excision.
A variety of techniques are available for tissue
reconstruction of major soft palate defects. A simple
approach to limited defects is to use the uvula.20 Larger
defects have been reconstructed with pedicled fl aps
such as the temporalis muscle.21 Free tissue transfer,
such as the radial forearm fl ap, has also been
described.22,23
POSTOPERATIVE MANAGEMENT
Pain and swelling may limit oral alimentation. Because
velopharyngeal closure is a dynamic process, prosthetic
rehabilitation takes advantage of residual mobile struc-
tures. The prosthesis is an extension of a maxillary
splint. It is confi gured to allow nasal breathing at rest.
During swallowing, the superior constrictor muscle

202
Section 2
Oral Cavity/Oropharynx
(Passavant’s ridge) makes contact with the prosthesis,
thereby establishing velopharyngeal closure. We insert
this appliance at the time of surgical resection. A lag
screw is placed through a hole provided in the prosthe-
sis to fi x it to the hard palate. This eliminates the need
for a nasogastric tube and allows immediate oral ali-
mentation. The prosthesis may be removed in 1 week
so that areas that heal by secondary intention can be
kept clean.
Postoperative radiation therapy should be consid-
ered in almost all patients with squamous cell carci-
noma of the soft palate. The primary sites of nodal
metastasis are the retropharyngeal nodes and skull
base, which do not lend themselves to elective neck
dissection. Inability to control disease in these sites is
the primary cause of failure.
Figure 26-7. At the completion of the procedure, the nasopharyn-
geal mucosa should be sutured to the oropharyngeal mucosa if pos-
sible. If oral-nasal separation is a problem, a prosthesis (see Fig. 26-2)
can be inserted.
References
1. Kissin B, Kaley MM, Su WH, Lerner R: Head and neck cancer in
alcoholics. The relationship to drinking, smoking, and dietary
patterns. JAMA 224:1174-1175, 1973.
2. Rothman K, Keller A: The effect of joint exposure to alcohol and
tobacco on risk of cancer of the mouth and pharynx. J Chronic
Dis 25:711-716, 1972.
3. Schottenfeld D: Alcohol as a co-factor in the etiology of cancer.
Cancer 43:1962-1966, 1979.
4. Slaughter DP, Southwick HW, Smejkal W: Field cancerization in
oral stratifi ed squamous epithelium. Clinical implications of mul-
ticentric origin. Cancer 6:963-968, 1953.
5. Gluckman JL: Synchronous multiple primary lesions of the upper
aerodigestive system. Arch Otolaryngol 105:597-598, 1979.
6. Leipzig B, Zellmer JE, Klug D, the Panendoscopy Study Group:
The role of endoscopy in evaluating patients with head and neck
cancer: A multi-institutional prospective study. Arch Otolaryngol
Head Neck Surg 111:589-594, 1985.
7. Eneroth CM: Salivary gland tumors in the parotid gland, subman-
dibular gland, and the palate region. Cancer 27:1415-1418,
1971.
8. Chaudry AP, Labay GR, Yamane GM, et al: Clinicopathologic and
histogenetic study of 189 intraoral minor salivary tumors. J Oral
Med 39:58-78, 1984.
9. Spiro RH: Salivary neoplasms: Overview of a 35-year experience
with 2,807 patients. Head Neck Surg 8:177-184, 1986.
10. Fee W Jr, Schoeppel SL, Rubenstein R, et al: Squamous cell car-
cinoma of the soft palate. Arch Otolaryngol 105:710-718, 1979.
11. Evans JF, Shah JP: Epidermoid carcinoma of the palate. Am J Surg
142:451-455, 1981.
12. Konrad HR, Canalis RF, Calcaterra TC: Epidermoid carcinoma
of the palate. Arch Otolaryngol 104:208-212, 1978.
13. Mantravadi RVP, Liebner EJ, Ginde JV: An analysis of factors in
the successful management of cancer of tonsillar region. Cancer
41:1054-1058, 1978.
14. Weller SA, Goffi net DR, Goode RL, Bagshaw MA: Carcinoma of
the oropharynx: Results of megavoltage radiation therapy in 305
patients. AJR Am J Roentgenol 126:236-247, 1976.
15. Thawley SE, Simpson JR, Marks JE, et al: Preoperative irradiation
and surgery for carcinoma of the base of the tongue. Ann Otol
Rhinol Laryngol 92:485-490, 1983.
16. Jesse RH, Lindberg RD: The effi cacy of combining radiation
therapy with a surgical procedure in patients with cervical metas-
tasis from squamous cancer of the oropharynx and hypopharynx.
Cancer 35:1163-1166, 1975.
17. Erkal HS, Serin M, Amdur RJ, et al: Squamous cell carcinomas of
the soft palate treated with radiation therapy alone or followed
by planned neck dissection. Int J Radiat Oncol Biol Phys 50:359-
366, 2001.
PEARLS
• Cervical metastasis from soft palate lesions may
include the retropharyngeal nodes.
• Adenoid cystic carcinoma is the most commonly
encountered minor salivary gland tumor.
• A prosthodontist may facilitate rehabilitation by
fabricating a speech prosthesis.
• Prosthetic management of a patient with an
edentulous maxilla is often a challenge. Maxillary
implants may need to be considered in an
edentulous patient.
PITFALLS
• Major soft palate defects result in velopharyngeal
insuffi ciency.
• Middle ear effusion commonly occurs if the levator
and tensor veli palatine are affected.
• Edentulous patients retain a speech prosthesis
poorly.
• Failure to secure hemostasis along the cut edge of
the palate may result in postoperative hemorrhage.
• Recurrent disease may commonly be due to
“geographic miss” of the combined efforts of the
surgeon and radiation therapist. Accordingly, it is
critical to discuss the important of at-risk areas of
the skull base and retropharyngeal soft tissue.

Chapter 26
Surgery of the Soft Palate
203
18. Har-El G, Shaha A, Chaudry R, et al: Carcinoma of the uvula and
midline soft palate: Indication for neck treatment. Head Neck
14:99-101, 1992.
19. Douglas WB, Rigual NR, Giese W, et al: Advanced soft palate
cancer: The clinical importance of the parapharyngeal space.
Otolaryngol Head Neck Surg 133:66-69, 2005.
20. Gillespie MB, Eisele DW: The uvulopalatal fl ap for reconstruction
of the soft palate. Laryngoscope 110:612-615, 2000.
21. Wong TY, Chung CH, Huang JS, Chen HA: The inverted tempo-
ralis muscle fl ap for intraoral reconstruction: Its rationale and
the results of its application. J Oral Maxillofac Surg 62:667-675,
2004.
22. McCombe D, Lyons B, Winkler R, Morrison W: Speech and swal-
lowing following radial forearm fl ap reconstruction of major soft
palate defects. Br J Plast Surg 58:306-311, 2005.
23. Sinha UK, Young P, Hurvitz K, Crockett DM: Functional out-
comes following palatal reconstruction with a folded radial
forearm free fl ap. Ear Nose Throat J 83:45-48, 2004.

Chapter 27
Inferior Maxillectomy
Eugene N. Myers
The hard palate is the site of origin of both benign and
malignant tumors.1,2 The most common tumor of minor
salivary gland origin in this site is pleomorphic adenoma,
a benign tumor that usually appears as a smooth sub-
mucosal mass. Approximately 5% of cancers of the oral
cavity involve the hard palate and maxillary alveolus.3
Squamous cell carcinoma accounts for approximately
two thirds of the malignancies of the hard palate and
the upper alveolar ridge (Fig. 27-1).4 Cancers arising
in the minor salivary glands are the most prevalent
non–squamous cell malignancies of the hard palate.
Adenoid cystic carcinoma is the most common of the
malignant salivary gland tumors, followed by mucoepi-
dermoid carcinoma, malignant mixed tumor, acinic
cell carcinoma, and other adenocarcinomas (Fig. 27-
2).4 Lymphoma and plasmacytoma are also found on
the hard palate (Fig. 27-3). Polymorphic reticulosis
(formerly called lethal midline granuloma) commonly
involves the hard palate and upper alveolus. There
is evidence to suggest that this process represents
a polyclonal T-cell lymphoma and should be treated
with combined chemotherapy and radiotherapy.4 Malig-
nant melanoma may also occur in the mucosa of the
hard palate (Fig. 27-4). Sarcomas of bone and soft tissue
have likewise been reported in the hard palate and
upper alveolus. These tumors are more common in
children.4
The evidence of a direct cause-and-effect relation-
ship between tobacco, alcohol, and cancer of the hard
palate is not as clear-cut from an epidemiologic point
of view as it is with cancer in other sites of the upper
aerodigestive tract. A striking exception, however, is the
high incidence of cancer of the hard palate in certain
parts of India and the Philippines, where the custom of
reverse smoking is practiced.5,6 Poor oral hygiene,
mechanical irritation, ill-fi tting dentures, syphilis, and
even mouthwash have been suggested as other possible
causative relationships.7-9
SURGICAL ANATOMY
The hard palate and alveolar ridge are the subsites that
form the superior boundary of the oral cavity; they are
lined by stratifi ed squamous epithelium, which also
contains numerous minor salivary glands. The hard
palate separates the oral cavity from the nasal cavity and
maxillary sinuses and therefore provides oral-nasal
separation. The maxillary sinus and nasal cavity are
air-containing spaces directly superior to the hard
palate.10
PATIENT SELECTION
A detailed history should be recorded with special con-
sideration given to the type and duration of symptoms,
including the rate of growth, loose dentition, ill-fi tting
dentures, pain, and numbness of the palate and face.
The neck should be examined for the presence of a
mass because in many patients metastasis to the neck
will have already occurred. A diagram should be made
and the area of the tumor mapped, including areas of
swelling suggestive of subepithelial spread of tumor.
Any loose dentition should be examined closely for the
possibility of malignant involvement of the dental
sockets and bone. Neurologic examination for numb-
ness of the palate may indicate malignant involvement
of the foramina and base of the skull. Detailed inspec-
tion of the fl oor of the nasal cavity with a nasal endo-
scope should be performed to determine the presence
of intranasal extension. Evaluation of the remainder of
the upper aerodigestive tract is performed to exclude
the possibility of a second primary cancer because
205

206
Section 2
Oral Cavity/Oropharynx
second primaries may occur in 20% to 25% of patients
with squamous cell carcinoma of the oral cavity and
oropharynx.11
Evaluation of a patient with a tumor of the hard
palate and alveolar ridge is not complete without
imaging studies. Computed tomography (CT) is the
most frequently used imaging method and is usually the
only one necessary to identify areas of bone invasion
because of its high degree of accuracy (Fig. 27-5). CT
will also be able to detect the size and extent of infi ltra-
tion, the possibility of involvement of the nasal cavity
and maxillary sinuses, and the presence of metastases
to the lymph nodes. CT is also very helpful in diagnos-
ing distant metastases, which occur most commonly in
Figure 27-1. Squamous cell carcinoma is the most commonly
encountered cancer of the hard palate.
Figure 27-2. Low-grade polymorphous adenocarcinoma.
Figure 27-3. This mass on the hard palate proved to be B-cell
lymphoma.
Figure 27-4. Malignant melanoma arising in the hard palate.
Figure 27-5. Computed tomography scan demonstrating marked
destruction of bone of the maxilla.

Chapter 27
Inferior Maxillectomy
207
the lung. Priority should be given to evaluation and
management of metastases before major surgery on the
primary cancer.
Positron emission tomography (PET)/CT scanning
is useful in pretreatment planning. This technique is
not valuable in evaluation of the primary cancer, but it
may be very helpful in evaluating the neck for meta-
static lymph nodes because they may be involved in up
to 50% of patients with squamous cell carcinoma of the
hard palate.10 PET/CT scanning is also valuable in eval-
uating the presence of distant metastasis.
A defi nitive biopsy is necessary to plan surgical
management. Many of these lesions will have already
undergone biopsy by oral maxillofacial surgeons before
referral. Squamous cell carcinoma of the hard palate
and alveolar ridge is usually ulcerative and exophytic,
and transoral biopsy with cup forceps under local anes-
thesia is generally satisfactory for accurate diagnosis.
Lesions such as pseudoepitheliomatous hyperplasia and
necrotizing sialometaplasia may appear to be malignant
lesions clinically.1 Diagnosis of these lesions requires a
high index of suspicion, and an incisional biopsy should
be carried out. Both benign and malignant tumors of
salivary gland origin may be covered by mucosa, and
incisional biopsy is usually necessary in such cases for
accurate diagnosis.
Surgery is the fi rst-line treatment of all benign and
most malignant tumors of the hard palate and alveolus.
Most benign tumors of the hard palate may be removed
without resecting bone, so there is no need for recon-
struction. Most malignant tumors of the hard palate will
require resection of part or all of the hard palate or
maxillary alveolus (or both) to remove bone that is
obviously involved or to remove bone as a deep margin.
Such surgery invariably results in lack of oral-nasal sepa-
ration, which interferes with speaking and swallowing.
A decision should then be made about whether the
patient will require restoration of oral-nasal separation
with a dental prosthesis, a local pedicle fl ap, or free fl ap
reconstruction. If dental prosthetic evaluation will defi -
nitely be required, the patient should be seen by a
maxillofacial prosthodontist before surgery. This allows
the patient to better understand the resulting defect
and the prosthodontist to do whatever restorative work
or dental extractions are necessary and to take impres-
sions so that a surgical splint will be ready at the time
of removal of the tumor. The surgical splint provides
oral-nasal separation and allows the patient to eat in the
immediate postoperative period, thus avoiding the
need for placement of a nasogastric tube or a gastros-
tomy. Tracheostomy is not usually necessary for airway
management, but plans should be made for tracheos-
tomy in the event that a free tissue transfer is used for
reconstruction.
STAGING
Most physicians stage the extent of the cancer after
evaluating all the clinical studies. The most common
staging system is that developed by the American Joint
Commission on Cancer Staging. It involves the TNM
system, which indicates the size of the primary tumor
(T), the extent of neck node metastases (N), and the
status of systemic spread of tumor (M). These indices
are used to determine progressive tumor stage from I to
IV. The various modalities of treatment and the ultimate
prognosis are related to the stage of the disease.11
Radiation therapy is not considered fi rst-line treat-
ment of cancer of the hard palate and alveolar ridge
because bone has a low oxygen supply and the cancer
is less curable in an oxygen-poor environment. Even if
the soft tissue component was curable, exposure of
radiated bone in the oral cavity leads to osteoradione-
crosis. When bone invasion or perineural invasion is
present, radiotherapy or chemoradiotherapy may be
used in the adjuvant setting. Patients found to have
more than two lymph nodes positive or extracapsular
spread have been shown to benefi t from chemoradia-
tion therapy.12
Squamous cell carcinoma is usually manifested as
an ulcerative lesion. Both pseudoepitheliomatous
hyperplasia and necrotizing sialometaplasia on the hard
palate may be malignant-appearing lesions clinically.
Clarifi cation of this histologic situation is critical be -
cause neither pseudoepitheliomatous hyperplasia nor
necrotizing sialometaplasia require extensive surgical
removal. Tumors of minor salivary gland origin, such as
pleomorphic adenoma, adenoid cystic carcinoma, and
mucoepidermoid carcinoma, may appear as a smooth,
submucosal mass that must be distinguished from a
torus palatinus. It is estimated that 50% to 70% of
minor salivary gland lesions will be malignant.13 Early
recognition facilitates surgical removal and may improve
outcome. Superfi cial biopsy may be inconclusive, and
incisional biopsy is often needed for defi nitive
diagnosis.
PREOPERATIVE PLANNING
A thorough and complete history and physical examina-
tion should be performed in all patients. Careful atten-
tion is paid not only to the palate and the maxillary
region but also to the cervical lymph nodes because
there is a high incidence of metastasis from squamous
cell carcinoma of the hard palate and alveolus. The
possibility of carcinoma extending posteriorly and supe-
riorly to involve the retropharyngeal lymph nodes (Fig.
27-6) and the skull base should be considered. The
presence of middle ear effusion may indicate extension
of the cancer into the nasopharynx or invasion of the
tensor veli palatini muscle or pterygoid plates. Absence
of the blink refl ex or palatal hypoesthesia may indicate
involvement of the maxillary division of the trigeminal
nerve in the sphenopalatine fossa. Wasting of the mas-
seter or temporalis muscle may be indicative of invasion
of the mandibular division of the trigeminal nerve.
Biopsy of the primary lesion is essential for plan-
ning treatment. Most patients can undergo transoral
biopsy in the offi ce with cup forceps.11 Satisfactory local
anesthesia can be achieved with either a local injection
or, at times, a topical spray. Biopsy samples should be
taken from the margin of the lesion to ensure that

208
Section 2
Oral Cavity/Oropharynx
viable tumor is obtained and not just necrotic debris.
Submucosal tumors may require a preliminary incision
through mucosa to yield an adequate tissue sample.
Tumors of the hard palate and alveolar ridge should
be investigated with imaging techniques to accurately
evaluate the extent of the tumor, particularly the third
dimension. The surgeon should indicate directly to the
radiologist the information that is needed to facilitate
treatment planning. Coronal CT images accurately
depict the relationship of the lesion to the palate, peri-
osteum, and bone. An axial CT study with contrast
enhancement helps defi ne the relationship of the
tumor to posterior structures and serves to assess involve-
ment of the infratemporal fossa or pterygoid plates.
The neck should be scanned in patients with high-grade
malignancies such as squamous cell carcinoma and
mucoepidermoid carcinoma in an effort to evaluate the
status of the cervical lymphatics. Cervical metastases
from cancer of the hard palate have been thought to
occur infrequently; however, our recent study of a series
of patients with squamous cell carcinoma of the hard
palate and maxillary alveolus has indicated otherwise.10
Metastasis may also be encountered in the retropharyn-
geal space (see Fig. 27-6), so this area should be evalu-
ated carefully. Because excision of these lymph nodes
is not included in the standard neck dissection, the
nodes have to be excised through the neck after the
standard neck dissection has been completed.
Information obtained on physical examination,
imaging studies, and biopsy allows the surgeon to stage
the tumor and to integrate therapeutic recommenda-
tions to meet the patient’s needs. Surgical therapy is
expedient and the defect can be reliably rehabilitated
with the use of a prosthesis or fl ap reconstruction.
The resection should be designed to completely re -
move the tumor with clear margins. The palate is a
midline structure, and areas at risk for metastatic
spread include the cervical and retropharyngeal lymph
nodes on both sides. It has been demonstrated that the
rate of metastatic spread to the cervical lymph nodes is
high in squamous cell carcinoma of the maxilla, even
in a clinically negative neck. Selective neck dissection
should be included for a unilateral lesion and bilateral
selective neck dissections if the lesion is in the
midline.
In the preoperative planning phase, the surgeon
must determine whether resection of palatal bone will
be required. Superfi cial and particularly benign lesions
that do not invade the periosteum do not require
through-and-through resection of the palate into the
sinus and nasal fossa. Conversely, lesions that clearly
infi ltrate or have eroded the palate will require more
extensive three-dimensional resection. Tumors involv-
ing the alveolus may gain access to bone through inva-
sion of the tooth sockets. In contrast, in well-localized
tumors that are centrally located in the hard palate,
preservation of the uninvolved alveolus is appropriate
and facilitates rehabilitation.
Patients with cancer extending into the maxillary
antrum or nasal cavity may benefi t from a surgical
approach that allows the surgeon to adequately visual-
ize the deep margin of resection. Improved exposure
through performance of an anterior antrostomy allows
visualization of the tumor, which contributes to ensur-
ing an adequate margin of resection in tumors extend-
ing into the maxillary sinus. In patients in whom the
tumor extends posteriorly into the infratemporal fossa
and pterygoid muscle, transoral resection may be inad-
equate and a surgical approach must be planned to
ensure adequate tumor removal. One approach is to
expose the infratemporal fossa through a preauricular
incision while taking care to identify and preserve the
facial nerve. When necessary, the mandible can be dis-
placed anteriorly to facilitate exposure to the infratem-
poral fossa during tumor extirpation.
The preoperative planning phase of patient care
must consider rehabilitation. Anticipated postoperative
diffi culties will, of course, refl ect the extent of resection
required. Patients with superfi cial lesions or benign
tumors can be treated by resection to the depth of the
palatal periosteum. These defects will heal by secondary
intention and thus make split-thickness skin grafting
unnecessary. Patient comfort will be greatly facilitated
if a temporary acrylic prosthesis is fabricated by a maxil-
lofacial prosthodontist before surgery. The prosthesis
will protect the palate during eating. It can be removed
between meals for local wound care.
If the dimensions and site of the tumor, whether
benign or malignant, require resection of the maxillary
alveolus or palatal bone, or both, a plan must be made
to achieve oral-nasal separation. In most circumstances
Figure 27-6. Computed tomography scan demonstrating the pres-
ence of metastasis from squamous cell carcinoma of the hard palate
to the retropharyngeal lymph nodes.

Chapter 27
Inferior Maxillectomy
209
this can best be accomplished through the use of
an “obturator.”14-16 The prosthodontist should always
be consulted preoperatively so that the appropriate
dental records and impressions can be taken. Aramany
devised a classifi cation of surgically created palatal
defects that is very helpful in designing a proper pros-
thesis.14 The prosthodontist should create a surgical
splint to be inserted at the time of surgery. Interim
prostheses and a fi nal prosthetic device are developed
postoperatively as the patient convalesces and the defect
matures.
Reconstruction of total palatal defects has usually
been accomplished with a temporalis muscle transposi-
tion. However, such management eliminates the possi-
bility of dentures. Reconstruction with an osseocutaneous
free fl ap is now a reality because many of the problems
of fi xation and preservation of a nasal airway have now
been overcome.17 This technique provides oral-nasal
separation, as well as the opportunity for osseointe-
grated dental restoration.
Surgical resection of a tumor involving the palate
usually results in less postoperative morbidity than is
the case with other procedures performed on the oral
cavity and oropharynx. Accordingly, a patient’s preop-
erative status relative to cardiopulmonary reserve, for
instance, tends to be less important in determining
operability. Immediate rehabilitation through insertion
of a surgical splint greatly enhances this aspect of patient
care. Most patients can anticipate institution of a soft
or liquid diet on the fi rst postoperative day. Insertion
of a nasogastric tube is rarely necessary. Tracheostomy
is rarely required for patients undergoing resection of
palatal lesions. These considerations are all important
for preoperative counseling and surgical planning.
SURGICAL TECHNIQUE
Approaches to the surgical management of cancer
limited to the hard palate and alveolar ridge include
• Partial lateral maxillectomy
• Inferior maxillectomy
• Total maxillectomy (see Chapter 11)
Partial Lateral Maxillectomy
This surgical approach is designed to be carried out
transorally for the excision of small tumors of the lateral
maxillary alveolar ridge and hard palate. The line of
incision should be drawn with a marking pen on the
mucosa and should allow margins of at least 1 cm. The
incision should be made with electrocautery to avoid
bleeding. The soft tissue should be elevated in the sub-
periosteal plane off the front and lateral walls of the
maxillary antrum while preserving the infraorbital nerve
to avoid permanent anesthesia of the soft tissues of the
face (Fig. 27-7). The maxillary antrum is entered with
a small osteotome, and bone is removed with a Kerrison
rongeur. This allows suffi cient visualization of the max-
illary antrum to evaluate the extent of the resection,
which depends on whether the maxillary antrum is
invaded (Fig. 27-8). A sagittal saw or powered instru-
mentation with reciprocating or sagittal blades is used
for very precise osteotomies. The hard palate is tran-
sected to the midline and into the maxillary sinus while
trying to avoid the lateral nasal wall and nasal cavity,
although this is not always possible. The posterior oste-
otomy is reserved for the fi nal step to avoid unnecessary
blood loss because bleeding from the pterygomaxillary
space can be completely controlled only after removal
Figure 27-7. Gingivobuccal incision with a periosteal elevator used
to elevate the periosteum up to the level of the inferior orbital nerve.
(Reprinted with permission from Simental AA Jr, Myers EN: Cancer of the
hard palate and maxillary alveolar ridge: Technique and applications. Op
Tech Otolaryngol Head Neck Surg 16:30, 2005.)
Figure 27-8. Anterior maxillotomy with visualization of the maxil-
lary sinus fl oor and infraorbital rim. (Reprinted with permission from
Simental AA Jr, Myers EN: Cancer of the hard palate and maxillary alveolar
ridge: Technique and applications. Op Tech Otolaryngol Head Neck Surg
16:30, 2005.)

210
Section 2
Oral Cavity/Oropharynx
of the specimen. A large osteotome is placed behind
the last molar tooth at a 90-degree angle to the hard
palate in a superomedial direction (Fig. 27-9). Once the
pterygoid plates are fractured, brisk bleeding will be
encountered from the pterygoid plexus and internal
maxillary artery. Curved Mayo scissors are used to com-
plete the transection of the soft tissues and soft palate.
Bleeding is then controlled with a clamp and ligature
technique. Frozen section analysis of the soft tissue
margins will confi rm the adequacy of the resection.
Unfortunately, there is no way of evaluating bone with
the frozen section technique. While the margins are
being examined, all the mucosa is removed from the
maxillary antrum to avoid contamination by oral cavity
microorganisms, which can result in edema of the sinus
mucosa and interfere with the use of a palatal prosthe-
sis. All sharp edges and bony spicules are removed, and
a split-thickness skin graft (0.001 inch) is sewn in place
to resurface the cheek fl ap (Fig. 27-10). The defect is
packed with Xeroform gauze. The previously formed
surgical obturator is then fi xed to the hard palate with
the use of a lag screw inserted through a hole made in
the obturator, and thus there is no need to sew the
prosthesis in place (Fig. 27-11). In patients who have
residual dentition, clips can also be used to further sta-
bilize the prosthesis.
Inferior Maxillectomy
This surgical approach is designed primarily for tumors
of the hard palate that do not involve the fl oor of the
maxillary sinus and nasal cavity. The extent of the tumor
resection is drawn with a marking pen on the mucosa
before beginning the actual osteotomies of the palate.
The incisions are made in a manner similar to that
described for tumors of the alveolar ridge (Fig. 27-12).
The maxillary sinus is entered and the inferior aspect
of the maxillary sinus is evaluated (Fig. 27-13). The
sagittal saw is used for very precise osteotomies. The
osteotomy is usually completed with the osteotome at
the level of the pterygoid plates. The nasal cavity is
entered and the septum is transected with heavy curved
Figure 27-9. Posterior osteotomy created by aiming superomedi-
ally. Great care is taken to not violate the orbital fl oor. (Reprinted with
permission from Simental AA Jr, Myers EN: Cancer of the hard palate and
maxillary alveolar ridge: Technique and applications. Op Tech Otolaryngol
Head Neck Surg 16:31, 2005.)
Figure 27-10. A split-thickness skin graft is used to line the raw
surfaces. The healthy maxillary sinus mucosa is left in situ. (Reprinted
with permission from Simental AA Jr, Myers EN: Cancer of the hard palate
and maxillary alveolar ridge: Technique and applications. Op Tech Otolar-
yngol Head Neck Surg 16:31, 2005.)
Figure 27-11. A lag screw (arrow) facilitates fi xation of the acrylic
splint.

Chapter 27
Inferior Maxillectomy
211
Mayo scissors. The soft palate is transected with electro-
cautery, and any residual soft tissue attachments are
transected with scissors. After the mucosa of the maxil-
lary antrum is removed as previously described, the
inferior turbinate is also removed to prevent infection
and edema, which interfere with the application of a
palatal prosthesis. Once the specimen is removed, it is
sent to the pathology laboratory for frozen section
diagnosis.
More extensive tumors limited to the hard palate
and alveolar ridge can be removed by simply extending
the osteotomies.
Management of the Neck in Squamous
Cell Carcinoma of the Hard Palate
and Alveolar Ridge
The incidence of occult metastasis from the hard
palate and maxillary alveolar ridge has not been studied
systematically. There are very limited clinical data
published on the actual incidence of cervical metasta -
sis from these individual subsites, but the rate is gener-
ally perceived to be low. Over the past 2 decades we
have observed that delayed cervical metastasis has
occurred in some patients after resection and control
of a primary cancer in the upper alveolar ridge and
hard palate. Some of these patients have died of regional
or distant metastasis despite control of their primary
cancer.
Few data have been reported specifi cally on
metastasis from squamous cell carcinoma arising in the
maxillary alveolar ridge and hard palate. A high inci-
dence of cervical metastasis (30%) in the subsites of
tongue and fl oor of the mouth cancer has been well
documented.18-20 Simental and colleagues studied a
series of patients with squamous cell carcinoma con-
fi ned to the maxillary alveolus and hard palate in an
effort to specifi cally evaluate the risk of regional
metastasis from these subsites.21 Our observed data
suggest the rate of metastasis to the neck from squa-
mous cell carcinoma of the hard palate and alveolar
ridge to be 37%, which is similar to that in other sites
in the oral cavity, such as the tongue and fl oor of the
mouth.
We usually dissect the neck before the oral cavity
because resection in this area is considered clean. If the
tumor is isolated to one side, we perform a unilateral
selective neck dissection. Midline lesions or lesions
involving the entire hard palate require bilateral neck
dissection. Once the neck dissection is completed, we
redrape and isolate the neck dissection wound from the
oral cavity procedure.
REHABILITATION OF A PATIENT WITH
LOSS OF ORAL-NASAL SEPARATION
Patients treated by inferior maxillectomy require a
means of restoring the oral-nasal separation lost
by removal of the palate and alveolar bone. Not
doing so results in patients who can neither speak
nor swallow, which gives rise to an unacceptable quality
of life.
The four major means of rehabilitation include
• Dental prosthetic management
• Local fl aps
• Regional fl aps
• Microvascular free tissue transfer
Figure 27-12. Mucosal incisions with exposure of the anterior
maxilla and infraorbital nerve. (Reprinted with permission from Simental
AA Jr, Myers EN: Cancer of the hard palate and maxillary alveolar ridge:
Technique and applications. Op Tech Otolaryngol Head Neck Surg 16:32,
2005.)
Figure 27-13. Anterior maxillotomy to visualize the fl oor of the
maxillary sinus. (Reprinted with permission from Simental AA Jr, Myers EN:
Cancer of the hard palate and maxillary alveolar ridge: Technique and appli-
cations. Op Tech Otolaryngol Head Neck Surg 16:32, 2005.)

212
Section 2
Oral Cavity/Oropharynx
Dental Prosthetic Management
A patient with a limited lesion of the alveolar ridge
alone or the alveolar ridge and palate that does not
involve more than half the hard palate can be rehabili-
tated relatively easily. The expertise of a prosthodontist
is indicated early in the course of evaluating the
patient.11 Preoperative dental impressions are made
and a palatal prosthesis is fashioned and inserted at the
time of resection as described earlier. A lag screw is
inserted through a hole in the prosthesis into the
remaining palatal bone to hold the prosthesis in place
(see Fig. 27-11). The screw is removed and the prosthe-
sis taken out. The packing is removed on the fi fth post-
operative day. The skin graft is healed by that time and
the sutures holding the skin graft may be removed (Fig.
27-14). The intraoperative prosthesis will be modifi ed
by the prosthodontist at that time to provide adequate
speech and swallowing. It will be modifi ed by the pros-
thodontist over the ensuing months as the surgical site
matures. These prostheses are designed according to
the Aramany classifi cation.14-16 The fi nal prosthesis will
A
B
Figure 27-14. A, This patient underwent resection of an adenocarcinoma of the hard palate. The defect is demonstrated. B, Retention of
the prosthesis is facilitated by residual dentition. The fi nal prosthesis achieves good oral-nasal separation.
A
C
B
D
Figure 27-15. Patient with a removable denture that provides good oral-nasal separation and restores a good cosmetic appearance. A, Pre-
operative appearance. B, Surgical defect. C, Removable prosthesis with clasps. D, Good cosmetic result with restoration of oral-nasal
separation.

Chapter 27
Inferior Maxillectomy
213
Table 27-1 DEFECT CLASSIFICATION SCHEME
Defect Class
Criteria
Ia
Limited defect in the central portion of
the palate that does not involve the
alveolus
Ib
Defect in the palate that involves the
alveolus but is located posterior to the
canine or is limited to the premaxilla
with preservation of the canine teeth
bilaterally
II
Hemipalatal defect that does not cross
the midline in a “conventional”
longitudinal resection and does not
extend posterior to the midpoint of the
palate for a defect that is created in the
horizontal orientation, thus preserving
at least half of the palatal surface
III
Subtotal or total palatectomy involving
more than half of the palatal surface
f
Indicates a defect in the fl oor of the
orbit
z
Indicates a defect in the body of the
zygoma
Reprinted with permission from Urken ML, Buchbinder D,
Okay D: Functional palatomaxillary reconstruction. Op Tech Oto-
laryngol Head Neck Surg 16:36-39, 2005.
have teeth similar to a denture; it can be removed and
cleaned by the patient as the patient also tends to
hygiene of the defect (Fig. 27-15). It is essential for the
surgeon and prosthodontist to coordinate their efforts
to restore the quality of the patient’s immediate post-
surgical healing period and ultimate prosthetic
rehabilitation. Patients undergoing partial inferior
maxillectomy can expect to enjoy a good quality of life
after such surgery and rehabilitation.
Local Flaps
Local fl aps have also been described. The palatal island
fl ap for reconstruction of palatal lesions was originally
described by Gullane and Arena in 1977.22 This single-
stage mucoperiosteal fl ap offers a reliable source of
regional vascularized soft tissue that obviates the need
for prosthetic rehabilitation. Genden,23 Moore,24 and
their colleagues also concluded that the palatal island
mucoperiosteal fl ap provides an effective means of
reconstructing hard and soft palate defects with few
complications and low morbidity.
Guzel and Altintas25 described repairing large ante-
rior palatal fi stulas with thin tongue fl aps in cleft palate
patients, and from the description of their procedure
it would appear that these fl aps could also be used in
patients with very limited lesions after resection for
cancer of the palate and maxillary alveolus.
Regional Flaps
The temporalis fl ap has the advantage of immediate
reconstruction with minimal morbidity for patients who
have undergone total excision of the hard palate and
alveolar ridge. The fi rst use of the temporalis muscles
as donor tissue was reported in 1898 by Golovine.26 The
temporalis muscle is an attractive option for reconstruc-
tion after inferior maxillectomy for the following
reasons: (1) the donor site and the defect are within
the same operative fi eld and therefore the need for
more complex free tissue transfers can be avoided; (2)
there is considerable tissue available; (3) the fl ap is well
vascularized; (4) the resulting functional defect is neg-
ligible; (5) the cosmetic deformity is limited to a mild
concavity in the area of the temporalis fossa, which in
women is covered by hair; and (6) the fl ap can be used
to correct unilateral and bilateral defects. This recon-
struction can be carried out in less time than it takes
for a free fl ap.
The limitation associated with use of this fl ap is that
no prosthetic rehabilitation with provision of teeth to
improve the cosmetic effect can be achieved. It also has
the disadvantage that direct vision of this area to monitor
for recurrent tumor is no longer possible. This latter
disadvantage has been largely overcome in recent
years with the use of PET/CT scanning and a nasal
endoscope.
Browne and Holland27 reported a procedure for
resection of palatal malignancies that involves the use
of a combined intraoral and lateral temporal fossa
approach to remove the primary tumor, resect tumors
spreading perineurally from the skull base, and recon-
struct the tissue defect with a temporalis muscle rota-
tion fl ap (Fig. 27-16). In 16 patients with a variety of
malignant tumors, the amount of palate resected varied
from 25% to 100%, with the average being 30% to 50%.
All the fl aps in their series survived, and the wounds
were mucosalized within 3 to 4 weeks of surgery. Patients
were typically allowed to start oral intake of fl uids on
the second postoperative day.
Microvascular Free Tissue Transfer
Reconstruction of defects after inferior maxillectomy
has recently been very well summarized by Urken and
colleagues under the theme of functional palatomaxil-
lary reconstruction.17 The authors state that palatomax-
illary defects are inherently more complex than defects
of the mandible because of their three-dimensional
shape and location in the midface region. The defects
are also at a distance from most of the recipient vessels
used in free tissue transfer. The authors divide the
defects into classes I, II, and III (Table 27-1) and discuss
them in detail. They include the use of dental restora-
tion with dental implants for support and anchorage to
provide the foundation for functional dental rehabilita-
tion. Urken’s group rehabilitated patients with limited
defects of the palate (Ia and Ib) with either an obtura-
tor or a soft tissue fl ap. These fl aps included a palatal
island fl ap for smaller defects and a radial forearm fl ap
for larger defects. The critical point that they make is
that placement of soft tissue into these defects elimi-
nates the midline palatal shelf and the lateral scar band
necessary for retention of a maxillary obturator and the

214
Section 2
Oral Cavity/Oropharynx
remaining dentition therefore becomes critical for
prosthetic retention.
In larger class II defects, it has been their policy to
provide restoration with either an obturator, if the
remaining bony and dental support is adequate, or a
free fl ap. The free fl ap must include vascularized bone
from either the fi bula, iliac crest, or scapula. Class III
defects are all restored with an osseocutaneous free
fl ap.
Other types of free fl ap reconstruction have been
reported by Gellrich and coworkers,28 who described
the lateral upper arm fl ap for intraoral reconstruction,
and by Genden and associates,29 who described iliac
crest internal oblique osseomusculocutaneous free fl ap
reconstruction of the postablative palatomaxillary
defect and considered it a reliable method of primary
reconstruction that allows complete orodental rehabili-
tation without the use of a prosthetic obturator. Futran
and Haller30 described the use of fi bular, rectus abdom-
inis, radial, and latissimus dorsi free fl aps for recon-
struction of the hard palate. They concluded that free
fl ap reconstruction of the palate provides reliable per-
manent separation of the oral and sinonasal cavities in
one stage. In addition, the potential for dental rehabili-
tation with restoration of masticatory function and
normal phonation exists. The choice of fl ap is tailored
to specifi c palatal defects, as well as patient needs.
POSTOPERATIVE MANAGEMENT
Patients who have undergone removal of benign or
low-grade malignant tumors in which the bone was pre-
served may ingest a bland pureed diet beginning on the
fi rst day. Frequent irrigation of the oral cavity, in par-
ticular, the use of half-strength hydrogen peroxide—
swish and spit—would be very useful in helping the
B
D
C
A
Figure 27-16. A, Patient with adenoid cystic carcinoma of the palate. B, After total inferior maxillectomy, the defect was reconstructed with
a temporalis muscle fl ap, which quickly became mucosalized. Complete healing was followed by a full course of radiation therapy. C, Removal
of the maxilla resulted in recession of the upper lip. D, Computed tomography scan disclosing multiple metastatic nodules that were discovered
13 years after the surgery and radiation therapy and were treated with radiation therapy. It has now been 15 years since the patient completed
his surgery, and he is asymptomatic despite the lung metastasis.

Chapter 27
Inferior Maxillectomy
215
defect to heal. The use of a dental splint will also help
protect the raw surface while it is re-epithelializing and
make the patient more comfortable. Patients who have
undergone prosthetic rehabilitation may be fed a liquid
or pureed diet on the fi rst postoperative day. The pros-
thesis should be removed and the bolus taken out on
postoperative day 5. The prosthesis should then be
removed after each meal, the oral cavity irrigated, and
the prosthesis cleaned. Patients who have undergone
reconstruction with a temporalis fl ap should resume
irrigation as described earlier. They may also be fed on
the fi rst postoperative day.
Patients who have undergone free fl ap reconstruc-
tion will begin to swallow at a later date after the suture
lines have healed satisfactorily and then can receive a
pureed diet with the aforementioned oral cavity
hygiene.
Patients who have undergone neck dissection in
conjunction with resection of the primary cancer will
have the neck wound managed as described in the
chapter on neck dissection (see Chapter 78).
Patients with bone invasion as part of their tumor
(T4 lesions) or with high-grade salivary gland cancers
are referred for postoperative chemoradiation therapy.
Patients who have perineural involvement in their
primary should be referred for chemoradiation therapy.
Similarly, patients who have more than two positive
nodes or extracapsular spread in the neck dissection
will be referred for chemoradiation therapy.
COMPLICATIONS
When palatal bone is removed as a deep margin of
resection for a limited tumor, great care is taken to
avoid perforation of the soft tissue on the nasal side of
the palate. Trauma to the mucosa of the fl oor of the
nose invariably results in an oral-nasal fi stula. When the
fl oor of the nose has been violated, immediate repair
with soft tissue is appropriate. An alternative is to
achieve oral-nasal separation with a prosthesis.
Resurfacing soft tissue defects with a split-thickness
skin graft when the hard palate is intact is rarely neces-
sary. The defect will heal by secondary intention. The
exception to this generalization is a situation in which
buccal mucosa is resected with adjacent alveolar bone.
In these circumstances, resurfacing the cheek fl ap with
a split-thickness skin graft serves to prevent excessive
contracture of the soft tissue. Additionally, the scar
band at the junction between the split-thickness skin
graft and the residual mucosa helps provide good reten-
tion for subsequent use of a prosthesis.
Complications in healing may occur. Loss of the
split-thickness skin graft used to line the cheek fl ap is
quite unusual but it is followed by healing by second
intention, which unfortunately may produce contrac-
ture of the upper lip. The fundamental success of free
tissue transfer is dependent on frequent examination
of the anastomosis by Doppler signal. This requires
dedicated and experienced nursing care so that if the
signal is lost, the patient can be taken back to surgery
to salvage the fl ap.
References
1. Myers EN, Simental AA Jr: Cancer of the oral cavity. In Myers EN,
Suen JY, Myers JN, Hanna EYN (eds): Cancer of the Head and
Neck, 4th ed. Philadelphia, WB Saunders, 2003, pp 279-319.
2. Shah JP: Oral cavity and oropharynx. In Shah JP (ed): Head and
Neck Surgery and Oncology, 3rd ed. Chicago, CV Mosby, 2003,
pp 173-233.
3. Inagi K, Takahashi H, Okamoto M: Treatment effects in patients
with squamous cell carcinoma of the oral cavity. Acta Otolaryngol
Suppl 547:25-29, 2002.
4. Petruzzelli GJ, Myers EN: Malignant neoplasms of the hard palate
and upper alveolar ridge. Oncology 8:43-48, 1994.
5. Mahboubi E: The epidemiology of oral cavity, pharyngeal and
esophageal cancer outside of North America and Western
Europe. Cancer 40(4 Suppl):1879-1886, 1977.
6. Reddy CR: Carcinoma of the hard palate in India in relation to
reverse smoking of chuttas. J Natl Cancer Inst 53:615-619, 1974.
7. Graham S, Dayal H, Rohrer T, et al: Dentition, diet, tobacco, and
alcohol in the epidemiology of oral cancer. J Natl Cancer Inst
59:1611-1618, 1977.
PEARLS
• A biopsy to obtain a diagnosis for making a rational
plan of management is essential because of the wide
variety of tumors, both benign and malignant,
found in the hard palate.
• Computed tomography is very helpful in evaluating
the extent of the tumor and whether it has
infi ltrated bone.
• Selective neck dissection should be part of the
surgical treatment because of the high rate of
metastasis to the neck.
• A maxillofacial prosthodontist should see the
patient for preoperative evaluation so that a surgical
obturator can be available in the operating room.
• A temporalis fl ap or free fl ap may be used for
immediate reconstruction of a total palatal defect.
PITFALLS
• Lack of an accurate pathologic diagnosis may result
in a fl awed plan of management.
• Failure to have imaging studies may lead to
understaging the disease, which may result in
undertreating the patient.
• Failure to include selective neck dissection will result
in a recurrence rate in the neck of greater than 30%
in patients with squamous cell carcinoma of the
hard palate.
• Not having a prosthesis available at the time of
surgery will deprive the patient of regaining
immediate oral-nasal separation.
• Not including postoperative radiation therapy or
chemoradiation therapy in the treatment of high-
grade cancer downgrades the possibility of achieving
locoregional control and survival.

216
Section 2
Oral Cavity/Oropharynx
8. Blot WJ, Winn DM, Fraumeni JF Jr: Oral cancer and mouthwash.
J Natl Cancer Inst 70:251-253, 1983.
9. Wynder EL, Kabat G, Rosenberg S, Levenstein M: Oral cancer
and mouthwash use. J Natl Cancer Inst 70:255-260, 1983.
10. Simental AA Jr, Myers EN: Cancer of the hard palate and maxil-
lary alveolar ridge: Technique and applications. Op Tech Otolar-
yngol Head Neck Surg 16:28-35, 2005.
11. Persky M: Carcinoma of the palate. News from SPOHNC 14:1-3,
2005.
12. Cooper JS, Pajak TF, Forastiere AA, et al: Postoperative concur-
rent radiotherapy and chemotherapy for high-risk squamous cell
carcinoma of the head and neck. N Engl J Med 350:1937-1944,
2004.
13. Spiro RH: Salivary neoplasms: Overview of a 35-year experience
with 2,807 patients. Head Neck Surg 8:177-184, 1986.
14. Aramany MA: Basic principles of obturator design for partially
edentulous patients. Part I: Classifi cations. J Prosthet Dent 40:544-
557, 1978.
15. Aramany MA: Basic principles of obturator design for partially
edentulous patients. Part II: Design principles. J Prosthet Dent
40:656-662, 1978.
16. Aramany MA, Myers EN: Maxillofacial prosthetic rehabilitation.
In Suen JY, Myers EN (eds): Cancer of the Head and Neck. Edin-
burgh, Churchill Livingstone, 1981, pp 165-184.
17. Urken ML, Buchbinder D, Okay D: Functional palatomaxillary
reconstruction. Op Tech Otolaryngol 16:36-39, 2005.
18. Pimenta Amaral TM, Da Silva Freire AR, Carvalho AL, et al: Pre-
dictive factors of occult metastasis and prognosis of clinical stages
I and II squamous cell carcinoma of the tongue and fl oor of
mouth. Oral Oncol 40:780-786, 2004.
19. Sparano A, Weinstein G, Chalian A, et al: Multivariate predictors
of occult neck metastasis in early oral tongue cancer. Otolaryngol
Head Neck Surg 131:472-276, 2004.
20. Kurokawa H, Yamashita Y, Takeda S, et al: Risk factors for late
cervical lymph node metastasis in patients with stage I or II car-
cinoma of the tongue. Head Neck 24:731-736, 2002.
21. Simental AA Jr, Johnson JT, Myers EN: Cervical metastasis from
squamous cell carcinoma of the maxillary alveolus and hard
palate. Laryngoscope 116:1682-1684, 2006.
22. Gullane PJ, Arena S: Palatal island fl ap for reconstruction of oral
defects. Arch Otolaryngol 103:598-599, 1977.
23. Genden EM, Lee BB, Urken ML: The palatal island fl ap for
reconstruction of palatal and retromolar trigone defects revisited.
Arch Otolaryngol Head Neck Surg 127:837-841, 2001.
24. Moore BA, Magdy E, Netterville JL, Burkey BB: Palatal recon-
struction with the palatal island fl ap. Laryngoscope 113:946-951,
2003.
25. Guzel MA, Altintas F: Repair of large, anterior palatal fi stulas
using thin tongue fl aps: Long-term follow-up of 10 patients. Ann
Plast Surg 45:109-117, 2000.
26. Holmes AD, Marshall KA: Uses of the temporalis muscle fl ap in
blanking out orbits. Plast Reconstr Surg 63:336-343, 1979.
27. Browne JD, Holland BW: Combined intraoral and lateral tempo-
ral approach for palatal malignancies with temporalis muscle
reconstruction. Arch Otolaryngol Head Neck Surg 128:531-537,
2002.
28. Gellrich N-C, Schramm A, Hara I, et al: Versatility and donor site
morbidity of the lateral upper arm fl ap in intraoral reconstruc-
tion. Otolaryngol Head Neck Surg 124:549-555, 2001.
29. Genden EM, Wallace D, Buchbinder D, et al: Iliac crest internal
oblique osteomusculocutaneous free fl ap reconstruction of the
postablative palatomaxillary defect. Arch Otolaryngol Head Neck
Surg 127:854-861, 2001.
30. Futran ND, Haller JR: Considerations for free-fl ap reconstruction
of the hard palate. Arch Otolaryngol Head Neck Surg 125:665-
669, 1999.

Chapter 28
Surgery of the Tongue
Robert L. Ferris
Cancer of the tongue principally occurs in middle-aged
and elderly males. Most cancers arising on the tongue
are squamous cell carcinomas. These lesions tend to be
ulcerative and may be either exophytic or infi ltrative.
The majority of these patients have a history of long-
term use of tobacco and alcohol. However, there is a
subset of patients who tend to be younger (20 to 40
years of age) who have no known risk factors (Fig.
28-1).1 Cancer of the tongue in this younger age group
can be aggressive and may have a very poor prognosis,
despite multimodality therapy. Large size of tumor
(T3/T4) of the oral cavity correlates with poor progno-
sis.2 Several authors also note that the probability of
occult cervical lymph node metastases is high among
patients with a cancer of the tongue, even when the
tumor is in an early stage (T1/T2).3 One of the crucial
factors in evaluating cancer of the oral tongue is tumor
thickness, with increasing rate of metastasis associated
with those tumors greater than 4 mm in vertical
dimension.4
Treatment planning in patients with cancer of the
tongue depends, as in other anatomic sites, on the size
of the cancer, involvement of the surrounding fl oor of
the mouth or mandible, and the presence or absence
of cervical lymph node metastasis. The cancer may be
treated either with radiation or surgery, although the
latter is nearly universally favored if the primary tumor
is resectable.5 A transoral partial glossectomy provides
for adequate margins of resection in most T1/T2
tongue cancers while retaining articulation and swal-
lowing function. Hemiglossectomy or total glossectomy
is usually necessary for T3/T4 cancers, in that these
tumors usually involve adjacent structures, such as the
fl oor of the mouth, tonsillar pillar, and/or mandible.
Cancer involving the mandible itself also requires
segmental
mandibulectomy
for
adequate
tumor
clearance.
Although T1/T2 cancers of the tongue can be con-
trolled by limited surgery with relatively minimal mor-
bidity, subsequent metastases to the neck may lead to
the demise of the patient. Even these early stage cancers
may be associated with rates of nodal metastasis of 30%
or more. Increased locoregional and disease-free sur-
vival after elective neck dissection mandate aggressive
management of the clinically tumor-negative neck.3
Thus, a comprehensive approach to controlling regional
nodal basin(s) has been adopted over the past 10 to 15
years.
O’Brien and associates6 developed an excellent
comprehensive treatment strategy whose key elements
follow:
• Initial radical surgery for the primary cancer
• Preservation of mandibular continuity whenever
possible
• Selective or modifi ed neck dissection of levels 1
through 4 for the clinically negative neck, and radical
(or modifi ed radical) neck dissection for the clini-
cally positive neck
• Appropriate reconstruction
• Tracheotomy for the more advanced cancers
• Speech and swallowing therapy after treatment
• Postoperative radiation therapy employed selectively
for patients with certain clinicopathologic fi ndings,
such as the following:
• T3/T4 primary cancers
• Positive surgical margins (although these are ideally
treated by excision)*
• Poor differentiation
• Perineural invasion
• Involvement of multiple nodes
• Extracapsular spread of nodal disease*
These principles apply to carcinoma of the tongue
as well as other primary cancers in the oral cavity and
oropharynx.
217
*Denotes features optimally treated with adjuvant chemoradio -
therapy.7

218
Section 2
Oral Cavity/Oropharynx
The issue of treatment of the N0 neck in patients
with cancer of the tongue has been given a great deal
of attention in the literature.8 Studies comparing sur-
vival rates among patients who have undergone elective
and therapeutic neck dissections seem to indicate
improved survival for those who have undergone elec-
tive neck dissection. In addition, more extensive surgi-
cal treatment and additional therapeutic modalities
may be necessary if disease recurs in the neck when the
“wait and see” approach is used.3 These studies lead to
the conclusion that both control of neck metastasis and
survival may improve if neck dissection is performed
before cervical metastases become clinically evident.
Hence selective neck dissection of levels 1 to 4 in
patients with an N0 neck is performed. It is not neces-
sary to dissect level 5, because only rarely does isolated
metastasis from the tongue affect this area.8
Likewise dissection of level 2B is not necessary
unless metastasis is apparent clinically. This approach
can signifi cantly reduce morbidity associated with mobi-
lization and dissection of the accessory nerve. Great
care must be taken to include the prevascular and post-
vascular lymph nodes associated with the facial artery
and vein adjacent to the mandible in the dissection.
This is a common site of involvement for metastatic
cancer of both the lateral tongue and the fl oor of the
mouth. There is a risk of injury to the ramus mandibu-
laris of the facial nerve in dissecting these nodes.
Recently we reported the signifi cant benefi t in
locoregional control in patients who received elective
neck dissection (END) compared with those undergo-
ing a “wait and see” approach of observation.3 The poor
salvage rate among patients in whom cervical metastasis
develops after initial treatment of the primary cancer
has been documented.3,9 A low salvage rate was seen if
treatment of the neck was delayed in patients with T1N0
squamous cell carcinoma of the oral tongue, who devel-
oped subsequent cervical metastasis after partial glos-
sectomy. The incidence of occult metastasis for early
stage carcinoma of the tongue varies from 20% to 50%,
whereas the incidence of salvage in patients in whom
the neck is not treated initially ranges between 29% and
50%.3 Routine pathologic staging may underestimate
micrometastatic deposits.10,11
A major clinical problem encountered is the diffi -
culty in detecting preoperatively occult cervical lymph
node metastasis. Palpation alone results in substantial
understaging in predicting neck node involvement.
Imaging studies, such as computed tomography (CT)
and magnetic resonance imaging (MRI) scans, have
established criteria for malignancy, including lymph
nodes greater than 1 cm in diameter or those with a
hypodense center. Combined positron emission tomog-
raphy (PET) and CT has not signifi cantly improved
preoperative prediction of metastatic disease.12 However,
it is important to remember that 20% of nodes involved
by metastatic cancer are less than 1 cm and thus are not
detected by palpation or imaging. These nodes may
already manifest extracapsular spread. Recent clinical
studies are evaluating sentinel lymph node mapping
and biopsy to determine sensitivity and specifi city for
predicting the status of the neck in early cancer of the
oral tongue.13
As mentioned, the incidence of cervical lymph
node metastasis appears to be related in many cases to
size and thickness of the primary tumor, the latter
feature measured in a fashion analogous to the Breslow
melanoma classifi cation. A signifi cantly decreased risk
of cervical metastasis exists when the thickness of the
tumor is less than 3 mm.4 Furthermore, it is known that
larger cancers have a greater tendency to metastasize
than smaller ones.
PATIENT SELECTION
Patients with biopsy-proven squamous cell carcinoma of
the tongue T1/T2 are treated by many surgeons using
partial glossectomy with either primary closure or skin
graft, depending on the extent of the resection, and
extension onto the fl oor of mouth. Selective neck dis-
section can be used for neck disease staged as N0 and
N15,14 and a modifi ed or radical neck dissection in
patients whose neck disease is clinically at N2 or
greater.
Patients who may be excluded in this comprehen-
sive treatment program are those who
• Refuse surgery
• Are not found to be physically fi t
• Have comorbidities and are not expected to survive
longer than the near term
• Appear to have early invasive disease, less than
3 mm depth
• Have evidence of distant metastases
PREOPERATIVE PLANNING
A thorough history should be obtained, including
details of the patient’s consumption of tobacco and
alcohol. Many of these patients are alcohol dependent
and may be at high risk for development of delirium
tremens in the postoperative period. They may also be
nutritionally depleted due to dysphasia or pain. The
Figure 28-1. Squamous cell carcinoma in a 26-year-old woman with
no known risk factors.

Chapter 28
Surgery of the Tongue
219
history of referred otalgia is of importance, in that the
presence of otalgia may be a sign of perineural and/or
deep muscular involvement of the cancer.
The physical examination should evaluate tongue
mobility. This can be done simply by asking the patient
to protrude the tongue. Deviation of the tongue to the
side of the tumor or limitation of mobility of the tongue
(Fig. 28-2) indicates deep infi ltration of the muscula-
ture of the tongue that may be observed even in the
presence of a tumor with small surface dimensions. The
tumor should also be noted as being endophytic (Fig.
28-3A) or exophytic (see Fig. 28-3B). A greater ten-
dency for metastasis exists in the endophytic, ulcerative,
deeply infi ltrating tumor than in the superfi cial, exo-
phytic tumor.
The third dimension must be determined, because
both regional recurrence and survivorship have been
demonstrated to be related to tumor thickness (>3-
4 mm).4 Bimanual palpation is extraordinarily impor-
tant in the evaluation of patients with cancer of the
tongue. Gloves should be worn and palpation of the
tumor performed to identify deep invasion and esti-
mate the tumor thickness (Fig. 28-4). The surface
dimensions of the tumor should be measured to cor-
rectly assign it to the proper stage. A complete examina-
tion of the oral cavity and indirect laryngoscopy or
nasopharyngoscopy should be performed to identify
synchronous primary cancers in the upper aerodiges-
tive tract.
The oral cavity examination must include a detailed
examination of the condition of the teeth and gums.
The patient with diseased residual dentition or in whom
advanced periodontal disease is present should have a
dental consultation (Fig. 28-5). Restorations can rarely
be done before surgery. If the patient is likely to receive
postoperative radiation therapy, extractions are done at
the time of surgery to prevent osteoradionecrosis. It
also prevents unnecessary delay in having the patient’s
teeth extracted after the extirpative surgery has been
carried out and the patient has healed. Furthermore,
extraction of the teeth may help in wound healing,
because the bacteria count associated with advanced
periodontal disease is considerably increased.
The neck is palpated to ascertain the presence or
absence of cervical lymph node metastasis. Palpable
lymph nodes should be measured for assignment of
appropriate N stage (Fig. 28-6). Radiographic evalua-
tion is important, and each patient should have a chest
radiograph. If dysphagia exceeds that expected based
on the tumor extent, barium swallow esophagram may
Figure 28-2. Deviation of the tongue due to tumor infi ltration.
A
B
Figure 28-3. A, Ulcerative endophytic squamous cell carcinoma
(SCC). B, Exophytic SCC.
Figure 28-4. Palpation of the tongue is important in evaluating the
depth of invasion.

220
Section 2
Oral Cavity/Oropharynx
be useful before operative endoscopic visualization to
rule out a second primary cancer of the esophagus.
Imaging of both the tongue and the neck with CT
or MRI scanning can be very useful in certain cases,
particularly in T3/T4 lesions. Some clinicians advocate
determining the depth of invasion and the extent of
involvement of the tongue with MRI scanning, which
seems to give a more detailed evaluation of infi ltration
between the muscle fi bers (Fig. 28-7). This information
may be helpful in treatment planning, especially
because it concerns extent of resection, type of recon-
struction, and patient counseling. However, this rarely
alters treatment modality or extent beyond the use of
CT scanning. Co-registered PET-CT may not be cost
effective, but occasional distant metastases are
identifi ed.
T1/T2 cancers of the oral cavity that have not previ-
ously been biopsied but clearly have the characteristics
of squamous cell carcinoma may be treated by exci-
sional biopsy in the form of partial glossectomy rather
than subjecting the patient to a punch or incisional
biopsy as an outpatient. Frozen sections are carried out
and a neck dissection can be performed during the
same operation once the diagnosis has been made.
SURGICAL TECHNIQUE
Partial or Hemiglossectomy
Patients with T1, T2, and select T3 lesions may be
treated by transoral partial glossectomy. Patients who
have a full set of teeth or who have a stocky, muscular
confi guration of the neck may not be good candidates
for extensive transoral surgery because of the diffi culty
Figure 28-5. Cancer of the tongue in a patient with poor dental
hygiene.
A
B
Figure 28-6. Cancer of the tongue (A) with metastasis (B) to the
neck.
Figure 28-7. Magnetic resonance imaging (MRI) scan of deeply
infi ltrating squamous cell carcinoma of the tongue.

Chapter 28
Surgery of the Tongue
221
in acquiring adequate exposure. These patients are best
approached through a mandibulotomy.
My usual sequence of surgery for patients who will
have partial glossectomy and neck dissection is to fi rst
perform the excision of the primary cancer using semi-
sterile (clean gloves and gown) procedures and to then
sterilely prepare and redrape in order to carry out the
neck dissection. This order allows for frozen section
margins to be obtained, eliminates a second draping,
and permits harvesting of a skin graft or fl ap precisely
suited to the defect created. In addition, the decision
whether to place a tracheotomy (for tongue swelling or
more commonly if a skin graft and bolster are required)
can only be made after the defect is created. The tra-
cheotomy is then performed during the neck dissec-
tion, incorporating it into the horizontal limb of the
neck incision. Perioperative antibiotics are adminis-
tered intravenously before the start of the procedure.
The patient is placed under a general anesthetic. If
the patient will not receive a tracheostomy, nasal-
tracheal intubation is preferred in order to have the
endotracheal tube out of the oral cavity, providing
better exposure. Direct laryngoscopy and esophagos-
copy are carried out at this time, if these procedures
have not been carried out previously. If no additional
primary cancers are found, the surgical procedure
begins. Partial glossectomy may be performed under
local anesthesia for poor-risk patients who will not
have a neck dissection. Most patients with T1/T2 lesions
who are treated by transoral partial glossectomy with
the wound closed primarily do not require a tracheos-
tomy. However, if a tracheostomy is required for
those with more extensive lesions or those in whom
skin grafts will be used for reconstruction, this proce-
dure may be performed during the neck portion of the
procedure.
A folded blanket is placed under the patient’s
shoulders if a neck dissection will be carried out later.
The patient’s face and neck are then prepared and
draped into the operative fi eld. The neck is draped out
with a towel stapled to the skin along the mandible and
chin. The patient’s thigh should also be prepared and
draped if there is a possibility that a skin graft will be
necessary for reconstruction.
A Jennings mouth gag or dental bite block is used
to keep the patient’s mouth open during the surgery.
Right-angled retractors are used to retract the buccal
mucosa for adequate exposure. A 2-0 silk suture is
placed 1 cm behind the tip of the tongue in the exact,
avascular midline in order to avoid bleeding and to
provide for adequate retraction. Additional sutures may
be used to provide sequential retraction as the resection
is performed. Traction is exerted on the tongue both
anteriorly and on the opposite side of the tumor in
order to bring the tumor into view (Fig. 28-8). The
tumor is inspected and palpated to ascertain the esti-
mated depth of resection. At least 1 cm of normal
mucosa on all sides of the tumor is drawn on the tongue
(Fig. 28-9) or marked out with the cautery. A 2-0 silk
suture is placed in the anterior margin of resection
before removing the specimen, because once the tumor
is excised orienting the specimen can be diffi cult. The
tumor is excised (Fig. 28-10). Frozen sections are
obtained from the resection bed or from edges of the
specimen. It is preferable that the pathologist come
into the operating room to see the operative site and
to receive face-to-face communication regarding orien-
tation of the specimen.
Local infi ltration anesthesia is not used to avoid
distortion of the tongue, unless the procedure is
being performed under local rather than general
Figure 28-8. The use of a Jennings mouth gag, a right-angled
retractor, and a traction suture in the midline of the tongue provides
adequate exposure for partial glossectomy.
Figure 28-9. The elliptical excision is outlined on the tongue.

222
Section 2
Oral Cavity/Oropharynx
anesthesia. A scalpel or a needle-tipped electrocautery
knife is used to make the mucosal incisions. The surface
margins of resection are easily seen. The deep margin
of resection is usually identifi ed by palpation. A substan-
tial amount of tongue muscle must be taken in order
to get an adequate deep margin of resection, particu-
larly in patients who have endophytic types of tumor
or in whom perineural involvement is known or
suspected.
Branches of the lingual artery are transected during
the surgery. If defi nite branches are identifi ed, they
should be clamped and ligated with 2-0 silk suture
before their division. After inadvertent transection, this
is diffi cult due to vessel retraction into the tongue mus-
culature. Absolute meticulous hemostasis is very impor-
tant, particularly if a tracheotomy is not performed,
to prevent postoperative edema/hematoma. Hemosta-
sis is obtained by clamping all of the bleeding areas and
using fi gure-of-eight 3-0 chromic catgut sutures. If the
resection of musculature is deep, the dead space
should be closed using chromic catgut interrupted
sutures. If the resection is more superfi cial, 3-0 Vicryl
or silk sutures may be used in a vertical mattress
technique, with the deep stitch closing the dead space
and the superfi cial stitch used to approximate and
evert the mucosal edges (Fig. 28-11). A nasopharyngeal
airway may be used to support the airway in the immedi-
ate postoperative period, but if postoperative swelling
is anticipated, a tracheotomy should be performed.
It is usually not necessary to administer intravenous
steroids, because the resection reduces tongue
volume.
Patients with a more extensive cancer may require
a hemiglossectomy, which is carried out in precisely
the same way as previously discussed, except the inci-
sion is begun at the tip of the tongue in the midline
and carried down the median raphe to avoid bleed -
ing. Posterior and lateral incisions are made to accom-
plish the excision. Frozen section examination of
the lesion is carried out to ensure adequacy of
resection.
Oral cavity crippling may result from restriction
of tongue mobility if the patient has a primary closure
of a large wound or one involving signifi cant fl oor of
mouth mucosa. In such situations, a split-thickness skin
graft taken from the ipsilateral thigh at 0.016 to 0.018
inches is used to resurface the tongue. After hemostasis
is obtained, the skin graft is sewn with a “pie-crusting”
technique to the edges of the defect.15 This may be
done in either an interrupted or a “quilting” technique.
During the closure, every other suture is left long in
order to tie over the bolus to provide adequate immo-
bilization of the skin graft.16 Because there is so much
motion of the tongue, it is important to secure the skin
graft well. The quilting technique is used, taking multi-
ple sutures through the skin graft into the substance of
Figure 28-10. The lesion, including muscle, is excised.
A
B
Figure 28-11. A and B, The
wound is closed with vertical mat-
tress sutures.

Chapter 28
Surgery of the Tongue
223
the muscle of the tongue to secure it to the underlying
tissues. A radial forearm free tissue transfer may be
more appropriate for a subtotal glossectomy defect
because it provides more bulk and pliability.
In addition to the reasons stated, if the oral cavity
becomes connected with the neck, this connection may
not be noticed at the time of the excision. If the neck
dissection had already been completed, it would then
be necessary to open the neck again to reconstruct the
fl oor of the mouth to prevent contamination of the
neck.
Following completion of the partial glossectomy,
the surgeon is regowned and gloved and the patient is
prepared and draped for a neck dissection.
Total Glossectomy
Whereas good local control of a small cancer of the
tongue may be achieved by either limited resection or
radiation therapy, the management of T3/T4 squa-
mous cell carcinoma is more complex. These cancers
may arise from the fl oor of the mouth and infi ltrate
posteriorly, effectively destroying much of the substance
of the tongue, and they may involve the mandible,
although they usually spare the larynx. A more diffi cult
cancer to manage is that arising in the base of the
tongue. These cancers are usually poorly differentiated,
ulcerative, and infi ltrative, and they often tend to extend
inferiorly toward the hyoid bone and preepiglottic
space. In these instances, laryngectomy becomes man-
datory even though the larynx is not involved. A larynx-
preserving procedure may be feasible, however, when a
margin is adequate posterior to the tumor.
PATIENT SELECTION
Properly selected patients can be successfully rehabili-
tated after total glossectomy without laryngectomy. Suc-
cessful rehabilitation begins with good patient selection
and preoperative preparation. Postoperative rehabilita-
tion requires the interplay of a highly motivated patient
and a well-coordinated health care team. The speech
pathologist, maxillofacial prosthodontist, dietitian, and
social worker all play important roles in maximizing the
postoperative quality of life for the patient. Because
many of my patients have been effectively rehabilitated
and have returned to a good quality of life, I advocate
preserving the larynx whenever possible if the patient
must undergo total glossectomy.
PREOPERATIVE PLANNING
Preoperative planning is extremely important in this
highly select patient population. Comprehensive
planning should include attention to the approaches
for extirpation of the primary cancer as well as the
accompanying neck dissections and reconstructive
procedures.
Imaging is important in formulating a plan of man-
agement. I prefer CT to evaluate invasion of the man-
dible and cervical lymph node metastasis but I have
come to rely on MRI for evaluating the extent of local
invasion of the cancer. MRI provides more information
about infi ltration into muscle and fascial planes and
helps better evaluate the extent of the lesion and the
possibility of laryngeal preservation (Fig. 28-12). Chest
radiographs should be obtained to rule out distant
metastasis or a second primary tumor. Barium swallow
esophagram is important to rule out a second primary
tumor in the esophagus.
When soft tissue replacement is the only concern,
I rely on regional pedicle fl aps, particularly the pecto-
ralis major myocutaneous fl ap (Fig. 28-13). This fl ap
provides adequate muscle bulk and epithelial coverage,
and is more expeditious than a free fl ap, which requires
Figure 28-12. Magnetic resonance imaging (MRI) scan demon-
strating a large cancer (arrow) infi ltrating the tongue.
Figure 28-13. Reconstruction with a pectoralis major fl ap in a
patient who has undergone total glossectomy.

224
Section 2
Oral Cavity/Oropharynx
A decision must be made as to whether the mandi-
ble, if excised, should be replaced. If mandibular re -
placement is necessary, I use osteocutaneous free fl aps
(see chapters devoted to reconstructive techniques).
Marginal mandibulectomy is occasionally necessary. It
is important to be certain that there is full-thickness
epithelial coverage of the bone to protect patients who
have undergone irradiation from the possibility of
osteoradionecrosis of the mandible.
The speech pathologist should be involved in the
early phase of patient evaluation. She or he must assist
in counseling the patient about the need for swallowing
therapy as well as the need for certain modifi cations in
the speech process that will change the quality and
intelligibility of speech. The maxillofacial prosthodon-
tist should also be involved early in the evaluation
process in order to fully examine the teeth, make rec-
ommendations for extractions when necessary, and
make impressions that will assist in the creation of an
artifi cial tongue prosthesis to help with both speech
intelligibility and swallowing. Consultation with internal
medical specialists is essential to assist in medical evalu-
ation, preoperative therapy, and postoperative manage-
ment. I have found that history taking and evaluation
of the patient’s exercise tolerance are more valuable
than pulmonary function tests in predicting adequate
pulmonary function. It is important that the patient
have good pulmonary function and a good cough to
prevent aspiration pneumonia in the postoperative
course.
Approach to Total Glossectomy
The goal of any surgical approach for patients with
cancer of the head and neck is to cure the cancer.
Patients requiring total glossectomy usually present
with advanced local and regional disease and often
have failed other treatment modalities. As a result,
they may be suffering from severe pain as well as from
impairment of speech and deglutition. Radical surgery
Figure 28-14. Midline mandibulotomy provides exposure for total
glossectomy.
A
B
Figure 28-15. A, The incision is
made along the fl oor of the mouth
and undermines the mandibular
periosteum.
B, The tongue is
released into the wound, and the
incision is made across the vallec-
ula to release the specimen.
a much longer operation. A midline mandibulectomy
provides exposure for total glossectomy (Fig. 28-14).
The incision is made along the fl oor of the mouth. The
tongue is released into the wound and the incision is
made across the vallecula to release the specimen (Fig.
28-15). The specimen, including anterior segment of
the mandible and total glossectomy, is removed for
frozen section analysis (Fig. 28-16).

Chapter 28
Surgery of the Tongue
225
A
B
gastrostomy tube, the latter of which is likely to be
needed for adjuvant therapy. A large wound such as
with total glossectomy with its inherent need for regional
or free fl ap reconstruction creates a wound that may
have already been irradiated. Therefore the tissue is
compromised in its circulation. These are two of the
many reasons that the patient’s nutritional condition
must be maximized in order to maximize successful
healing.
SURGICAL TECHNIQUE
The surgical approach for total glossectomy with pres-
ervation of the larynx is selected after consideration of
several factors:
• The size and location of the tumor
• Invasion of the mandible and the need for
mandibulectomy
• The need for neck dissection
Given these aspects of the selection process, there
are a number of possible approaches to the primary
tumor:
• Transoral
• Transhyoid pharyngotomy
• Midline mandibulotomy and mandibular swing
• Lateral pharyngotomy (Fig. 28-17).
Unless a midline mandibulotomy is to be carried
out (see Fig. 28-14), I prefer to design an apron fl ap
extending from mastoid tip to mastoid tip. Elevation of
this fl ap allows for performance of bilateral neck dissec-
tions. Depending on the staging of the neck, this might
include bilateral radical neck dissections, bilateral selec-
Figure 28-16. A, Postoperative appearance. B, The specimen,
including the anterior segment of the mandible and total
glossectomy.
with the goals of pain relief and rehabilitation of the
speaking and swallowing mechanism often becomes the
main objective, because cure is unlikely for these
patients.
Total glossectomy without laryngectomy was not
always well understood or accepted by the majority of
head and neck surgeons.17 Most surgeons, in fact,
thought that it was not possible to leave the larynx in
place following total glossectomy because breathing
and swallowing would be compromised. Until recent
years, use of this procedure was also limited by the lack
of reliable techniques for immediate reconstruction of
this large defect. Patients who are old or poorly moti-
vated, or who have substantial comorbidities, specifi -
cally poor pulmonary function, should have a total
laryngectomy with the total glossectomy because it is
unlikely that such patients would be able to tolerate the
attendant operation.
One of the most important aspects in preoperative
planning is nutritional assessment for advanced tumors.
Patients who have lost 15 to 20 pounds over the several
months before presentation are usually malnourished
even though they may not appear to be cachectic or
have a particularly low serum albumin. To ensure
proper healing, these patients should undergo rapid
nutritional replenishment, preferably via nasogastric or
Figure 28-17. Total glossectomy carried out via a lateral pharyn-
gotomy approach.

226
Section 2
Oral Cavity/Oropharynx
tive neck dissections, or modifi ed, radical, or selective
neck dissection on the N+ side and a selective neck dis-
section on the N0 side. This leaves the surgeon the
choice of following the neck dissection with any of
the previously mentioned techniques (except midline
mandibulotomy).
The choice of the approach to the oral cavity is
dictated not simply by the extent of the cancer but by
its proximity to other structures. For instance, for the
patient who has a cancer arising in the anterior aspect
of the oral cavity or fl oor of the mouth with involvement
of the anterior mandible, the approach would be as
follows: anterior mandibulectomy, leaving the anterior
segment of the mandible attached to the soft tissues of
the oral cavity; then, proceeding posteriorly along the
fl oor of the mouth, detaching the tumor from the hyoid
bone and then detaching soft tissues of the base of
tongue and oral cavity at the level of the vallecula, thus
preserving the larynx. When the larynx may have to be
removed because of the extent of the tumor, the dissec-
tion should not be carried out through a transhyoid
approach, because the pharyngotomy incision is being
initiated at the line of resection that is the most diffi cult
to evaluate preoperatively. A cancer of the tongue base
would be approached through a midline mandibulot-
omy or a pharyngotomy to give the best exposure to
work from the anterior and lateral boundaries of the
tumor. It is necessary to proceed toward the posterior
(laryngeal) aspect of the dissection in order to increase
the possibility of achieving a free margin of resection;
if this appears to be impossible, the specimen can be
left attached to the larynx, and a total laryngectomy can
be carried out.
Most advanced cancers of the tongue are associated
with clinically identifi able cervical lymph node metasta-
sis requiring neck dissection. The neck dissection is
usually bilateral because these tumors tend to cross the
midline. In patients with advanced cancer of the base
of the tongue who present without identifi able lymph
node metastasis, occult metastasis must be suspected.
Therefore surgical planning must include some form
of neck dissection in most of these patients. Extensive
lesions arising in the anterior portion of the mandible
may also require mandibulectomy, either marginal or
segmental, to ensure adequate tumor excision. Alterna-
tively, mandibulotomy may be required to provide
proper exposure for total glossectomy. Although
patients are counseled about the planned preservation
of the larynx, they must also be forewarned that if the
cancer is more extensive than the preoperative evalua-
tion indicated, the larynx may have to be removed.
Plans must also be made to include adjunctive proce-
dures such as tracheotomy and cricopharyngeal
myotomy, which I believe are important measures in
rehabilitating swallowing following major oral cavity
procedures. Reconstructive alternatives must consider
repair of soft tissue and possibly bone. The choices
for reconstruction include skin graft, regional pedicle
fl aps, or free fl aps (primarily for epithelial coverage) or
an osseocutaneous free fl ap (if a mandibulectomy is
required).
POSTOPERATIVE MANAGEMENT
Patients are treated with intravenous perioperative anti-
biotics over a 24-hour period. Nasogastric tube feedings
are begun when bowel sounds are present. In the
patient who does not have a skin graft, the nasogastric
tube may be removed when the edema has subsided
suffi ciently that the patient can take an adequate
amount of fl uids. Patients who have a skin graft in place
are fed by nasogastric tube or gavage feeding until the
bolster is removed on the fi fth day and the tongue
regains enough mobility thereafter to permit oral
feeding. Frequent suction of the mouth is performed,
and the mouth is cleansed three to four times a day with
gargles of half-strength hydrogen peroxide and saline
solution.
Perioperative antibiotics are used in patients with
major clean-contaminated surgical wounds. Great atten-
tion has to be paid to management of the neck dissec-
tions (see Chapter 78) to make certain that the drains
function properly and to detect the formation of hema-
toma or seroma, chylous leak, or evidence of salivary
drainage in the tubes, which may result from wound
separation in the oral cavity. Dressings are usually
applied to support the wound and to give some com-
pression to the neck fl aps. The postoperative care also
very much depends on the type of reconstruction. Care
of the tracheotomy tube and frequent and vigorous
suctioning of the tracheobronchial secretions are enor-
mously important in protecting the patient’s airway and
helping prevent pneumonia. If there is partial loss of
the fl ap or separation of the intraoral wound with drain-
age into the neck, every effort must be made to separate
the fl ow of saliva from the oral cavity into the neck to
prevent neck infection, particularly in a radical neck
dissection in which desiccation and destruction of the
carotid artery system may otherwise ensue, possibly
leading to carotid rupture.
Patients are downsized to a no. 4 cuffl ess tracheos-
tomy tube and decannulated when they can tolerate
capping of the tracheostomy tube. After the stoma
closes, the patient is given instruction in swallowing and
essentially uses the same type of swallowing technique
as do patients who have undergone supraglottic laryn-
gectomy. The process of swallowing is much down-
graded by a total glossectomy, because it essentially
converts the fi rst and second phases of swallowing into
one phase that is beyond the patient’s control. Recon-
struction after total glossectomy provides an adynamic
conduit between the lips and the pharynx so that the
bolus is literally dumped directly into the pharynx. The
normal protective features of elevation of the larynx are
eliminated because the musculature has been excised.
With the bolus spilling into the pharynx and epiglottis
area, aspiration is a certainty. The cricopharyngeal
myotomy is helpful in trying to eliminate the slight
delay in cricopharyngeal opening, which promotes
spillover into the larynx.
The patient is taught to take food into the mouth
and to do a form of the Valsalva maneuver to close the
glottis. As the involuntary stages of swallowing begin,

Chapter 28
Surgery of the Tongue
227
the patient coughs to clear the glottis and then com-
pletes the swallowing act and exhales. This new tech-
nique of swallowing requires that the patient be able to
comprehend and perform the required maneuver and
have an effective cough. The texture of food is also
important in helping the patient learn to swallow again.
The fi rst attempts at feeding are with a nonpourable,
puréed diet that holds together so that the bolus may
pass more easily into the esophagus without spillage
into the airway, as would be likely with thin fl uids. Once
this aspect is mastered, thin fl uids may be attempted. It
is often benefi cial to use soft drinks with carbonation
because the location of this fl uid is better “felt” by the
patient. Other mechanical adjustments are helpful,
such as gulping the bolus with the neck extended. A
spoon may be used to actually load the meal directly
into the pharynx. This may also be accomplished with
a large syringe and a short rubber feeding tube for
gavage feedings. Eventually, most of these patients will
be able to swallow a thick, puréed diet but not a soft or
a normal diet.
COMPLICATIONS
Complications following partial glossectomy may
include edema and airway obstruction, hematoma,
bleeding, partial slough of the tongue, or loss of skin
graft. All of these complications are preventable by
meticulous attention to surgical craftsmanship.
It is essential to maintain meticulous hemostasis.
The use of the electrocautery in the more superfi cial
tissues, ligatures or clips on the branches of the lingual
artery, and deep hemostatic stitches with 3-0 chromic
catgut suture provide excellent hemostasis. Closure of
the dead space by deep sutures, whether part of a verti-
cal mattress suture or absorbable catgut sutures in the
muscle (depending on the extent of the resection), will
assist in hemostasis. If a hematoma or bleeding from
the tongue develops, it is necessary to return the patient
to the operating room to evacuate the hematoma or to
ligate active blood vessels.
The constant threat in either of these complica-
tions is related to the very real danger of airway obstruc-
tion. I use a nasopharyngeal airway in patients with very
limited glossectomies but always employ tracheotomy in
patients with extensive tongue resection and those who
have a skin graft, because the bolus is bulky and the
sutures tend to tether the mobile parts of the oral cavity,
causing aspiration. The tracheotomy is carried out to
prevent airway obstruction and, just as importantly, to
provide access for suctioning of the tracheobronchial
tree to avoid atelectasis and pneumonia. Necrosis of
residual tongue may occur if tissue is devascularized by
interruption of the vascular supply or by excessive
tension of the skin graft bolus on the remaining tongue,
giving rise to interference of venous return. This can
be prevented by avoiding unnecessary ligation of the
vascular supply to the tongue and by ensuring that the
bolus is not too large or tied too tightly if a skin graft is
used.
PEARLS
• Systematic use of frozen section control is
fundamental to cure of the primary cancer.
• Underestimation of the size of the tumor is avoided
by judicious use of clinical and operative physical
examination and of imaging studies.
• Recurrence of cancer in the neck is avoided by
selective neck dissection at the time of the primary
resection.
• Bimanual examination and MRI scans may be very
useful in the estimation of the extent of depth of the
cancer.
• Total laryngectomy is usually mandatory for older or
debilitated patients undergoing total glossectomy to
prevent aspiration.
PITFALLS
• The development of recurrent pneumonia and lack
of ability to swallow may later necessitate a
completion laryngectomy or laryngotracheal
separation in patients with total glossectomy.
• Failure to properly mark the specimen may lead to
incorrect orientation of the specimen, which may
result in inaccurate pathologic evaluation.
• Failure to institute appropriate adjuvant treatment,
which is determined by aggressive prognostic
clinicopathologic features of the primary cancer
and/or metastatic lymph nodes (i.e., perineural
invasion, close positive margins, large tumor size,
metastasis, extracapsular spread) leads to tumor
recurrence in many of these patients.
• Performance of total glossectomy without
laryngectomy in a patient with poor pulmonary
reserve leads to chronic aspiration and pneumonia.
• Poor healing is predictable in patients who are
malnourished on presentation.
References
1. Myers JN, Elkins T, Roberts D, Byers RM: Squamous cell carci-
noma of the tongue in young adults: Increasing incidence and
factors that predict treatment outcomes. Otolaryngol Head Neck
Surg 122:44-51, 2000.
2. Franceschi D, Gupta R, Spiro RH, Shah JP: Improved survival in
the treatment of squamous carcinoma of the oral tongue. Am J
Surg 166:360-365, 1993.
3. Duvvuri U, Simental AA Jr, D’Angelo G, et al: Elective neck dis-
section and survival in patients with squamous cell carcinoma of
the oral cavity and oropharynx. Laryngoscope 114:2228-2234,
2004.
4. Sparano A, Weinstein G, Chalian A, et al: Multivariate predictors
of occult neck metastasis in early oral tongue cancer. Otolaryngol
Head Neck Surg 131:472-476, 2004.
5. Schiff BA, Roberts DB, El-Naggar A, et al: 2005. Selective vs modi-
fi ed radical neck dissection and postoperative radiotherapy vs
observation in the treatment of squamous cell carcinoma of the

228
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Oral Cavity/Oropharynx
oral tongue. Arch Otolaryngol Head Neck Surg 131:874-878,
2005.
6. O’Brien CJ, Lee KK, Castle GK, Hughes CJ: Comprehensive treat-
ment strategy for oral and oropharyngeal cancer. Am J Surg
164:582-586, 1992.
7. Cooper JS, Pajak TF, Forastiere AA, et al: Postoperative concur-
rent radiotherapy and chemotherapy for high-risk squamous-cell
carcinoma of the head and neck. N Engl J Med 350:1937-1944,
2004.
8. Jalisi S: Management of the clinically negative neck in early squa-
mous cell carcinoma of the oral cavity. Otolaryngol Clin North
Am 38:37-46, viii, 2005.
9. Johnson JT, Leipzig B, Cummings CW: Management of T1 carci-
noma of the anterior aspect of the tongue. Arch Otolaryngol
106:249-251, 1980.
10. Greenberg JS, El Naggar AK, Mo V, et al: Disparity in pathologic
and clinical lymph node staging in oral tongue carcinoma. Impli-
cation for therapeutic decision making. Cancer 98:508-515,
2003.
11. Ferris RL, Xi L, Raja S, et al: Molecular staging of cervical lymph
nodes in squamous cell carcinoma of the head and neck. Cancer
Res 65:2147-2156, 2005.
12. Zanation AM, Sutton DK, Couch ME, et al: Use, accuracy, and
implications for patient management of [18F]-2-fl uorodeoxyglu-
cose-positron emission/computerized tomography for head and
neck tumors. Laryngoscope 115:1186-1190, 2005.
13. El-Sayed IH, Singer MI, Civantos F: Sentinel lymph node biopsy
in head and neck cancer. Otolaryngol Clin North Am 38:145-160,
ix-x, 2005.
14. Kowalski LP, Carvalho AL: Feasibility of supraomohyoid neck
dissection in N1 and N2a oral cancer patients. Head Neck 24:921-
924, 2002.
15. Schramm VL Jr, Myers EN: “How I do it”—head and neck. A tar-
geted problem and its solution. Skin graft reconstruction follow-
ing composite resection. Laryngoscope 90:1737-1739, 1980.
16. Qureshi SS, Chaukar D, Dcruz AK: Simple technique of securing
intraoral skin grafts. J Surg Oncol 89:102-103, 2005.
17. Myers EN: The role of total glossectomy in the management of
cancer of the oral cavity. Otolaryngol Clin North Am 5:343-355,
1972.

Chapter 29
Suprahyoid Pharyngotomy
Eugene N. Myers
The surgical approach to the base of the tongue and
the posterior wall of the oropharynx and hypopharynx
is controversial. Carefully selected benign and malig-
nant tumors arising in these anatomic sites may be sur-
gically resected and reconstructed through a suprahyoid
pharyngotomy approach with excellent opportunity for
tumor clearance, very little morbidity, and very good
cure rates. Fundamental to success, however, is accurate
assessment of the tumor in preoperative planning and
meticulous attention to detail. Treatment results for
tumors of the base of the tongue are measured in terms
of speech and swallowing function; need for a gastros-
tomy or tracheostomy tube; local, regional, and distant
control; and the patient’s quality of life.1
Resection of isolated tumors of the base of the
tongue may be associated with signifi cant morbidity,
primarily impaired speech and deglutition, which may
at times also result in chronic aspiration. These sequelae
are due to decreased tissue volume and fi brosis after
muscle resection. Mandibulectomy procedures are asso-
ciated with additional morbidity beyond that of isolated
tongue base resection, including visible scarring of the
lip, facial depression, loss of support of oral cavity struc-
tures, salivary incontinence, malocclusion, temporo-
mandibular joint pain, nonunion, impairment of the
oral phase of swallowing, and the requirement for major
reconstruction of the defect.2-5 Oncologically sound
mandible-sparing procedures (mandibulotomy) may be
an alternative in selected cases to provide adequate
surgical exposure while avoiding the previously men-
tioned complications.2,6-10
Blassingame,8 in an excellent historical review of
suprahyoid pharyngotomy, stated that Vidal de Cassis,
an anatomist, was the fi rst to describe incising the ante-
rior pharyngeal wall to gain access to the base of the
tongue in 1826. Malgaigne in 1834 proposed a supra-
hyoid incision to approach the epiglottis and base of
the tongue after having carried out autopsy studies.8
Jeremitsch (1895) was the fi rst surgeon to use this
approach.11 His decision was based on observation of a
patient who had attempted suicide by slashing his neck.
During the attempt, a laceration was produced that
approximated a suprahyoid pharyngotomy. Jeremitsch
noted that bleeding was minimal, no nerves were
severed, the airway was good, and the patient healed
favorably. Hofmann reported good success with this
approach in the early 1900s.12 Unfortunately, Grün-
wald, an infl uential writer at the time, did not share this
success,13 and the technique was temporarily aban-
doned. Blassingame speculated that the lack of success
was due to Grünwald’s failure to suspend the larynx.
Even after Blassingame’s article in 1952, surgeons were
reluctant to perform either the suprahyoid or the lateral
pharyngotomy introduced by Orton.10 It was believed to
be oncologically unsound because of poor exposure
and violation of the preepiglottic space.4,14,15 It should
also be recalled that these attempts took place before
the advent of perioperative prophylaxis.
Barbosa, of Brazil, in 1974 included the classic
description of the technique of suprahyoid pharyngot-
omy in his textbook.16 Moore and Calcaterra2 reported
successful management of T3 cancer of the base of the
tongue with a version of the subhyoid approach pro-
posed by Rethi.17
The suprahyoid approach for T1/T2 squamous cell
carcinoma of the base of the tongue has been used in
our department for many years and has provided an
excellent cure rate, normal speech, good cosmesis, and
swallowing without clinical evidence of aspiration.18 In
a series of 13 patients with T1/T2 squamous cell carci-
229

230
Section 2
Oral Cavity/Oropharynx
noma of the base of the tongue, suprahyoid pharyn-
gotomy was used in every case. Patients with lymph
node metastasis underwent radical neck dissection, and
many patients received adjuvant radiation therapy.
Patients in whom extracapsular spread was demon-
strated received adjuvant chemotherapy. All of the
patients were decannulated before discharge no later
than 3 weeks after surgery. All patients were able to eat
a regular diet 2 months after discharge. Long-term
follow-up revealed stable weight after an initial weight
loss. No patient required a completion laryngectomy
for chronic aspiration. Speech was found to be easily
understood in all of the patients in this series. All these
patients have a minimum of 2-year follow-up with no
evidence of local recurrence of tumor. A paper by
Zeitels and coworkers19 showed strikingly similar results
when this technique was used primarily for limited
lesions of the tongue base.
This approach is also used in the management of
benign and malignant salivary gland tumors of the base
of the tongue, as well as early squamous cell carcinomas
of the posterior pharyngeal wall, with similar good
results. It should be noted that we now manage the
majority of early squamous cell carcinomas of the base
of the tongue with nonsurgical organ preservation pro-
tocols and have achieved excellent outcomes. Excision
via suprahyoid pharyngotomy is reserved for benign
tumors or those that are not radiosensitive or fail non-
operative therapy.
PATIENT SELECTION
Suprahyoid pharyngotomy is an excellent approach
when combined with neck dissection for the treatment
of T1/T2 lesions of the base of the tongue. It may also
be applied without neck dissection in patients with
benign or low-grade malignant salivary gland tumors.
Tumors of the tongue excised by suprahyoid pharyn-
gotomy should ideally be limited to the tongue base,
posterior to the circumvallate papillae. Involvement of
the lateral pharyngeal wall or tonsil may require exten-
sion of the approach, such as lateral pharyngotomy, for
adequate exposure. Tumor resection anterior to the
circumvallate papillae is a relative contraindication to
this approach because the defect would be diffi cult to
close primarily, the anterior margin of resection may be
compromised, and postoperative diffi culties with speech
and swallowing will be proportionately more severe.
This procedure should not be used for tumors of
the vallecula that involve the lingual surface of the
epiglottis. Moore and Calcaterra2 reported oncologic
success in T3 squamous cell cancer of the tongue base
with this approach together, in some cases, with supra-
glottic laryngectomy. We have tended not to use this
technique because of the considerable problems that
patients have with delayed deglutition and chronic
aspiration.
Excision of cancer of the posterior wall of the oro-
pharynx or hypopharynx may be accomplished with this
technique. Primary closure of the mucosa of the poste-
rior pharyngeal wall to the prevertebral fascia or the use
of a split-thickness skin or dermal graft will complete
the reconstruction.
PREOPERATIVE PLANNING
Correct preoperative staging is essential to determine
whether suprahyoid pharyngotomy is the best surgical
approach for early squamous cell carcinoma, adenocar-
cinoma, or benign tumors of the base of the tongue or
posterior pharyngeal wall. Magnetic resonance imaging
(MRI) has proved to be the most sensitive modality for
evaluating tumors involving the base of the tongue
because of the excellent soft tissue defi nition that it
provides. Gross invasion of the preepiglottic space and
the depth of infi ltration into the base of the tongue may
be determined by obtaining sagittal MRI scans of the
tongue base–larynx complex. The high signal intensity
of preepiglottic fat can usually be distinguished from
the dense fi bers of the hyoepiglottic ligament, tongue
base musculature, lingual lymphoid tissue, and cancer.19
Resectability of tumors of the posterior pharyngeal wall
is determined by size and fi xation. A barium pharyngo-
esophagogram can often assist in assessing mobility
of these tumors. However, physical examination, espe-
cially palpation, remains the most important aspect of
the evaluation. In most instances, endoscopy under
general anesthesia will be required at a separate proce-
dure performed at the time of biopsy.
In the event that the tumor is larger than antici-
pated and requires more exposure, alternative proce-
dures are described in Chapter 28.
The structure of the oropharynx and hypopharynx
plays a key role in swallowing. Temporary aspiration is
a predictable postoperative occurrence. Accordingly,
the patient’s functional status, especially as it pertains
to cardiopulmonary performance, must be considered
in patient selection. Patients with severe pulmonary
disease may require either laryngotracheal separation
or laryngectomy to protect them from life-threatening
postoperative aspiration. Many of these patients benefi t
from placement of a percutaneous endoscopic gastros-
tomy (PEG) or G tube at the time of surgery. As in all
patients with head and neck cancer, dental evaluation
with extraction or restoration of diseased teeth is
required, usually at a separate procedure.
SURGICAL TECHNIQUE
Suprahyoid pharyngotomy is always carried out under
general anesthesia, and a tracheotomy is performed.
When appropriate, the procedure is performed in con-
junction with either unilateral or bilateral neck dis-
section. Intravenous perioperative antibiotics are
administered. All patients must undergo preoperative
endoscopy with palpation as noted in the previous
section. This is usually performed as a separate proce-
dure at the time of biopsy.
A superiorly based apron fl ap is outlined, and the
fl ap is elevated. The suprahyoid muscles are sharply
separated from the hyoid bone. Care must be taken
laterally around the greater cornu of the hyoid bone to

Chapter 29
Suprahyoid Pharyngotomy
231
A
B
Figure 29-1. A, The tongue is grasped
with a tenaculum after the suprahyoid
musculature has been separated from
the hyoid bone. B, Approach depicted
from the lateral view.
avoid injury to the hypoglossal nerve and lingual artery.
Detailed illustrations of this step can be found in
Chapter 49. The dissection is facilitated by grasping the
hyoid bone with a tenaculum and pulling it into the
wound. Superior retraction of the separated suprahyoid
tongue musculature will defi ne the hyoepiglottic liga-
ment, which extends from its broad hyoid origin to its
narrow insertion into the epiglottis. The mucosa of the
vallecula is loosely attached to the epiglottic cartilage
and is elevated completely off the lingual surface of the
epiglottis as far as the tip. This provides an additional
inferior margin of resection in the vallecula. An inci-
sion through the mucosa just superior to the tip of the
epiglottis provides entry into the pharynx. A broad
right-angled retractor is inserted above the tongue base,
and traction is exerted on the hyoid bone while the
pharyngotomy is completed. The hypoglossal nerves
and lingual arteries are identifi ed and retracted later-
ally (Fig. 29-1). A tenaculum is placed on the tongue
base, and the tongue base is drawn into the wound (Fig.
29-2). After fi nal assessment, the lesion is excised from
the tongue base (Fig. 29-3). If disease extends to the
tonsillar fossa, the incision can be extended to resect
this area.
After the tumor has been removed and adequacy
of the resection has been verifi ed by frozen section
evaluation, a multilayer primary closure of muscle and
mucosa is carried out (Fig. 29-4). There has been no
need in our series of cases to use a skin graft or any type
of fl ap.
A nasogastric tube is inserted and the cervical
wound is closed over Hemovac drains. Special attention
must be paid to closing the subcutaneous tissues to the
strap muscles around the tracheostoma to prevent con-
tamination of the cervical wound when the patient
coughs. Safety features for the tracheotomy include the
placement of traction sutures (see Chapter 68) and
sewing the neck plate of the tracheostomy tube to the
surrounding skin. Tracheostomy tape is not used in
cases in which a large apron fl ap is used to avoid inter-
fering with circulation in the fl ap.
The technique is modifi ed in patients in whom the
pharyngotomy is used to approach a lesion of the poste-
rior pharyngeal wall. After the pharyngotomy is made,
the tumor is identifi ed and excised from the posterior
pharyngeal wall. Frozen section control is carried out,
and hemostasis is obtained. There are several possibili-
ties for reconstruction of the defect. The temptation to
simply close the defect primarily must be avoided
because primary closure will narrow the pharynx and
inevitably result in dysphagia with aspiration. Rather,
closure must maintain the preoperative pharyngeal cir-
cumference, which can be achieved by simply sewing the
mucosa either to the posterior muscular wall, if this
structure remains after resection, or more commonly, to
the prevertebral fascia. Alternative methods include the
use of a skin or dermal graft. The graft is immobilized
with a bolus of medicated gauze, which must be removed
endoscopically any time after the fi fth postoperative
day. If this technique is used, care is necessary to avoid
disrupting the pharyngotomy closure when the bolus is
removed. A nasogastric feeding tube is inserted.
POSTOPERATIVE MANAGEMENT
Our patients receive routine postoperative care for tra-
cheostomy and care of the cervical wound as described
in Chapters 68 and 78. Patients are fed by nasogastric
tube for approximately 7 to 10 days. Decannulation is
achieved before removal of the nasogastric tube and
initiation of oral feeding. Initial feedings take place
under the guidance of our speech pathologist, who
evaluates the patient’s readiness and instructs the
patient in swallowing strategies. During this initial

232
Section 2
Oral Cavity/Oropharynx
Figure 29-2. Excellent exposure of tumors limited to the
tongue base is achieved with this approach. The hypoglossal
nerves and lingual arteries are retracted.
A
B
Figure 29-3. A, Schematic drawing demonstrating the tissue to be excised. B, Lateral schematic of the area to be removed.

Chapter 29
Suprahyoid Pharyngotomy
233
retraining of the swallowing act, the speech pathologist
sits with the patient at mealtimes and helps the patient
attain the technique necessary for swallowing. There
are no special aspects of management for the pharyn-
gotomy wound.
In our series,18 a small pharyngocutaneous fi stula
developed in three of the patients, all of which healed
within 10 days. Pneumonia developed in one patient
immediately postoperatively, but it resolved quickly
with antibiotics. All patients were decannulated and
ingesting an oral diet before discharge.
Figure 29-4. The defect can be reapproximated
primarily.
PEARLS
• Direct laryngoscopy and imaging studies,
particularly MRI, are fundamental for accurate
staging, but palpation is the most accurate means
of evaluating the base of tongue.
• This approach should be limited to early (T1/T2)
cancer of the base of tongue or cancer of the
posterior pharyngeal wall to maximize tumor
clearance and limit diffi culty with deglutition.
• Excellent exposure for early tumors of the base of
the tongue, as well as the posterior pharyngeal wall,
is provided by this approach.
• Limited resection of tissue plus preservation of both
hypoglossal nerves leads to early return of functional
deglutition without aspiration.
• The apron fl ap that is used for this procedure lends
itself to the performance of bilateral neck dissection
when appropriate.
PITFALLS
• Lack of accurate preoperative assessment will lead
to an inappropriate plan of management.
• Evaluation under anesthesia as well as imaging is
required for assessment.
• Underestimating the size and location of the tumor
(e.g., extension to the vallecula, tonsil, supraglottic
larynx) will lead to positive margins or an inability to
remove the tumor entirely.
• The patient with a large tumor of the posterior
pharyngeal wall will not be a candidate for this
procedure.
• Recurrence of tumor in the neck may take place if
elective neck dissection is not included in the initial
procedure.
• Lack of frozen section control may lead to positive
margins and an inability to cure the patient.
References
1. Gopalan KN, Primuharsa Putra SH, Kenali MS: Suprahyoid phar-
yngotomy for base of tongue carcinoma. Med J Malaysia 58:617-
620, 2003.
2. Moore DM, Calcaterra TC: Cancer of the tongue base treated by
a transpharyngeal approach. Ann Otol Rhinol Laryngol 99:300-
303, 1990.
3. Sessions DB: Surgical resection and reconstruction for cancer of
the base of the tongue. Otolaryngol Clin North Am 16:309-329,
1983.
4. DeSanto LW, Thawley SE: Treatment of tumors of the orophar-
ynx. In Thawley S, Panje W (eds): Comprehensive Management
of Head and Neck Tumors. Philadelphia, WB Saunders, 1987,
pp 699-755.
5. Babin R, Calcaterra TC: The lip-splitting approach to resection
of oropharyngeal cancer. J Surg Oncol 8:433-436, 1976.

234
Section 2
Oral Cavity/Oropharynx
6. Barrs DM, DeSanto LW, O’Fallon WM: Squamous cell carcinoma
of the tonsil and tongue base region. Arch Otolaryngol 105:479-
485, 1979.
7. Stanley RB: Mandibular lingual releasing approach to oral and
oropharyngeal carcinomas. Laryngoscope 94:596-600, 1984.
8. Blassingame CD: The suprahyoid approach to surgical lesions at
the base of the tongue. Ann Otol Rhinol Laryngol 61:483-489,
1952.
9. Weisberger EC, Lingeman RE: Modifi ed supraglottic laryngec-
tomy and resection of lesions of the tongue base. Laryngoscope
93:20-25, 1983.
10. Orton HB: Lateral transhyoid pharyngotomy. Arch Otolaryngol
12:320-332, 1930.
11. Jeremitsch R: Pharyngotomia suprahyoides. Arch F Klin Chir
49:793-802, 1895.
12. Hofmann M: Pharyngotomis suprahyoidea traversa. Arch F Klin
Chir 83:308-332, 1907.
13. Grünwald L: Pharyngotomia suprahyoides. Zentralbl F Chir
33:972, 1906.
14. Whicker JH, DeSanto LW, Devine KD: Surgical treatment of squa-
mous cell carcinoma of the base of tongue. Laryngoscope
82:1853-1860, 1972.
15. Schechter GL, Sly DE, Roper AL, et al: Set-back tongue fl ap for
carcinoma of the tongue base. Arch Otolaryngol 106:668-671,
1980.
16. Barbosa JF: Surgical Treatment of Head and Neck Tumors. New
York, Grune & Stratton, 1974.
17. Rethi A: A new method of transverse pharyngotomy. J Laryngol
Otol 62:440-446, 1948.
18. Weber PC, Johnson JT, Myers EN: The suprahyoid approach for
squamous cell carcinoma of the base of the tongue. Laryngo-
scope 102:637-640, 1992.
19. Zeitels SM, Vaughan CW, Ruh S: Suprahyoid pharyngotomy for
oropharynx cancer including the tongue base. Arch Otolaryngol
Head Neck Surg 117:757-760, 1991.

Chapter 30
Lateral Pharyngotomy
Ricardo L. Carrau and Ryan J. Soose
Tumors of the base of the tongue and hypopharynx are
often silent until they have attained considerable size,
and regional metastasis has frequently occurred by the
time of diagnosis. In advanced-stage cancer, the thera-
peutic plan most often involves combined chemoradia-
tion therapy, but extirpative surgery with postoperative
irradiation remains a viable alternative as a primary
treatment modality or as salvage treatment of persistent
or recurrent tumors.
The surgical approach must provide adequate
exposure to visualize the entire cancer and allow wide
resection. Surgical approaches commonly used for
cancer of the base of the tongue include transoral trans-
endoscopy, mandibulotomy, mandibulectomy, trans-
hyoid pharyngotomy, and lateral pharyngotomy.
Cancer of the hypopharynx is commonly resected with
concurrent laryngectomy. Large cancers may require
total pharyngectomy, whereas some limited lesions may
be resected via lateral pharyngotomy. Advances in
transendoscopic techniques have reduced the indica-
tions for this technique; nonetheless, it remains an
important tool in the surgical armamentarium. This
chapter discusses the diagnostic, technical, and post -
operative factors related to lateral pharyngotomy. Other
approaches are discussed in Chapters 29 and 34.
The lateral pharyngotomy approach was fi rst
reported by Cheever in 1878, who used it to remove a
tumor of the tonsil.1 The approach was popularized by
Trotter in England and Orton in the United States, who
added their own modifi cations to the technique.2,3
Historically, lateral pharyngotomy was used as an
effective approach to selected squamous cell carcino-
mas of the oropharynx and hypopharynx.4,5 It also
remains a rare option for access to arteriovenous mal-
formations of the base of the tongue or benign tumors
of the larynx, pharynx, or retropharyngeal space (e.g.,
pleomorphic adenoma or neurofi broma).6-9 Other cir-
cumstances in which the lateral pharyngotomy approach
has reportedly been used include removal of a complex
foreign body, treatment of severe pharyngeal stenosis,
and transposition of a lingual thyroid.10-12
PREOPERATIVE ASSESSMENT
Clinical Evaluation
Cancer of the base of the tongue and hypopharynx
often does not produce symptoms until it reaches the
deep tissues of the tongue and pharynx or until the
bulk produces mechanical obstruction. Symptoms
include dysphagia, odynophagia, globus sensation,
blood in the saliva, trismus, and otalgia. Less frequently,
a patient will have a mass in the neck as the chief com-
plaint. These symptoms are nonspecifi c; however, pain
and odynophagia suggest invasion of the deeper planes
of the oropharynx, and trismus suggests invasion of the
masticator muscles or mandible.
Thorough examination of the head and neck,
including visualization of the pharynx and larynx with
indirect or fi beroptic pharyngolaryngoscopy, reveals
the cancer in the great majority of cases. Bimanual pal-
pation is essential to assess the extent of the cancer, to
detect submucosal extension, and to differentiate tumor
from the lingual tonsils. Palpation also helps evaluate
the mobility of the tumor.
Imaging
Computed tomography (CT) scanning of the orophar-
ynx and neck may delineate the extent of the lesion and
is especially useful in assessing erosion of the cortex of
the mandible. CT scanning also evaluates the presence
of lymphatic metastasis. We have adopted the use of
fused positron emission tomography (PET)/CT to eval-
uate extension of the primary and the presence of
metastasis (Fig. 30-1).
Magnetic resonance imaging (MRI) better defi nes
the extent of lesions of the base of the tongue and
extension into the bone marrow of the mandible.
235

236
Section 2
Oral Cavity/Oropharynx
Nevertheless, MRI is more time consuming and expen-
sive. The time required to complete the study leads to
swallowing and movement artifact, which downgrades
resolution of the images. In addition, approximately
10% of patients will not tolerate MRI because of anxiety
or claustrophobia. Either technique allows assessment
of the cervical and retropharyngeal nodes.
A barium swallow esophagogram and a chest radio-
graph are recommended to rule out a second primary
cancer. In addition, videofl uoroscopy is best to ascer-
tain the presence of fi xation of the posterior wall of the
pharynx to the prevertebral fascia. Patients with chronic
obstructive pulmonary disease or other parenchymal
disease who have advanced cancer (i.e., T3, T4) require
a CT scan of the chest. The chest radiographs of these
patients are very diffi cult to evaluate and may be associ-
ated with a signifi cant number of false-positive and
false-negative results. Patients with metastasis in zones
4 or 5 of the neck have a higher risk of metastasis to
the mediastinum and lungs; therefore, they are also
evaluated with a CT scan of the chest or, as previously
mentioned, a PET/CT fusion study.
Endoscopy
Endoscopic examination under general anesthesia
complements the clinical examination and imaging
evaluation. Bimanual examination of the primary site
and palpation of the neck are repeated under the para-
lyzing effects of general anesthesia. Palpation under
general anesthesia often yields better assessment of the
extent of the lesion and may reveal lymphadenopathy
that could not be palpated during the offi ce
examination.
Direct rigid laryngoscopy allows better assessment
of the vallecula and piriform sinuses than can be
achieved with fl exible laryngoscopy. Laryngoscopy also
allows the surgeon to evaluate for the presence of fi xa-
tion to the prevertebral fascia by assessing the mobility
of the posterior pharyngeal mucosa. Esophagoscopy
adds sensitivity and specifi city to the esophagogram to
rule out a second primary cancer in the esophagus.
Bronchoscopy is not warranted unless a lesion is
detected on the chest radiograph. Biopsies are per-
formed as needed during the pertinent endoscopic
procedure.
In selected cases, panendoscopy may be performed
just before the extirpative surgery (i.e., single stage) to
spare the patient a second visit to the operating room
and a second anesthesia. The single-stage approach
is also more cost-effective. However, this approach
requires that the offi ce examination and imaging
provide suffi cient information to defi ne the extent of
resection and reconstruction needed. It also requires
that the patient, family, and surgeon be comfortable
with this concept.
PATIENT SELECTION
Lateral pharyngotomy is used most commonly to expose
benign and malignant tumors of the lateral and poste-
rior walls of the oropharynx and hypopharynx, as well
as those arising at the base of the tongue and postcri-
coid areas.13-16 Benign tumors of the supraglottis, such
as adenomas and cystic lesions, may also be approached
through a lateral pharyngotomy. Most of these lesions,
however, are amenable to transendoscopic approaches.
An extremely rare indication for lateral pharyngotomy
is a complex or sharp foreign body that cannot be
retrieved transendoscopically.
Tumors of the base of tongue involving the vallec-
ula are not amenable to a transhyoid approach (see
Chapter 29) and may be resected through a lateral
pharyngotomy. Superfi cial lesions, requiring resection
of the mucosa only, that may be reconstructed with a
split-thickness skin graft can be approached with a con-
tralateral pharyngotomy. This provides direct visualiza-
tion of the lesion and enough access to suture and
bolster the skin graft. Alternatively, the remaining
mucosa may be tacked down to the prevertebral fascia
and the defect left to heal by secondary intention.
Patients with cancer who require a supraglottic or
total laryngectomy or in whom resection involves more
than a third of the pharyngeal circumference are not
candidates for a lateral pharyngotomy approach.
However, lateral pharyngotomy may be combined with
another approach, such as median mandibulotomy or
a pull-through approach, to provide optimal visu -
alization for extirpation of a large cancer of the oro -
pharynx.
SURGICAL PROCEDURE
A tracheotomy is usually performed at the beginning of
surgery because lateral pharyngotomy produces signifi -
Figure 30-1. Positron emission tomography–computed tomogra-
phy image showing increased uptake of fl uorodeoxyglucose in the
left base of the tongue and lateral pharyngeal wall suggestive of
recurrence.

Chapter 30
Lateral Pharyngotomy
237
A
B
Figure 30-2. A, A horizontal incision is placed over the thyrohyoid
membrane. Whenever feasible, the skin incision should be placed in
a skin crease. The incision can be extended medially and laterally to
facilitate neck dissection. B, The skin fl aps have been elevated to
expose the laryngotracheal complex and the contents of the carotid
sheath.
cant pharyngeal edema and dysphagia, which may lead
to airway obstruction and aspiration. In addition, an
orotracheal tube may interfere with exposure of the
tumor.
A horizontal incision that follows a midneck skin
crease is extended through subcutaneous tissue and the
platysma muscle. When neck dissection is necessary, the
incision can be designed to provide adequate access to
the entire cervical area (Fig. 30-2). If a vertical limb is
needed to provide better exposure of the posterior
aspect of the neck, the trifurcation should consist of
three 120-degree angles and be placed as far posterior
as possible (i.e., away from the carotid artery).
Subplatysmal fl aps are elevated to the extent appro-
priate for the intended procedure. If neck dissection is
necessary, the inferior fl ap is elevated to the level of the
clavicle. Superiorly, the fl ap is elevated beneath the
platysma until the inferior edge of the submandibular
gland is identifi ed. At this time the plane of dissection
is carried deep to the submandibular gland. The facial
vein is dissected, ligated, and transected, and the distal
stump is retracted superiorly with the cervical fl ap.
These two latter maneuvers protect the marginal man-
dibular nerve. Malignant tumors generally require some
type of neck dissection, as discussed in Chapter 78. The
supraomohyoid anatomy will be visualized clearly after
neck dissection, including zones 1, 2, and 3. Stern has
provided an excellent discussion of the anatomy of this
area.17
The sternocleidomastoid muscle is dissected from
the strap muscles to expose the carotid sheath. The
carotid sheath and its contents are retracted laterally to
allow identifi cation of the inferior constrictor muscle,
as well as the superior pole of the thyroid gland and its
vascular pedicle (Fig. 30-3). A double-pronged retractor
is placed at the posterior edge of the thyroid ala to
facilitate the dissection. The dissection is continued
superiorly to identify the origin of the superior thyroid
and superior laryngeal artery. Gentle retraction and
mobilization of the carotid bulb and external carotid
artery expose the superior laryngeal nerve, which travels
medial to the internal carotid artery. The entire supe-
rior laryngeal neurovascular bundle is easily identifi ed
after this maneuver. The hypoglossal nerve should be
identifi ed cephalad to the superior laryngeal nerve as
it curves anteriorly between the internal carotid artery
and the internal jugular vein into the submandibular
triangle.
The stage and site of origin of the primary cancer
dictate the extent of the lateral pharyngotomy. Lesions
of the oropharynx require a higher lateral pharyngot-
omy than do lesions of the hypopharynx. A lateral phar-
yngotomy can be extended superiorly to expose
the nasopharynx or inferiorly to expose the cervical
esophagus.
A high pharyngotomy requires cephalic retraction
of the laryngeal and hypoglossal nerves; however, the
mobility of the superior laryngeal nerve is limited, even
after skeletonization, and on rare occasion this nerve
must be transected to provide adequate exposure.
Mobilization of the soft tissues may be upgraded by
removing the lateral third of the ipsilateral hyoid bone
and superior cornu of the thyroid cartilage and tran-
secting the thyrohyoid ligament. To enter the orophar-
ynx, the incision is best carried out by placing the index
fi nger along the base of the tongue, inferior and poste-
rior to the tonsillar fossa, and away from the tumor. The
fi nger tenses the middle constrictor muscle and mucosa,

238
Section 2
Oral Cavity/Oropharynx
A
B
Figure 30-3. A, The contents of the carotid sheath and the sterno-
cleidomastoid muscle are retracted laterally to expose the inferior
constrictor muscle. The superior laryngeal nerve crosses anteriorly,
medial to the carotid bifurcation. The hypoglossal nerve (XII) is
shown in its horizontal position. The site for the inferior constrictor
myotomy, at the posterior edge of the thyroid ala, is marked with a
dotted line. B, In this axial view, the arrow shows the surgical route to
expose the inferior constrictor muscle.
thereby facilitating performance of the pharyngotomy,
and ensures that the incision is not carried through the
tumor (Fig. 30-4). The posterior belly of the digastric
muscle is retracted by superior and anterior dissection.
If necessary, it can be sacrifi ced for oncologic
margins.
Lesions located in the superior aspect of the hypo-
pharynx (i.e., posterior pharyngeal wall) may require
inferior extension of the pharyngotomy. The inferior
constrictor muscle is incised over the posterior edge of
A
B
Figure 30-4. A, The superior laryngeal nerve is retracted upward,
and an inferior constrictor myotomy is performed to expose the
mucosa of the piriform sinus and the lateral hypopharynx. B, Axial
view showing the surgical route (arrow) after myotomy.
the thyroid ala to expose the mucosa of the piriform
sinus, which is then dissected from the medial facet of
the thyroid ala. The piriform sinus pharyngotomy is
opened with sharp instruments or cautery as the surgeon
and assistant maintain the mucosa under tension
(Fig. 30-5).
After the extirpative surgery, a nasogastric tube is
placed and the pharyngotomy is repaired with a double-
layer technique. The mucosa is closed with an inverting
stitch (e.g., Connell) of absorbable suture. The inferior
and middle constrictor muscles are reapproximated

Chapter 30
Lateral Pharyngotomy
239
with interrupted simple or fi gure-of-eight sutures. A
suction drain is left in place, and the cutaneous wound
is repaired with a multiple-layer closure.
If the pharyngotomy cannot be closed primarily,
the surgeon will have to choose among other soft tissue
reconstructive techniques, such as skin grafting, pedi-
cled fl aps, and microvascular free fl aps. Skin grafting is
reliable, is associated with minimal donor morbidity,
and provides thin, supple tissue. Nevertheless, it lacks
bulk (e.g., it is not appropriate for base of the tongue
reconstruction) and is diffi cult to suture through a
lateral pharyngotomy (suturing is easier if the pharyn-
gotomy is combined with a mandibulotomy or pull-
through approach). Pedicled fl aps, such as the pectoralis
major myocutaneous fl ap (PMMF), are reliable and
easy to harvest. The main disadvantages of a PMMF are
its tendency to sag with gravity (i.e., increasing the
tension at the suture line) and its excessive bulk. A
PMMF obliterates the lateral oropharyngeal sulcus and
may form a ledge that directs the bolus into the larynx,
thereby leading to dysphagia and aspiration. The use of
a pectoralis myofascial graft may circumvent this
problem and it is most suitable for base of the tongue
defects or lateral pharyngeal wall defects when the
carotid is at risk of becoming exposed to the pharyngeal
lumen.
Microvascular free fl aps, such as the radial forearm
fl ap, provide supple tissue and adequate carotid cover-
age, thus making them ideal for large posterior or
lateral pharyngeal defects. Nonetheless, their use
requires microsurgical expertise, prolongs the surgical
time signifi cantly, and results in increased morbidity
and mortality. At present, all these methods fail to reha-
bilitate the swallowing mechanism because they lack
motor function and sensation.
POSTOPERATIVE CARE
The patient is transferred to an intermediate care unit
for postoperative monitoring. The head of the bed is
elevated 30 to 45 degrees to diminish wound edema
and decrease the probability of gastropharyngeal refl ux
or vomiting. Other maneuvers recommended to prevent
gastropharyngeal problems include intravenous proton
pump inhibitors and continuous low-pressure suction-
ing of the nasogastric tube. Broad-spectrum prophylac-
tic perioperative antibiotics are continued to complete
24 hours of treatment after surgery.
The suction drains are maintained at 80 mm Hg via
wall suction. These drains are kept in place until drain-
age diminishes to less than 20 mL per 24 hours.
The patient is administered humidifi ed air or
oxygen via a tracheotomy mask. The tracheotomy is
suctioned frequently, and wound care is provided three
to four times daily. The tracheotomy cuff is defl ated the
day after surgery, unless the patient is suffering signifi -
cant aspiration. The tracheotomy tube is kept in place
until the patient is able to handle the saliva and secre-
tions. Once the patient swallows the saliva, the tube can
be downsized to a no. 4 tube, plugged, and then
removed within a 24- to 72-hour period. The patient is
not fed by mouth until the tracheotomy tube is removed.
Until then, enteral nutrition is maintained through a
nasogastric tube.
COMPLICATIONS
Infection or Pharyngocutaneous Fistula
Diagnosis of infection or fi stula requires the presence
of purulent exudate or saliva arising from the wound.
This is important because erythema, edema, and fever
are very common in the postoperative period after head
and neck surgery and may lead to overdiagnosis and
unnecessary treatment.
A
B
Figure 30-5. A, Extirpation of cancer of the base of the tongue (T)
through a lateral pharyngotomy approach (arrows). The thyroid car-
tilage’s posterior edge (arrowheads) and the epiglottis (e) mark the
medial boundary of the exposure. B, Base of the tongue lesion
exposed through a lateral pharyngotomy.

240
Section 2
Oral Cavity/Oropharynx
The development of infection or a pharyngocuta-
neous fi stula requires initial treatment with systemic
antibiotics and adequate drainage to prevent sepsis.
The latter is probably the most important factor in -
fl uencing the outcome of a postoperative wound
infection.
Infection occurring while the suction drains are still
in place will not require opening of the wound as long
as the drains are functional and the wound appears to
be well drained (i.e., no abscess). If the drains have
been removed, the wound should be opened in a
manner that promotes drainage away from the carotid
artery.
Although most salivary fi stulas heal spontaneously
after conservative treatment, some require closure with
local or pedicled fl aps. This problem is more common
when the extirpative surgery requires signifi cant sacri-
fi ce of pharyngeal mucosa, which narrows the pharyn-
geal lumen and adds tension to the wound closure.
Causes of nonhealing, such as a foreign body, persistent
tumor, wound tension, malnutrition, and inadequate
blood supply because of previous surgery, radiation
therapy, or microvascular disease, should be kept in
mind and eliminated accordingly before planning any
complex reconstruction.
References
1. Cheever DW: Cancer of the tonsil: Removal of the tumor by
external incision. (A second case.) Boston Med Surg J 99:133-139,
1878.
2. Trotter W: Operations for malignant disease of the pharynx. Br
J Surg 16:482-495, 1928.
3. Orton HB: Lateral transthyroid pharyngotomy. Trotter’s opera-
tion for malignant conditions of the laryngopharynx. Arch Oto-
laryngol 12:320-338, 1930.
4. Holsinger FC, Motamed M, Garcia D, et al: Resection of selected
invasive squamous cell carcinoma of the pyriform sinus by means
of the lateral pharyngotomy approach: The partial lateral phar-
yngectomy. Head Neck 28:705-711, 2006.
5. Byers RM: Anatomic correlates in head and neck surgery. The
lateral pharyngotomy. Head Neck 16:460-462, 1994.
6. Dubey SP, Banerjee S, Ghosh LM, et al: Benign pleomorphic
adenoma of the larynx: Report of a case and review of 20 addi-
tional cases in the literature. Ear Nose Throat J 76:548-550,
1997.
7. Yucel EA, Guldiken Y, Ozdemir M, et al: Plexiform neurofi broma
of the larynx in a child. J Laryngol Otol 116:49-51, 2002.
8. Fuse T, Yoshida S, Sakakibara A, et al: Angiomyoma of the retro-
pharyngeal space. J Laryngol Otol 112:290-293, 1998.
9. Righi PD, Bade MA, Coleman JJ, et al: Arteriovenous malforma-
tion of the base of tongue: Case report and literature review.
Microsurgery 17:706-709, 1996.
10. Punke C, Dommerich S, Pau HW: Lateral pharyngotomy—a rare
method of access for removing foreign bodies from the upper
third of the esophagus. HNO 137-139, 2006.
11. Haller JR, Gray SD: Severe pharyngeal stenosis treated with infe-
riorly based sternocleidomastoid myocutaneous fl ap. Ann Otol
Rhinol Laryngol 108:731-734, 1999.
12. Rojananin S, Ungkanont K: Transposition of the lingual thyroid:
A new alternative technique. Head Neck 21:480-483, 1999.
13. Harris PF, Rosenfeld L, Ward PH: Lateral pharyngotomy approach
for lesions of the base of the tongue, pharynx and larynx. South
Med J 61:1276-1280, 1968.
14. Ferguson GB: Experiences in lateral pharyngotomy. Laryngo-
scope 86:1626-1632, 1976.
15. Moore DM, Calcaterra TC: Cancer of the tongue base treated by
a transpharyngeal approach. Ann Otol Rhinol Laryngol 99:300-
303, 1990.
16. Spiro RH, Kelly J, Vega AL, et al: Squamous carcinoma of the
posterior pharyngeal wall. Am J Surg 160:420-423, 1990.
17. Stern S: Anatomy of the lateral pharyngotomy approach. Head
Neck 14:153-156, 1992.
PEARLS
• The lateral pharyngotomy approach remains a
viable option for the resection of selected squamous
cell carcinomas of the oropharynx and hypopharynx.
• The lateral pharyngotomy approach can also be
used for exposure and removal of benign laryngeal
and pharyngeal lesions or even complex foreign
bodies.
• A thorough head and neck examination, imaging,
and rigid endoscopy are essential for proper
selection of patients for lateral pharyngotomy.
• Mucosal defects of the posterior pharyngeal wall
may be closed by primary closure, split-thickness
skin grafting, or secondary intention by tacking the
mucosal edges to the prevertebral fascia.
• Depending on the location and extent of resection,
reconstruction may be accomplished with a split-
thickness skin graft, pedicled fl ap, or microvascular
free fl ap.
• Care must be taken to avoid injury to the superior
laryngeal nerve, given its location and limited
mobility.
• The potential for airway compromise as a result of
postoperative pharyngeal edema and dysphagia
necessitates a temporary tracheotomy in most cases.
• A pharyngocutaneous fi stula, the most notorious
complication of the lateral pharyngotomy approach,
may be more likely to develop when signifi cant
sacrifi ce of pharyngeal mucosa has occurred.
• Failure of a postoperative pharyngocutaneous fi stula
to close with conservative therapy may require a
tissue fl ap for reconstruction.
PITFALLS
• The lateral pharyngotomy approach is inadequate
for patients with cancers that require a supraglottic
or total laryngectomy or that involve more than a
third of the pharyngeal circumference.

Chapter 31
Resection of the Floor of the Mouth
Eugene N. Myers
The fl oor of the mouth is the second most common site
of cancer of the oral cavity, and more than 95% of these
cancers are squamous cell carcinoma. Local control of
early lesions (T1/T2) is favorable when treated by
surgery. Studies suggest that surgery affords good local
control, facilitates histologic staging of the tumor
(thereby offering the opportunity to modify therapy),
and is associated with fewer long-term side effects (such
as xerostomia, loss of taste, trismus, and osteoradione-
crosis) than radiation therapy is. Unfortunately,
however, patients frequently have locally advanced
cancer (T3/T4) at initial evaluation, often with involve-
ment of the tongue, the mandible, or both. Increasing
tumor size correlates with poorer prognosis, as well as
increased treatment morbidity. Metastasis to the cervi-
cal lymph nodes is also common in oral cavity carci-
noma. Cervical metastatic disease occurs in 30% to 40%
of patients with T1/T2 tumors and is associated with
worsening of the prognosis.1,2
Carcinoma of the oral cavity is principally a disease
of the middle-aged and elderly. The average age at
diagnosis is 60 years, with 95% of lesions occurring
in persons 40 years or older.2 The majority of these
patients have a history of long-term tobacco and alcohol
use.
The therapeutic goals in the management of cancer
of the oral cavity are elimination of the tumor with
return of the patient to the best possible form and func-
tion.3 Speech is often impaired after excision of cancers
of the oral cavity.4 A number of treatment factors may
have an impact on this impairment. The extent of surgi-
cal resection, particularly the amount of oral tongue
resected, has been implicated as the primary correlate
of speech impairment, although fi brosis with lack of
tongue mobility is also an important factor. Larger
resection volumes and a greater percentage of oral
tongue resection have been correlated with reduced
intelligibility and articulation.5-9 Other retrospective
studies suggest that postoperative speech function is
more dependent on the method of reconstruction than
on the degree of resection.10 Patients who underwent
reconstruction with pedicled or free fl aps appeared to
have worse postsurgical speech function than those
whose wounds were closed primarily or with split-thick-
ness skin grafts.11-15
Schliephake and associates16 in 1996 studied a series
of 85 consecutive patients with squamous cell carci-
noma of the fl oor of the mouth. Reconstruction was
carried out with local tissue, jejunal grafts, and cutane-
ous and myocutaneous fl aps. Thirty percent of these
patients underwent marginal mandibulectomy and
31.7% underwent segmental resection of the mandible.
They concluded that rehabilitation of patients operated
on for cancer of the oral cavity is particularly diffi cult
in the case of large soft tissue defects and is not always
accomplished completely even with primary microsur-
gical fl ap reconstruction.
Treatment decisions in patients with carcinoma of
the fl oor of the mouth is dependent on the size and
depth of the tumor, the presence of invasion of the
mandible, and the presence or absence of cervical
lymph node metastasis. Over the years, treatment pro-
grams have consisted of
• Resection of the primary tumor with or without elec-
tive neck dissection
• Radiotherapy of the primary tumor and neck
• Radiotherapy of the primary tumor with or without
elective neck dissection
• Combination therapy, including resection of the
primary tumor followed by radiotherapy of the neck
Excellent local control of early-stage cancer of the
oral cavity (T1/T2) has been achieved with either
surgery or radiotherapy.2 Resection of T1/T2 lesions is
usually performed transorally, and the defect is resur-
faced with a split-thickness skin graft. A marginal man-
dibulectomy may be necessary, depending on the
location of the cancer. Three-dimensional en bloc
241

242
Section 2
Oral Cavity/Oropharynx
resection through an anterior mandibulotomy approach
is usually necessary for T3/T4 tumors because these
larger tumors may involve adjacent structures, such as
the tongue and tonsil, and require improved visualiza-
tion. Infi ltration of cancer into the mandible requires
segmental mandibulectomy for local control. A combi-
nation of external beam radiation followed by brachy-
therapy has been used with good results, although this
regimen requires a tracheostomy, is associated with
morbidity, and carries with it the potential complica-
tion of osteonecrosis of the adjacent mandible.
It is now recognized that although T1/T2 cancers
of the fl oor of the mouth can be locally controlled in a
high percentage of patients with minimal morbidity,
the untreated, clinically negative neck may be the site
of recurrent disease in 30% to 40% of patients. Failure
to control neck disease then leads to death of the
patient. Studies comparing survival rates of patients
with node-negative necks who have undergone elective
and therapeutic neck dissection seem to indicate
improved survival for those who undergo elective neck
dissection. Spiro and Strong17 have indicated that it is
benefi cial to remove occult cervical lymph node metas-
tasis before it becomes clinically apparent. These
authors reported that patients with stage N0 necks who
were subsequently discovered to have occult nodal
metastasis after elective neck dissection had longer sur-
vival than did patients with cervical metastasis at the
time of initial examination. Silver and Moisa18 reported
that both control of neck disease and patient survival
may be signifi cantly increased if neck dissection is per-
formed before cervical metastases become clinically
evident. Dias and colleagues studied a series of patients
with T1 squamous cell carcinoma of the tongue and
fl oor of mouth.19 The authors concluded that patients
who underwent elective neck dissection had a 23%
higher disease-free survival rate than did those who
underwent resection of the tumor only.
McGuirt and coworkers1 performed a retrospective
outcome analysis of 129 patients with TxN0 squamous
cell carcinoma of the fl oor of the mouth to evaluate the
role of neck dissection. The majority consisted of T1/
T2 lesions, and all were treated by transoral excision
with a split-thickness skin graft with or without marginal
mandibulectomy. Elective neck dissection was per-
formed in 26 patients. Histologic evaluation revealed
occult metastases in 23%. In contrast, of 103 patients
managed without elective neck dissection, cervical
lymph node metastasis eventually developed in 37%.
The determinant survival rate at 3 years was 100% for
patients with occult disease who underwent elective
neck dissection, whereas the 3-year determinant sur-
vival rate in patients receiving no initial treatment of
the neck was 85%. The salvage rate for those in whom
metastases to the neck did develop was 59%. We believe
that a more aggressive approach that includes elective
neck dissection in node-negative necks is warranted
because the limited morbidity of selective neck dissec-
tion seems to be a reasonable tradeoff to the high
failure rate in patients in whom metastasis to the neck
eventually develops.
We routinely perform selective neck dissection on
patients with cancer of the fl oor of the mouth and an
N0 neck. Levels I to III are dissected (supraomohyoid).
It does not appear to be necessary to dissect level IV
because this level seems vulnerable only to metastasis
from cancer of the lateral tongue.20 If the lesion is in
the midline, both sides of the neck should be dissected.
Care must be taken to include the prevascular and post-
vascular lymph nodes associated with the facial artery
and vein adjacent to the mandible in the dissection.
This requires identifi cation and preservation of the
ramus mandibularis of the facial nerve. These are fi rst-
echelon lymph nodes for metastatic cancer from the
fl oor of the mouth. Some surgeons may not routinely
dissect this area because of the risk of injury to the facial
nerve, which is adjacent to these lymph nodes, thereby
leaving potentially involved nodes in situ.
A major limitation in the evaluation of patients with
oral cavity carcinoma is the inability to detect which
patients with node-negative necks harbor occult cervi-
cal lymph node metastasis. Simple physical examination
leads to substantial error. Studies carried out with
computed tomography (CT) and magnetic resonance
imaging (MRI) have established criteria for malignancy,
such as lymph nodes greater than 1 cm in diameter,
matted nodes, or nodes with a hypodense center. Nev-
ertheless, imaging studies fail to detect microscopic
metastasis. Hence, we routinely perform selective (bilat-
eral in midline lesions) neck dissection in all patients
with fl oor of the mouth carcinoma.
PATIENT SELECTION
Carcinoma of the fl oor of the mouth is best managed
surgically. Rodgers and coworkers21 demonstrated that
although locoregional control rates for early lesions
(T1/T2) were similar for both surgery and radiation
therapy, radiotherapy was associated with a higher
overall incidence of complications, such as bone and
soft tissue necrosis. We concur with the recommenda-
tion that surgery be used for the management of early
cancer and that a combination of surgery followed by
radiation therapy be used for more advanced cancer. It
is worthwhile noting that in the approximately 15 years
that we have systematically been performing selective
neck dissection in patients with T1/T2 lesions (stage
I-II), approximately a third of the patients have been
upstaged to stage III based on pN1-N2 in a clinically N0
neck.
Surgical removal of the cancer plus selective neck
dissection is offered to all patients who are physically fi t
enough to undergo an extensive surgical procedure
under general anesthesia. Patients who do not qualify
for surgery because of ill health or because they refuse
surgery are referred for radiation therapy.
The success rate in achieving control of the primary
cancer in patients treated by transoral wide excision
and skin grafting is related to tumor depth of invasion,
as well as T stage. Patients with superfi cial cancer have
better survival than do those with deeply infi ltrating
cancer. Schramm and colleagues22 found that the

Chapter 31
Resection of the Floor of the Mouth
243
surface size of the cancer, even when it was larger than
4 cm, did not infl uence local control if complete exci-
sion was achieved. Brown and associates23 demonstrated
that tumor with a depth of invasion greater than 7 mm
was more likely to be accompanied by occult cervical
metastases than were thinner lesions.
PREOPERATIVE EVALUATION
History and physical examination remain the mainstay
of evaluation in patients with cancer of the fl oor of the
mouth. The anterior fl oor of the mouth is the most
common anatomic location of these tumors, although
cancer of the anterolateral or lateral area occurs occa-
sionally (Fig. 31-1). Most patients with symptoms of
pain or bleeding from the oral cavity or ill-fi tting den-
tures go to their dentist rather than their physician for
initial evaluation.
Patients with cancer in the anterior fl oor of the
mouth may complain of bleeding, low-grade pain, dif-
fi culty with ill-fi tting dentures, loosening of the teeth,
fetid breath, alteration of speech because of decreased
mobility of the tongue, or a mass in the neck. Unfortu-
nately, most patients who wear dentures are used to a
certain amount of discomfort in the oral cavity, and
they may seek to relieve the pain in the fl oor of the
mouth by simply removing their dentures. Although
this eases the discomfort, such patients may not seek
timely evaluation by their dentist, thereby resulting in
a delay in diagnosis. Further reduction in the number
of patients initially seen with advanced-stage oral cavity
cancer will depend on greater emphasis on examina-
tion of the oral cavity by primary care practitioners.
Complete examination of the head and neck must
be performed. Examination of the fl oor of the mouth
should consist of inspection and palpation (Fig. 31-2).
Palpation of the lesion is also of utmost importance
because it gives an indication of whether the lesion is
superfi cial and therefore easily excised through the oral
cavity or more deeply infi ltrative and requiring a “pull-
through” type of operation. Palpation should be used
to determine whether the mandible is involved by the
tumor. Lesions are generally ulcerative but may also be
exophytic or deeply infi ltrative. The patient should be
asked to protrude the tongue to determine whether
infi ltration of muscles has resulted in fi xation of the
tongue because this infl uences the treatment program.
The surface dimension of the cancer must be measured
to assign the proper tumor stage. The location of the
lesion should be clearly described and marked appro-
priately on a diagram of the oral cavity.
Mental nerve hypoesthesia may indicate invasion of
bone. Primary carcinoma of the oral cavity with man-
dibular involvement sometimes infi ltrates the skin of
the overlying mentum. This must be carefully palpated,
and infi ltration must be noted (Fig. 31-3A and B).
Attention must be paid to evaluation of the patient’s
dentition. Any salvageable teeth should be restored.
Patients with fractured or carious teeth or advanced
periodontal disease should undergo tooth extraction at
the time of the surgical procedure, particularly if radia-
tion therapy will be administered postoperatively. This
requires advanced planning with dental colleagues to
avoid unnecessary intraoperative delays.
The neck must be examined in detail, and any
masses palpated in the neck should be measured to
assign a proper nodal stage. Fine-needle aspiration
biopsy may be necessary to verify the presence of meta-
static cancer (Fig. 31-4). Examination of the neck is of
the utmost importance. A high percentage of patients
with T1/T2N0 tumors have occult metastasis. The
reported incidence of recurrent carcinoma in the
untreated cervical lymph nodes after treatment of only
the primary tumor is 15% to 50%.1
Imaging plays two major roles in the evaluation of
patients with carcinoma of the anterior fl oor of the
mouth. CT may be helpful in determining whether the
mandible is infi ltrated by cancer and, if so, to what
extent (Fig. 31-5). MRI may help estimate marrow
involvement by tumor, but like CT, it may overlook
subtle cortical involvement. If palpation indicates that
the cancer involves only the soft tissues of the fl oor of
Figure 31-1. Squamous cell carcinoma involving the anterior fl oor
of the mouth.
Figure 31-2. Palpation of cancer of the tongue and fl oor of the
mouth should be done routinely.

244
Section 2
Oral Cavity/Oropharynx
the mouth, imaging is not required because palpation
gives adequate information for planning treatment.
The second indication for scanning is to assist with
staging of the neck. This may also be unnecessary
because selective neck dissection is contemplated in all
patients regardless of the clinical status of the neck.
Imaging does help in staging a “hard to examine” (mus-
cular or obese) neck. Because most primary cancers
occur in the midline, there is a real risk of bilateral
lymph node metastasis.
Evaluation of the lungs is essential because patients
with squamous cell carcinoma of the upper aerodiges-
tive tract frequently have synchronous second primaries
in the upper or lower aerodigestive tract (Fig. 31-6).
Many surgeons obtain a chest CT scan in all patients.
Positron emission tomography (PET) or PET/CT scan-
ning has begun to play a greater role in the diagnosis
of cancer of the head and neck because PET may iden-
tify unexpected lesions in the neck or lungs, which
would infl uence the treatment program.
The cancer must be biopsied, or if it has been biop-
sied elsewhere, the slides must be reviewed and the
diagnosis verifi ed. Biopsy may be done under local
anesthesia in the outpatient setting. Panendoscopy
should be carried out to evaluate the other areas of the
upper and lower aerodigestive tract to rule out synchro-
nous second primaries. Endoscopy is usually performed
at the time of extirpative surgery.
The timing of surgical excision and neck dissection
is not critical, but with proper planning, effi cient use of
operative time can be optimized. If the primary tumor
is resected at the time of endoscopy, before neck dis-
section, the pathologist can examine and review the
specimen while the neck dissection is performed. The
A
B
A
B
R
L
Figure 31-3. A, Patient with advanced cancer of the fl oor of the mouth. B, Destruction of the anterior mandible and infi ltration of cancer
into the skin of the chin.
Figure 31-4. A, Patient with advanced cancer of the fl oor of the mouth with metastasis to the neck. B, Computed tomography scan demon-
strating necrotic lymph nodes.

Chapter 31
Resection of the Floor of the Mouth
245
defect can be reconstructed at the completion of the
neck dissection after the margins have been carefully
examined.
TRANSORAL EXCISION OF
LIMITED LESIONS OF THE
FLOOR OF THE MOUTH
Surgical Technique
The patient is placed supine on the operating table,
and a folded blanket is placed under the shoulders to
extend the neck. Perioperative antibiotics are begun
before the start of the procedure. General endotracheal
anesthesia is induced, and endoscopic evaluation of the
upper and lower aerodigestive tract is carried out if it
has not been done previously. Neck dissection can be
performed at this time or can be delayed until after
tumor excision.
The patient is then prepared and draped, including
the thigh for the skin graft. A tracheostomy is per-
formed if a skin graft or fl ap is to be used for reconstruc-
tion. The endotracheal tube is then placed in the
tracheostomy site. A Jennings mouth gag is placed in
the oral cavity and opened to provide exposure. Right-
angled retractors are used to retract the buccal mucosa.
A suture is placed in the tip of the tongue in the exact
midline, and upward traction is placed on the tongue
to expose the anterior fl oor of the mouth.
Preoperative evaluation would have revealed
whether the plan of management would or would not
include marginal mandibulectomy. Indications for mar-
ginal mandibulectomy include
• Inability to obtain an anterior margin of resection
without removing the alveolar process of the mandi-
ble, which is especially important in dentulous
patients
• Attachment of the cancer to the lingual aspect of the
mandibular periosteum
• A superfi cial tumor that crosses the mandible and
involves the gingival buccal sulcus in an edentulous
patient
If only soft tissue is being resected, a margin of
resection of at least 1 cm of normal tissue from the
periphery of the tumor is outlined with methylene blue
or a marking pen. The mucosa is incised with coagula-
tion current or a scalpel. Size 2-0 silk suture is then
placed through the anterior margin of resection (Fig.
31-7), and the circulating nurse is told to note this
marker on the pathology form. The soft tissue is sharply
dissected in an anterior-to-posterior direction with small
dissecting scissors. The deep margin of resection in
superfi cial cancers in this area is the sublingual glands.
Deep dissection will also transect Wharton’s ducts. The
remainder of the lesion is then excised from the ventral
surface of the tongue. There is always bleeding from
veins, as well as from branches of the lingual artery.
These vessels should be individually ligated to obtain
meticulous hemostasis so that the skin graft can heal
properly. Ligation can be done with 3-0 chromic catgut
suture in fi gure-of-eight fashion over the hemostats on
the bleeding vessels. No attempt is made to reconstruct
the submandibular gland ducts if the submandibular
glands will be excised as part of the neck dissection. In
complex cases, the pathologist comes into the operat-
ing room to see the operative site and to examine the
specimen with the surgeon. Margins for frozen section
examination are selected. If a margin appears close, it
is preferable to excise additional tissue and examine the
Figure 31-5. Computed tomography scan demonstrating erosion
of the anterior mandible.
Figure 31-6. A patient with synchronous primary cancers of the
larynx and fl oor of the mouth treated by laryngectomy, excision of
the fl oor of the mouth, and skin grafting.

246
Section 2
Oral Cavity/Oropharynx
additional margin. It is a great error to fail to accurately
identify any positive or close margins. Such error is
prevented by careful registration of the specimen in the
pathology department and on-site communication with
the pathologist.
The surgeon who will be taking the skin graft and
the surgeon’s assistant change into new gowns and
gloves and harvest the skin graft with freshly sterilized
instruments and supplies uncontaminated by oral secre-
tions. We use a Brown dermatome set at 61/100 of an
inch.24 The skin graft should be thick enough to handle
easily and not tear and yet thin enough to be pliable
and have a high possibility of a good take. Using a “pie-
crusting” technique (Fig. 31-8), the skin graft is sewn to
the mucosa of the fl oor of the mouth with a 3-0 silk
suture, with every other suture left long to tie over (Fig.
31-9). One or two “tacking” stitches of absorbable catgut
suture are placed in the fl oor of the mouth to aid adher-
ence of the skin graft to the underlying tissue. Several
antibiotic-impregnated gauze packs are used as a bolus
and tied over with the long sutures. A nasogastric tube
is inserted and sutured into place, and this aspect of the
procedure is terminated.
The inclusion of marginal mandibulectomy modi-
fi es the operation somewhat. At the outset of the opera-
tion, the margins of resection are outlined on the
mucosal surface with a marking pen (Fig. 31-10) (see
Chapter 32 for fi gures). The initial incisions are then
made in the soft tissue and carried over the alveolar
process down to bone and connected anteriorly. The
mucoperiosteum of the mandible is then elevated infe-
riorly to facilitate a precise osteotomy. In patients who
are dentulous, the location of the osteotomy must be
considered. If the patient has full or almost full lower
dentition, the osteotomies for an anterior marginal
mandibulectomy will usually encompass the central and
lateral incisors. In such cases, both canine teeth should
be extracted, and the osteotomy should be made in the
middle of the socket or medial to it. This preserves bone
around the remaining teeth, which will allow later
application of partial removable dentures with clasps. If
the incision is made just immediately adjacent to the
remaining teeth, lack of bone support will eventually
result in loss of these teeth.
Because the alveolar process is not involved with
the tumor but is a margin of resection around the
tumor, it is necessary to resect only the alveolar process
and not the body of the mandible. The vertical dimen-
sion of the mandible is substantial, even in edentulous
patients, but only the alveolar process should be taken.
The osteotomies are then traced on the bone with a
marking pen. A Stryker saw with a right-angled blade
should be used, fi rst to make the vertical osteotomies
(see Chapter 32) and then to connect them with a
horizontal osteotomy. It is important that the buccal
and lingual plates of bone be cut all the way through.
It may be tempting to use an osteotome or a heavy eleva-
tor to try to pry the bone open before the lingual cortex
is cut through, but this could fracture the mandible and
thus should be avoided.
Once the lingual cortex is cut through and the
mandibular fragment is freed, the bone is retracted
superiorly and posteriorly along with the soft tissue, and
the rest of the resection is then carried out as described
earlier (Fig. 31-11A and B). The sublingual glands are
identifi ed and included as a deep margin of resection.
The bony margins of the mandible are smoothed with
a cutting burr to remove any spicules or sharp corners.
A split-thickness skin graft can be used to resurface both
A
B
Figure 31-7. A, Soft tissue margins are marked and incised. B, The specimen.
Figure 31-8. Suture with the “pie-crusting” technique. The skin is
sewn around the cut edge of the mucosa to ensure proper healing.

Chapter 31
Resection of the Floor of the Mouth
247
the soft tissue and the residual mandibular bone. This
is possible because most of the residual bone of the
mandible is cancellous bone with a thin rim of cortical
bone on the buccal and lingual sides. The skin graft
heals nicely in this area if care is taken to provide immo-
bilization of the graft over the bone and soft tissue
(Fig. 31-11C). Use of the skin graft provides a strong
epithelial lining to accommodate dentures in the future
(Fig. 31-11D).
Skin grafting is contraindicated in patients who
have had radiation therapy in this area because if the
skin graft fails, the relatively avascular irradiated bone
will become exposed and osteoradionecrosis will almost
certainly develop. In such cases we prefer reconstruc-
tion with a radial forearm free fl ap with microvascular
anastomosis. If a microvascular surgeon is not available,
a pectoralis major myofascial fl ap may be applied
without a skin graft. This is done to avoid the bulk
associated with a pectoralis major myocutaneous fl ap,
which interferes with oral cavity function. Local fl aps
such as the nasolabial fl ap25 or regional fl aps such as
the temporal fasciocutaneous island fl ap,26 infrahyoid
myocutaneous fl ap, sternocleidomastoid fl ap, and pla-
tysma fl ap can be used.27
If neck dissection is to be performed at this time,
the patient is reprepared and draped and the appropri-
ate neck dissections carried out. We perform selective
neck dissection in levels I to III while being certain that
the prevascular and postvascular lymph nodes adjacent
to the mandible and anterior and posterior to the facial
artery and vein are taken because these nodes are part
of the fi rst echelon of lymph node drainage in cancer
of the fl oor of the mouth.
POSTOPERATIVE MANAGEMENT
Critical in postoperative management is routine trache-
ostomy care, including frequent suctioning, because
patients in this group all have tethering of their tongue
as a result of the skin graft, which makes it diffi cult
for them to handle their secretions. Frequent tracheal
suctioning is necessary to prevent atelectasis and
pneumonia. The nasogastric tube is placed on suction
until bowel sounds are present, at which time the patient
is fed through the nasogastric tube. Intraoral care is
provided by frequent suctioning and oral irrigation
with sprays of half-strength hydrogen peroxide. Periop-
erative antibiotics are administered for 24 hours.
The bolus is removed by cutting the tie-over sutures
on the fi fth postoperative day. Usually, the patient
can be decannulated when the bolus is removed.
The stoma is generally closed within a week after decan-
nulation. The patient may then begin a soft diet.
The average length of stay in the hospital is 7 to 10 days.
The patient is seen back in the offi ce, and the remain-
der of the silk sutures are removed from the oral cavity
and the graft is débrided. Any residual edema will
recede in time.
Postoperative care specifi c to neck dissections is
discussed in Chapter 78 and that specifi c to tracheos-
tomy in Chapter 68.
COMPLICATIONS
Elective neck dissection is required for all patients.
Examination of the margins via frozen section is
necessary.
A skin graft in this area will not be lost if the fol-
lowing details of the surgical technique are respected:
• Proper thickness of the skin graft
• Meticulous hemostasis
• Immobilization of the graft by proper suturing and
application of the bolus
C
B
A
Figure 31-9. A, The skin graft is sewn into place with 3-0 silk suture.
B, Gauze bolus secured with silk tie-over sutures. C, Skin graft healed
nicely.

248
Section 2
Oral Cavity/Oropharynx
A
B
Figure 31-10. Proposed excision
of a tumor with (A) and without (B)
marginal mandibulectomy.
C
A
D
B
Figure 31-11. A, Cancer of the fl oor of the mouth attached to the mandibular periosteum. B, Marginal mandibulectomy and excision of the
cancer of the fl oor of the mouth. C, The healed skin graft. D, Dentures in place.
EXTENSIVE LESIONS OF THE
FLOOR OF THE MOUTH WITH OR
WITHOUT BONE INVOLVEMENT
SURGICAL TECHNIQUE
Patients who have advanced lesions (T3/T4) that deeply
involve the substance of the tongue or involve the man-
dible may require a composite resection, often includ-
ing segmental mandibulectomy, to achieve locoregional
control. Preoperative evaluation of these patients
requires assessment by both physical examination and
imaging for evidence of bone involvement.
Patients with lesions of advanced stage are also
frequently found to have clinically evident cervical
lymph node metastases in one or both necks. If nodes
are positive, these patients will require radical or modi-
fi ed neck dissection and contralateral selective neck
dissection. If the necks are clinically negative (N0),

Chapter 31
Resection of the Floor of the Mouth
249
A
B
Figure 31-12. The digastric (A) and mylohyoid (B) muscles are
transected for access to the depth of the fl oor of the mouth.
these patients will require bilateral selective neck dis-
section. Patients who have deep infi ltration of the fl oor
of the mouth without bone invasion are not candidates
for transoral resection, and the approach should be
external via a “pull-through” operation or midline
mandibulotomy.
In these cases, endoscopic evaluation and dental
extractions are carried out as described earlier. Trache-
ostomy is performed and the patient is prepared and
draped for neck dissection. In the oral cavity, if soft
tissue only is involved, we often approach these tissues
through an anterior mandibulotomy. Therefore, an
anterior cervical fl ap is fashioned to allow a lip-splitting
incision. After neck dissection (see Chapter 78), ante-
rior mandibulotomy is carried out (see Chapters 33 and
34). Once the bone fragments are separated, as much
mucosa covering the lingual plate of the alveolus as
possible is preserved to facilitate closure. After these
anterior incisions in the mucosa have been made
around the perimeter of the tumor, the upper cervical
fl aps are retracted and the mylohyoid muscle and digas-
tric muscles are transected to enter the deep aspect of
the fl oor of the mouth (Fig. 31-12). Then, working from
both the oral cavity and the neck, three-dimensional
excision of the lesion is carried out (Fig. 31-13). If the
tumor has infi ltrated deeply into the tongue, total or
subtotal glossectomy may be required (see Chapter 28).
It is helpful to retain at least one hypoglossal nerve and
lingual artery when possible, but not at the expense of
compromising tumor resection. During neck dissec-
tion, the hypoglossal nerves and the lingual arteries
should be isolated so that during dissection in the
depths of the neck, these structures can be identifi ed
and, when possible, preserved. After complete excision
of the tumor and examination of the specimen by
frozen section, the appropriate reconstructive tech-
niques are carried out. Such techniques may include a
pectoralis major myocutaneous fl ap or a radial forearm
free fl ap with microvascular anastomosis (see Chapter
81).
PATIENTS WITH INVOLVEMENT OF
THE MANDIBULAR ALVEOLUS
Some deeply infi ltrative carcinomas arising in the fl oor
of the mouth invade the mandible (Fig. 31-14). If the
mandible is involved, segmental resection of the man-
dible should be carried out because penetration of the
mandible by cancer may involve the bone marrow. The
tumor is approached as described earlier with a lip-split-
ting incision. In some patients, a visor fl ap may be
created, which is cosmetically superior to a lip-splitting
incision (Fig. 31-15) but places the potentially unin-
volved mental nerve at risk. The visor fl ap is created by
developing superior cervical fl aps to the inferior margin
of the mandible. The lower gingivobuccal sulcus is then
excised intraorally from angle of mandible to angle of
mandible. The periosteum of the mandible is under-
mined, and the skin of the face, chin, and lower lip is
elevated with Penrose drains to elevate the fl ap upward
off the mandible. Care should be taken to preserve an
uninvolved mental nerve. Vertical osteotomies are then
made and the anterior portion of the mandible is
removed as a block. If the patient has residual teeth, a
tooth adjacent to the tooth to be preserved is extracted,
and the osteotomy is placed in the extraction site (Fig.
31-16) to preserve bone support for the residual teeth.
Preoperative planning is helpful to give an idea of how
much margin of bone is necessary to clear the tumor.
The patient will benefi t by preservation of the mental
nerves, although this is not always possible. After the
osteotomies, the bone fragments of the remaining man-
dible are distracted while leaving the anterior segment
of the mandible attached to the soft tissues. The tumor
itself is then approached as described earlier by enter-
ing the deep aspects of the fl oor of the mouth through
the digastric and mylohyoid muscles.
A modifi cation of this approach is necessary when
the cancer penetrates through the fl oor of the mouth
and the mandible (Fig. 31-17A) into the skin of the
chin. In this case, the skin of the chin is excised as far

250
Section 2
Oral Cavity/Oropharynx
A
B
Figure 31-13. A and B, Excision
of the tumor working from the neck
and intraoral approach.
Figure
31-14. Computed
tomography
scan
demonstrating
advanced cancer of the fl oor of the mouth with mandibular
invasion.
Figure 31-15. A visor fl ap may be used to obtain wide exposure
while preserving cosmesis.
peripherally as necessary to gain what appear to be clear
margins. The skin is left on the anterior segment of the
mandible and included in the en bloc resection (see
Fig. 31-17B). If the lower lip itself is not involved, pres-
ervation is possible, but care must be taken to not inter-
rupt the vascular supply of the lower lip. If it is necessary
to take all or part of the lip, appropriate reconstructive
techniques will be required.
Reconstruction of the anterior mandible is best per-
formed immediately by free fl ap reconstruction with
microvascular anastomosis (see Fig. 31-17C). Several
options may be used by the microvascular team for
reconstruction, including a fi bular osseocutaneous free
fl ap, perforator fl aps from the lateral aspect of the
lower part of the leg,28 a radial osseocutaneous free fl ap,
or a scapular osseocutaneous free fl ap. If microvascular
surgeons are not available, plating of the bone plus
epithelial coverage with a pectoralis major myocutane-
ous fl ap is an option. Both the regional and free fl aps