Sie sind auf Seite 1von 11

British Journal of Oral and Maxillofacial Surgery (1999) 37, 164–174

© 1999 The British Association of Oral and Maxillofacial Surgeons

BRITISH JOURNAL OF ORAL & M A X I L L O FA C I A L S U R G E RY

Squamous carcinoma of the tongue: review

S. Prince, B.M.W. Bailey


Department of Oral and Maxillofacial Surgery, Queen Mary’s University Hospital, Roehampton, London, UK

SUMMARY. Carcinoma of the tongue is a common condition treated by oral and maxillofacial surgeons. The
tongue is a complex anatomical site at the entrance of the oropharynx, bounded by the floor of mouth and lingual
mandibular cortex; its form and mobility are crucial for efficient swallowing; speech, and the appreciation of taste.
Single and multiple treatments have been used, but the tongue remains a difficult area to assess and treat. In this
paper, we have attempted to review some of the papers published over the last 20 years with particular reference to
prognosis and functional outcome. We have dealt exclusively with squamous cell carcinoma of the tongue and its
management by surgery, radiotherapy, brachytherapy, photodynamic therapy, and chemotherapy.

EPIDEMIOLOGY increase its mobility. Its blood supply is from the


bilateral lingual arteries, which send branches to the
The incidence of carcinoma of the tongue varies con- posterior dorsum and, at the anterior border of hyo-
siderably among countries, the highest rate being glossus, to the sublingual gland and floor of mouth.
found in India, where the incidence is roughly 9.4/100 Venous drainage from the tip of the tongue is from
000/year, compared with 1.1/100 000 in the UK.1 Over the superficial ranine veins that run posteriorly in the
the past three decades, the incidence of all oral can- floor of the mouth. The dorsal lingual veins drain
cers has increased in the UK and USA,2,3 particularly into the lingual vein alongside the lingual artery to
in the under 50–year-old age group in the USA and empty into the internal jugular vein. The lymphatics
for women in both the UK and USA.2–4 This largely from the tip of the tongue drain to the submental
reflects a change in the incidence of carcinoma of the nodes, the rest of the anterior two-thirds drains ipsi-
tongue. laterally to the submandibular nodes, but with some
Carcinoma of the tongue has always been regarded overlap in the midline. The posterior third of the
as a disease that affects men more than women, with tongue drains bilaterally to the jugulo-omohyoid
the highest incidence occurring in the sixth to the nodes. The submental and submandibular nodes
eight decades. It rarely occurs below the age of 20 also ultimately drain to the jugulo-omohyoid nodes
years.5 In England and Wales, between 1962–67 and (Fig. 1).
1980–84, registration of carcinoma of the tongue Sensory supply to the anterior two-thirds of the
increased by 6.5% for men and 15.5% for women (10% tongue is from the lingual nerve, taste being mediated
increase overall) suggesting a changing epidemiological by the chorda tympani. Sensation to the posterior
trend.2 third is supplied by the glossopharyngeal nerve, which
The increase in incidence of carcinoma of the also supplies taste. Motor supply to all the muscles of
tongue in young patients, particularly those less than the tongue except the palatoglossus is from the
40 years old, is extremely worrying as in this group the hypoglossal nerve, the palatoglossus being supplied by
disease tends to have aggressive tumour biology with a the pharyngeal plexus (Fig. 2).
correspondingly poor prognosis.6,7 Taste buds lie in spherical masses within the
Despite the efforts of the Cancer Registry, oral mucosa of the dorsum of the tongue and more specif-
cancer may be under-reported by up to 25% in the ically in the walls of the circumvalate papillae, open-
UK.8 ing on to the mucosal surface by a gustatory pore with
a tuft of minute hairs. These are the receptors that
mediate taste.
SURGICAL ANATOMY AND PHYSIOLOGY In addition to taste, the mobile tongue functions to
sweep around the mouth and clear the floor of mouth
The tongue is a complex organ composed largely of and sulci of food debris. It provides palatal and tooth
striated muscle and covered by a mucous membrane contact necessary for intelligible speech and to mix,
of stratified squamous epithelium. The anterior two- control and propel the food bolus towards the
thirds of the tongue (mobile tongue) is in the oral oropharynx.
cavity, and the posterior third in the oropharynx. The posterior third of the tongue is relatively
The tongue sits on the floor of the mouth (mylohy- immobile but raising of the floor of mouth and larynx
oid muscle and hyoid bone) and is connected to the allows the dorsal surface of the tongue to contact the
hyoid bone (hyoglossus), palate (palatoglossus) and palate and so propel the food bolus forcibly into the
the styloid process (styloglossus), all of which oropharynx.
164
Squamous carcinoma of the tongue 165

Fig. 1 – Lymphatic drainage of the tongue.

AETIOLOGY USA has suggested that carcinoma of the tongue and


floor of mouth have a stronger association with alco-
Contributory causes of oral cancer include use of hol than with smoking, which is more than at other
alcohol and tobacco (both chewed and smoked), and intraoral sites.8 Some forms of alcohol may be more
pre-existing leukoplakia or erythroplakia. In the past, harmful than others, and it may be that, if intake is
syphilis was also included but, as tertiary syphilis is moderate, wine is less harmful than beer and spirits.9,12
now rare, the association is difficult to confirm. Research into associations between other dietary
Smoking has been shown to be closely linked with components and carcinoma of the tongue has shown
carcinoma of the tongue.9–12 The risk of carcinoma of that a high intake of fresh fruit may be protective.9,14,15
the tongue increases both with number smoked and Isolated studies have claimed that a high intake of
duration of smoking, but is abolished after smoking vegetables, whole-grain bread and pasta, and vitamin
has been stopped for over 10 years.9 Smokers of high- E supplements9,15,16 are protective. Despite the theoret-
tar cigarettes also increase their risk ten-fold.9 ical benefit of vitamin E as an antioxidant (neutraliz-
Although there is a strong association between ciga- ing free radicals), and the improved mechanical
rette-smoking and carcinoma of the tongue, the asso- cleansing of a wholemeal diet, no consistent benefits
ciation between smoking and malignancy is not so have been found.
strong for the tongue as for the floor of the mouth.10 Viruses have been implicated in carcinomas at other
When smoking is combined with a high alcohol con- sites, but so far there is no clear convincing evidence of
sumption, the increased risk is multiplied rather than a primary viral aetiology for oral carcinoma.17,18
added to,12 and the carcinogenic effects of chewed and
smoked tobacco seem to be synergistic.13 It is possible
that the increased incidence of carcinoma of the TUMOUR BIOLOGY AND GENETICS
tongue in women may partly be accounted for by
increased smoking and drinking alcohol.3 We do not intend to provide an in-depth discussion on
A high alcohol intake has long been associated the cellular and molecular basis of carcinogenesis, but
with intraoral carcinoma and is often seen together to summarize some of the recent findings and their
with a history of smoking. Recent work from the clinical implications.
166 British Journal of Oral and Maxillofacial Surgery

Fig. 2 – Sensory nerve supply to the tongue.

The p53 gene lies on chromosome 17 p and factor, and decreased concentrations of insulin-like
encodes a protein of 53 kDa molecular weight. In growth factor have all been associated with poor prog-
healthy cells, this protein acts as a tumour supressor nosis.25 Increased concentrations of circulating pro-
by regulating the cell cycle. Wild type (normal) p53 lactin in male patients with carcinoma of the tongue
protein is thought to have a critical role in establishing are associated with a poor prognosis in the absence of
G1 cell cycle arrest when the cell is challenged by a tumour prolactin receptors.26 On a cellular level,
DNA damaging carcinogen.19 Wild type p53 is an tumour angiogenesis in carcinoma of the tongue (as
unstable protein that is present in only small concen- in carcinomas of the breast and colon) correlates
trations in normal cells and is difficult to detect. with aggressive disease and may possibly be used as a
Mutation of the p53 gene can result in the production predictor of nodal disease.27
of a stable p53 protein that accumulates in the dam-
aged cells and is easily detected. High concentrations
of abnormal p53 protein can be found in over half of PREMALIGNANCY
oral squamous cell carcinomas, particularly in those
patients who smoke and drink heavily.20–22 Mutations It is thought that up to half of oral carcinomas may
in the p53 gene occur in four highly conserved areas, arise in premalignant lesions,28 with somewhere
not all having the same functional effect; some muta- between 5% and 17.5% of leukoplakias undergoing
tions result in ‘gain of function’, giving such cells a malignant change if followed up for long enough.29
growth advantage.22,23 Erythroplakia and leukoplakia are well recognized
p53 protein accumulation does not seem to corre- premalignant lesions of the tongue. There is debate as
late with degree of differentiation or site21 but does to the rate of malignant transformation in these
seem to be associated with smoking and drinking. It is lesions, although it is known that erythroplakia has a
therefore possible that this is one of the sites of higher risk of malignancy than leukoplakia. There is
genetic damage induced by these carcinogens.20 an increased risk of malignant transformation in areas
Tumours with a high turnover have a poor progno- of leukoplakia on the tongue and on the floor of
sis, and in particular tumours with a high percentage mouth compared with other oral sites.29 This increased
S-phase have a worse outcome.24 Extrapolation from risk may reflect the floor of the mouth acting as a
these observations forms the theoretical basis for sump and the site of accumulation of carcinogenic
CHART (continuous hyperfractionated accelerated substances adjacent to the tongue. The highest risk of
radiotherapy).19 malignant change is in non-smoking patients, erythro-
Research has been done to look for molecular plakias, and in lesions with a verrucous–papillary sur-
markers of outcome for oral squamous cell carci- face. Most oral leukoplakias occur in patients who
noma. Increased concentrations of prolactin, tissue smoke, and almost a half of these lesions will undergo
polypeptide specific antigen, and epidermal growth some improvement if the patient stops smoking.29
Squamous carcinoma of the tongue 167

Elevated concentrations of p53 protein have been have been done on the initial assessment of the pri-
detected in cells of normal and dysplastic tissue mary tongue lesion, but MRI is inaccurate in the fol-
adjacent to squamous cell carcinoma, and in the more low-up of the irradiated tongue.36 The newer
basal cells of recurrence. It is possible that mutation techniques of single photon emission computed
of the p53 gene is an early event in carcinogenesis.30 tomography (SPECT) and positron emission tomog-
Wild type p53 protein and retinoids both act as regu- raphy (PET) are not widely available. From prelimi-
lators of the cell cycle. Accumulation of p53 protein nary studies, it would seem that PET using a
in cells of some premalignant lesions increases with radionuclide-labelled analogue of glucose (2-[18F]flu-
histological grade.31 Retinoids have been given to oro 2-deoxy-D-glucose) may be helpful in identifying
good effect in the treatment of leukoplakia but the recurrence and occult disease,35,37 whilst SPECT has
long-term effect on malignant transformation is yet to establish a useful role in head and neck imaging
unknown.32 Unfortunately, there is an inverse rela- of malignancy.38 Conventional radioisotope scanning
tionship between the level of accumulation of p53 has no role, as it lacks specificity and sensitivity.39–41
protein and response to retinoid treatment.31

PATHOLOGICAL CONSIDERATIONS
PRESENTATION
Squamous cell carcinoma of the tongue is usually
Carcinoma of the tongue usually presents clinically as graded by the histopathologist on its degree of differ-
an ulcer, an exophytic mass, or as a deep infiltration entiation into poor, moderate, and well differentiated.
with varying degrees of induration. These lesions are This is of use to the clinician, there being a loose cor-
often painless, which may account for the late presen- relation between prognosis and histological grading,
tation of patients with lesions of the posterior third of with the poorly differentiated lesions having a poorer
the tongue. Their silent nature may also result in pre- prognosis. A closer correlation between histology and
sentation with asymptomatic cervical nodal enlarge- survival has been found by using the modified
ment. Patients rarely present with dysphagia or Jakobbson histological grading, which looks at the
difficulty with speech. There is often a leukoplakic or degree of differentiation of the tumour cells and also
erythroplakic component to the lesion, and small size the host response in terms of the mode and stage of
does not exclude invasion.33 invasion and the host’s lymphocytic response.42 The
It is said that two-thirds of carcinomas of the Jakobbson score also correlated with tumour stage
tongue occur on the lateral borders and ventral sur- and the presence of metastases at diagnosis, while
face of the anterior two-thirds of the tongue, while interestingly there seems to be no clear relationship
only a quarter occur on the posterior third.5 between tumour thickness and the presence of nodal
Toluidine blue staining has been investigated as a metastases.43
possible screening method for the early detection of On a molecular level, Cooke et al looked at the cel-
malignant change in the oral mucosa. It has also been lular DNA content in squamous cell carcinoma of the
suggested that it can be used to aid the selection of a tongue and carried out flow cytometric analysis. They
biopsy site. Unfortunately, there is an unacceptably found no correlation between ploidy and tumour size,
high incidence of false positive and false negative nodal involvement, or survival.44 Byers et al. have,
results (2%–6% and 7.4%–9.3%, respectively), giving however, recently contested this, as they found an
this technique low sensitivity and specificity and limit- association between nodal involvement and depth of
ing its usefulness.34 muscle invasion, double DNA aneuploidy, and histo-
logical differentiation, in a large prospective study.45
The pattern of spread of metastatic carcinoma of
IMAGING the tongue is first to the draining cervical lymph
nodes. Cervical metastases are common and are
It is desirable to assess accurately the extent of a reported to be present in about 30% of clinically ‘neg-
tongue carcinoma preoperatively to plan both the ative necks’.46 Although metastatic spread may skip
resection and reconstruction, and to give the patient one or more levels of the neck, nodal disease is rarely
some indication of the likely postoperative functional detected clinically or histologically in nodes at level
impairment and likely prognosis. The clinical assess- V.47 Bilateral nodal metastases are not uncommon
ment of extent, particularly for lesions of the poste- from lesions of the posterior third of the tongue.
rior third of the tongue, is often difficult and Distant metastases may occur if control of locore-
inaccurate. gional disease has been lost. Although carcinoma of
Computed tomography (CT) scanning is widely the tongue often remains clinically confined to the
used as an aid to stage the neck preoperatively and to head and neck till late in the disease, necropsy has
assess the primary lesion. It has become the standard shown that, despite the primary lesion being cured in
against which other imaging techniques are com- almost half the cases, regional nodal metastases were
pared. In assessment of the neck, error rates for mag- present at death in 71% and distant nodal and
netic resonance imaging (MRI) of 16% were found haematogenous metastases were present in 35.4% and
compared with 20%–28% error for clinical examina- 58.5%, respectively. The most common site for
tion, and 7.5%–28% for CT.35 Little work seems to haematogenous spread was the lung.48
168 British Journal of Oral and Maxillofacial Surgery

TREATMENT patients are able to achieve adequate, if impaired,


speech but the main problem remains swallowing
Here, we intend to discuss controversial topics and without aspiration. Various manoeuvres have been
not to develop a treatment protocol. used to deal with aspiration, including laryngeal sus-
pension60 and laryngoplasty,61 but many patients
require laryngectomy to prevent this. The long-term
Conventional surgery prognosis after total glossectomy is poor; one series
reported that 85% died within 18 months,60 and other
Surgery is often the primary treatment of T1 and T2 series have claimed a three-year survival of less than
tumours of the anterior two-thirds of the tongue, and 50%.59,62
in combination with radiotherapy for the larger, more
posteriorly placed lesion and for those with
unfavourable histology. Small lesions of the anterior Laser surgery
tongue probably function better after surgery alone.49
The aim of curative surgery is to excise the carcinoma The carbon dioxide laser, in addition to making surgi-
with a margin of normal tissue, but in the tongue this cal incisions, is able to seal vessels with a diameter of
can be difficult. The tumour may be deeply infiltrating 0.5–1 mm, making it an ideal instrument for excision
or have an ill-defined tumour edge with islands of of a primary carcinoma of the tongue. This results in
tumour cells in advance of the clinical tumour edge, a good, dry operating field and reduces the need for
making it difficult to decide where the resection mar- blood transfusion. Laser surgery results in little post-
gin should be placed. In addition, the tongue may be operative oedema and pain, so speeding oral rehabili-
compared to a fascial compartment elsewhere in the tation and reducing duration of hospital stay.63
body, with no midline septum to restrict tumour Unfortunately, the laser loses its advantages when
spread. one is operating on previously irradiated tissues,
There is a high incidence of occult metastases from resulting in more postoperative complications includ-
carcinoma of the tongue. Occult nodal metastasis can ing pain, haemorrhage, and infection.64
be expected in over 30% of patients with T1 and T2
tumours and clinically NO necks.46,50–53 Nodal status
at presentation is the most important prognostic fac- Radiotherapy
tor, if the nodes are affected then the chance of cure
falls by half.46,54 If one examines causes of failure of Radiotherapy may be given as the sole treatment or as
local resection, then the most common site of failure an adjunct to surgery. It is as effective as surgery for
is the ipsilateral neck.46,50,52,53 Salvage surgery usually the small tongue lesion and may be chosen as a pri-
has a poor outcome with extra nodal spread being mary treatment when surgery would result in severe
more common in late neck dissection.46,55 disability and when clearance would be difficult to
Unfortunately, the compelling argument for elective achieve.
neck dissection has to be counterbalanced by the Radiotherapy is often used in addition to surgery
increased incidence of late, contralateral neck disease and currently tends to be given postoperatively, often
occurring after elective radical neck dissection, pre- because of unfavourable histology. Many oncologists
sumably resulting from the altered lymphatic would recomend adjunctive radiotherapy for large
drainage.50 In addition, one also has to consider the tumours if surgical margins are close to or involved
morbidity of the shoulder syndrome after radical with tumour, or after neck dissection where there are
neck dissection. Supraomohyoid neck dissection many positive nodes.65–67 We will confine our discus-
would remove most of the lymph nodes likely to be sion to treatment of the primary lesion, and, in partic-
involved in occult metastasis from the tongue (possi- ular, issues of interest to the surgeon.
bly up to 70%),46,51 whilst having a less profound effect Radiotherapy may be delivered by external beam,
on lymphatic drainage, and incurring less morbidity. by radioactive implant (brachytherapy) or by a combi-
Although the supraomohyoid neck dissection is the nation of the two. External beam radiotherapy used
logical solution to the problem of the NO neck, at to treat carcinoma of the tongue clearly results in the
present there is no definitive evidence of an improve- irradiation of a large amount of surrounding normal
ment in survival although, for theoretical reasons, this tissue, often resulting in the short-term complication
approach is being increasingly adopted. of painful mucositis and candida infection, plus the
Given the difficulties of surgical excision and the long-term complications of xerostomia, loss of taste,
high incidence of neck failure, most authors would and occasionally mandibular osteoradionecrosis.
agree to give postoperative radiotherapy to patients These complications can be reduced by the use of
with close or involved surgical margins, two or more paired irradiation fields converging on the tumour,
positive neck nodes, and those with evidence of extra- but they are not eliminated completely.68 In addition a
nodal spread.51,53,56 three-week rest period may be incorporated during
Total glossectomy is done for advanced carcinoma treatment but, to maintain treatment outcome, this
involving the base of tongue. It has high associated needs to be compensated by a 10% increase in total
mortality and morbidity57 and appreciable subsequent irradiation dose.69,70
functional impairment. There is a high incidence of Brachytherapy has the advantage of high radiation
failure to obtain clear surgical margins.58,59 Most dose delivery to the tumour while minimizing dose
Squamous carcinoma of the tongue 169

delivery to the surrounding normal tissues. When laser light is shone at the tumour, cells are destroyed
used alone for T1 and T2 tumours, five-year survival as a result of the triggered photochemical reaction.80
rates of 61% and 74%, respectively, can be achieved70 The most widely used sensitizing drug is a haemato-
but the results for the larger tumour are poor.71 Better porphyrin derivative (Photofrin). Photodynamic ther-
disease control is obtained by using brachytherapy in apy has been used with benefit in cases of oral field
conjunction with lower dose external beam irradia- cancerization and with microinvasive disease.81
tion, but this is associated with soft-tissue necrosis Photodynamic therapy is a repeatable treatment. With
and osteoradionecrosis; 2% require surgery for these the use of the newer metatetrahydroxyphenychlorine
complications.72,73 (mTHPC) tissue destruction of up to ~1 cm has been
When one looks at tumour morphology, there is a achieved.82 Aminolaevulinic acid has also been used
correlation between disease control with radiotherapy as a sensitizer, resulting in a short period of cutaneous
and tumour morphology, with better local control of photosensitivity, but there is only superficial tissue
disease achieved for superficial and exophytic necrosis up to a depth of about 1.3 mm.83
tumours when compared with infiltrative tumours.65,74 Unfortunately, the available sensitizers are all taken
Results comparable with surgery can be achieved up by normal tissue to some extent. The photosensi-
from the combination of brachytherapy with external tizing drugs also induce cutaneous photosensitivity,
beam radiotherapy for T1 and T2 carcinomas of the which may last for several months. In addition, treat-
tongue, but with some short- and long-term morbidity. ment times may be long, with heavy and expensive
Timing of postoperative radiotherapy is often dic- laser equipment.
tated by wound healing and the patient’s general Photodynamic therapy, therefore, has a useful role
recovery. Research indicates that locoregional control only in selected cases but it is at present available only
may be significantly worse if there is a delay between in a few centres.
treatment of more than seven weeks.75
Continuous, hyperfractionated, accelerated radio-
therapy (CHART) has been used in a limited number Cryotherapy
of oncology centres to treat head and neck malig-
nancy. Conventional radiotherapy regimens are based In this country, cryotherapy is occasionally used to
on a single daily dose given on five days a week. palliate the advanced, fungating tongue carcinoma
CHART is given in smaller individual doses/fraction, when other treatments have failed or are thought to be
but is given three times daily for a continuous period of inappropriate. Li described a series of 50 cases of car-
12 days. Interval-free treatment is of particular benefit cinoma of the tongue,84 mainly T2 tumours, where
in tumours with a rapid cell doubling time, so reducing cryotherapy has been used as the primary treatment of
the chance of tumour cell repopulation during breaks the tongue lesion. Control rates of 90% are claimed,
in treatment. In addition, radiotherapy given in many with a five-year survival of 72.3%. The treatment is
small doses may spare late damage to normal tissues. often used in combination with radical neck dissec-
Studies so far have shown improved survival and local tion, but carried out pre-operatively under local
tumour control when CHART is used in the treatment anaesthesia in the outpatient department. Clearly, it is
of locally advanced carcinomas of the head and neck. limited by the depth of tissue freezing that can be
When it is used to treat lesions of the tongue, a mem- achieved (~ 3 mm from the probe) and also by the
branous reaction occurs on the dorsum and lateral local soft tissue inflamatory response, which may
margins, which may take several months to heal.76–78 cause respiratory compromise.
Cryotherapy is an interesting option, but cannot be
seen as a serious challenge to existing treatments in
Chemotherapy this country.

Conventional chemotherapy has a limited role in the


primary management of carcinoma of the tongue, but RECONSTRUCTION
is sometimes considered as an adjunct in advanced
disease. The potential for immunotargeting has not After excision of all but the smallest lesions of the
yet been fully explored. Monoclonal antibodies have anterior tongue, reconstruction is required to main-
been raised against viable human head and neck squa- tain function. The ideal reconstruction would restore
mous carcinoma cells, which show high-affinity bind- the normal tongue volume and shape, have a supple,
ing with tumour cell surface antigens. It is possible non-hairy surface, and move freely in function. For
that this technology could be developed to target ther- speech and eating, mobility of the tongue tip is partic-
apeutic agents specifically at tumour cells and also in ularly important, while volume of the posterior third
the diagnosis of occult disease.79 is important in swallowing.
Excision of up to a quarter of the anterior two-
thirds of the tongue can usually be accomplished
Photodynamic Therapy without the need for introduction of extraoral tissues.
The options after excision of such small lesions are to
Photodynamic therapy involves giving a light sensitiz- leave the area to epithelialize and heal by secondary
ing drug systemically which is selectively taken up by intention, primary closure, split thickness skin grafting,
the tumour so that when the appropriate wavelength or the use of a local tongue flap.
170 British Journal of Oral and Maxillofacial Surgery

After laser excision, a good surface is left, which is


relatively painless and epithelializes readily with mini-
mal scaring and wound contracture.63 However, con-
ventional surgical excision (if left to heal by secondary
intention) may be painful whilst healing and often
lead to tethering. Because of the resultant distortion,
there is probably little place for primary closure.
Split thickness skin grafting helps to prevent
wound contracture and tethering but results in a
parchment-like surface.
Local tongue flaps may be used to retain the shape
of the anterior two-thirds of the tongue at the expense
of loss of overall tongue volume. At its simplest, the
lateral tongue may be advanced to reconstruct the tip,
but more extensive posterior rotational flaps have
been described to restore defects of over half the ante-
rior tongue.85 Clearly, these flaps have the advantage
of maintaining the tongue’s normal surface character,
and they do not involve a separate donor site, but they
do not address the loss of volume.
Distant flaps used to reconstruct the tongue may be
either pedicled, such as the pectoralis major flap, or
microvascular free flaps, of which a large number are
available for soft tissue reconstruction. Both types read-
ily tolerate postoperative radiotherapy once healed.
The pectoralis major flap is a good reliable pedicled
flap based on the thoracoacromial artery.86,87 Its disad-
vantage when used to reconstruct the tongue is its
bulk, which may be excessive and restrict the move-
ment of the normal residual tongue. The skin paddle
is of thick, hairy skin, but this problem may be over-
come by using a muscle only flap and leaving the raw
surface to epithelialize.88 The muscle bulk at the base
of the neck as the pedicle crosses the clavicle may
result in poor aesthetics, particularly in women, but
the great neck vessel coverage that it provides is an
advantage, particularly if the neck is to be irradiated.
An alternative pedicled flap is the latissimus dorsi flap,
but similar problems are encountered, in addition to
positional difficulties at operation, constriction of the
pedicle at the axilla, and donor site morbidity.
Free tissue transfer has been successfully used to
reconstruct the tongue. Perhaps the most widely
described free flap used to reconstruct the lingual soft
tissues is the radial forearm fasciocutaneous flap.89–92 Fig. 3 – Excised T2 tumour from left lateral border of tongue and
This is a reliable free flap based on the large calibre reconstruction with radial forearm flap.
radial artery and drained by its venae comitantes and
the cephalic vein. The skin is thin and pliable, being
better suited to replacing oral mucosa than the thicker volume of muscle and fatty tissue. Hernia at the
chest wall skin (Fig. 3), and easily moves with the resid- donor site is reported in 3.5%.95
ual tongue muscle. The radial artery is rarely effected The microneurovascualr transfer of the tensor fas-
by atheroma and age is not a contraindication to its cia lata musculocutaneous flap for tongue reconstruc-
use.93 This flap tolerates postoperative radiotherapy tion has been described in a small series of five
well, but is less reliable in previously irradiated tissues.94 patients. It is claimed that this flap provides adequate
In addition to the radial forearm free flap, free tis- bulk and restores some sensory and motor function.96
sue transfer of jejunum, inferior rectus abdominis,
and the microneurovascular transfer of tensor fascia
lata flaps have been described for tongue reconstruc- PROGNOSIS
tion. Free jejunum provides a supple oral surface with
low bulk, but mucous hypersecretion may be a prob- Over the past 20 years, better locoregional control of
lem, though this ceases after radiotherapy.95 Free infe- carcinoma of the tongue has been achieved, together
rior rectus abdominis provides bulk after total or with some improvement in survival.98 This improve-
subtotal glossectomy, and it is possible to adjust the ment may have resulted from a combination of elective
Squamous carcinoma of the tongue 171

neck dissection for the NO neck and the use of with eating and drinking. Interestingly, if one ques-
adjunctive radiotherapy for stage III and IV disease, tions a relative or carer, it seems that patients tend to
close or involved margins, multinodal metastases, and under-report functional short comings.105 Many
vascular or perineural involvement. attempts to assess function have been made but are to
Five-year survival rates of over 80% are quoted for some extent subjective. Videoflouroscopy is often
stage I and II disease, and in the region of 50% for used to assess swallowing but rarely is a similar
stage III and IV.90 Most T1 tumours are treated by detailed assessment made of speech.
surgery alone in this country. Mitchel and Crighton The anterior two-thirds of the tongue makes a
quote five-year survival rates of over 60% for T2 large contribution to swallowing, speech, and the con-
tumours with no significant difference between trol of food and saliva. Denervation postoperatively is
surgery and radiotherapy as the primary treatment.99 usually unilateral and of little functional conse-
It is clear from several series that the single most quence. Loss of anterior tongue volume is not a prob-
important clinical prognostic indicator is nodal status lem if tip mobility and reach are preserved.106 If these
at the time of diagnosis,100 but there is a particularly criteria are fulfilled, half the mobile tongue can be
high incidence of occult neck disease. When patients resected without swallowing problems.107 Resection of
with NO necks were followed up, one series claimed less than a quarter of the lateral tongue volume may,
that 17% with T1 tumours developed positive nodes, however, result in lateral air escape in speech but little
45% with T2, and 86% with T3/T4 tumours. It would trouble with swallowing. For T1 tumours, patients
therefore seem logical to carry out some sort of neck who had skin grafts had better preservation of tongue
dissection for patients with at least T2–T4 tumours mobility and therefore better function than those who
and negative necks.99 Neck dissection in this instance had undergone primary closure.108 Local flaps may
would be expected to have a therapeutic and a staging result in similar restricted tongue mobility and prob-
benefit, enabling the rational planning of adjunctive lems with chewing and swallowing.109
therapy.101 The consequences of surgery on the posterior
In a large series, 37% of treated cases of carcinoma tongue mainly relate to swallowing and the palatal
of the tongue developed locoregional recurrence, with contact necessary to eject the food bolus into the
over 75% of recurrences occurring within the the first pharynx. A major cause of dysphagia is the lack of
year of treatment.98,102 The most comon site of treat- the force needed to propel the bolus from the mouth
ment failure is the ipsilateral neck. Risk factors for to pharynx and pharynx to oesophagus. If the bolus
recurrence include an infiltrating pattern of tumour stays in the pharynx, then it will spill into the larynx
growth, diffuse histological invasion, and tumour when the larynx opens, resulting in aspiration.107
within 5 mm of the resection margin.102 Information Clearly restoration of tongue volume is crucial and
gained from the diagnostic biopsy specimen may necessitates the introduction of a flap for all but the
therefore give some indication of the aggressiveness of smallest of defects.
the tumour and may be helpful in planning surgery. After total or near total glossectomy, these prob-
Improved locoregional control undoubtedly results lems are compounded, which results in major prob-
in more patients being seen with a second primary lems with speech and swallowing. Considerable
tumour within the aerodigestive tract.103 In one study, aspiration is reported in 10%–37% of patients after
24% developed a second malignancy.98 This trend was total glossectomy.109 Laryngeal suspension is of benefit
seen particularly in patients under 60 years of age at in the prevention of aspiration but has little benefit for
first diagnosis and may reflect continued exposure to speech. Preservation of the superior laryngeal nerve is
carcinogens, field change, or a genetic predisposi- also important in the prevention of aspiration.110 To
tion.104 The benefits of extensive and invasive screen- achieve reasonable postoperative speech and swallow-
ing measures are in doubt, as the outcome for this ing, compensatory mechanisms develop such as pha-
group of patients (even if the second lesion is detected ryngeal widening for high vowels, compression or
early) is extremely poor. narrowing for low vowels, and exaggerated lip,
The place for adjunctive chemotherapy is yet to be mandibular, and laryngeal movements.109 In addition,
agreed. Some advocate its use when there are multiple head tilt may be used to help to move the food bolus
involved cervical nodes, in young patients, and in the into the pharynx.109 Speech therapy may help to speed
presence of adverse histological features. There seems the development of these alternative manoeuvres.111
to be no confirmed benefit to survival at present but In terms of the reconstructive techniques used, the
the results of large series are awaited. ideal flap will depend on the site and extent of resec-
tion. Good functional results are claimed for various
free flaps but the intelligibility of speech remains
FUNCTIONAL OUTCOME inversely proportional to the extent of resection.112,113
Unfortunately, most studies have looked at small
The functional ideal after treatment of carcinoma of numbers of patients and different reconstructive tech-
the tongue is that the patient should return to normal niques, and they lack good objective results. Despite
speech and swallowing. Studies have indicated that this, there does seem to be agreement that the combi-
many patients have appreciable problems with both. nation of surgery and radiotherapy gives a poorer
Questioning of patients postoperatively indicates that functional outcome than a single treatment.114
as many as one-third report difficulties with speech Maxillary prostheses may have a role in the rehabil-
and appearance, whilst almost a half have difficulties itation of speech. Oral volume is restored by providing
172 British Journal of Oral and Maxillofacial Surgery

palatal coverage and lack of tongue mobility and 18. Zeuss M S, Miller C S, White D K. In situ hybridisation
posterior tongue volume may be compensated for, analysis of human papillomavirus DNA in oral mucosal
lesions. Oral Surg Oral Med Oral Pathol 1991; 71:
resulting in improvement in speech.110,115 714–720.
Clearly, more objective studies are needed on func- 19. Johnson N W, Warnakulasurya K A A S, Tavassoli M.
tional outcome, but the difficulty with this remains Hereditary and environmental risk factors: clinical and
the heterogeneous nature of the group of patients laboratory risk markers for head and neck, especially oral
cancer and precancer. Eur J Cancer Prev 1996; 5: 5–17.
under consideration. 20. Langdon J D, Partridge M. Expression of the tumour
suppressor gene p53 in oral cancer. Br J Oral Maxillofac
Surg 1992; 30: 214–220.
21. Ogden G R, Kiddie R A, Lunny D P, Lane D P. Assessment
CONCLUSIONS of p53 protein expression in normal, benign, and malignant
oral mucosa. J Pathol 1992; 166: 389–394.
The important issues that have come to light as a 22. Langdon J D, Henk J M. Malignant tumours of the mouth,
result of this review include the changing incidence jaws and salivary glands. London: Edward Arnold, 1995.
23. Burns J E, Baird M C, Clark L J et al. Gene mutation and
and demography of the disease. There is debate about increased levels of p53 protein in human squamous cell
the optimal treatment of the NO neck, and this and carcinomas and their cell lines. Br J Cancer 1993; 67:
the optimal reconstruction await the result of detailed 1274–1284.
analysis of large series of patients. 24. Monasebian D M, Ruskin J D. Flow cytometric analysis of
squamous cell carcinoma of the tongue. J Oral Maxillofac
Surg 1994; 52: 574–578.
25. Bhatavdekar J M. Circulating markers and growth factors as
References prognosticators in men with advanced carcinoma of the
tongue. Tumour Biol 1993; 14: 55–58.
1. Muir C, Waterhouse J, Mack T et al. Cancer incidence in 26. Patel D D, Bhatavdekar J M, Vora H H, Balar D B.
five continents. Vol. V IARC Scientific Publications No. 88. Circulating prolactin and tumoural prolactin receptors in
Lyon: International Agency for Research on Cancer, 1987. men with tongue cancer: a preliminary study. Eur J Surg
2. Hindle I, Nally F. Oral cancer: a comparative study between Oncol 1994; 20: 155–159.
1962–67 and 1980–84 in England and Wales. Br Dent J 1991; 27. Shpitzer T, Chaimoff M, Gal R et al. Tumour angiogenesis
170: 15–20. as a prognostic factor in early oral tongue cancer. Arch
3. Chen J, Eisenberg E, Krutchkoff D J, Katz R V. Changing Otolaryngol Head Neck Surg 1996; 112: 865–868.
trends in oral cancer in the United States. J Oral Maxillofac 28. Frame J W. The management of oral premalignant lesions.
Surg 1991; 49: 1152–1158. Br J Oral Maxillofac Surg 1992; 30: 71.
4. Farr H W, Arthur K. Epidermoid carcinoma of the mouth 29. Silverman S, Gorsky M, Lozada F. Oral leukoplakia and
and pharynx 1960–1964. J Laryngol Otol 1972; 86: 243–253. malignant transformation. Cancer 1984; 53: 563–568.
5. Pindborg J J. Oral cancer and precancer. Bristol: John 30. Burns J E, Clark L J, Yeudall W A et al. The p53 status of
Wright, 1980. cultured human premalignant oral keratinocytes. Br J
6. Sakaria J N, Harari P M. Oral cancer in young adults less Cancer 1994; 70: 591–595.
than 40 years of age: Rationale for aggressive therapy. Head 31. Lippman S M, Shin D M, Lee J J et al. p53 and retinoid
Neck 1994; 16:107–111. chemoprevention of oral carcinogenesis. Cancer Research
7. Layton S A, Rintoul M, Avery B S. Oral carcinoma in 1995; 55: 16–19.
pregnancy. Br J Oral Maxillofac Surg 1992; 30: 161–164. 32. Hong W K, Edicott J, Itri L M et al. 13-cis-retinoic acid in
8. Warnakulasurya K A A S, Acworth P, Bell J, Johnson N W. the treatment of oral leukoplakia. N Engl J Med 1986; 315:
Incompleteness of oral cancer registration in south-east 1501–1505.
England. Br J Cancer 1994; 70: 736–738. 33. Mashberg A, Morrissey J B, Garfinkel L. A study of the
9. Franceschi S, Barra S, La Vecchia C et al. Risk factors for appearance of early asymptomatic squamous cell
cancer of the tongue and the mouth. Cancer 1992; 70: carcinoma. Cancer 1973; 32: 1436–1445.
2227–2232. 34. Mashberg A. Tolonium (toluidene blue) rinse – a screening
10. Barasch A, Morse D E, Krutchkoff D J, Eisenberg E. method for recognition of squamous carcinoma. Continuing
Smoking, gender and age as risk factors for site-specific study of oral cancer IV. JAMA 1981; 245: 2408–2410.
intraoral squamous cell carcinoma. Cancer 1994; 73: 35. Braams J V, Pruim J, Freling N J M et al. Detection of
509–513. lymph node metastasis of squamous cell cancer of the head
11. Boffeta P, Mashberg A, Winkelmann R, Garfinkel L. and neck with FDG-PET and MRI. J Nucl Med 1995; 36:
Carcinogenic effect of tobacco smoking and alcohol 211–216.
drinking on anatomic sites of the oral cavity and 36. Sugimura K, Kuroda S, Furukawa T et al.. Tongue cancer
oropharynx. Int J Cancer 1992; 52: 530–533. treated with irradiation: assessment with MRI imaging. Clin
12. Blott W J, McLaughlin J K, Winn D M et al. Smoking and Radiol 1992; 46: 243–247.
drinking in relation to oral and pharyngeal cancer. Cancer 37. Wong W-L, Chevretton E, McGurk M, Croft D. PET-FDG
Res 1988; 48: 3282–3287. imaging in the clinical evaluation of head and neck cancer.
13. Jayant K, Balakrishnan V, Sanghvi L D, Jussawalla D J. J R Soc of Med 1995; 88: 469–473.
Quantification of the role of smoking and chewing tobacco 38. Watkinson J C, Lazarus C R, Todd C, Maisey M N, Clark S
in oral, pharyngeal and oesophageal cancers. Br J Cancer E M. Metastatic squamous carcinoma in the neck: an
1977; 35: 232–235. anatomical and physiological study using CT and SPECT
14. La Vecchia C, Negri E, D’Avanzo B, Boyle P, Franceschi S. 99Tcm (V) DMSA. Br J Radiol 1991; 64: 909–914.
Dietar indicators of oral and pharyngeal cancer. Int J 39. Pretorius D, Taylor A. The role of nuclear scanning in head
Epidemiol 1991; 20: 39–44. and neck surgery. Head Neck Surg 1982; 4: 427–432.
15. McLaughlin J K, Gridley G, Block G et al. Dietary factors 40. Watkinson J C, Maisley M N. Imaging head and neck cancer
in oral and pharyngeal cancers. J Nat Cancer Inst 1988; 80: using isotopes: a review. J R Soc Med 1988; 81: 653–657.
1237–1243. 41. Font D, Hardoff R, Robinson E. Bone scintigraphy in
16. Grindley G, McLaughlin J K, Block G et al. Vitamin primary tumours of the head and neck. Cancer 1978; 42:
supplement use and reduced risk of oral and pharyngeal 111–117.
cancer. Am J Epidemiol 1992; 135: 1083–1092. 42. Holm L-E, Lundquist P-G, Silfversward C, Sobin A.
17. Cox M F, Scully C, Maitland N. Viruses in the aetiology of Histological grading of malignancy in squamous cell
oral carcinoma? Examination of the evidence. Br J Oral carcinoma of the oral tongue. Acta Otolaryngol 1982; 94:
Maxillofac Surg 1991; 29: 381–387. 185–192.
Squamous carcinoma of the tongue 173

43. Morton R P, Ferguson C M, Lambie N K, Whitlock R M L. implantation and external radiation alone. Int J Radiat
Tumour thickness in early tongue cancer. Arch Otolaryngol Oncol Biol Phys 1987; 13: 511–516.
Head Neck Surg 1994; 122: 717–720. 68. Robertson A G, McGregor I A, Soutar D S et al. Post-
44. Cooke L D, Cooke T G, Forster G et al. Flow cytometric operative radiotherapy in the management of advanced
analysis of DNA content in squamous carcinoma of the intra-oral cancers. Clin Radiol 1986; 37: 173–178.
tongue: the relationship to host and tumour factors and 69. Kajanti M, Holsti L R, Holsti P. Radical surgery and
survival. Clin Otolaryngol 1994; 19: 131–134. postoperative split-course radiotherapy in squamous cell
45. Byers R M, El-Naggar A K, Lee Y-Y et al. Can we detect or carcinoma of the mobile tongue: factors influencing local
predict the presence of occult nodal metastases in patients control and time to recurrence. Radiother Oncol 1991; 22:
with squamous carcinoma of the oral tongue? Head Neck 174–179.
1998; 20: 138–144. 70. Henk J M. Treatment of oral cancer by interstitial
46. Shah J P, Andersen P E. Evolving role of modifications in irradiation using iridium-192. Br J Oral Maxillofac Surg
neck dissection for oral squamous carcinoma. Br J 1992; 30: 355–359.
Maxillofac Surg 1995; 33: 3–8. 71. Podd T J, Carton A T M, Barrie R et al. Treatment of oral
47. Shah J P. The patterns of cervical lymph node metastasis cancers using iridium-192 interstitial irradiation. Br J Oral
from squamous carcinoma of the oral cavity. Cancer 1990; Maxillofac Surg 1994; 32: 207–213.
66: 109–113. 72. Decroix Y, Ghossein N A. Experience of the Curie Institute
48. Takagi M, Yamamoto H, Hoshina M, Enomoto S. Causes of in treatment of cancer of the mobile tongue. Cancer 1981;
oral cancer treatment failures. Cancer 1992; 69: 1081–1086. 47: 496–502.
49. Finlay P M, Dawson F, Robertson A G, Soutar D S. An 73. Harrison L B, Zelefsky M J, Sessions R B et al. Base of
evaluation of functional outcome after surgery and tongue cancer treated with external beam irradiation plus
radiotherapy for intraoral cancer. Br J Oral Maxillofac Surg brachytherapy: oncologic and functional outcome Radiology
1992; 30: 14–17. 1992; 184: 267–270.
50. Fakih A R, Rao R S, Borges A M, Patel A R. Elective versus 74. Shibuya H, Hoshina M, Takeda M et al. Brachytherapy for
therapeutic neck dissection in early carcinoma of the oral stage I and II oral tongue cancer: an analysis of past cases
tongue. Am J Surg 1989; 158: 309–313. focusing on control and complications. Int J Radiat Oncol
51. Lydiatt D D, Robbins K T, Byers R M, Wolf P F. Treatment Biol Phys 1993; 26: 51–58.
of stage I and II oral tongue cancer. Head and Neck 1993; 75. Vikram B. Importance of the time interval between surgery
15: 308–312. and postoperative radiation therapy in the
52. Hughes C J, Gallo O, Spiro R H, Shah J P. Management of combinedmanagement of head and neck cancer. Int J Radiat
occult neck metastases in the oral cavity squamous Oncol Biol Phys 1979; 5: 1837–1840.
carcinoma. Am J Surg 1993; 166: 380–383. 76. Dische S, Saunders M I. Continuous hyperfractionated,
53. Kraus D H, Vastola A P, Huvos A G, Spiro R H. Surgical accelerated radiotherapy (CHART). Br J Cancer 1989; 59:
management of squamous cell carcinoma of the base of the 325–326.
tongue. Am J Surg 1993; 166: 384–388. 77. Saunders M I, Dische S, Hong A et al. Continuous
54. Teichgraeber J F, Clairmont A A. The incidence of occult hyperfractionated radiotherapy in locally advanced
metastases for carcinoma of the oral tongue and floor of carcinoma of the head and neck region. Int J Radiat Oncol
mouth: treatment rationale. Head Neck Surg 1984; 7: 15–21. Biol Phys 1989; 17: 1287–1293.
55. Shingaki S, Kobayashi, Suzuki I, Kohno M, Nakajima T. 78. Dische S, Saunders M I. The rationale for continuous
Surgical treatment of stage I and II oral squamous cell hyperfractionated, accelerated radiotherapy (CHART). Int J
carcinomas: analysis of causes of failure. Br J Oral Radiat Oncol Biol Phys 1990; 19: 1317–1320.
Maxillofac Surg 1995; 33: 304–308. 79. Schrijvers A H G J. MAb U36, a novel monoclonal antibody
56. Foote R L, Olsen K D, Davis D L et al. Base of tongue successful in immunotargeting of squamous cell carcinoma
carcinoma: patterns of failure and predictors of recurrence of the head and neck. Cancer Res 1993; 53: 4383–4390.
after surgery alone. Head Neck 1993; 15: 300–307. 80. Davis R K. Photodynamic therapy in head and neck cancer.
57. Sultan M R, Coleman J J. Oncologic and functional Lasers in otorhinolaryngology, and in head and neck
considerations of total glossectomy. Am J Surg 1989; 158: surgery. Adv Otorhinolaryngol 1995; 49: 58–62.
297–302. 81. Grant W E, Hopper C, Speight P M, Macrobert A J, Brown
58. Rodrigues R, Perry C, Soo K C, Shaw H J. Total S G. Photodynamic therapy of malignant and premalignant
glossectomy. Am J Surg 1987; 154: 415–418. lesions in patients with ‘field cancerisation’ of the oral cavity.
59. Harrison D. The questionable value of total glossectomy. J Laryngol Otol 1993; 107: 1140–1145.
Head Neck Surg 1983; 6: 632–638. 82. Hopper C. The role of photodynamic therapy in the
60. Tiwari R M, Greven A J, Karim A B M F, Snow G B. Total management of oral cancer and precancer. Eur J Cancer
glossectomy: reconstruction and rehabilitation. J Laryngol 1996; 23B: 71–72.
Otol 1989; 103: 917–921. 83. Fan K, Hopper C, Speight P M et al. Photodynamic therapy
61. Biller H F, Lawson W, Baek S-M. Total glossectomy. Arch using 5-aminolevulinic acid for premalignant and malignant
Otolaryngol 1983; 109: 69–73. lesions of the oral cavity. Cancer 1996; 78: 1374–1383.
62. Suarez C, Rodrigo J B, Herranz J, Rosal C, Alvarez J C. 84. Li Z. Cryosurgery in 50 cases of tongue carcinoma. J Oral
Extended supraglottic laryngectomy for primary base of Maxillofac Surg 1991; 49: 504–506.
tongue carcinomas. Clin Otolaryngol 1996; 21: 37–41. 85. Friedman M, Rosenberg M. Anterior glossectomy:
63. Carruth J S. Resection of the tongue with the carbon reconstruction with a posterior tongue rotation flap. Head
dioxide laser: 100 cases. J Laryngol Otol 1985; 99: 887–889. Neck Surg 1987; 9: 353–355.
64. Frame J W, Morgan D, Rhys Evans P H. Tongue resection 86. Ariyan S. Pectoralis major, sternomastoid and other
with the CO2 laser: the effects of past radiotherapy on musculocutaneous flaps for head and neck reconstruction.
postoperative complications. Br J Oral Maxillofac Surg Clin Plast Surg 1980; 7: 89–109.
1988; 26: 464–471. 87. Mehta S, Sarkar S, Kavarana N, Bhathena H, Mehta A.
65. Weber R S, Gidley P, Morrison W H et al. Treatment Complications of the pectoralis major myocutaneous flap in
selection for carcinoma of the base of the tongue. Am J Surg the oral cavity: a prospective evaluation of 220 cases. Plast
1990; 160: 415–419. Reconstr Surg 1996; 98: 31–77.
66. Zelefski M J, Harrison L B, Armstrong J G. Long term 88. Johnson M A, Langdon J D. Is skin necessary for intraoral
treatment results of postoperative radiation therapy for reconstruction with myocutaneous flaps. Br J Oral
advanced stage oropharyngeal carcinoma. Cancer 1992; 70: Maxillofac Surg 1990; 28: 299–301.
2388–2395. 89. Soutar D S. Free flaps in reconstructive surgery. Ann R Coll
67. Housset M, Baillet F, Dessard-Diana B, Martin D, Surg Eng 1989; 71: 169–174.
Miglianico L. A retrospective study of three treatment 90. Soutar D S, Mcgregor I A. The radial forearm free flap in
techniques for T1–T2 base of tongue lesions: surgery plus intraoral reconstruction: the experience of 60 consecutive
postoperative radiation, external radiation plus interstitial cases. Plast Reconstr Surg 1986; 78: 1–8.
174 British Journal of Oral and Maxillofacial Surgery

91. Vaughan E D. The radial forearm free flap in orofacial 107. Hirano M, Kuroiwa Y, Tanaka S et al. Dysphagia following
reconstruction. J CranioMaxilloFac Surg 1990; 18: 2–7. various degrees of surgical resection for oral cancer. Ann
92. Vaughan E D, Bainton R, Martin I C. Improvements in the Otol Rhinol Laryngol 1992; 101: 138–141.
morbidity of mouth cancer using microvascular free flap 108. Hamlet S L, Mathog R H, Patterson R L, Fleming S M.
reconstructions. J CranioMaxilloFac Surg 1992; 20: 132–134. Tongue mobility in speech after partial glossectomy. Head
93. Bridger A G, O’Brien C J, Lee K K. Advanced patient age Neck 1990; 12: 210–217.
should not preclude the use of free flap reconstruction for 109. Kronenberger M B, Meyers A D. Dysphagia following head
head and neck cancer. Am J Surg 1994; 168: 425–428. and neck cancer surgery. Dysphagia 1994; 9: 236–244.
94. Tabah R J, Flynn M B, Acland R D, Banis J C. 110. Weber R S, Ohlms L, Bowman J, Jacob R, Goepfert H.
Microvascular free tissue transfer in head and neck and Functional results after total or near total glossectomy with
osophageal surgery. Am J Surg 1984; 148: 498–504. laryngeal preservation. Arch Otolaryngol Head Neck Surg
95. Habel G, O’Regan B, Carter J. Free jejunal transfer in oral 1991; 117: 512–515.
reconstruction. Br J Oral Maxillofac Surg 1990; 28: 159–163. 111. Greven A J, Meijer M F, Tiwari R M. Articulation after
96. Nakatsuka T, Harii K, Yamada A, Asato H, Ebihara S. total glossectomy: a clinical study of speech in six patients.
Versatility of a free inferior rectus abdominis flap for head Eur J Disord Commun 1994; 29: 85–93.
and neck reconstruction: analysis of 200 cases. Plast 112. Michiwaki Y, Ohno K, Imai S, Yamashita Y, Suzuki N.
Reconstr Surg 1994; 93: 762–769. Functional effects of reconstruction with a free radial
97. Cheng N, Shou B, Zheng M, Huang A. Microneurovascular forearm flap. J CranioMaxilloFac Surg 1990; 18: 164–169.
transfer of the tensor fascia lata musculocutaneous flap for 113. Salibian A H, Allison G R, Rappaport I, Krugman M E,
reconstruction of the tongue. Ann Plast Surg 1994; 33: McMicken B L, Etchepare T L. Total and subtotal
136–141. glossectomy: function after microvascular reconstruction.
98. Franceschi D, Gupta R, Spiro R H, Shah J P. Improved Plast Reconstr Surg 1990; 85: 513–524.
survival in the treatment of squamous carcinoma of the oral 114. Finlay P M, Dawson F, Robertson A G, Soutar D S. An
tongue. Am J Surg 1993; 166: 360–365. evaluation of functional outcome after surgery and
99. Mitchell R, Crighton L E. The management of patients with radiotherapy for intraoral cancer. Br J Oral Maxillofac Surg
carcinoma of the tongue. Br J Oral Maxillofac Surg 1993; 1992; 30: 14–17.
31: 304–308. 115. Knowles J C, Chalian V A, Shanks J C. A functional speech
100. Kalnins I K, Leonard A G, Sako K, Razak M S, Shedd D P. impression used to fabricate a maxillary speech prosthesis
Correlation between prognosis and degree of lymph node for a partial glossectomy patient. J Prosthet Dent 1984; 51:
involvement in carcinoma of the oral cavity. Am J Surg 232–237.
1997; 134: 450–454.
101. Fein D A, Mendenhall W M, Parsons J T et al. Carcinoma
of the oral tongue: a comparison of results and
complications of treatment with radiotherapy and/or The Authors
surgery. Head Neck 1994; 16: 358–365.
102. Kirita T, Okabe S, Izumo T, Sugimura M. Risk factors for S. Prince FDS RCPS, FFD RCSI, FRCS
the postoperative local recurrence of tongue carcinoma. J Specialist Registrar in Oral and Maxillofacial Surgery
Oral Maxillofac Surg 1994; 52: 149–154. B.M.W. Bailey MB, FRCS, FDS RCS
103. Carr R J, Langdon J D. Multiple primaries in mouth cancer Consultant Oral and Maxillofacial Surgeon
– the price of sucess Br J Oral Maxillofac Surg 1989; 27: Queen Mary’s University Hospital
394–399. Roehampton
104. Day G L, Blot W J. Second primary tumours in patients London SW15 5PN, UK
with oral cancer. Cancer 1992; 70: 14–19. Correspondence and requests for offprints to: Miss S. Prince FDS
105. Freedlander E, Espie C A, Campsie L M, Soutar D S, RCPS, FFD RCSI, FRCS, Maxillofacial Unit, Northampton
Robertson A G. Functional implications of major surgery General Hospital Trust, Billing Road, Northampton NN1 5BD, UK.
for intraoral cancer. Br J Plast Surg 1989; 42: 266–269.
106. McGregor I A. The persuit of function and cosmesis in Paper received 2 February 1998
managing oral cancer. Br J Plast Surg 1993; 46: 22–31. Accepted 13 February 1998