‫الر ِحيم‬

َّ ‫من‬
ِ ‫الر ْح‬
َّ ‫هللا‬
ِ ‫س ِم‬
ْ ‫ِب‬

Surgery of the
Tongue
LECTURE (1)
The oral cavity
Extends from the skin–vermilion border of the lips ant. to the junction
of the soft palate sup. & the line of circumvallate papillae on the
junction of the post. 1/3 and ant. 2/3of tongue posteriorly

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Gynaecology - Prof.S.N.Panda
 DEVELOPMENTAL ANOMALIES OF
TONGUE
AGLOSSIA= absence. Frequent with other
congenital or developmental defects (limb and other
cranio-facial defects).
CLEFT or BIFID TONGUE
failure of fusion of 2 lingual processes
• TONGUE TIE(ANKYLOGLOSSIA):
short thick lingual frenum .
Presentations
1. Impairment of tongue movements
2.Malocclusion, swallowing & speech defects.
Treatment by division of frenum near floor of
mouth (LA,GA) best at 3 years age

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Gynaecology - Prof.S.N.Panda
• GEOGRAPHIC TONGUE or benign migratory glossitis :
It is a benign condition common in patients with cong. heart
dis or acute GIT problems as alternating red & yellowish-
white areas due to alternating hypertrophy / atrophy of
filiform papillae of unknown etiology
Treatment : proper tongue hygiene.
• Black hairy tongue (or lingua villosa nigra) is a
painless benign disorder of unclear etiology

.
CONGENITAL FISSURED TONGUE
(FURROWING):
The surface of the tongue furrowed
with a deep median fissure & many
shorter fissures run transversely from
a median groove unlike syphilis which
are longitudinal. This sometimes get
infected by candida albicans resulting
12 Oct. 02 Electro surgery in Congenital syphilis
4
in median rhomboid glossitis.
Gynaecology - Prof.S.N.Panda
• Median rhomboid glossitis smooth, oval- or diamond-shaped nodule
on the dorsum of the tongue just ant.to the circumvallate papillae.
Treatment antifungals or surgical removal of the hyperplastic tissue.

LINGUAL THYROID
It is a red lobulated mass behind F.C
Treatment : excision after mTC99
scan to confirm presence of normal
thyroid gland.
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Gynaecology - Prof.S.N.Panda
TONGUE INJURIES
CAUSES:
1.Tongue biting (commonest) e.g. epileptics.
2. Associated with jaw # following road traffic accidents.
Bleeding occurs due to lingual vessels injury
Why serious especially in unconscious?
1. Tongue hematoma can cause airway obstruction
2. If laceration serious or delayed bleeding.
Treatment:
1.Arrest bleeding using pressure by hooking the tongue
forwards with a finger & compressing it against mandible.
2. Laceration can be sutured in operating
room under GA to estimate its depth
& avoid the risk of dehiscence.
3. Big tongue Hematoma if obstructs
airways may require tracheotomy.
.
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Gynaecology - Prof.S.N.Panda
 TONGUE ULCERS: (commonest lesions )
1-TRAUMATIC ULCERS:
DENTAL ULCER
Etiology
repeated trauma by
carious ,broken or ill-fitted denture.
Site
At tongue side near the site of irritation.
Clinically
Acute :Painful oval-round ulcers with
granulating floor , soft base & sloping
margin +/- enlargement of draining LN
Chronic : ulcer edge is raised & indurated
base + LN enlargement so biopsy is
indicated to rule out ca.
Treatment: Removal of cause & antiseptic
mouth wash.
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Gynaecology - Prof.S.N.Panda
2-INFLAMMATORY ULCERS:
A. IDIOPATHIC APHTHOUS ULCERS (dyspeptic)
-Most common lesion .
-Recurrent, very painful ulceration / healing
-Etiology: ??, nutritional deficiencies, stress, viral
TYPES
1)Minor
2)Major
3)Herpetiform
B. Oral LICHEN PLANUS
– Dermatologic disorder ?? due to autoimmune /HIV
– Ulcers + hyperkeratotic whitish tongue lesions
C. HERPETIC ULCERS( herpes simplex type 1).
Recurrent painless self limiting multiple small ulcers in children preceded by blisters at tip
of tongue
D.TUBERCULOUS
E. SYPHILITIC (snail track / gummatous ulcers)
F. CHRONIC SUPERFICIAL GLOSSITIS
3-NEOPLASTIC ULCERS:
A-Oct.
12 S.C.C
02 (most common) Electro surgery in 8
B-Lymphoma Gynaecology - Prof.S.N.Panda
 Oral cancer
Pre-malignant lesions ( not present in majority of cases)
High-risk lesions
• Erythroplakia
• Speckled erythroplakia
• Chronic hyperplastic candidiasis
Medium-risk lesions
• Oral submucous fibrosis
• Syphilitic glossitis
• Sideropenic dysphagia (Paterson–Kelly syndrome)
Low-risk/equivocal-risk lesions
• Oral lichen planus
• Discoid lupus erythematosus
• Discoid keratosis congenita

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Gynaecology - Prof.S.N.Panda
Potential for malignant change:
• With age usually >60 years; & age of the lesion;
• With chronic irritation 7 S (Smoking or tobacco
chewing, Sharp tooth, chronic dental Sepsis, Syphilis,
Spirits, Spices & Snuffing) .
• anatomical site of the pre-malignant lesion like
leukoplakia is risky on the floor of the mouth &ventral
surface of tongue in younger women, even in the absence
of associated risk factors.
FIELD CHANGE AND SECOND PRIMARY TUMOURS

Diffuse exposure to irritation leads to a separate tumors at different sites.

Presentations either
1. Simultaneously or within 6 months (synchronous 25%. ) where patients that
develop first tumour in the oral cavity & oropharynx are likely to develop a
2nd primary tumour in the upper oesophagus. Or
2. May be delayed within the first 2 years
of initial presentation (metachronous 75% ). i.e field change or ‘cancerisation’.

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Gynaecology - Prof.S.N.Panda
 Premalignant conditions
CLINICAL FEATURES
Leucoplakia
• White hyperkeratotic patches or plaque that cannot be
characterized clinically or pathologically.
• Size variable small, well-circumscribed, homogenous
white plaque to an extensive large surface areas .
• May be smooth or wrinkled, fissured and vary in
colour depending on the thickness giving appearance
of white paint coated tongue that can not be rubbed off
Speckled leucoplakia
• Variation of leucoplakia on erythematous base
• Has a highest rate of malignant transformation
Erythroplakia
• Bright red plaque which cannot be characterized
clinically or pathologically
• Are irregular in outline and separated from nearby
normal mucosa The surfaces may be nodular.
• They occasionally coexist with leucoplakia.

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Gynaecology - Prof.S.N.Panda
 Chronic hyperplastic candidiasis
• Dense plaques of leucoplakia, around commissures of mouth.
• May extend on to the vermilion or facial skin
• Have high incidence of malignant transformation, due to
invasion by C. Candida in immune deficient
Management :prolonged (6 weeks) topical or systemic anti-fungal
(2 weeks). If the lesions persist surgical excision or laser

Sideropenic dysphagia (Plummer–Vincent/Paterson–Kelly syndrome)

•Sideropenia (iron deficiency without anaemia) predisposes to

ca. due to epith. Atrophy so oral mucosa exposed to irritation .
Management treat sideropenia with iron to reduce epithelial
atrophy and risk of ca.
Oral submucous fibrosis
Associated with smoking , use of spicy nuts or alcohol. (only Asians)
A progressive epithelial fibrosis , atrophy + epithelial hyperplasia / dysplasia with
fibrous bands beneath the oral mucosa scarring , contracture, limited mouth
opening & restricted tongue movement.
Treatment of restricted mouth opening by either intralesional steroids or excision
and 12
skin grafts.
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Gynaecology - Prof.S.N.Panda
PATHOLOGY of oral cancer:
Main sites : the floor of the mouth, the lateral border of
the anterior tongue and the retromolar trigone:

GROSS TYPES:
1-Malignant ulcer: deep irregular necrotic floor, raised
everted or rolled edge& hard red indurated base.
2-Raised oval white plaque that fungates as cauliflower-
like mass +central necrosis .(commonest)
3-Hard sub mucous nodule (less common)
4-Deep indurated chronic fissure that does not heal.
5-Diffuse infiltrative wooden base i.e frozen tongue (rare)
MICROSCOPIC TYPES:
1-Ant. 2/3 well differentiated squamous cell ca. > 95%.
2-Post 1/3 ca are less differentiated
3-Basal cell ca & adenoca of minor
salivary glands (rare)

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Gynaecology - Prof.S.N.Panda
• SPREAD: CA in situ=no invasion to BM + no spread.
1- Direct (local) spread :
• Ca ant 2/3 invades lat. then to floor of mouth then to mandible.
• Post 1/3 ca invades tonsils, pharynx & larynx..
Fascial planes& periosteum act as barriers to direct spread
2-Lymphatic spread: occurs early with 30% clinical / subclinical
*Ca. tip of tongue drains bilaterally to submental LN.
*Ca. ant.2/3 to ipsilateral SMD& then to DCLN..
* Ca. post 1/3 drains bilaterally to upper DCLN.
3-Blood spread: very rare& occurs in post 1/3
ca & correlates with distant
metastases (bad prognosis)
4-Perineural invasion (bad prognosis)

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Gynaecology - Prof.S.N.Panda
Main clinical features of oral cancer
■ Elderly, males +/- risk factors .
■ Persistent oral swelling or mouth ulceration for > 4 weeks
■ Painless unless deeply invasive (sore tongue)
■ Difficulty swallowing
■ Jaw or facial swelling
■ Painless palpable submandibular or jugular L. nodes .
■ Unexplained tooth mobility
■ Trismus
■ Fixation of tongue (Ankyloglossia)

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Gynaecology - Prof.S.N.Panda
Complications
1-Inhalation of necrotic tissues bronchpneumonia.
2-Combined cancer cachexia & starvation due to pain
& dysphagia.
3-Bleeding due to erosion of lingual vessels& erosion
of ICA in post 1/3 tumors.
4-Asphyxia due to enlarged fixed LN or due to glottic
edema.

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Gynaecology - Prof.S.N.Panda
12 Oct. 02 Electro surgery in 17
Gynaecology - Prof.S.N.Panda