Macroglossia / Macroglosia

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A Retrospective Evaluation of Partial Glossectomy for Early Tongue Cancer Using a Carbon Dioxide Laser.

OBJECTIVE: The purpose of this study was to retrospectively evaluate the postoperative results of partial glossectomy for early tongue cancer using a carbon dioxide laser (CO2 laser). BACKGROUND DATA: CO2 lasers are frequently used for the excision or treatment of soft tissue in a range of diseases, including oral cancer, leukoplakia, mucocele, anomalies of the labial and lingual frenum, and peri-implantitis. MATERIALS AND METHODS: We retrospectively reviewed 31 primary cases of early superficial tongue cancer that were treated using CO2 lasers. In this study, early superficial cancer of the tongue is defined as a T1 or T2 tumor (TNM classification, NOMO; type, superficial spread, or exophytic; depth, <5 mm). The lesions were stained with 10% Lugol's solution and excised with a 5- or 10-mm safety margin from the nonstained area or induration using a CO2 laser. The raw surface was covered with a polyglycolic acid sheet using fibrin glue spray (n = 23), sutures (n = 6), or both (n = 2). Five of the patients showed a bleeding tendency: 1 was taking warfarin 100 mg per day, 1 was taking 350 mg per day, 2 were taking aspirin 100 mg per day, and 1 was taking aspirin 200 mg per day. RESULTS: There were no cases of postoperative bleeding. Regarding postoperative pain, all patients could stop taking analgesic drugs by 1 month after undergoing the operation. In regards to postoperative difficulty to swallow, all could start swallowing rice gruel 2 days after the operation. The surgical margin was unclear in two cases due to the thermal denaturation of the excisional margin. The 2-year local control rate was 100% and subsequent cervical lymph node metastasis rate was 6.5%. CONCLUSIONS: In terms of recurrence, metastasis, postoperative bleeding, postoperative pain, and swallowing, partial glossectomy for early tongue cancer using a CO2 laser might therefore help improve the postoperative course.

Assessing the suitability of medial sural artery perforator flaps in tongue reconstruction - An outcome study.

INTRODUCTION: Oncological resection of the tongue can be reconstructed using a multitude of free flaps. The medial sural artery perforator (MSAP) flap has been well described in the literature in terms of its anatomy and harvest. However, functional outcome studies of post-reconstruction tongue defects using the MSAP flap have not been reported. This study represents the largest outcome study of patients with tongue reconstructions using MSAP flaps and a comprehensive review of its use. MATERIALS AND METHODS: From December of 2010 to October of 2015, 579 patients with subtotal glossectomy and free flap reconstructions in Chang Gung Memorial Hospital were retrospectively reviewed. 27 patients were reconstructed with MSAP flap. The pre- and intra-operative factors, as well as flap-related factors were analyzed. Post-operative complications and functional outcomes were evaluated. Donor site assessment were also conducted. RESULTS: A 96.3% flap survival rate was found with an average total operating time of 6 hours and 18 minutes. 84.6% of patients had primary closure of the donor site with and the remaining either had skin grafts or delayed closure. Donor site closure can be achieved primarily with no functional deficit. Speech intelligibility remained for most patients. 100% of patients resumed normal oral feeding. CONCLUSION: The MSAP flap is a small to medium sized flap most suited for subtotal glossectomy defects where optimal outcomes can be achieved in terms of speech clarity and restoration of oral intake.

Functional assessment: Free thin anterolateral thigh flap versus free radial forearm reconstruction for hemiglossectomy defects

BACKGROUND: To compare free thin anterolateral thigh (ALT) flap with free radial forearm (FRF) flap in the reconstruction of hemiglossectomy defects, and to introduce our methods and experience in the tongue reconstruction with free thin ALT flap. MATERIAL AND METHODS: The clinicopathologic data of 46 tongue carcinoma cases hospitalized from December 2009 to April 2014 were obtained from Nangjing Stomatological Hospital, Medical School of Nanjing University. All the subjects were evaluated for the articulation and the swallowing function 3 months after the surgery. RESULTS: Among these 46 patients, 12 patients underwent tongue reconstruction after hemiglossectomy with ALT flap; 34 patients underwent tongue reconstruction with FRF flap. The differences in the incidence of vascular crisis, the speech and the swallowing function between two groups were not significant (P﹥0.05). CONCLUSIONS: Thin ALT flap could be one of the ideal flaps for hemiglossectomy defect reconstruction with its versatility in design, long pedicle with a suitable vessel diameter, and the neglectable donor site morbidity

[Wiedemann-Beckwith syndrome: a new approach for reduction glossoplasty using Ultracision(®)]. / Syndrome de Wiedemann-Beckwith - glossectomie de réduction par Ultracision(®) : une approche novatrice.

INTRODUCTION: A reduction glossectomy may be complicated by tongue and mouth floor edema and extend the recovery time for a normal tongue function. We performed reduction glossectomy using Ultracision(®), an ultrasonic vibrating device, so as to limit these complications. TECHNICAL NOTE: We performed a keyhole glossoplasty under general anesthesia. The initial tongue incision was performed with a cold scalpel, then the glossectomy was continued with Ultracision(®) only. We also used CURVED SHEARS(®). We evaluated our preliminary results with 3 patients presenting with Wiedemann-Beckwith syndrome. CONCLUSION: Ultracision(®) is a useful tool for intra-oral surgery, and should soon be more frequently used. It is an alternative to electrocautery for this type of surgery.

Transoral surgery using a novel single-port flexible endoscope system.

The transoral resection of pharyngeal and laryngeal tumors is challenging due to their location in a narrow anatomic space. In this study, the visualization and resection in the area of the pharynx and larynx using a novel computer-assisted flexible endoscopic robotic system are evaluated. The Medrobotics(®) Flex(®) System (Medrobotics Corp., Raynham, MA, USA) is an operator-controlled flexible endoscope robotic system that includes a flexible endoscope and computer-assisted controllers, with two accessory channels for the use of compatible, 3.5 mm flexible instruments. In six human cadavers, four basic procedures (tonsillectomy, base of tongue resection, hemi-epiglottectomy and resection of false vocal cords) were performed bilaterally by two surgeons. Success in appropriate visualization of the target structure and resection was documented. The driving and resection time was determined for each procedure. An appropriate exposure and resection within the pharynx and larynx was achieved in all cases. Both surgeons experienced a learning curve in driving the system and performing the procedures. The Medrobotics Flex(®) system is a promising tool for transoral resections within the pharynx and larynx. Good visualization, access, and resectability are hereby clear advantages of the system compared to commonly used systems.

Ultracision Harmonic Scalpel in oral and oropharyngeal cancer resection.

OBJECTIVE: The aim of this prospective study was to evaluate the benefits and risks when using an Ultracision Harmonic Scalpel in the surgical treatment of oral and oropharyngeal carcinomas. STUDY DESIGN: Prospective non-randomized. SETTING: Clinica Otorinolaringoiatrica, Azienda Ospedaliero-Universitaria. Trieste, Italy. SUBJECTS AND METHODS: In this study, conducted from April 2008 to August 2010, 36 consecutive patients underwent resection of oral or oropharyngeal carcinoma and lateral lymphadenectomy using the Ultracision Harmonic Scalpel. Evaluation criteria included length of the surgical procedure, intraoperative blood loss, quantity of neck drainage on the first, second and third postoperative days, postoperative complications, and a subjective assessment of postoperative pain and lymphatic oedema of the neck. Results were compared with previous surgical procedures carried out between May 2006 and March 2008 using cold knife and bipolar haemostasis (n = 36) when the Harmonic Scalpel was not available. RESULTS: In patients treated with the Harmonic Scalpel, operating time was significantly reduced, both for resection of the carcinoma and the lateral lymphadenectomy. Intraoperative blood loss and neck drainage on the first and second postoperative days were significantly less and pain scores were significantly lower than in the cold knife group. No postoperative complications were noted in the Harmonic Scalpel group. The only disadvantage noted in the Harmonic Scalpel group was the high incidence of lymphatic oedema of the neck. CONCLUSIONS: Use of the Harmonic Scalpel during resection of oral cancer and lateral lymphadenectomy is safe and confers some advantages over conventional methods.

Anatomical landmarks for transoral robotic tongue base surgery: comparison between endoscopic, external and radiological perspectives.

PURPOSE: To describe the transoral viewpoint of the tongue base anatomy, focusing on a superior to inferior perspective, which is less familiar to the head and neck surgeon but, at the same time, worthy to be known given the expanding interest and diffusion of the transoral robotic technique. METHODS: Seven heads were dissected, two with the Da Vinci(®) robotic system, three by means of a transoral endoscopic approach and another two by means of a lateral "traditional" external approach. Ten normal patients, with normal oral cavity and oropharynx, were studied as control samples by means of a 3-T MRI scanner. RESULTS: Major neurovascular elements are placed laterally and deeply within the tongue base. Dissection within intrinsic and genioglossus muscles is safe because the main trunk of the lingual artery lies on the lateral surface of genioglossus muscle, covered by the hyoglossus muscle. The hypoglossal nerve, with its comitant vein, is more lateral, lying on the external surface of the hyoglossus muscle. Radiological evaluation can visualize important details of this complex anatomy. The position of the vessels can be directly identified, whereas major nerves are more difficult to be visualized unless they are surrounded by fibro-fatty tissue. CONCLUSIONS: A medial to lateral dissection of the tongue base can be considered safe. A strict collaboration with the radiologist is helpful in approaching these cases by means of a robotic technique and in improving a true 3D understanding of this complex anatomy.

Management of macroglossia in Beckwith-Wiedemann syndrome.

Beckwith-Wiedemann syndrome (BWS) is a rare congenital disease of low prevalence. Its most common feature is macroglossia, being present in most cases. Clinically macroglossia can compromise the airway, cause dysphagia, drooling and poor cosmesis. Functionally it can cause dentoskeletal discrepancy, protrusion of teeth, and speech abnormalities leading significant psychological issues both with the patient and their families. Surgical excision remains the mainstay of management and a variety of techniques have been described. Because of the high vascularity of the tongue, intra-operative blood loss could be significant and have high morbidity in the pediatric patient. We present a technique for tongue reduction in macroglossia associated with BWS using the Ultrasonic Dissector (Harmonic Scalpel). The principles of Ultrasonic dissection are discussed along with the potential advantages of the technique.

Histopathological assessment in glossectomy: harmonic shears versus monopolar electrosurgery pilot study.

OBJECTIVES: The aim of the study was to gather information on outcomes and effect sizes of 2 surgical methods of glossectomy by using a grade system and an objective measure of artifacts in micrometers (µm). The collected data would be used to plan a definitive study. STUDY DESIGN: Pilot study. SETTING: Tertiary referral center. MATERIAL AND METHODS: Nineteen patients affected with tongue cancer were consecutively enrolled in a pilot study and treated by partial glossectomy. Eleven patients (57.89%) of group A were treated with monopolar electrocautery, while 8 patients (42.10%) of group B were treated with Harmonic Focus Curved Shears. Specimens were examined by a pathologist blinded to the surgical procedure, using a 4-grade system for margin artifact assessment (margin fragmentation, cautery/crush artifact, extravascular blood clot, capillary congestion) and for measuring artifact depth. RESULTS: Artifact depth was more relevant in group A (765,633 µm) than in group B (473,939 µm). The difference between groups was significant at the 95% confidence interval (P < .0001). Margin fragmentation and capillary congestion compared between the 2 groups were of no significance. There were less cautery/crush artifacts and extravascular blood clots observed in the harmonic shears group. CONCLUSION: When used to perform a partial glossectomy, Harmonic Focus Curved Shears produce less cautery/crush artifact and a smaller artifact depth compared with monopolar cautery.

Er,CR:YSGG lasers induce fewer dysplastic-like epithelial artefacts than CO2 lasers: an in vivo experimental study on oral mucosa.

Our aim was to assess wounds made by lasers (CO(2) and Er,Cr:YSGG) for their epithelial architectural changes and width of damage. We allocated 60 Sprague-Dawley(®) rats into groups: glossectomy by CO(2) laser at 3 different wattages (n=10 in each); glossectomy by Er,Cr:YSGG laser at two different emissions (n=10 in each), and a control group (n=10). Histological examination assessed both prevalence and site of thermal artefacts for each group. Both lasers (CO(2) and Er,Cr:YSGG) caused the same type of cytological artefacts. The 3W Er,Cr:YSGG laser produced the fewest cytological artefacts/specimen, and was significantly different from the other experimental groups: 3W CO(2) laser (95% CI=0.8 to 1.0); the 6W CO(2) laser (95% CI=0.1 to 2.0) and the 10W CO(2) laser (95% CI=1.1 to 3.0). CO(2) lasers (3-10W) generate epithelial damage that can simulate dysplastic changes with cytological atypia that affects mainly the basal and suprabasal layers. Irradiation with Er,CR:YSGG laser (2-4W) produces significantly fewer cellular artefacts and less epithelial damage, which may be potentially useful for biopsy of oral mucosa.

Harmonic scalpel for a bloodless partial glossectomy: a case report.

Tongue surgery is almost always complicated by intraoperative bleeding. Its rich blood supply especially from the lingual vessels makes the operative field bloody. Electrocautery has been widely used to replace cold scissors in order to achieve better hemostasis. The use of ultrasonic harmonic scalpel for glossectomy is still new in this country. We report a case of partial glossectomy using the harmonic scalpel in a patient who had a squamous cell carcinoma of the lateral border of the tongue.

Effect of glossectomy technique on histopathologic assessment in a rat model.

BACKGROUND: The purpose of this study was to compare the tissue effects of 3 surgical methods of glossectomy with respect to histopathologic assessment by a pathologist. METHODS: The anterior tongue of 30 Sprague-Dawley rats was excised using either a steel scalpel, monopolar electrosurgery, or ultrasonic scalpel (3 groups of 10). Specimens were examined by a pathologist blinded to the surgical procedure, using a previously described grading system for margin artifact assessment. RESULTS: Minimal tissue disruption at the surgical margin was produced by the steel scalpel, in contrast to monopolar electrosurgery and ultrasonic scalpel, which both produced varying levels of tissue distortion. Margin fragmentation was significantly greater with monopolar electrosurgery when compared to an ultrasonic scalpel. CONCLUSION: Ultrasonic scalpel creates less tissue distortion at the surgical margin than monopolar electrosurgery. Further study is required to determine the clinical relevance of these findings.

Pseudodysplastic epithelial artefacts associated with oral mucosa CO2 laser excision: an assessment of margin status.

Using a CO(2) laser beam for biopsy is compromised by thermal cytological artefacts that could be critical when assessing dysplastic changes, as they may simulate cytological atypia. This study examined wounds caused by CO(2) laser, evaluating their size and features, utilizing 25 Sprage rats randomly allocated to five groups: four glossectomized using a CO(2) laser at 3, 6, 9 and 12 W and a control group treated with a conventional scalpel. Samples were prepared in 4 microm sections, stained, and studied double-blind by two pathologists. The artefacts identified included cellular and nuclear polymorphism, nuclear hyperchromatism and loss of intercellular adherence; they were mainly located in the basal and suprabasal layers of the oral epithelium. Number of artefacts per specimen did not differ between experimental groups. The width of epithelial damage adjacent to the laser incisions revealed 298.7+/-150.7 microm of damaged tissue (range 100-750 microm), with no differences between low (3 W) and high wattages (6, 9 and 12 W) (X(i)-X(j)=41.6; 95% CI=-125.1 to 208.4). No changes were observed in the control group. CO(2) laser (3-12 W) generates epithelial damage that can simulate light dysplasia with atypias mainly affecting basal and suprabasal layers that may lead to erroneous therapy.

A comparison of histopathologic margin assessment after steel scalpel, monopolar electrosurgery, and ultrasonic scalpel glossectomy in a rat model.

EDUCATIONAL OBJECTIVE: At the conclusion of this presentation, the participants should be able to describe the tissue effects of steel scalpel, monopolar electrosurgery, and ultrasonic scalpel glossectomy with respect to histopathologic margin assessment in a rat model. OBJECTIVES: Histopathologic margin assessment is important in guiding treatment and determining prognosis for squamous cell cancer of the oral tongue. Energy based devices for glossectomy produce varying degrees of tissue distortion and artifact that can influence margin assessment. The purpose of this study is to compare the tissue effects of three surgical methods of glossectomy with respect to margin assessment by a pathologist. STUDY DESIGN: Blinded histopathologic study of three surgical techniques for glossectomy using a rat model. METHODS: The anterior tongue of thirty Sprague-Dawley rats was excised using either steel scalpel, monopolar electrosurgery, or ultrasonic scalpel (three groups of ten). Specimens were fixed in formalin and serially sectioned, and hematoxylin and eosin stains were examined by a pathologist blinded to the surgical procedure. Comparison between surgical techniques with respect to effect on the tissue margin was carried out using a previously described grading system for margin assessment. RESULTS: Minimal tissue disruption at the surgical margin was produced by the steel scalpel, in contrast to monopolar electrosurgery and harmonic scalpel, which both produced varying levels of tissue distortion. Margin fragmentation, cautery artifact, and artifact depth was greater with monopolar electrosurgery when compared to harmonic scalpel. CONCLUSIONS: Energy based devices cause tissue distortion which may in theory effect the ability to accurately assess surgical margins for tumor involvement on histopathology. In our rat model of glossectomy, the harmonic scalpel created less tissue distortion at the surgical margin than monopolar electrosurgery. Further study is required to determine the clinical relevance of these findings.

Ultrasonic glossectomy--simple and bloodless.

BACKGROUND: The aim of the study was the evaluation of the feasibility of glossectomy using an ultrasonic-activated surgical instrument. METHODS: This was a prospective study of 13 consecutive patients who underwent glossectomy (12 partial and one total) for carcinoma of tongue with the use of ultrasonic scissors. RESULTS: All 13 patients had glossectomy, with median blood loss of 0 mL. The glossectomies were done with an ultrasonic dissector alone. None of the glossectomies required diathermy, ligature, plication, or other methods for hemostasis. The lingual artery and veins of all 13 patients were controlled by use of the ultrasonic scissors alone. No operative complications occurred, including bleeding or wound healing problems. CONCLUSIONS: The excellent combination of coagulation and the cutting effect of ultrasonic scissors has made glossectomy a simple and bloodless procedure. It is a recommended surgical technique in our surgical armamentarium.