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MINI SYMPOSIUM: HEAD AND NECK
Year : 2012  |  Volume : 49  |  Issue : 1  |  Page : 11-14
 

Suspension of the tongue to the digastric tendon following resection of the anterior mandibular arch for oral cancer prevents postoperative tongue fall and avoids the need for tracheostomy


Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India

Date of Web Publication25-Jul-2012

Correspondence Address:
D Pandey
Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi
India
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DOI: 10.4103/0019-509X.98908

PMID: 22842162

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 » Abstract 

Background: Resection of the anterior arch of the mandible leads to tongue fall and postoperative stridor because of the detachment of tongue musculature from the mandible. In this article, a simple method of tongue suspension is described which would prevent such complications and the need for tracheostomy. Settings and Design: This study was carried out on patients with oral cancer requiring resection of the anterior arch of the mandible as a part of the surgical resection at a tertiary centre. Materials and Methods: This study was performed on 32 patients with oral cancer requiring resection of the anterior arch of the mandible as a part of the surgical resection. Following an appropriate resection of the oral cancer (including the anterior mandibular arch) and neck dissection, a silk suture is used to loop the tongue musculature on either side to the intermediate tendon of the digastric muscle. Result: This technique of tongue suspension was used in 32 patients who required resection of the anterior mandibular arch for oral cancer. Prophylactic tracheostomy was not performed. One patient developed stridor at extubation and required temporary tracheostomy. All other patients could be successfully extubated within 12 h of surgery and none experienced postoperative stridor or sleep apnea. One other patient required temporary tracheostomy for pulmonary toilet as he developed aspiration pneumonitis related to nasogastric feed. Conclusion: This simple method of tongue suspension to the digastric tendon prevents postoperative tongue fall and obviates the need for tracheostomy in most instances.


Keywords: Anterior mandibulectomy, stridor, tracheostomy, tongue suspension


How to cite this article:
Pandey D. Suspension of the tongue to the digastric tendon following resection of the anterior mandibular arch for oral cancer prevents postoperative tongue fall and avoids the need for tracheostomy. Indian J Cancer 2012;49:11-4

How to cite this URL:
Pandey D. Suspension of the tongue to the digastric tendon following resection of the anterior mandibular arch for oral cancer prevents postoperative tongue fall and avoids the need for tracheostomy. Indian J Cancer [serial online] 2012 [cited 2014 Dec 22];49:11-4. Available from: http://www.indianjcancer.com/text.asp?2012/49/1/11/98908



 » Introduction Top


Cancer of the oral cavity is one of the commonest cancers in India. [1],[2] The habit of chewing tobacco and keeping the quid in the gingivobuccal sulcus is responsible for a large proportion of cancers of the gingivobuccal sulcus. [3] Many patients present when the cancer has already invaded the mandible and require resection of the bone as a part of the surgical exercise. As long as the cancer involves the lateral part of the mandible and a segmental or hemi-mandibulectomy is needed, there is generally no problem of airway compromise postoperatively.

Cancer that involves the mid-portion of the alveolus and invades the mandible is a formidable surgical challenge. When the anterior arch of the mandible is resected either alone or as a part of extended hemi-mandibulectomy, the insertion of the tongue muscles to the mandible is severed. This may result in postoperative tongue fall causing stridor. A temporary tracheostomy may prevent such a catastrophe but the patient may still have sleep apnea after the closure of tracheostomy. [4] In this paper, a simple technique of tongue suspension is described following resection of the anterior mandible.


 » Materials and Methods Top


This study was performed on 32 patients with oral cancer who would require resection of the anterior mandibular arch as a part of the surgical resection. We have not included the patients who underwent hemi-mandibulectomy or lateral segmental mandibulectomy in which the attachment of the tongue muscle on at least one side is preserved. The technique of tongue suspension is described as follows.

A standard resection of the oral cancer and neck dissection is performed. As the lesions involve the anterior part of the mandible, this resection would entail either an anterior arch mandibulectomy or extended hemi-mandibulectomy (including resection of the anterior arch).

Following the appropriate neck dissection, the intermediate tendon of the digastric is easily exposed ipsilaterally. Submental lymphadenectomy would have also exposed the contralateral anterior belly of the digastric and this is dissected further to expose the intermediate tendon. Two generous bites are taken on the tongue musculature on either side using 1/0 silk and the sutures are then looped around the intermediate tendon of the digastric on the corresponding side [Figure 1]. Care is taken to safeguard the hypoglossal nerve, which lies immediately deep to the intermediate tendon of the digastric muscle. This procedure suspends the tongue musculature to the digastric tendon and prevents postoperative tongue fall.
Figure 1: A black silk suture looped between the tongue musculature and intermediate tendon of the digastric muscle. A similar suture can be seen on the contralateral side. These sutures, when tied, result in fixation of the tongue to the digastric tendons on either side, thus preventing tongue fall postoperatively. The cut ends of the mandible after anterior mandibulectomy can also be seen

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 » Results Top


The author has performed this procedure in 32 patients between July 2007 and December 2010. The demographic and clinical profiles of these patients and the surgical procedures performed have been tabulated in [Table 1]. Among these 32 patients, 14 underwent anterior arch mandibulectomy with mandibular plate reconstruction, and 18 patients underwent extended hemi-mandibulectomy with resection of the anterior arch. An appropriate neck dissection was performed in all the patients. Twenty-six patients also had pectoralis major myocutaneous (PMMC) flap reconstruction for the intraoral defect. When a mandibular plate was used to bridge the bony defect following anterior arch mandibulectomy, the plate was covered all around as completely as possible by the muscle of the PMMC flap to minimize the future extrusion of the plate. In all the patients, the described procedure of tongue suspension to the digastric tendon was performed.
Table 1: Demographic, clinical and surgical details

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Of the 32 patients, 31 could be extubated within 12h of surgery without requiring tracheostomy. None of these 31 patients experienced postoperative stridor. One patient developed stridor at the time of extubation and tracheostomy was immediately performed. His tracheostomy was closed on the fifth postoperative day and he was well thereafter. One another patient, who had an anterior arch mandibulectomy with mandibular plate and PMMC flap reconstruction, developed aspiration pneumonitis on the third postoperative day (related to nasogastric tube feeding), for which he required a temporary tracheostomy for adequate pulmonary toilet. He recovered well and the tracheostomy was closed in a week.

All the patients were specifically questioned about any stridor or sleep apnea during their follow-up visits. No patient experienced such problems.

In the initial postoperative period, there was some degree of tongue protrusion in all the patients. This improved as the wound healed and edema subsided. Later, there was no significant restriction of the mobility of the tongue. The patients had some difficulty in eating that was related to resection of the mandible, but there was no increase in problems of swallowing or speech that could be attributed to fixation of the tongue.


 » Discussion Top


The ideal procedure following anterior mandibulectomy would be a free flap using fibula, iliac crest or scapula for rigid reconstruction. [5],[6],[7] This would provide stabilization of the jaw as well as fixation of tongue musculature. Microvascular techniques are routinely used in several centers, but experience in complex reconstructions after mandibulectomy is limited, as different and difficult free flap reconstructions are necessary to achieve good postoperative results accompanied with a high standard of intensive care. Both are associated with high costs and therefore not routinely used in all cancer centers. Such patients require postoperative change of lifestyle and close follow-up. The prognosis of locally advanced squamous cell carcinoma of the oral cavity is uncertain. Once these patients have been rehabilitated from the oncological point of view, the option of secondary reconstruction also offers new possibilities for both reconstructive surgeons and patients with a good prognosis. [8]

In situations where free bone transfer is not feasible or not considered, mandibular plates are often used as an alternative following anterior arch mandibulectomy. This provides stability to the jaw, but it is often not possible to attach the tongue musculature to the plate as it interferes with the mucosal closure. Mandibular plates are also associated with a significant problem of extrusion, especially when the patients require postoperative radiotherapy. [9],[10]

The major problem in such a situation is postoperative stridor because of tongue fall, as the tongue muscles that were detached from their insertion into the anterior arch of the mandible remain unsupported. The answer to this problem is generally a temporary tracheostomy that gives time for the healing and fibrosis around the detached tongue musculature. Yet, sleep apnea remains a problem after the closure of tracheostomy. [4] Although tracheostomy is a very commonly performed procedure in surgeries for head and neck cancers and is often life-saving, there are potential complications associated with the procedure. [11],[12] Tracheostomy is an additional procedure as a safety measure following the already extensive surgery and may add to the inconvenience faced by the patient postoperatively. If such safety can be offered by a simple method of tongue suspension, tracheostomy with its attendant inconvenience and problems can be avoided. In addition, the problem of sleep apnea is also solved.

When the tongue musculature is sutured to the intermediate tendon of the digastric muscle, it regains its attachment. The intermediate tendon of the digastric is held to the body and greater cornu of the hyoid bone by a fibrous sheath. [13] Thus the tongue regains its stability and postoperative tongue fall is avoided. In the present series of 32 patients who underwent resection of the anterior mandibular arch, 31 could be successfully extubated without the need of tracheostomy. The lone patient who developed stridor at the time of extubation and required tracheostomy, also could be successfully decannulated on the fourth postoperative day. Although a definite cause of his stridor cannot be ascertained, it appears that he might not have fully recovered from the sedative effects of anesthesia at the time of extubation and this might be partly responsible for his stridor. Another patient in this series required temporary tracheostomy for pulmonary toilet as he developed aspiration pneumonitis related to nasogastric feeds. This patient was also successfully decannulated subsequently.

This simple procedure of tongue suspension to the digastric tendon prevents postoperative tongue fall and sleep apnea. It also obviates the need for tracheostomy and its attendant problems in the majority of patients undergoing resection of the anterior mandibular arch.

 
 » References Top

1.Manoharan N, Tyagi BB, Raina V. Cancer incidences in rural Delhi: 2004-2005. Asian Pac J Cancer Prev 2010;11:73-7.  Back to cited text no. 1
[PUBMED]    
2.Moore SR, Johnson NW, Pierce AM, Wilson DF. The epidemiology of mouth cancer: A review of global incidence. Oral Dis 2000;6:65-74.  Back to cited text no. 2
[PUBMED]    
3.Pathak KA, Gupta S, Talole S, Khanna V, Chaturvedi P, Deshpande MS, et al. Advanced squamous cell carcinoma of lower gingivobuccal complex: Patterns of spread and failure. Head Neck 2005;27:597-602.   Back to cited text no. 3
[PUBMED]    
4.Panje WR, Holmes DK. Mandibulectomy without reconstruction can cause sleep apnea. Laryngoscope 1984;94:1591-4.  Back to cited text no. 4
[PUBMED]    
5.Hölzle F, Kesting MR, Hölzle G, Watola A, Loeffelbein DJ, Ervens J, et al. Clinical outcome and patient satisfaction after mandibular reconstruction with free fibula flaps. Int J Oral Maxillofac Surg 2007;36:802-6.  Back to cited text no. 5
    
6.Takushima A, Harii K, Asato H, Momosawa A, Okazaki M, Nakatsuka T. Choice of osseous and osseocutaneous flaps for mandibular reconstruction. Int J Clin Oncol 2005;10:234-42.  Back to cited text no. 6
    
7.Yilmaz M, Vayvada H, Menderes A, Demirdover C, Kizilkaya A. A comparison of vascularized fibular flap and iliac crest flap for mandibular reconstruction. J Craniofac Surg 2008;19:227-34.  Back to cited text no. 7
    
8.Mücke T, Wagenpfeil S, Kesting MR, Hölzle F, Wolff KD. Recurrence interval affects survival after local relapse of oral cancer. Oral Oncol 2009;45:687-91.  Back to cited text no. 8
    
9.Mariani PB, Kowalski LP, Magrin J. Reconstuction of large defects postmandibulectomy for oral cancer using plates and myocutaneous flaps: A long-term follow-up. Int J Oral Maxillofac Surg 2006;35:427-32.  Back to cited text no. 9
    
10.Wei FC, Celik N, Yang WG, Chen IH, Chang YM, Chen HC. Complications after reconstuction by plate and soft-tissue free flap in composite mandibular defects and secondary salvage reconstruction with osteocutaneous flap. Plast Reconstr Surg 2003;112:37-42.  Back to cited text no. 10
    
11.Castling B, Telfer M, Avery BS. Complications of tracheostomy in major head and neck cancer surgery; a retrospective study of 60 consecutive cases. Br J Oral Maxillofac Surg 1994;32:3-5.   Back to cited text no. 11
    
12.Epstein SK. Late complications of tracheostomy. Respir Care 2005;50:542-9.   Back to cited text no. 12
    
13.De-Ary-Pires B, Ary-Pires R, Pires-Neto MA. The human digastrics muscle: Patterns and variations with clinical and surgical correlations. Ann Anat 2003;185:471-9.  Back to cited text no. 13
    


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