10.6\ Oral Cavity Tumor Resection

and Reconstruction

10.6.1  Discussion

Depending on the stage of oral tongue malignancies, such as squamous cell carcinomas, variable degrees of glossectomy may be performed, ranging from partial, subtotal, or total, with or without floor of the mouth resection, mandibulectomy, and laryngectomy (Figs. 10.41, 10.42, 10.43, 10.44, and 10.45). Of note, composite tumor resection consisting of glossectomy, mandibulectomy, and neck dissection known as “Commando,” an acronym for combined mandibulectomy and neck dissection operation, can be performed for advanced cancers of the oral cavity. Furthermore, the submandibular gland may be removed with rerouting of the duct as part of the approach or as part of the combined suprahyoid neck dissection. Alternatively, the submandibular gland may be the main target of surgery when it is involved by primary salivary gland neoplasms. There are a variety of options for reconstructing surgical defects in the oral cavity region, including myocutaneous flaps, such as single or double bilobed

radial forearm flaps, FAMM flaps, submental island flaps, and acellular dermal matrix, or a combination of these.

The role of imaging after glossectomy is to evaluate complications, such as infection, sialocele, and tumor recurrence (Figs. 10.46, 10.47, and 10.48). Of note, one must be particularly ­vigilant for the presence of perineural tumor spread on imaging before and after surgery, especially following resection of salivary gland malignancies, which is often along the maxillary division branches of the trigeminal nerve for oral cavity tumors. Furthermore, since radiation often accompanies surgical treatment of oral cancers, the mandible is at risk for osteonecrosis. This complication tends to occur at least 1 year after radiation therapy and appears as areas of cortical irregularity and lucency (Fig. 10.49). There can be superimposed infection and pathological fracture.

Fig. 10.41  Partial hemiglossectomy with primary closure. Coronal fat-suppressed post-contrast T1-weighted MRI shows a defect in the left lateral tongue (arrow), without graft reconstruction resulting in asymmetric prominence of the normal right side of the tongue

Fig. 10.42  Subtotal glossectomy. The patient had a history of squamous cell carcinoma of the tongue. Axial CT image shows that the majority of the oral tongue has been resected and reconstructed using a myocutaneous graft (arrow). Surgical clips are present along the margins of the graft

Fig. 10.43  Total glossectomy and laryngectomy. The patient had a history of chemoradiation for stage IV squamous cell carcinoma of the base of the tongue. Subsequently, total laryngectomy and total glossectomy with myocutaneous flap reconstruction were performed. Sagittal CT image demonstrates complete absence of the native tongue with placement of a myocutaneous flap with predominantly fat attenuation components (arrow). The flap provides near-anatomic contours for the reconstructed tongue

Fig. 10.44  Commando. Coronal CT image shows glossectomy, and right hemimandibulectomy with flap reconstruction. Neck dissection, which is not shown, was also performed

Fig. 10.45  Floor of mouth resection with marginal mandibulectomy. Sagittal CT image shows extensive resection of the floor of mouth contents along with the gingiva and alveolar portions of the mandible. The defect has been reconstructed using a myocutaneous flap

Fig. 10.46  Sialocele after floor of mouth resection and submandibular duct rerouting. Axial CT image shows a well-defined fluid collection in the right submandibular space (arrow)

a

b

Fig. 10.47  Locoregional tumor recurrence. Axial CT images (a, b) show recurrent tumor (arrow) at the glossectomy site (*) as well as bilateral lymphadenopathy (arrowheads) from metastatic squamous cell carcinoma