Malignant tumors of the head and neck represent about 6% of all human cancers, and squamous cell carcinoma of the oral cavity is the most frequent of these tumors. The majority occur in the tongue or floor of the mouth and are asymptomatic at onset, and, in spite of the easy access for clinical examination, the diagnosis is usually established at advanced clinical stages. By then, several major problems such as severe pain, dysphagia, bleeding, weight loss, and cervical lymph node metastasis are present.

The gold standard of care for patients with advanced cancer of the tongue and floor of the mouth has been surgery as the first therapeutic option, with radiation and/or chemoradiation used as adjuvant treatment. Nonsurgical modalities, such as radiotherapy alone or chemoradiation, are not considered the treatment of choice due to the low radiosensitivity, high cost, severe treatment-related symptoms, early and late morbidity, and expected lower survival rates when compared to primary surgical treatment. Patients initially not treated surgically because of comorbidities or refusal can be candidates for major salvage surgery for persistent or recurrent locoregional disease.

Current initial or salvage surgical treatment planning for patients with advanced stage cancer is based mainly on the site and size, adjacent areas involved, neck and distant metastasis, histology, comorbidities, and the patient’s performance status.

The surgical procedure is composed of three parts: the treatment of the cervical lymph nodes, wide resection of the primary cancer, and immediate reconstruction. Total glossectomy is a technically simple operation for head and neck surgeons, but it should be done only in tertiary hospitals with an experienced team who are prepared to deal with a difficult postoperative course. It is mandatory to have a multidisciplinary rehabilitation team with experience in the management of patients with significant long-term aesthetic and functional sequelae. Total glossectomy has been considered a major challenge because of the functional consequences that cause major effects on the patient’s quality of life. Recent advances in reconstructive techniques, including myocutaneous flaps, free flaps, prosthesis, and implants, along with the development of speech and swallowing therapy drastically changed this picture, and now it is considered an acceptable therapeutic option for a highly selected group of patients.

In the study published by Weber et al. with 27 patients who underwent total glossectomy with laryngeal preservation, a laryngeal suspension was done in 12 patients and 18 had a palatal augmentation prosthesis inserted. Only 2 out of the 27 patients required salvage laryngectomy due to persistent aspiration, and the rates of speech and swallowing rehabilitation were 92% and 67%, respectively. Similar results were described by Tiwari et al, Bova et al, and Yanai et al, in series of 21, 20, and 20 patients, respectively. According to Sessions et al, total glossectomy should be regarded as a major achievement in the treatment of advanced cancer of the tongue. The indication for this operation should be based either on the possibility of returning the patient to productive life or on the need for palliation of an intolerable clinical condition such as pain, hemorrhage, dyspnea, or dysphagia.

One of the largest series of total glossectomies was published by Gehanno et al. in 1992, which included 80 patients submitted to total glossectomy either primary (36 cases) or salvage (44 cases). The same authors recently published a series of 109 patents (Barry et al.). They have shown that the inclusion of a mandibulectomy and the need for laryngectomy had a negative impact on survival and functional outcomes. Their main recommendation was that this surgical procedure should be done only for patients who are well motivated and have good support systems. Yu and Robb in 2005 reviewed the Anderson experience of 94 patients submitted to total glossectomy describing some reconstructive innovations such as the use of a lateral thigh flap (21 patients) with reinnervation (11 patients). Unfortunately, these new reconstructive procedures did not add significant advantage in functional outcomes when the patients were also submitted to adjuvant radiation therapy after the total glossectomy.

Magrin et al. reviewed a series of 106 patients who underwent total glossectomy; the majority of patients had acceptable functional results except for a few patients who had persistent aspiration. The multivariate survival analysis identified T stage (T4), number of metastatic lymph nodes (>3), and male gender as predictors of the risk of death. It was also noted in univariate analysis that none of the patients with tumor extension to three or more adjacent sites survived for 5 years. This is a clear limit for the indication of an extensive and mutilating surgical procedure.

Initial clinical examination must be done to assess the primary tumor site and extension, presence of cervical lymph node metastasis, and to rule out the presence of a second primary cancer in the mucosa of the upper or lower aerodigestive tract. Squamous cell carcinoma is usually ulcerated (exophytic or invasive), whereas other malignant tumors present as submucosal nodules or infiltrating and nonulcerated lesions. The visual examination must be associated with palpation because the area of infiltration is usually much larger than the ulcer or nodule on the surface. The adequate examination includes the appearance of the tumor, location, areas involved, anatomic boundaries, proximity or involvement of the mandible, mobility, diameter, and estimated thickness. The presence of trismus and the patient’s dental status are also important findings. Examination of the oropharynx and a laryngoscopy complete the examination and are important in the detection of second primary cancers. Examination of the head and neck is concluded with a thorough palpation of the neck aiming to detect lymph node metastasis. The number, size, consistency, location (level), and mobility of the nodes must also be recorded.

More advanced cancers, involving the maxilla, nasopharynx, posterior oropharyngeal wall, and hypopharynx are usually not considered for this operation because of the very poor functional and survival outcomes that can be expected. However, with some technical variations, patients with advanced cancer confined to midline
structures, or with minor involvement of the lateral wall of the oropharynx that involves the vallecula and larynx, can be submitted to a total glossolaryngectomy. There is no indication for the operation in the patients with fixed N3 neck metastases nor with distant metastasis.

The indication of total glossectomy for surgical salvage has several additional limitations and usually can be defined only after a meticulous examination under general anesthesia because most of the times it is difficult to define the tumor limits in an area with different degrees of fibrosis resulting from chemoradiotherapy, and there is a high risk of major postoperative complications. However, salvage surgery must be always considered as an option in patients with locoregional recurrence because it is the only potentially curative option considering that chemotherapy is not curative, and in most cases it is not possible to use an additional course of radiotherapy particularly when the initial radiation was not curative. The most favorable group of eligible patients for salvage surgery is that with recurrent cancer at initial clinical stages and diagnosed after 1 year of initial treatment.

Several improvements in anesthetic and surgical ablative and reconstructive techniques allowed the implementation of more radical oncologic procedures for the treatment of advanced cancer of the head and neck. However, the indications for these procedures can be limited by the potential hazard of severe complications and sequelae. Unfortunately, there is no specific scoring system to predict rates and degrees of morbidity in patients with advanced cancer of the oral cavity.

Total glossectomy is a surgical procedure suited just to patients with a good performance status and without severe comorbidities. It also depends on the patient’s ability to handle saliva and secretions because the degree of postoperative aspiration can be intense in some patients. Other potentially significant factors are patient motivation, social factors, and family support. These factors are of paramount importance for patient’s acceptance of a surgical procedure that can cause significant sequelae requiring long period of hospitalization and compliance with an extensive rehabilitation program. Not surprisingly, we recently reported the long-term acceptance of major surgeries, including total glossectomy, in a series of 261 treated patients with advanced cancer of the head and neck. More than 60% reported a good-to-excellent global quality of life, and 95% reported that they would not like to change their present outcome for another treatment option with a lower chance of cure but with possible improvement of quality of life.

An incisional biopsy of the primary cancer is usually done at the time of the first examination. If a biopsy was previously done in another institution, the slides and paraffin blocks are requested in order to be reviewed by an experienced oral pathologist. It is also important to have histologic confirmation for recurrent cancers. An extensive and mutilating surgical procedure should not be done without histologic diagnostic confirmation. Biopsy of the cervical lymph nodes is not necessary and, in fact, most of the time is contraindicated.

A comprehensive preoperative clinical evaluation is always mandatory for all candidates for total glossectomy because the operation may produce remarkable functional deficits, and rehabilitation requires a motivated patient and the cooperation of an experienced multidisciplinary team (surgeons, dentists, and speech therapist). To be considered eligible for a total glossectomy with laryngeal preservation, the patient must have a good performance status, without significant comorbidities, and have an adequate pulmonary reserve to clear secretions. This is similar to the selection process for partial laryngeal surgery. All patients require a temporary tracheostomy after the operation due to aspiration.

Medical history, including the presence of comorbidities (ACE27), physical examination, as well as evaluation of the nutritional and performance status (Karnofsky or ECOG criteria) are important for treatment planning. Nutritional support can be indicated prior to surgical treatment using a nasogastric feeding tube or a percutaneous endoscopic gastrostomy (PEG). Consultation with a dentist is necessary for evaluation, possible dental extractions, and preparation of a prosthesis and dental implants. Most patients will require reconstruction with a myocutaneous or a free flap, and preoperative evaluation is important for planning this aspect of the surgical treatment.

Preoperative anesthesiology evaluation and grading of anesthesia risk by American Society of Anesthesiologists criteria and planning for airway management are also mandatory. Evaluation of airway changes, range of motion of the neck, and distance from the mandible to the thyroid notch is important to predict difficult tracheal intubation. Psychological or psychiatric evaluations should be recommended for selected patients and families. Consultation with physical therapy and speech and swallowing specialists must be done preoperatively, aiming to introduce these supportive care specialists who will be of paramount importance postoperatively.