Malignant Tumors of the Base of Tongue

  • Author: Talib Najjar, DMD, MDS, PhD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Jul 30, 2015
 

Background

The location of the base of tongue malignancy is critical in the diagnosis, management, and prognosis. The base of tongue is the site for the posterior opening of the oral cavity, the entrance of the pharynx and esophagus, and the inferior aspect of the nasopharynx .The surgical management of malignant neoplasms of the tongue base remains difficult despite recent advances in diagnostic techniques. Many patients present at an older age with advanced disease because of the occult nature of associated symptoms. The disease process and treatment often affect adjacent structures, such as the posterior floor of the mouth, larynx, and esophagus.

Careful multidisciplinary assessment and treatment selection based on the probability of cure and preservation of function are of paramount importance in the treatment of these patients. High recurrence rates, poor survival, and significant alterations in speech and swallowing function are common experiences for patients with malignancies in these anatomic sites. Despite these frustrations, patients are potentially curable and should be offered regimens that carefully consider morbidity and outcome within the context of the patient's overall medical condition.

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Etiology

Chronic alcohol and prolonged tobacco use, older age, geographic location, and family history are important risk factors for development of base of the tongue carcinoma. Environmental exposure to polycyclic aromatic hydrocarbons, asbestos, and welding fumes may increase the risk of pharyngeal cancer. Nutritional deficiencies and infectious agents (especially papillomavirus and fungi) may also play a significant role. For example, a Danish study, by Garnaes et al, attributed a rise in eastern Denmark in the incidence of squamous cell carcinomas of the base of the tongue between 2000 and 2010 (by 5.4% per year) to an increase in the number of such tumors (by 8.1% per year) that were positive for human papillomavirus.[1]

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Pathophysiology

The tongue is vital organ that plays a critical role in speech and swallowing. During the pharyngeal phase of swallowing, food and liquid are propelled toward the oropharynx from the oral cavity by the tongue and muscles of mastication. The larynx is elevated, effectively compressing the epiglottis and supraglottic larynx against the base of the tongue and forcing food, liquid, and saliva into the hypopharynx and cervical esophagus. The anatomic location of the hypoglossal nerve within the base of the tongue puts it at risk from invasion or compression from malignant neoplasms at the primary site or metastatic disease in the neck.

The tongue plays another important function in speech along with larynx and pharynx, which are the primary organs that shape sound into intelligible speech. Any alteration in tongue and pharynx mobility is immediately recognized as altered speech. Any loss of tissue from the base of tongue area prevents a watertight closure with the larynx during the act of swallowing. This mismatch allows food and liquid to escape into the pharynx and larynx, altering the carefully choreographed swallowing reflex and often resulting in aspiration. Both neurologic impairment and alteration in the coordinated act of swallowing from malignancies in this area can have devastating affects on speech and swallowing ability.

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Presentation

Dysphagia, odynophagia, sensation of a mass in the throat, or the presence of a mass in the neck are the most common clinical manifestations of the base of the tongue carcinoma. Patients also may complain of referred ear pain or hemoptysis. Delay in diagnosis is not uncommon because of the common and sometimes vague nature of symptoms and the relative inaccessibility of the base of the tongue to examination. Upon physical examination, a mass is usually palpable in this area. Extensive submucosal disease or a strong gag reflex may make palpation more difficult. Patients may have bilateral palpable adenopathy because of the midline location and the high propensity for regional lymph node metastases. Indirect or flexible fiberoptic laryngoscopy in the office is a useful adjunct to the physical examination.

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Relevant Anatomy

The base of the tongue is a subsite within the oropharynx and is bounded anterosuperiorly by the circumvallate papilla and the posterior aspect of the oral cavity, inferoposteriorly by the vallecula and lingual surface of epiglottis, and laterally by the glossoepiglottic folds.

Tongue development begins in the floor of the primitive oral cavity along with thyroid gland during the fourth embryonic week and develops from the region of the first 3-4 branchial arches. If the thyroid gland fails to migrate to the neck, it will result as a lingual thyroid. The tongue is eventually supplied by the lingual arteries and has complex capillary and venous systems.

Innervation of the tongue includes the lingual and hypoglossal nerves for sensation and movement and the sympathetic, parasympathetic, and special sensory fibers for salivation and taste ability. Tongue musculature includes both intrinsic and extrinsic muscles that contribute to the varied and subtle movements involved in speech and swallowing. Because the mucosa of the base of the tongue contains squamous epithelium, minor salivary glands, and lymphoid tissue, malignant neoplasms may arise from these tissues.

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Contraindications

Surgical excision and other modalities of treatment for the malignant base of the tongue tumors are based on the patient's comorbidities and his or her ability to tolerate surgery, radiation, and chemotherapy. An obvious contraindication is patient refusal. Of primary consideration is the patient's ability to tolerate some degree of aspiration as a consequence of treatment. Underlying lung disease must be carefully assessed prior to surgery. Informed consent must be obtained prior to surgical intervention. Additionally, tumors may be considered inoperable because of their size (ie, extent) or location.

As is true with other sites of the head and neck, early-stage mucosal squamous cell carcinomas of the base of tongue can be treated adequately with radiotherapy or surgical resection. Chemoradiation has been advocated because of the morbidity associated with extensive surgical resection. Recent advances in surgical techniques, including endoscopic/video-assisted resection and vascular tissue grafts, have decreased the morbidity historically associated with tongue base surgery.

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Contributor Information and Disclosures
Author

Talib Najjar, DMD, MDS, PhD Professor of Oral and Maxillofacial Surgery and Pathology, Rutgers School of Dental Medicine

Talib Najjar, DMD, MDS, PhD is a member of the following medical societies: American Society for Clinical Pathology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Nader Sadeghi, MD, FRCSC Professor, Otolaryngology-Head and Neck Surgery, Director of Head and Neck Surgery, George Washington University School of Medicine and Health Sciences

Nader Sadeghi, MD, FRCSC is a member of the following medical societies: American Head and Neck Society, American Thyroid Association, American Academy of Otolaryngology-Head and Neck Surgery, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Benoit J Gosselin, MD, FRCSC Associate Professor of Surgery, Dartmouth Medical School; Director, Comprehensive Head and Neck Oncology Program, Norris Cotton Cancer Center; Staff Otolaryngologist, Division of Otolaryngology-Head and Neck Surgery, Dartmouth-Hitchcock Medical Center

Benoit J Gosselin, MD, FRCSC is a member of the following medical societies: American Head and Neck Society, American Academy of Facial Plastic and Reconstructive Surgery, North American Skull Base Society, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Rhinologic Society, Canadian Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, College of Physicians and Surgeons of Ontario, New Hampshire Medical Society, Ontario Medical Association

Disclosure: Nothing to disclose.

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