Malignant Tumors of the Base of Tongue

Updated: Oct 23, 2020
  • Author: Talib Najjar, DMD, MDS, PhD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Practice Essentials

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.

Workup in malignant tumors of the base of tongue

Computed tomography (CT) scanning with intravenous contrast has been the standard imaging technique for base-of-tongue carcinoma. Magnetic resonance imaging (MRI) offers the advantages of finer tissue detail and multiplanar views and should be considered the imaging test of choice.

Metastases workup includes a chest radiograph, a CT scan, and serum chemistry studies.

In general, obtain a chest CT scan if the chest radiograph yields abnormal findings, obtain a bone scan if the alkaline phosphatase level is elevated or symptoms are present, and perform an ultrasonogram, a CT scan, or a magnetic resonance imaging (MRI) scan of the liver when liver function test results are significantly elevated, depending on tumor stage and associated comorbidities.

Positron emission tomography (PET) scanning alone or in combination with MRI is helpful when the diagnosis is unclear, in cases of unknown primary malignancy, or as a pretreatment assessment prior to nonsurgical treatment.

Biopsy via endoscopic examination of the primary site with the patient under anesthesia remains the definitive procedure for establishing the diagnosis of base-of-tongue tumor malignancy and accurately assessing the primary tumor.

Management of malignant tumors of the base of tongue

Base-of-tongue carcinomas can be managed with primary chemoradiotherapy, with elective planned neck dissection for patients with palpable lymph node metastases.

Cancer of the base of tongue has traditionally been removed by resecting the mandible or by using a translabial transmandibular approach. These procedures involve significant morbidity, including lip and chin scars, malocclusion, compromised deglutition, chronic aspiration, and altered speech articulation. Therefore, alternative techniques have been described to minimize the morbidity associated with transmandibular tongue resection. [1]

As compared with transmandibular tumor resection, transpharyngeal approaches show no measurable difference in terms of survival, tumor-free margins, speech, or swallowing; furthermore, transpharyngeal approaches result in less aspiration than does the transmandibular technique.



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 [2] 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 (HPV). [3]

A study by Ramqvist et al found that in patients with tonsillar squamous cell carcinoma (TSCC) or base-of-tongue squamous cell carcinoma (BOTSCC), those who were HPV-positive showed different expression of 34 proteins (primarily immunoregulatory proteins and cytokines) than did HPV-negative patients. The investigators reported that several of the proteins had a potential association with clinical outcomes, including, for HPV-positive tumors, those affecting angiogenesis and hypoxia. The fact that expression of the immune-related proteins varied between HPV-positive and HPV-negative cases was considered to be linked to the stronger immune defense activity found in cases of HPV-positive TSCC/BOTSCC. [4]



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.



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.

Cutaneous metastases in base-of-tongue malignancies are uncommon, with the incidence of such metastases from head and neck cancers in general being less than 1%. Rahman et al reported on a male aged 55 years with treated squamous cell carcinoma of the tongue who presented with cutaneous metastatic nodules on the face and thigh. [5]


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.



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.