|Year : 2020 | Volume
| Issue : 2 | Page : 127-129
Hyoid advancement in tongue reconstruction
Amborish Nath1, Akshay Kapoor1, SP Agrawal2, Vishal Mago1
1 Department of Burn and Plastic Surgery, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Surgical Oncology, AIIMS, Rishikesh, Uttarakhand, India
|Date of Submission||10-Jul-2019|
|Date of Acceptance||11-Jul-2019|
|Date of Web Publication||18-Mar-2020|
Dr. Vishal Mago
AIIMS, Rishikesh, Uttarakhand
Source of Support: None, Conflict of Interest: None
A new modification by hyoid suspension improves swallowing function and risk of aspiration in postglossectomy tongue reconstruction patients.
Keywords: Hyoid suspension, swallowing, tongue reconstruction
|How to cite this article:|
Nath A, Kapoor A, Agrawal S P, Mago V. Hyoid advancement in tongue reconstruction. Turk J Plast Surg 2020;28:127-9
| Introduction|| |
Speech and swallowing are dependent on tongue shape, size, and mobility. These functions are altered by the resection of tumors that involve the base of the tongue. Reconstruction of the tongue after composite resections helps to assist patients to swallow solid and liquid components.
There is a high incidence of aspiration in patients whose respiratory tract protection mechanism has been altered or failed. The aim of hyoid suspension is to remove hypopharyngeal obstruction by advancing the hyoid complex later in an anterior direction. Hyoid suspension may be performed as an isolated procedure or in combination to treat tongue base obstruction.
The purpose of suspending the hyoid was to assist in the stabilization of the mandibular osteotomy and to advance the tongue and subsequently further enlarge the pharyngeal airway. The hyoid is a U-shaped bone located in the anterior neck with three-directional force vectors pointing toward the mandible, sternum, and mastoid process. It gives insertion to the middle constrictor muscles, which form the lateral wall of the hypopharynx. The suspension of this bone to the thyroid cartilage restores the transverse collapse following decreased tone of the middle constrictor muscles in sleep apnea patients.
This is a case series of 5 patients who underwent hyoid advancement in tongue reconstruction with flaps to achieve optimum swallowing function and prevent aspiration in follow-ups.
| Case Report|| |
A 52-year-old male with a T4N1M0 lesion of the oral tongue was referred for treatment. After a lip-splitting incision, the patient underwent total glossectomy with bilateral modified radical neck dissections. Most of the base of the tongue was resected preserving the epiglottis. The radial artery forearm flap skin island was raised and inset posteriorly to the remaining base of the tongue, and the flap was revascularized to the right facial artery and common facial vein.
This procedure is performed by passing Ethibond suture twice around the body of the hyoid bone from inferior to superior margin [Figure 1], with the second pass medial to the first. The left side suture was similarly passed around the body of the hyoid bone, although superiorly to inferiorly [Figure 2]. After putting the head in a natural position without extension, the sutures were tightened to advance the hyoid bone by 10–15 mm keeping in mind that the tension of the lateral stitches should be lower than the tension of the anterior ones, to avoid hyoid bone fractures.
Patient's swallowing reflex improved with satisfactory speech on follow-up with this procedure.
| Discussion|| |
Patients of total glossectomy need modification that allows for long-term function of swallowing and airway protection. As tissue bulk is directly related to these goals, proper flap choice appears to be a critical factor.
Su found in patients with pectoralis major flap, transfer had speech problems, especially in the production of apical–alveolar stop consonants and lingua–velar consonants. Compared with pectoralis major flap transfer, the pronunciation of all consonants improved in patients who underwent free flap reconstruction.
Hara et al. found tongue mobility to be restricted in oral cancer patients after resection with microvascular reconstruction. Anterior oral cavity resection resulted in impairment in the tongue tip, mid-tongue, and posterior tongue movements whereas posterior oral resection only affected the posterior part of the tongue.
There is a decrease in vertical and horizontal dimensions, resulting in posterior collapse of the tongue base and a decreased oropharyngeal airway.
The function of swallowing following glossectomy is severely deficient in the treatment of patients of oral squamous cell carcinoma.
Hsiao et al. reported an increase in residue in the floor of the mouth with increase in oral transit times in reconstructed patients. Hirano et al. reported that postglossectomy patients have difficulty in propagating bolus posteriorly in addition to weakened pharyngeal propulsion.
Riley showed in his study how the hyoid bone can be advanced and suspended to the inferior border of the anterior mandible using fascia lata.
Kurosawa et al. demonstrated their technique of epiglottis suspension, which resulted in improved swallowing function without aspiration. It led to a wider airway for breathing in laryngectomy patients.
Kimata et al. proposed wider and thicker flaps, such as rectus abdominis musculocutaneous flaps, to be used which should be 30% wider than the defect, and laryngeal suspension can be supplemented to prevent prolapse of the transferred flap.
Satisfactory oral function is attained by reconstructing a tongue with a protuberant shape and sufficient volume. The authors used a de-epithelialised skin island of a rectus abdominis musculocutaneous free flap for tongue reconstruction in thin patients.
Hyoid suspension leads to the enlargement of the hypopharyngeal lumen and remodeling of the hyolingual complex to reduce aspiration and improve swallowing. Overcorrection with a bigger flap is considered optimum for adequate oral intake owing to atrophy and fibrosis caused by radiation therapy. They advocated static suspension procedures to prevent airway aspiration for better laryngeal preservation.
This study represents an important modification toward improving swallowing function and tongue mobility in oral tongue cancer patients. All patients in our series after hyoid advancement were found to be swallowing safely and efficiently. The risk of aspiration was also less in these patients. The aim of hyoid suspension is to create more space retrolingually and to expand and stabilize the upper airway.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Su WF, Chen SG, Sheng H. Speech and swallowing function after reconstruction with a radial forearm free flap or a pectoralis major flap for tongue cancer. J Formos Med Assoc 2002;101:472-7.
Hara I, Gellrich NC, Düker J, Schön R, Nilius M, Fakler O, et al.
Evaluation of swallowing function after intraoral soft tissue reconstruction with microvascular free flaps. Int J Oral Maxillofac Surg 2003;32:593-9.
Hsiao HT, Leu YS, Chang SH, Lee JT. Swallowing function in patients who underwent hemiglossectomy: Comparison of primary closure and free radial forearm flap reconstruction with videofluoroscopy. Ann Plast Surg 2003;50:450-5.
Hirano M, Kuroiwa Y, Tanaka S, Matsuoka H, Sato K, Yoshida T, et al.
Dysphagia following various degrees of surgical resection for oral cancer. Ann Otol Rhinol Laryngol 1992;101:138-41.
Riley R, Guilleminault C, Powell N, Derman S. Mandibular osteotomy and hyoid bone advancement for obstructive sleep apnea: A case report. Sleep 1984;7:79-82.
Kurosawa K, Imai T, Matsumoto K, Asada Y, Katoh K, Matsuura K, et al.
A novel laryngeal preservation technique following total glossectomy with hyoid bone resection. Plast Reconstr Surg Glob Open 2018;6:e1756.
Kimata Y, Sakuraba M, Hishinuma S, Ebihara S, Hayashi R, Asakage T, et al.
Analysis of the relations between the shape of the reconstructed tongue and postoperative functions after subtotal or total glossectomy. Laryngoscope 2003;113:905-9.
Sakuraba M, Asano T, Miyamoto S, Hayashi R, Yamazaki M, Miyazaki M, et al.
A new flap design for tongue reconstruction after total or subtotal glossectomy in thin patients. J Plast Reconstr Aesthet Surg 2009;62:795-9.
Yun IS, Lee DW, Lee WJ, Lew DH, Choi EC, Rah DK. Correlation of neotongue volume changes with functional outcomes after long-term follow-up of total glossectomy. J Craniofac Surg 2010;21:111-6.
[Figure 1], [Figure 2]