Surgical anatomy of tongue

Maxillofacial surgery

1. PRESENTED BY:- SIDDHARTH VERMA FIRST YEAR P.G. ORAL AND MAXILLOFACIAL SURGERY DEPARTMENT SURGICAL ANATOMY OF TONGUE GUIDED BY:- DR. SUMIT ASRANI

2. CONTENTS Introduction Development Morphology Anatomy Function Applied Anatomy Examination Diseases C0nclusion References

3. INTRODUCTION Tongue is a muscular organ situated in the floor of the mouth. It is associated with the function of taste, speech, mastication and deglutition. It has an oral part that lies in the mouth, & a pharyngeal part that lies in the pharynx. The oral and pharyngeal parts are separated by a V-shaped sulcus-the sulcus terminalis.

4. INTRODUCTION

5. DEVELOPMENT The tongue begins to develop around the fourth week of intrauterine life. By the following arches .First arch Third arch Fourth arch. Anterior 2/3 rd From 2 lingual swellings and 1 tuberculum impar i.e from 1 st brachial arch Supplied by lingual nerve(post- trematic ) and chorda tympani(pre- trematic ).

6. DEVELOPMENT Posterior 1/3 rd From the cranial half of the hypobranchial eminence i.e from the 3 rd arch Supplied by glossopharyngeal nerve. Posterior most From the fourth arch Supplied by Vagus nerve . Immediately behind the tuberculum impar, the epithelial proliferates to form a down growth thyroglossal duct from which the thyroid gland develops.

7. DEVELOPMENT Tongue seperates from the floor of the mouth by downgrowth of the ectoderm around its periphery degenerates to form lingual sulcus-mobility of tongue Muscles develops from occipital myotomes which are supplied by Hypoglossal nerve. Connective tissue develops from local mesenchyme. EPITHELIUM:Formed First by single layers of cell. Later- Stratified and papillae become evident. Taste buds are formed in relation to the terminal branches of innervating nerve fibers.

8. DEVELOPMENT

9. DEVELOPMENT Another important developmental aspect of tongue is it’s contribution for normal development of palate.

10. Morphology of the Tongue The Tongue has, A root A tip (apex) Body

11. Morphology of the Tongue The root It is attached to styloid process and soft palate above and to mandible and hyoid bone below. Because of these we are not able to swallow the tongue itself.

12. Morphology of the Tongue Tip of the tongue Lies behind the upper incisor teeth. Forms the anterior free end.

13. Morphology of the Tongue Body of the tongue 1. Dorsum : convex in all directions. a.Oral Part : anterior 2/3 b.Pharyngeal part : posterior 1/3 They are divided by faint V shaped groove called sulcus terminalis Two limbs of V meet at median pit named as foramen caecum.

14. 2. Inferior surface : is covered with a smooth mucous membrane , which shows a median fold called the ‘ frenulum linguae’ . On either side of frenulum , there is a prominence produced by deep lingual veins. More laterally there is a fold called plica fimbricata

15. INFERIOR SURFACE OF THE TONGUE

16. Pharyngeal part or lymphoid part of tongue : • It lies behind the palatoglossal arches and sulcus terminalis • Its posterior surface (base of tongue) forms anterior wall of oropharynx. • The mucous membrane has no papillae but has many lymphoid follicles that collectively constitute the lingual tonsil.

17. PAPILLAE OF TONGUE These are projections of mucous membrane (or) corium which give the anterior 2/3rd of tongue its characteristic roughness. They are – 1.Filliform papillae ( conical /thread shape) 2.Fungiform papillae (mushroom shape) 3.Circumvallate / vallate papillae (ring or circle shape ) 4.Foliate papillae ( leaf shape )

18. CIRCUMVALATE PAPILLAE : ( circular or ringed shape ) • They are larger in size i.e 1-2 mm in diameter . •Situated immediately in front of V- shaped sulcus terminals. •8-12 in number. •The walls of papillae have taste buds •They are associated with ducts of Von Ebner's glands

19. TASTE BUDS Small ovoid barrel shaped intrapapillary organ 40μm thick. They are modified epithelial cells arranged in a flask – shaped form. Also called as gustatory calyculi . Found in maximum numbers on circumvallate and fungiform papillae Outer surface- covered by few flat epithelial cells which is surrounded by small opening called taste pores Taste buds may have one or more taste pores

20. Taste buds contain the receptors for taste. • These structures are involved in detecting the five (known) elements of taste perception: salty, sour, bitter, sweet, and savory (or umami). • Via small openings in the tongue epithelium, called taste pores, parts of the food dissolved in saliva come into contact with taste receptors. TASTE BUDS The taste receptor cells send information detected by clusters of various receptors and ion channels to the gustatory areas of the brain via the seventh, ninth and tenth cranial nerves. • On average, the human tongue has 2,000–8,000 taste buds

21. TASTE BUDS

22. Muscles of tongue Tongue is made of intrinsic and extrinsic muscles •Divided into right & left by median sagittal septum of connective tissue. Intrinsic muscles • Inferior longitudinal • Superior longitudinal • Transverse • Vertical Extrinsic muscles •Genioglossus •Hyoglossus •Styloglossus •Palatoglossus

23. Muscles of tongue

24. SUPERIOR LONGITUDINAL MUSCLE: Lies beneath the mucous membrane Origin: sub mucosal connective tissue at the back of the tongue and from the median septum of tongue. Insertion: muscle fiber pass forward and obliquely to sub mucosal connective tissue and mucosa on margin of tongue. Innervation: Hypoglossal nerve. Function: Shorten tongue. curl apex and sides of tongue. INFERIOR LONGITUDINAL MUSCLE: Is a narrow band lying close to the Inferior surface of the tongue between genioglossus & hyoglosssus Origin: root of tongue Insertion: Apex of tongue. Innervation: Hypoglossal nerve. Function: Shorten tongue. Uncurls apex and turn it downward.

25. TRANSVERSE MUSCLE: Origin: median septum of tongue Insertion: submucosal connective tissue on lateral margin of tongue. Innervation: hypoglossal nerve Function: narrow and elongates tongue VERTICAL MUSCLE: Origin: submucosal connective tissue dorsum of tongue. Insertion: connective tissue in ventral region of tongue. Innervation: Hypoglossal nerve. Function: Flattens and widens tongue.

26. EXTRINSIC MUSCLES

27. Muscle Origin Insertion Action Palatoglossus Oral surface of palatine aponeurosis Lateral border of tongue Initiation of swallowing Styloglossus Anterior lateral styloid process of temporal bone Lateral border of tongue Pulls the sides of the tongue up and pulls tongue back (this creates a trough for swallowing) Hyoglossus Greatr cornua of hyoid bone Side of tongue Depresses the tongue Genioglossus Inferior mental spine ( process ) of mandible Tongue and hyoid Depresses and extends the tongue

28. Blood supply of tongue Arterial supply Mainly by lingual artery which is a branch of external carotid artery. The root is also supplied by tonsillar artery which is a branch of facial artery & ascending pharyngeal artery. Due to the median fibrous septum of tongue, there is no anastomosis of arteries between 2 sides.

29. VENOUS DRAINAGE The deep lingual veins are largest & principle veins. Seen along the inferior surface of tongue. 2 veins accompany the lingual artery & 1 vein is seen . alongside hypoglossal nerve. These veins unite at posterior border of hyoglossal muscle & form the Lingual Vein. This lingual vein drains into common facial or internal jugular vein

30. Neurovascular supply of tongue

31. NERVE SUPPLY: Motor – all intrinsic & extrinsic muscles, except the palatoglossus muscle is supplied by HYPOGLOSSAL NERVE ( XII) . Palatoglossus is supplied by –pharyngeal branch of the vagus nerve (CN X). Sensory components– 1. Lingual nerve is the nerve of general sensation 2. Chorda tympani is the nerve of taste for anterior 2/3rd of tongue except circumvallate papillae 3. Glossophayngeal nerve is the nerve for both general sensation & taste for the posterior 1/3rd of tongue including circumvallate papillae 4. Posterior most part of tongue is supplied by vagus nerve through the internal laryngeal branch.

32. NERVE SUPPLY:

33. Lymphatic drainage: Tip: drains bilaterally to submental nodes The right & left halves of remaining part of the anterior 2/3rd of tongue drain unilaterally to Submandibular nodes. A few central lympahtics drain bilaterally to the deep cervical nodes. Posterior most part & posterior 1/3rd of tongue drain bilaterally into upper deep cervical lymph nodes including jugulodiagastric. • The whole lymph finally drains into “ juguloomohyoid nodes ” • These are known as lymph nodes of tongue.

34. FUNCTIONS OF TONGUE : Mastication & deglutition Taste Perception Phonation Equilibrium & development of the dental occlusion Jaw Development

35. APPLIED ASPECTS Gag reflex: Posterior most part of the tongue when touched produces gagging. IX and X nerves are responsible for muscular contraction of each side of pharynx. When the genioglossus muscle is paralyzed, the tongue has a tendency to fall posteriorly obstructing the airway and creating the risk of suffocation. Total relaxation of the genioglosus muscle occurs during G.A therefore the tongue of an anesthetized patient must be prevented from relapsing by inserting an airway. Sublingual absorption of drugs possible due to thin mucosa & rich vasculature.

36. Trauma such as fractured mandible may injure the hypoglossal Nerve resulting in paralysis of tongue. The tongue deviated to the paralyzed side during protrusion because of the action of unaffected genioglosuss muscles on the other side. Injury on both sides causes tongue to be motionless. In many elderly patients, there is nodular enlargement of superficial veins on the ventral surface of the tongue. The presence of such lingual varicosities (varicose tongue) is not of special significance and should not be regarded as evidence of disease of blood vessels. APPLIED ASPECTS

37. The presence of rich network of lymphatics and loose areolar tissue in the substance of tongue is responsible for enormous swelling of tongue in acute glossitis. The undersurface of the tongue is a good site for observation of jaundice Carcinoma of Tongue is quite common. The affected side of the tongue is removed along with all the deep cervical lymph nodes Carcinoma of posterior 1/3 of the tongue is more dangerous due to bilateral lymphatic spread APPLIED ASPECTS

38. Snoring may be reduced by anterior displacement of the tongue with the intention to compensate inadequate pharyngeal muscle activity. Direct anterior displacement of the tongue leads to an amplification of the airway space, but is difficult to achieve with clinical manoeuvres at night. However, the use of tongue retaining devices & tongue repositioning manouvre has been reported to reduce the time of loud snoring during sleep APPLIED ASPECTS

39. EXAMINATION OF TONGUE

40. Inspection • Inspect the dorsum of the tongue at rest for variation in size,color, and texture. • Observe and note – the distribution of papillae, – margins of the tongue. – depapillated areas, – fissures, ulcers, and keratotic areas. • Note frenal attachment • Any deviations as the patient protrudes tongue and attempts to move it to the right and left. • Note tongue thrust on swallowing. • Wrap a piece of gauze (4 x 4 cm) around the tip of the protruded tongue to steady it.

41. CINERADIOGRAPHY : It is the making of a motion picture record of successive images appearing on a fluoroscopic screen. • Eg: use cineradiographic images to investigate tongue movement during deglutition in anterior open bite patients with tongue thrust. • Each subject had semi-spherical lead markers attached to the tip and dorsal surface of the tongue and was asked to swallow 5 ml of diluted liquid barium. • Tongue movement during deglutition was recorded in the midsagittal plane with an X-ray VTR system. ( video tape recorder)

42. Pulsed (Doppler) Ultrasound Noninvasive ultrasound technique has recently been applied to study laryngeal activity, pharyngeal wall displacement and tongue movements. Two types of echo ultrasound equipment can be used to monitor tongue movements in speech-1. A scan and 2.Sector scan. It has been used to study the characteristics of arterial blood flow in the tongue, and abnormal pulse waves have been noted in the lingual arteries of individuals with evidence of compromised flow in other branches of the carotid arterial tree. The most widely used applications in medicine are operative (usually has a frequency that ranges between 2-8 K Hz), therapeutic (between 20 K Hz-3 M Hz either in continuous or pulsed modes), and diagnostic (between 1.6-12 M Hz).

43. Electromyography: • Electromyography is a test to study the muscle functions. • It has been used to study the action potentials in actively contracting muscles and has contributed to an understanding of lingual and masticator muscular function and also in detecting uncoordinated muscular movements in diseases like dyskinesia, dystonia, and various neuromuscular disorders. • It is a noninvasive technique.

44. Computer-Assisted Tomography: It can be used to identify space occupying lesions and muscular atrophy secondary to hypoglossal nerve damage, in cases where the lesion is deep in the base of the tongue and not detectable by other approaches. Isotopic Scanning Techniques: It can be used when a mass in the tongue is composed of specialized secretory tissue or other tissue, such as thyroid, which selectively concentrates intravenously administered radioactive 131I or 99Tc-pertechnetate Scanning Electron Microscope: SEM is a well-established tool for in vitro study of the surface topography of tongue dorsum, the character and morphology of the different types of tongue papillae and distribution and morphology of bacteria on the papillated areas of the dorsum.

45. EXAMINATION OF TONGUE

46. Diseases of the tongue Inherited, congenital, and developmental anomalies Disorders of the lingual mucosa Diseases affecting the body of the tongue Tumors of tongue

47. CLASSIFICATION OF TONGUE DISORDERS A)Inherited, congenital and developmental anomalies: Minor variations: 1 .Ankyloglossia 2.Variations in tongue movement 3.Tongue thrusting 4.Fissured tongue 5.Patent thyroglossal duct and cyst 6.Lingual thyroid 7.Median rhomboidal glossitis

48. b) Major variations: 1.Cleft, lobed, bifurcated and tetrafurcared tongue 2.Aglossia, hypoglossia and macroglossia 3.Hamartoma and dermoid 4.Bald and depapillated tongue 5.Papilomatous changes B)Disorders of the lingual mucosa: A)Changes in the tongue papillae: 1.Geographic tongue 2.Coated or hairy tongue B)Non-keratotic lesions: 1.Thrush 2. White sponge nevus 3.Vesiculobulous and other desquamative disorders

49. C)Keratotic white lesions: 1.Lichen planus 2. Leukoplakia D) Depapillation and atrophic lesions: 1. Chronic trauma 2. Nutritional deficiency 3. Hematological abnormalities 4. Medication 5. Peripheral vascular disease 6. Diabetes and chronic candidiasis Tertiary syphilis and interstitial glossitis E)Pigmentation F)Ulcer and infectious disease G)Superficial vascular diseas e

50. C ) Disorders affecting body of tongue: 1.Amyloidosis 2.Infections 3.Neuromuscular disorders 4.Sleep apnea syndrome 5.TMJ Myofascial dysfunction 6.Vascular disease of body of tongue 7. Angioneurotic edema D ) Tumors of tongue: 1.Benign 2.Malignant

51. The ankyloglossia can be classified into 4 classes based on Kotlow's assessment as follows; Class I: Mild ankyloglossia: 12 to 16 mm, Class II: Moderate ankyloglossia: 8 to 11 mm, Class III: Severe ankyloglossia: 3 to 7 mm, Class IV: Complete ankyloglossia: Less than 3 mm Ankyloglossia • Types: 1.Complete Ankyloglossia (fusion of tongue to the floor of the mouth)

52. Syndromes associated are: Ankyloglossum superioris syndrome Trisomy of 13 Pierre robin syndrome Rainbow syndrome MANAGEMENT-1. Counselling 2. Surgery Clinical features: Restricted tongue movements Feeding problems Speech defects 4. Tongue biting Partial ankyloglossia: Partial ankyloglosia refers to congenital shortness of the lingual frenum or a frenal attachment that extends nearly tip of tongue,binding the tongue to floor of mouth and restricting its extention.

53. Frenectomy with the use of one hemostat A) Thick and short lingual frenulum with anterior insertion. B) Restricted central tongue tip elevation caused by abnormal attachment of the base of the tongue. C) Frenulum being held with a small curved hemostat with the convex curve facing the ventral surface of the tongue. D) First incision following the curvature of the hemostat, cutting through the upper aspect of the frenulum. E) Second incision at the lower aspect of the frenulum. F) Wound edges being dissected with the tips of blunt-ended scissors. G) Absorbable sutures placed over the wound. H) Clinical aspect of the surgical site on the seventh postoperative day 

54. Frenectomy with the use of two hemostats Clinical aspect of the tongue during protrusion. Short and tight lingual frenulum. Frenulum held with two hemostats, with their tips meeting in the deep aspect near the base of the tongue. Excised triangular tissue held with the hemostats. Excision of fiber remnants. Silk sutures placed over the wound 

55. Laser frenectomy   Laser frenectomy. A) Short lingual frenulum. B) Infiltrative anesthesia of the lingual nerve. C) Diode laser application to the central area of the frenulum. D) Laser application from the tip to the base of the tongue. E) Clinical aspect of the surgical site on the fourteenth postoperative day  The frenulum incision was carried out with diode laser at a wavelength of 800 nm and power of 2 W in non-contact mode, which was applied continuously to the central area of the frenulum from the tip to the base of the tongue.

56. Microglossia and Aglossia Uncommon developmental condition of unknown origin Characterized by abnormally small tongue Entire tongue may be missing ( aglossia ) Length of the mandibular arch will be smaller due to the smaller size of the tongue.

57. Treatment and prognosis • Depends on the nature and severity of the condition • Surgery and orthodontics may improve oral function • Speech development is quite good but depends on tongue size Clinical Features: • Difficulty in speech and mastication. •High arched palate, narrow constricted mandible •Missing lower incisors •There may be airway obstruction, due to negative pressure generated by deglutition and inspiration

58. Moebius syndrome Variable degrees of limb hypogenesis. Strabismus, micrognathia, mask-like faces. Small tongue

59. Macroglossia • Tongue enlargement which leads to functional and cosmetic problems. Classification: 1.True macroglossia Congenital- •Idiopathic muscle hyperthrophy •Hemangioma •Lymphangioma Acquired- a)Metabolic • Cretinism • Hypothyroidism • Diabetes 2.Pseudomacroglossia - maybe due to severe retrognathic maxilla or mandible. b)Inflammatory:• Syphilis• Rheumatic fever• Typhoid • Tuberculosis c)Traumatic• Surgery• Hemorrhage

60. Clinical features: • Age: more common in infants • Symptoms: tongue protrusion, which exposes the tongue to trauma. • Other symptoms include swallowing difficulties, airway obstruction, drooling and failure to thrive. • Signs: Displacement of teeth and malocclusion Crenation or scalloping of lateral borders of tongue Associated syndrome: i. Beckwith’s- Wiedemann syndrome ii.Down syndrome iii.Behmel syndrome iv.Laband syndrome Treatment: • Removal of primary cause • Majority of cases are treated surgically.

61. Surgical Treatment of Congenital True Macroglossia Figure 1: The tongue was increased both in length and in width, with anterior open bite with interposition of the tongue and loss of 31 and 41 teeth.  Figure 2: The tongue was pulled out of the oral cavity through three repairs with nylon suture 3-0 fixed to the surgical field to maintain the symmetry between the sides and facilitate the demarcation of the incisions, which was performed which methylene blue.  “keyhole” technique ,

62. Figure 3: A partial thickness elliptical wedge incision starting at the midline and 4mm distance from tongue taste buds using electrocautery, the dorsum, and incisions on belly anterior tongue were united resulting in a full-thickness flap, proceeding the excision of excess tissue. Surgical Treatment of Congenital True Macroglossia

63. Surgical Treatment of Congenital True Macroglossia Figure 4: The suture was made by planes with polyglactin 910 suture 3-0, good tissue repair, perfect symmetry, and no tongue interposition. 

64. PICHLER, MODIFIED KEYHOLE TECHNIQUE

65. By BUTLIN, ENSIGN Surgical Treatment of Macroglossia

66. BY HARDA,ENOMOTO Surgical Treatment of Macroglossia

67. Pierre Robin anomalad CLEFT PALATE , RETROGNATHIA , GLOSSOPTOSIS

68. Fissured/ Plicated /Scrotal tongue Clinical features: • In elderly, mentally retarded & psychotic individuals. • Deep furrows – food lodgement- symptomatic Associated syndrome: -Melkersson - Rosenthal syndrome - Down’s syndrome Treatment: no definative t/t. -oral hygiene- soft bristle brush, mouthwash/diluted H2O2. It is characterized by grooves that vary in depth and are noted along the dorsal and lateral aspect of the tongue .

69. CLEFT OR BIFID TONGUE It is a condition in which there is Cleavage of the tongue due to lack of fusion of lateral lingual swellings of the tongue. • Partial cleft tongue is more common and is manifest as a deep groove in the midline of the dorsum of tongue. Associated syndrome: oro-facial-digital syndrome

70. Surgical correction of the defect was undertaken under local anesthesia. The median parts of the defect were freshened and the tongue was reconstructed by suturing the muscles in layers. Post surgical healing was uneventful and no speech therapy sessions were required . SURGICAL REPAIR OF CLEFT TONGUE PREOP POSTOP Intraoperative

71. LINGUAL THYROID NODULE • It is an anomalous condition in which follicles of thyroid tissue are found in the tongue, arising from remnants of thyroid that may fail to migrate to its predestinated position or from remnants that became detached and were left behind. Symptoms : dysphagia, dysphonia, dyspnea,hemorrhage with pain or fullness in throat. Treatment and prognosis • Most cases require no treatment and biopsy should be considered with caution because of the potential for hemorrhage, infection or release of large amounts of hormone into the vascular system (thyroid storm). Surgical excision or radioiodine therapy

72. Median Rhomboid Glossitis: ‘central papillary atrophy of tongue’ Developmental defect resulting from an incomplete descent of tuberculum impar and entrapment of a portion between fusing lateral halves of the tongue. Management :Antifungal agents, Long standing cases:cryosurgery, excisional biopsy Papillomatous changes : In several congenital disorders the surface of tongue is covered with multiple papillomas. When extensive this abnormalities is known as pebbly tongue.

73. Geographic Tongue: Also called as benign migratory glossitis,wandering rash, glossitis areata exfoliativa, and erythema migrans It refers to irregularly shaped reddish areas of depapillation and thinning of the dorsal epithelium which is surrounded by a narrow zone of regenerating papillae that are whiter than the surrounding tongue surface. Management: For control of burning-topical local anaesthetic agents like lidocaine or diphenhydramine can be given. Topical therapy: topical corticosteroids and topical application of salicylic acid and tretinoin(retinoic acid) Psychological assurance

74. Oral leukoplakia : Oral leukoplakia may be found at all sites of the oral mucosa. • Nonsmokers have a higher percentage of leukoplakia at the border of the tongue compared with smokers. • The floor of the mouth and the lateral borders of the tongue are high-risk sites for malignant transformation Verrucous leukoplakia- Large, diffuse, and corrugated white lesions of the buccal mucosa and tongue .

75. Erythroleukoplakia Nonhomogeneous leukoplakia is subdivided into speckled and nodular types, both of which can be regarded as  erythroleukoplakia   Hairy leukoplakia Most common HIV lesion • Also associated with: – Immunosuppressive drugs Cancer chemotherapy – Organ transplantation • Etiology: EBV with low CD4+ T lymphocytes

76. HAIRY TONGUE •Also called as Lingua nigra, Lingua villosa, Lingua villosa nigra, Black hairy tongue. •Commonly observed condition of defective desquamation of the filiform papillae. •Lesion can also appear brown, white, green, pink, or any of a variety of hues depending on the specific etiology and secondary factors. CLINICAL FEATURES:- Affects the mid line just anterior to circumvallate papilla. Filliform papillae more than 15mm in length.

77. Thrush / Acute pseudomembraneous Candidiasis Acute Atrophic Candidiasis/ Erythmatous candidiasis The infection is predominantly encountered in the palate and the dorsum of the tongue of patients who are using inhalation steroids.

78. HERPES SIMPLEX Recurrent Aphthous Stomatitis (RAS): A 42-year-old woman with a recent increase in severity of recurrent aphthous ulcers. Iron deficiency was detected, and the ulcers resolved when this deficiency was corrected Within a few days of the prodrome, erythema and clusters of vesicles and/or ulcers appear on the keratinized mucosa of the hard palate, attached gingiva and dorsum of the tongue HSV-1

79. SYPHILIS Chancre of primary syphilis. Ulceration of the dorsal surface of the tongue on the left side . Characteristic slightly raised, grayish white, glistening patches ‘mucous patches,’ of the tongue caused by T. pallidum, spirochete .

80. TUBERCULOSIS Chronic mucosal ulceration of the ventral surface of the tongue SCARLET FEVER Strawberry tongue (also called raspberry tongue),refers to glossitis which manifests with hyperplastic (enlarged) fungiform papillae , giving the appearance of a strawberry.

81. Variations in tongue movement EDS Syndrome Hyperextensibility of tongue

82. NEUROLOGICAL DISORDERS Dyskinesias are involuntary movement that have no purpose and are not fully controllable by the patient.

83. Gustatory disorders of the tongue Stimulated dysgeusia - Distortion in perception of taste. Unstimulated dysgeusia/ phantogeusia - perception of taste in absence of . any recognized stimulus. Hypergeusia: Increased sensitivity for all taste stimuli.

84. Benign tumors of tongue : Fibroma - is a benign, tumor-like growth made up mostly of fibrous or connective tissue. Hemangioma: Hemangioma is a benign tumor of dilated blood vessels. It is also known as port-wine stain, strawberry hemangioma, and Salmon patch. Lipoma:

85. Malignant tumors of tongue: Cancer of the tongue is a malignant tumor that begins as a small lump, a firm white patch, or a sore (ulcer) on the tongue. If untreated, the tumor may spread throughout the tongue to the floor of the mouth and to the gum (jaws). As a tumor grows, it becomes more life threatening by spreading (metastasizing) to lymph nodes in the neck and later to the other organs of the body Eg: squamous cell carcinoma,

86. CLINICAL FEATURES Painless mass or ulcer later becomes painful Excessive salivation Offensive smell in mouth occurs due to bacterial stomatitis. Sore thraot Immobility of tongue-causes difficulty in speech. Hoarseness of voice and dysphagia It spread by infiltration and invasion. SQUAMOUS CELL CARCINOMA: The lesion usually appears as a nodular mass that often resembles a hyperplastic or reactive growth. Tongue is the site for 25% of SCC cases.

87. Treatment of carcinoma of the ant. 2/3rd of tongue with evidence of node involvement may include radical neck dissection, partial mandibulectomy, and intraoral dissection(commando operation) in addition to glossectomy Better cure rates obtained with combined chemotherapy( cis-platinum and bleomycin)-surgery-radiation Approaches, use of neutron irradiation, immunotherapy, and transoral laser resection for accessible early stage carcinoma. MANAGEMENT: Early carcinoma of tongue(T1 and small T2) responds equally well to surgical excision or by radiation. T1 and T2 with no evidence of lymph node metastasis, surgical treatment is usually restricted to partial glossectomy. If it is T2 or T3 without node involvement ,prophylactic neck dissection is advised.

88. Recurrent oral squamous cell carcinoma (OSCC) patient (A) Local recurrence of OSCC in the right side of the tongue; (B) regional recurrence in right cervical level II; (C) intraoperative hemi-glossectomy; (D) intraoperative view of the resected specimen; (E) classical radical neck dissection; (F) design of the "Iberic graft" technique for reconstruction of the defect with a radial forearm free flap (RFFF); (G) RFFF harvesting; (H) intraoral view of the reconstruction, with the RFFF showing arterial bleeding and viability The role of salvage surgery in oral squamous cell carcinoma Raúl González-García  

89. FOLLOW UP

90. FOLLOW UP

91. Tongue flap Distant full thickness pedicle flap Used to close large OAF Rich blood supply Disadvantage Requirement of GA Requirement of 2 stage and 3 stage procedure

92. Tongue flap for the closure of Oro antral fistula Posteriorly based Full thickness Lateral tongue flap Anteriorly based Partial thickness Dorsal tongue flap

93. Tongue flap for the closure of Palatal fistula

94. PEDICLE TONGUE FLAP SURGERY IN ORAL SUBMUCOUS FIBROSIS Muthubabu, Srinivasan M., Jeeva, Metali Rai, Gayathri RESULT: Pedicle tongue flap surgery facilitated better articulation, mastication and swallowing. Appreciable increase in the interincisor distance was noted. Colour of soft palate and cheek were noted to turn pink from the pale colour after surgery due to revascularisation of the areas. None of the patients complained of any impairment of taste sensation after surgery.

95. CONCLUSION The tongue is an important organ of the body. Any pathology concerning its boundaries may spread to distant areas of the body via its lymphatic and vascular supply. Correct and an early diagnosis during the examination of tongue. Differential diagnosis of the lesions need the knowledge, the skill and the experience of the clinician.

96. • REFERENCES Grays Anatomy;Textbook of Anatomy B.D. Chaurasia:A Textbook of Anatomy Textbook of Embryology: Inderbeer Singh Hine ,Levy , Shafer’s textbook of Oral Pathology Peterson’s principles of Oral surgery Fonseca volume 7 Netter’s Head and Neck Anatomy for Dentistry, 2nd Edition