A means of achieving more surgical exposure during transoral surgery on the tongue base and vallecula.

The removal of lesions of the tongue and vallecula can be achieved via different surgical approaches, including transpharyngeal, transmandibular, and transoral routes. These three approaches have both advantages and disadvantages:

* Surgery via the transpharyngeal approach affords excellent surgical exposure and may help preserve mandibular integrity, but it is associated with impaired articulation and deglutition. (1)

* With the transmandibular approach, adequate surgical margins can be obtained and various types of reconstructive procedures can be performed. However, complications such as malocclusion, chronic aspiration, and disturbance in the coalescence of the mandible bone might occur. (2)

* The transoral approach is associated with an earlier return to a normal diet and a lack of facial scarring. However, this approach is associated with inadequate exposure and poor access to bleeding sites. (3) Moreover, this approach is suitable only for benign lesions, such as noninfiltrating tumors of the minor salivary glands at the tongue base or vallecula.

We have developed a small modification of the transoral approach that provides for greater exposure of the surgical field. With the patient under general anesthesia, a silk suture is used to fix the tongue in a protruded position (figure, A). A mouth gag is inserted, and a tongue blade is applied to elevate the tongue base. After fixation of the protruded tongue, the tongue blade can be inserted at a more distal site (figure, B). This slight modification may not only provide the surgeon with greater exposure of the surgical field, it might also improve access to a bleeding site.

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For prolonged operations, we recommend releasing the mouth gag for a few minutes after 2 hours in order to prevent ischemic changes in the tongue.

To date, no standard surgical procedure for tongue base and vallecular lesions has provided satisfactory exposure without complications. If we can improve the surgical view of the tongue base and vallecula during transoral surgery, we can minimize recovery time and decrease morbidity. The surgical technique we propose here may be useful in achieving this goal, and it can be performed without increasing the risk of damage to surrounding tissues.

References

(1.) Nasri S, Oh Y, Calcaterra TC. Transpharyngeal approach to base of tongue tumors: A comparative study. Laryngoscope 1996; 106: 945-50.

(2.) Singh AM, Bahadur S, Tandon DA, Pande RM. Anterior mandibulotomy for oral and oropharyngeal tumours. J Laryngol Otol 1993;107:316-19.

(3.) Jones JE, Healy GB. Transoral surgical management of lesions of the base of the tongue. Arch Otolaryngol Head Neck Surg 1992;118:1350-2.

From the Department of Otolaryngology--Head and Neck Surgery, Mackay Memorial Hospital, Taipei, Taiwan.