Proposed Section Structure
This article is organized to reflect the clinical and scientific priorities of the study: highlights, disease burden and rationale, study design and methods, key volumetric and functional findings, clinical interpretation, limitations and generalizability, implications for reconstructive planning and counseling, and a brief section on funding and citation details.
Highlight
First, functional outcomes after glossectomy were strongly associated not only with the type of operation but also with quantified tumor burden and resection volume. Second, the study identified clinically useful volumetric thresholds: a preoperative tumor fraction greater than 31% and a resection volume fraction greater than 67% were associated with a Functional Oral Intake Scale, or FOIS, score of 3 or lower, a marker of gastrostomy dependence. Third, speech intelligibility also tracked with volumetric burden, with preoperative tumor fraction greater than 26% and resection volume fraction greater than 58% associated with poorly intelligible speech. Finally, nonlinear modeling suggested that restoring total tongue volume to approximately 100% of baseline was associated with better oral intake, underscoring the functional relevance of reconstructive volume restoration.
Background
Oral tongue cancer is the most common subsite of oral cavity malignancy, and its incidence has been rising. Although oncologic resection remains the cornerstone of treatment for resectable disease, surgery on the mobile tongue can impose substantial long-term morbidity. The tongue is central to bolus manipulation, oral transport, articulation, airway protection, and intelligible speech. Consequently, glossectomy often affects swallowing, aspiration risk, communication, nutritional autonomy, and health-related quality of life.
Clinicians have long recognized that larger resections generally yield worse function. However, broad procedural labels such as partial glossectomy, hemiglossectomy, subtotal glossectomy, and total glossectomy are imperfect surrogates for true functional tissue loss. Two patients undergoing operations within the same named category may have substantially different residual tongue volumes and distinct reconstructive results. For reconstructive surgeons and head and neck oncologists, this creates an important clinical gap: preoperative counseling and flap planning often rely on experience and qualitative estimation rather than measurable, patient-specific volumetric data.
The study by Wu and colleagues addresses that gap by integrating radiographic volumetric analysis with validated postoperative functional outcomes. In doing so, it moves beyond anatomic labels and asks a more clinically actionable question: how much tumor, how much resection, and how much reconstructed volume matter for speech and swallowing after glossectomy?
Study Design
This was a retrospective cohort study conducted at a tertiary-level academic institution including patients with squamous cell carcinoma of the oral tongue treated surgically between 2014 and 2025. The cohort comprised 357 patients with a median age of 62.3 years, ranging from 18 to 95 years; 51.0% were female. Procedures were grouped into partial or hemiglossectomy, abbreviated PG, and total or subtotal glossectomy, abbreviated TG. Most patients, 315 of 357 or 88.2%, underwent PG, while 42 patients or 11.8% underwent TG.
Tumor stage distribution reflected a mixed but predominantly earlier-stage population: 71.2% had T1 or T2 tumors and 28.8% had T3 or T4 tumors. Free-flap reconstruction was performed in 150 patients, representing 42.0% of the cohort, and adjuvant radiation was delivered to 186 patients, or 52.1%. Median follow-up was 36.1 months, with an interquartile range of 18.2 to 65.6 months.
The primary outcome was an FOIS score of 3 or lower, interpreted as gastrostomy tube dependence. This is a clinically meaningful endpoint because it captures a major patient-centered consequence of oral tongue surgery: inability to maintain full oral nutrition safely and effectively. The investigators also evaluated aspiration, tongue strength, tongue range of motion, speech understandability, and patient-reported quality of life using validated instruments.
A major methodological feature was radiographic volumetric analysis. The authors quantified preoperative tumor volume, native tongue volume, resection volume, flap volume, and total tongue restoration. They then used multivariable analysis to identify independent predictors of poor oral intake and applied both linear and nonlinear regression to model relationships between these measured volumes and function.
Key Findings
Procedure extent remained strongly associated with function
As expected, patients undergoing total or subtotal glossectomy had substantially worse outcomes than those undergoing partial or hemiglossectomy. Median FOIS was 2 in the TG group versus 5 in the PG group, indicating far poorer oral intake after more extensive surgery. The TG cohort also had worse aspiration scores, reduced tongue strength, markedly impaired tongue range of motion, poorer speech understandability, and lower patient-reported quality of life.
The magnitude of these differences is clinically striking. Median aspiration score was 3 in TG versus 1 in PG. Median tongue strength was 17 versus 36. Median tongue range of motion was 16 versus 88. Median speech understandability was 50 versus 100. Median quality-of-life score was 67 versus 77. These values reinforce that the functional penalty of larger tongue resections extends across multiple domains, not only swallowing.
Independent predictors of gastrostomy dependence
On multivariable analysis, several factors were associated with an FOIS score of 3 or lower. These included older age, current or former smoking status, use of a free flap, total or subtotal glossectomy, and greater resection volume. Some of these predictors likely reflect disease severity and treatment complexity rather than purely causal mechanisms. For example, free-flap use is commonly a marker of larger defects. Nonetheless, from a prognostic standpoint, these variables help identify patients at elevated risk for long-term feeding tube dependence.
The association between smoking history and poor intake is also clinically plausible. Tobacco exposure may be linked to worse baseline pulmonary reserve, impaired wound healing, coexisting frailty, and cumulative treatment toxicity. Age likely captures both physiologic reserve and increased vulnerability to dysphagia-related deconditioning.
Volumetric thresholds offer practical prognostic value
The most novel aspect of the study is the identification of specific volumetric cut points associated with major functional outcomes. A preoperative tumor fraction greater than 31% and a resection volume fraction greater than 67% were associated with FOIS 3 or lower. In practical terms, when nearly one-third of the native tongue is occupied by tumor preoperatively, or when more than two-thirds of tongue volume is resected, the probability of severe swallowing impairment appears to rise meaningfully.
Similarly, preoperative tumor fraction greater than 26% and resection volume fraction greater than 58% were associated with speech understandability scores below 75, interpreted as poorly intelligible speech. This finding is important because speech decline may emerge at a somewhat lower volumetric threshold than the threshold for feeding tube dependence. That pattern is biologically reasonable: subtle losses in tongue bulk and mobility may disrupt articulation before they fully eliminate oral intake.
These threshold data could become especially useful during preoperative counseling. Rather than providing only broad statements such as “larger surgery tends to worsen swallowing,” clinicians may be able to contextualize risk based on measured volumetric burden from preoperative imaging and anticipated resection plans.
Volume restoration matters, not just defect closure
The nonlinear regression analysis adds an important reconstructive insight. Restoration of total tongue volume to 100% of baseline value was associated with improved oral intake. This suggests that flap reconstruction should not be conceptualized simply as filling a defect or separating cavities, but as attempting to recreate a functional lingual mass capable of assisting bolus formation and propulsion.
That said, volume is unlikely to be the only determinant of function. Tongue mobility, flap pliability, denervation, tethering, fibrosis, and adjuvant radiotherapy all affect outcome. A bulky but immobile reconstruction may still compromise articulation and swallowing efficiency. Even so, the study supports the view that under-restoration of volume may leave patients functionally disadvantaged, and that volumetric planning deserves greater attention in reconstructive decision-making.
Clinical Interpretation
Several practical messages emerge from these data. First, standard operation categories remain useful, but they are too coarse to fully capture postoperative risk. Quantitative volumetry appears to add prognostic precision. Second, speech and swallowing should be discussed as partly overlapping but distinct outcomes. The volumetric thresholds associated with poor intelligibility were lower than those associated with feeding tube dependence, indicating that some patients may retain oral intake while still experiencing major communication deficits.
Third, the finding that 100% baseline volume restoration correlated with improved oral intake supports a reconstructive philosophy aimed at functional restoration rather than simple tissue replacement. This may influence flap design, inset strategy, and perhaps the choice between thin pliable tissue and bulkier flaps depending on the expected defect geometry and dynamic needs. It also reinforces the value of multidisciplinary planning involving ablative surgeons, reconstructive surgeons, speech-language pathologists, and dietitians.
Fourth, these results may help refine perioperative expectations. Patients with older age, smoking exposure, larger tumor fractions, and anticipated large-volume resections can be counseled more realistically about the probability of prolonged gastrostomy dependence and speech impairment. This information may also help target early swallowing therapy and more intensive rehabilitation.
Methodological Strengths
The study has several notable strengths. It includes a relatively large single-institution cohort for this specific disease and procedure spectrum, with more than a decade of surgical experience. Functional outcomes were assessed using validated tools rather than informal clinical impressions. The use of imaging-based volumetric measurements is particularly valuable because it introduces objective anatomic quantification into a field where descriptive terminology often dominates. The combination of multivariable and nonlinear modeling also strengthens the biological and clinical plausibility of the reported relationships.
Limitations and Cautions
As with any retrospective single-center cohort, residual confounding is unavoidable. The study design can establish association but not causation. Patients requiring total or subtotal glossectomy or free-flap reconstruction likely had more advanced disease, more extensive soft tissue loss, and more complex multimodality treatment, all of which may contribute to poorer function.
The abstract does not provide effect sizes such as adjusted odds ratios, confidence intervals, or calibration metrics for the volumetric thresholds, which would be useful when judging precision and clinical transportability. The thresholds identified may also be partly specific to the imaging methods, segmentation approach, reconstructive techniques, and rehabilitation practices of the study institution. External validation in other centers is essential before these cut points are used as universal standards.
Another important caution is that tongue function depends on more than bulk. Motor control, residual native musculature, floor-of-mouth involvement, suprahyoid integrity, sensory changes, fibrosis from radiation, and flap biomechanics all shape outcome. Therefore, a model based primarily on volume should be viewed as a major advance, but not as a complete representation of postoperative function.
Finally, survivorship outcomes evolve over time. Swallowing and speech can improve with rehabilitation but may also deteriorate after radiation-related fibrosis. Longitudinal modeling of functional trajectories would further strengthen this field.
Implications for Practice and Research
This study helps shift glossectomy planning toward a more quantitative era. In current practice, preoperative imaging is already central to staging and resectability assessment. Incorporating tumor fraction and estimated resection fraction into routine planning may be a feasible next step, especially in high-volume centers with radiology and surgical informatics support. Over time, such measurements might be integrated into counseling templates, multidisciplinary tumor board discussions, or even risk calculators.
For reconstructive surgeons, the findings invite further study of the optimal balance between volume, mobility, and contour. Not all reconstructed tongues with equivalent volume will function similarly. Future work could integrate volumetry with dynamic swallowing imaging, speech acoustics, patient-reported outcomes, and perhaps biomechanical or machine-learning models. Prospective validation could clarify whether intentional volume-targeted reconstruction improves function compared with standard approaches.
For speech-language pathology and rehabilitation teams, volumetric risk profiling could help prioritize early intervention. Patients crossing higher-risk thresholds may benefit from proactive dysphagia management, aspiration surveillance, nutritional support planning, and communication-focused therapy.
Conclusion
Wu and colleagues provide compelling evidence that tumor burden, resection extent, and reconstructed tongue volume are meaningfully linked to swallowing and speech after glossectomy for oral tongue squamous cell carcinoma. Beyond confirming that more extensive surgery worsens function, the study offers clinically interpretable volumetric thresholds associated with feeding tube dependence and poor intelligibility. The observation that restoration of tongue volume to baseline is associated with better oral intake gives reconstructive planning a measurable functional target. Although external validation is needed, this work meaningfully advances preoperative counseling and supports a more quantitative, function-oriented approach to glossectomy and tongue reconstruction.
Funding and ClinicalTrials.gov
No ClinicalTrials.gov registration is applicable based on the available report, as this was a retrospective cohort study. Funding information was not provided in the abstract and should be confirmed from the full-text article.
Citation
Wu SS, Jetly AS, Starmer HM, Finegersh A, Holsinger FC, Chen MM, Divi V, Pham N, Baik FM. Tumor and Flap Reconstruction Volumes and Functional Outcomes after Glossectomy. JAMA Otolaryngology–Head & Neck Surgery. 2026 May 1;152(5):513-522. PMID: 41854621. Available at: https://pubmed.ncbi.nlm.nih.gov/41854621/
