S3 - Lec 9: Head and Neck

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ANATOMIC PROBLEM MASS

Benign Malignant - smooth - fungating - well differentiated - ill differentiated - non invasive - invasive - non foul smelling - foul smelling - slow growing - fast growing

ORAL CAVITY PHARYNX

o Problem in speech o Problem in mastication o Problem in deglutition

o Problem in speech o Problem in deglutition o Problem in respiration

LARYNX PARANASAL SINUS

o Voice changes o Problem in respiration

o Nasal discharge o Headache o Problem in mastication

CONGENITAL LESIONS THYROGLOSSAL DUCT CYST o Anomaly in thyroid gland development o Midline neck mass in children o Elevates on tongue protrusion o Tx: Complete excision SISTRUNK

BRANCHIAL CLEFT ANOMALIES o Epithelium-lined cysts , sinuses , cartilaginous remnants o Present in 1st decade of life o Presence of lymphoid tissues

TYPES OF BRANCHIAL CLEFT ANOMALIES

FIRST BCR SECOND BCR

Connects to external ear canal or parotid

Opens into tonsillar fossa

Types

I- lie anterior the SCM

II-lie on jug v, attached to the muscle III-extend b/w int. & ext. carotid a. IV-lie near pharyngeal wall

THIRD BCR FOURTH BCR

opens to the piriform sinus Opens into the descending into the chest

*BCR-Brachial Cleft Anomalies HEMANGIOMAS & VASCULAR MALFORMATIONS

o Differ in terms of prognosis & management o Distinction based on cellular & clinical characteristics

HEMANGIOMA VASCULAR MALFORMATION

Absent at birth

Increased mitolic activity

Undergo spontaneous involution

Treatment: steroids

Always present at birth

Normal rate of endothelial cell tumover

Grows proportionally with individual

Short course systemic steroid

Intralessional steroid

Photodynamic laser therapy

Do not regress spontaneously

Classified by type of vessel involved

Highly infiltrative

Angiography needed

LYMPHANGIOMA o Benign lesion o Can be classified accdg to location/cause o Significance lie in possible pre-malignant potential

LIP o Hyperkeratosis

o thickening of stratum corneum with dysplastic changes o Manifested by scaling

o Mucus Retention Cyst o submucosal accumulation of mucus o No epithelial lining o Rupture of duct system o Small, smooth, rounded mass w/ bluish hue o Tx: excision

o Ranula o from Major Salivary Glands o Mucus extravasation o Tx: resection

o Epulis o granulomatous lesion of the gingiva

o Papilloma o epithelial proliferation o Soft, irregular pedunculated lesion o Tx: excision

o Polyps o invoves both sides o Obstruction, mucoid nasal discharges or ansomia o Allergic or infectious in origin

PARANASAL SINUSES o Mucus Retention Cyst

o From blockage of secretions of mucus glands w/in lining o Discrete masses surrounded by air o Location: maxillary sinus o Tx: rarely necessary

SINUSES o Mucocoele

o expansile, highly destructive lesion o Blockage of a sinus ostium o Thinning and destruction of wall o Location: frontal sinus o Tx: Surgery

LARYNX o Papilloma

o true vocal cord lesions o Present w/ hoarseness

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BONY STRUCTURE

Odontogenic tumor Non Odontogenic

Ameloblastoma - dental lamina - slow growing painless mass - multilocular radioluscent cyst - Tx- resection w/ margins

Torus - slow growing tumor - palatines & mandibularis - may erode underlying mucosa - Tx. Not needed

Odontogenic Cyst - less aggressive - assc w/ an impacted tooth - unilocular cyst

Exostoses - common in the mandible - bony overgrowth over specific areas - Tx: Excision

Osteoma - slow growing tumor of mature bone - arise at the periphery of involved bone - Tx: Excision

CARCINOMA o Similar in terms of general behavior to other solid tumors o Squamous cell carcinoma o Clinical presentation would dependent on the site of origin o Die w/o any evidence of distant /metastasis o Multidisciplinary approach to treatment

RISK FACTORS

Chemical o Chronic alcohol & tobacco

use o Reverse smoking o Betel nut chewing o Nickel

Physical o Ill fitting dentures o Viral infxn o Sun exposure

ETIOLOGY & RISK FACTORS

Chemical Infective Environment

o Tobacco o Alcohol

o EBV o HPV o HIV

o UV o Radiation o Wood dust o nickel

THEORIES ON CARCINOGENESIS

Chemical carcinogenesis o Initiating Factor → DNA→ Carcinoma (SCCA)

↓ Promoting agents: -alcohol

-vit deficiency -local inflame

Viral carcinogenesis o Its role is still unclear but suspicious o Evidence of HPV 16&18 in SCCA of paranasal sinuses, nasal cavity

and larynx o Elevated antibodies to EPV and NPCA

CARCINOMA o Increasing incidence w/age o Sequential presentation o Less protection compared to skin o Incidence of synchronous tumor

Epithelium → Hyperplasia / Papillomatosis ↑ Chronic irritation

ACQUIRED CAPABILITY OF CANCER CELL o Limitless replicative potential o Evading apoptosis o Self-sufficiency in growth signal o Insensitivity to anti-growth signals o Sustained angiogenesis o Tissue invasion and metastasis DIAGNOSIS & EVALUATION o History & PE most impt tool in diagnosis o Id of risk factors o Symptoms will depend on site involved

DIAGNOSIS OF HEAD AND NECK CANCER

History 4most common sx

1) Pain 2) Bleeding 3) Obstruction 4) Mass

PE o Inspection and palpation o Detailed neuro exam

Biopsy o Punch biopsy o Incisional biopsy o FNAB

- Exception very small lesions that can be completely removed by same biopsy procedure

- Salivary gland / parotid gland tumor

Additional Studies o Radiologic study o CT scan o MRI o Contrast studies/ barium swallow

DANGER SIGNS & SYMPTOMS

o Hoarseness persisting for > 4 weeks o Oral mucosa ulcer/swelling > 3 weeks o Red & / or white patches on the oral mucosa o Dysphagia persisting for > 3 weeks o Unilateral nasal obstruction , discharge or bleeding o Unexplained tooth bleeding o Unresolved neck masses > 3 weeks o Cranial neuropathies o Orbital swelling or proptosis

DIAGNOSIS & EVALUATION PRINCIPLES IN DOING P.E

o Visualization of entire upper aerodigestive tract mandatory o Systematic approach needed

DIAGNOSIS & EVALUATION

o Inspection of facial & cervical anatomy & contour o Intraoral examination (size , shape ,projection into cavity tongue

mobility) Mandibular involvement

o Panendoscopy Nasal cavity Pharynx Larynx Cervical easophagus

o Neurologic examination

o Evaluation of distant metastasis o Further investigation guided by history & PE o Minimum requirement: CXR

o Before treatment planning

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o DEFINITIVE HISTOLOGIC CONFIRMATION of the (primary lesion is NECESSARY)

o ANCILLARY PROCEDURES o Nasopharyngoscopy o Panorex o CT

**SIZE OF THE TUMOR CAN PREDICT RISK OF HAVING LYMPH NODE

METASTASIS!

STAGING

T N

T1 tumor 2 cm or less T2 tumor > 2 cm but not more than 4 cm T3 tumor > 4 cm T4 invasion of adjacent structures

N1 single ipsilateral, 3cm or less N2 single ipsilateral LN, > 3 cm but not more than 6 cm: or in mult . ipsilateral LN , none > 6 cm; or in bil. Or contralateral LN, none more than 6 cm N3 LN 6 > cm

M

M0 No distant metastasis M1 Distant metastasis

ESSENTIALS FOR STAGING

o Complete PE ( + bi-manual) including indirect laryngoscopy & nasopharyngoscopy

o Biopsy of primary tumor o Chest X-ray o Panorex film o X-ray of paranasal sinuses

Definitive or curative o Oriented toward total extirpation of local & locoregional disease

PALLIATIVE

o Relief of pain , airway obstruction, improvement in local function &

hygiene

o SUBTOTAL RESECTION OF NO BENEFIT TREATMENT

Definitive Treatment o Surgery o Radiotherapy

CHOICE OF TREATMENT

o Site o Patient volition & compliance o Associated disease o Interference w/ normal function available facilities

EN-BLOCK TREATMENT SIZE IS A MAJOR FACTOR o Likelihood of local control & ultimate cure w/ RT alone o Risk of having occult nodal metastases

HIERARCHY OF PRIORITIES

1. Survival 2. Symptom alleviation 3. Preservation/restoration of function 4. Cosmesis 5. Efficiency of treatment regimen

SURGICAL & PATHOLOGIC STAGING 1. Number of lymph nodes 2. Size of lymph nodes 3. Extracapsular extension 4. Fixation to skin or adjacent structures laterality

COMPLICATIONS OF UNCONTROLLED GROWTH

1. Carotid artery hemorrhage 2. Invasion of sympathetic ganglion 3. Erosion of cervical vertebrate 4. Cranial nerve invasion 5. Airway obstruction 6. Brachial plexus palsy

Types of Neck Dissection

o Radical neck dissection o Modified radical neck dissection

o Extended radical neck dissection

o Selective neck dissection

CLASSIFICATIONS OF NECK DISSECTION

I. COMPREHENSIVE NECK DISSECTION

1. Classical Radical neck dissection

2. Extended radical neck dissection

3. Modified radical neck dissection

Type I Type II Type III

-the spinal accessory nerve is preserved

-preserve the sp acc nerve and SCM -sacrifice the int. jugular v

-preserve the 3 structure: SAN SCM & IJV

II. SELECTIVE NECK DISSECTION

o Supraomohyoid neck dissection – for oral cavity tumors; remove levels 1,2&3

o Anterolateral neck dissection (jugular neck dissection) – for laryngeal and thyroid cancers; levels 2,3,4,&6

o Central Compartment Neck Dissection o Posterolateral Neck Dissection – for posterior scalp tumors; levels

2,3,4&5

TREATMENT INVOLVEMENT

o Segmental Mandibulectomy o Marginal Mandibulectomy

Mandibular swing o Reconstruction: soft tissue defects & bony defects

o GOALS: Restoration of continuity of alimentary tube & epithelial lining Provision of reliable external coverage for protection of the general

vessels and bony structures

Types of Reconstruction Multi-stage Reconstruction Single stage Reconstruction

o Improved method if reconstruction o Better pathologic analysis at surgery o More comprehensive understanding of the natural history of the

disease

SOFT TISSUE DEFECT RECONSTRUCTION

Skin grafts Rotational flaps Musculocutaneous flaps Free flaps

o COMPLICATIONS OF TREATMENT: o Anatomic o Physiologic

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o Technical o Functional

COMPLICATIONS OF RADIOTHERAPY o Dryness of mouth o Osteoradionecrosis o Taste discrepancies o Skin changes ADJUVANT THERAPY o Radiotherapy o Chemotherapy

ORAL CAVITY CANCER o Tongue & floor of the mouth considered midline structures o Importance of retromolar trigone o SCCA & minor salivary gland cancer o Tracheostomy at times needed o Skip metastases in tongue o Most common sites: o Lower lip o Tongue o Floor of the mouth

PHARYNGEAL CANCER o Difficult area in terms exposure & reconstruction o Nasopharyngeal cancer treated w/chemoradiotherapy o CT needed for complete assessment o Neck dissection performed if primary tumor is controlled

PARANASAL SINUSES o Minor salivary gland origin also common o LN metastasis not common o Extension of maxillectomy to contents of orbits

LARYNX o Different behavior depending on the level of larynx o Extension past midline increase risk of contralateral LN involvement o RT favored d/t preservation of function o Conservative forms of surgery available

CANCER OF THE LARYNX

Supraglottic o primarily radiation for small lesion o More advanced tumor – combined radiation & surgery; either total

or partial laryngiectomy

Glottic o radiation for early lesion o Partial vs. Total laryngiectomy

Subglottic o usually present in more advances stage o Total laryngiectomy w/neck dissection o Over-all 5-yr survival of pts w/ tx by surgery is 50-65%

CONNECTIVE TISSUE NEOPLASM o Soft tissue sarcomas – arise from mesodermal tissues o Painless mass o Evaluation of extent: CT or MRI o Incisional or tru-cut biopsy o Tx: surgery o LN metastases very low incidence

SALIVARY GLANDS o Production and excretion of saliva into upper aerodigestive tract

Major Salivary Glands

o Parotid – deep & superficial lobes o Contain LN o Stensen’s duct

o Submandibular – in submandibular triangle o Envelops mylohyoid muscle o Adjacent to inguinal and hypoglossal

o Sublingual – immediately beneath mucosa of floor of mouth o Intimately related to lingual artery

Pathology in the Salivary Glands

o Inflammatory conditions: o Diffuse enlargement / firmness of gland o Tenderness and erythema o Secondary to duct obstruction o Recurrence, occurs after eating o Stone present on x-ray

o Infectious disorders: o Bacterial infxn secondary to duct obstruction w/ retrograde infxn o Tx: hydration, antibiotics, drainage o Viral infxn: MUMPS o Tumors: 70%-80% in parotid, 70%-80% benign, 70%-80%

pleomorphic adenoma

o Benign Tumors: Pleomorphic adenoma – proliferation of both epithelial and

myoepithelial cells, most common o Solitary painless mass o Deep lobe tumors: parapharyngeal mass

Warthin’s tumor – papillary cystadenomal lymphomatosum o Tail of parotid o Lymphocytic infiltrate as well as cystic epithelial proliferation *Note: LN Enlargement can be mistaken for a parotid mass

o Malignant tumors: o Hard, fixed mass w/LN enlargement o Pain o Facial nerve dysfunction o Formication o Trismus o Skin involvement o Tumors:

o Mucoepidermoid carcinoma o Acinic cell carcinoma o Adenoid cystic carcinoma o Adenocarcinoma o Malignant mixed tumor o Squamous cell carcinoma

o Diagnosis: o Biopsy is rarely needed due to: risk of seeding, hemorrhage

and facial nerve injury o CT is needed for large, fixed tumor

ESSENTIALS IN PRE-OP MGMT

Determine if tumor is from salivary glands Determine if malignant or benign If malignant – determine if high grade or low grade Patient preparation Extent of surgery

TREATMENT

T1&T2, high grade

T1&T2, high grade

Any T, high grade

Level I-III

E, SP TP,SOHND,RT TP,SOHND,RT TP,SOHND,RT

*Grossly suspicious nodes, do FS

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*LEGEND -E-excision -SP-superficial parotidectomy -TP-total parotidectomy -SOHND-supraomohyoid neck dissection

*Radiotherapy – to preserve facial nerve

ISSUES REGARDING FACIAL NERVE o In the parotid, principles of en-bloc resection cannot be applied o Preserve FN if there is a plain b/w the tumor & the nerve o If grossly involved, remove w/the tumor

COMPLICATIONS OF SURGERY: o Defect caused by removal o Ear paresthesia o Facial nerve injury o Hemorrhage o Frey’s syndrome (facial sweating rather than salivation) o Treatment: o Chemotherapy: unlike other H & N tumors, chemotherapy has no

benefits in salivary gland tumors

BENIGN CONDITION OF THE HEAD AND NECK

EAR INFECTION o Acute otitis externa (swimmer’s ear)

o cause by moisture from water that initiates skin maceration and itching

o scrathing the ear may cause trauma from which infections arise o commonly caused by P. aeroginosa (alos cause by other bacteria

and fungi) o Clinical: otalgia and fever (<3 weeks) by S. pneumoniae, H

influenza, M. catarrhalis o Tx: topical neomycin/polymixin, quinolone eardrops, 2% acetic

acid o Malignant otitis externa

o Diabetic, elderly, and immunodeficient patients are susceptible

o progress to involvement of the adjacent skull base and soft tissues, meningitis, brain abscess, and death

o Tx: culture-directed therapy o Uncomplicated Otitis media

o Tx: oral AB therapy (cephalosphorin, macrolide) amox & sulfas as 1st line drugs

o Chronic Otitis media

o non healing perforation o Tx: surgical closure (tympanoplasty)

o Choleastoma

o epidermoid cyst of middle ear/mastoid o expansile and destructive to the bone o Tx: mastoidectomy

o Labyrinthitis

o inflammation of inner ear with assoc vertigo and sensorineural hearing loss

o Tx: AB and placement of myringotomy tube o Meningitis

o commonly cause by H. influenza o Tx: AB & myringotomy tube placement for complication

(abscess, otitic hydrocephalus, sigmoid sinus thrombophlebitis), mastoidectomy

o Idiopathic facial paralysis (Bell’s palsy) o considered an otologic dse o majority cause by herpes simplex but VZV can also cause it

in a condition known as Ramsay hunt syndrome

Microbiology of Common Otolaryngologic Infections

Condition Microbiology

Otitis externa and malignant otitis externa

Pseudomonas aeruginosa, fungi (Aspergillus most common)

Acute otitis media

Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis

Chronic otitis media

Above bacteria, staphylococci, other streptococci; may be polymicrobial; exact role of bacteria unclear

Acute sinusitis Viral URI, S. pneumoniae, H. influenzae, M. catarrhalis

Chronic sinusitis Above bacteria, staphylococci, other streptococci; may be polymicrobial; exact role of bacteria unclear; may represent immune response to fungi

Pharyngitis Viral, streptococci (usually pyogenes)

SINUS INFLAMMATORY DISEASE

Acute sinusitis - typically follows a viral infection - inflammation may close the sinus ostium that causes

secretion stasis, hypoxia and ciliary dysfunc - Tx: decongestant, saline, steroids

Chronic sinusitis - sometimes associated with nasal polyp (immunologic) - Dx: Nasal endoscopy>CT scan - Tx: AH & allergy immunotherapy (allergy caused), oral

steroids - SurgTx: removal of infected bone, ventilation & drainage

Fungal sinusitis - Tx: systemic steroid, surgery & nasal irrigation. Antifungal

Fungal ball - commonly caused by Aspergillus fumigatus - expulsion of fungal debris - Tx: removal & reestablish ventilation

PHARYNGEAL AND ADENOTONSILLAR DISEASE

Pharyngitis - commonly caused by S. pyogenes (cause strawberry

tongue) - atypical causes by C. diphteriae, B. pertussis, T. pallidum,

N. gonorrhea, fungi(C. albicans), EBV, CMV, HIV, HSV - may also be caused by mucositis from RT - Tx: antibacterial, antifungal, antiviral

Obstructive Adenotonsillar Hyperplasia - present w/ rhinorrhea,, voice change, dysphagia and sleep

disordered breathing - Tx: tonsillectomy and adenoidectomy

Obstructive sleep apnea (OSA) - associated w/ snoring, excessive daytime somnolence,

fatigue and frequent sleep arousal

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- Tx: tracheostomy (OSA+R heart failure), removal of the obstructing tissue

Adenotonsillar hypertrophy - Tx: surgery if it cause sleep DO

LARYNX

Recurrent respiratory papillomatosis (RRP) - caused by HPV 6 & 11 - Dx: office endoscopy - Tx:microlaryngoscopy w/ excision/laser ablation, oral cidofovir &

indole-3-carbinol - Prev: vaccination

Laryngeal granuloma - commonly found at the post. Larynx on the arythenoid mucosa - arise from reflux, voice abuse, chronic throat clearing, ET

intubation & vocal cord paralysis - Dx: fiberoptic laryngoscopy, voice analysis, laryngeal EMG, pH

probe testing - Tx: depending on the cause (e.g. voice rest for voice abuse),

surgical excision if carcinoma

Edema of the superficial lamina of the vocal cord - known as polypoid coditis, polypoid laryngitis, polypoid

degeneration of the vocal cord, reinke’s edema - arise from injury of the capillaries w/ subsequent fluid

extravasation - most px are heavy smokers - Tx: elective surgery under microlaryngoscopy to evacuate the

gelatinous matrix within the superficial lamina propria and trim excess mucosa.

Hemorrhagic vocal cord polyp - secondary to capillary rupture w/in the mucosa by shearing forces

during voice abuse - Tx: surgery using cold steel or by using the carbon dioxide laser

Cysts - *refer to Dr. Aleta’s lecture

Leukoplakia of the vocal fold - white patch on the mucosal surface, usually on the superior

surface of the true vocal cord - observed in association with inflammatory and reactive

pathologies, including polyps, nodules, cysts, granulomas, and papillomas

- Dx: laryngoscopy, excisional biopsy (growing lesion) - Tx: Antireflux therapy

Vocal cord paralysis - commonly iatrogenic in origin - secondary to malignant processes in the lungs, thoracic cavity,

skull base, or neck - DX: imaging, Flexible fiberoptic laryngoscopy - Tx: secureairway (if compromised) before vocal cord lateralization

or arytenoidectomy. Speech therapy

Vascular lesions *refer to Dr. Aleta’s lecture on Hemangioma & vascular malformation

TRAUMA OF THE HEAD AND NECK - Skin injuries may be classified as abrasions, contusions, or lacerations - bone fracture

Skin Injury Treatment

Abrasion cleansing, saline irrigation, and removal of dirt or other foreign bodies

Contusion -of-bed elevation to decrease tissue edema, application of ice, and drainage of hematoma

Laceration cleansed and irrigated, with removal of any associated dirt or foreign bodies, primary closure

Closure of trapdoor laceration

Closure of eye laceration -req. approximation of the gray line

Closure of lip laceration -req. approx of the vermillion border

Fracture

MANDIBLE

Treatment

Classical closed reduction and a 6-week period of intermaxillary fixation (IMF) with arch bars applied via circumdental wiring

Comminuted, displaced, or unfavorable fractures

open reduction and wire fixation in addition to IMF

MIDFACE FRACTURE

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Le Fort I -transversely across the alveolus, above the level of the teeth apices - the palatal vault is mobile while the nasal pyramid and orbital rims are stable (pure le fort I)

Le Fort II - extends through the nasofrontal buttress, medial wall of the orbit, across the infraorbital rim, and through the zygomaticomaxillary articulation - nasal dorsum, palate, and medial part of the infraorbital rim are mobile

Le Fort III -known as craniofacial disjunction - frontozygomaticomaxillary, frontomaxillary, and frontonasal suture lines are disrupted and the entire face is mobile from the cranium.

MANAGEMENT

Assess Entrapment confirmed by forced duction testing, where, under topical or general anesthesia, the muscular attachment is grasped with forceps and manipulated to determine passive mobility

Dx CT scan

Tx Fixation, bone grafting (if w/ significant entrapment)

TEMPORAL BONE FRACTURE - one-fifth of skull fractures

TUMORS OF THE HEAD AND NECK

Second primary tumors of the head and neck

Patients diagnosed with a head and neck cancer are predisposed to the development of a second tumor within the aerodigestive tract (14%)

Dx: direct laryngoscopy, rigid/flexible esophagoscopy, and rigid/flexible bronchoscopy known as panendoscopy. Barium swallow, esophagoscopy

TNM Staging for Oral Cavity Carcinoma

Primary tumor TX Unable to assess primary tumor T0 No evidence of primary tumor Tis Carcinoma in situ T1 Tumor is <2 cm in greatest dimension T2 Tumor >2 cm and <4 cm in greatest dimension T3 Tumor >4 cm in greatest dimension T4 (lip) Primary tumor invading cortical bone, inferior alveolar nerve,

floor of mouth, or skin of face (e.g., nose or chin) T4a (oral)

Tumor invades adjacent structures (e.g., cortical bone, into deep tongue musculature, maxillary sinus) or skin of face

T4b (oral)

Tumor invades masticator space, pterygoid plates, or skull base and/or encases the internal carotid artery

Regional lymphadenopathy NX Unable to assess regional lymph nodes N0 No evidence of regional metastasis N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in

greatest dimension N2a Metastasis in single ipsilateral lymph node, >3 cm and <6 cm N2b Metastasis in multiple ipsilateral lymph nodes, all nodes <6 cm N2c Metastasis in bilateral or contralateral lymph nodes, all nodes

<6 cm N3 Metastasis in a lymph node >6 cm in greatest dimension

Distant metastases MX Unable to assess for distant metastases M0 No distant metastases M1 Distant metastases

TMN staging (American Joint Committee on Cancer Staging Manual)

Stage 0 Tis N0 M0

Stage I T1 N0 M0

Stage II T2 N0 M0

Stage III T3 N0 M0

T1-3 N1 M0

Stage IVa T4a N0 M0

T4a N1 M0

T1-4a N2 M0

Stage IVb Any T N3 M0

T4b Any N M0

Stage IVc Any T Any N M1

UPPER AERODIGESTIVE TRACT Lip

Anatomy o transition from external skin to internal mucous membrane

that occurs at the vermilion border. o -underlying musculature of the orbicularis oris, innervated by

the facial nerve, creates a circumferential ring that allows the mouth to have a sphincter-like function.

Lip Malignancies o lower lip (88 to 98%)>upper lip (2 to 7%)>oral commissure

(1%) o predominantly squamous cell carcinoma> other tumors,

such as keratoacanthoma, verrucous carcinoma, basal cell carcinoma, malignant melanoma, minor salivary gland malignancies, and tumors of mesenchymal origin

o Basal cell carcinoma upper lip > lower

Lip cancer

Lymph node metastasis occurs in fewer than 10% of patients with lip cancer.

The primary echelon of nodes at risk is in the submandibular and submental regions

Tx: Small primary lesions may be treated with

surgery or radiation If w/ evident neck metastasis, neck dissection is

indicated. Postoperative radiation to the primary site and

neck for patients with close or positive margins, lymph node metastases, or perineural invasion.

Lip carcinoma surgical resection techniques

Karapandzic Labioplasty

Karapandzic flap uses a sensate, neuromuscular flap that includes the remaining orbicularis oris muscle, conserving its blood supply from branches of the labial artery

Abbe-Estlander

The lip-switch (Abbe-Estlander) flap or a stair-step advancement technique can be used to repair defects of either the upper or lower lip.

Note: -Microstoma (small mouth) is a potential complication with these types of lip

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reconstruction. -Webster or Bernard types of repair using lateral nasolabial flaps with buccal advancement used in large defects

Oral Cavity o The majority of tumors in the oral cavity are squamous cell carcinomas

(>90%)

Oral Tongue o Anatomy

o is a muscular structure with overlying nonkeratinizing squamous epithelium

o posterior limit of the oral tongue is the circumvallate papillae, whereas its ventral portion is contiguous with the anterior floor of mouth subsites including the lateral tongue, the tip the ventral tongue, and the posterior tongue.

o Tongue tumor Tx

o (T1-T2) primary tumors treatment use wide local excision with either primary closure or healing by secondary intention

o carbon dioxide laser may be used for excision of early tongue cancers or for ablation of premalignant lesions

o partial glossectomy removes portion of the lateral oral tongue, permitting effective postoperative function

o treatment of the regional lymphatics via modified radical or selective neck dissection

o Complication

o Removal of a significant portion of the tongue results in hypomobility and hypesthesia that impairs speech and swallowing function

o Note: Depth of invasion of the primary tumor can direct the

need for elective lymph node dissection with early stage lesions.

Floor of the Mouth o Anatomy

o mucosally covered semilunar area that extends from the anterior tonsillar pillar posteriorly to the frenulum anteriorly, and from the inner surface of the mandible to the ventral surface of the oral tongue

o ostia of the submaxillary and sublingual glands are contained in the anterior floor of mouth

o The muscular floor composed genioglossus, mylohyoid, and hyoglossus muscles (serve as a barrier to spread of disease)

o Note: invasion into these muscles can lead to tongue hypomobility and poor articulation. Tumor may spread along the salivary ducts, resulting to direct extension into the sublingual space

o Dx: CT scan, MRI, and Panorex radiography

o TX: Partial glossectomy in conjunction with resection of the floor of mouth (deep invasion), resection of involved gland, neck dissection (nodal involvement)

Alveola/gingival o treatment of lesions of the alveolar mucosa frequently require resection

of the underlying bone (mandibulectomy)

Retromolar Trigone

represented by tissue posterior to the posterior inferior alveolar ridge and ascends over the inner surface of the ramus of the mandible.

Clinically presents trismus indicating the muscle of mastication involvement and potential spread to the skull base

Tx: marginal or segmental mandibulectomy with a soft-tissue and/or osseous reconstruction, neck dissection (nodal involvement)

Buccal Mucosa

includes all of the mucosal lining from the inner surface of the lips to the line of attachment of mucosa of the alveolar ridges and pterygomandibular raphe

etiologies of malignancies in the buccal area include lichen planus, chronic dental trauma, and the use of tobacco and alcohol. -tumors in this area have a propensity to spread locally and to metastasize to regional lymphatic

Tx: resection (+RT in advance tumor)

Palate

semilunar area between the upper alveolar ridge and the mucous membrane covering the palatine process of the maxillary palatine bones.

Inflammatory lesions of the palate o Necrotizing sialometaplasia -appears on the palate as a

butterfly shaped ulcer and mimics carcinoma o Torus palatini -are exostoses or bony outgrowths of the

midline palate and maxillary bone and do not specifically require surgical treatment unless symptomatic

Cancer of the Palate o Squamous cell carcinoma and minor salivary gland tumors

are the most common malignancies of the palate o Other malignancies include adenoid cystic carcinoma,

mucoepidermoid carcinoma, adenocarcinoma, polymorphous low-grade adenocarcinoma, mucosal melanoma & KS

Tx-mucosal excision (superficial lesions), excision (+adj RT for advance), maxillectomy (bone involvement)

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Oropharynx o Anatomy

o from the soft palate to the superior surface of the hyoid bone (or floor of the vallecula) and includes the base of tongue, the inferior surface of the soft palate and uvula, the anterior and posterior tonsillar pillars, the glossotonsillar sulci, the pharyngeal tonsils, and the lateral and posterior pharyngeal walls.

o majority of tumors in this region is squamous cell carcinoma o Oropharyngeal cancer

o presents as an ulcerated, exophytic mass with tumor fetor o muffled or "hot potato" voice, dysphagia and weight loss are

common symptoms. o otalgia, mediated by the tympanic branches of CN IX and

CN X, is a common complaint o Trismus indicate advanced disease involving the pterygoid

muscle o Management: surgery alone, primary radiation alone,

surgery with postoperative radiation, and combined chemotherapy with radiation therapy

o Tx: composite resections (classic jaw-neck resection or "commando" procedure), glossectomy (tongue involvement)

Hypopharynx and Cervical Esophagus

o from the vallecula to the lower border of the cricoid cartilage and includes the pyriform sinuses, the lateral and posterior pharyngeal walls, and the postcricoid region.

Malignancies o Squamous cancers of the hypopharynx frequently present at

an advanced stage o Dx: flexible fiberoptic laryngoscopy o Tx: resection + postop RT, partial laryngopharyngectomy

(larynx preserving procedure), supraglottic laryngectomy or supracricoid hemilaryngopharyngectomy, bilateral neck dissection (nodal involvement), total esophagectomy + laryngectomy+CT +RT (esophageal cancer w/ skip lesions)

Laryngeal Preservation Techniques

o includes endoscopic vocal cord stripping, microflap dissection, partial cordectomy, and CO2 ablation

Speech and Swallowing Rehabilitation

Speech Swallowing

Esophageal speech (20% success)

- produced by actively swallowing and releasing air from the esophagus resulting in vibrations of the esophageal walls and pharynx.

Fistula between the trachea and esophagus.

Speaking valve (80%) - known as a tracheo-esophageal puncture valve (TEP).

Electrolarynx

- patient is instructed to do various swallowing techniques and evaluation for the appropriate diet consistency allow a patient to initiate oral intake of nutrition while minimizing the risk of aspirating - Flexible fiberoptic laryngoscopy can be performed transnasally and provides valuable information to assist in the assessment of dysphagia - oral intake of various consistencies of liquids and solids can be observed with endoscopic assessment and allow for the visualization of laryngeal penetrance.

- creates vibratory sound waves when held against the neck or cheek - mechanical quality of the sound

- modified barium swallow, with analysis of the various phases of swallowing

Unknown Primary Tumors o patients present with cervical nodal metastases without clinical or

radiologic evidence of an upper aerodigestive tract primary tumor o Dx: examination under anesthesia with directed tissue biopsies.

Ipsilateral tonsillectomy, direct laryngoscopy with base of tongue and piriform biopsies, examination of the nasopharynx, and bimanual examination

o Tx: empiric treatment of the mucosal sources of the upper aerodigestive tract at risk and the cervical lymphatics with radiation therapy is performed, postradiation neck dissection(nodal involvement)

Nose

Malignant tumors of the sinuses are predominantly squamous cell carcinomas

Dx: headlight and nasal speculum or nasal endoscope (for tumors)

Tx: resection+ RT (pospop for SCC), CTRTsurg (for rhabdomyosarcoma), sphenoethmoidectomy or medial maxillectomy (for ethmoid sinus tumor)

Nasopharynx

o extends in a plane superior to the hard palate from the choana, to the posterior nasal cavity, to the posterior pharyngeal wall including the fossa of Rosenmüller, torus tubarius and site of the adenoid pad

Malignancies o usually of squamous cell origin and range from

lymphoepithelioma to well-differentiated carcinoma o Dx: flexible or rigid fiberoptic endoscope, CT & MRI o Tx: RT+CT (undif. Nasophayngeal ca & SCC)

Ear and Temporal Bone o most common site is the EAC and the most common histology is

squamous cell carcinoma o Dx: temporal CT scan, MRI, angiography o Tx: en bloc resection+ RT, Mohs microsurgery with frozen section

margin control (ext ear ca) Neck

Pattern of Lymph Node Metastasis

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Level Description

I the submental and submandibular nodes

Ia the submental nodes; medial to the anterior belly of the digastric muscle bilaterally, symphysis of mandible superiorly, and hyoid inferiorly

Ib the submandibular nodes and gland; posterior to the anterior belly of digastric, anterior to the posterior belly of digastric and inferior to the body of the mandible

II upper jugular chain nodes

IIa jugulodigastric nodes; deep to sternocleidomastoid (SCM) muscle, anterior to the posterior border of the muscle, posterior to the posterior aspect of the posterior belly of digastric, superior to the level of the hyoid, inferior to spinal accessory nerve (CN XI)

IIb submuscular recess; superior to spinal accessory nerve to the level of the skull base

III middle jugular chain nodes; inferior to the hyoid, superior to the level of the hyoid, deep to SCM from posterior border of the muscle to the strap muscles medially

IV lower jugular chain nodes; inferior to the level of the cricoid, superior to the clavicle, deep to SCM from posterior border of the muscle to the strap muscles medially

V posterior triangle nodes

Va lateral to the posterior aspect of the SCM, inferior and medial to splenius capitis and trapezius, superior to the spinal accessory nerve

Vb lateral to the posterior aspect of SCM, medial to trapezius, inferior to the spinal accessory nerve, superior to the clavicle

VI anterior compartment nodes; inferior to the hyoid, superior to suprasternal notch, medial to the lateral extent of the strap muscles bilaterally

VII paratracheal nodes; inferior to the suprasternal notch in the upper mediastinum

Parapharyngeal Space Masses o potential space, shaped like an inverted pyramid spanning the skull

base to the hyoid o divided into prestyloid (containing parotid, fat, and lymph nodes) and

poststyloid (cranial nerves IX to XII, the carotid space contents, cervical sympathetic chain, fat and lymph nodes) compartments

o Note: Surgical access to these tumors may require mandibulotomy via

a transoral approach, lateral cervical approach, or a combination of the two

Deep Neck Facial Planes - determine the pathway of spread of an infection

Deep Neck Facial Planes

Three Layers of the Deep Cervical Fascia

Investing (superficial deep) - forms a cone around the neck and spans from skull

base and mandible to the clavicle and manubrium - surrounds the SCMs and covers the anterior and

posterior triangles of the neck Pretracheal - found within the anterior compartment, deep to the

strap muscles and surrounds the thyroid gland, trachea, and esophagus

- blends laterally to the carotid sheath Note: Infections in this region may track along the trachea or esophagus into the mediastinum Prevertebral fascias - extends from the skull base to the thoracic vertebra and

covers the prevertebral musculature and cervical spine Note. Infections communicating anteriorly through the prevertebral fascia would enter the retropharyngeal space thus complication arise because of its proximity to the buccopharyngeal fascia & extends from the skull base to the mediastinum

RECONSTRUCTION IN HEAD AND NECK SURGERY

Skin grafts Local flaps Regional flaps Free tissue transfer

TRACHEOSTOMY

for management of patients requiring prolonged intubation, assisted ventilation, and pulmonary toilet, and in neurologic deficits that impair protective airway reflexes

Its use in head and neck surgery is often for the temporary management of the airway in the perioperative period

also used to secure ventilation for surgical complication that obstructs airway

Complications

pneumothorax or pneumomediastinum, recurrent laryngeal nerve injury, formation of granulation tissue, tracheal stenosis, wound infection with large-vessel erosion, and failure to close after decannulation

Note: Cricothyroidotomy as an alternative to tracheostomy for patients who require prolonged intubation but risk include higher incidence of vocal cord dysfunction and subglottic stenosis