Escolar Documentos
Profissional Documentos
Cultura Documentos
Oral cavity
Pharynx
Larynx
Nasal cavity/ paranasal sinus
STAGING:
Recommended at initial evaluation of all patients with primary cancers of the upper aerodigestive tract
May involve:
o
Direct laryngoscopy
o
Rigid/ flexible esophagoscopy
o
Rigid/ flexible bronghoscopy panednoscopy- some surgeons argue against the use of bronchoscopy because of the low yield of the
examination in asymptomatic patients with a normal CXR
o
Barium swallow- used instead of esophagoscopy as a preoperative evaluation
Primary Tumor
TX
Unable to assess primary tumor
T0
Tis
Carcinoma in situ
T1
T2
T3
T4
(lip)
T4a
(oral)
T4b
(oral)
Regional Lymphadenopathy
NX
N0
N1
N2a
N2b
N2c
N3
MX
M0
M1
Distant Metastases
I. ORAL CAVITY
-regional spread: lymphatics of the submandibular and upper jugular region (levels 1,2 and 3)
- >90% SCC
1. Lips
Anatomy
Epidemiology
Risk factors
Clinical Findings
Negative prognostic
factors
Prognosis
Treatment
Surgery or radiation
Surgical excision with histologic confirmation of tumor-free margins is the preferred modality
b. presence of clinically evident metastasis
Burows triangle
Karapandzic flap
2. Oral Tongue
Anatomy
Epidemiology
Treatment
3. Retromolar trigone
Retromolar trigone- tissue posterior to the posterior inferior alveolar ridge and ascends over the inner surface of the ramus of the mandible
Early involvement of the mandible is common d/t lack of intervening soft tissue in the region.
Trismus- involvement of the muscles of mastication and may indicate spread to the skull base
4. Alveolar ridges
Alveolar mucosa- overlies the bone of the mandible and maxilla
from the gingivobuccal sulcus to the mucosa of the floor of mouth and hard palate
posterior limits: pterygopalatine arch and the ascending portion of the ramus of the mandible
tx of lesions requires resection of the underlying bone (d/t the tight attachment of the alveolar mucosa to the mandibular and maxillary periosteum)
Marginal resection of the mandible- for tumors of the alveolar surface that present with minimal bone invasion (anterior mandibulotomy)
Segmental mandibulectomy- for extensive tumors that invade into the medullary cavity
Preoperative radiographic evaluation of the mandible determine the type of bone resection required
Panorex views (demonstrate gross cortical invasion)
MRI best modality for demonstrating invasion of the medullary cavity of the mandible
Sectional CT scanning with bone settings optimum modality for imaging subtle cortical invasion
5. Floor of mouth
-
Mucosally covered semilunar area that extends from anterior tonsillar pillar posteriorly to the frenulum anteriorly and from the inner surface of the
mandible to the ventral surface of the oral tongue.
Genioglossus, mylohyoid and hyoglossus muscles comprises the muscular floor of mouth and prevents the spread of disease, with invasion results
decrease tongue mobility and poor articulation
Invasion to the salivary ducts can lead to direct extension into the sublingual space.
Anterior or lateral extension to the mandibular periosteum is of primary importance in the preoperative assessment. MRI,CT and Panorex Radiography
helpful in determining invasion
Bimanual palpation to assess adherence or fixation to adjacent bone is essential, its absence indicates that mandible sparing procedure is feasible.
Resection of large tumor of the floor of mouth may require a lip-splitting incision and immediate reconstruction. Its goal is to obtain watertight closure and
avoid tongue tethering.
6. Buccal mucosa
Buccal mucosa- 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:
lichen planus
chronic dental trauma
habitual use of tobacco and alcohol
Lymphatic drainage:
Facial
Submandibular nodes (level I)
7. Hard palate
Hard palate- semilunar area between the upper alveolar ridge and the mucous membrane covering the palatine process of the maxillary palatine bones
extends from the inner surface of the superior alveolar ridge to the posterior edge of the palatine bone
Most squamous cell carcinomas caused by habitual tobacco and alcohol use
chronic irritation from ill-fitting dentures also may play a causal role
treated surgically
advanced staged tumors- adjuvant radiation
Squamous cell carcinoma and minor salivary gland tumors most common malignancies of the palate
Kaposis sarcoma of the palate- most common intraoral site for this tumor
Malignancies may extend along the greater palatine nerve making biopsy important for identifying neurotropic spread
II. Pharynx
Anatomy
Metastasis
Oropharynx
- extends from soft palate to the supereior
surface of the hyoid bone
- includes: base of the tongue, inferior
surface of the soft palate and uvula, anterior
and posterior tonsillar pillars, glossotonisillar
sulci, tonsils and lateral and posterior
pharyngeal walls
Direct extension: spread into parapharyngeal
space; ascending ramus of mandible can be
involved when tumors invde the medial
pterygoid muscle
Regional metastasis: high (ipsilateral or
bilateral nontender cervical
lymphadenopathy is a common presenting
sign)
Epidemiology
Diagnosis
Clinical Findings
Treatment
Nasopharynx
- extends in a plane superior to the hard
palate from the choana to the posterior nasal
cavity to the posterior pharyngeal wall
- includes: the Rosenmuller, the Eustachian
orifices, and the site of the adenoid pad
- neck mass
- muffled or hoarse voice
- referred oatalgia
- dysphagia
- weight loss
- a common symptom is dysphagia, starting
with solids and progressing to liquids, leaving
patients malnourished at the time of
presentation
Standard: chemoradiation
III. Larynx
- Laryngeal carcinoma is a diagnosis typically entertained in individuals with prominent smoking histories and the complaint of a change in vocal quality
- borders span from the epiglottis superiorly to the cricoids inferirorly
- Lateral limits are the aryepiglottic folds
Anatomy
Histology
Minor salivary glands
Lymphatic drainage
Lymphatic spread
Clinical Findings
Diagnosis
Treatment
Supraglottic
Glottis
Subglottis
- includes the epiglottis, aryepiglottic
- includes: true vocal cords, anterior and
- inferior surface of the glottis to the lower
folds, arytenoids, and ventricular bands
posterior commissures
margin of the cricoids cartilage
(false vocal folds)
- inferior border: ventricles of morgani
PCCE that covers the false vocal cords
Nonkeratinized stratified squamous
PCCE
Present
Absent
Present
Pierce the thyroid membrane to the
Prelaryngeal node (delphian node), paratracheal LN, and deep cervical LN
subdigastric and superior jubgular nodes
Common (30-50%)
Limited (1-4%)
Common (40%)
- chronic sore throat, dysphonia (hot
- hoarseness is an early symptom (in contrast
- relatively uncommon and typically present
potato voice), dysphagia or neck mass
to supraglottic)
with compromise vocal cord paralysis
secondary to regional metastasis
- airway obstruction is usually a late
(usually unilateral) and or/or airway
- may cause vocal cord fixation by inferior
symptom and is the result of tumor bulk or
extension or by direct invasion of the
impaired vocal cord mobility
-40% present with regional adenopathy and
cricoarytenoid joint
special attention must be directed to the
- referred otalgia or odynophagia is
treatment of paratracheal lymph nodes
encountered with advanced supraglottic
cancers
Staging classification
clinical staging requires: flexible fiberoptic endoscopy and direct microlaryngoscopy or bronchoscopy
key areas to note for extension: the vallecula, base of tongue, ventricle, arytenoids, and anterior commisure
Severe dysplasia with carcinoma in situ
- total laryngectomy
MAJOR
Parotid
MINOR
Anatomy
Malignancy
Epidemiology
Diagnosis
o
o
Types
MRI
most sensitive study to determine soft-tissue extension and involvement of adjacent structures
FNA
provide an accurate preoperative diagnosis in 70 to 80% of cases
help the operative surgeon with treatment planning and patient counseling
surgical excision
confirms the final histopathologic diagnosis
BENIGN
Epithelial
- pleomorphic adenoma (80%)
- monomorphic adenoma
- Warthins tumor
- oncocytoma
- sebaceous neoplasm
Nonepithelial
- hemangioma
- neutral sheath tumor
- lipoma
MALIGNANT
a. Mucoepidermoid
- Low- grade (predominantly mucin-secreting)
- High- grade (perdominanlty epidermoid)
- most common malignant epithelial neoplasm of salivary gland
b. Adenoid cystic carcinoma
- has pa propensity for neural invasion
- second most common malignancy in adults
- skip lesion along nerves are common and lead to treatment failure
- high incidence of distant metastasis, but display indolent growth
- poor survival rate
**the most common malignancies in the pediatric population are
the mucoepidermoid and acinic cell carcinoma.
** for minor salivary glands: the most common are adenoid cystic,
mucoepidermoid and low grade polymorphous adenocarcinoma
Treatment
o
o
o
o
o
Radical resection
- tumors that invade the mandible, tongue, or floor of mouth
Diagnostic evaluation of a neck mass requires a planned approach that does not compromise the effectiveness of future treatment options.
o
Complete history
o
Full head and neck exam
In children, most neck masses are INFLAMMATORY or CONGENITAL
In adults, mass >2cm has a >80% probability of being malignant
Fine-needle aspiration can provide valuable info for early Tx planning
Imaging (CT or MRI) evaluate the anatomic relationships of the mass and the surrounding anatomy of the neck.
Lesions may be benign or may be metastases from distant sites evaluate potential primary sites
Open biopsy may be necessary if findings of FNA and imaging are inconclusive
Hyoid inferiorly
Medial to trapezius
Lymphatic malformations
A. lymphangiomas
B. cystic hygromas
o
mobile, fluid-filled masses
o
removal is challenging due to their predisposition to track extensively into the surrounding soft tissues
o
newborns and infants require tracheostomy
DEEP-NECK FASCIAL PLANES
provide boundaries
3 LAYERS
1. superficial layer of the deep cervical fascia
forms a cone around the neck and spans from skull base and mandible to the clavicle and manubrium
surrounds the SCM muscle and covers the anterior and posterior triangles of the neck.
2. pretracheal fascia
within the anterior compartment, deep to the strap muscles and surrounds the thyroid gland, trachea, and esophagus
infections in this region may track along the trachea or esophagus into the mediastinum.
3. prevertebral fascia
from the skull base to the thoracic vertebra and covers the prevertebral musculature and cervical spine
ionfectious extension into this space is complicated because this region extends from the skull base to the mediastinum
For patients with advanced neck disease (N2a or greater) or with persistent lymphadenopathy after radiation
Follow up Care
o
Aimed at monitoring recurrence and side effects of therapy.
o
Worsening of dyspahgia- maybe presenting symptom of parhygeal stricture
o
Patient may also develop hypothryroidism years after treatment
Post treatment
1st year
2nd year
3rd year
4th year
5th year and after
Follow-up Period
Every 3-4 mo
Every 2-3 mo
Every 3-6 mo
Every 4-6 mo
Every 12 mo