ENT Head and Neck Tumours
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Definition and Types of Sjogren's disease?
Autoimmune lymphocytic infiltration causing glandular hypofunction causing dry eye and mouth. more in 4th-6th
decade. 90% female
- Primary: limited to endocrine glands
- Secondary: associated with another autoimmune disease
Bacterial causes of Vincent's angina?
tonsillar abscess due to Fusiformis fusiformis, and Borrelia Vincenti
Cause of Ludwig angina?
submandibular abscess due to strep viridans, and bacteroids
subsites of hypopharynx?
- pyriform fossa
- posterior pharyngeal wall (till cricoarythenoid joint)
subsites of supraglottic?
- suprahyoid epiglottis ( lingual, laryngeal)
- infrahyoid epiglottis
- false cords
- aryepiglottic folds
Triangle of Ho in neck? ( supraclavicular)
- medial end of clavicle
- lateral end of clavicle
- point where shoulder meets the neck
What is the rate of synchronous tumor in h&n Ca?
Incidence, Age and gender issues regarding NPC?
Worldwide in 100.000. Very common in China/Hong Kong.
The age-specific incidence for both genders begins in th esecond decade, rises to a peak in the fifth decade and declines thereafter. The incidence is two to four times higher in men than in women.
Incidence of sinonasal cancer?
- 3.5 in 100.000.
- more common in Japan and Nigeria.
occupations related to sinunasal cancer?
- Leather workers, furniture manufacture and repair workers, and those exposed to cutting Oils have an increased risk of SNC.
- Nickel workers, chrome pigment manufacturers, furnace men and coal miners have asignificant increased risk of SNC.
- Wood dust (adenoCa by hardwoods but also SCC by softwoods).
Is there any correlation between smoking and sinunasal cancer?
No, but chronic sinusitis may have risk of SNC 1-2% per year.
Common subsites of involvement in oral ca?
oral tongue (33 percent), the floor of the mouth (28 percent), palate (12 percent), tonsil (10percent), other pharynx (10 percent), retromolar trigone(4 percent) and buccal mucosa (3 percent).
Occupation related issues in oral ca?
textile industry, especially in carpet installers due to the use of formaldehyde, and also in those involved in fossil fuel, semiconductor manufacture and heavy machinists.
Risk factors of oral ca?
- occupations related to formaadehyde or fossil fuel
- Infection with HPV 16
- Oral cavity hygiene
- Dietary deficiency (Vit A, C, E, iron)
Inicidence of Larynx Ca?
- 1.7% of all cancers
- 25% of all H&N cancers
- more in middle age men
Risk factors of larynx ca?
- Occupational: dust, gas, Asbestos, wood dust, Cement dust, tar
- Dietary deficiency of Vit A,C
- Viral: HPV 16,18
Aims of the TNM staging?
- to aid the clinician in the planning of treatment
- to give some indication of prognosis
- to assist in evaluation of the results of treatment
- to facilitate the exchange of information between treatment centres
- to contribute to the continuing investigation of human cancer
Stage grouping in H&N ca?
Boundaries of oropharynx?
- the portion of pharynx extending from the plane of the superior surface of the soft palate to the superior surface of hyoid bone.
- Anterior border is anterior tonsilar pillars.
- • anterior subsites (glossoepiglottic area);
- • base of tongue (posterior to the vallate papillae or posterior third);
- • vallecula;
- • lateral subsites;
- • lateral wall;
- • tonsil;
- • tonsillar fossa;
- • tonsillar pillar;
- • posterior wall;
- • superior subsites;
- • inferior surface of soft palate;
- • uvula.
Boundaries of nasopharynx?
The nasopharynx begins anteriorly at the posterior choana and extends along the plane of the airway to the level of the free border of the soft palate.
Boundaries of hypopharynx?
superior border of the hyoid bone (or floor of the vallecula) to the plane corresponding to the lower border of the cricoid cartilage.
Subsites of hypopharynx?
- • Postcricoid area (pharyngo-oesophageal junction)extends from the level of the arylenoid cartilages andconnecting folds to the inferior border of the cricoidcartilage, thus forming the anterior wall of thehypopharynx.
- • Piriform sinus extends from the pharyngoepiglotticfold to the upper end of the oesophagus. It isbounded laterally by the thyroid cartilage andmedially by the hypopharyngeal surface of thearyepiglottic fold and the arylenoid and cricoidcartilages.
- • Posterior pharyngeal wall extends from the superiorlevel of the hyoid bone (or floor of the vallecula) tothe level of the inferior border of the cricoid cartilageand from the apex of one pyriform sinus to theother.
Anatomical sites and subsites of larynx?
- • supraglottis:
- suprahyoid epiglottis (including tip. lingual (anterior), and laryngeal surfaces);
- aryepiglottic fold, laryngeal aspect;
- infrahyoid epiglottis;
- ventricular bands (false cords);
- • glottis:
- vocal cords;
- anterior commissure;
- posterior commissure;
- • subglottis
What are the most hazardous carcinogens for paranasal sinuses?
- Nickel: increases the risk of SCC 250 times.
- Hard wood increases the risk of adenoCa up to 70 times.(ethmoid)
- African Mahogany is the most dangerous.
- Soft wood increases the risk of SCC.
- Plycyclic hydrocarbons
What is the lymphatic drainage of nose and paranasal sinuses?
Two lymphatic pathways have been described, the anterior and posterior pathways. The lymphatics of the anteroinferior part of the nasal cavity and skin of the nasal vestibule drain via the anterior pathway to the facial, parotid and submandibular lymph nodes - the first eschelon nodes. These nodes then drain into the upper deep cervical chain. The remainder of the nose and the paranasal sinuses drain through the posterior pathway which runs anterior to the Eustachian tube to first eschelon nodes - the retropharyngeal lymph nodes, from where they drain to the upper deep cervical chain.
Which paranasal sinus tumour spreads more?
maxillary sinus tumours are the most common (55 percent) followed by the nasal cavity (35 percent), ethmoid sinuses (9 percent) and rarely frontal and sphenoid sinuses (1 percent).
Which nodes are more involved with SNC (sinonasal cancer)?
- Bilaterla if tumor near midline
Pathological types of SNC?
- SCC (most common, in old male, also from transformation of IP)
- AdenoCa (9%, slow growth, rare mets)
- Adenoid cystic Ca (slow growth, perneural spread)
- Olfactory neuroblastoma (20 y female)
Presentation of SNC?
- nasal blockage, stuffiness, bleed
- facial pain
- loosening the premolar and molar teeth
- ill-fit dentures
- buccal/ palate ulcer
- proptosis, diplopia
- cheek swelling
Surgery for maxillary tumours?
- -Lateral rhinotomy
- -Midfacial degloving
- -Anterior craniofacial resections:
- -- Type 1: transorbital
- --Type 2: wndow craniotomy
- --craniofacial resection
- -Lateral craniofacial resection
- -Orbital exenteration
Definition of JNA?
uncommon, benign and extremely vascular tumour that arises in the tissues within the sphenopalatine foramen of young male.
Radkowski classification for JNA?
- Ia: Limitedto the nose and nasopharyngeal area
- Ib: Extensioninto one or more sinuses
- IIa: Minimalextension into pterygopalatine fossa
- IIb: Occupation of the pterygopalatine fossa without orbital erosion
- IIc: Infratempora lfossa extension without cheek or pterygoid plate involvement
- IIIa: Erosion of the skull base (middle cranial fossa or pterygoids)
- IIIb: Erosion of the skull base with intracranial extension with or without cavernous sinus involvement.
Preoperative chemotherapy for advanced JNA?
- Flutamide (can shrink up to 7%)
Aetiology of NPC?
- Genetic factors: HLA A2, A33,B46, B58, Cwl and DR3
- EBV: There are EBV receptors on human pharyngeal epithelia
- Environmental carcinogens: formaldehyde, eating salted fish in childhood,
Serlogic tests for NPC?
IgA against viral capsid antigen (VCA) and early antigen (EA).The IgA anti-VCA appears to be more sensitive but less specific than IgA anti-EA.
What is the action of T cells which infiltrate NPC tumour? Is it good for tumour control?
No, as they seem to protect the NPC cells from the body's immunosurveillance.
Types of NPC (WHO):
- Type I: Squamous cell carcinoma (keratinizing):
- - well differentiated;
- - moderately differentiated;
- - poorly differentiated.
- Type II: Nonkeratinizing carcinoma.
- Type III: Undifferentiated carcinoma.
Which type of NPC is more common in endemic areas:
Type II: nonkeratinizing carcinoma
What is the commonest complaint of NPC?
- upper neck swelling (50%)
- Overall, 75 percent of all patients have palpable cervical lymphadenopathy at diagnosis.
Main symptoms of NPC?
- Cervical neck mass
- Nasal symptoms: blood stained nasal discharge, obstruction, PND, epistaxis
- Aural symptoms: deafness, tinnitus, otalgia
- Neurological: Headache, CN V & VI involvement
Differential diagnoses of NPC?
- sinonasal undifferentiated carcinoma
- amelanotic melanoma
What's the name of the incision for maxillary swing?
Prognosis of NPC?
- Mortality rate: 13.7 men, 2.2 for women (Hong Kong)
- Average 5 year survival: stage I: 90%, stage II: 80%, Stage III: 50%, Stage IVA-B: 30%. stage IVC: 6 months.
Poor prognosis for NPC?
- old age
- CN palsy
- level and fixity of lymph nodes
Name of salivary gland ducts?
- Parotid: stensen
- Submandibular: Warton
- Sublingual: Rivinus
What is the commonest salivary gland tumour?
Pleomorphic adenoma is the commonest turnour found at any site and outnurnbers all the other turnours in the major glands.
Whats the possible aetiology of pleomorphic adenoma?
Indications for CT or MRI in salivary gland assessment?
- Masses confined to the deep lobe of the parotid gland
- Tumours with involvement of both the deep and superficial lobes of the parotid gland (dumb-bell tumours)
- Parotid tumours presenting with facial weakness, other neural deficit or indication of malignancy
- Congenital parotid masses
- Submandibulargland tumours with neural deficit or fixation to the mandible
- Recurrent disease
- Tumours of the palate with suspected involvement of the nose or maxillary antra
- Any tumour with clinically ill-defined margins
In minor salivary glands, where are the most common spots for pleomorphic adenoma?
- retromolar fossa
Why parotidectomy ( and not just tumor resection) must be done for pleomorphic adenoma?
because the tumour capsule is absent in some parts, and focal infiltration of the capsule is common. Tumour itself is very fragile and can burst easily at operation.
Which cells are pleomorphic adenoma originated from?
derived from intercalated duct and myoepithelial cells which differentiate into epithelial and connective tissue structures.
What is a sign of malignant transformation in pleomorphic adenoma?
High cellularity with mitotic activity, particularly if associated with increased vascularity and areas of necrosis.
What are the other names for warthin's tumour?
- papillary cystadenoma lymphomatosum
Warthin's tumour in Brief:
- Most common monomorphic adenoma.
- Second most common (14%) of salivary gland neoplasms
- From ectopic salivary gland ducts within intra or paraparotid lymph nodes of parotid gland.
- 7th decade, m=1.5f ( used be considered 10 times more in male), uncommon in black.
- Soft, painless swellingat the lower pole of parotid.
- asoociated with a second tumour ( Pleo or warthin, synchronous, metachronous, ipsilt or contralat)
Why Warthin's tumour is not seen other than parotid?
Because it is originated from ectopic salivary cells in lymphoid tissue and other salivary glands don't have lymphoid tissue.
what is the most common salivary gland tumour?
what is the most common malignant salivary tumour?
What is Frey's syndrome?
- Gustatory sweating or flushing (Frey's syndrome) is a socially embarrassing complication of parotidectomy. It develops in nearly all patients following surgery to some degree. The frequency of this complication is sufficient to warrant preoperative explanation together with the reassurance.
- Tx: simple preventive measures such as the application of an anti-perspirant or local, subdermal injections of botulinum toxin.
What is the ultimate outcome of adenoid cystic ca of salivary gland?
it will inevitably potentially recur and kill the patient.
Predisposing factors for malignant salivary ca?
- Race (Canadian inuits)
- Polyunsaturated fatty acids
Main immunohistochemical markers of salivary gland malignancy?
- PCNA immunoreactivity is significantly increased in malignant salivary disease compared with benign disease.
- Ki-67 is a useful prognostic marker inadenoid cystic carcinoma.
- Cytokeratin 14, usually a marker for SCC,is also found in the myoepithelial component of salivary tumours.
- Fibroblast growth factor 1 and 2 and fibroblast growth factor receptor 1 are overexpressed in human salivary malignancy.
Histological types of salivary Ca?
• acinic cell carcinoma;• mucoepidermoid carcinoma;• adenoid cystic carcinoma;• polymorphous low-grade adenocarcinoma;• papillary cystadenocarcinoma;• mucinous adenocarcinoma;• adenocarcinoma;• carcinoma ex pleomorphic adenoma;• malignant mixed tumour;• squamous cell carcinoma;• undifferentiated carcinoma.
Acinic cell ca in brief:
- low grade, but aggressive
- high chance of being bilateral
- cystic appearance
- DD: thyroid ca, renal cell ca.
- Tx: Total conservative parotidectomy and ND +- RT
Mucoepidermoid carcinoma in brief:
- The most common major salivary gland malignancy (1/3)
- The most common cancer of parotid
- --painless mass in low grade
- --pain/swelling/facial palsy/cervical mets in high grade
- Tx: superficial parotidectomy with facial nerve preservation, if possible, is recommended, although a much more radical excisionis necessary for patients with large and/or high-grade lesions.
Adenoid cystic ca in brief:
- most commonly happens in minor salivary glands, oral cavity or hard palate.
- Subtypes: cribrifom, tubular, solid (prognosis drop relatively)
- -insidious growth over many years.
- -tendency for local recurrence and distant metastasis despite aggressive therapy at the primary site.
- -Sometimes severe pain due to peripheral nerve invasion,
- -facial nerve palsy may be evident.
- Ix: MRI H&N, CT lungs/liver, isotope bone scan
- Tx: Radical surgery +RT (ND not required)
Where is the location of primary Ca in metastatic salivary malignancies?
- Almost all metastases to the salivary glands arise from the skin of the head and neck (especially pinna) and involve the parotid lymph nodes.
- Tx: total parotidectomy + nerve dissection in pinna malignancy
What is the expected nature of a submandibular gland tumour?
- a tumour of the submandibulargland is twice as likely to be benign as it is malignant.
- 40 percent of submandibular tumours are malignant, adenoid cystic carcinoma (43 percent) and mucoepidermoid carcinoma and adenocarcinoma accounting for 17 and 11 percent.
Treatment option for submandibular gland malignancy?
Surgery + SOH ND
Poor prognosis of a salivary malignancy?
- • pain;
- • nerve palsy;
- • skin invasion;
- • neck nodes.
General modality of treatment for salivary malignancies?
- Surgical ablation + post op RT +-CT
- If No neck node: SOH ND
- If Neck node: RND
Main tumours arising in parapharyngeal space?
- Deep lobe parotid tumours 50% (mostly benign)
- Schwannomas 18%
- metastasis from NPC (poor prognosis), thyroid ca, breast ca.
- Ca lip
- 12 in 100000, m=14f
- 90% in lower lip
- Solar radiation, Tobacco, Viruses
Epidemiology of oral Ca?
- 7 in 100.000 in UK
- related to Tobacco, alcohol, low socioeconomic level, Dietary deficiencies (A, C, E, Fe, folate), HPV, oral hygiene,premaligant lesions
- The omst common Ca of men in Pakistan, India, Sri Lanka, Bangladesh
types of oral ca?
what is the most important feature in predicting subclinical nodal metastases and survival rate of oral can malignancy?
- Tumour thickness:
- <3mm: 86% survival for 5 years
- 4-7mm: 58.3%
- >7mm: 57%
Ix for oral lesion?
- > 2-3 weeks: Incisional biopsy
- DNA ploidy assessment for leukoplakia
- Imaging: MRI with selective fat suppression or Gadolinium
Management for oral Ca according to tumour thickness?
- <3mm: Partial glossectomy alone
- 4-9mm: Partial glossectomy + - elective, ipsilateral level I-IV, selective neck dissection
- >10mm: Partial glossectomy, neck dissection and postoperative radiotherapy to primary site and neck
For stage III, IV: partial or subtotal glossectomy +MRND if N(+) or ND I-IV for N(-)+ RT
TX for Ca base of tongue?
- • stage I-II: radiotherapy or wide local excision if exophytic and well-localized via lateral pharyngotomy or labiomandibulotomy;
- • stage III-IV: synchronous chemo/radiotherapy.
Neck dissection in oral cavity ca?
- the standard neck dissection for N0 or limited N+ disease is a levell-III or supraomohyoid neck dissection, otherwise RND.
- There may be some fast tracking to level IV in some tongue cancers.
What is the success rate of radial forearm free flap(RFFF)?
Management of oropharynx Ca?
- small: Radical RT ( both sides of neck as well)
- Surgery (1-2cm clear margin) + ND (SOH fo N0, MRD type II or RND for N+)
Surgical approaches for oropharyngeal Ca?
- Transpharyngeal ( supraomohyoid pharyngotomy and lateral pharyngotomy)
What is the advantage of Transmandibular approach for Ca oropharynx?
Tumour can be removed in continuity with the neck dissection.
- 1 in 120
- HPV 6c, 11 (non mutagenic), 16,18 ( mutagenic)
What is the spread pattern in Ca larynx?
- Local spread along tissue planes
- Lymphatic spread by boundaries between embryologic anlagen: to levels II, III, IV, VI.
Chance of lymphatic spread of Ca larynx based on staging?
<5 percent (TI), 7 percent (T2), 14percent (T3) and 33 percent (T4).
why Supraglottic laryngectomy is usually a good option for Ca supraglottic?
Supraglottic cancers tend to remain locally confined (even with pre-epiglottic or nodal spread) to their subsiteuntil relatively late.
What is the second most common laryngeal malignancy?
Why is it important to be ruled out?
- • avoiding laryngectomy for any presumed cancer until the surgeon has seen a written histology report excluding lymphoma.;
- • ensuring that the patient with laryngeal lymphoma is referred promptly to the regional multidisciplinary lymphoma service.
clinical presentation of supraglottic ca?
- globus or FB sensation
- hot patato voice
- referred otalgia
- true dysphagia
clinical presentation of subglottic ca?
- globus or FB sensation
- hoarseness with VC palsy
- shortened maximum phonation time
Tx for Tis Ca larynx?
- quit smoking/ drinking
- ML surgery (serial microflap excision)
Tx protocol for Ca larynx?
- Early glottic: Surgery or RT ( T1 95%, T2 85% SR5y)
- Ant. commisure: open partial surgery (poorer prognosis)
- Early supraglottic:
- --N0: RT
- --N+: horizontal partial laryngectomy (HPL)
- T3: Laryngectomy or RT
- T4 & transglottic: total laryngectomy and voice rehabilitation
What are the preop steps for total laryngectomy?
- full nutritional assessment with supplementary feeding as necessary.
- Speech and language review and a visit by aprevious laryngectomee.
- A week or so preoperatively, a percutaneous gastrostomy is placed, unless primary tracheooesophageal puncture is planned.
- As with all major cancer procedures, before anaesthesia, the surgeon checks both the pathology report and the multidisciplinary team (MDT) decision again.
What is the name of the U shaped skin flap before total laryngectomy?
What actions get problematic after total laryngectomy?
speech, swallowing, coughing, altered appearance, lifting, laughing, crying, smelling, tasting and even kissing
symptoms of hypopharyngeal ca?
- Unilateralsore throat (very rarely globus sensation)
- Pain on swallowing (odynophagia)
- Hoarsenessof voice - unilateral cord palsy
- Unilateral otalgia
- Weight loss
Tx protocol for hypopharynx ca?
- Radical RT
- Laryngectomy and partial phatyngectomy (+- flap)
- Total pharyngolaryngectomy + jejunal flap
- Total pharyngolaryngooesophagectomy + gastric transposition
- N0: lateral ND (II, III, IV)-> if HPT+, then post op RT
- CT as an adjuvant to RT or surgery
What is the overall 5 y survival rate in hypopharynx ca?
In Thyroid surgery, what are the borders of Joll's triangle? (SLN)
- lateral: upper pole and vessels of thyroid glands
- up: attachment of strap muscle to thyroid cartilage
- medial: midline
In Thyroid surgery, what are the borders of Beahr's triangle? (RLN)
- lateral: common carotid arterys
- up: Inferior thyroid artery
- medial: RLN
The epidemiology of papillary thyroid carcinoma?
- 60-70% of malignant thyroid cancers
- 30-40 y/0
Related diseases with papillary thyroid Carcinoma?
- Low dose radiation
- Cowder's syn: familial goitre, skin hematoma
- Gardener's syn: familial colonic polyps
- Familial polyposis
Related issues with follicular thyroid cancer?
- Iodine deficiency
- HLA DR1, DRw, DR7
What does Medullary thyroid cancer secret?
what is the background disease in anaplastic thyroid cancer in 40% of cases?
Related issues with Medullary thyroid carcinoma?
- Mutated RET gene
- MEN IIA
- MEN IIB
what is Killian's dehiscence?
postero-medial dehiscence of pharynx , place for deiverticulum of zenker
symptoms of diverticulum of zenker?
Blood supply to the pectoralis major myocutaneous flap?
Blood supply of deltopectoral flap?
Internal mammary artery
Blood supply of Lattisimus dorsi flap?
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