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Basic structure. The oral cavity extends from the lip anteriorly to the faucial arches posteriorly. It includes the lips, buccal mucosa, gingivae, retromolar trigones, hard palate, anterior two thirds of the tongue (the oral tongue), and floor of the mouth.

Lymphatic drainage is to the submental, submandibular, and deep jugular nodes.

B Etiology

Approximately 90% of patients are heavy users of tobacco (either smoking or chewing).

Approximately 80% of patients are heavy drinkers.

Syphilis accounts for a few cases.

Herpes simplex virus type 1 is currently under investigation as a cause.

C Clinical evaluation

Presenting symptoms can include loose teeth, painful or nonhealing ulcers, odynophagia, otalgia (with posterior lesions), and cervical adenopathy. The lip is the most common site of oral cavity carcinoma, followed by the oral tongue and floor of the mouth.

Diagnosis

Mandibular radiographs should be taken to assess the bony involvement by adjacent tumors.

Pain , which is often a late symptom, occurs after ulceration develops.

Nodal metastases (up to 30% of which are occult, microscopic metastatic disease) are found in 50% of patients with squamous cell carcinoma of the anterior tongue and in 58% of patients with cancer of the floor of the mouth (occult metastases in up to 12% of the patients).

Metastases are uncommon and usually occur late in cancer of the lip or the buccal mucosa.

D Staging

Stage T1: Tumor less than 2 cm in its greatest diameter

Stage T2: Tumor 2–4 cm in its greatest diameter

Stage T3: Tumor more than 4 cm in its greatest diameter

Stage T4: Massive tumor that involves the mandible, pterygoid muscles, antrum, root of the tongue, or skin

E Treatment

Stage T1, N0 tumors can be treated with either local excision or radiotherapy.

Stage T2 or larger lesions should be treated with combined surgery and radiation.

Surgery involves an en bloc resection of the tumor and radical neck dissection.

Either a partial mandibulectomy is included or the tumor is “pulled through” medially to the mandible into the neck (i.e., the tumor is removed en bloc with the radical neck specimen, leaving the mandible intact).

Presenting symptoms

The most common presenting symptom is a persistent sore throat.

This symptom is frequently accompanied by ipsilateral otalgia (referred pain via the tympanic branch of the glossopharyngeal nerve).

A vague sensation of throat irritation, restriction of tongue motion (“hot potato voice”), odynophagia, and bleeding may also be noted.

Most patients (especially those with large lesions) are significantly malnourished.

Many patients present with cervical adenopathy. Nodal metastases are found in 76% of patients with cancer of the base of the tongue and in 60% of patients with tonsillar cancer. Most of these nodes are palpable.

Initial examination must include careful palpation of the tonsils and base of the tongue. Many small tumors are difficult to see but may be palpated easily.

Diagnosis is often made late in the course.

Many patients are asymptomatic until tumors are quite large and ulcerated.

Other patients are treated conservatively for incorrectly diagnosed lesions.

All lesions should be evaluated by endoscopy under general anesthesia before treatment is chosen.

CT and MRI are useful in determining tumor extension

D Staging

(Table 19 -2)

Stage TIS: Carcinoma in situ

Stage T1: Lesion 2 cm or less in its greatest diameter

Stage T2: Lesion larger than 2 cm but less than 4 cm in its greatest diameter

Stage T3: Lesion larger than 4 cm in its greatest diameter

Stage T4: Lesion larger than 4 cm, with invasion of bone or soft tissues of the neck or the root of the tongue

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TABLE 19-2 International College of Surgeons Staging of Oropharyngeal Cancer

T, tumor; N, nodes; M, metastases.

E Treatment

T1 and T2 lesions are treated with radiotherapy.

Combined therapy offers improved survival rates for most large lesions and is indicated when nodal metastasis is present.

Composite resection (the jaw -neck or commando procedure) is most commonly used to resect T3 and T4 lesions of the oropharynx Fig. 19 -3).

It involves a radical neck dissection and a partial mandibulectomy in conjunction with excision of the tumor.

A tracheotomy is routine treatment.

Occasionally, the larynx is spared after total glossectomy in young and otherwise healthy patients. A laryngectomy is performed when either:

The tumor invades the pre -epiglottic space

The entire tongue base and both hypoglossal nerves are removed

F Prognosis

The poor prognosis of oropharyngeal cancers is directly related to their late diagnosis.

In tonsillar cancers , 5-year survival rates range from 63% for patients with T1 tumors to 21% for those with T4 disease.

Patients with tumors of the base of the tongue have 5-year survival rates of 40%–60% for T1 disease and 10%–20% for T4 disease. A high incidence of late presentation is reflected in the large number of patients with T4 disease.

For patients with tumors of the palatal arch , the 5-year survival rates range from 77% for T1 disease to 20% for T4 disease.

The presence of nodal metastases reduces the 5-year survival rate significantly: For N0, the survival rate is 75%; for N1, 25%.

VII Cancer of the Hypopharynx and Cervical Esophagus

A Anatomy

Basic structure

Boundaries. The hypopharynx extends from the pharyngoepiglottic fold to the inferior border of the cricoid area, excluding the larynx.

Contents. It includes the piriform sinuses, the postcricoid area, and the posterior pharyngeal wall.

Lymphatic drainage. The hypopharynx has a rich lymphatic network.

The piriform sinuses drain to jugulocarotid and midjugular nodes.

The posterior pharyngeal wall drains primarily to retropharyngeal nodes.

Lower hypopharyngeal areas drain to paratracheal and low jugular nodes.

The cervical esophagus is drained by mediastinal nodes.

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is poor because of extensive submucosal spread and the high incidence of cervical metastasis.

The overall 5-year survival rate is approximately 30% for patients with hypopharyngeal tumors.

The 5-year survival rate rises to 50% for those who qualify for supraglottic laryngectomy.

Chemotherapy is used with radiation therapy in organ-sparing protocols.

VIII Cancer of the Larynx

A Anatomy

Divisions. The larynx is divided into three regions.

The supraglottis extends from the tip of the epiglottis to include the false vocal folds and roof of the ventricle.

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FIGURE 19-4 Reconstruction of a circumferential pharyngeal defect with a jejunal free graft. The vascular pedicle has been anastomosed to branches of the external carotid artery and internal jugular vein.

The glottis extends from the depth of the ventricle to 1 cm below the free edge of the true vocal fold.

The subglottis extends from 1 cm below the free edge of the true vocal fold to the inferior border of the cricoid cartilage.

Lymphatic drainage

The supraglottis has a rich network that crosses the midline and drains to the deep jugular nodes.

The glottis has poorly developed, sparse lymphatics.

The subglottis drains through the cricothyroid membrane to the prelaryngeal (delphian) and pretracheal nodes.

B Etiology

More than 90% of patients have a significant history of smoking.

Heavy alcohol consumption is a common but not definite etiologic factor.

C Classification

Squamous cell carcinomas account for 95%–98% of the tumors.

Verrucous carcinoma is a variant of squamous cell carcinoma that is locally invasive but almost never metastasizes. It can undergo malignant transformation to a more aggressive malignancy, especially after radiotherapy.

D Clinical evaluation

Presenting symptoms

The most common symptom is hoarseness.

Stridor, cough, hemoptysis, dysphagia, and aspiration also occur.

Neck masses are uncommon at the time of presentation in glottic tumors.

Diagnosis

All patients require direct laryngoscopy and biopsy.

Laryngograms, a barium swallow, stroboscopic laryngoscopy, and CT scan may be helpful.

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E Staging

Stage TIS: Carcinoma in situ

Stage T1: Tumor confined to the site of origin

Stage T2: Tumor has spread to an adjacent laryngeal site or has impaired vocal fold mobility

Stage T3: Tumor confined to the larynx, with fixation of the hemilarynx

Stage T4: Tumor has destroyed cartilage or extends beyond the larynx

F Treatment

Carcinoma in situ is treated by excision of the involved vocal fold mucosa and is then monitored closely.

Most T1 lesions are treated with radiation because the resultant voice is usually of better quality than the one after surgical excision (at least initially). However, surgery is still indicated for many patients, and longterm results on the voice after radiation and surgery have not been studied adequately.