ENT CASE PRESENTATION

CC Fabros, CC Fernandez, CC Fullo, CC Ganancial, CC Luces

3/30/17
General Data
S.Z.C
68yo/F/W
Poblacion Ilaud Rizal, Calinog, Iloilo

CC: submental mass, right

2/23/2017, 3:15pm
HISTORY OF PRESENT ILLNESS

9 months PTA
Ulceration on the tongue
Tawas and salt gargle but without relief
Pain which caused difficulty eating
(-) loss of appetite
HISTORY OF PRESENT ILLNESS

7 months PTA
Increase in size of tongue ulceration
Consult to physician
Excision biopsy revealing SCCA, Well-Differentiated
HISTORY OF PRESENT ILLNESS

6 months PTA
Referred to a specialist
Advised operation but upon clearance patient had
pneumonia and decreased S. K+
Discharged and lost to follow up
Relief of symptoms
HISTORY OF PRESENT ILLNESS

2 weeks PTA
Swelling of right submental area with firm mass
Toothache
Advised for CT scan
HISTORY OF PRESENT ILLNESS

DOC
CT scan: Inhomogenously enhancing heterogenous
lesion, anterior tongue to consider neoplastic process
Lymphadenopathy, right submandibular area
Atherosclerotic thoracic aorta
 PAST MEDICAL HISTORY

(+) DOB BA 2015

(+) HPN 7 months of unrecalled
medication with poor compliance
(-) DM
(-) FDA
FAMILY MEDICAL HISTORY

(+) HPN maternal side

(+) DM maternal side
(+) CA maternal side (breast CA- 1st cousin)
(-) BA
PERSONAL SOCIAL HISTORY

Previously a farmer
Occasional alcoholic beverage drinker
27 pack year smoker
PERSONAL SOCIAL HISTORY
Congested village
3 dogs
8 children
Meat diet mixed with vegetable
Highest educational attainment Grade 5
PHYSICAL EXAMINATION
General survey
Awake coherent not in cardiopulmonary distress, warm to touch.
No cyanosis nor pallor noted.
Good skin turgor.
Hair black. No nail clubbing.
Head
Normocephalic, symmetrical face.

Eyes
Anicteric sclerae, pinkish conjunctiva, pupils are equally round reactive to light and accommodation, non-sunken
eyeballs

Ears
Grossly normal, pinnae soft and flexible, recoils readily, no masses and discharges noted, (+)cone of light with small
amount of cerumen at auditory canal

Nose
no alar flaring, no polyps, deformities, masses or lesions noted
Mouth, Throat and Tonsils
Pinkish lips, moist buccal mucosa, no deformities lesions and masses noted (+) hematoma

Neck
Neck vein not distended, no cervical lymphadenopathy (+) hematoma
(+) suture from AS to AD

Chest and Lungs

Chest wall intact no erythema and masses noted. Symmetric chest expansion, (+) bibasal crackles, no rhonchi nor wheezing
noted.

Heart and Blood Vessels

Apical impulse at 5th ICS Left MCL, no heaves nor thrill noted. Normal heart rate and regular rhythm, (-) murmurs
Abdomen
Normoactive bowel sound. Liver not palpable. Generally tympanic in percussion. Soft, non
distended and non tender. No masses noted upon palpation

Extremities
Grossly normal extremeties. No tremors, deformities, tenderness and swelling noted. Pinkish
nailbeds. Capillary refill < 2 seconds

Genitourinary
Grossly Female
Cranial nerve examination
CRANIAL NERVE RESPONSE
I Not assessed
II Able to read; Fundoscopy: (+) ROR, clear media
Direct and consensual papillary reflex intact at both
II, III
eyes. Pupil size is 3mm in both eyes.
Patient has no difficulty in moving her eyes upwards and
III, IV, VI downwards, to left and right.
No nystagmus noted.
Corneal reflex is intact at both eyes. Masseter and
V
temporalis on jaw bite is intact.
Able to smile no asymmetry noted, Eyes closing strength
VII is symmetrical and (5/5) on grade. No ticks or involuntary
movement noted.
VIII Patient is able to hear when engaged in a conversation.
IX, X Swallowing and gag reflex are intact.

(+) shoulder shrug, she is able to turn her neck on both

XI
sides with resistance (3/5).

Tongue is at midline, no deviation noted. No atrophy, no

XII
fasciculations noted.
 MASS AT THE LATERAL ANTERIOR NECK
ACUTE SUBACUTE CHRONIC

Common Uncommon Common Uncommon Rare Common Uncommon Rare

SCC of the upper Lymphoma Castlement disease Thyroid pathology Brachial cleft cyst Liposarcoma
CMV infection Acute sialadenitis aerodigestive tract Metastatic cancer Kikuchi disease Carotid body tumor Parathyroid
EBV infection AV Fistula Parotid tumor Kimura disease Glomus jugulare carcinoma
Staphylococcal or Hematoma Rosai-Dorfman tumor
Streptococcal HIV infection disease Glomus vagale tumor
infection Mycobacterial TB Laryngocele
Toxoplasmosis infection Lipoma
Viral upper Parotid Thyroglossal duct cyst
respiratory infection lymphadenopathy
Pseudoaneurysm
 SUBACUTE DIFFERENTIALS
LYMPHOMA?
LYMPHOMA
METASTATIC CANCER
PAROTID TUMOR Painless Lymph node
SQUAMOUS CELL CARCINOMA
Early constitutional
symptoms
Diffuse Lymphadenopathy
Splenomegaly
 SUBACUTE DIFFERENTIALS
METASTASIS?
LYMPHOMA
METASTATIC CANCER Constitutional symptoms
PAROTID TUMOR
SQUAMOUS CELL CARCINOMA
such as: fever, chills, night
sweats, weight loss

Supraclavicular
lymphadenopathy: FNAB
reveals malignancy in
more than half of cases
 SUBACUTE DIFFERENTIALS
PAROTID TUMOR?
LYMPHOMA
METASTATIC CANCER
PAROTID TUMOR
SQUAMOUS CELL CARCINOMA Unilateral
Asymtomatic
Slow-growing
Mobile masses
 SUBACUTE DIFFERENTIALS
SCC?
LYMPHOMA
METASTATIC CANCER nonhealing ulcers, dysarthria,
PAROTID TUMOR dysphagia, odynophagia, loose
SQUAMOUS CELL CARCINOMA
or misaligned teeth, globus,
hoarseness, hemoptysis, and
oropharyngeal paresthesias

Lymph nodes associated with

malignancy are usually firm,
fixed, and matted
DIAGNOSTICS
 SOFT TISSUE CT SCAN
A neck soft tissue CT scan with contrast provides superior
anatomical definition of any neck lump while also imaging the
remainder of the neck tissues. If there are metastatic nodes, this
procedure may also facilitate localisation of the primary tumour

provides valuable initial information regarding the size, extent,

location, and content or consistency of the mass. Additionally,
contrast media may help identify malignant lymph nodes that
are not enlarged and distinguish vessels from lymph nodes
 FNAB
most accurate diagnostic tool for investigating neck lumps
Although the accuracy of FNAB is high (approximately 90%),
false negatives do occur and hence a suspicious neck mass
should always be referred for comprehensive evaluation.
For example, an FNAB of a cystic nodal metastasis may reveal
degenerate benign-looking squamous debris from the central
fluid component while missing the solid peripheral tumour rim of
the lymph node.
 TISSUE BIOPSY
Any suspicious areas should be biopsied. Incisional or brush biopsy can be
done depending on the surgeon's preference
A tissue biopsy of the tumor is performed and sent to a laboratory for a
pathological examination. A pathologist examines the biopsy under a
microscope
Examination of the biopsy under a microscope by a pathologist is considered
to be gold standard in arriving at a conclusive diagnosis
Biopsy specimens are studied initially using Hematoxylin and Eosin staining. The
pathologist then decides on additional studies depending on the clinical
situation
SQUAMOUS CELL CARCINOMA
Oral cancer (OC) is considered a serious public health problem
that causes great morbidity and mortality in the population.
While OC has a lower incidence than other malignant tumors, it
is known to produce high mortality and serious disturbances or
discomfort in the patient as a consequence of either the tumor
itself or of the treatment
390 thousand new
cases are reported
every year
5th most frequent
malignanciesamong
males.
7th most frequentin
females
95%

5%
 SQUAMOUS CELL CARCINOMA(SCC)

An invasive epithelial neoplasm with varying degrees of

squamous differentiation and a propensity to early and
extensive lymph node metastases, occurring predominantly in
alcohol and tobacco-using adults in the 5th and 6th decades of
life.
MAJOR RISK FACTORS FOR ORAL CANCER

Tobacco use

Alcohol use

Age over 40
 Tobacco Risks
90% of patients with oral cancer use tobacco

Smokers have 6 times greater risk of developing oral cancer than

nonsmokers.

Tobacco users who regularly use alcohol are at greatest risk

 Alcohol
2nd major risk factor
Excess consumption of EVERY TYPE of alcohol(including hard
liquor, wine, and Beer) raises the risk status of oral cancer
Potentiates the effects of tobacco
Mechanism(s)
Dehydrating effects of alcohol on the mucosa
increasing mucosal permeability,
Irritation of mucosa
and it also acts as a solvent for carcinogens(especially those in tobacco)
Additional Risk Factors Linked To Oral Cancer
Exposure to UV radiation
Human Papilloma Virus (HPV)
Nutritional deficiencies
Oral lichen planus
Immuno-supression
Syphilis
Marijuana use
Chronic irritation
Chronic candidiasis
 PATHOGENESIS
NEOPLASIA: The process of transformation from a normal cell
to a cancerous one.
An abnormality of cell growth and multiplication characterised by:

At cellular level
Excessive cellular proliferation
Uncoordinated growth
Tissue infiltration

At molecular level
Disorder of growth regulatory genes
 NEOPLASTIC (malignant) CELLS

Increase Increase in
Increase Increase in signal
in growth factor activation of
in growth transduction
receptors transcription
factors

- Disturbed processes of mitosis and protein synthesis

 CLINICAL FEATURES
A sore in the mouth that does not heal (most common
symptom)
Pain in the mouth
A persistent lump or thickening in the cheek
A persistent white or red patch on the gums, tongue, tonsil, or
lining of the mouth
A sore throat or a feeling that something is caught in the throat
Increased salivation
 Difficulty chewing or swallowing
Difficulty moving the jaw or tongue
Swelling of the jaw that causes dentures to fit poorly or become
uncomfortable
Loosening of the teeth or pain around the teeth or jaw
Voice changes
A lump or mass in the neck
Weight loss
Persistent bad breath
 MACROSCOPICAL FEATURES
The most common presentations of intraoral squamous cell
carcinoma are:
exophytic (mass-forming)
endophytic (ulcerated)
leukoplakic (white patches)
erythroplakic (red patches) and
erythroleukoplakic (combined white and red patches)
 Leukoplakia

Leukoplakia describes a white patch or plaque on the oral mucosa that

cannot be wiped off and cannot be classified as another disease condition.
 Erythroplakia

Erythroplakia
appears as a red
lesion that may
demonstrate an
erosive
component.
 Erythroleukoplakia

Erythroleukoplakia has both white and red components.

 HISTOPATHOLOGICAL

Increased mitotic activity

Well differentiated
Keratin pearls (abnormal keratinization)
Hyperchromatic nuclei
Pleomorphism
Epithelium islands
Connective tissue stroma with chronic inflammation (histiocytes,
lymphocytes, etc.)
Keratinized cells

Mitotic figures

Inflamed
connective tissue
stroma
 LYMPH NODE LOCATIONS

Preauricular

Parotid

Retropharyngeal Occipital
(tonsillar)
Submandibular Postauricular
(submaxillary)
Submental Posterior
Cervical

Anterior Cervical

Supraclavicular
 DIAGNOSIS
Physical examination- Visual inspection and palpation of all
mucosal surfaces, bimanual palpation of the floor of the
mouth and clinical assessment of the neck for lymph node
involvement.
Biopsy- Confirmatory test
Fine needle aspiration cytology
Routine pan endoscopy
Three-dimensional imaging with computed tomography (CT)
and magnetic resonance imaging (MRI)
STAGING
 PROGNOSTIC FACTORS
Predictors of Poor prognosis:
Increasing tumor thickness(>4mm)
Poorly differentiated
High grade tumors
Perineural,Vascular and lymphatic invasion.
DNA ploidy status such as aneuploid carry worst prognosis
Verrucuous Ca has better one
 PROGNOSIS
Stage 1: 80 90 %

Stage 2: 70 80 %

Stage 3: 30 50 %

Stage 4: 20 30 %
MANAGEMENT
T1 Tumor <2cm in greatest dimension
N2c Metastasis in bilateral or contralateral LN, all nodes
<6cm
M0 No distant metastases
Stage IVa
 pushing margins vs infiltrative growth patterns
- better outcomes with pushing margins

Depth of Invasion Risk of LN 5-year survival

metastasis

< 2mm 13% 95%

2-9mm 46% 85%

>9mm 65% 65%

Second Primary Tumors
The overall incidence: ~14%

Synchronous lesion
- a second primary tumor detected simultaneously or within 6
months of the initial primary tumor

Metachronous (80%)
- emergence of a second primary lesion more than 6 months after
discovery of the index tumor
- with 50% of cases presenting within the first 2 years of initial

Most frequently site: cervical esophagus

Goal of Treatment

Should remain an oncologic approach

To achieve the best opportunity for long-term survival while
maintaining quality of life
Treatment Considerations

Is the patient medically fit for an extensive procedure?

Can the patients health status be optimized?
Does the patient comprehend the treatment options and possible
sequelae?
ANTIBIOTIC USE

Perioperative antibiotics
Prophylactic antibiotics
- most effective when administered immediately before surgery and
for up to 24 hours postoperatively.
Extended use of antibiotics in postsurgical patients
- no decrease in the risk of infectious complications or fistula
formation
SURGERY
Treatment of the Primary Lesion
Size, Location, and associated involved anatomy
Transoral wide local excision
- Majority of oral tongue carcinomas (75%) are T2 or smaller
- Frozen section confirmation of the margin status is necessary
before pursuing reconstruction
Mandibulotomy-based approach
- Advanced-stage oral tongue lesions
Visor or degloving approach
- Advanced-staged tumors of the anterior oral tongue and floor of
mouth
 SURGERY
Treatment of the Primary Lesion
Advanced-stage lesions (III or IV)
- require surgery and postoperative radiation therapy
- increase in locoregional control for stage III and IV patients from
57% to 71% with the postoperative radiotherapy
SURGERY
Treatment of the Neck
Location and incidence of metastasis vary according to the
primary site.
Primary tumors within the oral cavity and lip typically
metastasize to the nodes in levels I, II, and III
SURGERY
Treatment of the Neck
Sentinel node biopsy
- in the setting of the N0 oral carcinoma patient has a
negative predictive value of 100%
- not currently considered standard of care for oral cavity
carcinoma
Neck dissection
- serve as a staging procedure to determine the need for
postoperative adjuvant radiotherapy.
- for the clinically N+ neck, the surgical treatment of choice
has traditionally been modified radical neck dissection
(MRND) or radical neck dissection (RND)
SURGERY
Treatment of the Neck
Supraomohyoid neck dissection (SOHND)
- most common selective neck dissection
- includes removal of lymph node levels I, II, and III.
- regional recurrence after elective SOHND is as low as 3%
- Inclusion of level IIb nodes within the neck dissection is advocated because of a reported
10% incidence of spread to this region

Level I to IV neck dissection

- patients with lateralized oral tongue squamous cell carcinoma with an ipsilateral N0 neck
had a 15.8% rate of skip metastases
- possible involvement of nodes in levels III or IV
- advocated for patients with oral tongue carcinoma and an N0 neck.

Bilateral neck dissection

- Midline lesions have a high incidence of bilateral spread to cervical lymphatics
Surgery vs Radiation

Determined by the modality of treatment chosen for the primary tumor

- If the primary tumor is treated with surgery, the neck is generally
managed surgically
- If the primary tumor is treated with radiation, then the neck is treated
similarly.
N2, N3 or metastasis with extracapsular spread
- surgical management of the neck alone is inadequate
- postoperative adjuvant radiation therapy is necessary
Surgically debulking of metastatic disease does not improve survival
and is not advocated.
Surgical salvage for recurrent neck disease after comprehensive neck
dissection or radiation is associated with poor survival
RADIATION
Role of External Beam Radiation
Indications include
multiple pathologically positive nodes in the neck,
erineural invasion
angiolymphatic invasion
extracapsular spread,
close margins (<5 mm) at the primary site
tumor thickness of 10 mm or larger,
advanced T stage
RADIATION
Conventional dosing
1.8 to 2 gray (Gy) per fraction, once a day, 5 days a week, to
a dose of 62 to 70 Gy

Locally advanced head and neck cancer

provide better locoregional control with radiation delivered in
hyperfractionation and accelerated fractionation with
concomitant boost protocols
RADIATION
Complication of radiation therapy
Xerostomia
Most common
Osteoradionecrosis (ORN)
Less common but more serious complication
Predisposing factors:
poor dentition
inadequate soft tissue coverage of bony structures
mandibular tori
mucosal trauma.
RADIATION
Package Time
length of time from surgery to completion of radiation therapy
related to outcome for patients with locally advanced
squamous cell carcinoma of the head and neck.
less than 100 days - improved locoregional control and survival
emphasize the importance of developing a surgical treatment
plan that minimizes the risks of complications that would delay
the onset of radiation therapy and using a radiation protocol
that minimizes the need for treatment breaks.
RADIATION
Brachytherapy
limited role in the treatment of oral malignancies
as a primary treatment has not been advocated
because of the creation of post-treatment fibrosis
limiting monitoring for recurrence of disease, as well
as the risk of posttreatment ORN.
CHEMOTHERAPY

Induction chemotherapy (neoadjuvant)

- advocated to decrease the magnitude of resection
- however, clinical trials supporting this approach are
lacking
- not currently considered standard of care and
potentially delays the timing of the definitive therapeutic
procedure.
ADDITIONAL THERAPIES
Photodynamic Therapy
may have a potential role in the treatment of widespread premalignant and
superficial oral carcinoma
Use for residual tumor at positive resection margins has also been considered
has been used for palliative treatment of gastrointestinal tract, bladder, and
lung cancers
Photofrin, a light-activated dye, which theoretically localizes to tumor tissue, is
activated by exposure to a 620-nm light and produces oxidizing free radicals
disruption of the vasculature tumor necrosis
Ideally, PDT should preferentially affect tumor tissue; however, histologic
examination of post-PDT specimens have demonstrated the resultant tissue
damage is not absolutely tumor-specific because tissues separate from the
tumor also show evidence of necrosis

Advantage: multiple treatments with favorable functional cosmetic results

Disadvantage: prolonged skin photosensitivity that may last up to 6 weeks

Organ Preservation Protocols

Chemoradiation protocols have demonstrated effective organ

preservation for advanced cancers and would be an attractive
alternative for patients facing the need for total glossectomy if bony
involvement is absent
Attempts at intra-arterial chemotherapy for advanced disease have
demonstrated promising results; however, the toxicity and technical
ability to perform this therapy remain obstacles to widespread
utilization
Chemoprevention
Goals of treatment:
To reverse oral premalignancy
To prevent emergence of second primary tumors

Agents used:
peroxisome proliferator-activated receptor (PPAR)
Isotretinoin
COX-2 inhibitors.

Because of the side effects associated with some agents (in particular with
retinoids) and lack of proven efficacy, general application in the clinical
setting has not occurred
Chemoprevention
Lyophilized black raspberries and vitamins C and E
- Tested in animal models
- reduced the number of dimethylbenz(a)anthracene (DMBA)-
induced tumors within a hamster cheek pouch and may prove
to have a role in chemoprevention

Bowman-Birk protease inhibitor

- may be an agent of interest for treating premalignancy
- response was noted in 1/3 of patients treated for leukoplakia
with low associated toxicity
Chemoprevention
Aspirin
- Regular use has been shown to decrease the risk of
developing head and neck cancer
- effect was noted to be more significant in women and
low to moderate users of alcohol and tobacco
products
- heavy smokers and users of alcohol failed to
demonstrate a chemoprotective benefit from regular
aspirin use
Reconstruction
Considerations:
Maximizing mobility of the remaining tongue

reconstructing adequate bulk

obtaining adequate access to inset tissue for reconstruction

Performing a watertight closure

reconstructing the appropriate sulci such that prosthetic rehabilitation is not hindered

The method chosen for reconstruction depends on the nature of the defect and the
patients comorbidities

Options, after the resection of small lesions, include allowing the wound to heal by
secondary intention, primary closure, and split-thickness skin or dermal grafting.

Depending on the size and location of the defect, various advancement and
rotation flaps serve as reconstructive options. Use of buccal fat, temporoparietal
fascia, or pectoralis major flaps each offer unique options for soft tissue
reconstruction.
Long-Term Management and
Rehabilitation
Speech and Swallowing
To achieve the optimal functional outcome, it is important that the speech and
swallowing therapist evaluates the patient before treatment.
As a rule, the more limited the surgical resection, the less likely a patient is to
experience significant functional impact on speech and swallowing.
Patients requiring wide surgical resections of the retromolar trigone or procedures
that extend deep within the tongue base experience the most significant impact on
swallowing
Floor of mouth resections are associated with a detrimental effect on chewing
Radiation, alone or in combination with surgery, has a side effect profile including
problems such as xerostomia, lymphedema, and fibrosis with scar contracture
Pain Management

Comprehensive pain management plan

Initial postoperative pain management is accomplished by the use
of patient-controlled analgesia
Transition from intravenous analgesia to oral administration is
important as the patient progresses to discharge
A balance must be struck between providing adequate pain
control and excessive sedation, which delays ambulation and
rehabilitation.
Palliative Care
Should be considered for patients with unresectable disease
or when recurrence precludes curative therapy
Palliative chemotherapy and radiation can provide symptom
relief when pain and tumor growth adversely affect quality of
life
Decisions to place a tracheostomy and gastrostomy tube are
individualized and may provide significant comfort without
unnecessarily prolonging life
Hospice consultation is important for aiding the patient and
family with making end-of-life decisions.
 Initial phase
Follow-up - when the patient is recovering from
surgery or radiation therapy
- weekly follow-up may be necessary to
assess nutritional status and monitor
rehabilitation goals

Second phase
- cancer surveillance
- monitoring for locoregional recurrence
- an annual chest radiograph, liver
function tests, and comprehensive head
and neck examination are important for
detecting metachronous lesions
- biannual thyroid-stimulating hormone
(TSH) determination is necessary for
patients after neck irradiation, as are
frequent dental evaluations for dentate
patients.
Complications

Immediate postoperative period

pulmonary embolism
gastric ulceration
hemorrhage
delirium tremens
aspiration pneumonia.

Late complication
Osteoradionecrosis
Delayed pathologic fracture
Nonunion of mandible
Summary
The oral cavity is a unique site within the head and neck in that
the accessibility of the region readily allows for the identification
of premalignant and early-staged lesions
The preferred primary treatment modality for oral cavity
malignancies is surgical.
Given that speech and swallowing function are profoundly
affected by the treatment of oral tumors, oncologic resection
and reconstruction require careful preoperative planning.
For advanced-staged lesions, the use of combination therapy
surgery followed by postoperative radiation therapy remains
the optimal treatment option.
Management by a multidisciplinary team is critical to provide the
patient with the best chance for control of cancer while
achieving the best functional outcomes.
THANK YOU