DIAGNOSIS AND TREATMENT OPTIONS IN

HEAD AND NECK NEOPLASMSEVAN S. BATES, M.D.

DEPT. OF OTOLARYNGOLOGY

NASAL/SINUS TUMORSOverall incidence: 1:100,000

80% SCCA, 10% ACC/ACRisk factors: environmental exposure

DiagnosisCT/MRI, biopsy

TreatmentSurgical resectionChemotx/XRT

This 37 yo male presented with a 4-5 week H/O an enlarging left neck mass. 3 months earlier he noted episodes of left nasal congestion with eye discomfort.

PMH: ASD repair 3/96

H/O smoking 1ppd/15 yr., quit 5 yr. go

Exam:

nasal: polypoid mucosa left inf.turbinate

oropharynx: nl.

neck: 6 x 5 cm firm, mid. Cervical mass

CASE PRESENTATION

EVALUATIONFNAB:

+ for malignant cells immunostain profile suggests medullary CA

MRI: large left neck mass, adenopathy in levels 2-4, small

left intraparotid masses. Thyroid nl.CXR: nl.Laboratory:

calcitonin 2, CEA <0.7, TSH, LFT’s nl.

DIFFERENTIAL DIAGNOSISLymphomaPrimary salivary neoplasm

mucoepidermoid CA, squamous CA, adenoCA

Thyroid neoplasmanaplastic CA, medullary CA

Sinus neoplasmsquamous CA, adenoCA

Unknown Head & Neck Primary

SURGICAL MANAGEMENT

Left radical neck dissection

Left total parotidectomy

SURGICAL FINDINGSNormal thyroid glandMultiple parotid cystsLarge left neck mass w/ additional

adenopathyFrozen section

c/w malignant neoplasmPermanent section

c/w rhabdomyosarcoma, alveolar type

SURGICAL MANAGEMENTLeft endoscopic turbinectomy, resection

of nasal massfindings

large polypoid mass on posterior inf. Turbinate with extension superiorly along lateral nasal wall to middle meatus

pathrhabdomyosarcoma

RHABDOMYOSARCOMA: MD ANDERSON EXPERIENCE

5 yr. Survival 44%, 60% w/combined TX.Poor survival

adult onset of diseasealveolar histology-distant mets

Symptoms:nasal obstruction (60%), facial pain (41%), facial

swelling (38%), proptosis (35%), epistaxis (27%)

RHABDOMYOSARCOMA: UCLA EXPERIENCE

Orbit (35%), Maxillary sinus (15%)35% had CNS extension from sinus/orbitHistology not a factor in prognosisOverall survival 34%Trend toward conventional surgery

followed by intensive chemo/XRT

RHABDOMYOSARCOMAMost common head&neck tumor in children,

rare in adults69% advanced @ presentation (Group III,IV)Ethmoid sinus most common site (46%)Nodal mets (46%), systemic mets(26%)Management: chemo/XRT/surgery7.6% 5 yr. survival

NOSE EXAMINATION

Usually seen in chronic sinusitis or chronic allergy patients

Topical corticosteroids of minimal benefit

Polyps require sugical excision and biopsy followed by long term allergy management

NASAL POLYPS

OROPHARYNGEAL CARCINOMA

Usually presents with painful oral ulcerAdult males 50-70 yrs. old

Risk factors: smoking, ETOHMajority of tumors SCCA, lymphomaManagement:

Surgery/XRTXRT/CHemotx

TONSILLAR CARCINOMA20-30% present with neck metastasesEvaluation with CT/MRI, Chest CT, PET scan,

LFT’sManagement must include neck diseaseStage I survival 80-90%, Stage IV survival 25-

40%Treatment standard involves surgery/XRT

TONGUE NEOPLASMS3% of all CA in US, 50% of CA in India,

3rd most common malignancy in France>90% SCCA, associated with tobacco

use, ETOHSurvival rate decreased with lymphatic

involvementTreatment focused on surgery/XRTReconstruction of prime importance

TONGUE CARCINOMATongue lesions can be resected primarily

due to tongue redundancyPrimary closure vs. local flapXRT for incomplete resection, T2 or

greater lesions or nodal disease

TONGUE MASSNeurofibromaMucosal covered mass rather than

ulcerated lesionSurgical resection alone is sufficient

NECK EXAMINATION

NECK MASSES KEY TO DIAGNOSIS IS HISTORY

TIME COURSE OF MASS PAINFUL/TENDER RECENT

INFECTIONS/TRAUMA SMOKER?

PHYSICAL EXAM LOCATION OF MASS FIRM/CYSTIC/TENDER/

MULTIPLE MASSES

NECK MASSES IF YOU SUSPECT INFECTION,

TREAT WITH 1 COURSE OF ANTIBIOTICS

IF NO RESOLUTION, REFER TO ENT EVALUATION

HEAD & NECK EXAM FNA-B CT/MRI

NECK EXAMINATION

Large thyroid mass suspicious for malignancy

FNA-B important Surgical resection with

CN X monitor Post-operative therapy

dependent on path

THYROID MASS

Uncommon site for oral carcinoma

Usually managed with wide local excision

Frequently seen in pipe smokers

LIP CARCINOMA

HOARSENESS MANAGEMENT:

REFER TO ENT IF PROLONGED OR DIAGNOSIS UNCERTAIN

INDIRECT LARYNGOSCOPY

BE SUSPICIOUS OF MALIGNANCY IN SMOKERS AT ANY AGE

Usually seen in smokers

Extremely hoarse voice for several weeks

May have referred otalgia

Obviously needs laryngoscopy/biopsy

LARYNGEAL CARCINOMA

LARYNGEAL CARCINOMATreatment goals shifted to larynx preservation

based on 1992 VA study11,000 new cases annually, >90% have

smoking exposure Induction chemotx/XRT preserves larynx in

64% patientsXRT for T1/T2 lesions5 yr. Survival 70-80% for T3< lesions, 40% for

T4 lesions

LARYNX EVALUATION

Usually a gravelly/hoarse voice History of voice

overuse/singers Voice rest may help Often associated with GERD ENT eval. for laryngoscopy

VOCAL CORD NODULE

HOARSENESS ASSOCIATED WITH URI

SELF-LIMITED RESOLVES IN 7-21 DAYS PROLONGED RESOLUTION IN

SMOKERS MANAGEMENT

ANTIBIOTICS (S. AUREUS) HUMIDIFICATION STEROIDS

HOARSENESS CHRONIC HOARSENESS

VOCAL OVERUSE VOCAL FOLD POLYPS GERD PRESBYLARYNGIS

ACUTE HOARSENESS IF ASSOCIATED WITH NECK

TRAUMA--ER