Tumors of the oral cavity and oropharynx

Tumors of the oral cavity and oropharynxBy Lt Col Saeed Ullah MBBS, MCPS, FCPSClassified ENT, Head and Neck SurgeonCMH Quetta

Definition Tumour is an abnormal mass of tissue, the growth of which exceeds and is uncoordinated with that of normal tissues and persists in the same excessive manner after cessation of stimuli which evoked the change.

Oral cavitySubsites of oral cavityUpper and lower lipsBuccal cavityUpper and lower alveolusBuccal mucosaFloor of mouthAnterior 2/3 of Tongue Hard palate

Ca lip

Ca tongue

Ca buccal mucosa

Ca hard palate

Ca lower alveolus

Ca upper alveolus

Risk factorsSmokingAlcoholPaanGutkaNaswarReverse smokingsheesha

Tissue of originEpitheliumConnective tissuesMusclesBoneLymphoid tissuesSalivary glandsMinorMajor

Prognostic factorsLength of the tumorDepth of the tumorLocation of the tumorInvolvement of boneInvolvement of vessels and nervesMetastasisLymph nodesDistant metastasis

TNM classificationTumoreNodesMetastasis

Primary Tumor TXPrimary tumor cannot be assessed.T0No evidence of primary tumor.TisCarcinomain situ.T1Tumor 2 cm in greatest dimension.T2Tumor >2 cm but 4 cm in greatest dimension.T3Tumor >4 cm in greatest dimension.

Primary tumorT4aModerately advanced local disease.b(Lip) Tumor invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin of face, that is, chin or nose.(Oral cavity) Tumor invades adjacent structures only (e.g., through cortical bone [mandible or maxilla] into deep [extrinsic] muscle of tongue [genioglossus, hyoglossus, palatoglossus, and styloglossus], maxillary sinus, or skin of face).T4bVery advanced local disease. Tumor invades masticator space, pterygoid plates, or skull base and/or encases internal carotid artery.

Regional Lymph nodesNXRegional lymph nodes cannot be assessed.N0No regional lymph node metastasis.N1Metastasis in a single ipsilateral lymph node, 3 cm in greatest dimension.N2Metastasis in a single ipsilateral lymph node, >3 cm but 6 cm in greatest dimension.Metastases in multiple ipsilateral lymph nodes, none >6 cm in greatest dimension.Metastases in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension.

Regional lymph nodesN2aMetastasis in single ipsilateral lymph node, >3 cm but 6 cm in greatest dimension.N2bMetastases in multiple ipsilateral lymph nodes, none >6 cm in greatest dimension.N2cMetastases in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension.N3Metastasis in a lymph node >6 cm in greatest dimension

Distant Metastasis M0No distant metastasis.M1Distant metastasis.

How to reportT1N1M0T2N2M1

Investigations BiopsyOPGCT scanMRI

Treatment policyCurative: Radiotherapy SurgerySurgery plus post-operative radiotherapyPalliative:RadiotherapyRadiotherapy and chemotherapyTracheostomyPain relief

Surgery Resection of primary tumorNeck dissectionPrimary closureFlaps and grafts

Tumors of oropharynx

AnatomyOropharynx hard palate superiorly to the level of hyoid bone inferiorly.

AnatomyAnterior faucial pillar which is contiguous with retromolar trigone

Retromolar TrigoneIt is a small mucosal area on the mandibular ramus, behind the last molar tooth.

Boundaries of OropharynxThe Anterior wall base of tongue, the valeculla and lingual surface of the epiglottis. The Lateral wall anterior pillar, palatine tonsil and posterior pillar.The roof soft palate The oral surface of soft palate is part of oropharynx and the nasopharyngeal surface is part of nasopharynx.

The posterior wall hard palate to the level of hyoid bone and is anterior to second and third cervical vertebrae. It comprises of superior and middle constrictor muscles and buccopharyngeal facia which separates it from prevertebral facia.

Tongue BaseThe most important part area in the oropharynx is the tongue base. Genioglossus muscle, which is attached to hyoid bone. Tumour infiltration into this muscle by definition almost always involves whole of the tongue.

Types of tumorsThe oropharynx is lined by squamous epithelium squamous cell carcinoma represents the most common tumour. Abundant lymphoid tissue head and neck lymphomas. Soft palate minor salivary glands.

Squamous cell carcinoma most common malignancy (90%). Lateral wall (60%)Tongue base (25%)Soft palate (10%)Posterior wall (5%)

The minor salivary gland tumours have a predilection for soft palate.Minor salivary gland tumours are pleomorphic adenomas. adenoid-cystic and muco-epidermoid types.

LymphomasLateral wall (90%)Tongue base (10%)

StagingT1- Tumour measuring 2 cm or less in size.T2- Tumour measuring more than 2 cm or less than 4 cm in size T3 - Tumour measuring more than 4 cm in size in its largest diameterT4 Tumour invades adjacent structures e.g. Pterygoid muscles, mandible, hard palate, deep muscle of the tongue or larynx.

Lateral wall tumorsMost common tumour (50%) and often involves tonsil. Anteriorly spreads to retromolar trigone, on to buccal mucosa as well as muscles of tongue base. If the invasion gets deeper the pterygoid muscles are involved resulting in trismus.

Lateral wall tumorsLateral spread involves angle of mandible. Inferiorly the growth involve lateral pharyngeal wall, pyriform sinus, aryepiglotic folds and para-glottic space The lesions of the lower poleoften difficult to seeprimary tumours can lurk with in tonsillar crypts as occult primaries

Symptoms frequently apperas late

Tongue is a mobile structure tumors spread through genioglossus muscle and across midline and very quickly involve entire tongue.

Base of tongue tumours60% to 70% have positive palpable lymph nodes on presentation.20% to 30% have bilateral lymph nodes..20% of patients will present with neck nodes and no apparent primary.It is important to assess retropharyngeal lymph nodes.

Soft palate tumours: It may occur with leukoplakia heavy smokers or tobacco chewers.involve palatine nerves, back of the maxillary antrum and superior pole of the tonsil.

lymphomaThe lymphomas particularly affect younger individuals, who present with unilateral tonsillar enlargement.

Symptoms Sore throatOtalgiaDysphagiaUlcersPainTrismusNeck masses

InvestigationsCTto evaluate tongue base. To see the laterality of the lesionTo asses mandibular invasionMRIOrthopantomogramCXR

BiopsyPanendoscopyLaryngoscopy and esopahagoscopy. synchronous lesions and to assess neck.Incisional biopsyIf there is smooth regular involvement of tonsil then tonsillectomyDeep biopsy for base of tongue

Treatment policyCurative: Radiotherapy SurgerySurgery plus post-operative radiotherapyPalliative:RadiotherapyRadiotherapy and chemotherapyTracheostomyPain relief

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