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1. DIAGNOSIS AND TREATMENT OPTIONS IN HEAD AND NECK NEOPLASMS EVAN S. BATES, M.D.
DEPT. OF OTOLARYNGOLOGY
3. NASAL/SINUS TUMORS Overall incidence: 1:100,000
80% SCCA, 10% ACC/AC
Risk factors: environmental exposure
Diagnosis
CT/MRI, biopsy
Treatment
Surgical resection
Chemotx/XRT
4.
5. EVALUATION FNAB:
+ 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, LFTs nl.
6. DIFFERENTIAL DIAGNOSIS Lymphoma
Primary salivary neoplasm
mucoepidermoid CA, squamous CA, adenoCA
Thyroid neoplasm
anaplastic CA, medullary CA
Sinus neoplasm
squamous CA, adenoCA
Unknown Head & Neck Primary
7. SURGICAL MANAGEMENT Left radical neck dissection
Left total parotidectomy
8. SURGICAL FINDINGS Normal thyroid gland
Multiple parotid cysts
Large left neck mass w/ additional adenopathy
Frozen section
c/w malignant neoplasm
Permanent section
c/w rhabdomyosarcoma, alveolar type
9. SURGICAL MANAGEMENT Left endoscopic turbinectomy, resection of nasal mass
findings
large polypoid mass on posterior inf. Turbinate with extension superiorly along lateral nasal wall to middle meatus
path
rhabdomyosarcoma
10. RHABDOMYOSARCOMA: MD ANDERSON EXPERIENCE 5 yr. Survival 44%, 60% w/combined TX.
Poor survival
adult onset of disease
alveolar histology-distant mets
Symptoms:
nasal obstruction (60%), facial pain (41%), facial swelling (38%), proptosis (35%), epistaxis (27%)
11. RHABDOMYOSARCOMA: UCLA EXPERIENCE Orbit (35%), Maxillary sinus (15%)
35% had CNS extension from sinus/orbit
Histology not a factor in prognosis
Overall survival 34%
Trend toward conventional surgery followed by intensive chemo/XRT
12. RHABDOMYOSARCOMA Most common head&neck tumor in children, rare in adults
69% advanced @ presentation (Group III,IV)
Ethmoid sinus most common site (46%)
Nodal mets (46%), systemic mets(26%)
Management: chemo/XRT/surgery
7.6% 5 yr. survival
14. 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
15. OROPHARYNGEAL CARCINOMA Usually presents with painful oral ulcer
Adult males 50-70 yrs. old
Risk factors: smoking, ETOH
Majority of tumors SCCA, lymphoma
Management:
Surgery/XRT
XRT/CHemotx
17. TONSILLAR CARCINOMA 20-30% present with neck metastases
Evaluation with CT/MRI, Chest CT, PET scan, LFTs
Management must include neck disease
Stage I survival 80-90%, Stage IV survival 25-40%
Treatment standard involves surgery/XRT
20. TONGUE NEOPLASMS 3% of all CA in US, 50% of CA in India, 3rd most common malignancy in France
>90% SCCA, associated with tobacco use, ETOH
Survival rate decreased with lymphatic involvement
Treatment focused on surgery/XRT
Reconstruction of prime importance
22. TONGUE CARCINOMA Tongue lesions can be resected primarily due to tongue redundancy
Primary closure vs. local flap
XRT for incomplete resection, T2 or greater lesions or nodal disease
25. TONGUE MASS Neurofibroma
Mucosal covered mass rather than ulcerated lesion
Surgical resection alone is sufficient
28. 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
29. 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
31. Large thyroid mass suspicious for malignancy
FNA-B important
Surgical resection with CN X monitor
Post-operative therapy dependent on path THYROID MASS
33. Uncommon site for oral carcinoma
Usually managed with wide local excision
Frequently seen in pipe smokers LIP CARCINOMA
34. HOARSENESS MANAGEMENT:
REFER TO ENT IF PROLONGED OR DIAGNOSIS UNCERTAIN
INDIRECT LARYNGOSCOPY
BE SUSPICIOUS OF MALIGNANCY IN SMOKERS AT ANY AGE
36. Usually seen in smokers
Extremely hoarse voice for several weeks
May have referred otalgia
Obviously needs laryngoscopy/biopsy LARYNGEAL CARCINOMA
37. LARYNGEAL CARCINOMA Treatment goals shifted to larynx preservation based on 1992 VA study
11,000 new cases annually, >90% have smoking exposure
Induction chemotx/XRT preserves larynx in 64% patients
XRT for T1/T2 lesions
5 yr. Survival 70-80% for T3< lesions, 40% for T4 lesions
41. 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
42. HOARSENESS ASSOCIATED WITH URI
SELF-LIMITED
RESOLVES IN 7-21 DAYS
PROLONGED RESOLUTION IN SMOKERS
MANAGEMENT
ANTIBIOTICS (S. AUREUS)
HUMIDIFICATION
STEROIDS
43. HOARSENESS CHRONIC HOARSENESS
VOCAL OVERUSE
VOCAL FOLD POLYPS
GERD
PRESBYLARYNGIS
ACUTE HOARSENESS
IF ASSOCIATED WITH NECK TRAUMA--ER