Evaluation of patients with head and neck cancers is important for proper treatment planning. With advent of advanced fiberoptic system, assessment of the mucosal surfaces of upper aerodigestive tract is much easier and can be performed in office settings.
The term premalignant (precancerous) lesion has been replaced by the term potentially malignant lesion. Such lesions have as their cause, tobacco use, exposure to the human papilloma virus and the chewing of the betel nut. These substances contain carcinogens. The mucosa of the oral cavity is normally quite robust. Exposure to these substances can cause it to undergo change. These changes are usually initiated as a leukoplakic patch. While some leucoplakic patches recover and resolve, some progress into invasive squamous cell carcinoma. Oral submucus fibrosis is another such potentially malignant condition caused by the abuse of betel nut.
This article reviews the role of imaging, imaging characteristics and significance of individual imaging modalities as well as the newer imaging modalities in the evaluation of head and neck cancer. In the pretreatment evaluation, imaging is performed primarily to determine the stage of tumor and to look for an occult primary. It helps in obtaining tissue samples to establish the diagnosis, and treatment planning if radiotherapy is considered. Postsurgery and radiotherapy changes can be differentiated from residual or recurrent pathology on imaging. Imaging also plays an important role in assessing the response to treatment.
Whilst squamous cell carcinomas take center stage in the head and neck area, almost any mass disease that can occur in the rest of the body can theoretically occur here too. This includes the spectrum of adenocarcinomas, lymphomas, melanomas and sarcomas, not forgetting the diversity of salivary gland and thyroid tumors. Diagnoses by FNAC, open biopsy or frozen section have their own inherent, site specific, individualistic problems, and some of the basic principles will be highlighted. Frozen sections for resection margins and staging will be dealt with. Finally the challenge of the occult primary with metastasis in the head and neck, and understanding the need for immunohistochemistry are also touched upon.
Squamous cell carcinoma of the head and neck presents a treatment challenge owing to the complexity of the anatomy of the head and neck region. Till recently, tobacco and alcohol were thought to be the main risk factors. Recently, human papilloma virus (HPV) has gained significant attention in the etiology of oropharyngeal cancer. Depending on the location of the tumor, surgery as a primary treatment can be quite debilitating due to cosmetic as well as functional reasons. Nonsurgical (radiotherapy or chemoradiotherapy) modalities are preferred as initial treatments of oropharynx, hypopharynx and larynx primaries. A multidisciplinary approach is recommended for treatment of these malignancies.
Though early stage head and neck cancers can be cured either by surgery or radiation, patients with locally advanced disease continues to pose a therapeutic challenge. Locoregional failure is the major cause of death in head and neck cancers. As the outcome of locally advanced head and neck cancer is less than promising, a combined modality approach is generally undertaken in this group of patients. The combination of surgery, radiation and more recently, chemotherapy and targeted therapy can improve outcomes in locally advanced head and neck cancer patients. This overview discusses the rationale and role of postoperative radiotherapy (PORT) in advanced head and neck cancers, the radiotherapy technique in brief and methods of enhancing the efficacy of postoperative RT by altering the fractionation schedules and adding chemotherapy and targeted therapy.
The term ‘tracheostomy’ or ‘tracheotomy’ refers to the procedure whereby a communication is made between the anterior wall of the trachea and the exterior which bypasses the upper air passages. It results in the formation of a fistulous tract between the anterior aspect of the neck and the trachea allowing air to enter the lower respiratory passages without passing through the nose, pharynx and larynx.
It is performed at all ages, however, there are significant differences in the procedure when performed in adults and children.
‘Laryngotomy’ or ‘cricothyrotomy’ is the emergency operation where the airway is opened through the cricothyroid membrane in case of acute respiratory obstruction where there is no time for tracheostomy or inavailability of a competent surgeon to perform the tracheostomy. It is a relatively simple procedure and life-saving.
Surgical outcomes are more or less predictable with a reasonable degree of accuracy. Head and neck surgery has potential for many complications due to presence of a large number of major vessels and nerves. In head and neck surgery, complications can arise due to airway compromise, vascular injury, infections and rarely physiologic causes. Carefully performed surgery is the cornerstone of success. Step by step approach with attention to details and a thorough check after completion of the procedure will ensure optimal results without complications.
Pain is one of the feared effects of advancing cancer and can affect a vast majority of head and neck cancer (HNC) patients. HNC's have a devastating impact on patient's lives as both disease and treatment can affect the ability to speak, swallow and breathe due to involvement of the aerodigestive tract. The etiology of pain in this subgroup of patients could be as a result of direct tumor progression, nerve root compression or as a result of the treatment modalities including surgery radiotherapy and chemotherapy. Pain experienced could be nociceptive or neuropathic. A thorough initial and ongoing assessment of the patient is essential for diagnosis and planning the treatment bearing in mind its modification during treatment. Treatment involves a comprehensive approach which is centred around systematic pharmacotherapy, and supplemented by a range of therapeutic interventions and physical and behavioral approaches. In this article we discuss the incidence, etiology, assessment and treatment of this challenging problem using current modalities.
It is right time to review the management of head and neck squamous cancer (HNSC) because of fundamental changes in both diagnostic and therapeutic modalities. Head and neck cancer affects area highly associated with the individual's.
identity and can produce profound alteration in appearance, speech, and swallowing. Due to morbidity, disfigurement and problems of disease control clinicians used to have lot of reservations in treating complex HNSC cases. The field has taken a new vigor by incorporating important basic advances in understanding of cancer, new modalities of treatment and management of functional deficits. Although much progress has been made in understanding the molecular genetics of HNSC for novel diagnostic and therapeutic interventions, they are still far to go before becoming standard of care for head and neck cancer.
“Resection of malignancies of the skull base can result in significant functional and cosmetic morbidity as well as mortality. Reconstructive efforts provide not only functional and cosmetic rehabilitation, but also allow for the avoidance of potentially disastrous complications such as cerebrospinal fluid leak or meningitis. The optimal reconstruction is determined both by a patient based approach and a defect based approach. Skull base defects can be addressed by the separate components of the craniofacial skeleton in which they involve, and therefore the individual reconstructive issues which must be addressed. In this article, we describe an approach to skull base reconstruction and the technical aspects of the available reconstructive options.
Andrew J McWhorter
Transoral laser microsurgery (TLM) is an important option in the treatment plan for tumors of the oral cavity, oropharynx, larynx, and hypopharynx. For properly selected patients, TLM provides equivalent oncologic outcomes when compared to traditional therapies, while improving the functional aspects of postoperative speech, voice and swallowing.