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 Diagnosis Treatment
80% SCCA, 10% ACC/AC
Risk factors: environmental exposure
Diagnosis
CT/MRI, biopsy
Treatment
Surgical resection
Chemotx/XRT

4. CASE PRESENTATION
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

5. EVALUATION FNAB: MRI: CXR: nl. Laboratory: + 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.

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% 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

13. NOSE EXAMINATION

14. NASAL POLYPS
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

15. OROPHARYNGEAL CARCINOMA
Usually presents with painful oral ulcer
Adult males 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, LFT’s
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

26. NECK EXAMINATION

28. NECK MASSES TIME COURSE OF MASS PAINFUL/TENDER
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

30. NECK EXAMINATION

31. THYROID MASS Large thyroid mass suspicious for malignancy
FNA-B important
Surgical resection with CN X monitor
Post-operative therapy dependent on path

33. LIP CARCINOMA Uncommon site for oral carcinoma
Usually managed with wide local excision
Frequently seen in pipe smokers

34. HOARSENESS MANAGEMENT:
REFER TO ENT IF PROLONGED OR DIAGNOSIS UNCERTAIN
INDIRECT LARYNGOSCOPY
BE SUSPICIOUS OF MALIGNANCY IN SMOKERS AT ANY AGE

36. LARYNGEAL CARCINOMA Usually seen in smokers
Extremely hoarse voice for several weeks
May have referred otalgia
Obviously needs laryngoscopy/biopsy

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

40. LARYNX EVALUATION

41. VOCAL CORD NODULE Usually a gravelly/hoarse voice
History of voice overuse/singers
Voice rest may help
Often associated with GERD
ENT eval. for laryngoscopy

42. HOARSENESS ASSOCIATED WITH URI MANAGEMENT SELF-LIMITED
RESOLVES IN 7-21 DAYS
PROLONGED RESOLUTION IN SMOKERS
MANAGEMENT
ANTIBIOTICS (S. AUREUS)
HUMIDIFICATION
STEROIDS

43. HOARSENESS CHRONIC HOARSENESS ACUTE HOARSENESS VOCAL OVERUSE
VOCAL FOLD POLYPS
GERD
PRESBYLARYNGIS
ACUTE HOARSENESS
IF ASSOCIATED WITH NECK TRAUMA--ER