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BDS4 CDS Oral Surgery > head and neck oncology and maxillofacial surgery > Flashcards

head and neck oncology and maxillofacial surgery Flashcards

1
Q

oral/oropharyngeal cancer
prevalance and incidence

A

1200 new registrations per year in Scotland. 600 Rx in WoS. (6% of all cancers, 5% of all cancer deaths worldwide)

Increasing incidence (younger, both sexes)

90% Squamous Cell Carcinoma

Disease of deprivation

3/ 100,000 male deaths

5 year survival worldwide 46%

75% oral/oropharynx. 25% laryngeal Ca

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2
Q

main risk factor for oral/oropharyngeal cancer

A

¾ of head and neck cancers attributable to cigarettes and alcohol use.
* Synergistic (16x more likely to get SCC)

Other factors: Betel/pan, oral hygiene, diet, HIV, EBV and HPV.

Biggest risk is prev SCC (4% per year)

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3
Q

classic sites in oropharynx

A

base of tongue

tonsil

soft palate

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4
Q

classic sites in oral cavity

in order of prevalence

A

Lateral/Anterior 2/3 of tongue

Floor of mouth

Retromolar trigone

Buccal mucosa

Hard palate

Alveolus

Lip mucosa

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5
Q

7 red flags

URGENT REFERRAL TO MAXFAX

A

1) Ulcer perists (t > 2 weeks) despite removal of any obvious causation
2) Rolled margins, central necrosis (firm raised edges – concern)
3) Speckled (erythroleukoplakia) appearance
4) Cervical lymphadenopathy (enlarged (size > 1cm), firm, fixed – to skin or muscle, tethered – hard to move, non-tender, esp unilateral)
5) Worsening pain (neuropathic (nerve root pain, sharp), dysaethesia, paraesthesia)
6) Referred pain (ear, throat, mandible)
7) Weight loss (local / systemic effects – cachectic appearance, inc metabolic demands)

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6
Q

describe

A

area of shallow ulceration, pseudomembranous slough in central aspect, erythematous border, expect to feel soft (here it is a traumatic ulcer)

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7
Q

describe

A

white patch on left border of tongue, approx. 2-3cm in length and 1cm in width, not uniformly white – non-homogenous leukoplakia, rest of tongue looks normal

Refer to MaxFax

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8
Q

describe

A

lateral tongue border to ventral tongue/FOM, larger, irregular border, erytheroleukoplakia (high risk for malignant transformation when red/white patch mix)

urgent referral

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9
Q

describe

A

lesion on lateral/ventral surface of tongue, irregular, raised with depressed areas of necrosis in it (lumpy), erytheroleukoplakia

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10
Q

describe

A

attached gingivae in upper left quadrant, erytholeukoplakia, not normal, suspicion of progressive restiform leucoplakia – high malignant transformation rate

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11
Q

describe

A

EO, crusting region on lower right lip, differential dx: neoplastic process further down compared to infective (recurrent herpes simplex labialis virus), review in week time and see if resolved

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12
Q

describe

A

left oral commissure has white that enters onto buccal mucosa – raised, irregular, possible firm, suture present (biopsy taken), malignancy or chronic hyperplastic candidiasis (debatable premalignant condition) – referral to check for dysplasia

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13
Q

describe

A

left border of tongue, large area that is irregular, central ulceration, white and red patches, tongue may have limited movement, likely tender to touch

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14
Q

lymph nodes in neck

A

always examine

learn name/number as communication aid

1a – submental
1b – submandibular
2 – upper jugular chain (divided by spinal accessory nerve)
3 – middle jugular chain
4 – lower jugular chain
5 – posterior triangle (divided by spinal accessory nerve)

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15
Q

1a lymph node

A

submental

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16
Q

1b lymph node

A

submandibular

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17
Q

2 lymph node

A

upper jugular chain (divided by spinal accessory nerve)

18
Q

3 lymph node

A

middle jugular chain

19
Q

4 lymph node

A

lower jugular chain

20
Q

5 lymph node

A

posterior triangle (divided by spinal accessory nerve)

21
Q

describe

A

level 1b lymphadenopathy, oval shaped enlargement 2-2.5cm by 1cm (large than should be), angle of mandible

22
Q

describe

A

level 2 lymphadenopathy, oval shaped approx. 4mcm by 2cm

23
Q

describe

A

posterior triangle enlarged lymphadenopathy Va

24
Q

what to check lymph nodes for

6

A
  • Fixed
  • Tethered to underlying structures
  • painful
  • Symmetrical (uni or bilateral)
  • Firm
  • If intraoral cause
25
Q

inc lymphadnopathy description in referral?

A

yes

will be check on Ultrasound or if still unsure a fine needle aspirate of the lump

26
Q

possible investagations

A

CT scan of primary sites, neck and thorax
* sagittal, coronal, axial views

OPT – assess dentition to see if dentally fit (remove poor prognosis) prior to radiotherapy

US Scan of enlarged node in neck – check cells of lymphadenopathy if no obv primary site (US guided FNB)

Punch biopsy

27
Q

describe CT scan

A

Left maxilla is abnormal (different to RHS)
Loss of zygomatic buttress, maxillary sinus and subcutaneous swelling towards left cheek, possible invading ethomoidal sinus

3D
* bony window - left maxilla eaten away by pathology – likely malignant neoplasm
* vascular window – supply to tumours and recon purposes

28
Q

lymph nodes on CT

A

yes

check for large/abnormal lymph nodes and metastases

29
Q

unsure on extent of disease in theatre?

A

stain with Loogals iodine staining in theatre, highlights dysplastic tissue

dysplasia is associated with premalignancy – abnormal cells that can go onto to be malignant

30
Q

TNM staging

A

T - tumour - size, depth of invasion (inc risk of metastasis)

N – nodes – involved lymph nodes in neck (number and uni or bilateral), breached extra-nodule capsule of lymph node (clinically, radiology, pathology confirmed)* ENE extra-nodal expression or ECS extra-capsular spread*

M – metastases – distant metastases, most common site for H&N cancer is thorax

31
Q

tx plan process for head and neck oncology cases

A
  • Examination
  • Imaging (CT or MRI for primary site and CT Chest)
  • Tissue (Histology)
  • Provides a TNM staging
  • Present at MDT and produce management plan
32
Q

6 tx options for head and neck oncology

A
  • Curative vs Palliative vs Best Supportive care
  • Nil
  • Surgery alone
  • Radiotherapy alone
  • Chemo radiotherapy
  • Dual or Triple Modality

WHO guidance has performance status ranking which helps determine which Tx option pt can manage with

33
Q

primary sites surgical options

4

A
  • Resection and packing
  • Resection and Primary closure
  • Resection and reconstruction
  • Local flap, pedicled flap or free flap
34
Q

what are local flaps

A

FOM cancer edentulous and use buccal mucosa to repair

FANN flap, Pedicle flap – still attached to original blood supply rotated into area it is needed in (pectoralis major commonly used),

Free flaps – tissue is detatched with their blood supply and moved to another part of body and anstamosed to new blood supply – mainly used

35
Q

why reconstruct

A

restore form and function

36
Q

how to plan reconstruction

A
  • Planning with 3-D CT
  • +/- Model/mirror image if asymmetric tissue loss
  • Cutting guides & templates

Resection Planning
* tumour in anterior mandible, invading lower lip, FOM, tongue
can create cutting guides from plans

37
Q

possible donor sites for head and neck oncology

7

A
  • Radial Forearm - common for tongue recon
  • Rectus Abdominus - avoid, pneumonia post op risk
  • Latissimus Dorsi - good for bulk
    * Anterolateral Thigh - common for intra and extra oral lesions
  • DCIA - avoid, mobidity risk, hard to harvest
  • Fibula - most common composite site (combo soft tissue and bone)
  • Composite Scapula
38
Q

multiple flaps….

A

inc risk and complications

39
Q

Osteoradionecrosis

A

side effect of head and neck cancer

Necrotic bone in a previously radiotherapised field
* Hypoxia, hypocellular and hypovascualrity

Radiotherapy > 70 Gy, mandible > maxilla
* Incidence not decreasing despite IMRT

All new OSCC patients see restorative specialists

Management mainly preventative

40
Q

classification of ORN

A

I asymptomatic exposed bone
II
III cutaneous fistulisation +/- pathological fracture

Hard to manage when progress to III

BDS4 CDS Oral Surgery (19 decks)

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