Head & Neck

Question 1

What are the key goals of treatment in H&N cancer?

Answer 1

Loco-regional control
Long term survival
Quality of life 
- function incl airway, oral continence etc
- cosmesis

Question 2

Tell me about the epidemiology of H&N malignancy?

Answer 2

Accounts for ~4% of all cancer (3% of cancer deaths)
Incidence is increasing esp in younger females (link with HPV)
Majority still older men
Majority are SCC ~90%
Majority are in oral cavity (esp tongue) / larynx
Risk factors are
- “Smoking” (3x risk but reduces if stop smoking >20yrs)
- “Spirits”
- “Spices” e.g betel nut
- “Sex” i.e HPV 16 - related with no of sexual partners

NB. Pt who smokes and drinks has x38 risk of developing H&N cancer

Question 3

Tell me about your surgical management of this pt with biopsy proven oral cavity tumour?

Answer 3

Pre-op work up:
- Cross sectional imaging H&N - CT or MRI
- Staging CT c/a/p
- OPG to assess dentition
- USS guided FNA if palpable nodes
( + CT angiography if considering free fibula reconstruction)

Then MDT - TNM staging
T1 4cm
T4 Any size with involvement of other structures e.g extrinsic muscles of tongue, deep soft tissue, bone involvement etc

N1 6cm

M1 Any distant metastases - most commonly lung/bone

Surgical management:
Consider trache at time of excision
i.e. if large tumour, posterior or pt undergoing bilateral neck dissection BUT major morbidity assoc with trache

Wide local excision

• excision with 1cm clinical margin
• intra op frozen sections for oncological clearance

If N0 but >20% risk of occult mets (i.e. T3/4, tumour thickness >5mm) OR pt having flap recon
- Selective neck dissection (levels 1-3)

If N+ (i.e palpable or CT evidence of nodes)
- Modified radical neck dissection - usually preserving SAN/IJV/SCM

If N+ with N3 nodal disease OR involvement of SAN/IJV/SCM OR recurrent disease in irradiated neck
- Radical neck dissection

Appropriate reconstruction of defect

Post op

• consider HDU setting
• penrose drains
• flap monitoring as required
• NG feeding tube - start feeding immediately
• oral intake after 5/7 following SALT assessment

Adjuvant radiotherapy indications
Primary:
- close margin (1 level
- extracapsular spread

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Question 4

Pt presents with oral cavity lesion - how would you manage this pt?

Answer 4

Firstly I would undertake a directed history and examination for oral cavity tumours

Key features of history:

• age of pt
• history and progression of lesion
• assoc symptoms e.g bleeding, pain, ulceration, referred otalgia
• functional impairment e.g oral continence, trismus
• risk factors incl smoking, spices, spirits, sun, sex (HPV)
• dental hygiene
• general fitness incl comorbidites/medications affecting surgical risk
• support network

Key feature of examination: (LOOK, FEEL, MOVE)

• general assessment of pt
• size and site
• fixity to underlying structures
• lymphadenopathy

I would then obtain a tissue biopsy of lesion for histological confirmation
- usually GA EUA and full thickness biopsy

NB. >90% of H&N tumours are SCC

Oral cavity tumours are generally treated surgically because of risks of radiotherapy
- osteoradionecrosis of mandible
- xerostomia
- microstomia
Also not typically as responsive to chemoradiation as others.

Question 4

What are the reconstructive options for oral cavity tumours?

Answer 4

Aim of reconstruction is:

• seal mouth from neck
• restore normal speech and swallowing
• improve survival

Flaps generally best

• provide robust tissue if require radiotherapy
• reduced risk of secondary contracture