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Oral cavity and oropharyngeal cancer 

Oral cavity and oropharyngeal cancer
Chapter:
Oral cavity and oropharyngeal cancer
Author(s):

Cyrus Kerawala

and Carrie Newlands

DOI:
10.1093/med/9780199688401.003.0002
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Introduction

The management of oral and oropharyngeal cancer is a challenge to the head and neck surgeon. Whilst oral cancer presents in an environment that can be readily examined by patients and professionals alike, oropharyngeal tumours lie at the posterior aspect of what is visible and, as such, may often present late. Rarely, neglected tumours can cross both anatomical zones giving a unique spectrum of clinical presentations.

Cancer of the oral cavity and oropharynx is most frequently squamous cell carcinoma. Occasionally, rarer tumours can present at this site (lymphoma, salivary tumours) or tumours from deeper structures (e.g. deep lobe parotid tumours) can present in this anatomical region. This chapter will principally consider squamous carcinoma of the head and neck presenting in the oral cavity and oropharynx.

Anatomy

  • The oral cavity commences at the vermillion of the lips and extends posteriorly to the oropharynx (Fig. 2.1). It contains the hard palate, tooth-bearing tissues, and anterior two-thirds of the tongue.

  • The oropharynx is defined as that part of the upper aerodigestive tract that commences at the anterior pillar of the fauces, hard/soft palate junction, and the junction of the anterior two-thirds and the posterior one-third of the tongue. Comprises of soft palate, anterior and posterior tonsillar pillars, and tonsillar fossa, lateral and posterior walls, and the tongue base down to epiglottis (Fig. 2.2 and Fig. 2.3).

  • The surface of both oral cavity and oropharynx is lined with stratified squamous epithelium from which the most frequently presenting tumour arises.

  • Tissues at both sites have very rich lymphatic drainage, which has clinical significance in the loco-regional spread of malignant disease.

  • Various sub-sites are considered to have differing prognostic significance in the context of carcinoma, e.g. tumours of the palatine arch (anterior pillar, soft palate, and uvula) are less aggressive than those of the other oral cavity and oropharynx sites.

Fig. 2.1 Anterior view of oral cavity and oropharynx.

Fig. 2.1 Anterior view of oral cavity and oropharynx.

Fig. 2.2 Sagittal view of oral cavity and oropharynx.

Fig. 2.2 Sagittal view of oral cavity and oropharynx.

Fig. 2.3 Posterior view of oropharynx.

Fig. 2.3 Posterior view of oropharynx.

Epidemiology

  • Around 7500 cases of all head and neck cancer types occur in the UK per annum, making it the 6th most common form of cancer.

  • Approximately 2600 occur in the oral cavity and 900 in the oropharynx.

  • In the USA, approximately 30,100 new diagnoses of oropharynx carcinomas are made and an estimated 7800 deaths occur.

  • In India, oral cavity and oropharyngeal tumours comprise 40% of cancers.

  • There is between 2 and 5 times greater incidence in men than women depending on site.

  • Traditionally, it is most common in the 6th and 7th decades, although there is evidence that it is increasing in young adults.

Aetiology

  • Smoking and consumption of alcohol are the two principal aetiological factors in this disease. These factors act separately but also synergistically in causing this form of cancer.

  • Diet containing high proportions of vegetables and fruit might modulate carcinogenic effects and low body mass index (BMI) appears to increase the risk of oropharynx cancer.

  • Human papilloma virus (HPV) is now recognized as an independent risk factor for oropharyngeal squamous cell carcinoma—HPV type 16 is the most prevalent genotype present in 87% of cases of oropharyngeal squamous carcinoma in one large study.

  • Betel quid chewing is related to the high incidence of oral cancer in the Indian subcontinent.

Premalignant conditions

Conditions of definite premalignant potential

  • Leukoplakia.

  • Erythroplakia (Fig. 2.4).

  • Chronic hyperplastic candidiasis.

Fig. 2.4 Oral squamous cell carcinoma presenting in area of erythroplakia.

Fig. 2.4 Oral squamous cell carcinoma presenting in area of erythroplakia.

Conditions associated with an increased risk of malignant transformation

  • Lichen planus.

  • Oral submucous fibrosis.

  • Syphilitic glossitis.

  • Sideropenic dysphagia.

These include conditions are that not themselves premalignant, but confer an ↑ rate of malignancy by the atrophy that they produce within the mucous membranes (see Oral cavity and oropharyngeal cancer Lichen planus, p. [link], and Oral cavity and oropharyngeal cancer Syphilis, p. [link]).

Conditions erroneously considered to be premalignant

  • Stomatitis nicotina.

  • Habitual cheek biting.

  • White sponge naevus.

Diagnosis

This is made on the basis of clinical features and special investigations. Clinical features include symptoms and signs.

Symptoms

In early disease small tumours may produce very few or only specific symptoms, and are therefore difficult to detect. Presenting symptoms may include:

  • Painless ulcer.

  • Sore throat.

  • Sensation of a foreign body in the throat.

  • Change in voice, otalgia, or odynophagia (pain referred to the ear mediated via glossopharyngeal and vagus nerves).

  • Lump in the neck.

  • Weight loss.

With increasing tumour size, tongue movement may be impaired, affecting speech and swallowing. In late stage disease patients may complain of spontaneous bleeding and halitosis.

Signs

  • Indurated ulcer (Fig. 2.5).

  • Exophytic mass.

  • Area of abnormal mucosa, e.g. red patch.

  • Cervical lymphadenopathy: (Fig. 2.6) may be reactive or metastatic. A metastatic node will classically be:

    • hard;

    • non-tender;

    • may be fixed to surrounding structures.

  • Alteration of voice.

  • Cranial nerve lesions:

    • hypoglossal palsy (deviation towards affected side with wasting and fasciculation of ipsilateral side of tongue);

    • vagus nerve palsy (impaired movement of soft palate, ipsilateral vocal cord paralysis);

    • trigeminal nerve anaesthesia in territory supplied by lingual nerve and mental nerves.

Fig. 2.5 Oral squamous cell carcinoma presenting as indurated ulcer.

Fig. 2.5 Oral squamous cell carcinoma presenting as indurated ulcer.

Fig. 2.6 Upper deep cervical lymph node enlargement from oral cavity primary.

Fig. 2.6 Upper deep cervical lymph node enlargement from oral cavity primary.

Clinical examination must include a methodical examination of the oral cavity, as well as the anterior and posterior triangles of the neck. Fibre-optic naso-endoscopy must always be carried out when an oropharyngeal lesion is suspected. This can be carried out under topical anaesthesia.

Investigations

Plain radiography

Plain radiographs have a limited role to play in the diagnosis and pre-operative assessment of oropharyngeal tumours. Nonetheless, they are frequently performed as part of the diagnostic pathway, particularly in patients who present with non-specific symptoms.

The orthopantomogram

  • Frequently undertaken as a screening investigation for patients presenting with facial pain.

  • A rotational tomogram and, therefore, only of diagnostic value for those tissues that lie within the focal trough.

  • Of little practical value in assessing soft tissue pathology.

  • Bony pathology is only demonstrated where significant decalcification has occurred as a result of either pressure or direct invasion by a malignant process.

  • Occasionally useful in diagnosing the much rarer osteosarcomas where characteristic features, including the ‘sunray’ appearance, are almost pathognomonic.

  • Bone invasion by the more common squamous cell carcinomas is indicated by loss cortical outlines and irregular areas of radiolucency in either the mandible or maxilla (Fig. 2.7). Rarely resorption of dental roots can also be identified.

  • Malignant transformation within pre-existing benign pathology cannot be excluded with plain radiology.

  • Multiple lesions may occur with metastatic bony deposits, such as in myeloma or breast carcinoma.

  • Main value of the OPG in patients with oropharyngeal malignancy is in aiding dental assessment prior to surgery or radiotherapy:

    • planning of mandibular resections or access osteotomies must take into account the position of the teeth in order to minimize functional disability;

    • extent of caries and periodontal disease can be determined in order to ensure that appropriate therapy including dental extractions are undertaken preferably at the examination under anaesthesia (EUA) stage, and certainly prior to the commencement of major therapeutic interventions.

  • Finally, the OPG is used to confirm the appropriate reduction and fixation of access mandibulotomies and to ensure that, where mandibular reconstruction has been undertaken, bony contour, plate position, and accurate location of the condyle within the glenoid fossa have all been achieved.

Fig. 2.7 Orthopantomogram demonstrating mandibular invasion in molar region.

Fig. 2.7 Orthopantomogram demonstrating mandibular invasion in molar region.

Occipito-mental radiograph

  • Seldom used in modern diagnostic practice outside the realms of facial trauma.

  • Occasionally indicated in the investigation of facial pain thought to be of maxillary sinus origin.

  • Opacity of maxillary sinus coupled with bony destruction is most likely to indicate a malignant process although long-standing chronic suppurative disease (e.g. aspergillosis) can give rise to similar appearances.

Chest radiograph (CXR)

The pre-operative CXR still has a number of important functions in the overall assessment of patients with oropharyngeal malignancy.

  • Many patients present with cardiorespiratory co-morbidities and the CXR can form a valuable tool in supplementing clinical assessment of respiratory and cardiac function.

  • Given the high incidence of post-treatment complications involving the cardiorespiratory system, a pre-treatment baseline CXR can provide invaluable information about the developing clinical picture.

  • May demonstrate pulmonary metastases, although it is not as sensitive as other imaging modalities in the detection of smaller lesions. Nonetheless, a CXR that demonstrates widespread pulmonary metastases at the beginning of the diagnostic pathway may save a great deal of unnecessary time and investigation, and allows the patient to receive appropriate therapy at a much earlier stage.

  • The role of CXR as part of the routine follow-up of patients following definitive therapy is less certain. In general, follow-up radiography is only recommended where symptoms dictate. Follow-up screening for pulmonary metastases or second primary malignancies is not recommended.

Contrast radiography

Sialography

Whilst sialography has no role to play in the planned assessment of a patient with known oropharyngeal malignancy, occasionally patients with such a malignancy may present with symptoms consistent with obstructive sialoadenitis. It is important to recognize that space-occupying lesions within the major salivary glands or extrinsic compression of the ducts may be identified on sialography.

Carotid angiography

High-resolution contrast MRI, duplex ultrasound scans (DUSS), and subtraction angiography have largely superseded the need for carotid angiography in the pre-operative assessment of oropharyngeal malignancy. Occasionally, however, where previous neck surgery or radiotherapy has been undertaken, angiography may be required in order to assess the patency and condition of the vascular tree in order to facilitate appropriate reconstructive choice. In highly vascular tumours embolization may be of value as an adjunct to surgery.

Barium swallow

This investigation can give useful information about tongue base lesions. It is of particular value when coupled with naso-endoscopy in the post-operative assessment of swallowing function.

Cross-sectional imaging

Computed tomography

  • High-resolution CT scanning with and without contrast probably represents the best all-round imaging modality in the pre-operative assessment and staging of oropharyngeal malignancy.

  • Details of bony anatomy and potential bone involvement by tumour are superior to MRI.

  • Single CT scan of the head, neck, thorax, and upper abdomen allows a comprehensive staging scan to be undertaken rapidly at one sitting.

  • In order to assess the para-nasal sinuses coronal scans can be undertaken or reformatted and give excellent detail regarding involvement of the orbit and cranial base. Sagittal scans can also be of value in the fronto-nasal area.

  • CT is widely available and the criteria for determining the probability of nodal involvement are well developed.

  • Main drawbacks of CT:

    • distortion of images caused by amalgam artefact;

    • limitations of imaging smaller lesions in mobile areas of the oropharynx.

  • Whilst exposure doses have been significantly reduced with modern CT machines, this modality still has the disadvantage of subjecting patients to ionizing radiation.

  • CT scan provides a high level of accuracy in assessing the involvement of lymph nodes in the neck (Fig. 2.8). The criteria for identifying positive neck nodes are:

    • increase in size (short axis >8–10mm);

    • central necrosis and rim contrast enhancement;

    • extra-capsular extension;

    • obliteration of surrounding fat planes.

  • Surpasses plain radiography in diagnostic accuracy for determining the presence of pulmonary metastases or early primary lung tumours.

  • Since image acquisition times with modern spiral scanners are short, there is little reason for not undertaking chest examination as part of a standard head and neck staging protocol.

  • There remains the method of choice for radiotherapy treatment planning. However, an additional ‘planning CT scan’ is usually required with the patient positioned in the treatment position.

Fig. 2.8 Positive node identified on CT by imaging criteria.

Fig. 2.8 Positive node identified on CT by imaging criteria.

Magnetic resonance imaging

  • Superior to CT scanning for determining the depth and volume of primary soft tissue oropharyngeal tumours.

  • Not susceptible to dental amalgam artefact.

  • No exposure to ionizing radiation.

  • Coupled with administration of gadolinium gives excellent information about potential proximity to vascular and neural structures.

  • Acquisition times greater than for CT.

  • Some patients find it unbearably claustrophobic and noisy.

  • High false positive rate when assessing patients for recurrent tumour following therapeutic intervention.

  • High-resolution MRI scans can be of particular benefit in identifying small naso-pharyngeal tumours and recurrence at the base of skull.

  • Investigation of choice for assessing primary salivary gland malignancies and in particular is of value for identifying perineural spread.

  • Gives almost equivalent accuracy to the CT for detecting cervical node metastases (criteria used to determine nodal involvement are similar to CT).

  • Contraindicated in presence of ferrous implants.

Nuclear medicine

Bone scintigraphy

  • Radioisotope scanning with technetium 99-labelled methylene diphosphonate (MDP) can be of benefit in determining whether early bony invasion exists.

  • Computerized co-location on sectional anatomical images can be of benefit in identifying areas of bony invasion where no change is identified on either the CT or plain radiographs.

  • Highly sensitive test and false positives may occur where there is active dental pathology, if there has been a recent biopsy, or where there is simply a periosteal reaction.

  • Results of scintigraphy should be considered in the context of the clinical picture and other investigations. When positive, but where significant clinical doubt exists, an intra-operative periosteal strip should be performed before committing the patient to a segmental bone resection.

  • Also of value in assessing the viability of microvascular free bone transfers in the post-operative period.

Positron emission tomography (PET)

  • PET provides a functional assessment of tissue metabolism using radiolabelled fluoro-deoxy-glucose (FDG).

  • Should give the maximum diagnostic information by distinguishing between the metabolic behaviour of cancer and normal tissues.

  • Studies in the head and neck indicate that this test has a high diagnostic accuracy particularly for:

    • detecting primaries of unknown origin;

    • detecting tumour recurrence by distinguishing between active tumour and post-treatment scar tissue.

  • Requires the use of radiolabelled products that only have a short half-life—therefore expensive.

  • At present PET should be reserved for selected cases where a primary cannot be identified or where tumour recurrence is suspected, but cannot be detected by other methods, and patients should be considered for entry into ongoing clinical trials.

  • It is important that no therapeutic intervention or biopsy has been recently undertaken in order to limit the false positive rate.

Ultrasonography

  • Diagnostic ultrasound has become an important adjunct to the clinical assessment of neck masses—does not replace the requirement for either a CT or MRI scan since these give much more anatomical detail and permit staging of the neck, thorax, and abdomen.

  • Accurate determination of the size and morphology of neck masses can be made, and in many cases normal and abnormal architecture of cervical lymph nodes can be assessed.

  • When used in conjunction with fine needle aspiration cytology or biopsy (FNAC or FNAB) enhances diagnostic yields.

  • DUSS of value in assessing the patency of the vascular tree and vascularity of the tumour.

  • Does not expose the patient to ionizing radiation or strong magnetic fields.

  • Simple to undertake.

  • Highly operator dependent. Real-time imaging provides much more valuable information than can be conveyed in static images.

  • Has a high diagnostic accuracy in the detection of salivary gland tumours; however, its ability to discriminate between benign and malignant tumours is less certain.

  • If coupled with FNAC or FNAB, USS diagnostic accuracy for salivary neoplasms is improved, but high false positive and false negative rates for cytology still exist such that radical surgery cannot be justified on the basis of USS and cytology alone (however, demonstration of diffuse enlargement of gland may justify incisional biopsy to distinguish an inflammatory process from lymphoma). USS can be of benefit in monitoring patients with Sjögren’s syndrome and assess whether a discrete lymphoma is developing within sialectatic salivary tissue (see Oral cavity and oropharyngeal cancer Sjögren’s syndrome, p. [link]).

Fine needle aspiration for cytology or biopsy

FNAC

  • Of benefit when abnormal squamous cells are identified from aspiration of a mass in the neck—triggers diagnostic pathway in search of a primary oropharyngeal malignancy. Where a metastasis from a mucosal malignancy is suspected, every attempt should be made to reach a sound diagnosis without resort to compromising the neck with open surgery.

  • Where abnormal lymphocytes are identified suggesting lymphoreticular malignancy, cytology is rarely sufficient to determine the most appropriate therapy—next most appropriate diagnostic step is excision biopsy through a defensive neck incision (where the approach allow for a future neck dissection).

  • Risk of seeding using FNAC is believed to be extremely remote—nonetheless, where there is unequivocal histological diagnosis of the primary tumour, and imaging of the neck demonstrates abnormal nodes on size or architectural criteria, any additional information obtained by FNAC is of questionable benefit as it is unlikely to influence therapeutic decisions.

FNAB

  • Offers greater information regarding tumours because it provides not only evidence of abnormal cytology, but also information regarding the histology of the tissue.

  • Occasionally will provide sufficient information regarding lymphomas to initiate treatment without resort to formal nodal excision biopsy.

  • Theoretical risk of seeding using this technique, but there is no evidence to demonstrate a true risk.

Staging

Oropharynx cancer is staged using the TNM system (tumour, lymph nodes, distant metastases). Staging can be further classified as clinical, radiological (based on imaging), or pathological (based on the outcome of histopathological examination of excised tissue).

T stage

The primary tumour is staged on the basis of surface extent (Table 2.1).

Table 2.1 T stage

T stage

Tumour maximum surface diameter

Tx

Primary tumour cannot be assessed

T0

No primary tumour

Tis

Primary lesion contains in situ cancer only

T1

<2cm

T2

>2cm <4cm

T3

>4cm

T4a

Tumour invades larynx, deep/extrinsic muscles of tongue, medial pterygoid muscle, hard palate, or mandible

T4b

Tumour invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx or skull base, or encases carotid artery

N stage

The cervical lymph nodes are staged as shown in Table 2.2.

Table 2.2 N stage

N stage

Nodal status

Nx

Regional nodes cannot be assessed

N0

No regional lymph node metastasis

N1

Metastasis in a single ipsilateral node 3cm or smaller in maximum dimension

N2

Metastasis in a single ipsilateral node >3cm, but 6cm or less in greatest dimension, or in multiple ipsilateral nodes 6cm or less, or in bilateral or contralateral lymph nodes 6cm or smaller

N2a

Metastasis in a single ipsilateral lymph node >3cm, but <6cm

N2b

Metastases in multiple ipsilateral nodes 6cm or smaller

N2c

Metastases in bilateral or contralateral nodes 6cm or smaller

N3

Metastasis in a lymph node >6cm

When evaluating nodal metastases clinically the actual size of the mass is measured taking account of the intervening soft tissues. Most neck masses >3cm are not single nodes, but confluent nodes or tumours in soft tissues of the neck.

M stage

Distant metastases are staged as shown in Table 2.3.

Table 2.3 M stage

M stage

Distant metastasis

MX

Distant metastasis cannot be assessed

M0

No distant metastasis

M1

Distant metastasis

Disease stage

Taking the TNM status together for a tumour, the stage of disease is as shown in Table 2.4.

Table 2.4 Disease stage

Stage group

T Stage

N

M

0

Tis

0

0

I

T1

0

0

II

T2

0

0

III

T3

0

0

T1

1

0

T2

1

0

T3

1

0

IVA

T4a

N0

0

T4a

N1

0

T1

N2

0

T2

N2

0

T3

N2

0

T4a

N2

0

IVB

T4b

Any N

0

Any T

N3

0

IVC

Any T

Any N

M1

Principles of treatment

Treatment intent—to cure or palliate?

  • Having established a diagnosis of oropharyngeal malignancy, the histological type, and the stage of disease it is important to take account of the overall physical and mental state of the patient.

  • The relative risks and benefits of the various treatment options should be identified and it should be ensured that the patient, and preferably also their relatives and carers, fully understand the implications of treatment and are in a position to make an informed choice.

  • Where remediable factors exist in terms of general co-morbidities these should be addressed prior to treatment decision.

  • Treatment involves three potential modalities:

    • surgery;

    • radiotherapy;

    • chemotherapy.

  • Achieving loco-regional control is key and relates directly to overall survival.

  • Management of the primary cancer can be either surgical or by radiotherapy, and remains controversial. Surgery is often combined with adjuvant radiotherapy based on histopathological outcomes of surgical resection.

  • Ionizing radiation and chemotherapy are used increasingly for this patient group as a combined modality.

  • Management of stage III and IV resectable oropharynx cancer—there has been only one prospective randomized controlled trial (RCT) comparing chemoradiotherapy with primary surgery plus adjuvant therapy.

  • In early disease, surgery and primary radiotherapy are equally effective in eradicating primary disease.

  • All surgical complications are well known to be far more prevalent and complex in the post-radiotherapy patient.

  • Quality of life should be considered alongside the chances of survival.

  • All members of the multidisciplinary team (MDT) should have the opportunity to express their views about treatment options from their own perspectives. A designated member of the team should take a lead role and ultimately be responsibility for the management of an individual patient’s care.

  • A head and neck MDT should comprise of:

    • oral and maxillofacial surgeons;

    • ear, nose, and throat (ENT) surgeons;

    • reconstructive surgeons (oral and maxillofacial surgery (OMFS), ENT, or plastic);

    • specialist anaesthetists;

    • clinical/medical oncologists;

    • specialist nurses;

    • speech and language therapists;

    • palliative care physicians;

    • specialist radiologists;

    • specialist pathologists;

    • dieticians;

    • restorative dentists;

    • dental hygienists;

    • psychologists.

Having weighed the evidence and discussed all the treatment options with the patient it is vital that the intention of treatment is clearly understood by the whole team, patient, and carers. Where treatment is given with palliative intent it is important that this is targeted at the specific relief or prevention of symptoms, and that the treatment is designed to minimize side effects. Regular reassessment is required to ensure that therapeutic goals are being achieved and that the side effects of treatment are not outweighing the benefits. There must be a clear evidence-based stepwise strategy for managing common symptoms such as pain and nausea.

When appropriate, advance life directives should be discussed and an end of life resuscitation policy agreed with the patient and preferably carers.

Therapeutic options

The overwhelming majority of oropharyngeal cancers are mucosal squamous cell carcinomas. Most of the discussion regarding therapeutic options will be directed to the management of these relatively common tumours. There are three main treatment modalities to consider:

  • Surgery.

  • Radiotherapy.

  • Systemic anti-cancer therapies (SACT).

These modalities can be used in isolation or combination. When used in combination surgical resection normally precedes adjuvant radiotherapy as post-irradiation surgical resection carries with it a much higher risk of complications. Primary chemoradiation may be indicated for certain tongue base and tonsillar tumours. However, the use of chemotherapy as a stand-alone primary modality or as adjuvant treatment with surgery is often only undertaken in the context of clinical trials. It is not possible to consider every permutation and combination, but the following factors all have a bearing on the choice of treatment:

  • Site of primary tumour.

  • Stage of disease.

  • Proximity or involvement of bone.

  • Treatment intent.

  • Physical status of patient.

  • Patient preference.

As far as the physical status of the patient is concerned a number of risk stratification models are available to assist the MDT in advising the patient. At the simplest level, the American Society of Anaesthesiologists (ASA) I–V scale gives a reasonable prediction of the risk of morbidity and mortality (see Oral cavity and oropharyngeal cancer Anaesthesia, p. [link]). Pre-operative risk stratification not only assists in choosing the modality of treatment and even the extent of surgery, but is also a prerequisite for meaningful comparative audit.

Surgery

There are a number of different options available under the banner of surgery:

  • Conventional excision.

  • Laser surgery.

  • Thermal surgery.

The primary site

  • Choice of primary modality treatment depends upon the tumour site and histological features, coupled with the stage of disease and ultimately patient choice.

  • Size and location of tumour will determine whether a resection followed by primary closure or healing by secondary intention will be satisfactory, or whether reconstruction of the defect with a local or distant tissue will be necessary to restore form and function.

  • In borderline cases there may have to be careful consideration of the trade-off between loss of function and the risks of the procedure.

Access to the primary tumour

Many tumours in the anterior part of the oral cavity can be accessed via the transoral route. This is ideal since the oral sphincter is maintained and no scars are produced above the jaw line. The cosmetic result is usually excellent. However, as tumours increase in size and as their position becomes more posterior it may not be feasible to undertake a safe resection via the transoral route. Three main alternatives exist to achieve access under these circumstances:

  • Lip split and mandibulotomy (Fig. 2.9 and Fig. 2.10).

  • A ‘pull through’ technique via the neck.

  • For maxillary tumours, an upper lip and para-nasal incision (lateral infraorbital extension is rarely required and has a high complication rate).

  • Transoral robotic surgery may be of benefit in performing ablative surgery, in otherwise inaccessible site. However this technique is still under evaluation and should be restricted to a small number of specialist centres.

Fig. 2.9 Operative photograph of lip split and mandibulotomy.

Fig. 2.9 Operative photograph of lip split and mandibulotomy.

There are several options for the lip skin incision. However, in most circumstances, some form of stepped incision is desirable both in the upper and lower lip. This disguises and lengthens the scar to prevent post-operative wound contraction, which otherwise distorts the vermilion border. After a lengthy operation the tissues can become oedematous by the time closure is undertaken and it is therefore advisable to mark the skin with methylene blue temporary tattoos prior to incision in order to ensure accurate apposition during closure. It is also important to ensure that the orbicularis muscles are correctly realigned in order to maintain an effective oral sphincter and prevent unsightly post-operative clefting of the lip.

Ablation

  • Effective tumour ablation is achieved by ensuring that good visibility is maintained. This in turn results from appropriate access.

  • In order to maximize the chances of achieving complete tumour resection with a clear margin of normal tissue the surgeon must employ both visual inspection and palpation.

  • The method of cutting (cold steel, harmonic scalpel, laser, diathermy, or coblation) is, to some extent, a matter of personal preference. In many cases, a combination of techniques will be used.

  • For some small and superficial lesions laser vaporization may be employed; however, this does not permit histological assessment of the adequacy of tumour resection. Similarly, lasers and thermal techniques, whilst reducing the amount of intra-operative bleeding, cause morphological distortion of tissues at the margins, which can lead to histological artefacts and some difficulty in assessing the adequacy of tumour resection.

  • Coblation involves the generation of bipolar radiofrequency waves that generate tissue temperatures of around 60°C, much lower than temperatures generated by conventional diathermy. This is claimed to reduce post-operative pain, but the technique has been associated with ↑ levels of post-operative haemorrhage. It should therefore only be used by surgeons who have had specific training in its use.

  • Use of intra-operative frozen sections to assist marginal clearance is controversial:

    • given that the primary aim is tumour resection with a clearance preferably with clinical margin of 1cm (vital structures permitting) if the surgeon believes that close or positive margins could be possible then a wider resection should be undertaken if feasible;

    • random frozen sections are unlikely to be able to identify positive margins;

    • they may give a false sense of security to the surgeon and invariably prolong the operative time.

  • Intra-operative tumour tissue marking has been attempted (e.g. toluidine blue), but this has limited value at detecting mucosal margin clearance because of the high false positive rate. The technique is unsuitable for detecting deep margin clearance (area where resection is most likely to be inadequate).

  • Where bony resection is required extent is largely based on the clinical and radiological findings:

    • extensive subcortical spread of tumour within the mandible is a relatively rare phenomenon, but will usually be suspected pre-operatively;

    • prior to bone resection, a titanium reconstruction plate is fashioned to restore the contour of the resected bone (plate extended well beyond planned resection site in order to provide adequate fixation of the bone graft).

  • For posterior oropharyngeal tumours it is important to visualize the great vessels of the neck up to the skull base and ensure that these are lateralized prior to resection of the primary tumour in order to avoid inadvertent damage.

  • In rare instances where there is true tumour invasion of the major vessels, carotid resection is seldom warranted as the complications are severe, and neither palliation nor survival is enhanced.

  • Following resection and prior to reconstruction, it is of vital importance that meticulous haemostasis is achieved:

    • anaesthetist should be asked to restore the pre-operative blood pressure if hypotension has deliberately been employed;

    • patient should be tipped head down to enhance identification of potential bleeding.

Photodynamic therapy

  • Advocated as a technique that causes selective tumour destruction by cell apoptosis with minimal scarring and preservation of uninvolved tissue (thereby minimizing functional deficit).

  • Photosensitizing agents currently available are insufficiently selective to prevent normal tissue damage.

  • Patients must be protected from exposure to sunlight for several days.

  • Following tumour ablation, the wound sloughs and heals by secondary intention and scarring.

  • There does not appear to be any benefit of this technique over the more traditional resection methods.

The neck

  • Several classifications of neck dissection (ND) are in existence.

  • The term radical neck dissection should only apply to the classical ND described by Crile, which involves resection of the lymph nodes in level I–V of the neck together with sacrifice of:

    • sternocleidomastoid muscle (SCM);

    • spinal accessory nerve (SAN);

    • internal jugular vein (IJV).

  • All other neck dissections are selective and best described by the levels of lymph nodes resected, and which of the vital structures have been sacrificed, e.g. level I–IV with resection of IJV. This avoids confusion regarding the meaning of terms such as modified radical, functional, comprehensive, supra-omohyoid, and extended, which are all open to interpretation and lack clarity.

  • Whether elective (staging ND in cN0) or therapeutic (ND in clinically or radiologically N+ disease) most neck dissections performed today preserve the vital structures of the neck to minimize functional deficit. The following structures are preserved unless they are directly invaded by tumour:

    • SCM;

    • carotid artery;

    • IJV;

    • SAN;

    • vagus;

    • laryngeal nerves;

    • sympathetic chain;

    • phrenic nerve;

    • cervical plexus;

    • hypoglossal nerve;

    • mandibular branch of the facial nerve.

Neck access

There are four main types of incision described to access the neck:

  • Apron.

  • Wine glass.

  • ‘H’.

  • MacFee.

In most situations some form of the apron incision is the most appropriate. This should be raised in the sub-platysmal plane unless tumour invasion dictates otherwise. The subcutaneous blood supply is derived from a plexus of vessels with a vertical axis and therefore the MacFee (parallel transverse) incision, although preserving a bi-pedicle skin flap, does not make best use of the skin blood supply and produces poorer access to the neck. The ‘H’ and wine glass incision both give excellent access, but create points with reduced blood supply, which often lie over underlying vital structures. Where a previous incision has been made in the neck this should normally be excised and the neck incision planned around this.

Elective neck dissection (END)

  • Where there is no clinical or radiological evidence of nodal involvement, END may be indicated because up to 30% of patients with tumours of the floor of mouth or tongue will have occult micrometastases.

  • Access to the neck is also often required in order to facilitate microvascular reconstruction—under either of these circumstances a neck dissection will be indicated unless the patient is not fit enough for major surgery. When a simple local resection and ‘watch and wait policy’ can be employed.

  • At present there is insufficient evidence to know whether any survival advantage is gained in performing END and what detriment in may have in terms of quality of life. However, it is hope that the ongoing UK-wide clinical trial ‘selective elective neck dissection’ (SEND) trial will address this issue. This is a prospective RCT comparing survival in patients who undergo either an END, or a ‘watch and wait policy’ for early carcinoma of the tongue. Study start date January 2007 with estimated primary completion in December 2015.

  • Further benefit arising from END is accurate pathological staging of the neck that helps inform the need for adjuvant radiotherapy and increases prognostic accuracy.

  • The extent of END determined by the site and size of the primary tumour, e.g. in anterior tumours:

    • neck dissection should harvest levels I–IV (accounts for the possibility of skip lesions in level IV—particular phenomenon associated with primary tumours of the tongue and floor of mouth);

    • incidence of spread to level IIb (above the spinal accessory nerve) is very low—therefore only included in large, posterior tumours;

    • incidence of spread to level V in N0 neck is very low (1–3%)—therefore, level V not usually removed because morbidity to shoulder arising from devascularization of the spinal accessory nerve is high.

  • If metastases are detected pathologically in levels I–IV (more than one positive node or any positive node with extracapsular spotted) then post-operative adjuvant radiotherapy is usually employed to include level V.

Sentinel node biopsy

  • Advocated by some for the N0 neck.

  • Injection of radiolabelled dye 1 day pre-operatively of the primary tumour area with intra-operative blue dye injected at the time of surgery.

  • This then drains to the lymph nodes in the same order that tumour would spread.

  • Gamma camera then used to determine the pattern of lymph node drainage for that tumour.

  • Small incision made in the neck and the dye-bearing node(s) with high gamma signal excised and submitted for histology.

  • If metastasis subsequently detected pathologically, formal neck dissection is undertaken at a second operation.

  • Application of technique to oropharyngeal malignancies still under evaluation.

Therapeutic neck dissection

  • Where the neck is N+.

  • Where there is extensive disease in the neck with invasion of the SCM, SAN, and IJV, a radical ND is justified. On occasion it is necessary to extend the dissection beyond the boundaries defined by Crile (extended radical neck dissection (RND)).

  • In other N+ cases a selective ND is indicated with preservation of as many vital structures as possible. In the majority of cases clear tissue planes between the vital structures and involved nodes are preserved, which means that some preservation of function is feasible.

  • Occasionally it is not possible to safely resect involved nodes from a vital structure and, at that point, the ND should include the involved structure. This should be tailored to each individual patient. Whilst pre-operative imaging may give some idea about the likelihood of involvement, it is not infallible and often the decision will have to be made at operation.

  • If this inclusion involves SCM, IJV, and SAN, and levels I–V, the ND is said to be ‘radicalized’.

  • Care should be taken when undertaking the neck dissection to avoid unnecessary sacrifice of vessels that may have potential value for reconstruction—this should never take precedence, risking compromise of tumour resection.

Tracheostomy

The majority of patients who undergo resection of oropharyngeal tumours and ND do not require an elective tracheostomy provided that a level 3 critical care facility is available for the management of the patient in the immediate post-operative period. Where there has been a large oropharyngeal resection it is prudent to undertake a naso-endoscopic assessment of the airway prior to extubation. Occasionally, where the anaesthetist has assessed the intubation as difficult, it may be prudent to undertake an elective tracheostomy. Some units undertake elective tracheostomy where a bilateral ND or a large posterior resection has been carried out.

Where patients are taken back to theatre for re-exploration of the neck for flap insufficiency or bleeding it is usually wise to undertake a tracheostomy at that stage as swelling is likely to be much more significant (see Oral cavity and oropharyngeal cancer Anaesthesia, p. [link]).

Reconstruction

There have been major advances in this area over the last 3 decades. Previously, techniques available to repair defects following cancer ablation were limited. Patients were left deformed with little function. The use of free tissue transfer had transformed cancer treatment by extending what can be safely resected and with the resulting reconstruction, improved quality of life.

The oral cavity and oropharynx has many important functional roles. Resection of any tumour in this region may impact on function. The key functions to preserve with reconstruction of oropharyngeal cancer defects include:

  • Speech.

  • Swallowing.

  • Eating.

  • Chewing.

  • Sensation.

  • Cosmesis.

Reconstruction: issues to consider

The choice of reconstruction technique will depend on:

  • Defect: site and size.

  • Type(s) of tissue required.

  • Patient factors:

    • general fitness;

    • existing medical problems;

    • suitability of donor site;

    • patient’s preference.

  • Resources available.

General principles of reconstruction

  • Replace like with like.

  • Keep it simple.

  • Immediate reconstruction is better than delayed.

  • Minimize donor site morbidity.

  • Resection to achieve clear margins must not be compromised to enable easier reconstruction.

Reconstructive ladder

The techniques available for repair are usually described as a reconstructive ladder, with simple techniques at the bottom rung (less effort/expertise) and more complex ones higher up. The success of reconstruction may be compromised by bleeding, haematoma, breakdown of wound, and infection. A more complex treatment, such as free tissue transfer, is an all or none phenomenon—its failure will result in a persisting defect, donor site morbidity, and a weaker patient.

Reconstructive techniques

The techniques available are described from a simple to more complex order.

Open wound

A laser bed wound is left open and heals with good mucosa coverage and minimal contracture. Conventional non-laser wounds, if left open, will heal slowly, with a combination of contracture and re-epithelialization. The resultant scar is poor, deformed, and may have a deleterious affect function.

Primary closure

  • Ideal for small defects where the edges of the wound can be advanced for closure, enabling healing by primary intention.

  • No donor site morbidity with maximal preservation of function and cosmesis.

  • Use limited to small defects with lax adjacent tissues to advance for closure. Excessive tension to achieve primary closure may result in distortion, dehiscence and widened scar.

Graft

This involves using a piece of tissue (e.g. mucosa, skin graft, or bone) removed from its original donor site and transferred to a recipient site where it gains a new blood supply from the wound bed. The graft is usually harvested from the same individual (autograft), but may be from another individual of same species (allograft) or even different species (xenograft). A graft cannot be used if the recipient bed is absent (through and through defect) or hostile (no prospect of revascularization).

  • Mucosal grafts:

    • can be harvested from buccal mucosa (primary closure) or hard palate (allowed to re-epithelialize);

    • good match for mucosal repair;

    • easy to harvest;

    • healing of donor site may cause further distortion of the oral cavity.

  • Split-thickness skin graft:

    • epidermis and part of dermis taken with a manual or electric dermatome knife;

    • donor site left to re-epithelialize;

    • high success rate as little tissue thickness is required for re-vascularization, but has minimal intrinsic features and may contract;

    • donor site (e.g. thigh, upper arm) can be sore, requires dressing for several weeks, and has a paler appearance in the long term.

  • Full-thickness skin graft:

    • Reliable, but the success rate is slightly less than partial thickness counterpart;

    • better appearance than partial-thickness graft;

    • donor site (pre- or post-auricular, supraclavicular, abdomen) closed primarily.

  • Bone:

    • cancellous blocks (rich in osteogenic material), cortico-cancellous blocks, or cortical pieces;

    • long-established technique that provides rigid scaffolding (osteoconductive), whereby the bony structure is gradually replaced by new bone formation;

    • variety of donor sites, e.g. mandible, iliac crest, rib, tibia, or calvarium;

    • can be used for repairing bony defects, and to augment or reconstruct discontinuity;

    • as non-vascularized requires immobilization and a healthy vascular bed to take (radiotherapy will result in subsequent loss);

    • in addition to generic operative side effects/possible complications (bleeding, haematoma, dehiscence, infection, and scarring), each donor site will have some specific morbidity, e.g. anterior iliac crest (numbness side of leg and groin, aching, and deformity).

  • Cartilage grafts:

    • used in reconstruction of composite ear or nose defects;

    • usually harvested from the patient and has a good success rate if covered due to its low metabolic requirements;

    • can be harvested from nose, ear, and rib as a composite graft with skin/mucosa.

  • Nerve and vein grafts:

    • occasionally required and often taken locally, e.g. as part of flap harvest, great auricular nerve, or external jugular vein;

    • fascial grafts provide a band of firm tissue (from temporalis area or fascial lata of thigh) for use as slings or craniofacial dural repair.

Flaps

A flap is a piece of tissue retaining its attached vascular supply transferred to repair a defect within reach. Unlike a graft it is not dependent on initial re-vascularization since its blood supply is maintained. This also enables a more substantial bulk of tissue to be used, providing structure form and volume.

The vascular supply of a flap can be random or axial in pattern. The random pattern flap relies on subcutaneous vasculature. This limits the design on the length of flap before distal necrosis occurs (usually base width equal to length, but can be longer with the rich blood supply in the head and neck region). An axial pattern with specific associated vessels means a larger and longer flap can be raised safely.

  • Local flaps: there are many local flaps that can be used for defects around the face, oral cavity, and pharynx, as well as neck. Examples include:

    • local intra-oral options—buccal mucosal advancement/rotational flaps, tongue flap, palatal mucosal flap, and buccal fat pad flap. Suitable for small adjacent defects. Ease of harvest of a local flap and its matching tissue characteristics is offset by its limitation of size. Too large a harvest can distort anatomy and compromise function;

    • naso-labial flap—random finger of skin taken from the naso-labial fold (primary closure of donor site with good resultant cosmesis) is turned into the oral cavity through a created opening in the cheek and buccal mucosa. Can be used to repair small defects (buccal, alveolus, and floor of mouth). The inferiorly based pedicle is divided 2–3 weeks after gaining co-lateral vascularization from the bed of the defect. When used bilaterally can repair anterior floor of mouth while retaining good function of the tongue;

    • Karapandzic flaps—this sensate flap closes lower lip defects of up to 60% by advancing adjacent tissue, while preserving the peri-oral vascular ring and nerves (blunt muscular dissection technique). Microstomia can be a problem. There are numerous other rotational/advancement flaps for lip defects.

  • Regional flaps: temporalis flap—muscle flap based on deep temporal vessels, reflected over the zygomatic arch to reconstruct small defects in the upper cheek, pharynx, and palate. Limited by its arc of rotation. Has a role in facial reanimation.

  • Distant flaps:

    • pectoralis major myocutaneous flap (PMMF)—workhorse, pedicled non-microvascular option in reconstruction of medium to large oral defects. Provides large muscle and associated chest wall skin based on the pectoral branch of thoraco-acromial artery. Often raised as a myocutaneous (muscle and skin) or muscle-only flap, reflected over the clavicle into the neck, and can reach up to the zygomatic arch. Donor site is primarily closed. Reliable and can be raised without need to change position of patient on table for oral cancer ablation. Its bulk is both advantageous (protect neck vessels, good for big defects) and disadvantageous (too rigid for defects requiring a more pliable repair). The shoulder function can be impaired when combined with radical ND;

    • delto-pectoral flap—two-stage fasciocutaneous flap medially based on 2–3 perforating branches of the internal mammary artery. Limited by its reach into only the lower half of oral cavity and face. When collateral vascularization is achieved at 2–3 weeks, the tubed pedicle is divided and repositioned. The donor site defect is skin grafted (split-thickness). Superseded by other options but worth considering as a fall back in rare circumstances.

  • Free flap: involves harvesting a flap of soft tissue or bone with its associated vascular supply, detaching it and re-anastomosing with donor vessels in the neck using microsurgical techniques (loupes or microscope). Surgery is complex and technically challenging. However, the type of tissue available for repair is no longer restricted by its ability to reach the defect. Success rate is high (around 95%) in specialized units. Post-operative monitoring is essential as a haematoma or venous thrombosis can threaten the viability of the flap.

There are many flaps suitable for oral and oropharyngeal defects following cancer ablation.

Four common free flaps used

Radial forearm flap

This is a distal skin paddle of the forearm based on a pedicle of the radial artery, vena commitantes, and/or superficial subcutaneous vein (Fig. 2.11). The soft pliable skin paddle provides a good reconstruction for small to medium oropharyngeal defects, enabling the residual tissue (e.g. tongue, floor of mouth) to function. The skin paddle is usually taken from the volar surface.

  • Indications and strengths:

    • workhorse for oral soft tissue defects;

    • provides thin, pliable skin paddle with reliable long vascular pedicle;

    • good size vessels;

    • easy to raise;

    • permits two-team operating.

  • Modifications:

    • can include vascularized bone (part of radius, risk of fracture in 1/5 cases, but can reduce with prophylactic plating);

    • nerve (innervation);

    • tendon (sling effect with palmaris longus);

    • usually fasciocutaneous—can be suprafascial or fascia only.

  • Pre-operative assessment:

    • use non-dominant forearm;

    • check no previous surgery/injury or Raynaud’s disease;

    • ensure normal (negative) Allen’s test for patency of radial artery, ulnar artery, and collateral palmar arch;

    • if doubt use Doppler duplex assessment to investigate further, another limb or another flap;

    • ensure no venepuncture made in the donor arm.

  • Positioning:

    • supine with arm extended on side support board (<90°);

    • tourniquet applied to arm (above elbow), but do not inflate until flap is marked and ready to start harvesting.

  • Preparation:

    • radial artery is palpated and skin paddle is marked out;

    • forearm is elevated and the tourniquet inflated to twice the blood systolic pressure (usually 200–250mmHg).

  • Procedure:

    • dissection of skin paddle commenced on ulnar border of flap;

    • incise skin, fat, and fascia to underlying muscle (watch for superficial ulnar vessels ~2%);

    • haemostasis achieved with bipolar diathermy or ligation;

    • para-tenon left intact to maximize skin graft take;

    • dissection continued until the condensation of the inter-muscular septum between brachioradialis and flexor carpi radialis is reached (median nerve sits deep to the flexor muscles);

    • flap must be raised with care to preserve the connection between radial pedicle and skin flap;

    • distal and radial side of skin flap is raised;

    • brachoradialis tendon is used to guide dissection on radial side of flap/pedicle;

    • radial artery and venae commitantes at the distal end of the skin paddle are ligated and divided;

    • the skin paddle and associated radial pedicle is then elevated proximally, preserving the cephalic venous system if required;

    • preserve superficial radial nerve if possible;

    • perforators from the radial pedicle run into the adjacent muscles at regular intervals—they should be controlled with bipolar diathermy or ligation well away from the pedicle at the muscle surface;

    • once the flap is raised to an adequate length, the tourniquet is released, any bleeding controlled and the flap left to perfuse for at least 20min;

    • adequate residual circulation to the hand should be ensured at this stage; when ready for transfer the pedicle is divided.

  • Closure:

    • donor site is closed primarily apart from the distal end;

    • skin paddle site is repaired with a full-thickness skin graft (VY skin graft or abdominal skin graft), split-thickness skin graft, or local (ulnar) transposition flap;

    • the skin graft is pressure dressed;

    • a backslab can be applied to improve skin graft take.

  • Post-operative care:

    • elevate limb in Bradford sling for 2 days with regular checks on hand viability;

    • the transferred flap is also monitored regularly (Fig. 2.12);

    • forearm dressing is changed at 9–10 days and at weekly intervals thereafter. If heals uneventfully dress forearm for about 4–5 weeks;

    • function of the hand following harvest is usually normal unless complicated by skin graft loss or fractured radius (composite flap) (Fig. 2.13).

  • Complications (donor site):

    • bleeding (rare);

    • excess exudate can soak dressing and will require changing;

    • wound infection or skin graft loss with tendon exposure can occur; exposed tendon usually heals after lengthy regular dressings;

    • paraesthesia at root of thumb is common;

    • power and range of movements in hand not usually impaired;

    • scarring problematic in younger patients—camouflage can be offered.

Fig. 2.11 Composite radial forearm free flap.

Fig. 2.11 Composite radial forearm free flap.

Fig. 2.12 Oropharyngeal reconstruction with radial forearm free flap.

Fig. 2.12 Oropharyngeal reconstruction with radial forearm free flap.

Fig. 2.13 Fracture of residual radius following composite harvest.

Fig. 2.13 Fracture of residual radius following composite harvest.

Anterolateral thigh flap

  • Indications and strengths:

    • as per radial forearm soft tissue flap;

    • larger area can be harvested;

    • donor site morbidity is very low.

  • Anatomy and procedure:

    • a fasciocutaneous flap based on the septocutaneous or musculocutaneous perforators of the descending branch of the lateral circumflex femoral artery. A satisfactory perforator is generally found within 3cm of the midpoint of a line connecting the anterior superior iliac spine with the superolateral border of the patella. More than half of perforators traverse the substance of the vastus lateralis muscle. The descending branch of the lateral circumflex femoral artery, and its vena comitans, lies between the vastus lateralis and rectus femoris muscles, along with the nerve to the vastus lateralis. The descending branch can usually be safely dissected proximally to its major branch to the rectus femoris, which should be preserved during flap harvest;

    • skin paddles can be 20cm in length;

    • vascular pedicle can be up to 20cm;

    • primary closure is possible for paddles 8–9 cm in width;

    • in most cases, the fascia lata represents the deep aspect of the harvested flap, but suprafascial harvest is possible. Portions of vastus lateralis muscle can be harvested with the flap if necessary;

    • the position of the nerve to vastus lateralis is variable with respect to the vascular pedicle, and the nerve cannot always be left intact during harvest. It is likely that nerve division will result in morbidity.

Fibula flap

Up to 25cm of fibula bone ± skin paddle on lateral leg can be harvested based on the peroneal artery and veins. The bone is osteotomized to match mandible or maxillary alveolus. The skin paddle provides a good soft tissue reconstruction with the bone readily accepting implants, but does not match the height of a dentate mandible. Provided 6cm of bone is preserved at both ends of the donor site there is no significant impact on joint function or weight bearing. The donor site skin is closed primarily or with a split-thickness skin graft for larger defects.

  • Modifications:

    • bone and muscle cuff only;

    • lateral sural cutaneous nerve can be included to provide for sensate flap;

    • bone can be ‘double barrelled’ at the recipient site to increase the height of the neo-alveolus (Fig. 2.14).

Fig. 2.14 Post-operative view of double-barrelled fibula flap.

Fig. 2.14 Post-operative view of double-barrelled fibula flap.

  • Pre-operative assessment:

    • exclude previous trauma, surgery, or peripheral vascular disease;

    • mandatory investigation to ensure all three vessels in leg are patent and healthy (DUSS, conventional angiograms, or MRA are common options).

  • Positioning: supine position with the leg partly flexed and internally rotated to allow access to dissect the posterior part of skin paddle.

  • Preparation:

    • leg is prepped and landmarks marked (line from fibula head to lateral epicondyle of ankle inferiorly);

    • skin paddle is fusiform in shape, and includes the junction of the upper two-thirds and the lower third of the above line to capture a dominant septocutaneous or musculocutaneous perforators to the skin;

    • tourniquet is inflated to twice the systolic blood pressure.

  • Procedure (Fig. 2.15):

    • skin paddle is incised anteriorly through skin and subcutaneous tissue to the peroneus muscles;

    • dissection is continued backwards in a subfascial plane towards the intermuscular septum;

    • peroneus longus and brevis are dissected anteriorly off the fibula in a supra-periosteal plane;

    • when the anterior aspect of the fibula is reached, care is taken to keep close to bone to avoid injuring the anterior tibial vessels and deep peroneal nerve in the anterior compartment;

    • extensor hallucis longus is dissected off the fibula to expose the interosseous membrane;

    • after osteotomies of the distal and proximal ends of the fibula with saws (at least 6cm length preserved both ends to maintain integrity of joints) with protection of the tissue deep to bone, the distal ends of the peroneal vessels are identified, ligated, and transected;

    • interosseous membrane is then divided after external rotation of the osteotomized fibula for easier access;

    • chevron-orientated muscle fibres of the tibialis posterior are visualized to identify the fascial plane superficial to the peroneal vessels. Dissection along this plane enables continuous visualization of the peroneal vessels. The entire length is dissected to the bifurcation of the posterior tibial vessels;

    • posterior aspect of the skin paddle is dissected including a muscle cuff of flexor hallucis longus and soleus to preserve the musculocutaneous perforators to the skin paddle. The flexor hallucis longus is transected before the pedicle is freed;

    • tourniquet is deflated and haemostasis achieved. The fibula composite flap is hinged on the pedicle ready for transfer.

  • Closure:

    • primary closure possible with small fusiform skin paddle design;

    • larger defects need split-thickness skin grafting;

    • drain is employed as can be a catheter for long-acting LA infusion.

  • Post-operative care:

    • elevate foot with pillow;

    • viability of the foot must be checked regularly;

    • leg dressing is changed at 10 days;

    • patient is gradually mobilized with physiotherapy input and walking aids.

  • Complications:

    • muscular pain;

    • oedema;

    • paraesthesia—anterior and lateral side of leg and dorsum of foot;

    • weakness of dorsiflexion of the great toe;

    • ischaemia to foot.

Fig. 2.15 Intra-operative view of right fibular harvest.

Fig. 2.15 Intra-operative view of right fibular harvest.

Deep circumflex iliac artery flap

This is another common hard tissue flap used for oropharyngeal bony defects reconstruction. Bone from the anterior iliac crest ± internal oblique muscle (or thicker skin adjacent to bone) is harvested based on the deep circumflex iliac artery (DCIA) and veins. The pedicle is relatively short. The donor site muscle defect may need a mesh closure. Any skin defect is closed primarily.

  • Pre-operative assessment: clinical exclusion of previous abdominal injury/surgery.

  • Positioning:

    • supine position;

    • a sandbag can be used to improve access to more posterior part of the iliac crest to achieve a longer pedicle.

  • Preparation:

    • exposure from lower chest wall down to groin;

    • include midline medially.

  • Procedure (DCIA and internal oblique muscle flap):

    • skin incision runs obliquely from the pubic crest 2cm medial to the iliac crest in a supero-lateral direction to just below the costal margin;

    • dissection continues on a wide front down to the external oblique muscle which is then incised to expose the internal oblique muscle (fibres run in different plane);

    • internal oblique muscle is initially divided at its cephalad extent, the plane between the internal oblique, and transversus being revealed by a white fascial flash;

    • internal oblique muscle is dissected from cephalad to caudal leaving it hinged on the iliac crest;

    • ascending branch of the deep circumflex internal artery (and vein) runs on the deep surface of the internal oblique muscle and is used to identify the main DCIA pedicle;

    • DCIA is traced to the external iliac vessels;

    • lateral portion of the transversus abdominus is then transected about 2cm from the inner table of the iliac crest;

    • DCIA runs between the iliacus and transversus abdominus along the inner table of the iliac crest and the iliacus is transected (with 2cm cuff) to expose the inner table of iliac crest (Fig. 2.16);

    • lateral dissection is carried out next lifting the muscles of the lateral aspect of iliac crest;

    • pedicle is protected and a segment of iliac crest osteotomized according to the desired shape, and the anterior superior iliac spine is preserved with the inguinal ligament attachment;

    • the harvested flap is then ready for transfer (Fig. 2.17) and insertion (Fig. 2.18).

Fig. 2.16 Medial bone cut during DCIA harvest.

Fig. 2.16 Medial bone cut during DCIA harvest.

Fig. 2.17 DCIA harvest completed prior to division of pedicle.

Fig. 2.17 DCIA harvest completed prior to division of pedicle.

Fig. 2.18 Mandibular reconstruction with DCIA (post-operative image of Fig. 2.7).

Fig. 2.18 Mandibular reconstruction with DCIA (post-operative image of Fig. 2.7).

  • Closure:

    • meticulous closure is necessary to prevent hernia formation;

    • transversus muscle is approximated to iliacus. If a significant part of internal oblique muscle has been removed a mesh is used to repair the ensuing defect. The external oblique aponeurosis is then approximated to the tensor fascia lata and gluteus medius;

    • in addition to a drain, an infusion catheter is placed in the wound to permit the use of long-acting LAs to supplement pain control;

    • remaining subcutaneous tissues and skin are closed conventionally.

  • Post-operative care:

    • listen for bowel sounds to ensure no ileus;

    • patient is gradually mobilized from day 2 to 3. Physiotherapy input with walking aids is required.

  • Complications:

    • muscular pain;

    • weakening and bulging of abdominal wall;

    • hernia formation;

    • femoral nerve injury;

    • damage to intraperitoneal contents;

    • paraesthesia—lateral aspect of thigh.

There are many other flaps that include the anterolateral thigh, latissimus dorsi, lateral arm, scapula, and rectus abdominus. (For detailed descriptions please see Oral cavity and oropharyngeal cancer Further reading, p. [link].)

Reconstructive options and common defects

A common strategy is to use two-team operating, one to perform the ablation and the other reconstruction. Harvesting of a free flap should be carried out simultaneously, if at all possible, to reduce overall operating time.

Defects

  • Tongue and floor of mouth:

    • small defects may be left to re-epithelialized (laser) or closed primarily or with a local flap (e.g. naso-labial flap);

    • medium size defects require a pliable flap to allow residual tissue function (e.g. radial forearm flap, antero-lateral thigh flap);

    • large defects with little remaining organ/tissue will require bulkier flaps, such as pectoralis major, latissimus dorsi, or rectus abdominus flaps.

  • Buccal:

    • superficial tumours can be removed with a laser or skin grafted;

    • small defects can be closed with local flaps;

    • larger defects can be reconstructed with radial forearm flaps;

    • through and through defects will require a bi-paddled radial forearm flap or larger soft tissue flap such as the antero-lateral thigh.

  • Mandible: where mandibular invasion necessitates a segmental resection (full-thickness mandible producing discontinuity) vascularized bone is preferable due to the high rate of post-operative radiotherapy. Common flaps used include fibula, DCIA or scapular.

  • Maxilla: a low-level defect can be obturated with excellent oro-nasal seal, function, and cosmesis. Larger or more complex defects require free tissue transfer options such as fibula, scapula, or DCIA flaps.

  • Lip: this is a difficult area when the defect is too big for primary closure or local flaps. Free tissue transfer is often suboptimal in terms of colour match, oral seal, and function, even though tendon modification can be incorporated.

  • Pharynx: partial defects can be reconstructed with a pectoralis major flap or soft tissue flap, such as radial forearm flap. The latter can be tubed for full circumferential defects. Alternatives include antero-lateral thigh or jejunal flaps.

Developments

Recent and ongoing developments include modification to the planned flap site (e.g. tissue expansion), tissue engineering (i.e. prelamination or prefabrication of flaps), and transplantation. These techniques currently have limited roles in cancer patients as they require time for the modification. Immunosuppression is also best avoided with cancer patients.

Technology advances in medical modelling with 3D printers now enable surgeons to prefabricate accurate reconstruction plates for difficult composite defects (e.g. large tumours or pathological fractures) and produce templates to achieve optimal bony osteotomies. Operating times will also be shortened.

Perforator flaps may reduce donor site morbidity and improve reconstructive options for the defect.

Implants

This is a useful adjunct for reconstructed bony defects involving tooth- bearing segments. Retention of prostheses can be improved with the aid of implant placement. Chewing, and consequently quality of life, has been demonstrated to be significantly improved. Bone flaps suitable for implant insertion are favoured with this rehabilitation in mind during treatment planning.

Prosthetic rehabilitation

This well-established technique for small maxillary defects requires pre-operative planning with a maxillofacial technician. When chosen for the appropriate defect it provides an effective and well-accepted reconstructive option. An impression of the jaw is taken before surgery to make a dressing plate. The maxillary defect after resection is dressed with a suitable obturation material and plate to seal the oral cavity from the nasal and antral cavities. The raw inner surfaces are skin grafted to facilitate prompt healing. A dressing change is performed 2 weeks later to allow further accurate impressions or the fitting of a temporary hollow obturator. A more permanent obturator with teeth is fitted later. More complex defects can be filled with a multipieced prostheses or further retention gained with the aid of implants.

Surgical complications

A surgical complication is a development that is generally to the patient’s detriment arising at the time of the operation or within the post-operative period. Overall, complication rates as high as 60% have been reported in some surgical series treating oral cancer.

Risk factors in oral cancer patients

The factors influencing complications are often multifactorial. They include:

Patient factors

  • Age: usually older patients.

  • Poor performance status.

  • Medical co-morbidities, e.g. ischaemic heart disease, respiratory disease.

  • Excess alcohol and smoking.

  • Poor nutritional status.

Tumour factors

  • Advanced stage tumours are a common presentation.

  • Aggressive tumours.

Treatment factors

  • Complex surgery, i.e. lengthy operation.

  • Need for reconstruction.

  • Previous surgical treatment.

  • Previous treatment modalities, e.g. radiotherapy.

Consequence of complications

  • Major complications (~20%):

    • can be life threatening (up to 4% mortality reported);

    • increase length of stay;

    • cause further suffering with adverse effect on quality of life;

    • require further treatment;

    • incur ↑ cost;

    • delay adjuvant treatment;

    • all may result in poorer outcomes.

  • Minor complications: may not be life threatening, but can require further surgery or prolong inpatient stay. Nevertheless, they adversely affect patients and may contribute towards the development of major problems.

Prevention

Predisposing factors should be identified as part of pre-assessment and appropriate interventions used to optimize the patient’s status. The quantification of risk is also useful for formulating treatment plans, consent, and rehabilitation. With effective pre-assessment and optimization of any pre-existing conditions, careful surgery with advanced intra-operative monitoring and vigilant post-operative care, complications can be prevented or at least kept to a minimum.

Complications associated with oral cancer treatment

General anaesthetic and positioning complications

  • Nerve compression injury, e.g. ulnar.

  • Soft tissue problems, e.g. precipitation of pressure sores.

General medical problems or arising from existing co-morbidities

  • Pulmonary (atelectasis, pneumonia, acute respiratory distress syndrome (ARDS), respiratory failure).

  • Cardiovascular (myocardial infarction (MI), tachyarrhythmias, heart failure).

  • Neurological (cardiovascular accident (CVA), delirium).

  • Deep vein thrombosis (DVT) and pulmonary embolism.

  • Urinary tract infection.

  • Renal failure.

  • Alcohol withdrawal.

(See main surgical textbooks for specific diagnosis and management.)

The diagnosis and management of these conditions are dealt with in the conventional manner. Of these potential complications respiratory (up to 20%) and cardiovascular (~10%) make up a significant proportion of medical problems encountered following head and neck cancer surgery. Wound infections are next most common.

Specific surgical problems

Peri-operative complications

  • Carotid sinus sensitivity: manipulation or pressure of the carotid bulb (baroreceptors) during surgery may cause asystole/marked bradycardia and hypotension. Avoiding further pressure or, if continued manipulation is required due to tumour dissection, topical or injected lignocaine may be beneficial. Post-operative sensitivity may be due to scarring around the bulb.

  • Increased intra-cranial pressure (ICP): ligation of the IJV will cause a transient rise in ICP. This seldom causes overt symptoms, but may contribute to post-operative delirium or facial oedema and cyanosis. Simultaneous bilateral IJV ligations (rare nowadays) will give rise to spectacular acute facial swelling.

Immediate/early complications

Bleeding

Any bleeding immediately after oral cancer surgery usually declares itself quickly and is detected before vital signs deteriorate. Basic principles of controlling bleeding include:

  • Application of pressure.

  • Summoning of assistance.

  • Resuscitation.

  • Urgent return to theatre to identify and treat the cause and protection of airway (crucial).

Many major oral cancer ablation and reconstruction patients may have temporary tracheostomies. The cuffed tube will secure the airway and enable rapid return to theatre safely. Sources of bleeding include major vessels and their branches (usually slippage of ligation), suture lines, or from the undersurface of flaps (may be due to coagulated vessels reopening during hypertensive episodes). Any haematoma must be dealt with promptly as it can threaten free tissue transfer anastomoses, compress the airway, and subsequently promote infected.

Airway obstruction and tracheostomy problems

Surgery for oropharyngeal cancer has a significant risk of obstructing the airway through bleeding, soft tissue oedema, and haematoma in the neck.

  • Where the airway is felt to be at risk an elective temporary tracheostomy should be carried out. An emergency re-intubation for a compromised airway post-operatively is best avoided.

  • A patient with an in-dwelling tracheostomy tube can still be at risk of airway obstruction through a displaced or blocked tube.

  • Prevent blockage with meticulous nursing care, regular clearing of secretions, humidification, inner tube hygiene, and appropriate tube change.

  • Pressure of the inflatable cuff must not be excessive.

  • Breathing exercises should be encouraged and the tube adequately secured.

  • Decannulation should be attempted when the airway is no longer compromised (maintain self-ventilation), minimal suction is required for secretions, and the patient able to protect his or her airway through effective coughing.

Chylous leakage

~2% risk in neck dissections. Caused by damage to thoracic duct (left side) or lymphatic duct (right side). Diagnosed during surgery by the presence, pooling, or discharge of clear fluid. Promptly diagnose, and treat by ligating or over-sewing the affected vessels. Bipolar diathermy is not effective. If undetected at surgery a chylous leak will declare itself as a collection in the neck or excess fluid in drain. The fluid will be clear (if patient starved) or milky (if feeding due to fat content—biochemistry reveals high triglycerides). Management depends on volume of output:

  • High chylous output (>600mL/24h) will need surgical exploration with ligation of affected vessel/tissue. Can affect the patient’s fluid balance, deplete protein levels, produce immunocompromise, and prevent the neck from healing. Over-sewing, application of tissue glue, and pressure dressings are methods adopted to control the leakage.

  • Low chylous output can be treated non-surgically with medium-chain triglyceride enteral feeding, supraclavicular pressure dressings, and careful attention to the fluid and electrolyte balance. If persistent, total parenteral feeding may be necessary.

Seroma and salivary collection

  • A collection of fluid may form soon after removal or blockage of neck drains. It can result in separation of the skin flap from the underlying tissue bed and is usually gravity dependent at the base of the neck.

  • The tail of the parotid may have been transected during neck dissection resulting in a salivary collection.

  • The swelling is softer and more fluctuant than a haematoma.

  • Usually managed by repeated aspiration to allow healing—safeguard the anastomoses where present and prevent infection.

  • A sialocoele can be confirmed with high amylase content on analysis. Exclude an orocervical communication. If a sialocoele reforms regularly anti-sialogogues may be required.

Infection

Wound infections following oral cancer surgery (oral cavity—clean contaminated surgery category) is not uncommon. The incidence of wound infection is ~20% in most series. It is often multifactorial. The causative pathogens are often polymicrobial, with well-known pathogens including anaerobes. Risk factors for infection:

  • Advanced disease.

  • Existing co-morbidities.

  • Longer duration of surgery.

  • Previous treatment (chemotherapy and radiotherapy).

  • Smoking.

  • Excess alcohol intake.

  • Presence of tracheostomy tube.

  • Use of blood transfusions, often multifactorial. The causative pathogens are often polymicrobial, with well-known pathogens including anaerobes.

  • Antibiotic prophylaxis for clean contaminated surgery is warranted and should be broad spectrum, covering common pathogens and anaerobes. Shorter courses of antibiotics/perioperative prophylaxis have been shown to have similar infection rates to longer courses (see Oral cavity and oropharyngeal cancer General surgical principles, p. [link]).

  • Management of wound infection: drainage of pus, debridement, systemic antibiotics for systemic/severe local signs, with best-guess antibiotics followed by adjustment after microbiology results.

Dehiscence/failure of wound healing/fistula

  • Minor dehiscence or wound breakdown is not uncommon, and often has little impact on outcome.

  • Ideally, prevention with meticulous techniques, antibiotic prophylaxis, and good nutritional support is best.

  • Oral dehiscence is often associated with salivary collection/leakage through the neck, requiring nil by mouth (NBM) + enteral feeding approach.

  • There is a risk of neck vessels becoming exposed with danger of major secondary bleeding.

  • Larger wounds can be managed with the over-sewing of pack.

  • More significant defects will need further surgery to cover and seal the oral cavity.

Nerve injuries

  • Phrenic nerve injury: raised (ipsilateral) diaphragm may lead to impaired pulmonary function with ↑ risk of infection.

  • Sympathetic chain injury: Horner’s syndrome.

  • Accessory/cervical plexus injury (see Shoulder and neck problems in Oral cavity and oropharyngeal cancer Late complications, p. [link]).

  • Marginal mandibular branch of facial nerve: weak lower lip (transient or permanent), usually of cosmetic, rather than functional impact.

  • Superior laryngeal nerve injury: weaker voice. Not a common problem declared by patients following neck dissection.

  • Paraesthesia of neck skin, resection bed and peri-auricular region (associated cutaneous nerves from neck dissection or direct nerve resection during tumour ablation).

Flap failure

All flaps should be monitored frequently in the immediate post-operative phase so that circulatory problems can be detected early with a view to successful salvage:

  • Local flaps in the head and neck are usually robust due to the profuse vascular supply.

  • Pedicled flaps such as the PMMF may become compromised due to constriction of the pedicle as it is reflected over the clavicle or beneath a tight skin tunnel in the neck. The constriction may be exacerbated by post-operative oedema. Judicious removal of sutures may be enough to reverse the problem.

  • Free flaps demand close monitoring for the first 48h when problems such as venous engorgement (flap becomes blue and mottled) or arterial occlusion (pale, white flap) are most likely to occur. The latter can be difficult to diagnose, but a reduced or absent pulse can be detected by hand-held Doppler probe. Flap monitoring devices may provide earlier warning for successful salvage. Examples include in implantable Doppler probes and microdialysis. In addition to anastomotic problems external compression (neck haematoma) or systemic disturbance (e.g. hypotension, arrhythmias) may also threaten the flap.

  • Management of flap compromise includes resuscitation if required followed by urgent exploration to identify the cause of the circulatory insufficiency. Where surgical interventions have been exhausted or are not feasible (local flap), venous engorgement may be relieved with leeches, while waiting for collateral circulation to be established (7–10 days). In such circumstances antibiotic prophylaxis is required with attention to haemoglobin levels/fluid and electrolyte balance.

Donor site morbidity (see Oral cavity and oropharyngeal cancer Reconstruction, p. [link]).

Late complications

  • Recurrence:

    • can be local, regional (neck, including contralateral side), or distant (usually lung);

    • risk of recurrence depends on tumour margins, stage of the disease, tumour behaviour, and treatment modality employed; the risk is highest for large tumours;

    • in general, salvage rates are poor, in particular for high-staged tumours and previous combined modality treatment.

  • Altered sensation: in addition to being unpleasant (cold draught, shaving) swallowing can be affected (no oropharyngeal sensory feedback). Most patients adjust to numbness of the skin.

  • Shoulder and neck problems:

    • incidence—up to 80% in radical neck dissections and 50% in selective neck dissections;

    • neck may ache and there is limitation in range of movements;

    • shoulder may be painful (at rest and in motion) with limitation of abduction and flexion;

    • patient may have problems with raising the shoulder and so may be unable to carry out activities of daily living (e.g. combing hair, putting on clothes);

    • shoulder is affected by RND, MRND, and SND in descending order of proportion, as well as severity (quality of life measurements);

    • spinal accessory nerve and cervical plexus may be damaged during surgery (or sacrificed in radical neck dissection), and adhesive capsulitis of the shoulder joint may be a contributory factor;

    • affected shoulder will have an atrophied trapezius muscles, the shoulder girdle will take up an inferior position compared to the contralateral side and there may be hypertrophy of the sternoclavicular joint (shoulder syndrome);

    • management is mainly preventative with careful surgery to preserve the nerves and relevant plexus; progressive resistance exercise training have been shown to reduce shoulder pain and disability;

    • chronic shoulder pain can be debilitating—consider referral to chronic pain specialist to review medications/pain control measures and consideration of nerve/ganglion blocks.

  • Hypertrophic scars: lip split incisions and neck scars are designed to heal well. Most oral cancer patients tend to not worry about their scars (although with decreasing age incidence this may not always be the case). Occasionally, a scar may become hypertrophied particularly with infection or in young patients. Topical silicone gel may help and camouflage referrals should be considered.

  • Lymphoedema:

    • neck and face may be swollen in the early post-operative phase, but tends to settle with time;

    • oedema can affect the face and eyes—tends to be worse in the morning and lessen over the day with gravity-aided drainage;

    • manual lymphatic massage may be useful.

  • Fatigue:

    • common following major surgery (forewarn patient);

    • eliminate organic causes, e.g. anaemia, hypothyroidism;

    • develop a rehabilitation programme where gradual goals are set to build up patients’ confidence and improve their exercise tolerance.

  • Depression: the diagnosis and subsequent treatment of cancer is a major life event. Support from family and close friends will help. The clinical nurse specialist’s input is vital in this area. In some cases medical treatment may be necessary (see Oral cavity and oropharyngeal cancer Psychosocial aspects, p. [link]).

Combined treatment modalities

Usually necessary to improve control of advanced disease and where surgical treatment alone is insufficient (close/positive margins, neck disease, aggressive tumour parameters). Side effects and complication rates will be predictably higher.

Prediction of complications

Identifying those at higher risk of complications, optimizing their pre-existing medical co-morbidities, meticulous surgery, followed by vigilance at an early stage in the post-treatment pathway should reduce the incidence of complications. The use of objective measurements such as ACE-27, ASA may also be beneficial.

Other head and neck cancers

Maxillary sinus tumours

Epidemiology

  • <1% of all tumours.

  • 3% of head and neck malignancies.

  • ♂ > ♀.

  • Most prevalent in 5th decade.

  • Commonly presents late (T3/4 disease).

Risk factors

  • Tobacco.

  • Alcohol.

  • Occupation, e.g. hard wood dust, nickel, benzene.

  • Ionizing radiation.

  • Oncocytic papilloma.

  • HPV.

Classification

Based on site or pathology.

Pathology

  • Benign:

    • osteoma;

    • fibroma.

  • Malignant:

    • epithelial—squamous cell carcinoma (SCC), adenocarcinoma (more common in occupational disease), adenoid cystic carcinoma (ACC), small cell carcinoma, malignant melanoma (MM);

    • osseous—osteogenic sarcoma, Ewing’s sarcoma;

    • connective tissue—chondrosarcoma, fibrosarcoma.

Presentation

  • Nasal symptoms:

    • epistaxis;

    • rhinorrhoea;

    • obstruction.

  • Oral symptoms:

    • pain;

    • palatal swelling;

    • tooth mobility;

    • ulceration.

  • Eye symptoms:

    • epiphora;

    • diplopia;

    • proptosis;

    • ↓ acuity.

  • Cutaneous symptoms:

    • swelling;

    • sensory change (distribution of infraorbital nerve);

    • fixation;

    • erythema.

Investigations

  • OPG.

  • CT (posterior wall/pterygoid involvement).

  • MRI (more sensitive for orbital soft tissue involvement).

Presentation

  • T1: tumour confined to sinus mucosa.

  • T2: tumour invading bone but not posterior wall.

  • T3: tumour invading:

    • posterior wall;

    • pterygoid plates;

    • subcutaneous tissues;

    • orbital floor;

    • infra-temporal fossa;

    • ethmoid sinus.

  • T4: tumour invading:

    • orbital contents beyond floor;

    • naso-pharynx;

    • dura.

Management

  • Surgery followed by radiotherapy if resectable.

  • Consider orbital exenteration (if ocular involvement or post-radiotherapy ocular morbidity predicted to be high).

  • Reconstructive options:

    • obturation;

    • free tissue transfer;

    • implant-retained ocular prosthesis.

Prognosis

  • Local recurrence around 45% (mostly in first year).

  • At presentation:

    • 20% nodal disease;

    • 20% distant metastasis.

  • 40% 5-year survival.

Nasal cavity tumours

Clinical features

  • Epistaxis.

  • Congestion.

  • Obstruction.

  • Swelling.

  • Rhinorrhoea.

Differential diagnosis

  • Benign nasal polyps.

  • Rhinitis.

Treatment

  • Surgery ± radiotherapy.

  • Radiotherapy alone if there are cosmetic concerns.

  • Prognosis.

  • 15% of patients develop second primary—40% in head and neck, 60% subcapital.

Radiotherapy

  • Normally administered as external beam radiotherapy for oropharyngeal tumours in the UK.

  • In parts of Europe interstitial radiotherapy (brachytherapy) is more commonly employed:

    • insertion of iridium wires into the tumour in order to deliver a highly targeted dose of radiotherapy whilst minimizing dose to adjacent normal tissues;

    • in UK practice this technique is usually reserved for those patients who have received a full previous dose of external beam radiotherapy and where all other options have been exhausted.

  • Radiotherapy may be used as the primary modality to treat either the primary site, or the neck, or both. The fields covered and the dose delivered depend upon a complex number of factors, which involve careful planning and calculation. It is also important to decide whether treatment is being given with curative intent (radical) or in order to minimize or prevent symptoms (palliative).

  • Ideally, planning is undertaken on a CT scan that is performed with the patient in the treatment position.

  • A rigid facemask (constructed from moulds) is used to ensure that the head is always placed in exactly the same position in order that treatment is delivered accurately to the prescribed fields.

  • Conventional external beam radiotherapy using mega-voltage photons from a linear accelerator is administered in 2G fractions over each weekday until the prescribed dose is achieved.

  • There is some evidence to suggest that hyper-fractionating the dose to give three fractions per day, rather than one, and accelerating the time over which the total dose is delivered from 6 weeks to 12 days is beneficial.

  • Intensity-modulated radiotherapy (IMRT) utilizes enhanced computerized technology to improve the precision of delivering the radiation dose to the tumour and decreases the dosage to surrounding normal tissues—of particular benefit when delivering radiotherapy to the complex area of the head and neck (Fig. 2.19).

  • Electrons are occasionally used to treat superficial skin metastases or small lip tumours where minimal tissue penetration is required.

Fig. 2.19 Intensity-modulated radiotherapy plan.

Fig. 2.19 Intensity-modulated radiotherapy plan.

Primary treatment

  • As a general rule, most sites in the oral cavity and oropharynx are best managed with primary surgery, with or without adjuvant radiotherapy.

  • For small tumours of the soft palate, tongue base, and tonsil, where the morbidity of the surgery is significant and the cure rates of radiotherapy are high, radiotherapy may be indicated.

  • Where there is evidence of close proximity of the tumour to bone, radiotherapy is contraindicated as it is relatively ineffective and can give rise to osteoradionecrosis.

  • Adenocarcinomas of salivary gland origin are relatively radio-insensitive and should be managed with primary surgery.

  • Radiotherapy may also be indicated outside these criteria when the patient’s physical status contraindicates surgery or where the patient will not consent to surgery.

  • In the clinically N0 neck elective radiotherapy may be indicated to the neck where the primary site has a high incidence of occult metastasis, e.g. tongue and floor of mouth.

  • Where high-risk primary tumours cross the midline consideration should be given to treating bilateral neck fields.

  • Where there is clinical evidence of neck node metastasis, small volume disease without evidence of tumour necrosis may be managed by radiotherapy. However, for large volume disease or where there is tumour necrosis, a neck dissection should be performed prior to adjuvant radiotherapy.

  • Where the primary site might be best managed by radiotherapy due to the morbidity of primary surgery, but where there is bulky neck disease, it is often best to undertake a neck dissection followed by primary radiotherapy to the primary tumour and adjuvant radiotherapy to the neck.

Adjuvant treatment

  • Radiotherapy, in combination with surgery, has been demonstrated to deliver the best chance of cure for most oral cavity and oropharyngeal sites of advanced stage disease. When used in combination with surgery complications are minimized if surgery precedes radiotherapy.

  • Indications for adjuvant radiotherapy following surgery include:

    • close (<5mm) or involved margins at the primary site and where further excision is impracticable;

    • peri-neural or peri-vascular spread;

    • large tumours;

    • poorly differentiated tumours;

    • >1 lymph node involved;

    • extra-capsular spread in a lymph node.

Complications and side effects of radiotherapy

Acute effects

  • Mucositis.

  • Skin erythema or ulceration (Fig. 2.20).

  • Loss of taste.

  • Impaired nutrition and weight loss.

  • Bleeding.

  • Infection.

  • Lymphoedema.

Fig. 2.20 Acute skin reaction during radiotherapy.

Fig. 2.20 Acute skin reaction during radiotherapy.

Late complications

  • Fistula.

  • Impaired healing.

  • Osteoradionecrosis.

  • Impaired swallowing.

  • Impaired speech.

  • Impaired taste.

  • Xerostomia and radiation caries.

  • Susceptibility to dental caries and periodontal disease.

  • Loss of hair.

  • Skin atrophy, telangiectasia, and colour changes (e.g. hypopigmentation).

  • Radiation-induced tumours.

  • Neuropathies.

  • Lens cataracts.

  • Hypothyroidism, e.g. bilateral neck dissections and adjuvant radiotherapy.

  • Fibrosis.

Supportive care during radiotherapy

Nutritional support

Throughout the period of treatment many patients require nutritional support. Whilst, at one end of the scale, some patients will simply require careful dietary advice and possibly oral supplementation, others will require prolonged supplemental feeding with nasogastric tubes (NGTs) or feeding gastrostomies.

Mouth care

During active treatment and beyond, many patients have difficulty maintaining an adequate level of oral hygiene. Specialist hygienists should be available to provide dental hygiene instruction, support patients with fluoride treatments, and provide devices where manual dexterity is poor. A restorative dentist may be required to give expert advice regarding complex dental restorations or support the general dental practitioner in providing appropriate ongoing dental care. Those patients who have undergone radiotherapy require special attention as they are at high risk from dental caries and periodontal disease. If such problems can be minimized and anticipated then the incidence of osteoradionecrosis will be reduced.

Systemic anti-cancer therapies

Chemotherapy

The role of chemotherapy in oropharyngeal malignancy remains controversial. Most regimens rely on a combination of platinum-based drugs, fluorouracil, methotrexate, or the newer taxanes, and in some cases monoclonal antibody therapies, such as cetuximab (epidermal growth factor receptor inhibitor) There is no evidence that any existing regimens are as effective as a standalone curative treatment.

The timing of administration of chemotherapy can be:

  • Neoadjuvant/induction: given prior to radiotherapy or surgery with the intention of improving organ preservation. Little evidence for this and no evidence of survival advantage.

  • Concurrent: administered during the radiotherapy treatment schedule. When used as a primary modality treatment for tonsil, tongue base, and naso-pharynx, appears to offer an 8% survival advantage. Complication rates are high with many patients suffering severe toxicity reactions.

  • Adjuvant: given after radiotherapy or surgery. Survival benefit when used as an adjuvant to surgery is less certain, but when given with radiotherapy as a post-operative adjunct toxicity rates are very high. This should only be used in the context of clinical trials.

Complications of chemotherapy

Acute effects

  • Severe mucositis.

  • Nausea and vomiting.

  • Impaired nutrition.

  • Weight loss.

  • Diarrhoea.

  • Soft tissue necrosis.

  • Bleeding.

  • Hair loss.

  • Neurotoxicity.

  • Immunosuppression.

  • Septicaemia.

  • Neutropenia.

  • Thrombocytopaenia.

  • Multi-organ failure.

  • Neutropenic sepsis is a medical emergency, which requires rapid assessment, and the administration of appropriate IV antibiotics within 1h of presentation. Appropriate protocols must be in place so that these patients receive prompt care wherever they present, which is often not to the oncology treatment centre.

Late complications

  • Nephropathy.

  • Cardiomyopathy.

  • Pulmonary fibrosis.

  • Ototoxicity.

  • Peripheral neuropathy.

Gene therapy

Clinical trials investigating the value of genetically modified viruses that selectively infect and kill tumour cells, are presently being undertaken, but at this stage it is too early to anticipate whether this technology may be of benefit in the management of head and neck cancers.

Prevention

Reduction in population tobacco usage is likely to reduce the incidence of new cases of oral cavity and oropharynx cancer. Recent measures, such as banning tobacco smoking in public places are beginning to show reductions in smoking rates in the population. However, the inherent lead-time of carcinogenesis means that these effects will take many years to manifest. This disease can also be prevented by modification of alcohol consumption. One intriguing new area is vaccination against HPV-16. Given the current vaccination policy in the UK to vaccinate females only, there is a case–control (if sex biased) study in progress in the population already.

Nutritional support

It is well documented that malnourished patients perform less well following surgery than their nourished counterparts. They take longer to recover and suffer more complications. Over 25% of hospital patients are malnourished due to a variety of reasons. Identification of such patients is not always easy. Prevention of malnourishment is paramount.

Caloric needs

Most patients require 2000–2500kCal (20–40kCal/kg) and 7–14g of nitrogen every 24h. It is rare for even catabolic patients to exceed these requirements. Very high caloric diets can lead to fatty liver. Dietetic input is a must.

Nutritional support for oral cancer patients

  • Over 50% of head and neck cancer patients are malnourished because of the disease itself (e.g. pain, poor appetite, dysphagia), their pre-morbid lifestyle (e.g. excess alcohol and smoking, poor diet, poor social support) and co-morbidities, which affect their well-being and nutrition).

  • Cancer-related malnutrition is likely to be multifactorial and has a negative prognosis.

  • Side effects from cancer treatment (e.g. mucositis) will further exacerbate the problem.

  • A vicious cycle of deficient nutrition with gastrointestinal consequences may develop. The immune system may also become depleted, making the patient more susceptible to infections.

  • Malnourishment may be due to nutritional and/or swallowing difficulties.

  • Management of patients should be multidisciplinary, with dietetic and speech and language therapy (SALT) input.

Problems specific to oral cancer

  • The cancer itself: pain, restricted mouth opening, difficulties with mastication and swallowing.

  • Surgical treatment: further exacerbation of the aforementioned functions with ablation (severity depends on site, extent of resection, and reconstruction employed), scarring, altered sensation, and loss of teeth.

  • Radiotherapy or chemoradiation: mucositis, loss of taste, xerostomia, fibrosis, abnormality in motility and function of pharynx and oesophagus.

  • Combined treatment regimens will compound side effects.

Assessment

  • Detailed history and clinical assessment:

    • food intake;

    • weight change;

    • appetite;

    • ability to eat;

    • presence of nausea, vomiting, or diarrhoea;

    • psychological state;

    • risk factors associated with disease or likely treatment.

  • Look for dehydration and signs of malnourishment, e.g. loss of fat in skin folds, rough wiry hair.

  • Measure body mass index (BMI) = weight (kg)/height (m²). Normally 20–25. If <19 consider malnourishment.

Other investigations

Include:

  • Serum albumin.

  • Total lymphocyte count.

  • Body fat—generally unhelpful in routine practice.

Swallowing assessment

Dysphagia is assessed clinically and with the aid of special investigations such as videofluoroscopy and fibre-optic endoscope examination (see Oral cavity and oropharyngeal cancer Swallowing in oral cancer, p. [link]).

Nutritional support

Nutritional interventions and advice can positively influence outcomes. Three levels of nutritional support exist:

  • Meal fortification: after assessing the patient’s current intake and nutritional requirement, oral intake can be improved with advice and support, e.g. prescription of type, amount, and frequency of diet, and alleviation of symptoms affecting swallowing.

  • Oral nutritional supplements: indicated if a patient fails to meet nutritional requirements in spite of advice and support. There are a variety of liquid and powdered preparations high in energy, protein, vitamins, and minerals. They can be used as adjuncts or in isolation. Their often bland consistency and monotonous nature can result in taste fatigue and negatively affect compliance.

  • Non-oral feeding: whenever possible the oral route should be employed. If the swallow is not safe, try thickeners first (with SALT input) before using non-oral routes.

Enteral feeding

Nutrition administered by the stomach or jejunum via a tube. This route should be considered if the oral intake is inadequate (usually short term). It is ideal as oral cancer patients tend to have normal gut function. Enteral feeding includes:

  • NGT feeding:

    • usually via a fine-bore tube for comfort;

    • short-term option;

    • narrow tube diameter is reflected in longer feeding times;

    • complications include incorrect site placement, risk of aspiration, tube blockage, infections, and obvious visibility on the face.

  • Gastrostomy tube feeding:

    • placement of a tube from the abdominal surface into the stomach for feeding;

    • appropriate for longer-term use;

    • associated with reduced risk of displacement and blockage compared with NGT;

    • can be easily concealed beneath clothes;

    • complications include bleeding, wound infection, separation of stomach from abdominal wall with resulting leakage and peritonitis.

Types of gastrostomy tube

  • Percutaneous endoscopic gastrostomy (PEG): placed under local anaesthetic and sedation with the assistance of an endoscope. Its use before treatment of oral or pharyngeal cancer has rarely been associated with implantation of oral tumour into the abdominal wall if the pull-through technique is adopted.

  • Radiological-inserted gastrostomy (RIG): alternative technique that requires the stomach to be inflated via an NGT and external puncture with aid of radiological imaging. The technique avoids disturbing the oropharyngeal region (cancer, recent reconstruction, restricted mouth opening).

Parenteral feeding

Intravenous feeding has significant risks. In oral cancer the gut is usually functioning and parenteral feeding is rarely required.

Placement of NGT

Check NGT feeding is right decision for patient, right time to place with appropriate equipment available and sufficient knowledge or expertise available to make sure it is safe.

  • Preparation:

    • explain procedure to patient;

    • use an aseptic technique;

    • position patient almost upright (50–60º) with neck in neutral position;

    • apply topical LA to the nose (optional);

    • measure the radio-opaque fine-bore tube to know when to stop passing (reach stomach) by measuring the end from the xiphisternum to tragus of ear and the across the cheek to the alar rim.

  • Procedure:

    • pass lubricated (with aqueous gel) tube along the floor of the nose until its tip reach the naso-pharyngeal wall (encounter resistance);

    • ask patient to swallow and with gentle pressure the tube should pass downwards into the pharynx;

    • do not allow the patient to tilt their head back as this may encourage the tube to go into the trachea instead (a pillow to prop the head can help);

    • encourage the patient to swallow as the tube will pass more easily with the peristalsis;

    • once the desired length is reached the tube is secured with taping and record the external tube length in the appropriate notes.

  • Check position:

    • previous guide wire should be left in situ for radiological confirmation of tip beneath the diaphragm. A radio-opaque tube will be visible on the CXR;

    • pH testing is the first-line test method to confirm the NGT is in correct position (safe range pH between 1 and 5.5). Record whether aspirate obtained, its pH, and who checked and confirmed safe to administer feed/medication;

    • do not use litmus paper or air insufflation & auscultation of air turbulence method (National Patient Safety Agency);

    • CXR confirmation is second-line test method.

  • Caution: if patient complains of a sharp pain in chest during the procedure, stop, and withdraw as the tube may have passed down a bronchus.

  • Side effects: include nausea, vomiting, osmotic diarrhoea, tube blockage, or displacement.

  • Use: the feed is started with water before gradual building up to liquid low-residue food. A pump can be used for the feed. Check local policy for monitoring. Repeat checks will be made before each feed, administration of medication, and at least once daily as well as any signs or symptoms of suspected displacement.

Speech and language therapy

Role of oral cavity and pharynx in speech

Voice production is dependent on a steady flow of expired air from the lungs. The passage of air through the vocal folds causes a wave-like motion of the cords. The consequent air molecules vibrate creating sound (phonation).

Speech is formed by the active movement of the articulators (soft palate, tongue, and lips) that modifies the shape of the vocal tract. These changes in vocal tract shape cause the acoustic waveform to form into vowels and consonants. In order to produce clear articulation and smooth speech, the structure and function of the vocal tract must be intact.

Articulation of consonants

Consonants are produced by creating an obstruction of the air stream through the vocal tract. They are classified according to the place of articulation and manner of obstruction. They can be voiced or voiceless (no vibration when passed through vocal folds). The consonants may be oral or nasal (depend on position of soft palate and amount of nasal airflow).

In the English language, places of articulation are bi-labial (between lips, e.g. p, b, m), labiodental (lower lip to upper front teeth, e.g. f, v), dental (tongue tip to front teeth, e.g. th), alveolar (tongue tip to behind front teeth and alveolus, e.g. t, d), palatal (front of tongue and hard palate, e.g. ch, j) and velar (back of tongue and hard palate, e.g. k, g).

Three common manners of articulation exist:

  • Plosives: complete closure of articulators, e.g. p, t, k, b, d, g, m, n, ng.

  • Fricatives: closed approximation of articulators causing turbulence, e.g. s, sh, f.

  • Approximants: approximation of articulators, but no turbulence, e.g. r, j.

Articulation of vowels

Vowels are specified according to the position of the highest point of the tongue in the vocal tract, degree of lip rounding, or spread causing changes in the resonance of the vocal tract.

Effect of oral cancer and its treatment on speech

  • Any alteration of the physiology and anatomy of the system due to oral cancer and its subsequent treatment can give rise to:

    • dysphonia (impaired voice production); or

    • dysarthria (any weakness, slowness, or inco-ordination of speech production).

  • Speech, like swallowing, will be affected and cause problems with communication, psychosocial interaction, and impaired quality of life.

  • Common sites affected by oral cancer are the tongue, floor of mouth, mandibular alveolus, tongue base, and palate.

  • Speech will be affected depending on the site and size of the index tumour, mobility of the residual tongue or oral structures, presence or absence of teeth, and type of reconstruction. Other factors include age, hearing, pre-existing co-morbidities, and motivation.

  • Poorer speech outcome is more likely with large tumours, restricted or absent residual tongue movements, poor oral seal, or absent teeth, all of which will produce difficulties in articulation.

  • Tumours of the tongue base or soft palate can produce hypernasality, solid or liquid escape through the nose, and difficulty with oral plosives.

  • Maxillectomy patients often have hearing problems, with Eustachian tube dysfunction causing middle ear effusions.

  • Radiotherapy may contribute to speech problems as a result of xerostomia. Hearing defects can also occur from auditory canal inflammation, wax build-up, otitis media, fibrosis, and neuromuscular dysfunction.

  • Chemoradiation causes much higher acute toxicities compared to radiotherapy. When used to treat non-laryngeal head and neck cancer, its effect on voice and speech can be long term.

The role of speech and language therapist

Involvement of SALT on the patient journey is well proven to have better speech and swallowing outcomes:

  • Pre-operatively:

    • review what the patient understands and expects;

    • assess pre-operative communication;

    • prepare for the subsequent effects for treatment;

    • co-ordinate a rehabilitation plan.

  • Post-operatively:

    • reinforce pre-operative information;

    • assess communication impairment;

    • provide exercises and support;

    • liaise with clinicians including prosthetic rehabilitation and audiology referral.

The aim is to maximize residual function, develop compensatory mechanisms, suggest substitutes for sounds that are impossible to achieve, and provide appropriate communication aids or strategies. As impaired communication can be devastating on a psychosocial basis, support is important. Liaison with other specialities, such as otolaryngology, audiology, and prosthetic/restorative dentistry may be necessary.

Swallowing in oral cancer

Normal process of swallowing

An anatomically intact and physiologically functioning oral cavity and pharynx is necessary for swallowing to take place normally. Swallowing is a complex process where food is carried from the oral cavity through the pharynx into the oesophagus and stomach. Once initiated it becomes an involuntary, reflex process.

  • Oral stage:

    • this voluntary phase begins with entry of food or fluid into the oral cavity, and ends with start of the pharyngeal phase;

    • food is mixed with saliva to turn it into a consistency suitable for swallowing. For this process to occur normally it requires a competent lip seal and ability to manipulate food with saliva using oral cavity structures (jaws, teeth, tongue, floor of mouth, cheeks, and palate);

    • the mobile oral tongue is important in moving the food bolus around and propelling it backwards into the pharynx.

  • Pharyngeal stage:

    • arrival of a food bolus into the pharynx triggers an involuntary process where the airway inlet is closed with a temporary cessation in breathing to prevent food entering the lungs (larynx is raised, epiglottis displaced backwards and glottis closed);

    • soft palate elevates with pharyngeal wall contraction to seal off the nose (velopharyngeal seal);

    • tongue base contracts and with the pharyngeal constrictor muscles produces a peristaltic wave that pushes the bolus down into the oesophagus;

    • cricopharyngeus muscle relaxes to allow entry into the oesophagus.

  • Oesophageal stage: food bolus is propelled down the length of the oesophagus into the stomach as part of an involuntary process.

Impact of oral and oropharyngeal cancer

A large proportion of patients with oral and pharyngeal cancer will have swallowing problems. These problems may have significant impact on their recovery, physical, and emotional well-being, as well as psychosocial interactions. The standard curative treatment for early oral cancer is to try and embody one treatment modality only. The choice of that treatment modality will depend on site of tumour, and to some extent preference of MDT or patient. More advanced disease is usually treated with surgery and reconstruction followed by adjuvant radiotherapy. There is a trend towards chemoradiotherapy in the desire for organ preservation in oropharyngeal cancer. However, organ preservation may not be synonymous with preservation of function. All current treatment modalities have significant impact on swallowing.

Effect of cancer on swallowing

Oropharyngeal cancer may cause pain, as well as alteration in the anatomical and physiological functioning of eating and swallowing. As a result the nutritional status of an individual may be adversely affected.

Effect of surgery on swallowing

This is well documented and can manifest itself in the first few months. The effect of surgery on swallowing depends on site, size of resection, mode of reconstruction, and loss of cranial nerve function. Swallowing problems following surgery are more likely with:

  • Pre-treatment swallowing dysfunction.

  • Larger resection.

  • Posteriorly-placed tumours (e.g. base of tongue, soft palate).

  • Existing co-morbidities.

  • Reconstruction (may also be due to size, sensate flap may help).

  • Combined treatment (e.g. adjuvant radiotherapy).

For glossectomies, ensuring residual tongue mobility is important to maximize function. Patients who have undergone surgery have ↑ oral preparation times (impaired chewing), slower oral transit times, residual food bolus, and risk of aspiration.

Effect of radiotherapy on swallowing

Although there is no removal of tissue the effects of radiotherapy on swallowing occur on a more gradual basis. The effects are dependent on:

  • Total radiation dose.

  • Fraction size.

  • Radiated volume.

  • Site and size of tumour.

  • Treatment technique.

  • Whether patient continues to smoke.

  • Combined modalities.

Swallowing is affected acutely (after 10–14 days onwards) because of pain, mucositis, loss of taste, and lethargy. Late complications such as xerostomia, fibrosis, and neuromuscular dysfunction are delayed contributory factors to dysphagia.

Effect of chemoradiotherapy on swallowing

The addition of chemotherapy to radiation is associated with greater acute toxicity side effects in addition to nausea and vomiting. The resultant dysphagia (acutely and possibly more severe long term) are similar to radiotherapy alone, i.e. ↑ oropharyngeal transit times, ↓ tongue base contact with posterior pharyngeal wall, reduced laryngeal elevation, ↑ bolus residue, abnormal oesophageal sphincter function, and aspiration (attributed to xerostomia, fibrosis, and neuromuscular dysfunction).

Dysphagia and aspiration

The main problems following treatment are dysphagia (difficulty in swallowing) and aspiration (penetration of food/fluid through laryngeal inlet into lungs). Both are symptoms of abnormal oral and pharyngeal phases of swallowing. Bolus residue is contributory to aspiration, and a consequence of swallowing dysfunction and altered sensation. In the acute stage the presence of an indwelling tracheostomy tube may exacerbate dysphagia.

Assessment of swallowing

Bedside assessment

A trained SALT:

  • Takes a history.

  • Assesses the gag reflex, voluntary and reflex cough, vocal quality and volume, reflex and voluntary swallow, posture, respiration, oral motor strength, and range of motions.

  • Observes swallowing using a standardized dysphagia evaluation protocol with different food consistencies—the swallow performance can be classified.

Aspiration may be clinically apparent or inferred. However, silent aspiration can still take place leaving the dilemma of whether to restrict oral intake or not.

Methods of further investigation

  • Videofluoroscopy: this modified barium swallow is the cited gold standard in swallow assessment and allows for a descriptive dynamic study, as well as objective measurements of swallowing functions, such as transit times, detection of bolus residue, and aspiration.

  • Fibreoptic endoscopic evaluation: this can be used to enhance a bedside assessment, offering a view different from videofluoroscopy. It cannot demonstrate the oral phase, but does not involve radiation. The goal of this assessment is to determine the presence and cause of any aspiration, and determine whether behavioural therapy is available to eliminate aspiration.

Manoeuvres to help improve swallowing

  • Chilled food to help re-educate lost sensation.

  • Encourage chewing or manipulation of bolus in mouth to facilitate initiation of swallow reflex.

  • Altering the temperature, taste, and texture of food in a meal to keep awareness of swallowing process high.

  • Place food in parts of mouth where sensation is intact.

  • Viscous boluses (e.g. thickened liquid and purees) will enable poorly co-ordinated muscles to produce a more effective swallow than with thin liquids.

  • Head or body tilting in the appropriate direction can utilize gravity in the swallowing process.

Hints or risks of aspiration

  • Wet or gurgling noises with breathing—fluid in the airways.

  • Altered voice during eating—food on vocal cords.

  • Cough associated with swallowing.

  • Fatigue during a meal.

  • Lower cranial nerve palsies.

  • Extensive resections.

  • Aspiration pneumonia.

It is important to seek urgent advice of SALT if appropriate. Ideally, patients should be continually assessed and followed up throughout their care.

Strategies for reducing risk of aspiration

  • Patient should not eat unattended.

  • Patient should eat sitting upright—body or head tilt may be useful.

  • Avoid distractions at meal times.

  • Other techniques (depends on that particular situation):

    • turning head towards paralysed side of face, tongue, or treated neck (encourage passage down competent side);

    • flexing neck while swallowing;

    • double swallow;

    • supra-glottic or super supra-glottic swallow (SALT).

There is variable tolerance of aspiration between individuals and diagnostic groups. The incompetent swallow will need careful evaluation and NBM if considered a serious risk and therapeutic support/interventions.

Strategies to reduce dysphagia

Treatment of established dysphagia is difficult and rarely effective. Methods to prevent or reduce dysphagia include:

  • Swallowing exercise regimen (compliance reduces incidence of tube dependency).

  • Treatment modifications such as IMRT (sparing salivary glands and other critical swallowing structures, i.e. oral cavity, supraglottic and larynx, and pharyngeal constrictors).

  • Radioprotectors—mixed evidence in reducing xerostomia.

  • Technical advancements such as volumetric intensity modulated arc therapy and image guide radiotherapy may be beneficial.

Prognosis

There are few qualitative long-term studies in this area. Nevertheless, patients at high risk of swallowing dysfunction should be counselled pre-treatment. Patients are supported for some months following treatment when the healing is completed, residual swelling reduced, and main radiotherapy effects seen. It is concluded when both patient and SALT feel a maximum swallowing potential had been reached.

Alternative feeding routes

If the risk of aspiration is real and significant then the patient cannot take food orally. The enteral feeding routes will need to be used instead, e.g. nasogastric or gastrostomy tubes (see Oral cavity and oropharyngeal cancer Nutritional support, p. [link]).

The issue of optimal feeding method (nasogastric vs gastrostomy tube feeding) remains unclear in a recent systematic review. There is a variable approach with prophylactic and reactive gastrostomy tube placement instead of nasogastric tube feed. Prophylactic gastrostomy tube placement is associated with earlier better nutrition, earlier weight gains, and less hospital admissions. There are associated risks with procedure. Concerns with prolonged tube dependence and long-term dysphagia are additional reasons for a reactive gastrostomy tube practice.

Psychosocial aspects

Today’s society puts increasing emphasis on physical attractiveness and, thus, the face and mouth are central to social interaction. Oral cancer treatment can result in facial disfigurement and alteration of function, e.g. impaired speech, eating, or swallowing, and loss of non-verbal cues due to paralysis. These can have profound effects on the patient through altered body image, loss of self-esteem, negative feelings (e.g. depression, loneliness, anxiety), and loss of sexuality or sexual functioning. People’s reaction to facial disfigurement or abnormal communication cues can sometimes be obvious, and in so doing appear rude. This can result in the patient feeling stigmatized. Chronic pain will exacerbate any element of depression. Patients may become more sensitive to adverse reactions, react with aggression, and seek refuge by avoiding social interactions or use alcohol and drugs excessively.

Improving psychosocial outcomes

Depression

Depression is not always easy to detect as it shares some similar symptoms to fatigue and other consequences of cancer treatment. Input from the clinical nurse specialist is invaluable. The use of simple tools, like the Hospital Anxiety and Depression Scale (HADS), concern checklists, and quality of life measurements may help identify patients at risk. These patients should be given appropriate support and coping strategies. If necessary, they can be referred for psychological counselling.

Coping strategies

Psychosocial outcomes can be improved by:

  • Developing confidence in performing new self-caring skills, e.g. gastrostomy tube or prostheses care.

  • Confronting and acceptance of changed body image.

  • Teaching interventions to maximize recovery, e.g. physiotherapy and speech exercises.

  • Teaching adaptations (occupational therapy).

  • Providing nutritional and communication support (dietician and SALT).

  • Rehearsal of public encounters/questions and responses.

  • Educating family to improve support.

  • Encouraging active participation in support groups.

It has been shown that the majority of head and neck cancer patients have psychological problems and a perceived poorer quality of life compared with other cancer patients. Psychosocial support and interventions are as important as a patient’s physical care since improving outcome in these often neglected areas can maximize their level of functioning, social interaction, and therefore quality of life.

Health-related quality of life

Oral cancer and its treatment have a profound effect on patients. They may have physical, functional, psychosocial, and cosmetically disfiguring problems. Traditional outcomes have centred on control of disease and survival. Clinician-centred feedback and questionnaires tended to under-report patient problems and may even have been irrelevant from patients’ point of view.

Although ultimate survival remains relevant, an increasingly important measurement of outcome is quality of life (QOL). This commonly used term is recognized by lay people, often implies a sense of well-being, and is associated with patient satisfaction. It is a difficult term to define and is best considered as a multidimensional concept. Even when applied to health its definition remains controversial. In addition to areas such as physical, functional, psychological, and social functioning, other aspects to consider include economic/financial, occupational, and domestic/family (including sexuality) domains.

Many QOL tools have been proposed. There is no ideal QOL questionnaire. In order to measure outcome, the chosen QOL questionnaire should be acceptable, valid, reliable, and respond to the questions being asked, i.e. fit for purpose, as well as practical to use.

Health-related quality of life (HRQOL)

HRQOL is considered to be a specific subset of QOL, assessing symptoms, psychological aspects, and function in a structured way. It is used in many aspects of healthcare including cancer. There are many HRQOL tools available. They are now often questionnaire based and self-completed by patients. They can be used in a cross-sectional or longitudinal manner.

Other methods include semi-structured interviews and qualitative approaches. These are more time-consuming and can be influenced by the interviewer.

HRQOL tools used in head and neck cancer

In addition to global domains, HRQOL questionnaires commonly include head and neck specific domains. Even within the head and neck cancer questions there is recognition that oral cancer (and its subsequent treatment) will have influences on other sub-sites.

There are three commonly used HRQOL questionnaires.

University of Washington Quality of Life (UW-QOL)

  • An extensively used (and validated) patient-based, self-administered questionnaire consisting of 15 questions.

  • 12 disease-specific items (pain, appearance, activity, recreation, swallowing, chewing, speech, shoulder problems, taste, saliva, mood, and anxiety).

  • 3 general items measuring global HRQOL.

  • An importance rating section is included, where patients rate which domain changes were most significant to them.

  • There is also a free-text section allowing patients to address any issues not otherwise covered, as well as the clinician’s insight into patient’s concerns.

  • Disease-specific questions are scored 0 (worst) to 100 (best) with the 3 global questions being scored separately.

  • Considered a broad-based assessment of disease-specific functional status, suitable for routine low-cost use, and remains the most common questionnaire used by head and neck cancer surgeons.

EORTC QLQ Head and Neck-35 (QLQ-H&N 35)

  • Another extensively used (and validated) patient-based, self-administered questionnaire to assess head and neck cancer patients.

  • 7 domains (pain, swallowing, senses, speech, social eating, social contact. and sexuality) as well as 11 single items inquiring about dental problems, restricted mouth opening, sticky saliva, cough, feeling ill, analgesic use, nutritional supplement use, feeding tube, and weight loss/gain.

  • Used in conjunction with EORTC QLQ-C30, making it relatively long and more time-consuming for patients.

Functional Assessment of Cancer Therapy Scale (FACT-HNS)

  • This reliable and responsive questionnaire has been used in numerous head and neck cancer studies.

  • Contains 11 specific items covering topics, such as eating, swallowing, appearance, smoking, and alcohol habits.

  • Scored on a 0–4 Likert scale.

Factors affecting HRQOL in oral cancer

When followed over time the HRQOL of oral cancer patients decreases at 3 months after treatment before recovering to approach or attain pre-operative levels around 1 year after surgery (pattern for most site-specific issues except senses, mouth opening, saliva consistency, and coughing, all of which remain poor in the long term). The 1-year score is indicative and usually stays at that level over the longer term.

Factors associated with poorer HRQOL in treated oral cancer patients include:

  • Posterior tumours.

  • Advanced overall stage or T stage.

  • Pre-treatment depression.

  • Presence of co-morbidities.

  • RND.

  • More complex reconstruction.

  • Need for gastrostomy tube feeding.

  • Combine treatment (surgery + radiotherapy or chemoradiotherapy).

HRQOL measurements can be used to help:

  • In the process of treatment planning (patients and clinicians).

  • Provide patients with an overview of their proposed treatment, side effects, and recovery trajectory.

  • Evaluate therapeutic (curative and palliative) interventions.

  • Identify individual patient’s needs for additional supportive interventions, i.e. as a screening tool (e.g. Patients Concerns Inventory).

  • Identify areas for audit and research.

HRQOL provides a structured insight into the patient’s perspective. It has been demonstrated to be an effective and useful measurement of outcome. However, its use as a routine and universal clinical measurement tool is hampered by time constraints, manpower restrictions, traditional emphasis on survival and complication rates, and difficulty in deciding which validated HRQOL tool to use. This aside, its use in research continues to progress significantly. The ready availability of electronic data capture and immediate analysis with the aid of touch-screen technology along with clinic tools such as the Patients Concerns Inventory will increase the usefulness and acceptability of HRQOL assessment within day-to-day practice. HRQOL measurement will be essential to help evaluate efficacy of newer treatment options, symptom management, and long-term cancer survivor issues.

Palliative care

Palliative care is the active total care of patients whose disease is not responsive to curative treatment. Its aim is to achieve the best QOL for the patients and their relatives. The key principles of palliative care are:

  • Management of pain and other symptoms.

  • Disease management.

  • Provision of psychological, social, and spiritual support.

Oral cancer

The prognosis for oral cancer depends on many factors. Early stage disease if treated effectively has a 5-year survival of 80–90%. Stage 4 disease has a much poorer prognosis, with survivals of <30%. Although loco-regional control has improved with time, the overall survival rates (~55%) have remained static due to distant metastases and second primaries. Recurrence often heralds a poor prognosis.

Problems faced by terminal oral cancer patients

Oral cancer patients with incurable disease often have highly symptomatic problems, poor social or family support, addictive alcohol problems, and their palliative care can be challenging.

General problems

  • Fatigue.

  • Anorexia.

  • Disturbed sleep.

  • Weight loss and feeding problems.

  • Anxiety and depression.

  • Psychosocial problems.

  • Existing addictive problems with alcohol and smoking.

Head and neck specific problems

  • Pain.

  • Shoulder dysfunction.

  • Disfigurement and stigmatization (may lead to social isolation).

  • Speech, hearing, and communication problems.

  • Dysphagia.

  • Oral problems:

    • loss of teeth (impact on chewing and eating);

    • dry mouth/sticky saliva;

    • diminished taste;

    • infections, caries, and osteoradionecrosis.

  • Fistulae (cutaneous or mucosal).

  • Fungating and malodorous tumours.

  • Bleeding.

Communication

In order to achieve good palliative care there must be effective communication conducted in appropriate setting. The patient should be given time and space to voice his or her problems and fears. The clinician needs to listen with empathy, clarify the patient’s physical, emotional, and psychological needs, allay any fears, and correct any misconceptions. This approach will enable the patient to feel understood and cared for. His or her needs can be met where possible and informed choices made for the future, e.g. resuscitation, etc.

Prognostication of end of life

This is notoriously difficult to predict accurately. There are many good reasons for both patients and clinicians wanting to know when life is likely to end, e.g. for patient and family to plan ahead, provide insight for patient, help clinicians in treatment plan/care, establish patient’s eligibility for care programmes, and financial support packages. However, there are many hazards of getting it wrong. There has been a shift in attitudes with increasing patient expectation and, in response, clinicians being more open/candid in their disclosures. It is importance to put emphasis on QOL, rather than merely lengthening it chronologically.

Management of symptoms

Pain

Two-thirds of patients with advanced disease often have pain. Pain in oral cancer can be due to local tumour infiltration causing ulceration or infection, vascular and lymphatic occlusion, nerve involvement, referred pain, or treatment-related (e.g. mucositis). It is important to try and evaluate the type(s) of pain. Pains are often mixed, but mainly:

  • Nociceptive:

    • arising from stimulation of peripheral nerves transmitted from an undamaged nervous system;

    • often described as aching in skin or deeper tissues (account for three-quarters of pain type in studies).

  • Neuropathic:

    • arising from damage to the peripheral or central nervous system;

    • may present with hyperalgesia and allodynia;

    • often described as burning or stabbing.

Assessment

Take a detailed history, examine for masses, joint problems, dental and oral causes, cranial nerve involvement, etc. Investigations where appropriate, e.g. radiological.

Management

  • Nociceptive pain: usually respond to analgesics.

  • Neuropathic pain: may only partially respond to opioids.

Pain control is aimed at removing cause if possible and pain relief provided in line with the WHO analgesic ladder:

  • Step 1: non-opioids ± adjuvants:

    • paracetamol 1g every 4–6h regularly, maximum 4g over 24h;

    • if this does not work after 24h move up ladder.

  • Step 2: weak opioids + non-opioids ± adjuvants. Paracetamol 1g and codeine (30mg not 8mg) or dihydrocodeine regularly every 4–6h.

  • Step 3: strong opioids + non opioids ± adjuvants:

    • morphine 5–10mg every 4h (NB 60mg codeine equi-analgesic with 5mg morphine every 4h);

    • if pain controlled and no significant side effects (e.g. drowsiness, hallucinations, confusion, vomiting, myoclonus, pin point pupils) titrate dosage upwards (no more than 30–50%) every 24h until pain controlled;

    • give up to 50% more than usual late evening dose if woken up with pain;

    • give prophylactic laxative;

    • if nausea or vomiting give anti-emetics or consider alternative opioid;

    • if acute overdose, e.g. significant respiratory depression, consider naloxone (NB shorter half-life than opioids).

Adjuvants

These co-analgesics if combined with analgesics can enhance pain control:

  • Steroids: oedema pain.

  • Antidepressant or anticonvulsant: neuropathic pain.

  • Non-steroidal anti-inflammatory drug: inflammation.

  • Night sedative: if lack of sleep/reduced pain threshold.

  • Muscle relaxant: cramps.

  • Anxiolytic: anxiety.

  • Antibiotics: infection.

Breakthrough pain

  • If occurs before next dose due consider increasing background dose.

  • If associated with predicted activity give analgesia prior to it.

  • Consider slow release preparation.

  • If poor absorption or unable to take orally consider transdermal or transmucosal preparations, e.g. fentanyl.

Other methods of pain relief

  • Tumour mass reduction with surgery, radiotherapy, or chemotherapy.

  • Radiotherapy for bone metastases.

  • Nerve blocks.

  • Transcutaneous electrical nerve stimulation (TENS).

  • Acupuncture.

  • Psychological interventions.

Oral problems

  • Restricted mouth opening and paraesthesia.

  • Dry mouth/sticky saliva (xerostomia).

  • Mucositis with resultant poor oral hygiene.

  • Infections.

  • Fungating tumour.

Management

  • Oral hygiene care and adequate hydration.

  • Relief with sugar-free drops, pineapple chunks/juice.

  • Prescription of artificial saliva, sialogogues, pilocarpine.

  • Treatment of infection.

  • Treatment of mucositis: topical LA preparations, coating agents, steroids, or anti-inflammatory agents plus analgesia.

Communication problems

Problems with speech and hearing are common. Pharyngeal surgery or maxillectomy can cause Eustachian tube dysfunction. Empathy, time, and space are essential to lessen the impact. Regular input from SALT and communication aids are vital.

Dysphagia

Tumour mass or the effect of previous treatments may necessitate consideration of a gastrostomy tube placement. This can be a difficult decision with ethical dilemmas to consider, in particular if the end point is not clear-cut. A systematic evaluation is necessary to ensure treatable causes are not missed.

Respiratory obstruction

Obstruction of a tracheostomy tube may be due to secretions, crusting, displacement, or granulation tissue.

  • Prevent with humidification and good tracheostomy tube care.

  • Warning signs include:

    • increasing secretions;

    • difficulty with expectoration;

    • bleeding;

    • stridor.

Management of airway obstruction

  • Summon help.

  • Sit patient up and ask to cough.

  • Use suction.

  • Manipulate head to reduce any kinking of tube.

  • Give oxygen.

  • Remove inner tube and apply suction.

  • If terminal care advised and obstruction persists sedation should be considered to lessen the impact of the inevitable.

Fungating and malodorous tumours

A visibly fungating tumour will affect the patient, and his or her contacts, both physically and emotionally. There may be fistula formation and salivary leakage. Eating and drinking may become impossible.

Management

  • Reduce secretions with medication (but side effects).

  • Consider palliative radiotherapy, chemotherapy, or surgery.

  • Good wound care is mainstay treatment.

  • Debridement and desloughing.

  • Saline irrigation and frequent dressing.

  • Ensure good room ventilation and external deodorizers.

  • Frequent bedsheet or clothes changes.

  • Topical antibiotics (e.g. metronidazole gel) or other agents (e.g. flamazine, activated charcoal preparation, live yoghurt, honey).

  • Systemic antibiotics if signs of infection.

Major bleeding

Main source of major bleed is usually the carotid artery or its branches. The vessel wall may be breached by direct tumour invasion, post-operative infection, erosion by tracheostomy tube, or may be a late effect of radiotherapy. A sentinel bleed may herald a forthcoming carotid rupture.

Management

  • Resuscitation, stenting, or open surgical interventions, but may merely postpone the inevitable.

  • Forewarning patients and their carers: a difficult issue (where they can cope, being prepared may lessen the impact).

  • Avoid inappropriate resuscitation. This can happen if unfamiliar healthcare personnel are involved.

  • Adopt a reassuring confident approach (even if you don’t feel it!).

  • Prepare enough dressings/towels to contain the spillage (if anticipate).

  • Intravenous sedative (5–10mg midazolam) with strong opioid analgesia (diamorphine) to lessen the impact for patient.

Terminal phase

This is defined as the period when day-to-day deterioration, particularly strength, appetite, and awareness, is occurring.

Key aims of terminal care

  • Ensure the patient’s comfort physically, emotionally, and spiritually.

  • Make the end of life peaceful and dignified.

  • Provide support to the close ones.

Hospices

The proportion of patients dying at home is declining in the UK, while the proportion dying in hospital is conversely increasing. This shift may be due to increasing reliance on technology, social changes within the family, or the lesser availability of community or pastoral support.

The majority of terminally ill head and neck cancer patients deteriorate gradually with their demise being precipitated by bronchopneumonia or co-morbidity-related issues. Hospices and associated palliative care teams input are important in helping ease suffering for terminally ill patients. Other reasons for admission to hospices include pain and symptom control, respite, or intermediate care, e.g. for convalescence following radical radiotherapy.

Further reading

Bleier, B.S., Levine, M.S., Mick, R., Rubesin, S.E., Sack, S.Z., McKinney, K., et al. (2007). Dysphagia after chemoradiation: analysis by modified barium swallow. Ann Otol Rhinol Laryngol 116(11): 837–41.Find this resource:

Dwivedi, R.C., Kazi, R.A., Agrawal, N., Nutting, C.M., Clarke, P.M., Kerawala, C.J., et al. (2009). Evaluation of speech outcomes following treatment of oral cancer and oropharyngeal cancers. Cancer Treat Rev 35: 417–24.Find this resource:

D’Souza, G., Kreimer, A.R., Viscidi, R., Pawlita, M., Fakhry, C., Koch, W.M., et al. (2007). Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med 356: 1944–56.Find this resource:

Feber, T. (2000). Head and neck oncology nursing. Whurr Publisher Ltd, London.Find this resource:

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    Grobbelaar, E.J., Owen, S., Torrance, A.D., and Wilson, J.A. (2004). Nutritional challenges in head and neck cancer. Clin Otolaryngol 29: 307–13.Find this resource:

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                    Support resources

                    Cancer BACUP. Available at: Oral cavity and oropharyngeal cancer http://www.cancerbacup.org.uk

                    Changing Faces. Available at: Oral cavity and oropharyngeal cancer http://www.changingfaces.org.uk

                    Macmillan Cancer Relief. Available at: Oral cavity and oropharyngeal cancer http://www.macmillan.org.uk

                    Marie Curie Cancer Care. Available at: Oral cavity and oropharyngeal cancer http://www.mariecurie.org.uk