ENT Head and Neck Radiology Seminar

16-17 July 2010

Hospital Ampang

ASSOC PROF DR BAHARUDIN ABDULLAH

Dept of Otorhinolaryngology-Head & Neck Surgery

School Of Medical Sciences

Universiti Sains Malaysia

 Definition:
 Tumours (neoplasm) is a mass of tissue formed
as a result of abnormal, excessive and
inappropriate proliferation of cells, the growth
of which continues indefinitely and regardless
of the mechanisms which control normal
cellular proliferation.
Classification:
Benign-a single mass, localized, symptomless, can
be excised completely
Malignant-invade surrounding tissues,spread by
lymphatics and BV to other parts of body
 50% present before
age 20
 Midline (75%) or near
midline (25%)
 Elevates on
swallowing/protrusio
n of tongue
 Surgery
 Cystic mass anterior to  Video
SCM, below mandible
 May get infected
 Persistence of 2nd
branchial cleft
 May have small sinus
tract into tonsillar fossa
 Contains cholesterol
crystals
 Cystic swelling floor of mouth( ranula-little
frog)
 Mucous extravasation from sublingual salivary
gland.
 May extend through FOM muscles into neck-
“Plunging Ranula”
 1) Marking
 2) Skin incision
 3)Mobilization1,Mobilization2
 4) Preservation of Lingual Nerve
 5)Ligation of Submandibular Duct
 6)Specimen
International ORL Audiology Meeting 2007
Rosario, Argentina

Dr Baharudin Abdullah
Dr VMK Bhavaraju
Dr Win Mar@ Salma
Dr Mutum S Singh
1 Dept of ORL-HNS, School of Medical Sciences, Univ. Sains Malaysia.
2 Dept of Nuclear Medicine, School of Medical Sciences, Univ. Sains Malaysia.
3 Dept of Radiology, School of Medical Sciences, Univ. Sains Malaysia.
4 Dept of Pathology, School of Medical Sciences, Univ. Sains Malaysia.
 Case Presentation

 A 19yr Female was referred for left sided

neck swelling just below the ear of >4 years
duration
 History of:
 Recent increase in the swelling present
 Mild pain in the swelling occasionally with no
h/o radiation of pain
 LOA & LOW present
 No history of :
 Nasal discharge or blockage
 Hearing defects or ear discharge
 Any difficulty or pain while swallowing
 Facial asymmetry noted
 Voice changes
 Contact with Tuberculosis patient
 No other swelling over the body or any discoloration
noted
Oropharynx:
Bulging of the left lateral pharyngeal
wall
No evidence of inflammation

Nasopharynx:
No obvious mass seen at fossa of
Rosenmuller or at the roof
Loose stroma, psammoma body
Stained with vimentin and EMA-differentiate from glioma, schwannoma
 Patient underwent a tumor debulking via a
transparotid approach and received post operative
radiation to the residual tumor
 A dose of 45 Gy/25#/5 weeks delivered by a 6 Mv
Linear Accelerator
 Post operative Irradiation is given to reduce the
local recurrence
 To prolong the disease free survival
 A dose to be delivered depend on the normal tissue
tolerance
 In the present case cervical spinal cord is the
limiting factor for the radical dose of radiation to be
delivered
 Type 1 –direct extension from intracranial tumor
through foramina
 Type 2 –extra cranial growth from arachnoid within
the cranial nerve sheath
 Type 3- extra cranial growth from ectopic or embryonic
cell rest arachnoid without connection to skull base or
cranial nerve
 Type 4 – distant metastases from intracranial
meningioma
 1. Nasopharyngeal Carcinoma
 2. Laryngeal Carcinoma
 3. Oral cavity Cancers
 4. Thyroid Cancer
 5. Salivary Gland Cancer
 6. Skin Cancers of Head and Neck
 7. etc. such as Ca Ear, Ca Nose and Paranasal
Sinuses
 6th most common cancer worldwide
 HNSCC ~ 5% all cancers
 SCC most common upper aerodigestive tract
malignancy
 Smoking and alcohol
 Management presents considerable functional
and aesthetic problems
 Multidisciplinary approach imperative
 Complete History
 Physical examination
 Endoscopic assessment of upper aerodigestivetract.
 Imaging studies US/CT scan
 Biopsy
 Treatment
 Rim enhancement
 Central necrosis
 Nodal size > 1cm
 Obliteration of tissue planes
 FNAVery accurate
 Open Biopsy
 –Should be avoided
 –Can complicate future therapy
 Safe
 Rapid
 Inexpensive
 Presurgicalplanning, patient counselling.
 Avoids open biopsy
 No evidence of tumour seeding in HAN
 Safe
 Rapid
 Inexpensive
 Presurgicalplanning,
patient counselling.
 Avoids open biopsy
 No evidence of
tumour seeding in
HAN
 Primary tumour+ cervical nodes
 Surgery/DXRT/Chemotherapy
 Sometimes palliation
 Cervical neck disease reduces survival by 50%
 Cancers of the oral cavity are treated by primary
surgical resection. Adjuvant radiotherapy or
concurrent chemoradiation is indicated for high-risk
group.
 Tumors of the pharynx (oropharynx or hypopharynx)
are treated primarily with combined chemoradiation.
 Laryngeal cancers are also treated with chemoradiation
if the larynx is functional. However, if the tumor has
destroyed the laryngeal skeleton, surgery may be
required to restore an adequate airway and maintain
swallowing.
 Symptoms & Signs - Persistent SOM
 - Neck Mass (Laterally at level 2)
 - Nasal S&S - Nasal obstruction
 - Nose Bleed or Bloody discharge
 - etc.
 - Cranial Nerve 5, 6, 9, 10, 11 and 3 & 4
 - Miscellaneous - Headache
 - Feeling lump in throat
 Treatment - Radiation is a major role
 - External
 - Brachy therapy
 - Stereotactic Radiation or Gamma knife
 - Chemotherapy is an adjunctive modality
 - Surgery - Eradicate residual lymphnodes or
 primary resectable disease
 - PDT
 - etc
 The WHO classification based on the degree of differentiation.
 Type I: keratinizing squamous cell carcinoma (SCC), similar to
other head and neck cancer.
 Type II: nonkeratinizing carcinoma (IIa)
 Type III: undifferentiated carcinoma, has a typical morphology
with a prominent lymphoplasmacytic infiltrate, and is also
referred as “lymphoepithelioma.” (IIb)
 In endemic areas, WHO Type III accounts for more than 97%,
while keratinizing SCC is more common in the Western countries
(~75%).
 Latent EBV infection is uniquely present in almost all NPC from
endemic regions, but absent in WHO Type I NPC from non-
endemic regions.
 Baharudin Abdullah
Shahid Hassan
Department of ORL-HNS
School of Medical Sciences
Universiti Sains Malaysia
 Introduction

Benign, malignant skull base tumour not

uncommon
Conventional approach for early tumors
For extensive/intracranial/recurrent tumor
nasopharynx difficult to approach

adequate exposure for surg. control of tumour

 Nasopharyngeal Pathology
Total no.of case - 09
Extensive JNA - 02

Recurrent JNA - 03

Chordoma - 01

Recurrent NPC - 03
Hospitals - procedure carried out
Hospital Universiti Sains Malaysia 07 Cases

Tg. Ampuan Afzan Hosp. Kuantan 01 Case

General Hospital K. Bharu, Kelantan 01 Case

Approaches to central Skull Base

Superior Transcranial
Inferior Transpalatal
Lateral Infratemporal
Anterior Transantral
Anterolateral Maxillary Swing
 Exposure Achieved in C.S.Base

Other S.B.Approach Maxillary Swing Approach

Nasopharyngeal region In addition to C.S. Base

Eustachian tube Pterygopalatine fossa
Paranasopharyngeal area Infratemporal fossa
Floor of the orbit if eroded
 JNA - Introduction

Benign but recurrent disease

Incidence 1 in 5000 - 1 in 60 000
0.5% of all Head and Neck tumor
Origin - sphenopalatine foramen
Treatment - surgical resection
 JNA Management and Outcome

Type I & II Small one window approach

Type III External cervical approach
Type IV Combined N.surg. approach
Recurrent Resection by E.C. approach
Rx.for Intracranial extension
 JNA Problem of Recurrence

Difficult revision surgery

Inaccessible extension
Inadequate exposure
Adhesion and fibrosis
Infratemporal fossa approach
Difficult to perform
Inherited complication
JNA-Indication and Feasibility

Extensive or recurrent growth

Tumor eroding skull base
Intracranial extradural extension
Opportunity of I.M.A ligation
 Result - JNA

Fast and complete healing

Acceptable complications
Adequate tumour exposure
Feasible and complete excision
No recurrence in all 05 cases
 NPC - Introduction

Malignant and recurrent disease

Treatment of choice radiotherapy
8% of all malignancies in H & N clinic
18% in certain racial areas like HK
NPC- Management and Outcome

T1 N0 Lesion - claimed 50% cure

T2 N1 Lesion - 38% 5 yrs survival
T3 N2 lesion - 15% 5yrs survival
Problem of recurrent disease

Usually associated with neck gland metastasis

Radiotherapy/ chemotherapy/ Brachytherapy

Concomitant therapy effective but >morbidity

Greater dosage needed will increase morbidity

NPC-Indication and Prerequisite

Recurrent NPC
Not eroding S.B.
No neck metastasis
Tumor not > 2 cm in size
 Result - NPC

Avoid dose-effective radiotherapy

( Expected worst side effect)
Reported better prognosis
Complete excision
Acceptable complication
 Chordoma - Introduction

Rare malignant lesion with incidence<10%

Usually advance disease on presentation
Posterior extension- pressure on brain stem
Treatment surgery followed by radiotherapy
Problem of Management

Extensive tumor on presentation

Surgical resection rarely possible
Radiotherapy, dose-effect relationship
High dose, safety , meticulous technique
 Problem of Recurrence

Recurrent disease poorer prognosis

Limited choice of available treatment
Palliation radiotherapy with morbidity
Surgical resection a difficult procedure
Chordoma-Indication and
Prerequisite

History of late presentation

Difficult trans -cranial approach
Erosion of clivus and S. tursica
Extradural brainstem encroachment
 Result - Chordoma

Tumour excision by double swing procedure

Combined Ext cervical, Neurosurgical approach
Surgical resection a better prognosis
Neurosurgical excision under expert hand
Maxillary Swing
Procedure
Instruments for the Maxillary Swing Procedure
 Facial incision  Palatal incision
 Anterolateral wall
 Maxilla swung laterally
 Repair of anterior wall  Repair of zygoma
 Wound closure  Specimen
 Complications
Epiphora 01 case

Trismus 01 case

Palatal fistula 01 case

Complications of Maxillary swing Procedure
 Conclusion

Offers adequate exposure of NP

Excision of extensive and recurrent tumor
Combining with other approaches possible
Alternate to trans-cranial approach in chordoma
Re-radiation effects can be avoided in NPC
Better prognosis achieved in selected cases
 Ca oropharynx  Ca hypopharynx
 Divided into
- Glottic
- Supraglottic
- Sub glottic
- Transglottic
 Management -Surgery is
a major role (with or
without laser)
 Radiation
 Combination of Surgery
and Radiation
 Radiation +
Chemotherapy in Organ
preservation
 Ca Tongue 45%
 Ca Floor Of Mouth 25%
 Ca Alveolus(Upper& Lower) 20%
 Ca Buccal Mucosa 7.5%
 Ca Palate 2.5%
 Tongue Ca  Procedure:
 Specimen  1)MandibularSplit
 Postop  2)Marginal
Mandibulectomy
 3)Floor Of Mouth
Resection
 4)Glossectomy
 1. Well differentiated
-Papillary
-Follicular
-Mixed (Pap+Foll)
 2. Poorly differentiated

-Hurthle Cell
-Medullary
-Anaplastic
-Malignant Lymphoma
I.Epithelial tumour:
A. Benign- follicular adenoma (90%), Hurtle cell adenoma (10%)
B. Malignant- Papillary (80%), follicular (10%), Hurtle cell (3%),
Medullary(5%);Anaplastic(1%), squamous cell car.
II. Nonepithelial
III.Malignant lymphoma
IV.Miscellaneous e.g teratomas
V. Secondary tumours
VI.Unclassified tumours
VII. Tumour-like lesions e.g thyroiditis, thyroid cysts, hyperplastic
goitres, amyloid goitres.
 Commonest as a solitary thyroid nodule (10%
incidence malignant; increase after 50-60 years
of age ;males)
-cervical lymphadenopathy(20%)
-rapidly enlarging goitre
-pain in the neck ,stridor ,dysphagia ,
hoarseness, evidence of metastasis
 Majority of malignancy-euthyroid
 Family history and other tumours –in MEN
 Past history of ionising radiation
 Family history of thyroid cancer
 History of previous thyroid cancer
 Rapidly growing or painful
 Male pt
 Presence of neck or distant metastasis
 Hard, fixed nodule with vocal cord paralysis or
recurrence cystic nodule
 Under age of 14 or over 65 years of age
 Multidisciplinary
 Selection of combination modalities depend on
extent of disease, the prognostic factors and
risk group analysis
 Treatment modalities
1.Surgery
2.Radioactive iodine
3.External beam radiotherapy
4.Thyroxine therapy
5.Chemotherapy
-total lobectomy-complete removal of one thyroid lobe and the
isthmus
-near-total thyroidectomy :total lobectomy and isthmusectomy with
removal of more than 90% contralateral lobe
-total thyroidectomy: removal of both thyroid lobes and isthmus
Minimum operation for suspected or confirmed thyroid cancer is
total lobectomy on side of lesion; often, near total thyroidectomy
performed initially.

-Collar incision at least 2 cm above suprasternal notch-may need

extension to facilitate neck dissection or mediastinal exploration
-Preservation of recurrent laryngeal nerves ,parathyroids, external
laryngeal nerves important
-operation include level VI dissection
 Major arguments proposed for total thyroidectomy:
1.Presence of microscopic disease in opposite lobe
(multicentricity varies between 30-70%)
2.Local recurrence in opposite lobe 5-15%
3.Need for radioactive iodine follow up and thyroglobulin
as a tumour marker which can be used only after total
thyroidectomy
4. Hypothetical small risk of anaplastic transformation of
residual thyroid tissue
5. High incidence of complication in re-operative thyroid
surgery
 Proponents for less than total thyroidectomy :
1)Complication of routine total thyroidectomy
more disastrous
2)Microscopic multicentric papillary cancer has
little prognostic implication and local
recurrence in contralateral lobe less than 5%
Baharudin Abdullah, Shahid Hassan, Rosli M N.
University Sains Malaysia, Kuban Kerian, Kelantan, Malaysia

Lateral Tracheostomy in an Anaplastic thyroid carcinoma

Pak J Otolaryngol Apr 2008;24(2):21-2.

 The usual approach for airway

management in anaplastic thyroid
carcinoma involves debulking of the
tumour and doing an anterior
tracheostomy.
 However, debulking a big vascular
thyroid mass and doing an anterior
tracheostomy can be very difficult and
may lead to complications.
 Lateral tracheostomy performed by using
a tracheoflex tube can overcome the
difficulty encountered and minimize the
morbidity.
 Although performing tracheostomy in
patients with big neck mass continues to
be a challenge, we believe that lateral
tracheostomy using tracheoflex tube in
this type of case is helpful and can
necessitate post-operative tracheostomy
care.
 Malignant MixedTumor
 Mucoepidermoid Carcinoma
 -High Grade
 -Intermediate Grade
 -Low Grade
 Adenoid Cystic Carcinoma
 Adenocarcinoma
 Oncocytic Cell Ca
 Squamous Cell Ca.
 Undifferentiated Cell Ca
2007 ICD-9-CM Volume 1 Diagnosis Codes
Diseases Of Oral Cavity, Salivary Glands, And Jaws
ICD-9-CM Diagnosis 527
Diseases of the salivary glands
A non-neoplastic or neoplastic (benign or malignant) disorder involving the salivary gland.

ICD-9-CM Diagnosis 527.0

Atrophy of salivary gland

ICD-9-CM Diagnosis 527.1

Hypertrophy of salivary gland

ICD-9-CM Diagnosis 527.2

Sialoadenitis
Inflammation of the parotid gland.

ICD-9-CM Diagnosis 527.3

Abscess of salivary gland

ICD-9-CM Diagnosis 527.4

Fistula of salivary gland
A fistula between a salivary duct or gland and the cutaneous surface of the oral cavity.

ICD-9-CM Diagnosis 527.5

Sialolithiasis
Calculi occurring in a salivary gland. Most salivary gland calculi occur in the submandibular gland, but can also occur in the parotid
gland and in the sublingual and minor salivary glands. Presence of small calculi in the terminal salivary ducts (salivary sand), or
stones (larger calculi) found in the larger ducts.

ICD-9-CM Diagnosis 527.6

Mucocele of salivary gland
A form of retention cyst of the floor of the mouth, usually due to obstruction of the ducts of the submaxillary or sublingual glands,
presenting a slowly enlarging painless deep burrowing mucocele of one side of the mouth.

ICD-9-CM Diagnosis 527.7

Disturbance of salivary secretion
An oral condition in which salivary flow is reduced. Decreased salivary flow.
Dry mouth. It occurs when the body is not able to make enough saliva.
Increased salivary flow.

ICD-9-CM Diagnosis 527.8

Other specified diseases of the salivary glands

ICD-9-CM Diagnosis 527.9

Unspecified disease of the salivary glands
A non-neoplastic or neoplastic (benign or malignant) disorder involving the salivary gland.
WHO HISTOPATHOLOGICAL CLASSIFICATION

1.Adenomas
2.Carcinomas
3.Non-epithelial tumours
4.Malignant lymphomas
5.Secondary tumours
6.Unclassified tumours
 3 % of head and neck malignant tumours
 80 % occur in parotid gland
 10 % occur in the submandibular gland
 10 % occur in sublingual gland and the minor
salivary glands
 Benign tumors are more common
 Sublingual 70%
 Submandibular 40%
 Parotid 20 %
 Benign
 Pleomorphic adenoma 80%
 Monomorphic adenoma
 Adenolymphoma
 Oxyphil adenoma(oncocytoma)
 Others
 Malignant
 Mucopidermoid
 Adenoid cystic
 Acinic cell ca
 Adenoca
 Malignant
 Epidermoid
 Ca in pleomorphic adenoma
 Rare: squamous cell, undifferentiated ca
 40% of malignant tumours at all salivary types

 Infiltrative growth
 Marked tendency to invade nerve
 8% with Lnpathy at presentation
 Mets-lungs
 Most common childhood tumour
 4-9 % of malignant tumours
 Composed of epidermoid and mucous cells
 Solid or cystic
 90% or more tumour cells-high grade
 40 % LNpathy
 2.5-4% of tumors
 Predominantly parotid
 From terminal tubular intercalated duct
 Maybe bilateral
 Slow growing
 Local recurrence and mets after a long disease
free interval are common
 Malignant lymphoma
 Unclassified tumors
 1-3% in Head & Neck Cancer
 Squamous cell carcinoma
 Lymphoreticular tumors
 Ethesioneuroblastoma
 Minor salivary gland tumors
 Melanoma
 Cause & Risk Factors - Environment
- nickel refiners
- petroleum refiners
- woodworkers
- leather workers
- textile workers
- Genetic
 Symptoms & Signs
- Nasal obstruction
- Bloody discharge
- Facial pain
- Foul smell
 61st Annual General and Scientific Meeting
of the NZ Society of ORL-HNS

Baharudin Abdullah 1
Shamim Ahmed Khan1
Hillol K Pal 2
1 Dept of ORL-HNS, School of Medical Sciences, Universiti
Science Malaysia, 16150 K.Kerian, Kelantan, Malaysia
2 Dept of Neuroscience, School of Medical Sciences,

Universiti Science Malaysia, 16150 K.Kerian, Kelantan,

Malaysia
 A 50 years old man presented with a left sided
nasal block and epistaxis for one year.
 A rigid endocopic examination showed a
whitish-reddish mass occupying the whole of
the left nasal cavity.
 The mass was friable and bled on touch.
 The CT scan of paranasal
sinus showed a large
mass occupying the entire
left nasal cavity
 Extension into the left
maxillary sinus and
destruction of the medial
wall of the maxilla.
 The mass was in contact
with the cribriform plate.
 There was also mild
lateral bowing of the
left lamina papyracea
 No extension into the
left orbit was noted.
 There was no
effacement or
asymmetry of fossa of
Rosenmullar noted.
 A biopsy was taken from the intranasal mass.
 However, profuse bleeding occurred after the
biopsy which required nasal packing for 3
days.
 The biopsy showed an undifferentiated
carcinoma.
 The tumor at the left
nasal cavity and
adjacent to the
anterior skull base
/orbit was resected
using an ultrasonic
aspirator set at a
high frequency
mode of 100 Hertz.
 The tip of the Dissectron
ultrasonic aspirator
(Satelec Medical,
Bordeaux, France) was
calibrated with the
Omnisight Image Guided
System (Radionics,
Burlington,
Massachusetts)
 Precise removal could be
performed without injury
of other structures at the
skull base or the orbital
region.
 The patient recovered well postoperatively.
 His hemoglobin remained between eleven to
twelve g/dL.
 He didn’t require any blood transfusion or any
hematinics supplement.
 He did not have any CSF leak or any visual
impairment.
 The histological
report confirmed the
tumor was an
undifferentiated
carcinoma with a free
margin.
 He completed his
adjuvant
radiotherapy.
 Follow-up for nine
months showed no
tumor recurrence.
Apply ultrasonic energy
 The piezo electricity
applied to the
sonotrode creates on
the target cells a linear
vibration effect 30,000
times a second
 Achieving
fragmentation
through a mechanical
action.
Fragmentation
 The simultaneous
use of an irrigation
fluid begins to
induce the
selectivity of the
target cells.
Generate selectivity
 Selective exeresis is
achieved by
intracellular cavitation
as a result of the
cavitation in aqueous
tissues and of the
different elasticity of the
surrounding tissues
(nerves, blood vessels,
tumor tissue).
Aspirate the tissues
 The fragmented
tissues suspended in
the irrigation fluid
are sucked up,
leaving the
surrounding
structures intact.
ENT Head and Neck Radiology Seminar
16-17 July 2010
Hospital Ampang