MALIGNANT TUMORS

of the HEAD and NECK

Ramon P. Ramos III M.D, DPBO-
HNS, FPSO-HNS
 PARANASAL SINUS
MALIGNANCY
Uncommon in the general population
Most common malignancy is SCCA <1:200,000
per year.
Initially mimics benign disease
Diagnosis is evident only after advanced stage is
reached, thus the relative poor prognosis
PARANASAL SINUS ANATOMY
 SYMPTOMS OF PARANASAL
SINUS CANCER
Diplopia, vision loss
Epiphora
Facial swelling and maloclussion
Trismus
Neck mass
Hearing loss
Facial numbness
PHYSICAL FINDINGS OF PNS
MALIGNANCY
NASAL, FACIAL OR INTRA ORAL MASS
PROPTOSIS
CRANIAL NERVE DEFICITS
DIAGNOSTIC ASSESMENT
THOROUGH EXAMINATION
IMAGING STUDIES
CT scan (radiographs unnecessary)
angiography
ultrasound
PET scan
MRI
BIOPSY
 PARANASAL SINUS
LYMPHATICS by:Ohngen
Lateral retropharyngeal LN receive most
of the lymph vessels.
Drain to the deep jugular chain at the
carotid bi-furcaton
PATTERNS OF SPREAD
OHNGREN’S LINE
 DISTRIBUTION OF PRIMARY SITES
of NASAL and PNS TUMORS
 Overlapping sites
 Nasal cavity
 Maxilla
 Ethmoid
 Frontal
 sphenoid
 HISTOLOGIC DISTRIBUTION of
MALIGNANT TUMORS of NASAL CAVITY
and PNS
 SCCA
 Others
 Adeno. CA
 Adenoid cystic CA
 Mucoepideroid CA
 Melanoma
 Esthisioneuroblastoma
note: 75% of PNS and nasal cavity tumors are malignant. 25% is benign
STAGING CRITERIA: PRIMARY
TUMOR (T)
 COMPLICATIONS
Increase significantly when surgery breaches the
intracranial space.
When high dose irradiation is delivered
intracranially.

Examples:
Meningitis, brain abscess, CSF leak, post op
wound bleeding, cataracts, optic neuritis,
blindness, osteo-radionecrosis and
hypopituitarism
 MANAGEMENT
SURGERY
COMBINED SURGERY and
IRRADIATION
RADIOTHERAPY
CHEMORADIATION THERAPY
 SURGICAL OPTIONS
External ethmoidectomy
 Most limited OR

 For benign tumors of ethmoid region, biopsy,

drainage.
Inferior medial maxillectomy
Resection of medial wall of antrum and inferior
turbinate.
Often used for inverting papilloma
Medial maxillectomy
larger benign or intermediate tumors of the lateral
nasal wall with ext. to orbit, ant. Cranial fossa, lateral
maxilla or alveolus
Radical maxillectomy
standard operation for advanced CA of the maxilla.
Craniofacial frontoethmoidectomy
en bloc resection for tumors of ethmoid and frontal
regions. Dural resection when necessary.
Extended craniofacial resection
extensive tumors if the skull base,
pterygoid plates.
CARCINOMA of the ORAL
CAVITY and PHARYNX
Major therapeutic challenge due to the poor
prognosis of advanced disease, assoc medical
problems and adverse effects of treatment on
oral and pharyngeal function.
Common in parts of India, China and Asia.
Incidence incrases with age. Commonly seen at
6th-7th decade.
 ETIOLOGIC FACTORS
Tobacco smoking
Smokeless tobacco use
Betel nut chewing
Heavy alcohol consumption
Reverse smoking
Poor oral hygiene
Mechanical irritation
HPV
Syphilis
Erosive lichen planus
Oral sub mucus fibrosis
Sun light exposure (lower lip)
note: there is approx. 50% 5 year survival for all oral and
pharyngeal carcinoma patients
 PATHOLOGY
90% of all malignant tumors of oral cavity and
pharynx are SCCAs. Other tumor types - minor
salivary gland tumors, sarcomas, lymphomas
and melanoma.
SCCA morphologic types
 Ulcerative type – most common
 Infiltrative type – commonly in the tongue
 Exophytic type – least common form
Microscopically graded
 Well differentiated
 Moderately well differentiated
 Poorly differentiated

Note: degree of diff. does not appear to have strong prognostic

significance except in NPCA.
Leukoplakia – white patch of mucosa.
Appears to be pre-malignant.
Histologically shows epithelial hyperplasia
in 80%. It may harbor dysplasia, Cis or
even invasive CA. Should be biopsied.
Erythroplakia – rare red velvety plaque like
lesion. Higher rislk of malignancy than
leukoplakia.
 ORAL CAVITY
Lips
Buccal mucosa
Lower alveolar ridge
Upeer alveolar ridge
Retromolar trigone
Floor of the louth
Hard palate
Anterior 2/3 of the tongue
PHARYNX
 GENERAL PRINCIPLES and
EVALUATION
Patients with oral cavity and pharynx CA have
co existing medical illnesses
Heavy alcohol intake and may have liver
disease.
COPD is common.
Nutritional deficiency with a big tumor burden.
Multi disciplinary approach ; radiation oncology,
medical oncology, dentistry, social services,
nutrition, speech pathologist and nursing
services.
EVALUATION:
thorough history and examination.
biopsy of the primary.
FNAB of LN.
RADIOLOGY:
CT Scan
MRI
Radiography
ENDOSCOPY:
Under GA for accurate mapping.
Laryngoscopoy, esophagoscopy, bronchoscopy.
5%-10% incidence of synchronous malignancy.
 GENERAL MANAGEMENT
Most patients are treated with either surgery and
radiation or in combination.
chemotherapy alone has not shown to be effective. Its
role in adjunctive therapy of unresectable CA is
uncertain.
In general T1-T2 tumors of the oral cavity and pharynx
(except NP) can be treated effectively with RT or surgery
only.
Combination treatment is preferred for bulky tumors T3-
T4 tumors.
Post op RT is preferred. Pre op RT makes dissection
difficult and makes resection margins unclear.
CT and RT for organ preservation may be undertaken.
Small lesion of the oral cavity – surgery is preferred to
avoid SE of RT.
Small lesions of the soft palate and hypopharynx RT is
preferred to avoid functional problems.
Tracheostomy may be needed in large resections to
protect the airway.
NECK DISSECTION

Clinical neck mets in most cases require surgery.
 N1 necks may be treated with RT alone
 Most would recommend ND for clinically pos. nodes
 Combination therapy indicated in multiple and
extracapsular nodal extension.
 MRND in N1 and selected N2 dis.

RND for advanced dis. (N2,N3)
Incidence of occult metastasis for oral cavity
oral tongue – 24%
floor of the mouth – 30%
buccal mucosa – 9%
lower alveolar ridge – 19%

Incidence of occult metastasis for pharyngeal sites

pyriform sinus – 38%
base of the tongue – 22%
posterior pharyngeal wall – 0%
Occult neck metastasis (No) can be
equally managed effectively by either RT
or ND
Arguments of elective ND:
 High incidence of occult dis. in the neck
 Need for surgical violation of the neck for
treatment.
 Poor ff-up
 Obese, muscular neck (poor surveillance)
 Recognition of advance dis. at time of
treatment.
Arguments against elective neck
dissection:

Morbidity and deformity of ND, spinal acc.
nerve damage.
 Unnecessary surgery

RT effectively controls occult mets.
 Survival has not been shown worse if one
observes for occult dis. to be palpable,
 CARCINOMA OF THE LIPS
25%-30% oral carcinomas
98-99% SCCA
95% lower lip involved
5% upper lip
Basal cell CA most commo CA of the upper lip (chronic sun
expoxure)
Usually in patients 50-70 yrs old.
Male>females (95%)
Neck mets. is infrequent (<10%)
Upper lip CAs mets. to pre auricular, sub mandibular and sub
mental LN.
Lower lips CAs mets. to submandibular and submental LN. more
prone to bilat. Mets.
Surgical excision and RT for small lesions. Local flaps for larger
lesions
5 year survival stage I-II 90%. StageIII-IV with nodal dis.<50%
 BUCCAL MUCOSA CANCER
5% oral cavity CAs
7th decade of life with men>women
Frequently with tobacco and betel nut chewers.most
common in the lower third molar area.
Trismus noted if with masseter or pterygoid involvement.
Cervical mets in 50% of patients to the submandibula
and upper deep cervical LN.
Small lesion treated with surgery or radiation. Advanced
lesions treated with combined therapy.
Cervical mets indicates poor prognosis. 5 year survival
rate 25%
5 year survival rates for stage I-II-III-IV are 75%-65%-
30%-20% respectively.
 FLOOR OF THE MOUTH CANCER
10-15% of oral cavity CAs.
Occurs more in males with ave. age of 60 yrs.
Cervical mets is common and present in 50% of cases. (sub
mandibular LN)
Propensity of Mandibular involvement in advance dis. is not
unusual.
CT Scan used to det. Mandibular involvement (marginal vs
segmental mandibulectomy)
Early (T1-T2) lesions may be effectively treated with surgery or RT.
Larger lesions combined therapy is recommended.
Small lesions may be excised and may be closed primarily, skin
grafted or left to heal. Regional flaps are used for big
defects.(platysma, nasolabial)
5 year survival rates for Stage I-II-III-IV is approx. 90%-80%-65%-
30% respectively.
ALVEOLAR RIDGE CANCER
10% of oral cavity CAs. With mandibular involvement
more common than maxilla. (pre molar, molar regions)
Bone invasion 50%.Usually via an edentulous area,
some via inf. alveolar nerve.
CT Scan, panorex etc. help determine bony invasion
(sinus, palate, mandible)
CA of the lower alveolus has a > metastatic potential as
compared to the upper alveolus. (sub mandibular LN,
deep cervical LN).
30% incidence of neck mets.
Over all 5 year survival 65%. <35% if with neck mets.
Marginal, segmental mandibulectomy. Maxillectomy,
dental prostheses.
Combined treatment for advance dis.
RETRO MOLAR TRIGONE CANCER
Affect primarily elderly males (tobacco and
alcohol abuser)
Commonly involve ant. tonsillar pillar, lower
alveolar ridge, buccal mucosa, floor of the mouth
and soft palate.
Trismus – pterygoid muscles involved
Most present with advance dis. 50% have neck
mets. (upper deep cervical LN)
Radiation or surgery for early lesions.
Advance lesions combination therapy.
Survival rates is equal to that of the alveolar
ridge CAs.
CARCINOMA of the HARD PALATE
Rare. Salivary malignancy occur as frequently as SCCA.
Predominant in older males, smoker. Higher incidence
with reverse smokers.
CT Scan, radiographs determine bony involvement and
extension to nasal cavity , PNS.
30% present with neck mets. (sub mandibular and upper
cervical LNs.)
Surgery (maxillectomy, obturator, dental prosthesis)
5 year survival in SCCAs, approx. 40-60%.
 CARCINOMA OF THE ORAL TONGUE
2nd most common site for oral cancer. (20%) Can be highly
aggressive.
Male predominance and occurs at 6th-7th decade of life.
Tobacco, alcohol, poor oral hygiene, syphilis, Plummer-Vinson
synd.
50% occur at the lateral border of the mid tongue.
40% of cases will have neck mets.
40% of patients will occult mets.
Bilateral spread occurs frequently.
Surgery (partial glossectomy via mandibulotomy, mandibulectomy,
composite flap reconstruction)
Radiation for small lesions (xerostomia, long treatment)
Combination therapy for advance disease.
5 yr survival stage I-II is 75%; stage III-IV 40%.
CANCER OF THE OROPHARYNX
95% SCCAs. Male predomince at 4th-5th decade of life.
Poor cure rates due to advance disease at time of recognition and
frequency of mets. (sub mucosal, early lymphatic spread)
occurence of regional mets. 40% soft palate, 70% base of the
tongue, 30% will have bilat. spread.
Upper deep cervical chain, jugulo digastric nodes, retropharyngeal
nodes and posterior triangle nodes often involved.
Tonsil and tonsillar fossa most commonly involved.
Radiation for early lesions (T1-T2) to include neck due high
incidence of occult mets.
T3-T4 lesions have poor prognosis. Combination therapy (surgery-
glossectomy, laryngectomy,reconstruction & RTx) or organ
preservation techniques. (RTx & CTx)
Complications of chronic aspiration, swallowing problems, speech.
Survival rates stage I-II 80%. Stage III – 50%.
CANCER OF THE HYPOPHARYNX
95% SCCAs. Etio. Etiologic cause tobacco, alcohol,
GERD*
Commonly affect males 6th-8th decade.
Pyriform sinus most commonly involved in 70% of cases,
post. cricoid and PPW involved in 15% of cases
repectively.
Symptoms appear late in the disease. (throat pain,
referred otalgia, dysphagia, neck mass)
Incidence of neck mets is 75% for the pyriform sinus,
40% post cricoid lesions, 60% PPW. High rate of occult
mets.(depp cervical nodes, jugulo digastric nodes,
retropharyngeal, para tracheal, post. Triangle nodes)
T1-T2 lesions usually treated with RTx. Partial laryngo-
pharyngectomy is suitable (contr indicated if pyriform
apex and post cricoid area is involved)
Advance T3-T4 lesions combination therapy (total
laryngectomy, pharyngectomy, esophagectomy)
Distant mets occur in 10-25% of patients.
Reconstruction with myocutaneous pedicled flaps,
vascular free flaps, jejunum free flap, gastric pull up.
20% of gastric pull up patients will have occult
esophageal CA.
Over all 5 yr survival 40%
Staging of Hypopharyngeal
Cancer
MALIGNANT TUMORS of the
NASOPHARYNX
 NPCA epidemiology
Rare in the west
Endemic in the far east.
Highest incidence Guangdong Province of
Southern China 15-50:100,000
Highest incidence in HK and Singaporean
Chinese.
Incidence 1:100,000 in most countries.
Genetic pre disposition.
Implicated env. Factors
nitrosamines from salted fish
polycyclic hydrocarbons
chronic sinusitis
poor hygiene
nickel esposure
NPCA is assoc. with EBV. High levels of
the anti body to the virus often identified.
Peak incidence age 45-55.
 NPCA Pathology
WHO type 1 – keratinizing squamous ca.
graded into well, moderately or poorly
differentiated. 25% of NPCAs.
WHO type 2 – non keratinizing ca. transitional
cell ca. 12% of NPCAs.
WHO type 3 – undifferentiated ca.
lymphoepithelioma, anaplastic ca, spindle cell
and clear cell ca. 63% of NPCAs.
 SIGNS and SYMPTOMS
Neck mass – 60%
Aural fullness – 40%
Hearing loss – 37%
Epistaxis – 30%
Nasal obstruction – 29%
Head pain – 16%
Otalgia – 14%
Neck pain – 13%
Weight loss – 10%
Diplopia – 8%
 CLINICAL EVALUATION
High index of suspicion
Endoscopy
Biopsy
Serology – high anti bodies to EBV antigens are
tumor markers. >IgA-anti-VCA titer is highly
sensitive and > IgA-anti-EA is highly specific.
For early dis. Detection.
MRI imaging of choice (soft tissue)
CT better for bone involvement, LN.
compliments MRI.
 TREATMENT
Initial treatment for all forms is radiation
to the primary and both sides of the neck.
Chemo. And radiation – for distant mets.
Better over all survival and disease free
state in advance disease.
Neck dissection – for persistent neck
disease with control of the primary.
 STAGING
No universally accepted staging
classification for NPCA.

American Joint Committee for Cancer

Union Internationale Contre le Cancer
Ho System
 AJCC Staging
Nasopharynx:
T1 – confined to NP
T2 – tumor extends to soft tissues of orophaynx
and or nasal fossa
T2a – no pararpharyngeal (PP) extension
T2b – with PP extension
T3 – invades bony structures and/or PNS
T4 – intracranial extension/cranial nerves/infra
temporal fossa/hypo- pharynx/orbit involvement.
Nx – cannot be assessed
N0 – no LN mets.
N1 – single ipsi. LN < 3cm
N2a – single ipsi. LN >3cm but <6cm
N2b – multiple ipsi. LN <6cm.
N2c – bilat., contralat. LN >6cm
N3 – LN >6cm
Mx – cannot be assessed
M0 – no distant mets.
M1 – distant mets.
 STAGE GROUPING
STAGE 0 – Tis N0 M0
STAGE I – T1 N0 M0
STAGE II – T2 N0 M0
STAGE III – T3 N0 M0, T1-T2-T3 N1 M0
STAGEIV – T4 N0-N1 M0, any T
N2-N3 M0, any T any N M1
5 yr. survival WHO type 1 – 10%.

5 yr. survival WHO type II-III – 50%.

Poorer survival with higher stages.

CANCER OF THE SALIVARY
GLANDS
Rare and accounts for 6% of all head and
neck malignancies.
 RISK FACTORS FOR
MALIGNANCY
Increased risk
Radiation exposure
Full mouth dental x rays
Skin cancer
Rubber industry
Nickel exposure
Hair dye
Silica dust
Kerosene cooking fuels
Vegetables preserved in salt
Decreased risk
High intake of liver
High intake of dark yellow vegetables

note: high in vit A and C.

 DIAGNOSIS OF SALIVARY
GLAND CANCER
Clinical presentation is indistinguishable bet.
benign and malignant dis.
Mobile, painless non rapid growing mass is
common for both benign and malignant dis.
Malignant salivary neoplasms is painless mass
in 75% of patients.
6%-29% patients initially have pain.
6%-13% patients with facial palsy.
Pain, nerve palsy, trismus, LN pos., fixation,
numbness, loose dention and bleeding suggest
CA.
 IMAGING
Well defined mobile tumors may be
approached with out imaging.
Radiologic evaluation is helpful to det.
extent of disease.
SIALOGRAPHY-not useful in diagnosis of
malignancy of salivary glands.
ULTRASOUND-limited for tissue biopsy
guidance in FNAB.
CT SCAN- with contrast provides
excellent detail of tumor volume,
vascularity, bony structures and deep
tissue involvement as well as survey of
LN.
MRI- excellent soft tissue detail, vascular
anatomy.
PET SCAN- seems to have a role in
staging and to rule out distant and regional
spread
 FNAB
For histologic confirmation and
counseling.
Over all accuracy of FNAB is bet. 54%-
98%
False negative of 4%
False positive of 16%
Relies on ability and experience of
cytopathologist
 FROZEN SECTION
Distinguishes benign from malignant with
94.7% accuracy, sensitivity of 100%
specificity of 87.5%.
Other studies show false positive bet. 3%-
12%.
Analysis of salivary gland CA with FS is
risky.
It is helpful in determining LN
pathology/involvement.
STAGING
HISTOLOGIC TYPES
 MUCOEPIDERMOID CA
most common salivary gland malignancy.
Most common salivary malignancy in
children.
classified into low (G-I), intermediate (G-II)
and high grade (G-III) malignancy.
5 year survival for G-I, G-II, G-III is 95%,
72%, 0% respectively.
 ADENOID CYSTIC CA
Most common malignancy of minor salivary
glands and submandibular glands.
71% arising from the minor salivary glands.
Hard palate most commonly involved in the oral
cavity.
10%-15% malignancy of the parotid.
Tenacious tumor. Tendency towards local and
distant recurrences.
Prediliction for neurotropic/nerve spread.
LN involvement infrequent.
High degree of distant spread.
 ACINIC CELL CA
Rare and composes 6%-8% of salivary
malignancies.
Low grade behavior and assoc with best
survival rate of any salivary malignancy.
Second most common salivary
malignancy in children.
 SQUAMOUS CELL CA
Rare and most are a result of lymphatic or
direct spread from skin and aerodigestive
tract SCCA.
Over all 5 year survival 24%-50%.
Mucoepidermoid of high grade may be
mistaken for SCCA.
MALIGNANT MIXED TUMORS
Generic category encompassing carcinoma ex-
pleomorphic adenoma, carsinosarcoma and
metastasizing mixed tumor.
Account for 5%-12% of salivary malignancies.
Malignant degeneration of 3%-7% is seen in
pleomorphic adenomas (carcinoma ex-
pleomorphic adenoma)
True malignant mixed tumors are composed o
simultaneous elements of sarcoma and
carcinoma. Assoc with 50% mortality in 5 years.
 ADENOCARCINOMA
Comprise 16%-20% of salivary
malignancies.
Low and high grade forms.
Palate is most commonly affected in the
oral cavity.
Minor salivary glands-68%, Parotid-28%,
submandibular – 4%
 MANAGEMENT
SURGERY
Superficial parotidectomy is the minimal surgery
Total parotidectomy for deep tumor extension
Extended parotidectomy – involves resection of
masseterand part os ascending mandible.
facial nerve sacrifice is not advocated. Every
attempt is made to preserve the nerve. Grafting
when necessary with another sensory nerve.
NECK DISSECTION
advocated for clinically positive disease’
Elective neck dissection of levels 1-3 is
advocated for tumors > 4cm, SCCA,
adeno. CA, Undiff. CA and high grade
mucoepidermoid CA.
RADIATION

Indications of post op radiation:

high grade tumors
SCCA
malignant mixed CA
adeno CA
high grade mucoepidermoid CA
close of positive margins
CN VII involvement
perineural spread
bone/connective tissue involvement
LN mets.
extranodal extension
recurrent dis.
 CHEMOTHERAPY

Primarily for patients with recurrent,

metastatic or unresectable disease.
CANCER OF THE LARYNX
Risk factors:

Laryngeal Ca
- cigarette smoking
thirteenfold increase among smokers
- thirty-four fold increased risk if also a
drinker of 1.5 li/day of wine
- chemical carcinogens in workplace
(asbestos, nickel, mineral oils)
-genetics and susceptibility to cancer are hard
to separate from lifestyle and environment
- gastroesophageal reflux noted in 84% of cases
Diagnosis
evaluation of hoarseness of more than 4 weeks
dysphagia usually due to supraglottic or
hypopharyngeal lesions
airway obstruction with no apparent voice
changes may represent large supraglottic or
subglottic lesions
endoscopy with biopsy
imaging studies
 MANAGEMENT
Usually SCCa
hyperkeratosis, hyperkeratosis with atypia,
carcinoma in situ, superficially invasive
carcinoma (invasion deep to the basement
membrane), invasive carcinoma

Glottic Ca
less biologically aggressive than supraglottic
and hypopharyngeal Ca due to sparse
submucosal lymphatics
radiotherapy or consaervative management for
early stage
partial laryngectomy
salvage surgery with total laryngectomy/
postop radiotx
Sub glottic Ca
unusual
clinically present with airway obstruction
usually require total laryngectomy because
involvement of laryngeal framework is
frequent
ipsilateral thyroidectomy with paratracheal
node dissection is necessary
Supraglottic Ca
early (epiglottic) tumor may be excised
endoscopically or with carbon dioxide laser
preepiglottic space invasion worsens the
prognosis (due to lymphatic spread to both sides
of the neck)
partial (supraglottic) laryngectomy
transglottic involvement with cord fixation
warrants total laryngectomy
 NECK DISSECTION
Neck dissection or cervical lymphadenectomy
refers to the systematic removal of lymph
nodes with their surrounding fibrofatty tissue
from the various compartments of the neck

Eradicates cancer metastases to the regional

lymph nodes of the neck

Indications for neck dissection depend not only

on the presence of palpable disease
(therapeutic neck dissection) but on
factors that increase the risk of occult disease,
such as size and characteristics of the primary
tumor (elective neck dissection)
 CERVICAL LYMPH NODE GROUPS
Level I – submental and submandibular (lip, buccal mucosa,
anterior nasal cavity, soft tissues of the cheek)

Level II – upper jugular lymph nodes

- upper third of IJV adjacent to spinal
accessory, extending from level of
carotid bifurcation (surgical landmark)
or hyoid bone (clinical landmark) to
skull base
Level III – mid jugular nodes
- below level II to junction of omohyoid
muscle with internal jugular (surgical
landmark) or cricothyroid memberane
(clinical landmark)
Level IV – lower jugular chain
- from level III to clavicle

Level V – posterior triangle group

- nodes located along the spinal accessory,
along cervical transverse artery and
along supraclavicular area

Level VI – anterior neck compartment nodes

- from hyoid bone to suprasternal notch
- perithyroid, paratracheal, precricoid
(Delphian) nodes
- thyroid gland, apex of piriform sinus,
subglottis, cervical esophagus, trachea
CLASSIFICATION OF NECK DISSECTION

Radical Neck Dissection

– standard cervical lymphadenectomy
including nonlymphatic structures (SCM,
IJV, SA

Modified Radical
– preservation of one or more nonlymphatic
tissues (SCM, IJV, SA)

Selective
– preservation of one or more nodal groups

Extended
- removal of additional lymphatic and/or
nonlymphatic tissues
 RADICAL NECK DISSECTION
Definition
- removes all ipsilateral cervical node groups
extending from body of mandible to clavicle,
lateral border of sternohyoid, hyoid and
contralateral anterior belly of digastric, to
anterior border of trapezius
- levels I-V, SA, IJV, SCM, few nodes at tail of
parotid

Indication
- extensive lymph node metastasis or extension
beyond capsule of the node to involve the
spinal accessory and internal jugular
- node disease surrounding spinal accessory
even without gross SA or IJV involvement
 MODIFIED RADICAL NECK DISSECTION
Definition
- en bloc removal of lymph node bearing tissues
from one side of the neck (levels I-V) with
preservation of one or more nonlymphatic
tissues (SCM, SA, IJV)

Indication
- remove probable or grossly pathologic visible
lymph node disease that is not directly
infiltrating or fixed to the nonlymphatic tissue;
- because SA is rarely directly invaded by
metastatic disease like the hypoglossal and
vagus nerves which also lie in the same
proximity to the nodal disease
 SELECTIVE NECK DISSECTION
Definition
- en bloc removal of one or more nodal group
at risk for harboring metastatic cancer, an
assessment of which is based on the location
of the tumor

Rationale
- lymphatic drainage of mucosal surfaces
follow relatively constant and predictable
routes
- in the absence of metastasis to the first
echelon nodes, lower nodes are most likely
uninvolved
Supraomohyoid (Levels I-III)

- oral cavity cancer who are at risk for

harboring occult nodal disease
- 20% risk for occult disease even if no clinical
evidence of nodal disease
- done as elective neck dissection on contralateral
side for primary lesions involving floor of
mouth, ventral or midline tongue in whom
ipsilateral neck dissection is planned and no
definite postop irradiation is indicated
Lateral (Levels II-IV)

- removing nodal diseases associated with

carcinomas originating in the pharynx,
larynx,
and hypopharynx
- because the primary site is at midline with
bilateral lymphatic drainage, neck
dissection
is usually done on both sides.
Posterolateral (Levels II-V)

- removing nodal diseases associated with

cutaneous malignancies and soft tissue
sarcomas located in the posterior scalp,
nuchal ridge, occiput or posterior upper neck
- encompass the lympn node-bearing areas of
posterior and lateral compartments of the neck
Anterior Compartment (Level VI)

- eradicate nodal metastasis from the anterior

compartment of the neck, with cancers
originating in the thyroid gland, hypopharynx,
cervical trachea, cervical esophagus, and
laryngeal tumors below the glottis
- removal of perithyroidal, paratracheal,
pretracheal, precricoid (Delphian) nodes and
those along the recurrent nerve
- may be done on one side only for unilateral
laryngeal and hypopharyngeal lesions
EXTENDED NECK DISSECTION

- neck dissection extended to remove the

retropharyngeal nodes (primary sites from
pharyngeal wall or oral cavity ), hypoglossal
nerve, levator scapulae muscle or the
carotid artery
 COMPLICATIONS
Loss of trapezius function
due to removal of spinal accessory nerve
decreased ability to abduct shoulder above
90degrees at the shoulder with pain, weakness and deformity of
shoulder girdle
Air leaks
- circulation of air thru a wound drain
- communication of wound with tracheostomy

Facial/cerebral edema
- due to mechanical problems with venous
drainage
- resolves in time after collateral circulation
is established

Blindness
- 5 cases reported in literature
- intraorbital optic nerve infarction due to
intraop hypotension and severe venous
distention
Chylous fistula
- occurs in 1-2% of neck dissection
- when apparent immediately after surgery
and chylous leak exceeds 600 ml/day, early
exploration is preferred before the tissues
become markedly inflamed and fibrinous
materials coats the tissues which may
obscure important structures (e.g. vagus,
phrenic n.)
- if less than 600 ml/D and becomes apparent
only after enteral feeding, conservative
management with closed wound drainage,
pressure dressing and low fat nutritional
support
Bleeding

Carotid artery rupture

- most feared and most commonly lethal
complication
- exposure of carotid from flap breakdown
or fistula formation (malnutrition, DM,
infection, radiotherapy)
- use flawless surgical techniques in closure
of oral and pharyngeal defects, use of
dermal grafts, levator scapulae muscle flaps
and controlled pharyngostomes
LYMPHOMA OF THE HEAD AND
NECK
Usually present as cervical lymphadenopathy
Approximately 10% of lymphomas occur in head and
neck extranodal sites including
Waldeyer’s ring paranasal sinuses,
nasal cavity, larynx, oral cavity, salivary glands,
thyroid, and orbit
In the US, it is the second most common tumors in
the head and neck region
In children, presents as the most common
head and neck malignancy
Hodgkin’s Disease

usually present as cervical lymphadenopathy

unusual to present at an extranodal site
more common in male patients with a major
peak in the 3rd decade of life
Most important predictor of outcome is the
stage of the disease
increased risk for family members of patients
with the disease, 10X grater incidence
for same-sex siblings
may have a relationship with EBV
Reed-Sternberg cells pathognomonic
spread from the neck to the mediastinum,
spleen and liver (staging laparotomy)
bone marrow
Non-Hodgkin’s Disease

5X more frequent than Hodgkin’s disease

in the head and neck region
extranodal presentation is twice as frequent
as nodal presentation
predominantly disease of elderly, peak at
5th and 6th decade of life but is now
changing due to association with HIV
most important predictor of outcome is
histologic appearance of the node
classified according to morphologic appearance
with usual clinical behavior (low,
intermediate, high grade)
Ann Arbor Staging

I A single lymph node or extralymphatic site

II Two or more lymph node regions on the same side of
the diaphragm or localized extralymphatic site with
one or more lymph node regions on the same side
of the diaphragm
III Lymph ode regions on both sides of the diaphragm and
possible localized involvement of an extralymphatic
site or the spleen
IV Disseminated involvement of one or more extralymphatic
organs or tissues
Management
Hodgkin’s
Radiotherapy for early stage (Stage I, II)
Radiotherapy with chemotherapy for late stages

Non-Hodgkin’s
Low grade lymphomas are treated palliatively
because they are usually not curable
Truly localized diseases are treated with radiation
Advanced diseases in patients below 55 y/o may
evaluated for experimental chemotherapy
and bone marrow transplantation
Asymptomatic elderlies may be observed
Non-Hodgkin’s

Low grade lymphomas are treated palliatively

because they are usually not curable
Truly localized diseases are treated with radiation
Advanced diseases in patients below 55 y/o may
evaluated for experimental chemotherapy
and bone marrow transplantation
Asymptomatic elderlies may be observed
Intermediate or high grade types are approached
with curative intent with combined chemo- and radiotherapies
 EVALUATION OF UNKNOWN
PRIMARY NECK MASS
If history, PE and routine tests do not lead to a
definite diagnosis, any unknown neck mass,
particularly a unilateral, asymptomatic mass
corresponding to the location of known lymph
node groups must be considered a metastasic
neoplastic lesion unless proven otherwise

Endoscopy with guided biopsy

Fine needle aspiration and open biopsy

Open excisional biopsy

 MANAGEMENT OF UNKNOWN
PRIMARY
Assymmetric enlargement of one or more cervical
lymph node in an adult is almost always
cancerous
Primary cervical malignancy is rare
Almost all malignant cervical tumors are
metastatic except for lymphomas
Immediate removal of an enlarged lymph node
for diagnostic purposes is a disservice to the
patient with metastatic cervical carcinoma
(increased incidence of distant mets, late
regional recurrences and wound complications
due to disruption of lymphatic drainage and
manipulation of a metastasis decrease the
chance for clean surgical excision and cure)
50-67% of cases, primary sites identified by
careful routine PE
Independent second survey of less visible areas
of the upper digestive and respiratory tract
Needle biopsy of neck mass
Endoscopy is negative, sites most likely to
contain an occult tumor should be biopsied
Location of the node is a guide to sites for biopsy
posterior triangle – nasopharynx
jugulodigastric – tonsils, tongue base,
supraglottic larynx
supraclavicular – digestive tract, breast,
tracheobronchial tree, thyroid, genitourinary
If still negative, open excision with planned
surgery and neck dissection
Postop irradiation is sometimes advocated but
still controversial
- may compromise management of mucosal
carcinoma appearing later
- may induce later mucosal carcinoma
- cause prolonged morbidity in the form of
xerostomia, dysphagia, dental caries
- cure rates higher with surgery alone
- best candidates are those with N2, N3
(N1 with nodal capsular penetration)