Head and Neck Cancer Treatment Overview

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Questions and Answers

Which histologic type requires prophylactic neck dissections and radiotherapy?

High-grade mucoepidermoid carcinoma (correct)

Low-grade acinic cell carcinoma

Benign lympho-epithelial lesion

Pleomorphic adenoma

What is a common complication associated with parotidectomy?

Hypoglossal nerve injury

Frey's Syndrome (correct)

Craniofacial asymmetry

Ototoxicity

What is the male to female ratio for the occurrence of pleomorphic adenoma?

1:1

2:3

3:2 (correct)

1:2

Which type of carcinoma is an example of a low-grade malignancy?

Acinic cell carcinoma Signup and view all the answers

What percentage of pleomorphic adenomas that have been present for over 10 years undergo malignant transformation?

2-10% Signup and view all the answers

What is the most common primary malignant parotid tumor?

Mucoepidermoid carcinoma Signup and view all the answers

Which type of carcinoma has the highest recurrence rate when treated with lumpectomy?

Adenoid cystic carcinoma Signup and view all the answers

What is the estimated recurrence rate after superficial parotidectomy?

5% Signup and view all the answers

What is the most common benign neoplasm of the parotid gland?

Pleomorphic adenoma Signup and view all the answers

Which factor is strongly associated with an increased risk of laryngeal cancer?

Cigarette smoking Signup and view all the answers

What is the most common site for epistaxis?

Little's area Signup and view all the answers

Which histologic type of nasopharyngeal carcinoma is most commonly associated with endemic regions?

Undifferentiated carcinoma with lymphocytic infiltrate Signup and view all the answers

What anatomical feature is primarily affected by nasopharyngeal carcinoma, where most tumors arise?

Fossa of Rosenmuller Signup and view all the answers

Which symptom is most commonly associated with the obstruction of the eustachian tube due to nasopharyngeal carcinoma?

Unilateral otitis media with effusion Signup and view all the answers

Which cranial nerve is most frequently involved in nasopharyngeal carcinoma due to its proximity to the tumor's site of origin?

Cranial nerve VI Signup and view all the answers

What is the primary method used to confirm the diagnosis of nasopharyngeal carcinoma?

Histological examination of nasopharyngeal biopsies Signup and view all the answers

What is the primary treatment for a profuse anterior epistaxis when the bleeding source is known?

Nasal cautery Signup and view all the answers

Why should bilateral nasal cautery at equivalent sites be avoided?

It increases the risk of septal perforation. Signup and view all the answers

Which of the following methods is preferred for managing heavy posterior epistaxis initially?

Insertion of a double-lumen balloon Signup and view all the answers

What role does sedation play in treating a patient with anterior epistaxis?

It alleviates anxiety and reduces blood pressure. Signup and view all the answers

What is a common risk associated with the overzealous performance of unilateral cautery?

Septal perforation Signup and view all the answers

In which scenario is electrocautery considered more effective than chemical cautery?

In the presence of active bleeding Signup and view all the answers

What is the recommended duration for anterior nasal packs to remain inserted post-epistaxis treatment?

24-48 hours Signup and view all the answers

Which material is commonly used for nasal packing in cases of anterior epistaxis?

BIPP or petrolatum gauze strip Signup and view all the answers

What is a notable limitation of using Merocel sponges for epistaxis management?

They are less effective than traditional packs. Signup and view all the answers

What preliminary action should be taken for patients presenting with mild posterior epistaxis?

Topical decongestion and anaesthesia. Signup and view all the answers

What is the initial step to take when posterior endoscopic cautery and nasal packing fail to control epistaxis?

Examine nasal passages under general anaesthesia Signup and view all the answers

What is the consequence of not identifying the bleeding point during epistaxis management?

Ligation of the maxillary artery should be performed Signup and view all the answers

What is a potential advantage of ligating the maxillary artery during the first general anaesthesia?

Avoids the need for subsequent general anaesthesia Signup and view all the answers

What percentage of cases is ligation of the maxillary artery effective in treating epistaxis?

95% Signup and view all the answers

Which complication is associated with septodermoplasty in patients with hereditary haemorrhagic telangiectasia?

Recurrent epistaxis due to vessel regrowth Signup and view all the answers

What age demographic is most commonly affected by nasopharyngeal carcinoma in high-risk regions?

Those in their forties Signup and view all the answers

Which of the following ailments is closely associated with the Epstein-Barr virus?

Burkitt's lymphoma Signup and view all the answers

What dietary factor has been linked to an increased risk for nasopharyngeal carcinoma?

High intake of salted fish Signup and view all the answers

What is the male to female incidence ratio for nasopharyngeal carcinoma?

2-3:1 Signup and view all the answers

Which of the following factors is NOT considered an aetiological factor for nasopharyngeal carcinoma?

Cigarette smoking Signup and view all the answers

What structure drains the septum posteriorly?

Pterygoid venous plexus Signup and view all the answers

Which of the following conditions is NOT a local cause of epistaxis?

Warfarin therapy Signup and view all the answers

What is the primary arterial feature that can complicate control of epistaxis?

Anastomoses across the midline Signup and view all the answers

Which type of vascular abnormality can lead to prolonged epistaxis in hypertensive patients?

All of the above Signup and view all the answers

What is the most critical initial assessment when managing a patient with active epistaxis?

Pulse and blood pressure Signup and view all the answers

Which of the following drugs is a potent vasoconstrictor commonly used in treating epistaxis?

Cocaine Signup and view all the answers

What condition is associated with defects in platelet function leading to epistaxis?

Hemophilia Signup and view all the answers

Which nasal factor is mainly related to the initiation of posterior epistaxis?

Nasal polyps Signup and view all the answers

Study Notes

Neck Dissection and Radiotherapy

Clinically apparent cervical nodal metastases necessitate parotidectomy, radical neck dissection, and radiotherapy.
Aggressive histological types (e.g., high-grade mucoepidermoid carcinoma, malignant mixed tumor, high-grade adenocarcinoma, squamous cell carcinoma) require prophylactic neck dissections and radiotherapy.
For T3 lesions and those with facial nerve palsy, similar treatment protocols are recommended.

Complications of Parotidectomy

Potential facial nerve palsy may occur post-surgery.
Risk of hemorrhage from various arterial sources: retromandibular vein, postauricular artery, superficial temporal artery, maxillary artery, and external carotid artery.
Possible parasthesia in the greater auricular nerve distribution and neuroma formation.
Frey's Syndrome manifests as sweating in the parotid area when consuming food, attributed to aberrant nerve regrowth.

Secondary or Metastatic Parotid Tumors

Tumor-like swellings in the parotid may indicate Sjogren's syndrome, benign lympho-epithelial lesions, or sialosis.
Malignant tumors classified into low-grade (e.g., acinic cell carcinoma) and high-grade carcinomas (malignant mixed tumors, aggressive mucoepidermoid, and adenoid cystic carcinomas).

Pleomorphic Adenoma

Most common benign parotid tumor, accounting for 70% of cases, more prevalent in females (3:2 ratio).
Primarily occurs in the 5th decade of life with slow growth and rare facial nerve palsy.
2-10% malignant transformation risk for tumors present over 10 years.
Tumor appears firm and grey-white with mixed myxoid and chondroid areas.

Salivary Gland Tumor Statistics

Adenoid cystic carcinoma: 10% of salivary gland tumors.
Adenocarcinoma: 8%.
Carcinoma ex pleomorphic adenoma and malignant mixed tumor: 6%.

Risk Factors for Salivary Gland Cancer

Ionizing radiation is the only well-documented risk factor.
Increasing incidence of Warthin's tumor linked to cigarette smoking.

Causes of Epistaxis

Local contributors: trauma (including nasal fracture), inflammation (rhinitis), neoplasms (angioma, squamous cell carcinoma), drug abuse (e.g., cocaine), and vascular malformations.
General causes include coagulopathies (hereditary or acquired), thrombocytopenia, and abnormal platelet function (e.g., due to aspirin).

Management of Epistaxis

Establishing hemostasis and identifying hypovolaemia or shock is crucial.
Common interventions include nasal cautery, packing, and surgery for persistent cases.
Effective anterior epistaxis treatment utilizes vasoconstrictive agents like cocaine and techniques like nasal packing with BIPP or gauze strips.
Anticipating complications, such as septal perforation due to overzealous cautery, is also important.

Diagnostic Examination Overview

Pulse and blood pressure assessment; choice of patient position varies depending on stability.
Initial history must clarify bleed characteristics (anterior vs. posterior, unilateral or bilateral).
Nasal examination should ideally be conducted without prior vasoconstriction; suction aids visibility.

Treatment Techniques

Posterior epistaxis management may require double-lumen balloons for tamponade when source identification is challenging.
Maintenance of nasal balloons for 48-72 hours aids in managing persistent bleeding.
Endoscopic examination is suggested for non-responsive cases after balloon management.

Prognosis and Follow-Up

Recurrence rates post-surgery vary: superficial parotidectomy around 5%, while lumpectomy can range 20-35%.
Close monitoring of patients post-epistaxis treatment ensures early intervention for rebleeding episodes.### Management of Epistaxis
Saline can be used for nasal packing but carries a slight aspiration risk; however, it does not leak as easily as air.
Bilateral anterior nasal packs (petrolatum gauze strips) enhance the tamponade effect.
If initial treatments (posterior endoscopic cautery, nasal packs) are ineffective, examination under general anesthesia may be necessary to locate bleeding points.
Cauterization of identified bleeding sites may require fracturing turbinates for better access.
If bleeding cannot be pinpointed, ligation of the maxillary artery is advised, deemed effective in 95% of cases.
Embolization of the maxillary artery can control epistaxis but has a higher failure rate than ligation.
Rarely is ligation of the anterior ethmoidal vessels needed if maxillary artery ligation is successful.
Potential causes of epistaxis include malignancies requiring careful assessment and radiologic studies for identification.
Teenagers may present with angiofibroma, necessitating angiography and CT scans for surgical planning.
Management of hereditary hemorrhagic telangiectasia can include septodermoplasty and therapies like oestrogens and local radiotherapy.

Nasopharyngeal Carcinoma

A malignant tumor of epidermoid origin, predominant in certain ethnic groups.
Constitutes 90% of nasal malignancies, especially prevalent among Cantonese Chinese in Southern China, Hong Kong, and Singapore.
Age-adjusted incidence rates: Hong Kong (26/100,000 males), Jamaica (1.4/100,000 males, 0.5/100,000 females), North America (1/100,000), Northern China (3/100,000).
Aetiology includes genetic, viral (particularly Epstein-Barr virus), and environmental factors.
EBV infection precedes the onset of nasopharyngeal carcinoma in high-risk areas, with antibodies indicating increased risk.
Genetic links are suggested due to higher incidence in specific ethnic groups, with associations to HLA antigens and chromosomal deletions.
Environmental factor includes consumption of Cantonese-style salted fish linked to carcinogenic agents.

Histopathology of Nasopharyngeal Carcinoma

Classified into three types by WHO:
- Keratinising squamous cell carcinoma (30-50% in non-endemic areas)
- Non-keratinising squamous cell carcinoma
- Undifferentiated carcinoma with dense lymphocytic infiltrate, common in endemic areas.

Anatomy and Clinical Features

Nasopharynx dimensions: 4 cm x 4 cm x 3 cm, crucial for tumor spread assessment.
Symptoms include nasal obstruction, bloodstained discharge, and otitis media.
Cervical metastases occur in 60% of cases, with CT scans revealing 75-90% in specific histologic types.
Tumor may lead to cranial nerve palsies, involvement of multiple cranial nerves observed in 15-20% of cases.
Metastatic spread includes submandibular and parotid nodes.

Diagnosis and Treatment

Diagnosis confirmed via biopsy, often requiring deep sampling under general anesthesia due to submucosal lesion positioning.
Imaging (CT, MRI) essential for assessing tumor extent and planning treatment.
Predominantly treated with radiotherapy, doses of 65-70 Gy commonly given; hyperfractionation under investigation.
Surgery typically limited to biopsies and addressing residual tumors post-radiotherapy.
Prognosis related to tumor size, T stage, and nodal involvement; small nasopharyngeal cancers have a curable survival rate of 80-90%.

Management of Sinusitis

Acute sinusitis defined as inflammation resolving without residual changes; chronic sinusitis characterized by persistent symptoms or recurrent episodes.
Development involves maxillary and ethmoidal sinuses; the ostiomeatal complex's obstruction is a common initiation factor for sinusitis.
Common causative organisms include Streptococcus pneumoniae and Haemophilus influenzae, with amoxicillin and cefuroxime as first-line treatments.
Complications can range from chronic mucosal changes to orbital and intracranial issues.
Diagnosis relies on nasal endoscopy and CT imaging for accurate assessment of infection and potential complications.

Vocal Cord Function

True vocal cords adduct during phonation, resulting in controlled airflow and sound production.
Expiratory muscle contraction raises subglottic pressure until the cords separate, then return with elastic recoil and Bernoulli effect.
Mucosal wave vibration facilitates phonation, with ligaments maintaining an adducted state throughout the cycle. ### Vocal Cord Pathology
Voice deterioration linked to mucosal disease of true vocal cords.
Normal mobility requires intact recurrent laryngeal nerves, neuromuscular junction, glottic muscles, and cricoarytenoid joints.

Causes of Hoarseness

Intrinsic Lesions:
- Vocal cord nodules, vocal cord polyps.
- Reinke's oedema: submucosal edema of true vocal cords.
- Acute and chronic laryngitis.
- Granulomas: intubation, pyogenic, tuberculosis-related.
- Benign tumors: laryngeal papillomatosis.
- Malignant tumors: squamous cell carcinoma (95% of cases).
Trauma:
- Hematoma and edema due to injury.
- Foreign bodies lodged in the glottis.
Congenital Lesions:
- Vocal cord palsy, vocal cord webs.
- Laryngeal cysts, laryngocoele.
- Hemangioma or lymphangiomas.

Neurological Aspects

Nerve Palsy:
- Recurrent laryngeal nerve palsy potentially from supranuclear lesions affecting the vagus or due to cerebrovascular accidents.
- Acoustic neuromas and meningiomas as potential causes.
Bulbar and Motor Neuron Involvement:
- Bulbar poliomyelitis, motor neuron disease, lateral medullary syndrome can impact voice.

Thoracic and Cervical Lesions

Thoracic Issues:
- Malignancies of the esophagus or associated lymph nodes.
- Aortic aneurysms and effects of surgery can influence voice.
Cervical Complications:
- Penetrating neck injuries and surgeries affecting carotid body or neck dissection impact vocal cord integrity.
- Invasive malignancies from surrounding structures, such as thyroid and nasopharynx, can affect laryngeal function.

Myxedema and Systemic Disorders

Myxedema presents as dry, waxy swelling associated with hypothyroidism; it causes unique facial changes such as swollen lips and thickened nose.
Disorders affecting the neuromuscular junction, e.g., myasthenia gravis, and muscular dystrophies can also lead to hoarseness.

Cricoarytenoid Joint Dysfunction

Conditions like perichondritis, arthritis, or post-traumatic adhesions may cause dysfunction, leading to voice abnormalities.

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Description

This quiz focuses on the management of cervical nodal metastases in head and neck cancer patients. It highlights the significance of parotidectomy, radical neck dissection, and radiotherapy, particularly for aggressive tumor types. Participants will also explore associated complications and treatment protocols for advanced lesions.