Section 11

78-year-old gentleman has recently been diagnosed with an oropharyngeal tumour.

Name the different subsites for an oropharyngeal tumour.

  • Tonsils
  • Soft palate
  • Base of tongue
  • Posterior pharyngeal wall

What is the most likely histological diagnosis?

  • Squamous cell carcinoma

List two presenting complaints.

  • Neck lump
  • Sore throat
  • Dysphagia
  • Referred otalgia

Name three aetiological causes.

  • Smoking
  • Alcohol
  • Human Papillomavirus (HPV)

What is the classification system for this tumour?

TNM staging

What is p16 testing?

Overexpression of p16 protein is a useful screening method for HPV infection as HPV-associated carcinomas show strong nuclear and cytoplasmic expression of p16 in over 70% of malignant cells.

What is the cause of referred otalgia?

Occurs due to irritations of glossopharyngeal sensory nerve fibres which connect to the middle ear via Jacobson’s nerve. 

Supporting Information

British Association of Head and Neck Oncologists (BAHNO)
Head and Neck Cancer: United Kingdom National Multidisciplinary Guidelines
https://www.bahno.org.uk/_userfiles/pages/files/ukheadandcancerguidelines2016.pdf  

Laryngeal cancer

  • Mostly squamous cell carcinoma
  • 5:1 M:F
  • Smoking, alcohol, HPV 16 + 18
  • 5% synchronous tumour
  • Sites– supra, glottic and infraglottic
  • Presentation- hoarseness, dys/odynophagia, dyspnoea
  • Ix-
    • Simple tests– CXR, FBC/UE/LFTs,
    • MRI/CT TAP, panendoscopy/microlaryngoscopy
  • Mx
    • T1/2- RT or partial laryngectomy
    • T3- total laryngectomy  +/- post op RT
    • T4- total laryngectomy + neck dissection
    • Voice restoration procedure and speech therapy
    • Thyroid and PTH replacement
  • TNM for laryngeal carcinoma
    • T1 – one site
    • T2 – more than one site
    • T3 – fixed vocal cord or postcricoid invasion
    • T4 – extension beyond larynx

Laryngectomy– patient counselling is absolutely vital!
There are many types:

  1. Cordectomy– open or endoscopic- often used for benign tumours
  2. Hemilaryngectomy– tumours confined to the vocal fold- remove half thyroid cartilage, half cricoid cartilage and straps are fashioned into new vocal cord.
  3. Supraglottic laryngectomy– join of glottis to base of tongue, vocal cords in tact
  4. Supracricoid partial laryngectomy– may involve removal of vocal folds, thyroid cartilage, cricoid cartilage and one arytenoid
  5. Total laryngectomy – for cure remove thyroid, hyoid, cricoid, proximal trachea and thyroid gland. Tracheostomy with speech valve required. 

Nasopharyngeal carcinoma– 

  • Histology– squamous, squamous keratinising,  non-keratinising, or undifferentiated.
  • EBV is a risk factor with a genetic predisposition
  • Salt fish- Hong Kong
  • Most originate fossa of rosenmuller- postero-lateral recess
  • Facial nerve and eustachian tube involvement
  • Presents with neck lump, otalgia, epistaxis
  • Levator veli palatini- opens Eustachian tube on swallowing. If infiltrated will reduce mobility of the palate.
  • Trigeminal nerve irritation- pain over trigeminal area- hyperesthesia
  • Trotter’s triad
    1. Glue ear
    2. Reduced ipsilateral palate movement
    3. Trigeminal pain
  • TNM for nasopharyngeal carcinoma
    • T1 – confined to nasopharynx
    • T2 – extending to soft tissue of oropharynx or nassal fossa
    • T3 – invading bone or sinuses
    • T4 – extension into cranial fossa, hypopharynx, orbit, infratemoporal fossa

Treatment– local RT +/- bilateral neck RT +/- radical neck dissections

Angiofibroma– benign, consisting of fibrous and vascular tissue, involves the sphenopalatine foramen. It may present with epistaxis, nasal obstruction and bone erosion. 

Treatment– mid-facial degloving +/- pre-op embolisation. May require max-fax resection. 

Oropharyngeal cancer

  • 85% SCC
  • 10% non hodgkin’s lymphoma- palatine/lingual tonsil mostly
  • 2% minor salivary gland cancers- 50% adenoid cystic
  • 3% others
  • Male:female 5:1
  • 30% have 2nd primary in 10 years
  • Leukoplakia = premalignant – hyperkeratosis- smokers, alcohol, strong spices, prolonged sharp teeth/denture irritation. 3% undergo change in 5 yrs. need a biopsy and follow up.
  • Risk factors– smoking, betel nut chewing, HPV (gardasil HPV 6, 11, 16, 18)
  • Presentation– neck lump, sore throat, odynophagia, muffled speech, trismus if pterygoid involvement.
  • Investigations– MRI- soft tissue definition, CXR and liver USS, FNA of lump, panendoscopy + biopsy. Tonsil and tongue base ?blind biopsy.
  • Management
    • SCC/minor salivary gland cancer
      • T1/2– RT
      • T3-4– excision- 1-2cm margin +/- neoadjuvant chemoradiotherapy depends on site an size:
        • Mandibulotomy
        • Glossopharyngectomy
        • Palatectomy
        • Total lary/oesophagectomy
        • Reconstruction – ALT/ pec maj/ forearm
        • Neck dissection
      • Non-hodgkin’s lymphoma- CHOP/VAPEC- B chemo
      • May require stricture plasty, swallowing rehab etc.
  • TNM for oropharyngeal cancer
    • T1 – <2cm
    • T2 – 2-4cm
    • T3 – >4cm
    • T4 – extension beyond oropharyngeal

Hypopharyngeal carcinoma

  • 90% SCC
  • 3 areas
    • Postcricoid
    • Pyriform fossa
    • Posterior pharyngeal wall
  • Old age and M>W
  • Presentation– neck lump, hoarseness, dysphagia, pneumonia.
  • Investigations– FBC, barium swallow, MRI, SCR, panendoscopy, FNAC
  • Management
    • RT for early tumours
    • Surgery for larger tumours; laryngectomy + reconstruction, pharyngectomy,
    • Speech rehab
    • Hormone replacement for thyroidectomy.
    • Surgery + RT for large tumours and suspicious margins.
  • TNM for Hypopharyngeal carcinoma
    • T1 – one site and <2cm
    • T2 – more than one site or 2-4cm
    • T3 – >4cm or fixation or hemilarynx
    • T4 – invasion of adjacent structures
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