Primary Care Otolaryngology

Chapter 16

margination in the soft tissues of the neck. Cancer of the larynx, particu- larly glottic cancer, is usually smaller at presentation because of the rela- tively quick onset of symptoms, and a different staging system is used. Small or early tumors without metastases do well, and large or metastatic tumors do poorly. Unfortunately, however, 60–75 percent of patients do not present until the tumor is large or metastatic. In general, T1 and T2 cancers respond well to surgery or radiation therapy (75–80%, five-year survival). For larger or metastatic lesions, surgery and radiation therapy are usually recommended, and the prognosis is poorer (15–35%, five-year survival). In addition, chemotherapy potentiates the effects of irradiation, and has become an important adjunct in the treat- ment of head and neck cancer. When head and neck cancer patients receive radiation therapy as part of their treatment, it is usually given once a day for six weeks, although some physicians use twice-a-day protocols. It is generally felt that 5600 rads cen- tigray (cGy) is a minimum dose for a neck with microscopic disease. If there is a big, bulky tumor somewhere, the dose may go up to 7000–8000 cGy. Radioactive implants using a cesium source ( brachytherapy ) may be placed to deliver a very high, localized dose to a superficial tumor. There are acute and late effects of radiation therapy, which cause mucositis and xerostomia by way of destruction of the major and minor salivary glands’ ability to produce salivary secretion. Since teeth remineralize with the minerals in saliva, they are very prone to decay during and after this thera- py. If a patient has teeth in very poor condition, all the teeth are extracted before the patient begins radiation therapy. Metastasis Squamous cell carcinoma tends to metastasize early, first to the lymph nodes of the neck and then to the lung, liver, bone, and brain. A chest x-ray, or more often a CT scan of the chest, should be obtained to be cer- tain the patient has neither metastasis nor a second tumor (which is more likely) in the lung. If the tumor has metastasized to the lungs or liver, the role of surgery is limited to palliation. However, the lungs are infrequently involved with metastatic disease at the time of initial diagnosis. If the metastases are confined to the lymph nodes of the neck (the most com- mon scenario), then a neck dissection—removing lymph nodes from the neck—is performed at the time of surgery. The lymph nodes are nestled in fat and wrapped in fascia. Selective neck dissection involves removing only nodes, fat, and fascia most likely involved by metastasis. A radical

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Primary Care Otolaryngology