CHAPTER 15 - Tumors of the Head and Neck John J. Coleman III Mark R. ultan C!N"ENITA# #E I!

N Th$ro%lossal &uct C$sts The th$ro'd %land or'%'nates from the (har$n%eal floor at the foramen cecum dur'n% the fourth )eek of %estat'on. It enlar%es* +ecomes +'lo+ed* and descends ,entrall$ 'n the m'dl'ne of the neck 'n close a((ro-'mat'on to the de,elo('n% h$o'd +one. &ur'n% th's descent the (atent d',ert'culum 's called the th$ro%lossal duct. The duct normall$ resor+s +$ the tenth )eek of %estat'on. .hen all or a (ort'on of th's duct (ers'sts* th$ro%lossal duct c$sts or s'nuses are formed. Class'call$ these c$sts (resent as m'dl'ne masses 'n ch'ldhood* althou%h the$ ha,e +een re(orted to +e as much as / cm from the m'dl'ne and ma$ (resent for the f'rst t'me 'n adults. E'%ht$ (ercent occur at or 0ust +elo) the h$o'd +one. A maneu,er to d'fferent'ate them from &el(h'an l$m(h nodes or other central masses 's to ha,e the (at'ent (rotrude the ton%ue. The le,el of the c$st 's ele,ated +$ (rotrus'on* demonstrat'n% 'ts em+r$olo%'c or'%'n from the +ase of the ton%ue. 1nl'ke +ranch'al cleft remnants* th$ro%lossal duct c$sts %enerall$ do not ha,e e-ternal s'nuses. A s'%n'f'cant (ro(ort'on do +ecome 'nfected* ho)e,er* usuall$ dur'n% the course of an u((er res('rator$ tract 'nfect'on. A((ro-'matel$ 5 (ercent of the c$sts conta'n funct'onal th$ro'd t'ssue* and rare cases of th$ro%lossal duct carc'noma ha,e +een re(orted. The d'fferent'al d'a%nos's for m'dl'ne neck masses a+out the h$o'd +one 'ncludes l'n%ual th$ro'd t'ssue. In rare cases th's 's the (at'ent2s onl$ act',e th$ro'd %land. Therefore* the (resence of th$ro'd t'ssue 'n 'ts normal anatom'c locat'on must +e conf'rmed e'ther cl'n'call$ or +$ rad'oact',e scan +efore an$ m'dl'ne neck mass 's e-c'sed* and careful (osto(erat',e o+ser,at'on for h$(oth$ro'd'sm 's 'm(erat',e. 'strunk 's cred'ted )'th the de,elo(ment of a techn'3ue for e-c's'n% th$ro%lossal duct c$sts and s'nuses that m'n'm'4es the r'sk of recurrence. He descr'+ed resect'on of the c$st )'th the central (ort'on of the h$o'd +one* follo)'n% the s'nus su(er'orl$ to 'ts (resumed s'te of or'%'n* the foramen cecum* and e-c's'n% 't 'n 'ts ent'ret$. 5ranch'al Cleft Anomal'es 5ranch'al cleft c$sts* s'nuses* and cart'la%'nous remnants result from the 'ncom(lete fus'on of the +ranch'al clefts. The +ranch'al clefts* a((ear'n% 'n )eek 6 of em+r$on'c l'fe and normall$ 'n,olut'n% full$ +$ )eek 7* contr'+ute to the format'on of ,ar'ous head and neck structures 'n the de,elo('n% em+r$o. .hen a (ort'on of a cleft (ers'sts* e('thel'um-l'ned c$sts or s'nuses* )'th or )'thout cutaneous o(en'n%s and cart'la%'nous rests* ma$ result. These anomal'es usuall$ (resent 'n the f'rst decade of l'fe +ut ma$ %o undetected unt'l adulthood. The ma0or't$ of +ranch'al cleft c$sts and s'nuses are l'ned +$ s3uamous e('thel'um* althou%h c'l'ated columnar e('thel'um has +een re(orted as )ell. 5ranch'al cleft carc'noma occurs rarel$ )hen there 's a h'stor$ of a +ranch'al cleft c$st* the su+se3uent de,elo(ment of e('dermo'd cancer at that s'te* and no other (r'mar$ les'on. 5ranch'al cleft c$sts also conta'n l$m(ho'd t'ssue and ma$ enlar%e 'n res(onse to u((er res('rator$ tract 'nfect'ons.

The most common t$(es of +ranch'al cleft anomal'es are those of the second cleft and are found at the m'ddle and lo)er th'rds of the sternocle'domasto'd muscle. Cart'la%'nous rests from the f'rst +ranch'al cleft t$('call$ are su+cutaneous* usuall$ a((ear med'al to the tra%us* and ma$ +e mana%ed +$ s'm(le e-c's'on. C$sts and s'nuses often e-tend more dee(l$ 'nto the neck. The f'stulous tract courses su(er'orl$ alon% the carot'd sheath and then med'all$ o,er the h$(o%lossal ner,e +et)een the 'nternal and e-ternal carot'd arter'es to end at the (har$n- ad0acent to the tons'llar fossa. A sta'rste( 'nc's'on 's somet'mes needed to follo) th's c'rcu'tous route. 8'rst +ranch'al cleft c$sts and s'nuses are located a+o,e the le,el of the h$o'd +one 0ust +elo) the +od$ of the mand'+le and e-tend su(erolaterall$ throu%h the (arot'd %land to end )'th'n the mem+ranous e-ternal aud'tor$ canal. E-c's'on of these c$sts and s'nuses 's recommended to a,o'd the com(l'cat'ons assoc'ated )'th recurrent 'nfect'on. &'ssect'on must +e met'culous to a,o'd 'n0ur$ to the fac'al* h$(o%lossal* ,a%us* and l'n%ual ner,es and to the carot'd ,essels. Anomal'es of the th'rd +ranch'al cleft are rare. #'ke second cleft anomal'es* the$ ar'se anter'or to the m'ddle and lo)er th'rds of the sternocle'domasto'd muscle. Ho)e,er* the$ course +eh'nd the carot'd arter$ to end at the ($r'form s'nus. Heman%'omas and 9ascular Malformat'ons Con%en'tal ,ascular les'ons must +e clearl$ class'f'ed as heman%'omas or ,ascular malformat'ons 'n order to assess the'r (ro%nos's and esta+l'sh a((ro(r'ate mana%ement (lans. The d'st'nct'ons +et)een the t)o ha,e +een clar'f'ed on the +as's of cellular and cl'n'cal character'st'cs. Heman%'omas ha,e an 'ncreased m'tot'c act','t$ and as such ma$ +e cons'dered true neo(lasms. The$ are t$('call$ a+sent at +'rth or ma$ +e (resent as a fa'nt ,ascular +lush. &ur'n% the f'rst se,eral months of l'fe the$ ma$ under%o a ra('d (rol'ferat',e (hase* dur'n% )h'ch the$ somet'mes %ro) to lar%e s'4e. Althou%h the ma0or't$ of heman%'omas under%o s(ontaneous 'n,olut'on +$ the a%e of se,en* com(l'cat'ons such as ulcerat'on and +leed'n%* o+struct'on of the e$e )'th su+se3uent am+l$o('a* nasal a'r)a$ o+struct'on* and rarel$ throm+oc$to(en'a :;asa+ach-Merr'tt s$ndrome< ma$ mandate earl$ sur%'cal resect'on. $stem'c de-amethasone thera($* or the 'ntra,enous adm'n'strat'on of 'nterferon-a* for a short course has +een found to arrest the %ro)th of lar%e les'ons dur'n% the'r (rol'ferat',e (hase. The use of 'ntrales'onal stero'd 'n0ect'ons or scleros'n% a%ents ma$ +e successful 'n ach'e,'n% tem(orar$ control of smaller heman%'omas 'n certa'n locat'ons such as the l'( or e$el'd. Photod$nam'c laser thera($ ma$ +e hel(ful 'n (re,ent'n% the onset of the (rol'ferat',e (hase of heman%'omas. 9ascular malformat'ons* unl'ke heman%'omas* ha,e a normal rate of endothel'al cell turno,er. The$ result from con%en'tal errors 'n ,ascular mor(ho%enes's and are class'f'ed +$ the'r ,essel of 'n,ol,ement=ca('llar$* ,enous* arter'al* l$m(hat'c* or com+'ned. H'%h-flo) les'ons result from %ross a+normal't'es connect'n% the arter'al and ,enous s$stems and ma$ cause catastro(h'c (ro+lems of mass',e hemorrha%e* h'%h-out(ut con%est',e heart fa'lure* and hemol$t'c anem'a. Chron'c 'ncreased +lood flo) ma$ +e assoc'ated )'th skeletal a+normal't'es such as +one h$(ertro(h$ and d'stort'on. Ca('llar$* ,enous* and arter'al malformat'ons ma$ occur an$)here 'n the head and neck. #$m(hat'c malformat'ons :c$st'c h$%romas< class'call$ occur 'n the neck or the floor of the mouth. All malformat'ons are (resent at +'rth* althou%h the$ ma$ not +e cl'n'call$ e,'dent unt'l the ectat'c ,essels suddenl$ d'late under hormonal or other (h$s'olo%'c 'nfluences. The$ normall$ %ro) (ro(ort'onall$ )'th the ch'ld and

do not re%ress s(ontaneousl$* unl'ke heman%'omas. Therefore* the mana%ement of malformat'ons often 's sur%'cal. Ind'cat'ons for earl$ sur%'cal resect'on 'nclude recurrent 'nfect'ons* o+struct',e s$m(toms :e.%.* res('rator$ d'stress<* hemorrha%e* and s'%n'f'cant aesthet'c deform't'es. 5ecause ,ascular malformat'ons of the head and neck often are h'%hl$ 'nf'ltrat',e* a com(lete (reo(erat',e e,aluat'on of the e-tent of the les'on and 'ts ,ascular't$ must +e o+ta'ned. An%'o%ra(h$ usuall$ 's necessar$* somet'mes for d'a%nos's* +ut usuall$ to determ'ne the contr'+utor$ ,essels. .hen techn'call$ (oss'+le* com(lete e-t'r(at'on of the malformat'on should +e (erformed )h'le (reser,'n% normal anatom'c structures. Preo(erat',e em+ol'4at'on +$ arter'o%ra(h'c techn'3ue ma$ decrease +lood flo) tem(orar'l$* mak'n% sur%'cal resect'on safer and more (ract'cal. 9ascular +'rthmarks* 'n the (ast descr'(t',el$ named >stra)+err$? or >ca('llar$? heman%'oma* >(ort-)'ne sta'ns*? >ca,ernous heman%'omas*? and >c$st'c h$%romas*? are no) class'f'ed +$ the'r ma0or ,essel of 'n,ol,ement=ca('llar$* ,enous* or l$m(hat'c malformat'on. Accurate descr'(t'on 's cruc'al* s'nce the (ro%nos's and mana%ement of ,ascular +'rthmarks de(end d'rectl$ on the'r correct class'f'cat'on as heman%'omas or malformat'ons. In dee(-seated su+cutaneous ,ascular malformat'ons such as those somet'mes occurr'n% 'n the cheek or (har$n-* (h$s'cal e-am'nat'on ma$ +e 'nade3uate for accurate del'neat'on. 8urther e,aluat'on often 's necessar$ and ma$ 'nclude com(uted tomo%ra(h$ :CT< or ma%net'c resonance 'ma%'n% :MRI<* an%'o%ra(h$* or technet'umla+eled red +lood cell sc'nt'%ra(h$. &ef'n't',e d'a%nos's 'n an$ (at'ent )'th a ,ascular mass ma$ re3u're o(en +'o(s$ to rule out a mal'%nanc$* )h'ch ma$ occas'onall$ ha,e s'm'lar rad'o%ra(h'c character'st'cs. 5ENI"N #E I!N #'( The lo)er l'( ma$ +e su+0ect to chron'c 'rr'tants such as ('(e smok'n% or l'( +'t'n% and* more 'm(ortant* to the dama%'n% effects of chron'c act'n'c e-(osure. In affected 'nd','duals the e('derm's of the ,erm'l'on +ecomes atro(h'c and the derm's re,eals elastos's. The +asal la$er of the e('derm's then de,elo(s d$s(las'a* creat'n% th'cken'n% of the su(erf'c'al mucosal la$er* the stratum corneum. Th's th'cken'n% or h$(erkeratos's 's cl'n'call$ ,'s'+le and (al(a+le. .'th (ro%ress'on* the d$s(las'a e-tends u()ard 'nto the e('thel'um* (roduc'n% (arakeratos's* the accumulat'on of nucleated cells* near the e('thel'al surface. Th's 's man'fested cl'n'call$ +$ scal'n% of the l'(. A (rol'ferat'on and a+normal or'entat'on of e('thel'al cells* d$skeratos's* ma$ then follo)* ult'matel$ lead'n% to carc'noma 'n s'tu. .'th (enetrat'on of the +asement mem+rane* an 'n,as',e s3uamous cell carc'noma de,elo(s. .hen d$skeratos's or carc'noma 'n s'tu 's (resent o,er a lar%e e-tent of the surface of the lo)er l'(* e-c's'on of the ent're ,erm'l'on :>l'( sha,e?< should +e cons'dered. The l'( 's then resurfaced +$ ad,anc'n% the la+'al and +uccal mucosa to the mucocutaneous 0unct'on. !ral Ca,'t$ A ,ar'et$ of +en'%n les'ons ar'se 'n the oral ca,'t$. The$ ma$ +e %rou(ed +$ locat'on 'nto those affect'n% the +uccal mucosa* %'n%',a* or ton%ue or +$ the'r causat'on* such as 'nflammator$ or ulcerat',e. 8or man$* the'r s'%n'f'cance l'es 'n the'r (oss'+le (remal'%nant (otent'al or 'n the'r m'm'ck'n% of true mal'%nanc'es.

The oral l'n'n% conta'ns countless mucous %lands* the m'nor sal',ar$ %lands. A su+mucosal accumulat'on of mucus results 'n a mucous retent'on c$st. 'nce the ma0or't$ of these c$sts ha,e no e('thel'al l'n'n%* 't 's +el'e,ed that the$ are most often caused +$ ru(ture of the duct s$stem* )'th e-tra,asat'on of mucus* and not +$ ductal o+struct'on* as )as (re,'ousl$ thou%ht. The most common locat'on for a mucous c$st or mucocele 's the la+'al mucosa of the lo)er l'( :8'%. 15-1<. These les'ons are t$('call$ less than 1 cm 'n d'ameter* smooth* rounded* and ha,e a +lu'sh hue. The treatment of cho'ce 's e-c's'on. Marsu('al'4at'on alone 's reser,ed for e-tens',e les'ons. A ranula 's a t$(e of mucous retent'on c$st that ar'ses from ma0or sal',ar$ %lands* most commonl$ the su+l'n%ual %lands. Th's too 's mana%ed +$ e-c's'on* +ut %',en 'ts locat'on 'n the floor of the mouth and* 'n some cases* 'ts lar%e s'4e* 't ma$ re3u're a met'culous d'ssect'on to a,o'd ner,e 'n0ur$ and (osto(erat',e hemorrha%e. It 's fre3uentl$ necessar$ to resect the affected su+l'n%ual %land 'n-cont'nu't$ to (re,ent recurrence. An e(ul's 's a %ranulomatous les'on of the %'n%',a@ as else)here 'n the +od$* 't re(resents an e-a%%erated 'nflammator$ res(onse to m'nor 'n0ur$. T)o su+t$(es e-'stA con%en'tal e(ul's 's t$('call$ found 'n the anter'or ma-'lla of ne)+orns@ e(ul's %ra,'darum occurs 'n a((ro-'matel$ 1 (ercent of (re%nant )omen and normall$ resol,es s(ontaneousl$ )hen the (re%nanc$ 's concluded. !nl$ s$m(tomat'c e(ul'des need +e e-c'sed. Per'(heral %'ant cell re(arat',e %ranulomas also occur most commonl$ on the %'n%',a. The >%'ant? cell of or'%'n resem+les an osteoclast. These %ranulomas are (ol$(o'd* su+mucosal* and f'+rous. The$ can create ulcerat'on and hemorrha%e of the o,erl$'n% mucosa. Rad'o%ra(hs ma$ re,eal eros'on of the underl$'n% +one. E-c's'on must +e com(lete to (re,ent recurrence. The term >(er'(heral? refers to the soft-t'ssue or'%'n of these tumors as o((osed to the central %'ant cell re(arat',e %ranulomas* )h'ch* althou%h s'm'lar h'stolo%'call$* ar'se )'th'n +one. The (er'(heral %'ant cell re(arat',e %ranulomas are four t'mes more common than the central t$(e. The latter are e-(ans'le endosteal les'ons that t$('call$ (resent 'n the mand'+le of $oun% adults. The$ also ha,e +een re(orted 'n the (aranasal s'nuses* or+'t* cran'al ,ault* and tem(oral +one. The$ must +e d'st'n%u'shed from true %'ant cell tumors of +one :)h'ch ha,e mal'%nant (otent'al<* +ro)n tumors of h$(er(arath$ro'd'sm* traumat'c +one c$sts* and f'+rous d$s(las'a. Thorou%h curetta%e 's %enerall$ curat',e. The ton%ue and the lar$n- are common locat'ons for the de,elo(ment of (a('llomas. The$ are caused +$ the human (a('lloma,'rus* )h'ch 'nduces s3uamous e('thel'al (rol'ferat'on 'nto soft* 'rre%ular* (edunculated les'ons that ma$ recur and cause o+struct'on of the a'r)a$. Erad'cat'on ma$ +e accom(l'shed +$ e-c's'on or cauter'4at'on us'n% a car+on d'o-'de laser. !ther common +en'%n masses of the ton%ue 'nclude f'+romas* neurof'+romas* and l'n%ual th$ro'd nodules. The latter ma$ l'e dormant throu%h ch'ldhood and then ra('dl$ enlar%e dur'n% (u+ert$. In 1B/C A+r'kossoff descr'+ed rare +en'%n tumors 'n,ol,'n% the ton%ue* )h'ch he named %ranular cell m$o+lastoma +ecause of the'r (resumed em+r$onal muscle cell of or'%'n. The$ are no) +el'e,ed to der',e from ch)ann cells and ha,e +een found to ar'se throu%hout the aerod'%est',e tract* (art'cularl$ 'n the lar$n-. In the ton%ue

the$ t$('call$ occur as f'rm* su+mucosal s)ell'n%s 'n the m'ddle one-th'rd and ma$ therefore m'm'c s3uamous cell carc'noma. .ed%e e-c's'on 's curat',e. The oral l'n'n% 's su+0ect to a num+er of ulcerat',e cond't'ons. The 'd'o(ath'c a(hthous ulcer 's the most common t$(e. The c$cle of (a'nful ulcerat'on and s(ontaneous heal'n% ma$ occur se,eral t'mes a $ear and (ers'st for man$ $ears. !ther s'm'lar ulcers ha,e 'dent'f'a+le causat',e factors* 'nclud'n% ,'ral 'nfect'on )'th her(es s'm(le-* nutr't'onal def'c'enc'es 'nclud'n% ,'tam'n 5* folate* or 'ron* and emot'onal stress. These ulcers often res(ond to to('cal stero'ds. Mult'(le (a'nful oral ulcerat'ons ma$ +e a man'festat'on of (em(h'%us ,ul%ar's. Th's ma$ +e accom(an'ed +$ se,ere* %eneral'4ed to-'c't$. The d'sease t$('call$ occurs 'n the f'fth to se,enth decade of l'fe 'n (at'ents of Med'terranean descent. The ulcers +e%'n as 'ntrae('thel'al +ullae that su+se3uentl$ ru(ture and ulcerate. The o,erl$'n% e('thel'um ma$ +e ru++ed off eas'l$ :N'kolsk$2s s'%n<. In er$thema mult'forme* (ers'stent or recurrent (a'nful oral ulcerat'ons ar'se )'th'n a +ack%round of d'ffuse oral er$thema. 5'o(s$ e-am'nat'on re,eals a (er',ascular l$m(hoc$t'c cellular 'nf'ltrate. e(arate sk'n 'n,ol,ement ma$ or ma$ not +e (resent. A ,ar'et$ of causes ha,e +een (ro(osed. Mana%ement )'th s$stem'c stero'ds and ant'meta+ol'tes 's often necessar$. &'screte* (a'nful ulcers are also (resent 'n necrot'4'n% s'alometa(las'a. Th's 's a +en'%n 'nflammator$ d'sease of m'nor sal',ar$ %lands that usuall$ occurs on the hard (alate. It 's +el'e,ed that local trauma leads to (ro%ress',e local 'schem'a and ulcerat'on. The h'stolo%'c d'fferent'at'on from s3uamous cell cancer or mucoe('dermo'd carc'noma can +e e-tremel$ d'ff'cult +$ 'nc's'onal +'o(s$. Therefore* althou%h these ulcers )'ll ord'nar'l$ heal s(ontaneousl$ 'n C to 1D )eeks )'thout s(ec'f'c treatment* 'n cases )here the correct d'a%nos's rema'ns unclear after 'nc's'onal +'o(s$* com(lete e-c's'on of the ulcer 's (rudent. The descr'(t'on and s'%n'f'cance of leuko(lak'a and er$thro(las'a )'ll +e re,'e)ed later 'n th's cha(ter. !ther )h'te (la3uel'ke les'ons of the oral ca,'t$ 'nclude )h'te s(on%e ne,us* l'chen (lanus* and oral ha'r$ leuko(lak'a. H'stolo%'call$* all re,eal (arakeratos's. .h'te s(on%e ne,us 's a rare fam'l'al ectodermal d'sease that d'ffusel$ 'n,ol,es the oral ca,'t$ 'n a +en'%n* self-l'm'ted manner. #'chen (lanus 's a de%enerat',e mucocutaneous d'sease )'th a (ro+a+le auto'mmune +as's. !ral les'ons ma$ a((ear )'th or )'thout cutaneous man'festat'ons and ma$ at t'mes +ecome eros',e. !ral s3uamous cell carc'noma has +een found 'n assoc'at'on )'th l'chen (lanus )'th an 'nc'dence ,ar$'n% +et)een D.DB and 1D (ercent 'n d'fferent ser'es. Therefore* as 'n oral leuko(lak'a* s$stem'c and to('cal ret'no'ds are +e'n% e,aluated 'n the treatment of oral l'chen (lanus to re,erse the cond't'on 'tself and* more 'm(ortant* to su((ress the (resumed he'%htened (otent'al of the oral mucosa to)ard de%enerat'on 'nto 'n,as',e carc'nomas 'n these cond't'ons. !ral ha'r$ leuko(lak'a 's a form of (arakeratos's recentl$ descr'+ed 'n (at'ents )'th AI& or other forms of 'mmunosu((ress'on such as 'n (at'ents )'th renal trans(lants or leukem'a. Th'ck* sha%%$ (la3ues t$('call$ a((ear on the lateral surface of the ton%ue and +ecome s$m(tomat'c )hen su(er'nfected )'th Cand'da. Mana%ement 'ncludes ant'fun%al med'cat'on* ant','ral a%ents* or sur%'cal e-c's'on. Nose Pol$(s ar'se commonl$ )'th'n the nasal ca,'t$ and (aranasal s'nuses. The$ occur )'th e3ual fre3uenc$ 'n males and females and 'n all a%e %rou(s after adolescence. Ten

(ercent of ch'ldren )'th c$st'c f'+ros's ma$ also de,elo( nasal (ol$(s. The (ol$(s are often mult'(le* 'n,ol,'n% +oth s'des of the nasal ca,'t$ and the (aranasal s'nuses. The$ ma$ (resent )'th nasal o+struct'on* muco'd nasal d'schar%e* or anosm'a. Those that ar'se 'n the re%'on of the tur+'nates and ethmo'ds are ma'nl$ aller%'c 'n or'%'n* )h'le those of the (oster'or nasal ca,'t$ are most often 'nfect'ous. Med'cal mana%ement should 'nclude an e,aluat'on for aller%'es. As('r'n should +e sto((ed or a,o'ded* s'nce an assoc'at'on e-'sts +et)een as('r'n use and the format'on of nasal (ol$(s. If the aller%'c e,aluat'on 's ne%at',e* an em('r'c tr'al of ant'm'cro+'als 's +e%un. tero'd nasal s(ra$s ma$ +e hel(ful. .hen med'cal mana%ement fa'ls* sur%'cal 'nter,ent'on ma$ +e necessar$. 'm(le (ol$(ectom$ carr'es a h'%h rate of recurrence* and more e-tens',e endosco('c or o(en e-c's'on ma$ +e necessar$. Pa('llomatous %ro)ths ma$ occur on the nasal sk'n or )'th'n the nasal ca,'t$. The s3uamous (a('lloma 's an e-o(h$t'c ,errucous les'on caused +$ the (a('lloma,'rus and 's (resent on the sk'n of the nasal s'lls* columella* or alae. It 's mana%ed as are other cutaneous )arts. The 'n,erted (a('lloma :also called schne'der'an (a('lloma* s3uamous (a('lloma* or (a('llomatos's< 's a (ol$(o'd mass occurr'n% on the lateral nasal )all* t$('call$ 'n m'ddle-a%ed men. The name 's der',ed from 'ts h'stolo%'c a((earance of an >'n,erted? (rol'ferat',e %ro)th (attern. The s'%n'f'cance of th's les'on l'es 'n 'ts (resentat'on )'th s$m(toms of nasal o+struct'on* 'ts recurrence rate of 5D (ercent )'th (ol$(ectom$ alone* and 'ts assoc'at'on )'th concurrent :E (ercent< and su+se3uent :6 (ercent< 'n,as',e s3uamous cell carc'noma. More e-tens',e resect'on and close follo)-u( are therefore 'nd'cated and can lo)er the recurrence rate to C (ercent. Ju,en'le naso(har$n%eal an%'of'+romas are +en'%n +ut h'%hl$ e-(ans'+le and destruct',e f'+ro,ascular neo(lasms that t$('call$ ar'se 'n adolescent males +et)een 1D and /D $ears of a%e. !r'%'nat'n% 'n the su(er'or nasal ca,'t$* the$ can erode )'del$ 'nto the (aranasal s'nuses* or+'t* (ter$%oma-'llar$ fossa* and m'ddle cran'al fossa. Earl$ s$m(toms 'nclude nasal o+struct'on and e('sta-'s* and more ad,anced les'ons can (roduce anosm'a* (ro(tos's* or cran'al ner,e d$sfunct'on. Mana%ement commonl$ re3u'res (rel'm'nar$ an%'o%ra(h'c em+ol'4at'on follo)ed +$ sur%'cal e-t'r(at'on. A((ro-'matel$ 1D (ercent re3u're a com+'ned 'ntracran'alFe-tracran'al a((roach. Rad'at'on thera($ 's %enerall$ reser,ed for res'dual or recurrent d'sease* althou%h 'ts successful use as a (r'mar$ modal't$ has also +een re(orted. Paranasal 'nuses Althou%h the terms are often used 'nterchan%ea+l$* mucous retent'on c$sts and mucoceles of the (aranasal s'nuses are d'fferent ent't'es )'th d'st'nct (atho%eneses* natural h'stor'es* and connotat'ons. Mucous retent'on c$sts ar'se as a result of +locka%e of secret'on from m'crosco('c secretor$ ducts of mucous %lands )'th'n the l'n'n% of the (aranasal s'nus ca,'t$* (oss'+l$ as a se3uela of s'nus't's. The flu'd mass that results rema'ns se(arate from the +on$ )all of the s'nus and so cont'nues to +e surrounded +$ a'r )'th'n the s'nus* e-ce(t at 'ts +ase. Rarel$* the$ can enlar%e to occu($ the ent're s'nus* at )h'ch (o'nt 't )ould +e d'ff'cult to d'st'n%u'sh them from the more ,'rulent mucoceles. Rad'o%ra(h'call$ the$ a((ear as d'screte masses that are (rof'led +$ s'nus a'r. The most common locat'on for mucous retent'on c$sts of the (aranasal s'nuses 's 'n the ma-'llar$ s'nus* )here the$ usuall$ (resent as an as$m(tomat'c 'nc'dental f'nd'n% on --ra$. Ten (ercent of rout'ne s'nus rad'o%ra(hs

re,eal e,'dence of these c$sts 'n the ma-'llar$ s'nus. The$ are cons'dered the most common +en'%n les'ons of the ma-'lla. Treatment 's rarel$ necessar$. As o((osed to the 'ndolent mucous c$st* mucoceles of the (aranasal s'nuses* althou%h +en'%n* can +e e-(ans'le* h'%hl$ destruct',e les'ons. These result from macrosco('c +locka%e of a s'nus ost'um +$ e('thel'al or osseous neo(lasms or 'nflammator$ (rocesses* or as a result of trauma :e.%.* fac'al +one fractures<. Muc'nous secret'ons then accumulate )'th'n the ent're s'nus. .'th (ers'stent secret'on a (ressure effect on the ent're s'nus )all 's (roduced* d's(lac'n% +oth the e('thel'al l'n'n% and the +on$ )all. Th's ult'matel$ can result 'n th'nn'n% and destruct'on of the )all such that the mucocele can >'n,ade? ad0acent ,'tal structures. CT or MRI scann'n% 's needed to del'neate the com(lete e-tent of the (rocess* +ut cl'n'cal d'st'nct'on from a carc'noma can +e d'ff'cult. Mucoceles most commonl$ ar'se )'th'n the frontal s'nuses* follo)ed* 'n order of fre3uenc$* +$ the ethmo'dal* ma-'llar$* and s(heno'dal s'nuses. In the frontal s'nus locat'on the$ most often (resent )'th frontal headaches. '-t$ (ercent of frontal s'nus mucoceles erode throu%h the floor of the s'nus :the or+'tal roof< caus'n% (ro(tos's and frontal s)ell'n%. #eft untreated* d'(lo('a and e,en +l'ndness can result. $m(toms result'n% from mucoceles of the other s'nuses de(end on the'r d'rect'on of s(read. 8ortunatel$* 'ntracran'al e-tens'on 's rare. Mucoceles that +ecome 'nfected are called ($oceles and (resent )'th the add't'onal s'%ns and s$m(toms of s'nus't's. The most def'n't',e treatment of a mucocele 'ncludes the e,acuat'on of the contents of the s'nus throu%h an o(en a((roach. The ent're mucosal l'n'n% of the s'nus must then +e remo,ed and the s'nus duct occluded )'th muscle or +one. The 3uest'on rema'ns contro,ers'al as to )hether or not the rema'n'n% s'nus 'tself should then +e o+l'terated* and 'f so* )'th )hat mater'al :e.%.* muscle* fat* cancellous +one<. #ar$nThe most common +en'%n neo(lasm of the lar$n- 's the (a('lloma* account'n% for more than BD (ercent of lar$n%eal tumors. Pa('llomas* (ro+a+l$ caused +$ the human (a('lloma,'rus* usuall$ ar'se on the ,ocal cords and usuall$ (resent )'th hoarseness. The$ ma$ +e found at an$ s'te 'n the lar$n- as )ell as on the h$(o(har$n%eal or (har$n%eal )alls and (resent as (edunculated e-o(h$t'c masses. #ar$n%eal (a('llomas ma$ +e %rou(ed 'nto 0u,en'le or adult t$(es* de(end'n% on the a%e at onset. In the 0u,en'le %rou( there 's a /A1 female (redom'nance* and rat'o 's re,ersed 'n the adult %rou(. The t$('cal course of each t$(e 's also d'st'nctl$ d'fferent. In adults the masses are most often sol'tar$ and rarel$ recur after e-c's'on. In the 0u,en'le %rou( the les'ons tend to +e mult'(le and ma$ recur and s(read ra('dl$ after e-c's'on. The reason for these d'fferences 's not kno)n. #ar$n%eal (a('llomas are usuall$ treated )'th laser o+l'terat'on. !ther* less common +en'%n tumors of the lar$n- 'nclude oncoc$t'c tumors and %ranular cell m$o+lastomas. The former (resent as a smooth su+mucosal mass* and the latter as a sess'le mucosal mass. The most common locat'on for +oth 's the ,ocal cords* and so the$ too t$('call$ (resent )'th hoarseness. Chondromas of the lar$nare rare +en'%n cart'la%'nous neo(lasms most commonl$ occurr'n% on the cr'co'd cart'la%e. The$ can cause hoarseness* res('rator$ o+struct'on* or d$s(ha%'a. All of these +en'%n neo(lasms are mana%ed +$ conser,at',e e-c's'on. A lar$n%ocele 's a hern'at'on of the lar$n%eal ,entr'cle. Three forms e-'st* cate%or'4ed +$ the'r s'te of (resentat'on. An 'nternal lar$n%ocele rema'ns conf'ned to the lar$n-

and (resents as an enlar%ement of the false cord. An e-ternal lar$n%ocele (rotrudes throu%h the th$roh$o'd mem+rane* caus'n% s)ell'n% 'n the anter'or neck. Com+'nat'ons of these t)o t$(es* called m'-ed lar$n%oceles* occur as )ell. The (atho%enes's 's +el'e,ed to +e assoc'ated )'th chron'c 'ncreases 'n 'ntralar$n%eal (ressure. Corro+orat',e e,'dence for th's theor$ 'ncludes the fact that s'n%ers and mus'c'ans ha,e a (ro(ens't$ for the'r de,elo(ment. $m(toms de(end on the s'te of (resentat'on* )'th the 'nternal ,ar'et$ often caus'n% hoarseness and the e-ternal most commonl$ rema'n'n% as$m(tomat'c. Treatment 'ncludes l'%at'on of the stalk of the lar$n%ocele and re(a'r of the ,entr'cular )eakness. !donto%en'c and 5one Tumors !donto%en'c Tumors A ,ar'et$ of c$sts and tumors of the mand'+le and ma-'lla ma$ ar'se from the (ro%en'tor cells of tooth de,elo(ment. The ma0or't$ of these odonto%en'c les'ons are +en'%n and ma$ +e treated conser,at',el$. Amelo+lastomas :adamant'nomas< ar'se from dental lam'na and often are assoc'ated )'th 'm(acted teeth 'n $oun% (at'ents. The'r usual (resentat'on 's that of a (a'nless mass of the 0a) )'th a mult'locular* rad'olucent a((earance on --ra$. The$ occur four t'mes more fre3uentl$ 'n the mand'+le than 'n the ma-'lla. Althou%h slo)-%ro)'n%* the$ ma$ %ro) to lar%e s'4e and erode ad0acent +one :8'%. 15-/<. Treatment cons'sts of resect'on of the ent're les'on )'th a mar%'n of +one to (re,ent local recurrence. M$-omas and P'nd+or% tumors :calc'f$'n% e('thel'al odonto%en'c tumors< are s'm'lar 'n the'r (resentat'on and mana%ement* and the$ too re3u're an en +loc resect'on for cure. A second %rou( of odonto%en'c tumors* 'nclud'n% calc'f$'n% odonto%en'c c$sts :"orl'n2s c$sts<* amelo+last'c f'+romas* cementomas* and keratoc$sts* are %enerall$ less a%%ress',e than those d'scussed a+o,e and are treated effect',el$ +$ enucleat'on and e-c's'on of the ent're l'n'n% of the les'on. Nonodonto%en'c Tumors The tumors 'n th's %rou( ar'se from +one that 's not 'n,ol,ed 'n tooth de,elo(ment. Torus 's a +en'%n* slo)-%ro)'n% (ro0ect'on from the surface of +one. The torus (alat'nus occurs 'n the m'dl'ne of the hard (alate* and the torus mand'+ular's usuall$ de,elo(s on the l'n%ual surface of the mand'+le o((os'te the (remolars* often +'laterall$. The$ are +oth common les'ons. In the 1n'ted tates /D (ercent of the (o(ulat'on ha,e a torus (alat'nus and E (ercent a torus mand'+ular's. There 's e,'dence that the$ are %enet'call$ 'nher'ted +$ autosomal dom'nant %enes )'th 'ncom(lete (enetrance. Tor' often +e%'n around (u+ert$ and are slo)-%ro)'n%. The$ can 'nduce ulcerat'on of the o,erl$'n% mucosa* thus m'm'ck'n% a mucosal neo(lasm. No thera($ 's needed unless the$ 'nterfere )'th s(eech* mast'cat'on* or the use of dentures* at )h'ch t'me s'm(le e-c's'on 's (erformed. E-ostoses are s'm'lar to tor' and also commonl$ occur 'n the 0a)s. There are local'4ed o,er%ro)ths of +one that ma$ +e nodular* (edunculated* or flat and are often mult'(le. The$ most often (resent 'n the ma-'lla at the can'ne fossa as a hard* d'screte* su+mucosal mass. !nl$ s$m(tomat'c masses re3u're e-c's'on. !steomas are slo)-%ro)'n% tumors of mature +one that ar'se )'th'n :'ntraosseous< or at the (er'(her$ of the 'n,ol,ed +one. The (er'(heral les'ons often are attached to the cort'cal +one +$ a dense (ed'cle. In,ol,ement of the +ones outs'de of the face and

skull 's rare. The$ most commonl$ ar'se on the mand'+le on the l'n%ual as(ect of the ramus or on the lo)er +order of the an%le of the mand'+le. !steomas also ma$ occur 'n the (aranasal s'nuses* )here the$ ma$ %ro) to a lar%e s'4e. E-c's'on 's ad,'sed )hen cont'nued %ro)th encroaches u(on ,'tal structures or +ecomes cosmet'call$ unacce(ta+le. Mult'(le osteomas are one of the man'festat'ons of "ardner2s s$ndrome* the others +e'n% mult'(le 'nclus'on c$sts of the sk'n* su(ernumerar$ teeth* and fam'l'al (ol$(os's. 8'+rous d$s(las'a 's a +en'%n +one d'sorder of unkno)n cause 'n )h'ch cort'cal +one 's re(laced +$ 'mmature f'+rous t'ssue. The f'+rous t'ssue often (rol'ferates and e-tends +e$ond normal +oundar'es* d'stort'n% and com(ress'n% ,'tal structures. e,ent$ (ercent of (at'ents ha,e 'n,ol,ement of a s'n%le +one=monostot'c=and GD (ercent ha,e the (ol$ostot'c form. In the head and neck* the mand'+le or ma-'lla 's most often 'n,ol,ed. Al+r'%ht2s s$ndrome 'ncludes (ol$ostot'c f'+rous d$s(las'a* (recoc'ous (u+ert$* cafH- au-la't s(ots* and se,eral endocr'ne a+normal't'es. The mana%ement of the (at'ent )'th f'+rous d$s(las'a 's d'ctated +$ the a%%ress',eness of the d'sease and ran%es from o+ser,at'on onl$ to e-tens',e local resect'on and reconstruct'on. Mal'%nant de%enerat'on occurs 'n 1 (ercent of the (at'ents and ma$ +e related to (r'or rad'at'on thera($. Mal'%nant de%enerat'on should +e sus(ected 'n an$ les'on that under%oes ra('d %ro)th or (roduces s'%n'f'cant (a'n. CARCIN!MA "eneral Cons'derat'ons Mal'%nant neo(lasms that ar'se 'n the head and neck area or u((er aerod'%est',e tract share the %eneral +eha,'or of most sol'd tumorsA local %ro)th* locore%'onal s(read* and d'stant metastas's. The'r effect* ho)e,er* +efore thera($ and as a conse3uence of thera($* de(ends much more than most other neo(lasms2 on local d'sru(t'on of funct'on. The t)o ma'n ,e%etat',e funct'ons of the human +e'n%=al'mentat'on and res('rat'on=are effected +$ the 'ntr'cate s$ner%$ of the +one* ner,e* muscle* and mucosa- l'ned ca,'t'es that make u( the head and neck. In,as',e carc'noma d'sru(ts th's f'ne +alance* result'n% not onl$ 'n the (rol'ferat'on of a+normal cells +ut also 'n the deran%ement of feed'n%* +reath'n%* and s(eak'n%* )h'ch ma$ (resent as malnutr't'on* u((er a'r)a$ o+struct'on* and recurrent as('rat'on (neumon'a. Thus unl'ke the case of adenocarc'noma of the +reast* colon* and stomach* mal'%nant melanoma* s3uamous cell carc'noma of the lun%* and most other sol'd tumors* 'n )h'ch the fatal e,ent 's almost al)a$s d'ssem'nated mal'%nanc$* as man$ as CD (ercent of (at'ents )'th a fatal head and neck mal'%nanc$ d'e )'thout cl'n'cal e,'dence of metastas's +e$ond the localFre%'onal d'sease. Central ner,ous s$stem 'n,as'on* ru(ture of the %reat ,essels* a'r)a$ o+struct'on* and 'n,as',e local 'nfect'on are common causes of death 'n these (at'ents :8'%. 15-G<. 5ecause of the (redom'nant local and locore%'onal natural h'stor$ of th's d'sease* s'%n'f'cant attent'on must +e (a'd to local d'a%nos's and thera($. Most mal'%nant tumors that de,elo( a+o,e the cla,'cles are s3uamous cell carc'nomas :e('dermo'd carc'nomas< or'%'nat'n% from the res('rator$ and strat'f'ed s3uamous e('thel'um of the u((er aerod'%est',e tract. Althou%h there are some d'fferences 'n the natural h'stor$ of tumors ar's'n% at the ,ar'ous s'tes of the u((er aerod'%est',e tract* (ro+a+l$ de(endent on character'st'cs of +lood su((l$* l$m(hat'c dra'na%e* or h'stolo%'c ,ar'at'on s(ec'f'c to that area* most s3uamous cell carc'nomas of the head and neck +eha,e s'm'larl$. The'r un'3ue cl'n'cal e-(ress'on then de(ends on the

'nterru(t'on of normal act','t$ 'nherent 'n the'r e('center and those areas to )h'ch the$ s(read :8'%. 15-6<. o naso(har$n%eal carc'noma ma$ (resent )'th nasal stuff'ness and (ro%ress to cran'al ner,e d$sfunct'on and central ner,ous s$stem 'n,as'on as )ell as neck metastas's@ and carc'noma of the floor of the mouth ma$ (resent )'th (a'n* tether'n% of the ton%ue* and d$s(ha%'a* result'n% 'n malnutr't'on and* somet'mes* as('rat'on. Moreo,er* the thera(eut'c a((roach to the mal'%nanc$ ma$ 'nterfere )'th normal funct'on. #ar$n%ectom$ and %lossectom$ o+,'ousl$ 'm(a'r s(eech and s)allo)'n% tremendousl$. Rad'othera($* used alone or 'n com+'nat'on )'th sur%er$* ma$ result 'n def'c'enc'es of olfact'on* sal',at'on* and 'nfect'on control 'n the u((er aerod'%est',e tract. Hence the sur,',al of the (at'ent )'th head and neck cancer re3u'res cons'derat'on of +oth tumor %ro)th and res'dual local funct'on 'n formulat'n% the thera(eut'c (lan. The a((ro(r'ate select'on of rad'othera($* e-t'r(at',e sur%er$* chemothera($* and reconstruct',e sur%er$ 's cruc'al 'n the (h$s'c'an2s attem(t to (rolon% l'fe and restore reasona+le funct'on and a((earance. A mult'd'sc'(l'nar$ a((roach to th's %rou( of tumors 's essent'al. In +oth ch'ldren and adults neo(lasms other than s3uamous cell carc'noma* +en'%n and mal'%nant* and other cl'n'call$ 'm(ortant masses ar'se 'n the head and neck area :8'%. 15-5<. Althou%h some of these are more l'kel$ to (ro%ress to earl$ metastat'c d'sease* most ha,e s'%n'f'cant local effect 'n +oth the'r cl'n'cal e-(ress'on and thera($. In adults sal',ar$ neo(lasms are the ne-t most 'm(ortant %rou( of les'ons 'n the head and neck. E('dem'olo%$ 3uamous cell carc'noma of the head and neck 's not a ma0or (u+l'c health (ro+lem 'n the 1n'ted tates. Com+'ned u((er aerod'%est',e tract s'tes account for a((ro-'matel$ /G ne) cases (er 1DD*DDD males and E (er 1DD*DDD females* or rou%hl$ C (ercent of ne) cancers 'n males and / (ercent 'n females. There are GD*DDD to 6D*DDD ne) cancers of the head and neck and 1D*DDD to 15*DDD deaths (er $ear. A((ro-'matel$ one-th'rd of (at'ents )ho de,elo( a s3uamous cell carc'noma of the u((er aerod'%est',e tract )'ll d'e from 't. Inc'dence and mortal't$ rates 'n the 1n'ted tates ha,e rema'ned relat',el$ sta+le o,er the (ast 6D $ears 'n )h'te males +ut ha,e 'ncreased dramat'call$ for most s'tes 'n non)h'te males and 'n females of +oth %rou(s :8'%. 15-C<. #'ke man$ sol'd tumors* the 'nc'dence of d'sease 'ncreases )'th a%e 'n +oth se-es* +e'n% ,er$ rare +elo) a%e th'rt$ e-ce(t 'n 'mmunocom(rom'sed (at'ents. In the 1n'ted tates there seems to +e a clear-cut relat'onsh'( +et)een s3uamous cell carc'noma of the u((er aerod'%est',e tract and the chron'c use of to+acco and alcohol to%ether. Althou%h the use of e'ther to+acco or alcohol alone 'ncreases the l'kel'hood of s3uamous cell carc'noma of the u((er aerod'%est',e tract* the cumulat',e a+use %reatl$ 'ncreases the r'sk :8'%. 15-7<. Pre,'ousl$ noted 'ncreases 'n the 'nc'dence of s3uamous cell carc'noma 'n females )ere (ro+a+l$ a result of the more )'des(read acce(tance of c'%arette smok'n% amon% )omen o,er the (ast GD $ears. In the .estern )orld the com+'nat'on of to+acco and alcohol of ,ar'ous forms seems to +e the (redom'nant cause of th's d'sease@ and thou%h there 's some sl'%ht ,ar'at'on* the mortal't$ rate 's s'm'lar from countr$ to countr$. C'%arette* c'%ar* and ('(e smok'n%* che)'n% to+acco* and snuff ha,e all +een 'm(l'cated* as ha,e d'st'lled +e,era%es* +eer* )'ne* and e,en mouth)ash* )h'ch 'n man$ forms has a h'%h content of alcohol. The (re,'ousl$ demonstrated relat'onsh'( of as+estos and to+acco 'n the

carc'no%enes's of lun% cancer 's (ro+a+l$ o(erant 'n s3uamous cell carc'noma of the u((er aerod'%est',e tract as )ell. 3uamous cell carc'noma of the head and neck 's endem'c 'n other (arts of the )orld* )'th 'nc'dences reach'n% as h'%h as 5D (ercent of ne) cancers 'n 5om+a$* Ind'a* )here che)'n% of (an* a com+'nat'on of to+acco* +etel nut* and l'me :Ca!H/<* causes +uccal carc'noma. Throu%hout southeast As'a the use of +etel nut and to+acco com+'nat'ons s'm'larl$ results 'n a h'%h fre3uenc$ of oral cancers. In cultures such as those of outh As'a and outheast As'a* )here alcohol 's not commonl$ used* the (re,alence of ,'tam'n def'c'enc$ and local su+mucosal f'+ros's of the oral mucosa ma$ (la$ an 'm(ortant ad0u,ant role. Re,erse smok'n% :smok'n% of c'%arettes and c'%ars )'th the l'%hted end 'ns'de the mouth< s'm'larl$ contr'+utes to the h'%h 'nc'dence of (alate and oral cancers seen 'n Ind'a and some (arts of Central and outh Amer'ca. In outh Afr'ca unusuall$ h'%h rates of nasal and (aranasal cancers ha,e +een d'sco,ered* )here n'ckel contam'nates the to+acco 'nhaled as snuff* and )here 't and other su+stances are 'ndustr'al contam'nants amon% )orkers 'n the n'ckel* furn'ture* and shoe 'ndustr'es. In southern Ch'na and the Pac'f'c R'm countr'es* carc'noma of the naso(har$n- 's e-tremel$ common 'n +oth men and )omen* u( to t)ent$ t'mes more common than 'n the 1n'ted tates. The causat',e factors are unclear* althou%h 'nhaled fumes* cook'n% smoke* chem'cal (ollutants* or others ha,e +een (ro(osed* as has the 'n%est'on of salted f'sh. The role of the E(ste'n-5arr ,'rus :E59< 'n the causat'on and natural h'stor$ of naso(har$n%eal carc'noma 's unclear. Infect'on )'th E59 's (re,alent 'n th's %rou(* and there seems to +e a close relat'onsh'( +et)een ele,ated serum E59 t'ters and r'sk. &es('te the d'fferences 'n (ro(osed causat',e a%ents throu%hout the )orld* 't a((ears clear that an 'm(ortant factor 'n the or'%'n of s3uamous cell carc'noma 's a chem'cal carc'no%en and that a l'near dose- t'me r'sk rat'o 's l'kel$. Pre,ent'on should +e (oss'+le. Carc'no%enes's The s'm(lest e-(lanat'on of the causat'on of s3uamous cell carc'noma falls )'th'n the acce(ted (r'nc'(les of chem'cal carc'no%enes's* more s(ec'f'call$ cocarc'no%enes's* )here an 'n't'at'n% a%ent :(erha(s some contam'nant or meta+ol'te of to+acco< 'nduces an 'rre,ers'+le chan%e 'n the &NA of the affected cell. A (romot'n% a%ent :(erha(s alcohol* ,'tam'n def'c'enc$* local 'nflammat'on secondar$ to trauma* (oor h$%'ene* or su+mucosal f'+ros's< allo)s that 'rre,ers'+le chan%e to man'fest 'tself as a h'stolo%'call$ and cl'n'call$ 'dent'f'a+le mal'%nanc$. In't'at'on 'n,ol,es alterat'on of the &NA +$ add't'on throu%h co,alent +ond'n%* re(lacement* delet'on* or other mechan'sm. Promot'on theoret'call$ 'n,ol,es fac'l'tat'on of e-(ress'on of the a+normal &NA ,'a act',at'on of cell surface and c$to(lasm'c (rote'n rece(tors or other react'ons )'th the e('thel'al cell. Th's theor$ 's cons'stent )'th man$ of the e('dem'olo%'c and cl'n'cal character'st'cs of s3uamous cell carc'noma of the u((er aerod'%est',e tract. The 'nd'ctment of chron'c use 'm(l'es that 'n't'at'on alone 's not suff'c'ent for mal'%nanc$. In add't'on to the s'tes 'n the naso(har$n- and lar$n- )here 'nhaled and e-haled to+acco smoke contact* h'%h-dose e-(osure 's (oss'+le to the mouth* ton%ue* and +uccal mucosa as meta+ol'tes of to+acco are secreted 'nto sal',a and s't (ooled 'n the l'n%ual and +uccal sulc'. The chron'c 'nflammat'on attendant to fre3uent alcohol use ma$ st'mulate local (rol'ferat'on of e('thel'al cells and react )'th re(roduc'n% cells to allo) e-(ress'on of the (re,'ousl$ altered &NA.

The role of ,'ral carc'no%enes's ,'a 'n't'at'on or (romot'on 's unclear +ut certa'nl$ sus('c'ous. Pat'ents )'th (a('llomatos's caused +$ human (a('lloma,'rus of the nasal ca,'t$ and lar$n- ha,e +een noted to +e at h'%her r'sk for de,elo(ment of 'n,as',e s3uamous cell carc'noma. Recent stud'es of &NA from s3uamous cell carc'noma of the nasal ca,'t$ and (aranasal s'nuses us'n% the (ol$merase cha'n react'on ha,e 'dent'f'ed human (a('lloma,'rus :HP9< t$(es 1C and 1E* )hereas the$ )ere not 'dent'f'ed 'n tumors of other h'stolo%'c t$(e :adenocarc'noma* adeno'd c$st'c* etc.<. HP9 1C %enomes also ha,e +een found 'n s3uamous cell carc'noma of the lar$n-* +uccal mucosa* ton%ue* and cer,'cal l$m(h node metastases. Ele,ated ant'+od$ to E(ste'n-5arr ,'rus 's assoc'ated )'th the (resence of naso(har$n%eal carc'noma +ut 's not s(ec'f'c enou%h to +e of cl'n'cal use* s'nce ,'ral 'nfect'on 's common. That the ,'rus (la$s e'ther an 'n't'at'n% or a (romot'n% role 'n carc'no%enes's 's su%%ested +$ the (resence of the E(ste'n-5arr ,'ral %enome 'n cer,'cal metastases as )ell as 'n the (r'mar$ tumor ar's'n% 'n the naso(har$n- +ut 'ts a+sence 'n l$m(h nodes of E(ste'n5arr-ant'+od$-sero(os't',e (at'ents that d'd not conta'n tumor and 'ts a+sence 'n metastat'c tumors of other h'stolo%$. Althou%h mal'%nanc$ of the head and neck 's not commonl$ assoc'ated )'th fam'l'al s$ndromes* +en'%n tumors such as e-ostoses* se+aceous c$sts* and se+aceous adenomas ma$ +e seen 'n the %enet'c alterat'on that causes "ardner2s s$ndrome and Mu'r-Torre2s s$ndrome. !f the 'dent'f'ed onco%enes* se,eral ha,e +een d'sco,ered 'n s3uamous cell carc'noma. The 'nt-/ onco%ene related to f'+ro+last %ro)th factor and the C-m$c %ene that codes for a &NA-+'nd'n% (rote'n concerned )'th re%ulat'on of cell %ro)th ha,e +een demonstrated 'n 11 of /1 and / of /1 s3uamous cell carc'noma tumors stud'ed. Im(ro,ed methods of &NA character'4at'on )'ll clar'f$ the role of ,'ral transformat'on* hered't$* and 'ncreased susce(t'+'l't$ 'n the (atho%enes's of s3uamous cell carc'noma. Current molecular +'olo%'c and %enet'c 'n,est'%at'ons of s3uamous cell carc'noma of the head and neck ha,e not $et (roduced useful mechan'sms of thera($. !,ere-(ress'on of onco%enes and 'ncreased le,els of onco(rote'ns* such as the aC+6 'nte%r'ns :cell surface adhes'on molecules and rece(tors for e-tracellular matr'(rote'ns<* and the HER/Fneu onco(rote'ns ha,e +een assoc'ated )'th ra('d locore%'onal s(read and metastas's. Inact',at'on of tumor su((ressor %enes +$ delet'on or other mutat'ons seems to +e a common mechan'sm of tumor 'n't'at'on and su+se3uent (ro%ress'on. It has +een theor'4ed and (art'all$ demonstrated that the format'on of a head and neck tumor re3u'res man$ %enet'c e,ents. In ,'tro anal$s's of se,eral l'nes of s3uamous cell carc'noma ha,e demonstrated common allelot$(es )'th delet'ons at the B(/1* e(* and 17( chromosome s'tes. The le,el of (5G mutat'ons ma$ (red'ct the res(ons',eness of tumor to rad'othera($ and chemothera($. Another (otent'al thera(eut'c mechan'sm +e'n% 'n,est'%ated 's the ela+orat'on of humorall$ and cellularl$ med'ated ant'+od'es to these o,ere-(ressed tumor cell (rote'ns. The further del'neat'on of the %enet'c 'dent't$ of s3uamous cell carc'noma and the man'(ulat'on of (rote'n s$nthes's )'ll ha,e a ma0or role 'n future treatment. The (rotean man'festat'ons of AI& 'nclude a num+er of a+normal't'es 'n the head and neck. Prol'ferat',e l$m(hoc$te de(os'ts 'n the naso(har$n- ha,e +een noted to cause eustach'an tu+e d$sfunct'on and ma$ +e (recursors of the commonl$ seen e-tranodal l$m(homas. 3uamous cell carc'nomas of the u((er aerod'%est',e tract

a((ear to +e d's(ro(ort'onatel$ common and unusuall$ a%%ress',e 'n (at'ents )'th AI& * as 'n other 'mmunodef'c'ent states such as chron'c l$m(hoc$t'c leukem'a. !ral and (har$n%eal (resentat'ons of ;a(os'2s sarcoma are common 'n HI9-(os't',e (at'ents and occas'onall$ re3u're sur%'cal or rad'othera(eut'c 'nter,ent'on :8'%. 15-E<. C$st'c de%enerat'on of l$m(h nodes 'n the (arot'd and su+mand'+ular %lands also occurs* and 'n one ser'es th's )as the (resent'n% s$m(tom of ne)l$ d'a%nosed HI9 'nfect'on. Natural H'stor$ Mal'%nanc$ 'n the head and neck follo)s a relat',el$ (red'cta+le course alon% the cont'nuum of h'stolo%'c chan%es from earl$ e,'dence of h$(er(las'a )'th at$('a to (oorl$ d'fferent'ated 'n,as',e mal'%nanc$. The se3uent'al (resentat'on of these a+normal't'es f'ts )ell )'th a theor$ of chron'c e-(osure to one or se,eral chem'cal carc'no%ens. The normal oral and oro(har$n%eal ca,'t'es are l'ned )'th strat'f'ed s3uamous e('thel'um s'm'lar to the sk'n +ut )'thout the character'st'c kerat'n'4at'on. Another d'fference +et)een the sk'n and oral mucosa 's the lack of d'st'nct rete r'd%es 'n the mouth 'n normal states. Immed'atel$ su+0acent 's the +asement mem+rane* +eneath )h'ch l'es the su+mucosa* conta'n'n% l$m(ho'd a%%re%ates and l$m(hat'c channels* +lood ,essels* and mucous and serous %lands. In most areas of the oral ca,'t$ and oro(har$n-* mucosa and su+mucosa co,er muscle. .'th'n the e('thel'al la$er are term'nat'ons of the ner,es med'at'n% the s(ec'al senses of olfact'on and taste as )ell as other ner,e f'+ers. The lar$n-* nasal ca,'t$* and (aranasal s'nuses are l'ned +$ (seudostrat'f'ed columnar c'l'ated e('thel'um* )h'ch o,erl'es a s'm'lar arran%ement of m'nor sal',ar$ %lands* ner,es* and +lood ,essels. 9'ral 'nfect'on* chron'c 'rr'tat'on +$ 'll-f'tt'n% dentures* trauma* or 'nfect'on from (oor dental h$%'ene ma$ el'c't a res(onse from the e('thel'um kno)n as h$(er(las'a or (a('llomatos's* 'n )h'ch cells )'th normal &NA conf'%urat'on and or%anelle structure (rol'ferate* result'n% 'n more (rom'nent 'ntralum'nal (ro0ect'on as )ell as e-tens'on of the mucosa dee(er 'nto the su+mucosa. &es('te these chan%es there are none of the cellular man'festat'ons of mal'%nanc$ :m'toses* ($knot'c nucle'* (rom'nent nucleol'* etc.<* and the +asement mem+rane +eneath the mucosa rema'ns 'ntact. Most of the cl'n'cal chan%es that reflect these h'stolo%'c alterat'ons* 'nclud'n% h$(er(las'a* h$(erkeratos's* and (seudoe('thel'omatous h$(er(las'a :the a%%ress',e end of th's s(ectrum* )h'ch ma$ +e confused cl'n'call$ )'th mal'%nanc$<* ha,e +een %rou(ed under the term leuko(lak'a :)h'te (atch<. H'stolo%'c anal$s's sho)s h$(erkeratos's and (arakeratos's or orthokeratos's :a((earance of nucle' 'n the most su(erf'c'al la$ers of the mucosa )'th or )'thout 'nflammator$ cell 'nf'ltrate and acanthos's<. Earl'er a((roaches re3u'red the remo,al of all leuko(lak'a* )h'ch )as +el'e,ed to +e a (recursor of 'n,as',e mal'%nanc$. More recent th'nk'n%* ho)e,er* su%%ests that th's chan%e 's not 'n 'tself (remal'%nant +ut s'm(l$ e,'dence of chron'c 'rr'tat'on. Cellular man'festat'ons of mal'%nanc$ result 'n the d'a%nos's of e('thel'al d$s(las'a. #ack of a normal cellular (ro%ress'on to maturat'on character'4es d$s(last'c e('thel'um. Nucle' are lar%er* are h$(erchromat'c* and sho) m'tot'c act','t$. Cells ma$ +e (leomor(h'c )'th +aso(h'l'c c$to(lasm. Cell la$ers +ecome d'sor%an'4ed* )'th loss of the %radual ascent to the e('thel'al surface and the (resence of 'mmature cells at the +asement mem+rane as )ell as the e('thel'al surface. The e-tent of the

'nd','dual cellular chan%es and loss of normal (olar't$ determ'nes )hether the ent't$ 's termed d$s(las'a* se,ere d$s(las'a* or carc'noma 'n s'tu. All of these chan%es* ho)e,er* o,erl'e an 'ntact +asement mem+rane. The chan%e from h$(er(las'a to d$s(las'a 's thou%ht to +e 'rre,ers'+le and the 'n't'al ste( 'n carc'no%enes's. The cl'n'cal man'festat'on of these h'stolo%'c chan%es has +een termed er$thro(las'a or er$thro(lak'a* or red (atch. These les'ons a((ear redd'sh* are fre3uentl$ e-udat',e* and ma$ ha,e assoc'ated leuko(lak'a. 5'o(s$ or e-c's'on 's mandator$* +ecause the$ are (remal'%nant and ma$ also 'nd'cate the (resence of another ad0acent mal'%nanc$. The cellular chan%es of carc'noma 'n s'tu )'th loss of the 'nte%r't$ of the +asement mem+rane +ecome 'n,as',e s3uamous cell carc'noma. &eran%ed cellular funct'on results 'n 'ntracellular kerat'n'4at'on or kerat'n (earl format'on :8'%. 15-B<. "ro)th 'nto the oral ca,'t$ ma$ +e man'fested %rossl$ as an e-o(h$t'c carc'noma* )hereas 'n,as'on 'nto the ad0acent muscle or +one (roduces ulcerat',e les'ons. In add't'on to the cont'nuum of chan%es from h$(erkeratos's to 'n,as',e carc'noma* (at'ents )'th s3uamous cell carc'noma fre3uentl$ demonstrate another (henomenon cons'stent )'th the theor$ of chem'cal carc'no%enes's. 8'eld cancer'4at'on or the condemned mucosa (henomenon 's the f'nd'n% of e('thel'al a+normal't'es throu%hout the ent're u((er aerod'%est',e tract 'n a (at'ent )'th s3uamous cell carc'noma at one s'te :8'%. 15-1D<. Er$thro(lak'a 'n the oral ca,'t$ 'ncreases the r'sk of 'n,as',e carc'noma 'n the (har$n-* lar$n-* eso(ha%us* and lun%. The 'nc'dence of s$nchronous mal'%nanc'es 'n the u((er aerod'%est',e tract has +een re(orted to ran%e from 6.6 to more than 1D (ercent* )'th lun%* eso(ha%us* and other head and neck s'tes +e'n% most common. !ther anatom'c a+normal't'es and funct'onal d'sorders are also more fre3uent 'n (at'ents )'th u((er aerod'%est',e tract mal'%nanc$. 5arrett2s eso(ha%us and eso(ha%'t's ha,e +een re(orted to occur 'n GG (ercent of (at'ents under%o'n% lar$n%oeso(ha%ectom$ for ad,anced lar$n%eal carc'noma. An o,erall 'nc'dence of eso(ha%eal d'sease of 56 (ercent )as found* )'th s$nchronous eso(ha%eal cancer 'n /5 (ercent of these (at'ents. Metachronous or su+se3uent mal'%nanc'es also a((ear at a h'%her fre3uenc'es 'n (at'ents )'th s3uamous cell carc'noma of the u((er aerod'%est',e tract than 'n the %eneral (u+l'c. #un%* eso(ha%us* and other head and neck s'tes are more common* )'th a r'sk of u( to /7 (ercent. Cessat'on of smok'n% and alcohol 'ntake ma$ or ma$ not +e (rotect',e. The (henomenon of f'eld cancer'4at'on and the h'%h fre3uenc$ of s$nchronous and metachronous mal'%nanc'es 'n (at'ents )'th s3uamous cell carc'noma of the head and neck f't n'cel$ )'th the current theor'es of onco%enes's. .'th'n the condemned mucosa there ma$ +e mult'(le su+(o(ulat'ons of neo(last'c cells* each the clonal e-(ress'on of a common 'n't'al a+normal't$. &'fferent en,'ronmental cond't'ons* su+se3uent mutat'ons caused +$ the chron'c 'nsult of chem'cal carc'no%ens* and am(l'f'cat'on of %enet'c a+normal't'es at one s'te more than another ma$ e-(la'n the s'multaneous a((earance of er$thro(las'a* )ell-d'fferent'ated local carc'noma* and (oorl$ d'fferent'ated l$m(h node metastas's as the d'sease (ro%resses cl'n'call$ and h'stolo%'call$. The a((l'cat'on of the theor$ of tumor hetero%ene't$ to the ent're mucosal surface e-(la'ns man$ of the character'st'cs of 'nd','dual tumors such as res'stance to chemothera($ and rad'othera($ as )ell as the (at'ent2s s$stem'c res(onse to d'sease.

Althou%h theor'es of mal'%nanc$ that es(ouse a ste()'se (ro%ress'on from local to locore%'onal to metastat'c d'sease ha,e +een sho)n to +e 'naccurate for +reast and %astro'ntest'nal sol'd tumors* s3uamous cell carc'noma of the head and neck does seem to s(end a cons'dera+le (ort'on of 'ts natural h'stor$ 'n the local or locore%'onal sta%es. After (assa%e throu%h the +asement mem+rane* mal'%nanc$ 'n,ades the surround'n% mesench$mal t'ssue* +e 't muscle* cart'la%e* or +one. Proteases and colla%enol$t'c and osteoclast'c en4$mes fac'l'tate the destruct'on of the ad0acent t'ssues. In,as'on of su+0acent ner,es o(ens the (er'neural s(aces* and tumor em+ol' ma$ (ass 'n the (er'neural l$m(hat'cs. The usual s(read of tumor 's from the (r'mar$ s'te ,'a the su+0acent l$m(hat'cs :8'%. 15-11< to the neck or +$ cont'nued local 'n,as'on throu%h ner,e and +one to the +ase of the skull. The ,'rulence of the (r'mar$ tumor and 'ts l'kel'hood of metastas's or a+'l't$ to cause the death of the host ha,e +een est'mated +$ a num+er of methods. The s'4e of the (r'mar$ tumor 's the ma'n (arameter determ'n'n% 'ts cl'n'cal sta%e 'n the TNM :tumor-node- metastas's< sta%'n% s$stem ado(ted +$ the Amer'can Jo'nt Comm'ttee on Cancer :AJCC< and other )orld)'de or%an'4at'ons :8'%. 15-1/<. Althou%h 't 's a crude method* 't 's fa'rl$ rel'a+le 'n su%%est'n% the (ro%nos's of the (at'ent and the a((ro(r'ate form of thera($. H'stolo%'c character'st'cs such as de%ree of d'fferent'at'on :(r'mar'l$ a funct'on of nuclear mor(holo%$<* (attern of 'n,as'on :+lunt (ush'n% +orders ,s. noncohes',e 0a%%ed +orders<* m'cro,ascular 'n,as'on* (er'neural 'n,as'on* and tumor th'ckness ha,e +een used to (red'ct the l'kel'hood of l$m(h node metastas's and o,erall (ro%nos's. The amount of tumor an%'o%enes's )'th'n the cancer as measured +$ the 'ntens't$ of sta'n'n% of the endothel'um 's a co%ent (red'ctor of a%%ress',eness. Ad,ances 'n +'ochem'cal and molecular 'n,est'%at'on ha,e allo)ed more careful cons'derat'on of the (r'mar$ tumors. 8lo) c$tometr'c anal$s's of tumor sus(ens'ons sho)s that aneu(lo'd$ 's common 'n (r'mar$ tumors :CE (ercent< and 'n cer,'cal metastases :E/ (ercent<. Aneu(lo'd tumors are more l'kel$ to metastas'4e than are d'(lo'd tumors. Correlat'on also has +een found +et)een th$m'd'ne la+el'n% 'nde- and the T sta%e of s3uamous cell carc'nomas* )'th TG les'ons ha,'n% s'%n'f'cantl$ more act','t$ than T1. 8urther su+cellular anal$s's of s3uamous cell carc'noma has attem(ted to correlate a+normal't'es and thus (red'ct +eha,'or. E-(ress'on of h'stocom(at'+'l't$ ant'%ens H#A-1 and H#A-/ on s3uamous cell carc'noma demonstrates marked tumor hetero%ene't$* (art'cularl$ 'n (oorl$ d'fferent'ated tumors. The relat'onsh'( of %ro)th factors to (r'mar$ tumor de,elo(ment and (ro%ress'on 's unclear* +ut* as 'n other tumors* such as +reast and +ra'n* %ro)th factor rece(tors ha,e +een 'dent'f'ed on s3uamous cell carc'noma of the head and neck. H'%her a+solute le,els of e('thel'al %ro)th factor rece(tor and demonstrat'on of am(l'f'cat'on of the %ene for e('thel'al %ro)th factor rece(tor 'n s3uamous cell carc'noma of the u((er aerod'%est',e tract ma$ 'nd'cate that e('thel'al %ro)th factor (la$s an 'm(ortant role 'n local tumor +eha,'or. The h'stolo%'c* +'ochem'cal* and %enet'c character'st'cs of head and neck tumors also ha,e +een used 'n an attem(t to (red'ct res(onse to rad'othera($ and chemothera($. As )'th most sol'd tumors* the most co%ent (ro%nost'cator of head and neck cancer 's the (resence or a+sence of l$m(h node metastases. In the uno(erated (at'ent* (assa%e of tumor em+ol' throu%h the l$m(hat'cs follo)s an orderl$ (attern* )'th the anatom'c tr'an%les of the neck reflect'n% the s'te of (r'mar$ d'sease. In the (at'ent )ho has

under%one (re,'ous sur%'cal thera($ or rad'othera($ or )ho has e-tens',e tumor that +locks normal l$m(hat'c flo)* metastas's from a (r'mar$ tumor ma$ not follo) the usual (ath)a$s* and a neck mass ma$ not (red'ct accuratel$ the s'te of recurrence or ne) (r'mar$ d'sease :see 8'%. 15-G 5<. Cl'n'cal and ult'matel$ (atholo%'c sta%'n% of the neck accord'n% to the AJCC s$stem de(ends on num+er of l$m(h nodes* s'4e of l$m(h nodes* f'-at'on to the sk'n or su+0acent neck muscles* and lateral't$ )'th res(ect to the (r'mar$ tumor :'(s'lateral* contralateral* and +'lateral<. Althou%h there are man$ determ'nants of (r'mar$ tumor +eha,'or* s'4e and d'fferent'at'on are useful (red'ctors of the r'sk of metastas's. Increas'n% T sta%e 's %enerall$ reflected +$ 'ncreas'n% N sta%e. &'stant metastas's* ho)e,er* 's more closel$ related to N sta%e than to T sta%e. In a stud$ of 1CD (at'ents )'th e-tens',e d'sease 'n the neck* NGa* onl$ CG com(leted com+'ned thera($ )'th sur%er$ and rad'at'on and* of these* onl$ 1G sho)ed no e,'dence of d'sease at / $ears. &'ssem'nated d'sease )as the most common cause of death* follo)ed +$ fa'lure at the (r'mar$ s'te and 'n the neck. #$m(h node metastases a((ear to +eha,e 'n some )a$s s'm'larl$ to (r'mar$ d'sease 'n that m'crometastases are not as (oor a (ro%nost'c 'nd'cator as cl'n'call$ (al(a+le metastat'c d'sease. (read of the tumor outs'de the ca(sule of the l$m(h node ma$ occur 'n cl'n'call$ ne%at',e and (os't',e l$m(h nodes and 's a (oor (ro%nost'c s'%n* 'nd'cat'n% a more a%%ress',e tumor. In a stud$ of sta%e III carc'noma of the oral ca,'t$* the /-$ear sur,',al rate of (at'ents )'th no l$m(h node metastases )as E7 (ercent@ )'th 'ntraca(sular l$m(h node metastases* 75 (ercent@ and )'th cer,'cal metastases )'th e-traca(sular s(read* onl$ GB (ercent. The 'nc'dence of e-traca(sular s(read of cer,'cal d'sease 'ncreases )'th the s'4e of the l$m(h node. Pro(ort'onal to 'ncrease 'n e-traca(sular s(read 's the l'kel'hood of recurrent d'sease* and thus of death. 1ncontrolled %ro)th of s3uamous cell carc'noma 'n the neck results 'n carot'd arter$ hemorrha%e* 'n,as'on of the s$m(athet'c %an%l'a result'n% 'n Horner2s s$ndrome* eros'on of the cer,'cal ,erte+rae* 'n,as'on of cran'al ner,es II* I* and II :0u%ular foramen s$ndrome< and of cran'al ner,e III at the +ase of the skull* a'r)a$ o+struct'on* and +rach'al (le-us (als$. The s'te of the (r'mar$ tumor d'ctates not onl$ the s'te of cer,'cal metastas's +ut the fre3uenc$ as )ell. Althou%h the s'4e of the (r'mar$ les'on at (resentat'on 's 'm(ortant* 't seems that 'nde(endent of s'4e* s3uamous cell carc'nomas of the tons'l and the +ase of the ton%ue ha,e h'%h rates of metastas's to the neck* and les'ons of the +uccal mucosa and (alate ha,e lo) rates. &'stant metastases from s3uamous cell carc'noma ha,e +een re(orted to ran%e from G1 (ercent of (at'ents )'th no e,'dence of cer,'cal metastases to 5B (ercent of those )'th e-tens',e neck d'sease. &es('te th's relat',el$ h'%h 'nc'dence* the$ are not un'forml$ the cause of death. Althou%h an$ s'te 's (oss'+le* lun%* +one* sk'n* and l',er are the most common metastases. $stem'c effects of +oth local and s$stem'c d'ssem'nated tumors 'nclude h$(ercalcem'a from +one metastas's and ela+orat'on of (arathormonel'ke (e(t'des as )ell as s$ndrome of 'na((ro(r'ate ant'd'uret'c hormone secret'on : IA&H< from ,aso(ress'nl'ke su+stances. There 's some e,'dence that the )'des(read use of chemothera($ has chan%ed the natural h'stor$ of metastat'c s3uamous cell carc'noma* 'ncreas'n% the fre3uenc$ of (at'ents d$'n% )'th d'ssem'nated d'sease. &'a%nos's and E,aluat'on

H'stor$ and (h$s'cal e-am'nat'on are the most 'm(ortant cons'derat'ons 'n the d'a%nos's of carc'noma of the u((er aerod'%est',e tract. A h'stor$ of chron'c to+acco and alcohol a+use (laces the (at'ent 'n the h'%h-r'sk cate%or$. Males o,er fort$ )'th such a h'stor$ com(r'se 7D to ED (ercent of most ser'es of (at'ents )'th head and neck cancer. A (re,'ous occurrence of lun% cancer* eso(ha%eal cancer* or other head and neck mal'%nanc$* d'seases caus'n% 'mmunodef'c'enc$ such as renal fa'lure )'th 'ts thera($ +$ trans(lantat'on* malnutr't'on* and AI& are also s'%n'f'cant. $m(toms refera+le to the tumor 'tself usuall$ are m'ld and not commensurate )'th the s'4e of the tumor* often +ecause of the (at'ent2s %enerall$ sto'c (ersonal't$ and den'al. #ate-sta%e (resentat'on 's common 'n these (at'ents. 5arkle$ noted that GC (ercent of (at'ents (resent'n% )'th oro(har$n%eal les'ons had local d'sease alone and that the rema'n'n% C6 (ercent alread$ had cer,'cal or d'ssem'nated metastases. Pa'n at the s'te of the tumor 's not a fre3uent com(la'nt. 5ecause ot't's med'a and e-terna are relat',el$ rare (ro+lems 'n adults* (a'n 'n the ear 'n a (at'ent o,er fort$ ma$ +e a man'festat'on of tumor 'n the oral ca,'t$* oro(har$n-* or lar$n- ,'a referred (a'n (ath)a$s* 'nclud'n% the l'n%ual to aur'culotem(oral ner,es* %losso(har$n%eal to t$m(an'c ner,e* or ,a%us to aur'cular ner,e. Pro%rade neural s$m(toms such as form'cat'on :the feel'n% of ants cra)l'n% alon% the l'( or cheek< ma$ re(resent mental or 'nfraor+'tal ner,e 'n,as'on +$ +uccal* la+'al* or al,eolar carc'noma. 8am'l$ mem+ers or the (at'ent ma$ note chan%es 'n s(eech caused +$ tether'n% of the ton%ue :8'%. 15-1G<. Constant or ,ar'a+le hoarseness 's the s'%n of ,ocal cord 'm(a'rment +$ local %ro)th of lar$n%eal or h$(o(har$n%eal cancer or +$ (aral$s's 'n the neck of the recurrent lar$n%eal ner,e. The sensat'on of scratch'ness or t'ckl'n% 'n the throat* %a%%'n% on food* or nocturnal chok'n% secondar$ to as('rat'on ma$ all re(resent 'nterference )'th the s$ner%'st'c mechan'sms of s)allo)'n% and +reath'n%. A'r)a$ com(rom'se 's usuall$ a late s$m(tom +ut occas'onall$ ma$ +e the f'rst (resentat'on 'n an emer%enc$ sett'n%. The t$('cal Amer'can (at'ent* then* 's male* o,er fort$* )'th a lon% h'stor$ of to+acco and alcohol a+use* fre3uentl$ )'th underl$'n% (s$cholo%'c or +eha,'oral d'sorder such as de(ress'on or ant'soc'al (ersonal't$ )'th )'thdra)al. 9'sual'4at'on of the ent're u((er aerod'%est',e tract* us'n% a s$stemat'c a((roach that 'ncludes 'ns(ect'on of the fac'al and cer,'cal surface anatom$ and contour* 'ntraoral e-am'nat'on* and 'nd'rect :m'rror< lar$n%osco($ )'th naso(har$n%osco($* 's essent'al for d'a%nos's and sta%'n% :8'%. 15-16<. In add't'on to s'4e* sha(e* and (ro0ect'on 'nto the ca,'t$ :e-o(h$t'c or de%ree of ulcerat'on<* 't 's 'm(ortant to note the mo+'l't$ of the ton%ue and 'ts (os't'on relat',e to the m'dl'ne :h$(o%lossal ner,e funct'on<* an$ f'-at'on of the ton%ue to the ad0acent mand'+le* and an$ d'rect 'n,as'on of the mand'+le. M'rror e-am'nat'on of the oro(har$n- and h$(o(har$n- and lar$n- should note the (atenc$ of the ,allecula* the d'stens'+'l't$ of the ($r'form s'nuses* and the normal adduct'on to the m'dl'ne of the ,ocal cords. Interference )'th ,ocal cord funct'on ma$ result as h$(o(har$n%eal les'ons 'n,ade the med'al )all of the ($r'form s'nus or +$ (aral$s's of the recurrent lar$n%eal ner,e. 5$ retract'n% the soft (alate for)ard )'th a transnasal catheter* ,'sual'4at'on of the naso(har$n- 's (oss'+le )'th the m'rror. The ,ault of the naso(har$n-* the choanae* and the eustach'an tu+e should +e e-am'ned. The cond't'on of the teeth and %ums should +e e,aluated and the (resence of torus (alat'nus or torus mand'+ular's noted. #'m'ted mot'on of the mand'+le ma$ come from d'rect tumor 'n,as'on or* more fre3uentl$* from 'n,as'on of tumor throu%h the retromolar tr'%one area or tons'llar fossa to the (ter$%o'd muscles. Inf'ltrat'on or 'nflammat'on of the 'nternal and e-ternal (ter$%o'ds l'm'ts 0a) mot'on

and causes the uncomforta+le s$m(tom of tr'smus* an om'nous cl'n'cal s'%n. Com('lat'on of the a((ro(r'ate 'nformat'on a+out the (r'mar$ tumor allo)s cl'n'cal sta%'n%. The d'st'nct anatom'c s'te* s'4e* (attern of %ro)th* and 'n,as'on of ad0acent structures are all necessar$ to ass'%n the a((ro(r'ate T sta%e. E-am'nat'on of the neck )'ll re,eal the (resence or a+sence of l$m(h node metastases. The s'te of the (r'mar$ tumor should (red'ct the most l'kel$ s'te of metastat'c d'sease :see 8'%. 15-11<. Enlar%ement or 'nflammat'on of the su+mand'+ular %land ma$ 'nterfere )'th e,aluat'on of the neck. Careful (al(at'on* (refera+l$ (erformed )'th the e-am'ner stand'n% +eh'nd the seated (at'ent* allo)s s$stemat'c and se3uent'al e,aluat'on of the su+mental* su+mand'+ular* 0u%ulod'%astr'c* m'd0u%ular* 0u%uloomoh$o'd* (oster'or tr'an%le* and su(racla,'cular l$m(h node stat'ons. The num+er of l$m(h nodes* l$m(h node s'4e* and an$ f'-at'on to the sk'n or su+0acent muscle allo)s the e-am'ner to ass'%n an N sta%e. Tumors )'th no e,'dent (r'mar$ s'te are man'fested as l$m(h node metastases 'n G to 6 (ercent of mal'%nanc'es. Cer,'cal metastases of s3uamous cell carc'noma com(r'se t)o- th'rds of these cases. 8urthermore* the 'n't'al man'festat'on of the su+se3uentl$ d'sco,ered d'sease 's a neck mass 'n /5 (ercent of the (at'ents )'th carc'noma of the oral ca,'t$* oro(har$n-* and th$ro'd* and 'n 5D (ercent of (at'ents )'th carc'noma of the naso(har$n-. 5ecause of ,ar'a+le e-tens'on 'nto the neck* (arot'd %land masses ma$ (resent as a cer,'cal l$m(h node. The character'4at'on of masses 'n the neck can +e %u'ded lar%el$ +$ a%e. In ch'ldren con%en'tal and 'nflammator$ masses (redom'nate@ 'n $oun% adults* 'nflammat'on or (rol'ferat',e d'sorders of the l$m(hat'c s$stem@ and 'n adults* metastat'c d'sease from the u((er aerod'%est',e tract and sk'n. Careful (h$s'cal e-am'nat'on* 'nclud'n% neurolo%'c e-am'nat'on of the rema'nder of the head and neck area* ma$ re,eal e,'dence of more e-tens',e d'sease such as ca,ernous s'nus 'n,as'on* as documented +$ e-traocular mo,ement d'sorders* or 'n,as'on of the cer,'cal s$m(athet'cs* as 'nd'cated +$ Horner2s s$ndrome. &'stant metastases are e,aluated +$ h'stor$* (h$s'cal e-am'nat'on* la+orator$ (rocedures* and rad'olo%$. Pleur't'c (a'n or shortness of +reath ma$ 'nd'cate lun% 'n,ol,ement* and d'st'nct (a'n at a s(ec'f'c s'te ma$ 'nd'cate s(read to d'stant +one. 5efore treatment (lann'n%* def'n't',e h'stolo%'c conf'rmat'on of d'sease 's necessar$. If a (r'mar$ s'te 's ,'s'+le* a )ed%e +'o(s$ s(ec'men should +e taken at the ed%e of the tumor to 'nclude some ad0acent normal t'ssue* f'-ed 'n formal'n* and e-am'ned h'stolo%'call$. Touch (re(arat'ons and other c$tolo%'c methods are occas'onall$ hel(ful +ut suffer from lack of s(ec'f'c't$ and sens't','t$. Althou%h the e-tent of the tumor usuall$ can +e assessed +$ d'rect ,'sual'4at'on* the use of ,'tal d$es such as tolu'd'ne +lue ma$ hel( to del'neate the e-tent of the d'sease* sta'n'n% onl$ the mal'%nant and d$s(last'c e('thel'um and )ash'n% off the surround'n% 'nflamed t'ssue. Hemato(or(h$r'n d$es share th's character'st'c of d'fferent'al u(take +$ tumor and normal cells and ha,e occas'onall$ +een of use 'n demarcat'n% 'nde- tumors and 'dent'f$'n% and somet'mes treat'n% mult'centr'c d'sease. 5ecause of the s'%n'f'cant 'nc'dence of s$nchronous (r'mar$ tumors* e,aluat'on of the rest of the u((er aerod'%est',e tract ma$ +e useful. The ,alue of tr'(le endosco($=+ronchosco($* eso(ha%osco($* and d'rect lar$n%osco($=has +een de+ated* +ut 't 's ad,'sa+le for the 'deal )ork-u( of an ad,anced head and neck cancer 'n a (at'ent )'th a lon% h'stor$ of to+acco and alcohol use.

'nce treatment (lann'n% de(ends a %reat deal on the cl'n'cal sta%e of d'sease* and s'nce thera('es ,ar$ %reatl$ 'n mor+'d't$ to the (at'ent* (rec'se and accurate sta%'n% 's essent'al. E-tent of resect'on and ,olume of rad'othera($ de(end on a rel'a+le assessment of the de%ree of 'n,as'on of the (r'mar$ tumor. The use of ad0u,ant chemothera($ or rad'othera($ or the 'nclus'on of neck d'ssect'on 'n the sur%'cal (lan usuall$ 's determ'ned after careful anal$s's of the neck. 9ar'ous rad'olo%'c stud'es ma$ hel( to def'ne the e-tent of the d'sease. Rad'olo%'c e,aluat'on of 'ntraoral d'sease usuall$ 'n,ol,es assessment of the mand'+le. If tumor a+uts the mand'+le 'n the l'n%ual or +uccal sulcus and 's not eas'l$ mo+'le* 't ma$ (enetrate the corte-. In edentulous (at'ents* tumor descends throu%h the cort'cal defects left +$ the (re,'ous teeth alon% the occlusal r'd%e. !nce the medullar$ canal has +een 'n,aded* s(read ma$ occur locall$ or +$ )a$ of the 'nfer'or al,eolar ner,e. In dentulous (at'ents* d'rect 'n,as'on of the l'n%ual (late occurs* and s(read usuall$ does not e-tend )'th'n the +one +e$ond the e-tent of the soft- t'ssue tumor. &ental f'lms taken d'rectl$ at the s'te of tumor contact sho) cort'cal 'n,as'on or )'den'n% of the (er'odontal mem+rane. Panoram'c f'lms and mand'+ular ser'es sho) the e-tent of d'sease )'th'n the mand'+le +$ cort'cal d'sru(t'on and )'den'n% of the 'nfer'or al,eolar canal or mental foramen. 'm(le (la'n-f'lm rad'o%ra(h'c anal$s's of the mand'+le* ho)e,er* ma$ +e 'naccurate* )'th one ser'es of 111 (at'ents re,eal'n% a false-ne%at',e rate of 66 (ercent and a false-(os't',e rate of B (ercent. Technet'um-BBm rad'onucl'de +one scans ha,e +een ad,ocated for d'a%nos's of mand'+ular 'n,as'on. Althou%h the'r sens't','t$ 's %reater 'n %eneral than (la'n f'lms* the'r s(ec'f'c't$ 's not %reat* )'th false-(os't',e rates of 5G (ercent and false-ne%at',e rates of 1/ (ercent. In lar%e tumors +one scans are e,en more l'kel$ to +e false(os't',e +ecause of surround'n% 'nflammat'on. CT 's a h'%hl$ sens't',e method of d'a%nos'n% cort'cal 'n,as'on* +ut the (resence of metal tooth f'll'n%s 'nterferes )'th 'ts accurac$ :8'%. 15-15<. MRI 's (ro+a+l$ the most accurate and useful method of e,aluat'n% the mand'+le 'n sus('c'ous +ut not def'n't',e cases* +ecause 't can accumulate and reformat data 'n an$ (lane )'thout re(os't'on'n% the (at'ent* 't offers su(er'or se(arat'on of cort'cal and marro) 'ma%es* and 't 's unaffected +$ dental f'll'n%s. Anal$s's of the e-tent of 'ntraoral and (aranasal s'nus tumors 'n d'ff'cult- to-e-am'ne areas such as the (ara(har$n%eal s(ace* lar$n-* and naso(har$n- 's ass'sted +$ +oth CT and MRI. Correlat'on +et)een e-tent of d'sease determ'ned at o(erat'on and (reo(erat',e CT scann'n% )as found 'n 7E (ercent of /C (at'ents e,aluated +$ h'%hresolut'on CT* and B6 (ercent )hen MRI )'th contrast enhancement )'th %adol'n'um &TPA )as used. Part'cular ad,anta%e 's o+ta'ned 'n e,aluat'on of muscle and +one 'n,as'on* +ut mucosal deta'l 's d'ff'cult to assess )'th +oth CT and MRI :8'%. 15-1C<. The adm'n'strat'on of a%ents such as %adol'n'um )'th MRI (ro,'des +etter soft-t'ssue contrast and can su%%est the d'fferences +et)een tumor and surround'n% 'nflammat'on. 5$ reformatt'n% 'ma%es 'n se,eral (lanes* a three-d'mens'onal character'4at'on of the tumor 's (oss'+le that can +etter demonstrate tumor relat'onsh'(s to near+$ normal structures and can a'd 'n more accurate sta%'n%. MRId'rected stereotact'c sur%'cal techn'3ues ha,e +een used 'n neurosur%er$ and 'n the adm'n'strat'on of rad'othera($ and ma$ ha,e a role 'n sur%'cal e-t'r(at'on of carc'noma of the head and neck.

'nce sur,',al seems to de(end on erad'cat'on of re%'onal as )ell as local d'sease* e,aluat'on of the neck for the r'sk of metastat'c d'sease 's cruc'al to the o,erall treatment (lan. ur%er$ or rad'othera($ ma$ +e used to remo,e re%'onal d'sease 'n the l$m(h nodes 'f there 's d'sease that 's cl'n'call$ a((arent :(al(a+le NJ< or 'f there 's h'%h r'sk of d'sease 'n a cl'n'call$ ne%at',e neck :ND<. As has +een d'scussed* the s'4e of the (r'mar$ tumor :T sta%e<* 'ts h'stolo%'c (arameters* and 'ts s'te all ma$ su%%est an 'ncreased l'kel'hood of su+cl'n'cal d'sease 'n the neck. 1nfortunatel$* (h$s'cal e-am'nat'on of the neck ma$ +e fault$* )'th false-ne%at',e rates ran%'n% from 1C to CD (ercent. Althou%h of some 'm(ortance* the rates of false (os't','t$ are %enerall$ lo)er and usuall$ not as cl'n'call$ rele,ant. #$m(han%'o%ra(h$ has +een unre)ard'n% 'n the e,aluat'on of the neck. CT has recentl$ +een e,aluated and found 'n most stud'es to +e sl'%htl$ more sens't',e than (h$s'cal e-am'nat'onA E/ (ercent sens't','t$ ,ersus 75 (ercent* BG (ercent ,ersus 7D (ercent* and BD (ercent ,ersus E/ (ercent 'n three stud'es. Im(l'c't 'n th's ad,anta%e 's the a+'l't$ of CT to u(sta%e d'sease from ND to NJ and su%%est the need for neck d'ssect'on. "adol'n'um-enhanced MRI a((ears e,en more sens't',e=B/ (ercent sens't','t$ ,ersus E/ (ercent for CT scann'n% and 75 (ercent for (h$s'cal e-am'nat'on=and 's also useful 'n u(sta%'n% d'sease. Althou%h these technolo%'es are not necessar$ 'n e,er$ case of cl'n'cal sta%'n%* the$ are of s'%n'f'cant ,alue 'n dec's'on-mak'n% )hen (h$s'cal e-am'nat'on of the neck 's d'ff'cult +ecause of o+es't$* anatom'c ,ar'at'on* or (re,'ous sur%'cal or rad'at'on thera($. M'crometastases of less than G mm* ho)e,er* are st'll undetecta+le +$ an$ a,a'la+le technolo%$* althou%h (os't'on em'ss'on tomo%ra(h$ us'n% fluor'ne 1EKla+eled /-deo-$%lucose :PET-8&"< has demonstrated e-3u's'te sens't','t$ 'n earl$ stud'es of s3uamous cell carc'noma and melanoma metastat'c l$m(hadeno(ath$. Thera($ &ec's'on-mak'n% on thera($ 's +ased almost com(letel$ on the cl'n'cal sta%e :TNM< of the tumor at the t'me of (resentat'on. Althou%h h'stolo%'c character'st'cs ma$ to a sl'%ht de%ree 'nfluence the treatment* the s'4e of the local tumor and the e-tent of 'n,as'on of ad0acent structures :T sta%e<@ the (resence or a+sence* the num+er* and the lateral't$ of cer,'cal metastases :N sta%e<@ and the (resence or a+sence of d'stant metastat'c d'sease :M sta%e< d'ctate thera($. &ef'n't',e or curat',e treatment methods all are or'ented to)ard total e-t'r(at'on of local and locore%'onal d'sease* )'th the e-(ected su+se3uent decrease 'n d'ssem'nated d'sease. Pall'at',e (rocedures* )h'ch ma$ (roduce rel'ef of (a'n* rel'ef of a'r)a$ o+struct'on* or 'm(ro,ement 'n local funct'on and h$%'ene* s'm'larl$ re3u're com(lete macrosco('c tumor remo,al at the (r'mar$ s'te and 'n the neck and ma$ occas'onall$ +e 0ust'f'a+le 'n the (resence of d'stant metastases. u+total resect'on of local or locore%'onal d'sease 's unl'kel$ to +e of an$ +enef't 'n an$ s'tuat'on. &ef'n't',e thera($ ma$ cons'st of sur%er$ alone* rad'othera($ alone* sur%er$ )'th rad'othera($ as a (reo(erat',e or (osto(erat',e ad0u,ant* or chemothera($ del',ered e'ther s$stem'call$ +$ 'ntra,enous route or locall$ +$ 'ntraarter'al 'nfus'on +efore e'ther or +oth modal't'es as neoad0u,ant thera($. 8or small tumors :less than / cm* T1<* sur%er$ or rad'othera($* )ell (lanned and a((ro(r'atel$ e-ecuted* 'n most cases )'ll ha,e e3u',alent local control and sur,',al rates :8'%. 15-17<. The cho'ce of the method* then* de(ends on (at'ent com(l'ance* ,ol't'on* assoc'ated d'sease* e-(ense* 'nterference )'th normal funct'on* and a,a'la+le fac'l't'es. As the s'4e of the tumor 'ncreases to T/ sta%e or %reater* the l'kel'hood of local control and ult'mate cure )'th

rad'othera($ alone decreases* so sur%er$ or sur%er$ )'th ad0u,ant rad'othera($ +ecomes (refera+le :8'%. 15-1E<. In the lar$n-* )here sta%'n% 's more a funct'on of 'n,as'on of ad0acent structures than of tumor s'4e* and )here funct'on 's com(letel$ de(endent on (reser,at'on of structure* rad'othera($ 's usuall$ the f'rst cho'ce for T1 and T/ les'ons and 's occas'onall$ used as def'n't',e thera($ for TG les'ons. Ad,anced d'sease has a (oor (ro%nos's e,en )'th com+'ned treatments of sur%er$ and rad'othera($. 1nfortunatel$* (osto(erat',e ad0u,ant chemothera($ has +een unsuccessful 'n (rolon%'n% l'fe 'n controlled random'4ed tr'als. &es('te h'%h res(onse rates to (reo(erat',e adm'n'strat'on of c's(lat'n and 5-fluorourac'l there has not +een the sur,',al ad,anta%e that had +een demonstrated )'th chemothera($ for +reast d'sease. !ne (oss'+le role for chemothera($* ho)e,er* 's as a (red'ctor of successful thera($ and thus an 'nd'cator of )h'ch (at'ents ma$ +e treated )'th rad'othera($ 'nstead of sur%er$ )'th +etter (reser,at'on of funct'on. In se,eral (ros(ect',e stud'es (at'ents )'th TG or T6 lar$n%eal tumors )ere treated )'th c's(lat'n* 1DD m%Fm/ +od$ surface area* and 5-fluorourac'l* 1DD m%Fm/Fda$ L 6 for three courses. Pat'ents )'th com(lete res(onse :d'sa((earance of all tumor< )ere then treated +$ e'ther rad'othera($ alone or the more con,ent'onal a((roach of sur%er$ :lar$n%ectom$< )'th (osto(erat',e ad0u,ant rad'othera($. Pat'ents )'th less than com(lete res(onses )ere treated )'th sur%er$ (lus rad'othera($. Results sho) no d'fference 'n sur,',al +et)een (at'ents )ho res(ond com(letel$ to chemothera($ )hether the$ had +een treated (r'mar'l$ )'th sur%er$* rad'at'on thera($* or not. Pat'ents )'th 'ncom(lete res(onse to chemothera($ had much (oorer sur,',al than e'ther %rou( of com(lete res(onders. These f'nd'n%s ma$ 'nd'cate that the natural h'stor$ of tumors that res(ond com(letel$ )as more +en'%n and that the$ can +e treated less a%%ress',el$* (reser,'n% funct'on. A((ro-'matel$ GD to 6D (ercent of (at'ents treated )'th chemothera($ and rad'othera($ can sur,',e )'th a (reser,ed lar$n-. Nonres(onders (ro+a+l$ demonstrate %reater tumor hetero%ene't$ or clonal res'stance to thera($ and thus are unl'kel$ to ha,e the'r tumor controlled +$ an$ thera($. The results of these tr'als on carc'noma of the lar$n- ha,e st'mulated 'n,est'%ators to stud$ other head and neck s'tes for the (oss'+'l't$ of or%an (reser,at'on. "',en a 6D to 5D (ercent com(lete res(onse to chemothera($* 'm(ro,ed techn'3ues 'n (at'ent select'on :%enet'c anal$s's of tumors<* and rad'othera($* there 's s(eculat'on that h'%her cure rates )'th (reser,at'on of funct'on are (oss'+le. al,a%e sur%er$ 'n these (re,'ousl$ 'rrad'ated (at'ents* ho)e,er* 's d'ff'cult* )'th ma0or com(l'cat'on rates a((roach'n% 6D to 5D (ercent. The +as'c (r'nc'(le of sol'd tumor thera($ 's en +loc treatment* e'ther resect'on or rad'othera($ of the (r'mar$ tumor and the re%'onal d'sease 'n the neck. The dec's'on of )hether to treat the neck or not de(ends on the (resence of cl'n'call$ d'scern'+le metastat'c d'sease or the r'sk of m'crometastases to the neck. As (r'mar$ tumor s'4e 'ncreases* r'sk of neck d'sease 'ncreases at a %reater rate for some (r'mar$ s'tes than others :8'%. 15-1B<. .hen (al(a+le l$m(h nodes are (resent 'n the neck* conf'rmat'on of metastat'c d'sease ma$ +e o+ta'ned )'th f'ne-needle as('rat'on and c$tolo%'c e-am'nat'on* or the dec's'on to (roceed )'th thera($ ma$ +e made on (urel$ cl'n'cal %rounds. Pal(a+le or rad'olo%'call$ (os't',e l$m(h node metastases re3u're sur%'cal thera($ 'n the form of some t$(e of neck d'ssect'on* usuall$ (erformed 'n cont'nu't$ )'th the resect'on of the (r'mar$ tumor. u+cl'n'cal d'sease or m'crometastases ma$

+e treated +$ a mod'f'cat'on of neck d'ssect'on or rad'othera($* de(end'n% on the modal't$ chosen for treatment of the (r'mar$ s'te. The l$m(h nodes dra'n'n% the head and neck are conta'ned 'n a fasc'al en,elo(e* +et)een the su(erf'c'al and dee( la$ers of the 'n,est'n% fasc'a of the neck. .'th'n the la$ers of the 'n,est'n% fasc'a l'e the sternocle'domasto'd muscle and the s('nal accessor$ ner,e :CN II<. The cer,'cal l$m(h nodes l'e +et)een the 'n,est'n% fasc'a and the dee( cer,'cal fasc'a :8'%. 15-/D< or (re,erte+ral fasc'a and can +e remo,ed 'n toto )'th the 0u%ular ,e'n* the sternocle'domasto'd muscle* and the accessor$ ner,e* as 'n the class'cal rad'cal neck d'ssect'on descr'+ed +$ Cr'le 'n 1BDC :8'%. 15- /1<. The l$m(hat'c connect'ons +et)een the tumor and the cer,'cal metastases should rema'n 'ntact )'th en +loc resect'on* and all the l$m(h- node-+ear'n% t'ssue of the e-(osed s'de of the neck* 'nclud'n% the anter'or and (oster'or tr'an%le* 's remo,ed. The ma0or mor+'d't$ of neck d'ssect'on 's secondar$ to (aral$s's of the tra(e4'us muscle +$ resect'on of the accessor$ ner,e. 5ecause of th's* 5occa 'n 1BC7 su%%ested (reser,at'on of the ner,e. !ther sur%eons ha,e demonstrated techn'3ues 'n )h'ch the 0u%ular ,e'n and the sternocle'domasto'd muscle also can +e left 'ntact. These methods are (art'cularl$ useful 'n (ro(h$lact'c :elect',e< neck d'ssect'ons )hen there 's no cl'n'cal e,'dence of metastat'c d'sease to the neck. Althou%h there 's some de+ate a+out the 3ual't$ of funct'on after mod'f'ed neck d'ssect'on* 't seems l'kel$ that lon%-term funct'on 's 'm(ro,ed )hen the s('nal accessor$ ner,e 's (reser,ed* and the l'kel'hood of sur,',al 's not s'%n'f'cantl$ 'm(a'red +$ the lesser (rocedure. 'nce the s'te of (otent'al neck metastas's can +e fa'rl$ accuratel$ (red'cted +$ the locat'on of the (r'mar$ s3uamous cell carc'noma* and s'nce the l$m(h-nodeconta'n'n% areas of the neck ha,e +een descr'+ed as d'screte anatom'c areas demarcated +$ muscles* fasc'al condensat'ons* and the tr'an%les of the neck* 't has +een su%%ested that 'n add't'on to lea,'n% the accessor$ ner,e and the sternocle'domasto'd muscle 'ntact* onl$ those l$m(h nodes at r'sk should +e resected. The conce(t of select',e neck d'ssect'on* custom'4ed to the s'te of (r'mar$ d'sease* has %a'ned su((ort. Thus for carc'noma of the l'(* anter'or ton%ue* floor of the mouth* and +uccal mucosa* su(raomoh$o'd neck d'ssect'on m'%ht +e used* remo,'n% the su+mental* su+mand'+ular* u((er and m'd0u%ular l$m(h nodes :#e,els I* II* and III<. If a naso(har$n%eal les'on or (oster'or scal( melanoma )as the (r'mar$ s'te* the su+occ'('tal* retroaur'cular* u((er and m'd0u%ular* and (oster'or tr'an%le l$m(h nodes :#e,els II* III* I9* and 9< )ould +e remo,ed ,'a a (osterolateral neck d'ssect'on. In (r'mar$ s'tes of the (har$n- or lar$n-* a lateral neck d'ssect'on 'nclud'n% u((er* m'ddle* and lo)er 0u%ular nodes :#e,els II* III and I9< m'%ht +e a((ro(r'ate. In th$ro'd d'sease* remo,al of the (aratracheal* (er'th$ro'dal* and (recr'co'd nodes 'n an anter'or com(artment neck d'ssect'on m'%ht +e a((ro(r'ate :8'%. 15-//<. Althou%h 't seems o+,'ous that control of d'sease 'n the neck +$ 'ts sur%'cal remo,al )'th some form of neck d'ssect'on should 'm(ro,e sur,',al* there 's no )ell-des'%ned (ros(ect',e stud$ to (ro,e the e3u',alenc$ or su(er'or't$ of neck d'ssect'on or rad'othera($ for the cl'n'call$ ne%at',e :ND< neck or to su%%est )h'ch o(erat'on of the se,eral descr'+ed should +e used. A((ro-'matel$ 7D (ercent of (at'ents 'n the 1n'ted tates )ho (resent )'th s3uamous cell carc'noma of the u((er aerod'%est',e tract ha,e ad,anced d'sease* sta%e III or sta%e I9. E,en )'th a%%ress',e thera($ late- sta%e d'sease has a h'%h recurrence rate.

Recurrent d'sease ma$ occur at the (r'mar$ s'te 'n the (re,'ousl$ treated neck and 'n the contralateral neck. Just as )'th (r'mar$ d'sease* the thera($ of recurrent d'sease 's +ased on )'de local resect'on and clearance of the 'n,ol,ed or at-r'sk re%'onal l$m(h nodes. The e-tent of resect'on de(ends on 'n,ol,ement +$ tumor and the (ro-'m't$ to the %reat ,essels and the central ner,ous s$stem. If t'ssue tolerance to 'on'4'n% rad'at'on allo)s* (osto(erat',e ad0u,ant rad'othera($ ma$ +e useful* e,en as a second course. 8or unresecta+le recurrent d'sease* com+'nat'ons of chemothera($ and rad'othera($ or chemothera($ alone as )ell as laser or other non'n,as',e sur%'cal methods of tumor reduct'on ma$ (ro,'de some (all'at'on 'n reduc'n% +ulk* alle,'at'n% (a'n and a'r)a$ com(ress'on* +ut lon%-term sur,',al does not a((ear to +e 'm(ro,ed. The thera($ of d'stant metastases of s3uamous cell carc'noma of the u((er aerod'%est',e tract has +een unsuccessful. The lun% 's a common s'te of metastas's for head and neck cancer* +ut 't must +e real'4ed that a sol'tar$ les'on 'n the lun% of a (at'ent )'th a (re,'ous s3uamous cell carc'noma of the head and neck 's more l'kel$ to +e a (r'mar$ lun% cancer than a metastat'c de(os't. The (at'ent should +e a%%ress',el$ e,aluated and treated for that (r'mar$ cancer. Resect'on of metastat'c d'sease to the lun%* ho)e,er* has not (ro,ed salutar$ 'n most cases. econd (r'mar$ tumors or metachronous tumors are a s'%n'f'cant (ro+lem 'n head and neck cancer. Pre,ent'on of recurrent d'sease and of ne) (r'mar$ d'sease and re,ers'on of (oss'+le (remal'%nant ent't'es ma$ +e (oss'+le )'th chemo(re,ent'on. Isotret'no'n* a ,'tam'n A analo%ue* and +eta carotene ha,e reduced concom'tant (remal'%nant chan%es* and ha,e (oss'+l$ reduced the 'nc'dence of second (r'mar$ mal'%nanc'es 'n (at'ents )'th e('dermo'd carc'noma of the u((er aerod'%est',e tract. Immunothera($ 5ecause of (rolon%ed alcohol a+use and co'nc'dent malnutr't'on* man$ (at'ents )'th s3uamous cell carc'noma of the head and neck (resent )'th ,ar'ous man'festat'ons of 'mmunodef'c'enc$. There 's e,'dence that aner%$ and def'c'ent cellular 'mmun't$ result 'n (oorer sur,',al rates for s3uamous cell carc'noma of the head and neck as )ell as for other mal'%nanc'es. Cell-med'ated 'mmun't$ has +een demonstrated to +e de(ressed 'n head and neck cancer (at'ents. The cause of th's de(ress'on 's uncerta'n* ho)e,er* and sur%er$* rad'othera($* the mal'%nanc$ 'tself* and su((ress'on of natural k'ller cell funct'on +$ c'rculat'n% 'mmune com(le-es all ha,e +een 'm(l'cated. Natural k'ller cells ha,e +een sho)n to funct'on as a reco%n't'on and defense mechan'sm a%a'nst metastat'c d'sease from (r'mar$ s3uamous cell carc'noma. The effects of humoral or 5-cell-med'ated 'mmun't$ on the (ro%ress'on of head and neck carc'noma are not as clear. 1nl'ke some mal'%nant cells* the s3uamous cell carc'noma tumor cultures ha,e not +een (art'cularl$ 'mmuno%en'c* and cell-s(ec'f'c 'mmune man'(ulat'on has not $et +een ach'e,ed. Nons(ec'f'c cellular 'mmunost'mulat'on )'th ,ar'ous a%ents* such as le,am'sole* th$mos'n* and 'nterferon* ho)e,er* has sho)n some (rom'se +oth as an ad0u,ant and as (all'at',e method. Natural k'ller cells from (at'ents )'th head and neck cancer treated 'n ,'tro )'th 'nterleuk'n-/ :I#-/< sho) 'ncreased act','t$ after thera($* su%%est'n% that I#-/ ne%ates some of the su((ress',e a%ents 'n the serum. The use of I#-/ has +een e-tended to the cl'n'cal arena* )'th 'nfus'on of th's a%ent )'th 'ntramuscular 'nterferon-a re,ers'n% 'n ,',o de(ressed natural k'ller cell act','t$.

Per'les'onal 'n0ect'on of I#-/ 'n recurrent 'no(era+le head and neck carc'noma resulted 'n tem(orar$ +ut dramat'c res(onse 'n C5 (ercent of /D (at'ents treated. $stem'c recom+'nant 'nterferon-a %',en 'ntramuscularl$ resulted 'n one com(lete res(onse* one (art'al res(onse* and t)o sta+'l'4at'ons of d'sease 'n 16 (at'ents treated )'th a second c$cle* )'th salutar$ effect +e'n% attr'+uted to a r'se 'n natural k'ller cell act','t$. Althou%h the +enef't 's as $et uncerta'n* 't a((ears l'kel$ that more s(ec'f'c character'4at'on of the ant'%en'c 'dent't$ of s3uamous cell carc'noma and more (rec'se man'(ulat'on of effector cells throu%h natural or s$nthet'c l$m(hok'nes )'ll ult'matel$ hel( 'n the ad0u,ant thera($ of head and neck cancer. Reconstruct'on In the treatment of head and neck cancer* as 'n an$ other d'sease* there 's a h'erarch$ of (r'or't'es. ur,',al o+,'ousl$ 's of f'rst concern and de(ends a %reat deal on ade3uate sur%'cal or rad'othera(eut'c a+lat'on and (oss'+l$ ad0u,ant chemothera($ or 'mmunothera($. 8reedom from (a'n fortunatel$ 's accom(l'shed 'n most cases of successful a+lat',e thera($. Preser,at'on or restorat'on of funct'on as )ell as a((earance 's the ne-t cons'derat'on and rel'es lar%el$ on the a+'l't$ of the sur%eon to re(a'r the created defect )'th local* re%'onal* or d'stant t'ssues. 8'nall$* +ut (erha(s most (ract'call$ 'm(ortant to the (at'ent* 's the eff'c'enc$ of the treatment re%'men. Eff'c'enc$ d'ctates that the thera($ +e del',ered 'n a t'me (er'od commensurate )'th the natural h'stor$ of the d'sease. Ad,anced s3uamous cell carc'noma has a h'%h recurrence rate. E'%ht$-n'ne (ercent of (at'ents )hose local or re%'onal d'sease recurs ha,e the'r recurrence )'th'n / $ears of thera($. Thus restorat'on of funct'on and a((earance 'n th's %rou( of (at'ents )'th a h'%h fa'lure rate and short d'sease-free 'nter,als should +e (erformed as 3u'ckl$ as (oss'+le. A mult'(le-sta%e method of reconstruct'on carr'ed out o,er se,eral months ma$ (rolon% reco,er$. The most eff'c'ent methods are s'n%le-sta%e reconstruct'ons (erformed at the t'me of the a+lat',e sur%er$. In the (ast there )as cons'dera+le reluctance to (erform 'mmed'ate reconstruct'on after resect'on of mal'%nanc$. 8ear of cloak'n% (ers'stent or recurrent d'sease* cou(led )'th real'st'c assessment of the (oor results from mult'(le (rocedures* led to recommendat'ons that the (at'ent +e o+ser,ed for 1 to 5 $ears after sur%er$. The funct'onal d'sa+'l't$ 'nherent 'n ma0or oral or oro(har$n%eal resect'on usuall$ mandated (ermanent %astrostom$ for feed'n% and tracheostom$ for safe ma'ntenance of the a'r)a$. The attendant loss of taste* s(eech* s)allo)'n%* and other corollar$ funct'ons made the (osto(erat',e state of the (at'ent )'th head and neck cancer m'sera+le. Im(ro,ed methods of reconstruct'on* +etter (atholo%'c anal$s's at sur%er$* and a more com(rehens',e understand'n% of the natural h'stor$ of the d'sease ha,e made s'n%lesta%e reconstruct'on at the t'me of the 'n't'al sur%'cal resect'on the current standard of care 'n most 'nstances. Resect'on of the (r'mar$ d'sease and re%'onal metastat'c d'sease* conf'rmat'on of d'sease clearance +$ fro4en-sect'on e-am'nat'on of the mar%'n of resect'on* and 'mmed'ate reconstruct'on are usuall$ (oss'+le for s3uamous cell carc'noma of the u((er aerod'%est',e tract. In mal'%nanc'es for )h'ch fro4ensect'on anal$s's ma$ +e 'naccurate* )hen +one 's 'n,ol,ed* 'n recurrent d'sease )'th

(re,'ous rad'othera($* or )hen there 's uncerta'nt$ a+out other as(ects of the resect'on* secondar$ reconstruct'on ma$ +e more a((ro(r'ate. The u((er aerod'%est',e tract 's a com(le- m'-ture of cutaneous co,er* e('thel'al l'n'n%* +one* and cart'la%'nous frame)ork all 0o'ned 'n a com(le- arran%ement +$ muscle and dr',en 'n 'ntr'cate s$ner%$ to fac'l'tate the ma'n ,e%etat',e funct'ons of the or%an'sm* al'mentat'on and res('rat'on. Th's com(le- mo+'le structure and the hea,$ colon'4at'on of the mucosal surfaces +$ +acter'a as )ell as the deleter'ous effects of ad0u,ant rad'othera($ :acute 'nflammat'on 'n the earl$ sta%es and f'+ros's and ,ascul't's 'n later sta%es< all make reconstruct'on e-tremel$ d'ff'cult. The +as'c needs (resented +$ sur%'cal resect'on are restorat'on of cont'nu't$ of the al'mentar$ tu+e )'th e('thel'al l'n'n%* (ro,'s'on of rel'a+le e-ternal co,era%e for (rotect'on of the %reat ,essels and +on$ structures* and se(arat'on of the central ner,ous s$stem and u((er aerod'%est',e tract. Restorat'on of oral cont'nence* fac'l'tat'on of the coord'nated mot'ons of the ton%ue and lar$n-* and ma'ntenance of an o(en (assa%e for s)allo)'n% )h'le se(arat'n% the oral* oro(har$n%eal* and nasal ca,'t'es are ref'nements on the +as'c demand that are necessar$ for a reasona+le 3ual't$ of l'fe. Accurate anal$s's of the )ound created +$ the sur%'cal resect'on 's the f'rst element re3u'red for successful reconstruct'on. '4e* e-(osure of the central ner,ous s$stem* mo+'l't$ of the remo,ed (arts* (resence of +acter'al colon'4at'on or 'n,as',e 'nfect'on* t$(e of t'ssue remo,ed :mucosa* +one* cart'la%e<* h'stor$ of (re,'ous sur%er$ or rad'othera($* l'kel'hood of su+se3uent sur%er$ or rad'othera($* e-(osure of the carot'd or 0u%ular ,essels* and effect of e-ternal a((earance all are 'm(ortant )ound character'st'cs that affect the cho'ce of reconstruct',e techn'3ues. .hether to attem(t to sat'sf$ onl$ the +as'c reconstruct',e needs or to restore as man$ m'ss'n% elements as (oss'+le 's a d'ff'cult dec's'on 'n,ol,'n% (at'ent des'res and com(l'ance* sur%'cal sk'll* cons'derat'on of d'sease sta%e* and man$ other factors. The (ast 15 $ears ha,e +rou%ht enormous ad,ances 'n reconstruct',e techn'3ues that ha,e affected ma'nl$ the eff'c'enc$ of thera($ 'n restor'n% the (at'ent to reasona+le funct'on and a((earance ra('dl$. Ind'rectl$* ho)e,er* 'm(ro,ed reconstruct',e techn'3ues ha,e an 'm(act on sur,',al* s'nce more a%%ress',e resect'ons* sal,a%e of rad'cal rad'othera($* and decrease 'n (osto(erat',e com(l'cat'ons )'th attendant 'nfect'on and malnutr't'on are accom(l'shed )'th relat',e safet$. The fundamental 'm(ro,ement has +een the a+'l't$ to transfer lar%e ,olumes of )ell- ,ascular'4ed t'ssue to the area. Althou%h fla( reconstruct'on of the e-ternal surface of the nose )as tau%ht +$ the earl$ H'ndu sur%eon ushruta* and the Rena'ssance sa) a num+er of reconstruct',e attem(ts at nasal and other e-ternal defects :+$ d'stant fla(s attached to the defect and d','ded after (aras't'4'n% the'r +lood su((l$ from local t'ssues<* ma0or reconstruct'ons ha,e +een a relat',el$ recent (henomenon. Throu%hout the de,elo(ment of sur%'cal techn'3ue that follo)ed the 'ntroduct'on of %eneral anesthes'a 'n 1E6C* the (r'nc'(le of random fla(s of sk'n +e'n% attached and d','ded rema'ned the ma'nsta$ of the reconstruct',e effort. #ar%e se%ments of t'ssue from the chest and +ack )ere mo,ed 'n mult'(le sta%es to the oral ca,'t$* face* and (har$n-. In 1BC5 5akam0'an descr'+ed the delto(ectoral fla(* )h'ch (ossessed an a-'al or d'rect arter'al +lood su((l$ from the (erforat'n% ,essels of the 'nternal mammar$

arter$ and ,e'n to the sk'n of the chest and shoulder. Th's (ro,'ded a relat',el$ rel'a+le lar%e se%ment of t'ssue that )as (art'cularl$ useful 'n the reconstruct'on of the (har$n-. The forehead fla(* another a-'al (attern fla(* +ased on the su(erf'c'al tem(oral ,essels* )as descr'+ed 'n 1BCG and* des('te 'ts d'sf'%urement of the donor s'te* +ecame a useful method of reconstruct'on of the oral ca,'t$. .'th the real'4at'on 'n the 1B7Ds that the +lood su((l$ to the sk'n came not onl$ from the randoml$ or'ented su+dermal (le-us ,essels and a-'al cutaneous ,essels +ut also from (erforat'n% ,essels from the su+0acent muscles* the musculocutaneous conce(t transformed reconstruct'on* (art'cularl$ that of head and neck defects. #ar%e flat muscles of the thora- could +e rotated on the'r lon% ,ascular (ed'cles to su((l$ a lar%e ,olume of )ell-,ascular'4ed t'ssue 'n a s'n%le o(erat'on on the oral ca,'t$* (har$n-* or soft t'ssues of the face. Moreo,er* 'f recurrence of d'sease mandated a su+se3uent resect'on* another thorac'c musculocutaneous fla( )as a,a'la+le to re(a'r the defect. The (ectoral's ma0or* lat'ss'mus dors'* tra(e4'us* sternocle'domasto'd* and (lat$sma muscles all are useful* e'ther alone or )'th the'r o,erl$'n% sk'n. No) much lar%er and more com(le- )ounds could +e addressed at a s'n%le o(erat'on* return'n% the (at'ent to reasona+le funct'on and a((earance (rom(tl$. ome of the (ro+lems )'th the thorac'c musculocutaneous fla(s are the effect of %ra,'t$ on +ulk$ fla(s* add't',e mor+'d't$ to the shoulder %'rdle )hen neck d'ssect'on 's (erformed* and ,ar'a+le +lood su((l$ to the sk'n* (art'cularl$ 'n the (ectoral's ma0or musculocutaneous fla(* de(end'n% on )here the sk'n (ort'on of the fla( 's located. 8urthermore* there 's no rel'a+le method of trans(ort'n% ,ascular'4ed +one )'th a re%'onal musculocutaneous fla(. &es('te these d'sad,anta%es* the musculocutaneous conce(t has made 'mmed'ate reconstruct'on of the head and neck resect'on the acce(ted (rocedure 'n most cases. An offshoot of the success of reconstruct',e efforts )'th musculocutaneous fla(s has +een the 'ncreased 'nterest 'n ,ascular anatom$ :8'%. 15-/G<. u+se3uent research and 'm(ro,ements 'n m'crosco(e and 'nstrument technolo%$ ha,e resulted 'n the a+'l't$ to transfer t'ssue of man$ d'fferent t$(es from ,ar'ous s'tes of the +od$ +$ se(arat'n% arter'al su((l$ and ,enous dra'na%e of the t'ssue and reattach'n% 't to +lood ,essels 'n the head and neck. 5one* muscle* sk'n* fasc'a* and com+'nat'ons of these are a,a'la+le for ,ar'ous s'tes* as are 'ntraa+dom'nal ,'scera. M'cro,ascular reconstruct'on or free t'ssue transfer has made 't (oss'+le for the sur%eon to close ,'rtuall$ an$ defect 'n the head and neck* no matter ho) lar%e or com(le-. E,en more 'm(ortant* ho)e,er* 's that the lar%e num+er of methods a,a'la+le allo)s the reconstruct',e sur%eon to choose the method or methods most su'ta+le to a s(ec'f'c s'te and anal$4e the results :Ta+le 15-1<. Just as each )ound has 'ts o)n character'st'cs* so does each fla(. 9ascular (ed'cle len%th* +ulk* t$(e of e('thel'um* (resence and dura+'l't$ of +one* and th'ckness of soft t'ssue all can +e e,aluated to select the most a((ro(r'ate re(lacement for the 'nd','dual (ro+lem :8'%. 15-/6<. Com(l'cat'ons The thera($ of s3uamous cell carc'noma of the head and neck usuall$ re3u'res t)o (otent modal't'es=sur%er$ and rad'othera($=d'rected at an area that 's hea,'l$ contam'nated )'th sa(ro(h$t'c and (atho%en'c or%an'sms 'n a (at'ent )ho 's fre3uentl$ malnour'shed and 'mmunodef'c'ent* and ma$ +e noncom(l'ant. 'nce man$ (at'ents (resent )'th ad,anced d'sease* the fa'lure rate e,en for com+'ned

thera($ 's h'%h as a result of d'ssem'nated d'sease as )ell as local or locore%'onal fa'lure. It 's therefore 'm(erat',e to del',er the thera($ 'n a form that 's eff'c'ent and results 'n the (at'ent2s ra('d return to funct'on* reasona+le a((earance* and )hate,er soc'al s'tuat'on the (at'ent ma$ +e a+le to reco,er. Reco%n't'on of the 'ne,'ta+le se3uelae of thera($=com(l'cat'ons=and ra('d resolut'on or* (refera+l$* (re,ent'on are thus of %reat 'm(ortance. Com(l'cat'ons s(ec'f'c to head and neck cancer thera($ can +e cate%or'4ed as anatom'c* 'n0ur$ to ner,es or +lood ,essels )'th'n the f'eld of sur%er$@ (h$s'olo%'c* the results of 'nterference )'th +lood or l$m(hat'c su((l$ to the area secondar$ to sur%er$ or rad'othera($@ techn'cal* sur%'cal rearran%ements that result 'n secondar$ (ro+lems@ and funct'onal deran%ements of normal +eha,'or secondar$ to thera($. All of these can then +e %rou(ed 'nto catastro(h'c or noncatastro(h'c com(l'cat'ons* )h'ch )'ll 'n lar%e (art d'ctate the sur%eon2s a((roach to them* )hether (re,ent',e or thera(eut'c. The most a((ro(r'ate a((roach to com(l'cat'ons 's (re,ent'on. Restorat'on of (os't',e n'tro%en +alance* (reo(erat',e (ulmonar$ h$%'ene* control of d'a+etes mell'tus* and )ean'n% from alcohol and to+acco are 'm(ortant nons(ec'f'c measures. Preo(erat',e ant'+'ot'cs decrease the l'kel'hood of )ound 'nfect'on and 'ts se3uelae. Numerous stud'es ha,e sho)n that (re,'ousl$ adm'n'stered rad'othera($* (art'cularl$ 'f %',en 'n def'n't',e thera(eut'c doses* 'ncreases the r'sk of com(l'cat'on. &ental h$%'ene or reha+'l'tat'on +efore def'n't',e sur%er$ 's 'm(ortant 'n (at'ents )hose mand'+le has +een (re,'ousl$ 'rrad'ated to (re,ent su+se3uent osteorad'onecros's. Pat'ent educat'on 's cruc'al to ensure coo(erat'on 'n )hat ma$ +e a d'ff'cult (osto(erat',e reha+'l'tat'on. !ther than 'n0ur$ to the thorac'c duct* )h'ch ma$ result 'n s'%n'f'cant fat and (rote'n loss throu%h a ch$lous f'stula* most anatom'c com(l'cat'ons are ner,e 'n0ur'es* e'ther (ur(oseful or other)'se secondar$ to (r'mar$ tumor resect'on or rad'cal neck d'ssect'on. The accessor$* mar%'nal mand'+ular* m$loh$o'd* and cer,'cal (le-us sensor$ +ranches are fre3uentl$ sacr'f'ced 'n neck d'ssect'on. In0ur'es caused +$ tract'on* electrocauter$* or other techn'cal m'sad,enture ma$ occur to an$ structure +ut are most l'kel$ to affect h$(o%lossal* l'n%ual* mand'+ular* ,a%us* (hren'c* fac'al* recurrent lar$n%eal* motor +ranches to the cer,'cal (le-us and cer,'cal s$m(athet'c cha'n. Careful techn'3ue dur'n% sur%er$* ade3uate hemostas's to allo) %ood ,'sual'4at'on* and kno)led%e of normal and (atholo%'c anatom$ )'ll decrease the l'kel'hood of anatom'c com(l'cat'ons. Pre,'ous sur%er$* the (lanned sur%er$* and rad'othera($ all ma$ 'nterfere )'th +lood su((l$ to the head and neck* result'n% 'n local and s$stem'c (ro+lems. Irrad'at'on alone or com+'ned )'th sur%er$ result 'n a // to GD (ercent 'nc'dence of cl'n'cal h$(oth$ro'd'sm* (art'cularl$ 'n lar$n%eal sur%er$. H$(o(arath$ro'd'sm* trans'ent or (ermanent* ma$ result 'n u( to 1D (ercent of cases of th$ro'dectom$ and must +e cons'dered after lar$n%o(har$n%ectom$. !+struct'on of one or +oth 0u%ular ,e'ns* (art'cularl$ )hen com+'ned )'th l$m(hadenectom$* results 'n l$m(hedema of the face and ma$ result 'n 'ntracere+ral edema* (art'cularl$ 'f e-cess',e flu'd 's adm'n'stered dur'n% sur%er$. Head ele,at'on* d'uret'cs* and 0ud'c'ous flu'd mana%ement* ho)e,er* usuall$ allo) collateral flo) throu%h the ,erte+ral ,e'ns to resol,e these (ro+lems.

ur%'cal m'sad,enture* (oor (lann'n% or e-ecut'on* or the (resence of 'nfect'on )'ll result 'n techn'cal com(l'cat'ons. Res('rator$ (ro+lems can result from (neumothora(rec'('tated )h'le o(erat'n% 'n the med'ast'num or su(racla,'cular fossa. Hematoma ma$ cause acute u((er a'r)a$ o+struct'on. Tracheostom$ ma$ cause su+cutaneous em(h$sema* tracheo'nnom'nate f'stula* or su+%lott'c stenos's. The com+'nat'on of 'nfect'on and local 'schem'a of sk'n or mucosa ma$ result 'n )ound 'nfect'on* suture l'ne +reakdo)n* fla( necros's* osteom$el't's* and osteorad'onecros's. E-(osure of a (re,'ousl$ 'rrad'ated carot'd arter$ usuall$ results 'n a +acter'al 'nfect'on and ru(ture and must +e treated as a sur%'cal emer%enc$. Careful (lann'n%* met'culous attent'on to )atert'%ht closure of the (har$n- and oral ca,'t$* and (ro,'s'on of ade3uate 'nde(endentl$ )ell-,ascular'4ed t'ssue for reconstruct'on )'ll m'n'm'4e the l'kel'hood of techn'cal com(l'cat'ons. Restorat'on of funct'on 's one of the ma'n %oals of head and neck cancer thera($. Althou%h some d$sfunct'on 's 'nherent 'n all thera($* (ro(er select'on of reconstruct',e methods* attent'on to 'ntr'ns'c funct'on of the structures resected and those rema'n'n%* and careful and (at'ent (osto(erat',e reha+'l'tat'on )'ll decrease the se,er't$ of the common funct'onal com(l'cat'onsA chron'c a'r)a$ o+struct'on* as('rat'on (neumon'a* d$s(ha%'a* d$s(hon'a* and mental de(ress'on. The (otent'al for catastro(he 's %reat 'n head and neck cancer sur%er$. Reco%n't'on of a com(l'cat'on and real'4at'on of the l'kel'hood of ra('d deter'orat'on are 'm(ortant to (re,ent catastro(h'c com(l'cat'ons. Tetan$ from h$(o(arath$ro'd'sm* acute a'r)a$ o+struct'on from hematoma or a d'slod%ed tracheostom$ tu+e* tracheo'nnom'nate f'stula* and carot'd hemorrha%e all can lead to ra('d death. An$ com(l'cat'on that occurs 'n a (at'ent )ho has +een (re,'ousl$ 'rrad'ated must +e a%%ress',el$ resol,ed. Carot'd arter$ e-(osure* oro(har$n%ocutaneous f'stula* or sk'n fla( necros's 'n the 'rrad'ated neck could result 'n su+se3uent 'n,as',e 'nfect'on of the %reat ,essels and death :8'%. 15-/5<. !ro(har$n%ocutaneous f'stula 's relat',el$ common* ran%'n% from C to GE (ercent of head and neck cancer cases* and can +e treated e-(ectantl$ 'f sal',ar$ flo) can +e d',erted and the carot'd arter'es (rotected +$ )ell-,ascular'4ed t'ssue. The (ectoral's ma0or musculocutaneous fla( 's a useful method of clos'n% ma0or f'stulas and co,er'n% the %reat ,essels at the same t'me. Phar$n%ocutaneous f'stulas of moderate s'4e ma$ +e treated +$ the sternocle'domasto'd musculocutaneous fla( :8'%. 15-/C<. !ral Ca,'t$ Anatom$ and Ph$s'olo%$ The anatom'c +orders of the oral ca,'t$ are the mucosal surfaces of the l'( e-ternall$ and the anter'or tons'llar ('llar (oster'orl$. The oral ca,'t$ usuall$ 's cons'dered as a num+er of d'st'nct ent't'esA the l'(s* the +uccal mucosa* the %ums :mand'+ular and ma-'llar$* 'nclud'n% the retromolar tr'%one<* the floor of the mouth* the mo+'le ton%ue* and the hard (alate. Thus the oral ca,'t$ 's the ad'tus of the lon% seromuscular-mucosal tu+ular condu't of food and l'3u'd that allo)s the or%an'sm to o+ta'n nour'shment. As such 't 's mod'f'ed 'n se,eral )a$s to fac'l'tate the 'n't'at'on of al'mentat'on. The l'(s are a s(h'ncter that allo)s the oral ca,'t$ to +e sealed after 'ntake of food and l'3u'd. The +uccal surfaces and the +ucc'nator muscles hel( to colla(se and e-(and the oral ca,'t$ to fac'l'tate (assa%e of food +ack to the (har$n-. The hard (alate (ro,'des a sta+le (latform a%a'nst )h'ch the mo+'le ton%ue can (ush and se(arates the oral and nasal ca,'t'es. The floor of the mouth and the %ums are

structural com(onents of the reser,o'r and a'd 'n the (re(arat'on funct'ons of the oral ca,'t$ 'n the (rocess of eat'n%@ the mo+'le ton%ue 's the ma'n (ro(uls',e a%ent 'n the oral ca,'t$. Each s'te also has a d'st'nct contr'+ut'on to the modulat'on of a'r e-(elled from the lun%s that results 'n s(eech. Thera($ Carc'no%enes's 'n the oral ca,'t$ and the natural h'stor$ of su+se3uent d'sease are %enerall$ s'm'lar 'nde(endent of anatom'c area* althou%h TNM sta%'n% has not +een a (erfect (ro%nost'cator for all s'tes* and h'stolo%$ and s'te (la$ an 'm(ortant role 'n outcome. The conse3uences to the (at'ent of thera($* (art'cularl$ sur%'cal thera($* ho)e,er* are ,er$ d'fferent and de(end ,er$ much on the funct'on of the area 'n,ol,ed and the success )'th )h'ch 't can +e reconstructed. #'( Et'olo%$ In the 1n'ted tates and Canada* carc'noma of the l'( 's common* )'th a marked male (redom'nance of /DA1. The lo)er l'( 's +$ far the most common s'te* +e'n% 'n,ol,ed 'n a((ro-'matel$ B5 (ercent of cases* and has s3uamous cell carc'noma as the most common h'stolo%$. 5asal cell carc'noma (redom'nates 'n the u((er l'(. The ha+'t of ('(e smok'n%* )'th chron'c thermal 'n0ur$* )as for man$ $ears +el'e,ed to +e the carc'no%en'c st'mulus. Recentl$* ho)e,er* 't has +ecome clear that the (rotu+erant lo)er l'( 's e-(osed to h'%her doses of ultra,'olet rad'at'on* result'n% 'n mal'%nanc$ that +eha,es s'm'larl$ to 19-'nduced sk'n cancer. 8armers and other outdoor )orkers 'n the'r s'-th to n'nth decades* of Celt'c and northern Euro(ean or'%'n* )ho l',e 'n areas of h'%h sunl'%ht e-(osure are at h'%hest r'sk. Chron'c e-(osure to sun results 'n loss of the anatom'c ,erm'l'on +order* the 0unct'on +et)een the sk'n and mucosa of the l'(* follo)ed +$ leuko(lak'a or carc'noma 'n s'tu and +$ 'n,as',e mal'%nanc$ :8'%. 15-/7<. Patholo%$ .ell-d'fferent'ated sta%e I les'ons com(r'se the ma0or't$* CD to ED (ercent* of most cl'n'cal ser'es. #ocal recurrence after sur%er$ or 'rrad'at'on occurs 'n 1D to /D (ercent of cases* +ut sal,a%e thera($ :su+se3uent sur%er$ )'th or )'thout rad'at'on or chemothera($< ma$ +e successful. Nodal metastases* usuall$ to the su+mental or su+mand'+ular nodes* are (resent 'n 1D to 15 (ercent of cases and occur 'n tumors of all h'stolo%'c d'fferent'at'on. Treatment +$ local e-c's'on or rad'at'on results 'n cure rates of a((ro-'matel$ BD (ercent for sta%e I d'sease and 55 to ED (ercent 'n sta%e II locore%'onal d'sease. A%%ress',e carc'noma of the l'( seems to follo) a (attern of (er'neural 'n,as'on* do)n the mental ner,e to 'n,ol,e the mand'+le and (ter$%o'd s(ace* and ult'matel$ ,'a the tr'%em'nal ner,e to the +ase of the skull. Thera($ ur%'cal thera($ re3u'res resect'on of the d'sease )'th a clear mar%'n of normal t'ssue around 't. If l$m(h nodes are 'n,ol,ed* '(s'lateral or +'lateral neck d'ssect'on 's 'nd'cated. Elect',e or (ro(h$lact'c node d'ssect'on for the (at'ent )'th the ND neck usuall$ 's not recommended 'n e('dermo'd carc'noma of the l'(. The funct'onal %oal 'n l'( reconstruct'on 's restorat'on of oral cont'nence and reasona+le a((earance. 5ecause the lo)er l'( 's lon%er and more (rotu+erant than the u((er l'(* (r'mar$ closure of defects of a((ro-'matel$ /5 (ercent of the u((er l'( and G5 (ercent of the lo)er l'( )'ll result 'n sat'sfactor$ a((earance and funct'on. The l'( o((os'te the resect'on 's an 'm(ortant donor s'te for lar%er defects. Cross-l'( fla(s from e'ther the

u((er or lo)er l'( of the A++H or Estlander t$(e and ad,ancement of lateral la+'al and +uccal elements are useful* de(end'n% on the s'4e and s'te of the defect. Preser,at'on of sensor$ and motor funct'on of the rema'n'n% or+'cular's or's muscle also 's (oss'+le* to ma'nta'n the most eff'c'ent s(h'ncter mechan'sm* us'n% the ;ara(and4'c (r'nc'(le. .hen the ent're lo)er l'( 's resected* the damm'n% funct'on can +e restored +$ a rad'al forearm free fla( 'nclud'n% (almar's lon%us tendon* )h'ch 's 'nset to the ad0acent oral musculature to ser,e as a d$nam'c sl'n%. 'nce the t'ssue at r'sk 's oral mucosa on the (rotu+erant area of the l'(* (reneo(last'c chan%es of leuko(lak'a or d$s(las'a should +e treated +$ mucosal resect'on* ,erm'l'onectom$ :l'( sha,e<* and ad,ancement of the la+'al mucosa to the sun-e-(osed mar%'n of the sk'n :mucosal ad,ancement<. 5uccal Mucosa Anatom$ and Ph$s'olo%$ The +uccal mucosa e-tends from the comm'ssures of the l'(s to the (ter$%omand'+ular ra(he and from the ma-'llar$ :u((er< to the mand'+ular :lo)er< al,eol' on +oth s'des. The su+0acent structures 'nclude the +uccal fat (ad and +ucc'nator muscle* and the surface of the +uccal mucosa (erm'ts entr$ to the oral ca,'t$ of tensen2s duct from the (arot'd %land. Th's area modulates s(eech and oral ca(ac'tance. Patholo%$ 5uccal mucosa cancer com(r'ses a+out 5 (ercent of all oral cancers* and* as )'th other s'tes* there 's a s'%n'f'cant male (redom'nance :GA1<. There 's a h'%h 'nc'dence of ad,anced d'sease on (resentat'on* )'th 1E (ercent sta%e I* GC (ercent sta%e II* and 66 (ercent sta%e III* )'th a 5C (ercent 'nc'dence of nodal metastas's. #ar%e cancers of the +uccal mucosa are less l'kel$ than tumors of other oral s'tes to ha,e su+cl'n'cal metastases to the neck. A su+set of les'ons ar's'n% 'n the +uccal mucosa 's ,errucous carc'noma* )h'ch (resents as an e-o(h$t'c mass that has the cellular h'stolo%$ character'st'c of mal'%nanc$ +ut lacks the 'n,as',e as(ects. 9errucous carc'noma 's more common 'n females than 'n males and ma$ +e related to human (a('lloma,'rus. The +uccal mucosa 's the most common s'te of th's ,ar'ant of s3uamous cell carc'noma* )h'ch sho)s )art$ dense kerat'n'4at'on* shar(l$ c'rcumscr'+ed dee( mar%'ns* (ush'n% +orders* and 'nflammator$ 'nf'ltrate. There 's a h'%h 'nc'dence of mult'centr'c't$ of mal'%nanc$ 'n (at'ents )'th ,errucous carc'noma* )'th u( to 6D (ercent ha,'n% other s'tes of 'n,as',e carc'noma* so 't (ro+a+l$ re(resents a (art of the s(ectrum of f'eld cancer'4at'on :see 8'%. 15-1D E<. There 's some concern that rad'at'on of th's les'on ma$ result 'n ded'fferent'at'on or chan%e to a more mal'%nant h'stolo%$* +ut th's o+ser,at'on ma$ +e a man'festat'on of tumor cell hetero%ene't$ and clonal res'stance to rad'othera($ rather than actual mal'%nant de%enerat'on. Carc'noma of the +uccal mucosa* +oth ,errucous and 'nf'ltrat',e* occurs commonl$ 'n chron'c to+acco che)ers and snuff d'((ers 'n the 1n'ted tates and 'n (eo(le )ho use (an 'n Ind'a and outheast As'a. Thera($ ur%'cal resect'on )'th or )'thout ad0u,ant rad'othera($ results 'n sur,',al rates of 5D to CD (ercent* )'th CD to 75 (ercent for local'4ed d'sease and /5 to 65 (ercent for locore%'onal d'sease. The route of 'n,as'on of e('dermo'd carc'noma of the +uccal mucosa 's throu%h the +ucc'nator muscle and +uccal fat (ad dorsall$ to)ard the (ter$%o'd musculature or lateral to the sk'n. In e'ther case s'%n'f'cant l'm'tat'on of oral mot'on and d'scomfort on che)'n% :tr'smus< occurs.

ur%'cal resect'on fre3uentl$ creates a full-th'ckness defect of mucosa* muscle* and sk'n )'th or )'thout ad0acent mand'+le or ma-'llar$ tu+eros't$. 8or e-tens',e les'ons* restorat'on of funct'on re3u'res re(lacement of 'nternal l'n'n% as )ell as e-ternal sk'n co,era%e. Althou%h the forehead fla( +ased on the su(erf'c'al tem(oral ,essels and the delto(ectoral fla( from the shoulder )ere the standard 'n the 1BCDs and 1B7Ds* recent methods ha,e 'ncluded the com+'ned use of (ectoral's ma0or musculocutaneous fla( for l'n'n% and delto(ectoral sk'n fla( for sk'n co,era%e or the lat'ss'mus dors' musculocutaneous fla( folded on 'tself to (ro,'de +oth 'nternal and e-ternal surfaces :8'%. 15-/E<. 8asc'ocutaneous fla(s such as the sca(ula and rad'al forearm can (ro,'de am(le t'ssue for +oth defects and ,ascular'4ed +one as )ell )hen transferred as a m'cro,ascular free fla(. 8or smaller defects* 'ntraoral fla(s of mucosa and muscle such as ton%ue fla(s* (alate muco(er'osteal fla(s* or ad,ancement fla(s ha,e +een useful. (l't- th'ckness sk'n %rafts* thou%h successful 'n the short term* ult'matel$ result 'n f'+ros's and d'ff'cult$ )'th che)'n%. 8or su(erf'c'al les'ons that e-tend o,er the mand'+ular al,eolus and re3u're su((le co,era%e* the (lat$sma musculocutaneous fla( 's an e-cellent cho'ce :8'%. 15-/B<. Hard Palate Patholo%$ The roof of the mouth* +ounded +$ the soft (alate (oster'orl$ and the teeth anter'orl$ and laterall$* 's not a common s'te of 'ntraoral s3uamous cell carc'noma. More common 'n th's area are tumors* +oth +en'%n and mal'%nant* of the m'nor sal',ar$ %lands :8'%. 15-GD<. 3uamous cell carc'noma 'n the 1n'ted tates usuall$ 's a d'sease of elderl$ male smokers and rema'ns su(erf'c'al for (rolon%ed (er'ods +efore e-tend'n% throu%h (er'osteum and +one and s(read'n% e'ther ce(halad 'nto the nasal ca,'t$ or ma-'llar$ antrum or dorsall$ throu%h the (ter$%o(alat'ne fossa. E('dermo'd carc'noma of the hard (alate 's more common 'n Ind'a and 9ene4uela* )here re,erse smok'n% :)'th the l'%hted end of the c'%arette 'ns'de the mouth< 's (ract'ced. Thera($ Treatment 's sur%'cal resect'on )'th or )'thout ad0u,ant rad'othera($. 5ecause of the underl$'n% +one* def'n't',e rad'othera($ 's rarel$ useful. Cer,'cal metastases are relat',el$ rare 'n d'sease of the hard (alate* )'th onl$ 1D to /5 (ercent of (at'ents (resent'n% )'th d'sease at e'ther the (re,ascular fac'al nodes or the 0u%ulod'%astr'c nodes. !ccult metastases are rare* so elect',e neck d'ssect'on 's not (art of the thera(eut'c re%'men. 8',e-$ear sur,',al rates ran%e from GG to 75 (ercent* de(end'n% on sta%e* )'th an a,era%e of 55 to CD (ercent for all (at'ents. mall to moderate-s'4ed defects of the hard (alate are +est treated )'th a dental (rosthes's 'n +oth the dentate and edentulous (at'ent@ mass',e defects ma$ re3u're tem(oral's muscle fla( or local fla(s and sk'n %raft'n% or free t'ssue transfer* s'nce su((ort for the (rosthes's ma$ not +e a,a'la+le. The 'nflammator$ (rocess of the m'nor sal',ar$ %lands of the hard (alate* necrot'4'n% s'alometa(las'a* )h'ch (roduces an ulcerat',e les'on )'th er$thematous +orders s'm'lar to s3uamous cell carc'noma* ma$ +e confused )'th mal'%nanc$. 5'o(s$ e-am'nat'on* ho)e,er* )'ll sho) no e,'dence of mal'%nanc$* and the d'sease 's self-l'm'ted* usuall$ re3u'r'n% no thera($. 8loor of Mouth Anatom$ and Ph$s'olo%$ The floor of the mouth 's the horseshoe-sha(ed area +et)een the mo+'le ton%ue and the l'n%ual surface of the mand'+le. The (a('llae that allo) .harton2s ducts to em(t$

'nto the oral ca,'t$ l'e at the anter'or +order of th's area@ (oster'orl$* the floor of the mouth +lends 'nto the %losso(alat'ne fold and the retromolar tr'%one. In th's natural reser,o'r there ma$ +e (rolon%ed contact of the floor of mouth mucosa )'th carc'no%en'c a%ents d'ssol,ed 'n the sal',a after oral 'n%est'on or 'nhalat'on. Th's area (ro,'des ca(ac't$* allo)'n% the ton%ue to s't lo) 'n the mouth* thus 'ncreas'n% the ,olume of the oral ca,'t$ and (re,ent'n% o+struct'on of the d'rect route +et)een the l'(s and the (har$n-. Patholo%$ A((ro-'matel$ 1G to 17 (ercent of oral les'ons ar'se 'n th's area* the th'rd most common s'te after the l'( and mo+'le ton%ue. 5ecause of the (ro-'m't$ of the mucosa to the h$o%lossus and m$loh$o'd muscles of the su+mand'+ular tr'an%le* and +ecause of the r'ch l$m(hat'c su((l$* d'rect e-tens'on of tumor 'nto the neck and +'lateral cer,'cal metastases are fre3uent* es(ec'all$ 'n anter'orl$ located les'ons. Med'al %ro)th at the (r'mar$ s'te also 'n,ades the ,entral surface of the ton%ue* and lateral %ro)th 'n,ades the mand'+le. Ad,anced-sta%e d'sease 's common* )'th 6C to 5/ (ercent of (at'ents (resent'n% )'th sta%e III or sta%e I9 d'sease. u+cl'n'cal d'sease 'n the neck or m'crometastases 'n the cl'n'call$ ne%at',e neck are common* )'th o,erall neck 'n,ol,ement 'ncreas'n% )'th (r'mar$ tumor s'4e and ran%'n% from 15 (ercent for tumors less than / cm :T1< to 5D (ercent for tumors %reater than 6 cm :TG<. Thera($ 5ecause the tumor ma$ a+ut or act',el$ 'n,ade the mand'+le* resect'on )'th an ade3uate mar%'n of normal t'ssue 'n th's area fre3uentl$ re3u'res remo,al of the mand'+ular (er'osteum or actual resect'on of a se%ment of mand'+le. 1ncerta'nt$ a+out 'n,as'on of the mand'+le or (ro-'m't$ ma$ re3u're remo,al of the med'al corte:mar%'nal mand'+ulectom$< or a se%ment of the mand'+le. 5ecause of the (ro-'m't$ of the mand'+le* thera(eut'c doses of rad'at'on ma$ result 'n 'schem'c necros's of the +one* osteorad'onecros's. Com+'ned thera($* sur%'cal resect'on of the (r'mar$ tumor )'th neck d'ssect'on en +loc or (ull-throu%h resect'on follo)ed +$ ad0u,ant rad'othera($* 's a((ro(r'ate for ad,anced d'sease. ur,',al rates are stron%l$ de(endent on sta%e* ran%'n% from CE to B1 (ercent for sta%e I to G5 to 6C (ercent for sta%e III d'sease. Recurrence at the (r'mar$ s'te fre3uentl$ 'n,ol,es the mand'+le or the su(rah$o'd com(le- of muscles and ma$ re3u're lar$n%ectom$ +ecause of 'n,as'on of the (ree('%lott'c s(ace. Reconstruct'on of the floor of the mouth (resents a num+er of challen%es. The )atert'%ht seal of the oral ca,'t$* the cont'nu't$ of the mand'+ular arch* and the mo+'l't$ of the ton%ue all de(end on th's area. 8or su(erf'c'al les'ons )'th normal )ell-,ascular'4ed muscle +eneath them* s(l't-th'ckness sk'n %rafts ha,e +een ad,ocated. Althou%h the$ ma$ +e successful 'n't'all$ 'n co,er'n% the area* the contracture 'nherent 'n th's method ma$ result 'n tether'n% of the mo+'le ton%ue to the su+0acent muscle or to the mand'+ular (er'osteum. If the neck 's not 'n,ol,ed +$ tumor* a musculocutaneous 'sland fla( of (lat$sma muscle +ased on the fac'al arter$ (ro,'des su((le sk'n co,era%e. 5ulk$ thorac'c musculocutaneous fla(s* such as (ectoral's ma0or* (ro,'de sk'n for l'n'n% +ut ma$ +e com(ressed +$ the 'ntact mand'+le* result'n% 'n 'schem'c necros's* or ma$ (ush the ton%ue +ack 'n the oral ca,'t$* l'm't'n% mo,ement and o+struct'n% the (har$n- and a'r)a$. The th'n (l'a+le sk'n of the ,olar forearm* +ased on the rad'al arter$ and 'ts ,enae com'tantes as the rad'al forearm free fla(* (ro,'des an e-cellent l'n'n% for th's area that can dra(e o,er

the mand'+le and allo)s free mo,ement of the ton%ue )h'le (ro,'d'n% a )atert'%ht seal. 9ascular'4ed se%ments of +one and sk'n of ,ar$'n% s'4e also are a,a'la+le as free t'ssue transfers from the f'+ula* sca(ula* dorsum of the foot* and other s'tes )'th h'%h success rates 'f the mand'+le must +e resected :8'%. 15-G1<. "ums* "'n%',ae* Al,eolar R'd%e Patholo%$ 3uamous cell carc'noma ar's'n% on the %ums const'tutes 1D to 17 (ercent of oral ca,'t$ mal'%nanc'es. E'%ht$ (ercent of les'ons ar'se on the mand'+ular al,eolus. Althou%h the male (redom'nance (ers'sts at th's s'te* there seems to +e a less d'rect relat'onsh'( )'th to+acco and alcohol* and the causat'on ma$ +e related 'n some cases to chron'c trauma from (oorl$ fash'oned dentures or 0a%%ed teeth. The th'n la$er of mucosa allo)s 'n,as'on of the underl$'n% mand'+ular or ma-'llar$ +one 'n G5 to 5D (ercent of cases. &'rect 'n,as'on throu%h the (er'osteum 's most common 'n (at'ents )'th teeth* +ut s(read throu%h the em(t$ sockets alon% the occlusal r'd%e and su+se3uent (er'neural 'n,as'on are common 'n edentulous (at'ents. Cer,'cal metastases occur 'n GD to 65 (ercent of the cases* de(end'n% lar%el$ on the s'4e of the (r'mar$. Thera($ ur%'cal resect'on re3u'res remo,al of the su+0acent +one +$ (art'al or total ma-'llectom$ or total mand'+ulectom$. Ma-'llar$ defects of moderate s'4e can +e treated )'th dental (rostheses* and mand'+ular defects reconstructed )'th ,ar'ous com+'nat'ons of sk'n and +one as (re,'ousl$ descr'+ed. !ral Ton%ue Anatom$ and Ph$s'olo%$ The ton%ue 's a com(le- muscular structure co,ered )'th mucosa and rece','n% motor 'nner,at'on from the h$(o%lossal ner,e. The +ulk of the ton%ue 's made u( of the su(er'or and 'nfer'or lon%'tud'nal muscles 0o'ned +$ the ,ert'cal and trans,erse 'ntr'ns'c muscles. Infero(oster'orl$ and laterall$ the ton%ue 's connected to the h$o'd +one +$ the h$o%lossus muscle* and su(er'orl$ and anter'orl$ to the mand'+le +$ the %en'o%lossus muscles. The st$lo%lossus and (alato%lossus muscles attach the ton%ue su(er'orl$ to the +ase of the skull. These 0unct'ons allo) the ton%ue %reat mo+'l't$* (romot'n% s$ner%$ )'th the lar$n- and the (har$n%eal and (alat'ne muscles. 5eneath the smooth ,entral surface of the ton%ue* alon% the floor of the mouth* are the numerous o(en'n%s of the su+l'n%ual ducts. !n the dorsal surface are (a('llae* )'th s(ec'al'4ed sensor$ or%ans for taste at the +ase. Also o(en'n% onto the ton%ue are the ducts of the m'nor sal',ar$ %lands. ensat'on 's (ro,'ded to the ton%ue +$ the l'n%ual ner,e carr$'n% f'+ers of cran'al ner,e 9* and taste +$ the %losso(har$n%eal and chorda t$m(an' of 9II. &'fferent'at'on of s)eet* sour* salt* and +'tter taste rel'es a %reat deal on 'ntact funct'on of the ton%ue. As a mucosa-co,ered muscle* the ton%ue 's the ma0or (ro(uls',e force 'n the oral ca,'t$. It 'n't'ates and cont'nues mo,ement of the food +olus to the (har$n-* %enerat'n% (ressure of u( to 1/D mmH%. Numerous 'n,est'%ators ha,e demonstrated that d$sfunct'on after sur%er$ for oral cancer de(ends almost e-clus',el$ on the amount of ton%ue resected. Patholo%$ In most ser'es of oral cancers* the oral or mo+'le ton%ue 's second onl$ to the l'( as the most common (r'mar$ s'te. To+acco and alcohol are the most common assoc'ated factors* +ut chron'c 'rr'tat'on from 0a%%ed teeth or dental a((l'ances also ma$ +e 'n,ol,ed. Althou%h the s'-th and se,enth decades are the (eak (er'ods* s(orad'c

occurrence of s3uamous cell carc'noma 'n the ton%ue has +een descr'+ed 'n (at'ents under th'rt$ and 'n renal trans(lant and other 'mmunosu((ressed (at'ents and ma$ not +e l'nked to the usual carc'no%en'c st'mul'. In Ind'a* su+mucosal f'+ros's seems to +e a (red's(os'n% 'nfluence* and 'n cand'na,'a* Plummer-9'nson s$ndrome* %loss't's* 'ron-def'c'enc$ anem'a* and achlorh$dr'a ma$ +e related. Mal'%nanc$ of the mo+'le ton%ue occurs most fre3uentl$ at the m'd(ort'on of the lateral ton%ue and 's fre3uentl$ as$m(tomat'c :8'%. 15-G/<. Rad'al s(read throu%h the ton%ue ma$ e-tend su+mucosall$ to the +ase of the ton%ue and across the m'dl'ne or laterall$ to the floor of the mouth. 5ecause of the r'ch l$m(hat'c su((l$* '(s'lateral metastases are common to the su+mand'+ular and su+mental nodes. Cl'n'cal e,'dence of cer,'cal metastas's 's (resent 'n 6D to C1 (ercent of (at'ents* and su+cl'n'cal d'sease 'n the ND neck 's found 'n /5 to G1 (ercent. As 'n other s'tes* the (resence of l$m(h node metastases seems to +e the most 'm(ortant (ro%nost'cator* )'th sur,',al rates of 7G to B/ (ercent for local'4ed d'sease :T1* T/* ND< and onl$ G1 to 65 (ercent )'th re%'onal metastas's. Thera($ &ef'n't',e thera($ for carc'noma of the oral ton%ue can +e attem(ted )'th e'ther e-ternal +eam rad'othera($ or 'nterst't'al rad'othera($. E-ternal rad'at'on 'n doses to C5"$ ma$ +e useful* +ut )'th the 'm(lantat'on of afterload'n% de,'ces :tu+es 'nto )h'ch 'r'd'um-1B/ or rad'um needles can +e (laced< doses 'n the ran%e of 1DD"$ to 15D"$ can +e del',ered o,er a small area )'th %reater effect. The sur%'cal thera($ of carc'noma of the ton%ue cons'sts of resect'on of the tumor )'th a mar%'n of normal t'ssue and en +loc remo,al of the re%'onal l$m(h nodes. 1nfortunatel$* e,aluat'on of the e-tent of local d'sease 's d'ff'cult 'n ton%ue cancer. Althou%h se,eral authors ha,e demonstrated res(ecta+le 5-$ear sur,',al rates :6E to C/ (ercent< )'th (art'al %lossectom$ )'th or )'thout en +loc or d'scont'nuous neck d'ssect'on* a %enerall$ acce(ted uneas'ness a+out the a+'l't$ to o+ta'n clear mar%'ns has led to the common use of ad0u,ant rad'othera($. Hem'%lossectom$* or resect'on to the med'an ra(he* has +een ad,ocated +$ some for les'ons 'n,ol,'n% an$ (art of the lateral ton%ue. E-tens',e les'ons of the ton%ue ma$ e-tend (oster'orl$ to 'n,ol,e the lar$n-. E,en 'n those (at'ents )ho do not demonstrate 'n,as'on of the lar$n-* )'des(read 'n,ol,ement of the ton%ue or resect'on of the +ase of the ton%ue ma$ (red's(ose the (at'ent to as('rat'on and ult'mate res('rator$ fa'lure. &es('te ske(t'c'sm on the (art of some sur%eons* total %lossectom$ )'th or )'thout lar$n%ectom$ has +een sho)n to +e a ,alua+le (rocedure for +oth cure and (all'at'on. A G-$ear sur,',al of 5G (ercent has +een ach'e,ed 'n one ser'es* )'th ED (ercent of (at'ents demonstrat'n% 'ntell'%'+le s(eech 'f the lar$n- 's (reser,ed and BG (ercent re%a'n'n% the a+'l't$ to ma'nta'n the'r nutr't'onal status +$ oral al'mentat'on. Althou%h attem(ts ha,e +een made to 'nner,ate muscle of ,ar'ous t$(es trans(lanted to re(lace the ton%ue* there 's no sat'sfactor$ )a$ to reconstruct the ton%ue. &ener,at'on of the ton%ue +$ resect'on of* or 'n0ur$ to* +oth h$(o%lossal ner,es usuall$ renders the (at'ent 'nca(a+le of s)allo)'n% or of effect',e s(eech. After sur%'cal resect'on of a (ort'on of the ton%ue* the reconstruct',e %oal 's to allo) free mo+'l't$ of the rema'n'n% ton%ue )h'le (ro,'d'n% a )atert'%ht seal to the oral ca,'t$.

If the floor of the mouth 's not 'n,ol,ed 'n the resect'on* s'm(l$ sk'n %raft'n% of the ra) surface ma$ suff'ce. utur'n% the ed%e of the resected ton%ue to al,eolar or +uccal mucosa usuall$ tethers the ton%ue* 'm(ed'n% 'ts mo+'l't$. Ad,anc'n% the (oster'or mo+'le ton%ue or sett'n% +ack the e-cess anter'or ton%ue ma$ (ro,'de the o(t'mal solut'on. Althou%h the (ectoral's ma0or fla( has +een ad,ocated for 'ntraoral reconstruct'on* 'ts +ulk tends to (ush the ton%ue +ack or (ull 't do)n 'nto the neck* 'nterfer'n% )'th 'ts mot'on and the su+se3uent ele,at'on of the lar$n- necessar$ for effect',e s)allo)'n% and s(eech. 8urthermore* 'ts th'ckness and )e'%ht effect',el$ f'the ton%ue to the ad0acent mand'+le* further 'nterfer'n% )'th 'ts mot'on. The lateral arm or rad'al forearm free fla( (ro,'des l'%ht)e'%ht su((le t'ssue more a((ro(r'ate for restor'n% ton%ue* floor of mouth* and mand'+ular al,eolar e('thel'al l'n'n%. The defect of total %lossectom$ cons'sts of the ton%ue* floor of the mouth* and somet'mes (har$n%eal and lar$n%eal mucosa. Restorat'on of oral cont'nence usuall$ re3u'res s'%n'f'cant amounts of soft t'ssue. The (ectoral's ma0or fla( ser,es )ell to re(lace the ent're floor of the mouth* as does the 0e0unal free fla(* )h'ch also can re(lace the (har$n- and cer,'cal eso(ha%us. If the lar$n- 's (reser,ed 'n total %lossectom$* the rad'al forearm free fla( ser,es as an e-cellent d'a(hra%m to (ull the h$o'd +one anter'orl$ to)ard the mand'+le and ass'st 'n s)allo)'n%. .hen a (ort'on of mand'+le must +e resected for carc'noma of the oral ton%ue* the ur%enc$ of reconstruct'on de(ends on )hat (art of the mand'+le has +een resected. Althou%h an$ mand'+ulectom$ results 'n some d$sfunct'on* (art'al mand'+ulectom$ lateral to the mental foramen usuall$ 's )ell tolerated* the ma'n mor+'d't$ +e'n% )eakness of che)'n% and malocclus'on of the rema'n'n% teeth. Resect'on of the s$m(h$s's or anter'or se%ment of the mand'+le* ho)e,er* 's a much more de,astat'n% (ro+lem and re3u'res 'mmed'ate reconstruct'on. 9ascular'4ed +one from sca(ula* f'+ula* 'l'ac crest* rad'us* or metatarsal 's e-cellent for reconstruct'on. If a((ro(r'ate soft t'ssue 's not a,a'la+le* t)o free t'ssue transfers can +e (erformed to sat'sf$ the 'nd','dual needs of the )ound. Phar$nAnatom$ and Ph$s'olo%$ The (har$n- 's the cont'nuat'on of the muscular tu+e that const'tutes the al'mentar$ tract. It 's anatom'call$ d','ded 'nto three sect'ons* each )'th a sl'%htl$ d'fferent funct'onA the naso(har$n-* the oro(har$n-* and the h$(o(har$n- :see 8'%. 15-6<. An 'm(ortant role of the (har$n- 's se(arat'n% the res('rator$ and the al'mentar$ tracts* and 'ts s(ec'al'4ed structures reflect th's funct'on. The naso(har$n- 's un'3ue 'n the (har$n- 'n that 't 's a r'%'d ca,'t$ +ounded on three s'des +$ +one=su(er'orl$ +$ the +ase of the skull and (oster'or s(heno'd s'nus* anter'orl$ +$ the (oster'or r'm of the ethmo'd (late and the choanae* (assa%es from the nasal ca,'t$ 'nto the naso(har$n-* and (oster'orl$ +$ the (har$n%eal tu+ercle of the occ'('tal +one and the atlas and a-'s* )'th the'r (re,erte+ral fasc'al and muscular co,er'n%s. The 'nfer'or surface 's the nasal s'de of the soft (alate. The lateral s'des of the naso(har$n- %',e entr$ to the eustach'an tu+es :to decom(ress the m'ddle ear<* and the roof 's the s'te of a collect'on of l$m(ho'd t'ssue* the (har$n%eal tons'l. The oro(har$n- 's the muscular tu+e that ser,es as trans't area from the (ro(uls',e oral ca,'t$ and the rec'('ent nasal ca,'t$ to the al'mentar$ and res('rator$ tracts. Th's mucosa-l'ned muscular tu+e conta'ns the +ase of the ton%ue :from the c'rcum,allate

(a('llae +ack<* the tons'ls* the oral soft (alate* the lateral (har$n%eal )alls* and the (oster'or (har$n%eal )all. The dom'nant muscular ent't$ that rece',es the (ro(uls',e ener%$ of the ton%ue 's the su(er'or constr'ctor muscle* attached on +oth s'des to the (ter$%omand'+ular ra(he and )ra(('n% /7D de%rees to const'tute the (oster'or and lateral )alls. Contract'on of th's muscle closes the (alato(har$n%eal s(h'ncter* or Passa,ant2s r'd%e* ele,at'n% the (alate. Th's act'on closes the naso(har$n- and (ushes the +olus of food 'nto the h$(o(har$n-. 1(-and-do)n mot'on of the (alate 's re%ulated +$ the tensor ,el' (alat'n' and le,ator ,el' (alat'n' muscles :attached to the +ase of the skull< and the (alato(har$n%eus muscle :attached to the lateral (har$n%eal )all<. #ack of s$ner%$ 'n these muscles 's seen 'n (at'ents )'th cere+ro,ascular acc'dents and h$(o-'a neonatorum and markedl$ 'nterferes )'th s(eech and s)allo)'n%. The anatom'c +oundar'es of the h$(o(har$n- are reflect'ons of the anatom$ of the lar$n-. The (oster'or (har$n%eal )all runs from the t'( of the e('%lott's to the 'nfer'or +order of the cr'co'd cart'la%e. The anter'or +order 's the (ostcr'co'd mucosa* and the lateral surfaces are the mucosal ca,'t'es on +oth s'des of the lar$n- kno)n as the ($r'form s'nuses. The m'ddle (har$n%eal constr'ctor muscle* )'th 'ts attachments to the h$o'd +one and (re,erte+ral fasc'a* and the 'nfer'or (har$n%eal constr'ctor* )'th 'ts d'stal condensat'on of the cr'co(har$n%eus muscle attached to the lateral surfaces of the th$ro'd and cr'co'd cart'la%es* ser,e as the (har$n%eal s(h'ncters. .hen the$ contract the$ close off the entrance of the cer,'cal eso(ha%us to a'r and d'rect 't throu%h the lar$n-. .hen the$ rela- the$ allo) food throu%h the (har$n- and 'nto the cer,'cal eso(ha%us. The 'nfer'or constr'ctor and cr'co(har$n%eus muscles ser,e as the u((er eso(ha%eal s(h'ncter and ma$ +ecome h$(erton'c* a cond't'on kno)n as cr'co(har$n%eus s(asm. Menker2s d',ert'culum* a lateral out(ouch'n% of the (har$n%eal )all that ma$ collect und'%ested food and result 'n chron'c as('rat'on* 's the conse3uence of chron'c h$(ertens'on of the u((er eso(ha%eal s(h'ncter :8'%. 15GG<. Resolut'on of th's u((er eso(ha%eal s(h'ncter h$(ertens'on has +een o+ta'ned tem(orar'l$ +$ 'n0ect'on of +otul'num to-'n* +ut (ermanent treatment re3u'res transect'on of the muscle :cr'co(har$n%eus m$otom$< )'th or )'thout resect'on and closure of the mucosal d',ert'culum. 5ase of Ton%ue Patholo%$ Carc'noma ar's'n% +eh'nd the c'rcum,allate (a('llae 'n the +ase of the ton%ue fre3uentl$ rema'ns as$m(tomat'c and und'a%nosed unt'l late-sta%e d'sease has de,elo(ed. E,en )hen (at'ents com(la'n of (a'n* e'ther local or referred* as )'th otal%'a* d'ff'cult$ 'n e-am'nat'on or reluctance of (r'mar$ care (h$s'c'ans to (erform 'nd'rect lar$n%osco($ and (al(at'on of the +ase of the ton%ue results 'n m'sd'a%nos's and (rolon%ed thera($ for (har$n%'t's* tons'll't's* and other less ser'ous (ro+lems. The central locat'on %',es r'se to cer,'cal l$m(hat'c metastases 'n u( to 7D (ercent of (at'ents* and there are +'lateral metastases 'n 17 to /5 (ercent of cases. H'stolo%$ and %ross mor(holo%$ 'n th's re%'on (red'ct to some de%ree the +eha,'or of the les'on and the a((ro(r'ate thera($. In add't'on to e('dermo'd carc'noma* m'nor sal',ar$ %land les'ons are also seen. E-o(h$t'c les'ons* )'th cells resem+l'n% l$m(hoc$tes and a+sence of kerat'n (earls* ar'se 'n the t'ssues of .alde$er2s r'n%* the tons'ls :l'n%ual and (alat'ne<* and the +ase of the ton%ue. These l$m(hoe('thel'omas +eha,e l'ke naso(har$n%eal carc'noma and ha,e +een character'4ed as und'fferent'ated carc'nomas )'th l$m(hoc$t'c 'nf'ltrat'on. uch les'ons are more

rad'osens't',e* +oth at the (r'mar$ s'te and as cer,'cal metastases* than most other 'nf'ltrat',e kerat'n-(roduc'n% s3uamous cell carc'nomas* )'th /-$ear local control rates of 75 (ercent for T1 les'ons and C7 (ercent for T/ les'ons. Carc'noma ar's'n% 'n the +ase of the ton%ue s(reads anter'orl$ 'nto the oral ton%ue* su(er'orl$ u( to the tons'llar ('llar* and 'nfer'orl$ 'nto the lateral (har$n%eal )all and 'nto the ,allecula* (ree('%lott'c s(ace* and lar$n-. 5ecause of the (ro-'m't$ and funct'onal relat'onsh'( of the +ase of the ton%ue to the lar$n-* 'nterference )'th lar$n%eal ele,at'on and closure of the e('%lott's* )'th the attendant as('rat'on (neumon't's* 's a hallmark of carc'noma of the +ase of the ton%ue. Thera($ Ad,anced d'sease at the (r'mar$ s'te or d'sease )'th cer,'cal metastases re3u'res sur%'cal thera($. If the les'on 's lateral enou%h* (art'al %lossectom$ ma$ +e ade3uate. 'nce resect'on of the +ase of the ton%ue usuall$ remo,es the h$(o%lossal ner,e to the ton%ue 'n that area* su+total or (oster'or %lossectom$ 's unl'kel$ to lea,e funct'onal ton%ue. Rad'cal resect'on ma$ re3u're total %lossectom$ )'th or )'thout lar$n%ectom$ :8'%. 15-G6<. In most (at'ents* 'f the oncolo%'c re3u'rements of the resect'on do not d'ctate remo,al of the lar$n-* reconstruct'on )'th the lar$n- 'n s'tu 's a((ro(r'ate. ur%'cal thera($ or sur%er$ com+'ned )'th (osto(erat',e ad0u,ant rad'othera($ results 'n 5-$ear sur,',al rates of 5D to CD (ercent for sta%e III d'sease and /D to /5 (ercent for sta%e I9 d'sease. Ad,anced (r'mar$ d'sease or d'sease 'n the neck 's unl'kel$ to +e successfull$ controlled locall$ )'th rad'othera($ alone* and sur%'cal sal,a%e after rad'othera($ has +een d'smal* )'th a h'%h 'nc'dence of osteorad'onecros's of the mand'+le. Reconstruct'on of defects ar's'n% from resect'on of the +ase of the ton%ue should effect',el$ close the (har$n- and oral ca,'t$ )'th t'ssue that )'ll heal (r'mar'l$ and )'thstand su+se3uent 'rrad'at'on and st'll not 'nterfere )'th the funct'on of t'ssues left 'ntact +$ the curat',e resect'on. Ele,at'on of the lar$n-* the normal mot'on that occurs dur'n% the earl$ (har$n%eal (hase of s)allo)'n% to close the e('%lott's* cannot occur 'f the ton%ue 's tethered to the s'de of the (har$n- or oral ca,'t$ or 'f +ulk$ t'ssue such as the (ectoral's ma0or fla( 's 'nter(osed 'nto the area of the resect'on. The (ro,'s'on of sensate t'ssue 'nto the area surround'n% the lar$n-* to (re,ent as('rat'on* 's also an 'm(ortant cons'derat'on. !ccas'onall$ local t'ssue can +e mo+'l'4ed for closure )'thout tens'on to a,o'd f'stula format'on and to (ro,'de sensate mucosa. More commonl$* ho)e,er* mucosa or sk'n to l'ne the ton%ue* mand'+le* and (har$n%eal )all 's necessar$. 5uccal and (alatal fla(s ha,e +een descr'+ed for small and moderate-s'4ed defects* +ut free t'ssue transfer of sk'n from rad'al forearm or lateral arm or lateral th'%h fla(s are more a((ro(r'ate for the more common e-tens',e defects. Neurot'4ed free t'ssue transfer reconstruct'ons of the (har$n- and oral ca,'t$ ha,e sho)n t)o-(o'nt d'scr'm'nat'on and other measures of sens't','t$ that are character'st'c of the rec'('ent s'te :u((er aerod'%est',e tract< rather than the donor s'te :arm* +ack<* su%%est'n% that cere+ral cort'cal 'nte%rat'on of the reconstruct'on fa,ors the rec'('ent s'te. Tons'l Patholo%$ 3uamous cell carc'noma of the tons'l ma$ ar'se 'n the tons'l* the tons'llar +ed* or the tons'llar ('llars :8'%. 15-G5<. As one of the .alde$er2s r'n% structures* the tons'l sho)s a h'%her 'nc'dence of l$m(hoe('thel'oma than other s'tes. .hate,er the

h'stolo%$* 't 's second onl$ to the lar$n- 'n fre3uenc$ as a s'te of u((er aerod'%est',e tract (r'mar$ mal'%nanc$* )'th 1/*DDD ne) cases (er $ear 'n the 1n'ted tates. #'ke most u((er aerod'%est',e tract tumors* tons'llar carc'noma (resents )'th (redom'natel$ late-sta%e d'sease* )'th /E to G/ (ercent of (at'ents (resent'n% )'th sta%e I or sta%e II d'sease* G5 to 6D (ercent sta%e III* and 6D to 65 (ercent sta%e I9. Cer,'cal metastases at the t'me of (resentat'on are seen 'n u( to C7 (ercent of (at'ents* and su+cl'n'cal d'sease 'n the ND neck 'n 1D (ercent of (at'ents. &eterm'nat'on of the e-tent of local d'sease 'n ad,anced tumors 's of cons'dera+le 'm(ortance 'n dec's'onmak'n% and e-ecut'on of thera($. "ro)th of the tumor u()ard 'nto the soft (alate occurs 'n CD (ercent of (at'ents* do)n)ard to the +ase of the ton%ue 'n 5C (ercent* 'nto the naso(har$n- 'n B (ercent* and do)n the lateral (har$n%eal )all to the e('%lott's 'n /7 (ercent of cases. The s'te of local e-tens'on 's (art'cularl$ 'm(ortant* +ecause 'n treat'n% (at'ents )'th rad'othera($* %eo%ra(h'cal m'sses as a result of underest'mat'n% the local e-tent of d'sease )ere a common reason for fa'lure. Thera($ Carc'noma of the tons'l a((ears to +e more rad'osens't',e than other (r'mar$-s'te s3uamous cell carc'nomas. The usual a((roach to d'sease or'%'nat'n% at th's s'te 's to treat for curat',e 'ntent )'th rad'othera($ ran%'n% from 55"$ to 7D"$ to the (r'mar$ s'te and +'lateral cer,'cal l$m(h node dra'na%e areas :8'%. 15-GC<. If there 's +ulk$ neck d'sease or e-tens'on of the (r'mar$ tumor 'nto ad0acent +one or (ter$%o'd muscles* sur%'cal resect'on* reconstruct'on* and (osto(erat',e ad0u,ant rad'othera($ are safer and more effect',e. R'sk of local recurrence 's d'rectl$ related to s'4e of the (r'mar$ tumor* and recurrence 's e,en more l'kel$ )hen the (redom'nant s(read of tumor )as 'nto the +ase of the ton%ue. The challen%e of reconstruct'on 'n tons'llar d'sease 's a funct'on of the d'mens'ons of local %ro)th of the les'on and the h'stor$ of (re,'ous rad'at'on. The soft-t'ssue defect 'n the lateral )all of the (har$n- created +$ a su(erf'c'al les'on can eas'l$ +e resurfaced )'th a sk'n %raft* a delto(ectoral fla(* or a fasc'ocutaneous free fla(. Rad'al s(read u( to the soft (alate or do)n 'nto the (har$n- demands that the surface of the fla( +e contoured 'n se,eral (lanes )'thout o+struct'n% the (har$n-* usuall$ re3u'r'n% a free t'ssue transfer of relat',el$ (l'a+le sk'n* such as the rad'al forearm* lateral arm* or lateral th'%h. In,as'on of the ascend'n% ramus of the mand'+le can +e treated +$ address'n% the soft-t'ssue defect alone +$ trans(os'n% a (ectoral's ma0or musculocutaneous fla( 'nto the lateral (har$n-* us'n% the sk'n for 'nternal l'n'n% and the muscle for co,era%e of the carot'd ,essels 'n the neck. In the (at'ent )'th teeth* soft-t'ssue reconstruct'on alone )'ll lead to malocclus'on of the dental arches and other (ro+lems. k'n and +one to%ether are a,a'la+le )'th a num+er of methods. The sca(ula and the dee( c'rcumfle- 'l'ac arter$ free fla(s are (art'cularl$ su'ted to the lateral defect created +$ rad'cal resect'on of the tons'l and mand'+le. oft Palate Anatom$ and Ph$s'olo%$ The soft (alate 's the mucosa-l'ned fus'on of the 'nfer'orl$ +ased (alato(har$n%eus and (alato%lossus muscles and the su(er'orl$ +ased le,ator and tensor ,el' (alat'n' muscles. E-tend'n% +ack)ard from the (oster'or mar%'n of the (alat'ne +one* d'rectl$ o((os'te the su(er'or constr'ctor muscle and 'ts +ul%e* )h'ch creates Passa,ant2s r'd%e* 'ts ma'n funct'on 's to o(en and close the (assa%e)a$ +et)een the nasal ca,'t$ and naso(har$n- and the oral ca,'t$ and oro(har$n-. Th's o+turat'n% and modulat'n% effect has o+,'ous 'm(ortance 'n s(eech and 'n s)allo)'n%.

Patholo%$ Isolated carc'noma of the soft (alate 's rare* the d'sease usuall$ occurr'n% 'n com+'nat'on )'th other frank mal'%nanc'es or (remal'%nant ent't'es such as leuko(lak'a or er$thro(lak'a and not sho)'n% the usual male (redom'nance. The oral s'de of the soft (alate 's +$ far the most common s'te for mal'%nanc$* )h'ch usuall$ e-tends do)n the tons'llar ('llars to the +ase of the ton%ue. u(er'or and (osterolateral s(read to the naso(har$n- and (oster'or (har$n%eal )all 's less common. I(s'lateral cer,'cal l$m(h node metastases to the 0u%ulod'%astr'c nodes occur 'n 6D to 5D (ercent of cases* and* +ecause tumors often (ass o,er the m'dl'ne* +'lateral metastases are seen 'n 15 (ercent of cases. Thera($ Treatment of soft (alate carc'noma follo)s the usual (r'nc'(le that small (r'mar$ les'ons are effect',el$ erad'cated +$ rad'othera($ 'n the ran%e of C5"$ and that com+'ned thera($* sur%er$ )'th ad0u,ant rad'othera($* 's necessar$ for +est results 'n lar%er tumors. The 'm(ortance of rad'othera($ as a treatment )as (art'cularl$ em(has'4ed 'n the (ast +ecause of the 'na+'l't$ to reconstruct the soft (alate and the de,astat'n% funct'onal result. Nonrandom'4ed stud'es of sur%er$ and rad'othera($ ha,e sho)n 5- $ear sur,',al rates of G1 to 66 (ercent* )'th the s'4e of the (r'mar$ les'on* the a+sence of a s$nchronous (r'mar$ u((er aerod'%est',e tract tumor* the a+sence of cer,'cal metastases* and moderatel$ to )ell d'fferent'ated h'stolo%$ +e'n% fa,ora+le (ro%nost'c features. Resect'on or d$sfunct'on of the soft (alate results 'n esca(e of a'r and oral contents 'nto the nasal ca,'t$ and ult'matel$ out the nares. Ad,ances 'n (rosthet'c technolo%$ ha,e made the use of a dental (rosthes's a (oss'+le solut'on 'n some cases. 8or defects that do not 'nclude the lateral and (oster'or (har$n%eal )all* a su(er'orl$ +ased fla( of (har$n%eal mucosa and muscle sutured 'nto the mar%'n of the (alatal resect'on )'ll o+turate the o(en'n% +et)een the naso(har$n- and oro(har$n-. More e-tens',e defects re3u're the 'ntroduct'on of e('thel'um-l'ned soft t'ssue@ the lateral arm* lateral th'%h* and rad'al forearm free fla(s are 'deal )hen soft t'ssue alone 's needed* and the sca(ula free fla( )hen +oth sk'n and +one are necessar$ :8'%. 15-G7<. Poster'or Phar$n%eal .all Anatom$ The (oster'or and lateral (har$n%eal )alls e-tend from the oro(har$n- do)n 'nto the h$(o(har$n-* )here the lateral (har$n%eal )alls end as the lateral )alls of the ($r'form s'nus and the (oster'or )all e-tends to the cer,'cal eso(ha%us. The l$m(hat'c dra'na%e of the (oster'or (har$n%eal )alls 's to the 0u%ulod'%astr'c* m'd0u%ular* and 0u%uloomoh$o'd nodes +ut also d'rectl$ to the retro(har$n%eal %rou( of l$m(h nodes. Patholo%$ 5ecause of 'ts locat'on and the nons(ec'f'c s$m(toms of m'ld d$s(ha%'a and od$no(ha%'a* s3uamous cell carc'noma of the (oster'or (har$n- usuall$ 's detected at a late sta%e* )'th GB to 55 (ercent of (at'ents (resent'n% )'th (al(a+le cer,'cal metastases. #ocal s(read of d'sease 's ce(halad to)ard the naso(har$n- and lateral to the lateral (har$n%eal )alls and lar$n-.

Thera($ 1s'n% com+'nat'ons of sur%er$ and rad'othera($* G- to 5-$ear sur,',al rates of /5 to G/ (ercent o,erall ha,e +een re(orted. The locat'on of the (oster'or (har$n%eal )all as the farthest +order of the aerod'%est',e tract and 'ts (ro-'m't$ to the lar$n- ha,e (resented some (ro+lems +oth of access for sur%'cal resect'on and of (otent'al for a((ro(r'ate reconstruct'on. Accurate resect'on of local d'sease re3u'res ,'sual access. M'dl'ne d','s'on of the l'(* mand'+le* and ton%ue* the med'an la+'omand'+ular %lossotom$* allo)s ,'sual'4at'on of the (oster'or (har$n-. If d'sease 's l'm'ted to the (oster'or )all* the surface can +e rel'ned )'th a s(l't-th'ckness sk'n %raft or allo)ed to e('thel'al'4e. C'rcumferent'al d'sease re3u'res more com(lete (har$n%eal resect'on and somet'mes (har$n%olar$n%ectom$. Reconstruct'on of the com(lete or (art'al c'rcumferent'al defect ma$ +e accom(l'shed )'th a free auto%raft of 0e0unum or a rad'al forearm free fla(. If the lar$n- can +e (reser,ed* as('rat'on )'ll +e less l'kel$ 'f free mo+'l't$ of the lar$n- 's ma'nta'ned and sensate e('thel'um 's restored* e'ther +$ sensor$-'nner,ated free t'ssue transfer or +$ sk'n %raft'n%. H$(o(har$n- Patholo%$ In add't'on to the (oster'or (har$n-* the h$(o(har$n- conta'ns the ($r'form s'nuses and the (ostcr'co'd area. Tumor %ro)th 'n th's area* the lateral and (oster'or mucosal +order of the lar$n-* 's 'nt'matel$ related to the funct'on of the lar$n-* a facet reco%n'4ed 'n the sta%'n% s$stems used 'n assess'n% the e-tent of h$(o(har$n%eal d'sease :8'%. 15-GE<. Thus the T sta%e of the ($r'form s'nus les'on 'ncreases not )'th tumor s'4e +ut )'th e-tent 'nto the med'al )all or )'th f'-at'on of the ,ocal cord caused +$ d'rect e-tens'on of d'sease. Another cons'derat'on 'n h$(o(har$n%eal carc'noma* as 'n d'sease of the cer,'cal eso(ha%us* 's the (ro+lem of su+mucosal e-tens'on of tumor. (read of d'sease 'nto the cer,'cal eso(ha%us d'sco,ered at sur%er$ ma$ s'm(l$ re(resent cl'n'cal understa%'n% of d'sease* +ut 't also could +e mult'focal d'sease or f'eld cancer'4at'on. #ocal s(read of d'sease 's ce(halad to)ard the naso(har$n- or d'stal 'nto the cer,'cal eso(ha%us* as )ell as med'al and lateral to)ard the lar$n-. Ad,anced-sta%e local d'sease 's common* )'th onl$ 1D to 15 (ercent of cases conf'ned to onl$ one s'te 'n the h$(o(har$n-. The l$m(hat'c dra'na%e of the area 's co('ous* )'th (r'mar$ nodal stat'ons 'n the m'd0u%ular* 0u%uloomoh$o'd* and retro(har$n%eal l$m(h node cha'ns. E,en )'th small les'ons there 's a l'kel'hood of l$m(h node metastas's* )'th 55 to C6 (ercent of (at'ents (resent'n% )'th (al(a+le l$m(hadeno(ath$* and 61 (ercent of (at'ents )'th cl'n'call$ ne%at',e ND necks demonstrat'n% metastat'c d'sease after elect',e neck d'ssect'on. E,en )'th small (r'mar$ les'ons :T1< local'4ed to one (art of the h$(o(har$n-* the r'sk of cer,'cal m'crometastases 'n the cl'n'call$ ne%at',e neck 's h'%h :6D (ercent<. &'stant metastases at (resentat'on and )'th treatment of d'sease a((ear to +e more common than at other (r'mar$ s'tes* occurr'n% 'n u( to 67 (ercent of the cases. Thera($ 'nce 't 's unusual for h$(o(har$n%eal les'ons to (resent at an earl$ sta%e* the treatment usuall$ 's com+'ned* cons'st'n% of sur%er$ follo)ed +$ ad0u,ant rad'othera($. The e-tent of the o(erat'on de(ends on the (ro-'m't$ to the lar$n-* and the lar$n%o(har$n%ectom$ )'th +'lateral mod'f'ed neck d'ssect'on 's the (rocedure

that 's most fre3uentl$ necessar$. .'th such an a((roach* sur,',al rates of /D to 6D (ercent ha,e +een ach'e,ed. .hen the lar$n- can +e sa,ed* (r'mar$ closure of the sur%'cal defect 's the most effect',e method. Preser,at'on of the su(er'or lar$n%eal ner,es* the sensor$ 'nner,at'on to the area* 's an 'm(ortant cons'derat'on to allo) s)allo)'n% to (roceed )'thout as('rat'on. .hen the lar$n- 's remo,ed )'th the h$(o(har$n%eal les'on* ho)e,er* the %oals of reconstruct',e sur%er$ are rather s'm(le restorat'on of al'mentar$ cont'nu't$ )'th the least l'kel'hood of f'stula format'on or other de,astat'n% (ro+lems and )'th the a+'l't$ to restore eso(ha%eal s(eech. Pr'mar$ closure of the (har$n%eal mucosa after (art'al lar$n%o(har$n%ectom$ for ($r'form s'nus les'ons results 'n a h'%h l'kel'hood of f'stula format'on :6G (ercent< and stenos's :6E to 7G (ercent<* +oth of )h'ch 'nterfere )'th s)allo)'n% and eso(ha%eal s(eech :8'%. 15-GB<. Althou%h use of local t'ssue* 'nclud'n% the anter'or )all of the lar$n- and the +ase of the ton%ue* and sk'n of the neck has +een descr'+ed* the e-tent of sur%er$* the h'stor$ of (re,'ous rad'othera($* or the l'kel'hood of su+se3uent ad0u,ant rad'othera($ usuall$ re3u're the 'm(ortat'on of d'stant t'ssue. The delto(ectoral fla( from the chest )as the ma'nsta$ of (har$n%eal reconstruct'on after lar$n%ectom$ +ut 's at least a t)o-sta%e (rocedure )'th a fa'rl$ h'%h r'sk of fa'lure or (ers'stent f'stula. The (ectoral's ma0or musculocutaneous fla( has +een ad,ocated for +oth c'rcumferent'al and (art'al defects of the (har$n-. The effect of %ra,'t$* the 'nhomo%eneous +lood su((l$* and the +ulk of the fla( result 'n a h'%h rate of f'stula format'on and d$s(ha%'a* mak'n% a free auto%raft of +o)el or sk'n a (refera+le method. .hen a c'rcumferent'al defect 's (resent* the (ro+lem of +ulk and %ra,'t$ can +e c'rcum,ented some)hat +$ sk'n %raft'n% the (re,erte+ral fasc'a as the (oster'or )all of the neo(har$n- :ne) (har$n-< and us'n% the (ectoral's ma0or muscle and 'ts o,erl$'n% sk'n as a /7D- de%ree reconstruct'on to com(lete the (har$n%eal condu't. .hen total eso(ha%ectom$ 's (art of the treatment for carc'noma of the h$(o(har$n-* trans(os't'on of the stomach or colon throu%h the thora- can reconst'tute the al'mentar$ canal. "astr'c (ull-u(='n )h'ch the stomach* +ased on the r'%ht %astr'c and %astroe('(lo'c ,essels* 's +rou%ht throu%h the chest* and the fundus or card'a sutured to the +ase of the ton%ue or (har$n%eal remnant='s a fa'rl$ rel'a+le techn'3ue +ut has a mortal't$ rate of 1D to /D (ercent 'n most ser'es. R'%ht or left colon 'nter(os't'on usuall$ 's reser,ed for caust'c str'ctures +ut occas'onall$ 's useful 'n h$(o(har$n%eal or cer,'cal eso(ha%eal les'ons. Reconstruct'on of the c'rcumferent'al defect result'n% from (har$n%olar$n%ectom$ +$ transfer of a free auto%raft of +o)el and re,ascular'4at'on of m'cro,ascular anastomos's )as f'rst (erformed 'n the earl$ 1BCDs. Althou%h colon* stomach* and 0e0unum ha,e all +een used* the %reatest e-(er'ence has +een )'th 0e0unal free auto%raft. uccessful reconstruct'on us'n% the 0e0unum* e'ther 'n a tu+e reconstruct'on for c'rcumferent'al defects or as a (atch for (art'al defects* has +een ach'e,ed 'n B/ (ercent of (at'ents treated )'th th's method* allo)'n% EG (ercent of the total %rou( to ach'e,e total oral al'mentat'on. Mortal't$ )'th th's method has +een less than 5 (ercent* )'th fe) a+dom'nal or thorac'c (ro+lems. Com(l'cat'ons 'n the neck* thou%h fre3uent* usuall$ resol,ed )'thout further sur%er$* and the se%ment of +o)el )as a+le to )'thstand rad'othera($ )'thout ma0or (ro+lems :8'%. 15-6D<. Althou%h se%ments of

0e0unum ma$ +e used 'n the unusual s'tuat'on 'n )h'ch the lar$n- has +een left 'n s'tu* the secretor$ nature of the mucosa somet'mes makes as('rat'on a (ro+lem* and another method ma$ +e (refera+le. In add't'on to se%ments of +o)el* fasc'ocutaneous free fla(s from the rad'al forearm* lateral arm* lateral th'%h and (oster'or th'%h ha,e +een used as e'ther a tu+e or a (atch for h$(o(har$n%eal reconstruct'on. 3uamous cell carc'noma of the cer,'cal eso(ha%us (resents the same reconstruct',e demands as that of the h$(o(har$n-@ )hen d'sease 's local'4ed* the resected (ort'on eso(ha%us ma$ +e re(laced )'th a (atch of sk'n as e'ther a ,ascular'4ed trans(os't'on fla( or a free t'ssue transfer. The mode of s(read of the local d'sease* ho)e,er* ma$ 'n,ol,e su+mucosal sk'( areas and thus re3u're total eso(ha%ectom$. The l$m(hat'c dra'na%e of the cer,'cal eso(ha%us 's or'ented more to)ard the med'ast'num and (ara(har$n%eal nodes than laterall$ 'nto the neck* and hence a d'fferent a((roach 's re3u'red for l$m(hadenectom$. Naso(har$n- Et'olo%$ Carc'noma of the naso(har$n- 's seen 'nterm'ttentl$ 'n the .estern )orld* com(r's'n% a+out D./5 (ercent of ne) cancers 'n the 1n'ted tates. It 's endem'c 'n southeastern As'a* ho)e,er* (art'cularl$ 'n southern Ch'nese (o(ulat'ons such as those or'%'nat'n% from ;)antun% (ro,'nce and const'tutes /1 (ercent of cancers 'n Ta')an* 1E (ercent 'n Hon% ;on%* and 16 (ercent 'n Indones'a. The 'nc'dence 's much lo)er 'n As'ans )ho ha,e 'mm'%rated to North Amer'ca +ut st'll se,en t'mes h'%her than 'n the )h'te (o(ulat'on* su%%est'n% %enet'c susce(t'+'l't$ to an en,'ronmental carc'no%en. The s(orad'c and %enet'call$ l'nked cases of naso(har$n%eal carc'noma +eha,e 'n the same manner. There 's a h'%h assoc'at'on of the E(ste'n-5arr ,'rus )'th th's mal'%nanc$. Patholo%$ The naso(har$n- 's a small* mucosa-l'ned* +o-l'ke ca,'t$ at the +ase of the skull conta'n'n% the (har$n%eal tons'l and the o(en'n%s of the eustach'an tu+es and the s(heno'd s'nus. Tumors ar's'n% 'n th's area (resent local s$m(toms that ,ar$ )'th the'r (attern of %ro)th and s(read. #es'ons that are e-o(h$t'c and %ro) out 'nto the ca,'t$ ma$ o+struct the eustach'an or'f'ces or the choanae* lead'n% to hear'n% loss :15 (ercent<* nasal stuff'ness or o+struct'on :GD (ercent<* and e('sta-'s :// (ercent<. Inf'ltrat'on and +on$ eros'on of the +ase of the skull 'nto the ca,ernous s'nus results 'n cran'al ner,e (als'es 'n 1C to /5 (ercent of cases* the most commonl$ 'n,ol,ed +e'n% the a+ducens ner,e* follo)ed +$ the tr'%em'nal ner,e and the oculomotor ner,e* result'n% 'n (aresthes'as and d'(lo('a. The most common (resent'n% s'%n of naso(har$n%eal carc'nomas 's a mass 'n the neck secondar$ to cer,'cal metastas's :CD (ercent<. The s'te of cer,'cal metastas's ma$ +e the 0u%ulod'%astr'c nodes or the (oster'or tr'an%le. M'rror e-am'nat'on of the naso(har$n- 's an 'm(ortant (art of an$ e,aluat'on of sus('c'ous cer,'cal adeno(ath$. ta%'n% of naso(har$n%eal carc'noma 'n the (ast has +een relat',el$ 'naccurate +ecause of d'ff'cult$ )'th e-am'nat'on. CT has hel(ed to del'neate 'n,as'on of +oth the (aranaso(har$n%eal fasc'al (lanes and the +on$ skull 'n the a+sence of cran'al ner,e (als$. Recent sta%'n% s$stems ha,e 'ncluded h'stolo%$* mult'(le s$m(toms* t'me from onset of s$m(toms* locat'on of cer,'cal adeno(ath$ :su(racla,'cular<* and local e-tent of d'sease. 9ar'ance of h'stolo%$ also has +een related to sur,',al and thus 's 'm(ortant 'n (ro%nos's. ;erat'n'4'n% s3uamous cell carc'noma has the )orst 5-

$ear sur,',al rate at /1 (ercent@ the rate for s('ndle cell 's 61 (ercent* round cell 51 (ercent* and m'-ed nonkerat'n'4'n% 56 (ercent. These h'stolo%'c (red'ctors of thera(eut'c res(onse are cons'stent )'th the su+set of tumors ar's'n% as ,ar'ants from .alde$er2s r'n%* the l$m(hoe('thel'omas. Thera($ &es('te the fre3uent (resence of cer,'cal l$m(h node metastases* naso(har$n%eal carc'noma 's a cura+le d'sease. Rad'othera($ 'n doses ,ar$'n% from 5D"$ to E6"$ to the (r'mar$ s'te )'th 5D"$ to 7D"$ to +oth s'des of the neck results 'n 5-$ear sur,',al rates ,ar$'n% from 1DD (ercent for sta%e I d'sease to G6 (ercent for sta%e I9* )'th o,erall sur,',al rates ran%'n% from /B to 6B (ercent. The total dose of rad'othera($ has an effect on sur,',al* )'th (at'ents rece','n% lo)er total doses ha,'n% (oorer sur,',al. E,en the (resence of skull-+ase 'n,as'on and cran'al ner,e d$sfunct'on 's not a s'%n of 'ncura+le d'sease. '-t$-t)o (ercent of cran'al ner,e defects can +e re,ersed +$ rad'othera($* )'th an o,erall G1 (ercent sur,',al rate 'n th's su+set of (at'ents. Res'dual d'sease at the (r'mar$ s'te occas'onall$ ma$ +e resected +$ cran'ofac'al techn'3ue* and res'dual neck d'sease ma$ +e erad'cated +$ rad'cal neck d'ssect'on. &'stant metastat'c d'sease 'n naso(har$n%eal carc'noma 's common* (art'cularl$ 'n (at'ents )ho ha,e +ulk$ cer,'cal metastases. At (resent* ho)e,er* ad0u,ant chemothera($ has not +een (art'cularl$ successful 'n 'm(ro,'n% sur,',al. Nasal Ca,'t$ and Paranasal 'nuses Et'olo%$ The nasal ca,'t$ and (aranasal s'nuses :ma-'llar$* ethmo'd* frontal* and s(heno'd< are the ad'tus to the res('rator$ tract and funct'on to f'lter 'm(ur't'es from the 'ns('red a'r* re%ulate 'ts tem(erature* and hum'd'f$ 't. As such the$ are e-(osed to the man$ carc'no%ens 'n the a'r* and $et mal'%nanc'es 'n these s'tes are rare. In the .estern )orld the$ const'tute D.G (ercent of all mal'%nanc'es* )'th a sl'%htl$ h'%her 'nc'dence 'n men than 'n )omen. In the !r'ent th's 's a more common (r'mar$ s'te* com(r's'n% 1 (ercent of ne) cancers and /G (ercent of head and neck cancers 'n Ja(an. Endem'c areas are found 'n outh Afr'ca* )here 'ns('red snuff has a h'%h concentrat'on of n'ckel. There also ma$ +e an 'ncreased r'sk of adenocarc'noma of the (aranasal s'nuses 'n )ood)orkers secondar$ to 'ns('red )ood dust. The d'sease (resents most fre3uentl$ 'n the f'fth to se,enth decades. Patholo%$ 3uamous cell carc'noma 's the most common h'stolo%$ :CD to ED (ercent<* althou%h m'nor sal',ar$ %land les'ons* adenocarc'noma* adeno'd c$st'c carc'noma* and mucoe('dermo'd carc'noma make u( a+out /D (ercent of the tumors. !ther mal'%nanc'es* such as teratocarc'noma* l$m(homa* osteo%en'c sarcoma* sch)annoma* f'+rous d$s(las'a* carc'nosarcoma* and melanoma* occas'onall$ are encountered. #$m(h node metastases are uncommon* )'th onl$ 15 (ercent of cases (resent'n% 'n the neck* s'nce the retro(har$n%eal l$m(h nodes are the f'rst stat'on of dra'na%e. There 's a 3uest'ona+le relat'onsh'( +et)een nasal and s'nonasal mal'%nanc$ and the 'n,ert'n% (a('lloma of the nasal ca,'t$. #ate-sta%e d'sease 's common* s'nce s$m(toms usuall$ are rather d'ffuse* 'nclud'n% nasal o+struct'on :G5 (ercent<* local (a'n :1C (ercent<* e('sta-'s :1/ (ercent<* and cheek s)ell'n% :/B (ercent<. #oosen'n% of ma-'llar$ teeth or (aresthes'as also ma$ occur. &'a%nos's 's made +$ 'ntranasal +'o(s$ throu%h a s(eculum or +$ antrostom$

throu%h the lateral nasal )all or la+'al +uccal sulcus :Cald)ell-#uc (rocedure<. The ma-'llar$ s'nus 's +$ far the most common s'te of or'%'n of the d'sease :C/ (ercent<* follo)ed +$ the nasal ca,'t$ :/C (ercent<* ethmo'd s'nus :1D (ercent<* and s(heno'd s'nus :/ (ercent<. Thera($ Treatment of (aranasal s'nus tumors 's +$ a com+'nat'on of rad'othera($ and sur%er$. Rad'othera($ alone (ro,'des (oor (all'at'on and unacce(ta+l$ lo) sur,',al rates. Preo(erat',e rad'othera($ to CD"$ com+'ned )'th rad'cal sur%er$ has +een the usual a((roach* result'n% 'n G-$ear sur,',al rates ran%'n% from 1G to G/ (ercent for all s'tes* G5 to 6D (ercent for nasal ca,'t$* and GE to 5G (ercent for ma-'llar$ s'nus. 8a'lure of thera($ 's most commonl$ man'fested +$ local recurrence :7D (ercent< and onl$ rarel$ d'sease 'n the neck :5 (ercent<. ur%'cal resect'on 'n,ol,es en +loc remo,al of the affected s'nus and the surround'n% 'n,ol,ed structures. Total ma-'llectom$ )'th or )'thout or+'tal e-enterat'on ma$ +e re3u'red for ade3uate clearance. The 'ntroduct'on 'n 1BCG of the 'ntracran'ale-tracran'al a((roach to tumors* the cran'ofac'al techn'3ue* has 'm(ro,ed the a+'l't$ to safel$ remo,e tumors of the ethmo'd and other (aranasal s'nuses and has 'ncreased 5-$ear sur,',al rates from the ran%e of GD (ercent to 5E (ercent. Reconstruct'on of the (osto(erat',e defect that has +een (re,'ousl$ 'rrad'ated 's a d'ff'cult (ro+lem. 1nnatural (assa%e)a$s amon% the (aranasal s'nuses* oral ca,'t$* nasal ca,'t$* and e-ternal en,'ronment 'nterfere )'th the normal flo) of a'r* dr$'n% the mucosa and caus'n% d'scomfort and +leed'n% as )ell as 'nterfer'n% )'th al'mentat'on and s(eech. mall defects can +e o+turated )'th nasal or dental (rostheses. #ar%er defects* ho)e,er* re3u're three-d'mens'onal reconstruct'on )'th free t'ssue transfer )'th the 'ntent'on of restor'n% (ath)a$s of a'r and 'n%ested su+stances to as normal a state as (oss'+le to 'm(ro,e funct'on and a((earance :8'%. 15-61<. #ar$nAnatom$ and Ph$s'olo%$ The lar$n- 's a com(le-* mucosa-l'ned* +on$ and cart'la%'nous +o- )hose funct'on de(ends on mot'on coord'nated )'th the ad0acent ton%ue and (har$n-. The lar$n- 's d','ded 'nto three anatom'c areasA the su(ra%lott'c lar$n-* from the e('%lott's to the ,entr'cle* 'nclud'n% the (ree('%lott'c s(ace* h$o'd +one* ar$teno'd (rocesses* and false ,ocal cords@ the %lott'c lar$n-* 'nclud'n% the true ,ocal cords and the anter'or comm'ssures@ and the su+%lott'c area* surrounded +$ the cr'co'd cart'la%e. The d'fferent cl'n'cal +eha,'or of su(ra%lott'c les'ons comes 'n (art from the'r se(arate em+r$olo%'c or'%'n. The su(ra%lott's 's a der',at',e of the (har$n%o+uccal anla%e* and mal'%nanc$ ar's'n% 'n th's area +eha,es s'm'larl$ to (har$n%eal carc'noma* )'th earl$ metastat'c d'sease to the neck. The %lott's ar'ses from the tracheo+ronch'al anla%e* and mal'%nanc$ 's more l'kel$ to +e 'ndolent* )'th lo)er 'nc'dence of cer,'cal metastases. The (redom'nant funct'on of the lar$n- 's the modulat'on of a'r 'ns('red throu%h the nose and naso(har$n- and e-('red from the lun%s. Coord'nat'on of res('rat'on )'th s)allo)'n% 's a com(le- funct'on that (re,ents food from enter'n% the res('rator$ tree and a'r from enter'n% the d'%est',e tract. As a'r enters the (har$n- 't 's shunted to the lar$n-* )h'ch s'ts 'n 'ts neutral (os't'on )'th the e('%lott's o(en. A'r 's then dra)n

throu%h the lar$n- +$ ne%at',e (ressure from the thora- and (re,ented from enter'n% the eso(ha%us +$ the s(h'ncter act'on of the m'ddle and 'nfer'or constr'ctor muscles. al',a and other oral contents are (re,ented from enter'n% the lar$n- +$ sens't',e refle-es med'ated +$ the sensor$ com(onent of the su(er'or and recurrent lar$n%eal ner,es and the 'ntr'ns'c and e-tr'ns'c muscles of the lar$n-. In the act of s)allo)'n%* the food +olus 's (re,ented from enter'n% the lar$n- +$ the s'multaneous rela-at'on of the m'ddle constr'ctor muscle and the ele,at'on of the lar$n- to)ard the relat',el$ f'-ed e('%lott's* )h'ch seals the ad'tus. Th's ele,at'on 's 'n't'ated as the food (asses throu%h the fauc'al arch +$ the 'ntr'ns'c and e-tr'ns'c muscles of the ton%ue (ull'n% throu%h the h$o'd +one. (eech 's (roduced +$ a'r e-('red from the lun%s throu%h the lar$n-* mouth* and nose. The th'ckness and de%ree of a+duct'on or adduct'on of the cords (roduce tone and ,olume* and the act'ons of the ton%ue* (alate* l'(s* and +uccal mucosa mod'f$ the e-(elled a'r 'nto an art'culated (attern* s(eech. Althou%h the res('rator$ tract can +e short-c'rcu'ted and se(arated from the d'%est',e tract +$ tracheostom$* e'ther )'th or )'thout lar$n%ectom$* the ma'ntenance of normal s(eech and s)allo)'n% de(ends on ade3uate s$ner%$ 'n the (har$n%olar$n- and oral ca,'t$ of ton%ue* lar$n-* and (har$n%eal musculature and normal central ner,ous s$stem afferent and efferent s'%nals. Perha(s more than at an$ other +od$ s'te* thera(eut'c dec's'on-mak'n% 'n lar$n%eal carc'noma +$ +oth (at'ent and (h$s'c'an has +een 'nfluenced +$ the des're to (reser,e the ,o'ce. Et'olo%$ Carc'noma of the lar$n- 's the most common mal'%nanc$ of the u((er aerod'%est',e tract 'n the 1n'ted tates* )'th a+out 1D*DDD ne) cases (resent'n% each $ear. As )'th most other head and neck cancers the r'sk for de,elo(ment for lar$n%eal cancer 's d'rectl$ (ro(ort'onal to the amount of e-(osure to to+acco* )'th a lesser relat'onsh'( to alcohol 'ntake. Chan%'n% mores ha,e decreased the male-to-female rat'o for 'nc'dence of lar$n%eal carc'noma from 11A1 'n 1BCD to 6.5A1 'n 1BBD. 8urthermore* )omen )'th carc'noma of the lar$n- are more l'kel$ to ha,e su(ra%lott'c than %lott'c lar$n%eal cancers. Increas'n% a%e also 's a r'sk factor* althou%h d'sease 'n $oun% (at'ents has +een re(orted and l'ke)'se 's related to to+acco use. 5lack (at'ents 'n the 1n'ted tates ha,e an 'ncreased r'sk of de,elo('n% lar$n%eal carc'noma at a $oun%er a%e and a sl'%htl$ lo)er male- to-female rat'o :G.5A1< than the %eneral (o(ulat'on. !ther r'sk factors su%%ested ha,e +een metal dust :(art'cularl$ n'ckel<* as+estos* ha'r d$es* and )ood dust* +ut these are l'kel$ cofactors to the 'nsult created +$ to+acco smoke. The relat'onsh'( of (a('llomas of 0u,en'le or adult onset 'n the causat'on of the lar$n- 's unclear. &'a%nos's 5ecause of the o+,'ous s$m(toms of hoarseness* other ,o'ce chan%es* t'ckl'n% 'n the throat* and cou%h'n%* carc'noma of the %lott'c lar$n- 's more l'kel$ than man$ u((er aerod'%est',e tract mal'%nanc'es to (resent )'th earl$-sta%e d'sease. E,aluat'on of the (at'ent 'ncludes 'nd'rect :m'rror< lar$n%osco($ as )ell as (h$s'cal e-am'nat'on of the neck :8'%. 15-6/<. The %eo%ra(h'c s'te and e-tent of the les'on* )hether conf'ned to the lar$n- or s(read'n% +e$ond* are of 'm(ortance* +ut the mo+'l't$ of the ,ocal cords also 's cruc'al* s'nce 't (red'cts 'n,as'on of the tumor 'nto the dee( structures of the lar$n-. CT and MRI are useful 'n determ'n'n% )hether there 's 'n,as'on of the th$ro'd cart'la%e 'n the sta%'n% (rocess :8'%. 15- 6G<. &ef'n't',e sta%'n% and d'a%nos's to clearl$ def'ne e-tent usuall$ re3u're d'rect lar$n%osco($ and +'o(s$* )h'ch can +e

(erformed )'th a r'%'d lar$n%osco(e )'th the (at'ent anesthet'4ed or )'th a fle-'+le f'+ero(t'c sco(e )'th the (at'ent a)ake and a+le to 'ns('re and ,ocal'4e. Patholo%$ The +'olo%'c +eha,'or of mal'%nanc$ 'n the ,ar'ous areas of the lar$n- 's some)hat d'fferent and (la$s a ma0or role 'n the cho'ce of thera($. u(ra%lott'c lar$n%eal carc'noma or e-tr'ns'c lar$n%eal carc'noma 's more l'kel$ than %lott'c cancer to (resent )'th ad,anced-sta%e d'sease. There 's an a+undant l$m(hat'c su((l$ that e-tends anter'orl$ throu%h the (ree('%lott'c s(ace as )ell as laterall$ to the m'd0u%ular and (aratracheal l$m(h nodes. In,ol,ement of the (ree('%lott'c s(ace occurs 'n /B (ercent of cl'n'call$ unremarka+le su(ra%lott'c tumors. M'crometastases 'n the cl'n'call$ ne%at',e neck also are common* )'th /C to GG (ercent of necks sho)'n% metastases and /5 (ercent +'lateral metastases. In (at'ents )'th 'nade3uate (r'mar$ thera($ for su(ra%lott'c carc'noma recurrence 'n the neck and d'stant metastases 's more l'kel$ than local recurrence alone. The ,ocal cords :%lott's< or 'ntr'ns'c lar$n- 's a small area that 's 'n constant use and thus re%ularl$ e-(osed to carc'no%en'c st'mul'. .hen tumors are conf'ned to the small cart'la%'nous +o- )'th 'ts (auc't$ of l$m(hat'cs* the$ usuall$ +eha,e 'ndolentl$. .hen tumors e-tend outs'de the %lott's=trans%lott'c les'ons=a more a%%ress',e (attern 's noted. 1nl'ke su(ra%lott'c cancer* earl$ chan%es are not'cea+le and a((ear to ha,e a lon% natural h'stor$* mak'n% them amena+le to less rad'cal thera($. ;eratos's or th'cken'n% of the kerat'n la$er of the s3uamous mucosa results 'n transformat'on to carc'noma 'n s'tu 'n 16 (ercent of cases and m'cro'n,as',e cancer 'n /E (ercent of cases o,er a (er'od of / to /6 months. ;eratos's )'th at$('a (ro%resses to carc'noma 'n s'tu 'n 1E (ercent and 'n,as',e carc'noma 'n /5 (ercent 'n 1 to /6 months* and carc'noma 'n s'tu (ro%resses to 'n,as',e carc'noma 'n GE (ercent of cases 'n E to 6E months. Reco%n't'on and treatment of these earl$ chan%es 'n lar$n%eal mucosa 's cruc'al to (re,ent'on of d'sease and (rolon%ed sur,',al. Thera($ Th's rather 'ndolent +eha,'or and the lo) l'kel'hood of cl'n'call$ e,'dent or m'crometastat'c cer,'cal d'sease :1 to 7 (ercent 'n T1 and T/ les'ons* 1G (ercent )'th TG les'ons< make %lott'c cancer more su'ta+le for less rad'cal thera('es* )'th a h'%h (ro+a+'l't$ of sal,a%e after fa'lure of (r'mar$ thera($. 5ecause of the (ro(ens't$ for su+mucosal e-tens'on* ho)e,er* ad,anced- sta%e d'sease )'th cart'la%e 'n,as'on re3u'res 'n't'al rad'cal thera($. u+%lott'c carc'nomas are rare* com(r's'n% onl$ 1 to / (ercent of all lar$n%eal carc'nomas* and tend to s(read +$ su+mucosal e-tens'on do)n the trachea and throu%h the cr'co'd cart'la%e and cr'coth$ro'd mem+rane 'nto the soft t'ssues of the neck. 5ecause of the'r rar't$* the$ fre3uentl$ (resent )'th ad,anced-sta%e local d'sease* althou%h cer,'cal metastas's 's not as common as 'n su(ra%lott'c d'sease. Rad'cal com+'ned thera($* sur%er$ and rad'othera($* 's necessar$. &es('te the (ecul'ar't'es of %ro)th of s3uamous cell carc'noma of the %lott'c lar$n-* (ro%nos's for carc'noma at all s'tes 's related to s'm'lar ,ar'a+les (red'ct'n% other s'tes. 1n'factor'al and mult'factor'al anal$ses ha,e 'dent'f'ed the (resence of l$m(h node metastases* ad,anced local d'sease* ,ocal cord f'-at'on* h'stolo%'c %rade*

ulcerat'on* s'te )'th'n the lar$n-* male %ender* and GH-th$m'd'ne la+el'n% 'nde- as s'%n'f'cant factors 'n sur,',al after thera($ )'th +oth sur%er$ and rad'othera($. 5ecause of the 'm(ortance of (reser,'n% the ,o'ce and +ecause of the lo) 'nc'dence of su+cl'n'cal cer,'cal metastases 'n %lott'c cancer* rad'othera($ has +ecome the acce(ted treatment for most earl$ s3uamous cell carc'nomas of the lar$n-. Con,ent'onal rad'othera(eut'c techn'3ues that del',er doses of CD"$ o,er GD fract'ons o,er C )eeks result 'n cure rates of ED to BD (ercent for T1*ND carc'noma of the %lott's and 7D to BD (ercent for T/*ND. 8urthermore* sal,a%e of rad'othera($ fa'lures )'th ,o'ce (reser,at'on +$ su+total lar$n%ectom$ 's (oss'+le 'n 75 (ercent and o,erall sur%'cal sal,a%e 'n B/ (ercent of T1 (at'ents and E/ (ercent of T/ (at'ents. More ad,anced TG les'ons also ha,e +een a((roached )'th standard rad'othera($ and h$(erfract'onat'on :more than one course (er da$< 'n doses of C5"$ to 7C.E"$ throu%h (orts that 'nclude the cer,'cal l$m(hat'cs* result'n% 'n local control rates of GC to C7 (ercent o,er / to 6 $ears and sur%'cal sal,a%e of C7 to EG (ercent. uch h'%hdose rad'othera($ does* ho)e,er* result 'n s'%n'f'cant com(l'cat'on rates* such as (ers'stent lar$n%eal edema and chondronecros's. Rad'othera($ as treatment for su(ra%lott'c carc'noma 's some)hat more contro,ers'al +ecause of the late-sta%e (resentat'on and the tendenc$ for +'lateral cer,'cal metastases to occur. Althou%h control rates of 76 (ercent for T1 and T/ su(ra%lott'c les'ons ha,e +een o+ta'ned* and 6D (ercent for TG and T6 les'ons )'th rad'at'on and sur%er$ held as a sal,a%e method* the (oss'+'l't$ of (reser,'n% the ,o'ce )'th su(ra%lott'c lar$n%ectom$ and treatment )'th (reo(erat',e or (osto(erat',e ad0u,ant rad'othera($ has made th's com+'ned a((roach more (o(ular for late-sta%e d'sease or d'sease )'th om'nous h'stolo%'c features. The sur%'cal a((roach to the lar$n- 's ,ar'ed* )'th the un'f$'n% (r'nc'(le that local and locore%'onal d'sease ma$ +e erad'cated )'th (reser,at'on or restorat'on of )hate,er funct'on 's (oss'+le. Earl$ les'ons of the %lott's* such as keratos's )'th at$('a* carc'noma 'n s'tu* or m'n'mall$ 'n,as',e carc'noma* that 'n,ol,e the mo+'le cord and do not e-tend to the anter'or or (oster'or comm'ssures ma$ +e treated )'th reasona+le success +$ remo,al of the mucosa o,er the cord +$ ,ocal cord str'(('n%. Performed transorall$* +$ e'ther laser d'atherm$ or shar( d'ssect'on* th's techn'3ue has m'n'mal mor+'d't$* lea,'n% %ood ,o'ce 3ual't$. T1 les'ons of more +ulk +ut conf'ned to one cord ma$ +e remo,ed +$ cordectom$* occas'onall$ (erformed transorall$ +ut usuall$ +$ o(en'n% the lar$n- throu%h lar$n%of'ssure. Althou%h th's 'nterferes )'th ,o'ce 3ual't$* most (at'ents are cured* and sur%'cal sal,a%e +$ total lar$n%ectom$ 's a successful +acku( (rocedure. The con,ent'onal thera($ for cancers that cross the anatom'c +oundar'es of the su(ra%lott's and %lott's or the %lott's and su+%lott's* and the so- called trans%lott'c les'ons* 's total lar$n%ectom$. "lott'c les'ons that cross the anter'or or (oster'or comm'ssure and are not felt to +e amena+le to rad'othera($ s'm'larl$ re3u're total lar$n%ectom$. &e(end'n% on the (resence of (al(a+le l$m(h nodes or sus('c'on of metastat'c d'sease +ecause of the s'te of (r'mar$ d'sease* rad'cal or mod'f'ed rad'cal neck d'ssect'on ma$ +e 'nd'cated. Remo,al of all d'sease 's the a'm of total lar$n%ectom$* althou%h )hole-or%an (atholo%'c e-am'nat'ons ha,e sho)n (resence of m'crosco('c d'sease at the mar%'ns 'n u( to GD (ercent of cases* )'th anterolateral :1B (ercent<* (osterolateral :11 (ercent<* (ostcr'co'd :7 (ercent<* and su(er'or mar%'ns

+e'n% most commonl$ 'n,ol,ed. 8ree mar%'n status 's the most rel'a+le (red'ctor of local control* )'th 6E (ercent of (at'ents )'th (os't',e mar%'ns de,elo('n% local recurrence. .hen total lar$n%ectom$ 's used as def'n't',e thera($ for ad,anced-sta%e d'sease* G- to 5-$ear sur,',al rates of C5 to CB (ercent for TG*ND and TG*N1 les'ons and 65 to 56 (ercent for T6*ND les'ons ha,e +een re(orted. The %oal of ,o'ce (reser,at'on )hen sur%'cal e-t'r(at'on 's a necessar$ (art of thera($ 's met 'n t)o )a$sA +$ conser,at'on sur%er$* remo,'n% onl$ (art of the lar$n-* or +$ reconstruct'on of a ,o'ce-(roduc'n% mechan'sm after total lar$n%ectom$. In conser,at'on sur%er$ les'ons conf'ned to one (art of the lar$n- are remo,ed )'th the %oal of (reser,'n% enou%h lar$n- to allo) s(eech that 's su(er'or to eso(ha%eal or mechan'cal s(eech. tandard su(ra%lott'c lar$n%ectom$ or hor'4ontal hem'lar$n%ectom$ 's a((ro(r'ate 'n (at'ents )here les'ons are smaller than G cm* the ,ocal cords are mo+'le* a mar%'n of 5 mm 's (oss'+le at the anter'or comm'ssure* there 's no cart'la%e or (ree('%lott'c s(ace 'n,as'on* the ($r'form s'nus a(e- and (ostcr'co'd and 'nterar$teno'd areas are clear* and ton%ue mo+'l't$ 's normal. The a((roach to the lar$n- 's throu%h the th$ro'd cart'la%e* remo,'n% the e('%lott's* false cords* and ,entr'cular mucosa en +loc )'th the h$o'd +one. If (oster'or e-tens'on 'n,ol,es the ar$teno'd cart'la%e on one s'de* th's ma$ +e 'ncluded )'th the s(ec'men. Althou%h (osto(erat',e as('rat'on for a l'm'ted (er'od of t'me 's fre3uentl$ seen* %ood ,o'ce 3ual't$ 's usuall$ o+ta'ned and the tem(orar$ tracheostom$ can almost al)a$s +e remo,ed. Total lar$n%ectom$ as a sal,a%e (rocedure for 'ntracta+le as('rat'on* f'stula* or recurrent d'sease 's successful 'n GG to 5D (ercent of cases. 8',e-$ear sur,',al rates 'n the ran%e of 7D to E5 (ercent for su(ra%lott'c carc'noma make 't su(er'or to rad'othera($* althou%h no (ros(ect',e random'4ed stud'es ha,e tested th's thes's. 9ert'cal hem'lar$n%ectom$ 's the standard conser,at'on (rocedure carr'ed out for 'n,as',e carc'noma of one ,ocal cord or a ,ocal cord and the anter'or comm'ssure that does not 'n,ade the th$ro'd cart'la%e. Total resect'on of the cord and 'ts su+0acent muscle and ad0acent cart'la%e 's necessar$. Access to the lar$n- 's o+ta'ned (oster'or to the cord +$ cutt'n% throu%h the th$ro'd cart'la%e* lea,'n% the e-ternal (er'chondr'um sutured to the sternoth$ro'd muscle. The cord )'th or )'thout the '(s'lateral ar$teno'd cart'la%e 's resected* and 'f the comm'ssure 's 'n,ol,ed* the keel of the th$ro'd cart'la%e 's resected as )ell. The stra( muscles and (er'chondr'um or a cart'la%e %raft (ro,'des a +uttress a%a'nst )h'ch the normal cord can +e a((osed. 8',e-$ear sur,',al rates of 75 to E7 (ercent for sta%es I to III d'sease treated 'n th's fash'on ha,e +een re(orted* a%a'n su(er'or to rad'othera($ alone. As )'th su(ra%lott'c lar$n%ectom$* remo,al of the tem(orar$ tracheostom$ and resum(t'on of oral nutr't'on )'thout as('rat'on usuall$ 's (oss'+le* )'th ,o'ce (reser,at'on. E-tended hem'lar$n%ectom$ has +een descr'+ed for TG les'ons* )here a small se%ment of ,ocal's muscle )'th 'ts o,erl$'n% cart'la%e* )'th sensor$ and motor 'nner,at'on left 'ntact* 's used )'th the ad0acent h$(o(har$n%eal mucosa to create a (honator$ shunt throu%h )h'ch a'r from the lun%s can +e forced to (ro,'de s(eech. Althou%h (ermanent tracheostom$ 's necessar$* ,o'ce 3ual't$ has +een descr'+ed as su(er'or to eso(ha%eal s(eech and o+ta'na+le 'n a h'%h (ercenta%e of cases. 9o'ce restorat'on after total lar$n%ectom$ 's a d'ff'cult (ro+lem. &es('te )'des(read a,a'la+'l't$ of s(eech thera($ and e-tens',e (reo(erat',e teach'n% and a%%ress',e (osto(erat',e reha+'l'tat'on* onl$ /6 to 65 (ercent of alar$n%eal (at'ents ac3u're

eso(ha%eal s(eech. Ina+'l't$ to e-(el a'r from the stomach* cr'co(har$n%eus s(asm* and other (h$s'olo%'c reasons ha,e +een c'ted* +ut de(ress'on and soc'al and emot'onal )'thdra)al (la$ an 'm(ortant (art as )ell. Mechan'cal de,'ces 'nserted 'nto the a'r)a$ ha,e +een remarka+l$ unsuccessful* althou%h e-ternal ,'+rators do allo) 'ntell'%'+le s(eech of lo) ,olume. 9ar'ous attem(ts ha,e +een descr'+ed to create a neolar$n- or neo%lott's* a mucosal or e('thel'al d'a(hra%m )h'ch f'ts o,er the transected end of the cr'co'd or trachea and ser,es as a (ath)a$ for a'r 'ns('red throu%h the tracheostom$ to e-'t throu%h the oral ca,'t$ as s(eech. .'th these ,ar'ous methods* %ood s(eech 3ual't$ ma$ +e o+ta'ned 'n 5D to 75 (ercent of cases* +ut there 's a s'%n'f'cant r'sk of as('rat'on* re3u'r'n% takedo)n of the reconstruct'on. A s'm(le tracheoeso(ha%eal (uncture descr'+ed +$ 'n%er* ma'nta'ned (atent +$ a small tu+e* allo)s (ulmonar$ a'r to enter the eso(ha%us and thus the (har$n-* to +e modulated +$ the ton%ue* l'(s* and +uccal mucosa. Th's method has allo)ed fluent s(eech restorat'on 'n 71 to EE (ercent of (at'ents )'th l'ttle r'sk of as('rat'on or other ser'ous com(l'cat'on. Th's (rocedure ma$ +e (erformed e'ther at a second sta%e after heal'n% of the )ound or at the t'me of lar$n%ectom$* )hether closed +$ (r'mar$ a((ro-'mat'on or reconstructed )'th a (ectoral's ma0or fla(* %astr'c (ull-u(* or free t'ssue transfer. Trans(lantat'on of the lar$n- has as $et +een unsuccessful* +ut research 's cont'nu'n% )'th th's method. E-tens',e sur%er$ on the lar$n- 's assoc'ated )'th com(l'cat'ons. Phar$n%ocutaneous f'stula occurs 'n u( to GE (ercent of lar$n%ectom'es and has +een assoc'ated )'th (re,'ous rad'othera($* malnutr't'on* and cell- med'ated 'mmunodef'c'enc$. Pro(h$lact'c metron'da4ole has +een su%%ested as a method to (re,ent f'stula* +ut (rom(t reco%n't'on and closure )'th )ell-,ascular'4ed t'ssue )'ll (re,ent (rolon%ed dra'na%e and ru(ture of the ad0acent 'rrad'ated carot'd ,essels. Pro+lems s(ec'f'c to the method of reconstruct'on also occur* such as re%ur%'tat'on of ac'd and food after (har$n%o%astrostom$ after %astr'c (ull-u( or h$(ersecret'on of mucus after 0e0unal auto%raft. The (ro+lem of stenos's after lar$n%ectom$* (art'cularl$ 'n the (at'ent )ho rece',es ad0u,ant rad'othera($* 's s'm'lar to that after (har$n%olar$n%ectom$. Com+'ned )'th the alterat'ons 'n cr'co(har$n%eus funct'on :u((er eso(ha%eal s(h'ncter mechan'sm<* stenos's %reatl$ 'm(edes the ac3u's't'on of eso(ha%eal s(eech. Inter(os't'on of )ell-,ascular'4ed soft t'ssue* such as the rad'al forearm or lateral arm free fla(* can decrease the l'kel'hood of (ostlar$n%ectom$ s(eech and s)allo)'n% (ro+lems :8'%. 15-66<. None('dermo'd mal'%nanc'es of the lar$n- are uncommon. Adenos3uamous carc'noma 's a (oorl$ d'fferent'ated a%%ress',e les'on that +eha,es 'n a manner s'm'lar to ad,anced s3uamous cell carc'noma. Rha+dom$osarcoma* chondrosarcoma* sch)annoma* and other mesench$mal mal'%nanc'es ha,e +een re(orted 'n +oth ch'ldren and adults. Carc'no'd or moderatel$ d'fferent'ated neuroendocr'ne carc'noma +eha,es 'n a fash'on s'm'lar to mal'%nanc$ 'n other s'tes and ma$ +e treated +$ (art'al or total lar$n%ectom$* de(end'n% on 'ts sta%e. Ad0u,ant rad'othera($ and chemothera($ do not seem to contr'+ute to the cure of the (at'ent. Ana(last'c small cell carc'noma :oat cell< also occurs 'n the lar$n- rarel$ and* l'ke 'ts counter(art 'n the lun%* 's assoc'ated )'th smok'n% and 'ncreased a%e. Pro%nos's 's also s'm'lar to lun% d'sease* )'th a,era%e sur,',al of 1D months after d'a%nos's. Mult'modal thera($ )'th chemothera($ as the +as's 's the most a((ro(r'ate a((roach.

!ne of the most d'ff'cult (ro+lems assoc'ated )'th lar$n%ectom$ 's recurrence of d'sease at the stoma. !ccurr'n% 'n a((ro-'matel$ 5 (ercent of (at'ents* 't ma$ +e the result of su+mucosal su+%lott'c e-tens'on or unresected (retracheal or (aratracheal l$m(h node metastas's. Resect'on of d'sease 's (oss'+le 'n some (at'ents +$ med'ast'nal d'ssect'on* re(os't'on'n% the stoma lo)er and remo,'n% the soft t'ssues of the su(er'or med'ast'num to the 'nnom'nate ,essels. Eso(ha%eal reconstruct'on ma$ +e (erformed +$ %astr'c (ull-u( or 0e0unal free auto%raft* and 'nter(os't'on of ,ascular'4ed (ectoral's ma0or muscle usuall$ 's necessar$ to se(arate the %reat ,essels from the stoma. .'th th's a%%ress',e sur%'cal a((roach* 17 to /E (ercent of the (at'ents can +e treated successfull$. 5en'%n les'ons of the lar$n- ma$ (resent a d'a%nost'c (ro+lem +ut usuall$ are seen 'n d'fferent a%e %rou(s and rarel$ affect mo+'l't$ of the ,ocal cords. Tu+erculos's of the lar$n-* thou%h rare* ma$ m'm'c mal'%nanc$. Pa('llomatos's ma$ (resent 'n ch'ldren* (oss'+l$ secondar$ to contam'nat'on of the fetus at del',er$ +$ the human (a('lloma,'rus* a &NA ,'rus. Th's (ers'stent (ro+lem ma$ re3u're tracheostom$* s'nce re(eated e-c's'ons +$ laser or other means ma$ result 'n lar$n%eal or su+%lott'c stenos's. Adult-onset (a('llomatos's of the lar$n- ma$ come )'th 'mmunosu((ress'on of ,ar'ous t$(es as recurrent d'sease or as an o((ortun'st'c 'nfect'on. Immunothera($ )'th the +ac'lle Calmette-"uHr'n :5C"< has +een su%%ested as an ad0u,ant of sur%er$. 9ocal nodules or s'n%er2s nodules and (ol$(s and se+aceous c$sts also ma$ occur 'n the mo+'le cords and ma$ +e treated +$ s'm(le e-c's'on. C!NNECTI9E TI 1E NE!P#A M oft-T'ssue arcomas "eneral Cons'derat'ons oft-t'ssue sarcomas ar'se )'th'n t'ssues that de,elo( em+r$olo%'call$ from the mesoderm* such as skeletal and smooth muscle* ad'(ose and f'+rous t'ssue* and endothel'al cells. The$ are uncommon tumors o,erall* )'th fe)er than 5*DDD ne) cases d'a%nosed each $ear 'n the 1n'ted tates. #ess than 1D (ercent of all sarcomas ar'se 'n the head and neck@ the$ re(resent less than 1 (ercent of all head and neck mal'%nanc'es. Th's lo) 'nc'dence* )'th the attendant d'ff'cult$ 'n de,elo('n% a com(rehens',e mana%ement (lan* ma$ (art'all$ account for the (oor sur,',al rates 'n adults )'th soft-t'ssue sarcomas. 1nl'ke e('dermo'd carc'noma* the most 'm(ortant determ'nant of the +'olo%'c +eha,'or of sarcomas 's h'stolo%'c %rade. #o)-%rade tumors tend to recur locall$* )h'le h'%h-%rade les'ons often metastas'4e earl$ to d'stant s'tes* 'nclud'n% lun%* l',er* and +one. !ther (ro%nost'c 'nd'cators 'nclude the h'stolo%'c t$(e* the locat'on* the s'4e and the de%ree of local 'n,as'on of (r'mar$ les'ons* and the (resence of locore%'onal or d'stant metastat'c d'sease. T$('call$ soft-t'ssue sarcoma of the head and neck (resents as a (a'nless mass. The more ad,anced or more dee(l$ 'n,as',e les'ons ma$ cause (a'n* o+struct',e s$m(toms* or cran'al ner,e def'c'ts. E,aluat'on of local e-tent of d'sease 'n soft-t'ssue sarcomas 's s'm'lar to that of s3uamous cell carc'noma and 'ncludes 'nd'rect lar$n%osco($* (al(at'on endosco($* and CT or MRI. &e(end'n% on h'stolo%$ and sta%e of d'sease* a metastat'c )ork-u( should +e (erformed. Pleomor(h'c sarcomas of the head and neck* l'ke those ar's'n% 'n other areas* fre3uentl$ demonstrate cellular chan%es cons'stent )'th 'ndolent d'sease 'n one (art of the tumor and character'st'c of ,er$ a%%ress',e d'sease 'n another (art. A %enerous 'nc's'onal +'o(s$ often 's necessar$ to conf'rm the d'a%nos's. The ma'nsta$ of treatment for the ma0or't$ of

these les'ons 'n adults rema'ns e-tens',e local resect'on )'th clearl$ ne%at',e mar%'ns :tumor no less than 1 mm from the sur%'cal mar%'n<. Re%'onal node d'ssect'ons usuall$ are (erformed onl$ 'f nodal d'sease 's cl'n'call$ e,'dent. In adults* ad0u,ant rad'at'on thera($ and chemothera($ ma$ +e of some )orth* )hereas 'n ch'ldren the'r thera(eut'c ,alue has +een clearl$ esta+l'shed. 8'+rosarcoma Th's 's the most common t$(e of soft-t'ssue sarcoma 'n adults. There 's a +'modal a%e d'str'+ut'on* )'th the f'rst (eak 'n 'nfants under / $ears of a%e and the second 'n adults 6D to CD $ears of a%e. 8'+rosarcoma often (resents as a (a'nless mass of the face or neck. H'stolo%'call$* man$ f'+rosarcomas are lo) %rade. The rate of metastas's to re%'onal nodes 's 5 (ercent* +ut 5D (ercent metastas'4e to lun%s* l',er* or +one. .'th a%%ress',e local resect'on* 5-$ear sur,',al rates around 65 (ercent ha,e +een re(orted. Mal'%nant 8'+rous H'st'oc$toma The re(orted 'nc'dence of these tumors 'n the head and neck has %ro)n 'n recent $ears +ecause of the reclass'f'cat'on of other h'%h-%rade sarcomas as mal'%nant f'+rous h'st'oc$tomas. T)o h'stolo%'c ,ar'ants e-'st* m$-o'd and 'nflammator$* )'th the latter carr$'n% a (oorer (ro%nos's. .hereas local recurrence rema'ns the most common man'festat'on of treatment fa'lure* the 'nc'dence of nodal metastas's ma$ a((roach 5D (ercent. Therefore* 'n add't'on to a%%ress',e local resect'on* (ro(h$lact'c neck d'ssect'on 's ad,ocated 'n some centers* de(end'n% on sta%e of d'sease. The 5$ear sur,',al rate 's a((ro-'matel$ 5D (ercent. An%'osarcoma These rare cutaneous mal'%nanc'es most often (resent as an ulcerated (a'nless mass of the scal( or face 'n m'ddle-a%ed men. The$ are h'%hl$ a%%ress',e tumors* )'th (er',ascular e-tens'on most often c'ted as the cause of local fa'lure as )ell as of d'stant metastas's. Rad'at'on thera($ and chemothera($ ha,e +oth +een used as ad0u,ants to local resect'on* +ut 5- $ear d'sease-free sur,',al 's rare. Rha+dom$osarcoma Th's 's the most common t$(e of soft-t'ssue sarcoma 'n ch'ldren* and after l$m(homa 's the second most common mal'%nanc$ of the head and neck 'n ch'ldren. T)o 'm(ortant h'stolo%'c su+t$(es ha,e +een 'dent'f'ed. The em+r$onal ,ar'ant occurs 'n $oun% ch'ldren :a,era%e a%e four< and carr'es the +etter (ro%nos's. e,ent$-n'ne (ercent of or+'tal rha+dom$osarcomas are of the em+r$onal t$(e. Most of these neo(lasms are no) treated successfull$ )'th a com+'nat'on of rad'at'on thera($ and chemothera($ :,'ncr'st'ne* do-oru+'c'n* and c$clo(hos(ham'de<* $'eld'n% sur,',al rates of 77 to BD (ercent. Al,eolar rha+dom$osarcoma occurs 'n older ch'ldren :a,era%e a%e ten< and 'n the cer,'cal soft t'ssues. .h'le the 'n't'al res(onse rate to rad'at'on thera($ and chemothera($ 's com(ara+le to that of em+r$onal rha+dom$osarcoma* the rate of local recurrences and of d'stant metastas's 's s'%n'f'cantl$ h'%her* decreas'n% sur,',al rates to a((ro-'matel$ 5D (ercent at 5 $ears. The Inter%rou( Rha+dom$osarcoma tud$ has esta+l'shed s(ec'f'c mult'modal treatment (rotocols for each t$(e and sta%e of d'sease. To date the 'm(ro,ements 'n mana%ement of rha+dom$osarcoma 'n ch'ldren ha,e not $et +een real'4ed 'n adults. Neural Tumors Esthes'oneuro+lastoma :!lfactor$ Neuro+lastoma<

Th's rare tumor ar'ses from the su((ort'n% cells of the olfactor$ neuroe('thel'um at the a(e- of the nasal ca,'t$. In 'ts earl'er sta%es 't ma$ (resent as a flesh$ u((er nasal mass caus'n% e('sta-'s* un'lateral nasal o+struct'on* or rh'norrhea. In 'ts more ad,anced sta%es the tumor ma$ e-tend throu%hout the cr'+r'form (late 'nto the anter'or cran'al fossa* 'n,ad'n% the frontal lo+e and lead'n% to anosm'a* rh'norrhea* headaches* or e,en (ersonal't$ chan%es. .h'le th's tumor ma$ ar'se 'n all a%e %rou(s* 't has h'%her 'nc'dence 'n the th'rd and fourth decades of l'fe and a sl'%ht male (redom'nance. .hen esthes'oneuro+lastoma 's sus(ected on the +as's of the h'stor$ or CT scans sho)'n% +on$ eros'on* a +'o(s$ (rocedure of the nasal mass should +e (erformed 'n the o(erat'n% room +ecause 'ts h'%hl$ ,ascular nature. Metastas's occurs 'n /D (ercent of cases* most commonl$ to the cer,'cal l$m(h nodes :often +'lateral<* lun%s* and +one* +ut the ma0or't$ of (at'ents succum+ to a%%ress',e 'ntracran'al e-tens'on. Therefore* sur%'cal treatment 's d'rected at com(lete local control. Earl$ les'ons ma$ +e resected throu%h a lateral rh'notom$ and com(lete ethmo'dectom$. More e-tens',e tumors re3u're a com+'ned neurosur%'cal- cran'ofac'al effort* )'th e-(osure and com(lete resect'on of the cr'+r'form (late and ethmo'd s'nuses from +oth a su(er'or and 'nfer'or a((roach. Ad0u,ant rad'at'on thera($ ma$ 'm(ro,e local control and sur,',al* and 'no(era+le tumors often are treated )'th rad'at'on thera($ alone. Para%an%l'oma Para%an%l'omas or chemodectomas are neo(lasms that ar'se from neural crest cells and h'stolo%'call$ resem+le the'r adrenal %land counter(art* the (heochromoc$toma. The$ are class'f'ed +$ the'r locat'onA carot'd +od$* 0u%ular :ar's'n% from the %lomus 0u%ulare<* ,a%al +od$* or+'tal* and lar$n%eal. Althou%h these e-traadrenal (ara%an%l'on'c cells do conta'n small amounts of catecholam'nes* 't 's rare for them to (roduce a cl'n'call$ s'%n'f'cant e-cess of catecholam'nes. The most common of the (ara%an%l'omas* the carot'd +od$ tumor* usuall$ (resents as an as$m(tomat'c neck mass. Chemodectomas at other s'tes often (roduce com(ress',e s$m(toms result'n% 'n hear'n% loss* t'nn'tus* or fac'al ner,e (aral$s's. !nl$ C (ercent of these tumors are mal'%nant* and onl$ 6 (ercent metastas'4e. Mal'%nanc$ 's determ'ned +$ cl'n'cal +eha,'or rather than h'stolo%$. The$ are h'%hl$ ,ascular and ha,e a character'st'c a((earance on an%'o%ra(h$* )'th carot'd +od$ tumors se(arat'n% the 'nternal and e-ternal carot'd ,essels +$ a mass effect. .hen techn'call$ feas'+le* treatment should 'nclude com(lete resect'on* )h'ch 'n the carot'd +od$ tumor re3u'res su+ad,ent't'al d'ssect'on. The (oor-r'sk (at'ent )'th an as$m(tomat'c mass ma$ +e mana%ed more conser,at',el$. !steo%en'c arcoma Ten (ercent of osteo%en'c sarcomas occur 'n the head and neck. Most ar'se 'n the mand'+le or ma-'lla 'n the th'rd or fourth decade of l'fe. R'sk factors 'nclude (r'or rad'at'on thera($* f'+rous d$s(las'a* and ret'no+lastoma. These mal'%nanc'es (resent most fre3uentl$ as a hard mass )'th rad'o%ra(h'c chan%es of cort'cal destruct'on as )ell as ne) +one format'on. These tumors are h'%hl$ 'nf'ltrat',e not onl$ of +one +ut also of secondar$ mucosa and muscle and must +e resected )'th a )'de 4one of ad0acent soft t'ssue. Nodal metastas's 's uncommon@ ho)e,er* d'stant metastas's to lun% occurs 'n some (at'ents 'f local control 's not ach'e,ed. There has nonetheless +een some enthus'asm for chemothera($ adm'n'stered after sur%'cal resect'on. Rad'at'on thera($ 's %enerall$ reser,ed for curat',e s'tuat'ons. As )'th

rha+dom$osarcoma* the use of neoad0u,ant or ad0u,ant chemothera($ has +een effect',e 'n ch'ldren )'th osteo%en'c sarcoma +ut not 'n adults. AI& -RE#ATE& &I !R&ER HI9 'nfect'on and 'ts conse3uence* AI& * (roduce a lar%e num+er of a+normal't'es 'n the head and neck re%'on* +oth neo(last'c and nonneo(last'c. $m+'ot'c Infect'ons The %eneral'4ed 'mmunosu((ress'on allo)s normall$ s$m+'ot'c or latent or%an'sms to cause ser'ous d'sease and mor+'d't$. !ral cand'd'as's 's somet'mes one of the earl'est man'festat'ons of AI& . The com+'nat'on of -erostom'a* )h'ch ma$ +e related to the chron'c f'+ros's of the sal',ar$ %lands or +en'%n l$m(hoe('thel'al les'ons seen 'n HI9(os't',e (at'ents* and the d'stur+ance of normal flora of the oral ca,'t$ results 'n the (rol'ferat'on of $east and other fun%' to (atho%en'c le,els. Her(es s'm(le- ,'rus 'nfect'ons* result'n% 'n (a'nful ulcerat'ons of the l'(s* oral mucosa* and oro(har$n-* as )ell as ,ar'cella-4oster* )'th 'ts (a'nful d'str'+ut'on alon% the f'fth cran'al ner,e* also are common 'n (at'ents affl'cted +$ AI& * a%a'n (ro+a+l$ a result of %eneral'4ed 'mmunosu((ress'on. !ther 'nfect'ous d'sorders less commonl$ seen are human (a('lloma,'rus* c$tome%alo,'rus* cat-scratch d'sease* tu+erculos's* and o((ortun'st'c +acter'al 'nfect'on local'4ed to the oral ca,'t$ and oro(har$n-. #euko(lak'a !ral ha'r$ leuko(lak'a 's s'm'lar to the leuko(lak'a seen 'n chron'c smokers e-ce(t that 't has a sha%%$ or more nodular a((earance and 's more l'kel$ to (resent on the lateral +order of the ton%ue* fre3uentl$ as a +'lateral les'on. Cellular h$(er(las'a )'th (arakeratos's 's seen* and there 's a h'%h correlat'on* +oth serolo%'call$ and +$ electron m'crosco($* )'th the E(ste'n-5arr ,'rus. Th's les'on 's somet'mes an earl$ s'%n of ult'mate HI9 (os't','t$* a%a'n as an e-(ress'on of decreased 'mmunosur,e'llance. #$m(ho(rol'ferat',e &'sorders #$m(ho(rol'ferat',e d'sorders are character'st'c of AI& and fre3uentl$ occur 'n the head and neck. !+struct'on of the naso(har$n- secondar$ to o,er%ro)th 'n the .alde$er2s r'n% area has +een re(orted. Cer,'cal l$m(hadeno(ath$ 's commonl$ a (art of the AI& -related com(le- :ARC<* and 'n,ol,ement of the 'ntra(arot'd and su+mand'+ular l$m(h nodes* )'th c$st'c de%enerat'on and s$m(tomat'c accumulat'on of flu'd )'th'n them* causes enlar%ement of the nodes and 's an earl$ 'nd'cator of the full-+lo)n d'sease. Mal'%nant l$m(homas* most commonl$ of the 5-cell t$(e* also ha,e +een re(orted and are second onl$ to ;a(os'2s sarcoma 'n fre3uenc$* occurr'n% 'n u( to 1D (ercent of AI& (at'ents. These l$m(homas usuall$ are e-tranodular* )'th an unusual fre3uenc$ of (r'mar$ central ner,ous s$stem d'sease. #$m(homa also has +een re(orted 'n the neck* oral ca,'t$* and (aranasal s'nuses. Althou%h the tendenc$ to d'ssem'nate 's lo)er than 'n other l$m(homas* the d'sease course 's ra('d and lethal. #$m(homa occurs more commonl$ 'n 'ntra,enous dru% users than 'n (at'ents )ho ha,e de,elo(ed AI& from other sources. A%a'n there 's a h'%h correlat'on of l$m(homa )'th ele,ated ant'%en t'ters for E(ste'n-5arr ,'rus and electron m'crosco('c e,'dence of 'ts (resence. T-cell l$m(homas also occur +ut are less common. 8or d'sease local'4ed to one area* rad'othera($ ma$ +e an effect',e treatment. Mult'dru% s$stem'c chemothera($ also 's effect',e +ut (laces the alread$ 'mmunosu((ressed (at'ent at h'%her r'sk for d'ssem'nated 'nfect'on.

;a(os'2s arcoma ;a(os'2s sarcoma 's the most common mal'%nanc$ 'n AI& * ar's'n% 'n 15 (ercent of (at'ents. There 's (ro+a+l$ a se-ual mode of transm'ss'on* s'nce 't 's much more common 'n homose-ual AI& (at'ents than 'n those ac3u'r'n% the d'sease from 'ntra,enous dru% use or contam'nated +lood (roducts. 1nl'ke the class'cal form of ;a(os'2s sarcoma* )h'ch occurs 'n elderl$ males usuall$ on the lo)er e-trem't'es* th's form of the d'sease occurs 'n oral or (er'oral mucosa 'n 55 (ercent of the cases. The (alate 's the most common s'te* althou%h the ton%ue* (har$n-* and lar$n- ha,e +een descr'+ed as s'tes as )ell. 1suall$ mult'focal )'th'n the re%'on* 't ma$ ar'se 'n or metastas'4e to the cer,'cal l$m(h nodes or the sal',ar$ %lands. The tumor 'n't'all$ (resents as a flat +lue to (ur(le (atch and ma$ a((ear to +e a su+mucosal hematoma secondar$ to trauma. #ater 'n the course of %ro)th 't +ecomes nodular. 5'o(s$ e-am'nat'on re,eals endothel'al cell and f'+ro+last (rol'ferat'on* )'th 'ncreased ca('llar$ %ro)th* (rom'nent s('ndle cells* fe) m'toses* and e-tra,asat'on of er$throc$tes. The causat'on of ;a(os'2s sarcoma 's unclear* althou%h there 's some e,'dence l'nk'n% 't to c$tome%alo,'rus 'nfect'on or ,'ral 'nduct'on of local an%'o%en'c factors. As )'th all mal'%nanc'es 'n AI& (at'ents* the use of con,ent'onal mult'dru% s$stem'c thera($ 's some)hat ha4ardous +ecause of chron'c 'nfect'on. 'n%le-dru% treatment )'th ,'n+last'ne or eto(os'de* s$stem'call$ or +$ 'ntrales'onal 'n0ect'on* results 'n (art'al re%ress'on of tumor and s'%n'f'cant (all'at'on 'n u( to GD (ercent of (at'ents. Interferon-a* s$stem'call$ or as an 'ntrales'onal 'n0ect'on* also has +een moderatel$ effect',e. #ocal rad'othera($ )'th an ener%$ source* such as electrons* that has lo) (enetrat'on* 'n total doses of EDD to 1*5DD c"$* del',ered 'n ten fract'ons* also 's effect',e 'n shr'nk'n% les'ons and allo)'n% s'%n'f'cant (all'at'on. .'th all thera('es* med'an sur,',al of (at'ents 's / $ears* )'th a 5-$ear sur,',al rate of onl$ 1D (ercent. Carc'noma 3uamous cell carc'noma of the u((er aerod'%est',e tract has +een re(orted 'n the mouth* ton%ue* lar$n-* and other s'tes 'n AI& (at'ents. Althou%h the true r'sk 's uncerta'n* s3uamous cell carc'noma has a((eared 'n (at'ents of earl'er a%e and )'thout the usual r'sk factors of smok'n% and ethanol 'ntake. Th's (attern 's su%%est',e of a defect 'n 'mmunosur,e'llance s'm'lar to that seen 'n (at'ents ha,'n% under%one or%an trans(lantat'on. In AI& (at'ents* the med'an a%e of (resentat'on of s3uamous cell carc'noma 's G/ $ears* 'n contrast to CD $ears 'n the non'nfected (at'ent* and the cl'n'cal course seems to +e some)hat more a%%ress',e. A#I9ARN "#AN& Ph$s'olo%$ The (roduct'on and e-cret'on of the m'-ture of mucus* )ater* and electrol$tes kno)n as sal',a 'nto the entrance to the u((er aerod'%est',e tract are the funct'on of the sal',ar$ %lands. The ma0or sal',ar$ %lands are the s$mmetr'call$ (a'red (arot'd* su+mand'+ular* and su+l'n%ual %lands* )h'ch d'schar%e sal',a 'nto the oral ca,'t$ ,'a tensen2s ducts* .harton2s ducts* and the numerous small or'f'ces 'n the floor of the mouth* res(ect',el$. Clustered (r'mar'l$ 'n the soft and hard (alates +ut also found 'n the s'nuses and other s'tes of the u((er aerod'%est',e tract are the m'nor sal',ar$ %lands* )h'ch (roduce mucus for lu+r'cat'on. al',a cons'sts of ,ar$'n%

concentrat'ons of numerous su+stances. To some de%ree 'ts com(os't'on reflects the osmolal't$ and electrol$te concentrat'on of the e-tracellular flu'd* +ut 'ts s(ec'f'c funct'ons re3u're other com(onents as )ell. The normal ,olume of sal',ar$ secret'on 'n the adult male ran%es from 1*DDD to 1*5DD m# (er da$* ma'nl$ as serous flu'd from the (arot'd and su+mand'+ular %lands :B5 (ercent< +ut also com(osed of mucus :5 (ercent< from the su+l'n%ual and m'nor sal',ar$ %lands. Act',e )ater resor(t'on* sod'um and (otass'um 'on e-chan%e* and +'car+onate (roduct'on cou(le )'th (ass',e d'ffus'on of urea and ur'c ac'd to determ'ne the 'nor%an'c content of sal',a. Immuno%lo+ul'ns A* "* and M* al+um'n* l$so4$me* and other en4$mes also are secreted. In add't'on to 'ts lu+r'cat'n% (ro(ert'es* )h'ch allo) food to +e mo,ed throu%h the mouth* sal',a has ant'+acter'al and ant','ral (ro(ert'es* )h'ch (rotect the soft t'ssues of the oral ca,'t$ as )ell as the teeth. The neuro%en'c control of sal',ar$ secret'on de(ends on refle- arcs that carr$ afferent st'mul' from the s(ec'al'4ed sense or%ans ,'a cran'al ner,es I* 9* 9II* and II to the +ra'nstem and h$(othalamus* and efferent s'%nals* +oth s$m(athet'c and (aras$m(athet'c* alon% the +ranches of the e-ternal carot'd arter$* the su(erf'c'al (etrosal ner,e* and the chorda t$m(an'. Anatom$ Parot'd "land The (arot'd %land 's sha(ed l'ke a flattened ($ram'd* )'th 'ts a(e- 'n the (ara(har$n%eal s(ace +eh'nd the mand'+le ad0acent to the (ter$%o'd muscles and 'ts +ase e-tend'n% 'nto the (reaur'cular area from +elo) the an%le of the mand'+le 'n the neck* somet'mes as lo) as the m'dKsternocle'domasto'd muscle* to 0ust +elo) the 4$%omat'c arch. The med'al e-tent of the %land usuall$ reaches o,er the masseter muscle and the ,ert'cal ramus of the mand'+le. The (arot'd %land 's surrounded +$ the cont'nuat'on of the 'n,est'n% la$er of the cer,'cal fasc'a* the su(erf'c'al la$er of )h'ch 's cont'nuous )'th the (lat$sma. The (arot'd %land (arench$ma 's ar+'trar'l$ d','ded 'nto the dee( and su(erf'c'al lo+es +$ the fac'al ner,e* )h'ch e-'ts the skull ,'a the st$lomasto'd foramen and (asses throu%h the su+stance of the %land. A((ro-'matel$ 7D (ercent of the %land l'es su(erf'c'al to the (lane of the ner,e and GD (ercent dee( to 't. The l$m(hat'c dra'na%e of the m'dface* forehead* and anter'or (ort'on of the scal( em(t'es 'nto l$m(h nodes that l'e su(erf'c'al to the fasc'a of the (arot'd and )'th'n the %land 'tself +efore send'n% efferent channels to the 0u%ulod'%astr'c area. ensor$ su((l$ to the %land der',es from +ranches of the tr'%em'nal ner,e and from the %reat aur'cular ner,e* carr$'n% cer,'cal (le-us a-ons. tensen2s duct* the (arot'd duct* condenses from the lar%er 'ntralo+ular ducts and (asses ad0acent to the +uccal +ranch of the fac'al ner,e on a l'ne +et)een the tra%us of the ear and the m'dl'ne of the u((er l'(. It enters the oral ca,'t$ ad0acent to the second ma-'llar$ molar tooth. The fac'al ner,e* )h'ch su((l'es motor 'nner,at'on to the muscles of fac'al e-(ress'on and se,eral other muscles* e-'ts the +ase of the skull from the st$lomasto'd foramen* (ass'n% dee( to su(erf'c'al and caudad to ce(halad +efore +ranch'n% at the (es anser'nus 'nto an u((er and lo)er d','s'on. Althou%h there 's some ,ar'a+'l't$ 'n +ranch'n% (atterns* (art'cularl$ of the +uccal +ranch* the u((er d','s'on usuall$

'ncludes the tem(oral* 4$%omat'c* and +uccal +ranches* and the lo)er d','s'on* the mand'+ular and cer,'cal +ranches. u+mand'+ular "land The su+mand'+ular sal',ar$ %land 's surrounded +$ a condensat'on of the cer,'cal fasc'a that l'es +eneath the (lat$sma muscle* connect'n% to the (arot'd fasc'a and kno)n as the (ars 'nter%landular's* se(arat'n% the (arot'd and 0u%ulod'%astr'c areas from the su+mand'+ular tr'an%le. The anatom'c +oundar'es of the su+mand'+ular tr'an%le are the anter'or +ell$ of the d'%astr'c muscle med'all$* the (oster'or +ell$ laterall$* and the mand'+le su(er'orl$. The %land l'es on the h$o%lossus muscle and )ra(s +oth su(erf'c'al and dee( to the m$loh$o'd muscle med'all$. The su+mand'+ular %an%l'on of the l'n%ual ner,e carr'es efferent ner,e su((l$ ,'a the chorda t$m(an'. .harton2s duct con,e$s the secret'ons of the su+mand'+ular sal',ar$ %land 'nto the oral ca,'t$. u+l'n%ual "lands The su+l'n%ual sal',ar$ %lands l'e 'mmed'atel$ +eneath the mucosa of the floor of the mouth* 'nt'matel$ related to the l'n%ual arter$* and release the'r mucous secret'ons 'nto the oral ca,'t$ throu%h numerous or'f'ces alon% the al,eolol'n%ual sulcus. Inflammator$ and Infect'ous &'sorders Inflammat'on usuall$ (resents as d'ffuse enlar%ement or f'rmness of the %land* un'lateral or +'lateral* assoc'ated )'th tenderness and er$thema. 5acter'al 'nfect'on usuall$ 's the result of duct o+struct'on and retro%rade 'nfect'on )'th oral +acter'a. Acute +acter'al (arot't's ma$ +e seen 'n the elderl$ (osto(erat',e (at'ent )ho +ecomes deh$drated and 's usuall$ caused +$ ta(h$lococcus aureus. Althou%h reh$drat'on and ant'+'ot'c thera($ ma$ +e successful* dra'na%e of local'4ed a+scesses and e,en total (arot'dectom$ ma$ +e re3u'red for resolut'on. 5ecause of the se(tate nature of the (arot'd* s'm(le dra'na%e of the %land 's fre3uentl$ unsuccessful. Acute s'aladen't's of the su+mand'+ular %land also ma$ necess'tate %land resect'on. Mum(s* co-sack'e,'rus* and echo,'ruses also ma$ cause acute (arot't's* usuall$ (an%landular +ut occurr'n% as un'lateral %land enlar%ement. Tu+erculos's* act'nom$cos's* and cat-scratch d'sease also ma$ (resent )'th enlar%ement of the sal',ar$ %lands or of the'r ad0acent l$m(h nodes. $stem'c d'sorders such as sarco'dos's* 0O%ren2s s$ndrome* and c'rrhos's )'th l',er fa'lure also result 'n sal',ar$ %land enlar%ement. M'kul'c42s s$ndrome* enlar%ement of the %land )'th h'stolo%'c chan%es reflect'n% loss of ac'nar e('thel'um and re(lacement )'th chron'c 'nflammator$ cells* 's a nons(ec'f'c accom(an'ment of se,eral d'seases* such as leukem'a* l$m(homa* and tu+erculos's. Tumors Patholo%$ The cl'n'cal (ro+lem most fre3uentl$ (resented to the sur%eon 's that of a d'screte mass 'n the sal',ar$ %land* (art'cularl$ the (arot'd %land. !f sal',ar$ %land tumors* 7D to ED (ercent (resent 'n the (arot'd %land. !f (arot'd %land tumors* 7D to ED (ercent are +en'%n and* of the +en'%n tumors* ED (ercent are (leomor(h'c adenomas. Althou%h l$m(h nodes* l'(omas* c$sts* or other +en'%n ent't'es ma$ (resent as sol'tar$ masses* the +en'%n (leomor(h'c adenoma 's +$ far the most common mass. !ccurr'n% most fre3uentl$ 'n the f'fth decade* )'th a sl'%ht female (redom'nance* the +en'%n

m'-ed tumor or (leomor(h'c adenoma 's the (rol'ferat'on of e('thel'al and m$oe('thel'al cells of the ducts as )ell as an 'ncrease 'n the stromal com(onent* )h'ch h'stolo%'call$ ma$ a((ear s'm'lar to cart'la%e. A true e('thel'al +en'%n neo(lasm* 't ma$ %ro) to a lar%e s'4e )'thout caus'n% fac'al ner,e s$m(toms :8'%. 1565<. Pleomor(h'c adenomas usuall$ (resent as a sol'tar$ (a'nless mass 'n the su(erf'c'al lo+e of the %land. &ee( lo+e %ro)th ma$ (resent as an 'ntraoral (har$n%eal mass as %ro)th e-tends 'nto the (har$n- ,'a the (ara(har$n%eal s(ace. Mal'%nant de%enerat'on of (leomor(h'c adenomas occurs 'n / to 1D (ercent of adenomas follo)ed for lon% (er'ods* )'th carc'noma e- (leomor(h'c adenoma occurr'n% most fre3uentl$ as adenocarc'noma. The second most fre3uent +en'%n neo(lasm of the sal',ar$ %lands 's the (a('llar$ c$stadenoma l$m(homatosum or .arth'n2s tumor. .'th a marked male (redom'nance* 't usuall$ occurs 'n the ta'l of the (arot'd %land and (resents )'th a l$m(hoc$t'c 'nf'ltrate as )ell as c$st'c e('thel'al (rol'ferat'on. There 's a 1D (ercent 'nc'dence of +'lateral't$ and mult'centr'c't$. A su+set of the %rou( of monomor(h'c adenomas* .arth'n2s tumors com(r'se 6 to E (ercent of all (arot'd tumors. !ther +en'%n monomor(h'c adenomas 'nclude o-$(h'l'c adenoma* oncoc$toma* +asal cell adenoma* se+aceous adenoma* s'aladenoma (a('ll'ferum* and canal'cular adenoma* all of )h'ch are rare. Pleomor(h'c adenoma 's the most common +en'%n tumor of the (arot'd* su+mand'+ular* and m'nor sal',ar$ %lands. Mal'%nant tumors of the sal',ar$ %lands occas'onall$ :6 (ercent< (resent as a d'ffuse enlar%ement of a %land* almost al)a$s as a d'screte mass. Pa'n 's assoc'ated )'th mal'%nanc$ 'n 1/ to /6 (ercent of cases. !ther s$m(toms 'nclude form'cat'on :a (aresthes'a that 's descr'+ed as the feel'n% of ants cra)l'n% on the sk'n<* fac'al ner,e d$sfunct'on :E to /C (ercent<* or com(lete (ares's of the ner,e :7 to B (ercent<. All of these s$m(toms and s'%ns carr$ a (oorer (ro%nos's than as$m(tomat'c d'sease :8'%. 15-6C<. 8ac'al ner,e (als$ 's almost ne,er seen )'th +en'%n d'sease* so the (resence of ner,e (als$* e,en )'thout a d'screte mass* must +e cons'dered a (oss'+le s'%n of mal'%nanc$. 8'-at'on to the masseter muscle or (ter$%o'd muscles occurs 'n a((ro-'matel$ 17 (ercent of cases* and sk'n ulcerat'on 'n B (ercent. The r'sk of cl'n'cal or su+cl'n'cal metastases to the cer,'cal l$m(h nodes from sal',ar$ %land cancers de(ends on the h'stolo%$ and %rade of the (r'mar$ tumor. H'%h-%rade mucoe('dermo'd adenocarc'noma and s3uamous cell carc'noma ha,e a h'%h r'sk of metastat'c d'sease :8'%. 15-67<* )hereas adeno'd c$st'c ac'n'c cell and lo)er %rades of mucoe('dermo'd and s3uamous cell ha,e a lo) r'sk of metastas's. A((ro-'matel$ /D (ercent of (arot'd %land neo(lasms are mal'%nant. The r'sk of mal'%nanc$ 's 'n,ersel$ (ro(ort'on to %land s'4e* )'th the su+mand'+ular %lands ha,'n% 6D (ercent mal'%nant tumors and the m'nor sal',ar$ %lands CD (ercent. &'a%nos's The d'screte mass 'n the sal',ar$ %land must +e cons'dered a (oss'+le mal'%nanc$. H'stor$ and (h$s'cal e-am'nat'on ma$ (ro,'de some 'nd'cat'on that the les'on 's mal'%nant. Com(lete resolut'on after 1D da$s of ant'+'ot'cs and cl'n'cal features cons'stent )'th 'nflammat'on ma$ const'tute an ade3uate thera(eut'c tr'al. &ef'n't',e h'stolo%'c d'a%nos's* ho)e,er* 's ult'matel$ necessar$. 8'ne-needle as('rat'on ma$ +e hel(ful 'n (lann'n% sur%er$* +ut an$ uncerta'nt$ should +e treated )'th ade3uate

sur%'cal e-c's'on. CT scan of the (arot'd 's hel(ful 'n determ'n'n% e-tens'on of the tumor 'nto the dee( lo+e. MRI can +e formatted 'n +oth a-'al and coronal (lanes* %','n% e,en +etter anatom'c 'nformat'on. .hen carefull$ (erformed and anal$4ed MRI can (ro,'de 'nformat'on a+out the fac'al ner,e and 'ts anatom'c relat'onsh'( to the tumor. Contrast-enhanced stud'es ma$ allo) d'scr'm'nat'on +et)een the %land and metastat'c l$m(h nodes* (art'cularl$ 'n the su+mand'+ular area* d'fferent'at'n% metastases from the head and neck s'te to an 'ntra%landular or e('%landular l$m(h node from 'ntr'ns'c mal'%nanc$ of the sal',ar$ %land. 'alo%ra(h$* or 'n0ect'on of contrast mater'al 'nto tensen2s or .harton2s ducts* 's useful 'n demonstrat'n% the chron'c stenot'c chan%es of a +en'%n l$m(hoe('thel'al les'on or chron'c (arot't's and 'n sho)'n% com(lete occlus'on from stones. E'%ht$ (ercent of (arot'd duct stones are rad'olucent. E'%ht$ (ercent of su+mand'+ular %land stones are rad'o(a3ue. Treatment The sur%'cal a((roach to a sal',ar$ %land mass 's (red'cated on the assum(t'on that 't 's mal'%nant. The ma0or confound'n% factor 's the (resence of the fac'al ner,e 'n the (arot'd %land. 'nce the fac'al ner,e (asses throu%h the %land* the usual sur%'cal oncolo%'c a((roach to head and neck mal'%nanc$=en +loc resect'on=)ould re3u're e-c's'on of the ner,e 'n all cases. Th's a((roach* ho)e,er* 's not a((ro(r'ate 'n most s'tuat'ons. If there 's no e,'dence of ner,e 'n,ol,ement* the tumor should +e e-c'sed +$ su(erf'c'al lo+ectom$* remo,al of the (arench$ma a+o,e the ner,e )'th a mar%'n of normal t'ssue* (reser,'n% the ner,e. If the tumor 's mal'%nant* total (arot'dectom$ )'th (reser,at'on of the ner,e 's 'nd'cated* thou%h 't 's a ('ecemeal (rocedure :8'%. 15-6E<. In,ol,ement of a +ranch of the ner,e re3u'res remo,al of that +ranch. In $oun% (at'ents* ner,e %raft should +e used to re(lace the resected ner,e se%ment 'n the ho(e of a,o'd'n% the lon%-term se3uelae of fac'al ner,e (als$. In the e,ent of 'n,as'on of the ner,e +$ tumor* an$ (ro-'mal e-tens'on of the mal'%nanc$ to the +ase of the skull should +e e,aluated* and 'n some cases resect'on of the ner,e to clear mar%'n 'n the st$lomasto'd foramen or the fac'al canal ma$ 'm(ro,e sur,',al. If the fac'al ner,e 's not 'n,ol,ed +$ mal'%nanc$ +ut (reser,at'on of the ner,e )ould result 'n %ross d'sru(t'on of the tumor* the ner,e should +e remo,ed and re(laced )'th a ner,e %raft. .hen cl'n'cal e-am'nat'on* )'th or )'thout f'ne-needle as('rat'on c$tolo%$* does not clearl$ def'ne the (ro+lem* a +'o(s$ s(ec'men should +e o+ta'ned +$ su(erf'c'al lo+ectom$* )'th 'dent'f'cat'on and (reser,at'on of the ma'n trunk of the fac'al ner,e and 'ts +ranches. 5en'%n tumors of the su(erf'c'al lo+e should +e remo,ed )'th a clear mar%'n +$ su(erf'c'al lo+ectom$. If the dee( lo+e 's 'n,ol,ed* total (arot'dectom$ ma$ +e re3u'red e,en for +en'%n d'sease* althou%h (art'al (arot'dectom$ 's somet'mes (oss'+le. Treatment of the neck 'n (at'ents )'th mal'%nant d'sease of the (arot'd de(ends on the h'stolo%'c t$(e and the %rade of the tumor and 'ts r'sk of metastat'c d'sease or the (resence of the metastat'c d'sease 'tself. Node- (os't',e necks are treated +$ the a((ro(r'ate neck d'ssect'on=rad'cal neck d'ssect'on 'f there 's 'n,ol,ement 'n the sternocle'domasto'd muscle or the 0u%ular ,e'n* or mod'f'ed or select',e neck d'ssect'on de(end'n% on the s'te of metastas's. Althou%h elect',e or (ro(h$lact'c neck d'ssect'ons are not as fre3uentl$ necessar$ as 'n mucosal mal'%nanc$* the$ are

'nd'cated 'n h'%h- %rade mucoe('dermo'd carc'noma* s3uamous cell carc'noma* and h'%h- %rade adenocarc'noma. Neoad0u,ant :(reo(erat',e< or ad0u,ant chemothera($ has not +een effect',e 'n treat'n% mal'%nanc$ of the sal',ar$ %lands=(arot'd* su+mand'+ular* or m'nor %lands. Ad0u,ant (osto(erat',e rad'othera($* ho)e,er* 's effect',e. Rad'at'on (ortals should 'nclude the ent're s'te of sur%er$* the foramen o,ale* the +ase of the skull* 'nclud'n% the masto'd (rocess and the st$lomasto'd foramen* and the '(s'lateral neck de(end'n% on the r'sk of metastas's. The r'sk of recurrent d'sease and the (attern of recurrence also de(end on h'stolo%$ and %rade. Mucoe('dermo'd carc'noma* s3uamous cell carc'noma* and h'%h-%rade adenocarc'noma ha,e a h'%h fre3uenc$ of cer,'cal and d'stant metastas's as )ell as local recurrence. Adeno'd c$st'c carc'noma 's character'4ed +$ an 'ndolent course +ut relentless local (ro%ress'on and (er'neural 'n,as'on* )'th d'sease e,entuall$ e-tend'n% to the +ase of the skull and the +ra'n. 5oth adeno'd c$st'c and mucoe('dermo'd carc'noma ma$ demonstrate e-tens',e (ulmonar$ metastas's that rema'ns as$m(tomat'c for relat',el$ (rolon%ed (er'ods* and the (at'ent2s death ma$ +e caused +$ locore%'onal d'sease rather than +$ d'ssem'nated d'sease. Just as ad0u,ant chemothera($ has +een unsuccessful* so 's treatment of d'ssem'nated d'sease* althou%h +oth do-oru+'c'n and c's(lat'n ha,e demonstrated f'n'te res(onse rates )'thout (rolon%at'on of sur,',al. #ocal recurrence ma$ +e successfull$ treated +$ rad'cal resect'on )'th or )'thout ad0u,ant rad'othera($. The treatment of su+mand'+ular %land a+normal't'es follo)s the same +as'c rule as for the (arot'd %land. If def'n't',e d'a%nos's cannot +e made +efore sur%er$* total e-c's'on of the %land* )'th (reser,at'on of the un'n,ol,ed mar%'nal mand'+ular* h$(o%lossal* and l'n%ual ner,es* 's 'nd'cated and 's ade3uate thera($ for +en'%n tumors and 'nflammator$ or auto'mmune d'sorders. Rad'cal resect'on of the ner,es* (lat$sma* sk'n* and underl$'n% muscle 's reser,ed for e-tens',e local 'n,as'on. Adeno'd c$st'c carc'noma 's the most common mal'%nant h'stolo%$ of the su+mand'+ular %land* and (leomor(h'c adenoma the most common +en'%n tumor. Ad0u,ant (osto(erat',e rad'othera($ a((ears to +e hel(ful 'n the mal'%nant tumor. M'nor sal',ar$ %land d'sorders reflect the s(ectrum seen 'n the ma0or sal',ar$ %lands. Mucocele 's a c$st'c enlar%ement of the 'ntraoral %lands usuall$ seen 'n the l'( or the floor of the mouth. 0O%ren2s s$ndrome of keratocon0unct','t's s'cca 's d'a%nosed +$ l'( +'o(s$ and h'stolo%'c conf'rmat'on of the chron'c 'nflammator$ chan%es seen 'n the m'nor sal',ar$ %lands. Necrot'4'n% s'alometa(las'a* an ulcerat',e +ut self-l'm'ted d'sorder affect'n% the 0unct'on of the hard and soft (alates* cl'n'call$ m'm'cs mal'%nanc$ +ut e,entuall$ heals@ +'o(s$ e-am'nat'on re,eals no e,'dence of mal'%nant chan%e. Tumors of the m'nor sal',ar$ %lands* e'ther +en'%n or mal'%nant* ma$ occur 'n an$ of the mucosa-l'ned areas of the u((er aerod'%est',e tract +ut are most common 'n the hard and soft (alates. The'r (resentat'on ma$ +e as a su+mucosal or an ulcerat',e mass. Pleomor(h'c adenoma 's the most common +en'%n tumor* and mucoe('dermo'd and adeno'd c$st'c carc'noma :8'%. 15-6B< occur )'th rou%hl$ the same fre3uenc$ as mal'%nanc'es. Thera($ 's )'de local resect'on* 'nclud'n% su+0acent +one 'f the hard (alate 's 'n,ol,ed* )'th ad0u,ant rad'othera($ for mal'%nanc$. 'nce su+cl'n'cal

metastases to the neck are rare* cer,'cal l$m(hadenectom$ 's reser,ed for (at'ents )'th h'stolo%'call$ (ro,ed l$m(h node metastases. Palatal defects usuall$ can +e reha+'l'tated )'th dental (rostheses* thou%h local or d'stant t'ssue transfer ma$ +e necessar$ for e-tens',e d'sease. :5'+l'o%ra(h$ om'tted 'n Palm ,ers'on<