Department of Ear ,Nose and Throat

Head and Neck Surgery

Medical Faculty Padjadjaran University
Bandung

TUMOR

TYPE
SIZE
. LOCATION

BENIGN
MALIGNANT

.METASTASIS
-LOCAL
-DISTANT
2

ETIOLOGY
SYMPTOMS
SIGNS
PHYSICAL EXAMINATION
LAB & RAYS
PATHOLOGY EXAMINATION
THERAPY
3

ETIOLOGY (General)

IONISING RADIATION
UV RADIATION
AIR POLLUTION
PROFESSION FACTOR
FOOD
IATROGENIC CHEMICAL
HORMONAL

TOBACCO
SEX & REPRODUCTIVE LIFE
CIRCUMCISION
PARASITES
GENETIC
IMMUNODEFICIENCY
VIRUS

RADIATION SOURCES
RADIOACTIVE MINERAL MINING
RADIATION FROM MEDICAL AQUIPMENT
X RAY
THOROTHRAST
Ra 224
ATOM BOM

PROFESSION

TAR

MINERAL OIL CONTAINING DERIVAT ATHRACENE

ANILINE

- BENIZIDINE
- NAPHTHYLAMINE
- AMINOBIPHENYL

ASBESTOS
BENZENE

V I R U S
Human t cell leukemia v (htl.V-i)
Hepatitis b.V. (Hbv)
Human papilloma v (hpv 16, 18, 31)
Epstein-barr.V (ebv)
Chemical Carcinogenesis
- V. Chlorida
- Aflatoxin

CANCER DEVELOPMENT

- INDUCTION
15 30 tahun
- IN SITU
5 10 tahun
- INVASI
1 5 tahun
- DISSEMINATE
1 5 tahun

CHROMOSOME CHANGES :

1. RECIPROCAL TRANSFORMATION
2. ADDITION OF GENS IN SPECIFIC AREA
OF CHROMOSOM
3. NON RECIPROCAL CHANGES
DELETION
ADDITION

EXAMPLE

AD.1 : - CHRONIC MYELOID L

Between Chromosom 22 - 9
- ACUTE PROMYELYTIC L
BetweenChromosom 15 & 17
AD.2 : 11.q 13 is locus for
ONCOGENE :` INT 2
HST 1
bCL 1
PRAD 1
AD.3 : - DELETION 3p, Small Ca Paru
- DELETION of 3p 21, 3p24.

10

TUMOR & GEN p.53

GEN p.53 & TUMOR

SITE GEN p.53
FUNCTION GEN p.53
MUTATION GEN p.53 & ITS CONSEQUENCES
* FAMILIAL MULTIPLE TUMOR

ONCOGEN, PROTOONCOGEN

11

Chief complaint of the tumor of

the head and neck area

1. Lump/Lession
2. Nasal Obstruction
- nasal bleeding
- nasal deformity
3. Proptosis
- Blurred vission
- Double vission
Opthalmoplegia
4. Ear
: - obstruction
- hearing impairment
- blood/fluid from ear
- pain
- ear that pushed out
5. Face
: - numb/pain
- N VII paralysis

12

6. Mouth and Pharynx

- lump in the longue
- pain
- deformity
- bleeding
- food goes into nose
- trismus
7. Larynx
- hoarse
- dyspnue
- aspiration
- haemaptae
8. Esophagus : - lump in the throat
9. Lung : - cough
- haemaptae
- dyspnue
10.Thyroid : salivary gland
13

Signs of malignant tumor in head and neck area

Ear

: - middle ear mass

- external mass
- middle ear fluid
- bleeding

Nose
Face

:-

: - deformity
- nasal mass
- bleeding

N.VII paralysis
pain/numb
supraorbital
mental

Eye

:-

n.VI paralysis
opthalmoplegia
blurred vision
exopthalmus + proptosis

Mouth : - mass

- lesion
- stiff tongue

14

Pharynx : - Nasoph

soft
firm

mass
bleeding
eustachea tube obtruction

- Oro
Hypo

pharynx
- Mass
- lesion

Larynx : - Mass

- Vocal cord mobility

- deformity

15

X Ray : Ear

; Schuller, Stenvers
transorbital; polytome

Nose & SPN :

-Waters
-Caldwell
-Submentovertex
-Lateral PNS
Nasoph : - Schedel basis/Submentovertex
Oro; Hypo ph & Larynx :

- extension position of lat.soft tissue

- tomogram larynx
- laryngogram
Esoph : esophagogram
Tracheo bronchial : chest X Ray
- CT : - axial
- Coromal
- MRI

16

Material and Pathology tissue:

-Excisional biopsy
-Incisional biopsy
-Needle biopsy

Extension & metastasis of malignant head and neck tumo

Metastasis area of malignant head and neck tumor
- lymphogen (Ca)
- Haematogen (Sa)
- Percontinuitatum
Lymphogen : mucosa tumor
epithelial tumor

17

AREA METASTASIS FROM :

Nose :
Paranasal sinus:
Nasopharynx :
Oropharynx :
Mouth :

anterior
posterior

- Base of the tongue

- Hypopharynx
- Esophagus
Skin Sq cell Ca
Melanoma

18

THERAPY DEPENDS ON :
SIZE , EXTENSION, TYPE
EXOPHYTIC / INFILTRATION
INVOLVING THE MUSCLE / BONE
POSSIBILITY OF COMPLETE RESECTION
POSSIBILITY OF METASTASIS
GENERAL CONDITION
PRESERVATION :
- SPEECH
- SWALOWING
SOCIAL STATUS
CAPABILITY OF SURGEON, RADIOTHERAPIST
AND CHEMOTHERAPIST

19

THERAPY

SURGICAL
RADIATION
CHEMOTHERAPY
CRYO SURGERY, LASER
IMMUNOTHERAPY
COMBINATION

PURPOSE

- FOR CURE
- PALIATIVE

20

AREA TUMOR
HEAD & NECK

NOSE AND PARANASAL SINUS

EAR
MOUTH
PHARYNX
NASOPHARYX
OROPHARYX
HYPOPHARYX
LARYNX
CERVICAL ESOPHAGUS
SALIVARY GLANDS
. THYROID & PARATHYROID
VASCULAR TUMORS
21

CANCER H & N (Distribution)

ORAL CAVITY 40%

LARYNX 25%
PHARYNX 15%
SALIVARY GL 7%
OTHERS 13%

Ca H & N 10% ALL MALIGNANCY

22

STAGING (General)

I.

T1

N0

M0

II.

T2

N0

M0

III.

T3/4
ANY T

N0
N1/N2

MO
M0

IV.

ANY T
ANY T

N3
Any N

M0
M1

23

LIMPHADENOPATHY COLI (NECK)

UICC

AJC

24

Regional Lymph Nodes

NX
N0

: Neck lymph node status unknown

: No metastasis

N1

: Metastasis one side ipsi lateral LN 3 cm

N2a

: Metastasis one side ipsi lateral LN> 3 cm,

< 6 cm
: or multiple ipsi lateral LN, < 6 cm
: or bilateral/contralateral LN, < 6 cm

N2b
N2c
N3

: Metastasis pada regional LN, > 6 cm at

largest diameter

25

26

NOSE TUMOR AND PARANASAL SINUS

BENIGN :
- OSTEOMA
- OSSIFYING FIBROMA
- FIBROUS DYSPLASIA
- PAPILLOMA
- HEMANGIOMA
- LYMPHANGIOMA
- NASOPHARYNX ANGIOFIBROMA

27

NOSE AND PARANASAL SINUS

(Type and frequency of malignant)

SQUAMOUS CELL Ca ( 57% )

ADENOID CYSTIC Ca
ADENO Ca.
( 18% ) : UNDIF CELL Ca 10%
SARCOMA : - SPINDLE CELL Ca
(RARE) 15%
- ROUND CELL Ca
- OSTEO Sarcoma
- CHONDRO Sarcoma

CHILDREN : HIST & RHABDOMYO Sarcoma

PRIMARY SITE
ANTRUM
NOSE
ETHMOID
FRONTAL & SPH

60%
15%
20%
1%

28

MALIGNANT TUMOR

SUPERIOR SINUS (AREA)

FRONTAL
ETHMOID
SPHENOID
MAXILLO ETHMOID

T1
T2
T3
T4

:
:
:
:

1 AREA
1 REGION
> 1 REGION
SKIN, SKULL BASE, NASOPHAR

29

MAXILLARIS SINUS

SUPERIOR
INFERIOR
MEDIAL
LATERAL

30

Maxillaris Sinus
Tx
T0
T1S
T1
T2

:
:
:
:

Unknown primary tumor

No primary tumor
Ca in situ
Tumor confined to antral mucosa
without erosion/destruction
: Tumor with erosion /destruction of
palatum durum or meatus media or both

T3

: Tumor has invaded : cheek skin or posterior

wall,floor of the orbital or anterior of ethmoid

T4

: Tumor has invaded orbita or area cribosa/

ethmoid posterior/sphenoidalis sinus/nasopharynx/soft palate/pterygomaxillary/temporal
fosa/skull base.
31

NOSE TUMOR
LOCATION

ROOF + CONCHA SUP

LATERAL HIDUNG + C. INF & MEDIA
NASAL SEPTUM
NASAL FLOOR

32

THERAPY

: ( Nose & Paranasal sinus

malignat tumor)
1. OPERATION
- MAXILLECTOMY

T
+ ORBITAL EXENTERASI
- LATERAL RHYNOTOMY
- ANTERIOR SKULL BASE RESECTION
- FRONTAL BONE RESECTION

2. RADIO THERAPY : 6.000 Rad

- PRE OP
- POST OP.
3 3.CHEMO THERAPY : PALLIATIVE
5 years : 30-40 %

33

MOUTH TUMOR AND OROPHARYNX

BENIGN :

- HEMANGIOMA
- PAPILLOMA
- LINGUAL Thy

MALIGNANT :- SQUAMOUS CELL CA

- ANAPLASTIC
- AD. CA
RARE
- ADENO CA
- SARCOMA :- SPINDLE CELL
- MYXOMA
- M. LYMPHOMA
- RHABDOMYOSAR
34

MOUTH TUMOR :
B E N I G N
MALIGNANT
LOCATION :
-LIP
- BUCCAL MUCOSA
- LOWER ALVEOLUS
- UPPER ALVEOLUS
- RETROMOLAR TRIGONUM
- FLOOR OF THE MOUTH
- HARD PALATUM
- 2/3 ANTERIOR OF THE
TONGUE
STAGING & THERAPY

35

LIP TUMOR
TIS
T0
T1

2 CM

T2

2-4 CM

T3

> 4 CM

T 4

TUMOR INVASION INTO

ADJACENT STRUCTURE
36

Mouth & Oropharynx

T1S

- Ca in situ

T1

- Tumor < 2cm at largest diameter

T2

- Tumor > 2cm, < 4cm

T3
- Tumor > 4cm with antral invation
T4 Mulut - Massive > 4cm with invaded antral ,
M Platerygoid, base of the tongue or neck
skin
T4 Oropharynx : > 4cm with invaded the bone,soft
tissue or muscle of the tongue.
37

PHARYNX :
NASOPHARYNX
OROPHARYNX

HYPOPHARYNX

38

 NEOPLASMA NASOPHARYNX
- HISTO
: - UNDIFF. CA
- NON KERATINISNG CA
- SQUAMOUS CELL CA.
- CHORDOMA,
- CRANIOPHARYNGIOMA
- TH/.
OROPHARYNX

BASE OF THE TONGUE

ARCUS FAUCEUM
TONSIL + PILLAR
PHARYNGEAL WALL

- TH/.
39

Nasopharynx
T1S

: Ca in situ

T1

: Tumor confined to one location in nasopharynx

or tumor cannot be seen only biopsy +

T2

: Tumor confined to two location

( posterosuperior & lanteral wall or both )

T3

: Tumor with extention to the nose or oropharyx

T4

: Tumor had invaded at skull or cranial nerve

40

 HYPOPHARYNX
PIRIFORM SINUS
POST CRICOID
POST PHARYNX WALL
TIS
T0
T1 : 1 LOCATION
T2 ; EXTEND TO OTHER LOCATION
FIXATION (-)
T3 : EXTEND TO OTHER LOCATION
+ FIXATION
T4
: EXTENSION INTO ADJACENT
STRUCTURE
41

42

VASCULARY TUMOR OF
THE HEAD & NECK
CHEMODECTOMA
10% MALIGNANT
5% LOCAL METASTASIS
5% DESTANT METASTASIS

43

LARYNGEAL TUMOR
BENIGN

POLYPS
REINKES EDEMA
PAPILLOMA
RETENTION CYST
CHONDROMA

LEUCOPLACHIA

: Grade 1,2,3.

MALIGNANT :

- SQUAMOUS CELL CA.

- CHONDRO SARCOMA

44

MALIGNANT TUMOR OF
THE LARYNX
GLOTTIS
SUPRA GLOTTIS
SUB GLOTTIS

65%
30%
5%

STAGING
TH/.

45

Larynx
Supraglottic
T1S
: Ca in situ
T1

: Tumor confined to the original place with

normal movement

T2

: Tumor extend to adjacent supraglotis area

without fixation

T3

: Tumor still confine to the larynx with fixation

or extension or both to postcricoid,medial
pryfrom sinus wall or to pre epiglotic space

T4

: Massive tumor that had invaded to oropharynx

soft tissue of the neck or destruction from
46
thyroid cartilage.

Glottic
T1S

: Ca in situ

T1

: Tumor confine to vocal cord with

normal mobility

T2

: Extended to supra / subglotic or both with

normal / abnormal vocal cord movement

T3

: Tumor confine to the larynx with fixation

of vocal cord

T4

: Massive tumor with destruction of thyroid

47

cartilage or extra larynx extension or both

Subglotis
T1S

: Ca in situ

T1

: Tumor confine to subglotic area

T2

: Tumor extended to vocal cord ,normal

mobility/impairet

T3

: Tumor with cartilage destruction or

extra larynx extension or both

48

THERAPY
SURGERY
RADIO THERAPY
CHEMO THERAPY
SURGERY :
-DECORTICASI
- CORDECTOMY
- VERTICAL/HORISONTAL PARTIAL LARYNGECT.
- TOTAL LARYNGECTOMY
REHABILITATION :
- SPEECH
- SOCIAL

49

NEOPLASMA GLANDULA THYROID & PARATHYROID

WORK UP.
THERAPY

50

THYROID CA
1% dari All Ca.
: - 7-20 y
Age
- 40-65 y
MALE: FEMALE = 1 : 2
25% DARI NODULAR GOITER
RISE
NODULE, MALIGN.
IRRADIASI
PAPILLARY (60%)
- MULTICENTRIC 50% PD C. Lateral

51

 FOLLICULAR
UNIFOCAL
METASTASIS TO NECK
( & VASCULAR)
PAPILARY & ALVEOLARY ADENO Ca
> MALIGNANT PD ORANG TUA
MEDULLARY Ca,
FROM C Cells
Calcitonin MEA
L. NODE : EARLY METASTASIS
UNDIF THYROID Ca : 10%
52

Thyroid Gland
TX

: Tumor cannot be assessed

T0

: No primary tumor

T1

: Tumor < 1cm in largest diameter but

still confine to the thyroid

T2

: Tumor > 1 cm, < 4 cm

T3

: Tumor > 4 cm still confine to the thyroid

T4

: Any size of tumor with extra thyroid

extension
53

Staging of Malignant Thyroid Tumor

Papillary & Follicular
Under 45 years old
stage I : any T, any N M0
Stage II : any T, any N M1
Over 45 years old
stage I T1
stage II T2
stage III T3
any
stage IV any

N0 M 0
N 0 M0
N0 M 0
T N 1 M0
T any N M1
54

Medullary
Stage I
II

T1
N0
T2
N0
T3
N0
T4
N1
III any T N1
IV any T, any N

M0
M0
M0
M0
M0
M1

Undifferentiated
all stage IV
any T, any N,any M
55

5 y SURVIVAL RATE
PAPILLARY

: 80-90%

FOLLICUL. (ALV)

: 50-70%

MEDULLARY

: 30-40%

ANAPLASTIC

: 5%

56

SALIVARY GLAND TUMOR

PAROTIS
SUB MAXILLARY GLANDS
SUB LINGUAL GLANDS
BENIGN
MALIGNANT
SMALL SALIVARY GLANDS TUMOR

TH/.
57

AP MALIGNANT TUMOR
SALIVARY GLAND
ADENO Ca
MUCO EPIDERMOID Ca
SQUAMOUS CELL Ca
ADENO CYSTIC
ACINIC CELLS
MALIGNANT MIXED
58

Parotic Gland
TX
T0
T1
T2
T3
T4

:
:
:
:
:
:

Tumor cannot be assess

No primary tumor
Tumor < 2cm at largest diameter
Tumor 2-4 cm at largest diameter
Tumor antara 4-6 cm at largest diameter
Tumor > 6 cm
Are classified into :
a. without local extension
b. with local extension
59

CARCINOMA (Prognosis)
LIP.LOWER : 54 85%
TONGUE 2/3 ANTERIOR : T1 T2

FLOOR OF THE MOUTH : No LN

+ LN
TONSILS
75%

20%
SOFT PALATE
60 70%

20%
NASOPH
70%

35%
HYPOPH 5y 15 45%
PAROTIS 5y 30 50%

70-80%
30%
70%
30%

60