it encompasses the management of common oropharyngeal cancers.

1. Malignant neoplasm of oropharynx
By Dr. Wudie ORL-HNS R 3
12/5/20201 AAU,Ethiopia

2. outline
 Introduction
 Applied anatomy
 Etiology and epidemiology
 Histopathology
 Evaluation
 Staging
 Management
 References
12/5/20202 AAU,Ethiopia

3. Introduction
 The oropharynx is increasingly common site for
presentation of Upper airodigesitive tract malignancy.
 Incidence 2 per 100,000
 Histopatologically most common malignancies in
oropharynx are SCC.
 Occurs mainly in males
 Alcohol , HPV and smoking are major risk factors
12/5/20203 AAU,Ethiopia

4. Anatomy
 It has 4 subunits: soft palate, palatine tonsil, base of
tongue and posterior oropharyngeal wall.
 Soft palate- it incompletely separates nasopharynx
from oropharynx
 Formed by uvula and palatopharyngeal arch
 Composed of uvular muscle, levator and tensor palatani
muscles and palatopharygeal muscles
 Contains minor salivary glands
 Blood supply- by ascending palatine branch of facial
artery and dec. palatin atrtery from Internal maxillary atry
 Innervation- motor by branch of vagus nerve except
tensor palatine muscle by CN V
 Sensory by CN IX
12/5/20204 AAU,Ethiopia

5.  BOT
 Part of tongue bounded
 anteriorly,- by
circumvallate papillae
 laterally, the
glossotonsillar sulci and
 Inferiorly the hyoid bone or
floor of the vallecula.
 Composed of 4 intrinsic
and 4 extrinsic muscles
 Lied by non keratinized
squamous epithelium
 Contains lymphoid and
minor salivary glands
 Nerve and blood supply
 Hypoglossal nerve-
passes over hyoglossus
m. along sup. Surface of
hoid bone and deep to
genohyoid and mylohyoid
m.
12/5/20205 AAU,Ethiopia

6. Posterior phayngeal wall
 Externally covered by
stratified squamous
mucosal layer
 The area defined by
vallecula, posterior pillar
of palatine tonsil and soft
palate
 Made up of mucosal layer,
constrictor muscles,
buccopharygeal fascia,
perivertebral fascia and
colis longus muscle.
 Blood supply-
ascending pharyngeal
artery.
 Nerve – pharyngeal
plexus , motor
innervation by CN x
except stylopharygus
muscle
12/5/20206 AAU,Ethiopia

7. 12/5/20207 AAU,Ethiopia

8.  Palatine tonsil
Laterally with in orpharynx
Boundeg by palatoglussues and
palatophaygeus
 Coverd by stratified squamous
epithelium and capsule
laterally
Blood supply
superiorly.
 The tonsillar branch of the
ascending pharyngeal artery
 the descending palatine artery
branches
Inferiorly-
 tonsilar br. Of facial artery
 Dorsal lingual and ascending
palatine arteries
12/5/20208 AAU,Ethiopia

9. Lymphatic supply
 Depends on the size and location of primary
malignancy
 Soft palate lymphatic drainage devided in to 3 –
medially to level III , laterally to the RP LN,
anteriorly to the hard palate, and subsequently
Level IA and IB
 Post. Pharyngeal wall primarly drains to RP LN
followed by level II and III lymphnodes .
 BOT- primarily to level II,III and IV
 Palatine tonsil- II,III and IV, RP LN
12/5/20209 AAU,Ethiopia

10.  Skip metastasis is extremely rare
 Tumors of tongue base , soft palate and posterior
pharyngeal wall have higher incidence of bilateral
lymphadenopathy.
 RPLN involved most commonly from Posterior OP
wall tumors
 followed by soft palate, tonsil fossa, and tongue base
12/5/202010 AAU,Ethiopia

11. Epidemiology and etiology
 Comprises 10 to 12 % of all head and neck ca.
 SCC is the commonest malignancy.
 More common in males
 In 50 to 60s of age
 The number of newly diagnosed oropharygeal
malignancy increasing B/s of HPV.
 Risk factors
 Tobacco and alcohol.
 HPV infection – found in 40 % of cases
 P16 over expression in HPV
12/5/202011 AAU,Ethiopia

12. 12/5/202012 AAU,Ethiopia

13. Pathology
 Scc is the most common malignance of oropharynx
(90%)
 Other malignant transformations are lymphomas,
lymphoepithelial carcinoma, minor salivary gland
tumors
 Epithelial precursor lesions
 The frequency in the OP is less common than oral cavity
precursors
 Clinically presented as white patches (leukoplakia) , red
patches (erythropkiakia) or mixed variant
12/5/202013 AAU,Ethiopia

14.  SCC – accounts about 90 % of primary OP-
malignancy
 It has papillary, verrucous , basaloid , spindle cell
undifferentiated and adenosquamous histology variants
 Papillary and verrucous variants have good prognosis
 HPV related tumors have a poorly differentiated and
usual non keratinizing morphology
 Minor salivary gland tumors- 50 to 70 % are
malignant tumors
 Mucoepidermoid and adenoid cystic cancer are the
commonest
 Soft palate is commonest sit followed by BOT.
 Wide surgical excision is a preferred treatment approach
12/5/202014 AAU,Ethiopia

15.  Post op radiotherapy recommended for high and
intermediate grade mucoepidermoid and adeno cystic
carcinoma
 NHL- commonest type of lymphoma occurring in
waldyer’s ring
 Trx – radiotherapy or chemoraditherapy
12/5/202015 AAU,Ethiopia

16. Clinical presentation and pattern of spread
 Tumors originates from tonsil
 Represents 60 % of OPSCC.
 HPV + OPSCC are typically small and asymptomatic
 Pt may present with cervical Lymphadenopathy
 Most common sites of primary tumors in case of CUP
 presents as a foreign body sensation in the throat with
dysphagia, otalgia, or trismus in advanced cases.
 If it extends laterally to Parapharyngeal space
 Lower Cranial nerve palsy IX,X,XI or XII
 Horner’s syndrome
 Nodal metastasis is to level II primary but can involve level II and
IV
 Contralateral lymph node metastasis in 11 % of cases of tonsilar
ca and in 5 % case of ant. Pillar ca.
 Contralateral metastasis in T1 and T2 tumors is less than 5 %
12/5/202016 AAU,Ethiopia

17.  BOT tumor
 Make up to 30 % of all OPSCC
 otalgia, dysphagia, altered speech, impaired tongue
movement and bleeding
 Extending to epiglottic and supraglottic area-may presented
with difficulty of swallowing and breathing
 Local invasion cross midline as well as in the intrinsic and
extrinsic musculature of tongue.
 Bilateral lymph node metastasis in up to 20 % of cases
12/5/202017 AAU,Ethiopia

18.  Soft palate OPSCC
 Accounts 10 % of OPSCC
 present as a painful ulcerative lesion.
 Progression will result in involvement of the nasal
surface of the soft palate, the superior tonsillar pole
and/ or the hard palate.
12/5/202018 AAU,Ethiopia

19.  Oropharyngeal wall tumors
 Pain , dysphagia and bleeding
 Infiltration of deep cervical structures and vessels or
prevertebral fascia
 Lymphatic spread is found in 25 % of T1 and 75 % of T4
 Most tumors – bilateral lymphatic spread
 In general OPSCC starts on the surface and
invasion of vessels, thick fascia or periosteum is not
common in early stage
 Perineural invasion may occur any time
12/5/202019 AAU,Ethiopia

20. Diagnosis
 Hx-
 non specific symptoms
 Soar throat,
hemoptysis, unilateral
otalegia
 Difficulty of swallowing,
moving tongue or
speech
 Hx of smoking and
alcohol
 Prior treatment Hx
 P/E-
 patients should carefully be
investigated with focus on the
 tongue (appearance and
movement),
 tonsillar fossae,
 retromolar trigone,
 soft palate (appearance and
mobility),
 base of the tongue,
 vallecula, and pharyngeal walls
 Includes inspection and palpation
 Endoscopic examination
 Neck examination
 For all pts with head and neck
cancer- thoroughly investigation is
mandatory 12/5/202020 AAU,Ethiopia

21. Imaging
 Ct scan –to look for any bony involvement
 MRI- periosseous involvement , in deep invasion
 PET/PET-CT-synchronous primary tumors and
distant metastasis. Inflammation and muscle
involvement in examination may show false positive
 PET negative is more reliable in lesions >8 mm
 Reliability affected by previous surgery and
radiotherapy (accurate after 3months)
 U/S-
12/5/202021 AAU,Ethiopia

22. Endoscopy and biopsy
 Biopsy of easily visible OP tumors – at Opd with LA
(tonsilar or soft palate)
 Tumors from BOT and post pharyngeal wall – with GA
 FNAC – from enlarged lymph node
 Small tumors which are difficult to detect with P/E or
Imaging – farther evaluation by endoscopy
 Frozen section – to dx suspected malignancy and tumor
free resection.
12/5/202022 AAU,Ethiopia

23. Test for HPV
 P16 over expression- highly sensitive for
transcriptionaly active HPV
 IHS
 PCR
12/5/202023 AAU,Ethiopia

24. Staging of oropharyngeal ca
12/5/202024 AAU,Ethiopia

25. 12/5/202025 AAU,Ethiopia

26. Treatment
 The main criteria for succesfull treatment is loco
regional control
 For early-stage tumors,
 surgery or RT alone can be used for primary treatment.
 For advanced oropharyngeal cancers,
 surgery with radiation (with or without chemotherapy) or
 chemoradiotherapy is the available option.
 Considerations are patients comorbid condition,
experience, anatomical site of primary tumor.
12/5/202026 AAU,Ethiopia

27. Primary tumor management
 Surgery and radiation alone are similar in controlling
 Resection margin 1 to 2 cm
 T3 and T4 tumors - can be controlled with surgery
and postoperative radiation,
 concurrent chemoradiation or hyperfractionated radio
therapy is now considered standard
12/5/202027 AAU,Ethiopia

28. Surgical approaches
 Choice is depending on the location and size of
lesion
 Small and easily accessible lesions- trans orally
 Larger lesions and tumors located close to
supraglottic and hypo pharynx area, external
approach.
12/5/202028 AAU,Ethiopia

29. Transoral approach
 Most oropharygeal lesions can be removed
transorally
 Minimally invasive , suitable for small and medium
sized lesions
 Necessary exposure can be achieved by using
dingman mouth gaga or endoscope such as
kleinsasser or steiner for laser surgary of tongue
base
12/5/202029 AAU,Ethiopia

30. 12/5/202030 AAU,Ethiopia

31.  Candidates
 Mobile, exophitic tumors
 Adequate Mouth opening
 Size of tongue
 Low Mallampati score
 Maxillary incisors
 Body mass index
 Relative contraindications
 Tumor extent that require
removal of 50 % of tongue
base or
 More than 75 % of soft
palate
 Absolute
contraindications to
transoral surgical
treatment are
 invasion of the skull base,
 invasion or encasement of
the great vessels,
 invasion of the mandible,
 confluent extent of the
primary tumor and neck
metastasis.
12/5/202031 AAU,Ethiopia

32.  Trans oral surgery approaches are
1. Direct trans oral resection (DTR)
2. Trans oral laser micro surgary (TLM)
3. Trans oral robotic surgay (TORS)
12/5/202032 AAU,Ethiopia

33. Direct trans oral resection
 Used for tumors accessible without the benefit of
laryngoscopy, microscopy, or endoscopy
 Small tonsil tumors, tumors of the soft palate, and
tumors of the PPW
 Larger tumors with spread into the root of the
tongue, floor of the mouth, or retromolar trigone- are
not a good candidate for DTR.
12/5/202033 AAU,Ethiopia

34. Transoral Laser Microsurgery.
 It’s a less invasive procedure which done by using
endoscopy and CO2 laser
 Trans tumoral transection followed by multi bloc or
“piecemeal” resection
 Primary modality for treatment of all sites of
resectable OPSCC
 Advantage- it decrease the need for tracheostomy
and gastrostomy
 Disadvantage – air way fire
12/5/202034 AAU,Ethiopia

35. TORS
 FDA approved for treatment of oral and oropharygeal
ca
 Usually used for BOT and Tonsilar ca
12/5/202035 AAU,Ethiopia

36. Transoral surgical procedures
 1. Palatine tonsillectomy
 After inserting mouth gag, soft palate retracted by using
rubber tube that passes though nare.
 Holding tonsil with allis and poor medially
 Incision made at mucosa just parallel to anterior pillar at
border of tonsilar capsule.
 Dissection plane b/n tonsilar capsule and superior
constrictor
 Dissecting from superior pole to inferior
 This is used for palatine tonsil carcinoma insitu or to
take biopsy for unknown primary
12/5/202036 AAU,Ethiopia

37.  2. Lateral pharyngectomy (radical tonsilectomy)
 Expose the oropharyngeal region and palpate tumor for
any fixation.
 A mucosal incision is made in the buccal mucosa at the
retromolar trigone,
 Dissection is carried down to the pterygomandibular
raphe
 The tonsillar tissue is then grasped and pulled toward the
midline
 The lateral margin of the specimen becomes the superior
constrictor, palatoglossus, and palatopharyngeus
muscles
 Deep plane of dissection formed by buccopharygeal
fascia 12/5/202037 AAU,Ethiopia

38.  Medial pterygoid muscles and parapharygeal fat pad
can be seen
 If possible bucophaygeal fascia should be preserved
to preserve fat pad and protect carotid artery and
prevent oropharygeal neck communication
 As dissection continued medially , stylohyoid and
styloglossus muscle should be identified and CN IX
should be preserved
 Inferiorly, cuts are made through the anterior tonsillar
pillar at the BOT and along the glossotonsillar sulcus
or to the level of the vallecula .
12/5/202038 AAU,Ethiopia

39.  Once complete, cuts are made through the
posterior pharyngeal constrictor to the
prevertebral fascia, and the medial superior
constrictor is then dissected free from the
prevertebral fascia
12/5/202039 AAU,Ethiopia

40. 3. POSTERIOROROPHARYNGECTOMY
 Transoral resection of small posterior oropharyngeal
wall tumors is possible with DTR, TLM, and TORS
 Palpate for position of carotid artery
 Incision made over inferior, superior and lateral borders of
tumor through mucosa and constrictor muscle to level of
prevertebral fascia.
 Dissection cared out in deep plane and tumor resected
Complications- CN IX to XII injury , sympathetic trunk
injury ( if ca has lateral extension)
Wall defect- small defect – primary closure to
prevertebral fascia
Moderate defect -split thickness skin graft
12/5/202040 AAU,Ethiopia

41. 3. Soft palate resection
 For premalignant lesion
 elliptical excision of the lesion can be performed with narrow
margins.
 The lesion should be excised with the fascia of the
underlying muscle, and
 primary closure can be accomplished by using lateral
relaxing incisions.
 For malignant lesion-
 Palate incised through both the oral and the nasal
mucosa, including the muscular palate
 Tumor extends laterally to involve the tonsil or BOT,
modifications of the lateral oropharyngectomy and
BOT resection.
12/5/202041 AAU,Ethiopia

42. 12/5/202042
 Malignant tumors extending to maxilla, skull base and
infratemporal fossa needs – open surgery
AAU,Ethiopia

43. BOT resection
 To allow the tumor to fall posteriorly into the
operative field, the first mucosal cut should be made
anteriorly
 The posterior margin should be visualized.
 Tumor with adequate margin dissected by using
cautery
 Lingual artery bleeding – can be controlled by apply
pressure over greater horn of hyoid till it clipped
12/5/202043 AAU,Ethiopia

44. Post op care
12/5/202044
1. Airway- patients with out tracheostomy tube,
should evaluate for epiglottis edema at the end of
procedure
2. Drain management, Feeding and antibiotics
3. Anticoagulants- for high risk pts, age >60,
procedure >2 hrs, pts who have previous hx of
DVT and bed rest for >3 days
 Anticoagulant for 4 wks
AAU,Ethiopia

45. 12/5/202045
 Complication
1. Bleeding – rare complication , occur in 3 to 8 % of
cases
2. Pharygocutanous fistula – occur if concomitant neck
dissection done
3. Orocervical fistula- to identify , irrigate with sterile
saline
 If there is leak ,and defect less than 1 cm primary
repair
 Defect > 1 cm local muscle coverage with the
mylohyoid, digastric, or sternocleidomastoid muscles
 NG tube feeding for 24 to 48 hrs clear fluid if no
leak normal diet
AAU,Ethiopia

46. 12/5/202046
4. VPI- if the soft palate defect < 50 %- manage
conservativally-till 3 to 4 months
 Defect >50 % obturator
5. Delayed pharyngeal healing- present with pain and
ulceration
 Might be due to immuno- compromization, RT, or
tumor persistence
 If it persist till 3 moths, biopsy indicated to R/O
persistent tumor
AAU,Ethiopia

47. Open surgical approaches
Lateral and transhyoid pharyngotomy
 For inferior lesions or pts neck mobility might not allow
to do transoral surgery
 Lateral pharygotomy –used for tumors on tongue
base or posterior pharyngeal wall
 Skin incision made over one of skin crease just
superior to the thyroid cartilage from mid line to
anterior border of SCM muscle
 Subplatismal flap raised,
 The suprahyoid muscles are separated from the
lateral third of the hyoid,
 Pharyngeal mucosa divided
 leave the hypoglossal nerve cranially and
superior laryngeal nerve inferiorly
12/5/202047 AAU,Ethiopia

48. 12/5/202048 AAU,Ethiopia

49.  Ng tube feeding
 Place drain
 Complication
 - injury to superior laryngeal nerve
 -hypoglossal nerve
 Pharyngocutanous fistula
12/5/202049 AAU,Ethiopia

50.  Trans hyoid pharyngotomy
 is done by freeing the hyoid from supraglottic musculature
and entering vallecula medially
 For resection of T1 T2 tongue base tumors or posterior
phargeal wall
 lingual arteries, hypoglossal, and superior laryngeal
nerves at risk.
12/5/202050 AAU,Ethiopia

51. 12/5/202051 AAU,Ethiopia

52. Trans mandibular approach
 When there is inadequate access for transoral and
pharyngotomy approaches or for flap inset
 Radiological evidence of mandibular involvement-
mandibulectomy indicated.
 A tracheostomy is performed at the onset of surgery.
12/5/202052 AAU,Ethiopia

53. 12/5/202053 AAU,Ethiopia

54. Neck management
 Occult metastasis from OPSCC is 10 to 30 %
 Almost all pts with scc of OP needs neck
management
 Radiotherapy or surgery based on the management
of primary tumor
 N0 and N1 effectively treated by single modality
 Selective neck dissection from II to IV- for N+
 N0 elective neck dissection to the ipisilateral neck
when T> T2
 For mid line structure – contralateral neck treated
with either with SND or radiotherapy
12/5/202054 AAU,Ethiopia

55. Neck management
 RP LN must always be considered in the neck treatment
plan
 if negative include them to radiation
 For +N - can be addressed through primary tumor
incision or covered with adjuvant therapy
 lymph nodes are difficult to access surgically
 radiotherapy is often used even when the primary
is treated surgically
12/5/202055 AAU,Ethiopia

56.  Timing of neck dissection?? In Trans oral
approach
 After 2 wks of primary tumor resection
 At the same time when primary tumor resected
 Need for tracheostomy increased b/se of larygopharygeal
edema
 Risk of pharygo-cervical and pharygo-cutanous fistula increase
12/5/202056 AAU,Ethiopia

57. 12/5/202057 AAU,Ethiopia

58. Reconstruction and rehabitation
 The goal of reconstruction is to accelerate wound healing and
maintain its functionality
 Primary closure of tongue base and pharynx is rarely
recommended because of tethering and pharyngeal stenosis
 BOT- <1/3 of tongue volume primary closure, split thickness
skin grafft or left to heal by secondary intension.
 RFFFF
 Tonsil defect - < 4 cm – healed by secondary intention
 For defect involving tonsillar fossa and retromolar trigone –grafts or
local flaps can be used
 Lateral tongue or palatal island flap
 For larger defects RFFF
 Soft palate defect- small defect heal by secondary intention
 Larger(>75 % ) full thickness defect will result VPI
12/5/202058 AAU,Ethiopia

59.  uvulopalatal-rotation flap, superior or inferiorbased
posterior pharyngeal flap, superior constrictor
advancement rotation flap (SCARF), and palatal-island
flap.
 Posterior op wall defect-Split-skin graft or local
sliding muscular flaps may be used for superficial
pharyngeal wall defects
 For < 3cm defect, primary closure, split thickness skin
grafft or left to heal by secondary intension if it has no
communication with neck
12/5/202059 AAU,Ethiopia

60. Non surgical management of OPSCC
 consists of radiotherapy with or without concurrent
chemotherapy.
 Most chemotherapy regimens are based on platinum
agents.
 The radiation course usually consists of delivering a
dose of 60 to 70 Gy through an external-beam
shrinking field to the primary lesion and necks over a
6- to 7-week period.
12/5/202060 AAU,Ethiopia

61.  Radiation is typically delivered using IMRT.
 Patients treated nonsurgically should be evaluated
using a posttreatment PEI/CI to determine response
at 8 to 12 weeks after completion of therapy.
 Patients who presented with N2 and N3 disease
should undergo a neck dissection ,if PEI/CT-positive
disease persists.
 If a complete clinical response is obtained watchful
waiting approach as this usually predicts a complete
tumor control
12/5/202061 AAU,Ethiopia

62. 12/5/202062 AAU,Ethiopia

63. 12/5/202063 AAU,Ethiopia

64. References
 Cummings otolaryngology–head and neck surgery,
6th edition
 Scott-brown’s ORL head and neck surgary 8th edition
 Bailey otorhinolaryngology head and neck surgery,
5th edition
 Ballenger’s otorhinolaryngology head and neck
surgery,18th edition
 James MD- atlas of head and neck surgery
12/5/202064 AAU,Ethiopia