A clinical approach to oral cavity cancers for undergraduate students. An overview of anatomy, precancerous conditions, cancerous lesions and how to examine and approach a patient of Carcinoma oral cavity. An undergraduate can benefit greatly with the content. Even postgraduates can also benefit from the presentation. How to approach a case of Carcinoma oral cavity is comprehensively discussed in this presentation

1. CLINICAL CASE:
CARCINOMA ORAL CAVITY

2. Introduction
• Uncommon in Western world: 2-4% of all malignancies
• Indian subcontinent: 40%
• Male preponderance
• Incidence in females on the rise
• Highest female rates 10/100,000 in India

3. Clinical Scenario
• Carcinoma of Buccal Mucosa
- 45 years old female presenting with
ulcer over inner aspect of left cheek
- Duration: 6 months
- Associated with h/o dull aching local
pain
- Tobacco chewer x 20 years

4. HISTORY

5. Patient particulars
 Name
 Age
 Sex
 Education
 Occupation
 Address

6. Presenting complaints
a) Ulcer
b) Growth
c) Ulcer + growth
d) Whitish/ red patch
e) Reduced mouth opening

7. History of Present Illness
 Ulcer/ growth:
Onset, duration, progression
Location
 Pain:
Onset, duration, progression
Character, continuous or intermittent
Intensity
Radiation (external ear)
Aggravating/ relieving factors

8. History of Present Illness
 Discharge/ bleeding
 H/o excessive salivation
 H/o loosening of teeth
 H/o difficulty in swallowing
 H/o difficulty in speech/ change in voice

9. History of Present Illness
 H/o difficulty in tongue movements
 H/o reduced mouth opening
 H/o similar lesions elsewhere in the oral cavity
 H/o skin changes (erythema/ edema/ ulceration/ fungation/
open defect)

10. History of Present Illness
 H/o swelling in the neck
 H/o difficulty in breathing, cough, hemoptysis, bone pain, weight
loss

11. Past History
 H/o similar complaints in the past
 H/o diabetes, hypertension, tuberculosis, syphilis
 Any other chronic medical or surgical illnesses in the past

12. Family History
 H/o similar complaints in the family
 H/o of diagnosed oral cavity cancer in the family
 H/o other diseases (Eg:- Plummer Vinson Syndrome, Li-Fraumani
syndrome, p53 mutation, Bloom syndrome)

13. Personal History
 Diet
 Tobacco:
Smoking: pack years
Chewing: quantity, duration, h/o of keeping tobacco overnight
 Alcohol: quantity, duration
 Other chewing habits: quid – betel nuts, slaked lime/ pan masala/ kahini etc
 Sleep and appetite
 Bowel and bladder habits
 High risk sexual behaviour (HPV, Syphilis, HIV)

14. History
• How are you actually going to present the history?
• How will you summarise the history?

15. EXAMINATION

16. Examination
• General examination
• Local examination
a) Examination of oral cavity
b) Examination of cervical lymph nodes
• Systemic examination

17. General Examination
 ECOG score
 Orientation
 Built and nourishment
 Height, weight, BMI
 Temperature
 Pulse rate
 Respiratory rate
 Blood pressure
 Pallor/ Icterus/ Clubbing/ Cyanosis/ Generalised lymphadenopathy/
Pedal edema

18. Examination of Oral Cavity
• Intra-oral examination and extra-oral examination
• INSPECTION:-
 Oral hygiene
 Halitosis
 Mouth opening/ trismus

19. Inspection (..contd)
• Lesion (Ulcer/ growth):
 Number
 Site, size, shape
 Extent
 Surface
 Margin
 Colour
 Discharge/ bleeding
 Surrounding mucosa

20. Inspection (..contd)
• Any other abnormalities (similar lesions, whitish/ red patches) in
other sub-sites
• Tongue: Crack/ fissure, ulcer/ swelling, deviation on protrusion
• Teeth: Number, condition of teeth, staining

21. Palpation
• Local rise of temperature
• Tenderness
• Confirm findings of inspection
• Bleeding on touching
• Extent of involvement
• Base
• Mobility
• Fixity
• Bi-digital palpation

22. Palpation (..contd)
• Palpate other sub-sites
Extra-oral Examination
Describe any swelling/ erythema/ ulceration/ fungation/ induration/
open defect – on the skin of the cheek

23. Examination of Neck
• Palpate for all levels of cervical lymph nodes
• If a lymph node is palpable, then mention:
Level
Side
Size
Consistency
Mobility
Matted/ discrete
Tenderness
• If multiple lymph nodes are palpable, then describe each level as above

24. Systemic Examination
• CVS
• Abdomen
• Respiratory system
• CNS
 How will you summarise your examination findings?

25. Diagnosis
“Carcinoma oral cavity, sub-site: left buccal mucosa, TNM staging”
Invariably followed by-
How will you confirm your diagnosis? OR
How will you proceed? OR
How will you investigate the patient? OR
How will you manage this patient? OR
What are the differential diagnoses?

26. Q & A Section

27. • Expect the given questions during your case presentation at relevant
areas
Q- What is the extent of oral cavity?
Ans-
Superiorly:-
vermilion border of the lip to hard palate/ soft palate junction
Inferiorly:-
to circumvallate papillae
Laterally:-
to the anterior tonsillar pillars

28. Q: What are the sub sites of oral cavity?
Ans-
• Mucosal lip
• Floor of mouth
• Tongue (anterior 2/3rd)
• Buccal mucosa
• RMT
• Mandibular alveolus
• Maxillary alveolus
• Hard palate

29. Q- What is the most common site of oral cancer?
Ans-
Buccal mucosa/ GB sulcus (India)
Tongue (Western world)

30. Q- What is the extent of cheek or buccal mucosa?
Ans-
From the upper alveolar ridge to lower alveolar ridge and from the
commissure anteriorly to the mandibular ramus and the retromolar
region posteriorly
Or
From the line of contact of opposing lips to line of attachment of
mucosa of alveolar ridge and pterygomandibular raphe

31. Q- What is the extent of mucosal lip?
Ans-
From skin vermillion border to that portion which comes in
contact with opposing lip
Defined into upper and lower lip joined by commissures of mouth

32. Q- What is upper alveolar ridge?
Ans-
Mucosa overlying alveolar process of maxilla
From upper GBS to junction of hard palate, posteriorly upper end
of pterygopalatine arch

33. Q- What is lower alveolar ridge?
Ans-
Mucosa overlying alveolar process of mandible
From lower GBS to free mucosa of FOM, posteriorly to ascending
ramus

34. Q- Name muscles of mastication?
Ans-
• Masseter
• Temporalis
• Lateral pterygoid
• Medial pterygoid

35. Q- What are the layers of cheek?
Ans- From medial to lateral:
(a) Buccal mucosa
(b) Pharyngobasilar fascia
(c) Buccinator muscle
(d) Buccopharyngeal fascia
(e) Buccinator fat pad
(f) Masseter muscle
(g) Muscles of facial expression and the superficial muscular
aponeurotic system (SMAS)
(h) Subcutaneous tissue, and
(i) Facial skin

36. Q- What are the boundaries of RMT?
Ans-
Medially – Anterior tonsillar pillar
Laterally – Buccal mucosa
Anteriorly – 2nd or 3rd molar
Posteriorly – Maxillary tuberosity
Inferiorly – posterior mandibular alveolus
Superiorly – coronoid process of mandible

37. Q- What are the histological types of oral carcinoma?
Ans-
Squamous cell carcinoma (most common)
Adenocarcinoma (from minor salivary glands)
Melanoma (rare)
Sarcoma (rare)

38. Q- What are the gross types of carcinoma buccal mucosa?
Ans-
• Exophytic or proliferative lesion
• Ulcerative lesion
• Verrucous carcinoma

39. Q- What are the characteristics of proliferative lesions?
Ans-
Exophytic lesion projects into the oral cavity
Infiltrate adjacent tissues early

40. Q- What are the characteristics of ulcerative lesions?
Ans-
- A typical malignant ulcer with everted margin
- The ulcer may infiltrate the overlying skin and may fungate
outside with multiple sinuses

41. Q- What are the characteristics of verrucous lesions?
Ans-
Very slow growing superficial proliferative lesion
Minimal deep muscle invasion and induration
This may present as a white velvety lesion
Behaves as a low grade squamous cell carcinoma
Lymph node metastasis is late

42. Q- What are the stages in the development of oral cancers?
Ans-
Stage – I: Mild thickening with hypertrophy of papillae and
hyperkeratosis
Stage – II: Stage of leukoplakia
Stage – III: Irregular surface with dried paint like appearance
Stage – IV: Warty projections
Stage – V: Desquamation of abnormal mucosae (red glazed
tongue)

43. Q- What are the various ways a patient with Oral carcinoma present?
Ans-
 Persistent oral swelling > 4 weeks
 Mouth ulceration > 4 weeks
 Sore tongue
 Difficulty swallowing
 Painless neck lump
 Unexplained tooth mobility
 Trismus

44. Q- What are the pre-cancerous lesions of oral cavity?
Ans-
Lesions definitely premalignant
 Leukoplakia
 Erythroplakia
 Chronic hypertrophic candidiasis
Lesions associated with oral Ca
 Oral submucous fibrosis
 Syphilitic Glossitis
 Sideropenic dysphagia (Plummer-Vinson Syndrome)

45. Lesions doubtfully premalignant
 Oral lichen planus
 Discoid lupus erythematosus
 Dyskeratosis congenita

46. Q- What are the risk factors for Ca Oral Cavity?
Ans-
 Non-modifiable: Age, ethnicity, family/ hereditary history, socio-
economic status
 Modifiable: Smoking, tobacco chewing, betel quid, alcohol, diet/
nutritional status, lifestyle
 Others:
Viruses- HPV (16 & 18), EBV
Immunosuppression: BMT, organ transplantation, HIV/AIDS
UV exposure
Sharp tooth/ ill fitting dentures

47. Q- What are the carcinogens in tobacco?
Ans-
• Polycyclic Aromatic Hydrocarbons (PAH)
• 1,3-Butadiene
• Benzene
• N-Nitrosamines
• NNK ( 4-methyl nitrosamino-1-3-pyridine butanone)
• NNN ( Nitroso Nor Nicotine)
• Aromatic amines
• 2-Naphthylamine
• 4-Amino biphenyl

48. Q- What are the effects of alcohol in the development of oral cancer?
Ans-
Act as solvent facilitating entry of carcinogens into cells
Promotes cytochrome P450: increases activation of procarcinogens
(tobacco, alcohol)
Affects DNA repair mechanisms, susceptibility to mutations
Acetaldehyde

49. Q- What are the various chemicals in areca nut that affect carcinogenesis?
Ans-
Arecoline, Arecaidine:
Fibroblast proliferation
Stimulate collagen synthesis
Tannin, Cathechin:
Makes collagen fibrils resistant to collagenase

50. Q- What are the important Performance Status scoring systems used in
cancer patients?
Ans-
ECOG score
Karnofsky scale

51. Q- What is the full form of ECOG?
Ans-
Eastern Cooperative Oncology Group

52. Q- What is ECOG scoring system?
Ans-
ECOG PERFORMANCE STATUS
Grade 0: Fully active, able to carry on all pre-disease performance without restriction
Grade 1: Restricted in physically strenuous activity but ambulatory and able to carry
out work of a light or sedentary nature, e.g., light house work, office work
Grade 2: Ambulatory and capable of all selfcare but unable to carry out any work
activities; up and about more than 50% of waking hours
Grade 3: Capable of only limited selfcare; confined to bed or chair more than 50% of
waking hours
Grade 4: Completely disabled; cannot carry on any selfcare; totally confined to bed
or chair
Grade 5: Dead

53. Q- What is the WHO definition of leukoplakia?
Ans-
“White patch or plaque that cannot be characterized clinically or
pathologically to any other disease”

54. Q- What are the types of leukoplakia?
Ans-
Homogenous
Nodular—more potentially malignant
Speckled—highest malignant potential

55. Q- What is the malignant potential of leukoplakia?
Ans-
3-6% risk of malignancy overall
Increases with age of patient
Increases with duration of lesion
Maximal risk at floor of mouth / base of tongue

56. Q- What is the management of a leukoplakic patch?
Ans-
Cessation of smoking / chewing tobacco
Avoid alcohol
Biopsy mandatory
Follow up 4 monthly with biopsy if necessary
If biopsy shows dysplasia: surgical excision/CO2 laser excision

57. Q- What is erythroplakia?
Ans-
Erythroplakia is defined as a lesion in oral mucosa presenting
with red velvety plaque with irregular outline clearly demarcated
from the normal epithelium and cannot be characterized
clinically or pathologically as any other recognizable condition
In some cases, erythroplakia may be associated with adjacent
leukoplakia

58. Q- What are the types of erythroplakia?
Ans-
Homogenous
Granular
Speckled
Erythroplakia interspersed with leukoplakia

59. Q- What is the malignant potential of erythroplakia?
Ans-
17 times

60. Q- What is field cancerization?
Ans-
• The definition of field cancerization refers to a group of genetically
altered clones of cells in multifocal patches, which are prone to the
development of synchronous and metachronous tumors
• Diffuse chronic exposure of mucosa to carcinogen
• Widespread adverse changes in mucosal epithelium
• Development of separate tumors at different anatomical sites
• First tumour in the oral cavity and the oropharynx, more likely to develop
second primary tumour in upper oesophagus
• 15% develop second primary tumour
• 4% synchronous second primary tumour
• 80% metachronous tumours, 50% within the first two years of initial
presentation

61. Q- What is meant by Second Primary Malignancy (SPM) in oral carcinoma?
Ans-
A second malignancy in the oral cavity that presents either
simultaneously or after the diagnosis of an index tumor
Types:
a) Synchronous SPM
b) Metachronous SPM

62. Q- What is meant by synchronous lesions/ synchronous SPM?
Ans-
Malignancy that is diagnosed simultaneously or within 6 months
of diagnosis of the index tumor

63. Q- What is meant by metachronous lesions/ metachronous SPM?
Ans-
Malignancy that is diagnosed > 6 months after the index tumor

64. Q- What is trismus?
Ans-
Classically trismus refers to spasm/ tonic contraction of muscles of
mastication
Also used for limited or difficult mouth opening due to various causes
Mouth opening < 35 mm
Mouth opening < 3.5 fingers

65. Q- What are the grades of trismus?
Ans-
Grade I: Mouth opening > 35 mm
Grade II: 25-35 mm
Grade III: 15-25 mm
Grade IV: <15 mm

66. Q- What are the causes of trismus in oral carcinoma?
Ans-
Direct invasion of muscles of mastication (esp lat pterygoid) and
TM joint
Tonic spasm of muscles due to invasion of motor branch of
trigeminal nerve
Pain (muscle guarding)
Sub mucous fibrosis
Post RT
Post surgery/ reconstruction

67. Q- What is the cause of hyper-salivation in oral carcinoma?
Ans-
This is either due to excessive secretion of saliva due to an
irritative lesion in the tongue or due to difficulty inswallowing of
saliva due to restriction of tongue movement as a consequence
of infiltration into the floor of the mouth

68. Q- Why does pain of oral carcinoma radiate to external ear?
Ans-
It is usually a referred pain (referred otalgia). There is infiltration of
the lingual nerve (branch of mandibular division) and the pain is
referred via the auriculotemporal nerve which is also a branch of
mandibular division of trigeminal nerve

69. Q- What are the branches of Trigeminal nerve?
Ans-
V1: Ophthalmic branch (sensory)
V2: Maxillary branch (sensory)
V3: Mandibular ( sensory and motor)

70. Q- What are the muscles of tongue?
Ans-
Intrinsic muscles:
Transverse
Longitudinal
Vertical
Extrinsic muscles:
Genioglossus
Hyoglossus
Styloglossus
Palatoglossus

71. Q- Why are the causes of change in voice in patients with oral
carcinoma?
Ans-
Lesion on tongue/ palate and trismus can affect articulation and
pronunciation
Involvement of Superior laryngeal nerve by the primary
Lymph node mass compressing the Recurrent laryngeal nerve
Involvement of orbicularis oris muscle in carcinoma lip

72. Q- What is significance of history of loosening of teeth?
Ans-
Loosening of teeth indicates involvement of mandible/ maxilla

73. Q- What is halitosis?
Ans-
Halitosis is chronic bad breath

74. Q- What are the reasons for weight loss in Ca Oral Cavity?
Ans-
• Cancer “cachexia”
• Dysphagia due to various reasons (pain, trismus, reduced
tongue mobility, presence of a large mass, loss of teeth etc)

75. Q- What are the various lymph node levels in the neck?
Ans-
7 levels.
1) Level I: the submental and sub mandibular nodes
Ia: the Submental nodes.
[Medial to the anterior belly of digastric muscle
bilaterally, symphysis of mandible superiorly, and hyoid
inferiorly]
Ib: the submandibular nodes and gland.
[Posterior to the anterior belly of digastric, anterior to the
posterior belly of digastric, and inferior to the body of the
mandible]

76. 2) Level II: Upper jugular chain nodes
Level IIa: Upper jugular chain nodes
[anterior to the posterior border of the sternocleidomastoid
(SCM) muscle, posterior to the posterior aspect of the posterior
belly of digastric, superior to the level of the hyoid, inferior to
spinal accessory nerve (CN XI)]
Level IIb: Submuscular recess
[superior to spinal accessory nerve to the level of the skull
base]

77. 3) Level III: Middle jugular chain nodes
[inferior to the hyoid, superior to the level of
the cricoid, deep to SCM muscle from posterior
border of the muscle to the strap muscles
medially]
4) Level IV: Lower jugular chain nodes
[inferior to the level of the cricoid, superior to the clavicle, deep
to SCM muscle from posterior border of the muscle to the strap
muscles medially]

78. 5)Level V: Posterior triangle nodes
Level Va—lateral to the posterior aspect of the
SCM muscle, inferior and medial to splenius
capitis and trapezius, superior to the spinal
accessory nerve
Level Vb—lateral to the posterior aspect of SCM muscle, medial
to trapezius, inferior to the spinal accessory nerve, superior to
the clavicle

79. 6) Level VI: Anterior compartment nodes
[inferior to the hyoid, superior to suprasternal
notch, medial to the lateral extent of the
strap muscles bilaterally]
7) Level VII: Paratracheal nodes
[inferior to the suprasternal notch in the upper mediastinum]

80. Q- What is TNM staging of Ca Oral Cavity (AJCC 8th Ed)?

83. Q- What are the differential diagnoses in oral cancer?
Ans-
Actinic Keratosis: If patient presents with a lump on vermillion border of
the lip
Erythroplakia
Leukoplakia
Lichen Planus: Bilateral or symmetric reticular changes with or without
ulcers and erythema occurring anywhere in the oral cavity
Lichenoid lesions: A single white reticular patch with erythema and/or
ulceration either due to a drug reaction or adjacent to dental
material such as amalgam
Mucosal Candidiasis
Traumatic lesion: Appearing adjacent to a sharp or broken tooth
Stomatitis/ glossitis/ gingivitis

84. Q- What are the investigations required in a case of oral malignancy?
Ans-
Investigations for primary:
Incisional biopsy: Tissue diagnosis
FNAC: Metastatic node from unknown primary
Excisional biopsy if lymphoma suspected
Orthopantomogram: cheaper
CXR: Distant metastasis/synchronous lung primary
Triple Endoscopy: synchronous cancers

85. Investigations for staging:
• USG of neck or primary ± USG guided FNAC of suspicious
lymphadenopathy
• CECT base of skull to clavicle: loco-regional disease
• CT chest: N3 disease or N2 disease with LN below thyroid notch
20-30% chance of metastatic disease
• MRI: soft tissue delineation, Ca tongue
• PET-CT: metastatic workup

86. Q- Describe punch biopsy and wedge biopsy
Ans-
Punch biopsy:
A diagnostic test where a small, tube-shaped
piece of skin and some other tissue underneath
are removed using a sharp cutting tool
Wedge biopsy:
A biopsy in which a wedge-shaped sample of
tissue is obtained

87. Q- What precaution should you take while taking an incisional/ wedge
biopsy?
Ans-
The biopsy should be taken from the most suspicious area and
should include some normal adjacent mucosa
The biopsy should not be taken from the necrotic or infected
area as the result may be fallacious

88. Q- What all are included in Panendoscopy ?
Ans-
Laryngoscopy
Bronchoscopy
Esophagoscopy

89. Q- What are the available modalities of treatment?
Ans-
Surgery
Radiotherapy
Surgery with radiotherapy
Chemotherapy with or without surgery and radiotherapy

90. Q- What is NCCN?
Ans-
National Comprehensive Cancer Network (NCCN) is an alliance of 30
cancer centers in the United States, most of which are designated by
the National Cancer Institute (one of the U.S. National Institutes of
Health) as comprehensive cancer centers
It is a non-profit organization with offices in Plymouth Meeting,
Pennsylvania
It publishes the peer-reviewed medical journal- Journal of the National
Comprehensive Cancer Network

91. Q- NCCN treatment guidelines for Stage I (T1N0) and Stage II (T2N0)
disease
Ans-

92. Q- NCCN guidelines for T3N0, T1-3N1-3 and T4aN0-3 diseases
Ans-

93. Q- NCCN guidelines for T4bN0-3 or unresectable nodal disease or unfit
for surgery… (very advanced disease)
Ans-

94. Q- NCCN guidelines for M1 (metastatic) disease… (very advanced
disease)
Ans-

95. Q- What are the various modalities used in the reconstruction of carcinoma
oral cavity?
Ans-
Local flaps and skin grafts
Regional flaps (Eg: PMMC flap, Submental flap, Supraclavicular flap)
Free tissue transfer (Eg: Radial forearm flap, Antero-lateral thigh flap,
Lateral arm flap, Rectus flap, Latissimus dorsi flap, Fibula
osseo-cutaneous flap, Radial forearm osseo-cutaneous flap)

96. Q- What are the types of mandibular resections?
Ans-
i) Total mandibulectomy: Removal of the whole mandible including bilateral
disarticulation
ii) Partial mandibulectomy: Resection of any part of the mandible, leaving the
unaffected part intact
a) Segmental mandibulectomy: Resection of a portion of the mandible (i.e. a
segment of the mandible is resected)
Eg:-
- Hemimandibulectomy (Mandibulectomy involving the resection of
one half of the mandible starting from the midline)
-Subtotal segmental mandibulectomy: Mandibulectomy involving one half
of the mandible, crossing the midline to involve a portion of the other half
of the mandible

97. b) Marginal mandibulectomy: Resection of a portion of the
mandible without a continuity defect

98. Q- What are the common complications following surgery for carcinoma Oral
Cavity?
Ans-
Bleeding
Infection
Flap necrosis
Stiffness, contractures
Bad cosmesis
Cutaneous anesthesia
Speech issues
Swallowing issues

99. Q- What are the inoperable conditions in oral cancer?
Ans-
Pre-vertebral fascia invasion
Skull base invasion NACT is given
>270◦ circumferential encasement of ICA

100. Q- What are the indications of neck dissection?

101. Q- What are the types of neck dissection?
Ans-
Radical neck dissection (RND)
Modified radical neck dissection (MRND)
Selective neck dissection (SND)
- SOHND
- Posterolateral neck dissection
- Lateral neck dissection
- Anterior compartment neck dissection
Extended radical neck dissection

102. Q- What structures will you remove in radical neck dissection?
Ans-
The standard radical neck dissection as described by Crile in 1906
involves removal of:
All levels of lymph nodes (Level I to Level VI)
Sternocleidomastoid and omohyoid muscle
Internal jugular vein
Spinal accessory nerve and cervical plexus of nerves
Submandibular salivary gland and tail of parotid gland
All intervening lymphoareolar tissues

103. Q- What structures will you preserve in MRND?/ What are the types of
MRND?
Ans-
• Removes all the lymph nodes as in radical node dissection
• Preserve any one of the non-lymphatic strucutres removed in RND-spinal
accessory nerve, internal jugular vein and sternocleidomastoid muscle
• Types:
Type I: Spinal accessory nerve is preserved
Type II: Spinal accessory nerve and internal jugular veins are
preserved
Type III: Spinal accessory nerve, internal jugular vein and
sternocleidomastoid muscle are preserved

104. Q- What is functional neck dissection?
Ans-
A variation of MRND where group of lymph nodes from level I to
level VI are removed
All non-lymphatic structures are preserved

105. Q- What do you mean by selective neck dissection?
Ans-
Involves removal of cervical lymph nodes considered to be at
high risk for metastasis from a given primary site
The extent of elective dissection depends on the type of primary
lesion
Selective lymph node dissection is usually performed in N0 neck

106. Q- What is SOHND? When will you do SOHND?
Ans-
SOHND stands for Supra Omohyoid Neck Dissection
It is the most commonly performed SND
Lymph node levels I, II and III are removed en bloc
Other structure removed: Submandibular gland
Indication: Oral carcinoma with N0
Posterior limit: Cervical plexus and posterior border of SCM
Inferior limit: Omohyoid muscle overlying IJV

107. Q- What are the points against prophylactic neck dissection?
Ans-
Incidence of histologically positive node in prophylactic block
dissection exceeds the incidence of subsequent clinical nodal metastasis
Some micrometastasis in lymph nodes possibly are destroyed by body’s
own defense mechanism
The primary tumor may recur or a second primary may develop and
metastasis to dissected neck make subsequent management difficult
Block dissection of neck has considerable morbidity and some
mortality
There is no prospectively controlled trial to support the argument that
prophylactic neck dissection does improve the prognosis

108. Q- What are the indications of radiotherapy?
Ans-
Postoperative radiotherapy is indicated when—
• There are multiple lymph node metastasis on histology
• There is extracapsular extension of the tumor
Locally advanced primary lesion not amenable to surgical treatment,
then both the primary lesion and the lymph node metastasis may be
treated by irradiation
If the patient is unfit for surgery, the lymph nodal metastasis may be
treated with radical radiotherapy

109. Q- What are the different techniques for administration of radiotherapy?
Ans-
Radiotherapy may be administered either by—
Brachytherapy with implantation of radium needle, radioactive
tantalum wires or 192 Iridium wires. This can deliver very high dose
of radiation locally. The radium needles are kept for 9–10 days
Teletherapy: External beam radiation with a telecobalt or linear
accelerator

110. Q- What are the causes of death in patients with oral carcinoma?
Ans-
Advanced disease leads to death by :
Hemorrhage from the primary growth or hemorrhage from erosion of
carotid artery or internal jugular vein by a metastatic lymph node
Asphyxia resulting from growth in the tongue or huge lymph node
metastasis blocking the upper air passage
Edema of the glottis may aggravate the airway obstruction
Aspiration pneumonia
Starvation and malignant cachexia

111. THANK YOU