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38 Classifications and Lists in Oral and Maxillofacial Surgery
https://t.me/med1917
INVESTIGATIONS FOR A CARCINOMA
OFUNKNOWN PRIMARY (CUP) ORIGIN
e following list outlines investigations which can aid the diagnosis of carcinoma of unknown primary origin.
1. Whole-body PET-CT
2. Pan-endoscopy and biopsy of PNS/tongue base/piriform (or
pyriform) fossae (under 50% hit rate) and, if available, tongue
base mucosectomy with TORS (50% hit rate)
3. Bilateral tonsillectomy
4. MRI (if level 2/3 node), for example, skull base to clavicles
LIP DEFECT TYPES AND RECONSTRUCTION
OPTIONS
e following list outlines common types of lip defects following
oncological resection and various reconstruction options
●
Less than half of either lip – wedge excision and primary
closure
●
Half to two-thirds of lower lip – Karapandzic, reverse AbbeEstlander, Johannsen step, Schuchart
●
Half to two-thirds of upper lip – perialar crescenteric, AbbeEstlander, reverse Karapandzic
●
More than two-thirds of lower lip – Gillies’ fan aps/
McGregor’s aps/Nakajima’s aps (preserved facial artery),
Webster aps, gate aps, free ap
●
More than two-thirds of upper lip – Burrow-Dienbach
(bilateral perialar cresenteric), free ap
.
NB: Microstomia should be managed with Karapandzic and Gillies’
aps as they are advancement aps, but at least they retain muscle
sphincter and, therefore, oral continence (McGregor and Nakajima
do not retain oral continence).
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Head and Neck Oncology 39
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LYMPHOMA STAGING
e following list describes how the extent of lymphoma spread
can be ascertained.
1. Single node
2. Two or more nodes SAME side diaphragm
3. Both sides diaphragm
4. Extralymphatic
●
+B symptoms: 10% unintentional weight loss, fever, night
sweats
●
Stage 1 or 2 (A) get DXT
●
B symptoms or stage 3 and higher, get CHOP regimen
(cyclophosphamide, doxorubicin, vincristine sulphate,
prednisolone) ± rituximab (anti-CD20 on b cells)
MATHES AND NAHAI CLASSIFICATION OF
MUSCULAR FLAPS
is classication describes the patterns of blood supply and
perfusion in musculocutaneous free aps. Also listed here
are examples of muscles corresponding to dierent vascular
patterns.
1. Single dominant pedicle (tensor fasciae lata)
2. Dominant and minor pedicle (gracilis medial femoral circumex and deep branch)
3. Two dominants (rectus abdominis)
4. Segmental (sartorius)
5. Dominant with secondary segmentals (pectoralis major, latissimus dorsi)
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40 Classifications and Lists in Oral and Maxillofacial Surgery
https://t.me/med1917
NODE STAGING
e following list describes patterns of nodal spread of head and
neck malignancy.
●
N1 – single ipsilateral node up to 3cm
●
N2a – single ipsilateral node up to 6cm
●
N2b – two ipsilateral nodes up to 6cm
●
N2c – contralateral or bilateral nodes up to 6cm
●
N3a – Anode more than 6cm
●
N3b – extra-nodal spread (tethering/nerve involvement)
ORAL (AND OROPHARYNGEAL) CANCER
TUMOUR, NODE, METASTASIS (TNM)
e system outlined next describes the tumour component of
the TNM classication. A higher T classication corresponds
to invasion of local and more distant structures, as well as to a
greater size of tumour and increased depth of invasion.
●
T1 – up to 2cm (and depth of invasion up to 0.5cm)
●
T2 – up to 4cm (and depth of invasion up to 1 cm)
●
T3 – more than 4cm (or depth of invasion more than 1cm; or
onto lingual epiglottis in oropharyngeal)
●
T4a – includes local structures (medial pterygoid, larynx,
muscles of tongue, palate, mandible)
●
T4b – includes more distant structures (lateral pterygoid,
pterygoid plates, lateral nasopharynx, skull base, carotids)
OSTEORADIONECROSIS (ORN)
GRADESBYNOTANI
e classication that follows describes extent of osteoradionecrosis of the mandible according to extension of the lesion
into the medullary bone below or above the inferior dental (ID)
canal. Ahigher grade denotes extension into the medulla below
the ID canal and an associated fracture or stula.
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Head and Neck Oncology 41
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1. Alveolar
2. Into medulla above ID canal
3. Into medulla below ID canal (±fracture/stula)
ORN STAGES BY MARX
e classication that follows describes stages of osteoradionecrosis according to depth of bone damage and response to hyperbaric oxygen (HBO). e most advanced stage requires complete
surgical resection and reconstruction.
●
Stage I – exposed alveolar bone without pathological fracture,
responds to HBO therapy
●
Stage II – disease does not respond to HBO therapy, requires
sequestrectomy and saucerisation
●
Stage III – full-thickness bone damage or pathological fracture, requires complete resection and reconstruction with free
aps/tissue
ORN TYPES BY LYONS ET AL.
is system describes osteoradionecrosis in terms of the size of
the bone exposed and whether the exposure is symptomatic.
Debridement and local ap reconstruction can be employed to
manage symptomatic patients. Complications from primary
disease require free ap reconstruction and ORIF (in case of
pathological fracture).
1. <2.5cm bone exposed, asymptomatic
2. >2.5cm, asymptomatic (even if fracture)
ese get medical treatment only, unless sepsis or loose
necroticbone.
3. Symptomatic, debride and local ap
4. Complications (stula, fracture, IAN symptoms), ORIF and
free ap reconstruction
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42 Classifications and Lists in Oral and Maxillofacial Surgery
https://t.me/med1917
RESPONSE EVALUATION CRITERIA IN SOLID
TUMOURS (RECIST)
e criteria that follow help to evaluate the treatment response
of solid tumours.
●
CR – disappearance of all target lesions
●
PR – 30% reduction in sum of target lesions
●
PD – 20% increase
●
SD – small changes not meeting criteria
RESIDUAL TUMOUR CLASSIFICATION
e following classication describes the extent of residual
tumour following resection/treatment. Ahigher R grade is associated with visible residual pathology.
●
R0 – curative resection
●
R1 – microscopic residual disease
●
R2 – macroscopic residual disease
SHAMBLIN’S CLASSIFICATION OF CAROTID
BODY TUMOURS
is system describes the management of carotid body tumours
based on their size.
1. Small and easy to resect (≤180 degrees circumferential contact)
2. Medium/adherent (181–269 degrees)
3. Large (transmural), needs resection and gra (≥270 degrees)
SINO-NASAL TNM
e system that follows describes the substages of the tumour
component of TNM classication of sino-nasal malignancy.
●
T1 – mucosa only
●
T2 – bone invasion (not posterior wall antrum or pterygoid)
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Head and Neck Oncology 43
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●
T3 – into posterior wall antrum/SC tissues, oor and medial
wall orbit, ethmoids, pterygoid fossa
●
T4a – into pterygoid plates/anterior orbit, cheek skin, infratemporal fossa, cribriform plate, sphenoid/frontal sinus
●
T4b – into orbital apex, dura/brain, middle cranial fossa,
nasopharynx, clivus, cranial nerves other than V2 (maxillary
branch of the trigeminal nerve)
SINO-NASAL TUMOUR MANAGEMENT
e following summary provides an overview of management
strategies, surgical access and approach considerations for sinonasal tumours.
●
Craniofacial approach usually (but endoscopic possible with
small tumours of lateral nasal wall and anterior skull base).
ree types: type 1, transorbital (lynch and lateral rhinotomy); type 2, shield; type 3, lateral rhinotomy and frontal
craniotomy. All need excision and radiotherapy; elective neck
dissection for T3/T4, but not for small, low-grade tumours;
lifelong follow-up needed for T3/T4 as dicult to monitor.
●
Ohngren’s line – plane drawn between the medial canthus and
angle of mandible, can be combined with a midpupillary plane,
antero-inferomedial sino-nasal malignancies have the best prognosis, postero-superomedial ones have the most unfavourable.
WHEN TO USE PET-CT
Criteria outlined here describe when positron emission tomography-computerised tomography (PET-CT) is indicated in the
management of head and neck tumours.
●
Check for recurrence (12 weeks aer DXT/6 weeks aer surgery) – sensitive but poor
●
Specicity when post-operative inammatory changes still
present
●
Carcinoma of unknown primary
●
Staging of T4 hypopharynx/nasopharynx and N3
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44 Classifications and Lists in Oral and Maxillofacial Surgery
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WHEN TO USE FROZEN SECTION – THREE
POINTS
e following list describes when to use frozen sections in the
management of head and neck cancers.
●
Doubt over margins
●
To conrm diagnosis of benign disease
●
Lymph node involvement in thyroid cancer
FURTHER READING
Anneroth G, Batsakis J, Luna M. Review of the literature and a
recommended system of malignancy grading in oral squamous cell carcinomas. Scand J Dent Res. 1987;95:229–49.
Baumann D, Robb G. Lip reconstruction. Semin Plast Surg.
2008;22(4):269–80. doi: 10.1055/s-0028-1095886.
Brown JS, Barry C, Ho M, Shaw R. Anew classification for man-
dibular defects after oncological resection. Lancet Oncol.
2016;17(1):e23–30.
Byun SH, Lim HK, Yang BE, Kim SM, Lee JH. Delayed reconstruc-
tion of palatomaxillary defect using fibula free flap. J Clin
Med. 2020;9(3):884.
Cheson BD, Fisher RI, Barrington SF, etal. Recommendations
for initial evaluation, staging, and response assessment of
Hodgkin and non-Hodgkin lymphoma: The Lugano classification. J Clin Oncol. 2014;32(27):3059–68.
Dhawan A. Adjunctive therapy in oral cancer. In: Bonanthaya
K,Panneerselvam E, Manuel S, Kumar VV, Rai A, eds. Oral and
maxillofacial surgery for the clinician. Singapore: Springer; 2021.
Diagnosis and management of metastatic malignant disease of
unknown primary origin. n.d. www.nice.org.uk/guidance/
cg104/documents/metastatic-malignant-disease-of-unknownprimary-origin-prepublication-check-full-guideline2.
Ganeshalingam S, Koh DM. Nodal staging. Cancer Imaging.
2009;9(1):104–11.
Gastman BR, Mehta AR, Myers JN. Head and neck cancer.
In: Weinzweig J, ed. Plastic surgery secrets plus. 2nd ed.
London: Elsevier; 2010: 355–62.
t.me/Dr_Mouayyad_AlbtousH
Head and Neck Oncology 45
https://t.me/med1917
Limaiem F, Davis DD, Sticco KL. Chondrosarcoma [Updated 2023
Jan 1]. In: StatPearls [Internet]. Treasure Island, FL: StatPearls
Publishing; 2023.
Lyons A, Osher J, Warner E, Kumar R, Brennan PA.
Osteoradionecrosis—a review of current concepts in defining
the extent of the disease and a new classification proposal. Br
J Oral Maxillofac Surg. 2014;52(5):392–95.
Malloy K. AJCC 8th edition major updates in cancer staging:
Implications for OPC treatment? [online]. 2017. www.ahns.
info/wp-content/uploads/2017/07/AJCC-8th-Edition-MajorUpdates-in-Cancer-Staging.pdf.
Marechek A, AlShare A, Pack S, Demko C, Quereshy FA, Baur D.
Nonvascularized bone grafts for reconstruction of segmental
mandibular defects: Is length of graft a factor of success? J
Oral Maxillofac Surg. 2019;77(12):2557–66.
Marx RE. Anew concept in the treatment of osteoradionecrosis.
J Oral Maxillofac Surg. 1983;41(6):351–7.
Mathes SJ, Nahai F. Classification of the vascular anatomy of
muscles: Experimental and clinical correlation. Plast Reconstr
Surg. 1981;67(2):177–87.
Notani K, Yamazaki Y, Kitada H, Sakakibara N, Nakamura M.
Management of mandibular osteoradionecrosis
and the method of radiotherapy. Head Neck. 2003;25:
181–6.
Riemenschnitter CE, Morand GB, Schouten CS, etal. Need
for adjuvant radiotherapy in oral cancer: Depth of invasion
rather than tumor diameter. Eur Arch Otorhinolaryngol.
2023;280(1):339–46.
Schwartz LH, Litière S, de Vries E, etal. Recist 1.1-update and
clarification: From the RECIST committee. Eur J Cancer.
2016;62:132–7.
Shamblin WR, ReMine WH, Sheps SG, Harrison EG Jr. Carotid
body tumor (chemodectoma). Clinicopathologic analysis of ninety cases. Am J Surg. 1971;122(6):732–9. doi:
10.1016/0002-9610(71)90436-3.
Zanoni DK, Patel SG, Shah JP. Changes in the 8th Edition of the
American Joint Committee on Cancer (AJCC) staging of head
and neck cancer: Rationale and implications. Curr Oncol Rep.
2019;21(6):52.
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Salivary Gland Disease
SJÖGREN’S DIAGNOSIS CRITERIA –
AMERICAN-EUROPEAN CONSENSUS
GROUP(AECG) 2002
e following list outlines diagnostic criteria for Sjögren’s disease according to the AECG (2002); four or more of the six criteria are required together with at least one of them being labial
gland biopsy/auto-antibodies.
1. Eye symptoms
2. Eye signs – Schirmer’s test <5mm/5 min, Rose Bengal
Staining (RBS)
3. Mouth symptoms
4. Mouth signs (salivary ow, sialography, scintigraphy)
5. Labial gland biopsy (focal inltrative replacing acini)
6. Auto-antibodies (AABs) – SSA (anti-Ro), SSB (anti-La),
RF,ANA
DOI: 10.1201/9781003156895-5 47
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48 Classifications and Lists in Oral and Maxillofacial Surgery
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SJÖGREN’S DIAGNOSIS CRITERIA – AMERICAN
COLLEGE OF RHEUMATOLOGY (ACR) 2012
e following list outlines the ACR (2012) criteria for the diagnosis of Sjögren’s syndrome; all three are required for diagnosis.
1. Auto-antibodies
2. Labial gland biopsy
3. Rose Bengal stain
SURGERY FOR SALIVARY MALIGNANCY
e following list outlines surgical options for the management
of salivary gland cancer.
Submandibular:
●
Gland excision + SND 1, 2a (+3 if high grade/risk – mucoepidermoid, SCC, carcinoma ex pleomorphic adenoma, anaplastic, >4cm) PLUS DXT (if >4cm, recurrent, advanced, adenoid
cystic carcinoma)
Parotid:
●
Small, low-grade tumours managed surgically with supercial
parotidectomy alone
●
Everything else requires total conservative parotidectomy +
SND 1–3 (plus DXT as in the preceding)
Minor gland:
●
1cm WLE + SND (if not small low grade, plus DXT as in
preceding)
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