Carcinoma of Oral Cavity

Causes of referred otalgia

Ear receives nerve supply from Vth (auriculotemporal), 1Xth (tympanic br.) and Xth (auricular br.) cranial nerves; and from C2 (lesser occipital) and C2 and C3 (greater auricular), pain may be referred from these remote areas

1. Via Vth cranial nerve

• Dental; Caries tooth, apical abscess, impacted molar, malocclusion.
• Oral cavity; Benign or malignant ulcerative lesions of oral cavity or tongue.
• Temporomandibular joint disorders; Bruxism, osteoarthritis, recurrent dislocation,  ill-fitting denture.
• Sphenopalatine neuralgia.

2. Via IXth cranial nerve

• Oropharynx; Acute tonsillitis, peritonsillar abscess, tonsillectomy. Benign or malignant ulcers of soft palate, tonsil and its pillars.
• Base of tongue; Tuberculosis or malignancy.
• Elongated styloid process.

3.   Via Xth cranial nerve. Malignancy or ulcerative lesion of: vallecula, epiglottis, larynx or laryngopharynx, esophagus.

4.   Via C2 and C3 spinal nerves. Cervical spondylitis, injuries of cervical spine, caries spine.

Incidence of cervical metastasis in head and neck cancers (in decreasing order)

• Tongue (most common)
• Floor of mouth
• Lower alveolus
• Buccal mucosa
• Upper alveolus
• Hard palate

Verrucous carcinoma is also referred to as a giant condyloma accuminatum or buschke lowenstein tumor.

It is considered an intermediate lesion between condyloma accuminata and invasive squamous cell carcinoma.

These cancers tend to localize and are cured by wide excision, however they can undergo malignant transformation into an invasive squamous cell carcinoma.

The most common type of oral cancer in India is buccal mucosa (38%) followed by anterior tongue secondly (16%) and thirdly lower alveolus (15.7%).

So when the percentages of buccal mucosa and lower alveolus are combined it is alveobuccal complex (53.7%), the most common type of oral cancer in India.

Worldwide the most common type of oral cancer is the carcinoma of the lip and secondly carcinoma of the tongue.

Ref: Textbook of Preventive and Community Dentistry, 2nd Edition By SS Hiremath MDS, FICD (USA) 2nd Edition, Page 159; Global Clinical Trials: Effective Implementation and Management By Richard Chin, Menghis Bairu, Page 122.

Abbey-Estlander flap is used in the reconstruction of lip.

The Abbe – Estlander Flap is a transposition flap from the opposite lip.

In this reconstructive surgery the tissue is borrowed from the opposite lip at the oral commisure.

Otalgia can occur as a symptom of carcinoma on the base of tongue, pharynx or larynx.

Erythroplakia is similar to leukoplakia except for its colour.

Erythroplakia is a red patch or plaque on the mucosal surface. The red colour is due to decreased keratinization, and as a result, the red vascular connective tissue of the submucosa shines through.

Malignant potential for erythroplakia is 17 times higher than in leukoplakia. Treatment is excision biopsy and follows up.

Ans. is ‘a’ i.e., Leukoplakia

o There are two premalignant lesions for oral Cancer ‑

i) Leukoplakia

ii) Erythroplakia

o Leukoplakia is the most common premalignant lesions.

o But, the risk of malignant transformation of erythroplakia is much higher than that seen with leukoplakia.

o The most common predisposing factor for both these conditions is smoking.

Ans. is ‘c’ i.e., Verrucuous carcinoma

Verrucuous carcinomas also referred to as giant condyloma accuminatum or Buschke-Lowenstein tumor are considered an intermediate lesion between candyloma accuminatum and invasive squamous cell carcinoma. It is important to distinguish verrucuous carcinoma from squamous cell carcinomas as these tend to remain localized and are cured by wide excision, however they may undergo malignant transformation in to invasive squammous cell carcinomas.

Features of verrucuous carcinomas

o Prediliction for males > 50 years

o Predisposed in tobacco users, poor oral hygiene

Gross                                                         Microscopic

o Large                                                 o Cytological features of malignancy are absent or minimal and rare

o Soft                                                   o Epithelium is thickened and thrown into papillary folds

o Wart like lesions/                                o The folds project both above and below the level of surrounding mucosa

o Papillomatus                                       and crypt like surface grooves exhibit marked, prekeratin plugging

o Fungation may be present                (hyperkeratosis ?) ‑

o The rete projections are broad, bulbous and relatively smooth bordered and there may be chronic inflammatory infiltrate in the subjacent lamina propria. o The deep border of epithelial projections is ‘pushing’ and not infiltrative.

The patient in question is an elderly male (70 years) with a chronic history of tobacco use.

Gross features of a ‘large’, `soft’,’papillary’ lesion that has undergone fungation’ are all consistent with the diagnoses of verrucuous carcinoma. Benign appearing `papillomatoses’ with ‘hyperkaratosis’ further supports the diagnosis. Contiguous structures may be involved as the tumor grows. Tumor of the buccal mucosa can grow to become fixed to the periostium of mandible and with continued growth may eventually destroy the periostium and directly invade the mandible.

Ans. is ‘a’ i.e. Lip

A flap is a skin graft which has its own blood supply. (Normally a skin graft to survive is revascularized by the recipient bed. A flap has its own blood supply.)

Abbey flap is used for Lip reconstruction. It is based on main artery of the orbicularis oris, the labial artery.

Ans. is ‘c’ i.e., Alveobuccal complex

• According to the textbook of surgery by ‘Association of surgeons of India’, various cancers of the oral cavity are reported with the following frequency:
• The alveobuccal complex thus accounts for 53.7 percent of oral cancers and thus constitutes the commonest site in the Indian population.

• Site in India- buccal mucosa > anterior tongue > floor of mouth > palate > lips.

Also, Remember

• The most common site of oral cancer in the world is—> Tongue
• Tobacco is the most important risk factor

Answer is ‘d’ i.e. Lichen planus 

Ans. is ‘a’ i.e., Leukoplakia 

Leukoplakia is the most common (-85%) of the premalignant lesions of the oral cavity.

Ans. is ‘b’ i.e. Metastases uncommon; ‘c’ i.e. Responds to Radiotherapy

• As already mentioned Syphilitic glossitis & chronic irritation by jagged tooth predispose oral cancer.
• Metastases to distant sites are uncommon
• Treatment involves both surgery and/or radiotherapy (& chemotherapy for advanced lesions)
• Buccal mucosa is the most common site of oral cancer in India.
• Also Remember

– Over 95% of cancers of the oral cavity are squamous cell carcinomas.

Ans. is ‘D’ i.e., All of the above 

Risk factors associated with cancer of the head and neck

• Tobacco
• Alcohol
• Areca nut/pan masala
• Poor nutrition
• Inherited conditions (Fanconi anemia, Li-Fraumeni syndrome)
• Human papillomavirus
• Syphilis
• Sharp tooth or ill-fitting denture
• UV radiation

Ans. is ‘d’ i.e., Squamous cell carcinoma 

Ans. is ‘c’ i.e. Tongue

Incidence of oral cancer

• Tongue 50%
• Cheek: 20-25%
• Floor: 10-15%
• Gums: 10%

Ans. is ‘a’ i.e., Surgery and Radiotherapy

• Trismus in oral cancer is defined as a tonic contraction of the muscles of mastication resulting from any abnormal condition or disease with a mouth opening of ≤35 mm.
• It may be a result of tumor growth, infection, surgery or radiation.

Common causes of trismus

1. Temporomandibular joint involvement-such as ankylosis, dislocation, synovitis, etc.

2. Mandible fractures

3. Pterygoid muscle infiltration by growth in the retromolar region

4. Acute inflammatory lesions in the oral cavity

5. Tetanus and tetany

6. Radiation fibrosis of soft tissues/muscles of mastication

7. Surgery

Ans is ‘a’ ie Ca lip 

 These descriptions of carcinoma clearly rank Ca lip with best prognosis.

Ans. is ‘c’ i.e. Hard palate 

Incidence of cervical metastasis in oral cancers (in decreasing order)

• Tongue (most common)
• Floor of mouth
• Lower alveolus
• Buccal mucosa
• Upper alveolus
• Hard palate

Ans. is ‘b’ i.e. Lip

• Patients with head and neck squamous cell carcinoma (HNSCC) are at increased risk for the development of second primary malignancies compared with the general population.
• These second primary malignancies typically develop in the aerodigestive tract (lung, head and neck, esophagus).
• The most frequent second primary malignancy is lung cancer.
• The highest relative increase in risk is for a second head and neck cancer.
• The site of the index cancer influences the most likely site of a second primary malignancy.

–    In patients with an index malignancy of the larynx, the second primary tumor was commonly seen in lung, while

–    In patients with an index malignancy of the oral cavity, the second primary tumor was commonly seen in head and neck or esophagus.

Frequency of various cancer of oral cavity in India are :

• Buccal mucosa 38%
• Anterior tongue 16%
• Lower alveolus, floor of mouth 15%

Although M/C variety of buccal cancer is squamous cell cancer, Verrucous carcinoma is a variety of well-differentiated squamous cell carcinoma which is locally aggressive involving the bone but lymph node metastasis is uncommon. Histologically. these tumors show marked hyperkeratosis and acanthosis with dysplasia limited to deeper layers. Repeated biopsies report it as squamous papilloma. .

• Oral malignancy with best prognosis is carcinoma lips.
• Oral cancer with worst prognosis is floor of mouth carcinoma.

Ans. D. b and c

Ans. C: Squamous cell carcinoma

. Squamous cell carcinoma (SCC) is the most common histology and the main etiological factors are tobacco and alcohol use

correct Ans . B  T2N2aM0

Ans. is ‘b’ i.e., Ca oral cavity

 Most common cancer in males in India: Lip/oral cavity