chronic suppurative otitis media

204 OTOLARYNGOLOGY
T4 Carcinoma extending beyond oropharynx, e.g. into the pterygoid muscles, mandible, hard palate, deep muscle of
tongue or/and larynx.
Clinical features
Twenty per cent of patients present with a neck lump as the only symptom. Sore throat, referred otalgia,
odynophagia and muffled speech are common. Trismus is a late symptom and suggests pterygoid
involvement. A full head and neck examination is mandatory because of the high incidence of a second
primary. SCC is either exophytic or ulcerative but with NHL the tonsil is either large and vascular or small
and shrivelled, looking abnormal compared to its partner. Palpating the tumour and the neck is important to
assess the extent of infiltration of the primary and to assess the size, level, number and fixation of any
palpable neck lump(s). NHL requires assessment by an oncologist to properly stage the disease.
Investigations
1. An MRI scan with a STIR sequence will accurately define the extent of soft tissue invasion and neck
node involvement. It is preferred to CT scanning. A chest X-ray and liver ultrasound are performed as these
are the commonest sites for distant metastases.
2. Fine needle aspiration cytology (FNAC) of any palpable neck lump.
3. If a neck lump is not palpable but is defined on MRI or CT imaging FNAC should be performed
under either ultrasound or preferably CT guidance.
4. A panendoscopy under general anaesthesia is necessary to properly assess the hypopharynx,
oesophagus, trachea and bronchi for synchronous disease. If disease is limited to the tonsil a tonsillectomy
is performed in order to obtain macroscopic clearance. Suspicious tongue base lesions always require a deep
biopsy as the cancer may be submucosal.
Management
Most oncologists treat medium and high grade NHL as a disseminated disease and the CHOP regime
(cyclophosphamide, hydroxydaunorubicin, oncovine (vincristine) and prednisolone) is the most commonly
favoured. VAPEL-B (vincristine, adreomycin, prednisolone, etoposide, cyclophosphamide and bleomycin)
is a more recent regime favoured by some oncologists. In the relatively unusual event that the lymphoma is
very localized, radiotherapy may be used.
MSGC and SCC require a macroscopic margin of 1–2 cm and clearance must be confirmed by frozen
section. T1 and small T2 stage SCC can be treated with radio-therapy as can N1 neck disease. Large T2 and
T3 stage disease is treated with surgery. With many T4s macroscopic clearance is not possible.
Chemotherapy or radio-therapy may reduce tumour size for clearance to be attempted but this will depend
on the patient’s age, fitness and wishes.
To obtain adequate exposure of the lateral oropharynx, a stepped paramedian mandibulotomy is
necessary in order to preserve the inferior dental nerve. The exact site is determined after assessing an
orthopantomogram as the incisor and canine roots are often not parallel. One canine and an incisor may
need to be extracted at mandibulotomy to ensure the plating screws do not impinge on a root thereby
predisposing to a root abscess, osteomyelitis and non-union of the plated mandible. If involvement up to and
including the mandibular periosteum has occurred an inner table mandibulectomy is performed. Should the
dental canal be involved a partial mandibulectomy is performed with reconstruction using a composite radial