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Malignancies of the Paranasal Sinus

Key Points Paranasal sinus malignancies present insidiously and have poor survival outcomes due in part to advanced stage at initial diagnosis. Substantial heterogeneity in histology and corresponding biologic aggressiveness is encountered, with squamous cell carcinoma and rhabdomyosarcoma being the most common in adults and children, respectively. Advances in imaging, radiation modalities, and surgical approaches are crucial to clinical decision-making and have improved the morbidity and mortality…

Prosthetic Management of Head and Neck Defects

Key Points Dentoalveolar evaluations should be accomplished prior to radiation therapy (RT) in the interest of establishing lifelong prognoses for those teeth to be included in potential radiation fields. Teeth with poor prognoses should be extracted before RT, preferably at the time of a surgical ablation, if such is planned. The risk of osteoradionecrosis (ORN) secondary to invasive dentoalveolar procedures is substantial in areas that have…

Reconstruction of the Mandible

Key Points The most common causes of mandibular defects requiring reconstruction are malignancy, benign tumors, trauma, infection, and osteoradionecrosis. The goals of mandibular reconstruction are to (1) maintain oral competency, (2) maintain occlusal relationships of remaining teeth, (3) maintain the temporomandibular joint alignment and architecture, (4) maintain contour of lower third of the face, (5) and allow for dental rehabilitation. The gold standard for significant mandibular…

Malignant Neoplasms of the Oral Cavity

Key Points Early detection of oral cancer directly results in improved survival after treatment. Tobacco use and habitual alcohol consumption synergistically increase the risk of developing oral carcinoma. For most presentations of cancer of the oral cavity, the risk of occult spread to the regional lymphatics exceeds 20% and warrants elective treatment of the regional lymphatics. Functional recovery after a significant oral cavity resection depends on…

Benign Tumors and Tumor-Like Lesions of the Oral Cavity

Key Points Benign neoplasms of the oral cavity are typically best treated with complete surgical excision. Generally, recurrence is rare, as is malignant transformation. Treatment for tumor-like lesions involves either conservative medical management or surgical excision, depending on the particular clinical entity. Development of aphthous ulcerations occurs in up to 60% of the population of the United States. Ulcerations that persist beyond 2 weeks should be…

Temporomandibular Joint Disorders

Key Points Temporomandibular disorders is a collective term that describes intracapsular and muscular disorders and myofascial pain dysfunction. The general complaints of temporomandibular disorders include facial pain, earache, and headache. The temporomandibular joint (TMJ) is a diarthrotic joint, and each joint is incapable of independent movement. The TMJ is a ginglymoarthrodial joint, capable of both translational and rotational movement. TMJ dislocation occurs when a hypermobile joint…

Odontogenesis, Odontogenic Cysts, and Odontogenic Tumors

Key Points Odontogenesis Portions of the enamel organ Odontogenic cysts Nomenclature and other cysts of the oral region Orthokeratinizing odontogenic cyst (keratinizing odontogenic cyst), separation from keratocystic odontogenic tumor (odontogenic keratocyst) Odontogenic cyst of undetermined origin definition and discontinued use of primordial cyst term. Glandular odontogenic cyst, definition, and problems with diagnosis Odontogenic tumor General treatment considerations of odontogenic tumors Proper therapy for “simple unicystic ameloblastoma”…

Oral Mucosal Lesions

Key Points Leukoplakia carries a small but significant risk of malignant transformation. The proliferative verrucous form has a far greater incidence of recurrence, multifocality, and absence of the usual risk factors and transformation rates of typical leukoplakia. At the moment, no effective chemoprevention strategy for the management of leukoplakia has been proven, nor is there a predictable manner in which to judge its progression to carcinoma.…

Physiology of the Oral Cavity

Key Points Somatosensory innervation of the oral cavity is provided by cranial nerve V (trigeminal nerve), second and third divisions, and cranial nerve IX (glossopharyngeal nerve): (1) V2—maxillary, hard, and soft palates; oral mucosa of the maxillary vestibule; and maxillary teeth, gingivae, and periodontal ligaments; (2) V3—mandibular, oral mucosa of the cheek and mandibular vestibule; anterior two thirds of tongue; mandibular teeth, gingivae, and periodontal ligaments;…

Malignant Neoplasms of the Salivary Glands

Key Points Salivary gland malignancies are diverse and heterogeneous. Their behavior and resulting clinical management are highly dependent on their histologic type and, often, their grade. High-grade histologic types include high-grade mucoepidermoid carcinoma, squamous cell carcinoma, undifferentiated carcinoma, high-grade adenocarcinoma not otherwise specified, solid-type (Grade III) adenoid cystic carcinoma, small cell carcinoma, salivary duct carcinoma, and any tumor with so-called high-grade transformation. When lesions are resectable,…

Benign Neoplasms of the Salivary Glands

Key Points Salivary gland neoplasms are uncommon, representing less than 4% of all head and neck neoplasms. Most salivary gland neoplasms occur within the parotid gland, of which approximately 80% are benign in adults. 50% of submandibular gland and 20% of minor salivary gland tumors are benign. The palate is the most commonly affected minor salivary gland location. Pleomorphic adenomas are the most common benign salivary…

Inflammatory Disorders of the Salivary Glands

Key Points Sialadenitis, most commonly caused by sialolithiasis, should be treated medically in the acute care setting with warm compresses, sialogogues, hydration, and antibiotics. Chronic or persistent disease may require minimally invasive sialendoscopy for diagnostic and therapeutic purposes. Sialendoscopic techniques include endoscopic visualization of stenosis or calculi, balloon dilatation of stenoses, fragmentation of large stones with Holmium laser, and ensnarement of stones with a wire basket.…

Diagnostic Imaging and Fine-Needle Aspiration of the Salivary Glands

Key Points Computed tomography is the modality of choice for patients with inflammatory disorders of the salivary glands. Magnetic resonance imaging is the modality of choice for patients with a palpable lesion or expected neoplasm of the salivary glands. Ultrasound is useful in palpable salivary lesions and has been shown to assist the diagnostic accuracy of fine-needle aspiration. Although conventional sialography is the gold standard for…

Physiology of the Salivary Glands

Key Points Importantly, our current understanding of salivary gland physiology is largely derived from the study of nonhuman salivary glands. Saliva is a complex mixture of electrolytes and macromolecules secreted from three pairs of major salivary glands and numerous minor salivary glands. The basic unit of the salivary gland consists of an acinus, a secretory duct, and a collecting duct. Saliva is formed via active transport…

Management of Cutaneous Head and Neck Melanoma

Key Points The incidence of melanoma continues to increase at epidemic proportions. Warning signs for melanoma include lesion asymmetry, border irregularity, color variation, diameter greater than 6 mm, and evolving changes. A subset of cancers—such as nodular, amelanotic, and desmoplastic melanoma—lack these features. Any pigmented lesion that meets these criteria, has undergone change, or appears different from surrounding nevi warrants biopsy. Prognostic information from this biopsy guides…

Integrating Palliative and Curative Care Strategies in the Practice of Otolaryngology

Key Points The goal of palliative care is to provide relief of suffering regardless of life expectancy or treatment status. Palliative care requires a multidisciplinary approach to address the physical, emotional, and spiritual distress that a patient may be experiencing. Palliative care is now a medical specialty in its own right with services at most hospitals. Palliative care modalities include surgery, chemotherapy, radiation therapy, assorted pharmacologic…

Free Tissue Transfer

Key Points Free tissue transfer involves auto-transplantation of skin, soft tissue, muscle, or bone isolated on a supporting vascular supply. Although more than 40 donor sites for free tissue transfer have been described, forearm, fibula, scapula, and anterolateral thigh flaps account for the majority of all the free flaps used for head and neck reconstruction. A multidisciplinary team approach, especially for patients with head and neck…

Skin Flap Physiology and Wound Healing

Key Points Flap survival depends on adequate perfusion to meet the metabolic demands of the mobilized tissue. The primary insult that affects flap survival is impaired vascular supply and the resultant ischemia. Flap survival is the rule in the majority of flaps that are carefully designed and are accomplished in healthy patients. Careful clinical evaluation and monitoring methods must be used in at-risk cases to identify…

Chemotherapy and Targeted Biologic Agents for Head and Neck Cancer

Key Points Combined-modality therapy (CMT) is a treatment option for patients with locally advanced squamous cell carcinoma of the head and neck, most often in three clinical scenarios: (1) chemoradiation delivered concomitantly for an enhanced local treatment effect, known as concurrent chemoradiotherapy; (2) chemoradiation as adjuvant therapy after definitive surgical resection; (3) initial induction chemotherapy followed by concurrent chemoradiotherapy known as sequential chemoradiotherapy. Functional organ preservation…

Radiotherapy for Head and Neck Cancer: Radiation Physics, Radiobiology, and Clinical Principles

Key Points Basic Radiation Physics The unit of measure for radiation is gray (Gy), which corresponds to 1 joule (J) being deposited per kilogram of material. The two main energy sources in use are electrons and photons. Electrons differ from photons in that electrons travel only a certain (short) distance within the tissue. The deposition of the majority of their dose is in superficial tissues, so…