HEAD AND NECK

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The mucosa of the oral cavity is affected by chronic irritations which may be due to poor oral hygiene, problems of the teeth, dietary or other habits, such as smoking or drinking.  Other times, the cause of alterations to the mucosa may be indefinable. These alterations may be malignant altogether, or to suffer a malignant alteration in the process.

The complex anatomy of the oral cavity, with a gathering of many important anatomic elements in a small space and the delicate and complex functions performed, like speech, swallowing and the entrance of the upper respiratory track, do not allow for negligence in the diagnosis and treatment of these alterations.

Part of the responsibility for a timely diagnosis lies with the patient himself/herself who must be responsible enough to visit the doctor, when this patient detects any alteration in the oral cavity, or exhibits unusual symptoms.  Some patients try, using their own methods, to be relieved by their symptoms or they attribute them to injuries from certain foods (like a fish bone usually), bites etc, as if they wanted to reject from their thoughts the possibility of a malignant alteration.

On the other hand, the doctor too must be ready, not necessarily to diagnose the identity of the alteration from the first visit, but, first of all, to detect it and be in the position to apply a series of tests, in order to certify its histological identity and, then, to treat it properly.  And all this, with the doctor earning the trust of the patient, without terrifying him/her and without being carried away by the interpretations of the patient, loosing valuable time.

Usually the patient comes to the doctor complaining about a sore in the oral cavity which takes too much time to heal.  The sore bothers him/her especially when he/she is talking or eating and especially when the food is acidic.  Other times, he/she may see a swelling, covered by natural mucosa, on the tongue, the palate or elsewhere, and, fortunately more rarely, he/she comes with a swelling which he/she observed in the neck and which may finally prove to be a metastatic lymph gland.

The clinical examination is very important.  With this, the doctor will initially track down the alteration, will map its area and will look for possible swollen cervical lymph glands through palpation.

The clinical examination will indicate the surface extension of the alteration.  In order to identify the deeper borders, an imaging study is required.  The kind of the examination depends on the location of the alteration.  If we recon than the alteration is included in soft tissues, like the tongue, then we will choose to perform a MRI by administering a paramagnetic substance.  If the alteration is tangent to the bones of the upper or lower jaw, then we prefer a CT by intravenous administration of contrast, in order to trace possible invasion.  As far as the detection of lymphatic expansions is concerned, all three examinations, including an ultrasound of the neck that is, are valid and effective.

After the mapping of the tumor area is complete and we have looked for its possible lymphatic expansions, the next step is to identify the histological identity of the tumor before we plan and suggest a major and probably amputating operation to our patient.  This means that we will proceed with a biopsy of the alteration.

The biopsy may be performed under local anesthesia with the known advantages, it may, however, be necessary to apply general anesthesia, in which case we will have the chance to better palpate the lesion, and also to examine other anatomic areas for possible simultaneous alterations.   Parallel to this, a FNA in the palpable lymph glands will be done for the taking of material for a cytological examination.

A possible exception in the whole procedure may be a small alteration, at an early stage, the radical removal of which, among healthy tissues, does not mean the removal of a large tissue mass.  This alteration, therefore, may be considered as malignant from the beginning and be treated as such, without any previous histological verification.  In this case, that is, the procedures of biopsy and that of the radical removal coincide. Thus, the patient does not have to go through another general anesthesia.

In less than a week, our pathologist informs us about the histological identity of the tumor.  The advantages of a prompt and, of course, correct histological diagnosis are obvious.  Now we will need to discuss with our patient the available choices for dealing with the problem.  In the case of surgical treatment in particular, the discussion should be rather extensive as far as the extent of the operation is concerned the possible complications and the consequences of it for the patient’s everyday life.

A significant advantage today is the ability to use the laser, which allows cutting through the tumor and hence its transoral removal.  So in many cases, the traditional external operations are avoided while we have the same result for the tumor but with a better quality of life.

The surgical operations for the removal of tumors in the oral cavity may significantly affect the functions of breathing, eating and speaking.  They are necessary operations which require the cooperation with maxillary surgeons, plastic and reconstructive surgeons and implant and prosthetic device technicians.