• Oropharynx/Throat Cancer

    Oropharynx/throat cancer The pharynx is a muscular tube that connects the nose and mouth to the esophagus; it is commonly known as the throat. The oropharynx is the middle part of this that contains the opening from the back of the mouth. It includes the tonsils, the base of the tongue, the soft palate and the walls of the throat in this region. It connects to the nasopharynx (the upper part of the throat) above and the hypopharynx (lowest part of the throat) below. Its purpose is to allow passage of food and air into the hypopharynx.

    The growth and division of cells are normally regulated by the body. When cells divide in an uncontrolled manner they form a mass or tumor. Cancers, or malignant tumors, are masses that have the ability to spread to other parts of the body, and often invade or destroy tissues near to where they arise. Benign tumors do not have the ability to spread to other parts of the body and are not considered cancers.

    Oropharyngeal cancer is a malignant tumor arising in the oropharynx. The most common type of oropharyngeal cancer is squamous cell carcinoma, which develops from the cells that line the pharynx. Lymphomas can also develop from the tonsils, or the lymphoid tissue at the back of the tongue. (This will focus on squamous cell cancers of the oropharynx). 
     

    Risk Factors

    • Smoking
    • Alcohol use (especially when combined with smoking)
    • Chewing tobacco
    • Human papillomavirus infection (HPV)
    • Poor nutrition (lack of fruits and vegetables in the diet)
    • Race: Black males roughly two times as likely as white males
    • Sex: Males roughly three times as likely as women
    • More common in persons greater than 55 years old

    Symptoms

    • Sore throat or pain with swallowing
    • Burning sensation with acidic foods
    • Mass or lump in the neck
    • Specific changes in speech, sometimes called "hot potato voice" because it sounds as if you're talking around a mouthful of hot mashed potatoes
    • Ear pain
    • Coughing up blood
    • Difficulty opening the mouth
    • Difficulty swallowing
    • Airway obstruction

    Diagnosis

    • A detailed history of symptoms taken by your physician
    • A full examination of the head and neck
    • Endoscopy is usually performed by an ear nose and throat physician in the office. This involves passing a flexible scope through the nose to view the throat.
    • Biopsy may be performed in the office or in the operating room, depending on the location of the tumor. This obtains a sample of the tumor cells to prove the diagnosis of cancer.
    • Needle biopsy may be performed in the office if a neck mass is present
    • CT scan: this is a specialized X-ray performed with intravenously injected dye to look at the structures of the head and neck
    • MRI scan: uses powerful magnets to look at the structures of the head and neck
    • Chest X-ray (alternately a chest CT scan may be performed)

    Treatment 

    The stage (based on the size and spread of the cancer) and location of the tumor help the cancer team determine what type of treatment is most appropriate. The neck is often treated even if no neck mass is present, because spread of microscopic cancer cells is common.

    Surgery

    The type of surgery performed to resect an oropharyngeal cancer is determined by the size and location of the tumor. Partial pharyngectomy involves removing the part of the throat where the tumor is located; this may include parts of the tongue or palate. Pharyngectomy with partial laryngectomy involves removing parts of the throat and voice box, but typically preserves the voice. Total laryngopharyngectomy involves removing the pharynx containing the tumor and the entire larynx (voice box). This requires creation of a permanent hole in the neck for breathing and the normal voice is lost. If the jaw bone is involved by the tumor, part of it may need to be removed and reconstructed. Even if the jaw bone is not involved, it may need to be cut during the surgery to provide access to the tumor. This cut is repaired with titanium plates before completion of the surgery.

    The lymph nodes of the neck are usually removed at the time of surgery. This is called a neck dissection. Depending on the location of the tumor, the lymph nodes on the same side of the neck as the tumor, or both sides of the neck will be removed. All normal structures that are uninvolved by tumor will be preserved at the time of neck dissection.

    Some procedures that remove oropharyngeal cancers, but save part or all of the larynx, require tracheotomy. This is a temporary opening from the windpipe to the neck that is kept open with a plastic tube. This allows the airway to be safe, even if there is significant swelling in the throat and larynx in the days after the surgery. 

    Radiation Therapy 

    Radiation therapy uses radiation to kill cancer cells. Radiation may be used as the primary therapy for a cancer, with chemotherapy, or after surgery. The normal cells surrounding the tumor and lymph nodes are also affected by radiation therapy. The radiation is most commonly delivered from the outside with beams focused on the tumor, and the lymph nodes of the neck. This is performed in multiple treatments; usually daily for several weeks. Occasionally, radioactive materials are placed near the tumor at the time of surgery, and these radiation sources may later be removed. 

    Chemotherapy

    Chemotherapy is the use of medications to kill cancer cells. There are many types of chemotherapy medications, that may be given orally, or by injection. Chemotherapy can affect cancer cells throughout the body, but some of the body's normal cells are also affected by these medications. Chemotherapy may be given before radiation, during radiation, or both. 

    Rehabilitation

    The rehabilitation after surgery, radiation and chemotherapy is focused on preserving speech and swallowing function. Surgery has an immediate impact on function, while nonsurgical treatments may affect function during treatment, or at some point after treatment. At the time of surgery, reconstruction of the throat, tongue and palate is often performed to allow for continued swallowing and speech function. This may involve transfer of tissue from near the surgical site (such as skin and muscle from the chest), or a free tissue transfer. Free tissue transfer involves transplanting tissue and the blood vessels that supply that tissue, from some other part of the body (the forearm is used most often; when bone is needed to reconstruct the jaw bone the lower leg is most often used). These reconstructive tissues help keep the throat open, but do not have the same sensation and muscle function as the normal throat and tongue that is removed. Speech and swallowing therapists work with patients who have undergone surgical or nonsurgical treatment of hypopharyngeal cancer to improve speech and swallowing function. If a patient is unable to swallow, or cannot keep food from entering the airway, a temporary or permanent gastrostomy tube may be placed. This is an artificial tube inserted through the skin of the abdomen into the stomach, allowing food and medicine to be passed directly into the stomach for as long as swallowing difficulty is present.

    If the voice box is removed (total laryngectomy) there are several option for providing voice. The electrolarynx is an electronic device that provides sound through the neck, or through a tube inserted into the mouth. The mouth and tongue are then used normally to form words from this sound. Tracheo-esophageal puncture involves creating an opening between the windpipe (trachea) and the esophagus. A one way valve allows air to flow into the esophagus and pharynx that creates vibrations which produce sound. The type of tissue used to reconstruct the throat may affect how well this technique works. Rarely, some patients are able to speak by swallowing air, then releasing it (like burping) to produce sound that can be formed into words. This is the hardest technique to learn. All three techniques require therapy with a speech pathologist.
     

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