CHEEK

ANATOMY OF CHEEK
 They are fleshy flaps on either side of the face.
 It is composed of skin, superficial fascia with parotid duct, buccinator muscle, submucosa with
buccal glands and mucous membrane.
 LYMPHATICS: Submandibular and pre-auricular nodes.

 RETROMOLAR TRIGONE is the mucosa on the ANTERIOR SURFACE of the ASCENDING

RAMUS of the mandible. It is triangular in shape with the base being superior and apex
inferiorly behind the third molar tooth.

CARCINOMA CHEEK

 SQUAMOUS CELL CARCINOMA is the MOST COMMON TYPE OF CARCINOMA of the

cheek.
 OCCASIONALLY IT CAN BE ADENOCARCINOMA arising from the minor salivary glands or
mucus glands.
 Rarely it can also be MELANOMA.

MALIGNANCIES OF THE ORAL CAVITY

Squamous cell carcinoma—commonest
Minor salivary gland tumours
Melanomas
Adenocarcinomas—rare
Sarcomas—rare

PRECIPITATING FACTORS

 All ‘S’—SMOKING, SPIRIT, SYPHILIS, SHARP TOOTH, SEPSIS, SPICES.

 Incidence of oral cancer is SIX TIMES more in SMOKERS than NON-SMOKERS.
 PREMALIGNANT CONDITIONS
a. Leukoplakia
b. Erythroplakia
c. Submucosal fibrosis
d. Hyperplastic candidiasis

Betel nut chewing (Pan, with pan quid kept in cheek pouch for a long time) is an important causative
factor of carcinoma cheek.
 TYPES:-

1. ULCERATIVE
2. PROLIFERATIVE (EXOPHYTIC)
3. VERRUCOUS

VERRUCOUS CARCINOMA

 It occurs as a superficial proliferative exophytic lesion with minimal deep invasion, often
multiple.
 Lesion has WHITE, DRY, VELVETY or WARTY, KERATINIZED SURFACE.
 It is common in females.
 It is of LOW GRADE, very well-differentiated squamous cell carcinoma, which is locally
malignant without any lymphatic spread.
 It is a CURABLE MALIGNANCY.
 After biopsy treatment is WIDE EXCISION.
 RADIOTHERAPY is NOT given as it may lead to poorly differentiated carcinoma.
 CLINICAL FEATURES:-

 More common in POSTERIOR HALF OF CHEEK.

 ULCER in the cheek which gradually INCREASES IN SIZE in a patient with HISTORY OF
CHEWING PAN and SMOKING is the commonest presentation and initially it is painless.
EVERTED EDGE, INDURATION are the typical features of the ulcer. Ulcer bleeds on Touch
and may be

 It spreads into the DEEPER PLANE to involve:

-BUCCINATOR,
-PTERYGOIDS;
-RETROMOLAR TRIGONE(RMT) [indicates that it is an ADVANCED DISEASE, as the
lymphatics here communicate freely with the pharyngeal lymphatics.]
-BASE OF THE SKULL,
-PHARYNX.

 It spreads OUTWARDS to involve SKIN :

-FUNGATION,
-ULCERATION,
-OROCUTANEOUS FISTULA FORMATION.
fungation- fungus like lesion; foul odour

 PAIN occurs when it involves the skin, bone or if secondarily infected. REFERRED PAIN to the
ear signifies involvement of lingual nerve. Lingual and auriculotemporal nerves arise from
mandibular division of trigeminal nerve.

LESION MAY EXTEND INTO THE MAXILLA or MANDIBLE causing :-

SWELLING, PAIN TENDERNESS, IRREGULARITY and SITES OF FRACTURE.

 Lesion will later spread to involve ALVEOLUS.

Alveolus- is the Bony Socket for the Root of the tooth.

 TRISMUS AND DYSPHAGIA Once tumour extends into the RETROMOLAR REGION, SOFT
PALATE and PHARYNX

 LYMPH NODES:-
Lymph nodes commonly involved are SUBMENTAL, SUBMANDIBULAR, DEEP CERVICAL
and often LATERAL PHARYNGEAL GROUPS. Nodal spread is seen in 50% of cases.
LYMPH NODES involved which are HARD AND NODULAR; initially mobile and later get
fixed to each other and then to deeper structure.

Once lymph nodes get fixed it may INFILTRATE into:-

HYPOGLOSSAL NERVE TONGUE WILL DEVIATE TOWARDS THE SAME SIDE
SPINAL ACCESSORY NERVE DEFECTIVE SHRUGGING OF SHOULDER
CERVICAL SYMPATHETIC CHAIN HORNER‘S SYNDROME

Compression over EXTERNAL leads to ABSENCE OF SUPERFICIAL TEMPORAL

CAROTID ARTERY ARTERY PULSATION.
Eventually it causes bleeding from MAJOR VESSELS-
CAROTID BLOW OUT.

 Infection of the tumour area and soft tissues around is common, causing FEVER, FOUL
SMELLING ULCER, HALITOSIS.

 RESPIRATORY INFECTION is common in these patients.

 Note: Node involvement may be due to infection. So often trial antibiotic is given initially.

SUMMARY OF CLINICAL FEATURES

-More common in POSTERIOR HALF OF CHEEK
-ULCER
-PAIN
-Lesion may penetrate deeper structures- BUCCINATOR, PTERYGOIDS, RMT, BASE OF SKULL, PHARYNX
-Lesion may penetrate upwards involving Skin- FUNGATION, ULCERATION
-Lesion may PENETRATE MAXILLA / MANDIBLE—later ALVEOLUS
-TRISMUS, DYSPHAGIA
-Lymph Node- Submental, Submandibular , Deep Cervical, Lateral Pharyngeal
-Lymph Node- HARD and NODULAR
-Lymph Node may Infiltrate:-
HYPOGLOSSAL NERVE
SPINAL ACCESSORY NERVE
CERVICAL SYMPATHETIC CHAIN
EXTERNAL CAROTID ARTERY

INVESTIGATIONS:-

1. EDGE BIOPSY:- usually taken from TWO SITES.

Biopsy has to be taken from the EDGE as it contains active cells; NOT from the centre as it is the
AREA OF NECROSIS. Malignant squamous cells with epithelial pearls (Keratin pearls) are the
histological features.
**Note: Biopsy from the centre is taken only from post-radiotherapy ulcer and ulcerated minor
salivary gland tumours.

BRODER‘S HISTOLOGICAL GRADING:

1. Well-differentiated: > 75% epithelial pearls
2. Moderately differentiated: 50-75% epithelial pearls
3. Poorly differentiated: 25-50% epithelial pearls
4. Very poorly differentiated: < 25% epithelial pearls

2. FNAC from lymph nodes.

3. CT SCAN—to assess the extension of tumour and its secondaries.

4. ORTHOPANTOMOGRAM to look for the involvement of mandible—destruction and fracture

sites.

TREATMENT:-

Treatment may be CURATIVE or PALLIATIVE.

TREATMENT STRATEGY:

 SURGERY: Wide excision, hemimandibulectomy, neck lymph nodes block dissection.

 RADIOTHERAPY: Curative or palliative; external or brachytherapy.
 CHEMOTHERAPY: Intraarterial, IV or orally.
 SURGERY:-

1. EARLY GROWTH WITHOUT BONE INVOLVEMENT:

OPTION 1-
CURATIVE RADIOTHERAPY using 137CAESIUM NEEDLES or 192IRIDIUM WIRES, i.e.
brachytherapy.

Advantages:
i. Surgery is avoided,
ii. No surgical mutilation,
iii. Parts are retained,
iv. As it is a squamous cell carcinoma, primary is radiosensitive—90% cure rate.

OPTION 2-
Other option is wide excision with 1-2 cm clearance.
Often, the approach 0to the tumour is by raising the cheek flap (outside). After the wide excision,
the flap is placed back (Patterson operation).

2. CARCINOMA CHEEK FIXED TO THE MANDIBLE:-

Here along with WIDE EXCISION of the primary tumour,
HEMIMANDIBULECTOMY OR SEGMENTAL RESECTION of the mandible or
MARGINAL MANDIBULECTOMY
(using rotary electric saw) is done.
If growth is extending to upper alveolus: PARTIAL MAXILLECTOMY or TOTAL
MAXILLECTOMY may be required.
Very often, the whole thickness of the cheek is lost, which is reconstructed by using PMMC Flap.

3. CARCINOMA CHEEK with MOBILE LYMPH NODES:-

SUPRAOMOHYOID BLOCK DISSECTION- Along with Primary Tumour, the Lymph Nodes
of Level I, II and III are removed along with Submandibular Salivary Gland.

4. CARCINOMA CHEEK with FIXED LYMPH NODES:-

5. FIXED PRIMARY TUMOUR OR ADVANCED NECK LYMPH NODE SECONDARIES: Only

Both the Primary Lesion and the Lymph Nodes should be treated by Radiotherapy and
Reassessment should be done after 3-4 weeks.
Palliative EXTERNAL RADIOTHERAPY is given to PALLIATE PAIN, FUNGATION and to
prevent anticipated TORRENTIAL HAEMORRHAGE.
 RADIOTHERAPY
PREOPERATIVE RADIOTHERAPY IS OFTEN USED IN FIXED LYMPH NODES TO
DOWNSTAGE the disease so as to make it operable.

POSTOPERATIVE RADIOTHERAPY IS GIVEN IN T3 AND T4 TUMOURS: N2 and N3 nodal status

to reduce the recurrence and to improve the prognosis (in multiple nodes and nodes with
extracapsular spread).

CHEMOTHERAPY

ROLE OF CHEMOTHERAPY: Drugs used are METHOTREXATE, CISPLATIN, VINCRISTINE,

BLEOMYCIN, ADRIAMYCIN. Often it is given INTRAARTERIALLY through EXTERNAL
CAROTID ARTERY USING ARTERIAL PUMP or by increasing the height of the drip more than 13
feet, so as to attain a pressure more than systolic pressure. Chemotherapy can also be given IV or
orally - postoperatively.

INITIAL CHEMOTHERAPY to downstage the tumour followed by surgery and later again end with
chemotherapy.

CHEMORADIOTHERAPY is used in UNRESECTABLE TUMOURS – as consecutive therapies.

PROPHYLACTIC BLOCK DISSECTION HAS BECOME POPULAR IN N0 DISEASES:

Reasons are—even though clinically, lymph nodes are negative there may be microscopic
involvement of lymph nodes (25-65%). Clinically detectable disease in lymph nodes of the patient
signifies extra capsular spread which has got poor prognosis.

Recurrence rate is less after prophylactic block compared to block dissection with clinically positive
nodes because there is no extracapsular spread in the former even if there is microscopic spread of
tumour in many cases. Block dissection is an acceptable surgery as there is negligible mortality and
less morbidity.

RECONSTRUCTION AFTER SURGERY

 SPLIT SKIN GRAFT.

 DELTOPECTORAL CUTANEOUS FLAP.
 FOREHEAD FLAP, RADIAL ARTERY FOREARM FLAP.
 PECTORALIS MAJOR MYOCUTANEOUS FLAP.

 MANDIBLE RECONSTRUCTION by cortical bone graft or RIB, FIBULA OR SYNTHETIC

MATERIAL LIKE TITANIUM, STAINLESS STEEL PLATE.
 APPROACHES TO CARCINOMA CHEEK

 TRANSORAL/INTRAORAL APPROACH.
 LIP SPLIT INCISION.

 PATTERSON APPROACH.

 VISOR APPROACH for anterior mandible, floor of the mouth and tongue. Here skin over the
anterior curved margin of the mandible is incised to approach the floor of the mouth for needed
procedure. (Visor is French derived word which means mobile lower part of the helmet which
covers the chin).
PROBLEMS WITH RADIOTHERAPY:-

 When mandible is irradiated, chances of the dreaded problem, osteoradionecrosis is high which
requires the removal of mandible
 Loss of taste sensation and dryness
 Infection, mucositis
 Skin excoriation
 Trismus may get aggravated
 Can itself cause dysphagia, laryngeal oedema
 Hypothyroidism if neck is irradiated
 Radiation neuritis causing severe pain
 Carotid artery atherosclerosis
 Visual impairment
 Shoulder and neck dysfunction

PROBLEMS WITH CHEMOTHERAPY:-

 Bone marrow suppression

 Megaloblastic anaemia
 GIT symptoms
 Hepatotoxicity and renal toxicity
 Alopecia
 Nausea, vomiting and severe stomatitis