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Technique for Routine Screening for Carcinoma of the Base of Tongue
B R IE F
REPORTS
Technique for routine screening for carcinoma of the base of tongue Martin A. Shugar, MD Paul Nosal, MD Joseph P. Gavron,MD
S q u a m o u s cell carcinom a of the tongue base is a devastating disease with a poor prognosis. Fewer than 15% of its victim s survive for five years. Fortunately, this disease is not common, with only 1,500 new cases being diagnosed annually and fewer than 1,000 lives claimed each year. The base of the tongue extends from the line of circumvallate papillae to the anterior wall of the glossoepiglot tic fossa (vallecula) and includes the pharyngoepiglottic and glossoepiglot tic folds laterally.1 Special and general sensory innervation to the base of the to n g u e is c a r r ie d b y th e g l o s sopharyngeal nerves; the vascu lar supply is through the dorsal lingual branches of the lingual arteries. Lym phoid nodules of W aldeyer’s ring comprise the lingual tonsils, which occupy the base of the tongue. Unlike the anterior two thirds of the tongue (the mobile portion), the base of the tongue has a richly anastomosing su p e r fic ia l ly m p h a tic n etw ork and should always be considered to have bilateral lymphatic drainage. Lymphat i c s p a s s t h r o u g h th e l a t e r a l pharyngeal wall and drain into the upper nodes of the deep cerv ical chain. The “sentinel node” for the base of the tongue is the jugulodigastric node at the top of the chain.2 Carcinomas of the base of the tongue are more aggressive than carcinomas of the anterior part of the tongue,3 and tend to progress more rapidly; wide spread nodal disease is m ore fre quent.3-4 In addition, the primary le sion tends to remain silent, until it has a tta in e d c o n s id e ra b le siz e . C ar cinomas of the tongue base often in vade adjacent local structures or the deep tongue musculature.5 The late diagnosis of this tumor has been attributed to the relative lack of regional pain fibers, the often infiltra tive, rather than ulcerative, nature of 646 ■ (ADA, Vol. 104, May 1982
the lesion, and the inaccessibility of the area to exam ination.6 A lterna tively, the natural history of this dis ease may be due more to advanced tumor stage at the time of diagnosis rather than to the inherently aggres sive nature of tumors arising in this re gion.7 When carcinoma of the base of the tongue does become symptomatic, the patient’s most common concern is a vague soreness of the throat or tongue. Other signs and symptoms include dif ficulties in swallowing and speaking, referred pain (ear, jaw, and neck), neck m asses, w eight loss, and halitosis. These findings require investigation in the patient who is at high risk for development of malignancies of the head and neck. Such individuals are usually in the sixth or seventh decade, are predominantly male, and almost always have a history of excessive con sumption of tobacco and alcohol. As smaller lesions have a more fa vorable prognosis,4,8 it is proposed that routine screening of this high-risk population be used in an effort to diagnose these smaller tumors. A sim ple screening technique is described.
Description of technique When properly performed, palpation of the base of the tongue is not distres sing for either the patient or the clin i cian. The correct use of the technique always begins with an explanation, emphasizing the routine nature of the procedure. Transient discomfort may range from mild uneasiness to gagging (emesis is rarely encountered). Local anesthesia spray (benzocaine or tet racaine) may be administered to the o r o p h a r y n x to m in im iz e s u c h symptoms. The patient may be placed in either the upright or semirecumbent position. The clinician performs the examina tion by sw eeping the index finger across the base of the tongue from one side to the other (Illustration), while maintaining continuous gentle com pression. Beginning just posterior to the circumvallate papillae, the entire area can be examined in two or three sweeps. With each sweep, the examin-
Technique for palpation of base o f tongue. Note infiltrative character of tumor w ith ulceration and nodularity at tip o f exam ining finger. V indi cates vallecula; E, epiglottis.
ing finger is advanced more posteri orly, with care taken to avoid contact with the epiglottis. The normal tongue base has a fairly smooth surface and a uniformly pliant consistency. Abnor m alities may be discernible either as areas of induration or as d iscrete nodules with a consistency from firm to rubbery. Anything from a single small nodule to massive involvement of the base of the tongue may be en countered.
Discussion Any abnormality discovered during routine palpation of the base of the tongue is significant. In the high-risk patient, such abnormalities should be considered m alignant u ntil proved otherwise. Prompt referral to an appropriate specialist for definitive diagnosis and t r e a t m e n t is m a n d a to r y . O t o la r y n g o l o g i s t s — h ea d an d n e c k surgeons— or su rgical o n co lo g ists, well trained in the treatment of these problems, should be consulted. Defini tive diagnosis begins with an appraisal of the extent of the tumor and surgical biopsy with the patient under general anesthesia. Because of the potential
B R IE F
complications, surgical biopsies in the office should be avoided. After his tologic diagnosis, therapeutic modal ities include surgery, radiotherapy, or various combinations of regimens. As with most other malignant dis eases, early diagnosis is the cor nerstone of effective treatment. The dental clinician, clearly, is becoming the “watchdog of the oral cavity.”9 Current dental practice has progressed in the early diagnosis of malignancies of the anterior portion of the oral cav ity. This important trend must be ex tended to include more posterior structures. The base of the tongue is an area often neglected in this region. Palpation of the base of the tongue is the preferred technique for routine screening. Indirect mirror examina tion of the base of the tongue is com monly inaccurate for diagnosing these tumors because of the infiltrative na ture of the lesion; indeed, the entire tumor may be covered with normal mucosa. One limitation of this screening pro cedure must be mentioned. The pa tient at high risk for a malignancy in the head and neck region may be less likely to seek routine dental care. These patients are often alcoholic with
poor dentition. Furthermore, patients in this age group are commonly eden tulous. Despite these problems, the signifi cant advantage of early diagnosis of malignancy makes the pursuit of even a small number of patients worth while. An analogous situation is the proved benefit of early detection of cancer derived from routine digital rectal examination of selected pa tients. By application of this simple technique, the dental clinician may help to reduce significantly the mor bidity and mortality of this devastating disease.
Conclusion Cancer of the base of the tongue has a poor prognosis, which is due in part to late diagnosis. Routine palpation of the base of the tongue in high-risk pa tients (elderly men with histories of excessive consumption of tobacco and alcohol) is proposed as the preferred screening method to allow earlier de tection and improved survival. Dr. Shugar was assistant professor, department of otolaryngology, University o f Illinois Hospital and Eye and Ear Infirmary, and chief, section of
REPORTS
otolaryngology, West Side Veterans Administra tion M edical Center, Chicago. Dr. Nosal is a firstyear resident in general surgery, University of Il linois Hospital, Chicago. Dr. Gavron was assistant professor, department of otolaryngology, Univer sity of Illinois Hospital and Eye and Ear Infirmary, Chicago, Address requests for reprints to Dr. Shugar, 1131 N 35th Ave, Hollywood, Fla 33021. 1. Management guidelines for carcinom a of the oropharynx, Section 3-1, Management guidelines for head and neck cancer. NIH publication no. 80-2037, 1979. 2 . Ellis, H. Clinical anatomy, ed 6 . London, Blackw ell, 1976. 3. Batsakis, j.G. Squamous cell carinoma of the oral cavity and the oropharynx. In Tum ors of the head and neck, clinical and pathological consid erations, ed 2. Baltimore, W illiam s & W ilkins, 1978, pp, 144-176. 4. Spiro, R.H., and Strong, E.W. Surgical treat ment of cancer of the tongue. Surg Clin North Am 54 (4 ):7 5 9 -7 6 5 ,1974. 5. Strong, E.W. Carcinoma of the tongue. Otol Clin North Am 12 [1):107-114, 1979. 6 . Dupont, J.B .; Guillam ondegui, O.M .; and Jesse, R.H. Surgical treatment o f advanced car cinomas of the base of the tongue. Am J Surg 136 (4):501-503, 1978. 7. Barrs, D.M.; Desanto, L.W .; and O’Fallon, W.M. Squamous cell carcinoma of the tonsil and tongue base region. Arch Otolaryngol 105:479485, 1979. 8 . Frazell, E.L., and Lucas, J.L. Cancer of the tongues report of the management of 1554 pa tients. Cancer 15(6):1 0 8 5 -1 0 9 9 ,1962. 9. Castigliano, S.G. Oral cancer, chap 33, In Burket, L.W., ed. Oral m edicine, diagnosis and treatment, ed. 6 . Philadelphia, J. B. Lippincott, 1971.
Dentist-photographers The Journal is interested in receiving your black-and-white photographic prints
(on smooth photographic paper) of nature, people, places, or things that might enhance the space sometimes available at the end of scientific articles. Submit your photographs to the Editor for consideration. No honorarium, but the photo graphers will be identified. Prints, whether used in The Journal or not, will be re turned.
Shugar—N osal-G avron : SCREENING FOR CARCINOMA A T BA SE OF TONGUE ■ 647
REPORTS
Technique for routine screening for carcinoma of the base of tongue Martin A. Shugar, MD Paul Nosal, MD Joseph P. Gavron,MD
S q u a m o u s cell carcinom a of the tongue base is a devastating disease with a poor prognosis. Fewer than 15% of its victim s survive for five years. Fortunately, this disease is not common, with only 1,500 new cases being diagnosed annually and fewer than 1,000 lives claimed each year. The base of the tongue extends from the line of circumvallate papillae to the anterior wall of the glossoepiglot tic fossa (vallecula) and includes the pharyngoepiglottic and glossoepiglot tic folds laterally.1 Special and general sensory innervation to the base of the to n g u e is c a r r ie d b y th e g l o s sopharyngeal nerves; the vascu lar supply is through the dorsal lingual branches of the lingual arteries. Lym phoid nodules of W aldeyer’s ring comprise the lingual tonsils, which occupy the base of the tongue. Unlike the anterior two thirds of the tongue (the mobile portion), the base of the tongue has a richly anastomosing su p e r fic ia l ly m p h a tic n etw ork and should always be considered to have bilateral lymphatic drainage. Lymphat i c s p a s s t h r o u g h th e l a t e r a l pharyngeal wall and drain into the upper nodes of the deep cerv ical chain. The “sentinel node” for the base of the tongue is the jugulodigastric node at the top of the chain.2 Carcinomas of the base of the tongue are more aggressive than carcinomas of the anterior part of the tongue,3 and tend to progress more rapidly; wide spread nodal disease is m ore fre quent.3-4 In addition, the primary le sion tends to remain silent, until it has a tta in e d c o n s id e ra b le siz e . C ar cinomas of the tongue base often in vade adjacent local structures or the deep tongue musculature.5 The late diagnosis of this tumor has been attributed to the relative lack of regional pain fibers, the often infiltra tive, rather than ulcerative, nature of 646 ■ (ADA, Vol. 104, May 1982
the lesion, and the inaccessibility of the area to exam ination.6 A lterna tively, the natural history of this dis ease may be due more to advanced tumor stage at the time of diagnosis rather than to the inherently aggres sive nature of tumors arising in this re gion.7 When carcinoma of the base of the tongue does become symptomatic, the patient’s most common concern is a vague soreness of the throat or tongue. Other signs and symptoms include dif ficulties in swallowing and speaking, referred pain (ear, jaw, and neck), neck m asses, w eight loss, and halitosis. These findings require investigation in the patient who is at high risk for development of malignancies of the head and neck. Such individuals are usually in the sixth or seventh decade, are predominantly male, and almost always have a history of excessive con sumption of tobacco and alcohol. As smaller lesions have a more fa vorable prognosis,4,8 it is proposed that routine screening of this high-risk population be used in an effort to diagnose these smaller tumors. A sim ple screening technique is described.
Description of technique When properly performed, palpation of the base of the tongue is not distres sing for either the patient or the clin i cian. The correct use of the technique always begins with an explanation, emphasizing the routine nature of the procedure. Transient discomfort may range from mild uneasiness to gagging (emesis is rarely encountered). Local anesthesia spray (benzocaine or tet racaine) may be administered to the o r o p h a r y n x to m in im iz e s u c h symptoms. The patient may be placed in either the upright or semirecumbent position. The clinician performs the examina tion by sw eeping the index finger across the base of the tongue from one side to the other (Illustration), while maintaining continuous gentle com pression. Beginning just posterior to the circumvallate papillae, the entire area can be examined in two or three sweeps. With each sweep, the examin-
Technique for palpation of base o f tongue. Note infiltrative character of tumor w ith ulceration and nodularity at tip o f exam ining finger. V indi cates vallecula; E, epiglottis.
ing finger is advanced more posteri orly, with care taken to avoid contact with the epiglottis. The normal tongue base has a fairly smooth surface and a uniformly pliant consistency. Abnor m alities may be discernible either as areas of induration or as d iscrete nodules with a consistency from firm to rubbery. Anything from a single small nodule to massive involvement of the base of the tongue may be en countered.
Discussion Any abnormality discovered during routine palpation of the base of the tongue is significant. In the high-risk patient, such abnormalities should be considered m alignant u ntil proved otherwise. Prompt referral to an appropriate specialist for definitive diagnosis and t r e a t m e n t is m a n d a to r y . O t o la r y n g o l o g i s t s — h ea d an d n e c k surgeons— or su rgical o n co lo g ists, well trained in the treatment of these problems, should be consulted. Defini tive diagnosis begins with an appraisal of the extent of the tumor and surgical biopsy with the patient under general anesthesia. Because of the potential
B R IE F
complications, surgical biopsies in the office should be avoided. After his tologic diagnosis, therapeutic modal ities include surgery, radiotherapy, or various combinations of regimens. As with most other malignant dis eases, early diagnosis is the cor nerstone of effective treatment. The dental clinician, clearly, is becoming the “watchdog of the oral cavity.”9 Current dental practice has progressed in the early diagnosis of malignancies of the anterior portion of the oral cav ity. This important trend must be ex tended to include more posterior structures. The base of the tongue is an area often neglected in this region. Palpation of the base of the tongue is the preferred technique for routine screening. Indirect mirror examina tion of the base of the tongue is com monly inaccurate for diagnosing these tumors because of the infiltrative na ture of the lesion; indeed, the entire tumor may be covered with normal mucosa. One limitation of this screening pro cedure must be mentioned. The pa tient at high risk for a malignancy in the head and neck region may be less likely to seek routine dental care. These patients are often alcoholic with
poor dentition. Furthermore, patients in this age group are commonly eden tulous. Despite these problems, the signifi cant advantage of early diagnosis of malignancy makes the pursuit of even a small number of patients worth while. An analogous situation is the proved benefit of early detection of cancer derived from routine digital rectal examination of selected pa tients. By application of this simple technique, the dental clinician may help to reduce significantly the mor bidity and mortality of this devastating disease.
Conclusion Cancer of the base of the tongue has a poor prognosis, which is due in part to late diagnosis. Routine palpation of the base of the tongue in high-risk pa tients (elderly men with histories of excessive consumption of tobacco and alcohol) is proposed as the preferred screening method to allow earlier de tection and improved survival. Dr. Shugar was assistant professor, department of otolaryngology, University o f Illinois Hospital and Eye and Ear Infirmary, and chief, section of
REPORTS
otolaryngology, West Side Veterans Administra tion M edical Center, Chicago. Dr. Nosal is a firstyear resident in general surgery, University of Il linois Hospital, Chicago. Dr. Gavron was assistant professor, department of otolaryngology, Univer sity of Illinois Hospital and Eye and Ear Infirmary, Chicago, Address requests for reprints to Dr. Shugar, 1131 N 35th Ave, Hollywood, Fla 33021. 1. Management guidelines for carcinom a of the oropharynx, Section 3-1, Management guidelines for head and neck cancer. NIH publication no. 80-2037, 1979. 2 . Ellis, H. Clinical anatomy, ed 6 . London, Blackw ell, 1976. 3. Batsakis, j.G. Squamous cell carinoma of the oral cavity and the oropharynx. In Tum ors of the head and neck, clinical and pathological consid erations, ed 2. Baltimore, W illiam s & W ilkins, 1978, pp, 144-176. 4. Spiro, R.H., and Strong, E.W. Surgical treat ment of cancer of the tongue. Surg Clin North Am 54 (4 ):7 5 9 -7 6 5 ,1974. 5. Strong, E.W. Carcinoma of the tongue. Otol Clin North Am 12 [1):107-114, 1979. 6 . Dupont, J.B .; Guillam ondegui, O.M .; and Jesse, R.H. Surgical treatment o f advanced car cinomas of the base of the tongue. Am J Surg 136 (4):501-503, 1978. 7. Barrs, D.M.; Desanto, L.W .; and O’Fallon, W.M. Squamous cell carcinoma of the tonsil and tongue base region. Arch Otolaryngol 105:479485, 1979. 8 . Frazell, E.L., and Lucas, J.L. Cancer of the tongues report of the management of 1554 pa tients. Cancer 15(6):1 0 8 5 -1 0 9 9 ,1962. 9. Castigliano, S.G. Oral cancer, chap 33, In Burket, L.W., ed. Oral m edicine, diagnosis and treatment, ed. 6 . Philadelphia, J. B. Lippincott, 1971.
Dentist-photographers The Journal is interested in receiving your black-and-white photographic prints
(on smooth photographic paper) of nature, people, places, or things that might enhance the space sometimes available at the end of scientific articles. Submit your photographs to the Editor for consideration. No honorarium, but the photo graphers will be identified. Prints, whether used in The Journal or not, will be re turned.
Shugar—N osal-G avron : SCREENING FOR CARCINOMA A T BA SE OF TONGUE ■ 647