Incidence

The global incidence of oral cancer has been estimated at 274,000 cases per year. Approximately 126,000 deaths annually are attributed to oral cancer worldwide. In the United States, 23,110 new cases and 5370 deaths are expected in 2009. Squamous cell carcinoma is the predominant form of oral cancer and accounts for greater than 90% of malignant pathology. Other forms include salivary gland tumors, mesenchymal tumors, lymphoma, and melanoma. Despite technologic advances in detection and treatment, survival rates for patients with oral cancer have shown minimal improvement over recent decades.

Age

Oral cancer is predominantly a disease of older age. More than 92% of oral and pharyngeal cancers occur in individuals older than 40 years, with the average age being 63. Its incidence increases until the age of 70 to 74 and then declines slightly. A recent disturbing trend is the increase in oral cancer in younger adults in the United States and internationally. A review from one large institution revealed an increase in tongue cancer from 4% to 18% in patients younger than 40 years between 1973 and 1995. These patients ranged in age from 19 to 39 years; 59% were non-smokers, and 45% were non-drinkers. Assessment of 1973-2001 data from the Surveillance, Epidemiology and End Results (SEER) database revealed an increase in tongue cancer in young white men but a decrease in incidence in all other oral sites. Even though it has been suggested that oral cancer is more aggressive in younger patients, the evidence is conflicting. In a case-control study by Garavello and associates, young age was found to be an independent predictor of worse survival. In contrast, two separate reviews of SEER data from 1973 to 2001 showed that younger patients had an overall higher 5-year survival rate for oral tongue cancer than older adults. One meta-analysis found 3-year survival to be similar in patients younger than 40 and older than 40. Atula and co-authors agreed that the prognosis for younger patients is similar to that for older patients. A retrospective review of 76 patients by Manuel and colleagues found that patients younger than 45 years had similar outcomes and prognosis similar to older patients.

Gender

Once a predominantly male disease, females have experienced a steady rise in the incidence of oral cancer since the increase in female smokers began in the 1950s. A Swedish group reported on 132 patients and concluded that females have a greater risk for oral cancer than men given the same quantity of tobacco use. A report by Muscat and co-workers agreed that females are at higher risk than men who report the same number of pack-years of smoking. Their study also noted that the percentage of non-smokers with oral cancer was significantly higher in females, especially in women older than 50 years. This increased risk in older women was explored in a separate case-control study of 530 women with oral cancer. The authors suggested the possibility of a hormonal influence related to estrogen deficiency in postmenopausal women, although the data were not conclusive. A 1995 review of SEER data revealed that women have higher risk than men for the development of second primary tumors of the head and neck, although the authors were unable to offer an explanation. Conflicting data exist regarding how gender influences overall survival. In a review of cancer registry data from 1981 to 1998, an Italian study found that gender did not influence the prognosis for oral tongue cancer. Arduino and colleagues conducted a retrospective review of 347 patients and found no difference in prognosis in terms of gender, although the minimum follow-up period was just 12 months. A retrospective review of 193 patients older than 33 years found that survival was lower in men than in women for cancer of the tongue and floor of the mouth. Similar findings showing a worse prognosis in men have been reported by Choi and colleagues, Langdon and Rapidis, Franco and co-authors, and Funk and colleagues.

Race

African American men have the greatest risk for the development of oral cancer in the United States, whereas Hispanic men and women have the lowest risk. The incidence in whites is slightly higher than that in Asian Americans. The most striking disparity is the difference in both incidence and survival between African Americans and whites. Age-adjusted incidence rates for African American males are up to 20% higher than those for white males. For all stages, whites have a relative 5-year survival rate of 61%, whereas only 36% of African Americans are alive after 5 years. Reduced access to care has been suggested as one basis for this disparity because African Americans are more likely to lack health care coverage. However, a large case-control study concluded that the higher oral cancer rates seen in African Americans can be attributed to increased alcohol and tobacco consumption.

Risk Factors

Multiple factors have been associated with increased risk for oral cancer. Although the most compelling evidence implicates tobacco and alcohol, other associated factors, including viruses, nutritional deficiencies, previous upper aerodigestive malignancy, and immunocompromised status, have been proposed.

Population-based studies confirm the correlation between tobacco use and risk for oral cavity cancer. Tobacco smoking is an independent risk factor with a relative risk of up to eight times that of non-smokers. Oral cancer is twice as likely to develop in women as in men given the same amount of tobacco consumption. It is thought that exposure to carcinogens leads to malignant transformation of cells. Even though smoking cessation is effective in reducing risk, former smokers still have higher risk than never smokers. Individuals who refrain from smoking for 1 to 9 years showed a 30% reduction in risk, whereas a 50% reduction in risk was noted for individuals who ceased smoking for more than 9 years. Pipe and cigar smokers also have increased risk for oral cancer.

Smokeless tobacco’s role in the development of oral cancer and its use as a smoking cessation tool have engendered a great deal of controversy. In 1981, Winn and co-authors reported a four-fold increase in risk in women users of smokeless tobacco. However, a 1998 study reviewed statistics from West Virginia and found that the incidence and mortality of oral/pharyngeal cancer were less than the national average despite the remarkably heavy use of smokeless tobacco in this state. Given this and other similar studies, transitioning smokers to smokeless tobacco has been advocated by some to lower the health risks associated with smoking. In a 2008 report, smokers who switched to smokeless tobacco were more than twice as likely to remain smoke free than were smokers who attempted cessation with traditional nicotine replacement products. A recent meta-analysis of 89 studies (including 62 American and 18 Scandinavian studies) revealed only slight associations with oropharyngeal cancer, but the association disappeared for estimates published since 1990 and for alcohol-adjusted estimates. Still, smokeless tobacco may not be without risk for other cancers, with a number of reports suggesting a possible association with esophageal, pancreatic, laryngeal, and renal cancer. In summary, although the overall health risks associated with smokeless tobacco are clearly significantly less than the risks with tobacco smoke, patients should be advised that no tobacco product is considered completely safe at this time. The National Cancer Institute continues to recommended that the public avoid all tobacco products, including smokeless tobacco. A decision to use smokeless tobacco as a cessation method should take all these facts into consideration so that patients can act in an informed fashion regarding the risks and benefits of such an approach.

A final distinction should be made between smokeless tobacco manufactured in the United States and other forms used across the globe. Southeast Asia and India are known for heavy consumption of smokeless tobacco consisting of various combinations of betel nut and slaked lime. In addition to the high risk for the development of oral cancer, this habit has been associated with a significantly increased risk for leukoplakia, erythroplakia, and oral submucous fibrosis (a premalignant condition). In one study the incidence of oral cavity cancer was 123-fold higher in individuals who smoked and chewed betel nut. As a result, oral cavity cancer is one of the leading cancers in regions where this habit is practiced.

Alcohol is recognized as a distinct risk factor for the development of oral cancer, especially for consumers of dark liquors. The majority of patients in whom oral cancer develops are consumers of alcohol. Lewin and colleagues demonstrated that low to moderate alcohol use does not increase the risk for oral cancer but high intake (>50 g) was an independent risk factor with a relative risk of 5.5. The study also noted that smoking had a synergistic effect with alcohol, with a relative risk of 22.1 versus a relative risk of 6.5 with smoking alone. For consumers of very high levels of alcohol, risk for the development of oral cancer may be greater than that for smoking alone.

Multiple viruses have been implicated in the etiology of oral cancer, including Epstein-Barr virus, herpes simplex viruses, retroviruses, and human papilloma viruses (HPVs). Human herpesvirus-8 is recognized as the most important pathogen in Kaposi sarcoma, although presence of the virus alone is not sufficient to cause malignancy. Much of the recent research has focused on the link between HPV and upper aerodigestive malignancies. Patients with HPV-positive tumors have a significantly better prognosis than do those with HPV-negative tumors. Although data for the role of HPV in the development of oropharyngeal carcinoma are clear, the role of HPV in oral cavity cancer is not as well defined. A 2001 study found HPV-16 to be present in oral cancer at a rate five times that in normal mucosa. Over half of oral squamous cell carcinomas have been reported to harbor HPV. However, direct causation has not been established, and the methodology of some studies has been questioned. The literature shows a broad range of oral HPV prevalence in oral cavity cancer because of the multiple techniques used for detection of the virus, which vary in sensitivity. Detection rates are also higher in samples taken from frozen tissue than from paraffin-embedded tissue. These technical factors probably contribute to the wide range of reported prevalence rates, which makes causation difficult to establish.

Other factors are found in higher degrees in patients with oral cavity cancer, including poor diet and nutrition, poor oral hygiene, and ill-fitting oral prostheses. The chronic iron deficiency seen in patients with Plummer-Vinson syndrome has been associated with a higher incidence of oral and hypopharyngeal cancer. A deficiency in vitamins A, C, and E has been associated with oral cancer. Oral cancers have also been associated with low intake of fruits and vegetables, and a protective role may be afforded by diets high in fruits, vegetables, and fiber. Poor oral hygiene as measured by caries and periodontal disease is noted more frequently in oral cancer patients. A case-control study based in China found that poor oral hygiene was an independent risk factor for the development of oral cancer after controlling for smoking and alcohol. A Swedish study reported that ill-fitting dentures were an independent risk factor for oral cancer, whereas another study from the United States found no correlation. Although an association between these factors and oral cancer is recognized, causality has not been established.

History

The pretreatment evaluation of all patients begins with a thorough history of the disease process, as well as a comprehensive past medical and surgical history. Specific focus should be placed on common problems in the oral cancer population, such as alcohol abuse, smoking, and malnutrition. The history should also review the functional capacity of the patient with regard to cardiopulmonary status. Patients with decreased cardiopulmonary reserve may benefit from preoperative medical consultation with their primary care physician. Finally, the history in oral cancer patients should note the level of home or family support available postoperatively. Lack of caregivers often requires the use of home nursing or postoperative placement in a skilled nursing facility.

The review of systems should search for symptoms of second primary tumors of the pharynx, esophagus, and lungs, which may be a useful guide for further clinical or radiologic examination. Typical red flag symptoms for second primaries include hoarseness, dysphagia, odynophagia, otalgia, stridor, and hemoptysis.

Physical capacity and performance status should be assessed before determining treatment. Various rating systems have been used in oncology patients to assess a patient’s ability to conduct activities of daily living. The American Joint Committee on Cancer (AJCC) recommends recording the Karnofsky performance scale (KPS) along with standard staging data. This 100-point scale assesses performance status in 10-point increments to quantify physical capacity. Though not specific to head and neck cancer, the KPS has prognostic value in the general treatment of solid tumors. Performance status was shown to predict overall survival in a series of more than 700 laryngeal cancer patients. The author concluded that performance status probably reflected a patient’s ability to resist the tumor.

Physical Examination

The physical examination should document a comprehensive assessment of the head and neck. Attention should be directed to the tumor’s location, size, and relationship to adjacent anatomic structures. Bimanual palpation is useful to determine the extent of tumor in the floor of the mouth, buccal mucosa, and lips. Fixation to the mandible requires consideration of marginal versus segmental mandibulectomy. Proximity to the midline often guides the decision for unilateral versus bilateral neck dissection when indicated. Trismus or decreased tongue mobility may be an indication of invasion into deeper structures. Cranial nerve deficits suggest tumor involvement, which may increase suspicion for perineural spread. The status of the dentition should be assessed in patients in whom radiation therapy may be indicated because of the risk for xerostomia-related caries and osteoradionecrosis. Plans should be made for non-viable teeth to be removed at the time of surgery or before radiation therapy. Occasional difficulty is encountered in clinically determining the extent of the tumor in patients with trismus or pharyngeal extension. Although fiberoptic examination in the clinic may provide adequate visualization, direct laryngoscopy under general anesthesia is sometimes necessary before deciding on the final course of treatment. Biopsy of the primary tumor is required for histologic diagnosis and treatment planning.

Lymph nodes in the neck must be palpated carefully to assess for cervical metastasis or other abnormalities. The neck examination is performed by standing behind the patient and using both hands to evaluate for symmetry. The submandibular region is palpated with the fingers below the inferior border of the mandible. The examiner should not confuse the submandibular gland with lymphadenopathy. The sternocleidomastoid muscle is lifted between the thumb and fingers to palpate the jugular chain. The carotid bulb may be misinterpreted as a mass in thin patients, and feeling for a pulse will clarify any uncertainty. The supraclavicular and thyroid regions are palpated as well. Isolated supraclavicular adenopathy should raise suspicion for disease originating outside the head and neck region. The trachea is assessed with regard to the midline, and the larynx should elevate as the patient swallows. Palpable nodes should be evaluated for size, location, and fixation to skin or deeper structures.

The physical examination should also identify distant sites that may be used for reconstructive purposes. Ideal donor sites have healthy skin, adequate peripheral pulses, and should lack evidence of poor healing or chronic wounds. The Allen test is easily performed at the bedside if a radial forearm flap is anticipated. Scars from previous surgery should be noted because they may preclude the use of some donor sites. A pectoralis flap with a skin paddle is best avoided in patients who have previously undergone mastectomy, whereas axillary node dissection may render the latissimus flap unreliable. Previous abdominal procedures may prevent the use of a rectus flap.

Nutritional Status

Oral cancer patients commonly suffer from malnourishment related to pain, trismus, or dysfunction from their tumor. The high incidence of alcohol abuse in the oral cancer population further contributes to their nutritional compromise. Malnutrition has negative implications on immune function and wound healing, which may be exacerbated if postoperative radiation therapy is planned. Preoperative nutritional support in malnourished patients has been shown to improve complication rates and shorten hospital stays. Surgical treatment or radiation therapy may further compromise the patient’s ability to tolerate oral intake. Consideration should be given to placement of a gastrostomy tube in these patients, depending on the anticipated extent of surgery.

Radiographic Assessment

Pretreatment imaging is important for evaluation of the tumor’s size and involvement of adjacent anatomic structures. Additional cervical staging and prognostic information is available with radiographic evaluation of regional and distant sites. Common imaging modalities include computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (US), and positron emission tomography (PET). Each technique has its own set of indications and limitations that must be understood to optimize treatment planning and establish the prognosis. The two most common uses for radiographic studies are for staging the cervical lymphatics and evaluating the mandible for tumor invasion.

Radiologic criteria have been described for cervical nodal disease to characterize potentially positive nodes. Findings suggestive of nodal metastasis include enlarged size, rounder shape, and heterogeneity concerning for necrosis. Intranodal tumor necrosis is the most reliable criterion, but it is also a late sign. Therefore, nodal size and shape are the predictors commonly used in the assessment of palpably N0 necks. Perhaps the most important role for neck imaging is to evaluate patients with no palpable nodes. Radiographic findings help determine whether elective neck treatment is necessary and to what extent.

Computed Tomography

CT is the imaging modality most commonly used for assessment of oral tumors. Excellent bone detail, adequate soft tissue enhancement, and relatively low cost are advantages of CT for imaging the oral cavity. Debate exists among clinicians regarding the superiority of CT over MRI for the detection of cervical lymphadenopathy. A multi-institutional study of 211 patients found CT to perform only slightly better than MRI. In practice, the modality used to image the primary tumor is also used to image the neck as an additional sequence. A disadvantage of CT is the artifact created by metallic dental restorations. This is particularly problematic when evaluating tumors at the level of the occlusal plane, such as the retromolar trigone or buccal mucosa. Additionally, irregular tooth sockets or periapical disease seen on CT may be confused with tumor invasion.

Magnetic Resonance Imaging

Advantages of MRI include superior soft tissue detail and lack of ionizing radiation. However, MRI is more sensitive to motion artifact, is more expensive than CT, and can be difficult for patients who suffer from claustrophobia. Certain implants such as cardiac pacemakers and ferromagnetic aneurysm clips are absolute contraindications for MRI. For imaging of the cervical lymph nodes, the accuracy of MRI has been shown in multiple studies to be fairly equivalent to that of CT. MRI is superior when there is concern for perineural invasion, skull base involvement, or intracranial spread.

Positron Emission Tomography

Functional imaging with ¹⁸ F-fluorodeoxyglucose PET has been shown to be an effective tool in the diagnosis of head and neck cancer, although its role is still being defined. The integration of PET and CT technology is more accurate than either modality alone in the depiction of head and neck malignancies. PET has shown promise in the evaluation of metastatic disease, tumor recurrence, and treatment response after chemotherapy or radiation therapy. Although some centers recommend that it be used routinely for staging advanced (T3 or T4) tumors, the high false-positive rate inherent with metabolic imaging is problematic. Even though studies have demonstrated the ability of PET to alter the staging of head and neck tumors, it is still unclear whether this benefit outweighs the disadvantage of false-positive results in routine staging. The most widely accepted role for PET in patients with oral cancer is for the detection of recurrences. Tissue beds are often scarred and irradiated and have postsurgical alterations in anatomy, which limits the utility of conventional imaging techniques and makes metabolic imaging more appealing. Although PET has shown improved sensitivity over conventional imaging techniques, it is not accurate enough to preclude neck dissection in patients with no detectable cervical disease. This limitation is due to the inadequate spatial resolution of PET, which results in an inability to detect micrometastases smaller than 5 mm in diameter.

Ultrasound

High-resolution diagnostic US is quick, non-invasive, and relatively inexpensive when compared with CT or MRI. Although US is used extensively for thyroid/parathyroid evaluation, it is of limited utility in the oral cavity. Orientation of the probe is restricted by the oral aperture. Bone does not transmit sound, which further decreases the utility of US. Evaluation of regional lymph nodes by US has been shown to be more accurate than palpation, although this method has not been widely accepted. The greatest advantage of US involves the addition of fine-needle aspiration cytology, which greatly increases its efficacy and specificity. Lymph nodes may be sampled immediately under ultrasound guidance. Even though some authors report US to be superior to CT and MRI for the detection of cervical metastases, others report no significant advantage. Since US is highly technique-sensitive with a steep learning curve, this method has not gained wide acceptance.

Mandibular Invasion

The decision to resect the mandible deserves special consideration because of the functional sequelae and increased reconstructive complexity. Attention must be given to the appropriateness of marginal versus segmental resection when indicated. The inability to obtain reliable intraoperative frozen section analysis of bone places added emphasis on preoperative data. Although no single imaging technique accurately predicts invasion of tumor into the mandible, multiple modalities are available. Common techniques include CT, MRI, orthopantography, single-photon emission computed tomography (SPECT), conventional radionuclide scanning, and US.

CT is the most common method for assessment of mandibular invasion despite reports of variable efficacy. A prospective study by Close and colleagues examined 43 consecutive patients with CT preoperatively and compared the findings with the postoperative pathologic results. The authors reported a sensitivity of 100% and a specificity of 97%. Similar findings were noted by Mukherji and co-workers using contrast-enhanced CT with 3-mm cuts. However, other studies have produced less impressive results. Lane and associates analyzed preoperative CT data from 26 patients with retromolar trigone cancer. They noted that CT was unable to identify bone invasion in 7 of 14 pathologically confirmed cases whereas it did detect bone invasion in 11 of 12 confirmed negative cases. The authors concluded that CT has limitations in the retromolar trigone region because of poor sensitivity (50%).

Cone beam computed tomography (CBCT) has experienced dramatic growth in recent years through the field of dental implantology. These machines are becoming increasingly available in dental offices and produce images of similar quality to conventional CT with lower cost and radiation exposure. Only a handful of reports are available that address the utility of CBCT in identifying mandibular tumor invasion. In a 2007 report by Closmann and Schmidt, visualization of the extent of mandibular tumor involvement in three patients was better with CBCT than with MRI and Panorex. Brockenbrough and colleagues reported on the use of CBCT in a series of 36 patients with oral cancer and suspicion of mandibular invasion. The authors found a sensitivity of 95% and a specificity of 79%. Although no comparison was made with other imaging modalities, the authors concluded that CBCT was an accurate method for detecting mandibular invasion. At present, it is unclear whether CBCT technology will eventually play a greater role in assessing for bone invasion, especially given its inability to produce a contrast-enhanced soft tissue study. The majority of patients already require soft tissue imaging of the neck with CT or MRI for lymphatic staging, and the mandible is usually imaged in the same setting. For a separate CBCT to be worthwhile and routine, significant improvement in the detection of mandibular invasion will need to be demonstrated.

MRI offers the advantage of visualizing the marrow space of the mandible. Ator and co-workers reviewed data from 11 oral cancer patients and compared MRI with various conventional imaging methods. They concluded that MRI was superior to CT in assessing mandibular invasion. A study from the Netherlands compared the accuracy of CT, MRI, and orthopantography in 29 patients. The authors noted that MRI demonstrated the highest sensitivity (94%) but had more false-positive results and often overestimated the extent of tumor invasion. Brown and associates also noted the tendency for MRI to overestimate tumor invasion into the mandible. The authors compared multiple modalities for their ability to predict mandibular invasion and found that MRI and bone scans overestimated the degree of invasion whereas CT and orthopantography underestimated the extent. A prospective study from Italy compared the findings on preoperative MRI with the histologic findings in surgical specimens from 43 patients who underwent marginal or segmental mandibulectomy. For mandibular invasion, they found that the sensitivity of MRI was 93% with a specificity of 93% and a negative predictive value of 96%.

Nuclear imaging studies have demonstrated an impressive ability to detect mandibular invasion. SPECT has been shown in multiple studies to have high sensitivity, although its specificity is variable. Yamamoto and colleagues compared SPECT with CT and found the sensitivity and specificity of SPECT to be 100% and 88%, respectively, whereas that for CT was 45% and 95%. Imola and co-workers compared SPECT with Panorex and CT in a prospective study of 38 patients. The sensitivity of SPECT (95%) was significantly higher than that of CT (55%) and Panorex (50%), although its specificity was lower. Sensitivity for mandibular invasion has been shown to approach 100% in other studies as well. A 2006 study from the Netherlands found a 100% sensitivity for SPECT in detecting mandibular invasion as determined by final histology. The authors concluded that negative SPECT findings rule out mandibular invasion.

Panoramic and plain film radiography is less useful in the assessment of bone invasion. The lack of three-dimensional visualization is an inherent drawback when compared with other modalities such as CT and MRI. Early cortical erosion is easily missed on plain films. Panorex is most useful in planning osteotomies when marginal or segmental resection is indicated.

Of interest is the number of authors who place higher value on clinical examination than on radiographic assessment. Shaha reported that orthopantography and CT were not very useful in determining the need for marginal versus segmental mandibulectomy and that clinical examination was more reliable. In a later report by the same author in which 66 patients with floor of the mouth cancer were reviewed, the decision to perform marginal mandibulectomy was based primarily on clinical judgment. A review of imaging modalities by van den Brekel and colleagues concluded that no technique was sufficiently accurate in assessing mandibular invasion and that clinical examination should be the primary modality. Werning and associates reviewed 222 patients who underwent marginal mandibulectomy over a 30-year period. They found clinical examination to be more sensitive than radiologic modalities, although radiographic assessment had higher specificity. The authors concluded that combining clinical and radiographic assessment is more accurate than the use of either modality alone.

History

The pretreatment evaluation of all patients begins with a thorough history of the disease process, as well as a comprehensive past medical and surgical history. Specific focus should be placed on common problems in the oral cancer population, such as alcohol abuse, smoking, and malnutrition. The history should also review the functional capacity of the patient with regard to cardiopulmonary status. Patients with decreased cardiopulmonary reserve may benefit from preoperative medical consultation with their primary care physician. Finally, the history in oral cancer patients should note the level of home or family support available postoperatively. Lack of caregivers often requires the use of home nursing or postoperative placement in a skilled nursing facility.

The review of systems should search for symptoms of second primary tumors of the pharynx, esophagus, and lungs, which may be a useful guide for further clinical or radiologic examination. Typical red flag symptoms for second primaries include hoarseness, dysphagia, odynophagia, otalgia, stridor, and hemoptysis.

Physical capacity and performance status should be assessed before determining treatment. Various rating systems have been used in oncology patients to assess a patient’s ability to conduct activities of daily living. The American Joint Committee on Cancer (AJCC) recommends recording the Karnofsky performance scale (KPS) along with standard staging data. This 100-point scale assesses performance status in 10-point increments to quantify physical capacity. Though not specific to head and neck cancer, the KPS has prognostic value in the general treatment of solid tumors. Performance status was shown to predict overall survival in a series of more than 700 laryngeal cancer patients. The author concluded that performance status probably reflected a patient’s ability to resist the tumor.

Physical Examination

The physical examination should document a comprehensive assessment of the head and neck. Attention should be directed to the tumor’s location, size, and relationship to adjacent anatomic structures. Bimanual palpation is useful to determine the extent of tumor in the floor of the mouth, buccal mucosa, and lips. Fixation to the mandible requires consideration of marginal versus segmental mandibulectomy. Proximity to the midline often guides the decision for unilateral versus bilateral neck dissection when indicated. Trismus or decreased tongue mobility may be an indication of invasion into deeper structures. Cranial nerve deficits suggest tumor involvement, which may increase suspicion for perineural spread. The status of the dentition should be assessed in patients in whom radiation therapy may be indicated because of the risk for xerostomia-related caries and osteoradionecrosis. Plans should be made for non-viable teeth to be removed at the time of surgery or before radiation therapy. Occasional difficulty is encountered in clinically determining the extent of the tumor in patients with trismus or pharyngeal extension. Although fiberoptic examination in the clinic may provide adequate visualization, direct laryngoscopy under general anesthesia is sometimes necessary before deciding on the final course of treatment. Biopsy of the primary tumor is required for histologic diagnosis and treatment planning.

Lymph nodes in the neck must be palpated carefully to assess for cervical metastasis or other abnormalities. The neck examination is performed by standing behind the patient and using both hands to evaluate for symmetry. The submandibular region is palpated with the fingers below the inferior border of the mandible. The examiner should not confuse the submandibular gland with lymphadenopathy. The sternocleidomastoid muscle is lifted between the thumb and fingers to palpate the jugular chain. The carotid bulb may be misinterpreted as a mass in thin patients, and feeling for a pulse will clarify any uncertainty. The supraclavicular and thyroid regions are palpated as well. Isolated supraclavicular adenopathy should raise suspicion for disease originating outside the head and neck region. The trachea is assessed with regard to the midline, and the larynx should elevate as the patient swallows. Palpable nodes should be evaluated for size, location, and fixation to skin or deeper structures.

The physical examination should also identify distant sites that may be used for reconstructive purposes. Ideal donor sites have healthy skin, adequate peripheral pulses, and should lack evidence of poor healing or chronic wounds. The Allen test is easily performed at the bedside if a radial forearm flap is anticipated. Scars from previous surgery should be noted because they may preclude the use of some donor sites. A pectoralis flap with a skin paddle is best avoided in patients who have previously undergone mastectomy, whereas axillary node dissection may render the latissimus flap unreliable. Previous abdominal procedures may prevent the use of a rectus flap.

Nutritional Status

Oral cancer patients commonly suffer from malnourishment related to pain, trismus, or dysfunction from their tumor. The high incidence of alcohol abuse in the oral cancer population further contributes to their nutritional compromise. Malnutrition has negative implications on immune function and wound healing, which may be exacerbated if postoperative radiation therapy is planned. Preoperative nutritional support in malnourished patients has been shown to improve complication rates and shorten hospital stays. Surgical treatment or radiation therapy may further compromise the patient’s ability to tolerate oral intake. Consideration should be given to placement of a gastrostomy tube in these patients, depending on the anticipated extent of surgery.

Radiographic Assessment