Among all patients with oncology, the proportion of patients with cancer of the ENT organs is 23%, while the most common type of such cancer is laryngeal cancer, which occurs in 55% of patients.
Cancer of the ENT organs is usually diagnosed at fairly advanced stages of development. Misdiagnosis is very common; for example, when diagnosing nasal cavity cancer, the percentage of misdiagnosis is 74%.
Cancers of the ENT organs are a whole group of oncological diseases, which can be divided depending on the location of the malignant tumor. This group includes cancer of the oropharynx, nasopharynx, larynx, nose and paranasal sinuses, external and middle ear.
The success of treatment directly depends on the stage at which ENT cancer is detected. For example, when laryngeal cancer is detected at the first stage of development, the five-year survival rate of patients is 83-98%, and at the second stage it already ranges from 70% to 76%. However, the percentage of patients who consulted a doctor in the initial stages of the disease is only 14%.
The main difficulty in diagnosing cancer of the ENT organs is the strong similarity of its manifestations with the symptoms of other diseases. Therefore, when making a diagnosis, one cannot rely entirely on the results of a visual examination of the tumor and the extent of the process. In addition, another serious reason for late diagnosis is the lack of alertness of doctors due to a lack of diagnostic skills and oncological experience.
Diagnosis of nasopharyngeal cancer
- visual examination, during which the doctor palpates the cervical lymph nodes and, using a small mirror, examines the pharynx;
- rhinoscopy, which requires inserting a rhinoscope into the patient's nose. The device is a thin tube-shaped instrument with a lens and light. Sometimes there may be a special device on the rhinoscope that allows you to take a piece of tissue for subsequent microscopic examination;
- examination of the chest and skull using X-ray equipment;
- PET scans detect malignant cells by injecting small amounts of radioactive glucose into a patient's vein. During this procedure, the scanner, rotating around the patient, identifies the areas of greatest accumulation of sugar, i.e. places where malignant cells accumulate;
- A neurological examination is an examination of the nerves, as well as the spinal cord and brain;
- MRI allows you to obtain a detailed image of a selected area of the patient's body using a magnetic field;
- A CT scan uses x-rays to provide a detailed image of a selected area of the body. In some cases, patients may be given contrast to obtain the most accurate results;
- laboratory tests such as urine, blood, etc.
- A biopsy is still the most accurate way to diagnose cancer.
Diagnosis of oropharyngeal cancer
When diagnosing oropharyngeal cancer, the first step is a visual examination using a lamp, mirror and endoscope. The most accurate way to make a diagnosis is a biopsy, during which the doctor removes part of the affected tissue for microscopic examination to determine the presence of cancer cells.
Other diagnostic methods include MRI, chest x-ray, CT scan, as well as bone scanning, which makes it possible to detect any pathological neoplasms in the bones. To assess the general condition of the patient, a blood test is performed.
Diagnosis of cancer of the nose and paranasal sinuses
When diagnosing cancer of the nose and paranasal sinuses, the doctor performs an initial examination and takes an anamnesis, during which he finds out the presence of risk factors and the patient’s complaints. During the examination, the doctor palpates the lymph nodes and paranasal sinuses. Next, rhinoscopy is performed, i.e., examination of the nasal cavity, requiring the insertion of a rhinoscope into each nostril to expand the examination area.
If an even more detailed examination is necessary, it is possible to use an endoscope with a lamp and a video camera. The image obtained with its help is displayed on the monitor screen. An endoscope is also often used to perform a biopsy.
In addition, CT, MRI and radiography are possible.
Diagnosis of laryngeal cancer
Diagnosis of laryngeal cancer also begins with collecting anamnesis and clarifying the patient’s complaints. Next, an examination is carried out, special attention is paid to the area of the lymph nodes, and the throat is examined using a spatula.
Next, laryngoscopy is performed, which is divided into two types: direct and indirect. In the latter case, a small mirror is inserted into the patient’s throat, and the doctor pushes the tongue away with a spatula. Direct laryngoscopy, also called fibrolaryngoscopy, examines the larynx using a flexible laryngoscope through the nose. This procedure allows you to examine the vocal cords and the walls of the larynx.
Biopsy, as the main method for diagnosing cancer, allows one to identify pathological cells in tissue taken for examination during laryngoscopy.
Diagnosis of cancer of the outer and middle ear
It is sometimes possible to make a diagnosis of cancer of the outer ear by visual examination of the patient, however, in some cases this disease can be confused with diseases such as chronic suppurative otitis media. The most recognizable malignant tumors in this case are tumors of the auricle. However, a final diagnosis can only be made after histological examination.
In the diagnosis of the outer and middle ear, one of the main values is differential diagnosis with diseases such as specific granulomas, benign tumors, eczema, psoriasis, frostbite, ulcers, dyskeratosis.
FEDERAL EDUCATION AGENCY
BALTIC FEDERAL UNIVERSITY named after. I. KANTA
FACULTY OF MEDICINE
Report on the subject “ENT diseases” on the topic:
Oncology of ENT organs
Completed:
Third year student LD-1 SPO
Vaganova Olga
2 subgroup
Checked:
Demchenko E.V.
Kaliningrad
2012 Tumors of the respiratory tract
Tumors of the upper respiratory tract - the nose and paranasal sinuses, pharynx and larynx, as well as the ear - are relatively common. They make up about 4-5% of all tumor sites in humans. Among the organs of the upper respiratory tract, benign and malignant tumors are most often localized in the larynx, the second most common place is the nose and its paranasal sinuses, then the pharynx; Ear diseases are relatively rare. Malignant tumors, especially of the larynx, occur more often in men than in women between the ages of 40 and 70 years. However, they also occur in children.
In accordance with the International Classification, tumors are divided according to histological structure and clinical course into benign and malignant; they can come from epithelial, connective, muscle, nervous and pigment tissues.
The histological structure of the tumor characterizes the degree and characteristics of the degeneration of cells of the affected tissue, their germination (infiltration) into the surrounding tissue. The clinical course reveals the characteristics of tumor growth, its ability to metastasize and recur after treatment, etc. The histological picture usually corresponds to the clinical one, but sometimes a tumor that is benign in its histological structure clinically grows in a malignant form and, conversely, a histologically malignant tumor has the clinical features of a benign one.
Benign tumors
Tumors of the nose. These include papillomas, fibromas, angiomas and angiofibromas, chondromas, osteomas, neuromas, nevi, warts. Some also include mucous polyps here, but these formations do not have a tumor structure and represent inflammatory and allergic hyperplasia of the mucous membrane. Typical signs are persistent difficulty breathing through the half of the nose in which the tumor is located, hyposmia or anosmia; minor bleeding is possible. In later stages - deformation of the facial skeleton, headache, displacement of the eyeballs, visual disturbances. Diagnosis: nasal endoscopy, probing of the tumor, palpation, radiography, histological examination of a piece of the tumor. Papillomas are usually localized in the vestibule of the nose, grow relatively slowly, and often recur after removal. Removal must be radical. In order to prevent scarring after excision of papilloma, cryotherapy is applied to the wound surface. Vascular tumors form on the nasal septum, the bowl in its cartilaginous part, the inferior nasal turbinates, and the nasal cavity. They grow slowly, usually bleed periodically, sometimes very heavily, gradually increase in size and can fill the nasal cavity, grow into the ethmoid labyrinth, orbit and maxillary sinus. Treatment is surgical. Before removing the tumor, the external carotid arteries are often ligated on both sides.
A bleeding polyp resembles an angiofibroma in structure, is localized in the cartilaginous part of the nasal septum and usually has a wide stalk. More common during pregnancy and lactation. A constant symptom is frequent bleeding, usually not in small portions. Removal must be radical. After removal, galvanocaustics of the wound edges is performed. Nasal fibroma is rare and is usually localized in the vestibule of the nose, nasopharynx and in the area of the external nose. Treatment is surgical. Osteomas of the nose and paranasal sinuses usually appear at the age of 15-25 years, grow slowly, and are most often localized in the walls of the frontal sinuses and ethmoid bone. Long-term observation is carried out. Sometimes small osteomas, especially on the cerebral wall of the frontal sinus, are the cause of persistent headaches. After excluding other causes of headache, removal of such osteoma is indicated. In some cases, they deform the facial skeleton and cause brain disorders. Treatment. Surgical only. Osteomas of medium and large sizes, even in the absence of severe symptoms, must be completely removed.
Tumors of the pharynx. These include: fibroma, papilloma, hairy polyp, angioma, neuroma, neurofibroma, lipoma, cysts and retropharyngeal goiter.
The most common types of papillomas and fibromas are pedunculated.
Papillomas are usually located on the soft palate and palatine arches, are small in size and, as a rule, do not bother patients much. In some cases, papillomas originate from the nasopharynx, the lateral walls of the pharynx, and the lingual surface of the epiglottis. Treatment consists of removing single papillomas followed by galvanocaustics. Relapses of the disease with single papillomas are rare. With papillomatosis, relapses can occur repeatedly. Given the possibility of degeneration into cancer, timely radical treatment is necessary.
Fibroma occurs, as a rule, in young men aged 10-20 years, which is why it is called juvenile. After 20-25 years, juvenile fibroma undergoes a reverse development. In the early stage of development of nasopharyngeal fibroma, its manifestations are moderately pronounced - slight difficulty in nasal breathing, sore throat, minor catarrhal phenomena. Subsequently, breathing stops completely through one half of the nose and becomes difficult through the other, a nasal sound appears, the voice changes, the most severe symptom is periodically occurring heavy spontaneous bleeding. The fibroid usually fills the nasopharynx and may hang into the middle part of the pharynx.
Angioma is a relatively common benign neoplasm of the pharynx and can originate from various parts of the pharynx. Small angiomas may not grow for a long time, do not bother the patient and are detected only during examination. Medium and large angiomas cause a sensation of a foreign body in the nasopharynx, make nasal breathing difficult, and can bleed. There are hemangiomas and lymphangiomas.
Treatment is surgical; electrocoagulation is also used. A hairy polyp is a congenital tumor, has a long stalk, and is covered with skin with delicate hairs.
The polyp makes breathing and sucking difficult. Treatment is surgical. Relapses do not occur.
Pharyngeal cysts are not true tumors. They are localized in various parts of the pharynx, most often in the tonsils. The sizes are often small, so they often do not cause any particular concern, but sometimes there is a sensation of a foreign body in the throat; At an early age, cysts of the root of the tongue can cause suffocation.
Neuromas, mixed endothelioma tumors and other pharyngeal tumors are rare. They have slow, non-infiltrating growth and in rare cases can become malignant.
Tumors of the larynx. These include fibromas, papillomas and angiomas.
Fibroma (fibrous polyp) usually occurs at the free edge of the vocal fold on the border between the anterior and middle thirds, grows very slowly, and often does not reach large sizes. The main symptoms of the disease are hoarseness and possibly cough. The voice may change if the fibroma has a long stalk and is easily displaced. Treatment is surgical; relapses are possible if a piece of tumor is left behind.
Papillomas are single or papillary growths that look like cauliflower. Most often they are located on the vocal folds. Most often, papillomas occur between the ages of 1.5 and 5 years. By the beginning of puberty they often disappear. The main symptoms of the disease are hoarseness, reaching aphonia, and gradual difficulty breathing, which can turn into suffocation as the tumor enlarges. Treatment is surgical. Relapses of the disease after treatment are common, but the tendency to relapse varies from person to person: in some cases, papillomas have to be removed several times a year, in others – after several years.
Cysts are not common in the larynx. They are usually localized on the laryngeal surface of the epiglottis. More often, cysts develop as a result of blockage of the mucous glands; they grow slowly and do not reach large sizes. Small cysts usually do not cause any symptoms and do not require treatment.
Laryngeal angiomas originate from dilated blood vessels (hemangiomas, lymphangiomas). They can be localized on the vocal folds, sometimes on the ventricular or aryepiglottic folds. They grow slowly and are usually small in size. Sometimes the tumor reaches a large size and hangs into the lumen of the larynx, impairing breathing. Small angiomas are of concern only if they are localized on the vocal fold - this causes hoarseness. Medium and large angiomas also disrupt other functions of the larynx, so they must be removed.
Among benign formations of the ENT organs, otorhinolaryngologists most often have to deal with polyps and cysts. There are also cholesteatomas, angiomas, acoustic neuromas (vestibular schwannomas), etc.
Polyps are excessive growth of mucosal tissue and are most often localized in the nasal cavity, although in some cases they can grow in the paranasal sinuses and pass into the nasopharynx.
Cysts, unlike polyps, have a cavity filled with fluid and are covered with a membrane or capsule on top. They occur mainly in the upper respiratory tract and paranasal sinuses. Sometimes polyps and cysts develop in the outer ear.
Among the predisposing factors, especially noteworthy are allergic pathology, chronic inflammatory processes of the ENT organs, narrowness of the nasal passages, deviated nasal septum, disruption of the normal outflow of secretions and poor ventilation of the paranasal sinuses.
By the way, sometimes a person may not know all his life that he has a polyp or cyst, which, in fact, in this kind of situation turns out to be a random find. The presence/absence of clinical manifestations directly depends on the location of origin and size of the tumor. Typically, symptoms, if any, include impaired nasal breathing, nasal congestion, sensation of foreign matter in the ear or nose, decreased sense of smell, pain and/or discomfort in the ear or nose area, headaches, increased mucus production and frequent infections. -inflammatory diseases.
Thus, the picture of the disease is rather nonspecific, therefore, when the patient presents any of the above complaints, in order to verify the diagnosis, he must be sent for a thorough instrumental examination. Here, one of the most effective methods is endoscopy, which provides a high degree of visualization. For example, the endonasal technique allows for a thorough examination of the nasal cavity from various viewing angles and accurately determines the presence of even the smallest tumors and/or growths of the mucous membrane. With its help, the doctor determines the shape, size and location of pathological foci, and also judges the degree of their distribution and takes material for subsequent histological examination. In addition, depending on the specific situation, laboratory tests, radiography and computed tomography are prescribed.
Removal of tumors is carried out surgically. In combination with surgical measures, if indicated, conservative methods of treatment (drug therapy, physiotherapeutic procedures and inhalation of medicinal substances) are used to promote faster tissue restoration and consolidation of the effect achieved after surgery.
Surgical removal of polyps and cysts is currently carried out using modern high-tech equipment. After surgery, the patient must be under the supervision of the attending physician.
The floor goes to the chief freelance otorhinolaryngologist of the Ministry of Health of the Russian Federation, First Deputy Chairman of the Commission of the Public Chamber of the Russian Federation for the protection of citizens' health and healthcare development, director of the Federal Scientific and Clinical Center of Otorhinolaryngology of the FMBA of Russia, professor, corresponding member of the Russian Academy of Sciences Nikolai Daikhes.
There is contact!
Alexandra Tyrlova, AiF Health: Nikolai Arkadyevich, in your opinion, what is the main direction of development of otorhinolaryngology today?
Nikolay Dykhes: Today, all over the world, otorhinolaryngology is developing as an interdisciplinary specialty - head and neck surgery. And, naturally, we should not lag behind in this regard. Of course, this became possible only after the new Federal Scientific and Clinical Center for Otorhinolaryngology was opened. This is the largest center not only in Russia, but also in the world. Here, on one site, we provide all types of high-tech medical care related to diseases of the ear, nose and throat in both adults and children, we treat patients who need help from oncologists, maxillofacial and plastic surgeons, ophthalmologists, occupational pathologists, and much more other related to head and neck pathology.
- But oncology is a separate field of medicine?
Indeed, this has been the case for many years. Unfortunately, in the late 80s - early 90s, clinicians of narrow specialties were excluded from the structure of oncological care. This led to poor results. For example, currently there is an increase in oncological diseases of the ENT organs not only in Russia, but throughout the world, which is about 15-20% in the overall structure of oncological diseases, and this is a fairly high percentage. For example, 60-70% of patients with laryngeal cancer who seek help for the first time already have the third or fourth stage of the disease. How can such statistics be explained? There are several reasons. Firstly, this is the low oncological alertness of doctors conducting initial appointments in clinics, when inadequate treatment is prescribed and the disease becomes advanced. It is important that, first of all, the specialist always remembers the possibility of a hidden oncological process. I always remind outpatient otolaryngologists: examine the patient and make sure there is no oncological problem, then treat the inflammatory or other pathology. After all, malignant tumors, as a rule, are always preceded by background or pretumor conditions.
But this is not always the fault of non-oncologists, since during their postgraduate medical education they are not properly trained in oncology. Conversely, oncology clinicians are not sufficiently trained in the skills of a particular subspecialty. As a result, it is not always possible to perform gentle oncology surgery, which allows preserving the functionality of a vital organ.
- What should be done to establish contact between oncologists and doctors of other specialties?
Now the Russian Ministry of Health understands that such interaction is necessary - the development of joint clinical recommendations for oncologists and doctors of other specialties, and educational programs for postgraduate education of doctors aimed at improving their skills in oncology are being clarified. Many heads of leading cancer centers are ready to cooperate with medical centers in other areas. I hope that an interdisciplinary working group will be created that will deal with oncology problems in all areas.
Fighting for patients
- It is not possible to perform a complex operation everywhere. How to increase the availability of high-tech medical care?
One of the areas of development and accessibility of high-tech medical care is the creation of branches of leading institutes. For example, we have branches in Khabarovsk and Astrakhan. In addition, over the past year and a half, we have traveled to 50 regions of the country to sign agreements providing for the opportunity to directly refer patients for treatment to our center under the high-tech compulsory medical insurance system.
- How much effort does a patient need to make to get a referral for a high-tech operation? Is there competition between medical institutions here?
High-tech medical care in the Russian Federation consists of two parts - the basic high-tech compulsory medical insurance program (HT compulsory medical insurance) and the extra-basic, or federal, high-tech medical care program (VMP).
The difference between them lies in the methods of financing, the volume of assistance and the structure of tariffs for the provision of services. VMP is de facto a direct government investment that gives a certain clinic a guaranteed volume of patients. The question is different.
For example, our federal center annually carries out more than 7 thousand complex operations, and the allocated volumes of high-tech medical care are clearly not enough for us. Therefore, we travel to the regions to invite patients for treatment under the basic high-tech compulsory medical insurance program.I believe that in order to maintain a balance, it is necessary to expand the possibility of providing high medical care within the framework of compulsory medical insurance of the basic program and unify the tariffs of the basic high medical medical insurance program and the extra-basic high medical medical insurance program.
This will create real opportunities for patients to independently choose a medical institution to receive high-tech care, ensure competition between medical institutions, and therefore improve the quality of medical care.
According to the Moscow City Hospital, the number of ENT-oncology patients has increased over the past 5 years and this trend continues. In 79-84% of cases, the disease is diagnosed in stages III-IV, which adversely affects the results of treatment. The authors analyze some of the reasons for the late diagnosis of tumor diseases of the ENT organs and draw attention to the need to form oncological alertness among outpatient doctors. Modern methods for early diagnosis of cancer are presented.
Key words: oncological diseases of the ENT organs, cancer alertness, early diagnosis.
Like any disease, in the early stages, cancer is difficult to recognize, but can be successfully treated; on the contrary, it is much easier to diagnose a tumor at a late stage, but the effectiveness of treatment is sharply reduced and the prognosis becomes much less favorable.
According to the Department of Head and Neck Tumors at the Moscow City Oncology Center, for the period 2000-2006. Every year, 800-1190 primary patients with malignant neoplasms of the head and neck of various localizations were identified, and the tendency for this indicator to grow steadily persists. Unfortunately, increasingly, oncological diseases of the ENT organs are diagnosed at later stages: in 79-84% of cases, patients are referred to specialists at the oncology clinic in stages III-IV of the process (see table). The most common location of the lesion is the larynx, laryngopharynx, oropharynx; Tumors of various parts of the tongue, floor of the mouth, upper jaw, nasopharynx, and rarely of the ear are somewhat less common.
The unsatisfactory state of early diagnosis significantly affects long-term treatment results. So, according to the Institute. P.A. Herzen, with stage I laryngeal cancer, clinical cure without relapses and metastases lasting over 5 years after radiation treatment is achieved in 83-95% of patients, with stage II - in 70-76%, 5-year survival rate for T3N0M0 after combined treatment is 60 %, at T4 - 34.0%. However, only 14% of patients who first applied for malignant neoplasms had early forms of tumors.
It should be remembered that early diagnosis of malignant neoplasms presents certain difficulties due to the similarity of the initial manifestations of diseases with benign tumors, inflammatory and other pathological processes. The duration of the disease, the extent of the process, and the appearance of the tumor are not sufficiently reliable criteria for making a diagnosis. This is what explains their late detection.
And yet, the main reasons for late diagnosis of cancer of the larynx and other ENT organs are insufficient oncological alertness of outpatient doctors, lack of necessary diagnostic skills and proper clinical experience for correct assessment of the condition of ENT organs among outpatients and hospitals, lack of proper continuity in examination sick.
Improving methods for early diagnosis of oncological diseases of the ENT organs is an urgent task not only for the otorhinolaryngologist, but also for the general practitioner, to whom the patient often turns first with certain complaints.
Thus, early diagnosis of laryngeal cancer is based not on pathognomonic and constant symptoms, but on a combination of a number of banal signs that allow one to suspect a tumor. For example, with the development of cancer of the vestibular larynx, many patients experience dryness, soreness, and a sensation of a foreign body in the pharynx for several months before diagnosis. Somewhat later, fatigue and dullness of the voice, awkwardness when swallowing, and then pain appear.
| Stage | 2000 | 2001 | 2002 | 2003 | 2004 | 2005 | 2006 |
| I | 24/3,4 | 25/3,0 | 26/3,3 | 38/4,4 | 60/5,2 | 39/3,3 | 46/3,9 |
| II | 88/12,3 | 100/12,1 | 126/16,1 | 106/12,2 | 153/13,1 | 178/14,9 | 175/14,8 |
| III | 185/25,5 | 203/24,4 | 184/23,4 | 180/20,8 | 279/24,1 | 283/23,7 | 286/24,4 |
| IV | 427/58,8 | 501/60,5 | 442/56,3 | 531/61,4 | 668/57,6 | 692/58,1 | 665/56,8 |
| Total | 724 | 829 | 785 | 865 | 1160 | 1192 | 1172 |
The pain initially occurs only in the morning when swallowing saliva, later it intensifies, becomes constant, and can radiate to the ear. The similarity of these symptoms with signs of chronic pharyngitis or laryngitis is often the cause of a diagnostic error.
When the tumor is localized in the middle part of the larynx, hoarseness appears in the early stages and the patient is referred to an otolaryngologist, who, as a rule, detects the tumor in a timely manner. With a tumor of the subvocal region, one of the first symptoms may be an attack of suffocation, which often leads to an erroneous diagnosis of bronchial asthma. Tumors of the nasopharynx may cause hearing loss. However, these and other so-called “minor signs” should alert the doctor and suspect a tumor at a very early stage.
When identifying complaints and collecting anamnesis, attention is also paid to the duration of the pathological process, the appearance of bloody discharge against this background, sometimes (at later stages) determined by palpation of dense, often painless regional lymph nodes. The doctor should be alerted by the appearance of traces of blood in the sputum, recurrent (especially unilateral) nosebleeds, when the specific cause of the bleeding cannot be determined. The doctor should not ignore the appearance of dysphonia, especially if it is increasing and not amenable to usual therapeutic interventions, or complaints of swallowing disorders.
In many cases, the development of malignant tumors of the larynx is preceded by benign diseases that last for many months and sometimes years. Most authors include papillomas, pachyderma, chronic hyperplastic laryngitis and other diseases. According to the classification of the Committee for the Study of Head and Neck Tumors of the All-Union Society of Oncologists, a distinction is made between precancerous diseases with a high and low frequency of malignant changes. Precancerous diseases with a high incidence of malignancy (obligate) include leukoplakia, pachyderma, papilloma in adults, and precancerous diseases with a low incidence of malignancy include contact fibroma, cicatricial processes after chronic specific infectious diseases (silifis, tuberculosis, scleroma) and burns. The period of a precancerous condition in humans is considered to be one to two decades. In case of laryngeal cancer it is somewhat less: according to the observations of V.O. Olshansky - from 2-4 years to 11-12 years.
The possibility of benign diseases degenerating into cancer indicates the extreme importance of early detection of any pathological processes in the larynx and their effective treatment, which can be considered as secondary prevention of cancer. At the same time, it should be remembered that one of the important reasons for late recognition of laryngeal cancer in some cases is erroneous diagnostic tactics. It consists in the fact that the doctor observes the patient for a long time, providing inadequate treatment (anti-inflammatory, physiotherapeutic), and waits until the signs of the tumor are so typical that the diagnosis ceases to be in doubt. There is information in the literature that otolaryngologists at clinics observed 20.4% of patients with laryngeal cancer for 1 to 2 months and 50% for 2 to 8 months.
When examining a patient who has applied for any disease of the ENT organs, and when conducting a preventive examination, the otolaryngologist should follow a clear sequence so that, regardless of the presence or absence of complaints, all ENT organs are examined. It is also mandatory to examine and palpate the neck to detect metastases. When examining a particular organ, you should adhere to a certain pattern so as not to miss the slightest deviation from the norm. For example, during mesopharyngoscopy, attention is sequentially paid to the condition of the mucous membrane of the pharynx, examined first on the right, then on the left, the anterior and posterior palatine arches and the palatine tonsils themselves, the soft palate and the uvula. Then the condition of the posterior and lateral walls of the pharynx is assessed. If there is hypertrophy of the palatine tonsils, then to examine the posterior arch and lateral wall of the pharynx on the right and left, either displace the tonsil using a second spatula, or use a nasopharyngeal mirror, and, if necessary, an endoscope. In addition, palpation of the neck and elementor of the oropharynx is performed.
When examining any patient, an otorhinolaryngologist, regardless of the presence or absence of subjective manifestations of the disease, must perform indirect laryngoscopy and examine the nasopharynx. The latter is especially important in children and adolescents, if epipharyngoscopy fails in them, a digital examination, endoscopy using a fiberscope or rigid endoscope is performed, and, if necessary, radiography of the nasopharyngeal vault, CT or MRI.
Laryngoscopy is of utmost importance in the early diagnosis of laryngeal cancer. Examination of the larynx should be performed in such a way that all its sections are sequentially visible: the vallecula and the root of the tongue, the epiglottis, the aryepiglottic folds, the pyriform sinuses, the vestibular and vocal folds, the arytenoid and interarytenoid space, the commissure, the subglottic space. Laryngoscopy, especially when the tumor is localized on the vocal fold, makes it possible to determine the presence of a tumor even in cases where its size is minimal. In these cases, on one of the vocal folds, most often in the middle of it, there is a noticeable thickening, which often protrudes into the lumen of the glottis (exophytic growth). The base of the tumor is wider than the apex. This circumstance has very great diagnostic significance. Limitation of vocal fold mobility is also important, depending on cancer infiltration of the internal vocal muscle. It appears especially quickly during endophytic growth of the neoplasm. These two signs - a wide base of the tumor and limited mobility of the fold - with a significant degree of probability allow one to suspect a malignant neoplasm of the larynx and dictate the need for constant monitoring of the patient and histological examination of the tumor. Even before the mobility of the larynx is limited, stroboscopy can detect a violation of the vibration of the vocal fold.
However, the informative value of laryngoscopy is reduced when the tumor is localized in the area of the fixed part of the epiglottis, in the subglottic region. Inspection of the larynx is difficult due to some anatomical features: a folded or deformed epiglottis, a large tongue and a small mouth, the presence of trismus, etc.
Fibrolaryngoscopy allows you to examine in detail all hard-to-reach parts of the larynx, identify the tumor process at an early stage, and perform a targeted biopsy. This examination is performed through the nose, mouth, or retrogradely in the presence of a tracheostomy. However, the capabilities of this method are reduced during endophytic tumor growth.
In order to identify precancerous changes in the larynx, indirect and direct microlaryngoscopy is used. This study makes it possible to more accurately identify the endophytic component of the tumor due to the characteristic microlaryngoscopic signs of a malignant tumor: the disappearance of the transparency of the epithelium covering the tumor, disturbances in vascular architecture, thickening of the epithelium in the form of spines and papillae, hemorrhages, microulcerations.
The use of a toluidine blue test significantly increases the information content of this method for detecting early laryngeal cancer. Toluidine blue has a high affinity for amino acids contained in cell nuclei. During malignant degeneration, the cell nuclei contain a large amount of RNA and DNA, which leads to intense staining of these cells. The technique is as follows. Under local anesthesia, the area of the larynx suspected of a tumor is stained with a 2% solution of toluidine blue. After 2 minutes, the stain is washed off with saline and the intensity of the stain is assessed. The malignant tumor is intensely stained purple, and a targeted biopsy is performed from these areas. The information content of this sample is 91%.
A lot of useful information can be provided by the use of additional research methods that expand the doctor’s capabilities to identify and verify tumors. We are talking about conducting an examination using endoscopes - rigid or flexible, an operating microscope, radiography, computed tomography - X-ray or magnetic resonance imaging, ultrasound of the neck.
Currently, the Moscow City Hospital has developed an echosonography technique for early diagnosis of laryngeal cancer. Ultrasound examination is non-invasive, lacks radiation exposure, and allows for an unlimited number of studies in one patient. An important advantage of the method was the ability to detect endophytic forms of laryngeal cancer (in 37% of the patients examined), as well as determine the extent of the tumor, which is extremely important when choosing the extent of surgical intervention. In addition, this method allows for a puncture biopsy of the tumor under the control of an ultrasound monitor.
Without specifically considering the clinical issues and diagnosis of individual forms of neoplasms of the ENT organs, it should be noted that any neoplasm must be removed and should be sent for histological examination. However, in some cases, in order to develop optimal treatment tactics, it is necessary to determine the nature of the formation before surgery. In particular, it is very important to differentiate between a proliferative inflammatory and a tumor process, and in the latter case, a benign one or with elements of malignancy. For this purpose, a preoperative biopsy or cytological examination is performed in a specialized medical institution (oncology clinic).
Histological examination of biopsied material is often combined with cytological examination. In this regard, it is advisable to take a print or smear from its surface for cytological examination before immersing the excised piece of tissue in the fixing solution. This technique is especially valuable for emergency biopsy, when urgent histological examination is impossible or special histochemical reactions are required. In this case, cytological examination does not replace, but complements histological examination.
Histological examination often allows one to clarify and even change the clinical diagnosis. The final stage of diagnosis is a tumor biopsy for histological or cytological examination of the primary tumor or metastases. However, the diagnostic value of the biopsy results is not absolute; much depends on how well the material for the study was taken. A negative biopsy result in the presence of appropriate clinical data does not completely reject the diagnosis of a tumor.
In the complex of measures that contribute to the early detection of oncological diseases of the ENT organs, clinical examination plays an important role. Patients with laryngeal papillomatosis, chronic laryngitis, especially its hyperplastic form, with leukoplakia, recurrent polyposis of the nose and paranasal sinuses and other benign neoplasms of the ENT organs should be under dispensary observation; they should be examined every six months, recording changes in the course of the disease. If, in the opinion of the doctor, the course of the disease is unfavorable, the patient should be immediately referred for a consultation with an ENT oncologist in a specialized medical institution.
L.G. KOZHANOV, N.Kh. SHATSKAYA, L.A. LUCHIKHIN
Moscow City Oncologic Dispensary No. 1 (chief physician - Prof. A.M. Sdvizhkov), Department of ENT Diseases (Head - Corresponding Member of the Russian Academy of Medical Sciences Prof. V.T. Palchun) of the Faculty of Medicine of the Russian State Medical University, Moscow
BULLETIN OF OTORHINOLARYNGOLOGY, 5, 2008
LITERATURE
1. Abyzov R.A. Loroncology. St. Petersburg 2004;256.
2. Kozhanov L.G. Laryngofibroscopy and microlaryngoscopy in the combined treatment of laryngeal cancer with economical operations: Abstract of thesis. dis. ...cand. honey. Sci. M 1983;23.
3. Kozhanov L.G., Sdvizhkov A.M., Mulyarets M.V., Romanova E.S. Vestn oto-rinolar 2008;2:56-58.
4. Matyakin E.G. Malignant tumors of the nasal cavity and paranasal sinuses. In the book: Otorhinolaryngology, national guidelines. Ed. V.T. Palchuna. M 2008;502-512.
5. Olshansky V.O. Laryngeal cancer. In the book: Otorhinolaryngology. National leadership. Ed. V.T. Palchuna. M 2008;801-811.
6. Palchun V.T., Luchikhin L.A., Magomedov M.M. Practical otorhinolaryngology. M 2006;77-94.
7. Paches A.I. Tumors of the head and neck. M 2000;324-332.
8. Chissov V.I., Daryalova S.A. Selected lectures on clinical oncology. M 2000;76, 225.
9. Chissov V.I., Starinsky V.V., Petrova G.V. The state of oncological care to the population of the Russian Federation in 2004. M 2005;227.
10. Paavolainen M, Lanerma S. Minerva Otolaryng 1976;26:4:219-221.
