Evaluation And Planning

Initial approaches to oral cavity neoplasia, first described in detail in the early 1800s, involved transoral resection of relatively small lesions, limited by the patient's pain tolerance and the need to control blood and secretion aspiration while maintaining an adequate airway. With improvements in anesthesia in the early 20th century, more aggressive local interventions were tried, in combination with tracheostomy as necessary. With the advent of endotracheal intubation and an evolving understanding of the successful surgical management of metastatic adenopathy, extirpative techniques had almost reached the sophistication of current techniques by the 1950s: lip and mandibular splits to access large malignancies, combined with neck dissection(s), became commonplace (1-3,11). During the latter half of the 20th century, surgical advances have been made in the management of oral cavity neoplasia, such as the less deforming facial degloving approaches and selective neck dissections that can preserve form and function without compromising cure, and in three-dimensional planning and delivering of irradiation. That said, a preponderance of the differences in the treatment of oral malignancies between the 1950s and the

Figure 3 End result (three years postoperative) of granulation/scarring of defect from transoral resection of verrucous carcinoma (Fig. 2).

present has been the result of advances in surgical tumor-defect reconstructions, ranging from metal bridging plates and osseointegrated implants to composite free flaps.

When planning comprehensive treatment for an oral cavity neoplasm, the surgeon must consider many factors. Lesion location in the oral cavity, and its size and proximity to the mandibular or hard palatal bone are the first factors to consider (Table 1). Access is usually straightforward for anteriorly located lesions, as such are easier to inspect and palpate, and hence to excise, as the surgeon can retract adjacent normal tissues away from all but the most bulky lesions (1,2,4,7,15). Lesions abutting but not penetrating the outer cortex of bone can be excised transo-rally with a bony margin obtained via marginal mandibulectomy or partial hard palatectomy, or even by simply drilling off bone widely around the neoplasm. It is

Table 1 Issues Related to Head and Neck Surgical Approach

Structures Type of neck Location of needing

Table 1 Issues Related to Head and Neck Surgical Approach

Structures Type of neck Location of needing

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