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TUMOURS OF THE PHARYNX AND TONGUE 117
for a dissection of the glands in the neck. On account of the mutilating nature
of the surgery, many tumours, especially the less differentiated ones, are
treated in the first instance by irradiation, surgery being reserved for re-
currences. The cytotoxic drugs are of use in advanced cases.
Cancer of the Pharynx. Malignant disease in the pharynx is usually primary.
Secondary deposits .from a melanoma of the skin are rare. The average age of
onset is about 60 years, but sarcoma may occur in children. Males are more
often affected than females.
The tumour is nearly always a carcinoma, the most common type being a
The majority of these show little or no differentiation.
Undifferentiated squamous epitheliomata are sometimes referred to as
lympho-epithelioma or transitional-celled epithelioma. The less a tumour is
differentiated the greater is its propensity for spread to the lymph nodes. A
common site of origin of the carcinoma is the angle between the palatoglossal
fold and the tongue. From here it spreads along the edge of the tongue and on
to the floor of the mouth and the alveolus. In some cases it spreads upwards to
invade the fauces and soft palate, while occasionally spread occurs downwards
along the lateral wall of the pharynx. Exophytic tumours are less common
than the ulcerative invasive type.
Sarcoma may occur in children, but is found in adults of any age. The
tumour arises within the tonsil, and as the tumour grows the tonsil enlarges.
The sarcoma may remain within the tonsillar capsule for some time, but once
it erupts beyond it, spread is rapid.
SYMPTOMS. Pain is generally the first symptom, and is constant in position so
that the patient may indicate the site with the tip of a finger. The pain is most
marked on swallowing. There is foetor of the breath. In most cases the patient
does not seek advice until there is a neck swelling from spread to a regional
gland. If the tongue is involved there may be alteration of speech, and if the
tongue becomes fixed there may be excessive salivation. Later, pain radiates
to the ear, and there may be difficulty in opening the mouth.
CLINICAL FEATURES. Both in diagnosis and in the determination of the
extent of the tumour, palpation is of greater value than inspection. The early
induration may be detected by the gloved finger before the growth is readily
visible. Palpation should never be omitted. Biopsy should be performed hi all
cases. A routine palpation of the neck must be made for lymph nodes (p. 243).
On inspection the tumour may be seen either directly or with the help of a
laryngeal mirror. Chest radiography and a full blood count should be carried
out in every case, because the differential diagnosis lies between tumour and
tuberculosis, syphilis or blood disorders. A sarcoma causing a painful
swelling of one tonsil has frequently been mistaken for a quinsy, and many
have been incised as a result of this misdiagnosis.
PROGNOSIS. This varies with the tumour histology, the length of the
symptoms and the presence of enlarged lymph nodes. The more extensive the
tumour, the worse the outlook; 30 per cent of carcinomata treated before
gland involvement may be expected to survive 5 years, but this percentage
drops to about 12 per cent if there are unilateral glands when the patient is
first treated, and to less than 5 per cent should bilateral gland involvement be
present. With sarcomata, the 5-year survival rate in patients with no glandular
invasion is something over 65 per cent, but is only about 15 per cent with