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 gland metastasis.