The Early Diagnosis of Carcinoma of the Oral and Laryngeal Pharynx

IT is hardly necessary to emphasise the importance of the earliest possible diagnosis of carcinoma of the pharynx in order that these distressing cases may be successfully treated by excision. Early diagnosis in cases of carcinoma of the tongue has been established with great success by Butlin, but unfortunately it has not been done in cases of carcinoma of the more inaccessible pharynx. Waggett and Trotter, at the International Congress, 1913, urged the necessity of early diagnosis, and with that object in view I have kept careful notes of fourteen cases of growth involving the base of the tongue and pharynx, thirty-one cases involving the pyriform sinus, and twenty-four of post-cricoid growth, and also studied twenty-five selected specimens of such cases in the different museums of the London hospitals. Cases of growth of the upper end of the oesophagus which have extended to the pharynx have not been included. There are three types of cases of carcinoma of the pharynx frequently seen by the laryngologist: (1) The carcinoma in the region of the base of the tongue and epiglottis. (2) The pyriform sinus carcinoma. (3) The post-ericoid epithelioma.


THE EARLY DIAGNOSIS OF CARCINOMA OF THE ORAL
IT is hardly necessary to emphasise the importance of the earliest possible diagnosis of carcinoma of the pharynx in order that these distressing cases may be successfully treated by excision. Early diagnosis in cases of carcinoma of the tongue has been established with great success by Butlin, but unfortunately it has not been done in cases of carcinoma of the more inaccessible pharynx. Waggett and Trotter, at the International Congress, 1913, urged the necessity of early diagnosis, and with that object in view I have kept careful notes of fourteen cases of growth involving the base of the tongue and pharynx, thirty-one cases involving the pyriform sinus, and twenty-four of post-cricoid growth, and also studied twenty-five selected specimens of such cases in the different museums of the London hospitals. Cases of growth of the upper end of the oesophagus which have extended to the pharynx have not been included.
There are three types of cases of carcinoma of the pharynx frequently seen by the laryngologist: (1) The carcinoma in the region of the base of the tongue and epiglottis.
(2) The pyriform sinus carcinoma. The cases in this group with one exception all occurred in men, and, in spite of the accessible position, the growth had not been diagnosed until inoperable, and in 3 cases the symptoms were attributed to neurasthenia. In others the patients reported with a mass of malignant glands at the angle of the jaw, and were sent to the laryngologist for a search for the primary growth. The exact site of origin of this growth is often difficult to ascertain, but cases have been , observed to commence as a small ulcer in three definite situations: (1) The junction of the anterior pillar of the fauces and the tongue.
(2) Immediately below the tonsil at the junction of the lateral wall of the pharynx and the tongue. - (3) In the vallecula, either on the base of the tongue or on the anterior surface of the epiglottis.
The growth excavates the base of the tongue and rapidly extends to the surrounding structures, and the deep cervical and submaxillary lymphatic glands of. both sides are soon involved.
The early symptoms are, persistent, severe pain on swallowing located by the patient to the root of the tongue, with blood-stained frothy expectoration and slight enlargement of the deep cervical gland or glands at the angle of the jaw. Occasionally a chronic paroxysmal cough is the first symptom. Later the movement of the tongue becomes limited, as shown by incomplete and painful protrusion of the tongue to one side, and this incomplete protrusion with the accompanying trismus impedes laryngoscopic examination. All these cases were inoperable when first seen, in spite of the fact that the growth is within easy reach of the palpating finger, and does not require a skilled laryngoscopist or endoscopist to detect and gauge the extent of the growth. In the later stages haemorrhage, more or less severe, occurs.
All the cases of this type occurred in men, and the growth, so far as can be ascertained, commenced in the majority of cases as an ulcer Fio. 3.-An early pyriform sinus carcinoma. on the arytseno-epiglottidean fold, or in others on the floor of the fossa, and sometimes even lower, on one side of the posterior surface of the cricoid and crept upwards to the pyriform sinus, involving the same side of the larynx with fixation of the vocal cord and the characteristic oedema of the false cord and that half of the larynx. In late cases the base of the tongue and epiglottis are involved, and by downward extension the lumen of the pharynx is surrounded. The first symptoms are sore throat, followed by a characteristic hoarseness or roughness of the voice, with a copious frothy, blood-stained expectoration. The deep cervical glands are soon enlarged, and the neighbouring tissues of the neck are infiltrated, as shown by the fulness of the ala of the thyroid cartilage on the same side. Complete dysphagia is uncommon, as the growth does not occlude the lumen of the lower pharynx except in a few advanced cases. Haemorrhage is frequent and tracheotomy occasionally necessary. This type of case is usually inoperable at the first inspection, and any attempt at removal means a laryngectomy with excision of a large area of the pharynx, The Journal of Laryngology, [uovemter, 1920. 3. THE POST-CRICOID CARCINOMA (24 CASES : 22 WOMEN AND 2 MEN).
This growth is frequently a slow-growing superficial tumour, which appears to commence on the lower portion of the posterior surface of the cricoid cartilage and well below the area seen in an ordinary laryngoscopic examination. It may also commence on the posterior pharyngeal wall at the level of the cricoid or a little higher, and in this position is more easily seen. It tends to surround the lumen of the pharynx, and spreads upwards to form the whitish, warty upper edge seen in the later stages behind the cedematous arytsenoids. These patients first complain of a soreness or pricking sensation, with radiating pain in the ears during swallowing. Pressure of the larynx backwards against the spine or lateral movement of the larynx produces pain in practically all cases. Dysphagia occurs early, and when these symptoms are present without a satisfactory explanation the patient should be examined by suspension laryngoscopy or by the oesophagoscope. The laryngoscopic mirror will not show any signs in the early stage, and when the upper edge of the growth is visible the disease is advanced, and matters are still more hopeless when a vocal cord is paralysed. Neither is the growth within reach of the longest finger, and the passage of a bougie is valueless and even harmful. In the absence of physical signs the dangerous diagnosis of neurasthenia is still made, but such a diagnosis should never be concluded until the presence of a growth has been eliminated by a direct examination.
I have not seen any condition which could be called precancerous, and the glazed atrophic mucous membrane and tongue described by Patterson was seen in one case in which syphilis was not excluded. It is advisable to have a Wassermann reaction done, as I have seen two cases of syphilis which closely resembled a post-cricoid growth, but of the 24 cases in this class, with the one exception mentioned above there was no history of syphilis, and the Wassermann reactions were negative.
The great majority of the above cases of carcinoma were associated with very septic teeth, and there is no doubt that the growth is aggravated by this sepsis; moreover it has been proved by the Imperial Cancer Eesearch that the cachexia of malignant disease is the result of added sepsis and is not a sign of cancer per se. The removal of the septic teeth is not only an essential preparation for operation, but it improves the patieAt's condition, and can be done at the time of the examination by the direct method.
The problem of early diagnosis is intensified by the fact that cancer in itself does not produce any specific clinical signs or symptoms, and it is only when the cancer-cells form a tumour that a series of mechanical symptoms and signs appear. These symptoms also develop slowly and insidiously, and it is unusual for the patient to consult a doctor until such symptoms are well marked, and often too late for a successful removal of the growth. It is true that most of the cases of post-cricoid growth are inoperable when first seen, and only 5 of the above 24 cases were subjected to operation, two of which died of mediastinitis in four days; a third did well for ten months, and then died of mediastinitis following the removal of a recurrence of the growth. The fourth survived operation, but a recurrence occurred within twelve months. The fifth was successful, and remained well for twelve months, and then died of an apparent recurrence in the cervical glands. Logan Turner records 8 cases in which the tumour was excised, and in six the results were decidedly encouraging. Though these results are by no means satisfactory, the tumour is often superficial, of slow growth, metastases are late, and, except for its position, the tumour should be most favourable for excision provided an early diagnosis is possible and the technique of the operation is improved by experience.
The success of excision depends on the depth of the growth. Some growths are warty and superficial, and do not invade the submucous tissue or surrounding structures until late. Others are more infiltrating, and rapidly extend into the submucous tissue, as is shown by the paralysis of a vocal cord from involvement of the recurrent laryngeal nerve, and when this occurs the case is inoperable. I have not seen a case in which the growth has penetrated the constrictor muscles and invaded the surrounding structures, and even during operation it is difficult to detect the superficial type of growth by palpation when the' constrictor muscles are intact. Secondary growths in the deep cervical glands along the jugular vein are a late manifestation and when present contra-indicate operation. The lobe of the thyroid gland may be pushed forward and made prominent by the underlying growth, but secondary growths in the thyroid in the true post-cricoid growths are rare, and are more common when the upper end of the gullet is involved. The duration of the symptoms and growth are very variable, and cannot be taken into consideration in ascertaining the advisability of operation.
A direct examination by suspension laryngoscopy or bv the cesophagoscope should be made to ascertain the character and extent of the growth. When the growth surrounds the lumen of the pharynx the lower.limit cannot be determined, because it is difficult and not safe to pass the oesophagoscope through the annular growth, but such cases are inoperable. A piece of the growth can be removed for section, but the pathologist is rarely satisfied with the examination of so small a piece of tissue usually obtained. Unfortunately when the growth is exposed by operation it is often found to be more extensive than expected in spite of careful examination by the direct method, and it is claimed by Trotter that clinical evidence obtained by examination with the laryngoscope or direct method has proved to be misleading, and the only means which can give exact information is the direct observation of these tumours in their early stages at operations undertaken for their removal. This observation can also be made if cesophagostomy is done, but in my experience cesophagostomy is unsatisfactory, and I understand that it is not done in the Cancer Wards of the Middlesex Hospital. Hence it is up to the laryngologist to prove his value by making an early diagnosis and by giving an accurate estimation of the possible success of operation. (Revised with additions from the Abstract of an Epidiascopic Demonstration given before the Section of Laryngology, Eoyal Society of Medicine, on May 7, 1920. 1 ) SIR HENRY BUTLIN S stated that in his experience during the operation of thyro-fissure he had never seen bleeding which could occasion the least anxiety, and Sir Felix Semon 3 records that he had only lost one patient from secondary haemorrhage, followed by pneumonia, and this he attributed to the use of adrenalin. Those of us, however, who have had a larger experience than these surgeons have realised that haemorrhage may at times not' only unexpectedly occur and give rise to serious anxiety, but also tax the ingenuity and skill of the operator. Haemorrhage may occur either during removal of the growth, immediately following removal or some hours after the operation.

HEMORRHAGE DURING REMOVAL OF THE GROWTH.
During removal of the growth a considerable amount of bleeding may at times occur, but this can generally be easily controlled by gauzepressure, dry adrenalin gauze being the best for the purpose, and if there is a bleeding point artery forceps may be necessary.
Persistent oozing frequently occurs after separation of the muscular attachment round the arytaenoid cartilage, and a small vessel may be found between the arytaenoid and lateral wall of the thyroid cartilage, which occasionally spurts and may give considerable trouble. It should be picked up with pressure-forceps and may perhaps require ligaturing.