(A) T2 N0 M0
(B) T2 N1 M0
(C) T3 N0 M0
(D) T4 N1 M0
(E) T4 N1 M1
The correct response is Option D.

The staging of squamous cell carcinomas of the lip involves three descriptors: T, N, and M. The T descriptor is based on the diameter or surface area of the tumor. The N descriptor describes nodal status. The M descriptor indicates distance of metastasis beyond the neck. This staging criteria allows physicians to predict patient outcomes and to choose appropriate therapy based on comparisons with patients in large studies.

In this patient who has a 2.2 * 1.5-cm squamous cell carcinoma of the right lower lip with involvement of one lymph node only, the tumor is correctly classified as T4 N1 M0. Although the tumor can be classified as T2 based on size alone, any tumor that involves infiltration of skeletal muscle, nerve, cartilage, or bone (ie, extradermal structures) is classified as T4. Metastasis to one regional lymph node is N1, and absence of distant metastases is M0. Any T4 lesion is classified as Stage IV; a tumor with lesser T classification combined with an N1 would be designated as Stage III.

A TNM classification table is shown below.

Status of Tumor (T)
TX - Primary tumor cannot be assessed
T0 - No evidence of primary tumor
Tis - Carcinoma in situ
T1 - Tumor 2 cm or less in greatest dimension
T2 - Tumor more than 2 cm but not more than 4 cm in greatest dimension
T3 - Tumor more than 4 cm in greatest dimension
T4 (lip) - Tumor invades adjacent structures (eg, through cortical bone, inferior alveolar nerve, floor of mouth, skin of face)
T4 (oral cavity) - Tumor invades adjacent structures (eg, through cortical bone, into deep [extrinsic] muscle of tongue, maxillary sinus, skin. Superficial erosion alone of bone/tooth socket by gingival primary tumor is not sufficient to classify as T4).

Stages of Lymph Nodes (N)
NX - Regional lymph nodes cannot be assessed
N0 - No regional lymph node metastasis
N1 - Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension
N2 - Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimensions; or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
N2a - Metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension
N2b - Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension
N2c - Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension

Status of Metastasis (M)
MX - Distant metastasis cannot be assessed
M0 - No distant metastasis
M1 - Distant metastasis

References
1. Piccirillo JF, Pugliano FA. Evaluation, classification, and staging. In: Myers EN, Suen JY, eds. Cancer of the Head and Neck. Philadelphia, Pa: WB Saunders Co; 1996:33-49.
2. Weber RS, Callender DL. Clinical assessment and staging. In: Weber RS, Miller MJ, Goepfert H, eds. Basal and Squamous Cell Skin Cancers of the Head and Neck. Baltimore, Md: Williams & Wilkins; 1996:65-77.

Chronic exposure to which of the following substances is associated with the development of squamous cell carcinoma of the nasal sinus cavity?

(A) Alcohol
(B) Asbestos
(C) Benzene
(D) Nickel
(E) Tobacco

The correct response is Option D.

Chronic exposure to nickel has been shown to be associated with the development of squamous cell carcinoma of the nasal sinuses. This is the most common malignancy of the sinonasal tract, affecting the maxillary sinus most frequently, followed by the nasal sinus cavity, ethmoid sinus, and sphenoid sinus. In one study, workers at a nickel refinery in Norway developed squamous cell carcinoma at 250 times the expected rate, with a latent period varying from 18 to 36 years.

Exposure to alcohol and tobacco has been associated with squamous cell carcinoma of the upper aerodigestive tract, not the sinonasal tract. Exposure to asbestos has been shown to increase the risk for development of pleural mesothelioma, and benzene exposure is associated with the development of hemopoietic malignancies.

References
1. Pedersen E, Hogetvite AC, Andersen A. Cancer of respiratory origins among workers at a nickel refinery in Norway. Int J Cancer. 1973;12:32.
2. Wong RJ, Kraus DH. Cancer of the nasal cavity in the paranasal sinuses. In: Shah JP, ed. Cancer of the Head and Neck. Hamilton, Ontario: BC Decker Inc; 2001.

A 38-year-old woman has onset of gustatory sweating and flushing of the left cheek one year after undergoing superficial parotidectomy on the left for removal of a parotid tumor. The most likely cause of her current symptoms is dysfunction of which of the following nerves?

(A) Auriculotemporal
(B) Chorda tympani
(C) Facial
(D) Infraalveolar
(E) Lingual
The correct response is Option A.

This 38-year-old woman with gustatory sweating has findings consistent with Frey syndrome, a condition that occurs in more than 50% of patients who have undergone parotidectomy. Frey syndrome is thought to be caused by the development of anastomoses between postganglionic parasympathetic fibers from the otic ganglion, which are carried by the auriculotemporal nerve, and postganglionic sympathetic fibers in the sweat glands that lie within the vascular plexus of the skin. The fibers of both systems are cholinergic and mediated by acetylcholine.

The Minor starch-iodine test can be used to establish a diagnosis of Frey syndrome in symptomatic patients. In this test, 10% povidone-iodine is applied to the cheek, allowed to dry, and covered with cornstarch. Following the administration of a lemon drop stimulus, a region of blue discoloration will elicit the location of the gustatory sweating. Intracutaneous botulinum toxin, which relieves the hyperhidrosis and flushing associated with Frey syndrome by blocking neurotransmission of acetylcholine, can be administered to confirm the diagnosis. Although one series of botulinum toxin injections may result in relief of symptoms for as long as one year, repeat injections are frequently required.

Appropriate operative management is direct excision of involved skin and interposition of any one of a number of autologous tissues, including sternocleidomastoid muscle, fascia lata, lyophilized human dura, a SMAS flap, or a dermal graft between the skin and the parotid gland. Human preserved dermal allograft has been used recently with some success for interposition grafting.

The chorda tympani mediates taste sensation to the anterior two-thirds of the tongue via the facial (VII) nerve, which innervates the muscles of facial expression. The infraalveolar nerve provides sensation to the teeth, while the lingual nerve provides sensation to the tongue.

References
1. Clayman MA, Clayman LZ. Use of AlloDerm as a barrier to treat chronic Frey's syndrome. Otolaryngol Head Neck Surg. 2001;124:687.
2. Linger TE, Hubert A, Schmid S. Salivary tumors experience 30 years. Clin Otolaryngol. 1997;4:247.