AAO-HNSF Primary Care Otolaryngology Handbook

CHAPTER 16

with immediate pathologic examination under a microscope to ensure complete removal. This tech- nique takes significantly longer than any of the other methods, but the recurrence rate can be lower. For this reason, certain tumors with a higher-than-usual chance of recurrence with conventional excisions may be better managed with Mohs’ surgery. It is also performed near cosmetically and functionally sensi- tive structures , such as the eyelids, nose, and ears, in order to preserve as much uninvolved tissue as possible. Morpheaform basal cell carcinoma , a subtype of basal cell carcinoma, has very indistinct borders without the characteristic features of the nodular variant. It is very difficult to excise without the use of real-time, histologic feedback. Therefore, this type of basal cell carcinoma is ideally suited for Mohs’ surgery. Unfortunately, Mohs’ surgery is also costly. Squamous cell carcinoma is more aggressive and may metastasize (Figure 16.4). It generally requires exci-

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Figure 16.3. Very large basal cell carcinoma of the facial skin. Note the rolled edges with central ulceration, indicating subepithelial extension. Excision must ensure that the tumor is completely removed or recurrence is highly likely.

sion of a 5–6-mmmargin to ensure complete removal. Metastasis often occurs in the setting of deep-lesion ulceration and recurrent lesions. Evaluation of the neck nodes and careful follow-up to detect early recur- rence or metastasis are necessary. Larger tumors are usually treated with wide excision and neck dissection to remove any possible metastases. Malignant Melanoma

Cutaneous malignant melanoma is a capricious tumor that affects patients of all ages and has a high mortality rate. There is mounting evidence that sun exposure in childhood is a strong risk factor. It is very common in Australia, and public education in that country has led to the widespread frequent wearing of broad-brimmed hats and the use of sunscreen lotions among 50 percent of adults and chil- dren. Both adults and children should be protected from the sun when outside in the summer and in warmer

Figure 16.4. A large neglected squamous cell carcinoma of the face is present in this individual.

Primary Care Otolaryngology