Definition
A.Head and neck cancers can arise in the oral cavity, pharynx, larynx, nasal cavity, paranasal sinuses, and salivary glands and include a variety of histopathologic tumors.
Incidence
A.In the United States, head and neck cancer accounts for 3% of malignancies, with approximately 63,030 Americans developing head and neck cancer annually and 13,000 dying from the disease.
B.Head and neck squamous cell carcinoma (HNSCC) comprises more than 90% of head and neck cancers.
Pathogenesis
A.Pathophysiology of cancers of the head and neck usually begin in squamous cells of the mucosal lining of the aerodigestive tract.
B.Viral infection, smoking, and alcohol consumption can encourage differentiation of squamous cells.
Predisposing Factors
A.Tobacco products.
B.Alcohol.
C.Viral infections.
1.Epstein–Barr virus (nasopharyngeal cancers).
2.Human papilloma virus (HPV; oropharyngeal cancers).
a.HPV is accepted as a risk factor in the development of squamous cell carcinomas of the oropharynx, especially cancers of the lingual and palatine tonsil and base of tongue.
b.HPV vaccine reduces HPV oral infection, but the impact on HNSCC incidence is yet unknown.
D.Betel nut use: Combination of areca palm nuts, betel leaf, slaked lime, +/− tobacco commonly used in South Asia.
E.Radiation exposure.
F.Periodontal disease.
G.Immunodeficiency (immunosuppressant use, HIV/AIDS, bone marrow, or organ transplantation).
H.Occupational exposure.
I.Genetic factors (polymorphisms, Fanconi anemia, etc.).
J.Iron deficiency (Plummer-Vinson) associated with elevated risk of squamous cell carcinoma.
K.Gastroesophageal reflux or laryngopharyngeal reflux (laryngeal cancers).
Subjective Data
A.Common complaints/symptoms.
1.Symptoms and signs vary depending on the subtype and location of the tumor.
2.Patient may be asymptomatic, but common symptoms include:
a.Oral mass.
b.Dsyphagia.
c.Pain: Odynophagia and/or otalgia.
d.Dysarthria.
e.Cervical adenopathy.
f.Hoarseness.
g.Hearing loss.
h.Facial numbness, paresthesias, or paralysis.
i.Trismus.
j.Loose teeth.
3.Patients may present with precursor lesions that transform into oral cancer.
a.Can develop from area of leukoplakia or erythroplakia.
b.Transformation of severe dysplasia or carcinoma in situ.
Physical Examination
A.Identify the key elements of the mass: The size, firmness, associated pain, and overlying skin changes.
B.Head and neck: Assess for dysarthria, tongue mobility; visual examination and palpation of mucous membranes, floor of the mouth, tongue, buccal and gingival mucosa, palates, and posterior pharyngeal wall.
C.Ears: Inspect ear canal for drainage and tympanic membrane; grossly assess hearing.
D.Lymphatics: Palpate the neck for cervical lymphadenopathy.
E.Neurological: Assess cranial nerves II through XII; assess for facial twitching.
Diagnostic Tests
A.History and physical examination.
B.Direct laryngoscopy and biopsy of the primary site.
C.CT or MRI of the head and neck.
D.PET/CT (optional, preferred in lymph node positive disease).
E.Chest imaging as clinically indicated.
F.Fine needle aspiration (FNA) and/or biopsies of primary tumor and/or nodal disease.
G.Videostroboscopy for patients with dysphonia.
H.Epstein–Barr virus (EBV) quantitative polymerase chain reaction (PCR; for nasopharyngeal cancers).
I.Dental, nutrition, speech/swallowing evaluation, and audiogram if indicated.
J.Staging.
1.Staging for all oral cancers utilizes the tumor, node, metastasis (TNM) staging outlined by the American Joint Committee on Cancer (AJCC).
2.TNM staging varies depending on the primary tumor site.
Differential Diagnosis
A.Inflammatory process.
Evaluation and Management Plan
A.General plan: Subtypes and treatment.
1.Treatment for all head and neck cancers depends on TNM stage at diagnosis.
2.Treatment recommendations vary depending on primary site of tumor. However, generalized guidelines are outlined here.
a.Early stage (localized) disease (stage I or II): Definitive radiation therapy (RT) and/or localized resection may be all that is indicated.
b.Advanced disease (stage III or IV) or resections without clear margins.
i.Adjuvant or neoadjuvant chemotherapy or radiation may also be indicated in addition to surgery.
ii.High risk of local recurrence and distant metastasis.
B.Acute care issues in head and neck cancers.
1.Patients with HNSCC are rarely admitted except for postoperative management.
2.RT sequelae.
a.Sore throat.
b.Dry mouth.
c.Alteration in taste.
d.Swelling in the neck.
e.Soft tissue necrosis leading to chondritis (<1%).
f.Sensation of lump in the throat.
3.Xerostomia.
a.Due to salivary gland destruction/injury.
b.May be prevented by administering amifostine during RT.
c.Management.
i.Submandibular gland transfer.
ii.Pilocarpine.
iii.Hyperbaric oxygen.
4.Mucositis.
a.Frequent severe complication of RT and chemoradiotherapy.
b.Management.
i.Avoid acidic or spicy foods.
ii.Monitor closely for infections (e.g., oral candidiasis or herpes simplex virus).
iii.Topical anesthetics.
iv.Doxepin rinse.
v.Palifermin (keratinocyte growth factor).
5.Weight loss and malnutrition.
a.Due to difficulty eating, mucositis, trismus, and difficult mastication.
b.Management.
i.Consider parenteral, enteral, or oral nutritional support.
ii.Refer to nutritionist.
Follow-Up
A.Follow-up should occur every 1 to 2 months for the first 6 months after the completion of treatment and every 2 to 3 months in the next 6 months, then every 3 to 4 months during the second year and then every 6 months from years 3 to 5.
Consultation/Referral
A.Otolaryngology, medical oncology, and radiation oncology.
B.Nutritionist for weight loss and malnutrition.
Special/Geriatric Considerations
A.Patients older than 70 years should not be denied chemotherapy based solely on age.
B.Discuss aggressive treatment with the patient.
C.Take life expectancy, quality of life, and patient’s functional status into consideration.
Bibliography
National Cancer Institute. (2016, September 12). Surveillance, epidemiology, and end results program. Retrieved from https://seer.cancer.gov/faststats/selections.php?series=cancer
Poon, C. S., & Stenson, K. M. (2018, November 19). Overview of the diagnosis and staging of head and neck cancer. In R. F. Connor (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/overview-of-the-diagnosis-and-staging-of-head-and-neck-cancer
Popescu, C. R., Bertesteanu, S. V., Mirea, D., Grigore, R., Ionescu, D., & Popescu, B. (2010). The epidemiology of hypopharynx and cervical esophagus cancer. Journal of Medicine and Life, 3, 396–401.