Head and Neck Flashcards
What are the head and neck cancers?
Oral cavity/oral cancers Tongue cancer Oropharynx, tonsils, nasopharynx, hypopharynx Nasal and sinus cancer Salivary glands Middle ear
Laryngeal
(Thyroid)
What is the lymphatic drainage of the oral cavity?
Superficial nodes - submandibular nodes
Submental nodes
Superficial cervical nodes along external jugular vein and drain skin over angle of the jaw
Deep nodes
Jugulodigastric node drains tongue and tonsils
Jugulo-omohyoid
What are the cervical lymph node levels?
IA - submental IB - submandibular II - upper jugular deep to SCM III middle jugular IV inferior jugular V posterior cervical triangle VI anterior neck compartment
What is the classification of oral cavity cancers?
Over 90% are squamous cell, oral mucous comprises of stratified squamous epithelium
Basal cell on upper lip
Minor salivary gland cancers - Kaposi, lymphoma or sarcoma
What are the non-modifiable risk factors for oral cavity cancer?
Male gender Age Past cancer history Family history of head and neck cancer Past radiation exposure
Plummer-Vinson syndrome inc iron deficiency
What are modifiable risk factors for oral cavity cancer?
Alcohol consumption Tobacco smoking Use of smokeless tobacco e.g. betel quid, chews Sun exposure Poor oral hygiene Chronic oral inflammation
Oral sex via transmission of HPV
What are premalignant lesions of the oral cavity?
Leukoplakia - thick white patches on inside surface
Erythroplakia - red mucosal patches
What is included in oral cavity cancer?
Buccal mucosa Retromolar triangle Hard palate Anterior two third of tongue Alveolus - part of the jaw and gums where teeth held in place Floor of mouth Mucosal surface of lip
What are some differentials for oral cavity cancer?
Actinic keratosis
Oral candidiasis
Leukoplakia
Lichen planus
What is the presentation of tongue cancer?
May grow significantly before any symptoms
Often well differentiated
Usually more than 2cm in size
May develop speech and swallowing dysfunction, pain if tumour involves lingual nerve
Pain may be referred to ear
What is the presentation of tonsillar cancer?
Most are SCC
Could be secondary mets from breast, lung, renal, pancreatic, colorectal
Neck mass
Sore throat, ear pain, foreign body or mass sensation
Bleeding may occur
Trismus - ominous sign that there is involvement of pharyngeal space - spasm of jaw muscles so jaw tightly closed
Weight loss, fatigue
When should an oral cavity cancer be referred?
Unexplained ulceration in oral cavity lasting >3 weeks
Or persistent unexplained lump in the neck
Lump on lip or oral cavity
Red/red and white patch in oral cavity; assessment urgent by dentist
What is the management of oral cavity cancer?
Early cancer:
Surgical resection or brachytherapy in accessible well demarcated lesions
External beam radiotherapy, selective neck dissection for prophylaxis in N0 disease
Post op radiotherapy if positive nodes
Cisplatin chemo and post op radiotherapy
For advanced cancer:
Surgical resection and reconstruction
Radical neck dissection
External beam radiotherapy and concurrent cisplatin chemo if tumour cannot be adequately resected, or patient preference
What are the features of buccal mucosa cancer?
Painless in early stages Becomes ulcerated Secondarily invades adjacent nerve Deeply ulcerative lesion Easily treatable
What are the cancers of the pharynx?
Oropharynx - base of tongue, tonsil, soft palate
Hypopharynx - postcricoid area, pyriform sinus, posterior pharyngeal wall
Nasopharynx - behind nasal cavity and above soft palate
Usually squamous cell carcinomas originating in epithelial cells lining the throat
What is the presentation of pharyngeal cancers?
Oropharynx - persistent sore throat, lump in mouth or throat, pain in ear
Hypopharynx - problems with swallowing and ear pain, hoarseness
Nasopharynx - lump in neck, nasal obstruction, deafness, postnasal discharge
Bleeding causing haemoptysis, halitosis, truisms, weight loss
What is seen on examination for pharyngeal cancers?
Neck mass
Mouth lesion
Regional pain
Unexplained red or white patches
Palpate for nodes
What are appropriate investigations for H&N cancers?
Persistent hoarseness - CXR
LFTs - ?abdo mets - CT
CXR - pulmonary mets
Normal bloods, TFTs
Thorough examination Endoscopy, FNA/biopsy of any masses CT/MRI of primary tumour CT of thorax PET-CT
When should a patient be referred for suspicion of H&N cancer?
Laryngeal cancer - people over 45 with:
unexplained hoarseness
unexplained lump in neck
Oral cancer: Unexplained ulceration >3 weeks Persistent unexplained lump Lump on lip/oral cavity consistent with oral cancer Red or red and white patch
Thyroid cancer - unexplained thyroid lump
What is the management of oropharyngeal cancer?
Surgery and resection
Radiotherapy
Chemotherapy
Transoral carbon dioxide laser surgery - laser beam to excise
Prophylactic treatment of same side of neck for tumours clearly confined to one side of oropharynx
Bilateral treatment if encroaching on base of tongue or soft palate
What are some of the complications of pharyngeal cancer?
Surgical resection or contracture after radiotherapy of soft palate - nasal regurg of liquids and solids
Hypernasal speech
Dysphagia
Middle ear effusion from scarring of tube or loss of function of levator palatini
Hypothyroidism following external beam radiation therapy
What are nasopharyngeal tumours?
In lateral nasopharyngeal recess
Undifferentiated most common
Can be associated with EBV
What are the risk factors for laryngeal cancer?
Smoking Alcohol Occupational exposures - asbestos, formaldehyde fruit and veg diet protective HPV
What is the presentation of laryngeal cancers?
Chronic hoarseness
Pain, dysphagia, lump in neck, sore throat, cough
Breathlessness, aspiration, haemoptysis, fatigue, weakness, weight loss
What are the investigations for laryngeal cancer?
Head and neck exam
Palpation of oral cavity and oropharynx, and neck
Urgent CXR - particularly if over 50, heavy smoker, heavy drinks, hoarseness over 3 weeks
Flexible laryngoscopy
Fine needle aspiration
CT, MRI, CXR, PET-CT
What is the management of laryngeal cancer?
Total and partial laryngecetomy
Transoral laser microsurgery
External beam radiotherapy if early
Organ preservation using concurrent chemoradiation
What are some of the complications of laryngeal cancer?
Dysphagia, malnutrition Loss of voice Tracheo-innominate artery fistula Loss of taste Complications of surgery, chemo - immunosuppression, radiotherapy - fibrosis, scarring, oesophageal stricture, dry mouth
What are the general principles for H&N cancer management?
Medical - oncology treatment
Surgical - assessment of tumour, sample and biopsy, removal, reconstruction
Supportive - swallowing, feeding, voice rehab, pain management, supportive care
MDT approach - oncologists, surgeons, radiologists, pathologists, CNS, SALT, dieticians
What is the general treatment of pharyngeal cancers?
Small tumours excise and repair defect
Radiotherapy
Larger tumours that do not respond to radiotherapy may need extensive surgery
What are the types of thyroid cancer?
Papillary and follicular most common
Thyroid follicular epithelial derived - papillary, follicular, anaplastic
Medullary thyroid cancer
Primary thyroid lymphoma
What are the risk factors for thyroid cancer?
Radiation exposure, part in childhood Family history, familial thyroid cancer Female sex FAP Obesity Endemic goitre
What are the clinical features of thyroid cancer?
Thyroid nodule/mass
Hoarseness/change in voice
Cervical lymphadenopathy
Stridor
Who should be referred on 2WW for thyroid cancer?
Unexplained thyroid lump
Thyroid lump and lymphadenopathy
Thyroid lump and voice change
Rapidly increasing size
Admit if any signs of airway obstruction - stridor, ENT review
What are the investigations for thyroid cancer?
History, examination - any thyroid hormone imbalance and lymphadenopathy
Thyroid function tests
Ultrasound scan of thyroid lumps, score of U1-5
1 - normal, 2 - benign, 3 - indeterminate, 4 - suspicious, 5 - malignant
Fine needle aspiration cytology
Thy5 = malignancy
What is the management of thyroid cancer?
Surgical resection, total thyroidectomy - but increased risk of hypoparathyroidism
Lymph node dissection
Monitoring of serum calcium +- PTH monitored post op
Evaluate vocal cord function post op
Adjuvant therapy
Radioiodine remnant ablation
External beam radiotherapy
TSH suppression with supra-normal levels of levothyroxine can reduce risk of recurrence
What are some complications following treatment of thyroid cancer?
Recurrent laryngeal nerve injury, vocal cord dysfunction, change in patient’s voice
Bilateral injury - stridor
Haematoma - can threaten airway
Hypoparathyroidism - will need calcium, alfacalcidol after total thyroidectomy
