Head and Neck Cancer

Question 1

Head and Neck Cancer - Definition

Answer 1

• Tumours arising from the epithelial lining of the upper aerodigestive tract
• Includes oral cavity, larynx, pharynx, paranasal sinuses, salivary glands
• Vast majority are squamous cell
• Often associated with comorbid disease as risk factors (eg smoking, alcohol) lead to other conditions)

Question 2

Risk Factors for Head and Neck cancers

Answer 2

• Tobacco
• Alcohol
• HPV infection
• EBC
• Mucosal irritation (ill fitting dentures, roughened dental edges)

Question 3

Social issues specific to Head and Neck Cancers

Answer 3

• Disfigurement secondary to disease and treatment is common
• Body-image disturbance is common and may lead to major social problems
• Social interaction may be altered, communication difficulties may arise, and patients with visible scars or distorted features may feel stigmatized
• Normal social activities (speaking and eating) can be significantly disrupted
• Financial issues may arise due to patients being unable to work

Question 4

Symptoms that should prompt a swallowing assessment in Head and Neck cancers

Answer 4

• Most likely to occur in patients with hypopharyngeal/laryngeal patients
  1. Inability to control food, liquids, or saliva in the oral cavity
  2. Pocketing of food in the cheek
  3. Excessive chewing
  4. Drooling
  5. Cough, choking, or throat clearing with swallowing
  6. Abnormal vocal quality after swallowing (wet or gurgled)
  7. Build up or congestion after a meal
  8. Patient indicates difficulty swallowing
  9. Nasal regurgitation
  10. Weight loss

Question 5

Swallowing assessment

Answer 5

1. Modified barium swallow
   - Shows both oropharnygeal swallow and the etiology of aspiration
   - Gold standard
2. Fibreoptic endoscopic evaluation of swallowing

Question 6

Dysphagia/Odynophagia due to radiation: Contributing toxicities and prognosis

Answer 6

Acute radiation toxicities contributing to dysphagia:

• Mucositis
• Tissue edema
• Xerostomia
• Hyperviscous secretions
• Typically resolve in 4-12 weeks

Late effects of radiation

• Decreased tongue base retraction
• Decreased laryngeal elevation
• Decreased epiglottic inversion
• Decreased pharyngeal wall motion
• Aspiration

Question 7

Use of a PEG tube for dysphagia

Answer 7

• May be required for nutritional support
• Risk is disuse atrophy (in as little as 2 weeks) that predict poorer swallowing outcomes
• If a PEG is replaced as a temporary measure, patients should continue to swallow or perform exercises to maintain pharyngeal function and advance diet as quickly as possible
• SLPs should be involved

Question 8

Voice in head and neck cancer - pathophys, presentation

Answer 8

• Treatment of head and neck cancer often results in resection of structures involved in normal speech
• Rads may further affect vocalisation
• Tumours may disrupt CN IX or X, involved in normal speech production

Presentation
- Soft, breathy voice or whisper due to laryngeal paralysis

Question 9

Communication rehabilitation in head and neck cancer

Answer 9

• Artificial larynx (electrolarynx), provides an external sound source and produces a mechanical-sounding voice
• Esophageal speech, requires ongoing physical therapy - air pumped via swallow or inhaled into cervical esophagus, then exhaled in a ‘controlled belch’ to produce speech
• Prosthetic speech, creation of a trachea-esophageal tract to insert a one way valve

Question 10

Airway control in Head and Neck Cancer

Answer 10

• Obstruction can occur anywhere along the area

Sonorous mouth breathing

• Obstruction at the level of base of the tongue or oral cavity
• Palliate with nasal trumpet and upright positioning

Inspiratory/biphasic stridor
- Fixed laryngotracheal obstruction (may require tracheostomy)

Anxiety/agitation/confusion

• Progressive hypercarbia due to obstruction
• Immediate assessment - may require laryngoscopy

Question 11

Auditory function in head and neck cancer

Answer 11

• May experience a decrease as a result of chemo or rads
• Sensorineural hearing loss is common
• If present, refer for hearing aids

Predictive factors:

• Age
• Pre-treatment hearing deficit
• Dose to cochlea
• Concurrent chemo

Question 12

Dermatitis in head and neck cancer

Answer 12

• Common with external beam radiation
• Typically 2-3 weeks after therapy and begins to heal in 2-4 weeks
• manifests as erythema, edema, blistering, ulceration, and sloughing

Late changes:

• Atrophy
• Change in pigmentation
• Development of telangiectasias
• Hair loss

Question 13

Lab abnormalities in head and neck cancer

Answer 13

Anemia

• Common - anemia of chronic disease
• May lead to radiation resistance as it increases number of hypoxic cancer cells, which require higher doses of rads to kill
• EPO may reduce cancer control and is not recommended

Hypothyroidism

• Common due to rads and lobectomy as part of resection for laryngeal cancer
• Ensure ongoing screening and periodic lab surveillance

Question 14

Lymphedema

Answer 14

• Common in head and neck cancer due to surgery, rads, and cancer itself
• Most often occurs in head and neck
• Presents initially with subtle swelling, which may lead to heaviness, tightness, and stiffness
• Over time, may lead to fibrosis and impaired ROM

Treatment:

• Manual lymphatic drainage
• Compression garments
• Education
• Ensure treatment is undertaken by lymphedema therapists

Question 15

Osteoradionecrosis in head and neck cancer

Answer 15

• Common in head and neck cancer, particularly of the mandible
• Varies according to radiation doses and dentition (more common in edentulous patients)
• Pre-rads extraction of disease teeth is recommended, with antibiotic prophylaxis and healing prior to rads
• To prevent, patients should avoid alcohol and maintain good oral hygiene