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Cancer Care > Head & Neck > Flashcards

Head & Neck Flashcards

1
Q

what are the areas affected by head and neck cancer?

A

Oropharyngeal tract, nasal sinuses, nasal cavity, oral cavity, tongue, salivary glands, larynx, pharynx

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2
Q

what is the most common head and neck cancer?

A

tongue

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3
Q

which head and neck cancers have the best and worse chance of survival?

A

Best chance of survival – salivary gland

Worst chance of survival - Hypopharyngeal

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4
Q

what is the peak age of onset for head and neck cancer?

A

70-74 years old

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5
Q

what are some risk factors for head and neck cancer?

A

smoking and drinking in combination - direct exposure to carcinogens

HPV type 16

betel nut chewing

ionising radiation

asian ancestry

family hx

EBV

leukoplakia/erythroplakia

erosive lichen planus

immunosuppression - HIV, post transplant

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6
Q

describe some features of HPV positive oropharyngeal cancer?

A

73% of oropharyngeal cancer cases are HPV +ve

larynx and oral also

has better outcomes than non-HPV related cancer

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7
Q

describe some features of paranasal sinus/nasal cavity cancer

A
  • Constant nasal congestion
  • Headache
  • Chronic infections
  • Facial Swelling
  • Epistaxis Eye/dental pain
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8
Q

describe some features of oral cavity cancer

A
  • Leuko/Erythroplakia
  • Jaw swelling
  • Unexplained ulceration
  • Persistent neck lumps
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9
Q

describe some features of salivary gland cancer?

A
  • Chin/jawbone swelling
  • Numbness/paralysis facial muscles
  • Facial/chin/neck pain
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10
Q

describe some features of pharynx cancer

A
  • Dysphagia
  • Odonyphagia
  • Neck/throat pain
  • Oral pain
  • Ear pain/tinnitus
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11
Q

describe some features of laryngeal cancer

A
  • Persistant unexplained hoarseness
  • Odonyphagia
  • Neck lumps
  • Airway obstruction
  • Dysphagia
  • Ear pain
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12
Q

what are the NICE guidelines on 2ww for head and neck cancer?

A
  • Persistent unexplained neck lump
  • Persistent unexplained hoarseness
  • Unexplained oral ulceration >3 weeks duration
  • Lip/oral cavity lump >3 weeks duration
  • Erythro/Leukoplakia
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13
Q

what are some red flag symptoms that may also require urgent referral?

A
  • Dysphagia
  • Odonyphagia
  • Cough
  • Ipislateral Otalgia
  • Unilateral Nasal obstruction/epistaxis
  • Sore throat
  • Misaligned teeth
  • Haemoptysis
  • Sensation of lump in throat
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14
Q

what is lichen planus?

A

Mucocutaneous inflammatory disease of uncertain origin

Can affect skin, mucous membranes, genitalia and nails

Wickham’s striae, erosions present

Tx- Hygeine, topical CCS, oral analgesia/anaesthetic

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15
Q

what are apthous ulcers aka Canker lesions

A
  • Most common ulcerative condition of oral mucosa
  • Uncertain cause- FH, stress, trauma, vitamin deficiency, meds, viral infection all can precipitate
  • Round yellowish spot with red halo, breaking into punched out ulcer
  • Tx- cause, mouthwash, analgesia
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16
Q

what is erythroplakia?

A
  • Red velvety plaque or patch on oral mucosa
  • 75-90% prove to be cis or cancer
  • 6th-7th decades most common
  • Investigate - avoid alcohol/tobacco
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17
Q

what is leucoplakia?

A
  • White patch or plaque on oral mucosa
  • DDx- cis, nicotine stomatitis, candida, habitual cheek biting, SLE
  • If no clear cause-investigate and tx
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18
Q

what are some important things to look for on examination of a pt with suspected head and neck cancer?

A
  • General- Cachexia, malnutrition, trismus, poor dentition
  • Intraoral- Looking for lesions, may be more than one
  • Lymph Node exam- Secondary spread
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19
Q

what are some key investigations to be done for head and neck cancer?

A
  • Key to confirming diagnosis, cancer type and grade
  • May need to be performed under GA
  • FNA of neck masses/LN- can be done under US guidance
  • Excision biopsy- if FNA inconclusive
  • Triple Endoscopy- exclude 2nd primaries
20
Q

what is the most common histological head and neck cancer?

A

squamous cell carcinoma

other types - less common =

lymphoma, blastomas, sarcomas, neuroendocrine tumours

21
Q

what is P16 Immunohistochemical expression?

A

considered a surrogate marker for HPV infection - overexpression correlates with good prognosis

22
Q

what imaging is done for head and neck cancer and what is being looked for?

A

CT-PET

  • Imaging of choice for Oropharyngeal Cancers
  • More accurate for detecting distant mets than CT and PET More accurate detecting disease recurrence also
  • Not as readily available

CT Neck with Contrast

  • Laryngeal Cancer
  • Needs to have contrast- unable to differentiate otherwise

MRI Head and Neck

•More accurate round dentition

CT Chest

Common site for mets

23
Q

how is head and neck cancer staged?

A

TNM staging

varies between site of cancer

24
Q

how does head and neck cancer spread?

A

Local Disease

  • Through muscle layers
  • Multiple routes for haematogenous spread

Lymphatic Spread

  • Main route of spread for Squamous Cell Carcinoma
  • Cervical Lymph Nodes predominant
  • Can facilitate further local spread of cancer

Distant Mets

  • Less common
  • Lungs main spot for distant mets, Bone/liver also
  • Increasingly recognized- cause of death in 1/3 patients

Multiple Primaries

  • Particular risk → Carcinogenic effects not limited to one site
  • Common- 1 in 8 patients
  • Very poor for prognosis
  • 1/3 tongue cancers develop 1+ primaries
25
Q

how is head and neck cancer managed?

A

usually a combination of surgery, radiotherapy, chemotherapy - dependent on site, spread and physical status of the patient

extensive MDT

26
Q

describe surgery for head and neck cancer

A

Primary Treatment of choice in most H/N cancer presentations

Principle of stepwise spread through lymphatics

  • Bloc Dissection- Tumour, Nodes and intervening lymphatics should control disease
  • Radical neck Dissection- Nodes, Sternomastoid, IJV, Spinal accessory nerve removed à Effective but disabling

Invading structures also need removed

  • Therefore…. Major Reconstruction frequently needed
  • May be multi stage surgeries- distant flap reconstruction
  • Long, physically challenging procedures
  • Requires complex airway management- often ITU admissions post op
  • Can lead to unforeseen complications…
27
Q

what are some complications of head and neck surgery?

A

massive scarring in visible places - neck

skin grafts coming from hairy places may mean hair grows when skin is used ie in mouth

28
Q

describe the use of radiotherapy in head and neck cancer?

A

1st line alternative to surgery

spares disabling aspects of surgery, effectiveness comparisons to surgery vary between specific sites

can be given neo adjuvant or adjuvant

can be used alongside chemotherapy

needs planning appointments and potentially creation of facial mold

29
Q

what are the 2 main types pf chemotherapy used in head and neck cancer?

A

external beam therapy - high energy x ray beam delivered to tumour, tx plans spare normal tissue from exposure

brachytherapy - radioactive implants, can be used in combination with external beam therapy

newer treatments - intensity modulated therapy - more targeted to 3D structure

also has palliative role

30
Q

what are some side effects of head and neck radiotherpy?

A

dry mouth

change in taste

weight loss

eating difficulties

mucositis

dysphagia

radiation necrosis

infection

31
Q

what symptom management strategies can be used to help relieve radiotherapy side effects

A

May need periods of NG/PEG feeding as part of regime

Oral care

Oral hydration

Saliva management

Analgesia

Physiotherapy/SLT

32
Q

describe the use of chemotherapy in head and neck cancer?

A

can be used curatively as mono therapy with SCCs

can be given alongside surgery/radiotherapy

dependent on site, extent, spread

can be used as palliative treatment

32
Q

describe the use of chemotherapy in head and neck cancer?

A

can be used curatively as mono therapy with SCCs

can be given alongside surgery/radiotherapy

dependent on site, extent, spread

33
Q

give an example of when chemo radiotherapy is used

A

locally advanced SCC - respond better to cisplatin based chemo compared to Rxt alone

34
Q

name some commonly used chemotherapies in head anc neck cancer?

A

Cisplatin

Carboplatin

Docetaxel

Paciltaxel

35
Q

name some things that contribute to mouth problems in head and neck cancer

A
  • Smoking and Alcohol
  • Dry mouth- treatment, dehydration
  • Poor dental hygiene
  • Infection/bleeding from friable tumours
  • Trismus, restricting mouth opening
  • Poor nutrition
  • Underlying osteomyelitis
36
Q

how might mouth issues present?

A
  • Xerostomia (Dry Mouth)
  • Dribbling
  • Sticky, Viscous saliva
  • Mucositis
  • Infections- Thrush
37
Q

how is xerostomia managed?

A
  • Dental Hygeine
  • Adequate Hydration
  • General measures- sucking on fruit drops, pineapple chunks
  • Synthetic Saliva- little evidence of effectiveness, caution with ingredients
  • Simple Sialogogues- Salivix tablets
  • Pilocarpine tablets/eye drops- can cause sweating/GI issues
  • Tx Cause if possible
38
Q

what can be done to help excess dribbling?

A

Anti Muscarinic Drugs- TD/SL Hyoscine

Tricyclic Antidepressants

Botox injections

Surgery

Antimuscarinics- Can cause Delirium, Hysocine butylbromide/Glycopyrronium preferred

39
Q

what can be done t help with sticky, viscous saliva?

A

Frequent complication of Rxt

  • Hydration/oral care
  • Beat Blockers (BP mgmt. warning)
  • Mgmt of intraoral infection
  • Carbocisteine (little evidence)
40
Q

what can be doe to help with mucositis?

A

Usually follows Rxt/ chemo with (5FU, Methotrexate, cyclophosphamide)

  • Sucralfate
  • Cryotherapy (ice chips)
  • Oral analgesics/topical LA agents
  • Morphine
41
Q

what are the risk factors for a catastrophic bleed?

A
  • Previous Neck Rxt
  • Fungating Tumour
  • Post op- flap necrosis
  • Infection
  • Salivary fistula
  • Systemic factors- Malnutrition, cachexia, increased age
42
Q

what are the warning signs of a catastrophic bleed?

A
  • Minor bleed from wound, tracheostomy, or mouth
  • Pulsations from artery/trachy- false aneurysm formation
  • Sternal/High epigastric pain before rupture if carotid involved
  • Restless/irritable
43
Q

what is the management of a catastrophic bleed?

A
  • assess risk - ?preventive embolisation/stent/ligation
  • stop anticoagulation
  • may need to discuss with patient/family re risk
  • tx infection
  • planning is OP

acute management -

stay with patient and reassure, keep calm, pressure to site with dark towels, gentle suctioning

IV/IM midazolam 10mg 10-15 if necessary

44
Q

how are non-catastrophic bleeds managed?

A
  • Review medications- anticoags, anti plt, SSRIs, NSAIDS
  • Topical- silver nitrate sticks
  • Mouth- Sucralfate suspension
  • Wounds- Adrenaline 1/1000, Xylometazoline nasal spray
  • Tranexamic Acid- can be given IV or orally or topically

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