Head & Neck Flashcards
what are the areas affected by head and neck cancer?
Oropharyngeal tract, nasal sinuses, nasal cavity, oral cavity, tongue, salivary glands, larynx, pharynx
what is the most common head and neck cancer?
tongue
which head and neck cancers have the best and worse chance of survival?
Best chance of survival – salivary gland
Worst chance of survival - Hypopharyngeal
what is the peak age of onset for head and neck cancer?
70-74 years old
what are some risk factors for head and neck cancer?
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
describe some features of HPV positive oropharyngeal cancer?
73% of oropharyngeal cancer cases are HPV +ve
larynx and oral also
has better outcomes than non-HPV related cancer
describe some features of paranasal sinus/nasal cavity cancer
- Constant nasal congestion
- Headache
- Chronic infections
- Facial Swelling
- Epistaxis Eye/dental pain
describe some features of oral cavity cancer
- Leuko/Erythroplakia
- Jaw swelling
- Unexplained ulceration
- Persistent neck lumps
describe some features of salivary gland cancer?
- Chin/jawbone swelling
- Numbness/paralysis facial muscles
- Facial/chin/neck pain
describe some features of pharynx cancer
- Dysphagia
- Odonyphagia
- Neck/throat pain
- Oral pain
- Ear pain/tinnitus
describe some features of laryngeal cancer
- Persistant unexplained hoarseness
- Odonyphagia
- Neck lumps
- Airway obstruction
- Dysphagia
- Ear pain
what are the NICE guidelines on 2ww for head and neck cancer?
- Persistent unexplained neck lump
- Persistent unexplained hoarseness
- Unexplained oral ulceration >3 weeks duration
- Lip/oral cavity lump >3 weeks duration
- Erythro/Leukoplakia
what are some red flag symptoms that may also require urgent referral?
- Dysphagia
- Odonyphagia
- Cough
- Ipislateral Otalgia
- Unilateral Nasal obstruction/epistaxis
- Sore throat
- Misaligned teeth
- Haemoptysis
- Sensation of lump in throat
what is lichen planus?
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
what are apthous ulcers aka Canker lesions
- 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
what is erythroplakia?
- 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
what is leucoplakia?
- White patch or plaque on oral mucosa
- DDx- cis, nicotine stomatitis, candida, habitual cheek biting, SLE
- If no clear cause-investigate and tx
what are some important things to look for on examination of a pt with suspected head and neck cancer?
- General- Cachexia, malnutrition, trismus, poor dentition
- Intraoral- Looking for lesions, may be more than one
- Lymph Node exam- Secondary spread
what are some key investigations to be done for head and neck cancer?
- 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
what is the most common histological head and neck cancer?
squamous cell carcinoma
other types - less common =
lymphoma, blastomas, sarcomas, neuroendocrine tumours
what is P16 Immunohistochemical expression?
considered a surrogate marker for HPV infection - overexpression correlates with good prognosis
what imaging is done for head and neck cancer and what is being looked for?
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
how is head and neck cancer staged?
TNM staging
varies between site of cancer
how does head and neck cancer spread?
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
how is head and neck cancer managed?
usually a combination of surgery, radiotherapy, chemotherapy - dependent on site, spread and physical status of the patient
extensive MDT
describe surgery for head and neck cancer
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…
what are some complications of head and neck surgery?
massive scarring in visible places - neck
skin grafts coming from hairy places may mean hair grows when skin is used ie in mouth
describe the use of radiotherapy in head and neck cancer?
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
what are the 2 main types pf chemotherapy used in head and neck cancer?
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
what are some side effects of head and neck radiotherpy?
dry mouth
change in taste
weight loss
eating difficulties
mucositis
dysphagia
radiation necrosis
infection
what symptom management strategies can be used to help relieve radiotherapy side effects
May need periods of NG/PEG feeding as part of regime
Oral care
Oral hydration
Saliva management
Analgesia
Physiotherapy/SLT
describe the use of chemotherapy in head and neck cancer?
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
describe the use of chemotherapy in head and neck cancer?
can be used curatively as mono therapy with SCCs
can be given alongside surgery/radiotherapy
dependent on site, extent, spread
give an example of when chemo radiotherapy is used
locally advanced SCC - respond better to cisplatin based chemo compared to Rxt alone
name some commonly used chemotherapies in head anc neck cancer?
Cisplatin
Carboplatin
Docetaxel
Paciltaxel
name some things that contribute to mouth problems in head and neck cancer
- Smoking and Alcohol
- Dry mouth- treatment, dehydration
- Poor dental hygiene
- Infection/bleeding from friable tumours
- Trismus, restricting mouth opening
- Poor nutrition
- Underlying osteomyelitis
how might mouth issues present?
- Xerostomia (Dry Mouth)
- Dribbling
- Sticky, Viscous saliva
- Mucositis
- Infections- Thrush
how is xerostomia managed?
- 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
what can be done to help excess dribbling?
Anti Muscarinic Drugs- TD/SL Hyoscine
Tricyclic Antidepressants
Botox injections
Surgery
Antimuscarinics- Can cause Delirium, Hysocine butylbromide/Glycopyrronium preferred
what can be done t help with sticky, viscous saliva?
Frequent complication of Rxt
- Hydration/oral care
- Beat Blockers (BP mgmt. warning)
- Mgmt of intraoral infection
- Carbocisteine (little evidence)
what can be doe to help with mucositis?
Usually follows Rxt/ chemo with (5FU, Methotrexate, cyclophosphamide)
- Sucralfate
- Cryotherapy (ice chips)
- Oral analgesics/topical LA agents
- Morphine
what are the risk factors for a catastrophic bleed?
- Previous Neck Rxt
- Fungating Tumour
- Post op- flap necrosis
- Infection
- Salivary fistula
- Systemic factors- Malnutrition, cachexia, increased age
what are the warning signs of a catastrophic bleed?
- 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
what is the management of a catastrophic bleed?
- 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
how are non-catastrophic bleeds managed?
- 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
