Head + Neck Carcinoma Flashcards
What are differentials for a hoarse voice (dysphonia)?
- allergies and chemical/environmental irritants
- direct trauma
- infections
- laryngopharyngeal or gastrooesophageal reflux
- medications
- vocal abuse
- benign vocal fold lesions
- dysplasia and squamous cell carcinoma
- age-related vocal atrophy
- MS, myasthenia gravis, Parkinsons, stroke
- acromegaly, amyloidosis, hypothyroidisim
- inflammatory arthritis, lupus, sarcoidosis
What is the anterior triangle?
- lower border of mandible
- midline of neck
- anterior border of SCM
What is the posterior triangle?
- posterior border of SCM
- anterior border trapezius
- middle part of clavicle
What are the common types of head and neck cancer?
- 90% arise from squamous epithelial mucosa
- “squamous cell carcinoma” (HNSCC)
- features dependent on anatomical site
Other types include salivary (adenocarcinoma), lymphoma, melanoma and sarcoma.
What are the (3) main risk factors for HNSCC?
- smoking → inc x7.5
- alcohol XS → inc x6
- alcohol + smoking → inc x38
-
HPV
- HPV 16 associated w/ oropharyngeal cancer
- very common infection
- almost always cleared w/ no adverse effect
- presents in younger pts → more aggressive, increasing incidence, more amenable to treatment + vaccine available
What is the mode of spread of HNSCC?
- different to other cancers
- metastasises to cervical lymph nodes first
- hard, fixed neck lump
- still curable
- neck radiotherapy
- surgical lymph node clearance (“neck dissection”)
- distant mets usually to lung
What are the relevant investigations for suspected HNSCC?
- referral to 2-week-wait ENT clinic
- thorough ENT history + examination
- flexible nasolaryngoscopy
- CT neck + chest
- some tumours need MRI to assess extent
- lymph nodes → FNA +/- ultrasound guidance
- core or exicision biopsy risks seeding of SCC
- usually need GA to biopsy primary tumour via panendoscopy
Clinical features are dependent on the anatomical subsites.
What are the anatomical subsites for HNSCC?
How does nasopharyngeal cancer present?
- presents late → v poor diagnosis (50% 5 year survival)
- unilateral middle ear effusion
- epistaxis
- nasal blockage
- common in south china (salt fish diet + genetic risks)
How does oropharyngeal cancer present?
- usually tonsillar - beware asymmetric tonsils
- may be SCC or lymphoma
- consider tonsillectomy
- persistent pain in throat / ear
- feelings of lump in throat
- dysphagia
How does hypopharyngeal cancer present?
- often presents late
- 50% w/ nodal metastases
- due to distensability of the hypopharynx
- 5 year survival <40%
- throat/ear pain
- dysphagia
- dysphonia (late sign)
When should you suspect oral cavity cancer?
- cigar smoking + chewing tobacco/betel nut
- poor oral hygeine
- non-healing ulcer, lump or lesion
- refer if >14 days
- not always painful
Treated by maxfax - but keep an eye out!
How does parotid cancer present?
- gradually growing parotid lump
- usually always benign
- facial palsy very suspicious
- symptoms rare (late)
- trismus
- pain
- dysphagia
All parotid lumps need referral!
How does laryngeal cancer present?
- most common tumour site
- persistent unexplained hoarseness → 2-week-wait referral
- dysphagia
- throat pain
- otalgia
- cough
What causes vocal cord palsy and what are the investigations?
- recurrent laryngeal nerve dysfunction
- course of RLN - longer on right than left
- caused by: trauma, neoplasm, stroke
- investigation → nasoendoscopy, imaging whole course of RLN
Treatment option → thyroplasty, the affected cord is medialised with silastic
How would a patient communicate after laryngectomy?
- ‘speaking valve’ gold standard of care
- allows air from trachea to neopharynx
- difficult to learn
- frequent care required
- SALT input vital
Other options: electrolarynx, oesophageal speech, written communication
