Head + Neck Carcinoma

Question 1

What are differentials for a hoarse voice (dysphonia)?

Answer 1

• 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

Question 2

What is the anterior triangle?

Answer 2

• lower border of mandible
• midline of neck
• anterior border of SCM

Question 3

What is the posterior triangle?

Answer 3

• posterior border of SCM
• anterior border trapezius
• middle part of clavicle

Question 4

What are the common types of head and neck cancer?

Answer 4

• 90% arise from squamous epithelial mucosa
  
  • “squamous cell carcinoma” (HNSCC)
  • features dependent on anatomical site

Other types include salivary (adenocarcinoma), lymphoma, melanoma and sarcoma.

Question 5

What are the (3) main risk factors for HNSCC?

Answer 5

• 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

Question 6

What is the mode of spread of HNSCC?

Answer 6

• 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

Question 7

What are the relevant investigations for suspected HNSCC?

Answer 7

• 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

Question 8

Clinical features are dependent on the anatomical subsites.

What are the anatomical subsites for HNSCC?

Answer 8

Question 9

How does nasopharyngeal cancer present?

Answer 9

• 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)

Question 10

How does oropharyngeal cancer present?

Answer 10

• usually tonsillar - beware asymmetric tonsils
• may be SCC or lymphoma
• consider tonsillectomy
• persistent pain in throat / ear
• feelings of lump in throat
• dysphagia

Question 11

How does hypopharyngeal cancer present?

Answer 11

• often presents late
• 50% w/ nodal metastases
• due to distensability of the hypopharynx
• 5 year survival <40%
• throat/ear pain
• dysphagia
• dysphonia (late sign)

Question 12

When should you suspect oral cavity cancer?

Answer 12

• 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!

Question 13

How does parotid cancer present?

Answer 13

• gradually growing parotid lump
• usually always benign
• facial palsy very suspicious
• symptoms rare (late)
  
  • trismus
  • pain
  • dysphagia

All parotid lumps need referral!

Question 14

How does laryngeal cancer present?

Answer 14

• most common tumour site
• persistent unexplained hoarseness → 2-week-wait referral
• dysphagia
• throat pain
• otalgia
• cough

Question 15

What causes vocal cord palsy and what are the investigations?

Answer 15

• 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

Question 16

What causes bilateral vocal cord palsy?

Answer 16

• airway emergency
• cords sit together, near midline
• stridulous patient
• most common causes → large neck tumours, thyroid surgery, idiopathic
• may need tracheostomy
• may resolve w/ time

Question 17

What is the treatment for head + neck cancer?

Answer 17

• primarily surgical excision or radiotherapy
• chemotherapy as adjuvant treatment
• complex treatment decisions
• all cases discussed in head + neck MDT
• try to treat using consensus decision

Question 18

What is discussed at the head and neck MDT?

Answer 18

• case history
• imaging
• histology
• treatment options
• social factors

Shown to improve outcomes in complex cases

Question 19

Morbidity is significant regardless of treatment modality and there is often need for radiotherapy and surgery. Surgery depends on the site and extent of the tumour.

What worsening symptoms can radiotherapy result in?

Answer 19

• dry mouth (xerostomia)
• dysphagia
• dysphonia
• pain

Question 20

What do the speech and language therapy teams provide?

Answer 20

• pre-treatment assessment + counselling
• alleviation of morbidity → esp swallowing + speech
• specialised treatments after laryngectomy

Question 21

What is a laryngectomy?

Answer 21

• removal of the larynx +/- local lymph nodes
• fashioning of new pharynx (neopharynx)
• permanent laryngeal stoma
• significant consequences
  
  • speech
  • swallowing
  • psychological

Question 22

How would a patient communicate after laryngectomy?

Answer 22

• ‘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