Hoarseness and Head/neck cancer

Question 1

What is hoarseness?

Answer 1

Hoarseness is a subjective term and usually refers to a weak or altered voice. Dysphonia is similar but may also mean difficulty making sounds.

NB: any patient with unexplained hoarseness persisting >3 weeks requires investigation to exclude malignancy

Question 2

Which condition should be excluded in a patient presenting with hoarseness?

Answer 2

Hoarseness may be a feature of laryngeal obstruction - so can be a warning of impending airway obstruction.

Question 3

When can laryngeal obstruction occur?

Answer 3

Infections - acute epiglottitis, diphtheria, croup, laryngeal abscess.

Inflammation/oedema - airway burns, anaphylaxis, physical trauma, angio-oedema, hereditary angio-oedema.

Vocal cord immobility - laryngeal nerve palsy (depending on the position of the cords) or cricoarytenoid joint disease

Question 4

What are the signs of laryngeal obstruction?

Answer 4

Dyspnoea, stridor, wheeze, exertional dyspnoea, anxiety or signs of hypoxia.

Dysphagia or drooling.

Facial or oral oedema.

Question 5

What is the management of laryngeal obstruction?

Answer 5

Do not examine the throat or attempt distressing procedures; allow the patient to find the most comfortable position.

Obtain senior help/anaesthetist.

Emergency procedures such as tracheostomy may be needed.
Treat the specific cause where feasible.

Question 6

What are the risk factors for dysphonia?

Answer 6

Smoking (also the main risk factor for laryngeal carcinoma).
Excess alcohol consumption.
Gastro-oesophageal reflux.
Professional voice use - e.g., teachers, actors and singers.
Environment: poor acoustics, atmospheric irritants and low humidity.
Type 2 diabetes (neuropathy, poor glycaemic control)
Upper respiratory tract infection
Scarring: for example, after prolonged intubation
Age-related loss

Question 7

What are the causes of dysphonia?

Answer 7

Functional dysphonia
Infections such as acute laryngitis
Benign laryngeal conditions such as voice overuse and singer’s nodes
Malignancy such as laryngeal and lung cancer
Neurological conditions such as laryngeal nerve palsy , stroke, parkinson’s disease and ALS.
Systemic causes such as RA, TB, syphilis, GPA and hypothyroidism.

Question 8

What are the causes of laryngeal nerve palsy?

Answer 8

Laryngeal nerve palsy: this has various causes, including lung cancer, other tumours and thoracic aortic aneurysm.

Question 9

What are the causes of dysphonia in children?

Answer 9

Congenital - eg, laryngeal web, laryngomalacia, a congenital cyst.

Older children: vocal cord nodules, voice overuse, gastro-oesophageal reflux, papilloma (as for adults).

Very rarely, malignancy.

Question 10

What should you ask in the history of a patient presenting with hoarseness?

Answer 10

Symptoms - duration, onset and pattern of symptoms; check the patient’s meaning of ‘hoarseness’.
Precipitating factors - recent upper respiratory tract infection, change in voice use - e.g., shouting or singing.
Occupation, normal pattern of voice use, impact of voice problem on the patient’s life.
Other ENT symptoms - dysphagia, aspiration, throat or ear pain, nasal blockage.
Smoking, alcohol.
Reflux symptoms - eg, acid taste in the mouth in the morning, throat clearing, cough or ‘choking’ sensation, sensation of a lump in the throat.
Past medical history, particularly chest disease, thyroid surgery, neck trauma, and neurological symptoms.

Question 11

What should you examine in patients presenting with hoarseness?

Answer 11

Signs of airway obstruction

Laryngeal function - listen to the patient’s voice and assess cough and swallowing.

Examine the neck - scars, lymph nodes, thyroid gland. Localised tenderness suggests infection or abscess.

Any signs of an underlying cause - e.g., fever, hypothyroidism, tremor, weight loss.

Chest or neurological examination may be appropriate.

Inspection of the larynx - by indirect laryngoscopy and/or fibreoptic nasendoscopy.

Voice quality can be evaluated using the GRBAS (= Grade (severity), Roughness, Breathy voice, Asthenia (weakness) and Strain) assessment.

Question 12

What are the investigations done to assess a patient presenting with dysphonia?

Answer 12

Hoarseness persisting for >3 weeks requires investigation to exclude malignancy:
Carcinomas of larynx and lung must be considered, so CXR and/or laryngoscopy are indicated.
NICE guidance on suspected cancer states that for patients with hoarseness persisting for >3 weeks, particularly smokers aged ≥50 years and heavy drinkers:
-Arrange urgent CXR.
-Refer patients with positive findings urgently to a team specialising in the management of lung cancer.
-Refer patients with a negative finding urgently to a team specialising in head and neck cancer.

Question 13

What is the management of dysphonia?

Answer 13

Management depends on the specific cause but voice therapy and other non-surgical management is the first-line treatment for most benign lesions of the larynx.

Non-surgical management:

• Voice hygiene advice:
• Treat GORD (if suspected)
• Voice therapy
• Referral to a specialist voice clinic

Surgical management

• Laryngeal papilloma require surgery first-line
• Persistent nodules and polyps may require surgery
• Voice therapy is often used as an adjunct to surgery

Question 14

What is the voice hygiene advice given?

Answer 14

Adequate hydration.
Avoidance of vocal strain (shouting, throat clearing, excessive voice use).
Smoking cessation, alcohol reduction.
Reduction in caffeine intake

Question 15

What can be done to prevent dysphonia?

Answer 15

Prevention measures include:

• ‘Vocal hygiene’ measures.
• Recognising early warning signs of voice problems, such as an unintentional change in pitch, voice fatigue (the voice gets weaker with increasing use) and sore throat not due to infection.
• Biofeedback is sometimes a useful prophylactic measure for high-risk populations (e.g., call centre agents)

Question 16

What is head and neck cancer?

Answer 16

Squamous cell carcinoma (SCC) represents more than 90% of all head and neck cancers.

The majority of cancers of the head and neck arise from the surface layers of the upper aerodigestive tract (UAT).

Question 17

What is the classification of head and neck cancers?

Answer 17

Oral cavity cancers
Cancers of the pharynx
Laryngeal cancer

Question 18

What is included in oral cavity cancers?

Answer 18

Oral cavity cancers, which include tumours of the buccal mucosa, retromolar triangle, alveolus, hard palate, anterior two-thirds of the tongue, floor of the mouth, and the mucosal surface of the lip.

Question 19

What is included in pharyngeal cancers?

Answer 19

Cancers of the oropharynx, which include tumours of the base of the tongue, the tonsil and the undersurface of the soft palate.

Cancers of the hypopharynx (bottom part of the throat), which include tumours of the postcricoid area, pyriform sinus and the posterior pharyngeal wall.

Cancers of the nasopharynx (behind the nose).

Question 20

What are the risk factors for head and neck cancers?

Answer 20

Heavy smoking, heavy alcohol consumption (the two act synergistically) and poor dentition are the principal risk factors in western countries.

Poor diet

Genetic factors

HPV-16

Excessive sunlight exposure

Question 21

What are the differentials for head and neck cancers?

Answer 21

Other causes of presenting features, including persistent hoarseness, sore throat, cough, earache, neck lumps and mouth lesions.

Question 22

When should you refer a patient to rule out laryngeal cancer?

Answer 22

Refer any patient who presents with symptoms suggestive of head and neck or thyroid cancer to an appropriate specialist or the neck lump clinic, depending on local arrangements.

For referrals for patients with possible head and neck cancer, NICE recommends:
Laryngeal cancer: consider a suspected cancer pathway referral (for an appointment within two weeks) for laryngeal cancer in people aged 45 and over with:
-Persistent unexplained hoarseness; or
-An unexplained lump in the neck.

Question 23

When should you refer a patient to rule out oral cancer?

Answer 23

Oral cancer: consider a suspected cancer pathway referral for oral cancer in people with either:

• Unexplained ulceration in the oral cavity lasting for more than three weeks,
• A persistent and unexplained lump in the neck.
• A red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia; or
• A lump on the lip or in the oral cavity consistent with oral cancer.

Question 24

When should you refer a patient to rule out thyroid cancer?

Answer 24

Thyroid cancer: consider a suspected cancer pathway referral for thyroid cancer in people with an unexplained thyroid lump.

Question 25

Which investigations are done to assess suspected head and neck cancers?

Answer 25

With the exception of persistent hoarseness (urgent CXR to decide where to refer), investigations in primary care are not recommended, as they can delay referral.

LFTs may raise suspicions of abdominal metastases (in which case, a CT scan of the abdomen is warranted).

CXR will identify pulmonary metastases. An urgent CXR is also warranted in individuals who have an unexplained change in the quality of their voice (hoarse, husky or quiet) for more than three weeks, particularly in smokers and heavy drinkers.

Other investigations will include a baseline and monitoring of renal function tests, electrolytes, TFTs and pulmonary function tests.

Question 26

How do you diagnose head and neck cancers?

Answer 26

Diagnosis and staging of head and neck malignancy includes thorough clinical examination by an experienced clinician, fibre-optic endoscopy, fine-needle aspiration (or biopsy) of any neck masses, followed by further examination under anaesthetic, with additional biopsies if needed.

Biopsy is the only way to establish the diagnosis. Fine-needle aspiration cytology should be used in the investigation of head and neck masses. Lesions that are harder to reach may require an endoscopy.

Positron emission tomography (PET) using radioisotope fluorodeoxyglucose (18 F) (FDG-PET) should be performed as the next investigation of choice in patients presenting with:

• Cervical lymph node metastases, where CT or MRI does not demonstrate an obvious primary tumour.
• Suspected recurrent head and neck cancer, where CT/MRI does not demonstrate a clear-cut recurrence.

Direct pharyngolaryngoscopy and CXR are recommended for patients with SCC of the head and neck, while oesophagoscopy and bronchoscopy might be reserved for patients with associated symptoms.

Question 27

How do you stage head and neck cancers?

Answer 27

CT or MRI scanning of the primary tumour site should be performed to help define the spread of the tumour and to stage the neck for nodal metastatic disease.
MRI should be used in preference to CT:
-For staging of oropharyngeal and oral tumours.
-For assessment of laryngeal cartilage invasion.
-For the assessment of tumour involvement of the skull base, orbit, cervical spine or neurovascular structures.

All patients with head and neck cancer should have a CT of the thorax.

The ‘tumour, nodes, metastases’ (TNM) staging system is used for staging head and neck cancers. With increasing depth of invasion of the primary tumour, the risk of nodal metastases increases and survival decreases.

Question 28

What is the management of head and neck cancers?

Answer 28

Early-stage cancers are usually treated either by surgery or by radiotherapy. More advanced tumour usually require both surgery and chemoradiotherapy.

Plastic or reconstructive surgery and specialised dentistry are often needed.

Patients need considerable help and support with nutrition and communication, both during and after primary treatment.

Cancers of the head and neck should be managed by specialists as part of a multidisciplinary team.

Patients should be seen frequently and regularly within the first three years following treatment.

Patients with head and neck cancer with dysphagia should receive appropriate speech and language therapy to optimise swallowing function and reduce the risk of aspiration.

In patients with metastatic or locally recurrent head and neck cancer, treatment is usually palliative.

Question 29

How can a patient prevent head and neck cancer?

Answer 29

The risk of developing head and neck cancer can be reduced by:

• Not smoking or chewing tobacco.
• Limiting alcohol consumption.
• Increasing the intake of fruit and vegetables (especially tomatoes), olive oil and fish oils.
• Reducing the intake of red meat, fried food and fat.

High-risk patients should be encouraged to visit the dentist regularly.