Chapter 084. Head and Neck Cancer (Part 2)

Clinical Presentation and Differential Diagnosis Most head and neck cancers occur after age 50, although these cancers can appear in younger patients, including those without known risk factors. The manifestations vary according to the stage and primary site of the tumor. Patients with nonspecific signs and symptoms in the head and neck area should be evaluated with a thorough otolaryngologic exam, particularly if symptoms persist longer than 2–4 weeks.Cancer of the nasopharynx typically does not cause early symptoms. However, on occasion it may cause unilateral serous otitis media due to obstruction of the eustachian tube, unilateral or bilateral nasal...
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Chapter 084. Head and Neck Cancer (Part 2) Chapter 084. Head and Neck Cancer (Part 2) Clinical Presentation and Differential Diagnosis Most head and neck cancers occur after age 50, although these cancers canappear in younger patients, including those without known risk factors. Themanifestations vary according to the stage and primary site of the tumor. Patientswith nonspecific signs and symptoms in the head and neck area should beevaluated with a thorough otolaryngologic exam, particularly if symptoms persistlonger than 2–4 weeks. Cancer of the nasopharynx typically does not cause early symptoms.However, on occasion it may cause unilateral serous otitis media due toobstruction of the eustachian tube, unilateral or bilateral nasal obstruction, orepistaxis. Advanced nasopharyngeal carcinoma causes neuropathies of the cranialnerves. Carcinomas of the oral cavity present as nonhealing ulcers, changes in thefit of dentures, or painful lesions. Tumors of the tongue base or oropharynx cancause decreased tongue mobility and alterations in speech. Cancers of theoropharynx or hypopharynx rarely cause early symptoms, but they may cause sorethroat and/or otalgia. Hoarseness may be an early symptom of laryngeal cancer, and persistenthoarseness requires referral to a specialist for indirect laryngoscopy and/orradiographic studies. If a head and neck lesion treated initially with antibioticsdoes not resolve in a short period, further workup is indicated; to simply continuethe antibiotic treatment may be to lose the chance of early diagnosis of amalignancy. Advanced head and neck cancers in any location can cause severe pain,otalgia, airway obstruction, cranial neuropathies, trismus, odynophagia, dysphagia,decreased tongue mobility, fistulas, skin involvement, and massive cervicallymphadenopathy, which may be unilateral or bilateral. Some patients haveenlarged lymph nodes even though no primary lesion can be detected byendoscopy or biopsy; these patients are considered to have carcinoma of unknownprimary (Fig. 84-1). If the enlarged nodes are located in the upper neck and thetumor cells are of squamous cell histology, the malignancy probably arose from amucosal surface in the head or neck. Tumor cells in supraclavicular lymph nodesmay also arise from a primary site in the chest or abdomen. Figure 84-1 Evaluation of a patient with cervical adenopathy without a primarymucosal lesion; a diagnostic workup. FNA, fine-needle aspiration. The physical examination should include inspection of all visible mucosalsurfaces and palpation of the floor of mouth and tongue and of the neck. Inaddition to tumors themselves, leukoplakia (a white mucosal patch) orerythroplakia (a red mucosal patch) may be observed; these premalignant lesionscan represent hyperplasia, dysplasia, or carcinoma in situ. All visible or palpablelesions should be biopsied. Further examination should be performed by aspecialist. Additional staging procedures include CT of the head and neck toidentify the extent of the disease. Patients with lymph node involvement shouldhave chest radiography and a bone scan to screen for distant metastases. Thedefinitive staging procedure is an endoscopic examination under anesthesia, whichmay include laryngoscopy, esophagoscopy, and bronchoscopy; during thisprocedure, multiple biopsy samples are obtained to establish a primary diagnosis,define the extent of primary disease, and identify any additional premalignantlesions or second primaries. Head and neck tumors are classified according to the TNM system of theAmerican Joint Committee on Cancer. This classification varies according to thespecific anatomic subsite (Tables 84-1 and 84-2). Distant metastases are found inincrease the number of patients with clinically detectable distant metastases in thefuture.