Head and Neck CA

1. oral cavity

2. pharynx

3. larynx

4. nasal cavity and sinuses

5. salivary glands

what five categories are head and neck cancers divided into?

-lips

-buccal mucosa

-floor of mouth

-hard palate

-upper gingiva

-lower gingiva

-retromolar trigone

what sites are included in oral cavity cancers?

nasopharynx, oropharynx, hypopharynx

what sites are included in pharyngeal cancers?

-supraglottic (epiglottis)

-glottic (vocal cords)

-subglottic (space right below cords)

what sites are included in laryngeal cancers?

-parotid (Stenson's duct)

-submandibular (Wharton's duct)

-sublingual

-minor salivary glands located throughout submucosa

what sites are included in salivary gland cancers?

squamous cell carcinoma

what are more than 90% of head and neck cancers?

skin, thyroid, eye, brain malignancy, lymphoma

what does the phrase "head and neck cancer" generally exclude?

squamous epithelium which lines the surface of most head and neck mucosa

what does squamous cell carcinoma (SCCa) arise from?

squamous metaplasia to dysplasia to malignancy

what is the typical progression of mucosal changes leading to head and neck cancer?

keratin pearls

what is a microscopic hallmark of SCCa?

can be raised and exophytic (growth outward) or flat and ulcer like

how can head and neck cancers present on the mucosa?

oropharynx

what does cancer of the oral cavity NOT include?

-tonsil

-base of tongue

-soft palate

-posterior pharyngeal wall

what are the main sub-sites of the oropharynx?

-pyriform sinuses

-posterior surface of larynx

what are the main sub-sites of the hypopharynx?

-nose: floor, septum, turbinates, meatuses

-sinuses: maxillary, ethmoid, sphenoid, frontal

what sites are included in nasal cavity cancer?

3-5%

what percentage of all cancers does head and neck cancer account for?

65,630

in 2020, how many new cases of head and neck cancer were in the US?

14,500

in 2020, how many deaths due to head and neck cancer were in the US?

7,000

in 2020, how many of head and neck cancer were in the US out of the 65, 630 cases were HPV positive?

males (3:1)

is head and neck cancer more common in males or females?

whites/blacks

in which populations is head and neck cancer most common?

hispanic

In which populations is head and neck cancer less common?

age 40 and up

at what age does head and neck cancer most commonly occur?

-TOBACCO

-alcohol

-age (50+)

-ethnicity

-sun exposure (lip)

-radiation exposure

-industrial carcinogens

-EBV

-Betel Nut (Asia)

-HPV!

what are the risk factors for head and neck cancers?

tobacco use (includes marijuana and 2nd hand smoke)

what is up to 85% of head and neck SCCa related to?

salivary cancer

what kind of head and neck cancer does radiation exposure cause?

nasopharyngeal cancer

what kind of head and neck cancer does industrial carcinogens like wood dust and nickel cause?

nasopharyngeal cancer, Asia

what kind of head and neck cancer does Ebstein Barr Virus (EBV) cause and where is it much more common?

oropharyngeal cancers

what type of head and neck cancer has 70-80% of HPV positive cases in America?

tonsils and base of tongue

where is HPV positive oropharyngeal cancers most common?

strain 16

what is the most common HPV strain that causes head and neck cancer?

increased lymph node involvement but better overall prognosis

how does lymph node involvement affect prognosis in HPV-positive head and neck cancer?

ages 40-55

in what age group is HPV+ head and neck cancer most common?

neck mass, rarely pain

what is the most common presentation of p16+ head and neck cancer?

cervical cancer caused by HPV

what has incidences of oropharyngeal cancer caused by HPV recently surpassed?

p16+ squamous cell carcinoma

what is HPV-positive head and neck cancer commonly called?

squamous papilloma

what type of lesions does HPV cause that are generally benign in the head and neck?

subtypes 6 and 11

which HPV subtypes are normally associated with benign squamous papillomas?

-weight loss (20-30lbs)

-fatigue

-poor appetite

-night sweats

-hoarseness/dysphonia/aphonia

-non-healing sore/lesion in mouth

-throat or neck pain

-dysphagia/odynophagia

-neck mass or swelling

-unilateral ear fluid/hearing loss/otoalgia

-jaw pain or loose teeth

-airway obstruction: stridor

-nasal obstruction or persistent congestion

-frequent nose bleeds or unusual discharge

-unilateral serous otitis

-numbness/tingling in face or head

-facial nerve weakness

poor-fitting dentures, foul odor not explained by hygiene

what are the sx of head and neck cancer?

leukoplakia and erythroplakia

what are the two premalignant changes associated with head and neck cancers?

white plaque-like area on the oral cavity mucosa, does not rub off, sometimes sore

what is leukoplakia?

up to 25%

what percentage of leukoplakia is cancerous or precancerous?

biopsy and close evaluation/surgical excision

what should you do if you find leukoplakia on examination?

leukoplakia

what can be described as a sharply defined white area?

erythroplakia

what can be described as a sharply defined red area?

red patches or plaques that may bleed easily when scraped and are often raised/tender

what is erythroplakia?

up to 70%

what percentage of erythroplakia is cancerous or precancerous?

multiple biopsies, consider complete excision

what should be done if erythroplakia is found during examination?

oral candidiasis (oral thrush)

what is easily scraped off and bleeds when scraped off?

-oral corticosteroids

-antibiotics

-immunosuppressed

what are the causes of oral candidiasis (oral thrush)?

white areas, often on the tongue or buccal mucosa that tend to have fern or lacy pattern, often associated with pain/discomfort

what is lichen planus?

lichen planus

what is "chronic inflammation" that may be autoimmune and is often found on the tongue or buccal mucosa?

biopsy (RARE to be cancer, ~1%)

how is lichen planus diagnosed?

round, yellow-grey center, surrounded by red halos

what is aphthous ulcer (canker sore)?

symptomatic, "magic mouthwash" (Benadryl Maalox Lidocaine, BMX)

what is the tx for aphthous ulcer?

trauma/sharp tooth

what is the source of a traumatic ulcer?

remove/treat cause, symptomatic, biopsy if does not resolve

what is the tx for a traumatic ulcer?

geographic tongue

what is erythema migrans aka?

-map-like appearance of tongue due to loss of papillae

-NO PAIN

-benign, no tx needed

what is geographic tongue (erythema migrans)?

-lengthening of tongue

-NO PAIN

-easily stained (coffee, tobacco, pepto bismol)

-benign, no tx needed

what is hairy tongue?

wavy or rippled edges along sides of tongue

what is scalloped tongue?

-swelling/inflammation most commonly from TMJ

-anxiety

-OSA

what causes scalloped tongue?

-horizontal streak of buccal mucosa level with the biting plane

-very common finding, benign

what is linea alba?

chronic friction, biting, clenching

what causes linea alba?

-scar-like

-long standing irritation

-"traumatic fibroma"

what is a fibroma?

mucus-filled cyst often on inside of lower lip

what is a mucocele?

sialolithiasis

what is the term for a salivary stone?

tonsilloliths

what is the term for a tonsil stone?

-chronic inflammation

-allergies

-infection

-immune disorders

what are the causes of nasal polyps?

-corticosteroids: Flonase, Xhance (fluticasone)

-surgery

-biologics (new): Dupixent (Dupilumab), Xolair (Omalizumab), Nucala (Mepolizumab)

what is the tx for nasal polyps?

vocal cord nodules

what are "singer's nodes"?

-symmetric on free edges of vocal fords

-results of trauma

-teachers, actors, singers

-hoarseness, vocal fatigue

describe vocal cord nodules

-conservative or surgical

-speech therapy

what is the tx for vocal cord nodules?

surgical excision

what is the tx for vocal polyps?

granuloma

what is a contact ulcer?

-vocal abuse

-intubation

-GERD

what are the causes of contact ulcers?

-speech therapy

-reflux meds

-surgical excision

what is the tx for contact ulcers?

bilateral symmetrical swelling of the vocal cords

what is Reinke's edema?

chronic irritation due to vocal abuse, heavy smoking, chronic sinusitis, or GERD

what causes Reinke's edema?

annually

how often should you evaulate pts with risk factors for head and neck cancers?

refer to ENT for evaluation with laryngoscope, may represent initial sx of laryngeal cancer

what should you do if a adult pt has otoalgia with normal ear exam and why?

may be initial sign of nasopharyngeal cancer, should do a nasal endoscopy

why does any adult over age 40 with social risk factors who presents with unilateral serous effusion need an ENT referral?

CT

what is the imaging modality of choice to check for head and neck cancers?

US

what imaging is used for neck masses and thyroid gland and is best for children?

MRI

what imaging is used if suspected nerve involvement?

PET scan

what imaging is used when there is suspected advance/unknown primary for head and neck cancer?

neck masses, thyroid nodules, salivary masses

what is a fine-needle aspiration (FNA) used for?

oral cavity, nasal cavity, skin

what biopsies for head and neck cancers are done in office?

unknown primary (neck mass), direct laryngoscopy

when is surgical biopsy done?

-location of tumor

-extent of primary tumor

-lymph node status

-distant mets?

what does staging depend on?

T- tumor size, extent of invasion

N- nodes (size, #, location)

M- metastases (Y or N)

what is TNM?

-surgical excision (depends on tumor location/size)

-radiation

-chemotherapy

what are the tx options for head and neck cancers?

surgery or surgery plus radiation

what tx is used for smaller tumors?

combined radiation and chemotherapy

what tx is used for advanced tumors, organ preservation?

complete surgical excision (excisional biopsy)

what was the tx for head and neck cancers 20+ years ago?

incisional biopsy of tumor for pathologic diagnosis with/without neck dissection

what is the usual treatment now for head and neck cancers?

oral cancer and salivary cancer

what cancers have a better prognosis if complete excision is done?

removal of lymph nodes and surrounding tissues from the neck

what is neck dissection?

all tissue removed from jaw to collarbone, includes muscle, nerves, blood vessels, salivary glands

what is radical neck dissection?

removes lymph nodes but may spare other structures

what is a modified neck dissection?