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Head and neck cancers: What to look out for

Symptoms in such cancers may be minimal or absent initially, so delays in diagnosis and treatment should be avoided

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Lump in the neck from an unknown primary - later found to be from an NPC.

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Endoscopic view of a laryngeal cancer affecting the vocal fold. The patient presented with hoarseness.

HEAD and neck cancers (HNC) comprise a group of malignant tumours from a variety of sites and sub-sites that include the ear, nose and sinuses, throat (including both the upper gullet and voice box), mouth, tongue, upper and lower jaws, teeth, thyroid gland, salivary glands and the overlying skin. By definition, cancers of the brain, spinal cord, vertebral column and eyeball are not part of the categorisation.

HNCs contribute to about 12 per cent of all cancers in the world and are the fifth most common cause of cancer-related death worldwide.

They affect more male adults partly because of the higher likelihood of smoking and alcohol intake in this group although this is not always the case, for e.g. thyroid cancers affect more women. Genetic factors can increase the risk in some of these malignancies and are seen more commonly in thyroid cancer and nasopharyngeal cancer (NPC) - the commonest head and neck cancer in Singapore. HNCs are rarely seen in children and comprise most commonly of cancers of the lymph nodes/glands (known as lymphomas) although other cancer types do exist.

Sites, symptoms and signs

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Symptoms and signs of cancer may not always be indicative of a particular site of cancer. As such, a detailed history of the nature of the patient's complaint/s with associated problems should be obtained. For example, ear pain does not necessarily indicate an ear pathology - it can be the harbinger for throat, tongue base or tonsillar malignancy.

Consequently, symptoms that do not improve within a fortnight despite primary care intervention should warrant referral to an Ear, Nose and Throat/Head and Neck Surgeon. Among the more common symptoms and signs - by no means exhaustive for the multiple ways the complex myriad of HNCs present and progress - are:

Aural (Ear) Symptoms

Malignant tumours of the middle and inner ear are very rare. Hearing loss, tinnitus (ringing in the ear), ear blockage/ fullness, pain and bleeding from the ear may very occasionally be signs of sinister ear pathology. Chronic discharge - foul smelling or clear and/or odourless are also rare signs of ear cancer. Facial weakness and taste disturbances can also be due to ear disease.

The external ear is however an area exposed to sunlight, making it more susceptible to skin cancers - more common in fairer skinned individuals. The presence of moles and other skin blemishes that bleed, itch, change colour or grow should be taken seriously and referred for specialist attention.

Nasopharyngeal cancer presents fairly often as hearing loss or muffled hearing, or a feeling of ear blockage. This is due to the physical occlusion of the Eustachian tube, which connects the middle ear to the back of the nose. This symptom in an adult (southern Chinese in particular) should be taken seriously. Ear pain without ear pathology especially when swallowing can be associated with tumours of the throat (pharynx), tongue base and tonsil. Referral for specialist examination in recalcitrant or high-risk groups (heavy smokers and drinkers) is strongly recommended.

Nasal and eye symptoms

Nasal blockage/congestion, pain and bleeding (epistaxis) can be symptoms associated with sino-nasal cancer. Some cancers however present fairly insidiously, grow slowly and asymptomatically. Pain therefore is not a feature that is always present. The loss of smell for no apparent reason can also be a feature of a malignant process.

Some tumours of the nose are benign but have the potential for malignant transformation (e.g. inverted papilloma). These are usually always single-sided and may appear as nasal polyps. Single-sided symptoms should be treated with caution and referred to a specialist for further investigation.

Occasionally, patients may present with a watery eye. The tear flow system and drainage via the nose is blocked in these cases and may be secondary to a malignancy affecting the tear duct within the nose.

Advanced sino-nasal cancers can invade the orbit, shifting or pushing out the eyeball (globe) and compressing the optic nerve resulting in visual loss. As with the ear, the tip of the nose is exposed to the sun and is susceptible to ultra-violet damage changes in pigmentation, moles and skin cancer.

Oral symptoms

Cancers of the oral cavity are usually associated with smoking, chewing tobacco, areca nut (betel) and alcohol. They can initially present as white patches - often painless. Painful ulcers such as aphthous ulcers are benign and hence pain as a symptom is not always indicative of malignancy. White patches (leukoplakia) and variants of leukoplakia can be pre-malignant conditions and should be monitored and biopsied accordingly. Swellings of the roof of the mouth (hard palate) which are not congenital or genetic (e.g. torus palatinus) may be minor salivary gland malignancies.

These cancers can appear anywhere in the oral cavity too. Tongue tumours present most often on the side of the tongue where they may be mistaken for benign ulcers or traumatic ulcers from accidental injury from teeth.

A thorough history is essential in establishing the correct diagnosis. Swellings of the gums, jaw and loosening of teeth for no obvious dental reason should raise suspicion and instigate further specialist investigation. Lip cancer presents as an ulcer of the lip. It is either related to sun-exposure (upper lip) in mainly fair-skinned races, i.e. Caucasians, or the lower lip due to pipe smoking (where the pipe stem rests).

Throat symptoms

The region of the upper aerodigestive tract beyond the hard palate down to the gullet (pharynx) and voice box (larynx) consists of several structures. These include the tonsils, soft palate, tongue base, larynx and lower pharynx. Pain, difficulty swallowing, sensation of a lump in the throat (globus), bleeding, referred pain to the ear when eating or drinking, coughing, hoarseness and noisy and/or effortful breathing when awake are all features of cancers in these areas.

Swelling of the tonsil (asymmetrically) and ulcers should be referred on quickly. Voice changes for more than a fortnight with no obvious precipitating factor merit specialist review. As with most other cancers of the upper aero-digestive tract, smoking and alcohol intake is an important risk factor.

Human papilloma virus (HPV)-related tonsillar cancer is reaching almost "epidemic" levels in the western world. Unlike before, when tonsillar tumours were seen in heavy drinkers and smokers (often older males), the population presenting with HPV-related oropharyngeal (mainly tonsillar) cancer are younger (early 30s onwards), of both genders and do not always smoke or drink. Presentation can be as a unilateral swelling - painful or painless, ulcers and a sore throat among others.

Face and neck symptoms

Head and neck cancers mainly spread via the lymphatics to the nodes in the neck. They rarely spread to lung, bone or the brain unless quite advanced. Neck swelling and pain when not easily explained by musculoskeletal overuse or injury should be assessed for malignancy.

Midline swellings in the lower neck are usually related to the thyroid gland. Cancer of the thyroid can affect swallowing, breathing, air intake during exercise, voice and swallow. A solitary lump in the side of the neck (small or large) may be a sign of the spread of cancer from a separate site of the upper aerodigestive tract.

Common cancers that spread with little or no sign or symptom in their primary (original) location are from the nasopharynx, tongue base and tonsil ('the unknown primary'). Swellings of the neck related to the angle of the lower jaw and side of the face may be cancers of the salivary glands (submandibular and parotid). Pain is not a common feature. More advanced cancers can affect the nerve that moves the face resulting in facial weakness (paresis).

Summary

Cancers of the upper aerodigestive tract and head and neck are complex and present in a variety of ways. Symptoms may be minimal and on occasion absent until spread to the neck or adjacent structures occurs.

Referral for specialist opinion in cases where symptoms exist, persist or worsen beyond a reasonable amount of time (a fortnight or so) is important to avoid unnecessary delay in diagnosis and treatment of these cancers.

This series is produced in collaboration with Singapore Medical Specialists Centre.