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13.03.14 Head and neck cancer

Classification
  • Primary
    • SCC (90%)
    • Salivary gland
    • Lymphoma
    • Thyroid
    • Melanoma
  • Secondary


History

  • Local symptoms
    • Pain
    • Odynophagia
      • Static/changing?
      • With solids/liquids?
      • Still able to eat meals?
    • Dysphagia
    • Voice change
    • Stridor (late sign)
    • Bleeding
    • Trismus
      • Unable to open jaw => Pterigoids, Bone
    • Otalgia
      • Referred pain from throat (glossopharyngeal, vagus)
    • Epistaxis
    • Nasal obstruction
    • Globus
      • Subjective feeling of a lump or foreign body in the throat
  • Regional symptoms
    • Neck lumps
  • Constitutional symptoms (often late sign)
    • LOW
    • LOA
    • Sweats
    • Bone pain


Risk factors

  • Smoking (x40) + Alcohol
    • Synergise: 50% more than additive effect
  • Previous radiation
  • Previous cancer
  • Wood dust
  • Heavy metals
  • HPV
    • From oral sex
    • Suppresses p53
  • Family history


Sites

  • Larynx
    • 95% SCC, 1% adenoma
    • 90% 5-year survival for stage 1
  • Nasopharynx
    • Southern China, EBV, Salted fish
    • Present with neck mass (already very big!) or unilateral middle ear effusion (GP: worrying sign => refer)
    • Treat with chemoradiotherapy - No surgical option
  • Hypopharynx (hyoid => cricoid cartilage)
    • SCC
    • Very poor prognosis
  • Oropharynx
    • >95% SCC; Some lymphoma
    • Tonsil/lateral pharyngeal wall most common
    • Poor prognosis: Often present with cervical mets




Anatomy

  • Supraglottis
    • Hyoid to apex of ventricle
  • Glottis
    • Apex of venticle to 1 cm below true folds
  • Subglottis
    • 1 cm below cords to cricoid cartilage


Laryngectomy

  • Can't breathe at all through mouth
    • cf Intubation, oxygen etc
  • Blom-Singer valve allows air into oesophagus + mouth


Notes
  • Rich blood + lymphatic supply => Rapid local spread
    • But rarely spread further
      • Lung > Bone > Liver if they do
      • Never brain, except melanoma
  • MRI is useless for lung as it moves
  • FNA is much better than open or core biopsy as there's less risk of seeding
  • NEVER remove a neck node in isolation without FNA/MRI for diagnosis/to check for others
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