Makindo Medical Notes

Head and neck cancers are a diverse group of malignant tumours arising in or around the throat, larynx, nose, sinuses, and mouth. 👉 Most are squamous cell carcinomas from mucosal lining. ⚠️ They carry high morbidity due to effects on speech, swallowing, and breathing.

🌬️ Strongly linked to tobacco + alcohol use, but HPV-related cancers are increasing in younger adults.

📊 Epidemiology

• ~4% of all cancers worldwide.
• 🌍 Incidence: ~650,000 new cases/year.
• ⚰️ Mortality: ~330,000 deaths/year.
• 👨 More common in men (~2:1 ratio).
• 📈 Usually >50 years, but HPV-driven cancers rising in younger groups.
• 🌏 Higher rates in SE Asia (betel nut chewing, tobacco use).

⚠️ Risk Factors

• 🚬 Tobacco (smoking & smokeless).
• 🍷 Alcohol (synergistic with smoking).
• 🦠 HPV (esp. type 16): linked to oropharyngeal cancers; better prognosis.
• 🦠 EBV: associated with nasopharyngeal carcinoma.
• 👴 Age >50, 👨 male gender.
• 🥗 Poor diet (low fruit/veg).
• 🏭 Occupational exposure (wood dust, asbestos, chemicals).
• ☢️ Prior head/neck radiation.
• 🧬 Genetic syndromes (Fanconi anaemia, dyskeratosis congenita).
• 🔴 Premalignant lesions: leukoplakia, erythroplakia.
• 🌰 Betel nut chewing (oral cancers, Asia).

🔬 Pathology

• 💢 Histology: - SCC (>90%) - Adenocarcinoma (salivary) - Lymphoma - Sarcoma - Mucosal melanoma
• 📈 Spread: - Local invasion → adjacent tissues - Lymphatic → cervical nodes (very common) - Perineural → along cranial nerves - Haematogenous (less common) → lungs, liver, bone

📍 Anatomical Sites

• 👄 Oral cavity (lips, tongue, floor, palate).
• 🧑‍⚕️ Pharynx: naso-, oro-, hypopharynx.
• 🎤 Larynx: supraglottis, glottis, subglottis.
• 👃 Nose & sinuses.
• 💧 Salivary glands (parotid, submandibular, sublingual).
• 👂 Ear (external canal, middle ear).

🩺 Clinical Presentation

• 🧩 Neck mass (cervical lymphadenopathy).
• 😷 Persistent sore throat / hoarseness.
• 🍽️ Dysphagia, odynophagia.
• 🩸 Non-healing oral ulcer, leukoplakia, erythroplakia.
• 👃 Nasal obstruction/epistaxis.
• 👂 Otalgia (referred pain).
• 😬 Trismus.
• ⚖️ Weight loss, anorexia.
• 😮‍💨 Breathing difficulty (laryngeal tumours).
• 😶 Facial numbness/paralysis (perineural spread).

🔍 Diagnosis & Investigations

• 👨‍⚕️ Clinical: thorough ENT exam, cranial nerve assessment.
• 🧪 Bloods: FBC, renal/liver function, coagulation.
• 🖼️ Imaging: - CT neck + chest (extent, nodes, mets) - MRI (soft tissue, perineural spread) - PET-CT (distant mets, synchronous tumours)
• 🔎 Endoscopy: nasoendoscopy, panendoscopy with biopsy.
• 💉 Biopsy: FNAC (nodes), incisional/excisional (lesion).
• 🧬 Histopathology: tumour type, grade, HPV/EBV testing.

📈 Staging (TNM)

• 📏 T = primary tumour size/extent.
• 🧩 N = nodal involvement.
• 🌍 M = metastases.

Staging drives prognosis & treatment planning.

🛠️ Management Principles

🎯 Aim = cure when possible, while preserving function (speech, swallow, appearance). Always delivered in a multidisciplinary team (ENT, oncology, radiology, dietetics, speech therapy, palliative care).

• 👀 Early detection improves survival.
• 👄 Rehabilitation (nutrition, speech, psychosocial support) is integral.

⚔️ Treatment Modalities

• 🔪 Surgery: excision, laryngectomy, neck dissection, reconstructive flaps.
• ☢️ Radiotherapy: EBRT, IMRT, brachytherapy (side effects: mucositis, xerostomia, dysphagia).
• 💉 Chemotherapy: cisplatin, 5-FU, taxanes. - Neoadjuvant, concurrent with RT, or palliative.
• 🎯 Targeted therapy: EGFR inhibitor cetuximab.
• 🛡️ Immunotherapy: checkpoint inhibitors (pembrolizumab, nivolumab) in recurrent/metastatic disease.

🤝 Supportive Care

• 🥣 Nutritional support (dietitian, PEG feeding if needed).
• 🗣️ Speech/swallowing therapy.
• 💊 Pain control.
• 🧠 Psychological support, smoking/alcohol cessation.

🧭 Follow-Up

• Regular clinical exams, imaging, endoscopy.
• Monitor for recurrence, second primaries, late complications (xerostomia, dental problems, hypothyroidism).

📉 Prognosis

• 📏 Early stage = good prognosis.
• 📍 Site matters (hypopharynx worse).
• 🦠 HPV-positive oropharyngeal cancers = better outcomes.
• ⏳ 5-year survival overall: 40–60% (site + stage dependent).

🛡️ Prevention

• 🚭 Stop tobacco + alcohol.
• 💉 HPV vaccination (esp. for oropharyngeal cancer prevention).
• 🦷 Regular dental/oral checks for premalignant lesions.
• 🏭 Occupational protection from carcinogens.
• 🥗 Healthy diet rich in fruit & veg.

🧠 Teaching Pearls

💡 Any persistent hoarseness >3 weeks = laryngeal cancer until proven otherwise (NICE red flag).
💡 A painless neck mass in an adult should always be assumed malignant until biopsy confirms otherwise.
💡 HPV-positive oropharyngeal SCCs paradoxically have a better prognosis than traditional tobacco-related SCCs.

📚 References

• NCCN Guidelines: Head and Neck Cancers (v1.2021).
• Argiris A et al. Lancet. 2008;371:1695–1709.
• Chaturvedi AK et al. J Clin Oncol. 2011;29:4294–4301.
• Marur S, Forastiere AA. Mayo Clin Proc. 2016;91:386–396.
• Colevas AD et al. JNCCN. 2018;16:479–490.