Head and Neck Cancer

What is head and neck cancer?

Head and neck cancer begins with the abnormal growth of cells. These cells multiply out of control, eventually forming a tumor in part of the head or neck. As the tumor grows, it can form a lump in the neck, or a sore or abnormal patch of white or discolored tissue in the mouth or throat.

Without treatment, the tumor can invade and destroy nearby bones and soft tissues. Eventually, it can spread (metastasize) to lymph nodes in the neck and to other parts of the body.

In many cases, head and neck cancers are triggered by carcinogens. These are substances that cause cancer. Common carcinogens include tobacco smoke, smokeless (chewing) tobacco, and snuff. Chronic or heavy alcohol use also contributes to head and neck cancer. The disease is especially prevalent in those who both use tobacco and drink alcohol.

The human papilloma virus (HPV), which causes cervical cancer in women as well as some vaginal, penile, and anal cancers, has been linked to a growing number of throat cancers. (Throat cancer is one type of head and neck cancer.)

Head and neck cancers are classified based on where they are found:

Upper aerodigestive tract: This includes the lips, tongue, mouth, throat, and voice box (larynx). Of all head and neck cancers, those involving the upper aerodigestive tract are the most common. Almost all cancers in this part of the head are squamous cell carcinomas, which arise from cells that line structures in the head and neck. Squamous cell carcinomas can also occur on the skin of the head and neck, but they are not considered to be skin cancer. Upper aerodigestive tract cancers are more common in people over age 45. Men are affected two to five times more often than women. Most of these cancers are related to tobacco use. Alcohol increases the risk, especially when it's used heavily and constantly. More and more cases of throat cancer in men have been tied to HPV.
Salivary glands: Salivary gland cancer is rare and varies in aggressiveness. Exposure to radiation increases the risk of this type of cancer. Smoking may play a role in certain types of salivary gland cancer. People who have had chronic salivary gland stones and inflammation of the salivary glands may be more prone to this disease. A subtype of salivary gland cancers called adenoid cystic cancers are not associated with any known risk factors.
Nasopharynx: The nasopharynx is the upper portion of the back of the throat, where the throat meets the back of the nasal cavity. Unlike other head and neck cancers, this one is not associated with tobacco or alcohol use. However, some cases are associated with HPV infection. In parts of northern Africa, Asia, and the Arctic, where this cancer is more common, it has been linked to infection with the Epstein-Barr virus, the cause of infectious mononucleosis; eating salt-cured fish; high exposure to dust and smoke; and eating a lot of fermented foods.
Sinuses and nasal cavity: The majority of cancers found in the sinuses (behind the bones of the forehead and cheeks and inside the nose) are squamous cell carcinomas. Rarely, other types of cancer occur in this area. In many cases, these cancers grow fairly large before they are diagnosed. This is because the tumors have room to grow before they block the sinuses or nasal passages or cause other symptoms.

Symptoms of head and neck cancer

Symptoms of head and neck cancer depend on where the cancer is located.

Lips and mouth: You may see or feel a lump, open sore or area of bleeding, or an abnormal white or red patch inside the mouth or on the lip or tongue. You may have a sore throat that doesn't go away, an earache, discomfort while chewing or swallowing, and a swollen jaw.
Throat and larynx: Symptoms include hoarseness; discomfort or trouble swallowing; pain in the neck, jaw, or ear; a lump or swelling in the neck; and a feeling that something is stuck in the throat.
Salivary glands: The most common symptom is a slow-growing lump in the cheek, under the chin, on the tongue, or on the roof of the mouth. These cancers may cause pain because of their tendency to grow into nerve tissue. Other symptoms can include facial numbness, weakness on one side of the face, and difficulty swallowing or opening your mouth widely.
Nasopharynx: Symptoms include painless, enlarged lymph nodes (swollen glands) in the neck, a blocked or stuffy nose that doesn't go away, frequent nosebleeds, hearing loss, frequent ear infections, a sore throat, and headaches.
Sinuses and nasal cavity: Symptoms include a blocked or stuffy nose; nosebleeds; numbness in the face; pain in the forehead, between the eyes, or behind the cheeks; and a bulging eye.

Diagnosing head and neck cancer

Your doctor will ask about your symptoms and whether you smoke, chew tobacco, dip snuff, or drink alcohol. Your doctor may ask about your diet, ethnicity, job, and any history of radiation exposure. Next, he or she will examine you, focusing on your mouth, throat, nose, ears, and the lymph nodes in your neck.

If a lump or suspicious lymph node is found, your doctor will refer you to a specialist for a biopsy. In a biopsy, a small piece of tissue is removed and examined in a laboratory. Depending on your symptoms and the location of the lump or lymph node, the specialist might be an ear, nose, and throat surgeon; an oral maxillofacial surgeon; or a general surgeon.

Once cancer has been diagnosed, more tests will be done to determine how far it has spread.

The main way to evaluate head and neck tumors is with a procedure called fiber-optic endoscopy. The doctor inserts a flexible fiber-optic tube into the throat to look at areas that might be cancerous. This procedure can be used to examine the upper airways, larynx, lungs, and esophagus, as well as the nasal passages and sinuses.

Based upon the part of the head and neck to be evaluated, the tests may vary:

Lips and mouth: x-rays, computed tomography (CT) scans, or magnetic resonance imaging (MRI) of the head and chest
Throat: fiber-optic endoscopy to examine the throat and larynx, and possibly the esophagus and lungs; x-rays; CT or MRI scans of the head, neck, and chest; angiography of the neck to check blood flow through vessels (these tests can determine whether the cancer has spread or if it started in more than one place)
Larynx: fiber-optic endoscopy of the larynx to examine the tumor and to determine whether the vocal cords are moving normally; x-rays and CT or MRI scans of the head and neck
Salivary glands: CT and MRI scans of the head and neck
Nasopharynx: fiber-optic endoscopy to examine the tumor in the nasopharynx; a neurological examination to check for nerve damage in the head and neck; hearing tests; a thorough dental exam; x-rays and CT and MRI scans of the head and neck; blood tests
Sinuses and nasal cavity: fiber-optic endoscopy to examine the tumor within the nasal cavity or sinus; CT or MRI scans of the head.

Expected duration of head and neck cancer

Once it develops, cancer in the head or neck will continue to grow and spread until it is treated.

Preventing head and neck cancer

To reduce your risk of head and neck cancer:

Avoid smoking cigarettes, cigars, or pipes. If you smoke, get the help you need to quit.
Avoid chewing tobacco and dipping snuff.
Avoid excessive alcohol use. Besides being a risk factor by itself, chronic or excessive alcohol use multiplies the risk of head and neck cancer in people who also use tobacco. If you drink, aim for no more than one drink a day if you are a woman and no more than two if you are a man.
Practice good oral hygiene.
Visit your dentist regularly. A dental checkup includes an examination of the inside of your mouth.
If you are eligible, get vaccinated against HPV.

Treating head and neck cancer

The type of treatment usually depends on how advanced the tumor is. This is called the tumor "stage." For most head and neck cancers, the stage is based on the type of tumor, its size, and whether it has invaded nearby tissues, lymph nodes, or other parts of the body.

Upper aerodigestive tract: These tumors usually are treated with radiation alone, or radiation and surgery combined. Chemotherapy may be added to improve the results of surgery and radiation. (Chemotherapy is the use of anticancer drugs.) In general, the more advanced the cancer, the more treatments will be required.

Larynx: Smaller cancers can be treated with radiation or with surgery that preserves the ability to speak. Adding chemotherapy and radiation may decrease the chances of having to remove the entire larynx. If the entire larynx is removed, other treatments can restore the voice. Your doctor may suggest an external microphone device (electrolarynx), esophageal speech (in which air is expelled from the esophagus to make speech), or a tracheoesophageal puncture (in which a valve is inserted to allow air to leave the trachea and travel to the esophagus to provide esophageal speech).

Salivary glands: Smaller, early-stage tumors can be treated with surgery alone. Larger tumors that have spread usually require surgery followed by radiation. Tumors that cannot be removed surgically are treated with radiation or chemotherapy.

Nasopharynx: High-dose radiation is the primary treatment. Chemotherapy and surgery can be used if the cancer does not respond well to radiation. Nasopharyngeal cancers that are associated with infection with the human papilloma virus (HPV) may be very responsive to chemotherapy as well.

Sinuses and nasal cavity: Cancer in this area is usually advanced by the time it's discovered. The major concern is that the tumor will invade the skull near the eye and the brain. Surgery removes as much of the tumor as possible; radiation therapy follows, to kill any remaining cancer. Sometimes, radiation treatment is started before surgery to shrink the tumor.

Some surgeons use robotic surgery, such as a procedure called transoral robotic surgery, to operate on head and neck cancers. The robot can perform very delicate, minimally invasive surgery in hard-to-reach areas. The robot can reach places a surgeon's hands cannot easily access. It has shortened the time it takes to do complicated operations in the head and neck area and reduced surgical complications.

For selected patients with any of the head and neck cancers, your doctor may recommend immunotherapy or targeted therapy, instead of traditional therapies or in addition to them.

When to call a professional

See your doctor as soon as possible if you have any of the following problems, especially if you use or have ever used alcohol or tobacco:

a sore, lump, area of bleeding, white patch, or discolored area on your lips or anywhere inside your mouth
a lump or swelling on your neck, jaw, cheek, tongue, or roof of your mouth
a sore throat that doesn't go away
hoarseness or trouble swallowing that lasts for more than two weeks
persistent nosebleeds or blocked nose
frequent ear infections.

Prognosis

The outlook depends on the stage of the cancer and its location:

Upper aerodigestive tract: In general, the closer to the lips the cancer is, the better the prognosis. This may be because it is easier to detect lip tumors while they are still small. Small, early-stage tumors on the lips and mouth can almost always be cured. Even many tumors that have spread to the lymph nodes are potentially curable. The prognosis is poorer for larger tumors and those that have spread to other parts of the body.

Throat and larynx: If the cancer is small and has not spread to the lymph nodes, the vast majority of cases can be cured.

Salivary glands: Early-stage salivary gland cancer often can be cured with surgery alone. The outlook is poorest for cancers under the tongue or in the minor salivary glands, cancers that have invaded the facial nerve, and bulky cancers that have spread.

Nasopharynx: Most early-stage cancers of the nasopharynx can be cured. The prognosis is poorer for advanced cancers.

Sinuses and nasal cavity: Because most tumors in these cavities are diagnosed at an advanced stage, the prognosis is often poor. Cancers diagnosed earlier, before they have spread, have a higher cure rate.

The prognosis for head and neck tumors continues to improve as advances in radiation therapy and anticancer drugs show promise in their ability to attack cancer cells while sparing other tissues.

Additional info

National Cancer Institute (NCI)
https://www.cancer.gov/

American Cancer Society (ACS)
https://www.cancer.org/

American Academy of Otolaryngology – Head and Neck Surgery
https://www.entnet.org/

American Academy of Oral and Maxillofacial Radiology
https://www.aaomr.org/