Head and Neck Cancer

What Is It?

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, a sore, or an abnormal patch of white or discolored tissue. 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, has been linked to a growing number of throat cancers in men. Although a cause and effect relationship has not been proven, oral sex may be to blame for the transmission of HPV.

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 four 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.

• 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.

  In the United States, nasopharyngeal cancer has not been associated with any particular cause. But 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 Cantonese salted fish; high exposure to dust and smoke; and eating a lot of fermented foods.

• Sinuses and nasal cavity. About three-quarters 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

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. Sometimes the lump causes pain.

• 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.

Diagnosis

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 fiberoptic endoscopy. The doctor inserts a flexible fiberoptic 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), magnetic resonance imaging (MRI) of the head and chest

• Throat. Fiberoptic 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. Fiberoptic 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. Fiberoptic 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. Fiberoptic endoscopy to examine the tumor within the nasal cavity or sinus; CT or MRI scans of the head

Expected Duration

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

Prevention

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.

Treatment

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.

• 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.

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. Radiation cures people with small nasopharyngeal cancers that have not spread at least 80% of the time. 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. At best, only half of all patients with sinus or nasal cavity cancer are cured.

The prognosis for head and neck tumors is expected to improve in the near future. 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)
U.S. National Institutes of Health
Public Inquiries Office
Building 31, Room 10A03
31 Center Dr., MSC 8322
Bethesda, MD 20892-2580
Phone: 301-435-3848
Toll-Free: 1-800-422-6237
TTY: 1-800-332-8615
http://www.nci.nih.gov/

American Cancer Society (ACS)
1559 Clifton Rd., NE
Atlanta, GA 30329-4251
Toll-Free: 1-800-227-2345
TTY: 1-866-228-4327
http://www.cancer.org/

American Dental Association
211 East Chicago Ave.
Chicago, IL 60611-2678
Phone: 312-440-2500
http://www.ada.org/

American Academy of Otolaryngology -- Head and Neck Surgery
One Prince St.
Alexandria, VA 22314-3357
Phone: 703-836-4444
http://www.entnet.org/

American Academy of Oral and Maxillofacial Radiology
P.O. Box 1010
Evans, GA 30809-1010
Phone: 706-721-2607 
http://www.aaomr.org/