ENT

Head and Neck Cancer

Head and neck cancer is usually a squamous cell carcinoma of the upper aerodigestive tract; persistent hoarseness, oral ulceration, dysphagia, unilateral otalgia or an unexplained neck lump needs prompt specialist assessment, with urgent escalation for airway compromise or major bleeding.

In a nutshell

Most upper aerodigestive tract head and neck cancers are squamous cell carcinomas. Persistent hoarseness, oral ulceration beyond 3 weeks, dysphagia, unilateral referred otalgia or an unexplained neck lump needs prompt assessment; airway compromise or major bleeding is an emergency. Diagnosis uses specialist endoscopy, needle sampling/biopsy and stage-appropriate imaging. Treatment is subsite- and stage-specific through a specialist MDT, with early attention to nutrition, swallowing, voice, smoking cessation and follow-up.

Classic presentation

An adult aged 45 or over with persistent unexplained hoarseness, or an adult with a painless unexplained neck lump or oral ulcer lasting more than 3 weeks; HPV-related oropharyngeal disease may present as a cystic cervical node.

Key points

NICE suspected-cancer referral criteria include persistent unexplained hoarseness or neck lump at age 45 or over and unexplained oral ulceration lasting more than 3 weeks.
A suspicious neck lump is sampled with FNA or core biopsy, with ultrasound guidance considered; do not treat a cystic neck node as a benign branchial cyst without specialist assessment.
p16 is a surrogate marker used in the HPV-related oropharyngeal pathway; HPV positivity does not justify curative treatment de-intensification outside a clinical trial.
Early treatment is site-specific; choices can include surgery or radiotherapy, while advanced disease may need multimodality treatment.
Nutrition, swallowing, speech/voice, smoking cessation, psychosocial care and recurrence/late-effect follow-up are part of management, not optional extras.
Stridor, inability to handle secretions or major bleeding requires emergency airway/haemorrhage management.

First-line investigation

Urgent specialist head and neck examination with flexible nasendoscopy, tissue diagnosis and stage-appropriate CT/MRI or PET-CT; sample a neck node with FNA or core biopsy when it is the presenting lesion.

Management

Refer the persistent red flag

Use NICE suspected-cancer criteria for persistent hoarseness/neck lump at age 45 or over and unexplained oral ulceration lasting more than 3 weeks; urgent dental assessment is appropriate for suspicious oral lumps or red/red-and-white patches.³

Protect the airway and control bleeding

Stridor, rapidly worsening breathing, inability to handle secretions or major bleeding requires emergency senior ENT, anaesthetic and critical-care assessment while maintaining monitoring and a coordinated airway/haemorrhage plan.^1,2

Confirm the subsite and stage

Use flexible nasendoscopy, biopsy or needle sampling and stage-appropriate CT/MRI/PET-CT; for metastatic nodal SCC with no primary, PET-CT and then specialist occult-primary investigations guide the search.¹

Plan through the MDT

Treatment is site- and stage-specific and may be surgery, radiotherapy, chemoradiotherapy or combinations; involve the patient in decisions about tumour control, laryngeal preservation, swallowing, voice and long-term function.¹

Preserve nutrition and function

Assess nutrition and enteral-feeding need at diagnosis and involve speech and language therapy, dietetics and rehabilitation early; offer smoking-cessation support at diagnosis.^1,2

Surveil recurrence and late effects

Give tailored recurrence and late-effect information and arrange structured risk-adapted follow-up; use the NICE post-chemoradiotherapy PET-CT response pathway where the primary site and nodal criteria apply.¹

Exam traps

A normal ear does not make unilateral otalgia benign; consider referred pain from the pharynx or larynx.
Do not label a persistent oral ulcer as aphthous or traumatic without reassessment and referral when it meets the 3-week criterion.
Do not assume every head and neck cancer is treated with the same surgery, radiotherapy or chemotherapy pathway.
Do not de-intensify curative treatment solely because an oropharyngeal tumour is HPV/p16 positive outside a clinical trial.
A negative or non-diagnostic initial view does not end evaluation of a suspicious neck node; follow the occult-primary pathway.

Illustrations

Resected laryngeal cancer specimenA gross surgical specimen of a dissected larynx showing a large ulcerated and infiltrative laryngeal tumour.PaweÅ‚ KuÅºniar (Jojo_1, Jojo), Wikimedia Commons · CC-BY-SA-3.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.