Clinical Presentation and Differential Diagnosis

Most head and neck cancers occur after age 50, although these cancers can appear in younger patients, including those without known risk factors. The manifestations vary according to the stage and primary site of the tumor. Patients with nonspecific signs and symptoms in the head and neck area should be evaluated with a thorough otolaryngologic exam, particularly if symptoms persist longer than 2 to 4 weeks.

Cancer of the nasopharynx typically does not cause early symptoms. However, on occasion it may cause unilateral serous otitis media due to obstruction of the eustachian tube, unilateral or bilateral nasal obstruction, or epistaxis. Advanced nasopharyngeal carcinoma causes neuropathies of the cranial nerves.

Carcinomas of the oral cavity present as nonhealing ulcers, changes in the fit of dentures, or painful lesions. Tumors of the tongue base or oropharynx can cause decreased tongue mobility and alterations in speech. Cancers of the oropharynx or hypopharynx rarely cause early symptoms, but they may cause sore throat and/or otalgia.

Hoarseness may be an early symptom of laryngeal cancer, and persistent hoarseness requires referral to a specialist for indirect laryngoscopy and/or radiographic studies. If a head and neck lesion treated initially with antibiotics does not resolve in a short period, further workup is indicated; to simply continue the antibiotic treatment may be to lose the chance of early diagnosis of a malignancy.

Advanced head and neck cancers in any location can cause severe pain, otalgia, airway obstruction, cranial neuropathies, trismus, odynophagia, dysphagia, decreased tongue mobility, fistulas, skin involvement, and massive cervical lymphadenopathy, which may be unilateral or bilateral. Some patients have enlarged lymph nodes even though no primary lesion can be detected by endoscopy or biopsy; these patients are considered to have carcinoma of unknown primary (

Fig. 74-1). If the enlarged nodes are located in the upper neck and the tumor cells are of squamous cell histology, the malignancy probably arose from a mucosal surface in the head or neck. Tumor cells in supraclavicular lymph nodes may also arise from a primary site in the chest or abdomen.

The physical examination should include inspection of all visible mucosal surfaces and palpation of the floor of mouth and tongue and of the neck. In addition to tumors themselves, leukoplakia, a white mucosal patch, or erythroplakia, a red mucosal patch, may be observed; these “premalignant” lesions can represent hyperplasia, dysplasia, or carcinoma in situ. All visible or palpable lesions should be biopsied. Further examination should be performed by a specialist. Additional staging procedures include computed tomography of the head and neck to identify the extent of the disease. Patients with lymph node involvement should have chest radiography and a bone scan to screen for distant metastases. The definitive staging procedure is an endoscopic examination under anesthesia, which may include laryngoscopy, esophagoscopy, and bronchoscopy; during this procedure, multiple biopsy samples are obtained to establish a primary diagnosis, define the extent of primary disease, and identify any additional premalignant lesions or second primaries.

Head and neck tumors are classified according to the TNM system of the American Joint Committee on Cancer. This classification varies according to the specific anatomic subsite (

Tables 74-1 and

74-2). Distant metastases are found in <10% of patients at initial diagnosis, but in autopsy series, microscopic involvement of the lungs, bones, or liver is more common, particularly in patients with advanced neck lymph node disease.

In patients with lymph node involvement and no visible primary, the diagnosis should be made by lymph node excision. If the results indicate squamous cell carcinoma, a panendoscopy should be performed, with biopsy of all suspicious-appearing areas and directed biopsies of common primary sites, such as the nasopharynx, tonsil, tongue base, and pyriform sinus.

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Revision date: July 8, 2011
Last revised: by David A. Scott, M.D.