It is indeed a tragedy that even today the vast majority of these cancers are diagnosed at a late stage, given their characteristic symptoms; the fact that well over 90% occur in a high-risk population (i.e., tobacco and alcohol abusers); and how easily accessible most of these lesions are to clinical evaluation. If possible, all patients who are at high risk (e.g., heavy smokers) should be examined on a regular basis to detect premalignant lesions or early malignancies.
Clinical examination of the head and neck should be carried out in a systematic manner. First, the neck should be examined for any evidence of cervical metastases, and the thyroid and salivary glands palpated. All nodal groups should be carefully examined. Involvement of certain nodal groups may indicate the site of the primary tumor (e.g., posterior triangle nodes are more likely to enlarge with nasopharyngeal cancer) and, conversely, primary cancers at certain sites are more likely to spread to certain groups (e.g., oral cancer to submental, submandibular, and upper deep cervical nodes), although this does not always hold true.
Examination of the oral cavity and oropharynx can easily be accomplished by direct inspection, but palpation, particularly of the base of the tongue, should always be performed, as a carcinoma may be almost entirely submucosal and not visible on examination. Evaluation of the nasopharynx, hypopharynx, and larynx can be accomplished by indirect mirror examination or more easily by using a fiberoptic endoscope. Likewise, examination of the nasal cavity can be accomplished using a nasal speculum for anterior rhinoscopy and rigid or fiberoptic scopes for posterior endoscopy.
Imaging may be used to augment the physical examination in evaluating areas not accessible to direct or indirect visualization. To this end, chest x-ray, an esophagram, and computed tomography (CT) scan of the sinuses are most useful. Other imaging studies are ordered at the discretion of the clinician and depend on the clinical problem. It is our belief that CT or magnetic resonance imaging (MRI) scans or other contrast studies should be ordered only to obtain information essential to the therapeutic decision-making process and not performed indiscriminantly or routinely (e.g., CT scan can evaluate mandible and base of skull erosion; MRI can accurately determine the extent of tongue invasion). An extensive metastatic workup above and beyond x-ray chest and blood chemistry is usually not indicated unless the patient is symptomatic or the locoregional disease is extensive.
If at all possible, an examination under anesthesia should be performed before making the appropriate therapeutic decision for a particular cancer. The purpose of this is to more accurately delineate the extent of the tumor; take adequate and, if necessary, multiple biopsy specimens; and exclude the possibility of a simultaneously developing second cancer, which is present in 8% to 10% of cases. To this end, concomitant laryngoscopy, bronchoscopy, esophagoscopy, and even nasopharyngoscopy, if appropriate, are recommended. Biopsy is obviously necessary to establish diagnosis, and an adequate sample should always be taken. Fine-needle aspirate biopsy is useful for diagnosis of nodal, salivary gland, and thyroid masses.
Revision date: July 3, 2011
Last revised: by Jorge P. Ribeiro, MD