Head and neck cancer is a term used to denote cancer that develops in the mouth, throat, neck, nose, sinuses, salivary glands, thyroid or other areas of the head and neck. Most of these cancers are squamous cell carcinomas, or cancers that begin in the lining of the mouth, nose and throat. Eighty-five percent of head and neck cancers are linked to tobacco use, and 75 percent are associated with a combination of tobacco and alcohol use.

The chronic effect of carcinogens cause changes in the lining of the mouth. Features like white patches (leukoplakia), red patches (erythroleukoplakia), tightening of the mucosa (oral submucous fibrosis) or lace-like patches (oral lichen planus) are called pre-cancers or pre-malignant conditions, and indicate that the lining has started on its path to becoming cancerous. They can sometimes be halted by stopping the addictions.

If you are unfortunate enough to be diagnosed with this disease, please do not lose hope. There are many treatment modalities available which are tailored to the patient’s site, type and extent of cancer. The general fitness of the patient plays a role in his/her ability to tolerate the treatment. The treatments mainly used are:

Surgery

• Tumor removal, also called curative or primary surgery : Surgery is used to remove the tumor and some of the nearby healthy tissue. The tissue around the tumor is called the margin. Tumor removal may be the primary treatment in some types of cancer and may be used as the sole treatment, or in conjunction with other modalities, such as chemotherapy or radiation therapy.
• Salvage surgery- Patients whose disease recurs after treatment with chemotherapy and/or radiation therapy are treated with salvage surgery. There is an extremely small window of opportunity for such patients, and they must be evaluated promptly.
• Diagnostic surgery :  A biopsy may be used to diagnose certain cancers. During a surgical biopsy, the surgeon makes an incision into the skin to remove some or all of the suspicious tissue. This is sent to the pathologist to examine the tissue and diagnose the type of tumor, which dictates further treatment.

Radiation Therapy - Radiation therapy is the use of high-energy x-rays or other particles to destroy or shrink cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time, and maybe used either as the sole modality or I conjunction with surgery, chemotherapy or immunotherapy.

Chemotherapy - Chemotherapy is the use of drugs to destroy cancer cells. It acts on all rapidly growing cells, but more so on the cancer cells. Therefore, they can also cause damage to healthy cells, which account for the side effects of chemotherapy. The types of chemotherapy are:

• Neoadjuvant - Before surgery, to shrink tumors, and make it operable.
• Adjuvant (usually along with radiation)- After surgery, to consolidate the gains of surgery.
• Curative - To treat cancers of the blood or lymphatic system, such as leukemia and lymphoma.
• Palliative - For cancer that comes back after treatment, called recurrent cancer, or for cancer that has spread to other parts of the body, called metastatic cancer.

• Since majority of them are caused by tobacco-alcohol addiction and/or poor nutrition, they are preventable cancers. Yet, they form the bulk of head neck cancers in our country, with untold suffering and massive socioeconomic loss.
• Head neck cancers and their treatment involve critical aspects of living like breathing, smelling, talking, eating, swallowing, and appearance. As the treatment modalities have evolved, there have been improvement in survival, and patients therefore have to live longer with its sequelae.
• A lifetime of frequent and careful follow-up is important because such patients have an increased risk of developing a recurrence or a second cancer in the head or neck.

Most of them are tobacco induced. Tobacco in any form, whether smoked (cigarettes, bidi, cigar, pipe etc) or smokeless (gutkha, pudiya, gulmanjan, soorti, paan masala etc) is the strongest risk factor. The habit of stuffing paan in the mouth while working long hours, is a unique risk factor not found elsewhere in the world, except the Indian subcontinent. Each individual ingredient of paan, ie supari, tobacco, masala and kathha wrapped in betel leaves, is carcinogenic.

Alcohol acts as an independent risk factor, and also potentiates the effect of tobacco by making its carcinogens more soluble, which can then be easily absorbed by the lining of the oral cavity and oropharynx. Therefore, alcohol and tobacco together are synergistic, not additive, ie 1+1=11, not 2.

Since the entire lining of the mouth, throat, airway and foodpipe is affected by smoking and drinking, patients are susceptible to develop second primary tumours. These tumours which occur in another place after successful treatment of the first one.

The mouth, throat and neck are the most common areas affected by head neck cancers. Symptoms depend on where the cancer develops and how it spreads. These tumors often cause symptoms that are similar to less serious conditions. So, these symptoms and signs are not diagnostic for throat cancer because many other problems like common cold, sinusitis or acid reflux can mimic head neck cancer. However, any person who develops these symptoms and has risk factors should immediately consult in the clinic.

• A non-healing ulcer in the mouth
• A lump in the throat or neck, with or without pain
• A persistent sore throat
• Trouble swallowing (dysphagia)
• Unexplained weight loss
• Frequent coughing
• Change in voice or hoarseness
• Ear ache or blocked ears
• A red or white patch in the mouth
• Bad breath that’s unexplained by hygiene

a.Mouth (oral cavity) cancer

Symptoms - Symptoms of oral cancer may include red, white and/or a mixture of these colors in patches, a non-healing sore in the mouth or on the lips, bleeding, loose teeth, new denture problems, lumps or bumps on the neck.The lumps and bumps in the neck denote lymphnodes where the cancers spread. Pain is typically a late feature.

Evaluation - An evaluation should be done by individual head-and-neck specialists before any treatment begins. It is diagnosed by the patient’s history and physical examination. Usually endoscopies are not required, as oral cancers can be seen by simple torch-light examination. If any suspicious area is noted, a piece of tissue is taken(biopsy) to establish the diagnosis. This is usual done under local anesthesia in the minor OT. Imaging by CT scan, MRI and in rare cases, PET-CT will be requested to stage the tumour. Investigations to assess general fitness of the patient are done before a comprehensive decision can be taken to proceed with the treatment.

Treatment - The treatment for oral cancer is primarily surgical, if the tumour is operable and the patient is otherwise fit. Surgery can cause scars in face, neck, altered appearance, difficulty in chewing, maloccusion of teeth, change in speech quality. Reconstruction of surgical defect by local, regional and free flaps, is therefore an important part of treatment. After treatment and rehabilitation, regular checkups are needed to make sure that the oral cancer does not recur. Oral cancer treatment can result in significant lifestyle changes; most patients are advised to discuss lifestyle problems with professionals to help patients get the care they may need.

b.Throat cancers (oropharynx, hypopharynx including cervical oesophagus and larynx cancers)

What is throat cancer - Throat cancer is a layman’s term that usually refers to cancer of the back of the mouth(oropharynx), the voice box (larynx) and the food pipe (hypopharynx). The most common symptoms of throat cancer are non-specific, and not all patients exhibit all of them.

Oropharynx - The soft palate, uvula, tonsils, posterior pharyngeal wall and posterior one-third of tongue constitute the oropharynx. Foreign body sensation of the throat, persistent one-sided ear aches and difficulty in swallowing are some of the subtle symptoms which herald cancers of the oropharynx. They can grow unnoticed before being diagnosed, because these tumours lie in an area which is relatively spacious. A lump in the neck may be present, indicating that it has spread to the neck nodes, and may be the first indication that something is wrong.

Hypopharynx - This is that part of the throat that directs our food into the food-pipe without letting it enter the airway. It shares common boundary walls with the voice box (larynx), and at times it is difficult to discern where the tumour originally arose from. Throat discomfort, feeling of something caught in the throat, difficulty in swallowing certain foods, a mass or lump in the neck, change of voice, difficulty in breathing, cough, repeated throat clearing, unilateral earache and unintentional weight loss can be features of hypopharynx cancers.

Cervical oesophagus - It is the part of the food pipe that is present in the neck(main part is in the chest). Its cancers are very common in Indian women who are malnourished and anemic, starting in the form of oesophageal webs and progress to life threatening cancers. Sadly, it is also a preventable cancer. Cancers of the foodpipe present with difficulty in swallowing dry solid foods initially, later progressing to include semisolid and liquids too. There may be vomiting or regurgitation of food, unexplained weight loss, coughing or hoarseness and feeling of food stuck in the throat.

Larynx (voice box) - The voice box has three parts-- the supraglottis, the glottis and the subglottis, named as the part above the vocal cords, the vocal cords themselves, and the part below the vocal cords, which continue as the trachea. The symptoms of the supraglottis growths overlap with those of the hypopharynx. (see above). The glottis is the narrowest part of the airway, and any growth here typically cause persistent progressive hoarseness of voice and difficulty in breathing. Subglottis cancers usually do not occur in isolation, but spread from tumours above, and cause difficulty in breathing as their predominant symptom.

As stated above, these symptoms and signs are not diagnostic for throat cancer because many other problems can mimic the throat cancer. However, any person who develops these signs and symptoms and/or has risk factors for throat cancer should immediately discuss them with his or her physician.

Diagnosis of throat cancers - The person’s individual history (especially the presence of potential risk factors) and physical examination may provide a physician with enough suspicious information that the physician will consider throat cancer as a possible diagnosis.

Consequently, the physician may strongly suggest doing additional tests, like endoscopies to confirm or exclude the diagnosis. Endoscopes are narrow flexible or rigid tubes with a light and camera attachment, which are introduced through the nose or mouth. They can look into the various nooks and corners, and project a picture on a computer screen. Imaging tests such as CT and MRI give an indication of the depth and extent of disease, and hence the stage.

This is generally followed by a biopsy if any growth is seen. The biopsy is usually done under general anesthesia because the tumours are not easily accessible. If a neck node can be felt, it is easier and cheaper to perform an FNAC (fine needle aspiration cytology), rather than a formal biopsy. Either way, a tissue testing is a must to establish the diagnosis.

Tests for general fitness are then ordered, so that the patients ability to tolerate the treatment is assessed.

Treatment options for throat cancers - According to the current guidelines, the treatment of choice in these cases is non-surgical. Radiation and/or chemotherapy with modern drugs and technology, tailored to the individual, provide him/her with the best chance for a successful outcome. Treatment strives to preserve the patient’s ability to eat, speak, and live a normal healthy life.

The role of surgery is mostly limited to biopsy alone. Sometimes, it is possible that the growth can be entirely removed in the process, and can be considered complete treatment in itself. These surgeries come under the purview of minimally invasive surgeries, including transoral laser microsurgery, endoscopic and robotic surgeries. At the other extreme, the role of surgery is magnified in cases of advanced tumours, where primary surgery and reconstruction, followed by radiotherapy is the protocol. Surgery also has a major role in chemoradiation failures, where residual and recurrent tumours. This is known as salvage surgery, and always carries more morbidity in terms of wound healing and outcomes.

c.Nose & paranasal sinus cancers

Risk factors - Paranasal sinus and nasal cavity cancers are rare and form a very heterogenous group, among which squamous cell carcinoma is the commonest. Apart from smoking, the other common risk factor is exposure to certain chemicals or dust in the workplace.

Symptoms - There may be no signs or symptoms in the early stages. Signs and symptoms may appear as the tumor grows. Early signs resemble common cold, but once the tumour leaves the confines of the paranasal sinus, they involve critical areas very fast. Check with the doctor if you have:

• Blocked sinuses that do not clear, or sinus pressure.
• Headaches or pain in the sinus areas.
• A runny nose.
• Nosebleeds
• A lump or sore inside the nose that does not heal.
• A lump on the face or roof of the mouth.
• Numbness or tingling in the face.
• Swelling of the eyes, double vision, watering of the eyes or the eyes pointing in different directions.
• Pain in the upper teeth, loose teeth, or dentures that no longer fit well.
• Pain or pressure in the ear.

Diagnosis - Tests that examine the sinuses and nasal cavity are used to diagnose paranasal sinus and nasal cavity cancer. The following tests and procedures may be used:

• History
• Physical exam of the nose, face, and neck
• Endoscopic examination of the nose
• CT scan or MRI
• Biopsy

Treatments -The treatment is usually surgical, depending on site, size, extension of the tumour and the general condition of the patient. Since they are usually advanced at the time of diagnosis, they require extensive reconstructions. The decision making regarding the eyeball is tough, specially if it is involved, but vision is intact. Extension to the brain also has to be evaluated carefully.

d.Thyroid tumours / cancer

Symptoms - The most common symptoms of thyroid tumour include a lump or nodule, that can be seen and felt in the front of the neck. The neck lump is typically long-standing, and slowly growing. Ominous features include change of voice, difficulty in swallowing, rapid growth, difficulty in breathing, appearance of neck nodes and bone pain.

Diagnosis - If a lump in the thyroid is found, the first investigations are FNAC and a neck imaging (ie ultrasound or contrast CT scan). These two investigations taken together can decide whether a thyroid lump is malignant or not. However, sometimes the only way to tell its nature is to surgically remove the involved lobe of the thyroid gland and send it for histopathological examination. This may occasionally be the definitive curative treatment too.

Treatment - Surgery is the of treatment for choice for majority of thyroid tumours. Chances of surgical complications like bleeding, recurrent laryngeal nerve paralysis and hypoparthyroidism will be explained in detail by the operating surgeon. The report after surgery dictates whether radio-iodine treatment is required or not.

Thyroid cancer is not a preventable disease, but it is certainly a tumour with better outcome than all other cancers of the head neck. The survival rate and prognosis of thyroid cancer depends upon the individual’s age, the size of the tumor, and whether or not there is metastasis to the neck nodes, chest or bones.

e.Salivary gland tumours / cancer

Three pairs of major salivary glands are situated on either side of the face below the ear (parotid), below the jaw line (submandibular) and in the floor of the mouth (sublingual). Minor salivary glands are scattered all over the mouth, nose, and other parts of the neck. Both benign and cancerous tumors can begin in any of the major or minor salivary glands. Most of the tumors (80%) that develop in the parotid gland, and about half of the tumors in the submandibular gland, are benign. Sublingual gland and minor salivary gland tumors are rare, but usually (80%) cancerous.

Symptoms

• A lump on the face just below the ear lobule, slowly growing and painless
• A lump just below the jawline
• A discrete lump anywhere in the mouth or lips.
• A deviation of angle of the mouth indicates a tumour involving the facial nerve.

Diagnosis - For a salivary gland tumor, a fine needle aspiration cytology FNAC is the preferred test for making a diagnosis. A surgical (incisional) biopsy should be avoided in almost every case. Imaging tests like MRI may be used to find out the extent of the tumour and to plan surgical removal.

Treatment - The treatment is primarily surgical. Complete removal of the tumour with preservation of the function of the nearby nerves is very important. The final histopathological report dictates the adjuvant treatment.

f.Nasopharynx

The nasopharynx is the part of the airway that lies behind the nose. Its tumours cause subtle symptoms like persistent blocked ear, minimal hearing loss, blocked nose, snoring and lightly stained sputum in the early stages, which is dismissed by patients and doctors alike as nothing more than a common cold. But, its first manifestation of disease is usually a neck mass, which needs to be thoroughly investigated with the help of endoscopy and biopsy. Its treatment is again non-surgical.

g.Metastasis of unknown origin(MUO)

This denotes a neck lump which is cancerous in nature, but it cannot be discovered from where the cancer has originated. The cancer may be too small to manifest, or it may have started in some hidden corner of the head neck area, the so called coffin-corners. It is the surgeon’s job to discover its origin by all means possible, including endoscopies, imaging and biopsies. Sometimes additional markers may also be required before labelling the metastasis as truly unknown.

h.Skin and scalp tumours

Skin tumours arise in areas of sun exposed regions, like the face and scalp. Common among these are squamous cell carcinoma and basal cell carcinoma. Although Indians are less prone to it than the western world, by virtue of our melanin-protected skin, it nevertheless is seen among people who have been exposed to the harsh UVrays of the sun for prolonged duration. Again, it is a preventable disease, by simply using umbrella, caps/hats and sunscreen. The diagnosis is clinical and by biopsy, and the treatment is surgical.

In contrast, melanoma skin cancers are more aggressive, and tend to spread fast. They have a poor prognosis. The treatment is surgical and immunological.

i.Lymphomas

Lymphomas are tumours of the lymph nodes, and often present as a neck lump. The role of surgery is limited to performing a lymph node biopsy.

j.Rare tumours of head neck

There are many other varieties of tumours, each arising out of different cells which populate the head neck area. They are too extensive to enumerate, and need to be differentiated by a specialist. It is only after the receipt of the reports that the doctor can explain to the patient and the attenders about the site, stage and type of cancer and the treatment options available to him/her.

Head neck cancers affect the most critical aspects of speech, swallowing, smell and appearance. Therefore, its treatment also has implications in the day-to-day activities of the patient.

Due to surgery

• Changes in breathing- Occasionally, some people need a tracheostomy, which is an opening of the trachea directly onto the skin, kept open by a tracheostomy tube. It may be temporary or permanent, depending on the disease. Some patients may also need a feeding tube on a temporary or permanent basis.
• Changes to appearance- There will be surgical scars on the face and/or neck, which are permanent. Attempts will be made to keep the scars hidden in skin creases or do the surgery trans-orally, but this may not always be possible. If part of the jaw, nose or skin is removed, the face will look different. Reconstruction with a prosthesis, local flap, regional flap or free flap will restore the appearance to a great extent.
• Changes in speech- In tongue cancers, certain consonants will not be clearly pronounceable depending on the site and extent of surgery. In total laryngectomy, the voice box is removed, and the patient can be rehabilitated by other means.
• Changes in eating- Chewing and swallowing involves lips, teeth, tongue and the muscles in mouth, jaw and throat working together. Patients with a head and neck cancer have difficulty swallowing (dysphagia) before, during or after treatment. A temporary nasogastric tube is almost always placed after a major head neck surgery, but eating patterns do change depending on the site and extent of surgery. Maneuvers to overcome these difficulties will be taught to the patient as he/she recovers from the surgery.

Due to chemotherapy and radiation therapy - Mouth ulcers, nausea, vomiting, weakness, loss of hair, diarrhea, fever, loss of appetite, electrolyte imbalance etc are some of the common side-effects of chemotherapy. Radiation therapy causes dryness of mouth, difficulty in chewing, difficulty in swallowing, dental caries (saliva is protective) and altered taste sensation, but these are minimized nowadays due to sophisticated radiation techniques. If the patient needs these modalities, he/she will be referred to the concerned specialist, who will explain the implications in greater details.