Head and neck carcinomas

Head and neck carcinomas arise in the squamous cells of the mucosal epithelium in the nasal cavity, paranasal sinuses, oral cavity, pharynx, larynx, and trachea. Other nonsquamous cell carcinomas arise in salivary glands, sinuses, muscles, and nerves of the head and neck. Excluding nonmelanoma skin cancer, oral cavity malignancy is the most common head and neck carcinoma. Nasal cavity, oral cavity, and larynx cancers are generally associated with tobacco and/or alcohol use, whereas pharyngeal carcinomas are typically caused by infections with human papillomavirus and Epstein-Barr virus. Clinical features depend on the site and etiology of the primary tumor. Treatment usually involves surgery followed by radiotherapy and/or chemotherapy. Cancers of the brain, eye, ears, esophagus, thyroid gland, and skin of the head and neck are generally not classified as head and neck cancers and are discussed in other articles.

Oral cavity carcinoma, pharyngeal carcinoma, and laryngeal carcinoma are discussed in more detail in their respective articles.

• Sixth most common type of cancer worldwide
• Accounts for ∼ 4% of cancers in the US ^[1]
• Oral cavity, pharynx, and larynx carcinomas are the most common head and neck cancers.
• Most common subtype: squamous cell carcinoma (SCC)
• Median age of diagnosis: 50–60 years of age
• Sex: ♂ > ♀

Definition

Tumors arising in the nasal cavity and/or paranasal sinuses.

Epidemiology ^[5]

• Peak incidence: ≥ 60 years of age
• Prevalence: < 3% of tumors in the respiratory tract
• Sex: ♂ > ♀
• Most common malignant tumors: cutaneous squamous cell carcinoma, adenocarcinoma, neuroendocrine tumors, mucosal melanoma

Etiology ^[15]

• Nasal cavity carcinoma
  • Chronic and/or occupational inhalation exposure to tobacco, wood dust, glues, and adhesives
  • Associated with HPV infection
• Paranasal sinus carcinoma
  • Chronic and/or occupational inhalation exposure to air pollution, tobacco, wood dust, leather, textiles, and formaldehyde
  • Associated with HPV infection, EBV infection, and sinonasal tract lymphomas

Clinical features

• Most common sites: nasal cavity, followed by the maxillary sinus
• Unilateral nasal obstruction
• Epistaxis
• Chronic sinusitis
• Hyposmia/anosmia
• Advanced disease: a triad of facial asymmetry, palpable or visible tumor in the oral cavity, and visible intranasal tumor

Diagnostics

• Nasal endoscopy
• Biopsy and histopathological examination
• Imaging: CT and MRI

Treatment

• Resectable tumors: surgical resection and radiotherapy (pre- or postoperative)
• Unresectable tumors: radiation therapy combined with chemotherapy

Complications

• Involvement of adjacent structures (e.g., eye orbits, sinuses, palate) causing neuralgias, facial pain, impaired vision, ocular symptoms (e.g., exophthalmos, diplopia), and/or dentalgia

Prognosis ^[16]

The five-year relative survival rate for nasal cavity and paranasal sinus carcinomas is ∼ 80%.

A patient with unilateral difficulty breathing through the nose may have a malignant tumor.

Definition

A malignant tumor of the lips.

Epidemiology

• Peak incidence: ∼ 66 years of age ^[8]
• Sex: ♂ > ♀

Etiology ^[17]

• Risk factors
  • Tobacco use, alcohol use, prolonged UV exposure
  • Associated with HPV infection

Histological subtype ^[17]

• SCC (most common)
• Basal cell carcinoma

Clinical features

• Infiltrative or exophytic lesion of the lips
• Ulcer lesion
• Pain, numbness, and/or bleeding of the lip
• Advanced stage: loss of sensation around the chin and/or invasion of the premaxilla and nasal cavity

Diagnostics

• Physical examination of the lips
• Exfoliative cytology and direct microscopy
• Biopsy and histopathology of the lesion
• See “Diagnostics for cSCC” and “Diagnostics for BCC” as needed

Treatment ^[17]

• Surgical excision and/or radiation therapy
• See “Treatment of cSCC” and “Treatment of BCC§ as needed.

Prognosis ^[8][18]

• Early stage SCC has a five-year survival rate of ∼ 90%.
• SCC that originates in the upper lip and/or labial commissure has a worse prognosis than SCC of the lower lip.

Definition

A malignant tumor of the trachea.

Classification

• Primary tracheal carcinomas
  • Uncommon: approx. 0.2% of all respiratory malignancies in the US ^[19]
  • Main subtypes: SCC (∼ 85%) and adenoid cystic carcinoma (∼ 15%)
  • Very rare: mucoepidermoid carcinoma, carcinoid tumors, pleomorphic adenoma
  • Usually malignant in adults and benign in children
• Secondary tracheal carcinomas (most common): may arise from hematogenous or lymphatic sites of metastasis, or by direct extension from adjacent structures (e.g., thyroid, esophagus)

Epidemiology ^[19]

• Peak incidence: 60–70 years of age
• Sex: ♂ > ♀

Etiology

• Risk factors: tobacco smoking, inhalation exposure to hydrocarbons
• Direct invasion of the trachea from carcinoma of the lung, esophagus, larynx, or thyroid gland
• Hematogenous spread from carcinoma of the breast, colon, kidney, and melanoma

Clinical features ^[13]

• Usually mimics other conditions
• Only symptomatic if obstructing the tracheal lumen
• Symptoms vary based on the location of the tumor and histological subtype.
  • Airway obstruction: wheezing, stridor, cough, dyspnea, and hemoptysis
  • Invasion of adjacent structures (e.g., larynx, pharynx): dysphagia, hoarseness (due to recurrent nerve palsy)

Diagnostics

• Usually a diagnosis of exclusion, after lack of response to treatment for alternative diagnoses (e.g., COPD, bronchitis)
• Imaging: chest x-ray or CT to rule out other conditions
• Bronchoscopy with biopsy (confirmatory test)
  • SCC: exophytic or ulcerous lesions that can be multifocal (up to 10%) or arise as an intraluminal nodule
  • Adenoid cystic carcinoma (ACC): polypoid lesions in the trachea or main stem bronchi
  • Mucoepidermoid carcinoma: polypoid lesions from bronchial glands in the central airways

Treatment ^[20]

• SCC
  • Localized carcinoma: complete surgical resection with postoperative radiation or chemoradiotherapy
  • Unresectable, nonmetastatic carcinoma: chemoradiotherapy
• ACC: radiotherapy or chemoradiotherapy
• Mucoepidermoid carcinoma: surgical resection
• See “Airway management in head and neck cancer” if sedation and/or intubation is required.

Prognosis

The five-year overall survival rate for ACC is approx. 80% and approx. 10% for SCC. ^[13]

Head and neck cancers involving the oropharynx or larynx may result in a difficult airway. ^[21]

• Before administering procedural sedation and/or attempting airway intubation:
  • Optimize oxygenation with high-flow nasal cannula oxygen therapy.
  • Assess the patient for red flags for a difficult airway.
  • Plan for difficult airway management in consultation with a specialist.
  • Have the equipment for difficult airway management immediately available.
• Intubation is required urgently, but not immediately:
  • Consult otolaryngology and/or anesthesiology.
  • Consider nebulized epinephrine (e.g., racemic epinephrine) and IV steroids (e.g., dexamethasone).
  • Consider transferring the patient to the OR for further airway management.
• Immediate intubation is needed:
  • Consider intubation via video laryngoscopy or awake fiberoptic intubation.
  • Consider using intubation adjuncts.
  • Be prepared to place an emergency surgical airway.
  • Follow the failed intubation checklist if intubation is unsuccessful.
• Extubate in consultation with an airway expert.

Use airway adjuncts with caution; even mild trauma to the tumor and/or irradiated tissue may cause significant hemorrhage. ^[22]

Administer analgesics and/or procedural sedation with caution to reduce the risk of sudden complete airway obstruction. ^[22]

Placement of a conventional endotracheal tube may not relieve distal airway obstruction caused by tracheal or bronchial obstruction: rigid bronchoscopy or endobronchial intubation may be required.