Cancer is a disease where abnormal cells grow out of control and spread quickly, forming a mass called a tumour. Tumours can be non-cancerous (benign) or cancerous (malignant). Sometimes cancer cells break away from the original tumour and travel to other areas of the body, where they keep growing and go on to form new tumours. This is called metastasis

Head and neck cancer describes a range of tumours that originate in the head and neck area. These areas exclude the brain and the eye. These cancers can start in the:

1- In the nose or sinuses (nasal and paranasal carcinoma)
2- At the back of the nose (naso-pharyngeal carcinoma)
3- In the mouth including the tongue, the gums and roof or floor of mouth (oral cavity carcinoma, tongue carcinoma)
3- On the lips (lip carcinoma)
4- Back of mouth (oropharyngeal carcinoma)
5- Tonsils (tonsillar carcinoma)
6- Throat (hypopharyngeal carcinoma)
7- Larynx / voice box (laryngeal carcinoma)
8- Salivary glands (salivary carcinoma)

Symptoms depend a lot on where exactly the cancer originates from. It is important to note that all the symptoms listed can be caused by conditions that are not cancerous.

A lump in the neck

Cancers that begin in the head or neck usually spread to lymph nodes or the glands in the neck before they spread elsewhere. A lump in the neck that lasts more than two weeks should be seen by an ENT doctor as soon as possible. Of course, not all lumps are cancer. But a lump (or lumps) in the neck can be the first sign of cancer of the mouth, throat, voicebox (larynx), thyroid gland, or of certain lymphomas and blood cancers. Such lumps are generally painless and continue to enlarge steadily.

Change of voice

Most cancers in the larynx cause some changes in voice. While most voice changes are not caused by cancer, you shouldn’t take chances. If you are hoarse or notice voice changes for more than two weeks, see the ENT doctor.

A growth or sore in the mouth

Most cancers of the mouth or tongue cause a sore or swelling that doesn’t go away. These may be painless, which can be misleading. Bleeding may occur, but often not until late in the disease. If an ulcer or swelling is accompanied by lumps in the neck, you should be concerned. In addition, any sore or swelling in the mouth that does not go away after 2 weeks should be evaluated by a dentist or ENT doctor. The dentist or ENT doctor can determine if a biopsy (tissue sample test) is needed.

Bringing up blood

This is often caused by something other than cancer. However, tumours in the nose, mouth, throat, or lungs can cause bleeding. If blood appears in your saliva or phlegm for more than a few days, you should see your physician

Swallowing problems

Cancer of the throat or esophagus (swallowing tube) may make swallowing solid foods and sometimes liquids difficult. The food may “stick” at a certain point and then either goes through to the stomach or come back up. If you have trouble almost every time you try to swallow something, you should be examined by an ENT doctor. Usually a barium swallow x-ray or an esophagoscopy (direct examination of the swallowing tube with a scope) will be performed to find the cause.

Changes in the skin

If there is a sore on the lip, lower face, or ear that does not heal, consult a dermatologist or ENT doctor. Any mole that changes size, colour, or begins to bleed may mean trouble. A black or blue-black spot on the face or neck, particularly if it changes size or shape, should be seen as soon as possible by a dermatologist, ENT doctor or other physician.

Persistent ear ache

Constant pain in or around the ear when you swallow can be a sign of infection or tumour growth in the throat. This is particularly serious if it is associated with difficulty in swallowing, hoarseness, or a lump in the neck. These symptoms should be evaluated by an ENT doctor.

The two greatest factors that increase the risk of head and neck cancer are tobacco and alcohol.

Tobacco:

This is the leading cause of head and neck cancer. It includes all tobacco products, including cigarettes, cigars, pipes, smokeless tobacco, chewing tobacco, snuff and betel quid
Alcohol: Frequent or heavy consumption of any type of alcohol, such as beer, wine, or liquor, also raises the risk
While tobacco and alcohol play a significant role in head and neck cancer, other risk factors include:

HPV infection:

HPV is a sexually transmitted infection and it increases the risk of oropharyngeal cancers (cancers of the back of the mouth)

Prolonged sun exposure:

prolonged exposure to harmful UV light increases the risk of skin and lip cancer
EBV infection: Epstein-Barr virus, a life-long infection, is a cause of infectious mononucleosis and other illnesses. It lays dormant in the cells of the throat and immune system. It can raise the risk of cancers in the nose, behind the nose (NPC), and cancers of the salivary glands.

Male gender:

head and neck cancer is 2-3 times more common in men than in women
Age: head and neck cancer is more common the older one gets
Poor dental and oral hygiene: poor dental hygiene has been linked to head and neck cancer
Environmental and occupational exposure

GERD and LPR:

this may increase the risk of head and neck cancer.
Weakened immune system: a poor immune system from conditions like HIV increase the risk of head and neck cancer

Environmental/occupational exposure:

Exposure to certain chemicals and substances, including asbestos, wood dust, and paint fumes, increase a person’s risk of developing head and neck cancer

You can lower your risk of getting head and neck cancer in several ways:

1- Don’t smoke. If you smoke, quit. Quitting smoking, it lowers the risk for cancer.
2- Don’t use smokeless tobacco products.
3- Limit the amount of alcohol you drink.
4- If you are 26 years old or younger, talk to your doctor about HPV vaccines. These vaccines were developed to prevent cervical and other genital cancers. HPV vaccines also may prevent some kinds of head and neck cancer.
5- Use condoms during oral sex, which may help lower the chances of giving or getting HPV.
6- Use lip balm that contains sunscreen, wear a wide-brimmed hat when outdoors.
7- Visit the dentist regularly. Checkups often can find head and neck cancers early, when they are easier to treat

Getting to a diagnosis starts with a history and a physical examination of the area of concern.

If the history and physical examination make the ENT doctor less suspicious that your lesion is cancer, he or she might try some medications and rehabilitation before jumping to a diagnosis of cancer.

If the ENT doctor raises the possibility of head and neck cancer, a cancer work up is initiated. The tests ordered vary depending on the symptoms.

A biopsy is the removal of a small piece of tissue to examine under a microscope to see if it is cancerous. A fine needle aspirate is done is commonly done if you have a lump in the neck. The doctor puts a thin needle in the lump and removes a small sample of tissue. Then a pathologist looks at the tissue under a microscope. These are the only ways to be certain if you have cancer.

If the diagnosis is cancer, the ENT doctor will want to learn the stage (or extent) of disease. Staging is a careful attempt to find out whether the cancer has spread and, if so, to which parts of the body. Staging may involve an examination under anesthesia (in an operating room), endoscopy (a tube with a camera passed down your nose, throat or windpipe), imaging procedures (Xrays, ultrasound, CT scans or MRIs), and laboratory tests. Knowing the stage of the disease helps the ENT doctor plan treatment.

If you came to the ENT doctor after having a lesion removed and found it was cancer only after having the lesion removed, the doctor might skip some of the tests and jump to follow-up or additional treatment.

Be sure to bring all the reports and images with you from any prior treatment or if it is for a second opinion

Staging is a process that tells the doctor if the cancer has spread and if it has, how far. It depends on the severity of the original tumour, and whether the cancer has spread to lymph nodes or distant parts of the body. Staging is an important step in evaluating treatment options. Staging is slightly different for each specific type of head and neck cancer, but can be generalized as follows:

Stage 0: Also called “carcinoma in situ,” meaning it has not yet invaded nearby tissue.
Stage 1: Cancer has invaded nearby tissue, but has not yet spread to lymph nodes or other parts of the body
Stage 2: Cancer has grown even deeper into nearby tissue, but still has not spread to lymph nodes or other parts of the body.
Stage 3: Cancer has either grown much deeper into surrounding tissue or started to spread to one lymph node.
Stage 4a: Cancer has grown completely through surrounding tissue into adjacent structures (such as tissue, cartilage, bone, or nerves) and may have spread to a few lymph nodes OR cancer has spread to more than one lymph node.
Stage 4b: Cancer has spread (metastasized) to other parts of the body

In deciding which treatment strategy would be suitable for an individual patient, important considerations include location of the cancer, stage of disease, ability to tolerate treatment, expected functional outcomes and associated illnesses.

Treatment options depend on one or more of the following:

Surgery: If surgery is selected as the best treatment option, the treatment goals will be to remove as much of the cancer as possible in addition to preserving form and function of surrounding anatomic structures. If surrounding anatomic structures are damaged during the removal of the tumour, reconstructive surgery will be performed to rebuild or restore the structure, function and cosmetic appearance of the structures that were removed. Surgery to aid in breathing and eating may be performed as well.

Radiotherapy: Radiotherapy uses high energy rays produced by a machine to kill cancer cells. One advantage of radiation over surgery is that it can be administered on an outpatient basis, which means you will not have to be admitted to the hospital. Also, it avoids the risks of general anaesthesia during surgery, which is particularly important in patients with many medical problems or even just one severe medical problem. Also, radiation therapy as a treatment allows for the possibility of organ preservation; for example, patients can be treated for cancer of the larynx (voice box) without the need to remove the larynx. One disadvantage of radiation is that patients need to come into a treatment facility five days per week for six to eight weeks (though this schedule can vary). Also, there are a number of side effects, both immediate and long-term, that need to be considered

Chemotherapy: Chemotherapy is the use of drugs to target rapidly growing cells in an effort to destroy cancer cells. In many cases, chemotherapy can be delivered on an outpatient basis. This means you go to a special chemotherapy infusion centre for the day. The frequency you will need to receive chemotherapy and how long will be determined by your doctor and may change from the original plan depending on what type of side-effects you have and how the tumour responds. In some cases, the chemotherapy might be administered once per week for three weeks. In other cases, it might be delivered three days in a row and then every week for a few weeks.

Surgery: Surgery retains a pivotal role in management of head and neck cancers. Side effects are both general and specific to the location of the tumour. They include:
Anaesthesia risks
Infections-wound contamination
Blood loss-blood loss is inevitable though it can be minimised by surgical techniques or treated with a blood transfusion
Air embolus-this is air entering into the blood stream, it is very rare but serious.
Chyle leak-damage to the thoracic duct leads to a chyle leak.
Nerve damage-nerves may be inadvertently damaged because of extensive tumour involvement and removal. Repair may be done immediately or later or rehabilitation instituted.
Radiotherapy: There are number of side effects of radiation therapy. The likelihood and severity of complications depends on a number of factors, including the total dose of radiation delivered, over what time it was delivered and what parts of the head and neck received radiation.
Xerostomia (dry mouth)-The most common long-term side effect of radiation therapy for the treatment of head and neck cancer is xerostomia (dry mouth). It occurs when salivary glands are radiated or in the line of radiation. Aside from being bothersome to patients, including making it difficult to eat and speak, there is great risk of dental cavities and dental disease because saliva helps prevent dental disease.
Osteoradionecrosis (bone death)-This is necrosis (or death) of bone that has been exposed to radiation. The bone often becomes exposed through the skin or mucosa and can progress to an actual fracture of the bone. Osteoradionecrosis (ORN) can cause severe pain as well as chronic and persistent infections. Treatment is essentially by visiting a dentist before radiotherapy to make sure the teeth are in the best possible health.
Odynophagia (and mucositis)-This is pain with swallowing. It can be caused as the mouth and throat lining starts sloughing off and becomes inflamed (mucositis).
Skin changes-Patients will usually lose hair in the region that received radiation.
Hypothyroidism-The thyroid gland is located immediately in front of many parts of the throat. Therefore, damage to the thyroid gland can occur following radiation for head and neck cancers. This will result in hypothyroidism, or an underactive thyroid, which can actually be quite delayed in its presentation. Feeling tired and weight gain are the common complaints.
Pharyngoesophageal stenosis-This can be another delayed problem caused by radiation. Pharyngoesophageal (PE) stenosis is an area of narrowing in the throat or oesophagus (feeding tube). This narrowing can make it difficult to eat, particularly solid food.
Secondary cancers-Paradoxically, even though radiation is used to treat cancer, years later it can actually result in new cancers appearing. The risk increases with high dosage and greater time since treatment. The secondary cancer can be quite different from the original. Secondary cancers are rare.
Chemotherapy: You will almost certainly experience side effects from chemotherapy. While chemotherapy targets cancer cells, these medications can also cause damage to normal cells. Finding the right balance can be difficult, and your medical oncologist will speak to you about those issues. Also, while some side effects are common to most chemotherapies, other side effects are specific to certain drugs.
The most common side effects are:

Mucositis- This is inflammation and ulceration of the lining of your mouth and throat. Mucositis can cause severe pain and difficulty with eating and drinking
Hearing loss- Associated symptoms might include ringing in the ears (tinnitus).
Kidney problems-This is a problem with all chemotherapy drugs.
Nausea and vomiting-This is common and you might require additional medication to reduce the nausea.
Rash- The rash looks similar to acne. Fortunately, the rash goes away after stopping treatment, and there is no significant pain or problems related to rashes
Neuropathy- This is a nerve problem that usually starts as a feeling of numbness or tingling in the fingers or toes. It can also feel like an electric bolt that shoots down an arm or a leg. It may not be bothersome and easy to deal with; or it may be severe enough to stop the drugs.
Other side effects include:

Diarrhea / constipation
Low blood counts
Tiredness
Loss of appetite
Bleeding problems
Sexual and fertility changes
Infection
Urination changes
Swelling
Memory changes

Getting prepared

If you have recently been diagnosed with a head and neck cancer, there are some initial steps you can make to get prepared. Some common challenges you may meet in the course of the disease s well as treatment are difficulty with feeding, swallowing and breathing.

Strategies for success to optimize speaking and swallowing include assessment prior to treatment by:

Evaluation by a speech pathologist– Changes in voice and swallowing are common during and after treatment Evaluation by a speech pathologist may be done prior to treatment, especially to obtain baseline measurements of your ability to speak and swallow as well as to assess the likelihood of your experiencing side-effects in your voice or ability to speak as a result of your treatment. The speech pathologist can also provide you with recommendations to preserve your ability to swallow, which may include changes in your oral hygiene routine. In addition, you can learn swallowing exercises and practice them during therapy to maintain your ability to swallow
Evaluation by a nutritionist– Patients with head and neck cancer are often undernourished before initiating treatment, which may be due to complications associated with the tumour. Many patients with head and neck cancer may experience weight loss during the course of the disease. Therefore, a nutritionist may assess your nutritional needs at your baseline and periodically throughout the course of your cancer journey. The nutritionist can provide you with strategies for treatment-associated side effects that may disrupt eating through the course of treatment. If your nutritionist determines that you are currently not getting adequate nutrition at any time during the course of your disease, you may temporarily receive nourishment intravenously or through a feeding tube.
Evaluation by a dentist– Radiation therapy has been associated with an increase in cavities and bone loss. Prior to treatment, you should have a dental evaluation. If you are likely to receive radiation therapy, then prophylactic fluoride treatment should be done to protect your teeth during treatment and for the rest of your life, which can decrease the likelihood of developing cavities

The treatment options depend on the location, type and stage of the head and neck cancer, comorbid diseases and patient values and priorities. The 3 main treatment options are surgery, chemotherapy and radiotherapy in combination or stand alone. Staying on top of the treatment plan involves assessment by a speech pathologist, nutritionist and dentist prior and during treatment

Life during treatment

During your treatment, you will likely experience treatment-related side effects.

The following side effects can worsen during the course of treatment and can negatively impact your quality of life:

Fatigue
Changes in your speech (e.g., hoarseness, loss of voice)1
Pain
Changes in hearing; over 85 percent of patients with head and neck cancer who had chemoradiation therapy experienced hearing loss
Decreased salivation, which often increases dental caries and other dental problems
Problems swallowing (e.g., delayed swallowing or other complications)
Decreased ability to eat

One of your biggest allies in battling cancer is your ENT doctor and cancer doctor (oncologist). Questions are your primary resource to gain a better understanding of your disease and enhance your quality of care. Well-thought-out questions can help you get the most out of your appointments and can make all the difference. Here are some questions you may want to ask:

1- What type of head & neck cancer do I have? Where is the tumour located?
2- What diagnostic tests do I need? What do they involve?
3- Can you explain my pathology report and test results to me?
4- What is the stage of the disease? What is the prognosis?
5- What is the goal of treatment? What are my treatment options?
6- What are the benefits of each treatment?
7- What are the risks and side effects of each treatment?
8- How will my condition be monitored during treatment?
9- Do you have any advice on managing side effects? What can I do to take care of myself during treatment?
10- What is treatment recovery like?
11- What should I tell other people (kids, parents, siblings, friends, etc.) about my cancer when they ask?
12- What will my follow-up appointment schedule be like?