Head and Neck Service Introduction



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Head and Neck Service

Introduction
The Head and Neck Cancer, broadly classified include squamous cancers of the upper aero-digestive tract (HNSCC), nasopharyngeal cancer (NPC) and benign and malignant tumours of the thyroid and major salivary glands. Management of head and neck cancers often requires a multidisciplinary approach, involving surgical extirpation, external beam radiation and chemotherapy.
The Head and Neck Service consists of three senior Head and Neck surgeons, all having received their advanced training in Head and Neck Surgical Oncology from the United States, and all certified by the American Head and Neck Society. In addition to the routine surgical procedures for thyroid, parathyroid and parotid disease, they specialize in complex head and neck surgeries involving the paranasal sinuses, orbit, oral cavity, oropharynx, larynx, hypopharynx and skull base.
Individualized treatment strategies are discussed and formulated for patients at the Multidisciplinary Head and Neck Tumour Board held every Monday at the National Cancer Centre. These weekly forums are attended by radiation oncologists, medical oncologists, pathologists and radiologists in addition to head and neck surgeons to ensure that treatment recommendations are be best suited to the individual needs of each patient.
The Head and Neck Service is well supported by an experienced team of nurse clinicians, speech pathologists, physiotherapists and social workers to ensure the complete physical, emotional and functional rehabilitation of every patient undergoing major head and neck surgery.
Conditions we treat:

  • Head and neck cancer

  • Thyroid nodules


Head and Neck Cancer


Introduction

Classification



  • Oral cavity

  • Nasopharynx

  • Larynx

  • Hypopharynx

  • Oropharynx

Symptoms

Treatment

Prognosis


Introduction:
Head and neck cancers are the 6th most common cancer worldwide. They consist of a group of biologically similar cancers originating from the upper aerodigestive tract, including the oral cavity (mouth), nasal cavity, paranasal sinuses, pharynx (throat) and larynx (voice box). The majority of head and neck cancers are squamous cell cancers (SCC). In the Asian subcontinent, however, a slightly different cancer, nasopharyngeal cancer (NPC), is endemic, and although originates from the back of the nose (nasopharynx), it behaves, and is treated differently, from squamous cancer. SCC and NPC often spread to the lymph nodes of the neck, and this is may be the first manifestation of the disease at the time of diagnosis. SCC is strongly associated with lifestyle risk factors, including tobacco use, alcohol consumption, and certain strains of the sexually transmitted human papillomavirus. Risk factors for NPC include Ebstein Barr virus exposure and salted fish consumtion, and is seen with highest frequency in Cantonese from the Quangdong province in Southern China. Head and neck cancers are curable if detected early; most often involve a combination of surgery, radiation therapy and chemotherapy.


Classification:

Oral cavity


Squamous cell cancers are common in the oral cavity, including the inner lip, tongue, floor of mouth, buccal mucosa (cheek), gingivae (gums), and palate. Cancers of the oral cavity are strongly associated with tobacco use, especially use of chewing tobacco as well as heavy alcohol use. Cancers of this region, particularly the tongue, are more frequently treated with surgery than are other head and neck cancers.
Surgeries for oral cancers include

  • Maxillectomy (can be done with or without orbital exenteration)

  • Mandibulectomy (removal of the mandible or lower jaw or part of it)

  • Glossectomy (tongue removal, can be total, or partial)

  • Radical neck dissection (removal of lymph nodes of the neck)

The defect is closed primarily, or reconstructed using tissue from another part of the body (flap) or prosthesis.

Nasopharynx

Nasopharyngeal cancer (NPC) arises in the nasopharynx, the region in which the nasal cavities and the Eustachian tubes connect with the upper part of the throat. The large majority of NPCs consist of poorly differentiated or undifferentiated carcinoma, distinct from squamous carcinoma. NPC is distinct in its epidemiology, biology, clinical behavior, and treatment, and is treated as a separate disease.




  • NPC is treated primarily with external beam radiation therapy, with or without combination chemotherapy. Surgery, in the form of Nasopharyngectomy, is occasionally considered for patients with recurrent disease.

Oropharynx

Oropharyngeal cancer begins in the oropharynx, the middle part of the throat that includes the soft palate, the base of the tongue, and the tonsils. Squamous cell cancers of the tonsils are more strongly associated with human papillomavirus infection than are cancers of other regions of the head and neck.




  • Treatment for oropharyngeal cancers may involve surgery, followed by radiation and chemotherpy

OR


  • Combined chemoradiotherapy, with surgery as a salvage procedure for persistant or recurrent disease.

Hypopharynx

The hypopharynx (throat) includes the pyriform sinuses, the posterior pharyngeal wall, and the postcricoid area. Tumors of the hypopharynx frequently have an advanced stage at diagnosis, and have the most adverse prognoses of pharyngeal tumors. They tend to spread early to the lymph nodes and blood stream due to the extensive lymphatic network around the larynx.




  • Treatment consists of combined chemoradiotherapy, with surgery as a salvage procedure for persistent or recurrent disease. Surgery on the hypopharynx of requires removal of the larynx as well.



Larynx

Laryngeal cancer begins in the larynx or "voice box." Cancer may occur on the vocal cords themselves ("glottic" cancer), or on tissues above and below the true cords ("supraglottic" and "subglottic" cancers respectively). Laryngeal cancer is strongly associated with tobacco smoking.


Larynx cancer may be treated with surgery, radiation therapy or chemotherapy.
Surgeries for larynx cancer include


  • Partial laryngectomy (removal of part of the larynx), which may be horizontal or vertical




  • Supracricoid laryngectomy




  • Total laryngectomy (removal of the whole larnyx). If the whole larynx has been removed the person is left with a permanent tracheostomy opening and learns to speak again in a new way with the help of intensive teaching and speech therapy and/or an electronic device.

Symptoms

The most common presentation for head and neck cancers are




  • Mass or lump in the neck

  • Persistent voice change or hoarseness

  • Dysphagia (difficult) or odynophagia (painful swallowing)

  • Otalgia (ear pain, often referred pain from throat cancer)

  • Nasal congestion of bloody nasal discharge


Treatment
Improvements in diagnosis and local management, as well as targeted therapy, have led to improvements in quality of life and survival for head and neck cancer patients.

After a histologic diagnosis has been established and tumor extent determined, the selection of appropriate treatment for a specific cancer depends on a tumor site, clinical stage, relative morbidity of various treatment options, patient performance and nutritional status, and comorbid medical problems.


Individualized treatment planning is done at a Multidisciplinary Head and Neck Tumor Board, involving specialist surgeons, medical and radiation oncologists, pathologists and radiologists.
Surgical resection and radiation therapy (with or without chemotherapy) is the mainstay of treatment for most head and neck cancers and remain the standard of care in most cases.


  • For small primary cancers without regional metastases (stage I or II), surgical excision alone or curative radiation therapy alone is used.




  • More extensive primary tumors, or those with regional metastases (stage III or IV), may be treated with surgery followed by combined chemoradiation, or primary combined chemoradation with surgery as a salvage procedure for persistant or recurrent disease. Survival and recurrence risk has been roughly equivalent between surgical and radiation-based approaches



Prognosis



Although early-stage head and neck cancers (Stage I and II) have high cure rates with 80 – 90% 5-year survival, more than two thirds of head and neck cancer patients present with advanced disease. Cure rates decrease in locally advanced disease (Stage III and IV) decreases to between 30 – 40%, with recurrent local disease, systemic metastasis (spread in the blood stream to organs like the lungs, liver and bone) and new primary cancers being the main cause of mortality. The American Joint Committee on Cancer/International Union against Cancer (AJCC/UICC) Staging System is the most commonly used, using the TNM Classification of Malignant Tumours (TNM), where T is the size of the tumor, N is the presence or absence of lymph node metastases, and M is the presence or absence of distant metastases. The T, N, and M characteristics are combined to produce a “stage” of the cancer, from I to IVB.

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