Head and neck cancer information symptoms treatment

This information has been prepared to help you understand more about head and neck cancer.

Many people feel understandably shocked and upset when they are told they have cancer. This information is intended to help you understand the diagnosis and treatment of this type of cancer.

We cannot advise you about the best treatment for you. You need to discuss this with your doctors. However, we hope this information will answer some of your questions and help you think about the questions you want to ask your doctors or other health carers.

The head and neck region

This website provides information about four main types of head and neck cancer:

  • oral (mouth) cancer
  • pharyngeal (throat) cancer
  • laryngeal (voice box) cancer
  • nose, nasal cavity and paranasal sinus cancer.

The nose and sinuses
The nasal cavity is the large, air-filled space located behind the nose. The nose and upper respiratory tract warm, moisten and filter the air you breathe.

Paranasal sinuses are air-filled spaces within the head that help to lighten the weight of the skull. They also produce mucus and vibrate sound when you speak. The sinuses are in four locations:

  • frontal sinuses – behind the forehead
  • ethmoid sinuses – between the eyes
  • sphenoid sinuses – at the base of the skull
  • maxillary sinuses – under the eyes within the maxillary (cheek) bones.

Mouth (oral cavity)
The mouth includes the lips, gums and tongue. The tongue is the largest organ in the mouth and is made of muscular tissue.

The roof of the mouth is formed by the hard palate. Behind the hard palate is the soft palate, which is an arch of muscle behind the hard palate, going into the throat. The soft palate lifts to close off the passageways to the nose so food does not go through the nose on swallowing.

Throat (pharynx)
The throat (pharynx) is the tube that runs from the back of the nose to the oesophagus and trachea. It has three parts:

  • nasopharynx – the open cavity behind the nose and above the soft palate
  • oropharynx – the area from the soft palate and base of the tongue to the back of the mouth, including the tonsils
  • hypopharynx or laryngopharynx – the lowest part of the back of the throat, behind the voice box (larynx).

Halfway down the neck, the throat branches into two tubes:

the oesophagus – the tube that carries food to the stomach
the trachea – the tube that brings air into and out of the lungs.

Voice box (larynx)
The larynx sits on top of the trachea. It contains the vocal cords (glottis), which vibrate on air coming up from the lungs to allow you to produce the sounds required for speech.

Above the vocal folds is a small flap of tissue called the epiglottis, which prevents food going into the trachea when you swallow.

The area below the glottis is called the subglottis.

Under the voice box, in front of the trachea, is the thyroid gland

Types of head and neck cancer

Mouth or oral cancer – includes cancer that starts anywhere in the mouth, such as the lips, inside cheeks, the front two-thirds of the tongue and the gums.
Salivary gland cancer – can occur in any of the paired major glands in front of the ears or beneath the jaw or tongue.
Pharyngeal cancer – cancers in the pharynx (throat): nasopharyngeal, oropharyngeal and hypopharyngeal cancers.
Laryngeal cancer – starts in the larynx (voice box).
Nasal cancer or paranasal sinus cancer – includes cancers starting in the nose, nasal cavity or the sinuses.

How common is head and neck cancer?

About 900 people in NSW are diagnosed each year. About 70% men and 30% women.

Average age at diagnosis is 67 for men; 63 for women. Statistically, lip cancer is considered separately.

About 180 new cases of lip cancer are diagnosed in NSW each year.

Causes of head and neck cancer

The main risk factor of head and neck cancers (excluding skin cancer) is tobacco use.

Alcohol is also strongly linked.

Using both tobacco and alcohol together further increases a person’s risk. Other risk factors include:

Age – head and neck cancer is most common in people aged 50 and older.
Sex – men are about 3 times more likely to develop head and neck cancer Race – people from some cultural backgrounds may be more likely to develop certain types of head and neck cancer.
Inhalation of certain chemicals or dusts – breathing in sulphuric acid mist, asbestos fibres, dry-cleaning solvents, certain types of paint or nickel may increase the risk.
Chewing areca nut (known as betel nut or paan) – may cause oral cancer.
Diet – some studies suggest a diet low in beta-carotene (found in some fruits and vegetables) may be a slight risk factor.
White patches or red patches – Having leukoplakia (white patches in the mouth) or erythroplakia (red patches in the mouth) may lead to oral cancer.
Human Papillomavirus (HPV) – HPV may be associated with some cancers of the oropharynx. This may be related to oral sex, which transmits the virus.

Symptoms of head and neck cancer

You may have a sore or swelling in your mouth, neck, throat or jaw that does not go away, or difficulty chewing or swallowing. These symptoms, along with pain in your head and neck region, are common to oral, pharyngeal, laryngeal and nasal or paranasal cancer.

Oral cancer symptoms

  • mouth pain or pain on swallowing
  • a white patch on your gums, tongue or lining of your mouth (leukoplakia) a red patch on your gums, tongue or lining of your mouth (erythroplakia)
  • change in your speech or difficulty pronouncing words
  • difficulty swallowing food, or food that gets ‘stuck’
  • a lump in your neck
  • loose teeth or dentures that no longer fit well

Pharyngeal cancer symptoms

  • throat pain
  • a persistent sore throat or cough coughing up bloody phlegm
  • difficulty swallowing
  • a change in the sound of your voice, or hoarseness
  • a feeling that your air supply is blocked
  • dull pain around your breastbone
  • a lump in the neck
  • an earache
  • numbness of the face

Laryngeal cancer symptoms

  • swelling in your neck or throat
  • a change in the sound of your voice, or hoarseness
  • a lump in the neck
  • difficulty swallowing
  • a persistent sore throat

Nasal and paranasal cancer symptoms

  • a persistent blocked nose, particularly in one nostril
  • decreased sense of smell
  • nosebleeds
  • mucus drainage in the back of your nose or throat
  • frequent headaches or a feeling of sinus pressure
  • a bulging or watery eye, double vision or complete or partial loss of eyesight
  • a lump on your face, or in your nose or mouth
  • loose or painful teeth
  • pressure or pain in your ears

Tests to diagnose head and neck cancer

Your doctor will often do a number of tests before they diagnose head and neck cancer.

Physical and visual examination

Your doctor will examine your mouth, tonsils and soft palate (oropharynx), neck, ears and eyes. A spatula may be used to see inside the mouth more clearly. The doctor may also insert a gloved finger into your mouth to feel areas that are difficult to see, and will check your lymph nodes (lymph glands) by gently feeling the sides of your neck.

Nasendoscopy

A nasendoscopy is used to examine the nose, pharynx and larynx. Your doctor will use a flexible tube called an endoscope. The back of your nose and throat will be numbed by spraying a local anaesthetic. The doctor will insert the endoscope into your nose to look at your nasal cavity, nasopharynx, oropharynx, hypopharynx and larynx.

The test is not painful as the tube is soft and flexible. However, it can feel uncomfortable. You will be asked to breathe lightly through your nose and mouth. You may be asked to swallow and to make some vocal noises. The doctor may also take some tissue samples (biopsies).

The test takes 5-15 minutes. Avoid eating and drinking for 30 minutes afterwards.

Laryngoscopy

A laryngoscopy is a procedure that allows a doctor to examine your larynx and pharynx, and take a tissue sample from your voice box.

Can be performed in two ways:

Indirect laryngoscopy – a mirror is inserted into the back of the pharynx the larynx is examined tissue samples (biopsies) may be taken.

Direct laryngoscopy – a tube with a light is inserted into the back of the pharynx, the larynx is examined and tissue samples (biopsies) may be taken.

The procedure is done under a general anaesthetic so that you don’t feel anything. It will take 10-40 minutes, and you can go home when you’ve recovered from the anaesthesia. Afterwards, you may have a sore throat for a couple of days.

Biopsy

A biopsy is when the doctor removes a small amount of tissue for examination under a microscope. It shows whether cancer cells are present and what type of cancer it is. It can often be done during a physical examination, nasendoscopy or laryngoscopy. You will have either a local or general anaesthetic so that you do not feel the procedure. Biopsy results are usually available in about a week.

CT scan

A computerised tomography (CT) scan uses x-ray beams to take pictures of the body. Before the scan, you may have dye injected into your veins to make the pictures clearer. The dye may make you feel flushed or hot for a few minutes.

You will lie still on a table that moves slowly through the CT scanner. The scanner is large and round like a doughnut. The CT scan itself takes a few minutes and is painless, but the preparation takes 10-30 minutes. You can go home when the scan is complete.

MRI scan

Magnetic resonance imaging (MRI) uses magnetism and radio waves to build up detailed cross-section pictures of the body. You may be injected with a dye before the scan to make the pictures clearer. The pictures are taken while you lie on a table that slides into a narrow metal cylinder – a large magnet – that is open at both ends.

This test is painless, but some people find lying in the cylinder too confined and noisy. If you think this will be a problem, let the doctor or nurse know beforehand as they can give you medication to ease this feeling. The test takes about an hour and you can go home once it’s over.

PET scan

A positron emission tomography (PET) scan produces a three dimensional colour image that shows where some cancers are in the body. It is sometimes recommended to help diagnose oral, pharyngeal or laryngeal cancer, or to see if the cancer has spread. It is only available at some hospitals.

You will be injected in the arm with a radioactive glucose solution that takes 30-90 minutes to go through the body. You will need to lie quietly during this time. You will then be scanned for high levels of radioactive glucose. This shows where cancer cells are in the body, as they take up more glucose than normal cells.

X-rays

You may need x-rays of your head and neck to check for tumours or damage to the bones. The x-rays are quick and painless. There are different types of x-rays, some of which include:

Orthopantomogram (OPG) – This is used to examine the jaw and teeth of people with mouth cancer.

Chest x-ray – This is sometimes done for people with mouth, pharyngeal or laryngeal cancer to check their general health and see whether the cancer has spread to the lungs.

X-ray of facial bones – If you have a nasal or paranasal sinus cancer, the bones in your face will be checked for signs of cancer spreading.

Ultrasound

A scan that uses soundwaves to create pictures of part of your body. It is sometimes used to diagnose pharyngeal cancer or to see if another type of cancer has spread (metastasised).

A gel is spread over the area where the doctor is scanning and a paddle- shaped device is moved over the area. It takes a few minutes and is painless.

Staging

Staging tells the doctor how far the cancer has spread. This helps your health care team decide what treatment is best for you. Most cancers follow a general, international staging system called TNM.

T (tumour) 1-4 – Refers to the size of the primary tumour. The higher the number, the larger the cancer.

N (nodes) 0-3 – Shows whether the cancer has spread to the regional lymph nodes of the neck. No nodes affected is 0; increasing node involvement is 1, 2 or 3.

M (metastasis) 0-1 – , Cancer has either spread (metastasised) to other organs (1) or it hasn’t (0).

Prognosis

Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis and treatment options with your doctor, It is not possible for any doctor to give you a 100% accurate prediction on the course of the illness. Test results, the rate and depth of tumour growth, how well you respond to treatment, and other factors such as age, fitness and your medical history are all important factors in assessing your prognosis.

Which health professionals will I see?

If these tests do not rule out cancer, your GP will refer you to a urologist, who will examine you and may do more tests. The following list includes a range of health professionals that you may see throughout your treatment and recovery. Depending on the type and stage of your cancer you may not see all of these health professionals.

  • General practitioner – a doctor who arranges the first tests to check out your symptoms.
  • ENT specialist – diagnoses and treats disorders of the ear, nose and throat.
  • Oral (maxillofacial) surgeon – specialises in reconstructive surgery to the face and jaws.
  • Head and neck surgeon – operates on cancer in the head and neck region.
  • Medical oncologist – plans and administers chemotherapy.
  • Radiation oncologist – prescribes and coordinates the course of radiotherapy.
  • Cancer nurse coordinator or clinical nurse consultant – coordinates your care and supports you throughout treatment.
  • Dentist or oral medicine specialist – evaluates and treats the mouth and teeth.
  • Gastroenterologist – specialises in the digestive system and its disorders.
  • Ophthalmic surgeon – deals with surgery affecting the eyes and visual pathways.
  • Prosthodontist – a dentist who specialises in replacing missing teeth psychologists and counsellors – help people cope with changes to life as a result of cancer or treatment.
  • Dietitian – supports and educates patients about nutrition and diet, including tube feeding.
  • Audiologist – diagnoses and treats hearing problems.
  • Reconstructive surgeon – restores, repairs or restructures the appearance and function of the body using surgery.
  • Social worker, physiotherapist and occupational therapist – link you to support services and help you get back to normal activities.

Treatment

Head and neck cancers are treated differently depending on their location and size. Surgery, radiotherapy or chemotherapy, or a combination of these treatments are used to treat the cancer.

Oral cancer treatment – Cancers of the oral cavity are commonly treated with surgery, then radiotherapy if required. Chemotherapy is sometimes used in combination with these treatments.

Different types of oral surgery include:

  • glossectomy – removes part of the tongue
  • mandibulotomy – cuts through the lower jaw
  • mandibulectomy – removes part/all of the lower jaw
  • maxillectomy – removes part/all of the upper jaw (hard palate)
  • transoral primary tumour resection – removes part of the tumour through the mouth.

Your surgeon may remove some lymph nodes in your neck. This is called a neck dissection or lymphadenectomy.

The surgeon will try to remove the smallest possible area so there are few long-term side effects. In some cases, a laser is used. You will be under general anaesthesia.

Salivary gland cancer treatment – Surgery is done in most cases. This is usually followed by radiotherapy. Chemotherapy is not usually given unless the cancer has spread, and it may be offered as palliative treatment.

Most salivary gland tumours affect the parotid gland, which has two parts. Surgery to remove this gland is called a parotidectomy. Surgeons can often cut inside or under the jaw to reach the area but sometimes they need to cut through the jaw. Reconstructive surgery will restore any removed tissue.

The facial nerve, which controls movement and muscle tone in the face, runs through the parotid gland. It may be damaged during surgery or part of it may be removed if the cancer has grown around it. If the facial nerve is affected, the surgeons may be able to rejoin it using a nerve from another part of the body, often the leg (a nerve graft). If successful, this will improve movement and appearance on that side of the face.

Pharyngeal cancer treatment – This is usually treated with surgery or radiotherapy. If radiotherapy does not destroy all the cancer cells or if the cancer comes back, surgery may be performed. If surgery is done first, radiotherapy may be used afterwards to destroy any remaining cancer cells. Chemotherapy may also be offered, usually with radiotherapy.

Different types of pharyngeal surgery include:

  • pharyngectomy – removes part or all of the pharynx
  • mandibulotomy – cuts through the lower jaw
  • mandibulectomy – removes part or all of the lower jaw
  • maxillectomy – removes part or all of the upper jaw
  • laryngopharyngectomy – removes part or all of the voice box (larynx) and pharynx.

Laryngeal cancer treatment – Where possible, early laryngeal cancer is treated with either laser surgery or radiotherapy. For larger cancers, radiotherapy is usually combined with chemotherapy (chemoradiation). For advanced cancer, surgery is only used if the cancer comes back or it’s not all killed by radiotherapy. Chemotherapy may be given first to ease the pressure on a person’s airway while chemoradiation is being planned. Radiotherapy (with or without chemotherapy) will be given after surgery to reduce the chance of the cancer coming back.

Different types of laryngeal surgery include:

  • Total laryngectomy – This removes the larynx and separates the windpipe (trachea) from the oesophagus. Without your vocal cords, you won’t be able to speak naturally after this procedure, but you will work with a speech pathologist to learn ways to communicate.
  • Partial laryngectomy – This takes out part of the larynx. It is a rare operation because laser surgery has become more common. You will keep part of your voice box and be able to speak but after surgery your voice may be hoarse.

Nasal or paranasal sinus cancer treatment – These are commonly treated with surgery, followed by radiotherapy and/or chemotherapy.

There are various operations for cancers of the nasal cavity and paranasal sinuses – the type you have depends on the location of the tumour. Surgery for paranasal sinus cancer, in particular, varies, depending on which sinuses are affected.

Different types of surgery for nasal cancer include:

  • maxillectomy – removes part or all of the upper jaw, possibly including upper teeth, part of the eye socket and/or the nasal cavity
  • craniofacial resection – removes tissue between the eyes, requiring a cut along the side of the nose
  • lateral rhinotomy – cuts along the edge of the nose to gain access to the nasal cavity and sinuses
  • orbital exenteration – removes the eye
  • rhinectomy – removes part or all of the nose
  • endoscopic sinus surgery – removal of part of the nasal cavity or sinuses through the nostrils, using an endoscope
  • midface degloving – gaining access to your nasal cavity or sinuses by cutting under the upper lip, which means there will be no scar on the face.

Some people also have surgery to remove lymph nodes in the neck (neck dissection or lymphadenectomy).

Radiotherapy

Radiotherapy is the use of high-energy x-rays or electrons to kill or damage cancer cells. It can be used alone or with another treatment, such as surgery or chemotherapy.

Your medical team will help you decide what treatment to have. Before your treatments begin, you will probably go to a planning (simulation) session and have x-rays be fitted with a mask to wear during treatment. You may also visit a dentist or oral medicine specialist.

If you receive radiotherapy, you will usually have daily treatment sessions Monday to Friday, for about 6-7 weeks.

There are two types of radiotherapy:
External beam radiation – This is the traditional (conventional) way radiotherapy is given. This form of treatment is common for oral, salivary gland, laryngeal, pharyngeal, nasal and paranasal sinus cancers. During treatment you will lie on a table while radiation is directed from a machine into your body. Treatment itself is painless.

Intensity modulated radiation therapy (IMRT) – IMRT is a type of external radiation. It is more common for cancers of the tongue, larynx and paranasal sinuses. The radiation can be shaped around the tumour, which reduces possible damage to healthy tissue. This means a higher dose can be given than in conventional radiotherapy. You will have treatment for 1-6 weeks.

Internal radiation – Also known as brachytherapy, this treatment is only occasionally used for oral cancers. Small tubes are inserted into and around the tumour while you are under a general anaesthetic. Radioactive material is then placed in the tubes. Your doctor will give you more information about this treatment.

Chemotherapy

Chemotherapy is the treatment of cancer with anti-cancer (cytotoxic) drugs. The aim of chemotherapy is to kill cancer cells while doing the least possible damage to healthy cells.

It can be given during the course of radiotherapy (chemoradiation). Other times, it may be given before surgery or radiotherapy to shrink a tumour (neoadjuvant chemotherapy). It can also be given as a palliative treatment for symptom management. This aims to reduce pain or discomfort by stopping the cancer from growing and pressing on nerves and other tissue.

Chemotherapy is usually given by injection into a vein (intravenously). You will probably have sessions of chemotherapy over several weeks, however your medical team will determine your treatment schedule.

Palliative treatment

Palliative treatment helps improve people’s quality of life by alleviating symptoms of cancer, without trying to cure the disease.

Often treatment is concerned with pain relief and stopping the spread of cancer, but it also involves the management of other physical and emotional symptoms. Treatment may include radiotherapy, chemotherapy or other medications.

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