Head & neck cancers: What you’ll see, how to proceed
What physical findings should raise your suspicion? How are tumors treated and what follow-up care can you provide? Here’s what you need to know.
PRACTICE RECOMMENDATIONS
› Do not treat a neck mass with antibiotics unless it has features consistent with infection. C
› Order laryngoscopy for all patients with hoarseness that does not resolve after 3 months—or sooner, if malignancy is suspected. C
› Order ultrasonography-guided fine-needle aspiration for diagnostic evaluation of salivary gland masses. B
› Manage a thyroid nodule based on its sonographic features, including size, consistency, and the presence of concerning features. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Anaplastic thyroid cancer, a rare form of thyroid cancer, carries a high mortality rate, with a median survival of 5 months from diagnosis and 1-year survival of 20%. Patients require expeditious total thyroidectomy and neck dissection, followed by external-beam radiation with or without chemotherapy. If this strategy is not feasible, tracheostomy might be necessary to maintain a patent airway.2 Family physicians treating a patient who has anaplastic thyroid cancer can fulfill a crucial role by ensuring that an advance directive is established, a surrogate decision-maker is appointed, and goals of care are well defined.
Follow-up care for head and neck Ca
The risk of adverse effects after radiation therapy for head and neck cancer calls for close monitoring, appropriate treatment, and referral and counseling as needed. See “Follow-up care after treatment of head and neck cancer.” 35-39
SIDEBAR
Follow-up care after treatment of head and neck cancer35-39
Challenge: After radiation to the head and neck, as many as 53% of patients develop subclinical hypothyroidism and 33% develop clinical hypothyroidism.35Strategy: Measure the thyroid-stimulating hormone level within 1 year of the completion of radiotherapy and every 6 to 12 months thereafter.36
Challenge: Radiation to the head and neck can decrease the function of salivary glands, causing xerostomia in as many as 40% of patients. This condition can lead to problems with oral hygiene and difficulty with speech, eating, and swallowing.37Strategy:
- Treat xerostomia with artificial saliva, sugar-free candy and gum, or muscarinic cholinergic agonists, such as pilocarpine and cevimeline.
- Consider treatment with pilocarpine or cevimeline. Pilocarpine alleviates xerostomia in approximately 50% of patients who develop the condition, although its use can be limited by adverse cholinergic effects.3,7 Cevimeline causes fewer and less pronounced adverse effects than pilocarpine because it acts more specifically on receptors in the salivary glands.38
- Mention the possibility of acupuncture to your patients. There is evidence that it can stimulate salivary flow.39
Challenge: Patients who have had radiation to the head and neck have an increased risk of dental caries from xerostomia and the direct effect of radiation, which causes demineralization of teeth.
Strategy: Following radiation, instruct the patient about appropriate oral hygiene:
- regular flossing
- brushing and application of daily fluoride
- regular visits for dental care.39
Challenge: Trismus occurs in 5% to 25% of patients, depending on the type of radiation.36Strategy: Recommend exercise-based treatment, the treatment of choice. Surgery is indicated for severe cases.
Challenge: Dysphagia occurs in approximately 25% of patients treated with radiation.36Strategy: Provide a referral for swallowing exercises, which might be helpful. Some cases are severe enough to warrant placement of a feeding tube.37
Last, counsel all patients who have been treated for cancer of the head or neck, with any modality, about cessation of smoking and alcohol.
CORRESPONDENCE
Anne Mounsey, MD, Family Medicine Residency, The University of North Carolina at Chapel Hill, 590 Manning Dr., Chapel Hill, NC 27599; Anne_mounsey@med.unc.edu
