Faster Triage of Veterans With Head and Neck Cancer

Physical Examination

The GP should perform a bimanual examination of the oral cavity, ears, nose, thyroid, and cranial nerve function with the help of a headlight. The physician should use 2 tongue blades to explore the oral cavity and palpate for suspicious oral lesions. It is often possible to feel a lesion before visualizing it on the base of the tongue. If there is a presenting mass, the physician should document the mass site, size, shape, consistency, tenderness, mobility, and accompanying deficits or symptoms.

Also recommended is a thorough examination of the facial, submandibular, and other cervical lymph nodes. The drainage patterns of these nodes can help the GP track potential routes of malignant infiltration. The submental and submandibular lymph nodes (level 1) drain the lower lip, floor of mouth, anterior tongue, and side of nose. The nodes along the mid and internal jugular vein (levels 2-4) and between the sternocleidomastoid and trapezius muscles (level 5) drain the oropharynx, mid tongue, larynx, hypopharynx, parotid gland, and skin of the face and ear. Nontender hard nodes are more likely to be malignant, as are nodes of the posterior triangle (level 5).¹⁷

Malignancy by Site

Oral cavity. The oral cavity includes the lips, buccal mucosa, teeth, gums, anterior two-thirds of tongue, floor of mouth, alveolar ridge, retromolar trigone, and hard palate. The oral cavity is the most common site for HNCs.¹⁸ The most common symptoms of malignancy of the oral cavity include dysphonia, nonhealing oral ulcers, loose teeth, bleeding, change in denture fit, and chin numbness, which could indicate mandibular invasion with inferior alveolar nerve involvement.¹⁹

For thorough assessment of the oral cavity, the patient should remove all temporary dental appliances. Then, with a tongue blade in each hand, the physician should thoroughly examine the oral mucosa, moving the tongue laterally to evaluate the floor of mouth, and palpate the mucosal surfaces to identify submucosal cancers in the posterior tongue and floor of mouth. Minor salivary glands are ubiquitous in the oral cavity and may be involved by cancer. Ulcerated painful lesions that last longer than 2 weeks are less likely to be common viral or aphthous ulcers. For either an oral cavity mass or a nonhealing ulcer that persists more than 4 weeks, malignancy should be suspected, and the patient should be referred for imaging and biopsy.

Leukoplakias are white patches in the oral cavity that develop from squamous epithelial hyperplasia and cannot be scraped away with a tonghpvue blade. The lesions are usually benign, but, if there is an element of redness (erythroplakia), the risk for harboring dysplasia is much higher, though the differential diagnosis includes trauma from adjacent teeth or lichen planus. If leukoplakia is seen, the physician should accurately note the size, location, and site and should monitor every 3 to 4 months. If erythroplakia, enlargement of leukoplakia, or any evidence of mucosal invasion is noted, the physician should refer to otolaryngologyhead and neck surgery (Oto-HNS). The authors advise against lasering leukoplakia; it is unnecessary, can make subsequent evaluation more difficult, and can mask recurrent malignancy.

Oropharynx. The oropharynx includes the posterior third of tongue, soft palate, palatine and lingual tonsils, and the posterior and lateral pharyngeal walls superior to tip of epiglottis. Cancers can arise in any of these locations and may present with dysphagia, odynophagia, referred
otalgia, hoarseness, and enlarged lymph nodes. In advanced cases, there may be bleeding, airway obstruction, and aspiration. Nonsmokers with oropharyngeal SCC are likely to be HPV positive and may be younger than the typical patient with alcohol- or tobacco-related HNC. Human papillomavirus positive oropharyngeal carcinoma has a much better prognosis than its tobaccorelated counterpart does. Physical examination should include assessment of tonsillar size and symmetry, palpation of neck lymph nodes, and palpation of base of tongue. Treatment may involve surgery, radiation, or chemoradiation, depending on factors such as extent of disease and comorbidities.

Nasopharynx. The nasopharynx extends from the nasal cavity (posterior to nasal septum) to the oropharynx. The most common NPC symptoms are middle-ear effusion and enlarged neck nodes. Nasal obstruction, epistaxis, or cranial nerve deficits also may occur. The nasopharynx
is best assessed with a fiberoptic scope. Most NPCs are associated with EBV infection, and viral levels can be used to monitor response to treatment.20 Early biopsy is indicated if a nasopharyngeal mass is found.

Larynx. As with the nasopharynx, the larynx is best seen with a fiberoptic scope. Malignancy generally presents with hoarseness, voice changes, cough, sore throat, or, if more advanced, airway compromise such as stridor and neck adenopathy. As larynx HNCs may be associated
with aspiration, the authors recommend asking “Does food go down the wrong pipe?” or “Do you cough when you eat?” and having the patient drink and document any difficulty. A smoker with hoarseness lasting more than 2 weeks should be referred to Oto-HNS for endoscopic assessment. Among veterans, other causes of hoarseness include polyps,Candida infection associated with inhalation of steroids for chronic obstructive pulmonary disease, and recurrent nerve paralysis from thyroid or lung cancer.

Neck. Patients with HNCs commonly present with a neck mass. Fifty percent to 80% of adults with a nontender neck mass are harboring a malignancy.^21,22 In a patient without HIV, a neck mass larger than 2 cm should be evaluated for cancer, especially if the mass is hard and nontender.²³ Computed tomography (CT) is recommended for initial evaluation, which, if there is FNA confirmed carcinoma, should be followed by positron emission tomography (PET). If there is concern for parotidor skull base tumors, magnetic resonance imaging (MRI) is preferable for demonstrating soft-tissue definition and disease extent.