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ENT malignancies

ENT consultants from Queen Elizabeth Hospital Birmingham discuss the most common ENT cancers, their key features and referral criteria

ENT consultants from Queen Elizabeth Hospital Birmingham discuss the most common ENT cancers, their key features and referral criteria

The nose and sinuses

Cancers of the nose and sinuses account for 1% of all malignancies, and men are twice as likely to be diagnosed as women. Squamous cell carcinoma is the most common malignancy, but almost any type of cancer can be found in the sinonasal tract. Patients frequently present late because malignancies here often do not cause symptoms until they have expanded significantly or have extended through the bony walls of the sinonasal cavity.

Early symptoms are also non-specific, so a high index of suspicion is needed to avoid delays.

Key features

Nasal symptoms include persistent unilateral nasal obstruction, epistaxis, reduced sense of smell and excessive mucus production. Eye symptoms include proptosis, diplopia, reduced acuity, pain and epiphora (watery eye).

Patients may also have other symptoms, such as a lump or growth in the face, nose or roof of mouth, loose teeth, pain or numbness in the face, enlarged lymph nodes in the neck or trismus.

Referral criteria

A patient with recent onset of unilateral nasal symptoms, which do not improve with a short course of medical treatment, should be referred. Orbital and neurological symptoms should also be referred urgently. The Department of Health has issued specific guidelines in suspected head and neck cancer – see table 1 for a summary.

Management

Treatment of cancer of the paranasal sinus and nasal cavity depends on where the cancer is, the stage of the disease, and the patient's age and overall health.

But surgery is the mainstay of treatment and is usually done endoscopically.

Mr Shahz Ahmed and Mr Alan Johnson are consultant ENT surgeons

Competing interests None declared

Thyroid

While thyroid disease is common, thyroid cancer is uncommon. Between 15-20% of the UK population have a palpable goitre, of which half are nodular. Thyroid cancer has an incidence in the UK of approximately 1,200 cases per year. This figure is rising, partly due to over-investigation and subsequent detection of small cancers and coincidental microcarcinomas, combined with better data collection. Thyroid cancer most commonly presents as a solitary thyroid nodule in a young euthyroid patient – the incidence of malignancy in this situation is approximately 10%.

Key features

Mandatory investigations are thyroid function tests and five-needle aspiration cytology (FNAC). Serum calcium and antibody status are highly recommended, and an ultrasound scan can also be done.

Referral criteria

The British Thyroid Association published guidelines in 2009 advising which patients should be referred and on what timescale – for a summary, see table 2.

Management

Survival rates remain static. The most common treatment is total thyroidectomy followed by radioiodine remnant ablation, and in the majority of cases the prognosis is excellent.

Both nodal disease and extensive extra-thyroidal spread can increase recurrence rates and reduce survival.

Mr John Watkinson is a consultant ENT and thyroid surgeon and Dr Neil Sharma is an ENT SpR and MRC clinical research fellow

Competing interests None declared

Mouth cancer

Oral cancer is the eighth most common cancer worldwide – over 300,000 new cases are diagnosed each year. In England, the annual incidence is six per 100,000 in men and four per 100,000 in women, with 90% being squamous cell carcinomas. Smoking and alcohol consumption are the most common aetiological factors and are synergistic.

Betel quid chewing is also implicated in the development of the disease in patients of South-East Asian origin.

Key features

The majority of oral cancers present as red or white patches, non-healing ulcers, pain or bleeding in the mouth. The most common sites are the floor of the mouth and the tongue. Patients may also present with a lump in the neck, difficulty swallowing, slurred speech or pain in the throat or ear.

Referral criteria

Investigations for head and neck cancer in primary care are not recommended because they can delay referral. The DH has issued specific referral guidelines in suspected head and neck cancer – see table 1. The diagnosis is made following an incisional biopsy. Most oral cancers can be adequately assessed and staged by clinical examination and imaging.

Management

Surgery is the mainstay of treatment. Small cancers may be resected without the need for reconstruction. But, more commonly, function is improved by the use of free tissue transfer to reconstruct the defect. If the mandible or maxilla is involved, complex reconstruction may be required, using free flaps incorporating bone. Post-operative radiotherapy is recommended for large tumours or positive margins. Primary radiotherapy is best avoided because the post-treatment effect on the oral mucosa is likely to result in poor oral function.

Mr Paul Pracy is a consultant ENT surgeon

Competing interests None declared

Laryngeal cancer

Laryngeal cancer comprises 2-5% of all cancers diagnosed worldwide. It is four times more common in men than women – incidence peaks in men aged 55-65. The vast majority are squamous cell carcinomas.

The most common site – in 50-60% of cases – is glottic (arising from the true vocal cords). Supraglottic tumours account for most of the rest, while subglottic tumours are uncommon (occurring in only 5-10% of cases). Smoking and drinking alcohol are the two most important causative factors.

Key features

The cardinal symptom is progressive continuous hoarseness. Subglottic tumours may present with dyspnoea and stridor. Supraglottic tumours may present with dysphagia, earache, haemoptysis or a neck mass. While distant metastases are rare at presentation, 70% of patients with supraglottic tumours will have cervical nodal disease and the possibility of a second primary tumour should be considered – this occurs in 5-10% of patients.

Referral criteria

Again, investigations in primary care are not recommended as they can delay referral. See table 1 for the DH's specific referral guidelines. A history and examination with flexible nasendoscopic laryngoscopy is followed by cross-sectional imaging.

Management

While the presence of distant metastases or significant co-morbidity may preclude treatment, 95% of patients are amenable to treatment. Surgery and radiotherapy with or without chemotherapy are the mainstays. Early disease can be treated with equal success using either approach as a single modality. Dual modality treatment – either chemoradiation or surgery and post-operative radiotherapy – is commonly used in more advanced disease. Surgery for advanced disease with cartilage invasion usually requires total laryngectomy.

Mr Paul Pracy is a consultant ENT surgeon

Competing interests None declared

Salivary gland cancer

Salivary cancers are uncommon, comprising 3% of primary head and neck cancers in the UK, or one per 100,000 population. Salivary malignancy can also be secondary, in the form of metastatic spread from skin malignancy to the parotid gland and the floor of the mouth in the case of the submandibular gland.

Salivary cancer can also occur in a previously benign lesion. Pleomorphic adenomas are the most common salivary swelling – forming 90% of parotid lesions – but the risk of malignant transformation is about 1% per year. Lymphomas may also present with salivary swelling.

Key features

Salivary cancer usually presents as lumps over the major salivary glands, but may also present with neck node metastasis. Benign salivary lumps are much more common (80%), but a sudden increase in size and pain are the cardinal symptoms of malignancy.

Nerve palsy – especially of the facial nerve – also strongly suggests malignancy. Minor salivary glands exist around the lip and palate and a swelling here can also indicate salivary malignancy.

Referral criteria

Investigations in primary care are not recommended as they can delay referral – see table 1. A salivary lump should be referred urgently to the local neck lump specialist via the two-week wait system.

Management

Investigations usually include cross-sectional imaging and FNAC. Ultrasound examination can yield useful diagnostic information and direct the FNAC, which is especially useful in small tumours.

Treatment usually consists of excision surgery followed by radiotherapy. This should only be performed in specialist head and neck cancer units. Prognosis depends on surgical margins, grade and presence or absence of metastasis.

Mr Chris Jennings is a consultant ENT surgeon

Competing interests None declared

Table 1 - DH guidelines on suspected head and neck cancer

• Any patient with persistent symptoms or signs related to the oral cavity should be referred or followed up. If the symptoms persist after six weeks, urgent referral should be made.
• Red and white patches of the oral mucosa that are painful, swollen or bleeding require urgent referral.
• If oral lichen planus is present, the patient should be monitored for oral cancer as part of routine dental examination.
• Ulceration of the oral mucosa or a mass persisting for more than three weeks requires urgent referral.
• Adults with unexplained tooth mobility for more than three weeks need urgent dental referral.
• Any patient with hoarseness persisting for more than three weeks needs urgent referral for a chest
X-ray. Positive findings indicate urgent referral to a lung cancer team. Negative findings indicate urgent referral to a head and neck cancer team.
• A new lump in the neck or an undiagnosed lump that has changed over three to six weeks needs urgent referral.
• Unexplained persistent swelling in the parotid or submandibular gland requires urgent referral.
• Patients with persistent sore or painful throat require urgent referral.
• Unilateral unexplained pain in the head and neck area for more than four weeks, associated with otalgia but with normal otoscopy, requires urgent referral.

Table 2 - British Thyroid Association guidelines 2009

Patients with thyroid nodules who may be managed in primary care:
• patients with a nodule or a goitre that has not changed for years and who have no other worrying features (such as an adult patient with no history of neck irradiation, no family history of thyroid cancer, and no palpable cervical lymphadenopathy).
• patients with a non-palpable asymptomatic nodule, discovered coincidentally by imaging of the neck, less than 1cm in diameter without other worrying features.

Patients who should be referred non-urgently:
• patients with nodules who have abnormal TFTs
• patients with sudden onset of pain in a thyroid lump
• patients with a new thyroid lump or a lump which is increasing in size over months.

Symptoms needing urgent two-week referral:
• unexplained hoarseness or voice changes associated with a goitre
• a thyroid nodule in a child
• a cervical lymphadenopathy associated with a thyroid lump
• a rapidly enlarging painless thyroid mass over a period of weeks.

Symptoms needing immediate (same day) referral:
• stridor associated with a thyroid lump.

Early right vocal chord carcinoma Early larynx carcinoma

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