Head and neck cancer typically refers to epithelial malignancies of the upper aerodigestive tract and may include neoplasms of the thyroid, salivary glands, and soft tissue, bone sarcomas, and skin cancers. Two-thirds of patients present with advanced disease involving regional lymph nodes at the time of diagnosis. A thorough history and detailed examination are integral to oncologic staging and treatment planning. This article begins with an overview of the head and neck examination (with special attention to detailed findings with clinical implications), followed by a discussion of the major head and neck subsites, and clinical pearls surrounding the examination.
Key points
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The head and neck is a complex region, with many anatomic sites.
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A thorough detailed head and neck examination can adequately evaluate and stage patients with head and neck cancer.
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Endoscopic evaluation is an important complement to the head and neck examination.
Head and neck cancer typically refers to epithelial malignancies of the upper aerodigestive tract, which include the oral cavity, the oropharynx, larynx/hypopharynx, nasopharynx, nasal cavity, and paranasal sinuses. In addition, the term may also include neoplasms of the thyroid, salivary glands, and soft tissue, bone sarcomas, and skin cancers. Head and neck cancer accounts for an estimated 3% to 5% of all cancer in the United States. Two-thirds of patients present with advanced disease involving regional lymph nodes at the time of diagnosis. In view of the broad range of disease and discrete anatomic relationships, a thorough history and detailed examination of the patient with head and neck cancer are often required to define the clinical problem. This careful examination is integral to oncologic staging and treatment planning.
This article begins with an overview of the head and neck examination (with special attention to detailed findings with clinical implications), followed by a discussion of the major head and neck subsites, and clinical pearls surrounding the examination.
History taking in the head and neck
Evaluation of the patient with head and neck cancer begins with the patient’s history. This history should be solicited, with attention to time course of symptom onset and progression. Symptoms such as shortness of breath, hoarseness, dysphagia, odynophagia, otalgia, globus sensation, hearing loss, aural fullness, epiphora, or trismus may be elicited while obtaining the history and often direct the examiner to the primary malignancy. A mass in the neck, or of the face, scalp, mouth, or nose, may be the presenting complaint.
A detailed history of previous malignancies and previous treatments should be obtained. Patients with a previous head and neck malignancy harbor substantial risk for developing a second primary lesion. The annual risk of patients with head and neck cancer developing a metachronous second primary malignancy is estimated between 1.5% and 5.1%. In addition, a variety of tumors can metastasize to the head and neck, with melanoma, breast, lung, kidney, and gynecologic malignancies having been reported in the literature.
In addition to the patient’s comorbid conditions, a family history should be obtained. Birthplace and ethnicity may play a role in head and neck cancer because of ethnic and regional predilections of some diseases. For example, nasopharyngeal carcinoma (NPC) is an uncommon malignancy in most countries of the world, with an average annual incidence of less than 1 per 100,000 per year. However, in the central region of Guangdong province of southern China, the incidence is more than 24 cases per 100,000 per year. Increased incidence of NPC is observed in patients from North Africa, the Middle East, and the Arctic. Although the risk of NPC among Chinese individuals who immigrate to North America remains high, American-born Chinese have significantly lower rates of NPC, approaching the geographic average.
Substance Abuse and Occupational Risk Factors
A focused social and occupational history should be secured. Tobacco use and alcohol consumption account for an estimated 74% of squamous cell carcinoma (SCC) of the head and neck (SCCHN). In individuals who smoke 2 or more packs of cigarettes a day and drink 4 or more alcoholic beverages, there is a 35-fold increased risk in the development of oropharyngeal cancer. Similarly, smokeless tobacco products, such as chewing tobacco and snuff, are well-established risk factors in the development of oral and oropharyngeal cancer. Betel quid, with and without tobacco, which is commonly used by South Asians, is a risk factor in the development of oral cavity as well as larynx, esophageal, liver, and pancreatic cancer. Occupational exposures to asbestos, cement dust, and arsenic are also known risk factors for head and neck cancer. Nickel refining and exposure to wood and leather dust are established risk factors for the development of sinonasal cancers.
History taking in the head and neck
Evaluation of the patient with head and neck cancer begins with the patient’s history. This history should be solicited, with attention to time course of symptom onset and progression. Symptoms such as shortness of breath, hoarseness, dysphagia, odynophagia, otalgia, globus sensation, hearing loss, aural fullness, epiphora, or trismus may be elicited while obtaining the history and often direct the examiner to the primary malignancy. A mass in the neck, or of the face, scalp, mouth, or nose, may be the presenting complaint.
A detailed history of previous malignancies and previous treatments should be obtained. Patients with a previous head and neck malignancy harbor substantial risk for developing a second primary lesion. The annual risk of patients with head and neck cancer developing a metachronous second primary malignancy is estimated between 1.5% and 5.1%. In addition, a variety of tumors can metastasize to the head and neck, with melanoma, breast, lung, kidney, and gynecologic malignancies having been reported in the literature.
In addition to the patient’s comorbid conditions, a family history should be obtained. Birthplace and ethnicity may play a role in head and neck cancer because of ethnic and regional predilections of some diseases. For example, nasopharyngeal carcinoma (NPC) is an uncommon malignancy in most countries of the world, with an average annual incidence of less than 1 per 100,000 per year. However, in the central region of Guangdong province of southern China, the incidence is more than 24 cases per 100,000 per year. Increased incidence of NPC is observed in patients from North Africa, the Middle East, and the Arctic. Although the risk of NPC among Chinese individuals who immigrate to North America remains high, American-born Chinese have significantly lower rates of NPC, approaching the geographic average.
Substance Abuse and Occupational Risk Factors
A focused social and occupational history should be secured. Tobacco use and alcohol consumption account for an estimated 74% of squamous cell carcinoma (SCC) of the head and neck (SCCHN). In individuals who smoke 2 or more packs of cigarettes a day and drink 4 or more alcoholic beverages, there is a 35-fold increased risk in the development of oropharyngeal cancer. Similarly, smokeless tobacco products, such as chewing tobacco and snuff, are well-established risk factors in the development of oral and oropharyngeal cancer. Betel quid, with and without tobacco, which is commonly used by South Asians, is a risk factor in the development of oral cavity as well as larynx, esophageal, liver, and pancreatic cancer. Occupational exposures to asbestos, cement dust, and arsenic are also known risk factors for head and neck cancer. Nickel refining and exposure to wood and leather dust are established risk factors for the development of sinonasal cancers.
Overall function
It is important to assess the patient’s baseline functional status and recent changes in their ability to perform activities of daily living (ADLs). The Eastern Cooperative Oncology Group performance status scale is a commonly used clinical tool for patient assessment. Because head and neck malignancies affect eating, drinking, breathing, swallowing, and talking, progressive disease often has a dramatic impact on performance status, as a result of trouble eating, weakness, and inability to perform ADLs. A patient’s performance status influences treatment planning. Low performance status suggests a poor surgical candidate, problems completing radiation, or an inability to tolerate high-dose cisplatin chemotherapy. Such information informs the patient’s treatment plan.
It is important to assess the patient’s nutritional status, inquiring about weight loss and dysphagia. Dysphagia is an independent predictor of poor survival outcomes. A variety of validated questionnaires, such as EAT-10 (eating assessment tool-10) and SWAL-QOL (swallowing quality of life) , can be used in the office to assess baseline dysphagia. Patients with severe dysphagia and weight loss may need nutritional support, which may include tube feeding.
An assessment of shortness of breath or difficulty breathing should always be performed. Patients with some head and neck cancer (such as larynx cancer) may present with progressive airway obstruction. These patients must be urgently identified and treated. Indirect laryngoscopy to evaluate the airway is probably the best approach to rapid evaluation.
Physical examination
A complete head and neck examination should be performed for all patients with suspected head and neck cancer, even if the location of the primary malignancy is already known. Of patients with head and neck cancer, 3% to 4% present with a synchronous second primary lesion in the head and neck.
Evaluation begins with an assessment of the patient’s general appearance. Difficulty breathing or stridor, nutritional status, affect, and mood are readily assessed by observation alone. Smell of smoke and tar-stained teeth may be signs of heavy tobacco use.
Stridor presents as a high-pitched respiratory sound resulting from turbulent airflow through a partially obstructed airway. Inspiratory stridor is commonly associated with obstructive supraglottic masses, whereas biphasic stridor usually accompanies fixed obstruction either of the trachea or at the level of the glottis (such as in bilateral vocal cord paralysis). Individuals with significant dysphagia and difficulty tolerating secretions may drool. Drooling should be considered a worrisome sign. All such patients should undergo timely evaluation including airway inspection by indirect laryngoscopy.
Stertor is an inspiratory sound comparable with snoring and occurs when there is an airway obstruction above the level of the larynx. Stertor often occurs with benign presentations such as obstructive sleep apnea, or in patients with Pickwickian syndrome. It can also be a presenting sign of malignancy. For example, new onset stertor may be reported with a cancer of the uvula, tonsil, or nasopharynx.
Appreciate the quality and power of the patient’s voice. A breathy voice suggests a unilateral vocal cord paralysis and may be seen in lung cancer, thyroid cancer, larynx cancer, or with other lesions along the vagus nerve tract (eg, vagal paraganglioma). Hoarseness may be a sign of laryngeal disease. A hot potato voice or inability to articulate words clearly suggests posterior oral cavity or oropharyngeal disease. Hyponasality may be a sign of a mass involving the nasopharynx.
Inspect the face for symmetry. Masses of the parotid gland may be appreciated. Tumors causing incomplete facial nerve paralysis may present with asymmetric facial wrinkling, asymmetric eye blink, blunting of the nasolabial fold, or ptosis of the oral commissure.
Skin and Scalp
Evaluation of the skin should be performed systematically, with particular attention to sun-exposed areas such as the ears, scalp, and posterior neck. Note any chronic burns, scars, and ulcers. Inspect all masses and lesions for color variegation and asymmetry. Note the size of all lesions and whether there is ulceration or bleeding.
Intralymphatic regional metastases in the form of satellite or in-transit metastases may be appreciated surrounding a primary melanoma. Satellite metastases occur within 2 cm of the primary lesion, whereas in-transit metastases occur more than 2 cm from the primary lesion.
Neurologic
A complete cranial nerve examination provides considerable information surrounding the affected patient. The cranial nerves course throughout the head and neck, and therefore, cranial neuropathies may indicate the location of a primary malignancy and the extent of tumor invasion.
Although the olfactory nerve is not routinely tested in the office, patients may present with subjective changes in their sense of smell, or its complete loss. Tumors of the olfactory epithelium such as esthesioneuroblastomas, primary sinonasal tumors, and other nasal tumors may present with hyposmia/anosmia.
With tumors involving the nasopharynx, sinuses, orbital cavity, or suprasellar masses such as craniopharyngiomas, visual acuity and extraocular movements should be assessed. The oculomotor, trochlear, and abducens nerves are assessed through evaluation of eye mobility. Tumors of the sphenoid or other paranasal sinuses may extend into the orbit and result in palsy. In the case of a suprasellar mass, bitemporal hemianopsia may be the presenting symptom.
The trigeminal system should be tested. Numbness or paresthesias can greatly inform the clinical scenario. A forehead SCC with V 1 numbness suggests perineural invasion. Loss of V 2 sensation in conjunction with a maxillary sinus mass may suggest invasion into the nerve. Some oral cavity cancers present with a loss of sensation to the chin during shaving, caused by cancer involving the mandibular canal and disruption of mental nerve. Paresthesias of the trigeminal system are not to be taken lightly; anatomic imaging should be used to evaluate the course of these nerves with any dysfunction.
Facial nerve deficits may occur from disruption anywhere along its course and could reflect tumors of the parotid, an acoustic neuroma, or perineural invasion from cutaneous malignancies.
Masses along the course of the main trunk of the vagus nerve such as vagal paragangliomas can result in asymmetric palatal elevation or vocal cord paralysis. Loss of laryngeal sensation may result in symptoms of aspiration or choking. Evaluation of vocal cord movement is discussed separately.
The spinal accessory nerve innervates the sternocleidomastoid and trapezius muscles and is therefore important in rotation of the head, shoulder elevation, and adduction of the arm. Cervical metastasis may also invade the spinal accessory nerve. It is best assessed through shoulder adduction.
The hypoglossal nerve innervates the tongue and is responsible for movement. Invasion of the hypoglossal nerve may result in the inability to protrude the involved side of the tongue. Unilateral weakness results in deviation of the tongue to the ipsilateral side. Loss of function of the hypoglossal nerve may accompany deep tongue invasion into the extrinsic muscles of the tongue within the oral cavity, involvement of the nerve near the external carotid artery caused by metastatic lymphadenopathy, or direct invasion at the skull base by tumor. These possibilities should all be considered on examination.
Ear Examination
Inspect the outer ear for any masses, lesions, or signs of deformity. The ears are particularly prone to solar damage and are a common site of cutaneous malignancies. Inspect the tympanic membrane. Malignancies of the nasopharynx may result in eustachian tube dysfunction and unilateral serous effusions. Hearing loss may be a presenting symptom. Pneumatic otoscopy allows for assessment of the mobility of the tympanic membrane. Normally, the middle ear space is filled with air, and the tympanic membrane is highly mobile. An effusion dampens the mobility of the tympanic membrane.
Nasal Examination
Anterior rhinoscopy should be performed with a nasal speculum. The anterior septum, inferior and middle turbinate, and middle meatus should be readily seen. The nasal cavity should be examined for masses, ulcers, polyps, or evidence of bleeding.
Oral Cavity
The oral cavity begins at the white line or the junction between the skin and the vermilion border of the lip. The oral cavity is subdivided into the lips, tongue (to the level of the circumvallate papillae), hard palate, floor of mouth, retromolar trigone (RMT), and buccal membranes. The RMT is a triangular region with its base of the last mandibular molar and apex at the maxillary tuberosity. It is composed of the ascending ramus of the mandible with its overlying mucosa. Each of these subsites within the oral cavity should be examined for masses, lesions, ulcers, or asymmetry.
Oral cavity examination begins with inspection of the lips and competence of the oral commissure. Next, the dentition, gums, floor of mouth, tongue, alveolar ridge, RMT, and palate should be inspected. Dentures should be removed.
Assess for trismus by instructing the patient to open their mouth as much as they can. Trismus has many causes. It may be caused by pain, for example as a result of a cancer of the buccal mucosa. It may also be a sign of invasion of pterygoid musculature, as seen with advanced oropharynx cancers. When patients present with an oral cancer, resectability of oral cavity lesions should be evaluated.
A gloved finger should be used to palpate for any submucosal masses. The Wharton ducts should be appreciated as they open on either side of the lingual frenulum in the floor of the mouth. The papilla of the Stenson ducts may be seen exiting the buccal mucosa adjacent to the second maxillary molar tooth. A bimanual examination is performed using a gloved finger to palpate the floor of the mouth while providing external neck manipulation.
Evaluate tongue protrusion and mobility. As noted earlier, tumors of the tongue or floor of mouth may limit tongue mobility.
Oropharynx
The oropharynx is subdivided into the tonsil/tonsillar pillars, soft palate/uvula, posterior pharyngeal wall, and tongue base. The oropharynx should be inspected for symmetry. A gloved finger should be used to palpate the tonsillar fossae and tongue base. A mirror may be used to inspect the vallecula.
Neck, Parotid, and Submandibular Gland
The trachea and larynx are palpable in the midline neck. The hyoid bone, thyroid cartilage, and cricoid should be appreciated. Visible and palpable pulsations in the suprasternal notch may herald a high-riding innominate artery and should be noted. The thyroid may be palpated below the level of the cricoid and any masses noted. Fixation of thyroid nodules to the musculature or overlying skin is a worrisome sign of potentially aggressive thyroid disease.
The neck is divided into 7 levels ( Fig. 1 ). Laterality, size, mobility, and firmness of all lymph nodes should be noted. Submandibular lymphadenopathy should be differentiated from prominent submandibular glands.
