AAO-HNSF Primary Care Otolaryngology Handbook

HEAD AND NECK CANCER

The evaluation for a suspicious neck mass requires a comprehensive head and neck examination to identify the origin of the primary cancer. Additionally, a fine-needle aspiration biopsy (FNAB) of the neck mass in the clinic is performed. An open-neck biopsy should be avoided, as this approach will impede the appropriate definitive care. A computed tomography (CT) scan of the neck and chest and possible positron emission tomography (PET) scan for complete staging and treatment planning should be ordered. The patient may be taken to the operating room (OR) for “panendoscopy” (i.e., laryngoscopy, esophagoscopy, bronchoscopy), although imaging has all but erased the need for intra- operative bronchoscopy as a screening tool. Hoarseness Patients with persistent hoarseness and smoking history should also be referred to an otolaryngologist for examination of the larynx. The most common cause of hoarseness is an upper respiratory infection (URI) resulting in edema (swelling) of the true vocal folds. Symptoms may last several weeks, but rarely last six weeks. Six weeks of hoarseness in an adult with a history of heavy tobacco use is very suspicious for a precan- cerous (dysplastic) or malignant lesion of the larynx. If the lesion is not malignant, other causes of hoarseness may include inflammation from reflux, also known as laryngopharyngeal reflux , allergic rhinitis causing postnasal drip, laryngeal papillomatosis , vocal fold nodules, vocal fold polyps, and unilateral vocal fold paralysis. Otalgia A patient who has HNC may also present to a primary care physician with pain in the throat or pain in the ear ( otalgia ) that has no obvious cause. The oropharynx and hypopharynx are innervated by the ninth and tenth cranial nerves. These nerves also send branches to the ear, and sometimes a cancer in the throat can generate referred pain to the ear. The oral tongue is served by the lingual nerve (fifth cranial nerve) and may cause jaw pain and otalgia as well. If a patient presents with ear pain and the ear exam is normal, the pain may be caused by some other otolaryngologic problem and not the ear. A common cause of ear pain with a normal ear exam is temporomandib- ular joint syndrome (TMJ) . This inflammation of the jaw joint can be diagnosed by pain on palpation of the joint (just in front of the tragus ) when the patient opens and closes the jaw. If the joint is nontender without crepitus and there is no other obvious cause of ear pain, the patient needs further evaluation. Difficulty swallowing ( dysphagia ), pain

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