Let’s Talk about Head & Neck Cancers

Head and neck cancers, or ENT (ear, nose and throat) cancers, may not always cross our minds when we are looking out for cancer symptoms. Obvious signs and symptoms of some of these cancers may also be absent or trivialised at the start, which delays their diagnosis.

Being informed about the signs and symptoms these cancers present is therefore useful in helping you detect a potential issue, so you can get a diagnosis and start treatment as soon as possible.

Read on to learn about some common ENT cancers such as nasopharyngeal cancer, throat cancer, voice box cancer and thyroid cancer, their warning signs and treatment options.

Nasopharyngeal Cancer

Nasopharyngeal cancer ranks among the top 10 cancers faced by men aged 30 – 59 years in Singapore*. It occurs when the cells in the tissues behind the nose, just above the mouth and throat, become cancerous.

*National Registry of Diseases Office: Incidence of cancer among men from 2015 – 2019

Symptoms

Nasopharyngeal cancer may mimic other more common conditions, and is often undetected until its advanced stages.

Below are some signs and symptoms to look out for:

• Lumps on the neck (when cancer cells have spread to the lymph nodes)
• Blocked ear, hearing loss or tinnitus (ringing in the ear), especially on one side
• Blood-stained phlegm from the nose and throat
• Recurring nosebleeds
• Blocked nose, especially on one side, and occurring suddenly

Risk Factors

Certain risk factors that can increase one’s chance of developing nasopharyngeal cancer include:

• Family history
• Ethnicity (higher incidences noted among the Chinese)
• A diet comprising high consumption of salt-preserved fish, and lacking in fresh fruit and vegetables
• Past Epstein-Barr virus* (EBV) infection

*EBV infection is a common viral infection that usually results in mild symptoms like fever and sore throat, and has been linked to nasopharyngeal cancer development. On its own, EBV does not cause nasopharyngeal cancer. However, it is the interaction between EBV and other factors such as genetic susceptibility and / or environmental risk factors that may subsequently lead to development of nasopharyngeal cancer.

Diagnosis

Diagnosis begins with a general examination by your doctor, who will ask you more about your symptoms, and check for any swollen lymph nodes. Diagnostic tests may be required to determine the presence of the cancer. Examples of such tests include:

• Nasendoscopy – a long, narrow and flexible tube with a camera at the end is inserted into the nose to examine the back of the nose for abnormalities.
• Biopsy – a small sample of suspicious tissues are removed and examined under a microscope to check for cancer cells.
• Blood test – due to the association between EBV and Nasopharyngeal cancer, blood tests help to detect antibodies to EBV, or EBV DNA can aid early diagnosis and screening for Nasopharyngeal cancer.

If cancer is confirmed, your doctor would administer further tests such as CT (Computed Tomography) scan, MRI (Magnetic Resonance Imaging) and PET (Positron Emission Tomography) scan to determine the stage of the cancer, so that appropriate treatment can be given.

Treatment

Early stage nasopharyngeal cancer is usually treated with radiation therapy, while advanced stages of the cancer will involve treatment with a combination of radiation therapy and chemotherapy. Surgery is reserved for residual disease – when some cancer remains after treatment, or recurrence – when the cancer returns after the previous course of treatment.

Cancers of the Throat (Pharyngeal Cancer) and Voice Box (Laryngeal Cancer)

These refer to tumours developing in the throat (around the voice box) or in the voice box itself. The voice box is divided into the area above the vocal cords (supraglottis), the vocal cords themselves (glottis) and the area under the vocal cords (subglottis).

Symptoms

The voice box allows us to swallow and speak, and symptoms would typically affect these functions.

Signs and symptoms to look out for include the following:

• Voice changes such as hoarseness for more than a month
• Persistent sore throat
• Lump(s) in the neck
• Difficulty or pain while swallowing
• Difficulty breathing
• Earache

Risk Factors

Factors associated with an increased risk of cancer include:

• Smoking
• Excessive consumption of alcohol
• A human papillomavirus (HPV) infection

Diagnosis

Diagnosis begins with a discussion of your medical history and symptoms experienced. Following this, a physical examination will be conducted to check for sores and lumps in the mouth, or swollen lymph nodes in the neck.

Further checks that may be administered include:

• Nasopharyngolaryngoscopy – an endoscope is inserted into the nose, throat or voice box to examine it for signs of cancer. A biopsy will be taken to confirm the diagnosis should lumps or tumours be found.
• Laryngoscopy – an endoscope is inserted into the throat and larynx to evaluate the exact extent of tumours that have been detected. This is done under anaesthesia and usually accompanied by a biopsy to confirm the diagnosis.
• Panendoscopy – an endoscope is inserted to examine the larynx, oesophagus, mouth, nasal cavity, and the lungs in one session under anaesthesia. Biopsies will be taken as necessary to rule out another cancer in similar risk sites.

If throat or voice box cancer is found, your doctor would administer further tests such as CT scan, MRI and PET scan to determine the stage and extent of the cancer, so that the appropriate treatment plan can be advised.

Treatment

Treatment would be recommended depending on where the cancer is located, the size of the tumour(s), cancer stage, and overall health. Early stage cancers may require surgical removal of the tumour or radiation therapy. Advanced stage cancer would involve surgical removal of the tumour, then a combination of radiotherapy and chemotherapy. Following this, surgery may also be recommended to remove any residual or recurrent cancer cells.

Thyroid Cancer

Thyroid cancer is the 8th most frequent cancer amongst women in Singapore. It affects the thyroid gland, which is located at the base of the neck, just below the Adam’s apple. The thyroid produces hormones that regulate the heart rate, blood pressure, cholesterol levels, body temperature and weight.

Thyroid cancer occurs when cells in the thyroid gland mutate and grow, forming tumours. Most thyroid cancers are highly treatable, especially in younger patients, with excellent long-term cure rates.

Symptoms

In its initial stages, thyroid cancer presents few to no symptoms. However, as the cancer develops, patients may notice a lump or mass in the neck. Most thyroid lumps are benign, but further investigation would be necessary to differentiate between cancer and non-cancerous lumps. Some signs to look out for include:

• Lump(s) at the front of the neck
• Voice hoarseness
• Difficulty swallowing
• Pain in the neck, at the location of the thyroid
• Lumps at the sides of the neck (swollen lymph nodes)

Risk Factors

Factors that can increase one’s risk of thyroid cancer include:

• Family history of thyroid cancer.
• Exposure to high levels of radiation, especially to the head and neck area.

Diagnosis

Diagnosis begins with a discussion of any symptoms, family history of thyroid issues, and any exposure to risk factors. Your doctor may conduct a physical examination of your neck to check for abnormalities, such as the presence of a thyroid nodule (lump). Additionally, your doctor may request for one or more of the following tests:

• Blood test – to check your thyroid hormone levels to determine if your thyroid is functioning properly.
• Ultrasound Imaging – high-frequency sound waves will be able to show an ‘image’ of the thyroid, and if it has any nodules. A biopsy may be ordered should suspicious lumps be found.
• Fine-needle aspiration biopsy – using ultrasound to locate the nodule or lump, a very thin needle is inserted into it to extract cells from the nodule, which are then examined under a microscope to look for cancer.

Other imaging scans such as CT scan or MRI may be necessary if the cancer is suspected to have spread to the lymph nodes in the neck.

Treatment

The treatment recommended would depend on the size and type of thyroid cancer, and whether the cancer has spread beyond the thyroid. Treatment procedures include:

• Surgery – This may involve removal of half or the whole thyroid gland. Sometimes removal of lymph nodes from the centre of the neck or the sides of the neck may be necessary depending on the stage of the cancer.
• **Radioactive iodine treatment – **Sometimes required after surgery, this involves the patient consuming a small, and safe amount of radioactive iodine. This is done to destroy any remaining thyroid tissue still present after surgery or remaining cancer cells that might have spread, but are still undetectable. This reduces the chances of the cancer coming back.
• **Hormone therapy – **As the body is unable to produce the hormone thyroid once the entire gland is removed, it needs to be replaced artificially with medication. A higher dose is usually given to suppress thyroid stimulating hormone (TSH) which would encourage the growth of cancer cells, thus lowering the risk of recurrence.
• **Radiation Therapy – **Used in situations where surgery is unable to completely remove the tumour, or to control thyroid cancer that has spread to other localised sites like the bone.
• **Chemotherapy – **Chemotherapy or targeted therapy is rarely necessary and only used in advanced thyroid cancer that has spread beyond the lymph nodes to other parts of the body, and if it does not respond to radioactive iodine treatment.

Early Detection is Key

While the symptoms mentioned in this article are not always due to cancer, and may be caused by many common illnesses, stay alert and look into symptoms that seem unusual to you, especially when they are new symptoms that do not go away after some time (usually 1 month). Cancer treatments have higher rates of success when the cancer is diagnosed early. Should you need medical advice, consult an ENT (Otorhinolaryngology) specialist.