head and neck cancer

Question 1

What are the emergency symptoms of head and neck cancer?

Answer 1

Stridor
Persistent unexplained h+n lumps for >3 weeks
Ulceration or unexplained swelling of the oral mucosa for >3 weeks
All red or mixed red and white patches of the oral mucosa for >3 weeks
Persistent hoarseness lasting for >3 weeks (request chest x-ray at same time)
Dysphagia or odynophagia (pain on swallowing) lasting for >3 weeks
Persistent pain in the throat lasting for >3 weeks

Question 2

What special investigations are carried out for head and neck cancer?

Answer 2

New pt assessment in OMFS
Biopsy to confirm diagnosis
CT scan to investigate extent of tumour and any metastasis
LN biopsy
Baseline medical testing
Stage and grade of cancer

Question 3

Who is involved in the MDT for head and neck cancer?

Answer 3

Oncologist
Radiologist
Surgeon
Dietician
Dentist
Physio
Psychologist

Question 4

What dental tx should be carried out pre-cancer assessment?

Answer 4

Prevention - OHI, fluoride, dietary advice coinciding with dietician
PMPR to stabilise perio
Definitively restore carious teeth
XLA teeth with dubious prognosis no less than 10 days before starting cancer tx
AB prophylaxis if neutrophils are low
Ortho - discontinue and remove fixed appliances

Question 5

What are the different types of cancer tx?

Answer 5

Surgical resection with or without reconstruction
Radiotherapy
Chemotherapy
Adjuvant radiotherapy or chemotherapy may be required following surgical resection

Question 6

What are the side effects of cancer tx?

Answer 6

Alterations to normal anatomy - affecting function and appearance
Radiation damage to normal tissues - affecting short and long term function
Acute mucosal haematological toxicity - worse if chemo with radio
Adverse effects on respiration, mastication, swallowing, speech, taste, SG function and mouth opening

Question 7

What is the dentists role during cancer tx?

Answer 7

Hygiene support
Chlorhexidine mouthwash - shot term alt to brushing
Diet advice
Fluoride preparations
High risk of viral and fungal infections
Symptomatic relief of mucositis and xerostomia
Emergency tx - liaise with cancer team
Avoid dental tx

Question 8

What is oral mucositis and when does it take place?

Answer 8

Severe pain produced by inflammation and ulceration of the oral mucosa
Begins 1-2 weeks after tx starts
Lasts until roughly 6 weeks after tx is complete
Has severe impact on eating - necrotising gingivitis associated

Question 9

Give 8 management options for oral mucositis

Answer 9

Any from:
- calcium phosphate mouth rinse
- muco-adhesive oral rinse
- soluble aspirin
- difflam spray
- aloe vera
- manuka honey
- zinc supplements may prevent
- low level laser therapy in radiotherapy without chemo
- good OH - won’t prevent but can help it resolve faster
- morphine and opioids as analgesics
- OHI

Question 10

What antifungals are used to treat candida infections from cancer tx?

Answer 10

Nystatin not effective
Chlorhexidine mouthwash or gel
Miconazole - topical
Fluconazole - systemic

Question 11

How may reactivation of HSV present in cancer pts?

Answer 11

Cold sore virus
Painful oral ulceration with a prodromal period
High index of clinical suspicion

Question 12

How does xerostomia usually present in cancer pts?

Answer 12

Reduced salivary flow 50-60% in first week with a further 20% in the next 5-6 weeks

Question 13

What does xerostomia affect?

Answer 13

Chewing
Swallowing
Speech (dysarthria)
Taste (dysgeusia)
Quality of life

Question 14

What causes xerostomia in h+n cancer pts?

Answer 14

Ionising radiation damage to salivary tissue in the radiotherapy fields

Question 15

What are the consequences of xerostomia in cancer pts?

Answer 15

Higher risk of caries, periodontal disease, candida infections, sialadenitis and prosthodontic difficulties

Question 16

Give 5 management options for xerostomia

Answer 16

Oral gel or lubricants to coat lips and soft tissues
Prilocarpine HCl to enhance secretions in pts with some SG function
Sugar free chewing gum - limited evidence
Acidic pastilles (Salivix) - erosion and sensitivity risk
Saliva replacement eg - Saliva orthana, Biotene Oral Balance Gel

Question 17

When can glandosane be used?

Answer 17

Only in edentulous pts - it is acidic

Question 18

What causes trismus in h+n cancer pts and what should be excluded as a cause?

Answer 18

Caused by post surgical inflammation - fibrosis of tissues as a result of chemo and radiotherapy
Exclude reduction of mouth opening due to tumour

Question 19

What may cause erosion in cancer pts?

Answer 19

Low saliva pH
Use of glandosane
Drinking acidic drinks due to dry mouth

Question 20

What is ORN?

Answer 20

An area of exposed bone of at least 3 months in duration in an irradiated site and not due to tumour recurrence

Question 21

What is the incidence of ORN?

Answer 21

7% risk after XLA in an irradiated pt
Using hyperbaric O2 therapy as prophylaxis during XLA - only 4% risk
No conclusive evidence but AB prophylaxis used too

Question 22

What increases the risk of ORN?

Answer 22

If total radiation dose exceeds 60Gy
More at risk after trauma
More at risk if dose fraction is large with a high number of fractions
More at risk if pt is immunodeficient or malnourished

Question 23

Give 6 methods of ORN prevention

Answer 23

Any from:
- regular exams less than 6 months apart
- radiographs
- hygienist visits
- avoid invasive tx
- decoronating and leaving roots in situ
- full or partial coverage crowns if good OH
- avoid routine restorative tx until pt in remission
- antimicrobials for acute conditions

Question 24

When are implants used in h+n cancer pts?

Answer 24

Great for rehabilitation
Reduced success in irradiated bone - failure less likely with radiation dose lower than 45Gy

Question 25

When are dentures used in h+n cancer pts?

Answer 25

Should be avoided - denture hygiene is essential

Question 26

What proportion of head and neck cancers are due to cigarettes and alcohol use?

Answer 26

3/4

Question 27

Where are oropharynx cancers found?

Answer 27

Base of tongue
Tonsils
Soft palate

Question 28

List 6 characteristic oral cancer prentation descriptors

Answer 28

Ulcerated
Uneven surface
Indurated (hard)
Rolled edges
Well defined margins
Exophytic

Question 29

What are CT scans used for in head and neck cancer imaging?

Answer 29

Assess primary tumour
Assess regional spread
Assess for distant metastasis or unrelated second cancers

Question 30

Why and what are MRI scans used for in head and neck cancer imaging?

Answer 30

No radiation
Improved soft tissue definition
Not affected by amalgam
Looks at extent of bone involvement, extent of nerve involvement and surgical planning

Question 31

When are ultrasounds used for head and neck cancer imaging?

Answer 31

For neck mass or salivary gland mass

Question 32

What is important where respecting tumours?

Answer 32

You must take 1cm margin of healthy tissue around the cancer when resecting it

Question 33

What is the role of the pathologist in head and neck cancer?

Answer 33

Establish the diagnosis, subtype and grading of the cancer
To examine the surgical margins of the specimen to see if they are free of malignant cells

Question 34

How should tissue specimens be handled?

Answer 34

Put in pot with formaldehyde to prevent necrosis of tissue
Specimen in pot for 24 hours but in larger specimens it should be no longer
Must be labelled clearly with pt details

Question 35

What are the radiographic signs of head and neck cancer?

Answer 35

Moth eaten bone
Pathological fractures
Non-healing sockets
Floating teeth
Spiking root resorption
Unusual perio bone loss
Speculated periosteal reaction
Generalised PDL widening and loss of lamina dura
Loss of bony outlines for anatomical features
Thinning of cortico-endosteal margins

Question 36

What are the ultrasound signs of head and neck cancer?

Answer 36

Rounded LNs
Enlarged LNs
Conglomerate nodes
Necrosis of nodes
Increased vascularity or Avascular
Loss of hilum
Internal calcification
Extracapsular spread

Question 37

Why is CT used for staging?

Answer 37

Quick
Good for soft tissue and bone
Iodinated contrast is given

Question 38

Why is MRI used for staging?

Answer 38

No ionising radiation
Good for soft tissue and bone marrow involvement
Can see perineural spread

Question 39

What is the imaging choice when you can see the tumour?

Answer 39

PET or CT scan
PET looks for metabolically active tissues

Question 40

What imaging should be used if recurrence?

Answer 40

CT scans and PET-CT to show distant metastasis
Not MRI - may give false positives

Question 41

What imaging is used for implant planning?

Answer 41

CBCT