Diagnosing head & neck cancers

Monday 1 May, 2017

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On this page: Physical examination | Nasendoscopy | Laryngoscopy | Biopsy | Testing lymph nodes | X-rays | Imaging tests | Staging head and neck cancers | Prognosis | Which health professionals will I see? | Key points


If you notice any symptoms, see your general practitioner (GP). You can also mention any mouth sores, swelling or change of colour in your mouth to your dentist.

To diagnose a head and neck cancer, your GP or dentist may do some general tests and then refer you to a specialist for additional tests. Depending on your symptoms, tests will include examinations, tissue sampling (biopsy) and imaging tests. You may also have blood tests. Further tests may be needed to work out whether the cancer has spread. The tests you have will depend on your specific situation.

Physical examination

The doctor will examine your mouth, throat, nose, neck, ears and eyes depending on your symptoms. A spatula may be used to see inside the mouth more clearly. The doctor may also insert a gloved finger into your mouth to feel areas that are difficult to see, and check your lymph nodes by gently feeling both sides of your neck.

To see some areas of the head and neck, such as the nasopharynx, tongue base and pharynx, the doctor may use viewing equipment (see below) and take a tissue sample.

Nasendoscopy

A nasendoscopy examines the nose and throat area using a thin flexible tube with a light and camera on the end. This device is called a nasendoscope. Before the nasendoscope is inserted, a local anaesthetic is sprayed into the nostril to numb the nose and throat.

You may find that the spray tastes bitter. The doctor will gently pass the nasendoscope into one of your nostrils and down your throat to look at your nasal cavity, nasopharynx, oropharynx, hypopharynx and larynx. Images from the nasendoscope may be projected onto a screen. This test may feel uncomfortable, but should not hurt.

You will be asked to breathe lightly through your nose and mouth, and to swallow and make sounds. The doctor may also take tissue samples (biopsy). A nasendoscopy usually takes a few minutes. If you need a biopsy, the test may take longer, and you will be advised to not have any hot drinks for about 30 minutes after the procedure, but you can go home straightaway.

Laryngoscopy

A laryngoscopy is a procedure that allows a doctor to look at your larynx and pharynx, and take a tissue sample (biopsy). A tube with a light and camera on it (laryngoscope) is inserted into your mouth and throat and shows the area on a screen. The procedure is done under a general anaesthetic and takes 10–40 minutes. You can go home when you've recovered from the anaesthetic. You may have a sore throat for a couple of days.

A bronchoscope is similar to a laryngoscope, but it allows doctors to examine the airways to see if cancer has spread to the lungs. The tube (bronchoscope) is inserted into the lungs via the mouth and throat. It may be done under a local or general anaesthetic.

Biopsy

A biopsy is when doctors remove a sample of cells or tissue from the affected area, and a pathologist examines the sample under a microscope for any cancer cells.

The sample may be taken during a nasendoscopy or laryngoscopy. A biopsy can be taken from hard to reach areas using a fine needle to collect the sample. An ultrasound or CT scan (see imaging tests) can help the doctor guide the needle. Biopsy results are usually available in about a week. If the cancer can't be diagnosed from the sample of tissue, the mass may be removed and checked for signs of cancer during surgery.

Testing lymph nodes

The lymph nodes in the neck are often the first place cancer cells spread to outside the primary site. To see whether the cancer has spread, some or all of the lymph nodes are removed and checked for cancerous cells.

The first lymph node cancer cells spread to is known as the sentinel node. There can be more than one sentinel node. A small amount of radioactive material is injected near the tumour to find the sentinel node. A scan is taken to show which node the substance flows to first. This node will be removed for testing.

If the sentinel nodes are clear of cancer cells, the cancer has not spread to the lymph nodes. If one or more sentinel nodes contain cancer cells, a neck dissection may be needed.

X-rays

You may need x-rays of your head and neck to check for tumours or damage to the bones. X-rays are quick and painless and may include the following:

Orthopantomogram (OPG)

This type of x-ray is used to examine the jaw and teeth of people with mouth cancer.

Chest x-ray

Sometimes used to check the general health of people with mouth, pharyngeal or laryngeal cancer, or to see whether the cancer has spread to the lungs. However, most people have a CT or PET scan to look at these areas.

Overview of the lymph nodes

Lymph nodes, also called lymph glands, are small, bean-shaped structures that are part of the lymphatic system. These are a key part of the immune system, which helps protect the body against disease and infection. Lymph nodes are found throughout the body, including in the head and neck area. The majority run down the sides of the neck and under the jaw.

A diagram of the lymph nodes

Imaging tests

You will usually have at least one of the tests described below:

CT scan

A CT (computerised tomography) scan uses x-rays to take pictures of the inside of your body and then compiles them into one detailed, cross-sectional picture. Before the scan, you may have an injection of dye (called contrast) into one of your veins, which makes reading the scan more accurate. It may make you feel flushed and hot for a few minutes.

For the scan, you will need to lie still on a table that moves in and out of the CT scanner, which is large and round like a doughnut. The scan itself takes about 10 minutes.

The dye used in a CT scan usually contains iodine. If you have had an allergic reaction to iodine or dyes during a previous scan, let your medical team know beforehand. You should also tell them if you are diabetic, have kidney function problems or are pregnant.

MRI scan

An MRI (magnetic resonance imaging) scan uses a powerful magnet and radio waves to build up detailed crosssectional pictures of the inside of your body. Let your medical team know if you have a pacemaker or any other metal implant, as some types can interfere with an MRI. As with a CT scan, a dye may be injected into your veins before an MRI scan. During the scan, you will lie on a treatment table that slides into a large metal tube that is open at both ends.

The noisy, narrow machine makes some people feel anxious or claustrophobic. If you think you may become distressed, mention this beforehand to your medical team. You may be given medicine to help you relax, and you will usually be offered headphones or earplugs. MRI scans usually take between 30 and 90 minutes.

PET scan

A PET (positron emission tomography) scan is usually recommended to help diagnose oral, pharyngeal or laryngeal cancer, or to see if the cancer has spread. A PET scan is a specialised imaging test that is available at some major hospitals.

Before the scan, you will be injected with a glucose solution containing some radioactive material. You will be asked to wait for 30–90 minutes as the solution spreads through your body. You will need to lie still during this time. The glucose solution gathers in cells, including cancer cells, which are using more energy. These show up as "hot spots" during the scan. However, a PET scan can find hot spots that are not cancer. The scan itself takes about 30 minutes.

Ultrasound

An ultrasound is sometimes used, especially to look at the thyroid, salivary glands and lymph glands in the neck.

For this scan, you will lie down and a gel will be spread over your neck. A small device called a transducer is moved over the area. The transducer sends out soundwaves that echo when they encounter something dense, like an organ or tumour. The ultrasound images are then projected onto a computer screen. An ultrasound is painless and takes about 15–20 minutes.

Staging head and neck cancers

The tests described above help show whether you have a head and neck cancer and whether it has spread. Working out how far the cancer has spread is called staging and it helps your health care team recommend the best treatment for you.

In Australia, the TNM system is the method most commonly used for staging head and neck cancers. In this system, letters are assigned numbers to describe the cancer.

Based on the TNM numbers, the doctor then works out the cancer's overall stage (I–IV). Stages I–II are considered early head and neck cancer, and stages III–IV are considered advanced. Usually the earlier cancer is diagnosed, the better the outcome, but people with more advanced head and neck cancer may also respond well to treatment.

TNM staging system

T (Tumour) 1-4
Indicates the size of the primary tumour. The higher the number, the larger the cancer.
N (Nodes) 0-3
Shows if the cancer has spread to nearby lymph nodes. N0 means the cancer has not spread to the lymph nodes; the more nodes affected, the higher the number.
M (Metastasis) 0-1
Shows if the cancer has spread (metastasised) to other parts of the body. M0 means the cancer has not spread; M1 means the cancer has spread.

In most cases, the earlier head and neck cancer is diagnosed, the better the chances of successful treatment.

To work out your prognosis, your doctor will consider your test results; the type of head and neck cancer and rate of growth; how well you respond to treatment; and other factors such as your age, general fitness and medical history.

Which health professionals will I see?

Your GP will usually arrange the first tests to assess your symptoms. If these tests do not rule out cancer, you will usually be referred to a specialist. The specialist will arrange further tests.

If head and neck cancer is diagnosed, the specialist will advise you about treatment options. Once your treatment for head and neck cancer begins, you will be cared for by a range of health professionals who specialise in different aspects of your treatment. This is often referred to as a multidisciplinary team (MDT) and it may include some or all of the health professionals listed in the table below.

Health professional  Role
ENT (ear, nose and throat) specialist* treats disorders of the ear, nose and throat
head and neck surgeon* ENT or general surgeon specialising in cancer of the head and neck
oral (maxillofacial) surgeon* specialises in surgery to the face and jaw
reconstructive surgeon* performs surgery that restores, repairs or reconstructs the body’s appearance and function
radiation oncologist* prescribes and coordinates the course of radiotherapy
medical oncologist* prescribes and coordinates chemotherapy, hormone therapy and targeted therapy
radiation therapist plans and delivers radiotherapy treatment
nurses and cancer care coodinators coordinate your care, liaise with other members of the MDT, and support you and your family throughout treatment
audiologist diagnoses and treats hearing problems
dentist or oral medicine specialist evaluates and treats the mouth and teeth
prosthodontist specialises in replacing any missing teeth
gastroenterologist specialises in disorders of the digestive system, and inserts a feeding tube if required
speech pathologist evaluates and treats communication, voice and swallowing difficulties during and after treatment
dietitian recommends an eating plan to follow while you are in treatment and recovery
social worker links you to support services and helps you with emotional, practical and financial issues
counsellor, psychologist provide emotional support and help manage any feelings of depression and anxiety
physiotherapist, occupational therapist assist with physical and practical problems, including restoring range of movement after surgery and managing lymphoedema
palliative care team specialise in pain and symptom control to maximise wellbeing and improve quality of life

* Specialist doctor

Key points

  • There are many types of tests used to diagnose a head and neck cancer. These tests are arranged by your GP, dentist or specialists.
  • Your doctor will do a physical examination of your oral cavity, neck, ears and eyes.
  • You may have a nasendoscopy to check the tissue in your nose and throat. A flexible tube with a camera on the end (nasendoscope) is inserted into your nose, and the images appear on a screen.
  • The stage of the cancer shows how far the cancer has spread in the body. Head and neck cancer is assigned a stage using the TNM system. TNM stands for tumour, nodes, metastasis.
  • A laryngoscopy allows the doctor to examine the larynx and pharynx. This is done while you are under general anaesthetic.
  • A tissue sample (biopsy) is taken to examine the cells under a microscope to see whether cancer is present. A biopsy can be done during a physical examination, under guidance of ultrasound or CT scan, or occasionally under general anaesthetic.
  • A range of imaging tests may be done. These will show where the cancer is located and whether it has spread (the stage).
  • Your prognosis is the expected outcome of the disease. It is based on the cancer's stage, and factors such as your age, medical history and fitness. Your doctor will discuss your prognosis with you.
  • You will be cared for by a team of health professionals who work together as a multidisciplinary team.

Reviewed by: A/Prof Ardalan Ebrahimi, Head and Neck Surgeon, Liverpool, Macquarie, St George Private and Sydney Southwest Private Hospitals, NSW; Jenne Farrant, Senior Physiotherapist, Intensive and Critical Care Unit, Flinders Medical Centre, SA; Merran Findlay AdvAPD Executive Research Lead – Cancer Nutrition, and Oncology Specialist Dietitian, Royal Prince Alfred Hospital, NSW; Dr Tsien Fua, Radiation Oncologist, Peter MacCallum Cancer Centre, VIC; Dr Craig Gedye, Medical Oncologist, Calvary Mater Hospital, Newcastle, and Conjoint Senior Lecturer, School of Biomedical Sciences and Pharmacy, The University of Newcastle, NSW; Jenny Holland, Head and Neck Oncology Nurse Consultant, Monash Health at Moorabbin Hospital, VIC; Dr Steven Kao, Medical Oncologist, Chris O’Brien Lifehouse, NSW; Cindy Lyons, Social Worker (Radiology), Gosford Hospital, NSW; Dr Elishka Marvan, Dental Oncologist, Peter MacCallum Cancer Centre, VIC; Dr Julia McLean, Speech Pathologist, St George Swallow Centre, St George Hospital, NSW; Rohan Miguel, Senior Physiotherapist, Community Services, Disability SA; Tracey Nicholls, Nurse Practitioner Ear Nose and Throat, Department of ENT Otolaryngology Head and Neck Surgery, Flinders Medical Centre, SA; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council WA; Gail Williams, Consumer.

Updated: 01 May, 2017