Diagnosing head & neck cancers

Monday 1 June, 2015

Download PDF Order FREE booklet

On this page: Physical examination | Biopsy | CT Scan | MRI Scan | PET Scan | Ultrasound | X-rays | Staging | Prognosis | Which health professionals will I see? | Key points


After initial tests, your general practitioner (GP) will refer you to a specialist for further tests. Depending on your symptoms, tests will include examinations, tissue sampling (biopsy) and imaging tests. You will probably also have blood tests.

Physical examination

Your doctor will examine your mouth, tonsils and soft palate (oropharynx), neck, ears and eyes. 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 (lymph glands) by gently feeling the sides of your neck.

Some head and neck cavities are difficult to see, so for other locations, such as the nasopharynx, tongue base and pharynx, the doctor may use viewing equipment (see below). A tissue sample (biopsy) may also be taken at this time.

If you notice a sore, swelling or change of colour in your mouth, make an appointment to see your dentist. Any unexplained changes that are present for more than two weeks may need to be biopsied.

Nasendoscopy

A nasendoscopy is an examination of the nose and throat using a flexible fibre-optic tube with a light and camera on the end of it (endoscope). A local anaesthetic is sprayed gently into the nose.

You may find that the spray tastes bitter. Your nose and throat will remain numb for up to 20 minutes.

The doctor will insert the endoscope into your nose to look at your nasal cavity, nasopharynx, oropharynx, hypopharynx and larynx. Images from the endoscope may be projected onto a screen.

A nasendoscopy is not painful as the tube is soft and flexible. However, it can feel unusual. You will be asked to breathe lightly through your nose and mouth. You may be asked to swallow and to make some vocal noises. The doctor may also take some tissue samples. The test takes 5–15 minutes. Afterwards, you can’t eat or drink for about 30 minutes, but you can go home straight away.

Laryngoscopy

A laryngoscopy is a procedure that allows a doctor to examine your larynx and pharynx, and take a tissue sample (biopsy) from your larynx. 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 will take 10–40 minutes. You can go home when you’ve recovered from the anaesthestic. You may have a sore throat for a couple of days.

A bronchoscopy is similar to a laryngoscopy, 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 used to diagnose all head and neck cancers. During a biopsy, a small amount of tissue is removed from the affected area under local or general anaesthetic. The sample is sent to a lab where a pathologist examines the tissue under a microscope. This test enables the pathologist to see whether cancer cells are present, and determine what type of cancer it is. Biopsy results are usually available in about a week.

If you have a biopsy on a lump in your neck or on a tumour that is difficult to access, it will probably be done with a needle that is guided using an ultrasound or a CT scan.

CT scan

A CT (computerised tomography) scan is used to assess the extent of many head and neck cancers. A CT scan uses x-ray beams to take pictures of the inside of your body. Before the scan, you may have iodine contrast injected into a vein in your arm to show the blood vessels and make the pictures clearer. The dye may make you feel flushed or hot for a few minutes.

You will lie still on a table that moves slowly through the CT scanner. The scanner is large and round like a doughnut. The CT scan itself takes a few minutes and is painless, but the preparation takes 10–30 minutes. You can go home when the scan is complete.

The dye that is injected into your veins before a CT or MRI scan may contain iodine, and may affect your kidneys. Tell your doctor if you are pregnant, have any allergies or kidney problems before preparing for your CT scan. You may need to have blood tests to check your kidney function.

MRI scan

An MRI (magnetic resonance imaging) scan is used to assess the extent of many head and neck cancers. An MRI uses magnetism and radio waves to build up detailed cross-section pictures of the body. As with a CT scan, a dye may be injected into your veins before the scan to make the pictures clearer. The pictures are taken while you lie on a table that slides into a narrow metal cylinder – a large magnet – that is open at both ends.

An MRI takes about an hour and you will be able to go home when it is over. The test is painless, but the noise of the machine can be a source of distress. In addition, some people feel anxious or claustrophobic lying in such a confined space. If you think this will be a problem, let the doctor or nurse know beforehand, as they can give you medication to help you relax. Cancer Council also has a number of relaxation and meditation resources, which may assist. Call Cancer Council 13 11 20 for more information.

You will not be able to have an MRI if you have a pacemaker or another iron-based metallic object in your body, because the scan may damage these devices.

PET scan

A PET (positron emission tomography) scan is nearly always 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 most major hospitals. Before the scan, you will be injected with a glucose solution that contains 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 the cells, including cancer cells, which are using more energy. These show up as ‘hot spots’ during the scan. Not all PET hot spots indicate cancer. The scan itself takes around 30 minutes.

If you have diabetes, you may need to follow a different procedure for a PET scan. Your blood sugar levels may need to be checked before the scan. Tell your doctor so the test can be adjusted.

Ultrasound

An ultrasound is sometimes used to assess pharyngeal cancer or to see if another type of cancer has spread.

A gel will be spread over your neck, and a paddle-shaped device called a transducer will be moved over the same area. The transducer creates soundwaves that echo when they meet something dense like an organ or a tumour. The ultrasound images are then projected on to a computer screen. An ultrasound is painless and takes about 15 minutes to perform.

X-rays

You may need standard 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): 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 CT scans and PET scans to look at these areas.
  • X-ray of facial bones: Used in the case of nasal or paranasal sinus cancer to check whether the cancer has spread.
Cancer of Unknown Primary (CUP)

CUP, or cancer of unknown primary, is a metastatic cancer (cancer that has spread) with an unknown starting point. If CUP first shows up as a tumour in the head or neck, doctors may call it metastatic neck cancer and treat it like a head and neck cancer.

Staging head and neck cancer

Staging determines how large the cancer is and whether the cancer has spread from the original site to nearby structures and other parts of the body. Your doctor will give the cancer a stage from 1–4 to help determine the best treatment.

The head and neck staging system is called the TNM system. This system is also used to stage cancers in other parts of the body.

TNM system

T (Tumour) 1-4
Refers to the size of the primary tumour. The higher the number, the larger the cancer.
N (Nodes) 0-3
Shows whether the cancer has spread to the regional lymph nodes of the neck. No nodes affected is 0; increasing node involvement is 1, 2 or 3.
M (Metastasis) 0-1
Cancer has either spread (metastasised) to other organs (1) or it hasn’t (0).

Prognosis

Prognosis means the expected outcome of a disease. However, it is impossible for any doctor to predict that exact course of the disease. Test results, the type and stage of the cancer, how well you respond to treatment, and factors such as age and medical history are all important in assessing your prognosis. The results of head and neck cancer treatment are best when the cancer is found and treated early.

Rene's story

"The first indications of a problem were food getting stuck in my throat and soreness there. Later a lump developed on the right side of my neck.

"My GP referred me to an ENT specialist. He did a biopsy of the lump on my neck, which showed it was a squamous cell carcinoma. I also had x-rays, a CT scan, and a second biopsy in my throat area. They found a primary oropharyngeal cancer in my tonsil and at the back of my tongue. The lump on my neck was a secondary tumour. In hospital, I had several scans to see whether the cancer had spread beyond my neck.

"I had radiotherapy to both sides of my throat, as well as chemotherapy. I had to have my back teeth removed as they were in the path of the radiation. Six months later, I had a neck dissection to remove the lymph nodes on the left side.

"I now have a dry mouth and difficulty swallowing. Exercises to strengthen my neck muscles have improved my swallowing.

"I am grateful for the wonderful care I received in hospital during pre/post treatment and the supportive friendships found at my head and neck cancer support group."

Tell your cancer story.

Which health professionals will I see?

Your GP will usually arrange the first tests to assess your symptoms. If you need further tests, you will be referred to a specialist, who will make a diagnosis and advise you about treatment options. You will be cared for by a team of health professionals who meet regularly to discuss and plan your treatment. This team may include some or all of the health professionals listed 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 jaws
reconstructive surgeon performs surgery that restores, repairs or reconstructs the body’s appearance and function
medical oncologist prescribes and coordinates chemotherapy, hormone therapy and targeted drug therapies
audiologist diagnoses and treats hearing problems
dietitian supports and educates patients about nutrition, diet and tube feeding
gastroenterologist specialises in disorders of the digestive system, and inserts a feeding tube if required
radiation oncologist prescribes and coordinates radiotherapy
dentist or oral medicine specialist evaluates and treats the mouth and teeth
radiation therapist plans and delivers radiotherapy treatment
prosthodontist specialises in replacing any missing teeth
nurses and cancer nurse coordinators coordinate your care and support you throughout treatment
speech pathologist helps with communication and swallowing
social worker, psychologist and counsellor provide emotional support and help manage anxiety and depression
physiotherapist and occupational therapist assist in restoring range of movement after surgery

Key points

  • You will have several tests to diagnose a head and neck cancer. These tests are arranged by your GP 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 it (endoscope) is inserted into your nose, and the images appear on a screen.
  • A laryngoscopy allows the doctor to examine the larynx and pharynx. This is done while you are under general anaesthetic.
  • A bronchoscopy examines the airways. This is also done under general anaesthetic.
  • A tissue sample (biopsy) is taken to examine the cells under a microscope to see whether cancer is present. A biopsy is either done during a physical examination or under anaesthetic.
  • A range of imaging tests will be done to take different types of pictures of the body. These will show where the cancer is located and whether it has spread from its original site.
  • The tests help the doctors to stage the cancer, and work out the best treatment and the expected outcome of the disease (prognosis). Staging indicates how large the cancer is and how far it has spread.
  • You will by cared for by a team of health professionals but will have one primary doctor.

Reviewed by: Dr Jason Bonifacio, Chief Radiation Therapist, Radiation Oncology Associates & Genesis Cancer Care Pty Ltd, St Vincent’s Clinic, NSW; A/Prof Suren Krishnan, Consultant Otolaryngologist & Head and Neck Surgeon, Royal Adelaide Hospital, SA; Dr David Boadle, Senior Staff Specialist in Medical Oncology, Royal Hobart Hospital, TAS; Dr Debra Phyland, Clinical Research Coordinator, ENT/Head & Neck Dept, Monash Health, VIC; Dana Middleton, Clinical Trials Coordinator – ENT, Princess Alexandra Hospital, QLD; Iwa Yeung, Senior Cancer Physiotherapist, Princess Alexandra Hospital, QLD; Lauren Muir, Accredited Practising Dietitian, Peter MacCallum Cancer Centre, VIC; Dr Peter Foltyn, Dentist, Department Head, Dental Department at St Vincent’s Centre, NSW; Haley McNamara, Social Worker, Royal Brisbane and Women’s Hospital, QLD; Marty Doyle, Co-Founder and Facilitator, Head and Neck Cancer Support Group, QLD; Frank Hughes, 13 11 20 operator, Cancer Council Queensland, QLD.

Updated: 01 Jun, 2015