Nose & Throat Cancers

Introduction

Often, cancers of the nose and throat are considered together by doctors because of certain similarities. Among the similarities are the causes. Most people who have cancers of the nose and throat use tobacco, drink alcohol, or both.

 

Nose and throat cancers occur in the voice box (larynx), the hollow spaces located in the bones around the nose (paranasal sinuses), the nasal passages and upper throat (nasopharynx), and the tonsils. Cancer of the mouth is very similar to nose and throat cancers in a number of ways. Because these cancers can cause death, a person with nose and throat cancer that has not responded to treatment should make all necessary plans. The person should have frank discussions with the doctor about wishes for medical care and the need for end-of-life care.

  • People may be hoarse or have a lump in the neck or difficulty breathing or swallowing.
  • A biopsy is needed for diagnosis.
  • Prognosis depends on how advanced the cancer is.
  • Treatment is usually with surgery and radiation therapy, but sometimes chemotherapy is also used.

Cancer of the voice box (larynx), a common area of cancer within the head and neck, occurs more often in men than in women. It is linked to cigarette smoking and alcohol consumption.

 

Symptoms and Diagnosis

This cancer commonly originates on the vocal cords or the surrounding structures and often causes hoarseness. A person who has been hoarse for more than 2 to 3 weeks should seek medical attention. Cancer in other parts of the larynx can cause weight loss, pain, pain in the ear, and difficulty in swallowing or breathing or a combination. Sometimes, however, a lump in the neck resulting from the cancer's spread to a lymph node (metastasis) may be noticed before any other symptoms.

 

To make the diagnosis, a doctor initially examines the larynx with a mirror or with a thin viewing tube used for direct viewing of the larynx (laryngoscope) and removes a tissue sample for examination under a microscope (biopsy). A biopsy is most often performed in the operating room with the person under general anesthesia. Occasionally, it may be performed in the doctor's office, after a topical anesthetic has been applied. If cancer is present, people also may undergo a computed tomography (CT) scan of the neck and a chest x-ray or CT scan of the chest. A positron emission tomography (PET) scan also may be done.

 

Staging and Prognosis

Staging is a way for doctors to describe how advanced the cancer has become, taking into account both the size and spread (metastasis) of the cancer (see Symptoms and Diagnosis of Cancer: Staging). Staging helps the doctor guide therapy and assess prognosis. Cancer of the larynx is staged according to the size and location of the original tumor, the number and size of metastases to the lymph nodes in the neck, and evidence of metastases in distant parts of the body. Stage I cancer is the least advanced, and stage IV is the most advanced.

 

The larger the cancer and the more it has spread, the worse the prognosis. If the tumor also has invaded muscle, bone, or cartilage, cure is less likely. About 85 to 95% of people with small cancers that have not spread anywhere survive for 5 years, compared with fewer than 50% of those who have cancer that has spread to the local lymph nodes. For people who have metastases beyond the local lymph nodes, the chance of surviving longer than 2 years is poor.

 

Treatment

Treatment depends on the stage and the precise location of the cancer within the larynx. For early-stage cancer, doctors may use either surgery or radiation therapy. Usually, radiation is aimed not only at the cancer but also at the lymph nodes on both sides of the neck, because many of these cancers spread to those lymph nodes. When the vocal cords are affected, radiation therapy may be preferred over surgery because it may preserve a more normal voice. However, for very early-stage cancers of the larynx, microsurgery, sometimes performed with a laser, provides identical cure rates with equal preservation of the voice and can be completed in a single treatment. Using an endoscope to remove a laryngeal tumor has gained in popularity and is a viable alternative to radiation for larger tumors as well.

 

Tumors larger than ¾ inch (about 2 centimeters) and those that have invaded bone or cartilage are usually treated with combination therapy. One combination consists of surgery to remove part or all of the larynx and vocal cords (partial or total laryngectomy) followed by radiation therapy. Radiation therapy is also commonly combined with chemotherapy as the primary treatment for advanced laryngeal cancers. This treatment provides cure rates equivalent to the surgery and radiation combination, and the voice is preserved in a significant number of people. However, surgery still may be required to remove any cancer that remains after this treatment. If the cancer is too advanced for surgery or radiation therapy, chemotherapy can help reduce the pain and the size of the tumor but is unlikely to provide a cure.

 

Treatment almost always has significant side effects. Surgery often affects swallowing and speaking. In such cases, rehabilitation is necessary. Using an endoscope to remove cancer reduces side effects on swallowing and speech when compared to surgery done through a neck incision. A number of methods have been developed that allow people without vocal cords to speak, often with good results. Depending on the specific tissue removed, reconstructive surgery may be performed. Radiation may cause skin changes (such as inflammation, itching, and loss of hair), scarring, loss of taste, and dry mouth, and occasionally, destruction of normal tissues. People whose teeth will be exposed to the radiation treatments must have dental problems corrected and any unhealthy teeth removed, because radiation makes any subsequent dental work more likely to fail, and severe infections of the jawbone may occur. Chemotherapy typically causes a variety of side effects, depending on the drug used. These side effects may include nausea, vomiting, hearing loss, and infections.

Cancer of the nasal passages and upper throat (nasopharynx) may occur in people of any age group. Although rare in North America, cancer of the nasopharynx is one of the most common cancers in Asia. This cancer is also more common among Chinese people who immigrated to North America than other Americans. It is less common among American-born Chinese than their immigrant parents or grandparents.

 

The Epstein-Barr virus, which causes infectious mononucleosis, plays a role in the development of nasopharyngeal cancer. There is also a hereditary predisposition. In addition, children and young adults who eat large amounts of salted fish (especially people with a poor intake of vitamins) are more likely to develop nasopharyngeal cancer.

 

Often, the first symptom is persistent blockage of the nose or eustachian tubes, which causes a sensation of fullness or pain in the ears and may cause hearing loss, particularly in one ear. If a eustachian tube is blocked, fluid may accumulate in the middle ear. A person also may have a discharge of pus and blood from the nose, swollen lymph nodes, and nosebleeds. Rarely, part of the face or an eye becomes paralyzed. Often, the cancer spreads to lymph nodes in the neck.

 

A doctor diagnoses the cancer by performing a biopsy of the tumor, in which a sample of tissue is removed and examined under a microscope. Computed tomography (CT) of the base of the skull and magnetic resonance imaging (MRI) of the head and neck are performed to evaluate the extent of the cancer. A positron emission tomography (PET) scan also commonly is done to assess the extent of the cancer.

 

The tumor is treated with radiation therapy and chemotherapy. If the tumor is large or persists, surgery may be needed, although these tumors are often not amenable to surgical removal. Overall, 35% of the people survive for at least 5 years after diagnosis. Early treatment improves prognosis significantly.

Cancer of the paranasal sinuses occurs mainly in the maxillary and ethmoid sinuses. Although rare in the United States, these cancers are more common in Japan and among the Bantu people of South Africa. Doctors are not sure what causes these cancers, but they are more common among people who regularly inhale certain types of wood and metal dust. Doctors do not think chronic sinusitis causes these cancers.

 

Because the sinuses provide room for the cancer to grow, most people do not develop symptoms until the cancer is well advanced. Symptoms, including pain, a sensation of nasal obstruction, double vision, nosebleeds, and loosened teeth in the jawbone underneath the affected sinus, result from the pressure of the cancer on nearby structures.

 

Doctors treat cancer of the sinuses with a combination of surgery and radiation therapy. Recent advances in surgical techniques have allowed doctors to remove the tumors completely, spare uninvolved parts of the face, such as the eye, and reconstruct the area with much better appearance. The earlier the cancer is treated, the better the prognosis. However, survival is generally poor. Only about 10 to 20% of people live more than 5 years.

Cancer of the tonsils occurs predominantly in men. It is strongly linked to smoking and alcohol consumption. Recent evidence suggests that human papillomavirus (HPV) is associated with tonsil cancer as well. People who have HPV-related tumors and who are non-smokers seem to have better survival rates. This cancer often spreads to the lymph nodes in the neck. Cancer of the tonsils occurs most often in people between the ages of 50 and 70.

 

A sore throat is often the first symptom. Pain usually radiates to the ear on the same side as the affected tonsil. Sometimes, however, a lump in the neck resulting from the cancer's spread to a lymph node (metastasis) may be noticed before any other symptoms. A doctor diagnoses the cancer by performing a biopsy of the tonsil, in which a sample of tissue is removed for examination under a microscope. Evaluation usually includes laryngoscopy (examination of the larynx), bronchoscopy (examination of the lungs), and esophagoscopy (examination of the esophagus). These areas are evaluated because of the high risk of additional cancers being present (up to 10%). A chest x-ray is done, and a computed tomography (CT) scan of the head and neck usually is also done.

 

About 50% of the people survive for at least 5 years after diagnosis, although the exact number depends on the stage of the cancer at the time of treatment.

 

Treatment typically includes radiation therapy, surgery, and chemotherapy. Small tumors may be treated with surgery alone or radiation therapy. Large tumors commonly are treated with a combination of chemotherapy and radiation therapy. Surgery may be needed for tumors that do not respond to the combination. Surgery may involve removal of the tumor, lymph nodes in the neck, and part of the jaw. There have been notable advances in the reconstruction used after surgery to remove the cancer, resulting in significant improvements in function and appearance.