It is important that every effort be made to locate the primary tumor. If found, the primary can be adequately and appropriately treated and the patient's prognosis therefore better assessed. In addition, locating the primary lesion may avoid extensive mucosal radiation and therefore avoid the often severe adverse effects of wide-field mucosal irradiation. These adverse effects include severe xerostomia, dental caries, laryngeal edema, osteoradionecrosis of the mandible, laryngeal chondritis, persistent pain, dysphagia due to submucosal fibrosis of the pharynx, hypothyroidism, hypopituitarism, and aspiration.5-8
Most patients with head and neck cancer have squamous cell carcinoma arising from mucosal surfaces of the head and neck. Most of these patients are more than 40 years of age with a 4 or 5 to 1 male/female ratio. The vast majority of these patients relate a history of tobacco use, usually cigarette smoking, and many have a history of alcohol abuse. A patient presenting with a mass in the neck that is nontender and enlarging and who matches the above profile, should be regarded as having cancer until proven otherwise. An orderly stepwise approach should be taken in evaluating these patients. Most physicians treating these patients agree that open biopsy of the neck mass should be delayed until later stages of evaluation.
A careful history may elicit symptoms of pain in the oral cavity, the oropharynx, or hypopharyngeal areas, possibly with referred otalgia. Symptoms of hoarseness, dysphagia, odynophagia, or hemoptosis, or the awareness of a mass or ulcer in the oral cavity or the oropharynx, may alert the physician to the possible site of a primary tumor. One should inquire about symptoms such as weight loss, fever or night sweats, abdominal pain, melena, diarrhea, and hematuria. The patient should be questioned about history of thyroid or skin cancer or other tumors, including tumors below the clavicles (i.e., in the GI tract, lung, or GU tract). For example, renal cell carcinoma may metastasize to the head and neck 10 to 15 years or more after the initial diagnosis.
A detailed examination of the head and neck should follow. The number and location of lymph nodes in the neck are then assessed. Contralateral neck disease should not be overlooked. The site of lymph node involvement may suggest the location of the primary tumor.8'9
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