Leukoplakias are white patches in the oral cavity that develop from squamous epithelial hyperplasia and cannot be scraped away with a tonghpvue blade. The lesions are usually benign, but, if there is an element of redness (erythroplakia), the risk for harboring dysplasia is much higher, though the differential diagnosis includes trauma from adjacent teeth or lichen planus. If leukoplakia is seen, the physician should accurately note the size, location, and site and should monitor every 3 to 4 months. If erythroplakia, enlargement of leukoplakia, or any evidence of mucosal invasion is noted, the physician should refer to otolaryngologyhead and neck surgery (Oto-HNS). The authors advise against lasering leukoplakia; it is unnecessary, can make subsequent evaluation more difficult, and can mask recurrent malignancy.
Oropharynx. The oropharynx includes the posterior third of tongue, soft palate, palatine and lingual tonsils, and the posterior and lateral pharyngeal walls superior to tip of epiglottis. Cancers can arise in any of these locations and may present with dysphagia, odynophagia, referred
otalgia, hoarseness, and enlarged lymph nodes. In advanced cases, there may be bleeding, airway obstruction, and aspiration. Nonsmokers with oropharyngeal SCC are likely to be HPV positive and may be younger than the typical patient with alcohol- or tobacco-related HNC. Human papillomavirus positive oropharyngeal carcinoma has a much better prognosis than its tobaccorelated counterpart does. Physical examination should include assessment of tonsillar size and symmetry, palpation of neck lymph nodes, and palpation of base of tongue. Treatment may involve surgery, radiation, or chemoradiation, depending on factors such as extent of disease and comorbidities.
Nasopharynx. The nasopharynx extends from the nasal cavity (posterior to nasal septum) to the oropharynx. The most common NPC symptoms are middle-ear effusion and enlarged neck nodes. Nasal obstruction, epistaxis, or cranial nerve deficits also may occur. The nasopharynx
is best assessed with a fiberoptic scope. Most NPCs are associated with EBV infection, and viral levels can be used to monitor response to treatment.20 Early biopsy is indicated if a nasopharyngeal mass is found.
Larynx. As with the nasopharynx, the larynx is best seen with a fiberoptic scope. Malignancy generally presents with hoarseness, voice changes, cough, sore throat, or, if more advanced, airway compromise such as stridor and neck adenopathy. As larynx HNCs may be associated
with aspiration, the authors recommend asking “Does food go down the wrong pipe?” or “Do you cough when you eat?” and having the patient drink and document any difficulty. A smoker with hoarseness lasting more than 2 weeks should be referred to Oto-HNS for endoscopic assessment. Among veterans, other causes of hoarseness include polyps, Candida infection associated with inhalation of steroids for chronic obstructive pulmonary disease, and recurrent nerve paralysis from thyroid or lung cancer.
Neck. Patients with HNCs commonly present with a neck mass. Fifty percent to 80% of adults with a nontender neck mass are harboring a malignancy. 21,22 In a patient without HIV, a neck mass larger than 2 cm should be evaluated for cancer, especially if the mass is hard and nontender. 23 Computed tomography (CT) is recommended for initial evaluation, which, if there is FNA confirmed carcinoma, should be followed by positron emission tomography (PET). If there is concern for parotidor skull base tumors, magnetic resonance imaging (MRI) is preferable for demonstrating soft-tissue definition and disease extent.
