AKT · ENT/Neck & thyroid

Head and neck cancer (oral/laryngeal/salivary)

Mucosal/glandular malignancy of the upper aerodigestive tract

Overview

Malignancy of the upper aerodigestive tract — oral cavity, oropharynx, larynx, and salivary glands. Most are squamous cell carcinomas driven by smoking and alcohol (and increasingly HPV in the oropharynx). Recognising the red-flag presentations and referring on the 2-week-wait pathway is the core skill.

Recognise

Oral: a persistent (>3 weeks) mouth ulcer, red (erythroplakia) or white (leukoplakia) patch, or a lump; loose teeth
Laryngeal: persistent hoarseness >3 weeks; oropharyngeal: a neck lump (often the first sign of an HPV-related tonsil/tongue-base cancer), sore throat, otalgia
Salivary gland: a persistent parotid/submandibular lump (a lump + FACIAL NERVE palsy or pain suggests malignancy)

Red flags

Persistent mouth ulcer/patch >3 weeks, hoarseness >3 weeks, unexplained neck lump, dysphagia, or a salivary lump with facial weakness → 2-week-wait referral

Differentials & how to tell them apart

Benign mouth ulcer (aphthous)heals within 2 weeks — a persistent (>3 week) ulcer must be referred/biopsied

Leukoplakia/erythroplakiapre-malignant patches — erythroplakia carries the higher malignant risk; biopsy

Pleomorphic adenoma (benign salivary)slow-growing, mobile, NO facial palsy — malignancy suggests a lump + facial weakness/pain

Reactive lymphadenopathytender, mobile, resolves — a persistent firm neck node needs investigation

Oral squamous cell carcinoma — tongue
Alaa / CC BY-SA 3.0 — Wikimedia Commons

Investigations

2-week-wait ENT/maxillofacial referral. Examination + endoscopy; biopsy of the lesion; FNA/core of a neck or salivary lump; imaging (CT/MRI, USS) for staging. HPV (p16) testing in oropharyngeal disease.

Management

2-week-wait referral → head-and-neck cancer MDT (surgery/radiotherapy/chemo)

1Recognise the red flags and refer on the 2-week-wait pathway; do not "watch" a persistent ulcer/patch/lump. Treatment is planned by the head-and-neck MDT (surgery, radiotherapy, chemotherapy) by site and stage.Gate: Any mouth ulcer or oral patch persisting >3 weeks, hoarseness >3 weeks, or an unexplained neck/salivary lump (especially with facial nerve palsy) is a 2-week-wait referral — these do not get a trial of treatment first
2Staging investigations + HPV (p16) status for oropharyngeal disease (better prognosis); MDT treatment; smoking/alcohol cessation; surveillance for recurrence and second primaries.

Surgery / radiotherapy / chemotherapy (MDT) — treatment is by the head-and-neck cancer MDT and depends on site/stage

Risk-factor modification — smoking cessation, reduce alcohol; HPV vaccination (prevention)

Key points

Smoking + alcohol (and HPV in the oropharynx) are the drivers. The recurring rule is the >3-week red flag (ulcer, patch, hoarseness) + the unexplained neck/salivary lump → 2-week-wait. A salivary lump WITH facial palsy = malignant until proven otherwise.

Monitor & prognosis

Staging, MDT treatment response, recurrence, second primaries.

Better for early-stage and HPV-positive oropharyngeal disease; worse when advanced.

Source: NICE NG12 (suspected cancer); ENT UK