Viral infections are risk factors for development of oral cavity, oropharyngeal, laryngeal, and nasopharyngeal carcinoma (NPC). Sixty percent of oropharyngeal cancers are positive for human papillomavirus (HPV) infection, 15 and most NPCs are associated with prior Epstein-Barr virus (EBV) exposure, particularly in populations from southern China, Southeast Asia, North Africa, and the Middle East. 16
Evaluation
Workup of a possible HNC starts with taking a thorough history. Early HNC symptoms that may prompt a patient to seek medical care include neck mass, nonhealing oral ulcer, voice change, sore throat for more than 2 weeks, ear pain, nasal obstruction, serous otitis media, dysphagia, and odynophagia. Patients with advanced HNC may present with unintentional weight loss, decreased appetite, and cranial nerve deficits. For alcohol or tobacco users who present with any of the symptoms, SCC should lead the differential diagnosis, prompting examination of the head and neck. The authors present a general outline for performing this examination and detail the most common types of HNC encountered in the GP setting.
Physical Examination
The GP should perform a bimanual examination of the oral cavity, ears, nose, thyroid, and cranial nerve function with the help of a headlight. The physician should use 2 tongue blades to explore the oral cavity and palpate for suspicious oral lesions. It is often possible to feel a lesion before visualizing it on the base of the tongue. If there is a presenting mass, the physician should document the mass site, size, shape, consistency, tenderness, mobility, and accompanying deficits or symptoms.
Also recommended is a thorough examination of the facial, submandibular, and other cervical lymph nodes. The drainage patterns of these nodes can help the GP track potential routes of malignant infiltration. The submental and submandibular lymph nodes (level 1) drain the lower lip, floor of mouth, anterior tongue, and side of nose. The nodes along the mid and internal jugular vein (levels 2-4) and between the sternocleidomastoid and trapezius muscles (level 5) drain the oropharynx, mid tongue, larynx, hypopharynx, parotid gland, and skin of the face and ear. Nontender hard nodes are more likely to be malignant, as are nodes of the posterior triangle (level 5). 17
Malignancy by Site
Oral cavity. The oral cavity includes the lips, buccal mucosa, teeth, gums, anterior two-thirds of tongue, floor of mouth, alveolar ridge, retromolar trigone, and hard palate. The oral cavity is the most common site for HNCs. 18 The most common symptoms of malignancy of the oral cavity include dysphonia, nonhealing oral ulcers, loose teeth, bleeding, change in denture fit, and chin numbness, which could indicate mandibular invasion with inferior alveolar nerve involvement. 19
For thorough assessment of the oral cavity, the patient should remove all temporary dental appliances. Then, with a tongue blade in each hand, the physician should thoroughly examine the oral mucosa, moving the tongue laterally to evaluate the floor of mouth, and palpate the mucosal surfaces to identify submucosal cancers in the posterior tongue and floor of mouth. Minor salivary glands are ubiquitous in the oral cavity and may be involved by cancer. Ulcerated painful lesions that last longer than 2 weeks are less likely to be common viral or aphthous ulcers. For either an oral cavity mass or a nonhealing ulcer that persists more than 4 weeks, malignancy should be suspected, and the patient should be referred for imaging and biopsy.
