Head and Neck Cancer
Pathophysiology – Damage to cellular DNA from toxins (often tobacco and alcohol) results in cellular division
malfunctions.
This leads to uncontrolled cellular growth, often starting superficially with squamous cells and spreading to
deeper tissue.
5-Year Survival Rate - 65.0% for men; 59.8% for women
How It Is Diagnosed
Laryngoscopy: examination of throat by use of a tube with a small lighted camera
Neck or Cranial CT Scan: will also help to see if lymph nodes are involved
Biopsy: analysis of the tissue will confirm cancerous cells
Signs/Symptoms of Cancer:


Nagging cough or
hoarseness
Constitutional S/S for
systemic illness:
Change in bowel or bladder
habits
 A sore that does not heal in
 Fever
6 weeks
 Unusual bleeding or
 Diaphoresis
discharge
 Night Sweats
 Thickening or lump in
 Nausea
breast or elsewhere
 Vomiting
 Indigestion or difficulty in
 Diarrhea
swallowing
 Pallor
 Obvious change in a wart or
 Dizziness/Syncope
mole
Common metastatic sites of head and neck cancers:


 Fatigue
 Weight Loss
For the PT:
 Proximal muscle weakness
 Change in deep tendon
reflexes
 Pain: rarely an early
warning sign of cancer;
Night pain that is constant
and intense is a red flag
symptom of primary or
recurring cancer
Regional lymph node involvement generally follows regular patterns according to the location of the primary tumor.
Major node zones are submental, submandibular, deep jugular (upper, middle, and lower), and posterior triangle.
Other zones in which involvement can occur from particular tumors are posterior auticular, juxta-parotid,
retropharyngeal (often involved in hypopharyngeal cancer), pretracheal, and juxta-thyroid.
Commonly used treatment of hypopharyngeal cancer:
 Small cancers can be cured by radiation therapy.
 Moderate sized and those with node involvement which is not extensive: fair survival achieved by surgery with
primary tumor resection, usually with laryngectomy plus a radical neck dissection.
 More extensive lesions: radiation and surgery are used in various combinations. Combined surgery and radiation may
consist of either pre-op or post-op radiation which are equally effective.
o Pre-operative radiation advantages:
 Can theoretically decrease the viability of cancer cells that may be dislodged into the bloodstream
during surgery.
 Reduced ability to respond to radiation if given post op because of decreased oxygenation of the
involved tissue from surgically disrupted arterial supply.
 Pre-op might decrease tumor volume, making a questionably resectable tumor definitely resectable.
o Post-op radiation advantages:
 Bulk of residual tissue is significantly less post-op pt. so radiation to a smaller tumor would be more
effective.
 True extent of the tumor can be determined during surgery and radiation given to only those who
would benefit
 Radiation targeted to known areas of positive margins to help retard or prevent local recurrence if
there is any residual disease.
 Post-op healing more assured in unirradiated tissue.


Chemotherapy: single and combination; no evidence that chemotherapy increases prognosis; mainly used for
unresectable, recurrent, or metastatic cancer in which reradiation cannot be delivered (median duration of survival
in this case is 6 months). No standard single agent for therapy for advanced head and neck cancer
Radical Neck Dissection: Unilateral cervical lymphadenectomy in which a block of tissue is removed from the
level of the clavicle below up to the mandible above, from the trapezius muscle posteriorly to near the midline
anteriorly. SCM and omohyoid muscles and jugular vein are included. In modified neck dissections internal
jugular vein, spinal accessory nerve, SCM, or all 3 may be preserved.
Carotid blowout


Can be a complication in patients with head and neck malignancy
Radiation
o Decreases blood flow to carotid artery
o Less blood flow mean it’s easier for the artery to rupture
 Precautions in Physical therapy for a patient with a risk of carotid blowout
o Be gentle with cervical stretching and ROM in the acute phase
o Be gentle with any scar massage in the acute phase
o Be cautious when doing neck musculature strengthening not to overstrain
 But it can happen…and the patient can die from hypovolemic shock in minutes
 Symptoms preceding a carotid blowout
o salivary fistula - An opening between a salivary duct or gland and the skin surface or the oral cavity.
o Local infection
o ‘herald bleed’ – A brisk gastrointestinal bleed that stops spontaneously, then recurs hours later
 If it happens
o Apply pressure to stop bleeding
o Call for nursing or medical support
o Send out crash call or call 911
 The risk of carotid artery rupture has been virtually eliminated because of several factors:
o radiation therapy is usually administered postoperatively (within 4-6 wk of surgery), which allows for healing
prior to the start of effects.
o muscle flaps that can cover the carotid artery provide it with a healthy source of uninvolved, unirradiated (not
having been exposed to radiation) tissue
 Carotid rupture today, when it occurs, usually is preceded by a history of radiation therapy, tumor erosion into the
carotid artery, and the development of a fistula to the aerodigestive tract
Psychosocial Aspects:
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Patients with cancer may experience depression upon being diagnosed, this depression often worsens as they begin
aggressive and painful treatments such as chemotherapy.
Because they are so ill, many cancer patients are no longer able to work and enjoy leisure activities they did prior to
illness. This causes them to be isolated and feel very alone at times.
As PTs, we need to motivate cancer patients by emphasizing strengths, giving positive feedback, and empowering
patients with activities that they will succeed in.
If you suspect that your patient may be depressed, refer them to a psychologist.
References submitted, but not included, due to space limitations