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Referral and warning signs
When to refer
Refer urgently to ENT/Head & Neck specialist for: Persistent sore throat/mouth ulcer (>2-3 weeks). Persistent hoarseness (>3 weeks). Unexplained neck lump. Persistent unilateral ear pain without ear pathology. Dysphagia/Odynophagia.
Red flags
- Non-healing oral ulcer or sore
- Persistent neck lump
- Persistent hoarseness (>3 weeks)
- Unilateral ear pain with normal ear exam
- Dysphagia / Odynophagia
- Unexplained weight loss
- Cranial nerve palsy
Signs and symptoms
- Persistent sore throat or mouth sore/ulcer that does not heal (>2-3 weeks).
- Painless or painful lump/mass in the neck (cervical lymphadenopathy).
- Dysphagia (difficulty swallowing) or Odynophagia (painful swallowing).
- Hoarseness or voice change persisting >3 weeks.
- Persistent ear pain (otalgia), often unilateral (referred pain).
- Difficulty moving tongue or jaw.
- Loosening of teeth.
- Unexplained weight loss.
- Persistent nasal obstruction or bleeding (nasal/sinus cancer).
- Unilateral hearing loss or serous otitis media (nasopharyngeal cancer).
- Cranial nerve palsies.
Risk factors
- Tobacco use (smoking, chewing).
- Excessive alcohol consumption (synergistic effect with tobacco).
- Human Papillomavirus (HPV) infection (esp. type 16 - major cause of oropharyngeal cancers).
- Epstein-Barr Virus (EBV) infection (associated with nasopharyngeal carcinoma).
- Poor oral hygiene.
- Occupational exposures (wood dust, nickel, formaldehyde).
- Betel quid chewing.
- Genetic predisposition (rare).
Diagnosis
Clinical assessment
Suspect based on persistent symptoms (>2-3 weeks). Requires thorough examination of oral cavity, pharynx, larynx (indirect/flexible laryngoscopy), and neck palpation.
Investigations
- Biopsy of suspicious lesion: Essential for diagnosis. Via endoscopy or direct biopsy.
- Fine Needle Aspiration (FNA) Biopsy: Of suspicious neck lymph nodes.
- Imaging: CT Scan (Neck/Chest +/- Abdomen/Pelvis), MRI Scan (soft tissue/base of skull/tongue), PET-CT Scan (metastases/unknown primary).
- Panendoscopy (Examination under anaesthesia): Laryngoscopy, pharyngoscopy, oesophagoscopy, bronchoscopy.
- HPV testing (p16) on oropharyngeal SCC biopsies.
Diagnostic criteria
Histopathological confirmation from biopsy.
Management
Non-pharmacological management
- Referral to specialized multidisciplinary Head & Neck Oncology team.
- Management depends on site, stage, histology, HPV status, patient factors.
- Surgery: Resection of primary tumour +/- neck dissection.
- Radiotherapy: Primary treatment (often with chemo), adjuvant, or palliative.
- Speech and Swallowing Rehabilitation.
- Nutritional Support (often requires feeding tube).
Pharmacological treatment
- Chemotherapy: Concurrent with radiotherapy (chemoradiation - e.g., Cisplatin), induction/adjuvant/palliative.
- Targeted Therapy (e.g., Cetuximab - EGFR inhibitor).
- Immunotherapy (e.g., PD-1 inhibitors) for recurrent/metastatic.
- Pain management.
Monitoring
Close follow-up with clinical exam, endoscopy, imaging. Monitor swallowing and speech function. Monitor thyroid function after neck radiation.
Complications
- Airway obstruction
- Difficulty swallowing / Malnutrition
- Speech impairment
- Local recurrence
- Regional/Distant metastasis
- Treatment side effects: Mucositis, xerostomia, dysphagia, fibrosis, dental problems, hypothyroidism, hearing loss, secondary malignancies.
Prevention
- Tobacco cessation.
- Limit alcohol consumption.
- HPV vaccination.
- Good oral hygiene.
- Avoid betel quid.
Patient education
- Explain diagnosis, site, stage.
- Discuss treatment options and multidisciplinary approach.
- Potential impact on speech, swallowing, appearance.
- Importance of smoking/alcohol cessation.
- Need for dental assessment before radiation.
- Nutritional support needs.
- Importance of rehabilitation and follow-up.
Uganda-specific notes
Nasopharyngeal carcinoma (EBV-associated) relatively common. Oral cancers linked to tobacco/alcohol. Access to specialized H&N surgery, radiotherapy (IMRT), chemotherapy, and supportive care limited.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 12, Section 12.3.2