HEAD AND NECK

Principles and management

of head and neck cancer

Background
HNC of all sites and types has a prevalence of 9.9 cases per
100,000 and incidence of 8.3 new cases per 100,000 annually.
The incidence of laryngeal SCC steadily fell until 1990 at which
point it levelled out. The incidence of oropharyngeal SCC has
been on the rise during the past decade, with a 51% increase
between 1989 and 2006 in the UK.1 Human papillomavirus
(HPV) associated with orogenital sex is widely believed to be
responsible for part of this increase.2
The emergence of HPV-related oropharyngeal carcinoma
resulted in changing demographics in the head and neck cancers.
Previously a typical head and neck cancer patient would have
been a male in his 50s with a significant history of tobacco and
alcohol use. Whilst this remains true for laryngeal cancer, there
has been a sharp rise in the incidence of oropharyngeal malignancies and over 25% of cases are now diagnosed in the under55 age group.3
Management of head and neck cancer is a complex process
with specialties such as otolaryngology, oromaxillofacial surgery
(OMFS), plastic surgery and oncology working together. Along
with radiology, pathology, specialist nurses, speech and language therapy, dietetics and restorative dentistry, clinical psychology these specialties form the multidisciplinary team (MDT)
which is a key organization for optimum management of all HNC
patients.
The ideal composition of a head and neck MDT was described
in Guidance on Cancer Services: Improving Outcomes in Head and
Neck Cancer. The Manual, which was published in 2006,4 was
updated in May 2012.5 The key recommendations are that a head
and neck MDT should work in a cancer centre serving a population of greater than a million, and manage at least 100 new SCC
cases of the UADT per year. In 2011, a consensus guideline on
the management of head and neck cancer was published by ENT
UK and professional bodies for other clinical disciplines.

Shane Lester
Woo-Young Yang

Abstract
Head and neck cancer is predominantly squamous cell carcinoma and affects the whole of the upper aerodigestive tract. It is traditionally associated with tobacco and alcohol use in older males. Cancer of the
oropharynx has the most rapid increase in incidence at the present
time due to human papillomavirus-related malignancy, with a younger
age presentation in both sexes. This subtype has been termed a viral
epidemic of cancer. This article outlines the relevant anatomy, aetiology,
presentation, examination and investigatory pathway for this group of patients including relevant national guidelines. An overview of surgical and
non-surgical managements available for early and late stage tumours is
given. This is supported by information about the multidisciplinary
approach to these cancers which is current best practice. Potential future
developments in management are discussed.

Keywords Cancer; diagnostic; head; malignancy; neck; squamous;

treatment

Introduction
Head and neck cancer (HNC) refers to malignancy presenting in
the anatomical area below the skull base and above the clavicles.
A wide variety of malignancies are found in the head and neck,
including sarcoma, lymphoma and salivary gland carcinomas.
This article will concentrate on primary squamous cell carcinoma
(SCC) of the upper aerodigestive tract (UADT) as it represents
over 90% of primary malignancy in the head and neck.
The head and neck region is divided into six overall sites:
nasal cavity, pharynx, oral cavity, oropharynx, larynx and hypopharynx (Figure 1). This area of the body is responsible for
airway protection, swallowing and speech production, and malignancies can affect all of these functions.
Management of HNC can be a challenging task. Being
inaccessible to simple clinical examination, it is not uncommon
to have late presentation of disease. Therefore patients may
present with: life-threatening airway obstruction; starvation
due to near total dysphagia; torrential bleeding due to carotid
invasion. Treatment can cause further difficulties due to the
delicate nature of the tissues of the UADT which are difficult to
replace or reconstruct once damaged by the disease or the
treatment.

Aetiology
Multistep carcinogenesis
As with other malignancies, head and neck cancers follow a
multistep model of carcinogenesis. In order for a normal cell to
evolve into a malignant cell, it must go through genetic alteration
of multiple independent genes. The genes that are altered are
almost invariably either proto-oncogenes, tumour suppressor
genes, or both.6 The current evidence indicates that signal
pathways involving p53 and Rb, both tumour suppressor proteins, are among the commonest molecular mechanisms through
which head and neck SCC is manifested.7 There may be premalignant changes such as various grades of dysplasia and carcinoma in-situ. External carcinogens which potentiate HNC
include tobacco, ethanol alcohol and viruses (EpsteineBarr virus
and HPV).

Shane Lester FRCS (ORL HNS) is a Consultant Head and Neck Surgeon at
Darlington Memorial and James Cook University Hospitals,
Middlesbrough, UK. Conflicts of interest: none declared.

Tobacco and alcohol

Over 90% of patients have a history of smoking. The relative risk
(RR) of developing laryngeal cancer for a smoker of up to 10
cigarettes per day is 4.4, this goes up to 34.4 if smoking 40 or
more per day. Stopping smoking leads to a reduction in the
relative risk, however heavy smokers retain a threefold lifelong

Woo-Young Yang MB BS MRCS is a Specialist Registrar in ENT at

Darlington Memorial and James Cook University Hospitals,
Middlesbrough, UK. Conflicts of interest: none declared.

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EpsteineBarr virus (EBV)

EBV is associated with endemic type nasopharyngeal malignancy. The antibody titre to EBV antigen may have positive
correlation with the stage of nasopharyngeal carcinoma. The use
of specific antibodies to parts of the EBV DNA may be useful in
the future for monitoring disease activity.7,8

Presentation and pathways

The Government White Paper entitled The New NHS e Modern,
Dependable enshrined the idea of the 2-weeks rule whereby GPs
could refer patients on a fast track for suspected cancer when
certain criteria were met (Box 1). The guidelines, updated in 2011,
provide a framework for identifying suspicious signs and symptoms that could indicate HNC. As oral and oropharyngeal malignancies can be discovered by dental examinations, much work
has been done to involve dentists in the recognition of suspicious
signs requiring onward referral. As for all cancers the clock starts
at the day of referral, with a 31-day target for completion of investigations and a 62-day target for starting treatment.
There has been much discussion about whether the 2-weeks
rule improves patient care and this has been investigated by
several studies looking at whether patients were more accurately
diagnosed when these criteria were applied. One study10 of 1079
HNC patients found most patients were diagnosed by the
routine referral route and that 2-weeks wait referral did not
lead to earlier stage referral. It noted that only 78% of the referrals actually conformed to the guidelines and that the referrals
following the guidelines were better at identifying cancers than
those not following guidelines. It is therefore essential that as
long as this pathway continues, there is feedback to primary care
when the guidelines are not followed.

Figure 1 Anatomical subsites of the head and neck. (From http://www.

headandneckoncology.org).

risk compared to non-smokers even after 10 years of smoking

cessation.8
Alcohol potentiates the carcinogenesis of tobacco and may be
an independent risk factor in some subsites. The RR from their
combined use is 50% more than expected from a purely additive
effect.4 Grain alcohol (spirits and beer) has a more significant
effect than wine. A moderate amount of wine intake (7e21 units
per week) appears in one study to have a mildly protective effect
(RR 0.5). The RR of excess alcohol intake (>21 units per week)
was notably higher for grain alcohol (5.2) than for wine drinkers
(1.7).
Social deprivation
Social deprivation has a complex relationship with HNC. National audit data have demonstrated a higher number of laryngeal and hypopharyngeal cancers in areas with relative social
deprivation. For laryngeal cancer, the most deprived have the
greatest incidence, being 20% above the national average for
some networks (especially North of England). However these
risks are multifactorial and also represent higher uses of tobacco,
alcohol and drugs, poor diet, little or no exercise,5 poorer education and poor use of the health services.9 This is an area for
further research.

Primary care 2-weeks wait criteria for head and neck

cancer urgent referral
Refer urgently patients with:
C

Inhaled carcinogens
Nickel and chromate refinery workers have an increased incidence of laryngeal SCC, whereas woodworkers are at a higher
risk of developing adenocarcinoma of the sinonasal tract due to
wood dust.7

Human papillomavirus (HPV)

HPV serotypes 16 and 18 are most commonly linked to head and
neck carcinogenesis via oncoproteins E6 and E7. HPV infection is
commonly found in tonsil cancer (74%), as well as larynx,
tongue and nasopharynx (20e30%). HPV-positive tonsil cancers
may to be found in younger, non-smoking, and non-drinking
patients.7 Possibly due to the different molecular pathogenesis,
HPV-positive tonsil cancers show a better prognosis with a
hazard ratio of death from cancer of 0.77 compared with HPVnegative tumours.

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an unexplained lump in the neck, of recent onset, or a previously undiagnosed lump that has changed over a period of
3e6 weeks
an unexplained persistent swelling in the parotid or submandibular gland
an unexplained persistent sore or painful throat
unilateral unexplained pain in the head and neck area for
more than 4 weeks, associated with otalgia (earache) but a
normal otoscopy
unexplained ulceration of the oral mucosa or mass persisting
for more than 3 weeks
unexplained red and white patches (including suspected
lichen planus) of the oral mucosa that are painful or swollen
or bleeding.

For patients with persistent symptoms or signs related to the oral

cavity in whom a definitive diagnosis of a benign lesion cannot be
made, refer or follow up until the symptoms and signs disappear. If
the symptoms and signs have not disappeared after 6 weeks, make
an urgent referral.
Box 1

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History
Early presentation of HNC provides a greater opportunity for cure
with the use of less morbid treatment options than later stage
disease. A full history includes assessment of breathing, swallowing and speech. Referred otalgia is usually a strong indicator
of disease due to the sensory innervation of the ear and UADT by
branches of the vagus and glossopharyngeal nerves. Weight loss
may be marked due to dysphagia or odynophagia.
A full smoking and alcohol history should be taken, and any
previous cancer treatments or radiation therapy should be noted.
HNC patients have a 5e30% incidence of second primary cancers including lung cancers.
As one of the major functions of the larynx is to provide a safe
airway, dysfunction at this site can lead to one of the emergency
presentations of head and neck cancer e stridor or airway
obstruction. Equally pharyngeal or oesophageal obstruction with
severe or total impedance to swallowing can require an urgent
admission to avoid starvation. Otherwise most HNC can be
investigated as an urgent outpatient.

being 5e30%, it is important to fully assess the whole UADT.

Finally, if the patient has been diagnosed with metastatic cervical
malignancy with unknown primary, rigid endoscopy may help
locate the occult primary by palpation or by biopsies of typical
sites for occult primary including tongue base and tonsillectomy.
Imaging
Imaging is routinely required in the staging process of HNC patients. The relationship between the lesion and its surrounding
anatomical structures not only determines the oncological stage,
but also the surgical resectability. If a lesion invades the carotid
artery or the pre-vertebral tissues, it is deemed irresectable.
Primary tumour assessment: with laryngeal carcinoma,
involvement of the thyroid cartilage is an important aspect of
staging. With CT evidence of invasion of the thyroid cartilage,
local control by radiotherapy has been shown to drop from 95%
in uninvolved cases to 42%. In such cases, laryngectomy may be
the more appropriate treatment for the surgically fit patients. CT
has a reported sensitivity of 68% and specificity of 84% in the
assessment of cartilage invasion. In comparison, peritumoural
oedema and inflammatory changes make MR images difficult to
interpret, thus lowering the specificity 62%. However, MR has a
superior sensitivity of 97%.
MRI is often considered preferable for assessment of oropharyngeal lesions as it provides better soft tissue resolution, however choice of investigation is dependent on familiarity and
preference of local specialist radiologists.
Bone erosion of the mandible in oral cavity or oropharyngeal
cancer determines whether mandibulectomy may be necessary.
Although the CT is thought to be the superior modality in the
assessment of bone erosion, some authors maintain that MR can
provide highly accurate assessment.

Examination
A full ENT examination includes examination of oral cavity
including gums and buccal mucosa, inspection of the oropharynx
with a tongue depressor and palpation of the neck. Suspicious
areas on the tongue or in the mouth are palpated. Some patients
will tolerate palpation of the oropharynx.
All patients with suspicion of HNC will undergo a fibreoptic
transnasal endoscopy to examine the pharynx and larynx. It is
important to document the movement as well as the structure of
the vocal cords. Standard fibreoptic laryngoscopy cannot assess
the pyriform fossae or post-cricoid region and therefore some
departments have introduced transnasal flexible oesophagoscopy
to fully assess this area.

Investigation

Assessment of neck disease: CT and MR criteria for normal

lymph nodes include short-axis diameter of less than 1 cm, an
oval shape with smooth well-defined border, and absence of
central necrosis. The accuracy of CT and MR on the diagnosis of
metastatic involvement of cervical lymph node on size criteria
alone is low, with sensitivities of 65 and 88%, and specificities of
47 and 41%. However, with central necrosis, the sensitivities and
specificities of both modalities improve to the region of 90%.
Extracapsular spread of the lymph node metastases, a negative
prognostic factor, may be assessed with CT and MR.
Ultrasound is useful in the investigation of superficial lesions.
It enables differentiation between solid and cystic masses, and
gives information on the cervical lymph nodes such as vascularity and hilar structure which other cross-sectional imaging
modalities such as CT or MR cannot. It is often used to guide
cytological assessment of indeterminate nodes.

Fine-needle aspiration cytology (FNAC)

For a neck lump, FNAC is the initial investigation of choice. A 21G needle and a 20-ml syringe are used to obtain the sample,
which should be sent in both air-dried and fixed conditions for
different staining. The sensitivity and specificity described in the
literature are in the region of 90% when reported by a head and
neck cytopathologist. A gold standard neck lump clinic is
multidisciplinary; with ultrasound-guided FNA to ensure a
representative sample and cytological assessment to assess
whether there is sufficient material in the sample. Open biopsy of
a neck lump is generally avoided due to the possibility of seeding
of the lesion and is only attempted where repeated cytology
testing is non-diagnostic.
Endoscopy
Patients with an UADT tumour undergo rigid endoscopy under
general anaesthesia. Angled fibreoptic endoscopes and rigid
endoscopy provide clinical staging information and enables biopsy. Information such as fixity to bone and pre-vertebral tissues
can be gleaned from this type of clinical assessment. A panendoscopy is an opportunity for the surgeon to assess suitability
for endoscopic resections in appropriate cases. With the risk
of a second (synchronous) primary disease within the UADT

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Positron emission tomography: during the past decade, positron emission tomography (PET) has become increasingly more
widespread in the assessment of head and neck cancer. It utilizes
the higher metabolism of the cancer cells. The fluorine-labelled
deoxyglucose (18F-FDG), a glucose analogue labelled with
radio-isotope, is taken up by metabolically active tissue, which is
then localized by the scanner. However, as 18F-FDG is also taken
up by physiologically active organs (brain, tonsils, contracting

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muscles) as well as inflammatory tissue (post-biopsy, infection),

caution is needed in its interpretation. It is commonly used coregistered with non-contrasted CT images, as PET on its own
gives poor anatomical detail and spatial resolution.
The role within the investigation of head and neck cancer is
still evolving. One area where it is thought to be particularly
useful is in the detection of occult primary in cervical lymph node
metastasis of unknown primary. Several studies have demonstrated that the diagnostic yield of PET-CT is better than CT
alone. Other areas of use for PET-CT include assessment of
distant metastasis and post-treatment surveillance (PET NECK
trial) (Figure 2).

patient in this shell and the doses are planned with the aid of
computers. The most up-to-date treatment is known intensitymodulated radiotherapy (IMRT) and due to multidirectional
beam delivery enables greater doses to be given to the tumour
mass with lower doses to surrounding tissues. By relatively
sparing tissues such as the salivary glands and the pharyngeal
constrictors, it is hoped that side effects such as xerostomia and
post-treatment pharyngeal strictures will be less prevalent.
Tumours of all stages and sites of the head and neck may be
treated with radiotherapy alone. It can be used as sole modality
for early stage tumours.
Chemotherapy
Platinum-based chemotherapy (e.g. cisplatin) has been shown,
when used concurrently with radiotherapy, to have a radiosensitiser effect. It is used in advanced stage tumours of all sites.
The reported improvement in survival over radiotherapy alone is
6e8% over 5 years. Chemoradiotherapy is often called organpreserving treatment as there is no tissue removed. Advanced
laryngeal cancers treated with concurrent chemoradiotherapy as
primary treatment have a similar overall survival to those treated
with surgery and two-thirds of patients will keep their larynx. Of
the one-third that go on to have a laryngectomy, some will be for
salvage of recurrent tumour and some will have laryngeal
dysfunction or destruction as a result of the treatment.
Patients undergoing radio or chemoradiotherapy will need
significant support (see multidisciplinary challenges later).
Alternative feeding routes (nasogastric tubes or gastrostomies)
are routinely used, as are high-dose opiate analgesia. The side
effects may continue many months after the treatment and a
small number of patients never return to full oral diet despite
intensive rehabilitation.

Staging and treatment

With radiology and clinical staging completed each case should
be discussed in a weekly MDT meeting. Specialist head and neck
radiologists and pathologists give opinions on the investigations
results. Once the diagnosis is confirmed the staging is agreed on
based on the International Union Against Cancer (UICC) version
8 tumour/node/metastasis (TNM) staging system. Treatment is
then agreed with the patient in a combined surgical/oncology
clinic with multidisciplinary involvement. Treatment might be
surgery, radiotherapy (plus or minus chemotherapy) or best
supportive care with palliative treatment depending on stage of
presentation, patient fitness and preference.
Radiotherapy
Radiotherapy uses high-voltage X-rays produced in a linear
accelerator to ionize oxygen in tissues causing free oxygen
radical production and tumour death. It is a high-precision
technique requiring exact delivery of known radiation doses
in divided fractions. A typical head and neck radiation prescription will be a total of 65 Gy given in 30 fractions over 6
weeks, with daily fractions being given 5 days a week. To
enable precise delivery of the dose and to minimize the dose to
important susceptible tissues (spinal cord, optic nerve) the patient has a custom fitted plastic mask or shell made of their neck
and head, which is used to immobilize the area during each
fraction (20 minutes at a time). A planning CT is taken with the

Surgery to the neck

As the regional lymphatic drainage site for the UADT, it is
important to treat the neck to gain control of the disease. As a
rule of thumb, positive neck disease (palpable or radiologically
enlarged lymph nodes in the neck) at presentation halves the
5-year survival. A basic tenet of treatment is that whenever
possible there should be the same modality of treatment used for
treating the neck as used for the primary site, to minimize
morbidity.
Predictable lymphatic drainage
Professor Jatin Shah, in 1990, reported the results of 1119 radical
neck dissections performed in the previously untreated neck.
This work made it clear that there is predictable regional
drainage for a given primary site. Therefore treatment to the neck
can be targeted to the areas at risk, whether this treatment is
radiotherapy or surgery. The surgery to the neck has developed
over the second half of the 20th century.
Neck dissection
Crile in 1906 published the use of the radical neck dissection
(RND) to clear all at-risk structures from the neck in the case of
primary UADT squamous cell cancer. This approach was popularized in the 1950s by Hayes Martin and although it was effective, has significant morbidity associated with it.

Figure 2 Positron emission tomography-CT showing tracer uptake along

the lateral tongue, indicating recurrence.

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laryngeal cancer this is usually performed with a selective neck

dissection to treat the regional disease. The functions of the
larynx each need reconstructing.
The most important of these functions is airway protection.
The cut upper end of the trachea is fixed to the skin as an end
tracheostomy, thereby preventing aspiration. However the
airway is unprotected and therefore artificial filters are used to
help prevent direct inspiration of foreign bodies, whilst also
warming and humidifying the air.
The larynx acts as a valve, selectively permitting food to pass
into the oesophagus. When the pharynx is reconstructed, this
forms a single tract from mouth to oesophagus. It is important to
ensure that this is wide enough to allow unrestricted passage of
chewed food, therefore if a partial or total pharyngectomy is also
performed then it may be necessary to use a soft tissue flap to
replace some of this tissue and prevent a stricture.
In the evolutionary scale, speech is a late function of the
larynx, yet it is extremely important for modern living. Therefore
much work has been done to reconstruct the speech function of
the UADT post-laryngectomy. The air stream from a functioning
larynx is a vibrating column of air which is shaped into speech by
the resonators of the head and mouth, the tongue and the lips.
Therefore to create alaryngeal speech it is necessary to recreate a
vibrating column of air as the rest of these structures are still
present.
Oesophageal speech is the term for swallowing down air and
bringing it back into the mouth in a controlled manner e in a
manner similar to talking whilst belching. Only about 20% of
patients who try this method, are able to produce intelligible
speech.
An electrolarynx (e.g. Servox) is a vibrating device which is
placed on the neck to transmit vibrations into the pharyngeal
column of air. In order to best transmit the vibrations, they need
to be low-frequency. This gives the voice a deep, robotic quality
with little or no intonation and no ability to project.
The current gold standard for voice restoration is surgical
voice restoration (SVR), whereby an artificial fistula between
trachea and oesophagus is made and a valve is sited (Figure 3).
This valve permits flow of air from trachea, to oesophagus,
causing the pharyngo-oesophageal segment to vibrate and air to
flow into the mouth to be formed into words. The valve closes
when the pressure in the pharynx rises, such as swallowing,
preventing aspiration. These valves require maintenance and
therefore the patient needs to take responsibility for managing
this in close partnership with a highly specialized SALT.

A classical radical neck dissection is rarely performed in

modern HNC surgery. It involved removing all lymph nodes in
the anterior and posterior triangles (levels IeV), two glandular
structures (submandibular gland and tail of parotid) and three
other structures e internal jugular vein (IJV), sternocleidomastoid muscle (SCM) and the accessory nerve (AN). Apart from the
cosmetic morbidity, the loss of AN leads to shoulder syndrome;
a winged, unstable shoulder which leads to an aching dragging
feeling and an inability to abduct the shoulder beyond 90 degrees
(e.g. brushing the back of your hair).
Modern selective neck dissection is a relatively low-morbidity
procedure taking about 90 minutes with a well-hidden scar,
little change to the contour of the neck and low risk of
damage to important structures. The preservation of the nonlymphatic structure (especially AN) has significantly reduced the
morbidity of neck dissection. A patient will expect to wake with a
neck drain which will often be left in place for 3 days to ensure
adherence of the skin flap, but will be mobile and active on the
day of surgery with only minimal discomfort.

Surgery to the primary site

Depending on the primary site, primary surgery may be offered
by the MDT. The article will discuss the two most common sites
e larynx and oropharynx.
Larynx e early stage
Early-stage laryngeal cancer is often very appropriate for
transoral laser microsurgery (TLM) which was developed
following the work of Professor Wolfgang Steiner from Keil.
Using rigid laryngoscopy Steiner demonstrated that small laryngeal tumours were accessible and resectable via a transoral
route. He showed that the tumour could be safely cut through
with the laser and this facilitated removal, by demonstrating
clearly the interface between tumour and normal tissue. A small
margin, tailored to the size of the tumour could be removed and
by removing the tumour a piece at time a mosaic resection was
performed. With a 95% 5-year survival rate for T1 tumours and
82% for T2 tumours, this mode of treatment is widely accepted.
Side effects of treatment include the risk of aspiration especially
with posterior and larger lesions, the possible need for sequential
resections following histological examination of the specimen
and voice change (similar voice results to radiotherapy unless the
anterior commissure is involved). Therefore this technique must
be used where there is a good relationship between surgeon,
pathologist and specialist speech and language therapist (SALT).

Oropharyngeal primary

Late-stage laryngeal cancer

Late-stage T3 or T4 lesions are less commonly treated with TLM
due to the impact of significant volumes of resection on swallowing and airway protection, and the difficulty in ensuring
clearance with possible laryngeal cartilage invasion. Partial open
surgery is performed more in certain centres in mainland Europe
but is less popular in the UK. Larger laryngeal tumours are
offered either chemoradiotherapy or a laryngectomy.

Early stage
Increasingly early-stage oropharyngeal tumours are being resected transorally with the laser using the principles set forward by
Steiner in the larynx. Early results are good with patients
avoiding open surgery. Tumours into the tonsil and tongue base
have a good blood supply from the lingua-facial trunk of the
external carotid and resections may expose these branches to
saliva, risking late life-threatening bleeding. Therefore most
proponents of this type of surgery recommend ligating the
external carotid beyond the superior thyroid artery to minimize
this risk.

Laryngectomy
First successfully performed by Bilroth in 1873, the total laryngectomy is the removal of the laryngeal apparatus and reconstruction of the pharynx. When performed for advanced

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best option for reconstructing the defect. With the increasing

popularity of transoral laser surgery it has been recognized that
the simplest method (secondary intention healing) is actually of
more use than was previously thought in the head and neck.
Significant laryngeal, oral cavity and oropharyngeal defects have
been shown to fill in well by secondary intention, often providing
better function than a bulky insensate flap.
There are situations where leaving a defect is not an option,
such as where this would lead to salivary fistula or where skin
has been resected. Therefore either a pedicled flap or free flap are
commonly utilized to reconstruct the structures. With closer
multidisciplinary working, it is common to find separate resection and reconstruction teams working together on the same
case. These may be formed from any combination of ENT, OMFS
and plastic surgery, depending on the case and individual
expertise.
Pedicled flaps
The commonest pedicled flaps used in the head and neck are the
pectoralis major flap and the deltopectoral flap, the former being
far and away the commonest.
The pectoralis major flap is either a muscular or musculocutaneous flap and is based on the acromioclavicular artery
and is a very reliable pedicled flap which can be raised in about
an hour. The donor site can be closed primarily but can be uncomfortable as it moves with respiration.
Free flaps
The use of microvascular free flaps have revolutionized head
and neck reconstruction, providing single-stage flaps which can
be selected based on thickness, pliability and tissue requirements. They can provide skin, muscle or bowel (for
pharyngeal reconstruction) and the donor tissue can be raised
by the reconstruction team whilst the resection team are still
working. The first and commonest flap used is the radial
forearm free flap (RFFF) which was pioneered in the 1970s and
it is flexible enough to be used as a patch or to be tubed for a
total pharyngeal replacement. The donor site can be a challenge with exposed forearm tendons and delayed healing and
discomfort, and requires a split skin graft to close with a second donor site.
Other commonly used flaps are the anterolateral thigh flap
which provides bulk when required and the donor site can be
closed primarily. The harvest can be quick if the pedicle follows
the septum, but can be more protracted and difficult if it travels
through the muscle belly. Reconstruction of a bony defect such
as the mandible can be performed with a fibula free flap, usually
with a skin paddle. A jejunal free flap is a good choice for
pharyngeal reconstruction, but requires a laparotomy for harvesting, produces mucus which can be unpleasant and may be a
challenge for swallowing rehabilitation.

Figure 3 Schematic of a laryngectomy patient with speech valve fitted (for

more information see: http://www.forthmedical.com/BlomSinger-SVR.
html). Courtesy of InHealth Technologies and Forth Medical Ltd.

Late stage
For larger primary tumours and small primaries with neck disease, laser surgery is increasingly an option. However open
surgery is required for patients with radiorecurrent disease and
those not suitable or keen on primary chemoradiotherapy. Access to the oropharynx involves some form of mandibulotomy or
partial mandibulectomy, mandibular swing and soft tissue
reconstruction. A tracheostomy may be required for airway
protection due to oropharyngeal oedema.
The classical COMMANDO (COMbined MAndibulotomy and
Neck Dissection Operation) which was the mainstay of surgery
for the oropharyngeal primary, is much less frequently used but
is still valuable. The steps involve a lip split, a stepped mandibulotomy (pre-plated to ensure good alignment), division of
the attachments of the floor of mouth, lateralization of the
mandibular segment, resection of the tumour and reconstruction
of the defect with a soft tissue flap (see later), suturing of the
floor of mouth tissues, plating of the jaw and suture of the lip,
chin and neck skin over drains (Figure 4). Patients are fed by
nasogastric tube for a week or longer depending on the preoperative condition of the tissues.

Multidisciplinary challenges
The head and neck MDT is essential for the psychological and
physical rehabilitation of this challenging group of patients. The
need and minimum content of the team is set out in the
Improving Outcomes guide4 and enshrined in annual peer review
measures.

Reconstruction
Where a soft tissue defect is created the surgeon needs to
consider the reconstructive ladder to choose the simplest and

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inspection and biopsy in head and neck clinics, however often

the mucosa will look normal. Narrow band light imaging, contact
endoscopy and tissue staining with Lugols iodine are some of
the methods being used for identifying pre-malignant lesions for
early treatment.
Early-stage disease is simpler to treat and has a better prognosis than late-stage disease. Therefore increased awareness of
HNC can encourage early presentation. Many groups, such as the
Look A Head Cancer Campaign (LAHCC, www.headandneck.
info) run campaigns to disseminate this information and help
educate both public and health professionals to this end.
When a late-stage HNC has been diagnosed, there are
increasingly less invasive methods of treatments being developed. The increasing use of endoscopic laser resection is
reducing the number of people requiring mandibulotomy and
free flaps. The growth of transoral robotic surgery (TORS) using
the DaVinci surgical robot system as a non-invasive tool for
oropharyngeal resections may extend this scope further.
The epithelial growth factor receptor (EGFR) has been identified as a target for anti-tumour chemotherapy. The commercially available EGFR receptor antagonist has a very limited remit
following a review by NICE of the evidence for its use, however
this may expand as the results of ongoing trials in the UK.

Figure 4 Hemiglossectomy for a lateral tongue tumour. This is a second

primary tumour as the patient already has had a laryngectomy.

Clinical nurse specialist (CNS)

Starting with breaking the bad news of the diagnosis of cancer
the CNS is involved in all facets of patient care. Patients have
differing psychological and social needs depending on their
backgrounds and these issues need to be addressed early on to
enable a patient to cope with the rigours of treatment.

Conclusion
HNC is a cancer with increasing incidence and the rise in HPVrelated malignancies has led to a wider range of people at risk.
Early treatment is more favourable but with the increased use of
chemoradiotherapy and endoscopic surgical techniques, more
patients are having organ-preserving treatments. The MDT
approach is essential to support patients through a challenging
diagnostic and treatment pathway.
A

Speech and language therapist (SALT) and dietician

SALTs and dieticians are essential to MDT working. With accurate pre-treatment assessment of dietary need and swallowing
ability, patients nutritional needs can be better managed, and
this requires specialist input. It is also vital for any patient
considering a laryngectomy to discuss speech and swallowing
issues preoperatively with the SALT. The understanding of the
rehabilitation phase enables a patient to engage earlier and more
effectively after surgery.

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2 Mehanna H. Head and neck cancerdpart 1: epidemiology, presentation, and prevention. Br Med J 2010; 341: c4684.
3 Cancer Research UK. http://cancerhelp.cancerresearchuk.org/type/
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4 National Institute for Health and Care Excellence. Improving outcomes in head and neck cancers 2006, www.nice.org.uk/nicemedia/
pdf/csghn_themanual.pdf.
5 http://www.evidence.nhs.uk/evidence-update-17.
6 Barrett JC. Mechanisms of multistep carcinogenesis. Environ Health
Perspect 1993; 100: 9e20 (Pub. National Institute of Environmental
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7 Stell and Marans textbook of head and neck surgery and oncology.
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8 Scott Browns otorhinolaryngology head and neck surgery. 7th edn,
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9 DAHNO report, 2010. www.ic.nhs.uk. The NHS Information Centre.
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Restorative dentist and hygienist

With radiotherapy affecting blood supply to the mandible and
risking osteoradionecrosis it is important that a thorough
specialist dental assessment is performed for all patients. Often
by advising better hygiene regimens or dental extractions, future
problems can be avoided.
Palliative care
With an overall mortality at 2 years being 35%, some of which
associated with socially obvious and disabling tumour growth,
patients with incurable HNC may need palliative care support.
CNS and palliative care teams work to enable the patients to have
the best palliation possible and to have a comfortable and
dignified death when the time comes.

Future developments and challenges

Primary prevention would be the ideal for HNC and the national
vaccination programme against HPV in girls may affect the
prevalence of HPV-related oropharyngeal HNC in the future.
There are welcome suggestions to extend this vaccination to
boys, which would increase this impact.
Early detection of pre-malignant change is used in screening
in other cancers. Oral and laryngeal dysplasia are followed up by

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