In my years of practice as an ear, nose and throat (ENT) specialist, I have come across many cases of ENT cancers. In this article, I share about 8 common ENT cancers, their symptoms, risk factors and diagnoses.
If you don't have time to read, this is the TL; DR version:
- if you smoke, quit
- if you drink, do so in moderation
- if you work around chemicals, stay protected
- get screened to detect cancer early
Most ENT cancers are carcinomas, meaning that they are cancers that arise from the epithelium, the layer of cells which line the surface of the structures in the head and neck region.
The type of lining may vary slightly depending on the location. On the face and in the external ear canal, the keratinised squamous epithelium (flat cells) give rise to the familiar layer we call “skin”.
In the mouth and throat, it is also the squamous epithelium, but the layer is not keratinised; directly beneath this lining is where you find mucous secreting glands.
If cancer is only found within the epithelium, it is called carcinoma-in-situ; it does not have the ability to invade or spread. However, if cancer has grown beyond this layer and has moved into the deeper tissue, then it is called invasive cancer.
Cancer in the oral cavity (mouth)
Oral cancer is one of the most common diseases in the world, especially in developing countries. Oral cancer may involve the lips, tongue or the lining of the mouth.
Who is at risk?
People who smoke and drink alcohol have an increased risk of oral cancer.
Besides tobacco and alcohol use, other common risk factors include:
- consumption of betel quid and areca nut
- human papillomavirus (HPV)
- a family history of cancer, especially squamous cell carcinoma
- not eating enough vegetables and fruit
- a weakened immune system
- lichen planus
- poor oral health
Diagnosing oral cancer
If you have a persistent ulcer or lump on the lips or in the mouth, I highly recommend that you make an appointment with your ENT surgeon. He/she will perform a comprehensive assessment, which includes:
- endoscopy
- biopsy
- MRI
- CT scan
- PET scan (used to evaluate whether there is regional or distant cancer spread)
Pharyngeal cancer (throat)
The pharynx is the part of the throat between the back of the oral cavity and the beginning of the oesophagus. The middle and lower divisions of the throat are called the oropharynx and hypopharynx, respectively.
Who is at risk?
Again, pharyngeal cancers are more common in people who smoke and consume alcohol. In addition, HPV is associated with some forms of oropharyngeal cancer.
Other risk factors include:
- exposure to industrial chemicals
- being male; men are more prone to pharyngeal cancer than women
- age
- not eating enough vegetables and fruit
- being of Asian ethnicity
- presence of Epstein-Barr virus
Diagnosing pharyngeal cancer
A persistent sore throat, the sense of a lump in the throat and blood-stained secretions are signs of possible cancer. Sufferers may also experience pain in the jaw or in the ear.
If you have any of these symptoms, you should get an assessment by your ENT surgeon. A comprehensive assessment may include:
- nasopharyngoscopy
- biopsy
- MRI
- CT scan
- PET scan (used to evaluate whether there is regional or distant cancer spread)
For tumours that are deeper in the throat, you may need an examination and biopsy under anaesthesia.
Laryngeal Cancer
Laryngeal cancer is a disease in which cancer cells form in the tissues of the larynx (voice box).
Who is at risk?
The risk factors are very similar to pharyngeal cancer. In addition, because frequent acid reflux causes damage to the cells around the throat, people with gastroesophageal reflux disease (GERD) are also at risk of developing laryngeal cancer.
Diagnosing laryngeal cancer
A sudden and unexplained change in your voice is the most common symptom of laryngeal cancer. However, patients with advanced cancers may have stridor — sudden shortness of breath accompanied by a very harsh breathing sound.
A comprehensive assessment may include:
- nasolaryngoscopy
- biopsy
- MRI
- CT scan
- PET scans (used to evaluate whether there is regional or distant cancer spread)
To properly evaluate you for laryngeal cancers, your ENT surgeon may require a direct examination and biopsy under anaesthesia. He/she will be able to assess you if you have any symptoms you are concerned about.
Hypopharyngeal cancer
As mentioned earlier under “Pharyngeal cancer”, the lowest part of the throat surrounding the entrance to the voice box is called the hypopharynx. Hypopharyngeal cancer refers to cancer that affects the hypopharynx.
Who is at risk?
Just like cancer of the oral cavity and larynx, tobacco and (especially) high alcohol intake increases your risk of developing hypopharyngeal cancer.
How do you know if you have cancer of the larynx?
In addition to throat discomfort, you may feel like you have a lump in your throat and/or have blood-stained phlegm.
Hypopharyngeal cancer can also cause hoarseness and difficulty in swallowing. You should consult an ENT surgeon if you have any worrying symptoms. He/she may order a:
- nasopharyngoscopy
- biopsy
- MRI
- CT scan
- narium esophagogram
- oesophagoscopy
- examination and biopsy under anaesthesia (usually required)
- PET scan (used to evaluate whether there is regional or distant cancer spread)
Nasopharyngeal cancer (NPC)
The nasopharynx is the uppermost portion of the pharynx (throat) lying above the soft palate. Unfortunately, this area cannot be visualised well through the mouth.
Who is at risk?
NPC is more common in men than in women. In fact, it is the 8th-most common cancer among men in Singapore, especially among those from 30 to 60 years old. Also, people of southern Chinese and South-east Asian descent are more at risk than those of other ethnicities.
People exposed to the Epstein-Barr virus (EBV) are also associated with increased risk of NPC.
As NPC originates deep within the head (at the junction of the nose and throat), early tumours often go unnoticed. Therefore, if you have a family history of NPC, I would advise you to go for screening and monitoring.
Other risk factors include:
- family history of cancer
- a diet high in salt and processed/preserved food
- exposure to industrial chemicals
Diagnosing laryngeal cancer
Most patients present with late-stage tumours, with the 3 most common symptoms being:
- blood-stained phlegm
- enlarged lymph nodes in the neck
- a blocked ear.
Nose bleeds are much less common.
NPC may be evaluated by a:
- nasopharyngoscopy
- MRI
- CT scan
- biopsy of the nasopharynx
- PET scan (used to evaluate whether there is regional or distant cancer spread)
A hearing evaluation may be required if you present with a blocked ear before commencing treatment.
Your doctor may also order a blood test to check for the level of specific EBV tumour markers (antibodies or EBV DNA markers) during the cancer screening or monitoring.
Salivary gland cancer
The salivary glands in the mouth produce and secrete saliva, which contains enzymes to initiate food digestion. Saliva is also important in maintaining oral health.
The larger salivary glands include the submandibular and parotid glands.
The good and bad news
Bad news: There is a diverse range of salivary gland cancers.
Good news: The majority of tumours involving the parotid (in front of the ear) and submandibular glands (below the jawline) are benign, i.e. not cancerous. However, most tumours require surgery for definitive diagnosis and treatment.
Diagnosing salivary gland cancer
Patients usually notice a lump below the jawline (submandibular) or just below and in front of the ear (parotid).
If the nerves are affected, you may experience pain or even weakness of the facial muscles. Just like the other ENT cancers, your doctor may order the following to evaluate salivary gland tumours:
- a physical examination
- nasopharyngoscopy
- CT scan
- MRI
- PET scans (used to evaluate whether there is regional or distant cancer spread)
Fine needle aspiration cytology (FNAC), a technique of sampling cells from the tumour so that they can be examined under a microscope, may also be needed.
Thyroid tumours
The thyroid is a butterfly-shaped gland located at the lower half of the front of the neck. The endocrine gland produces the thyroid hormone, which regulates your metabolism and is vital for the normal function of many systems in the body.
Who is at risk?
Thyroid nodules are very common, particularly in women. Thyroid cancer occurs 3 times more in women than in men, and it is still unclear why.
While thyroid cancer can occur at any age, the majority of cases are reported in women in their 40s to 50s and men in their 60s to 70s.
Other risk factors include:
- a family history of cancer
- a diet low in iodine
- radiation exposure
Diagnosing thyroid tumours
The symptoms of thyroid disease are usually related to the presence of a lump in the thyroid. This may cause difficulty in swallowing. When the lump is large, it can also cause difficulty in breathing due to the distortion of the windpipe.
A change in your voice is a particularly worrisome sign of cancer. If you have a thyroid lump, you should consult your ENT surgeon for a thorough evaluation, which includes:
- a physical examination of the neck
- nasolaryngoscopy
- imaging of the thyroid and neck (via ultrasound, CT scan or MRI)
- FNAC to obtain samples of tumour cells for microscopic examination
- a blood test to assess thyroid function and thyroid markers
Sinonasal cancer
Sinonasal cancers are uncommon cancers that arise from the tissues of the paranasal (this means “around the nose”) sinuses and nasal cavity.
The paranasal sinuses are hollow, air-filled spaces that develop in the bones surrounding the nasal cavity. They are lined with cells that make mucus. When healthy, the mucus carpet is constantly moving, keeping the surface moist and sweeping dust and germs away from these areas into the throat.
While sinonasal cancers are rare, they need to be differentiated from 2 other types of growths in the area:
- the more common nasal polyps (due to inflammation and infection)
- benign nasal tumours
Since many important structures lie around and between the paranasal sinuses (e.g the brain, the eye), sinonasal tumours, especially cancers, can have devastating effects.
Who is at risk?
Once again, smoking and heavy consumption of alcohol puts you at risk of sinonasal cancer. Other factors that may increase your risk include:
- being male; sinonasal cancers occur twice as often in men than in women
- an age of between 45 and 85
- HPV infection
- exposure to industrial chemicals and particles
- exposure to air pollution
Diagnosing sinonasal cancer
Symptoms of early tumours such as:
- nasal obstruction
- nasal discharge, or
- minor nasal bleeding
may go unnoticed, or be attributed to other more common diseases like sinusitis.
A comprehensive evaluation of nasal tumours requires an evaluation with
- nasopharyngoscopy
- CT scans
- MRI scans
- an endoscopic biopsy of tumour tissue
Fortunately, advancements in surgical techniques over the last 20 years have enabled us to completely and endoscopically remove most benign tumours, and even some cancers, through the nostrils without any visible external incisions.
