Head and Neck Cancer

Presenting Signs and Symptoms

Presenting signs and symptoms of HNC vary based on location of the primary tumor, lymph node involvement, and subsequent metastases, and may include the following:

  • Foul mouth odor (halitosis) not explained by hygiene
  • Frequent nosebleeds and/or unusual nasal discharge
  • Generalized symptoms that include loss of appetite, unexplained weight loss with or without dysphagia, fatigue, and fever
  • Loosening of teeth or dentures
  • Lump, bump, or mass in the head or neck area, with or without pain
  • Nasal obstruction or persistent nasal congestion
  • Neuropathic pain at sites distant from the location of the tumors (resulting from invasion of the sensory nerves by the cancer cells; e.g., ear pain [otalgia])
  • Noisy breathing (stridor) and/or breathlessness (dyspnea) due to airway obstruction
  • Nonhealing ulcer in the head and neck region
  • Numbness or weakness of a body part in the head and neck region
  • Persistent cough (sometimes marked by coughing up blood [hemoptysis])
  • Persistent sore throat
  • Painful swallowing (odynophagia)
  • Red or white patches in the mouth
  • Reduced range of motion of the jaw (trismus) or of the tongue affecting speech and swallowing
  • Globus sensation
  • Referred pain in the ear/jaw
  • Sensory changes (e.g., changes in or loss of smell and taste; double vision)

Functional Signs and Symptoms

Depending on the location of the malignancy and time of presentation along the continuum of medical/surgical management (i.e., prior to, during, or after treatment), signs and symptoms may include functional impairments in one or more of the following domains (see box below).

Speech

Reduced overall intelligibility resulting from one or all of the following:

  • Articulation errors (e.g., omissions, substitutions, and distortions of stops, fricatives, and affricates; vowel errors)
  • Imprecise speech (e.g., due to dysarthria from cranial nerve palsies)
  • Distortions of lingual phonemes consistent with lingual resection and/or reconstruction

Voice

  • Dysphonia (e.g., changes in vocal pitch, loudness, and/or quality) resulting from untreated tumors within the larynx or supraglottic larynx, surgical resection of the larynx, and/or radiation
  • Aphonia (i.e., loss of voice) postsurgery (e.g., with tracheostomy tube or total laryngectomy)

See ASHA's Practice Portal page on Voice Disorders for more details related to signs and symptoms of dysphonia.

Resonance

  • Hypernasality (e.g., surgical resection to the soft palate, immobility as a result of radiation sequelae and/or a soft-palate defect)
  • Hyponasality (e.g., due to obstruction in nasal passage)
  • Cul-de-sac resonance (associated with base of tongue lesions)

See Classification of Velopharyngeal Inadequacies.

Swallowing

Severity of swallowing problems in HNC depends on tumor size and location, staging, and treatment protocol (e.g., surgical resection and reconstruction, radiation therapy, chemotherapy).

Total laryngectomy surgery typically does not result in swallowing disorders. However, they occasionally occur due to scar tissue at the tongue base, reduced tongue base posterior motion, stricture or narrowing of the esophagus, and poor bolus clearance through the pharynx if a portion of the tongue base is included in the resection.

Functional signs and symptoms of swallowing problems include the following:

Changes in structural integrity and changes in sensation, strength, range of motion, and coordination of orofacial musculature may result in one or more of the following:

  • Oral phase dysphagia:
    • Increased oral transit time
    • Impaired bolus manipulation
    • Increased oral residue
    • Impaired mastication
    • Premature spillage
    • Anterior bolus loss
  • Pharyngeal phase dysphagia:
    • Delayed triggering of pharyngeal swallow
    • Velar leak resulting in movement of materials into the nasopharynx
    • Impaired tongue base movement
    • Reduced pharyngeal contraction
    • Decreased laryngeal and hyoid elevation and anterior motion
    • Reduced epiglottic closure, resulting in increased risk for aspiration
    • Reduced glottic closure
    • Reduced upper esophageal opening
    • Aspiration
    • Residue in valleculae and pyriform sinuses

See ASHA's Practice Portal page on Adult Dysphagia for more details related to signs and symptoms of swallowing disorders.

Hearing

  • Changes in hearing acuity (e.g., as a result of surgery, radiation, or ototoxicity from chemotherapy)
  • Tinnitus

See, for example, Dell'Aringa et al. (2009).

See also ASHA's Practice Portal pages on Hearing Loss Beyond Early Childhood and Tinnitus and Hyperacusis.

Side Effects of Medical/Surgical Management

Side effects of medical (i.e., radiation therapy and chemotherapy) and surgical management, radiation therapy, and chemotherapy can have an impact on function and treatment planning. These side effects can include

  • pain (related to treatment and/or as a result of residual tumor);
  • dental problems (e.g., surgical removal of teeth or portion of jaw; dental caries; dental pain; and osteoradionecrosis);
  • facial and other structural changes, including damage to auditory pathways and structures;
  • hearing loss due to ototoxicity;
  • head and neck lymphedema;
  • loss of appetite;
  • mouth sores and mucositis;
  • nausea and vomiting;
  • numbness/reduced range of motion in the head, neck, and shoulder areas;
  • odynophagia;
  • pharyngeal/upper esophageal stenosis;
  • reduced/altered sense of taste and smell;
  • swelling of the mouth and/or throat;
  • xerostomia; and
  • trismus.

Related Signs and Symptoms

Related signs and symptoms that can have an effect on speech and language assessment and treatment include the following:

  • Cognitive deficits (e.g., changes in executive function as a consequence of radiation or chemotherapy; withdrawal from alcohol abuse)
  • Psychosocial issues resulting from the diagnosis and impact of medical/surgical management (e.g., changes in lifestyle, family and social roles, and employment)
  • Comorbidities such as cancer-related fatigue, depression, and anxiety

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.