UCSF specialist Chase Heaton, MD, presents a guide to identifying head and neck cancers, including steps, tools and tips for a comprehensive exam; alarm-bell statements from your patients; and the one assumption you want to make about any neck lump.
me. Thank you, everyone, for joining this evening. Tau teach you a little bit about what I think about when I do the head neck exam and a little bit of background on head neck cancer in some of the work up in management that I take care of. So I am originally from Chicago. I did my training at Loyola University in Chicago that came out to San Francisco to UCSF for my otolaryngology residency, which is five years long. After that, I did one extra year and trained specifically in head neck, oncological surgery and also reconstructive surgery. Right now we have a team of U. C s F five surgeons who are involved with removal of head neck tumors and then also three surgeons who do reconstruction. I do both of those parts of the surgery, depending on what day and what patient it is. Our main university, just for a little bit of the background of where we work, is down at Mission Bay, which is, if you know the city. It's down by the 18 tee ball parks. We have a fairly new facility, was built in 2015. We actually have a new wing already attached toe to the main building here with our new Precision Center cancer building, which has been great place to work. We also do cases over at the main tertiary care larger hospital at Moffett, which is near Golden Gate Park. Primarily, though, this is our cancer, uh, institution where the vast majority of cases take place. So just for a little bit of an outline of today's talk, um, specifically about the head neck exam, I'll give you some general thoughts that I have about the examine. What I think about what I'm seeing. Patients go through an equipment check list. We'll talk very briefly about a focused head neck cancer history, and then we'll go through the exam in detail, and I'll try to throw in some pictures and a little case vignettes along the way. So I wish I had more time to talk about some other topics and had that cancer. Uh, today specifically, I'm just going to focus on mucosal, uh, malignancy, specifically squamous cell carcinoma. But we see all types of cancers of the head, neck, skin cancer, thyroid cancer, skull base, salivary gland cancer, which are very broad topics by themselves and would deserve another lecture on again. I do reconstructive surgery as well, which is a big part of head neck cancer care. Andi. That would be another thing to talk about at a future talk. But please feel free to email me if you have any questions after the fact. So I think it's good to start lectures with some key pearls, things to think about right from the beginning and think about as the lecture goes on. Eso for the head neck exam. Uh, when I see patients, I always ask them where the abnormality is. They often know they've been dealing with this for some time. Sometimes it's not obvious by reading notes. Eso have the patient to be part of their care. In general, any neck mass and an adult should be considered cancer until proven otherwise. And what I recommend is if you see a patient who is an adult over 30 years of age or so with a neck mass, Unefon, a fine needle aspiration is likely warranted. I always start with an F in a or rarely do we do incision, a laure exceptional biopsies of lymph nodes, especially in cases where we think it is truly a malignancy. Brief course of antibiotics can be tried. There are cases where, um, adults could have an infectious lymph. Edna apathy. It is rare. Eso if you do that and the mass does not resolve, a referral would be warranted much along the same lines. Any adult with hoarseness, especially if they're smoker, needs to be evaluated with a Lauren gossipy, which is a scope exam that I'll talk about in a bit. Especially symptoms. Don't resolve within two weeks or so. Ear pain is common in our patients, but it's on. It's also common to see a normal ear exam. Eso patient who you think is at risk for head and neck cancer is complaining of your pain, but they're here. Looks normal on exam. You should really be thinking about some sort of mucosa, lee based malignancy and the back of the mouth. Due to the multiple nerve connections between the two areas, any cranial nerve dysfunction is a sign of really aggressive pathology. So make sure Thio do a really good cranial nerve. Examine your patients. Uh, a key thing that I hope you take away Today also is the difference between the an atomic areas of the oral cavity and oral pharynx. Uh, squamous cell carcinoma effects both of these areas, but the, uh, epidemiology the, uh, pathology the treatment and prognosis differs between the two. So aural cavity, squamous cell carcinoma, eyes primarily due to smoking and drinking. This is a surgical disease and is not related to HPV virus. I'm sure you have heard of HBV associated head and neck cancer. This affects the Oro pharynx, which is the back of the mouth, and we'll get into that in a little detail, uh, further and finally, especially during these times, make sure you have the appropriate PP when you're doing your physical exams. So for an equipment check list, here is a list of things you should have a really bright light. I prefer a headlight because by manual exam is really important. If you could have one hand free to hold the tongue with the piece of gauze and the other having holding a tongue depressor to dunk tongue depressors, it's really important to have a really nice bright light tongue compressors and notice scope to look in the ear and nasal speculum toe Look in the nose. I think a ruler is important to do measurements of some of the lesions that you see both for your note. So if you see these patients later on, you could, uh, look back and see if it's grown or not, and also for staging tumors. If there is a tumor, it's important to know the size. A dental mirror can be used with the headlight toe. Look at the back of the tongue in the base of the tongue area. In our clinic, we use ah, flexible scope exam a scope as seen here to do that. So for PPE especially important right now in the cove it air, I think the area we're gonna be looking at here is gonna be are asymptomatic patients who we don't know their co vid status. If you're gonna be doing an aerosol generated procedure, which we'll talk about on the next slide, you should definitely be wearing an N 95 with face shield or paper with down and gloves if you're not doing an aerosol generating procedure. Uh, the key thing is wearing eye protection so you can imagine doing the head and neck exam. You are having the patient take the mask off, looking in their mouth, looking in their nose for an extended period of time. Just make sure you have a mask and eye protection. I actually have switched when possible, to wearing an n 95. If I'm doing very involved in extended length of time aural cavity exams. So these aerosol generating procedures that we do in clinic are the lair. Angus, copy. Which is the scope exam through the nose or mouth toe. Look at the voice box. Uh, in pharynx. Tracheotomy changes. We perform as well. Then they have this certain TNT procedures. I'm not entirely sure with this involves, but I I would assume this is biopsies in the mouth. So any sort of procedure that you're doing inside the oral cavity, that man involved aerosolized particles you should be wearing. And then and then you five as well. So, for ah, very brief review overview of head neck cancer. The vast majority of cancers of the head neck are squamous cell carcinoma, generally affecting patients and their fourth to 2nd 7th decade of life. Historically, these have been related to smoking and drinking, which have ah ah synergistic carcinogen capability. They primarily affect the aural cavity, which is the front of the mouth, the larynx and the hypo pharynx. But we have seen a rise in the incidence of oral pharynx squamous cell carcinoma, which is of the back of the mouth of the tonsils and base of tongue specifically. And these have been noted to be associated with HPV virus. For all of our head neck cancers, Cervical lymph node spread is incredibly common. Uh, some of these cancers is the presenting symptom. Eso Ah, good neck examine. Looking out for lymph nodes, eyes important. So back to this, uh, key that I really want you to understand with the oral cavity or in oral pharynx aural cavity is all the structures of the mouth in front of the circum ballot. Papillon. I'm sorry, this does This picture doesn't show it well, but it's kind of the line of large taste buds and the back of the tongue that separates the anterior aural cavity from the post cheerier oral pharynx. And the oral pharynx is made up of the the Palatine tonsils, the tonsils that we could see through the back of the mouth, the adenoid tissue in the back of the nose and the base of tongue, which is actually linguine, uh, lymphoid tissue just like the palatine tonsils. So if your toe look at this in cross section, it actually makes a ring of one point tissue in the back of the mouth. When the nasal pharynx, they annoyed the Palatine tonsils on the sides down to the base of tongue all one point tissue. And this is the area primarily affected by HPV virus. While the oral cavity is primarily affected, uh, squamous cells primarily are results of smoking, right, So oral cavity, squamous cell carcinoma, tumors of the tongue, tumors of the ginge of ah, of the gums and the mandible. These occur in the smokers. They're often older and appear older than their stated age. They're copacetic. You could tell they've they're really struggling with their tumors. They often have painful, obvious bleeding tumors in the front of their mouth, as opposed to the patients with oral pharynx. Squamous cell carcinoma. These patients tend to be younger. They often are minimal smokers or never smokers. They often present with the neck mass, so they don't have an obvious tumor in the back of their mouth. They're not symptomatic. They have no problems breathing, no problems eating, no pain. But they've had a neck mass that's been present for a month or two, and it's not gotten any better. So for a focused head neck history, obviously you're gonna be doing your full history. That way. You normally would. Some of the things that I think about specifically for, uh, possible had cancer patient. Obviously, age plays an important role location of the abnormality or the problem duration for sure. Again, if anything is present for more than two weeks, especially in a smoker, you should be thinking cancer. Personal habits, including smoking a swell is drinking and then red flag symptoms such as any lumps, dysplasia, problems swallowing hoarseness, ear pain with a normal ear exam, bleeding and weight loss. And, of course, if they have a history of heading that cancer history of head neck radiation, you should have a higher concern that they may have a second malignancy. So for some general considerations for the head neck exam, I do perform a complete head neck exam. But I do focus on the area where the cancer pathology is, and the sites that may be involved by a spreading cancer. There is no correct sequence to do a head neck exam. Just as there is no correct sequence to go Full body exam. You just need to find your preferred approach on. Then keep it consistent. So you don't miss any steps along the way. A Z I mentioned earlier asked the patient to point out where the pathology is located on. Then if you notice something different that seems abnormal to you. Ask them, uh, they have any if they know about that. And then the other important thing is not just look, but palpate everything on the head neck. Right. Okay, so now to get into the head neck exam, I'm just gonna go through kind of a checklist of everything. I dio talk about some abnormals and then some case vignettes along the way. So, of course, we're going to start with vitals. It's not uncommon for heading that cancer patients, uh, to be, uh, pathetic, hypoxic and tachycardic because of a surge type picture. A normal exam, Obviously you're gonna describe someone is well developed, well nourished, but Texas is incredibly common with head neck cancer. On about 40% of patients will present with Caixa, so that first impression is always likely most of time, right? I should say so when that patient walks in your clinic, you might get a gestalt or feeling that they may have something wrong with them, and you're probably right. I always listen to them. So introduce myself and then talk to them, and you could really get a quick sense of the functions of the pharynx, larynx and mouth. Patients with head and neck cancer in the mouth or in the throat will have problems with breathing with speaking and articulation. Eso a larynx cancer patient. You might notice that their voices really weak or breathy. They're losing air as they're trying to speak. Or it's horse because their vocal cords aren't coming together very well. Someone has a large aural cavity tumor. You might notice that they're able to project their voice fine, but the problem they're having is with articulation. They're not ableto pronunciation words because their tongue is not moving on. Then, of course, the scope exam goes with that, and I'll go through that in more detail in a bit. Yeah, I then always do a full skin exam looking everywhere, including the head on in the hair. Patients, uh, with skin cancer often have signs of sun damage. Eso patients who look like they may be at risk. You should definitely do a full exam of the skin. It's important to ask them about their skin history. A lot of patients will have a history of having a lesions removed well in the past and have forgotten about it until you bring up the fact that you're seeing a scar in the area where they had the procedure done. Okay, then I do a neurologic exam, including looking at the eyes. They should have obviously normal movement and no obvious discharge. We occasionally see a Pifer or tearing of eyes when patients have obstruction from Sino nasal malignancy. So that's something to look for. Of course, they should be a neurologically intact, and then the cranial nerves, eyes incredibly important. I think it's important to go through all of them on, but it's something that seems like maybe it could be daunting and take a lot of time, but it's a fairly quick exam, So how I do it is I just have them follow my finger to get the extra tacular movements of 34 and six. You can check their pupils. Uh, cranial nerve five or V one through three. Remember, the fifth cranial nerve has three divisions. One on the forehead, one on the cheek area and one on the chin. Eso quickly touch all those areas and make sure they're sensations intact for facial nerve function. I just have a do. All the different motions include raising their eyebrows, closing their eyes, scrunching their nose, flowing a kiss and then trying to curl their lower lip down. I do test hearing. I think it's, ah, fairly quick thing to do just by doing a little rubbing test in front of the year. Have them then raised their palate, and this is to assess cranial nerve. 10. If their palate rises symmetrically, cranial nerve 10 is intact. If it does not, uh, the palate. The side of the palette with the cranial defect will not rise. Shoulder shrug, test cranial nerve. 11. And finally, I have been protruding tongue to make sure Cranial 12 or the Hippo Glassell there is intact like nerves most commonly affected, and heading that cancer of these eso the trigeminal or fifth the facial nerve running through the prodded 10 vagus nerve in the neck. 11 cranial spinal accessory nerve in the lateral neck. And then 12 the hippo Glassell Nerve, which is in the superior neck traveling towards the tongue. Okay, Eso you could see here all these nerves air right in the area where we're doing surgeries and right in the area. Uh, the oral cavity and oral pharynx where all the mucosa lee based tumors appear. So just for some case vignettes, Case one. This is a 65 year old. He's a tobacco chewer with a mass of his gum and he's noted some new chin chin numbness. So obviously we're dealing with some sort of malignancy. See, here it's very ulcerative. The key finding in his exam, though, is the fact that he's noted some chin numbness. So the inferior Olive Euler nerve coming off the third division of the trigeminal is gonna pass through the jawbone and exit the chin right below the incisor and supply sensation to that chin area. So if the patient is chin numbness, which is nowhere near the mass, that's a sign that this tumor is invaded bone and involved the third division of the fifth Nerve, which is showing it to be, Ah, very aggressive malignancy. Here's an 80 year old with history of scalp cancers and then, all of a sudden he developed a facial paralysis. Ah, sometimes these get referred to us a little late because they're worked up for Bell's palsy. But the fact that he had skin cancer in the past should make you think early that this is not a Bell's palsy picture, but something different. And it's not uncommon to have tumors invade the prodded gland and, UH, then invade the nerve and cause facial nerve paralysis. This is a 65 year old. She had a history of surgery and radiation reading that cancer quite some time ago, and this had long standing shoulder weakness. So this is someone who may come in. You may see and be somewhat concerned that she has this deformed shoulder and unable lift it. But if you understand what she had done in the past, back in the day, they performed routinely what are called radical next day sections, which is removing all the lymph nodes but also some very important structures, including the 11th cranial nerve, which helps you raise your shoulder past the midline. So not an uncommon finding for patients who have survived cancer. Finally, is a 55 year old smoker with a growing base of tongue tumor, and some dis are tria. And on his exam, you see, when he sticks his tongue out the protrudes to the left eso this is called the will barrel effect. Uh, the side that's week. If you could imagine if you're pushing a wheel barrel and drop one of your arms, the wheelbarrow will turn to that side. So the fact that this is pointing to the left tells you that the left the left cranial 12 is we're weak here. If this were a video, you'd also see, some are may see some fib relations of the tongue that show that the muscle is kind of slowly dying away without innovation. So for the years and knows, I do look in the years, uh, for all my patients on dime most of time, expecting them to look normal. But I'm not surprised when patients today they're having problems with their ears. This is because cranial nerves nine. I intend specifically a supply sensation to the ear and also sensation in the back of the mouths of the patient, has cancer in their oral cavity. Orel pharynx. They often present with your pain as well. When I'm looking in the nose, I think it's important. Just make sure that you recognize what a turban it is in the fact that it's normal and they could be big. That could be small. Could depend on the time of the day for the patient, but that it is a normal structure. Uh, acceptance can be deviated. Eso make sure that you look to see that it's just a deviated septum and nothing abnormal. Rarely do we see tumors invading into the nasal cavity from the mouth or the oral parents. But we occasionally seem excellent science tubers doing that. I think what you would see and thes scenarios, though, is that the mucosa itself is invaded, so it looks ulcer thio. It's bleeding. It's painful. So the oral cavity, um, is again everything in front of circum ballot capella. So in terms of actual sub sites, it's the lips, the tongue, the floor of mouth, the hard palate, the area that kind of connects the Max Illa or the upper jaw to the mandible, the lower jaws. This area right here. It's called the retro Moeller Trigon, and then on the sides of the mouth, the buccal mucosa. So, just like for the overall head neck exam, I think it's really important that you have some sort of consistency and how you go through the oral cavity exam just so you don't miss any areas. I always start just by getting a sense of their dentition and then go stepwise through all these areas, both looking and palpitating. Uh, I also look at both the Stenson's and warns Duck ducks, which are where the paraded gland and the some independent land stream eso. Here are some aural cavity lesions, and we'll just kind of look at them and talk about what they represent. So, first case here, this is a 27 year old with recurring multifocal, painful tongue lesions and see here they're separated in space. They looked fairly painful, ulcerative but overall flat on. Not that invasive, I would say, based on look, the fact that this patient is 27 the recurring and multifocal your concern for malignancy is low thes air at this ulcers or canker sores, that shallow based ulcers. We really don't know the ideology behind them, but fortunately they're self limiting. And there's no malignant potential, Uh, case to this is a 65 year old smoker with a non painful patch on their hard palate. For five years, this would be described, I would describe, This is kind of white because that's what it is flat on. Some people described this as a kind of a lacy type appearance to it. The fact that this patient is a smoker is concerning, But fortunately, things has been here for many years and hasn't progressed. Eso We're not right from the start thinking malignancy. This is an aural loop like, Yeah, this is definitely something that needs to be followed pretty closely. These are pre malignant lesions, low conversion rate, but smoking continued smoking certainly doesn't help that, and I think that number is quite a bit higher if the patient continues to smoke. And here we have a 65 year old smoker, and here is a more obvious one. This one is painful. It's bleeding, it's on. Lee been present for four weeks and is getting bigger by the minute. Eso this is ah, true invasive squamous cell carcinoma. If your toe feel this, it would be a difficult exam for the patient. They'd be quite tender. They'd be dis our trick when trying toe talk to them. My guess is they be having more and more difficulty eating and are probably just on a soft diet. At this point, you feel very for mass, Aziz. Well, so next steps for a normal cat of the squamous cell carcinoma. Obviously, when you see them in clinic, you're going to complete your examination. And then really, the key is to get a biopsy to confirm the pathology. If it's the tumor on the side in front of the tongue like this and you could do it in clinic, that's what I would dio Thea. Other option is to see if there any lymph nodes toe perform a fine needle aspiration biopsy on the next thing after that is to get imaging toe. Look for both the primary site and assess for both regional and metastatic disease. There are many options available. SETI is very good for looking at bone and seen here, so the SETI is showing that the mandible is eroded, which is an advanced age tumor. Memories are good for looking at soft tissue, so if you have a question about whether it's invading ah, muscle or some soft tissue structure, those air good pet CT scans are good at looking at distant, metastatic disease and also for smaller primary tumors or lymph nodes that may be involved with tumor. So staging for oral cavity cancer, uh, is based on size and depth of invasion. And as we know, staging is what estimates prognosis for the patients. So the patients really want to know their stage to give them a sense of, uh, what their potential outcomes are after treatment. Uh, eso for aural cavity staging just toe briefly Look at the size or the staging of the primary tumors. It's based on both the size of the tumor, what you could see and what you could measure, and also how deeply it invades into the tongue on. You could see that for Stage four disease survival over five years. Uh, quite low around 50%. One of the key. Take Wait, uh, point for this oral cavity squamous cell carcinoma is that these tumors are primarily treated with surgery. Eso the goal of a treatment for a tumor of the front of them out there oral cavity is to remove the disease with the surgery. Try to respect it with negative margins. Likely remove all the lymph nodes in the neck below the disease to see if it's spread or to take care of the disease that has spread and then radiation. Chemotherapy are used in an agile and setting, depending on some of the final pathology characteristics. Eso back to the exam, the oral pharynx again and they compromised of the Palatine tonsils in the back of the mouth and the lymphoid tissue in the base of the tongue. So again, you'll want to look at these and palpate both of these structures. Tonsils are easy to look at. Easy to palpate base of tongue is a little more challenging. It's easy, more easy to palpate if the patient can tolerate it without a strong gag, harder to look at. That's where the dental near comes into play or referring to someone who could perform a scope exam. And then, of course, not every tonsils the same. Some people have had their tonsils removed Some people have had multiple infections of their tonsils. It's okay for councils to not be symmetric. Aziz. Long as, uh, theme mucosa appears intact on there's not a firm underlying mass on then neck Mass. So the going now into the oral pharynx cancer. Ah, part of the talk. This is something where we're seeing quite a bit of eso. We know that head neck cancer three incidents of head neck cancer has been on the rise, but we've seen less patient smoking and again, historically, cancers of the head neck have been related to smoking and drinking. We've also noted that younger people are getting head neck cancer as opposed to the older smoking drinking population. And what we've seen is that specifically Orel Pharynx cancer, squamous cell carcinomas have been on the rise over the past couple of decades and what this has been found to be from is the human papilloma virus. Eso HPV, specifically 16 and 18 are the types that are high risk for head neck cancer. This is a pretty much a ubiquitous virus. The vast majority of the population has it, but for unknown reasons Uh, 99% of these people clear the virus. And what that really means is that they become test negative. It's not necessarily out of their system for an unknown mechanism. Uh, some patients go on to develop head that cancer. It's also squamous cell carcinoma, same name, but again from a different ideology and often in a different location, affecting the base of the tongue and the tonsils. The typical patient presentation here is a 45 year old or a young man who presents to primary care doctor with the neck mass that hasn't gone away again. They're asymptomatic. They've often never smoked andare feeling well. Eso they're quite distressed, surprised when a fine needle biopsy is done of the neck mass and it shows squamous cell carcinoma the main risk factors for between the associative heading that cancer, our lifetime sexual partners is seen here. Uh, so for next steps for oral pharynx cancer just like oral cavity cancer, you're going to complete your examination biopsy eyes well to confirm this diagnosis and again, since most of these patients present with the neck mass as opposed to some large tumor in the back of their mouth, we often start with a fine needle aspiration, and you could test for a protein marker that's a surrogate for HPV virus. To know that it's an HPV related tumor, well, often perform a scope exam toe. Look for where this tumor started because it did not start in the neck. These air all squamous cell carcinoma, meaning it's aligning cell so they do start in the back of the mouth. But for whatever reason, the primary tumors often aren't large. And this is a scenario with pet CTS work. Really well, toe, look for that staging. I'm not going to get into in much detail here, but what's interesting and important to know is that, uh, previously just two years ago, Orel Pharynx cancer in oral cavity cancer were staged the same way. But we quickly realized that these patients behave very differently and you can't really compare stage for oral pharynx cancer to a stage for, uh, cancer of the mouth and so on who smoke their whole life. Patients, uh, do much better with oral pharynx cancer after treatment. Now they have their own staging system, and we're really trying to think about ways to obviously treat these patients so they don't have cancer but limits some of the side effects associated with the treatment. So for these patients, unlike aural cavity cancers, they have a couple routes that they could go one being a surgery route with radiation, possibly afterwards, depending on the pathology. The second would be to avoid surgery and just do radiation with potentially chemotherapy. In this ah, lot of things that go into the discussion both about the tumor characteristics, the tumor, location and size etcetera, as well as the long queued in long term side effects of the treatment back to the examination. Then, uh, take a look at the neck. Obviously do visual exam to make sure that there's, uh, no obvious lumps or bumps, and that the neck is overall symmetric between these two sides and then do a very thorough a manual exam. Palpatine, the some individually and prodded glands, all the lymph node levels as well as the thyroid. We save this portion of the exam for last the scope exam. This definitely should be performed on all patients with head and neck cancer. They do have a high risk of second primary malignancies most of time. If a patients being referred for head and neck cancer for work up of potential head neck cancer. They're going to get this examination or procedure done in our clinic. So for those with cancer, this is a good exam toe map where the tumor is located. Uh, we always spray the patient with anesthetic and a decongestant beforehand. And unlike in this picture here, we are now wearing full PPE, including in 95 some sort of face shield. And we also have, ah, full gown on a swell, a zealous gloves. Eso What we're looking at when we take a look with scope is the larynx, which is comprised of three sites being the super Gladys, which is where the epiglottis sits. The Gladys, which is really just the vocal folds as well as the sub Gladys, which is down into the trachea below There. Here's a picture of what a normal Lawrence should look like when you're looking at it down from the nose. When facing the patient down here is anterior. This is posterior here, the vocal cords that come together with faux nation. This is looking down into the trachea. Here is the epiglottis. So every time the patient swallows this collapses over the the Gladys to protect the airway theosophy. Jill Inlet is sitting behind the glass here and remains relatively close in the resting position. Here's an example of a patient with an abnormal scope exam on what you'll see is a exotic tumor of what is the left vocal cord, and you could see this right cord is moving. It's trying to come together, but it's hitting this large mass and also, uh, this left vocal cord to stop moving. So here's an example of a primarily based GLAAD IQ tumor. So the clinical presentation for patients with larynx cancer if it's in the Gladys or right at the truth, the vocal folds, as in that last video they're gonna present with dysphonia. So these tumors are gonna be small. That airway is only one or two centimeters in size, so a very small tumor will affect their voice as opposed to a patient with a tumor of the super Gladys. Or were that epic lattices they're often going to present with swallowing difficulty. Eso Asai mentioned earlier any patient with voice issues for greater than two weeks, especially if they're smoker. You should definitely be thinking that this could be a cancer. Chronic laryngitis is incredibly rare. Eso again Watch these patients closely and have a scope exam done or for them on eso back to the key pearls again and neck masses cancer Until proven otherwise, cancer could occur in anyone, not just smokers, especially with the new HPV related tumors. It's important understand the difference between the world cavity and Darrel Franks. Because of this, look out for those cranial nerve dysfunctions and keep your exam consistent.
