Evaluation and Diagnosis
Evaluation of these patients should (as always) begin with a thorough history and physical examination of the head and neck, with special attention paid to the common symptoms listed above. A review of symptoms at each visit ideally includes those symptoms as well, since many patients may not bring up the symptoms initially because of the belief that they are minor or will correct themselves. Physical examination should include close inspection of the tonsillar complex, inspection and palpation of the base of tongue, and a careful examination for cervical lymphadenopathy. Because currently there are no standard tests to evaluate for precancerous OPSCC lesions (such as the Papanicolaou test and HPV DNA testing for cervical cancer), a detailed review of systems and physical examination remain the most important method for early detection.
Suspicious lesions found during the physical examination require timely diagnostic workup and referral to an otolaryngologist. As mentioned above, the most common physical examination presentation for patients with HPV+ OPSCC is a unilateral neck mass because of high rate of cervical lymph node metastases, even when the primary tumor volume is small. In the case of an adult with a unilateral neck mass, fine-needle aspiration (FNA) and computed tomography (CT; Figure 1) are 2 diagnostic modalities that provide useful information and can be performed in the primary care setting, if available. FNA is associated with minimal discomfort to the patient and can be performed in the office, although it is dependent on the experience of the physician performing the procedure and the availability of cytologic examination. In one study the sensitivity and specificity for detecting head and neck cancer via FNA of lymph node metastases were 88.2% and 100%, respectively. Cells obtained by FNA can also be examined for HPV biomarkers, further increasing their diagnostic value. CT can provide information related to primary tumor size and location as well as metastatic spread (Figure 1). A preliminary workup of suspected OPSCC should always include a CT scan of the head and neck. Any patient who presents with a unilateral neck mass and who does not respond to a short course of antibiotics or has a history that is suspicious for head and neck cancer should receive an FNA and a CT scan in a timely manner. As noted above, patients with a unilateral neck mass that have HPV + OPSCC will become increasingly common in the future, thus making a high index of suspicion crucial for early identification and referral. Further diagnostic evaluation, such as positron emission tomography/CT and surgical biopsies, if necessary, can be obtained after referral to an otolaryngologist/head and neck oncologist.
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Figure 1.
Computed tomography scan of a 44-year-old male who presented with a unilateral neck mass. The arrow indicates location of the mass.