General Assessment

Head and neck cancer screening can easily be accomplished in five minutes or less. The exam is simple, painless, and inexpensive, and consists of observation and palpation of the structures of the head and neck. It is important for clinicians to explain to the patient exactly what you are doing and what you are looking for. This is a good opportunity to educate the patient about the signs and symptoms of oral cancer in order to raise awareness and enable the patient to perform regular self-screenings.

Clinicians must be aware that early symptoms of malignancies may be weight loss or fatigue. Observe the general appearance of the patient and ask questions regarding unexplained weight loss and fatigue. A general assessment of the patients’ overall health begins upon first meeting. While walking to the treatment room, observe the patient’s gait and stability. Listen to the patients voice quality while you are asking questions regarding health changes and chief concerns. A raspy, hoarse voice may be a sign of oropharyngeal or laryngeal cancer. A change in voice quality should always be noted.

Extra-Oral Examination

The Face

Observe the patient for facial asymmetry, skin lesions, discoloration, swelling, facial paralysis, and other abnormalities.

Cancers of the palate or the sinuses may invade the eye area. If you observe swelling of the eye or periorbital area, it should be noted and the patient should be examined further by an opthalmologist. Visual acuity, extraocular movement, and drainage may also be affected by head and neck cancers.

Note any pigmented lesions, raised, ulcerated, or firm areas of the skin. Palpate the face and question the patient about any changes in moles or other skin lesions. Observe the skin on the head and the skin under facial hair as much as possible.

Utilize the ABCDE’s of moles:

Asymmetry: one half of the mole does not look the same as the other half.

Borders: the edges of the mole are irregular, ragged, blurred

Color: the mole has more than one color or a variety of different colors

Diameter: the diameter of the mole is larger than the eraser on a pencil or bigger than 6mm

Evolving: the mole is changing. This is the most important sign.

Refer to a dermatologist for any suspicious lesions.

Palpate the face across the zygomatic arch and question the patient about sinus pressure. Palpate the parotid gland and the temporomandibular joint. Ask the patient to open and close the mouth and move jaw from side to side. Note any constriction in movement. Palpate the pre auricular and post auricular nodes, the submental and submaxillary nodes.

Observe and palpate the auricle of the ear, noting any lesions. The superior sun-exposed regions of the auricle are most likely to develop skin cancers. Palpate the pre auricular nodes and post auricular nodes as you observe the ears. Examination of the interior auditory canals and tympanic membranes are inspected with an otoscope by a physician.

Palpation of the nose and sinus regions should be performed. Examination of the interior aspects of the nasal cavity may be beyond the scope of practice of the dentist or dental hygienist. If a lesion is suspected, referral to a physician or an ENT specialist should be made. The physician will use a nasal speculum, an otoscope, or a nasopharyngolaryngoscope to examine the entire nasal cavity.

The lips should be observed and palpated with the mouth open and closed. The vermillion boarder is the most common site of oral cancer of the lip. Both squamous cell carcinoma (SCC) and basal cell carcinoma ur.(BCC) are found in the lips. Note any abnormalities in color, symmetry, texture or contour. Revert the lower lip and observe the labial mucosa for any abnormalities. The labial mucosa should be smooth and uniform in color. Note any ulcers, discolorations or other abnormalities. Inspect the frenum of the lip and palpate the lip bi-digitally. Observe the gingival sulcus, the gingival mucosa and the teeth. Repeat the same with the upper lip.

The Neck

The neck is palpated bimanually, checking for enlarged lymph nodes. Palpation of a mass located in the submaxillary area is performed by insertion of a gloved finger in the mouth, pressing the tissues of the floor of the mouth against the other hand, which is pressing upwards under the chin. Examine the sternocleidomastoid muscles from under the chin to the clavicle. The tissues under the chin can be pressed up over the mandible in order to more easily detect swollen lymph nodes. The supraclavicular spaces on either side are palpated.

Palpate along the length of the larynx for signs of enlargement. Examine the thyroid gland visually and by palpation. The thyroid gland is often difficult to feel in normal patients. Ask the patient to swallow in order to check for immobility or signs of obstruction. Note any signs of nodules or masses. A thick neck may be very difficult to examine. Standing behind the patient with the patients’ head turned to the side may facilitate the examination.

Any painless mass in the neck is highly suspicious for head and neck cancer. An enlarged lymph node caused by infection would most commonly be tender to palpation.

Intra-Oral Exam

All dental appliances must be removed in order to visualize all oral tissues. It’s helpful to dry the mucosal surfaces to make any changes easier to detect.

Mouth

Palpate all oral structures and observe for irregularities in color and texture, presence of red, white or mixed lesions, as well as ulcerations and raised lesions, and any fixed masses or nodules.

Observe and palpate the labial and buccal mucosa extends from the commissure to the tonsillar pillars. Observe and palpate the tissues on each side. Observe and milk the Stenson’s duct of the parotid gland to be sure it’s producing saliva and doesn’t contain any hard nodules.

Tongue

Observe the movement of the tongue as the patient extrudes the tongue and moves it from side to side. Deviation to one side or inability to move freely may indicate a cancerous lesion. Observe the dorsal surface of the tongue noting any discoloration, ulcerations or lesions. A smooth, pink to red surface is expected. Observe the circumvallate papillae and lingual tonsils. Examine the ventral surface by having the patient touch the tip of the tongue to the roof of the mouth. It should be pink to red and some vasculature may be visible.

The lateral borders of the tongue are among the most common sites of oral cancer. With gauze, extrude the tongue and roll it gently to one side. Examine the entire lateral surface paying particular attention to the posterior most aspect. Try to visualize the base of the tongue with a mouth mirror. This can be difficult due to the gag reflex of the patient. Repeat with the tongue rolled to the opposite side. Palpate the tongue to discover any nodules or firm, fixed masses.

Floor of the Mouth

The floor of the mouth is best palpated by using on finger to push down on the floor of the mouth while simultaneously pushing up on the tissues under the chin to capture the tissues between the fingers. Bi-digitally palpate the entire submandibular and submental area. Any firm, fixed masses should be highly suspect as this area is one of the more common sites of oral cancer. Ask patient to elevate the tongue and observe the floor of the mouth, including the frenulum and the submandibular and sublingual glands looking for any abnormalities. Mandibular torus, a benign bony growth on the floor of the mouth, may be mistaken for cancer.

The Palate

The hard palate should be palpated and observed for any red or white lesions, ulcerations, raised lesions or asymmetry. The soft palate may be observed visually but palpation may be difficult due to the patients’ gag reflex. Ask patient to say “Ah” to elevate the soft palate and allow more thorough observation. The uvula should be present in the midline and deviation from that may indicate a nerve issue. Palatal torus, a benign bony growth on midline of the palate, may be mistaken for cancer.

The Tonsils and Oropharynx

To examine the tonsils, ask the patient to open widely and say “Ah” to relax the tongue and allow the best view of the posterior portion of the oral cavity. It may be necessary to press down on the posterior portion of the tongue with a mirror or tongue depressor to visualize the oropharynx. It can be difficult due to the gag reflex or due to an enlarged tongue. Observe the anterior and posterior tonsillar pillars, the retromolar trigone and the palatine tonsils for any asymmetry, discoloration, ulceration, or masses. Cancers in the oropharyngeal structures are often overlooked as a result of the difficulty in visualizing these regions.

Examination of the nasopharynx and the larynx are typically not accomplished in the dental office due to the difficulty of visualizing these structures. A fiber optic scope is often used in the physician’s office for visualizing these structures, often with a topical anesthetic spray. In order to best visualize this area, ask the patient to open widely and breathe through the mouth to cause the soft palate to rise. Depress the tongue with a tongue blade and use the mouth mirror to see as much as possible of the nasopharynx. Then elevate the chin, grasp the tip of the tongue with gauze, and extrude the tongue. Insert the mirror and inspect the larynx as thoroughly as possible.

Any firm, fixed mass must be suspected of malignancy and referred for biopsy. Early detection and diagnosis save lives.