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  • Paranasal Sinus
  • Larynx
  • Oral Cancer
  • Oropharynx Cancer
  • Hypopharynx
  • Nasopharynx
  • Salivary Glands
  • Cancer of the Ear
  • Thyroid Cancer
  • Facial Nerve Tumour
  • Tracheal Stenosis
  • Cancer of Paranasal Sinus

    The paranasal sinuses are small hollow spaces around the nose. There are several paranasal sinuses (Fig.1). A pair of frontal sinuses present above the nose, in the forehead. Largest of all, the maxillary sinus, present in the upper jaw one either side of nose and below the eyes. The ethmoid sinuses are present between the two eyes and the sphenoid sinuses lie behind the nose.

    The sinuses and nose are lined with cells that produce mucous, which keeps the nose moist; the sinuses are also a space through which the voice can echo to make sounds when a person talks or sings. The nasal cavity is the passageway just behind the nostrils through which air passes on the way to the throat during breathing.

    Malignant tumours of the sinonasal tract are very uncommon, occurring in approximately 1 in 100,000 people and representing only 3% of all head and neck cancers. The incidence in males is twice that of females, due to the fact of a greater occupational exposure to certain carcinogens. These tumours most frequently develop during the 5th to 7th decades. About 80% of paranasal sinus cancers originate in the maxillary sinus. However, because a majority of them present at advanced stages, it is sometimes difficult to determine the exact primary site of the tumour.

    Risk Factors:

    1) Tobacco smoking
    2) Occupational exposure of carcinogens


    There is a significant high incidence of adenocarcinoma of the paranasal sinus among the furniture workers with chronic exposure to wood dust and in leather tanning industry. Nickel and chromium refining process have been implicated in the development of squamous cell and anaplastic cancer. Snuff and thorium dioxide, a radiological contrast agent, also have been associated with an increased incidence of sinonasal cancer.

    Otolaryngology

    Clinical Picture:

    1) Nasal obstruction that does not clear
    2) Nasal bleeding
    3) Headache or pain in the sinus region
    4) Pain in the upper teeth
    5) Problems with dentures
    6) Swelling or trouble with the eyes
    7) A lump or sore that does not heal inside the nose
    8) Swelling in the cheek

    Because these symptoms are similar to those of chronic sinusitis, there is always a big delay between the onset of symptoms and final diagnosis. As a result, most patients usually present at late stages.



    Diagnosis:

    Anyone with such symptoms requires careful evaluation and examination with fibreoptic endoscopy. If an abnormal tissue is found, the doctor need to cut out a small piece and look at it under the microscope to see if there are any cancer cells. This is called a biopsy. Sometimes the doctor will need to cut into sinus to do a biopsy. CT scan helps to find out the extent of the mass, bone destruction and to find out whether it is involving the eye or extending intracranially. MRI scan gives better picture of intracranial extension, orbital involvement, perineural spread (adenoid cystic carcinoma spreads along the nerve) and differentiates an obstructed sinus with fluid collection from a space-occupying lesion.


    Treatment:

    Currently most of the early carcinomas of the sinus are treated by surgery alone, whereas large lesions are treated by a combination of surgery and radiotherapy.


    Surgery:

    A number of surgical procedures available viz.

    1) Medial Maxillectomy
    2) Infrastructure Maxillectomy
    3) Total Maxillectomy
    4) Total Maxillectomy with orbital exenteration
    5) Total maxillectomy with infratemporal fossa clearance
    6) Craniofacial resection
    7) Endoscopic Craniofacial resection


    In medial maxillectomy, only the lateral wall of the nose is removed. In infrastructure maxillectomy, only the lower part of the maxillary antrum, bearing the teeth was removed. Whereas in total maxillectomy whole of maxilla (upper jaw) is removed. This leaves a defect in the hard palate, which makes it difficult to talk and eat. This problem can be overcome by wearing a prosthesis made by the dentist. Since teeth can be fit into this prosthesis, it gives a good functional and cosmetic result. This prosthesis needs removal and cleaning by the patient. The current and preferable technique is to close the defect in the palate permanently using micro vascular flaps by the plastic surgeon.


    Tumours reaching the skull base or extending into the infratemporal fossa were considered inoperable and therefore incurable. With the current techniques of skull base surgery, these tumours are removed safely and completely (Craniofacial resection). This requires a team approach wherein ENT-Head & Neck Surgeon, Neurosurgeon and Plastic surgeon join together to remove these skull base tumours safely and reconstruct in such a way to bring function as well as appearance as close to normal as possible.


    With newer endoscopic skull base surgical techniques, surgeons can completely remove ethmoid malignant tumours, without opening the skull (craniotomy) and retracting the unaffected normal brain. Covering of the brain (dura) is also excised and repaired endoscopically. Endoscopic craniofacial resection has the advantages of completely removing the tumour without facial scar or opening the skull (craniotomy). The complications associated with brain retraction in open surgery are avoided. This is appropriate only for a small tumours.


  • Cancer of Larynx

    The larynx or voice box is located in the neck. The large cartilage that forms the front of the larynx produces a sharp bulge in the neck in men and is called the ‘Adams apple’. It contains the vocal cords and the muscles, which move them. The vocal cords vibrate and make sound when air is directed against them. The sound echoes through pharynx, mouth, nose and sinuses to make a person’s voice. Air passes through the pharynx, then the larynx on the way to the windpipe and lungs. The food passes through the pharynx to the esophagus. The larynx has a leaf like structure called epiglottis, which prevents the food going into the airway. (Fig. 1 & 2)


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    Fig.1. Adam's apple

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    Fig.2. Larynx

    The Larynx include the:

    1. Vocal cords (glottis)
    2. Area above the vocal cords, including epiglottis (supraglottis), and
    3. Area below the vocal cords (subglottis) that connects the larynx to the wind pipe (trachea)

    Like other parts of the body, the larynx is made up of many types of cells. When cells divide in an abnormal, uncontrolled way, they can form a non-cancerous (benign) or cancerous (malignant) tumour. Approximately 95% of laryngeal cancers are squamous cell cancers arising from the mucous membranes. Cancers forming in the glands and connective tissues of the larynx are rare.

    Cancers of the larynx is especially common in smokers. It is typical for the cancers of the squamous cells of the larynx to begin as pre-cancerous conditions, such as an abnormal growth (dysplaisa). Not all pre-cancerous conditions develop into cancer. They sometimes go away without treatment, especially if the person stops smoking or eliminates other risk factors. Approximately 25% of patients diagnosed with laryngeal cancers have another cancer in a nearby area, such as mouth, oesophagus or lung. Another 15% will later develop cancer in one of these areas. That’s why patients should continue with follow-up examinations throughout their lifetime.


    Risk Factors:

    1) Use of Tobacco Products: This includes cigarettes and smokeless tobacco. Smokers are 5 to 35 times more likely to develop laryngeal cancers than non-smokers. Statistics show that 37 % of head and neck cancer patients who continue smoking will develop a recurrent tumour or second cancer. Compare that to only 6% of the head and neck cancer recurrence in patients who stop smoking.


    2) Excessive Consumption of Alcohol:


    3) Occupational Hazard: Over exposure to paint fumes, wood dust; some chemicals and even asbestos may increase the risk of developing laryngeal cancers.


    Clinical Presentation:

    An ENT surgeon should be seen if any of the following symptoms exist for more than two weeks. Pain is not an early symptom. Symptoms of laryngeal cancer include:

    1. Hoarseness of voice
    2. A lump in the neck
    3. A sore throat or ear ache
    4. Difficulty in breathing
    5. Pain and difficulty in swallowing


    Most of the cancers of the larynx begin on the vocal cords (atleast 70%). These tumours are seldom painful, but they almost always cause hoarseness. Tumours that begin in the area below the vocal cords are rare. Such tumours can make it hard to breathe. Breathing may even become noisy.


    Early detection of laryngeal cancer is important because treatment is most effective before the disease has spread. These types of cancers usually spread to lymph nodes in the neck, the back of the tongue, other parts of the throat and neck and the lungs. Spread of cancer to lymph nodes of patients with true cord cancer is extremely rare. The reverse is true for patients with supraglottic cancers, where up to 40% of patients will have some spread of cancer to the lymph nodes of the neck.


    The ENT surgeon with the help of small mirrors or a fibreoptic endoscope will examine the larynx. The fibreoptic flexible laryngoscopy can be done as an outpatient procedure under local anesthesia by passing a thin endoscope through the nose in to the pharynx.


    If something suspicious is seen, then the next step is doing endoscopy under general anesthesia. The larynx is examined with the help an operating microscope (Microlaryngoscopy). If some area looks abnormal, then biopsy is done from that area.


    If neck nodes are enlarged, fine needle aspiration is done for cytological examination (FNAC) by the pathologist to rule out metastatic carcinoma. If cancer is found, the doctor will need to know the extent of the disease. This is called staging. In most cases, the most important factor in considering treatment options is the stage of the disease. The stage is based on the size of the tumour, as well as whether or not the cancer has spread (metastasized) and where it has spread. To obtain more information about the location and extent of the cancer, the doctor may perform the following investigations.


    1. CT scan of neck
    2. X-ray / CT scan of chest
    3. Ultrasound of liver
    4. MRI neck


    Treatment Options:

    Treatment of small cancers of the larynx usually results in a good outcome. The cure rate for such a cancer that has not spread is 75-95 percent. Radiation often is the first treatment option for this type of cancer because this helps to preserve the voice. There are numerous surgical procedures now available that result in just partial removal of the voice box in order to retain normal breathing patterns and speaking.


    Surgery may also be needed later if the cancer recurs. Advanced laryngeal cancer may be treated with chemotherapy and radiation therapy in an effort to avoid surgical removal of the larynx. Locally advanced lesions, intermediate-sized cancers and recurrent cancers require different treatment therapies altogether. The treatment plan should be individualized depending on the location of the cancer, its size, the stage of the disease and the patient’s general health.


    Surgery:

    Surgery for cancer if the larynx involves removal of the affected portion of the larynx with significant normal healthy tissue around it. Complete surgical clearance of the tumour is achieved with the help of the pathologist who examines the removed tissue at the time of surgery (Frozen section) and says whether removal was complete or needs further removal.


    Patients with laryngeal cancer may undergo one of these types of surgeries.


    1. Cordectomy – removal of the vocal cord
    2. Supraglottis laryngectomy- removal of the supraglottis
    3. Partial laryngectomy – removal of part of the larynx
    4. Supracricoid laryngectomy with CHP or CHEP
    5. Transoral laser microsurgery (Video)
    6. Transoral robotic-assisted partial laryngectomy
    7. Total laryngectomy – removal of the entire larynx


    VOICE PRESERVATION SURGERY

    In voice preservation surgery, surgeon aims at preserving the uninvolved portion of larynx without compromising cancer clearance. Based on clinical examination as well as CT/MRI findings surgeon decides whether the patient is suitable for voice preservation surgery. With a partial laryngectomy, the surgeon creates a temporary breathing hole in the neck. The part of the larynx containing tumour is resected with sufficient normal tissue around it and then the larynx is reconstructed. Once the stoma closes, they are able to breathe normally and speak.


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    Fig.3. Transoral laser microsurgery (TLM) assisted partial laryngectomy

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    Fig.4. Transoral robotic-assisted partial laryngectomy

    Transoral Laser Microsurgery (TLM) Assisted Partial Laryngectomy: (Fig.3) This is a partial laryngectomy performed through the mouth. In this procedure, the voice box is exposed using special instruments. A laser attached to the microscope is used to cut out the tumor, with the aim of getting a margin of normal tissue around it. This remains an option for small primary or recurrent cancers after non-surgical therapy. (VIDEO)


    Transoral Robotic-Assisted Partial Laryngectomy: (Fig.4) This procedure simply uses a robot to get exposure and to remove a tumor of the larynx through the mouth. The principles are the same as transoral laser microsurgery with the exception that the instruments are different.


    Open Partial Laryngectomy: In small tumours, portion of the larynx involved by the tumour alone is resected without compromising cancer clearance. Various procedures viz. vertical partial laryngectomy, supraglottic laryngectomy and supracricoid laryngectomy (cricohyoidopexy & cricohyoidoepiglottopexy).


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    Fig.5. Normal anatomy. Passage for air and food is common upto larynx. The larynx is marked in this picture. Yellow arrow - food passage.

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    Fig.6. After removal of larynx, the wind pipe (trachea) is stitched to the skin in the lower part of neck. Normal food passage is maintained.

    Total Laryngectomy: : (Fig.5 & 6) When the tumour involves a large portion of the larynx, a more aggressive surgery is done to remove entire voice box. This procedure is called total laryngectomy. In order to complete this operation the windpipe must be brought out to the neck to form a permanent opening called stoma. Air can no longer pass from the lungs into the mouth and nose. The inhaled air passes directly through the stoma into the trachea and then into the lungs. The connection between the mouth and oesophagus is usually not affected, so food and liquid can be swallowed just as they were before the operation. As the vocal cords were removed, a laryngectomee patient will no longer have laryngeal speech. This does not mean that speech is lost and there are ways to talk without a larynx.


    Management of Lymph nodes will be included in whatever treatment plan is felt to be appropriate for the patient. This will involve surgery or radiotherapy. Many times an operation called a neck dissection is done to remove lymph nodes of the neck that may be involved with cancer.


    Alaryngeal Speech: Even when the patient loses the voice box in total laryngectomy, he/she can still learn to talk. There are basically 3 methods by which patient can learn to talk.


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    Fig.7. Oesophageal speech

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    Fig.8. Artificial larynx or Electrolarynx

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    Fig.9. Tracheo-oesophageal puncture and voice prosthesis

    Oesophageal Speech: (Fig.7) In this method, patient is taught to swallow the air and then to belch out. When the air comes out, the junction of the pharynx and food pipe acts like vocal cord and with the movement of tongue, palate and lips, speech is produced. The voice will be rough and monotonous. It requires lots of practice and perseverance on the part of the patient. About 50 – 60% of patients develop reasonable speech with this method. Patient has to periodically break the speech to swallow air. (VIDEO)


    Electronic Larynx: (Fig.8) It is a hand held electronic device, which has a diaphragm at one end, that vibrates. This end of the device is held over the floor of mouth and the patient start to articulate the tongue and lip musculature. The sounds of these movements are amplified by this device and speech is produced. The speech sounds like robotic speech. (VIDEO)


    Voice Prosthesis: (Fig.9) This device is a valve that is placed surgically between the airway in the neck and the oesophagus (food pipe). By covering the breathing hole (stoma) in the neck with a finger, a patient is able to force air through the valve into the food pipe (oesophagus) and out of the mouth. Relatively normal speech is achievable. This valve can be inserted at the time of the cancer surgery itself or later on if the patient does not develop oesophageal speech. (VIDEO)


  • Cancer of Oral Cavity

    Introduction

    Every year in India, approximately 650,000 patients develop cancer. Of these, 10% (65,000) of patients develop cancer in the oral cavity (ICMR Report 1992). Oral cancer is also known as mouth cancer. More than half of these patients die of the disease, because they present late.


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    Fig.1.

    By contrast, early diagnosis and treatment is associated with a good outcome. Late detection makes more radical treatment necessary, leading to increased morbidity associated with loss of function, aesthetics and psychological problems. Since oral cancers are readily detectable and identifiable at an early stage it should be possible to improve detection and hence the prognosis.


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    Fig.2a. Leukoplakia

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    Fig.2a. Leukoplakia

    Oral cavity(Fig.1) includes the:

    1. Lips
    2. Front two-thirds of the tongue
    3. Upper and lower gums (the gingiva)
    4. Lining of the inside of the cheeks and lips (the buccal mucosa)
    5. Floor of the mouth under the tonguev
    6. Bony top of the mouth (hard palate)
    7. Small area behind the wisdom teeth(the retromolar trigone)


    Oral cavity is made up of many types of cells. When cells divide in an abnormal, uncontrolled way, they can form a non-cancerous (Benign) or cancerous (Malignant) tumours. Oral cancer typically spreads through the lymphatic system that produces, stores and carries infection and disease fighting cells. When it spreads, oral cancer usually travels to the lymph nodes in the neck.


    Causes:

    Although the aetiology of oral cancer is complex, most Western studies have implicated tobacco smoking and alcohol drinking as the major cause of this disease. But in South Asia, in addition to the above factors chewing of tobacco, betel nut and “pan masala” seems to be the main cause of this problem. Repeated trauma from a sharp tooth or ill-fitting denture may promote neoplastic change over a long period of time.


    Clinical Presentation:

    If a patient has any of the following symptoms for more than 2 weeks, they should see a doctor. Pain is not an early symptom. A tiny spot , ulcer or small lump should not be ignored, especially if a person is a smoker or drinker.


    Patients may have one or more of the following symptoms:

    1. Non-healing ulcer, painless/painful
    2. Swellings in the gums, palate, tongue etc.
    3. Loose teeth
    4. Inability to wear the denture properly
    5. Difficulty in chewing or swallowing
    6. Blood in spit
    7. Lumps in the neck
    8. Pain in the ear
    9. A white patch (Leukoplakia) or a red patch


    Oropharynx Cancer

    Fig.3. Erythroplakia

    Hypopharynx

    Fig.4. Oral sumucous fibrosis. Scar bands in submucosa of buccal mucosa, retromolar area (yellow arrow) and soft palate. Contracture of this scar tissue makes mouth opening difficult.

    Pre-Cancerous Conditions:

    While the majority of oral cancers arise from a clinically normal mucosal lining, some oral cancers are preceded by pre-malignant changes. They may appear as white patches (Leukoplakia) or red patches (Erythroplakia). These may be caused by chronic trauma from sharp tooth or ill-fitting dentures or chemical irritants (tobacco, betel nut etc). Another condition very common among Indians is known as sub mucous fibrosis. This is caused by chronic irritation from tobacco juice and pan masala. The lining of whole of mouth and throat are exposed to this irritation, resulting in fibrosis (scarring) underneath the mucosa. The mouth looks pale and the mouth slowly closes due to scar contracture. They are unable to open the mouth, always have a burning sensation in the mouth and have a tendency to develop cancer in multiple areas. Response to radiation therapy is also poor because of poor blood supply in the scarred areas.


    Types of Cancer:

    Over 90% of oral cancers arise from the cells that line the mouth and are known as squamous cell carcinoma. Another source of cancer in the mouth is the minor salivary glands that are found just underneath the surface. These are much less common. There are a few other cancers of the oral cavity that are very uncommon, such as lymphoma, sarcoma and melanoma.


    Detection:

    Early detection is more important because treatment is most effective before the disease has spread. After complete clinical examination, the doctor may recommend CT scan or MRI scan or an endoscopic procedure to know the extent of the growth and the structures it is involving. PET scan is done not only to know about the locoregional disease but also to find out whether the disease has spread to other parts of the body. The endoscopic procedure may be done under general anaesthesia and local anaesthesia. If the physical examination shows an abnormal area, the doctor will advise for a biopsy. A biopsy is the only way for a doctor to know for sure whether or not the suspicious area is cancerous. The biopsy specimen is examined by a pathologist for the presence of cancer cells. Incisional or punch biopsies are done under local or general anesthesia using special instruments. Doing open biopsy of glands in the neck can lead to spreading of disease to skin. Therefore, the surgeon does Fine Needle Aspiration Cytology (FNAC) in which the surgeon uses a thin needle to remove cells from the mass.


    If cancer is found the doctor needs to know the extent of the disease. In most cases, the most important factors in considering treatment options is the stage of the disease. The stage of the disease is based on the size of the tumour, as well as whether and where the cancer has spread.


    Treatment Options:

    Nearly half of all head and neck cancers are found in the mouth and throat. Treatment for head and neck cancers may change the way person looks, breathes, talks, eats or swallows. Therefore multidisciplinary approach to patient care is so important. The team includes:

    1. ENT – Head and neck surgeon
    2. Plastic Surgeon
    3. Radiation Oncologist
    4. Medical Oncologist
    5. Dental Surgeon
    6. Prosthodontist
    7. Speech Therapist
    8. Swallowing Therapist
    9. Dietician

    The treatment options are surgery, radiation therapy and chemotherapy either alone or in combination depending on the stage of tumour. In choosing a treatment plan, factors to consider include overall physical health, the type and stage of cancer, the probability of curing the disease, and the impact of treatment on functions like speech, chewing and swallowing. Surgery or radiotherapy or both modalities combined is usually the most appropriate treatment form for curative intent. Chemotherapy is mostly reserved for patients with very advanced cancers.


    If the patient undergoes surgery for oral cancer, the surgeon may remove the cancer and some of the healthy, adjoining tissue. Complete surgical clearance of the tumour is achieved with the help of the pathologist who examines the removed tissue at the time of surgery itself (Frozen Section) and says whether the removal was complete or needs further removal.


    Small tumours of the oral cavity can be quickly and successfully treated by surgical excision, leaving behind little cosmetic or functional change. Among the advantages for treating early stage cancer with surgery is that it is completed quickly usually requiring a few days of hospital care, instead of 6 weeks of daily Radiotherapy. Dryness of mouth and radiation induced damage to teeth can be avoided. Most importantly, if the patient subsequently develops another cancer in the mouth, throat or voice box, radiotherapy would still be available as treatment option. This will avoid a more significant and disfiguring operation.


    Very early cases of oral cancers can be treated with removal of the primary tumour alone. But as the size of the tumour increases, the possibility of some cancer cells spreading through the lymphatic to the lymph nodes in the neck is high. When the index of suspicion is high that there may be cancer cells present in the lymph nodes, an operation called a neck dissection is performed. For large primary tumour the surgeon may need to remove part of the palate, tongue or jaw. After resection of tongue or cheek, the resected areas are reconstructed using microvascular technique.


    The lower jaw bone (mandible), which gives shape to the lower part of the face, is essential for chewing food. This bone is removed when the tumour invades it. If the bone is not reconstructed, chewing food is difficult and the facial appearance also changes. Currently, the lower jaw is reconstructed with a bone from the leg (fibula) using microvascular technique. It helps in retaining the facial contour and the patient is able to chew well with the remaining teeth. Teeth can also be fixed onto titanium screws that are implanted into the bone either at the time of the primary surgery or later ( known as Osseo-integrated dental implants). Removal of fibula bone from the leg does not change the appearance or function of the leg.


    Nasopharynx

    Fig.5. Rim resection of mandible. Only the shaded upper half of bone bearing teeth is removed. No need to reconstruct the bone.

    Salivary Glands

    Fig.6. Segmental mandibulectomy. Shaded area of bone is removed. Needs reconstruction of bone.


    When a large portion of the tongue is removed (hemiglossectomy/subtotal glossectomy), the defect is immediately reconstructed using microvascular technique to improve speech and swallowing. Whenever total glossectomy (complete removal of tongue) is performed, aspiration of food into the voice box resulting in recurrent lung infection is common. In the past, to avoid this problem, voice box was also removed at the same time. But, the current technique in reconstruction has reduced the aspiration and therefore the need for the removal of voice box.


    Such operations are likely to change the patient’s ability to chew, swallow or talk. Newer techniques in reconstruction using micro vascular free flaps provide the patient with better function of the oral cavity by providing lining with sensation or restoring the jaw with bone. After the surgery the patient’s face may be swollen. This swelling usually goes away within a few weeks. Until the wound heals and swallowing improves, the patient will be fed through a tube passing through the nose into the stomach. Rehabilitation may include speech and swallowing therapy.


    Follow-up Care:

    Regular follow-up examinations are very important for anyone who has been treated for oral cancer. The doctor will watch the patient closely to check the healing process and to look for signs that the cancer may have returned. Patients with dryness of mouth from radiotherapy should have regular dental examination. The patient may need to see a dietitian if weight loss or eating problem continues. Oral cancer patients are strongly advised to stop using tobacco and limit alcohol intake to reduce the risk of developing another cancer.


    Questions patients should ask before deciding about the treatment:

    1. What are my treatment options?
    2. What are the risks and benefits for each of my treatment options?
    3. How will treatment affect my everyday activity? How long?
    4. How often will I need to return?
    5. Has my doctor explained various surgical options to my satisfaction?
    6. Have I been seen by a surgeon who has expertise with removal of cancer, as well as, with reconstruction? Have I seen by a surgeon, radiation oncologist, prosthodontist and dentist?
    7. Do I know all I need to know about prostheses and prosthetic techniques?
    8. How often has the surgeon performed the kind of surgery he is recommending?
    9. What will the surgical site look like after healing?
    10. Will my appearance and physical capabilities be affected? If so how?
    11. Should I consider combination therapy (both surgery and radiation therapy)?


  • Cancer of Oropharynx

    The oropharynx is the part of the throat directly behind the mouth(Fig.1). It includes the tonsils, base of tongue, soft palate and posterior pharyngeal wall.


    Cancer of the Ear

    Fig1.png

    Thyroid Cancer

    During TORS training with Dr. Weinstein

    Squamous cell carcinoma is the commonest malignant tumour that occurs in oropharynx. It is often seen in older men who have a history of smoking and drinking. However, over the last 10 to 20 years, oropharynx cancers are increasing in incidence and seen in patients who are younger, healthier and non-smokers. This is attributed to human papillomavirus (HPV) and is associated with oral sex.


    HPV-associated oropharynx cancers have a better prognosis than patients with non-HPV associated oropharynx cancer with current treatment.


    Clinical Picture

    People with oropharyngeal cancer may experience the following symptoms or signs.


    1. Lump on the neck, or throat
    2. Persistent sore throat or feeling that something is caught in the throat
    3. Hoarseness or change in voice
    4. Difficulty chewing, swallowing, or moving the jaws or tongue
    5. Ear pain
    6. Changes in speech
    7. Unexplained weight loss

    Because the oropharynx helps in breathing, eating, and talking, patients may need special help adjusting to the side effects of the cancer and its treatment. Depending upon the tumour size, location and stage, your doctor may recommend surgery.


    Treatment

    Traditional open surgery to remove cancer requires your surgeon to make a long incision through the jaw and throat. A mandibulotomy(Fig.4), in which the jawbone is split to access the tumor, may also be required.This can cause disfigurement as well as difficulty in eating, talking and swallowing. Reconstructive or plastic surgery may be needed to rebuild the bones or tissues removed during surgery.


    In small tongue base tumours, the lip, mandible and tongue can be split in midline to expose the tumour. After resection, anterior tongue is set back to close the defect. Since there is no injury to the sensory or motor nerve, patient’s speech or swallowing are not affected. Chemoradiation, therefore had been the treatment of choice for throat cancer. However, the side effects may permanently affect the long-term ability to speak, and eat normally. Open surgery was reserved for residual or recurrent tumours. There is a minimally invasive option for patients diagnosed with early to moderate stage throat cancer. Using the da Vinci robot, the surgeon removes the tumour through the mouth. For early tumours of tonsil, base of tongue, posterior pharyngeal wall and supraglottis, TORS should be the treatment of choice. It avoids the morbidity of chemoradiation as well as open surgery. For advanced tumours, chemoradiation should be the treatment of choice and open surgery should be reserved as a salvage procedure.


    Transoral Robotic Surgery (TORS)

    Tumours in the throat, base of the tongue(Fig1), and tonsils(Fig.2) are difficult to reach through the mouth. Therefore, these have traditionally been removed through surgeries requiring a large neck incision and cutting of the lower jaw(Fig.3). These types of surgeries often require tracheostomy, long hospital stay, and may result in difficulty in swallowing and speaking.Therefore,chemoradiation had been the treatment of choice for throat cancer. However, the side effects of chemoradiationmay permanently affect the long-term ability to speak, and eat normally. Open surgery was reserved for residual or recurrent tumours.


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    Fig.1.Tumour of base of tongue

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    Fig.2. Carcinoma of tonsil

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    Fig.3. In open surgery, the lip is split in midline and the lower jaw (mandible) is divided to expose the tumour

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    Fig.4. Surgeon's console

    Advances in surgical equipment have made it possible to reach these tumours through the mouth by using robotic technology. During transoral robotic surgery, surgeon sits at a remote control console (Fig.4)a short distance from the operating table.The mouth is kept open with special retractor. Three arms of the robot go through the open mouth armed with camera and two instruments(Fig.5). Using two special joystick-like instruments known as endowrist instruments, the surgeon guides very small tools at the ends of the robot arms to remove the cancer(Fig.6). Robot allows more-precise tremor-free movements in tiny spaces. The surgeon’s console displays a magnified, 3-D view of the surgical area that enables the surgeon to visualize the procedure in much greater detail.Tumours can be dissected free from surrounding tissue safely.The machine is not a true robot (it does not operate or move by itself), but is a “master slave” unit. This means the surgeon is in complete control throughout the procedure, and controls the instruments at all times.


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    Fig.5. Three arms of the robot go through the open mouth armed with camera and two instruments.

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    Fig.6. Using two special joystick-like instruments known as endowrist instruments, the surgeon guides very small tools at the ends of the robot arms to remove the cancer.

    Patients with early stage tumours (T1 or T2) with limited lymph node involvement in the neck are suitable candidates for TORS. Approximately 20 to 30 percent of patients with oropharygeal (tonsils and tongue base) tumours may be considered ideal candidates for the procedure. Patients with certain tumours of the larynx and throat may also be candidates. Patients who smoke tobacco or have Human Papillomavirus (HPV) negative tumours are especially encouraged to receive surgical treatment for their cancer, as these cancers often do not respond as well to radiation and chemotherapy.


    Compared with open surgical approaches, TORS offers the patient numerous potential benefits that include:


    1. Avoidance of a jaw split approach
    2. Avoidance of tracheotomy
    3. Quicker return to normal speech and swallowing
    4. Significantly less pain
    5. Less blood loss
    6. Shorter hospital stay
    7. Minimal scarring
    8. Minimization or elimination of need for chemoradiation therapy


    Contraindications for TORS:

    1. Jaw bone invasion.
    2. Anticipated tongue base involvement requiring removal of more than 50%.
    3. Presence of trismus (inability to open jaw easily).
    4. Carotid artery involvement.
    5. Fixation of tumour to prevertebral fascia (layer in front of spine).


  • Cancer of Hypopharynx

    The hypopharynx is situated behind the voice box(Fig.1). The upper part communicates with the oropharynx and the lower part forms the entrance of the food pipe (oesophagus). Because the hypopharynx is behind the voice box, the front wall of the hypopharynx is actually the back wall for the voice box covered by mucosa (known as post cricoid area). On either side of the front wall, are the funnel shaped pyriform sinuses directing food down towards the oesophagus.


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    Fig.1.

    Risk Factors:

    Incidence of hypopharyngeal cancers is much less compared to the laryngeal cancers and is nearly always squamous cancers. Approximately 80% of cancers occur in men. This is because smoking and alcohol abuse are common among men.


    Clinical Presentation:

    Unfortunately hypopharyngeal tumours produce few symptoms until they are advanced. They may cause:

    1. Sore throat
    2. Ear pain
    3. Voice change
    4. Pain or difficulty in swallowing
    5. Appreacnce of a lump in the neck
    6. Feeling of food sticking in the throat.

    Atleast 70% of hypopharyngeal cancer arise in the pyriform sinus. Diffuse local spread is common and is due to tumour extension underneath the mucosal lining. Abundant lymphatic drainage results in a higher incidence of spread to lymphnode than other head and neck tumours. At presentation, 70-80% of the patients with hypopharyngeal cancers have a lump in the neck; in half of these patients lymphnode metastases is the presenting complaint. Bilateral metastases are seen in only 10% of the patients with pyriform sinus cancers but in 60% of those with postcricoid tumours. The hypopharynx will be examined by the ENT surgeon with a help of small mirrors or fibreoptic endoscope. The flexible fibreoptic hypopharyngoscopy can be done as an out patient procedure under local anesthesia by passing a thin endoscope through the nose into the pharynx.


    If something suspicious is seen, then the next step is doing endoscopy under general anesthesia. If some area looks abnormal, then biopsy is done from that area. If the neck nodes are enlarged, fine needle aspiration is done for cytological examination (FNAC) by the pathologist to rule out metastatic carcinoma. If cancer is found, the doctor will need to know the extent of the disease. This is called staging. In most cases, the most important factor in considering treatment options is the stage of the disease. The stage is based on the size of the tumour, as well as whether or not the cancer has spread (metastasized) and where it has spread. To obtain more information about the location and extent of the cancer, the doctor may perform the following investigations.


    1. CT scan of neck
    2. X-ray/CT scan of chest
    3. Ultrasound of liver
    4. Barium swallow
    5. PET-CT


    Treatment:

    The three main types of treatment for these cancers are surgery, radiation and chemotherapy. Most of these cancers will need surgery and /or radiotherapy. Chemotherapy is usually given when the cancer has spread too far to be treated with surgery and radiotherapy. It is also given before or along with radiation with goal of preserving the voice box.


    Radiation:

    Since surgical treatment for hypopharyngeal cancer involves removal of voice box, radiotherapy has been the ideal treatment for small tumours. Radiotherapy is most commonly used after surgery to kill cancer cells that are not visible during surgery. In some cases when the tumour is extensive and cure is not possible, radiotherapy is given for easing symptoms like pain, bleeding and swallowing.


    Surgery:

    With small tumours, a number of conservative surgical procedures are available viz

    1. Partial pharyngectomy
    2. Partial laryngopharyngectomy
    3. Near total laryngectomy

    All these procedures are designed to preserve the natural voice by preserving the voice box, fully or partly. With large tumours, surgical removal of the voice box along with the tumour becomes inevitable.


    Total laryngopharyngectomy:

    In this, the continuity between the pharynx and oesophagus is lost. This is reconstructed in a number of ways. The latest technique is to use a small portion of the small intestine (Jejunum). The blood supply to this segment of the transposed intestine is reestablished in the neck by connecting its blood vessels to the blood vessels in the neck using microsurgical techniques.


    In cases where the tumour extends into the food pipe (oesophagus), total laryngopharyngo oesophagectomy is done. The stomach is brought to neck and connected to the pharynx. When the voice box is removed, the patient will no longer have normal speech. This doesn’t mean that speech is lost and there are ways to talk without larynx. Further information about Alaryngeal Speech can be obtained in the section for cancer of larynx.


    Questions patients should ask before deciding about the treatment:

    1. What are my treatment options?
    2. What are the risks and benefits for each of my treatment options?
    3. How will treatment affect my everyday activity? How long?
    4. How often will I need to return?
    5. Has my doctor explained various surgical options to my satisfaction?
    6. Has a surgeon who has expertise with removal of cancer, as well as, with reconstruction seen me? Have I seen by a surgeon, radiation oncologist, prosthodontist and dentist?
    7. Do I know all I need to know about prostheses and prosthetic techniques?
    8. How often has the surgeon performed the kind of surgery he is recommending?
    9. What will the surgical site look like after healing?
    10. Will my appearance and physical capabilities be affected? If so how?
    11. Should I consider combination therapy (both surgery and radiation therapy)?


  • Cancer of Nasopharynx

    The nasopharynx is the air passageway at the upper part of the pharynx (throat) behind the nose and lies just above the soft palate(Fig.1). The nostrils lead through the nasal cavity into the nasopharynx.An opening on each side of the nasopharynx (called the Eustachian tube opening) leads into the middle ear on each side. Inferiorly, it communicates with the oropharynx (part of pharynx behind the oral cavity).


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    Fig.1.

    Several types of tumours can develop in the nasopharynx. Some of these tumours are benign (non-cancerous), but others are malignant (cancerous). Several types of benign tumours, including angiofibromas, hemangiomas and tumours in the lining of the nasopharynx that include the minor salivary glands.


    The nasopharynx contains several types of tissue, and each contains several types of cells. Different cancers can develop in each kind of cell. The differences are important because they determine the seriousness of the cancer and the type of treatment needed. Squamous cell carcinoma (nasopharyngeal carcinoma - NPC) is the most common malignant tumour of the nasopharynx. Other nasopharyngeal cancers include adenoid cystic and mucoepidermoid carcinomas, malignant mixed tumours, adenocarcinomas, lymphomas, fibrosarcomas, osteosarcomas, chondrosarcomas, and melanomas.


    NPC is one of the most common cancers among people of Chinese, especially Southern Chinese, and Southeast Asian ancestry, including Chinese immigrants to North America. Over several generations, the prevalence among Chinese-Americans gradually decreases to that among non-Chinese Americans, suggesting an environmental component to etiology. Dietary exposure to nitrites and salted fish also is thought to increase risk. Epstein-Barr virus is a significant risk factor, and there is hereditary predisposition.


    Clinical Presentations:

    1. Nasal obstruction
    2. Hearing loss due to a middle ear effusion (eustachian tube obstruction)
    3. Purulent bloody nasal discharge
    4. Frank epistaxis
    5. Cervical lymphadenopathy
    6. Pain in the side of the head (due to involvement of fifth cranial nerve)
    7. Blurred or double vision (3rd, 4th, and 6th cranial nerve palsies)


    These symptoms may be caused by other conditions also. Therefore, there is always a big delay between the onset of symptoms and final diagnosis. As a result, most patients usually present at late stages.


    Diagnosis :

    Anyone with such symptoms requires careful evaluation and examination with a nasopharyngeal mirror or endoscope, and lesions are biopsied. Open cervical node biopsy should not be done as the initial procedure, although a needle biopsy is acceptable and often recommended. Gadolinium-enhanced MRI (with fat suppression) of the head with attention to the nasopharynx and skull base is done; the skull base is involved in about 25% of patients. CT also is required to accurately assess skull base bony changes, which are less visible on MRI. A PET scan also commonly is done to assess the extent of disease as well as the cervical lymphatics.


    Treatment :

    Primary treatment of NPC is concomitant chemoradiotherapy, in which chemotherapy is given in combination with radiation therapy. Patients achieve quite satisfactory cure rate. About one third of the patients fail locally in the nasopharynx. Up until recently there were no good treatment options available other than re-irradiation.


    Re-irradiation improves survival in less than 30% of patients but associated with high incidence of complications like temporal lobe necrosis, trismus, deafness, endocrine dysfunction and osteoradionecrosis causing severe pain, foul odour and massive bleeding. Even though the incidence of complications has come down with intensity modulated radiotherapy (IMRT), the cure rate remains the same.


    Surgery improves survival in more than 50% in these lesions with minimal morbidity. Todays evidence favours surgery in these recurrent or residual tumours.


    Surgery :

    Removing the tumour (Nasopharyngectomy).


    For long, nasopharynx was considered unresectable because of its central location and was surrounded by uninvolved bony structures. Access to the nasopharynx has been pioneered by many surgeons in the last three decades using various open techniques e.g.,. Trans temporal approach by UgoFischin 1983. William Wei in 1989 translocated the upper jaw bone (facial translocation or maxillary swing) to expose this region well for an en-bloc resection. Paul Donald described the Transfacial Subcranial approach for nasopharyngectomy. This has doubled the 5-year survival in patients with recurrent disease.


    With newer endoscopic surgical techniques, surgeons can completely remove some nasopharyngeal tumours, but this is appropriate only for a small tumours. Factors determining the surgical approach are the extent of tumourand the structures involved. For planning the surgery, we should know whether the tumour is limited to nasopharynx or spread to infratemporal fossa or involving theinternal carotid artery or intracranial extension.


    Nasopharyngectomy is indicated as a salvage procedure in persistent or recurrent nasopharyngeal carcinoma. But it is done as a primary treatment in radioresistent tumours like adenocarcinomas, minor salivary gland tumours and sarcomas. These complex procedures are done only in specialized centers.


    Removing lymph nodes :

    Cancers of the nasopharynx often spread to the lymph nodes in the neck. These cancers often respond well to treatment with radiation therapy (and sometimes chemotherapy). But if some cancer remains after these treatments, an operation called a neck dissection may be needed to remove these lymph nodes.


    Questions Patients should ask before deciding about the treatment:

    1. What type of nasopharyngeal cancer do I have?
    2. What is the stage of the cancer? What does this mean?
    3. What are the treatment options?
    4. What treatment option do you recommend?
    5. Should I get an additional consultation or second opinion?
    6. What can be done to relieve the possible side effects?
    7. If surgery is needed, will it be necessary to have reconstruction done to replace lost tissue ?
    8. If surgery is needed, will there be a need for a neck dissection (removing lymph nodes)? If so, what type of dissection will be done? What does this mean?
    9. What are the possible side effects of this treatment, both in the short term and the long term?
    10. When can I expect to recover from the treatment effects?
    11. What follow-up tests will be needed, and how often will I need them?
    12. Will there be any lasting or late side effects that will need special care?


  • Tumours of Salivary Glands

    The salivary glands are located around the mouth. The saliva they produce moistens food to help with chewing and swallowing. It contains enzymes that begin the digestion process, and help cleanse the mouth by washing away bacteria and food particles.


    maxillectomy-postop-003

    Fig.1. Major salivary glands

    There are three pairs of major salivary glands(Fig.1). The largest are the parotid glands, located in each cheek over the jaw in front of the ears. Two submandibular glands are at the back of the mouth on both sides of the jaw. Two sublingual glands are under the floor of the mouth. There are also thousands of minor salivary glands and are widely distributed in the mucosa of the lips, cheeks, hard and soft palate, uvula, floor of mouth, tongue, and peritonsillar region. All of the salivary glands empty saliva into the mouth through ducts that open at various locations in the mouth.


    About 85% of salivary gland tumours occur in the parotid glands, followed by the submandibular and minor salivary glands, and about 1% occur in the sublingual glands. About 75 to 80% are benign, slow-growing, movable, painless, usually solitary nodules beneath normal skin or mucosa. Occasionally, when cystic, they are soft but most often they are firm.


    Benign Tumours:

    The most common type is a pleomorphic adenoma (mixed tumour). They are slow-growing and lobular and may become very large without interfering with facial nerve function. Malignant transformation is possible, resulting in carcinoma ex pleomorphic adenoma, but this usually occurs only after the benign tumour has been present for more than a decade. Other benign tumours include monomorphic adenoma, oncocytoma, and papillary cystadenoma lymphomatosum (warthin’s tumour). These tumours rarely recur and rarely become malignant.


    Malignant Salivary Gland Tumours:

    Malignant tumours are less common and are characterized by rapid growth or a sudden growth spurt. They are firm, nodular, and can be fixed to adjacent tissue. Pain and neural involvement (facial nerve paralysis) are common. Eventually, the overlying skin or mucosa may become ulcerated or the adjacent tissues may become invaded. Surgery, followed by radiation therapy, is the treatment of choice for resectable disease. Currently, there is no effective chemotherapy for salivary cancer.


    Mucoepidermoid carcinoma is the most common salivary gland cancer, typically occurring in people in their 20s to 50s. It can manifest in any salivary gland, often in a minor salivary gland of the palate. Intermediate and high-grade mucoepidermoid carcinomas may metastasize to the regional lymphatics, which must be addressed with surgical dissection or postoperative radiation therapy.


    Adenoid cystic carcinoma is the most common malignant tumour of minor salivary glands. Its peak incidence is between ages 40 and 60, and symptoms include severe pain and, often, facial nerve paralysis. It has a propensity for perineural invasion and spread, with disease potentially extending many centimeters from the main tumour mass. Lymphatic spread is not a common feature of this tumour, so elective nodal treatment is less common. Pulmonary metastases are common, although patients can live quite long with them.


    Acinic cell carcinoma, a common parotid tumour, occurs in people in their 40s and 50s. This carcinoma has a more indolent course, as well as an incidence of multifocality.


    Carcinoma ex mixed tumour is adenocarcinoma arising in a preexisting benign tumour. Only the carcinomatous element metastasizes.


    Symptoms and Signs :

    Most benign and malignant tumours manifest as a painless mass in front of the ears, under the chin, or on the floor of the mouth. However, malignant tumours may invade nerves, causing localized or regional pain, numbness, paresthesia, causalgia, or a loss of motor function. Sudden onset of pain, increase in size and facial palsy should raise the suspicion of malignancy.


    Diagnosis :

    1. Needle biopsy
    2. CT and MRI for knowing the extent of disease

    CT and MRI locate the tumour and describe its extent. Biopsy confirms the cell type. A search for spread to regional nodes or distant metastases in the lung, liver, bone, or brain may be indicated before treatment is selected.


    Treatment :

    Treatment of benign tumours is surgery. The aim of the operation is to completely excise the tumour with an adequate margin of normal tissue and preserve the facial nerve and its branches. There are lots of variations in the branching of extracranial facial nerve (Fig.2). Magnification with surgical loupe (Fig.3) or microscope helps in identification as well as preservation of facial nerve and its branches. Facial nerve monitoring(Fig.4) is a simple, effective adjunct method that is available to surgeons to assist with the functional preservation of the facial nerve during parotid surgery. Although it does not improve the facial prognosis in first-line surgery, it does improve the facial prognosis in reoperations.


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    Fig.2. Anatomic variations in the branching of the extracranial facial nerve

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    Fig.3. Surgical loupe

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    Fig.4. Electrophysiological monitoring

    Although mixed tumours are benign, they will recur after surgery unless they are completely removed. Enucleation is inadequate and the tumour recurs. When tumour recurs in the parotid region, the facial nerve is at greater risk from damage during re-operation than it was during the initial procedure. When the tumour is in the superficial lobe, the tumour is removed along with the superficial lobe of parotid gland (Superficial Parotidectomy) after identifying and preserving the facial nerve and its branches. When a tumour arises in the parotid gland deep to the facial nerve (deep lobe), the portion of the parotid gland superficial to the facial nerve is elevated or removed, the facial nerve is then dissected off the deep lobe containing the tumour, and finally the tumour deep to the nerve is removed along with the remaining parotid tissue. Benign tumours of the submandibular gland require total removal of the gland for diagnosis and treatment.


    Surgical treatment for malignant tumours of the parotid depends on its extent. Unless the patient has facial nerve paralysis before surgery or the nerve is found to be directly invaded or surrounded by malignant tumour at surgery, it is preserved. When the facial nerve must be divided, it is repaired. The facial nerve can be reconstructed using a nerve graft, e.g., the greater auricular or sural nerves. It takes many months for the facial function to recover and is often incomplete. If the proximal segment of the facial nerve is not available for grafting, the distal segment or branches of the facial nerve is connected (anastamosis) to the hypoglossal nerve either directly or with a nerve graft.


    For low-grade salivary gland cancers, complete excision is sufficient treatment. For high-grade cancers, postoperative radiation therapy is indicated for the primary cancer site and regional lymph nodes. Clinically involved lymph nodes are removed by a radical or modified neck dissection.


  • Cancer of the Ear

    The ear has three parts – outer ear, middle ear and inner ear (Fig.1). The outer ear is made of external ear (pinna) and external ear canal. Ear drum (tympanic membrane) is at the medial end of ear canal and it separates the outer ear from middle ear. The middle ear lies medial to the ear drum. Eustachian tube connects the middle ear to the nasopharynx. Medial to the middle ear lies the inner ear concerned with hearing and balance. The inner ear has three parts viz. cochlea, labyrinth and semicircular canals. From the inner ear nerve goes to the brain. The inner ear, middle ear and part of the outer ear canal are housed in the temporal bone. The nerve that controls the movement of face (facial nerve) runs above the inner ear and through the middle ear. The internal carotid artery and internal jugular vein & sigmoid sinus are closely related to the temporal bone.


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    Fig.1 EAC-External auditory Canal, TM-Tympanic membrane, JB-Jugular bulb, ICA-Internal carotid artery, IJV-internal jugular vein, Lab-Labyrinth, SCC-semi circular canal, ME-Middle ear.

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    Fig.2. Temporal bone is shaded green at the side of the skull, medial to the pinna.

    Cancer of the ear is rare. It can occur in any part of the ear (external ear or ear canal, middle ear or inner ear). Those that develop inside the inner ear are rare. Most of the cancers are squamous cell carcinomas. Other types include basal cell cancer, melanoma, adenoid cystic carcinoma and adenocarcinoma.


    These cancers are usually found in individuals who have neglected long-term drainage and infection in the mastoid or middle ear. The exact relationship of the infection to the formation of the squamous cell cancer is unclear. Presumably, it is related to chronic inflammation.


    Squamous cell cancer of the middle ear is often quite advanced before a correct diagnosis is made. Pain is a significant feature of squamous cell cancer of the middle ear and mastoid. Intermittent hemorrhage, bleeding and drainage for long periods of time are also usual. Hearing loss is significant. Some people may also have swollen lymph nodes in their neck. Occasionally people cannot move their face on the side of the affected ear.


    Generally an early stage cancer is small and just within the area it started in. Later it grows into the surrounding structures and much later it spreads to another part of the body. Diagnosis depends upon a biopsy of the tissue. Surgeon will take a small amount of tissue from the abnormal area of the ear and to examine it under a microscope. If the biopsy shows a cancer, surgeon will do CT scan and MRI scan to know the extent of disease to decide which treatment is needed. The main treatments for these cancers are surgery and radiotherapy. Depending on the stage of the cancer, patient may also have chemotherapy. The treatment depends on which part of the ear is involved, type of cancer, size of tumour, spread to adjacent structures like parotid salivary gland, dura, brain as well as general health of the patient.


    The type and amount of surgery needed depends on the area of ear affected, and whether it has spread into nearby structures, such as the bone, dura, parotid etc. Surgeon will remove the tumour together with an area of tissue surrounding it that is completely free of cancer cells. Doing this helps to lower the risk of the cancer coming back.


    Surgery may involve having some or all of the following removed.

    1. The ear canal
    2. Part or all of the temporal bone
    3. The middle ear
    4. The inner ear


    The temporal bone is the bone at the side of the skull, by the ear (Fig.2). The operations to remove the temporal bone tumour may range from a mastoidectomy to total temporal bone resection. They may also need to remove the lymph nodes nearby in the neck and the salivary gland on that side of the head. Rarely, surgeon may need to remove the facial nerve, which runs through the temporal bone. In that case, nerve grafting is done to regain the facial movement.


    If the middle and inner ear were removed it is unlikely that the patient will be able to hear on that side. Balance may be affected and the patient may feel dizzy temporarily. Sometimes it is possible for the surgeon to rebuild (reconstruct) some of the ear so that hearing can be preserved. With this operation, appearance won’t change for most people. Scar line is likely to be behind the ear.


    Radiotherapy

    Radiotherapy uses high-energy rays to treat cancer. Radiotherapy may be taken as main treatment or, if the surgeon hasn’t been able to remove a clear margin of tissue from around the tumour. Then radiotherapy can lower the risk of the cancer coming back.


    Chemotherapy

    Chemotherapy uses anti cancer (cytotoxic) drugs to destroy cancer cells. Chemotherapy on its own won’t cure cancer of the ear but doctors may use it to relieve symptoms if your cancer comes back or you can’t have other treatments.


  • Thyroid Cancer

    Thyroid gland is a butterfly-shaped gland that lies over the wind pipe (trachea) (Fig.1)that carries air to lungs. It produces a hormone known as thyroxin which helps to regulate body’s metabolism. Behind the thyroid gland, there are four small glands known as parathyroid glands(Fig.2). These secrete a hormone known as parathormonethat controls calcium level in the body Thyroid tumour begins when cells in the thyroid gland begin to change and grow uncontrollably, forming a nodule (tumour). Ninety percent of all thyroid nodules are benign (noncancerous), but a few are malignant (cancerous). Malignancy should be suspected when there is a prior history of radiation, rapid growth of the nodules, males, extremes of age (less than15 yrs or more than 45 yrs), family history of thyroid cancer, associated with difficulty in swallowing and change in voice.


    maxillectomy-postop-003

    Fig.1.

    maxillectomy-postop-003

    Fig.2.

    It is one of the most curable types of cancer — approximately 95 percent of people with a thyroid tumour survive at least five years beyond their diagnosis. Ultrasound done by an expert sonologist is the investigation of choice. Tissue sample is aspirated using small bore needle and send for pathological examination (FNAC). It helps in reaching a diagnosis and plan treatment.


    There are different types of thyroid cancers:


    Papillary Carcinoma

    The majority of all thyroid cancers are papillary carcinoma, a slow-growing tumour. They can spread to the lymph nodes in the neck. Most people with this type of cancer can be cured.


    Follicular Carcinoma

    This slow-growing thyroid cancer is less common and can often be cured. Follicular carcinoma rarely spreads to the lymph nodes, although it can spread to other parts of the body, such as the lungs and bones.


    Hurthle Cell Carcinoma

    Hurthle cell carcinoma is a rare type of follicular carcinoma. They absorb less radioactive iodine than papillary and follicular thyroid tumors and therefore surgery is the only treatment.


    Medullary Thyroid Carcinoma (MTC)

    This rare type of thyroid cancer begins in the C cells, which make the hormone calcitonin. High levels of calcitonin and a protein called carcinoembryonic antigen (CEA) are a common indication of MTC. MTC usually occurs in older adults and often affects only one lobe of the thyroid. Some patients have familial MTC, an inherited form of thyroid cancer that develops during childhood or early adulthood and in several areas of each lobe. These tend to spread to large numbers of lymph nodes very early on, and therefore require a much more aggressive operation than the more localized thyroid cancers, such as papillary and follicular thyroid cancer.


    Anaplastic Carcinoma

    Anaplastic carcinoma, also called undifferentiated carcinoma, usually develops from an existing papillary or follicular carcinoma. This aggressive type of cancer, which spreads rapidly throughout the neck and to other parts of the body, is very difficult to control.


    Symptoms

    Many patients with thyroid cancer have no symptoms. When they do occur, the first symptom is often a swelling or a small nodule (lump) on the front of the neck. Thyroid nodules are common and are usually painless. The vast majority of them are benign. Other less common symptoms of thyroid cancer are hoarseness of voice, difficulty in swallowing, swollen glands in the neck and difficulty in breathing.


    Treatment

    Once an accurate diagnosis is made, your doctor may recommend any of several treatment options, depending on the type, size, and extent of the tumor, and your general health.


    Surgery

    Surgery is the main treatment. Both papillary and follicular thyroid cancers are typically treated with complete removal of the lobe of the thyroid that harbors the cancer, in addition to the removal of most or all of the other side. Surgeon will take sufficient care to safeguard the recurrent laryngeal nerve (nerve that controls the movement of vocal cord) as well as parathyroid glands while removing the thyroid gland(Fig.3). Medullary carcinoma tend to spread to large numbers of lymph nodes very early on, and therefore require a much more aggressive operation than the more localized thyroid cancers, such as papillary and follicular thyroid cancer.


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    Fig.3. After removal of left lobe of thyroid. White arrow points at the recurrent laryngeal nerve in tracheo-oesophageal groove

    Sometimes the tumours are extensive when the patient seeks advice and the tumour is found invading the trachea (wind pipe). In these patients, the segment of trachea invaded by the tumour is resected safely along with the thyroid. After that, the cut ends of trachea are sutured together. Basically, surgery would involve resecting the structures involved by the tumour like windpipe and food pipe and then reconstructing the food pipe and windpipe. Removal of the lymph nodes in the neck, also called lymph node dissection, may be required if the tumor has spread or is at risk of spreading to the lymph nodes.


    Radioactive Iodine Therapy

    Thyroid cells are unique among all cells of the human body. They are the only cells that have the ability to absorb iodine. Iodine is required for thyroid cells to produce thyroid hormone, so they absorb it out of the bloodstream and concentrate it inside the cell. Most thyroid cancer cells retain this ability to absorb and concentrate iodine. This provides a perfect treatment strategy.


    Radioactive Iodine is given to the patient with thyroid cancer after their cancer has been removed. If there are any normal thyroid cells or any remaining thyroid cancer cells in the patient's body, then these cells will absorb and concentrate the radioactive iodine. Since all other cells of our bodies cannot absorb the radioactive iodine, they are unharmed. The thyroid cancer cells, however, will concentrate the radioactive iodine within themselves and the radioactivity destroys the cell from within without causing sickness, hair loss, nausea, diarrhea, or pain.


    Patients with medullary thyroid cancer and anaplastic cancer usually do not need iodine therapy because these cancers almost never absorb the radioactive iodine. Thyroid stimulating hormone (TSH), produced by the pituitary gland, helps thyroid tissue absorb iodine. However, thyroid hormone therapy can reduce TSH levels and decrease the effectiveness of RAI therapy. Patients are required to stop taking thyroid replacement pills for a period of 4 weeks prior to RAI therapy to increase TSH production. This results in hypothyroidism (low thyroid hormone), which causes a variety of symptoms such as fatigue, depression, weight gain, constipation, muscle aches, and reduced concentration.


    Now, we have an alternative method of raising TSH levels. A recombinant TSH may be given at the beginning of RAI therapy to raise TSH levels without having to stop taking thyroid replacement medication.


    Thyroid Hormone Therapy

    Thyroid hormone is essential for normal function of human body. After removal of thyroid gland, the thyroid hormone needs to be replaced in a tablet form. Thyroid hormone therapy also helps to combat the recurrence of thyroid cancer by suppressing the Thyroid-stimulating hormone (which can stimulate the growth of cancer cells) produced by the pituitary gland. Therefore patients are advised to take thyroid hormone pills after surgery.


    Thyroid cancer is a unique cancer which has good survival even if the disease has spread to other parts of the body. Main stay of treatment is surgery. Radioactive iodine therapy (RAI) destroys remnant thyroid tissue and is also used to treat the tumour cells that have spread to other parts of body. Thus RAI is beneficial in the post-operative management of high risk differentiated thyroid carcinoma.


    Thyroid Hormone Therapy

    1. Tumour invading trachea
    2. Tumour invading larynx & hypopharynx
    3. Retrosternal goitre


  • Facial Nerve Tumour

    Facial nerve neuromas are uncommon benign neoplasms of Schwann cells. They compose only 0.8% of all intrapetrous mass lesions. These tumors can arise from any segment of the nerve from the cerebellopontine angle to the extratemporal peripheral portion.


    For Doctors

    Case 1

    Case 2

    The clinical picture may vary depending upon the location of the tumour and their proximity to the middle or inner ear. Slowly progressive or sudden facial weakness, often preceded by facial twitching, is a common presenting complaint. However, one quarter of patients have normal facial nerve function. Depending on its site of origin, either proximal or distal to the geniculate ganglion, the patient may have sensorineural or conductive hearing loss. As for the diagnosis of facial nerve neuroma, high-resolution CT should be performed to visualize the facial canal followed by MRI to demonstrate the actual tumor.

    Surgical excision is the definitive treatment for facial nerve neuromas. If possible, the neuroma should be dissected of the nerve. These tumors usually must be resected with the affected portion of the nerve because they are diagnosed after facial palsy is present, or in advanced stages because of their insidious progression. Thus, the nerve should be repaired immediately by primary repair or by a nerve interposition graft. Regardless of the type of repair, patients can expect no better recovery than an eventual House-Brackmann Grade III palsy.

    The surgical approach should be chosen based on the anatomic location and extension of the tumor. A middle fossa craniotomy is used for patients with intracanalicular neuromas and useful hearing. The translabyrinthine or transpetrosal route is useful for patients without useful hearing and a facial nerve neuroma in the internal acoustic canal. Tumours involving tympanic segment or vertical mastoid segment, tympanomastoid approach is indicated to remove the tumour and to reconstruct the ossicular chain destroyed by the tumour.

  • Tracheal Stenosis

    The trachea, commonly called the windpipe, is the airway between the voice box and the lungs. When this airway narrows, the condition is known as tracheal stenosis, which restricts the ability to breathe normally.


    This condition may present from birth or acquired later in life. Most cases of tracheal stenosis develop as a result of prolonged breathing assistance known as intubation when a breathing tube is inserted into the trachea to help maintain breathing during a medical procedure — or from a tracheostomy, which is a surgery to create an opening in the neck to access the trachea. Sometimes it happens following external injury to the throat. Benign or malignant tumours arising in or outside the trachea can narrow the trachea.

    Patient will have difficulty in breathing with a high-pitched noise while breathing in. Sometimes mistaken as asthma. Tracheal stenosis should be suspected if the breathing difficulty does not respond to treatment. Laser or dilators can be used to widen the airway and these are temporary solutions only.

    A tracheal stent is a tube made out of metal or silicone that is placed in the collapsed airway to help keep it open. Tracheal Resection and Reconstruction — During a tracheal resection, the narrowed section of the trachea is removed and then the upper and lower sections of trachea are joined together. This is usually a very successful treatment for stenosis, with excellent long-term results.


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