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People with neck lumps can be investigated by many different specialities as referrall patterns vary for neck lumps. What people do not realise is that often some specialities have a specific slant on investigations. For example endocrine clinics concentrate on thyroid lumps, haematology clinics are concerned about cervical lymph nodes and importantly lymphoma.

The key however is for investigation through a clinic that deals with all type of neck lumps, that offers a multi disciplinary (surgical, radiology and cytology) assesment. The Modern day Head and Neck Clinic has thus evolved and all types of neck lumps are seen as a result offering the patient rapid swift diagnoses by experts in the field.

A change in voice producing hoarseness is a common complaint but not one to be completely dismissed. Most of us develop some hoarseness in association with an uper respiratory tract infection however, if hoarseness persists past 4 weeks it does require further investigation.

In your general practice / family practice your local doctor can assess your upper throat. They can also assess your risk factors too. An urgent referral is sensible for patients with hoarseness who are smokers and high / regular alcohol intakers. These patients are more at risk of developing a laryngeal cancer and should be seen if suspicious by a surgeon who is part of a head and neck cancer centre.

Not all hoarseness is cancer, however, and there are other conditions that are benign such as nodules, vocal cord polyps and laryngititis that can be diagnosed at a ENT consultation rapidly. Occasionally an examination under anaesthetic is neccesary to look at the larynx under magnification and this is referred to as a microlaryngoscopy.

The submandibular gland is one of the major salivary glands, the other 2 being the parotid and sublingual salivary glands. Unfortunately stones can develop in the duct that drains the submandibular gland and as a result can block the outflow to the gland.

Classically the patient complains of pain under the jaw in association with eating food and this area may swell because of the obstruction to normal saliva into the mouth. The stones are radioopaque usually therefore, they can be demonstrated on a simple XRay or an Ultrasound.

Occasionally these stones may pass into the mouth through the duct opening under the tongue. If the stones are troublesome and located in the floor of mouth then they can be removed there. If the stones are based further back and symptomatic it is better to remove the duct as an excision of the submandibular gland.

The submandibular gland is situated under the jaw line and helps produce saliva along with the parotid, sublingual and minor salivary glands. It is intimately related to the facial artery and vein as well as to three nerves. These nerves include the marginal mandibular nerve which supplies the muscles of the face mainly the lower lip, the lingual nerve that carries sensation and special taste to the tongue and the hypoglossal nerve that carries innervations to muscle of the tongue. All these nerves are in the territory of the gland and should be protected at all times during the operation.

The submandibular gland is typically removed for classically 3 reasons:

·         Tumour- Both benign and malignant tumours may grow in the gland

·         Sialadenitis- This is inflammation of the gland that typically happens as a result of stasis of secretions or stones in the duct that drains the gland

·         Diagnostic- Occasionally we are uncertain as to why there is a gland enlargement and it is useful to be able to send it for pathological examination

Occasionally people present with tonsils that are different in size to me. This is an important scenario. Assymetric tonsils may be associated with a number of conditions but most patients, unless significantly unwell will come to a surgical removal.

The reason for this is because there is a risk of one of the tonsils being associated with a malignant pathology. However, some people end up with assymetric tonsils after recurrent infections (tonsillitis). Occasionally tumours from outside the tonsil push the tonsil into the oropharynx making it look assymetrical.

One of the indications for a tonsillectomy is clearly an assymetric tonsil for a histological diagnosis and this should be carried out fairly quickly to get the diagnosis.

Snoring in children is not an infrequent occurence. However if significant and also mixed with obstructive symptoms this can be very disconcerting for the parent.

Obstruction of the airway causes the snoring and this is most often due to enlarged tonsils and adenoids relative to the space in the oral cavity and the back of the nose. It is for this reason that this condition can be treated by removal of the tonsils and adenoids - adenotonsillectomy a combination of both adenoidectomy and tonsillectomy.

However this operation is not to be underestimated because it is associated with risks that include bleeding, pain and infection. Careful selection of patients is therefore important and most children who have this procedure are having significant obstruction patterns with the snoring (obstructive sleep apnea), failing to thrive and are often tired and lethargic.

What is Thyroidectomy?

Anatomy and Physiology

The thyroid gland is a structure that sits in the midline of the neck. It comprises of two lobes (left and right) joined by an isthmus. The gland produces a hormone that is integral in maintaining the body’s metabolic status amongst other things. The gland is supplied by at least 2 major arteries on either side and approximately 3 major veins on either side. Intimate to the thyroid gland is the trachea (windpipe), oesophagus (swallowing tube) and most importantly from an operative perspective the recurrent laryngeal nerve on both sides that supply the voice box musculature and are integral to voice production. In addition there are approximately 4 parathyroid gland associated with the thyroid gland that are important with the maintenance of calcium metabolism.

Indications for thyroidectomy

There are a number of indications to consider removal of the thyroid gland:

1. Malignancy or risk of malignancy (cancer)
2. Pressure symptoms related to the thyroid gland on the airway or the oesophagus
3. Uncontrolled thyrotoxicosis (overactivity of the thyroid gland) with medical treatment.
4. Cosmesis

It is important to investigate any lump or mass in the thyroid gland that sits in the midline of the neck. This typically is undertaken using an Ultrasound scan. It is not uncommon especially if there is a solitary lump in the thyroid gland for this to be further investigated using a fine needle aspirate cytology (FNAC).This involves a needle directed into the nodule and a few cells withdrawn from it which are then looked at microscopically. This often can be helpful but is dependant upon the person undertaking the FNAC and then the person who examines the cells microscopically.

Thyroidectomy

A number of operations are mentioned in the literature and can be confusing for the patient. In the present day most people are practicing the following operations.

Total thyroidectomy - Removing all of the thyroid tissue

Hemithyroidectomy - Removing one lobe of the thyroid and the isthmus.

Isthmusectomy - Removal of the section of thyroid that joins the two lobes (uncommonly used)

Surgery is undertaken using a general anaesthetic and a low neck incision is made. The thyroid gland is mobilized and Mr Vaz is trained in traditional techniques and the use of the harmonic scalpel to do this. The upper pole of the thyroid and the major vessels are divided and the recurrent laryngeal nerve is identified followed and preserved. If only a hemithyroidectomy is performed then the free lobe is separated from the isthmus and then sent for histology (microscopic examination).

Every patient will have a scar that typically is quite well hidden in the neck given time and only occasionally does this scar become prominent.

There is a risk to the recurrent laryngeal nerve and if this is damaged on one side then the voice becomes hoarse. If damaged on both sides then the vocal cords become immobile and can pose difficulties with breathing.

All operations carry the risk of bleeding and infection but thankfully this is low with thyroidectomy.

Occasionally with total thyroidectomy the calcium level may fall due to the removal of the above mentioned parathyroid glands. This may require long term replacement with Calcium.

With a total thyroidectomy the patient will be rendered hypothyroid (underfunctioning thyroid) and will require supplementation with thyroxine.

Most patients will require a drain in the neck postoperatively and this will be removed when the drainage is minimal. After this the patient may go home with some simple pain relief.

Anatomy and Physiology

The larynx and oesophagus are hidden areas to the general practitioner and therefore if someone has a complaint related to these areas it is difficult to visualize without the correct equipment.

The larynx is composed of three subsites the supraglottis (above the vocal cords) the glottis (the vocal folds) and the subglottis (below the vocal folds and is in continuity with the trachea). The larynx sits in front of the inlet of the oesophagus the so called hypopharynx (composed of the posterior pharyngeal wall, pyriform fossae and the post cricoid region).

With swallowing the larynx is protected by the epiglottis and false cords (from the supraglottis) and the closure of the vocal cords (glottis). Voice itself is created by air from the lungs being vibrated through the vocal folds and then articulated by the oral cavity, teeth and the paranasal areas.

Microlaryngoscopy and Oesophagoscopy

Occasionally it is necessary to visualize the oesophagus or the larynx to exclude or treat disease.

Oesophagoscopy is undertaken using a rigid oesophagus to carefully inspect areas of the hypopharynx and then the oesophagus lower.

Microlaryngoscopy uses a suspension frame and microscope with the benefits to the surgeon of the following

Bimanual handling of instruments

Depth of field

Magnification

Steroescopic vision

The ability to use other surgical implements such as the laser

Post-operatively the patient will have a sore throat and there is a risk of dental injury although this is small as is the risk of oesophageal perforation with an oesophagoscopy.

What is Tonsillitis?

Tonsillitis is an infection involving inflammation of the tonsils. There are two tonsils, situated on either side of the back of the throat and they form part of the body’s immune system. Like the rest of the immune system they contain special cells to trap and kill bacteria and viruses travelling through the body. When the main site of infection is within the tonsils they swell, become red and inflamed and may show a surface coating of white spots.

Tonsillitis is extremely common in children and young people but it can occur at any age. The characteristics of the disease are pain in the throat, trouble swallowing, fever, glandular enlargenment in the neck and in severe conditions, trismus (difficulty opening the mouth).

How do we contract Tonsillitis?

Whether due to viruses or bacteria, the infection is spread from person to person by airborne droplets, hand contact or kissing hence the term “kissing disease”. It is typically seen in young people but can on occasion effect the older adult, in these cases other possible causes need to be investigated.

There are many different individual viruses and bacteria that can potentially cause tonsillitis e.g. the Epstein-Barr virus, which causes glandular fever. The streptococcus group A is the most common cause of tonsillitis and sore throats - often known as ’strep throat’. The incubation period between picking up the infection and the disease breaking out is two to four days - sometimes it can be less. Tonsillitis is usually a self-limiting condition, i.e. it gets better without treatment, and generally there are no complications.

Rarely pus can collect just deep to the tonsil itself as a result of infection. This typically produces one sided throat discomfort severe difficulty swallowing and often trismus (difficulty opening the mouth). This is referred to as a “Quinsy” and requires medical intervention.

Signs and symptoms of tonsillitis

• Sore throat.
• Pain or discomfort when swallowing.
• Inability to swallow oral secretions.
• Tonsils may be coated or have a covering of white spots on them.
• Fever.
• Trismus (difficulty opening the mouth).
• Glands in the neck and at the angle of the jaw may be swollen and painful.
• Loss or change in voice.
• In children, tonsillitis may include symptoms that appear less focused on the throat, such as poor feeding, runny nose, ear pain, and a slight fever.

Treatment

1. Visit to the general practitioner (GP) who may commence a course of appropriate antibiotics and analgesia, with advice on oral intake, hygiene and to return if condition does not improve.
2. If the condition does not improve the GP should refer the patient either to a local ear, nose and throat (ENT) referral clinic or to accident and emergency (A&E) for review and treatment by an ENT specialist.
3. If there is an inability to swallow the oral secretions the patient will need to be admitted for a minimum of 24 hours for re-hydration, pain relief and intravenous (IV) antibiotics and reviewed on a daily basis.

Inpatient monitoring

• Visual examination of the tonsils.
• Blood tests, including the mono-spot test to rule out glandular fever.
• Insertion of a venflon for administration of fluids and IV antibiotics.
• Regular temperature check
• Routine observations including oxygen saturation monitoring.
• Analgesia for pain relief both regular and as required. This is also to assist in reducing any above normal temperature. Paracetamol is the most common one given.
• Aspiration if thought to be a quinsy by a trained practitioner.
• If oral medication is not suitable then intra-muscular (IM) or per rectum (PR) should be prescribed.
• Fan therapy if necessary but taking care not to reduce the pyrexial patients temperature too suddenly.
• Documentation of fluid and oral intake.
• Ongoing reviews of care delivered and appropriate alterations, depending on patient response and results of investigations undertaken.

Within 24 hours of analgesia, IV fluids and antibiotics the patient often makes a dramatic recovery and is suitable for discharge home.

The patient is ready for discharge when;

• They are apyrexial
• Are managing adequate oral fluids and diet.
• Their pain is controlled on oral analgesia.
• Any investigations are complete and show no other underlying condition that requires immediate investigation / treatment.

What happens when discharged?

• The patient will continue on a course of oral antibiotics, which must be completed otherwise the infection may return.
• A seven-day supply of appropriate analgesia will be prescribed.
• Verbal and written advice on areas such as dietary advice, when to return to work & refraining or cessation of smoking and oral hygiene should be given to the patient or carer once discharged.
• If the patient suffers from tonsillitis i.e. 3-4 episodes annually and it affects work/ school attendance, they should be offered a tonsillectomy and if agreed, added to the ENT waiting list.
• A copy of their discharge letter will be given to the patient and one posted to their GP.
• They should be advised if their symptoms return they should see their GP and if appropriate the GP will refer them back to the hospital.

Tonsillectomy

What is a Tonsillectomy?

Recurrent tonsillitis, quinsy, obstructive sleep patterns in children are all indications to remove the tonsils in the form of a tonsillectomy.
This procedure is performed under general anaesthetic. Post-operatively patients require regular analgesia and strongly encouraged to continue eating and drinking to speed up their post-operative recovery.
Having a tonsillectomy generally requires an overnight stay in hospital.

Gastro-oesophageal and Pharyngeal Reflux

The stomach produces acid that is corrosive and irritant. It is possible in some situations that the acid can reflux up into the oesophagus and even into the pharynx causing irritant symptoms of indigestion, burning, sore throat, hoarseness, coughing fits or a lump sensation in the throat.

There are things one can do to prevent the production and the reflux of the acid and thereby decrease the symptoms incurred by the patient. It is important to adhere to the advice given to decrease the reflux and its effect.

Medications

Over the counter antacids such as Rennies or gelusil or gaviscon a liquid preparation that prevents the acid irritation are available without prescription and can be of help. It is useful to take them before going to sleep but if symptoms are sever then it is useful to take them 30-45 mins before eating meals.
Proton pump inhibitors (PPI’s) are often prescribed in this situation by your GP or ENT surgeon. These should be taken as instructed by your doctor and instructions should be meticulously adhered to. PPI’s decrease the production of acid from the stomach and therefore decrease the effects of the acid when it refluxes.
Beware that some medications increase acid production such as anticholinergics, beta blockers, aspirin, theophylline and non steroidal anti-inflammatory drugs.
Also smoking increases acid production and it’s cessation is beneficial to the treatment reflux.

Weight

An increased Body mass index (BMI) above the normal level increases the chances of reflux. In this situation it is beneficial to try to lose weight to reach your target weight for height (BMI).

Posture

Acid reflux is not an uncommon symptom at night and is related to the fact that lying down allows for the easier refluxing of acidic contents. Elevating the head end of the bed between 4-10 inches will decrease the chances of reflux whilst not being too high so as to feel like you are sliding off the bed.

Diet

Smaller frequent meals are more conducive to avoiding reflux. The avoidance of irritating foods and drinks such as caffeine, chocolate, alcohol should be avoided. Also any specific foods that cause an individual heartburn should be avoided.

Vocal Hygiene Advice

Ensure adequate fluid intake of water / squashes (NOT coffee or tea which contain caffeine and will dry the throat). Approximately 8-10 drinks per day is appropriate.

Steam inhalations to be undertaken carefully if possible twice a day. This may include the steam in a shower. Also ensure humidification of your bedroom / living room (a bowl of water near the radiators).

Avoid smoky noisy environments where you will strain your voice whilst irritating it.

Eat regular balanced meals avoiding late night eating which is associated with indigestion.

Get adequate amounts of sleep as the larynx is a complex muscular organ that will under perform if you are tired.

Chewing gum or sucking ordinary pastilles can keep the mouth moist. Try to avoid medicated lozenges as they may numb the throat or the menthol can dry it.

Avoid aspirin gargles especially if having an acute infection.

Over the years tonsillectomy has had a bad press and this may be related to the fact that previously many people had their tonsils removed surgically without a correct indication.

As an ENT surgeon tonsillectomy is a satisfying operation as it is now performed with specific indications and the results therefore are gratifying for the surgeon and satisfying for the patient.

Clearly you will not die of tonsillitis but it is a huge problem to adults and children. However, when thinking about state services paying for operations, those that are deemed the most life saving will always be paid for and those deemed not serious may not be seen to be value for money (amongst the politicians). It is imperative to understand that tonsillectomy for reccurrent tonsillitis significantly improves an individuals lifestyle and whilst tonsillitis is not life threatening a tonsillectomy can significantly improve the quality of life of individuals.

It is not uncommon for people to come to me feeling a lump in the throat being present. It is a very common phenomenon that more often is benign but requires a careful ENT evaluation in the history and examination.

It is imperative to take a clear history in order to elicit high risk cancer association factors such as a smoking and or high alcohol intake. Safer aspects to the history include the ability to continue to eat and drink, no weight loss and if the lump sensation comes and goes.

It is essential that a thorough ENT examination is undertaken to visualise the upper aerodigestive tract and this can be undertaken using nasendoscopy. This allows a direct picture of the upper airway that cannot be undertaken by the patients General Practitioner. It is often for this reason that patients are referred for a specialist opinion.

A wide differential diagnosis exists for this symptom thankfully the majority of cases are related to a ‘globus’ phenomenon which may be related to reflux or stresses however, the high risk malignant conditions have to be excluded.

This is an exciting, developing area of Head and Neck Cancer treatment. Up until more recent years the mainstay for treatment of laryngeal cancer included options such as radiotherapy, total or partial laryngectomy (removal of the voice box) or a comination. The use of the laser has now added an extra option to the treatment arms available to a patient and as it does not require a major open operation can be very attractive to the patient.

The laser is a precise cutting tool that can be used with an operating microscope for magnification to accurately excise a cancer in the larynx. The benefit of this can be that a relatively simple procedure can be used to excise a laryngeal cancer in one or two visits to the operating theatre.

The patient must however, be carefully counselled with regards to the chances of success of resection and the complications that can ensue from the operation. Clearly removing part of the larynx can have an effect on voice production, if the cancer is small this effect is not often too significant but equally so for these cancers treatment with radiotherapy can also have an effect on voice. Which is better for voice is being investigated at the present time by a number of institutes around the world. Too much of a resection in the larynx may also affect the protective function of the voice box (increase the risk of aspiration) it is for this reason that discussion with a speech and language therapist is always prudent.

Whatever, the risks and benefits, transoral laser surgery is certainly an option of treatment for a laryngeal cancer that should not be overlooked and with the increasing development of robotic surgery this area of Head and Neck Cancer surgery could improve even further.

A change in voice is an important symptom. It can be important to an individual because of the fact that the person requires their voice for their job or they are a professional voice user. It can also be important because this symptom can herald the early onset of a laryngeal cancer. There is however, a wide mix of diagnoses related to this symptom.

If a change in voice persists greater than 4 weeks than it does warrant an ENT examination. An ENT surgeon will take a careful history and perform a thorough examination to elicit the cause of the change in voice See ENT Consultation.

It is important to bear in mind risk factors for cancer in the form of smoking and drinking and clearly patients with these and a change in voice should not delay in seeking a specialist opinion.