Surgical evaluation: The first step in a neck lump clinic is that the surgeon takes a careful history and examines the patient. Examination is not only of the neck lump but also other areas such as the oral cavity,  the back of the tongue, the tonsils and the larynx. The reason for this is that a neck lump may be related to any point of the upper aerodigestive tract and therefore if appropriate all of this aerodigestive tract should be examined.

Radiological Examination: Following the surgical evaluation the surgeon often sends the patient on for an ultrasound examination of the neck. It is critical when this investigation is undertaken that it is done so by an expert Head and Neck radiologist. In my clinic I work with dedicated radiologists who solely examine scans related to the Head and Neck area so their level of expertise assessing a neck lump is far and beyond that of an average radiologist. In addition if required the neck lump can be sampled for cells (fine needle aspiration cytology – FNAC) or sometimes formal pathology can be taken in the form of a tru-cut biopsy. If the neck lump is thought to be malignant, other tests can be made available on the day including CT scans and MRI scans. These are also reviewed by the same expert Head and Neck Radiologists.

Ultrasound guided fine needle aspiration

Cytology Examination: If an FNAC has been taken by the radiologist, then these cells need assessment. Whilst information can be got by looking at them immediately often more needs to be done with them before a formal assessment can be reported. Most importantly in my clinic these cells are looked at by world class cytopathologists allowing for as accurate a diagnosis as can be possible for the patient.

Microscopic appearance of a cancer from fine needle aspiration

Neck lump clinics run successfully not because of the surgeon alone but because of the Team that work together to make the diagnosis – Surgeon, Radiologist and Cytopathologist. Neck lump clinics exist both within the NHS and privately but whatever and wherever you go to it is essential that all three components exist and the level of expertise must be involved to come to an accurate and speedy diagnosis

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.

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.

This new type of physiologically correct surgery is called FESS (functional endoscopic sinus surgery) and is aimed at using the bodies normal sinus physiology and encouraging it to work better to help the sinuses drain. An endoscope is used to visualise within the nose and specially designed instruments can be used to open up the nasal anatomy.

Commonly a small vein or an area of irritation from nose picking is the cause. It is quite common practice is to use naseptin ointment in the first instance. If it is evidently a small vein easily seen then it is sensible to cauterise this. It is very unusual to have to cauterise a childs nose under general anaesthesia this is most often done in the out-patient setting.

At home basic first aid should be employed. If this fails a child should be taken to the emergency department for further treatment and investigation

1. Lean the patient forward and encourage them to spit out any blood. Blood swallowed is hidden and causes significant stomach irritation.

2. Pinch the lower soft partof the nose firmly in order to cause compresssion for approximately 10 mins. There is no point putting pressure on the non compressible bony part of the nose as this has no effect and the majority of bleeding occurs lower in the softer cartilaginous part of the nose.

3. Sometimes an icepack on the bridge of the nose or on the nape of the neck is of some benefit.

If these measure fail then the patient should go to the emergency department for further treatment.

If people try to remove wax themselves they can perforate their eardrum. It is for this reason that it should be removed by a trained practitioner. The safest method of wax removal is under direct vision with the microscope instrumentation and suction. This however, is difficult to do in the general practitioners setting and therefore often irrigation with a low pressure system is the correct technique in primary care. The days of old style syringing (high pressure) are gone due tothe risk of trauma to the ear canal and ear drum.

Wax is protective to us but if problematic due to narrow earcanals or excessive production this can be remedied easily in the out patient department usually with immediate relief. I would alway suggest that the wax is softened before visiting the out-patient setting to allow for an easier removal.

The perforation leads to an annoying conductve hearing loss perceived as a dulling of the hearing on that side. It is also is painful over the first few days in the affected ear with mucoid discharge.

It is important to have the ear examined properly. A hearing test should be undertaken as although a perforation can cause a decrease in the level of hearing more significant losses can occur as well if the ossicular chain (small bones that conduct sound in the middle ear) is damaged or if the inner ear is damaged.

I usually take a careful history, examine the ears and if it is a clean perforation advise the patient about appropriate ear care hygeine. I usually do not give oral antibiotics or ear drops if the perforation looks clean. Most traumatic peforations heal if given 6-8 weeks  and if they do not then an operation to close them may be considered - myringoplasty.

My choice of incision is a lazy S cervico facial incision. This is an incision that starts in the skin crease just in front of the ear, goes under the lobe and then heads down in a neck skin crease 2 finger breadths below the jaw line. This approach gives excellent access to find the facial nerve and to remove the tumour. Aesthetically this works very well too. Some people favour the face lift approach, where after the incision in front of the ear the incision is taken behind the ear and down the hair line. This does work and hides more of the incision but does limit access in some situations, especially when undertaking malignant workload.

The concept behind it in comparison with the traditional parotidectomy is that the facial nerve is not sought for prior to the removal of the tumour. The tumour is removed from the parotid gland alone, not with any parotid tissue.

The benefits include not so large an operation with potentially decreased complications

The problems associated with it include the incidental malignant tumour being found, poor margins/spillage on tumour removal (therefore risk of recurrence), the potential risk to a branch of the facial nerve deeper than the tumour.

I do not perform a extracapsular dissection. It is my feeling that this operation is suitable for very small localised superficial tumours. I also feel happier identifying the nerve at the start of the operation which anatomically is in a set position and I fell I perform a thourough operation for the patient with minimal risk of tumour spillage.

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.

Radiotherapy can be used as an adjunct to surgery for microscopic disease control but is of little benefit if it is the only upfront treatment of this salivary gland tumour.

Unfortunately patients with adenoid cystic carcinoma can develop distant metastasis many years after surgery typically in the lungs but can also have local nerve spread referred to as perineural invasion.

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

It is imperative that these lumps are seen by ENT surgeons that regularly investigate them, namely with an interest in Head and Neck cancer. This will ensure that the appropriate imaging is undertaken by radiologists who are used to reading scans of the head and neck and also used to taking samples for cytology (examination of aspirates of cells from a lump).

In my clinical practice both in the NHS and privateley I am lucky to be supported by a dedicated Head and Neck radiologist and cytologist, in order to give the patient a rapid diagnosis but with a degree of certainty from clinicians who deal with this every day. It is extremely helpful to the patient with a neck lump to attend one of these rapid access Head and Neck Lump clinics as if benign the patient is reassured immediately and if malignant there is no delay in organising the appropriate investigations.

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.

Shah grommets are a shorter lasting grommet that I often say to patients should stay in for approximateley 9-18 months.They are relatively atraumatic with few long term sequelae.

T tubes are inserted as a long term ventilation tube and are rarely, first line treatments and are often only placed after multiple short term grommet insertions. Unfortunately as a result of staying in place for significantly longer, when they extrude they can leave a perforation in the eardrum.

If warned preoperatively few patients have a problem from the phenomenon. However in some the problem is significant and extremeley problematic. Peole have advocated redivision of the nerves and interposition of soft tissue, the use of Botox or simply the use of antiperspirants in the area.

Freys syndrome occurs because of division of branches of the auricultemporal nerve which carry sympathetic nerve supply to sweat glands and parasympathetic fibres to the parotid. Rerouting causes the abnormal sweating on eating.

In the vast majority of patients the correct treatment is do nothing at all.

A chyle leak can occur at the time of a neck dissection clearing lymph nodes from the territory where the thoracic duct enters the venous system. A chyle leak has been incurred by every regularly practicing surgeon who undertakes neck dissection. More often than not it occurs when large nodes have to be cleared from the root of the neck where the duct is.

It can lead to a profuse loss of this milky fluid which is protein rich and patients can therefore become fluid depleted and malnourished rapidly with a high output fistula. Special feeds can be instituted to decrease output, pressure can also help decrease output. Surgical exploration can sometimes localise the leak. Occasionally thoracoscopic ligation of the duct in the chest can be undertaken.

This is a serious condition and is best avoided and when incurred should be carefully managed from a surgical and dietetic perspective.

When the cause is not known and especially if the hearing loss is sudden and is referred to as a sensori-neural hearing loss then this requires further investigation. Most ENT surgeons would want to perform a MRI of the Internal Auditory Meatus.This is an area in the skull through which the nerves of hearing and balance pass. Occasionally a benign swelling (acoustic neuroma) of one of theses nerves can cause pressure and lead to a assymetric and or sudden sensori-neural hearing loss. The chances of picking one of these up is rare but most surgeons do tend to investigate for this.

A number of types of thyroid cancer exist:

Papillary Cancer

Follicular Cancer

Medullary Cancer

Anaplastic cancer

Lymphoma

Papillary and follicular cancers are the most common cancers and thankfully usually have a better prognosis. Treatment has to be planned depending on the staging of the disease and may involve any of the following

Surgical treatment - Hemithyroidectomy,Total thyroidectomy, Neck Dissection

Oncological treatment -Radioactive Iodine, External beam radiotherapy

Medical treatment - Thyroxine

The majority of localised well differentiated cancers are treated with surgery in the form of thyroidectomy followed by radio iodine treatment and then thyroxine treatment. However, treatment has to be tailored to the individual.