Head Neck Oncosurgery is a specialized branch of cancer surgery, wherein malignancy arising from the mouth, throat, voice box, neck, face, nose and paranasal air sinuses, nasopharynx, skull base, ear canal and temporal bone, parotid and other salivary glands, thyroid and parathyroid glands, bones nerves and blood vessels of the neck, and skin of the head-neck area, including melanoma, are treated.
The super-specialty branch of has grown in importance because of two main reasons. 1. Head Neck Cancers usually, (but not always) arise due to tobacco and alcohol addiction, which is extremely common in our country from a very young age. As such, the affected patients are economically productive, young people who are in the prime of their lives. 2. These cancers arise from critical areas that affect talking, chewing, swallowing, voice, breathing and appearance, hence affecting the activities of daily living and quality of life. It takes great skill to remove the disease while maintaining near-normal functioning of vital systems of the body.
This highlights the need for a separate specialty, which can cater exclusively to cancers of the Head- Neck region. Our treatment philosophy is based on multi-disciplinary team approach emphasizing organ preservation and restoration of form and function by advanced reconstructive surgery, and rehabilitative services.
In the Head Neck Oncosurgery Department of Deenanath Mangeshkar, there is a team of doctors, supported by state-of-the-art infrastructure to screen, diagnose, evaluate, treat and rehabilitate such patients.
The range of Head Neck surgeries is very vast, and can be tailored to suit the disease stage and the patient’s requirement, and sometimes his/her choice. Special techniques such as endoscopic surgeries, microscopic laser surgeries, open conventional surgeries or robotic surgeries may be used to preserve functionally important aspects of voice, deglutition or cosmesis. Intricate, complex, open or closed surgeries are a part and parcel of Head Neck surgeries. The range of surgeries is too vast to be listed here. The following is a list of some of the common surgeries done by Head Neck Oncosurgeons.
The Department of Head Neck Oncosurgery possesses many precise equipments for the diagnosis and treatment of cancers of the head neck area, because the tumours are almost always hidden in nooks and corners not directly visible to the eye.
Most of them are tobacco induced. Tobacco in any form, whether smoked (cigarettes, bidi, cigar, pipe etc) or smokeless (gutkha, pudiya, gulmanjan, soorti, paan masala etc) is the strongest risk factor. The habit of stuffing paan in the mouth while working long hours, is a unique risk factor not found elsewhere in the world, except the Indian subcontinent. Each individual ingredient of paan, ie supari, tobacco, masala and kathha wrapped in betel leaves, is carcinogenic.
Alcohol acts as an independent risk factor, and also potentiates the effect of tobacco by making its carcinogens more soluble, which can then be easily absorbed by the lining of the oral cavity and oropharynx. Therefore, alcohol and tobacco together are synergistic, not additive, ie 1+1=11, not 2.
Since the entire lining of the mouth, throat, airway and foodpipe is affected by smoking and drinking, patients are susceptible to develop second primary tumours. These tumours which occur in another place after successful treatment of the first one.
a.Mouth (oral cavity) cancer
Symptoms - Symptoms of oral cancer may include red, white and/or a mixture of these colors in patches, a non-healing sore in the mouth or on the lips, bleeding, loose teeth, new denture problems, lumps or bumps on the neck.The lumps and bumps in the neck denote lymphnodes where the cancers spread. Pain is typically a late feature.
Evaluation - An evaluation should be done by individual head-and-neck specialists before any treatment begins. It is diagnosed by the patient’s history and physical examination. Usually endoscopies are not required, as oral cancers can be seen by simple torch-light examination. If any suspicious area is noted, a piece of tissue is taken(biopsy) to establish the diagnosis. This is usual done under local anesthesia in the minor OT. Imaging by CT scan, MRI and in rare cases, PET-CT will be requested to stage the tumour. Investigations to assess general fitness of the patient are done before a comprehensive decision can be taken to proceed with the treatment.
Treatment - The treatment for oral cancer is primarily surgical, if the tumour is operable and the patient is otherwise fit. Surgery can cause scars in face, neck, altered appearance, difficulty in chewing, maloccusion of teeth, change in speech quality. Reconstruction of surgical defect by local, regional and free flaps, is therefore an important part of treatment. After treatment and rehabilitation, regular checkups are needed to make sure that the oral cancer does not recur. Oral cancer treatment can result in significant lifestyle changes; most patients are advised to discuss lifestyle problems with professionals to help patients get the care they may need.
b.Throat cancers (oropharynx, hypopharynx including cervical oesophagus and larynx cancers)
What is throat cancer - Throat cancer is a layman’s term that usually refers to cancer of the back of the mouth(oropharynx), the voice box (larynx) and the food pipe (hypopharynx). The most common symptoms of throat cancer are non-specific, and not all patients exhibit all of them.
Oropharynx - The soft palate, uvula, tonsils, posterior pharyngeal wall and posterior one-third of tongue constitute the oropharynx. Foreign body sensation of the throat, persistent one-sided ear aches and difficulty in swallowing are some of the subtle symptoms which herald cancers of the oropharynx. They can grow unnoticed before being diagnosed, because these tumours lie in an area which is relatively spacious. A lump in the neck may be present, indicating that it has spread to the neck nodes, and may be the first indication that something is wrong.
Hypopharynx - This is that part of the throat that directs our food into the food-pipe without letting it enter the airway. It shares common boundary walls with the voice box (larynx), and at times it is difficult to discern where the tumour originally arose from. Throat discomfort, feeling of something caught in the throat, difficulty in swallowing certain foods, a mass or lump in the neck, change of voice, difficulty in breathing, cough, repeated throat clearing, unilateral earache and unintentional weight loss can be features of hypopharynx cancers.
Cervical oesophagus - It is the part of the food pipe that is present in the neck(main part is in the chest). Its cancers are very common in Indian women who are malnourished and anemic, starting in the form of oesophageal webs and progress to life threatening cancers. Sadly, it is also a preventable cancer. Cancers of the foodpipe present with difficulty in swallowing dry solid foods initially, later progressing to include semisolid and liquids too. There may be vomiting or regurgitation of food, unexplained weight loss, coughing or hoarseness and feeling of food stuck in the throat.
Larynx (voice box) - The voice box has three parts-- the supraglottis, the glottis and the subglottis, named as the part above the vocal cords, the vocal cords themselves, and the part below the vocal cords, which continue as the trachea. The symptoms of the supraglottis growths overlap with those of the hypopharynx. (see above). The glottis is the narrowest part of the airway, and any growth here typically cause persistent progressive hoarseness of voice and difficulty in breathing. Subglottis cancers usually do not occur in isolation, but spread from tumours above, and cause difficulty in breathing as their predominant symptom.
As stated above, these symptoms and signs are not diagnostic for throat cancer because many other problems can mimic the throat cancer. However, any person who develops these signs and symptoms and/or has risk factors for throat cancer should immediately discuss them with his or her physician.
Diagnosis of throat cancers - The person’s individual history (especially the presence of potential risk factors) and physical examination may provide a physician with enough suspicious information that the physician will consider throat cancer as a possible diagnosis.
Consequently, the physician may strongly suggest doing additional tests, like endoscopies to confirm or exclude the diagnosis. Endoscopes are narrow flexible or rigid tubes with a light and camera attachment, which are introduced through the nose or mouth. They can look into the various nooks and corners, and project a picture on a computer screen. Imaging tests such as CT and MRI give an indication of the depth and extent of disease, and hence the stage.
This is generally followed by a biopsy if any growth is seen. The biopsy is usually done under general anesthesia because the tumours are not easily accessible. If a neck node can be felt, it is easier and cheaper to perform an FNAC (fine needle aspiration cytology), rather than a formal biopsy. Either way, a tissue testing is a must to establish the diagnosis.
Tests for general fitness are then ordered, so that the patients ability to tolerate the treatment is assessed.
Treatment options for throat cancers - According to the current guidelines, the treatment of choice in these cases is non-surgical. Radiation and/or chemotherapy with modern drugs and technology, tailored to the individual, provide him/her with the best chance for a successful outcome. Treatment strives to preserve the patient’s ability to eat, speak, and live a normal healthy life.
The role of surgery is mostly limited to biopsy alone. Sometimes, it is possible that the growth can be entirely removed in the process, and can be considered complete treatment in itself. These surgeries come under the purview of minimally invasive surgeries, including transoral laser microsurgery, endoscopic and robotic surgeries. At the other extreme, the role of surgery is magnified in cases of advanced tumours, where primary surgery and reconstruction, followed by radiotherapy is the protocol. Surgery also has a major role in chemoradiation failures, where residual and recurrent tumours. This is known as salvage surgery, and always carries more morbidity in terms of wound healing and outcomes.
c.Nose & paranasal sinus cancers
Risk factors - Paranasal sinus and nasal cavity cancers are rare and form a very heterogenous group, among which squamous cell carcinoma is the commonest. Apart from smoking, the other common risk factor is exposure to certain chemicals or dust in the workplace.
Symptoms - There may be no signs or symptoms in the early stages. Signs and symptoms may appear as the tumor grows. Early signs resemble common cold, but once the tumour leaves the confines of the paranasal sinus, they involve critical areas very fast. Check with the doctor if you have:
Blocked sinuses that do not clear, or sinus pressure.
Headaches or pain in the sinus areas.
A runny nose.
A lump or sore inside the nose that does not heal.
A lump on the face or roof of the mouth.
Numbness or tingling in the face.
Swelling of the eyes, double vision, watering of the eyes or the eyes pointing in different directions.
Pain in the upper teeth, loose teeth, or dentures that no longer fit well.
Pain or pressure in the ear.
Diagnosis - Tests that examine the sinuses and nasal cavity are used to diagnose paranasal sinus and nasal cavity cancer. The following tests and procedures may be used:
Physical exam of the nose, face, and neck
Endoscopic examination of the nose
CT scan or MRI
Treatments -The treatment is usually surgical, depending on site, size, extension of the tumour and the general condition of the patient. Since they are usually advanced at the time of diagnosis, they require extensive reconstructions. The decision making regarding the eyeball is tough, specially if it is involved, but vision is intact. Extension to the brain also has to be evaluated carefully.
d.Thyroid tumours / cancer
Symptoms - The most common symptoms of thyroid tumour include a lump or nodule, that can be seen and felt in the front of the neck. The neck lump is typically long-standing, and slowly growing. Ominous features include change of voice, difficulty in swallowing, rapid growth, difficulty in breathing, appearance of neck nodes and bone pain.
Diagnosis - If a lump in the thyroid is found, the first investigations are FNAC and a neck imaging (ie ultrasound or contrast CT scan). These two investigations taken together can decide whether a thyroid lump is malignant or not. However, sometimes the only way to tell its nature is to surgically remove the involved lobe of the thyroid gland and send it for histopathological examination. This may occasionally be the definitive curative treatment too.
Treatment - Surgery is the of treatment for choice for majority of thyroid tumours. Chances of surgical complications like bleeding, recurrent laryngeal nerve paralysis and hypoparthyroidism will be explained in detail by the operating surgeon. The report after surgery dictates whether radio-iodine treatment is required or not.
Thyroid cancer is not a preventable disease, but it is certainly a tumour with better outcome than all other cancers of the head neck. The survival rate and prognosis of thyroid cancer depends upon the individual’s age, the size of the tumor, and whether or not there is metastasis to the neck nodes, chest or bones.
e.Salivary gland tumours / cancer
Three pairs of major salivary glands are situated on either side of the face below the ear (parotid), below the jaw line (submandibular) and in the floor of the mouth (sublingual). Minor salivary glands are scattered all over the mouth, nose, and other parts of the neck. Both benign and cancerous tumors can begin in any of the major or minor salivary glands. Most of the tumors (80%) that develop in the parotid gland, and about half of the tumors in the submandibular gland, are benign. Sublingual gland and minor salivary gland tumors are rare, but usually (80%) cancerous.
A lump on the face just below the ear lobule, slowly growing and painless
A lump just below the jawline
A discrete lump anywhere in the mouth or lips.
A deviation of angle of the mouth indicates a tumour involving the facial nerve.
Diagnosis - For a salivary gland tumor, a fine needle aspiration cytology FNAC is the preferred test for making a diagnosis. A surgical (incisional) biopsy should be avoided in almost every case. Imaging tests like MRI may be used to find out the extent of the tumour and to plan surgical removal.
Treatment - The treatment is primarily surgical. Complete removal of the tumour with preservation of the function of the nearby nerves is very important. The final histopathological report dictates the adjuvant treatment.
The nasopharynx is the part of the airway that lies behind the nose. Its tumours cause subtle symptoms like persistent blocked ear, minimal hearing loss, blocked nose, snoring and lightly stained sputum in the early stages, which is dismissed by patients and doctors alike as nothing more than a common cold. But, its first manifestation of disease is usually a neck mass, which needs to be thoroughly investigated with the help of endoscopy and biopsy. Its treatment is again non-surgical.
g.Metastasis of unknown origin(MUO)
This denotes a neck lump which is cancerous in nature, but it cannot be discovered from where the cancer has originated. The cancer may be too small to manifest, or it may have started in some hidden corner of the head neck area, the so called coffin-corners. It is the surgeon’s job to discover its origin by all means possible, including endoscopies, imaging and biopsies. Sometimes additional markers may also be required before labelling the metastasis as truly unknown.
h.Skin and scalp tumours
Skin tumours arise in areas of sun exposed regions, like the face and scalp. Common among these are squamous cell carcinoma and basal cell carcinoma. Although Indians are less prone to it than the western world, by virtue of our melanin-protected skin, it nevertheless is seen among people who have been exposed to the harsh UVrays of the sun for prolonged duration. Again, it is a preventable disease, by simply using umbrella, caps/hats and sunscreen. The diagnosis is clinical and by biopsy, and the treatment is surgical.
In contrast, melanoma skin cancers are more aggressive, and tend to spread fast. They have a poor prognosis. The treatment is surgical and immunological.
Lymphomas are tumours of the lymph nodes, and often present as a neck lump. The role of surgery is limited to performing a lymph node biopsy.
j.Rare tumours of head neck
There are many other varieties of tumours, each arising out of different cells which populate the head neck area. They are too extensive to enumerate, and need to be differentiated by a specialist. It is only after the receipt of the reports that the doctor can explain to the patient and the attenders about the site, stage and type of cancer and the treatment options available to him/her.