BIG C – HEAD & NECK AND THYROID CANCERS
NOT SEXY!!
Mr MAHESHWAR FRCS(ORL-HNS), FRCS (Ed), DLO
CONSULTANT E N T, LEAD HEAD & NECK , THYROID SURGEON
COLCHESTER HOSPITAL
BROOMFIELD HOSPITAL
SPRINGFIELD HOSPITAL
OAKS HOSPITAL
Boreham House, 14th November 2018
WHAT FACTORS DO WE NEED TO CONSIDER?
Onset and progress:
Duration of lump
Sudden / Gradual Onset
Rapid / Slow growing
Does it wax and wane?
Painful?
Does it vary with food intake?
WHAT FACTORS DO WE NEED TO CONSIDER?
Associated symptoms:
Hoarseness
Dysphagia / Odynophagia
Recurrent sore throats/ tonsillitis
? Associated with U.R.T.I
? Thyroid dysfunction
Oral ulceration/ tumours
‘Lymphoma-type’ symptoms
Loss of weight
Pyrexia
Night sweats
WHAT FACTORS DO WE NEED TO CONSIDER?
Associated symptoms:
Hoarseness
Dysphagia / Odynophagia
Recurrent sore throats/ tonsillitis
? Associated with U.R.T.I
? Thyroid dysfunction
Oral ulceration/ tumours
‘Lymphoma-type’ symptoms
Loss of weight
Pyrexia
Night sweats
Unexplained tooth mobility
Unexplained persistent unilateral nasal obstruction
associated with purulent / sanguinous discharge
COMMON HEAD & NECK PRESENTATIONS
NECK LUMPS DYSPAHGIA HOARSENESS
Laryngitis
Functional / Paralysis
LPR
Vocal nodules
Ca larynx
GORD
Benign strictures
Tumours
Pharyngeal pouch
Globus/ ‘FOSITT’
Salivary glands-
Infection/tumours
Malignancy-
carcinoma/lymphoma
Branchial & Thyroglossal cyst
Lymphadenopathy-
Reactive/Atypical TB
Thyroid lumps
PATIENT PRESENTS TO YOU WITH ‘RED FLAG’
SYMPTOMS…
Suspected Head & Neck (inc. Thyroid) Cancer Referral Form ALL FIELDS ARE MANDATORY
Please submit this form via Choose & Book ( If Choose & Book is not available – email this form to
twoweek.waitreferral.nhs.net )
Please do not use this form to refer children<16 years – these should be
referred direct to the Paediatric Consultant via the Switchboard (01206
747474) Guidance relating to Head & Neck Referrals is attached at Page 3
Patient required Support & Assistance Please indicate if any of the following are relevant to the patient
Please state specifically what mobility assistance is required for this patient.
Attachments from GP system accompanying 2ww referral
COMMON CAUSES OF NECK LUMPS
CONGENITAL: Lymphangiomas, Dermoids, Thyroglossal cysts,
Branchial cysts and fistulae, Thymic cyst, Haemangioma
ACQUIRED: Ranulas, Laryngoceles
LYMPH NODE ENLARGEMENT:
Infective: Bacterial, Viral, TB
Malignant Neck Masses:
Primary: Lymphomas- Hodgkins, Non-Hodgkins
Secondary: Metastatic from UADT, intrathoracic, intra abdominal
TUMOURS ARISING FROM
Submandibular salivary gland
Parotid salivary gland
Thyroid gland
CERVICAL LYMPHADENOPATHY
VIRAL FIRM + TENDER + WARM + ERYTHEMATOUS + GENERALIZED
INFECTIOUS MONONUCLEOSIS, ADENOVIRUS, HERPESVIRUS, COXSACKIEVIRUS
BACTERIAL FIRM + TENDER + WARM + ERYTHEMATOUS + LOCALIZED
STAPHYLOCOCCUS AUREUS, STREPTOCOCCUS PYOGENES
ATYPICAL MYCOBACTERIA – CLARITHROMYCIN / EXCISION NODE
MYCOBACTERIUM TUBERCULOSIS- COLD ABSCESS ; Rx- ATT
NOTE: OCCIPITAL NODES ARE PALPABLE IN 5% OF HEALTHY CHILDREN
NOTE: LEFT SUPRACLAVICULAR NODES =? INTRA ABDOMINAL MALIGNANCIES
CT SCAN HEAD, NECK CHEST, ABDOMEN, PELVIS
BLOOD TEST- INCLUDING LDH; NODE BIOPSY
THYROGLOSSAL DUCT CYSTS
75% PRESENT AS MIDLINE SWELLINGS; REST- AS FAR LATERAL AS TIP OF HYOID BONE
THE CYST ELEVATES ON PROTRUSION OF THE TONGUE
ASYMPTOMATIC MASSES IN THE MIDLINE OF THE NECK
65% < 30 YEARS; OCCASIONALLY SEEN IN 80-90 YEARS
WHEN INFECTED THE CYST ENLARGES AND AN ABSCESS MAY FORM. SPONTANEOUS
RUPTURE WITH SECONDARY SINUS TRACT FORMATION CAN ALSO OCCUR
SISTRUNK OPERATION: EXCISION OF THE CYST IN CONTINUITY WITH THE MID PORTION
OF THE BODY OF THE HYOID BONE AND A SMALL BLOCK OF MUSCLE AROUND THE
FORAMEN CECUM
RECURRENCE RATE
SIMPLE EXCISION = 50% SISTRUNK = 5%
SUBMANDIBULAR GLAND
SM GLAND ENLARGEMENT: IS MORE LIKELY DUE TO CHRONIC SIALADENITIS
STONE IN SUBMANDIBULAR DUCT IS MORE COMMON THAN IN THE PARTOID DUCT
WHY?- ANTI GRAVITY, VISCOUS SALIVA, DEBRIS IN THE F.O.M BLOCKS DUCT
X-RAY FLOOR OF MOUTH, U/S SCAN, FNAC
Rx- EXTRACTION OF STONE IF POSSIBLE; EXCISION OF GLAND
TUMOURS LESS LIKELY, MORE LIKELY TO BE MALIGNANT
PAROTID TUMOURS
NEOPLASMS OF THE SALIVARY GLANDS FORM ONLY 6% OF H & N NEOPLASMS
80% OF ALL SALIVARY NEOPLASMS ARE IN THE PAROTID. 70-80% ARE BENIGN
80% ARE IN THE SUPERFICIAL LOBE. 80% ARE PLEOMORPHIC ADENOMA
ASYMPTOMATIC MASS (81%); PAIN (12%) OR VII N PALSY (7%) ? MALIGNANCY
SITE OF TUMOUR- LOWER POLE, OR TAIL, AND IN THE SUPERFICIAL LOBE
FNAC, ULTRA SOUND SCAN
DO PAROTID TUMOURS NEED SURGERY ?
MALIGNANT DEGENERATION OCCURS IN 2-10% OF ADENOMAS
OBSERVED FOR LONG PERIODS, THEY GET BIGGER, MORE DIFFICULT TO OPERATE,
GREATER RISK OF VII NERVE INJURY
THYROID ADENOMAS ARE BENIGN : FOLLICULAR OR PAPILLARY
FOLLICULAR ADENOMAS ARE THE MOST COMMON
THYROID NODULES
RISK OF CARCINOMA IN THYROID NODULE IS GREATER IN:
MEN, RADIATION EXPOSURE (15-30% HIGHER RISK), INCREASED SIZE
NOTE: SIZE IS USED IN TUMOR STAGING AND IS HIGHLY PREDICTIVE OF OUTCOME
NODULAR DISEASES OF THYROID GLAND ~ 4-7% OF GENERAL POPULATION.
MOST THYROID NODULES ARE BENIGN HYPERPLASTIC LESIONS
BUT 5-20% OF THYROID NODULES ARE TRUE NEOPLASMS.
CARCINOMA IN AN ASYMPTOMATIC NODULE IS 3-30%
PALPABLE NODULAR DISEASE IS 6 TIMES > FEMALES COMPARED TO MALES
INVESTIGATIONS: 1. TFT 2. U/S SCAN 3. FNAC
BRANCHIAL CYST
COMMONEST CONGENITAL NECK MASS
2-3% OF CASES ARE BILATERAL
PRESENTS AS A SOLITARY, PAINLESS MASS IN THE NECK
H/O INTERMITTENT SWELLING & TENDERNESS OF THE LESION DURING U.R.T.I.
SURGICAL EXCISION IS DEFINITIVE TREATMENT
RECURRENCE IS < 3%, UNLESS PREVIOUS SURGERY OR RECURRENT
INFECTION HAS OCCURRED, IN WHICH CASE, IT MAY BE AS HIGH AS 20%
BEWARE THE ‘BRANCHIAL CYST’ IN AN ADULT- IT OCULD BE A METASTATIC
DEPOSIT FROM AN OROPHARYNGEAL CANCER
During this patient pathway we did not enquire
about his or her sexual habits
Can one’s sexual practice have an impact on neck cancer?
It very much does- a proportion of these neck lumps, particularly
“branchial cysts” are metastatic secondaries arising from a potential
oropharyngeal cancer ‘OPC’
OPCs are on the rise and often they are due to Human Papilloma Virus
In 1983, it was first suggested that HPV might be the agent for oral cancers
In 2007 the W.H.O stated HPV is a cause for oral cancers.
INCIDENCE OF OPSCC CANCERS IN THE U.K
1975-1999: No Change
1999 to 2006: 22% increase (1.87/100,000)
In men, same period: 51% increase (11/100,000)
H& N SCC 6th common cancer, 600,000 across the world
10% of these are Oropharyngeal cancers
90% of all OPC are in the tonsil and tongue base
In the U.K: last year, 6200 oral cancers; 2/3 were in men
INCIDENCE
INCIDENCE
Increase in incidence noted despite reduction in smoking: HPV positive OPC on the increase.
In 1980s, 16% of OPC were HPV +; last decade more than 70%
Increased incidence noted in most western countries- Europe/ USA
HPV accounts for 80% of Tonsil cancers in Sweden; 60% in the U.S
Cervical cancer has declined due to screening over time but OPC has
increased for which there is no screening currently
70% of cervical cancers and 70% of OPC are HPV +
7% of Americans have oral HPV (16 million), but less than 15,000 will get
HPV positive OPC
8 out of 10 Britons will contract HPV during their life time- mostly
harmless
PREVALANCE
>120 HPV types, about 40 of which infect anogenital region. About
15 of these are carcinogenic, of which HPV 16 is the most
prevalent and carcinogenic
Cancer typically takes 20 to 30 years to develop after exposure to
HPV
Risk factors are
high number of sexual partners (25% increase >= 6 partners)
history of oral-genital sex, (125% >= 4 partners)
history of anal–oral sex,
female partner had a history of either an abnormal Pap smear or
a cervical dysplasia
among men, decreasing age at first intercourse and history of
genital warts.
Boys are more prone to get throat cancer from oral sex because the virus
is found in higher concentrations in the female genital tract.
SEXUAL HISTORY
Carriers of HPV 16 or 18 can show no symptoms for many years before
the cancer develops, so it is entirely possible to have just one sexual
partner and contract the virus without even knowing it.
Since 2008, British girls between the ages of 12 and 13 have been given 3
shots of HPV vaccine, Cervarix, which protects against HPV 16 and 18.
It needs to be administered as early as possible before the onset of sexual
activity as exposure to any strain of the virus renders the vaccine
ineffective.
There is no law to ensure every girl gets the vaccine, 70 to 80 per cent is
the estimated uptake
VACCINE
Girls and women 13 through 26 who have not been vaccinated should
also get the shots.
About 95% of the HPV-positive oropharynx cancers are caused by
HPV16, a strain targeted by Gardasil and Cervarix
VACCINE
Until receiving a full government recommendation, many insurance
companies would refrain from covering the cost of the vaccine, like
many do for the vaccination of girls. At $120 per dose, this would cost
$360 for the 3 shots. In the US, parents are already paying privately to
get their sons vaccinated
VACCINE
Boys 11 years and above should get the Gardasil vaccine to protect
them against HPV infections, which can cause genital warts as well as
oral, penile and anal cancers, although this protection is incomplete.
Vaccinating boys is also likely to protect women indirectly by
preventing them from catching the viruses in the first place, i.e,
improving herd immunity.
Majority of HPV infections have no symptoms and often do not
require treatment, but a small percentage of those who contract high-
risk strains may go on to develop cancer. OPC is still relatively
uncommon and most people who contract HPV probably wouldn't
develop throat cancer
We used to think of oropharyngeal cancer as one cancer, and now we
know the disease is comprised of two biologically and epidemiologically
distinct cancers.
CONCLUSION
HEAD & NECK CANCERS
LARYNGEAL CANCERS
SUPRAGLOTTIC
GLOTTIC
EARLY:
RADIOTHERAPY
LASER
LATE:
SURGERY- TOTAL LARYNGECTOMY + NECK DISS
WITH POST OPERATIVE RADIOTHERAPY
PHARYNGEAL CANCERS
PYRIFORM FOSSA
POST CRICOID
UPPER OESOPHAGUS
EARLY:
LOCAL RESECTION
RADIOTHERAPY
LATE:
TOTAL LARYNGO PHARYNGECTOMY + NECK DISS
HEAD & NECK CANCERS
ORAL & OROPHARYNGEAL CANCERS
EARLY:
RADIOTHERAPY
LOCAL EXCISION
LATE:
WIDE EXCISION & RECON. WITH FLAPS
POST-OP RADIOTHERAPY
CHEMORADIOTHERAPY
HEAD & NECK CANCERS
NODAL STAGING
NX: NOT ASSESSABLE
N0: NO CLINICALLY POSITIVE NODES
N1: SINGLE CLINICALLY POSITIVE IPSILATERAL NODE < 3 CM
N2: 3 CM - 6 CM
N2A: SINGLE, IPSILATERAL
N2B: MULTIPLE IPSILATERAL, NONE GREATER THAN 6 CMS
N2C: BILATERAL OR CONTRALATERL NODE/S < 6 CMS
N3: > 6 CM
LPR – LARYNGO PHARYNGEAL
REFLUX
‘ Silent Reflux’
WHAT IS REFLUX?
GORD
LPR
WHAT CAUSES DAMAGE?
pH?
pepsin?
active pepsin
severity and duration
GORD chronic disease
supine reflux
oesophagitis
heartburn / regurgitation
abnormal acid clearance
diagnose by endoscopy
low dose PPI
LPR in <3%
LPR
often intermittent
upright reflux
oesophagitis only 30%
heartburn / regurgitation only 35%
normal acid clearance
diagnose by pH monitoring
high dose PPI for 6/12
GORD in 20-30%
LPR HISTORY
Smoking / Drinking
Medication: which drug, dosage, frequency, timing,
duration
Diet / Fizzy drinks / Fruit juice
Occupation / voice use
LPR SYMPTOMS
dysphonia
dysphagia (“pseudodysphagia”)
globus
throat clearing / tickle in throat
cough / choking
thick mucus in throat “PND” or “Catarrh”
Laryngospasm / cough syncope
sore throat
FIRST LINE TREATMENT TRIAD
Diet and Lifestyle advice
Alginate
PPI
Gaviscon Advance
10ml tds
+
nocte
PPI low dose bd
+
Gaviscon Advance
10ml at night
PPI high dose bd
+
Gaviscon Advance
10ml at night
MILD MODERATE SEVERE
Advice sheet
LPR Treatment
Reassess
3 months
DIET AND LIFESTYLE
Advice sheet
Food: avoid high fat foods
Drink: avoid caffeine, spirits, white wine, fizzy and/or highly acidic drinks
Raising head of bed / lying on left
Bend from knees
Clothing
Exercise
Weight
Smoking
Chewing gum
Steward et al Otolaryngol Head Neck Surg 2004;131:342-50
PPI (PROTON PUMP INHIBITOR)
Medication which suppresses secretion of HCL into the stomach
Designed for the treatment of GORD so treatment protocol is adapted for treatment of LPR. Twice daily dose required for LPR.
MUST BE ½ HR BEFORE MEALS
Aiming for 12 hour separation between 2 PPI doses so patient gets 24 hr coverage.
PPI DOSAGES ( BD 1/2 HR BEFORE MEALS)
PPI Full Half
Rabeprazole (Pariet) 20mg 10mg
Lansoprazole (Zoton) 30mg 15mg
Pantoprazole (Protium) 40mg 20mg
Omeprazole (Losec) 40mg 20mg
(10mg)
Esomeprazole (Nexium) 40mg 20mg
It all started in 2004 when I looked like this …….
And with all this ‘FOSIT’ …….
Consultant E.N.T, Head & Neck and Thyroid Surgeon
Colchester General Hospital
Broomfield Hospital
Oaks Hospital
Springfield Hospital
Mr Maheshwar
Mobile: 07791266523
