Head / Neck

A.  Snoring/ Sleep Apnea

iStock_000013453689_MediumCauses:

In adults, blockage may be from problems of from deviated nose septum, large inferior turbinates, redundant/ low lying soft palate and medialized posterior tonsil pillars, poor pharyngeal tone, obesity, tongue base collapse/ hypertrophy, laryngeal collapse and mandibular retrognathia. More rarely from a central brain pathology.

Importance:

Snoring may disturb your partner but without health concerns, as in simple snoring. However, it needs to be evaluated to exclude central or obstructive sleep apnea (OSA) and upper airway resistance syndrome, where there is blood oxygen deprivation and increased work of breathing leading to disturbed sleep and daytime sleepiness. Long term, oxygen deprivation may increase the risks of heart, blood pressure, hormonal, neurological and memory problems.

Investigations offered:

  • Flexible nasolaryngoendoscopy to determine the sites of obstruction.
  • Sleep study (home or hospital based) to determine the severity and pattern of obstructive/ central sleep apnea.

Treatment offered:

  • Non surgical treatment targeted to the obesity, allergic rhinitis and sleep habits/ position
  • Central apnea will prompt a referral to respiratory/ neurology colleagues
  • Continuous positive airway pressure mask (CPAP) is highly effective for OSA. Correct use of and maintenance of the mask and a clear nasal airway is important
  • Dental guards during sleep to advance the jaw
  • First line surgery addresses the nose and oral cavity sites of blockage
  • Second line surgery addresses the soft palate, base of tongue and larynx sites of blockage
  • Simple surgeries like radiofrequency reduction of the inferior turbinates and elevation of the soft palate are possible in clinic, but more invasive surgeries like more extensive uvulopharyngopalatoplasty, base of tongue reduction would require general anaesthesia
  • Third line surgeries like tongue base and mandibular advancement surgeries

 

B.  Head and Neck Lumps

Thyroid problemsCauses:

Some common lumps:

  • Salivary gland lumps – These could be benign or cancerous tumors, or swelling due to acute or chronic infections or stones blocking the salivary ducts. The main glands are the parotid, submandibular and sublingual glands.
  • Neck lymph nodes – These could be benign or cancerous nodes, and due to infections, systemic disorders and blood disorders. All nodes should be further evaluated if they are increasing in size and numbers, last more than 3 weeks, are fixed to the skin or ulcerate.
  • Thyroid lumps – These can be benign or cancerous, a Multinodular Goitre or generalised swelling eg in Grave’s Disease. May be associated with thyroid hormone disorders.
  • Thyroglossal cyst – This is a congenital cyst that is usually sited in the midline of the upper part of the neck, and moves with swallowing. Cancerous change is possible but rare.
  • Branchial cyst – This is a congenital cyst that is usually sited at the upper half of the lateral neck.
  • Ranula – This usually presents as a floor of mouth and sometimes below the chin soft cystic swelling. Due to trapping of salivary mucus.

Rarer lumps include:

  • Hemangioma and Lymphangioma – These are vascular and lymphatic malformations, filled with blood or lymphatic fluid.
  • First branchial cysts/ sinuses – These present as lumps/ openings around the ear region or angle of the jaw. The sinus tract is often complexly related to facial nerve and vessels in the head and neck.
  • Parathyroid, neck nerve and vessel tumors

Importance:

Besides presenting as a lump, head and neck tumors may present as blood stained sputum, nose bleed, hearing loss, ringing in the ear and ear block. The lumps may swell with infections and reduce in size in between episodes. Destruction of structures closely related in the head and neck region results in various problems with breathing, swallowing, eating, voice, dentition, cosmesis and bleeding. Seeking evaluation and treatment as early as possible is critical for ensuring the best outcomes for cancer cases. Investigations:

  • Blood tests for screening of some cancers like nasopharyngeal carcinoma (NPC), especially with family history of NPC
  • Blood tests for blood disorders
  • Fine needle aspiration cytology (FNAC) in the clinic to differentiate benign and cancer pathology, with or without ultrasound guidance
  • Ultrasound scans are useful for neck lumps to determine size, numbers, and suggest if the tumor is likely to be benign or cancerous.
  • Excision biopsy under local or general anaesthesia for definitive histopathology and diagnosis
  • CT scan, MRI scans to determine complexity of anatomy, extent of disease, spread and recurrence

Treatments:

  • Excision of the lump tailored to specific diagnosis. For non-cancer lumps, the prognosis is good and there is significantly less risk to other structures in the head and neck
  • For cancer lumps that are not discovered early or contained, surrounding head and neck structures often need to be removed enbloc to reduce the risk of recurrence. Where possible, efforts are made to preserve important structures to allow for swallowing, voice, breathing without a tracheotomy and cosmesis
  • Various chemotherapy and radiotherapy options may be required additionally, for optimal tumor clearance and to reduce the risk of recurrence

 

C.  Hoarse voice

Photo 35 Vocal cord NodulesCauses:

Most commonly due to infection, haemorrhage into or allergic reaction of the vocal cords (voice box) if of sudden onset. May be from excessive strenuous voice use, smoking, hypothyroidism and drugs leading to polyps, cysts and nodules. May be cancer change in the larynx or invasion from surrounding thyroid or other neck region tumors. Trauma to the larynx may dislocate the laryngeal cartilages. Post surgery or radiation therapy for cancer or tumors in the head and neck and pathology in the chest.

Importance:

The voice may become raspy, harsh, of different pitch and low volume. Hoarseness lasting more than 3 weeks requires evaluation to exclude more sinister causes.

Investigations offered:

  • Throat examination
  • Flexible nasolaryngoendoscopy in the clinic with patient voicing
  • Biopsy via endoscopic non-open methods under general anesthesia (Endoscopic Laryngeal Microscopic Surgery)
  • CT scan and MRI radiology of the base of skull, neck and chest

Treatments offered:

  • Observation for spontaneous recovery in acute infections.
  • Voice rest. Avoid voice overuse of wrong use. Voice training and rehabilitation by speech and swallow therapist.
  • Stop smoking. Better control of gastroesophageal reflux (eg avoid spicy, sour and oily food and caffeine).
  • Medications for cough, gastroesophageal reflux and allergies as appropriate.
  • Surgery for benign nodules, cysts and polyps
  • Surgery for trauma to the larynx/ vocal cords
  • Surgery for cancer of the larynx would require further investigations for extent of involvement and spread. Endoscopic, laser or open surgery, with or without chemotherapy and radiation therapy.

 

D.  Feeding/ Swallowing Disorder

Causes:

  • The problems can affect the oral, pharyngeal or esophageal phase.
  • Due to poor dentition, neurological conditions (eg stroke, vocal cord, brain and spinal cord injury, Parkinson’s disease, sclerosis, Alzheimer’s disease) and head and neck pathologies (mouth, throat, esophagus cancers, injury and surgery).

Importance:

  • There may be coughing/ gurgling/ increased effort and time/ drooling when eating and drinking. There may be recurrent lung infections from aspiration, weight loss and dehydration.

Investigations:

Work with gastroenterologists, swallow pathologists, physiotherapists.

  • Observe feeding to see the patient’s posture, behavior, and oral movements during eating and drinking.
  • Modified barium swallow
  • Swallowing process viewed on X-ray (Videofluoroscopy)
  • Nasolaryngoendoscopy when patient feeds for phase and types of food affected

Treatments:

  • Medication for acid reflux
  • Address the underlying cause
  • Swallow therapy to improve feeding coordination and acceptance of different food
  • Direct feeding therapy designed to meet individual needs, eg postural changes
  • Nutritional changes (optimize calories and types of food)

 

E.  Stridor

Photo 36 Airway papillomatosisCauses:

Include tumor, papillomatosis of the larynx and trachea, compression of the trachea by neck masses like thyroid lumps, base of skull tumors affecting the vagal nerve, strokes, vagal nerve pathology that impair mobility of the vocal cords, swelling and inflammation of the vocal cords due to infection, chemotherapy, drugs, trauma and idiopathic causes.

Importance:

Stridor is noisy breathing arising from blocked airway at the level of the voice box and trachea. When significant, there is risk of acute oxygen lack, respiratory distress leading to cardiac arrest and death. Feeding, swallowing, voice and lung function are often concurrently affected.

Investigations:

  • Nasolaryngoendoscopy in the clinic
  • Xray neck, Chest Xray, CT scan and MRI
  • Microlaryngobronchoscopy (MLB) under GA to evaluate the lower trachea and lung airways, and for biopsy
  • Feeding and swallowing evaluation
  • Voice evaluation
  • Lung function evaluation

Treatment:

  • Emergency medications
  • Emergency intubation with ICU care
  • Surgical tracheotomy
  • Treatment tailored to the underlying cause (eg laser or microdebrider removal of papillomatosis, lateralisation of the vocal cords, repositioning of acute dislocation of vocal cord cartilages, cardiothoracic surgery for cardiac and thoracic trachea pathology)
  • In subglottic stenosis and trachea involvement, balloon dilatation, plastic and wire stents, anterior and posterior rib graft trachea reconstruction, cricotracheal resection, segmental trachea resection and tracheoplasty are some options available to avoid permanent tracheotomy
  • In cancers of the larynx, preservation techniques for voice and swallowing is attempted where possible.