Chandan Institute of ENT and Head & Neck Surgery
Dr. Priyanjal Gautam
Former Senior Resident Dept. of ENT& Head-Neck Surgery, KGMU, Lucknow
Former ENT Surgeon Balrampur Hospital, Lucknow
Microscopic Ear Surgery, Endoscopic Ear Surgery
Endoscopic Sinus Surgery, Septoplasty, Nasal Endoscopy, Nasal Fracture Repair, Endoscopic Electro/chemical cauterization for Epistaxis
Microlaryngeal Surgery, Tonsillectomy, Laryngoscopy
Head & Neck Surgery
Foreign body removal from Ear, Nose & Throat
Otorhinolaryngology at Chandan Hospital deals with conditions of the ear, nose, and throat (ENT) and related structures of the head and neck.
Otorhinolaryngology (also called otolaryngology and otolaryngology-head and neck surgery) is a surgical subspecialty within medicine that deals with conditions of the ear, nose, and throat (ENT) and related structures of the head and neck. Doctors who specialize in this area are called otorhinolaryngologists, otolaryngologists, ENT doctors, ENT surgeons, or head and neck surgeons.
Otology and neurotology
- BPPV – benign paroxysmal positional vertigo
- Labyrinthitis/Vestibular neuronitis
- Ménière's disease/Endolymphatic hydrops
- Perilymphatic fistula
- Acoustic neuroma
- Hearing loss
- Otitis externa – outer ear or ear canal inflammation
- Otitis media – middle ear inflammation
Perforated eardrum (hole in the eardrum due to infection, trauma, explosion or loud noise)
Rhinology includes nasal dysfunction and sinus diseases.
- Nasal obstruction
- Sinusitis – acute, chronic
- Environmental allergies
- Pituitary tumor
- Empty nose syndrome
- Severe or recurrent epistaxis
- Caustic ingestion
- Cricotracheal resection
- Laryngotracheal reconstruction
- Myringotomy and tubes
- Obstructive sleep apnea – pediatric
- Reinke's edema
- Vocal cord nodules and polyps
- Spasmodic dysphonia
- Cancer of the larynx
- Vocology – science and practice of voice habilitation
Head and neck cancer-
Head and neck cancer is a group of cancers that starts in the mouth, nose, throat, larynx, sinuses, or salivary glands. Symptoms for head and neck cancer may include a lump or sore that does not heal, a sore throat that does not go away, trouble swallowing, or a change in the voice. There may also be unusual bleeding, facial swelling, or trouble breathing.
About 75% of head and neck cancer is caused by the use of alcohol or tobacco. Other risk factors include betel quid, certain types of human papillomavirus, radiation exposure, certain workplace exposures, and Epstein-Barr virus. Head and neck cancers are most commonly of the squamous cell carcinoma type. The diagnosis is confirmed by tissue biopsy. The degree of spread may be determined by medical imaging and blood tests.
Not using tobacco or alcohol can reduce the risk for head and neck cancer. While screening in the general population does not appear to be useful, screening high risk groups by examination of the throat might be useful. Head and neck cancer often is curable if it is diagnosed early; however, outcomes are typically poor if it is diagnosed late. Treatment may include a combination of surgery, radiation therapy, chemotherapy, and targeted therapy. Following treatment of one head and neck cancer, people are at higher risk of a second cancer.
Together, they are the seventh most frequent cancer and the ninth-most-frequent cause of death from cancer.
SIGNS AND SYMPTOMS-
Throat cancer usually begins with symptoms that seem harmless enough, like an enlarged lymph node on the outside of the neck, a sore throat or a hoarse sounding voice. However, in the case of throat cancer, these conditions may persist and become chronic. There may be a lump or a sore in the throat or neck that does not heal or go away. There may be difficult or painful swallowing. Speaking may become difficult. There may be a persistent earache. Other possible but less common symptoms include some numbness or paralysis of the face muscles.
Presenting symptoms include :
- Mass in the neck
- Neck pain
- Bleeding from the mouth
- Sinus congestion, especially with nasopharyngeal carcinoma
- Bad breath
- Sore tongue
- Painless ulcer or sores in the mouth that do not heal
- White, red or dark patches in the mouth that will not go away
- Unusual bleeding or numbness in the mouth
- Lump in the lip, mouth or gums
- Enlarged lymph glands in the neck
- Slurring of speech (if the cancer is affecting the tongue)
- Hoarse voice which persists for more than six weeks
- Sore throat which persists for more than six weeks
- Difficulty swallowing food
- Change in diet or weight loss
Squamous cell cancers are common in the mouth, including the inner lip, tongue, floor of mouth, gingivae, and hard palate. Cancers of the mouth are strongly associated with tobacco use, especially use of chewing tobacco or "dip", as well as heavy alcohol use. Cancers of this region, particularly the tongue, are more frequently treated with surgery than are other head and neck cancers.
- Surgeries for oral cancers include
- Maxillectomy (can be done with or without orbital exenteration)
- Mandibulectomy (removal of the mandible or lower jaw or part of it)
- Glossectomy (tongue removal, can be total, hemi or partial)
- Radical neck dissection
- Mohs procedure
- Combinational e.g., glossectomy and laryngectomy done together.
The defect is typically covered/improved by using another part of the body and/or skin grafts and/or wearing a prosthesis.
Nasopharyngeal cancer arises in the nasopharynx, the region in which the nasal cavities and the Eustachian tubes connect with the upper part of the throat. While some nasopharyngeal cancers are biologically similar to the common HNSCC, "poorly differentiated" nasopharyngeal carcinoma is lymphoepithelioma, which is distinct in its epidemiology, biology, clinical behavior, and treatment, and is treated as a separate disease by many experts.
Oropharyngeal squamous cell carcinomas (OSCC) begins in the oropharynx (throat), the middle part of the throat that includes the soft palate, the base of the tongue, and the tonsils. Squamous cell cancers of the tonsils are more strongly associated with human papillomavirus infection than are cancers of other regions of the head and neck.
HPV-positive oropharyngeal cancer generally has a better outcomes than HPV-negative disease with a 54% better survival, but this advantage for HPV associated cancer applies only to oropharyngeal cancers.
People with oropharyngeal carcinomas are at high risk of developing second primary head and neck cancer.
The hypopharynx includes the pyriform sinuses, the posterior pharyngeal wall, and the postcricoid area. Tumors of the hypopharynx frequently have an advanced stage at diagnosis, and have the most adverse prognoses of pharyngeal tumors. They tend to metastasize early due to the extensive lymphatic network around the larynx.
Laryngeal cancer begins in the larynx or "voice box." Cancer may occur on the vocal folds themselves ("glottic" cancer), or on tissues above and below the true cords ("supraglottic" and "subglottic" cancers respectively). Laryngeal cancer is strongly associated with tobacco smoking.
Surgery can include laser excision of small vocal cord lesions, partial laryngectomy (removal of part of the larynx) or total laryngectomy (removal of the whole larynx). If the whole larynx has been removed the person is left with a permanent tracheostomy. Voice rehabilitation in such patients can be achieved through 3 important ways - esophageal speech, tracheoesophageal puncture or electrolarynx. One would likely require the help of intensive teaching and speech therapy and/or an electronic device.
Cancer of the trachea is a rare cancer which can be similar to head and neck cancer, and is sometimes classified as such.
Most tumors of the salivary glands differ from the common carcinomas of the head and neck in cause, histopathology, clinical presentation, and therapy. Other uncommon tumors arising in the head and neck include teratomas, adenocarcinomas, adenoid cystic carcinomas, and mucoepidermoid carcinomas. Rarer still are melanomas and lymphomas of the upper aerodigestive tract.
Alcohol and tobacco-
Around 75% of cases are caused by alcohol and tobacco use.
Tobacco smoke is one of the main risk factors for head and neck cancer and one of the most carcinogenic compounds in tobacco smoke is acrylonitrile.
However, cigarette smokers have a lifetime increased risk for head and neck cancers that is 5- to 25-fold increased over the general population. The ex-smoker's risk for squamous cell cancer of the head and neck begins to approach the risk in the general population twenty years after smoking cessation. The high prevalence of tobacco and alcohol use worldwide and the high association of these cancers with these substances makes them ideal targets for enhanced cancer prevention.
Smokeless tobacco is cause of oral and pharyngeal cancers (oropharyngeal cancer). Cigar smoking is an important risk factor for oral cancers as well.
Other environmental carcinogens suspected of being potential causes of head and neck cancer include occupational exposures such as nickel refining, exposure to textile fibers, and woodworking. Use of marijuana, especially while younger, is linked to an increase in squamous-cell carcinoma cases while other studies suggest use is not shown to be associated with oral squamous cell carcinoma, or associated with decreased squamous cell carcinoma.
Excessive consumption of eggs, processed meats, and red meat were associated with increased rates of cancer of the head and neck in one study, while consumption of raw and cooked vegetables seemed to be protective.
Vitamin E was not found to prevent the development of leukoplakia, the white plaques that are the precursor for carcinomas of the mucosal surfaces, in adult smokers. Another study examined a combination of Vitamin E and beta carotene in smokers with early-stage cancer of the oropharynx, and found a worse prognosisin the vitamin users.
Betel nut chewing is associated with an increased risk of squamous cell cancer of the head and neck.
Some head and neck cancers are caused by Human papillomavirus (HPV). In particular HPV16, is a causal factor for some head and neck squamous-cell carcinoma(HNSCC). Approximately 15 to 25% of HNSCC contain genomic DNA from HPV, and the association varies based on the site of the tumor, especially HPV-positive oropharyngeal cancer, with highest distribution in the tonsils, where HPV DNA is found in (45 to 67%) of the cases, less often in the hypopharynx (13%-25%), and least often in the oral cavity (12%-18%) and larynx (3%-7%).
Some experts estimate that while up to 50% of cancers of the tonsil may be infected with HPV, only 50% of these are likely to be caused by HPV (as opposed to the usual tobacco and alcohol causes). The role of HPV in the remaining 25-30% is not yet clear. Oral sex is not risk free and results in a significant proportion of HPV-related head and neck cancer.
Positive HPV16 status is associated with improved prognosis over HPV-negative OSCC.
HPV can induce tumor by several mechanisms:
- E6 and E7 oncogenic proteins.
- Disruption of tumor suppressor genes.
- High-level DNA amplifications, for example, oncogenes.
- Generating alternative nonfunctional transcripts.
- interchromosomal rearrangements.
- Distinct host genome methylation and expression patterns, produced even when virus isn't integrated into the host genome.
Induction of cancer can be associated for the expression of viral oncoproteins, the most important E6 and E7, or other mechanisms many of them run by the integration such as the generation of altered transcripts, disruption of tumor suppressors, high levels of DNA amplifications, interchromosomial rearrangements, or changes in DNA methylation patterns, the latter being able to find even when the virus is identified in episomes. E6 sequesters p53 to promote p53 degradation while pRb inhibits E7. p53 prevents cell growth when DNA is damaged by activating apoptosis and p21, a kinase that blocks the formation of cyclin D / Cdk4 avoiding pRb phosphorylation and thereby prevents release of E2F is a transcription factor required for activation of genes involved in cell proliferation. pRb remains bound to E2F while this action phosphorylated preventing activation of proliferation. Therefore, E6 and E7 act synergistically in triggering cell cycle progression and therefore uncontrolled proliferation by inactivating the p53 and Rb tumor suppressors.
Viral integration tends to occur in or near oncogenes or tumor suppressor genes and it is for this reason that the integration of the virus can greatly contribute to the development of tumor characteristics.
Epstein-Barr virus (EBV) infection is associated with nasopharyngeal cancer. Nasopharyngeal cancer occurs endemically in some countries of the Mediterranean and Asia, where EBV antibody titers can be measured to screen high-risk populations. Nasopharyngeal cancer has also been associated with consumption of salted fish, which may contain high levels of nitrites.
Gastroesophageal reflux disease
The presence of acid reflux disease (GERD - gastroesphogeal reflux disease) or larynx reflux disease can also be a major factor. Stomach acids that flow up through the esophagus can damage its lining and raise susceptibility to throat cancer.
Hematopoietic stem cell transplantation
Patients after hematopoietic stem cell transplantation (HSCT) are at a higher risk for oral squamous cell carcinoma. Post-HSCT oral cancer may have more aggressive behavior with poorer prognosis, when compared to oral cancer in non-HSCT patients. This effect is supposed to be owing to the continuous lifelong immunesuppression and chronic oral graft-versus-host disease.
Other possible causes
There are a wide variety of factors which can put someone at a heightened risk for throat cancer. Such factors include smoking or chewing tobacco or other things, such as gutkha, or paan, heavy alcohol consumption, poor diet resulting in vitamin deficiencies (worse if this is caused by heavy alcohol intake), weakened immune system, asbestos exposure, prolonged exposure to wood dust or paint fumes, exposure to petroleum industry chemicals, and being over the age of 55 years. Another risk factor includes the appearance of white patches or spots in the mouth, known as leukoplakia; in about ? of the cases this develops into cancer. Other heightened risks: breathing or inhaling silica
from cutting concrete, stone or cinder-blocks, especially in enclosed areas such as a warehouse, garage or basement.
A person usually presents to the physician complaining of one or more of the above symptoms. The person will typically undergo a needle biopsy of this lesion, and a histopathologic information is available, a multidisciplinary discussion of the optimal treatment strategy will be undertaken between the radiation oncologist, surgical oncologist, and medical oncologist.
Throat cancers are classified according to their histology or cell structure, and are commonly referred to by their location in the oral cavity and neck. This is because where the cancer appears in the throat affects the prognosis - some throat cancers are more aggressive than others depending upon their location. The stage at which the cancer is diagnosed is also a critical factor in the prognosis of throat cancer. Treatment guidelines recommend routine testing for the presence of HPV for all oropharyngeal squamous cell carcinoma tumours.
Squamous-cell carcinoma is a cancer of the squamous cell - a kind of epithelial cell found in both the skin and mucous membranes. It accounts for over 90% of all head and neck cancers, including more than 90% of throat cancer. Squamous cell carcinoma is most likely to appear in males over 40 years of age with a history of heavy alcohol use coupled with smoking.
The tumor marker Cyfra 21-1 may be useful in diagnosing squamous cell carcinoma of the head/neck (SCCHN).
Adenocarcinoma is a cancer of epithelial tissue that has glandular characteristics. Several head and neck cancers are adenocarcinomas (either of intestinal or non-intestinal cell-type).
Avoidance of recognised risk factors (as described above) is the single most effective form of prevention. Regular dental examinations may identify pre-cancerous lesions in the oral cavity.
When diagnosed early, oral, head and neck cancers can be treated more easily and the chances of survival increase tremendously.
Improvements in diagnosis and local management, as well as targeted therapy, have led to improvements in quality of life and survival for people with head and neck cancer.
After a histologic diagnosis has been established and tumor extent determined, the selection of appropriate treatment for a specific cancer depends on a complex array of variables, including tumor site, relative morbidity of various treatment options, concomitant health problems, social and logistic factors, previous primary tumors, and the person's preference. Treatment planning generally requires a multidisciplinary approach involving specialist surgeons and medical and radiation oncologists.
Surgical resection and radiation therapy are the mainstays of treatment for most head and neck cancers and remain the standard of care in most cases. For small primary cancers without regional metastases (stage I or II), wide surgical excision alone or curative radiation therapy alone is used. More extensive primary tumors, or those with regional metastases (stage III or IV), planned combinations of pre- or postoperative radiation and complete surgical excision are generally used. More recently, as historical survival and control rates are recognized as less than satisfactory, there has been an emphasis on the use of various induction or concomitant chemotherapy regimens.
Surgery as a treatment is frequently used in most types of head and neck cancer. Usually the goal is to remove the cancerous cells entirely. This can be particularly tricky if the cancer is near the larynx and can result in the person being unable to speak. Surgery is also commonly used to resect (remove) some or all of the cervical lymph nodes to prevent further spread of the disease.
CO2 laser surgery is also another form of treatment. Transoral laser microsurgery allows surgeons to remove tumors from the voice box with no external incisions. It also allows access to tumors that are not reachable with robotic surgery. During the surgery, surgeon and pathologist work together to assess the adequacy of excision ("margin status"), minimizing the amount of normal tissue removed or damaged. This technique helps give the person as much speech and swallowing function as possible after surgery.
Radiation mask used in treatment of throat cancer Radiation therapy is the most common form of treatment. There are different forms of radiation therapy, including 3D conformal radiation therapy, intensity-modulated radiation therapy, particle beam therapy and brachytherapy, which are commonly used in the treatments of cancers of the head and neck. Most people with head and neck cancer who are treated in the United States and Europe are treated with intensity-modulated radiation therapy using high energy photons. At higher doses, head and neck radiation is associated with thyroid dysfunction and pituitary axis dysfunction.
Chemotherapy in throat cancer is not generally used to cure the cancer as such. Instead, it is used to provide an inhospitable environment for metastases so that they will not establish in other parts of the body. Typical chemotherapy agents are a combination of paclitaxel and carboplatin. Cetuximab is also used in the treatment of throat cancer.
Docetaxel-based chemotherapy has shown a very good response in locally advanced head and neck cancer. Docetaxel is the only taxane approved by US FDA for head and neck cancer, in combination with cisplatin and fluorouracil for the induction treatment of inoperable, locally advanced squamous cell carcinoma of the head and neck.
While not specifically a chemotherapy, amifostine is often administered intravenously by a chemotherapy clinic prior to IMRT radiotherapy sessions. Amifostine protects the gums and salivary glands from the effects of radiation.
Photodynamic therapy may have promise in treating mucosal dysplasia and small head and neck tumors. Amphinex is giving good results in early clinical trials for treatment of advanced head and neck cancer.
Targeted therapy, according to the National Cancer Institute, is "a type of treatment that uses drugs or other substances, such as monoclonal antibodies, to identify and attack specific cancer cells without harming normal cells." Some targeted therapy used in squamous cell cancers of the head and neck include cetuximab, bevacizumab and erlotinib.
Although early-stage head and neck cancers (especially laryngeal and oral cavity) have high cure rates, up to 50% of people with head and neck cancer present with advanced disease. Cure rates decrease in locally advanced cases, whose probability of cure is inversely related to tumor size and even more so to the extent of regional node involvement.
Audiometry is a branch of audiology and the science of measuring hearing acuity for variations in sound intensity and pitch and for tonal purity, involving thresholds and differing frequencies. Typically, audiometric tests determine a subject's hearing levels with the help of an audiometer, but may also measure ability to discriminate between different sound intensities, recognize pitch, or distinguish speech from background noise. Acoustic reflex and otoacoustic emissions may also be measured. Results of audiometric tests are used to diagnose hearing loss or diseases of the ear, and often make use of an audiogram.
Auditory Brainstem Response-
The brainstem evoked response audiometry (BERA) is an objective neurophysiological method for the evaluation of the hearing threshold and diagnosing retrocochlear lesions. The aim of the study is to investigate the hearing level in children with suspected hearing loss or pathological speech development. The auditory brainstem response (ABR) is an auditory evoked potential extracted from ongoing electrical activity in the brain and recorded via electrodes placed on the scalp. The measured recording is a series of six to seven vertex positive waves of which I through V are evaluated. The ABR is considered an exogenous response because it is dependent upon external factors.
- It is an effective screening tool for evaluating cases of deafness due to retrocochlear pathology i.e. (Acoustic schwannoma). An abnormal BERA is an indication for MRI scan.
- Used in screening newborns for deafness
- Used for intraoperative monitoring of central and peripheral nervous system
- Monitoting patients in intensive care units
- Diagnosing suspected demyelinated disorders
BERA findings suggestive of retrocochlear pathology:
- Latency differences between interaural wave 5 (prolonged in cases of retrocochlear pathology)
- Waves I - V interaural latency differences - prolonged
- Absolute latency of wave V - prolonged
- Absence of brain stem response in the affected ear
BERA has 90% sensitivity and 80% specificity in identifying cases of acoustic schwannoma. The sensitivity increases in proportion to the size of the tumor.
Criteria for screening new born babies using BERA:
- Parental concern about hearing levels in their child
- Family history of hearing loss
- Pre and post natal infections
- Low birth weight babies
- Cranio facial deformities
- Head injury
- Persistent otitis media
- Exposure to ototoxic drugs