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Head & Neck

Swallowing Diffculties

Through the links on the left we hope you will find useful information on some common conditions affecting the Head and Neck.

If dysphagia is present for any length of time or if it is accompanied by any of the following symptoms it is important to seek an ENT referral to ascertain the cause.

  • Weight loss
  • A lump in the neck or glands
  • Breathing difficulties
  • Regurgitation of food or drink
  • Hoarseness or voice difficulties

Submandibular Gland

This is one of the salivary glands that is situated under your jaw. Approximately 60% of the lumps in the submandibular gland are benign (not cancerous) and the rest can be cancerous. They occur as a result of overgrowth of the cells in the gland. Swelling can also arise, as a result of stones blocking the duct draining the gland. This often leads to infection and pain, restricting routine activity.

Investigation and treatment of submandibular lumps

During the initial consultation a detailed history is taken and a thorough assessment is carried out. This is usually followed by an ultrasound scan performed by our radiologist. During the ultrasound scan test a needle may be inserted into the gland to collect a sample of cells from the lump. These cells are then analysed under the microscope by the pathologist to assess the nature of the swelling. If stones are suspected X-rays are often performed first. Occasionally, other tests such as a CT scan, MRI scan or a sialogram may be required.

Treatment depends on the nature of the lump and the results of the tests. Removal of the swelling is usually recommended because the exact nature of the swelling is often ascertained after removal and analysis of the whole lump. Additionally, if the lumps are not removed, the majority of them will grow further, often becoming cosmetically unacceptable and may even turn cancerous. Large, cancerous lumps are difficult to remove and complicate surgery.

Submandibular gland surgery explained

The operation involves removing the whole of the gland. This is performed under general anaesthetic, which means that you will be asleep throughout the procedure. An incision is made well below the jaw line in the neck. The cut is usually placed along a skin crease so that over a period of time the scar is barely visible. At the end of the operation, a drain (plastic tube) is placed through the skin in order to prevent any blood or fluid collecting under the skin. This tube is usually removed the next day when you will be able to go home.

Potential complications

Weakness of the corner of the mouth

The nerve that moves the corner of the mouth lies in close proximity to the gland and is at risk during surgery. Damage to this nerve results in weakness of the corner of the mouth. This deformity is more obvious when one smiles. One may also experience drooling of saliva on the affected side. In most cases, the nerve works normally after surgery, although occasionally (about 10% of cases) you may notice a temporary weakness of the corner of the mouth. This usually lasts for a few weeks before full recovery takes place.

Numbness and stiffness of the neck

Stiffness and numbness of the neck are common and this resolves spontaneously over a period of few months. Use of moisturisers and creams to supple the scar and skin is very useful.

Blood and saliva collection

Blood and/or saliva can collect beneath the skin. Occasionally, it may be necessary to return to the operating theatre to remove this clot. Usually, this collection is minor and our body mops it away completely.

Altered taste

The nerve, which helps us appreciate taste, runs very close to the duct of the submandibular gland. This nerve may get bruised or damaged resulting in altered taste in the mouth. Usually, the altered taste sensation recovers fully over a period of few weeks.

Weakness of the tongue

Very rarely, the nerve that moves the tongue may get bruised/damaged during surgery. Usually this recovers fully over a period of a few weeks.

Parotid Gland and Parotid Surgery

This is the gland that is affected by Mumps. Lumps (tumours) in the parotid gland are common and are seen in all age groups. They are the result of an abnormal growth of cells within the gland, though the exact reasons for this are not clear. The vast majority (approximately 80%) of these tumours are not cancerous and are called benign tumours. Rarely, however, some tumours can be cancerous.

Other common causes of lumps in the gland include stones in the duct of the gland, which often block the flow of saliva. This blockage often gives rise to infections, which can sometimes be troublesome. Whatever the cause, however, it is prudent to establish the EXACT NATURE of the swelling.

Investigations and treatment of parotid problems

During the initial consultation, a detailed history is taken and also an assessment of your problem. This is usually followed by an ultrasound scan, which is performed by an expert radiologist. During the ultrasound scan, a needle may be inserted into the lump to collect a sample of cells. These cells are then analysed under the microscope by the pathologist who will often determine the nature of the swelling. Rarely, other tests such as a plain X-ray, CT scan, MRI scan or a sialogram may be required. These will be discussed with you where necessary.

Treatment depends on the nature of the lump and the results of the tests. Removal of the swelling is usually recommended because the exact nature of the swelling is often ascertained after removal and analysis of the whole lump. Additionally, if the lumps are not removed, the majority of them will grow further and often become cosmetically unacceptable and even turn cancerous. Large, cancerous lumps are difficult to remove and complicate surgery.

Surgery (Parotidectomy) explained

The surgery to remove the parotid lump is called a parotidectomy. This involves removing either part or all of the parotid gland. The operation is usually performed under a general anaesthetic, which means that you will be asleep throughout the procedure. A skin incision (cut) is made, which runs from the front of the ear curving towards the back of the ear just to the level of the hair line. Most surgeons differ in making the skin cut and tend to extend the cut into the neck. This is nearly the same incision as that used in face-lift surgery and has excellent cosmetic results. At the end of the operation a small drain (plastic tube) is placed through the skin to facilitate drainage of blood and tissue fluids. The skin cut is closed with stitches and the drain is removed in 24-48 hours, when you will be able to go home.

Potential complications

In the following section some of the common and serious risks of parotidectomy are discussed briefly. Please note that the chances of these happening are very low.

Weakness (Paralysis) of the face

The facial nerve that moves the muscles which help the eyes to close and the mouth to smile and eat runs through the parotid gland. We always diligently identify and preserve the nerve. We also use a specialised nerve monitoring technique which adds further safety to the procedure. In most cases, the nerve works normally after surgery. Occasionally, however, (about 15-20% of cases) where the lump has been very close to the nerve, a temporary weakness of the face may occur. This usually lasts for a few weeks and then recovers back to normal. Permanent damage, resulting in permanent weakness of the face, is rare in surgery of the benign (non cancerous) tumours.

Bleeding and leakage of saliva

Rarely, blood can collect beneath the skin resulting in swelling in the operated area. It is also normal for small quantities saliva to leak from the cut surface of the gland and cause it to swell. Most often this blood and saliva is mopped up by our body and therefore the swelling is self limiting. Occasionally, however, it may be necessary to return to the operating theatre to rectify the problem.

Numbness/Altered sensation of the face and the ear

The nerves that are responsible for appreciating sensation on the face, side of the neck and the ear lie just under the skin and are damaged to a variable degree. This transpires as numbness of the ear, particularly felt in the ear lobe and to a variable degree on the side of the face and neck. One is more likely to be aware of it when wearing earrings and whilst shaving in men. Generally speaking, with time the numbness and altered sensation improves.

Cosmetic deformity

You may notice some hollowing under the skin at the back of the jawbone from where the gland and swelling has been removed. This is usually mild and is not a concern to the majority of patients. There are various ways of treating this should it become troublesome.

Skin changes - sweating and flushing (Frey's syndrome)

You may notice that the cheek skin on the operated side becomes flushed and sweaty, particularly associated with eating or thought of food. Should this occur and become troublesome, it can generally be treated by the application of simple roll-on antiperspirant and very occasionally further surgery may be required.

Pain and stiffness

You may notice pain and stiffness in the area of the neck and shoulder. This recovers quickly. Gentle daily massage with your regular skin cream starting two to three weeks after surgery helps to supple the scar and eases the discomfort.

The Thyroid Gland and Thyroid Surgery

The thyroid gland lies in front of the neck just below the Adam’s apple and is butterfly shaped. The right and left wings (lobes) are joined by a small bridge of thyroid tissue (body) called the isthmus. The two lobes lie on either side of the windpipe. The thyroid gland manufactures hormones, which are chemicals that circulate in the bloodstream and affect the function of the cells and tissues in the body. Thyroid hormones are essential for survival.

What is goitre?

Any enlargement of the thyroid gland is called goitre. When the whole gland is diffusely enlarged it is called a diffuse goitre. If there is a single nodule, it is termed a solitary nodule. The majority of goitres are not cancerous. However, a small proportion of goitres may harbour cancer cells and this is the reason why I recommend investigations for all thyroid swellings (goitre).

Investigation and treatment of thyroid lump

During the initial consultation, we will take a detailed history of your problem and assess you. This is followed by an ultrasound scan, which is performed by an expert radiologist. During the ultrasound scan, a needle may be inserted into the lump to collect a sample of cells, this is called fine needle aspiration cytology test (FNAC). These cells are then analysed under the microscope by the pathologist who will determine the nature of the swelling.

There are other tests, such as a CT scan, MRI scan or nuclear isotope scan which may be required in some cases. Often no treatment may be necessary for the thyroid lump (goitre) and you will be advised to adopt a ‘watch and wait policy’. Alternatively, surgery may be advised. This is commonly undertaken when there is a suspicion of cancer, pressure symptoms, uncontrolled over activity, and cosmetic concerns. The surgery is called thyroidectomy and is discussed briefly below.

Thyroidectomy

There are many different terms used to describe thyroid surgery. Total thyroidectomy implies removal of all the thyroid gland, whereas a hemi-thyroidectomy or lobectomy only part of the gland is removed. You will be advised about the exact procedure you will need based on your problem.

The operation is performed under a general anaesthetic, which means you will be asleep throughout the procedure. A skin cut (incision) is made across the midline in the neck over the gland. This cut is usually placed along a crease line, so when it heals it is barely visible. The required part or the entire gland is removed after making sure all important nerves, blood vessels and parathyroid glands are preserved. At the end of the operation, a drain (plastic tube) is placed through the skin in order to prevent blood collection in the operated area. Most patients usually spend 24hours in hospital after the operation. The drain is removed before leaving hospital.

Risks involved in thyroidectomy

In the following section we have briefly discussed some common and serious risks of thyroid surgery. Please note that the chances of any of these complications are small and great care is taken to avoid any risks.

Changes in voice

Nerves called the recurrent laryngeal nerve (RLN) and the superior laryngeal nerve (SLN) that maintain normal function of the voice box (larynx) are in close proximity to the thyroid gland. If these nerves are damaged, you may notice that your voice is hoarse and weak and your singing voice is affected. This occurs as a result of minor bruising of the nerves and usually recovers. Very rarely the damage may be severe, which means the voice will be permanently affected.

Bleeding

Bleeding is generally minimal, self-limiting and requires no action. Rarely, excess bleeding can occur which may lead to neck swelling and occasionally difficulty in breathing. If this is the case, it is necessary to return to the operating theatre to rectify the problem.

Parathyroid - calcium problems

This is applicable to you if you are having a total thyroidectomy. The parathyroid glands that control the level of calcium in the blood lie close to the thyroid gland. If these glands are affected, the calcium levels may fall. As a result, you may experience tingling sensations in your hands, fingers, toes, in your lips or around your nose. If you experience any of these symptoms please inform us immediately.

We monitor the levels of calcium in your blood after the operation and treat you as necessary. Generally speaking, parathyroid glands recover quickly following surgery and you suffer no ill effects. If a quick recovery is not anticipated, you will be sent home on medication to maintain your calcium levels.

Neck and shoulder stiffness

You may feel some discomfort and stiffness around your neck and shoulders. You will be given adequate painkillers to control this effectively and generally the recovery is quick. Regular massaging of the area after stitch removal is also helpful.

Affects of removing the thyroid gland

If the entire thyroid gland is removed you will need to take replacement thyroid hormones in the form of a tablet called thyroxine (T4) everyday for the rest of your life. The amount of thyroxine you need will be monitored based on blood tests and as long as one takes the correct prescribed dose, you will suffer no ill effects. If, on the other hand, only part of the thyroid gland is removed, then generally you do not need to take thyroxine. This is because the part of the thyroid gland that is left behind in your neck will produce enough hormones to meet the demands of the body. Blood tests will be done to confirm this after the operation.

Head & Neck Cancer

We specialise in the diagnosis and management of head and neck cancers

As many as 90 percent of head and neck cancers arise after prolonged exposure to specific factors. Use of tobacco (cigarettes, cigars, chewing tobacco or snuff) and alcoholic beverages are closely linked with cancers of the mouth, throat, voice box and tongue.

Some of the common presenting features are:

A lump in the neck...

Cancers that begin in the head or neck usually spread to lymph nodes in the neck before they spread elsewhere. A lump in the neck that lasts more than two weeks should be seen by a physician as soon as possible. Of course, not all lumps are cancer. But a lump (or lumps) in the neck can be the first sign of cancer of the mouth, throat, voicebox (larynx), thyroid gland, or of certain lymphomas or blood cancers. Such lumps are generally painless and continue to enlarge steadily.

Change in the voice...

Most cancers in the larynx / voice box cause some change in voice. Any hoarseness or other voice change lasting more than two weeks should alert you to see your physician. We can examine your vocal cords easily and painlessly. While most voice changes are not caused by cancer, you shouldn't take chances.

A growth in the mouth...

Most cancers of the mouth or tongue cause a sore or swelling that doesn't go away. These sores and swellings may be painless unless they become infected. Bleeding may occur, but often not until late in the disease. If an ulcer or swelling is accompanied by lumps in the neck, be very concerned.

Swallowing problems...

Cancer of the throat or oesophagus (swallowing tube) may make swallowing solid foods difficult. Sometimes liquids can also be troublesome. The food may "stick" at a certain point and then either go through to the stomach or come back up. If you have trouble almost every time you try to swallow something, you should seek attention.

Persistent earache...

Constant pain in or around the ear when you swallow can be a sign of infection or tumor growth in the throat. This is particularly serious if it is associated with difficulty in swallowing, hoarseness or a lump in the neck. These symptoms are best evaluated by an otolaryngologist.

What you should do...

All of the symptoms and signs described here can also occur with no cancer present. In fact, many times complaints of this type will be due to some other condition. But you can't tell without an examination so to be safe seek attention.

Facial Skin Cancers

The most common head and neck cancer is basal cell cancer of the skin. Fortunately, this is rarely a major problem if treated early. Basal cell cancers appear most often on sun-exposed areas like the forehead, face, and ears, although they can occur almost anywhere on the skin. Basal cell cancer often begins as a small, pale patch that enlarges slowly, producing a central "dimple" and eventually an ulcer. Parts of the ulcer may heal, but the major portion remains ulcerated. Some basal cell cancers show color changes.

Other kinds of cancer, including squamous cell cancer and malignant melanoma, also occur on the skin of the head and neck. Most squamous cell cancers occur on the lower lip and ear. They may look like basal cell cancers and, if caught early and properly treated, usually are not much more dangerous. If there is a sore on the lip, lower face, or ear that does not heal, consult a physician.

Malignant melanoma classically produces dense blue-black or black discolorations of the skin. However, any mole that changes size, color, or begins to bleed may be trouble. A black or blue-black spot on the face or neck, particularly if it changes size or shape, should be seen as soon as possible by a dermatologist or other physician.

Disclaimer
The advice and information contained herein is provided in good faith as a public service. However the accuracy of any statements made is not guaranteed and it is the responsibility of readers to make their own enquires as to the accuracy, currency and appropriateness of any information or advice provided. Liability for any act or omission occurring in reliance on this document or for any loss, damage or injury occurring as a consequence of such act or omission is expressly disclaimed.