Head & Neck Oncology

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Overview of Head & Neck cancer

In modern era of medical field lot of medical research is going on for early diagnosis and management of cancer. Although in last few years we progressed very fast to fight cancer, still we are not able to cure the all cancers especially of last stage. Cancer is a Latin word meaning 'Crab'. Basically cancer is the rapid uncontrollable growth of the cells in any part of the body which do not function normally and not divide & die as normal cells. Cancer cells develop because of damage to DNA, the substance which directs all activity of the cells. Most of the time the DNA is damaged by some environmental irritants like smoking, alcohol, lime, pan, hot spicy food, arsenic etc or by genetic inheritance. Once DNA is damaged in cancer cell it is not repaired itself as in usual cell. If cancer is not treated at early stage cancer cell keeps on multiplying, erodes surrounding structure and spreads to the surrounding lymph nodes and other organs like lungs, Bones,Liver, Brain, Kidneys etc. These tumours may erodes in form of ulcer in neck or form huge swelling (Fig. 1) and some time flies may hatch maggots which lead extremely painful condition.

Head & Neck cancer are most common type of the cancers in india. It is estimated that there are approximately 2 - 2.5 million cases of the cancers in India at any given time out of that about 40% of cases arises from head & neck region.

Is this cancer preventable?

Approximately 90% of oral cavity cancer is related to environmental irritants like alcohol & tobacco and avoiding consumption of these irritants may prevent cancer formation. In oral cavity white patch (leucoplakia), red patch (erythroplakia) or red or purple erosive lines (lichen planus) is precancerous condition which has high potential to turn out malignant. However oral cancer may develop even without any precancerous condition and it is not necessary that all premalignant lesions lead to cancer. Treatment or regular check-up of this early lesion may help to prevent or early detection of the cancer.

What are the Symptoms of Head & Neck cancer

• Oral ulcer not relieved by medicine.
• Oral/gum/dental growth progressively increasing in size.
  
• Swelling in neck region progressively increasing in size.
  
• Change in voice.
  
• Difficulty or pain during swallowing.
• Difficulty in breathing.
  
• Burning sensation during swallowing.
  

How the Head & Neck Cancer Diagnosed

Following Methods help to diagnose head and neck cancer:-

• Physical Examination.
  
• Laboratory Tests.
  
• Endoscopy (Nasopharyngoscopy/Direct Laryngoscopy/Oesophagoscopy/Bronchoscopy)
• X-ray, CT scan, MRI scan.
• Histopathological :- F.N.A.C., Biopsy.
  

Is the Head & Neck Cancer treatable?

It is a myth that once cancer is diagnosed it is only way to horrible death but same is not true. If cancer is diagnosed in early stage it will be cured up to 95% of cases and at this stage only one modality of treatment is required even the patients who presented in stage III OR IV are also cured by multimodality approach up to 65-75% cases.

Only very advanced cases require palliative or symptomatic management. In India early diagnosis is a big challenge due to ignorance of patients toward the symptoms and most of the cases even after being diagnosed as cancer do not take proper treatment probably due to fear of hospital, more faith in quakes, inadequate knowledge of the disease and poverty which turn the early stage cancer in very advance stage where we can offer only palliative management. Only awareness, faith in multimodality treatment and avoid ignorance make head & neck cancer completely curable.

What is multimodality treatment?

There are three modalities (Surgery, Radiotherapy, Chemotherapy) to fight the cancer. In multimodality approach the case is discussed in tumour board, in which surgeon, radiotherapist and chemotherapist discuses the clinical, pathological and radiological aspect of the disease and dispense best combination of the treatment, best suited to the patient. Treatment plans depends on exact location, stage, histology, person's age and general health.

When and Why surgery is necessary in Head & Neck Cancer?

Usually cancer situated in anterior part of oral cavity is best treated with surgery and cancer situated in posterior part of oral cavity is best treated with radiotherapy. Basic principle behind this is that if tumour involving the bone (mandible), just near to the bone or involving the thyroid cartilage is not completely responding to the radiotherapy and chances of osteoradionecrosis is also there. Patient who has disease spread to the neck nodes (>3cm) is also candidate for surgery. Since cancer of oral cavity has high potential to spread into neck nodes neck dissection is usually necessary to clear complete disease. In short we can say tumour involving tongue,buccal mucosa, lower upper gum and advance hypopharyneal and laryngeal cancer require surgery as first line of management where as tumour involving tonsil, base of tongue, nasopharynx, oropharynx, and early hypopharyneal and laryngeal cancer require radiotherapy as a definitive treatment.

Cancer Tongue

In early stage of tongue cancer patient require only surgery but if disease is advanced it's require multimodality treatment. For surgery of small growth there will be no defect in speech and swallowing. After surgery of larger tumour there may be slurring of the speech but the speech is usually understandable and there may be little difficulty in swallowing at early post operative period. If the total tongue is removed for the cancer and defect is repaired with some flap then there will be permanent defect in speech and swallowing.

Cancer buccal mucosa and gum

These tumours also require surgery as the first line of management. excision of the bone depends on exact location, stage, and erosion of the bone. Usually neck dissection is also required along with primary excision. Defect of excision depends on tumour site & size and usually repair is in the form of skin graft or PMMC flap in which muscle of the chest is rotated up and put into oral cavity. In advances cases patient will require radiotherapy ± chemotherapy postoperatively.

Nasal cavity and Paranasal Sinus Tumour

Surgery with or without postoperative radiotherapy is treatment of choice in resesctable tumours. But if disease is inoperable radiotherapy is considered as the treatment of choice. Neck dissection is required in cases with involved neck nodes.

Cancer or Nasopharynx and Oropharynx

In this type of cancer radiotherapy ± chemotherapy is the first line of management. Surgery is required only in cases where neck nodes did not respond to the radiotherapy ± chemotherapy and where primary disease is controlled.

Cancer larynx

In this type of tumour in stage I, II and some cases of stage III radiotherapy is the treatment of choice but in stage IV and some cases of stage III surgery is the first line of management. Neck dissection is also necessary in supraglottic, subglottic and transeglottic lesion. Postoperative radiotherapy ± chemotherapy is required in stage IV. After near total laryngectomy patient can speak around 3 weeks after surgery but after total laryngectomy patient require some additional instrument like electrolarynx or tracheo-esophageal prosthesis for voice production. After laryngeal cancer surgery speech is not as normal as in a normal person but it is definitely understandable.

Usually after total laryngectomy patients stars swallowing after two weeks and patient has to breath through stoma made into the neck which can be covered by muffler type gauge piece.

Salivary gland and Thyroid gland tumour

These types of tumour can be best managed by surgery and postoperative radiotherapy sometimes required in salivary gland tumour specially in stage IV tumour. In thyroid cancer postoperative radioiodine is required in about half of the cases.

What is Palliative Management?

Palliative management is offered in patients who have advance disease and in whom cure is not possible. The main intention of this treatment is to relieve the symptoms without curing the disease. It may be in form of surgery radiotherapy and chemotherapy. Although with this treatment disease is not cured but patient is relieved symptomatically from pain in oral cavity, bleeding through mouth, difficulty in swallowing etc.

Department of Head & Neck and ENT Surgery

Facility Available:-

• Oral cancer Surgery
• Laryngeal Cancer Surgery
• Voice Rehabilitation procedure after Total Laryngectomy
• Neck Cancer Surgery
• Thyroid Cancer Surgery
• Nose & Pranasal Sinus Cancer surgery
• Surgery for Carcinoma of Face
• Ear and salivary gland Cancer surgery
• Plastic Reconstruction of facial, Oral & Neck defects
• Benign Neck Surgery
• Oesophagoscopy & Bronchoscopy Diagnostic & theraptic
• Nasal Endoscopy Diagnostic & theraptic
• Functional Endoscopic Sinus Surgery
• Septoplasty
• Adenoidectomy & Tonsillectomy
• Direct laryngocscopy and Microlaryngeal surgery
• Audiometry
• Ear surgery

BCC MEDIAL CANTHUS

Carcinoma Alveolus (Bipaddle PMMC)

T4 BM tumour Involving skin	Mucosal & skin Defect after Composite resection
Marking of Bipaddle PMMC	Defect after suturing Bipaddle PMMC

Carcinoma left maxilla ( Total Maxillectomy)

PRE OP TUMOUR	PLAN OF INCISION
BASE OF SKULL AFTER MAXILLA REMOVAL	INCISION AFTER SUTURING UPPER FLAP

CA PAROTID

Ca Tongue (Wide Excision with Left MNDType III)

INCISION MARK FOR NECK DISSECTION	NECK AFTER MND TYPE III
TONGUE AFTER WIDE EXCISION	EXCISED TONGUE & NECK SPECIMEN

Ca Thyroid (Completion Thyroidectomy with Rotational flap repair)

PRE OP NECK SWELLING & INCISION MARKING	NECK AFTER EXCISION OF RT. HEMITHYROID
INCISION AFTER CLOSURE	EXCISED PRIMARY AND SND SPECIMEN

Notes

Oral cancer is most common type of cancer in India which is closely related to the tobacco chewing & smoking. In our hospital to treat this common condition all facility available. Surgery is the preferred mode of the treatment and in our hospital all modern equipments available to perform all cancer surgeries at sub site of oral Cavity like Tongue, Gum, Buccal Mucosa and Floor of mouth.

Laryngeal cancer is a cancer of voice box & respiratory tract. In early stage radiotherapy is the treatment of choice but in stage III or IV surgery is management of choice. In our hospital voice preserving surgery like Supraglottic or Vertical Partial or Near Total Laryngectomy is performed. If these are not feasible then Total laryngectomy can be done. In our hospital we have all facility to treat every type of laryngeal cancer.

Voice restoration is most common problem after Total laryngectomy we have facility to overcome this problem. We usually put tracheo-oesophageal prosthesis through patient can speak after putting his thumb over stoma. If TEP insertion not feasible we can dispense Eletrolarynx or we can taught oesophageal voice, whose results is inferior then TEP insertion.

Neck dissection is back bone for every Head & Neck cancer surgery we usually Modified Neck Dissection Type I, Type II or Type III depending on extent of disease perform. Some time selective neck dissection or radical neck dissection also executed if conditions demands for that.

Thyroid cancer have best prognosis and treated mainly by the surgery in this type of cancer Total or Hemi thyroidectomy can be done, neck dissection or sampling of the neck is usually required to complete dissection. Postoperative Radioiodine therapy may be required. Dose of radioiodine depends on tumour stage & excision of the tumour. We have full facility for diagnostic & thereptic management of thyroid diseases.

Nasal & pasranasal sinus tumour are rare type of tumor in Head & neck region. We have facility to treat this type of cancer by surgery, radiotherapy and /or chemotherapy.

Basal cell carcinoma (BCC) is quite common type of cancer in Punjab. We have all modality to treat and reconstruction of BCC. Other type of carcinoma of face is rare & treatment can be done accordingly.

For all salivary gland and ear canal tumour, surgery is the main stay of the treatment.
We have facility for microscope and micro instruments for ear cancer surgery.

All mucosal, skin or skeletal defects need reconstruction. In our hospital all Head & neck defects reconstructed appropriately with various type of flap like PMMC flap, DP flap, forehead flap, glabellar flap etc. depends on site & extent of the defect.

Benign swelling of the neck is quite common which usually require surgical intervention. Benign disease of thyroid swelling, salivary gland, neck nodes, skin tumour and other rare tumour treated appropriately in our hospital.

Oesophagoscopy & Bronchoscopy is the procedure to visualize upper food pipe & respiratory passage. It can be done for diagnostic purpose to see both passage or can be done thereptic to remove foreign body or for stricture dilatation.

Nasal endoscopy is the backbone for all nasal surgeries. Nasal surgeries like Functional Endoscopic Sinus Surgery (FESS) , Endoscopic Septoplasty, Removal of Foreign body, bleeding nose, nasal tumour can be assessed and treat accordingly with nasal Endoscope. We have all endoscopic equipments for all nasal surgeries.

Recurrent tonsillar & adenoid infection is the common problem especially in children. In our hospital we have facility to remove tonsil with conventional as well as with bipolar cauterization method.

Direct laryngoscopy is used to visualize laryngeal and pharyngeal framework. It is also useful before microlaryngeal surgery which is performed to treat benign laryngeal disease.

Audiometry is graphical record of the hearing it is useful before the ear surgery. Ear surgery is usually performed with the help of microscope and microinstuments.