Head & Neck

Head & Neck

The head and neck include some of our body’s most vital organs, which can be especially susceptible to tumors and cancer. In addition to cancers of the head and neck, ENT specialists treat neck masses, Thyroid and Parathyroid disorders, and more.

Head & Neck Conditions frequently evaluated by ENT Physicians

• Bell’s Palsy (facial muscle weakness)
• Thyroid and Parathyroid disorders
• Head and Neck Cancer
• Neck Mass
• Sialadenitis (saliva gland infections)
• Skin Cancer
• Temporo-Mandibular Joint (TMJ) Pain

Head and Neck Cancer

Each year, more than 55,000 Americans will develop Head and Neck cancer (most of which is preventable).  Nearly 13,000 will die from cancer of the head and neck.  Head and Neck cancers are curable if caught early.  Fortunately, most of them produce early symptoms.  You should know potential warning signs, so you can alert your doctor as soon as possible.  Successful treatment of head and neck cancer depends on early detection.  Knowing and recognizing its signs can save your life. 

Symptoms of head and neck cancer can include:

• A lump in the neck
• Change in voice (hoarseness)
• Growth in the mouth
• Coughing or bringing up blood
• Difficulty Swallowing
• Changes in skin
• Persistent earache

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, voice box (larynx), thyroid gland, salivary glands, or of certain lymphomas and blood cancers. Such lumps are generally painless. Commonly, antibiotics may be prescribed as initial treatment for adults with enlarged lymph nodes in the neck under the assumption that an infection may be responsible. If the lump persists or is enlarging despite antibiotics, further investigation to determine the cause and nature of the enlarged lymph node(s) is essential.

Change in the voice—Most cancers in the voice box cause voice change. An ENT (ear, nose, and throat) specialist, or otolaryngologist, can examine your voice box easily and painlessly. While most voice changes are not caused by cancer, you shouldn’t take chances. If you are hoarse or notice voice changes for more than two weeks, see your doctor.

A growth in the mouth—Most cancers of the mouth or tongue cause a sore or swelling that doesn’t go away. These may be painless, which can be misleading. Cancer is often painless. Bleeding may occur, but often not until late in the disease. If an ulcer or swelling is accompanied by lumps in the neck, you should be concerned. In addition, any sore or swelling in the mouth that does not go away after two weeks should be evaluated by a physician. Your dentist or doctor can determine if a biopsy (tissue sample test) is needed, and can refer you to an ENT specialist who can perform this procedure.

Bringing up blood—This is often caused by something other than cancer. However, tumors in the nose, mouth, throat, or lungs can cause bleeding. If blood appears in your saliva or phlegm for more than a few days, you should see your physician.

Swallowing problems—Cancer of the throat or esophagus (swallowing tube) may make swallowing solid foods (and sometimes liquids) difficult. 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 see your doctor. Usually, a barium swallow X-ray or an esophagoscopy (direct examination of the swallowing tube with a scope) will be performed to find the cause.

Changes in the skin—The most common head and neck cancer is basal cell skin cancer. Fortunately, this is rarely serious if treated early. Basal cell cancers appear most often on sun-exposed areas like the forehead, face, and ears, but 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 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 dangerous. If there is a sore on the lip, lower face, or ear that does not heal, consult a physician. Malignant melanoma typically produces a blue-black or black discoloration of the skin. However, any mole that changes size, color, or begins to bleed may mean 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.

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 should be evaluated by an ENT specialist.

What Causes Head and Neck Cancer?

Tobacco use is the most preventable cause of these deaths. In the United States, up to 200,000 people die each year from smoking-related illnesses. The good news is that this figure has decreased due to the increased number of Americans who have quit smoking. The bad news is that some of these smokers switched to smokeless or spit tobacco, assuming it is a safe alternative. This is untrue. By doing so, they are only changing the site of the cancer risk from their lungs to their mouths.

While lung cancer cases are decreasing, cancers in the head and neck, such as those caused by the human papillomavirus (HPV), are on the rise.

As many as 90 percent of head and neck cancers arise after prolonged exposure to specific risk factors. Use of tobacco (cigarettes, cigars, chewing tobacco, or snuff) and alcoholic beverages are the most common cause of cancers of the mouth, throat, voice box, and tongue. In adults who do not smoke or drink, cancer of the mouth and throat can occur as a result of infection with HPV. Prolonged exposure to sunlight is linked with cancer of the lip and is also established as a major cause of skin cancer.

All of the symptoms and signs described here can occur with no cancer present. In fact, many times complaints of this type are due to some other condition. But you cannot tell without an examination. If they do occur, see your doctor to be sure.

Remember: When found early, most cancers in the head and neck can be cured with few side effects. Cure rates for these cancers could be greatly improved if people would seek medical advice as soon as possible. Play it safe. If you detect warning signs of head and neck cancer, see your doctor immediately. And practice health habits which help prevent these diseases.

Neck Mass

A neck mass is an abnormal lump in the neck. Neck lumps or masses can be any size—large enough to see and feel, or they can be very small.  A neck mass may be a sign of an infection, or it may indicate a serious medical condition. It does not necessarily mean you have cancer, but it does mean you may need additional evaluation to receive an accurate diagnosis.

What Are the Symptoms of a Neck Mass?

Common symptoms in patients with a neck mass at higher risk for cancer (see “What Causes a Neck Mass” below) include:

• The mass lasts longer than two to three weeks
• The mass gets larger
• The mass gets smaller but does not completely go away
• Voice change
• Trouble or pain with swallowing
• Trouble hearing or ear pain on the same side as the neck mass
• Neck or throat pain
• Unexplained weight loss
• Nasal blockage in one side of the nose
• Breathing difficulty
• Bleeding from nose and oral cavity
• Coughing up blood
• Skin lesion on the face or scalp that is growing or changing color

What Causes a Neck Mass?

Neck masses are common in adults and can occur for many reasons. You may develop a neck mass due to a viral or bacterial infection. Ear or sinus infection, dental infection, strep throat, mumps, or a goiter may cause a neck mass. If your neck mass is from an infection, it should go away completely when the infection goes away.

Your neck mass could also be caused by a noncancerous (benign) tumor or a cancerous (malignant) tumor. Cancerous neck masses in adults are most often due to head and neck squamous cell carcinoma (HNSCC). Other causes for a neck mass may be due to cancers such as lymphoma, thyroid or salivary gland cancer, skin cancer, or cancer that has spread from somewhere else in the body.

Long-term tobacco use (cigarettes, cigars, chewing tobacco, or snuff) and alcohol use are the two most common causes of cancers of the mouth, throat, voice box, and tongue. Another common risk factor for cancers of the neck, throat, and mouth is a human papillomavirus (HPV) infection. HPV infection is usually transmitted sexually. HPV found in the mouth and throat is called “oral HPV.” Some high-risk types of oral HPV infection can cause head and neck cancers.

HNSCC of the tonsil and base of the tongue has gone up because of the increase in HPV infections. HPV-related cancers often lack the common risk factors of tobacco and alcohol use and tend to affect younger adults. Patients with HPV-positive HNSCC may have some of the symptoms listed here, but many times a neck mass will be the only sign of this type of cancer.

When Should I See a Doctor?

See your doctor and/or an ENT (ear, nose, and throat) specialist, or otolaryngologist, if the lump in your neck lasts longer than two to three weeks. This is a persistent neck mass, which means that the lump has not gone away. You should also see a doctor if you are not sure how long you have had the neck mass because your neck mass may mean that you have a serious medical problem. If you have any of the head and neck symptoms listed above, in addition to the neck mass, you should see your doctor right away. It may not be cancer, but you need to be evaluated. Your doctor will discuss any tests needed for diagnosing your neck mass and your follow-up care.

What Are the Diagnostic and Treatment Options?

Your doctor will ask about your medical history and examine your head and neck. They may perform (or recommend) an endoscopy, which is a procedure that inserts a small tube with an attached camera through your nose to look inside your throat, voice box, and the opening of your esophagus. If a more detailed examination is required, the endoscopy will be performed in an operating room under anesthesia.

In addition, your doctor may order tests to help diagnose your neck mass, such as a CT, MRI, or PET (positron emission tomography) scan (if needed) to get a more detailed picture of the neck mass than normal X-rays can provide.

A biopsy involves taking a sample of tissue from the neck mass to make a diagnosis. There are different types of biopsies based on your medical history and the location of your mass, including:

Fine Needle Aspiration Biopsy (FNA)—An FNA is the best initial test to diagnose a neck mass. A small needle is put into the mass and tissue is pulled out. An FNA is often done in your doctor’s office. It is well-tolerated by most patients. It can be done with or without an ultrasound-guided needle biopsy.

Core Biopsy—A core biopsy is another way to diagnose a neck mass, typically performed if an FNA did not confirm a diagnosis. A core biopsy uses a slightly larger needle and gets a larger piece of tissue. It is well tolerated and has a low risk of complications.

Open Biopsy—An open biopsy should typically be done only after FNA and/or core biopsy have failed to make the diagnosis. It is the next step to diagnose a neck mass. It is a more invasive procedure. An open biopsy is done by a surgeon in the operating room and you will need anesthesia. An open biopsy may remove only a portion of the mass or the whole mass. Because open biopsies are more invasive, there is a somewhat higher risk for complications.

Your doctor will explain the next steps and discuss a follow-up plan once a diagnosis has been made. If the neck mass is found to be cancerous, treatment options include surgery, radiation therapy with or without chemotherapy, or a combination of these treatments depending on the diagnosis and stage of the disease. Some neck masses may be thought to be benign (not cancerous) at first, but are later found to be cancer, which is why a follow-up plan is so important. You and your doctor need to discuss the method for follow-up that works best for you. You should call for your results if you have not heard from the doctor or do not have a follow-up appointment.

Sialadenitis

Sialadenitis is inflammation and enlargement of one or more of the salivary (spit) glands. The salivary glands are responsible for producing and storing saliva.  The three major salivary glands are the “parotid” (on the sides of the face in front of the ears), “submandibular” (under the jaw), and “sublingual” glands (under the tongue).   All of these glands empty saliva into the mouth through small tubes called ducts.

Sialadenitis can occur due to infection, salivary stones, or an underlying autoimmune disorder. It usually affects the parotid and submandibular glands and is most common among the elderly.

What Are the Symptoms of Sialadenitis?

The symptoms of sialadenitis can include:

• Swelling in the cheek and neck region, especially after eating
• Mouth or facial pain
• Dry mouth
• Foul taste or gritty feeling in the mouth
• Fever
• Chills
• Redness over the side of the face or upper neck
• Pus in the mouth

What Causes Sialadenitis?

Sialadenitis can be caused by a viral infection (such as mumps), bacterial infection, or an autoimmune disease such as Sjogren’s syndrome (see below). Bacterial infections can happen when the flow of saliva is blocked due to stones in the salivary duct or a narrowing of the duct. Dehydration can also cause bacterial infections by reducing saliva flow. Recent illness and the use of antihistamines, beta-blockers, or diuretics can lead to dehydration. Radioactive iodine (RAI), sometimes used for treatment after surgery of thyroid cancer, can also result in salivary gland scarring and sialadenitis because some of the radioactivity can be accumulated in the salivary glands.

Sjogren’s syndrome is an autoimmune disease which affects salivary glands and the “lacrimal” glands of the eyes. This chronic inflammatory disorder causes decreased saliva production in the mouth and decreased tear production in the eyes. In addition to dry mouth and eyes, there may be symptoms of fatigue, muscle aches, or rashes. In extreme cases, Sjogren’s syndrome may affect the lungs, kidneys, liver, and nervous system. People with Sjogren’s syndrome may also have swelling of the parotid or submandibular glands, as well as an unexplained increase in dental cavities or tooth decay.

An ENT (ear, nose, and throat) specialist, or otolaryngologist, may diagnose Sjogren’s syndrome based on persistent symptoms of dry eyes and/or mouth, parotid gland enlargement, and abnormal blood test results. A lip biopsy can confirm the diagnosis. Sjogren’s syndrome is treated conservatively with symptomatic relief. Oral rinses and hydration are advised along with lubricating eye drops.

What Are the Treatment Options?

Treatment for sialadenitis includes good oral hygiene, increasing fluid intake, massaging over the affected gland, applying a warm compress, and using candies or foods which increase saliva (such as lemon drops). In some cases, if the cause is bacterial, antibiotics may be prescribed. Antibiotics are not useful for viral infections. An endoscopic procedure with a very small camera (called Sialendoscopy) can be used in certain cases.

Most salivary gland infections resolve or are cured with conservative treatment after one week. In rare cases of recurrent sialadenitis, surgery may be necessary to remove part or all of the gland.

Thyroid and Parathyroid

The thyroid is a butterfly-shaped gland located at the base of the front of the neck. It produces thyroid hormone, which controls your metabolism, temperature regulation, and keeps your muscles and organs working properly.  The parathyroid glands are small pea-sized glands that sit behind or near the thyroid and are responsible for regulating Calcium within the body.  Calcium is not only important for bone growth and strength; it is a vital nutrient for muscle and heart health as well. 

Commonly treated conditions include:

• Goiter (enlargement of the thyroid gland)
• Thyroid nodules
• Thyroid Cancer
• Hyperthyroidism (overactive thyroid)
• Hyperparathyroidism (overactive parathyroid gland – decreased whole body Calcium)

Thyroid Nodules

A thyroid nodule is an area of abnormal growth within the thyroid. The thyroid is a butterfly-shaped gland located at the base of the front of the neck. It produces thyroid hormone, which controls your metabolism, temperature regulation, and keeps your muscles and organs working properly.

Diseases of the thyroid, whether functional (hypothyroidism, hyperthyroidism) or structural (nodule, goiter, cancer), occur very commonly. Some people have a single nodule while others have multiple nodules within the gland. Thyroid nodules, which are particularly common in women, can be tiny to very large in size.

Most thyroid nodules are non-cancerous, do not cause symptoms, and do not need any treatment. In some cases, however, because of the size, appearance (on radiology tests), or symptoms caused by the nodule, additional evaluation and treatment may be needed.

What Are the Symptoms of Thyroid Nodules?

Because many thyroid nodules are small, they may cause no symptoms. However, some nodules can cause the thyroid to grow (called a goiter), some can be overactive and lead to hyperthyroidism, and some can be thyroid cancers. If patients do experience symptoms they may include:

• A lump in the neck
• Difficulty swallowing
• Pressure in the neck

What Are the Treatment Options?

Most thyroid nodules require no treatment. Depending on the type of nodule and related symptoms, different treatment options may be appropriate. In some cases, thyroid surgery is needed. Your endocrinologist or ENT (ear, nose, and throat) specialist may order or perform:

• Thyroid function tests, including thyroid-stimulating hormone (TSH)
• Blood tests, or radiology examination
• An ultrasound to see the size and appearance of the nodule

A fine-needle aspiration (FNA) biopsy, which is a safe, relatively painless procedure. In this procedure, a small needle is passed into the lump, and tissue samples containing cells are taken and then sent to a pathologist for testing.

Thyroid Cancer

The thyroid is a butterfly-shaped gland located at the base of the front of the neck. It produces thyroid hormone, which controls your metabolism, temperature regulation, and keeps your muscles and organs working properly.

Thyroid cancer is very common, particularly in women. It is now one of the most common cancers found in women. Most forms of thyroid cancer are slow-growing and well-treated with surgery and sometimes other therapies.

Thyroid cancers are often found within nodules that are either felt by the patient or their doctor. These nodules are also frequently found incidentally, for example, when the patient has an imaging test not related to the thyroid.

What Are the Symptoms of Thyroid Cancer?

Many patients with thyroid cancer do not report any symptoms, though the following symptoms may be present:

• Difficulty swallowing
• Voice changes
• A lump in the neck

What Are the Types of Thyroid Cancer?

There are several types of thyroid cancer including:

• Papillary—This is the most common form of thyroid cancer. This type of cancer, which tends to grow slowly, has a good prognosis. It often spreads to neck lymph nodes.
• Follicular—This type of thyroid cancer also typically has a good overall prognosis except when a significant invasion of other tissues is present.
• Medullary—This form of thyroid cancer develops from cells in the thyroid gland that are different from papillary and follicular thyroid cancers. While the prognosis with medullary cancer is not as favorable when compared with those types of thyroid cancers, it is also much less common (between five- and 10-percent of all thyroid cancers). While medullary thyroid carcinoma can be associated with several inherited syndromes, more often it occurs in patients without any family history.

Anaplastic—This is the least common type of thyroid cancer, but it is very aggressive, and the prognosis is poor. It presents as a rapidly enlarging neck mass.

What Are the Treatment Options?

A biopsy with a needle (called fine needle aspiration or FNA) may be performed based on physical exam and ultrasound, or radiographic findings. In some patients, a biopsy may show cancer, and surgery will be recommended. In others, biopsies may be indeterminate, and a cancer diagnosis is confirmed only after surgical removal. At times, a genetic analysis may be added to the biopsy, to help further clarify the risk of cancer and guide treatment decision-making.

The primary treatment for thyroid cancer is surgery. This surgery involves removing the thyroid gland and sometimes enlarged lymph nodes. Surgical treatment is determined on a case-by-case basis and is determined by the patient’s biopsy and imaging, as well as other factors. Treatment options include:

• Papillary—This type of cancer is treated with thyroid surgery and, in selected cases, radioactive iodine.
• Follicular—This type of thyroid cancer is treated similarly to papillary carcinoma, with thyroid surgery and, in selected cases, radioactive iodine.
• Medullary—Treatment for medullary thyroid cancer is primarily surgical. If the cancer is found to be inherited then family members of the patient may need genetic screening testing.
• Anaplastic—This cancer often grows very quickly and requires a medical team comprised of several specialists to determine the best treatment plan.

A consultation with your ENT Head and Neck surgeon will help determine what is the best evaluation and management of your thyroid disease.  A great resource for patients and families with thyroid disease can be found at the American Thyroid Association website www.Thyroid.org   Here patients can find current guidelines, support links, and ongoing clinical trials. 

Hyperthyroidism

The thyroid is a butterfly-shaped gland located at the base of the front of the neck. It produces thyroid hormone, which controls your metabolism, temperature regulation, and keeps your muscles and organs working properly.  In hyperthyroidism, the thyroid gland is producing too much hormone. This excess of thyroid hormone causes the body’s metabolism to be overactive. A simple blood test can diagnose hyperthyroidism.

What Are the Symptoms of Hyperthyroidism?

Patients with hyperthyroidism can have one or more of these symptoms:

• A racing heart or palpitations
• Tremors
• Feeling jittery
• Unplanned weight loss
• Feeling hot all the time
• Feeling anxious
• Difficulty sleeping

If Graves’ disease is the cause of the hyperthyroidism (see below), a person may also experience:

• A goiter
• Eye problems, like swelling, redness, bulging, dryness, itching, blurry vision, double vision

What Causes Hyperthyroidism?

Hyperthyroidism can be caused by all or part of the thyroid being overactive. In some patients, hyperthyroidism is caused by the whole gland being overactive, which is called Graves’ disease, one of the most common forms of hyperthyroidism. In addition to the thyroid gland, the eyes can be affected.

Some people’s hyperthyroidism is due to a single, or multiple, areas in the thyroid (nodules) that are overactive. This is referred to as a “toxic nodule” or “toxic multinodular” goiter.

What Are the Treatment Options?

Treatment for hyperthyroidism includes daily medications, radioactive iodine, or thyroid surgery. The therapy depends on the cause of the hyperthyroidism, response to treatment, and the preferences of the patient. Discuss any possible symptoms or concerns you may have with your primary care provider, an endocrinologist, or an ENT (ear, nose, and throat) specialist.

Copyright 2019. American Academy of Otolaryngology-Head and Neck Surgery Foundation