Head & Neck Tumour Conditions
Head & Neck Tumour Conditions and their Management Comprehensive Care 40 Medical Specialties 150 Sub-specialties
SingHealth provides tertiary medical care across a comprehensive spectrum of over 40 medical specialties with the in-depth expertise of 150 sub-specialties. Supported by a faculty of over 1000 internationally qualified medical specialists and well-equipped with advanced medical diagnostic and treatment technology, the group is recognised in the region for charting new breakthroughs in treatments.
As an Academic Medical Centre, we seek to transform patient care by integrating clinical services, teaching and research. Patients at SingHealth enjoy the benefit of leading-edge treatments with a focus on quality and holistic care, in an integrated and multi-disciplinary setting. FOREWORD
Holistic, integrated care of the highest standard that is truly centred on the patient – this is the vision of the SingHealth Duke- NUS Head and Neck Centre. We bring together different specialists across the SingHealth cluster to organise care around the patient and their needs.
As a one-stop facility, patients with multiple medical conditions have the convenience of seeing their doctors in the same place. This innovative model of care also enables us to excel in research advancements and continue to set new standards for education, training and clinical service.
Since May 2012, the SingHealth Duke-NUS Head and Neck Centre has reviewed more than 15,000 patients referred for a range of signs and symptoms requiring further evaluation.
This booklet is prepared for you to help understand and manage your condition better. It focuses on Head and Neck tumours, which are increasing concerns in this region. The booklet also serves as a ready reference for General Practitioners who have patients who present with these conditions.
For easy reading, we have four main sections: 1. Common signs and symptoms; 2. Common diseases in the Head and Neck region; 3. Head and Neck reconstruction; and, 4. Support services within the Head and Neck Centre.
Articles have been contributed by specialists from the SingHealth Duke-NUS Head & Neck Centre comprising clinical specialists, advanced nurse practitioners and allied health professionals.
Dr N Gopalakrisha Iyer Head and Senior Consultant SingHealth Duke-NUS Head and Neck Centre Common Signs and Symptoms Neck Lumps...... 6 Dysphagia (Difficulty in Swallowing)...... 9 Odynophagia (Pain on Swallowing)...... 12 Recurrent/Non-Healing Mouth Ulcers...... 14 Enlarged Neck Lump Nodes...... 16 Skin and Subcutaneous Lumps...... 19 Epistaxis...... 20 Hemoptysis...... 22
Diseases in the Head & Neck Region MOUTH/THROAT Salivary Gland Disorders...... 26 Oral Cancers...... 28 Oropharyngeal Cancers...... 30 Esophageal Cancer...... 32 Hypopharyngeal Cancers...... 34 Laryngeal Cancer...... 36 NECK Thyroid Nodules...... 38 Thyroglossal Duct Cysts...... 40 Thyroid Cancer...... 41 EAR/ NOSE Nasopharyngeal Carcinoma...... 46 Paranasal Sinus Tumour...... 48 MANDIBLE Jaw Cysts/Tumours...... 50 Common Head & Neck Reconstruction LOCAL FLAPS Nasolabial Flap...... 52 Rhomboid Flap...... 53 REGIONAL FLAPS Pectoralis Major Flap...... 53 Latissimus Dorsi Flap...... 54 FREE FLAPS Anterolateral Thigh...... 55 Radial...... 55 Fibula...... 56 Support Services Allied Health Professional Services...... 58 Common Oral Complications and Therapy...... 64 About the Centre...... 69 COMMON SIGNS AND SYMPTOMS
• Neck Lumps • Dysphagia (Difficulty in Swallowing) • Odynophagia (Pain on Swallowing) • Recurrent/Non-healing Mouth Ulcers • Enlarged Neck Lump Nodes • Skin and Subcutaneous Lumps • Epistaxis • Hemoptysis
Specialist services available at:
Head & Neck Centre @ Singapore General Hospital Tel: 6321 4377 (for appointments)
Head & Neck Centre @ National Cancer Centre Singapore Tel: 6436 8088 (for appointments) COMMON SIGNS AND SYMPTOMS Neck Lumps
What are neck lumps? acute infections such as upper respiratory tract infection, skin Lumps or swellings in the neck are infections, ear infections. They can common. Although the patient may also be enlarged due to chronic discover the lump by himself or infections such as tuberculosis. herself, very often the patient only becomes aware of the lump when Sometimes an enlarged lymph another person points it out to them. node in the neck can also be Although most neck lumps are benign, the first sign of underlying they sometimes can be a presentation cancer. Certain cancers (e.g. of a more serious underlying disease. nasopharyngeal cancers, melanoma, oral cancers) tend What are the causes of lumps in the neck? to spread to lymph nodes and an enlarged lymph node can There are many causes of lumps/ sometimes be the first sign of swellings in the neck. Below are some underlying cancer. Some cancers of the more common causes. like lymphoma also first develop in 1. Lymph Nodes lymph nodes. There are many causes for lymph 2. Thyroid Nodules nodes in the neck to be enlarged, The thyroid is a butterfly-shaped but one of the most common gland located in the front of the causes is due to infection. Lymph neck. It produces hormones that nodes may be enlarged due to control and regulate the growth and
6 SingHealth Healthy Living Series COMMON SIGNS AND SYMPTOMS
rate of function of many systems • Other lumps appearing around in the body. The thyroid gland can the lump sometimes develop solid or fluid- • Enlarged lymph nodes filled lumps. It is important to seek a medical Although most of these lumps opinion if you have any of these are not cancerous lumps, a symptoms. small proportion of them will be cancerous. Some of these lumps 4. Salivary Gland Enlargement may also cause problems when Salivary glands are organs in the they grow larger and compress neck that secrete saliva, which on other structures in the neck helps us digest our food. These causing swallowing and breathing glands can sometimes become difficulties. enlarged for various reasons that include tumours, infection or Some of these lumps may also secondary to an underlying medical secrete too much thyroid hormone condition. that may cause symptoms of hyperthyroidism. 5. Thyroglossal Cysts/Branchial Cysts It is important to see a doctor to These are lumps/cysts that occur evaluate these lumps, as it is not during the body’s development. easy to tell which lumps need Although present at birth, they may treatment without doing proper only enlarge and be discovered investigations. later on in life. These lumps/ 3. Skin and Subcutaneous Lumps cysts should usually be removed Lumps in the neck can also surgically to prevent complications. arise from the skin or just below What tests should I go for? the skin. Most of these lumps are not cancerous and do not If you find a lump in a neck that you cause symptoms. However a are worried about, the first step you small proportion of these lumps take is to get it checked by a doctor. can occasionally turn out to be Depending on what he finds, he may cancerous. Worrying signs include: order one or more of the following tests: • Change in size of a lump 1. Imaging Tests • Change in colour of surface of Depending on the condition, the the lump doctor may order one or more • Bleeding
All About Head & Neck Diseases 7 COMMON SIGNS AND SYMPTOMS Dysphagia (Difficulty in Swallowing) 2. Fine-needle Aspiration Cytology (FNAC) Your doctor may advise you to undergo a biopsy to evaluate the lump if he feels it is needed.
A fine-needle aspiration biopsy is a procedure where the doctor will pass a small needle through the lump to aspirate some cells for the lump for further testing. To improve accuracy, most FNAC are performed under ultrasound guidance.
What kind of treatment will I undergo? Depending on what the doctor finds, the doctor may advise you to have imaging tests to investigate the the lump removed surgically. In cases lump. These tests can include: where the lump is cancerous, it may • Ultrasound scans be necessary to remove the lymph nodes in the neck as cancer cells may • X-rays have spread to them. • Computer Tomographic (CT) scans Some lumps in the neck can be safely observed. Your doctor may advise you • Magnetic Resonance Imaging to have a follow-up test at a later date (MRI) scans to check if there are new changes. • Positron Emission Tomography (PET) scans
Role of GPs General Practitioners (GPs) should assess patients presenting with neck lumps to look for any suspicious or worrying features. A proper examination of the skin of the scalp, ears, oral cavity and throat should be done. Patients with thyroid nodules should be referred for further assessment. Patients with persistent enlarged lymph nodes, which fail to resolve, should also be referred for further evaluation in the SingHealth Duke-NUS Head & Neck Centre.
8 SingHealth Healthy Living Series COMMON SIGNS AND SYMPTOMS Dysphagia (Difficulty in Swallowing)
Difficulty swallowing can happen in any of these three phases.
Oropharyngeal Dysphagia Patients with dysphagia affecting the oropharyngeal phase of swallowing may complain of the following symptoms: • Difficulty initiating swallowing • Sensation of food “stuck” in the throat • Coughing or choking during swallowing • Recurrent chest infections
What is Dysphagia? Causes of oropharyngeal dysphagia Dysphagia refers to difficulty in include: swallowing. 1. Neurological Disorders The process of swallowing comprises Patients who have suffered a of three phases: previous stroke or spinal cord injury can have difficulty swallowing. 1. The oral phase: This is when Other neurological conditions such food is prepared in the mouth and as Parkinson’s disease, muscular propelled towards the pharynx atrophy, multiple sclerosis can (throat). This stage can be cause difficulty in swallowing. consciously controlled. 2. Cancer/Tumours 2. The pharyngeal phase: This The presence of certain cancers is where food moves through may cause difficulty in swallowing the pharynx (throat) towards the (e.g. tongue cancer). Additionally, oesophagus. This stage cannot be patients who have undergone consciously controlled. surgery or radiotherapy to the head and neck region may also develop 3. The oesophageal phage: This difficulty swallowing. is where food is transferred through the oesophagus into the Oesophageal Dysphagia stomach. This stage also cannot be Patients with dysphagia affecting the consciously controlled. oesophageal phase of swallowing may
All About Head & Neck Diseases 9 COMMON SIGNS AND SYMPTOMS
complain of the following symptoms: 5. Connective Tissue Disease Connective tissue diseases such • Sensation of food “stuck” in the as scleroderma can sometimes throat or chest cause hardening of the tissue in • Symptoms of heartburn, burping, the oesophagus and cause it to regurgitation become stiff. This can in turn cause difficulty in swallowing. • Recurrent chest infections
Causes of oesophageal dysphagia 6. Oesophageal Spasm In this condition, multiple include: involuntary poorly co-ordinated 1. Oesophageal Tumour contractions of the oesophagus Tumours in the oesophagus occur after swallowing. can cause obstruction. Difficulty swallowing is usually progressive 7. Foreign Body and usually starts, with solid food Objects that get lodged can block and later as the tumour grows the passage of food down the larger, liquids. oesophagus. This is seen more commonly in older people who 2. Achalasia may have difficulty chewing their This is a condition where the lower food well and resultantly swallow a oesophageal muscle (sphincter) large piece of food bolus that gets fails to relax adequately to allow lodged in the oesophagus. food to enter the stomach from the oesophagus. What tests can be done to investigate Dysphagia? 3. Gastro-oesophageal Reflux Depending on your symptoms and Disease your doctor’s findings, he or she may When the muscle in the lower order one of the following tests: oesophagus (sphincter) is inappropriately lax, acid from 1. Nasoendoscopy the stomach can reflux back into A thin flexible tube with a camera the oesophagus. This can lead and light source can be passed via to spasm and even scarring and one of the nostrils to look at the narrowing of the oesophagus. back of the nasal passage, throat and voice box. This is a quick test 4. Oesophageal Stricture that can be done in the clinic itself Narrowing in the oesophagus to look for abnormalities in the can be a result of scarring from upper aerodigestive tract. repeated irritation by acid reflux from the stomach or other caustic 2. Oesophago-gastro- substances, previous radiotherapy duodenoscopy (OGD) or previous procedures done. In an OGD, the doctor will pass
10 SingHealth Healthy Living Series COMMON SIGNS AND SYMPTOMS
barium to outline the stomach. This test is good to assess for mechanical causes of obstruction such as tumours and strictures.
5. Manometry In manometry, a small tube is inserted into your oesophagus to record the pressure and pattern of the contractions of your a flexible tube with a camera and oesophagus. This test is useful light through your mouth into your to diagnose functional causes of oesophagus, stomach and the dysphagia such as achalasia and duodenum (first part of the small diffuse oesophageal spasm. intestine). An OGD is useful for looking for mechanical causes What kind of treatment do I have to undergo? of dysphagia (e.g. tumours, strictures). It is usually a day The type of treatment you will need to procedure. undergo will depend on the underlying cause of the dysphagia. Your doctor 3. Videofluoroscopic swallow (VFS) will usually discuss this with you. Study This procedure is where a speech therapist examines your Role of GPs oropharyngeal swallow with the Causes of dysphagia are aid of a video X-ray. You will be varied and it is important instructed to take a variety of liquid to recongnise cases which and solid food in an X-ray suite. are required to be referred This is useful to look for anatomical for further investigations. and functional changes in the Cases in which cancer is oral and pharyngeal phases of strongly suspected (e.g. swallowing. The procedure is not associated with loss invasive and takes about half an of weight, progressive hour. swallowing difficulty from solids to liquids) should 4. Other Imaging Studies Your doctor may order some be referred urgently to X-rays or scans. One of these the SingHealth Duke- NUS Head & Neck X-rays is a barium swallow. In a barium swallow, an X-ray of Centre to avoid delays in your oesophagus and stomach is diagnosis. taken after swallowing some dilute
All About Head & Neck Diseases 11 COMMON SIGNS AND SYMPTOMS Odynophagia (Pain on Swallowing)
What is Odynophagia? voice box (larynx), tongue and Odynophagia refers to pain on oesophagus can also sometimes swallowing. cause pain when swallowing.
What are the causes of 3. Inflammation Odynophagia? Inflammation of the mouth, pharynx and oesophagus can Some of the common causes of sometimes occur when they are odynophagia include: exposed to caustic substances. 1. Infections These can sometimes be ingested Infections involving the tonsils, substances (e.g. hot fluids, acidic throat, epiglottis and oesophagus substances). Medical conditions may cause pain on swallowing. such as gastro-oesophageal reflux Some of these infections include: disease (GERD) can also cause a. Acute viral/bacterial pharyngitis inflammation when these organs are are constantly exposed to acid b. Acute tonsillitis reflux from the stomach. c. Oral and oesophageal candidiasis 4. Foreign Body d. HIV infections Foreign bodies (e.g. fish-bones) sometimes can get stuck when e. Herpes simplex infections they are swallowed. They can 2. Tumours lodge in the tonsils, throat or Cancers of the mouth, throat, oesophagus and cause pain on swallowing.
12 SingHealth Healthy Living Series COMMON SIGNS AND SYMPTOMS
5. Oesophageal Disorders co-ordination of the contractions Sometimes, pain on swallowing of your oesophagus. This test can be due to a disorder in the is useful to investigate motility motility of the oesophagus. These disorders affecting swallowing. include: 4. Imaging Studies a. Oesophageal spasm Your doctor may order some b. Achalasia X-rays or scans. One of these c. Nutcracker Oesophagus X-rays is a barium swallow. In a barium swallow, an X-ray of What tests can be done to your oesophagus and stomach is investigate odynophagia? taken after swallowing some dilute Depending on your doctor’s findings, barium to outline the stomach. This he or she may ask you to undergo one test is good for looking for tumours or more of the following investigations: and strictures.
1. Nasoendoscopy What kind of treatment do I have to A flexible camera with light is undergo? passed through one of your nostrils The type of treatment you will need to to look at the back of your nose, undergo will depend on the underlying larynx and throat. This test can cause of the odynophagia. Your doctor be done in the clinic and is useful will usually discuss this with you. to look for conditions affecting the throat, larynx and back of the tongue (e.g. ulcers and tumours). Role of GPs 2. Oesophago-gastro- It is important to recognise duodenoscopy (OGD) cardinal signs of odynophagia In an OGD, the doctor will pass which are required to a flexible tube with a camera and be referred for further light through your mouth into your investigations. Cases in oesophagus, stomach and the which cancer is strongly duodenum (first part of the small suspected (e.g. loss of intestine). An OGD is useful for weight or unresolved looking for mechanical causes pain on swallowing and of dysphagia (e.g. tumours, progression to swallowing strictures). It is usually a day difficulty) should be procedure. referred early at the SingHealth Duke-NUS 3. Manometry Head & Neck Centre for A tube with pressure sensors is further investigations. passed down your oesophagus to measure the strength and
All About Head & Neck Diseases 13 COMMON SIGNS AND SYMPTOMS Recurrent/Non-Healing Mouth Ulcers
What is a mouth ulcer? Non-healing ulcers - could it be A mouth ulcer is a loss of part of the cancer? mucous lining of your mouth. Most If an ulcer fails to heal within 2-3 single mouth ulcers are the result weeks, it is important to have it of minor trauma (e.g. accidentally evaluated by a doctor. In some biting yourself while eating) and will instances, these ulcers can turn out heal within a week or two. Although to be cancerous. If you smoke, drink troublesome and painful, these ulcers alcohol or chew betel nuts, you are are usually benign and are no cause at a higher risk of developing mouth for worry. or tongue cancers. However, even if you do not smoke, drink alcohol or Recurrent or non-healing mouth chew betel nut, it is still important to ulcers see a doctor if your ulcer fails to heal Some people develop ulcers in after 2-3 weeks as it may still be a the mouth that keep coming back. cancerous ulcer. Although in many cases the cause is not clear, certain underlying medical 1. Viral Infections conditions can predispose a person to The Herpes Simplex Virus causes having recurrent ulcers. cold sores. The virus causes
14 SingHealth Healthy Living Series COMMON SIGNS AND SYMPTOMS
painful ulcers that are usually eye inflammation, skin rashes as located over the lips or mouth. well as genital sores. Although the ulcers may recover, the virus usually lies dormant 6. Connective Tissue Diseases (inactive) but can be activated by Patients with connective tissue various triggers such as stress, or diseases such as Systemic Lupus in women, their menstrual period. Erythematosus (SLE), Reactive Other virus such as the Coxsackie, Arthritis and Sweet’s Syndrome Varicella and HIV viruses can also (rare skin disease, characterised cause mouth ulcers. by fever and appearance of tender solid red lumps). 2. Nutritional Deficiencies Deficiencies of certain vitamins (e.g. vitamin B12) and minerals (e.g iron, folate) can also Role of GPs predispose a person to recurrent GPs should refer cases of ulcers. ulcers that fail to heal after 2-3 weeks of treatment 3. Medications for biopsy. Mouth Certain medications can ulcers that have rolled cause ulcers as a side effect. or heaped-up edges These include drugs such as should be viewed with a bisphosphonates (used for high-index of suspicion osteoporosis), NSAIDs (a class and referred for early of pain-killer), beta-blockers and review at the SingHealth certain cytotoxic drugs. Duke-NUS Head & Neck Centre. 4. Inflammatory Bowel Disease Patients with inflammatory bowel disease especially Crohn’s disease may also develop recurrent mouth ulcers.
5. Behçet’s Disease Behçet’s disease is a poorly understood disease that causes inflammation of the blood vessels throughout the body. Patients may develop recurrent mouth ulcers,
All About Head & Neck Diseases 15 COMMON SIGNS AND SYMPTOMS Enlarged Neck Lymph Nodes
Cancers Another common cause of lymph node enlargement is from cancer. The cancer may arise primarily from the lymph nodes (e.g. lymphoma), but often they have spread to the lymph nodes from somewhere else (e.g. tongue cancer, nasopharyngeal cancer).
1. Primary Malignancies These include: • Leukemia • Lymphoma
Lymph nodes are small bean-shaped 2. Secondary (Metastatic) organs found throughout the body and Malignancies linked by lymphatic channels. Lymph These are cancers that have nodes are an important part of the spread to the lymph nodes immune system and act as “filters” from elsewhere in the body. It is which can trap foreign particles and important to examine the areas cancer cells. from where the cancers might have spread to look for a primary cancer In their normal state, they are usually (e.g. oral cavity, nasopharynx, skin, smaller than a pea in size, but in scalp, ears). Common cancers certain conditions, such as infections that can spread to the neck lymph and cancers, they may become nodes include: enlarged. When the lymph nodes in your neck are enlarged, you may be • Tongue and Oral cancers able to feel them as round to oval • Skin/Scalp cancers shaped swellings in your neck. • Thyroid cancers What are the causes of enlarged • Nasopharyngeal cancers neck lymph nodes? • Gastrointestinal cancers (e.g. There are many reasons why the stomach and colon cancers) lymph nodes in the neck may become enlarged, but the two most common • Breast cancers causes are due to infection and • Lung cancers cancers.
16 SingHealth Healthy Living Series COMMON SIGNS AND SYMPTOMS
Infections Streptococcal infections of the 1. Viral Infections throat (Streptococcal Pharyngitis) Lymph nodes in the neck can can be a source of lymph node often be enlarged as a reaction enlargement in the neck. after an upper respiratory tract 3. Other Infections infection. Many viruses can cause Other infections that can cause enlargement of the lymph nodes. enlargement of the lymph nodes in These include the following: the neck include tuberculosis and • Epstein-Barr Virus (EBV) syphilis. • Cytomegalovirus (CMV) Other causes • Varicella-Zoster Virus Some other less common conditions • Rubella in which lymph nodes of the neck can be enlarged include: • Human Immunodeficiency Virus (HIV) • Systemic Lupus Erythematosus (SLE) 2. Bacterial infections • Juvenile chronic arthritis Lymph nodes in the neck may also be enlarged from bacterial • Rheumatoid arthritis infections. The source of the • Sarcoidosis infection may not be in the neck itself but may be from the areas of • Kawasaki Disease lymph drainage (e.g. throat, skin, What tests will I have to undergo? ears). It is important to examine the areas where the lymph nodes drain Depending on the presentation and to look for a source of infection. findings, your doctor may need to
All About Head & Neck Diseases 17 COMMON SIGNS AND SYMPTOMS perform a thorough head and neck test, the doctor passes a small examination that will include: needle through the lymph node and aspirates some cells from it for • Examination of the oral cavity and testing. The cells from the lymph pharynx nodes are smeared onto a glass • Neck examination side for staining and analysis by a • Otoscopy (examination of the ears) cytologist. • Nasoendoscopy (examination of 4. Surgery the nasal cavity, back of the nose At times, more tissue than and larynx with a flexible camera) obtainable from a fine-needle aspiration will be required. In these A breast examination and abdominal cases your doctor will schedule you examination may be also required. to go to the operating theatre to Further tests may be ordered that may remove a lymph node for testing. include: This can usually be done as a day surgery procedure and can 1. Ultrasound Scan be done under local or general In this scan, a probe that produces anaesthesia. sound waves is used to create an image of your neck and its lymph nodes on a screen. This test is Role of GPs non-invasive, painless and does not involve any ionising radiation. Patients who present with enlarged lymph nodes 2. Computer Tomographic (CT) should undergo a thorough scans and Magnetic Resonance history taking and physical Imaging (MRI) examination to look for the Your doctor may order a CT or underlying cause. In patients MRI scan for you. These scans where enlarged lymph nodes will usually entail you lying down are suspicious of an on a motorised bed that will pass underlying malignancy through a scanner to obtain an (rubbery or hard nodes, image. The CT scan uses ionising lymph nodes >3cm, fixed radiation to produce an image or matted lymph nodes, whereas an MRI scan entails the evidence of a primary use of a strong magnetic field and cancer, associated loss radio frequency waves. of appetite and weight) should be referred for 3. Fine-needle Aspiration Biopsy early evaluation at the Sometimes your doctor may decide SingHealth Duke-NUS if it is necessary to obtain a biopsy Head and Neck Centre. of an enlarged lymph node. In this
18 SingHealth Healthy Living Series COMMON SIGNS AND SYMPTOMS Skin and Subcutaneous Lumps
3. Epidermoid cysts These are benign cysts that arise from the skin. They are usually slow growing and painless. They can however become infected and when this happens the lump may become red, painful and have discharge.
What treatments are available? If the lump is troublesome or your doctor feels it is necessary to remove it, you may be advised to undergo an excision biopsy. This is usually done in an operating theatre under local or general anaesthesia and is usually done as a day surgery procedure. Lumps in the neck can arise from the skin and the subcutaneous tissue. Two of the most commonly seen lumps are Role of GPs lipomas and epidermal cysts. Skin cancers can appear as painless areas of raised skin/ 1. Skin Cancers moles which can develop Skin cancers are cancers that arise into non-healing ulcers. It from the skin. It is usually slow- is important to identify and growing and of low malignancy. It recognise symptoms that often appears as a painless raised requires further investigation. area of skin which result in non- Cases in which skin cancer healing ulceration of the area. is strongly suspected (e.g. increase in size of 2. Lipomas Lipomas are benign tumours abnormal skin area and composed of adipose (fat) tissue. moles and non-healing They are soft, small and usually ulcers on the skin) painless but can enlarge gradually should be referred early over time. Sometimes the lumps for further investigations can become troublesome if they at the SingHealth Duke- enlarge and may need to be NUS Head & Neck removed surgically. Centre.
All About Head & Neck Diseases 19 COMMON SIGNS AND SYMPTOMS Epistaxis
the breaking of the overlying mucus membrane of the Little’s Area. 2. Trauma: Blunt trauma can result in nasal contusion or nasal bone/ cartilage fractures. Patients can experience epistaxis immediately after the trauma and the bleeding may persist indefinitely until some first aid measures are instituted. Most of such cases will cease without a need for any surgical intervention.
3. Sinonasal Infections/ Inflammation:Conditions such as allergic rhinitis and infective rhinosinusitis can cause inflammation of the nasal mucosa, Epistaxis refers to bleeding from the sometimes resulting in breakage nose and is a common complaint with and bleeding. both adults and children. The exact incidence is hard to determine as 4. Cancer most cases are minor and patients Nasopharyngeal cancers (NPC) do not seek treatment. Patients may is the most common cancer of complain of per-oral bleeding or blood- the nose. Common symptoms of stain sputum as well since blood can NPC include blood-stained nasal flow backwards and down the throat. drainage, blocked ears and nose, loss of weight and pain over facial Causes area. It is commonly linked with 1. Little’s Area Epistaxis: By far, the infection by the Epstein-Barr virus most common cause of epistaxis (EPV), smoking and inherited is the rupture of small blood characteristics. vessels (Kiesselbach’s Plexus) at the Little’s Area of the nose. 5. Nasal Tumours This is often precipitated by minor Nasal tumours are abnormal trauma, such as nose-picking or growth in the nose. It can occur rubbing, but can sometimes occur as a benign or malignant tumour. spontaneously in dry air, resulting Associated symptoms of numbness
20 SingHealth Healthy Living Series COMMON SIGNS AND SYMPTOMS
or pain, swelling in areas of the If the cause is deemed to be infective face or lymph nodes in the neck, sinusitis, the patient should be given change in symmetry of the eyes appropriate oral antibiotics. In cases or face and visual changes are where cancer is highly suspected, cardinal signs to be investigated. examination with a nasoendoscopic and a biopsy is recommended. Management First aid measures for Little’s Area Less common causes Epistaxis includes applying pressure Occasionally, epistaxis may herald over the bleeding vessels by pinching uncommon conditions such as the firmly on the soft, cartilaginous portion following: of the external nose and tilting the • Blood coagulation disorders head forward and downwards for 3-5 minutes. Cold-compress over the • Excessive anti-coagulation forehead and ice-water gargles can • Vascular malformations also help. • Auto-immune disorders The underlying cause should be determined and treatment directed at that. For example, if the clinical impression is that of a Little’s Area Epistaxis, the patient can be given the advice to avoid nose-picking and a barrier ointment (like white soft paraffin) to apply over the Little’s Area.
Role of GPs When to seek specialist review 1. Do not forget the ABC (airway, breathing, circulation) for any patient with excessive epistaxis and have them reviewed and managed at the nearest Accident & Emergency department. 2. Repeated consultations for recurrent epistaxis despite medical treatment. 3. Family history of head & neck and hematological malignancies. 4. Previous history of head & neck and hematological malignancies.
Cases in which cancer is strongly suspected, an early referral to the SingHealth Duke-NUS Head & Neck Centre for further investigations is encouraged to avoid delay in diagnosis.
All About Head & Neck Diseases 21 COMMON SIGNS AND SYMPTOMS
Hemoptysis nausea and vomiting as well as food particles that can be seen. The colour of the blood can range from bright red to dark, almost black doted (“coffee ground” like) and should be best assessed by a physician as well.
What causes Hemoptysis? The lungs, which are situated in the chest with the heart sitting between the right and the left lung lobe, usually get their blood supply from 2 different sources.
Most of the blood (95%) comes from the low-pressure pulmonary arteries and ends up in the pulmonary capillary bed, where gas is exchanged. A small portion (about 5%) of the blood supply What is Hemoptysis? circulates via high-pressure bronchial arteries, which come from the aorta Hemoptysis is best described as and supply the structures of the major “coughed up blood”. Often hemoptysis airways with blood. is not a disease itself but can signify a variety of underlying problems and In most cases of hemoptysis the should therefore be properly assessed blood originates from the pulmonary by a doctor. Blood can manifest in capillary bed (low pressure) and only many different forms, however often it in more rare cases (e.g. due to trauma is frothy and bright red. or injury) from the high-pressure bronchial arteries. The amount can be as minimal as blood stains in the spit (sputum) If large volumes of blood enter the to more obvious larger amounts of airway there is a risk of drowning and blood or clots that would need a massive hemoptysis may result in more immediate attention of a doctor. severe anemia, both of which are life Amounts larger than 600ml are usually threatening. regarded as massive hemoptysis and do require emergency medical The reasons for hemoptysis can vary attention. widely, common causes of hemoptysis include: Hemoptysis should not be confused a. Infection: An infection of the main with hematemesis – which describes airways (called bronchitis) and the the vomiting of blood and, unlike lung tissue (called pneumonia) hemoptysis, is often associated with
22 SingHealth Healthy Living Series COMMON SIGNS AND SYMPTOMS
are perhaps the most common c. Bronchiectasis: One or more (approximately 70%) causes of airways are unusually widened. mild episodes of hemoptysis. Often This can lead to an extra other symptoms such as fatigue, production of mucous that collects fever or even shortness of breath in these areas – which explains the are present as well. Usually with main symptom of a recurrent cough treating the underlying infection, with large amounts of phlegm. the hemoptysis will disappear These widened airways have a as well. Another typical cause of preponderance of getting infected, hemoptysis is still tuberculosis, which can result in blood being which can present with night mixed in the phlegm. sweats and loss of weight. d. Inhalation of foreign bodies: The b. Cancer: Cancer of the lung can inhalation of small objects such develop from the cells lining the as peanuts or small toy parts can bronchi (airways). One of the cause injury and bleeding from earliest symptoms of lung cancer the airways. This can frequently can be the coughing of blood; in happen in children and when fact, it can be the first symptom suspected, should be addressed by before others develop. Usually lung a pediatrician (doctor specialising cancer develops in people above in children care). the age of 50 and who are smokers e. Pulmonary embolism: A or have had a history of smoking pulmonary embolism is a blood or passive smoking. There are also clot blocking the main blood other types of lung cancer that can vessels of the lung. This is a develop in younger, non-smoking potentially life-threatening condition patients. that can present with (severe) breathlessness, chest pain and hemoptysis. f. Heart failure: Severe heart failure can lead to a build-up of fluids in the lungs and which, besides breathlessness, can also lead to blood stains in the sputum – which often is frothy. g. Inflammation and abnormal tissue deposits: Usually these are much more rare conditions, which may not only affect the lung tissue but can lead to abnormal tissue deposits in a variety of organs.
All About Head & Neck Diseases 23 COMMON SIGNS AND SYMPTOMS
Sometimes these inflammatory – is performed to identify a source of lesions and tissue deposits can the bleeding or to even get a tissue lead to bleeding which then biopsy from suspicious lesions. causes hemoptysis. Some conditions that would fall under Besides these, your doctor might this category would be Wegener’s order an electrocardiogram (ECG) granulomatosis, Goodpasture’s or echocardiogram (Echo) if a heart syndrome, lupus pneumonitis or problem or a pulmonary embolism is endometriosis. suspected. h. No cause identified: Some Other tests such as sputum analysis patients (about 5%) may fall under and culture, full blood count and this category, where no clear cause tests of the blood clotting ability can be established even when might be ordered. In unclear cases all necessary investigations have more sophisticated tests such as been performed. CT angiograms (CT to show specific blood vessels) or even Positron What investigations do I have to go Emission Tomography/CT (PET or for? PET/CT) may be ordered to further Ideally, all patients presenting with investigate. hemoptysis should undergo further tests to rule out any underlying sinister What is the treatment for causes. Besides the routine physical Hemoptysis? examination, your doctor will order a Depending on the underlying cause chest x-ray as a first assessment. If of the hemoptysis the treatment might that is normal, further investigations range from observation and antibiotic might be necessary such as a treatment to more invasive treatment computed tomography (CT) of the such as bronchoscopy or open chest. Often a bronchoscopy – an surgery. endoscopic examination of the airways
Role of GPs A detailed history, including currently used medications, performing a physical examination and auscultation of the lungs are important steps in the investigation of the underlying causes. If available a chest x-ray should be taken. If the cause is unclear or a more significant diagnosis such as lung cancer, underlying heart problems or infections (especially tuberculosis) are suspected, a specialist referral should be made. If a massive hemoptysis is noted or a inhaled foreign body is suspected, send the patient to the Department of Emergency immediately as these conditions are potentially life threatening.
24 SingHealth Healthy Living Series DISEASES IN THE HEAD & NECK REGION
• Salivary Gland Disorders • Oral Cancers • Oropharyngeal Cancers • Esophageal Cancer • Hypopharyngeal Cancers • Laryngeal Cancer • Thyroid Nodules • Thyroglossal Duct Cysts • Thyroid Cancer • Nasopharyngeal Carcinoma • Paranasal Sinus Tumour • Jaw Cysts/Tumours
Specialist services available at:
Head & Neck Centre @ Singapore General Hospital Tel: 6321 4377 (for appointments)
Head & Neck Centre @ National Cancer Centre Singapore Tel: 6436 8088 (for appointments) DISEASES IN THE HEAD AND NECK REGION
MOUTH/THROAT Salivary Gland Disorders
Salivary gland disorders can be lumen. There are special forceps and divided into infection/inflammation or catheters that can be passed through tumours. this scope that enable extraction of stones and administration of Salivary gland infection/ medication such as steroids. Hence, inflammation (sialedenitis) this procedure is both diagnostic and Any patient with salivary gland therapeutic. infection will complain of a painful swelling that developed over a few Is there a role for surgery in days. Pain and swelling usually sialadenitis? increase with meals. These episodes In cases whereby the salivary ductal may be recurrent especially if they are stones are too large or too deep within precipitated by salivary duct stones the salivary gland parenchyma to be causing obstruction to the salivary reached by the sialendoscope, surgery flow. is then advised.
Acute treatment consists of painkillers Salivary Gland Tumours and antibiotics. However, if the Salivary gland growths make up 6% of episodes are recurrent, a computed all head and neck tumours. They can tomography scan or sialendoscopy is be benign or malignant. Salivary gland performed to look for possible stones cancers are rare with an incidence of or other causes of ductal obstruction. 1 in 100 000 per population per year in What is a sialendoscopy? Singapore. Salivary glands are divided into two groups: major and minor salivary glands. • The major salivary glands are the parotid, submandibular and sublingual glands. • The minor salivary glands are numerous and they are scattered throughout the upper aerodigestive tract.
A sialendoscopy is a tiny scope that Majority of salivary gland tumours is passed into the salivary duct which grow in the parotid glands, fortunately, allows visualization of the ductal most of them are benign. 50% of submandibular gland growths are
26 SingHealth Healthy Living Series DISEASES IN THE HEAD AND NECK REGION
enlarging lump. Those with advanced parotid cancers may also suffer from unilateral facial weakness. Rarely in cases of laryngeal minor salivary gland tumours, patients may complain of shortness of breath as a result of airway obstruction from the tumour mass.
How do we investigate a salivary gland tumour? After a thorough head and neck physical examination, we will perform a fine needle aspiration cytology of the lump and a computed tomography scan or magnetic resonance imaging to determine the size of the growth, its extent and infiltration and possible nodal spread.
What are the main modalities of treatment? For benign growths, surgery alone will be adequate. However in cancerous while 75% of sublingual cancerous growths, patients may and minor salivary gland tumours are need to undergo radiotherapy with or cancerous. without chemotherapy after surgery is performed. How do salivary gland tumours present? Patients with salivary gland tumours usually complain of a painless slowly
Role of GPs GPs play a pivotal role in identifying suspicious lesion around the salivary glands. Red flag signs include increasing growth, lymph nodes enlargement and facial weakness or asymmetry, and for these patients, early referral to a specialist at the SingHealth Duke- NUS Head & Neck Centre is highly recommended.
All About Head & Neck Diseases 27 DISEASES IN THE HEAD AND NECK REGION
MOUTH/THROAT Oral Cancers
Overview Oral cancers are more commonly seen in the middle-aged group and elderly, affecting men more than women.
Risk factors include: 1. Smoking 2. Heavy alcohol consumption 3. Betel nut chewing 4. Tobacco chewing 5. Chronic irritation from ill-fitting dentures 6. Sun exposure (for lip cancer) 7. Poor immunity states, e.g. despite medication. Other complaints patients on immunosuppressants include: or HIV 1. Persistent presence of blood in 8. Human Papilloma Virus (HPV) saliva infection 2. Lump/nodule with contact bleeding 9. Poor nutrition especially diets low in fruits and vegetable 3. Numbness of chin or lower lip 10. Premalignant oral lesions: 4. Pain upon eating/swallowing –– Leukoplakia, which is a 5. Persistent earache persistent white patch in the 6. Lump in the neck (which usually oral cavity indicates a spread of the cancer to –– Erythroplakia, which is a the lymph nodes) persistent brightly coloured How do we and diagnose oral smooth area in the oral cavity cancers? (erythroplakia has higher risks of turning cancerous than A thorough head and neck leukoplakia) examination is performed which includes examination of the oral cavity, What are the symptoms of the neck and a nasoendoscopy. A oral cancers? biopsy of the oral cavity lesion is then Patients usually present with non- performed under local anesthesia healing ulcers of more than 3 weeks as a clinic procedure. A fine needle
28 SingHealth Healthy Living Series DISEASES IN THE HEAD AND NECK REGION
aspiration cytology is also performed on any neck node. Either a computed tomography scan or magnetic resonance imaging (CT or MRI) is done to evaluate the extent of the oral cavity lesion and possible neck node involvement. If the biopsy confirmed the diagnosis of cancer, then a CT scan of the thorax and liver are done as part of the staging work-up, looking for distant spread to the lungs or the The preferred treatment is surgery liver. of the oral cavity cancer and the How do we treat oral cancers? associated lymphatic/nodal drainage pathway in the neck. The surgical All cases will be discussed at the defect may require reconstruction multidisciplinary tumour board where to ensure a functional and cosmetic the best recommended treatment outcome (refer to chapter on Head options will be detailed. Treatment & Neck Reconstruction). Post- modality depends on: operative radiotherapy with or without 1. Age and general health of the chemotherapy will be decided based patient on tumour characteristics.
2. Extent of the oral cavity lesion Even after completing treatment of infiltration the cancer, patients often have to 3. Stage of the cancer undergo months of rehabilitation as 4. Patient’s expectations and surgery can result in altered speech preferences and swallowing. Hence, intensive speech and swallowing therapy as well as regular dietician review is to be expected by our patients.
Role of GPs The oral cavity is an easy area to be examined even in the primary care setting. Any premalignant oral cavity lesions, non-healing ulcers, suspicious ulcers with heaped up edges, nodules or ulcers with contact bleeding and patients with oral cavity lesions with associated neck nodes should be referred urgently to the SingHealth Duke-NUS Head & Neck Centre for further evaluation. In addition, counselling by the primary care physician to manage modifiable risk factors is extremely essential in the primary prevention of oral cavity cancers.
All About Head & Neck Diseases 29 DISEASES IN THE HEAD AND NECK REGION
MOUTH/THROAT Oropharyngeal Cancers
Overview 1. Persistent presence of blood in Oropharyngeal cancers are usually saliva seen in the middle-aged group and 2. Pain upon eating/swallowing elderly, with the exception of Human 3. Chronic sore throat Papilloma Virus (HPV) related cancers which occur in the younger age group. 4. Change in voice Men are more commonly affected than 5. Persistent feeling of lump in throat women. 6. Persistent earache Risk factors include: 7. Difficulty in mouth opening 1. Smoking 8. Lump in the neck (which usually indicates a spread of the cancer to 2. Heavy alcohol consumption the lymph nodes) 1. Human Papilloma Virus (HPV) infection How do we work-up and diagnose oropharyngeal cancers? 1. Poor nutrition especially low in dietary fibre A thorough head and neck examination is performed which 2. Immunocompromised states, e.g. includes examination of the oral cavity, patients on immunosuppresants, the neck and a nasoendoscopy. HIV A biopsy of the oropharyngeal lesion Where exactly is the oropharynx? may be attempted in the clinic under The oropharynx lies between the local anaesthesia if it is visible nasopharynx and hypopharynx. and accessible via the oral cavity. Otherwise, a panendoscopy and It consists of: biopsy under general anaesthesia 1. Soft palate are done in the operating theatre. For tonsillar cancers, a tonsillectomy 2. Tonsils may be performed during the 3. Back of throat (posterior panendoscopy for diagnosis. pharyngeal walls) A fine needle aspiration cytology is 4. Posterior one-third of the tongue also performed of any neck node. What are the symptoms of Either a computed tomography scan oropharyngeal cancers? or magnetic resonance imaging (CT or MRI) is done to evaluate the extent of Most patients complain of: the oropharyngeal lesion and possible neck node involvement. If the biopsy
30 SingHealth Healthy Living Series DISEASES IN THE HEAD AND NECK REGION confirmed the diagnosis of cancer, a CT scan of the thorax and liver is done as part of the staging work-up, looking for distant spread to the lungs or the liver.
How do we treat oropharyngeal cancers? All cases will be discussed at the multidisciplinary tumour board where operative radiotherapy, with or without the best recommended treatment chemotherapy. options will be detailed. Treatment modality depends on: Surgery for oropharyngeal cancers can be done through the mouth 1. Age and general health of the (transoral approach) or may require patient open approaches that involve splitting 2. Extent of the oropharyngeal lesion the lip and/or the mandible or through infiltration the neck. With the increasing use of 3. Stage of the cancer robotic surgery, transoral approach can be applied to many more cases of 4. Patient’s expectations and oropharyngeal cancers that previously preferences needed the open approaches for For early stage disease, single access. modality treatment is considered Even after completion of treatment of either with radiotherapy or surgery cancer, patients often have to undergo of the primary oropharyngeal lesion months of rehabilitation due to altered and the associated nodes in the speech and swallowing. Hence, neck. For more advanced stages, intensive speech and swallowing multi-modality treatment is needed, therapy, as well as regular dietician either a combination of chemo- review, is to be expected by our radiotherapy or surgery with post- patients.
Role of GPs Unlike oral cavity lesions, oropharyngeal lesions are not easily visualised and examined. Good history taking is imperative in suggesting malignant oropharyngeal pathology in the primary care setting. Patients who complain of chronic sore throat, earache with adnormal ear examination findings or non-resolving globus sensation should be referred to the SingHealth Duke-NUS Head & Neck Centre for further evaluation.
All About Head & Neck Diseases 31 DISEASES IN THE HEAD AND NECK REGION
MOUTH/THROAT Esophageal Cancer
Overview The esophagus is a long muscular tube, that connects the throat to the stomach, transporting food that is swallowed to the stomach for digestion. Esophageal cancer is more common in males, and usually appears in patients 60-70 years of age.
Risk factors include: 1. Smoking 2. Heavy alcohol consumption 3. Diet low in fruits and vegetable 4. Obesity 5. Reflux 6. Barret’s esophagus (in this condition, the esophageal lining is altered as a complication of long- standing poorly controlled reflux)
What are the symptoms of esophgeal cancers? How do we work-up and diagnose Patients complain of: esophageal cancer? 1. Difficulty swallowing A thorough head and neck examination is performed which 2. Weight loss includes the examination of the oral 3. Bloody vomit cavity, the neck and a nasoendoscopy. 4. Black tarry/sticky stools Physical examination is usually 5. Central chest pain normal, unless there is a lymph node spread in the neck or enlarged 6. Heartburn liver due to distant spread. An 7. Hoarse voice OGD (esophagoduodenoscopy) is performed to visualize the growth and for biopsy.
32 SingHealth Healthy Living Series DISEASES IN THE HEAD AND NECK REGION
Endoscopic ultrasound may also be 3. Stage of the cancer done to determine the depth and local 4. Patient’s expectations and extent of the growth. A Computed preferences Tomography scan (CT) evaluates the extent of the tumour and invasion For early stage disease, endoscopic of the surrounding structures. If the surgery may be performed. However biopsy confirmed the diagnosis of in more advanced disease, a cancer, then a CT scan of the thorax combination of chemo-radiation and and liver is done as part of the staging surgery is usually preferred. Surgery work-up, looking for distant spread to of more advanced disease is done the lungs or the liver. via open approaches (transhiatal or transthoracic e.g. through the How do we treat esophageal diaphragm or the chest respectively). cancers? Suitably selected cases can be done All patients will be discussed at the via minimally invasive techniques. multidisciplinary tumour board where the best recommended treatment options will be detailed. Treatment options depends on: 1. Age and general health of the patient 2. Extent of the esophageal lesion infiltration
Role of GPs All patients complaining of unexplained weight loss or difficulty swallowing warrants an early referral at the SingHealth Duke-NUS Head & Neck Centre for early evaluation. An OGD is usually done as part of the initial investigation.
All About Head & Neck Diseases 33 DISEASES IN THE HEAD AND NECK REGION
MOUTH/THROAT Hypopharyngeal Cancers
Where exactly is the hypopharynx? The hypopharynx is the most inferior part of the pharynx that leads into the esophagus.
It consists of 3 parts: 1. Posterior pharyngeal wall 2. Pyriform sinus 3. Post-cricoid area What are the symptoms of hypopharyngeal cancers? Hypopharyngeal cancers are usually silent in the early stages. Larger Overview tumours are responsible for majority Hypopharyngeal cancers are usually of patient’s complaints. Patients may seen in the middle-aged group and complain of: elderly, with the incidence rising 1. Persistent sore throat above the age of 40. Men are more 2. Difficulty swallowing commonly affected than women with a 3:1 ratio. It accounts for 7% of all 3. Persistent feeling of lump in throat cancers of the upper aerodigestive 4. Persistent earache tract. 5. Blood in saliva or sputum Risk factors include: 6. Change in voice 7. Lump in the neck (which usually 1. Smoking indicates a spread of the cancer to 2. Heavy alcohol consumption the lymph nodes) 3. Chewing tobacco 4. Poor nutrition especially low in dietary fibre 5. Plummer-Vinson syndrome (a disease marked by iron-deficiency anaemia, and formation of web-like membranes in the throat causing difficulty swallowing)
34 SingHealth Healthy Living Series DISEASES IN THE HEAD AND NECK REGION
How do we work-up and diagnose the primary hypopharyngeal lesion hypopharyngeal cancers? and the associated nodes in the A thorough head and neck neck. Conservative surgery may examination is performed which be performed for small tumours, includes examination of the oral cavity, especially if robotics expertise is the neck and a nasoendoscopy. A available. For more advanced stages, panendoscopy and biopsy under multi-modality treatment is needed, general anaesthesia is done in the either a combination of chemo- operating theatre for tissue diagnosis. radiotherapy or surgery with post- A fine needle aspiration cytology is operative radiotherapy, with or without also performed of any neck node. chemotherapy. Either a computed tomography scan Even after completion of treatment of or magnetic resonance imaging (CT cancer, patients often have to undergo or MRI) is done to evaluate the extent months of rehabilitation due to altered of the hypopharyngeal lesion and speech and swallowing. Hence, possible neck node involvement. If intensive speech and swallowing the biopsy confirmed the diagnosis of therapy as well as a regular dietician cancer, a CT scan of the thorax and review is to be expected by our liver is done as part of the staging patients. work-up, looking for distant spread to the lungs or the liver.
How do we treat hypopharyngeal Role of GPs cancers? Hypopharyngeal cancers are All patients will be discussed at the not easily detected due to its multidisciplinary tumour board where anatomical position. A detailed the best recommended treatment history is important in the options will be detailed. Treatment evaluation of the condition. modality depends on: Cases where cancer is highly suspected (e.g. persistent sore 1. Age and general health of the throat, globus sensation patient during swallowing, 2. Extent of the hypopharyngeal voice changes and lesion infiltration lymph nodes in the 3. Stage of the cancer neck) should be referred early to the 4. Patient’s expectations and SingHealth Duke-NUS preferences Head & Neck Centre For early stage disease, single for early evaluation and modality treatment is considered investigations. either with radiotherapy or surgery of
All About Head & Neck Diseases 35 DISEASES IN THE HEAD AND NECK REGION
MOUTH/THROAT Laryngeal Cancer
2. Glottis, the area of the vocal chords 3. Subglottis, the part below the vocal chords leading into the trachea
What are the main functions of the larynx? The larynx is responsible for: 1. Maintaining an open airway (breathing) Overview 2. Voice production Laryngeal cancers are the most 3. Preventing aspiration (preventing common cancers of the upper food particles from accidentally aerodigestive tract, affecting men entering the windpipe) more than women and in the older age group. 4. Protecting the lungs from harmful or irritative substances Risk factors include: What are the symptoms of laryngeal Smoking 1. cancers? 2. Heavy alcohol consumption Patients complain of: 3. Human papillomavirus infection 1. Voice hoarseness 4. Low dietary fibre or diets rich in preserved meats and fats 2. Shortness of breath 5. Exposure to industrial fumes or 3. Recurrent lung infection due to reagents such as paint, asbestos, aspiration diesel, gasoline fumes 4. Blood stained sputum 6. Chronic laryngopharyngeal reflux 5. Difficulty swallowing Where exactly is the larynx? 6. Lump in the neck (which usually indicates a spread of the cancer to The larynx opens into the trachea the lymph nodes) (windpipe). 7. Persistent throat pain or earache It divided into 3 main parts: 1. Supraglottis, the part above the vocal chords
36 SingHealth Healthy Living Series DISEASES IN THE HEAD AND NECK REGION
How do we work-up and diagnose 2. Extent of the laryngeal lesion laryngeal cancers? infiltration A thorough head and neck 3. Stage of the cancer examination is performed which 4. Preservation of voice includes examination of the oral cavity, the neck and a nasoendoscopy. A 5. Patient’s expectations and panendoscopy and biopsy under preferences general anaesthesia is done in the For early stage disease, single operating theatre for tissue diagnosis. modality treatment is considered A fine needle aspiration cytology is either with radiotherapy or surgery also performed of any neck node. of the primary laryngeal lesion Either a computed tomography scan and the associated nodes in the or magnetic resonance imaging (CT neck. For more advanced stages, or MRI) is done to evaluate the extent multi-modality treatment is needed, of the laryngeal lesion and possible either a combination of chemo- neck node involvement. If the biopsy radiotherapy or surgery with post- confirmed the diagnosis of cancer, a operative radiotherapy, with or without CT scan of the thorax and liver is done chemotherapy. as part of the staging work-up, looking for distant spread to the lungs or the Even after completion of treatment of liver. cancer, patients often have to undergo months of rehabilitation due to altered How do we treat laryngeal cancers? speech and swallowing. Hence, All patients will be discussed at the intensive speech and swallowing multidisciplinary tumour board where therapy as well as a regular dietician the best recommended treatment review is to be expected by our options will be detailed. Treatment patients. modality depends on: 1. Age and general health of the patient
Role of GPs Any patient with progressive worsening hoarseness, breathlessness, persistent sore throat and difficulty swallowing should be referred early to the SingHealth Duke-NUS Head & Neck Centre for further evaluation and investigations.
All About Head & Neck Diseases 37 DISEASES IN THE HEAD AND NECK REGION
NECK Thyroid Nodules
What are thyroid nodules? What tests will I have to undergo? The thyroid is a butterfly-shaped 1. Thyroid function tests gland located in the front of the neck. This is a blood test where the It produces hormones that control levels of your thyroid hormones metabolism in the body. The thyroid (T4) and thyroid-stimulating gland can sometimes develop solid or hormone (TSH) are measured. If fluid-filled lumps (cysts). These lumps your levels of thyroid hormones often do not cause symptoms and are too high (hyperthyroidism), you many of them are found incidentally may experience symptoms such during a medical consultation for as palpitations, feeling hot easily, another problem or during routine irritability, diarrhoea, weight loss check-ups. and increased appetite.
Although most of these lumps are not If your thyroid hormone levels are cancerous lumps, a small proportion too low (hypothyroidism) you may of them will be cancerous. Some of feel easily tired and lethargic, gain these lumps may also cause problems weight easily, constipation, memory when they grow larger and compress loss and feeling cold easily. on other structures in the neck causing swallowing and breathing Thyroid-related diseases cannot difficulties. Some of these lumps be excluded even if the thyroid may also secrete too much thyroid function test is within normal hormone that may cause symptoms of ranges. hyperthyroidism.
38 SingHealth Healthy Living Series DISEASES IN THE HEAD AND NECK REGION
2. Ultrasound Scan In this scan, sound waves are used to produce a picture of your thyroid gland and neck structures on a screen. The ultrasound scan is very useful for evaluating thyroid nodules and to look for features that may indicate that the thyroid nodule is suspicious for cancer. It is also useful for looking for any enlarged lymph nodes in the neck. However if there is a chance the lump This scan is painless and there is may be a cancerous lump, or the lump no ionising radiation involved. is causing symptoms, your doctor may advise you for surgery. Surgery will 3. Fine-needle Aspiration Cytology usually involve removal of the thyroid (FNAC) gland (thyroidectomy). Your doctor may advise you to undergo a biopsy to evaluate the Some thyroid cancers can spread to lump if he feels that it is needed. the lymph nodes in the neck and your doctor may need to remove some of A fine-needle aspiration biopsy is the lymph nodes in your neck during a procedure where the doctor will the operation as well. pass a small needle through the lump to aspirate some cells for the lump for further testing. These Role of GPs cells will be examined under a Patients who present with microscope to look for signs of neck lumps that are suspicious cancer. or have worrying features This biopsy is often done using an should be referred for further ultrasound to guide the doctor to investigation. Cases where biopsy the correct place. cancer is highly suspected (e.g. What treatment will I need to firm to hard lesions, undergo? compressive symptoms If the results of the ultrasound and or hoarseness and fine-needle aspiration show that the enlarged lymph nodes) thyroid nodule is unlikely to be cancer, should be referred early your doctor may choose to observe to the SingHealth Duke- the lump and repeat an ultrasound NUS Head & Neck scan 6-12 months later to look for any Centre to avoid delays growth or changes in the lump. in diagnosis.
All About Head & Neck Diseases 39 DISEASES IN THE HEAD AND NECK REGION
NECK Thyroglossal Duct Cysts
front of the neck in the midline. These lumps tend to move with swallowing and protrusion of the tongue. These lumps are usually painless, however they can become infected and if they do, they may become painful and red.
What tests will I have to undergo? (Please refer to page 38 & 39)
What treatment will I undergo? These lumps are usually treated with surgery. The operation to remove them is called a Sistrunk operation. It involves removal of the lump as well What are Thyroglossal Cysts? as the middle part of one of the bones These are lumps found in the front in the front of the neck called the hyoid of the neck in the midline. They bone which the lump is usually are formed due to a persistent attached to. thyroglossal duct.
During the development of the thyroid gland before birth, the thyroid gland in Role of GPs the foetus migrates from the bottom Patients who present with of the tongue to its final position in the neck lump that is painful and neck. The path that the thyroid gland infected are to be treated with takes during its descent into the neck antibiotic and referred to the usually disappears, but sometimes SingHealth Duke-NUS persists as a persistent thyroglossal Head & Neck Centre duct. for further investigation. Neck lumps that are This persistent duct can give rise to increasing in size and cysts (fluid-filled lumps) or sinuses causes compressive (blind-ending tracts that lead to the symptoms with enlarged skin). lymph nodes should be reviewed early as How do Thyroglossal cysts present? there is a 1% chance of malignancy. These lumps usually are hemispherical lumps that appear in the
40 SingHealth Healthy Living Series DISEASES IN THE HEAD AND NECK REGION
NECK Thyroid Cancer
Overview notice the lump and other people may Thyroid cancer is cancer that arises have pointed it out to them. from the thyroid gland. It is more Thyroid cancers are also sometimes common in women than men. In found incidentally when there are Singapore, it is the 9th most common nodules in the thyroid gland noted cancer diagnosed in women. It is on a scan done on the neck for other commonly diagnosed at a younger reasons. These cancers found this age than most other cancers and most way very often cannot be felt and can cases occur in patients less than 60 only be seen on ultrasound scans. years old. The incidence of thyroid Nevertheless, just because a lump cancer appears to be rising, but this cannot be felt does not mean it is appears to be mostly due to the not a cancerous lump and all thyroid increased use of ultrasound scanning, nodules should be investigated picking up more thyroid nodules that properly to exclude cancer. may not have been discovered in the past. Patients who have advanced thyroid cancer can sometimes present with What are the symptoms and signs hoarseness. This can occur when of thyroid cancer? cancer invades the nerves that Patients with thyroid cancer often first control the movement of the larynx present with a lump in the neck. Often (voice-box). If the cancer has spread they may not have been the first to to the lymph nodes in the neck, the
All About Head & Neck Diseases 41 DISEASES IN THE HEAD AND NECK REGION
patient may also be able to feel other Other types of Thyroid Cancers enlarged lumps in the neck. Cancers 3. Medullary Thyroid Cancer can also cause breathlessness if they Medullary thyroid cancer is much cause compression of the trachea and less common and accounts for problems swallowing if they compress about 5% of thyroid cancers. on the oesophagus. These cancers arise from the What kinds of thyroid cancer are parafollicular C cells in the thyroid there? gland. These cells usually are responsible for producing a There are many types of thyroid hormone called calcitonin, which cancers. helps to control the level of calcium Differentiated Thyroid Cancers in the body. 1. Papillary Thyroid Cancer About 20% of these cases are This is the most common kind of hereditary (familial medullary thyroid cancer seen, accounting carcinoma). Patients with familial for about 75% of thyroid cancers. medullary thyroid carcinoma tend Papillary thyroid cancers usually to develop thyroid cancers at are slow growing but they have a an earlier age in childhood and tendency to spread to the lymph may also develop other types of nodes in the neck. However, most cancers (e.g. phaeochromocytoma, of these cancers can still be treated parathyroid tumours). successfully. Although the outcome of treatment There are many subtypes of for medullary thyroid cancer is papillary thyroid cancer. Some not as good as for papillary and less common subtypes (follicular follicular thyroid cancers, many variant, tall cell, insular, diffuse patients can still be treated sclerosing) tend to have more successfully. aggressive behaviour and may grow and spread more quickly. 4. Anaplastic Thyroid Cancers This type of cancer accounts for 2. Follicular Thyroid Cancer about 2% of thyroid cancers. These Follicular thyroid cancer is the cancers tend to be very aggressive second most common type of tumours and grow very quickly and thyroid cancer seen, accounting for spread rapidly to other parts of the about 15% of cases. These cases body. Treatment of these cancers tend to spread via the bloodstream is usually very difficult. to other parts of the body such as the lungs and bones.
42 SingHealth Healthy Living Series DISEASES IN THE HEAD AND NECK REGION
5. Thyroid Lymphoma This scan is painless and there is This is a very rare cancer that no ionising radiation involved. sometimes develops in the thyroid gland. Lymphoma is a type of 3. Fine-needle Aspiration Cytology cancer that arises from white blood (FNAC) cells. These cancers are usually Your doctor may advise you to treated with chemotherapy, with or undergo a biopsy to evaluate the without radiotherapy. lump if he or her feels it is needed. A fine-needle aspiration biopsy is What investigations will I need to a procedure where the doctor will undergo? pass a small needle through the 1. Thyroid Function Tests lump to aspirate some cells for This is a blood test where the the lump for further testing. These levels of your thyroid hormones cells will be examined under a and thyroid-stimulating hormone microscope to look for signs of (TSH) are measured. If your cancer. This biopsy is often done levels of thyroid hormones are using ultrasound to guide the too high (hyperthyroidism), you doctor to biopsy the correct place. may experience symptoms such 4. Computer Tomographic (CT) as palpitations, feeling hot easily, scan irritability, diarrhoea, weight loss This scan will usually entail you and increased appetite. If your lying down on a motorised bed thyroid hormone levels are too that will pass through a scanner to low (hypothyroidism) you may feel obtain an image. The CT scan uses easily tired and lethargic, gain ionising radiation to produce an weight easily, constipation, memory image and may involve the use of loss and feeling cold easily. contrast injected through a vein to 2. Ultrasound Scan make the details of the scan easier In this scan, sound waves are to interpret. used to produce a picture of your How are thyroid cancers usually thyroid gland and neck structures treated? on a screen. The ultrasound scan is very useful for evaluating thyroid Surgery nodules and to look for features The treatment of most thyroid cancers that may indicate that the thyroid will usually involve surgery. Depending nodule is suspicious for cancer. It on what the doctor finds he will usually is also useful for looking for any recommend one or more of the enlarged lymph nodes in the neck. following operations.
All About Head & Neck Diseases 43 DISEASES IN THE HEAD AND NECK REGION
a. Thyroidectomy cases, your doctor may ask you to A thyroidectomy is a removal of the undergo an operation to remove whole or part of the thyroid gland. lymph nodes in the neck which are In cancers, most of the time your positive for cancer. doctor will recommend removing Radioactive Iodine Treatment the whole thyroid gland (Total thyroidectomy). In certain patients This is a form of targeted radiotherapy with low risk cancers, an option that uses a radioactive form of iodine to remove only half of the thyroid (iodine-131/I-131). Thyroid cells take gland may be recommended up and concentrate iodine much (Hemi-thryoidectomy). more than the rest of the cells in the body, radioactive iodine can be used b. Central compartment dissection to selectively administer radiation to In patients with papillary and thyroid cancer cells with little effect on medullary thyroid cancer, the the rest of the cells in the body. cancer tends to spread to the lymph nodes around the thyroid Radioactive iodine treatment works gland. Your doctor may advise you better for well differentiated thyroid to remove the lymph nodes around cancers such as papillary and follicular the thyroid gland and trachea thyroid cancers as these cancers together with the thyroid gland. usually take up iodine well. Other cancers such as medullary and c. Modified radical neck dissection anaplastic cancers tend not to take up Thyroid cancer may spread to iodine as well thus do not respond well lymph nodes in the neck at the to radioactive iodine treatment. side of the neck as well. In these
44 SingHealth Healthy Living Series DISEASES IN THE HEAD AND NECK REGION
surgery is unable to remove cancer completely. It is also sometimes used in cases where cancer cells do not readily take up iodine (e.g. anaplastic, medullary thyroid cancers).
Thyroid Hormone Treatment After removal of the thyroid gland, you will need to take medication to replace your thyroid hormone as there will no longer be thyroid hormone produced in your body.
Thyroid hormone is sometimes given at a higher dose than usual in some cases of cancer to suppress the TSH Radioactive iodine treatment can (thyroid stimulating hormone) levels. be used after surgery to kill any This helps to reduce the chance of the remnant cancer cells left in the body. cancer relapsing. Radioactive can also be used in cases where cancer has spread to other parts of the body. It can also be used in cases where cancer has come back Role of GPs after being treated previously. Patients who present neck Radioactive iodine is usually lumps that are suspicious administered orally in either a capsule or have worrying features or liquid form. You may be required to should be referred for further be admitted in a single room during investigation. Cases the treatment to minimise radiation where cancer is highly exposure to other people around you. suspected should be referred early (e.g. External Beam Radiotherapy compressive symptoms This treatment involves using ionising or hoarseness and radiation to kill cancer cells. This enlarged lymph nodes) treatment usually involves directing an to the SingHealth external source of radiation into the Duke-NUS Head & part of the body treated (e.g. neck) Neck Centre for further while the patient is lying down. investigation.
This treatment is not commonly used but may be used in cases where
All About Head & Neck Diseases 45 DISEASES IN THE HEAD AND NECK REGION
EAR/NOSE Nasopharyngeal Carcinoma (NPC)
The nasopharynx is part of the upper aerodigestive tract and it lies at the back of the anterior nasal space. Due to its inaccessible location, lesions of the nasopharynx are not easily detected, and hence tumours of the nasopharynx may present only at a later stage. NPC is a malignant neoplasm that arises from the epithelium of this anatomical site. It has a low incidence in the western population but in the local context, it is seen more commonly amongst people of Southern Chinese and Javanese descent.
Types of NPC World Health Organisation (WHO) 3. Epistaxis (Nose bleed) classifies NPC into the following three types, based on their histological 4. Blocked hearing (Middle ear appearance: effusion) 5. Diplopia (Cranial nerve IV 1. Type I – Keratinising Squamous involvement) Cell Carcinoma (SCC) 6. Numbness over cheek (Cranial 2. Type II – Non-keratinising nerve V2 involvement) Squamous Cell Carcinoma (SCC) 7. Nasal obstruction 3. Type III – Undifferentiated Carcinoma Risk factors 1. Family history of NPC – persons In the local context, it is Type III that is with first-degree relatives who had by far the most common of the three. NPC are 20-25 times more likely to Common presentations develop NPC The following are some ways in which 2. Diet high in preserved foods early NPC can present in patients: in life (Eg. salted fish, preserved vegetables) 1. Neck lump (Cervical lymphadenopathy), usually upper 3. Prior Epstein-Barr virus infection – neck in levels II and Va. this is almost ubiquitous in adults 2. Blood-stained sputum
46 SingHealth Healthy Living Series DISEASES IN THE HEAD AND NECK REGION
Screening Treatment Blood investigations such as serum NPC is treated primarily with EBV VCA-IgA (viral capsid antigen), radiotherapy or concurrent chemo- EBV Ea-IgA (early antigen) and EBV radiotherapy. The role of surgery DNA have been used as a method is only necessary in recessive or for screening for NPC but routine recurrent setting. screening of the general population who is not at increased risk is not Role of GPs advised. A detailed history of the Diagnosis presenting symptoms and Patients require nasoendoscopic performing a physical examination and diagnosis are examination is important in confirmed when a biopsy performed establishing a provisional showed histological evidence of diagnosis. Cases in which NPC. Post-nasal space biopsy is cancer is strongly suspected usually performed under topical local (e.g. positive family anaesthesia and nasoendocopic history of NPC, persistent guidance in the outpatient setting. epitaxis, lymph node enlargement, pain or The procedure is often uncomplicated numbness around cheek and takes less than 10 minutes. area and blocked ears) For patients on anti-coagulants or should be referred to the anti-platelets, their medication may SingHealth Duke-NUS be stopped prior to the procedure to Head & Neck Centre for prevent excessive bleeding. further investigations.
All About Head & Neck Diseases 47 DISEASES IN THE HEAD AND NECK REGION
EAR/NOSE Paranasal Sinus Tumours
Benign Tumours • Inverted papilloma • Juvenile angiofibroma • Osteoma • Capillary hemangioma • Pleomorphic adenoma
Malignant Tumours • Squamous cell carcinoma • Undifferentiated carcinoma • Adenoid cystic carcinoma • Adenocarcinoma • Esthesioneuroblastoma
Paranasal Sinuses Tumours The paranasal sinuses are air-filled The following are some ways in spaces and comprises of the maxillary which paranasal sinuses tumours can sinuses, the ethmoid sinuses, the present in patients: sphenoid sinuses and the frontal sinuses. As they are air-filled, tumours 1. Nasal obstruction that arise in the paranasal sinuses 2. Blood-stained nasal discharge or often only present when they are sputum large enough to obstruct the sinuses, 3. Epistaxis (Nose bleed) or when they cause compressive symptoms on neighbouring structures 4. Visual disturbances such as (such as the orbit). diplopia Epiphora (obstruction of lacrimal Types of Tumours 5. duct) Various neoplasms ranging from benign to malignant tumours can arise 6. Facial fullness or pain in the paranasal sinuses. Fortunately, Risk Factors malignant neoplasms of the paranasal sinuses are uncommon and account Certain environmental agents have for <1% of all neoplasms. Several been linked to the development of more commonly seen neoplasms are certain paranasal sinus malignancies. listed in the table here: Squamous Cell Carcinoma (SCC)
48 SingHealth Healthy Living Series DISEASES IN THE HEAD AND NECK REGION
has been associated with things Treatment like aflatoxin, which is produced by Treatment depends on the histology of Aspergillus fungi that can colonize and the tumour. Generally, most tumours contaminate grain; chromium, nickel, of the paranasal sinuses are treated hydrocarbons and other organic surgically with possible post-surgery chemicals. Adenocarcinoma has been radiotherapy +/- chemotherapy linked with wood dust exposure. Both for certain malignant tumours. An these malignancies are also linked endoscopic operative approach is with exposure to tobacco smoke, often preferable as it avoids any facial salted and smoked foods and heavy incisions and scars but much depends metals. Although inverted papillomas on the size and location of the tumour. are benign, there is a risk of malignant Patients will need to have an open transformation to SCC. discussion with the surgeon on the Diagnosis most appropriate treatment option. Patients require nasoendoscopic examination and the diagnosis is made with a biopsy. Depending on Role of GPs the location of the tumour, sometimes A detailed history of the radiologic investigations such at CT- presenting symptoms and scan or MRI-scan with intra-operative performing a physical biopsy may be necessary. examination is important in establishing a provisional diagnosis. Cases in which cancer is strongly suspected (e.g. persistent blocked nose/ ears, abnormal discharges from nose, diplopia or face fullness/ pain) should be referred for further investigations.
All About Head & Neck Diseases 49 DISEASES IN THE HEAD AND NECK REGION
EAR/NOSE Diagnosis Jaw Cysts/Tumours A biopsy (whereby a sample of the tissue is taken for study) is usually What are Jaw Cysts and Tumours? indicated for accurate diagnosis of the lesions. Jaw cysts and tumours can develop in the upper or lower jaw bone and can X-rays and CT scans can be used to affect anyone from children to adults. assess the severity of jaw cysts and Cysts and tumours can develop as a tumours. single lesion or as multiple lesions in the upper and lower jaws. Treatment Treatment of jaw cysts and tumours They usually go unnoticed when usually require a surgery for removal. they are small but some might The surgery can range from simple progress to significant swelling of the removal of the lesion and/or part jaws which then prompt patients to of the jawbone which will require seek consultation. Because of their reconstruction (refer to Head & Neck generally slow growth, most cases Reconstruction). Treatment might are discovered through x-rays either be indicated for the teeth involved in during routine checks or during the form of extractions or root canal investigation of other problems in the treatment. jaws.
Causes of Jaw Cysts and Tumours Role of GPs The lesions can arise from The oral cavity is easily accessible odontogenic (tooth related) or non- for examination in the primary odontogenic causes. Most lesions care setting. A detailed history are developmental but some of the of the onset of symptoms and multiple lesion types can be hereditary examination of the oral cavity, in nature. face and neck region is useful in Symptoms the evaluation of any associate symptoms. Any oral lesions Below are some of the signs and suspicion of cancer with symptoms that might occur with jaw associated enlarged lymph cysts and tumours: nodes, facial asymmetry • Swelling of the jaw and numbness around • Pain from the jaw (infection in cysts tongue, lips and chin and tumours) should render a referral to • Numbness of lower lips and chin the SingHealth Duke-NUS • Numbness of anterior part of the Head & Neck Centre for a tongue thorough examination and • Difficulty in biting or chewing further investigations. • Facial deformities
50 SingHealth Healthy Living Series COMMON HEAD & NECK RECONSTRUCTION
• Nasolabial Flap • Rhomboid Flap • Pectoralis Major Flap • Latissimus Dorsi Flap • Radial Forearm Flap • Anterolateral Thigh Flap • Fibula Free Flap
Specialist services available at:
Head & Neck Centre @ Singapore General Hospital Tel: 6321 4377 (for appointments)
Head & Neck Centre @ National Cancer Centre Singapore Tel: 6436 8088 (for appointments) HEAD AND NECK RECONSTRUCTION About Head and Neck Reconstruction
Operative treatment of head and neck 1) Nasolabial Flap cancers can result in impairment of The nasolabial flap utilizes skin swallowing, speech, respiration and laxity around the nasolabial appearance. Alongside control of the fold to close nasal, perioral and disease, rehabilitation is an essential intraoral defects, with the option of goal of treatment. Reconstruction, performing a bilateral procedure for often in the form of flap surgery, larger defects. aims to restore form and function for rehabilitation. The flap can be harvested as a random pattern flap or an axial Flap surgery refers to the transfer of flap based on perforators from the tissue, with its blood supply, from a facial and angular arteries, and can healthy part of the body (donor site) to be used as a one-stage or two- the defect (recipient site). Flaps can stage flap. be categorized into local, regional and free flaps. For the two-stage procedure, the flap is divided 2 to 4 weeks after A) Local Flaps the initial surgery and appropriately Local flaps are harvested from thinned and contoured. The tissue adjacent to the defect. Local nasolabial flap provides good flaps are favoured in the head and aesthetic outcomes, and a low neck when compared to distant incidence of post-operative trismus flaps due to its excellent colour and due to the proximity of the donor texture match. They are commonly site. used for closure after resection of small skin cancers. Examples of local flaps include the nasolabial and rhomboid flap.
Nasobial Flap
52 SingHealth Healthy Living Series HEAD AND NECK RECONSTRUCTION
Rhomboid Flap
2) Rhomboid (Limberg) Flap In addition to reconstructing large Rhomboid flaps are transposition defects, these flaps serve to flaps that are rotated about a pivot protect the great vessels after neck point. They are designed with 60- dissection, especially against the and 120- degree angles, and the effects of radiation therapy. longitudinal axis of the rhomboid 1) Pectoralis Major Flap parallels the line of minimal skin tension. This technique can be The pectoralis major flap is expanded to create a double or the most widely used regional triple rhomboid flap. The donor site flap in head and neck cancer of the flap can be closed by direct reconstruction due to its versatility, sutures. reliability and ease of harvest. Its skin paddle is designed over the B) Regional Flaps medial aspect of the muscle. When there is inadequate tissue adjacent to the defect for coverage, regional flaps are harvested from tissue in the vicinity of the defect. Regional flaps are raised based on a specific vascular system. The flap is rotated into the recipient site with its pedicle attached at its base.
Donor sites can be closed by direct suture or skin graft. Examples of regional flaps commonly used in the head and neck include the
pectoralis major and latissimus Pectoralis dorsi flap, which are pedicled Major Flap flaps usually harvested as a myocutaneous flap consisting of muscle and skin.
All About Head & Neck Diseases 53 HEAD AND NECK RECONSTRUCTION
The flap is raised based on excellent pedicle length that can the pectoral branch of the reach the anterior midline, and thoracoacromial artery and defects as high as the skull vertex. tunneled through the neck. The The skin paddle is hairless and the pectoralis major flap can be used donor scar is less noticeable. for defects up to the temporal line, and as a tubular flap to reconstruct C) Microsurgical Free Flaps the hypopharynx and cervical The arrival of microsurgical esophagus. techniques, which uses special operating microscopes and 2) Latissimus Dorsi Flap instruments, has allowed the The skin paddle of the latissimus possibility of performing intricate dorsi flap is designed over the operations on tiny blood vessels in upper two-thirds of the muscle. our body. This, in turn, has made The flap is raised based on the tissue transfer from a distant site to thoracodorsal artery and tunneled reconstruct defects in the head and through the axilla into the defect. neck region after surgical resection feasible. The latissimus dorsi flap is the largest soft tissue flap that can The tissue that is harvested from be harvested in the body with the patient’s own distant body site for reconstruction is known as a free flap. This may include the skin layer and the underlying muscles and tissues together with its
Latissimus supplying blood vessels. This flap Dorsi Flap is then transferred to the head and neck area where the blood vessels are reconnected under microscopic magnification and the skin used to resurface the defect.
This has allowed surgeons to adopt a more aggressive approach in resecting tumours that would have resulted in defects that were previously deemed too extensive for reconstruction.
Besides allowing for a larger volume of tissue to be transferred
54 SingHealth Healthy Living Series HEAD AND NECK RECONSTRUCTION
to these defects, the use of free The doctors and nurses will flaps has also resulted in more ensure that the graft is healthy precise reconstruction of head and by monitoring the reconstructed neck defects. Reconstruction of area and donor site (where graft complex defects involving bone, is obtained) closely. It is important muscle and soft tissue can also be for you to start exercising (as reliably achieved. indicated by the doctors) your hip and knee to ensure that you The common free flaps that are regain full movement. There may used for reconstruction of head be some restriction in movement and neck defects in our institution after surgery due to swelling, are the anterolateral thigh flap bandaging or drains in your leg. (outer border of thigh), fibula free Gentle lower limb exercises can flap (lower leg) and flap radial also help to reduce any swelling. forearm flap (lower arm). Each Complete recovery of the leg can patient is unique and the expertise be expected within 3 months. of the reconstructive surgeon is harnessed to plan the most 2) Radial Forearm Flap suitable method of reconstruction A radial forearm flap is an area to achieve both functionally and of skin and tissue obtained from aesthetically acceptable outcomes. the lower arm. It is a commonly 1) Anterolateral Thigh (ALT) Flap used flap for reconstruction of the mouth area following head An anterolateral thigh (ALP) flap and neck surgery. It is considered is obtained from the outer border one of the most reliable flaps for of the thigh. This is often used in reconstruction surgery. reconstruction in the mouth and throat after removal of tumour. The area where the flap is taken The flap is connected to the blood from the forearm is usually covered vessels in the neck as it is a living graft.
Radial Forearm Flap Anterolateral Thigh
All About Head & Neck Diseases 55 HEAD AND NECK RECONSTRUCTION
with a skin graft. The doctors You will need to avoid placing any and nurses will ensure that the weight on the leg where the flap is graft is healthy by monitoring the obtained as it may be sore after the reconstructed area and donor surgery. To help reduce the pain site (are where graft is obtained) and improve the movement in the closely. leg, gentle exercise can be done on while on the bed or chair. It is important to exercise your elbow, wrist and fingers (as Your leg will be bandaged and indicated by the doctors) in order placed on a plaster cast to stabilise to regain full movement. You will the area. You may start mobilising need to wear a splint to stabilize with a walking frame or crutches the forearm after the bandages initially and progress to a walking are removed. Gentle exercises will stick when the leg can take more help to reduce any swelling, and weight as it recovers. Complete prevent stiffness at the elbow and recovery of the lower leg can be wrist joints. Complete recovery of expected in 3 to 6 months. the arm can be expected within 3 months. Our multidisciplinary team of Allied Health Professionals, which 3) Fibula Free Flap includes the physiotherapist, A fibula free flap is obtained occupational therapist, dietitian from the lower leg (fibula) where will aid in your recovery during tissue and bone is taken for the hospital stay and after you are reconstruction. The area commonly discharged. reconstructed using this flap is the jaw area where bone replacement is needed following surgery. The doctors and nurses will ensure that the graft is healthy by monitoring the reconstructed area and donor site (where graft is obtained) closely.
Fibula Free Flap
56 SingHealth Healthy Living Series SUPPORT SERVICES
• Allied Health Professionals
• Common oral complication post head and neck therapy • Oral Rehabilitation • About SingHealth Duke-NUS Head & Neck Centre
Specialist services available at:
Head & Neck Centre @ Singapore General Hospital Tel: 6321 4377 (for appointments)
Head & Neck Centre @ National Cancer Centre Singapore Tel: 6436 8088 (for appointments) SUPPORT SERVICES Allied Health Professionals (AHP) Services
Head and Neck cancers can involve a wide variety of sites, including the lips, oral cavity, pharynx, larynx, nasal cavity, paranasal sinuses, major salivary glands and thyroid glands. Tumours affecting these sites require multimodality treatment including surgery, radiotherapy and chemotherapy. Treatment-related side effects may leave the patient with psychological, physical and nutritional issues that can directly impact their treatment. Thus, a multidisciplinary team is paramount in a patient’s treatment process.
A pre-treatment assessment is done in order to develop an individualised care plan for the patient. Most patients 2. This will prepare the patient and scheduled for major head and neck their caregivers on pre & post- surgery will be referred to the Allied surgery rehabilitation, nutritional Health Professionals (AHP) clinic. In and psychosocial needs. this clinic, patients are assessed on Speech Therapist their pre- and post-surgery needs. Our AHPs are introduced and speak Speech and language therapists to patients and their loved ones to (SLTs) are allied health professionals adequately prepare and support them who assess, treat, and manage in their rehabilitation, nutritional and communication and swallowing emotional needs. difficulties.
1. Most of the patients scheduled for Head and neck cancers and their major head and neck surgery will treatment can cause changes in a be referred to the Allied Health patient’s voice, speech and swallowing Professional clinic for education on abilities. pre, during and post- surgery care Our SLTs help in the compensation & management and assessment by and rehabilitation of these the group. difficulties. They work closely in the multidisciplinary team, and are
58 SingHealth Healthy Living Series SUPPORT SERVICES
involved in a patient’s care from one-way valve that allows air to diagnosis through to supporting pass from the lungs to the throat. them back to work and life long after treatment is complete. The SLT can also work with you on using external communication Communication aids, such as electronic tablets and Before your treatment, the SLT communication charts to help you will speak with you about your communicate. communication habits and needs. Swallowing She will explain to you the possible changes in voice and speech that may Before your treatment, the SLT occur during and after your treatment. may assess the way you swallow, If necessary, the SLT will work with so as to identify and help you with you to establish an alternative method any difficulties you may have. She of communication in the time when will explain to you the changes in you may find speaking difficult. swallowing that may happen during and after your treatment. After your treatment, the SLT will work with you to improve the precision The SLT will work with you to develop and clarity of your speech. Close strategies to compensate for your collaboration with your surgeons and swallowing difficulties, and exercises prosthodontists allow for customised to rehabilitate your swallowing rehabilitation. function.
If your surgery involves removal of These may include: your voice box, the SLT will work with • Posture and positioning changes you and your surgeon to find a method when eating and drinking of rehabilitating your voice that is most suitable for you.
These methods may include: 1. Oesophageal speech: Talking by swallowing and burping out air from the oesophagus. 2. Artificial larynx: Using external or electronic devices to produce a voice. 3. Tracheoesophageal prosthesis (TEP): Speaking through a small
All About Head & Neck Diseases 59 SUPPORT SERVICES
• Special swallowing techniques This is because symptoms associated • Muscle-strengthening exercises with cancer e.g. ulceration/difficulty in swallowing can directly affect the After surgery, you may need to patient’s intake. Malnutrition is found undergo a videofluoroscopic to be associated with increased risk swallow (VFS) study or a fibre-optic for infections, decreased response to endoscopic evaluation of swallowing treatment and poorer quality of life. (FEES). A VFS is a video X-ray study that allows the SLT to review the oral Nutritional status can further be and pharyngeal phases of swallowing. compromised when treatment A FEES is where an SLT passes a starts due to their adverse effects. small flexible endoscope through the Common side effects of surgery nose to the throat to look at how the include difficulty in swallowing or swallowing muscles move. In both pain during swallowing, while those studies, you will be given a range of of radiotherapy and chemotherapy food consistencies to try. include difficulty in swallowing, mucositis, stomatitis, nausea, anorexia Dietitian and altered taste sensation. Malnutrition is highly prevalent in These adverse effects experienced patients with cancer and it is well by the patient lead to a reduction in recognised that patients with head nutritional intake, and thus causing and neck cancer are among those at unintentional weight loss and highest nutritional risk, even before malnutrition. treatment starts. Nutrition screening and assessment At the Head and Neck Centre, a quick and simple questionnaire that can be administered by the patient, nursing staff or doctor, is used to help identify patients at high risk of malnutrition before the surgery. These patients are then referred to the Dietitian for a detailed nutritional assessment and intervention. Early nutrition intervention The intervention includes medical nutrition therapy recommended by the
60 SingHealth Healthy Living Series SUPPORT SERVICES
Dietitian to help optimise the nutritional status and thus minimise the risk of malnutrition-related complications.
Individualised nutrition care plan may include food texture modification if there are chewing or swallowing difficulties, food choices, food fortification, use of oral nutritional supplements and devising tube feeding regimen.
Physiotherapist Physiotherapists (PT) are professionals who provide services through specific exercises to help that develop, maintain and restore them regain functional mobility and people’s maximum movement and joint movement and maintenance of functional ability. All patients who are pulmonary hygiene. seen by a PT will be assessed on the domains of fitness, respiratory health During the early post-operative and functional limitation. The PT will period, the assistance and guidance then prescribe and guide patients by the PT for patients post head and neck surgery is critical as they may experience pain, stiffness, swelling and weakness in the affected and surrounding areas.
Limitation in mobility may worsen after surgery due to immobility associated with the post-operative discomfort. PTs will gradually introduce patients and carers to various exercises to optimise posture, strengthen neck and shoulders muscles and prevent limb swelling.
Additionally, PTs can perform procedures and teach patients techniques to assist in clearing secretions.
All About Head & Neck Diseases 61 SUPPORT SERVICES
Occupational Therapist educate patients on compensatory Occupational Therapists (OT) are techniques when there is impaired professionals who help to improve function e.g. blindness/loss of a limb. your ability to perform activities in your Home visits and caregiver daily living and working environment trainings are provided for patients to a desired level of functioning. and their caregivers who may They assess patients and carry out require modifications to their treatment interventions that help home environment post-surgery. improve patient basic motor function Assessments on physical and work and reasoning ability. demands would be conducted by OTs Activities of daily living such as to facilitate early return to work and eating, dressing and showering resumption of roles in the family. are incorporated into treatment The OT trained in the management interventions to maximize patient’s of lymphoedema uses specialised independence in self-care. OTs also massage techniques to manage advise on assistive devices and swelling post-operatively or as a result
62 SingHealth Healthy Living Series SUPPORT SERVICES
of cancer treatment. Customised Clinical psychologists aim to enhance pressure garments are also provided and promote well-being and manage to patients to manage swelling and/or emotional distress. They will work scarring. closely with you and your loved ones to help strengthen the way you cope In SGH, the OTs conduct a weekly and manage your illness concerns. group therapy session to educate Treatment effects from surgery, patients and their caregivers on the chemotherapy and radiotherapy often importance of exercises post-surgery, bring about concerns about body and to facilitate discussion on issues image, implication on lifestyle and related to activities of daily living. other practical matters. It is also a channel for patients to overcome their fears through the Our clinical psychologist will assist support and sharing during the group to develop an individualised plan to session. help you be more prepared for the upcoming treatment journey ahead Our team of occupational therapists, and support you as you come to terms with their skills and knowledge of with the illness and the treatment health management, ensure that there required. You may speak to your is a high standard of service provision doctor for a referral to our service. to people with diverse needs. We hope that the provision of these quality services would help our clients reduce the cost of injuries and disabilities and lead a better quality of life.
Clinical Psychologist Head and Neck Cancers and its treatment bring extraordinary challenges for patients and their families. You and your family may experience significant emotional challenges from dealing with the shock of the diagnosis and the implications of treatment to an acceptance of the illness. Psychosocial and emotional support can ease the strain of a challenging illness and enhance coping during your cancer journey.
All About Head & Neck Diseases 63 SUPPORT SERVICES Common Oral Complications of Head and Neck Cancer Therapy
Is there anything I should do before What are the common side effects starting my radiation therapy? of head and neck cancer therapy? Radiation therapy of the head and Most of the side effects start within neck can increase your risk of getting 2-3 weeks of treatment but can dental decay. Oral care is therefore increase throughout the duration of aimed at preventing oral problems the radiation. Some side effects are before they occur. Before starting temporary and will improve with time; radiation therapy, your radiation however, others may be permanent. oncologist will refer you for a dental examination. Dental X-rays will Some common side effects: be taken and a comprehensive • Skin redness and irritation examination will be carried out to • Changes in taste (Dysgeusia) check for: • Tooth decay (caries) • Sores in the mouth (Mucositis) • Gum (periodontal) disease • Dry mouth (Xerostomia) • Infected teeth • Tooth decay (Caries) • Retained root tips • Bone death (Osteoradionecrosis)
Any other conditions that may cause • Limited mouth opening (Trismus) problems during or after radiation • Difficulty in Using Dentures or therapy. Prosthesis
It is important to undergo the Skin redness and irritation necessary dental treatments before The skin area undergoing radiation radiation therapy starts and continue may become red and itchy. Be very to see a dentist after you have careful not to apply anything unless completed your radiation therapy. instructed by your radiation oncologist. Depending on the area treated and dosage used, your skin may or may not return to normal.
64 SingHealth Healthy Living Series SUPPORT SERVICES
Changes in taste (Dysgeusia) the mouth before eating or brushing. If Food will taste differently during your you experience difficulties with these radiation therapy. The taste buds are activities, your physician or dentist can affected by the radiation. Usually the prescribe the appropriate medication sense of taste will improve over time. for you. In most people the ability to taste Dry mouth (Xerostomia) foods return to normal within 6 months to a year. Saliva serves to lubricate the mouth and protect teeth. Radiation affects the salivary glands resulting in a decrease in normal salivary flow. Saliva will thicken and make swallowing difficult.
Drinking as much fluid as possible will loosen the thick saliva and lubricate the mouth. When eating, try to take a drink between each bite of food. Pureed food will be easier to eat, as with foods served with sauces, gravy and butter.
Eating more often with smaller portions will be easier than eating the traditional three meals daily. If you have difficulty eating, ask your
Sores in the mouth (Mucositis) Soreness in your mouth will usually appear in the second and third week of the radiation therapy. It is likely to decrease from the fifth week onwards up to a month after your treatment ends. The sores and ulcers can get uncomfortable and may interfere with proper intake of food, speech and oral hygiene. You can soothe the soreness by rinsing with warm alkaline solution or applying anaesthetic gel to numb
All About Head & Neck Diseases 65 SUPPORT SERVICES
physician for liquid food supplements. the destruction of small vessels which If the dryness worsens, salivary carry nutrients and oxygen to the living substitutes are available to help your bone. This reduces the bone’s ability mouth feel more comfortable. to heal itself. Should you require tooth extraction after radiation therapy, you Tooth decay (Caries) are at risk of developing bone death. When salivary flow is decreased, the protective mechanism of the This is a difficult condition to treat; saliva is diminished, resulting in teeth therefore, it is important that dental being susceptible to decay. It is very extractions are done before the start of important that you avoid foods high in radiation therapy and after treatment, sugar and brush regularly after each maintenance of good oral health is meal to prevent decay. crucial.
The use of fluoride will help prevent Limited mouth opening (Trismus) caries and your dentist can fabricate a Trismus is another complication that customised tray to help apply fluoride may develop after radiation therapy. to your teeth. It is important to see It is a result of scarring of the facial your dentist regularly every 3 to 6 muscles from radiation. Limited mouth months to check on your dental health. opening, combined with dry mouth, may interfere with speech, eating and Bone death (Osteoradionecrosis) the ability to maintain oral hygiene. The most debilitating side effect of radiation therapy is bone death from Stretching exercises are important to minimise post-treatment trismus. Your
66 SingHealth Healthy Living Series SUPPORT SERVICES
doctors and therapists may prescribe dentist before you begin to wear jaw stretching exercises suitable dentures again. If you find major for you. It is advisable to do these differences in fit, your dentist will be exercises as often as prescribed to able to help you correct it. minimise post-treatment trismus.
Difficulty in Using Dentures or Prosthesis Due to less saliva and soreness in the mouth, you should avoid wearing dentures during the treatment period. After completing your radiation therapy, you should consult your
GENERAL CARE TIPS
Do’s Don’ts • Rinse with warm alkaline • Avoid using deodorants or solution (1 teaspoon salt deodorant soap on radiated skin areas and 1 teaspoon baking soda dissolved in a 240ml glass of • Avoid rubbing the skin in the warm water) to lubricate and areas that have been exposed to radiation soothe sore tissues • Avoid direct sun exposure on • Brush and apply fluoride the radiated areas regularly to prevent decay • Avoid shaving with a razor; • Exercise mouth opening to using an electric razor is safer reduce trismus • Avoid alcoholic beverages & tobacco use • Avoid very sweet and spicy foods • Avoid alcohol-based mouthwash as it may worsen mouth sores • Avoid wearing dentures during the treatment period
All About Head & Neck Diseases 67 SUPPORT SERVICES Oral Rehabilitation
After cancer therapy, depending on Also, it is important to get regular your oral health status, missing teeth dental check ups and routine dental can be replaced by: cleaning by a dentist or dental hygienist to ensure healthy gums and • Removable prostheses such as treat dental decay early to avoid the partial or complete dentures need for complex dental treatment like • Fixed prostheses such as bridges root canal therapy or tooth extraction. or implants In those who had undergone radiation • Combination of removable and therapy, it is important to eliminate any fixed prostheses possible sources of bone infection that can lead to osteoradionecrosis of the jaw bones.
68 SingHealth Healthy Living Series SUPPORT SERVICES About SingHealth Duke-NUS Head & Neck Centre
The SingHealth Duke-NUS Head pursuit of comprehensive oncological & Neck Centre specialises in resection, aesthetic reconstruction and management of diseases and functional rehabilitation. tumours of the head and neck region. It provides a disease-based Cases are discussed at a multi- multidisciplinary one-stop service disciplinary tumour board comprising dedicated to complex Head & Neck of surgeons, medical oncologists, diseases/tumours. The centre is radiation oncologists, speech helmed by five specialties which are: therapists and other allied health professionals. • General surgery • Otolaryngology (ENT) Our team of specialists are experienced in the assessment and • Plastic Reconstructive and management of complex head and Aesthetic surgery neck diseases and tumours. Besides • Oral and Maxillofacial surgery providing clinical services to our local • Allied Health Professional population, we are also a regional referral centre and a leading centre for The Centre forms a unique platform clinical research. for the collaborative work of a multidisciplinary team of healthcare The multidisciplinary one-stop professionals to meet the needs of SingHealth Duke-NUS Head and Neck the patient throughout the disease Centre is currently located at Block trajectory. 3, Singapore General Hospital, and Clinic C, National Cancer Centre Our clinicians work closely together Singapore. with the nurses and allied health professionals, to achieve the best We will see all referrals within two outcomes for our patients in the weeks for specialist evaluation.
All About Head & Neck Diseases 69 SUPPORT SERVICES
Our Services Allied Health Professionals Evaluation and treatment of confirmed Speech and Language Therapist or suspected head and neck tumours, Speech and Language Therapist (SLT) including: are allied health professionals who • Thyroid and Parathyroid gland assess, treat and manage patients swellings with communication and swallowing difficulties. Head and neck cancer • Salivary gland tumours and its treatment can cause changes • Tumours of the oral cavity, in voice, speech and swallowing. oropharynx, nasopharynx, Our SLTs will work with you and your hypopharynx and larynx loved ones/ caregivers to support and • Nasopharyngeal carcinoma rehabilitate your communication and swallowing difficulties. • Skin tumours and sarcomas in the head and neck region Our services include: • Sinonasal tract tumours • Speech and swallowing therapy • Cervical lymphadenopathy • Post-laryngectomy voice rehabilitation We are specialised in the following treatment/procedures: • Prosthetic speech and swallow rehabilitation (PSSR) • Oncological resections of complex head and neck malignancies Dietitians • Transoral robotic & endoscopic Dietitians are qualified healthcare robotic skull base surgery professionals who assess patients’ • Head and neck oncologic nutritional status, diagnose and plan reconstructive surgery & skin the necessary intervention for the malignancy patients’ requirements based on their • Salivary gland, thyroid and medical, dietary and psychosocial parathyroid surgery including history. endoscopic and robotic The adverse effects experienced thyroidectomy by the patient lead to a reduction in • Resection of salivary gland nutritional intake which can result tumours in unintentional weight loss and • Paediatric head and neck surgery malnutrition. Thus, dietitians play a pivotal role in ensuring that the • Oral and maxillofacial surgery and nutritional needs of our Head and rehabilitation
70 SingHealth Healthy Living Series SUPPORT SERVICES
Neck patients are met to minimise the risk of malnutrition-related complications.
Services include: • Nutrition assessment • Early nutrition intervention including food texture modification, food fortification, use of nutritional supplements and devising tube feeding regimen if indicated, (taking into account the patient’s other medical conditions where applicable) clients reduce the cost of injuries and Occupational Therapist disabilities, leading to better quality of Occupational Therapy is a health care life. profession concerned with people of Services include: all ages whose everyday life has been affected by physical, cognitive, and/or • Upper limb rehabilitation mental health problems. • Activity of Daily Living Re-training Occupational therapists use everyday • Scar management activities (occupations) in a purposeful • Lymphedema management and meaningful manner, and a variety of treatment methods to obtain a Physiotherapist desired level of functioning to perform their roles and tasks in daily living Patients with head and neck tumours such as productivity (work/education), sometimes experience pain, stiffness self-care, play and leisure. and swelling in the affected and surrounding areas. They also may Our team of occupational therapists, present with difficulty clearing their with their skills and knowledge of own secretions. After surgery, health management, ensure that they these problems may worsen. The continue to provide a high standard of physiotherapist can assess and service to people with diverse needs. initiate exercises to help improve your mobility and strengthen your neck and We hope that the provision of these shoulders. The physiotherapist will quality services would help our also assess your posture and advise
All About Head & Neck Diseases 71 SUPPORT SERVICES
you accordingly. Physiotherapists Psychosocial Oncology can perform treatment and advise The Department of Psychosocial on various techniques to help with Oncology from National Cancer clearing of your secretions and Centre Singapore provides a manage the swelling in your limbs. comprehensive range of psychosocial Services include: services to support patients and their loved ones deal with psychological, • Teaching of airway clearance emotional, social and practical techniques demands of the treatment and • Advice on posture recovery process. • Advice on stretching exercises for It supports the Head & Neck service shoulder and neck with a competent team of allied • Advice on range of motion health professionals, many of whom exercises are Medical Social Workers and additionally qualified as Clinical • Issue of anti-embolism stockings Psychologist, Art Therapist, • Issue of incentive spirometer Psychotherapists or Counsellors. if applicable (patients with tracheostomies, laryngectomies Services include: and not for surgery on the face or 1. Pre-operative/treatment jaw) psychosocial assessment and preparation 2. Psychological, emotional and social support and intervention for effective coping throughout treatment and recovery process through: • Individual counselling • Family counselling • Psychotherapy • Caregiver support
72 SingHealth Healthy Living Series SUPPORT SERVICES
We have a dedicated team of sub- specialist surgeons and allied health professionals to provide unparalleled holistic and comprehensive care for our patients with Head and Neck diseases.
This multidisciplinary team with complementary skillset enable the relentless pursuit of comprehensive oncological resection, aesthetic reconstruction and functional rehabilitation.
All About Head & Neck Diseases 73 SUPPORT SERVICES Acknowledgements
Special thanks to Singapore General Hospital, National Cancer Centre Singapore, National Dental Centre Singapore and the following doctors and allied health professionals for their contributions:
DOCTORS Dr Pek Wan Sze Senior Resident, Department of Plastic, Professor Soo Khee Chee Reconstructive & Aesthetic Surgery (SGH) Director, National Cancer Centre Singapore Dr Jolin Hwee Jingyi Dr Tan Hiang Khoon Resident, Department of Plastic, Reconstructive Chairman, Division of Surgery (SGH) & Aesthetic Surgery (SGH) Senior Consultant, SingHealth Duke-NUS Head & Neck Centre ALLIED HEALTH PROFESSIONALS Dr N Gopalakrishna Iyer Mrs Tan Yee Pin Head & Senior Consultant, SingHealth Duke- Head, Psychosocial Oncology, Clinical NUS Head & Neck Centre Psychologist/ Medical Social Worker, NCCS
Dr Tan Ngian Chye Ms Pamela Ng Senior Consultant, SingHealth Duke-NUS Head Senior Occupational Therapist, SGH & Neck Centre Ms Aisyah Omar Dr Constance Teo Physiotherapist (Cardiorespiratory), SGH Consultant, SingHealth Duke-NUS Head & Neck Centre Ms Peh Hui Yee Dietitian, SGH Dr Jeremy Ng Chung Fai Head & Senior Consultant, Department of Ms Elizabeth Roche General Surgery (SGH) Senior Principal Speech Therapist, SGH
Dr Andrew Tay Ban Guan Ms Yee Kai Sin Head & Senior Consultant, Department of Oral Speech Therapist, SGH & Maxillofacial Surgery (NDCS) Division of Nursing, SGH & NCCS Dr Gerald Tay Ci An Associate Consultant, SingHealth Duke-NUS Department of Dietetics, SGH Head & Neck Centre Department of Occupational Therapy, Dr Harold Head Hon Wei Associate Consultant, SingHealth Duke-NUS SGH Head & Neck Centre Department of Physiotherapy, SGH Dr Siti Radhziah Bte Sudirman Associate Consultant, SingHealth Duke-NUS Department of Speech Therapy, SGH Head & Neck Centre
Dr Chelsia Sim Qiu Xia Associate Consultant, Department of Oral & Maxillofacial Surgery (NDCS)
74 SingHealth Healthy Living Series SINGHEALTH HEALTHY LIVING SERIES The SingHealth Healthy Living Series of booklets aim to bring health information to the public. Our booklets cover a range of medical conditions and are written to empower you to take charge of your health. The books aim to help you understand your medical conditions better and the various treatments available.
Our booklets in the series are:
UP CLOSE Get the answers to common Ear, Nose, and Throat conditions
UP CLOSE : Get the answers to common Ear, Nose, and Throat conditions 1
SNEC Eyebklt D8.indd 1 9/14/11 6:17 PM PD_Bone&Joints.indd 1 17/10/2011 5:17 PM PD_ENT_FA .indd 1 12/04/2011 2:18 PM Heart to Heart: Bones and Joints: Up Close: Eye Check: All you need to know All you need to know Get the answers to A look at common eye about heart health common Ear, Nose and conditions Throat conditions
The facts on common Sleep Matters et s Urology Conditions Get the answers to L ’ common sleep conditions Conquer Stay Healthy anCer Take the bite out of C 20 common health conditions
M11-016 SH Straight Talk D10.indd b 5/9/12 5:06 PM Straight Talk: Sleep Matters: Let’s Conquer Stay Healthy: The facts on common Get the answers to Cancer Take the bite out of urology conditions common sleep conditions 20 common health conditions
All about common Download your FREE health booklet at gynaecological conditions www.singhealth.com.sg/shl
Straight Talk: Gynae Conditions All About Digestive and Liver Diseases Published by SingHealth Marketing Communications Department www.singhealth.com.sg
For enquiries, consult your GP/family doctor or contact us at:
SingHealth Hospitals
Tel: (65) 6321 4377 Tel: (65) 6294 4050 Tel: (65) 6472 2000 www.sgh.com.sg www.kkh.com.sg
National Specialty Centres
Tel: (65) 6436 8088 Tel: (65) 6704 2000 Tel: (65) 6227 7266 www.nccs.com.sg www.nhcs.com.sg www.snec.com.sg
Partner in Academic Medicine
Tel: (65) 6324 8802 Tel: (65) 6357 7095 www.ndc.com.sg www.nni.com.sg
Primary Healthcare Community Hospital
Tel: (65) 6643 6969
PMS 362 C PMS 301 C PMS 801 C C78 M0 Y99 K0 C93 M60 Y13 K0 C91 M6 Y4 K0 polyclinic.singhealth.com.sg R39 G177 B76 R7 G102 B160 R0 G168 B222
For international enquiries: 24-hr Hotline: (65) 6326 5656 Fax: (65) 6223 6094 Email: [email protected]
Information correct as at 1 February 2016. Reg. No.: 200002698Z