Dr David Vokes: Head & Neck Disorders, Problems and Conditions Treated

A Head & Neck Surgeon is a surgical specialist who cares for people with neck lumps, thyroid lumps, salivary gland disorders, and cancers of the head and neck, which include throat cancers, mouth cancers, larynx cancers, salivary gland cancers, sinonasal cancers and complex skin cancers.

For more information about specific Head & Neck disorders please click on a link below:

Neck Lumps

Lumps may occur in any part of the neck and at any age. Neck lumps are common, and while most neck lumps are benign, some neck lumps are caused by cancer.

Head & Neck Surgeons consider any newly discovered lump in the neck of an adult older than 40 years of age as suspicious for cancer until proven otherwise. Therefore, it is crucial that neck lumps are evaluated by a Head & Neck Surgeon to determine the cause of the neck lump and to undertake the appropriate treatment.

There are many possible causes of a neck lump. When evaluating a neck lump, the important characteristics to consider when determining the nature of a neck lump are:

  • The age of the person with the neck lump
  • The location of the neck lump
  • Whether there are associated symptoms or examination findings

The Age of the Person with a Neck Lump

Neck lumps in children (15 years or younger) are most commonly inflammatory (caused by infections). The next most common cause is that the neck lump is a congenital lump, meaning that the lump was present at birth, and is the result of a variation in the normal process of growth and development in the womb. Examples of congenital neck lumps include branchial cleft cysts, thyroglossal duct cysts, dermoid cysts, and lymphovascular malformations. Tumours (also referred to as neoplasms) may cause neck lumps in children but are the least common cause.

In younger adults (between the age of 15 and 40 years), the most common causes of neck lumps are similar to those in children: inflammatory, congenital and then neoplastic. In older adults (> 40 years of age), the most common causes are different: neoplastic neck lumps are most common, followed by inflammatory neck lumps, and then congenital neck lumps.

The Location of the Neck Lump

Different types of neck lumps occur more commonly in different parts of the neck. In the front of the neck the most common lumps are thyroid nodules (most of which are benign) and congenital lumps such as thyroglossal duct cysts. In the preauricular region of the face (the area of the face in front of the ear) the most common lumps are tumours in the parotid gland (a salivary gland), and most of these are benign. In outer part of each side of the neck, under the SCM, a muscle that passes from below the ear to the collarbone, neck lumos are most commonly enlarged lymph nodes. In younger people these lymph nodes are most coften enlarged owing to infection, but in older adults these lymph nodes are more commonly enlarged owing to cancer that has spread from another part of the head and neck region, such as the throat or mouth. 

Symptoms or Examination Findings associated with a Neck Lump

If a person with a neck lump has associated symptoms such as an ulcer or a mass in the mouth, a loose tooth, an ulcer or mass in the throat, a sore throat, a sore or blocked ear, hoarseness, difficulty breathing, difficulty swallowing, or weight loss, there is more concern that the neck lump may be caused by a cancer inside the head and neck region.

Similarly, if examination reveals an abnormality in the mouth or throat, such as an ulcer or a mass, this increases the risk that the neck lump may be caused by cancer.

Evaluation of a Person with a Neck Lump

A person with a neck lump requires a thorough and systematic evaluation, including a complete examination of the head and neck region (including endoscopy), radiological imaging (such as an ultrasound scan, or a CT scan , or an MRI scan), and in some cases a biopsy (such as a fine needle aspirate, or FNA). An examination of the throat under general anesthesia may also be required in some cases.

The treatment of the neck lump will depend on the ultimate diagnosis and on the symptoms that the lump is causing.

Cancer of the Head & Neck

Cancers of the Head & Neck region, also referred to as Head & Neck Cancer (HNC), are a group of different types of cancers that affect different organs and regions in the head and neck region, and include:

  • Throat Cancer
  • Oropharyngeal Cancer
  • Laryngeal Cancer
  • Hypopharyngeal Cancer
  • Oral Cancer
  • Salivary Gland Cancer
  • Nasopharyngeal Cancer
  • Skin Cancer

HNC excludes cancers that arise in the brain, the spine and the eyes. As a group, these cancers are the sixth most common cancer type in New Zealand.

The symptoms of HNC are many and varied, and depend on the organ and/or region in the head and neck region that is affected. These symptoms include:

  • A lump in the neck (usually a painless lump)
  • A sore throat (usually localized to one side only)
  • A sore ear (without any abnormality of the ear)
  • A hoarse voice
  • Difficulty swallowing and/or painful swallowing
  • Difficulty breathing and/or noisy breathing (stridor) and/or shortness of breath on exertion
  • A lump or an ulcer on the face
  • A lump or ulcer in the mouth or on the lips
  • A white or red patch in the mouth or on the lips
  • Bleeding from the nose (epistaxis), mouth or throat
  • Numbness or weakness on one side of the face

Please remember that these symptoms may also be caused by conditions that are more common and less serious than head & neck cancer, but if you have any of the symptoms listed above that last for more than 3 weeks, it is important to see your doctor (GP) for a face to face consultation.

Evaluation of a Person with Suspected Head & Neck Cancer

If a person has symptoms suggestive of a head & neck cancer a complete examination of the head and neck region is required. An Otolaryngologist Head & Neck Surgeon is the best specialist to undertake this evaluation as they are able to exam this entire region, including the upper aerodigestive tract, using endoscopy. It is crucial to have endoscopy as part of this evaluation.

Investigations that may be required to either diagnose or exclude a head and neck cancer include:

  • Radiological imaging, such as an ultrasound scan, a CT scan, an MRI scan, and/or a PET-CT scan
  • A biopsy, such as an FNA (fine needle aspirate) or a larger biopsy (for example, an incisional biopsy or a punch biopsy)
  • An examination of the aerodigestive tract under general anaesthetic (for example, panendoscopy, pharyngoscopy, microlaryngoscopy, nasendoscopy)

If a person is diagnosed with a head and neck cancer, it is recommended that their case is presented at a Multidisciplinary Meeting (MDM) for discussion regarding treatment options. Dr Vokes has been an active member of the Auckland City Hospital Head & Neck MDM for over 15 years, and ensures that all his patients receive the benefit of a multidisciplinary approach through this MDM.

Treatment for Head & Neck Cancer

A number of treatment options are available for patients with HNC. Surgery and radiation therapy (RT) are the two most important treatment modalities. Chemotherapy may also be combined with RT (CRT).

As a general principle, early stage HNC (stage I or II) is treated with single-modality therapy – either surgery or RT, and advanced HNC (stage III or IV) is treated with combined-modality therapy – either initial surgery followed by RT or CRT, or initial CRT (which in turn may be followed by surgery if required).

Thyroid Lumps & Goitre

The thyroid is an endocrine gland that is in the bottom part of the neck adjacent to the trachea (windpipe) and the larynx (voice box). It has two halves, called lobes (a right lobe and a left lobe), and these two halves are connected to each other in the midline by the isthmus of the gland.The thyroid gland secretes thyrosine, the thyroid hormone, into the blood stream to regulate the body’s metabolism.

Several different disorders may affect the thyroid gland – it may become underactive (hypothyroidism) or overactive (hyperthyroidism). The thyroid may become swollen and painful in cases of thyroiditis. Most of these conditions are treated with medications by a General Practitioner or an Endocrinologist.

The two thyroid disorders that may require surgical treatment are lumps in the thyroid (thyroid nodules) and goitre (diffuse enlargement of the thyroid gland). Both of these conditions are common and not every person with a thyroid nodule or a goitre requires surgery.

Thyroid Nodules

Thyroid nodules are extremely common. A thyroid nodule may be discovered when it becomes visible in the neck, or when it can be felt in the neck, or when it grows to a size that it causes pressure in the neck. Sometimes an asymptomatic thyroid nodule may be found incidentally on a scan undertaken for an unrelated condition.

Thyroid nodules should be evaluated in a systematic way. The recommended initial investigations for a nodule are thyroid function tests (a blood test) and an ultrasound scan (USS) of the neck. The USS gives important information about the location, size and characteristics of the nodule. On the basis of the USS, some nodules require a biopsy, which is carried out using the USS to guide the biopsy, which is called an ultrasound guided fine needle aspirate (USS FNA). The biopsy result is reported using the Bethesda system, which places each result into one of six categories. According to the USS FNA result, a decision is made to either observe or to remove the thyroid nodule for further analysis.

Goitre

Goitre is the term for a diffusely enlarged thyroid gland. This is a common condition and many people who have a goitre do not have any symptoms. However, if a goitre grows progressively larger it may cause symptoms, including a sensation of pressure or constriction in the neck, difficulty breathing, difficulty swallowing, or the appearance of a large neck swelling.

Goitres are also evaluated with thyroid function tests and an USS. Some goitres also require an USS FNA and/or a CT scan of the neck as part of their evaluation.

How goitres are treated depends on the symptoms they are causing, and on the results of the investigations. In many cases goiters are observed and no active treatment is required. In some cases, goitres may be treated with medications, while in other cases the thyroid may need to be removed.

Thyroid Surgery

There are essentially two types of thyroid operations: a hemithyroidectomy (or thyroid lobectomy), in which one thyroid lobe (usually with the isthmus) is removed, leaving the second lobe in place; and total thyroidectomy, in which the entire thyroid gland (both lobes and the isthmus) are removed. The extend of thyroid surgery depends on the underlying condition being treated and the symptoms it is causing.

Thyroid surgery is undertaken under general anaesthetic through an incision in the lower part of the neck. The size of the incision varies according to the size of the thyroid. A special breathing tube with electrodes is used to monitor the nerves to the vocal cords, two of which pass behind the thyroid (the recurrent laryngeal nerves) and two of which pass close to the top part of the thyroid on each side (the superior laryngeal nerves). Injury to these nerves may result in voice change and/or breathing difficulties and so it is very important to take care when dissecting around the thyroid to preserve these nerves. There are also four small glands, called parathyroid glands, that are located behind thyroid gland. These glands control the amount of calcium in the blood, and so it is also very important to take care when dissecting around the thyroid to preserve these glands. Injury or inadvertent removal of these glands may result if low calcium levels in the blood (hypocalcaemia) requiring treatment with calcium and Vitamin D medications.

After a hemithyroidectomy, the remaining thyroid lobe is usually able to produce sufficient levels of thyroid hormone to maintain normal metabolism. However, after a total thyroidectomy, thyroid hormone medication (thyroxine) must be taken every day (for the rest of that person’s life) to maintain normal metabolism.

 

Salivary Gland Disorders

Saliva is the watery fluid in your mouth that helps you chew and digest food, protects your teeth, and keeps the lining of your mouth healthy. This fluid is produced by the major and minor salivary glands. There are three pairs of major salivary glands located in and adjacent to the mouth: the Parotid glands, the Submandibular glands and the Sublingual glands. There are also hundreds of minor salivary glands scattered around the mouth and the throat.

The Parotid glands are the largest salivary glands in the body and are found on the side of the face. The Submandibular glands are located under the mandible (jawbone). The Sublingual glands, the smallest of the major salivary glands, are located in the floor of the mouth, under the tongue.

A number of disorders may affect the salivary glands, especially the major salivary glands, including infection/inflammation (sialadenitis), tumours (also referred to as neoplasms), and generalised painless enlargement (sialadenosis).

Sialadenitis (Infection & Inflammation)

The most common salivary gland disorder is a painful enlargement of a gland caused by infection and inflammation. This is called sialadenitis. This inflammation is usually caused by blockage of the duct that drains saliva from the affected gland. This blockage may be caused by a narrowing of the duct (a stricture), or by a stone (also called a calculus) that may form in the duct. If the duct is blocked the gland cannot discharge the saliva it is making into the mouth, and the gland swells up. A secondary bacterial infection may then occur.

These episodes of infection and inflammation are usually treated with antibiotics and pain relief. It is also important to maintain good hydration (drink plenty of water), to massage the gland (to encourage salivary flow into the mouth), and to use sialogogues, which are substances that increase salivary flow to flush the duct clear. Useful sialogogues include citrus flavoured sweets – preferably sugar free.

If infections become a recurrent problem further investigations may be required, such as an ultrasound scan, a CT scan, a sialogram (an x-ray of the ductal system of a gland obtained by injecting a special dye into the duct opening) or an MR sialogram (a non-invasive scan of the ductal system of a gland).

Occasionally a surgical procedure may be required to prevent recurrent infections. The types of surgery used include:

  • Removal of a stone
  • Ductal dilation
  • Ductoplasty
  • Removal of the affected gland (Parotidectomy, Submandibualr Gland Excision, Sublingual Gland Excision)

Tumours (Neoplasms)

Any salivary gland (major or minor) may develop a tumour, that is usually noticed as a localised lump within the gland. Salivary gland tumours occur most commonly in the parotid gland. The majority of tumours within the parotid gland are benign, and most of these are of one particular type: a pleomorphic adenoma.  Salivary glands may also develop malignant tumours (cancers), and so it is important to have all salivary glands lumps evaluated thoroughly. The investigations used most often for salivary gland tumours are a fine needle aspirate (FNA) of the lump, and imaging, such as an ultrasound scan or a CT scan.

The treatment for a salivary gland tumour is removal of part or all of the affected gland: either a Parotidectomy, Excision of the Submandibular Gland, or Excision of the Sublingual Gland. Sometimes additional surgery, such as a Neck Dissection, is performed at the same time if the tumour is a cancer.

Sialadenosis

Sialadenosis is the generalised enlargement of a major salivary gland, without any infection, inflammation or tumour present. The parotid glands are the salivary glands most commonly affected by this disorder. This enlargement is not usually painful, which differentiates it from swelling cause by infection or inflammation.

There are many causes of sialadenosis including:

  • Diabetes mellitus
  • High alcohol intake
  • Nutritional disorders
  • Vitamin deficiencies

The investigations for sialdenosis include blood tests, imaging (an ultrasound scan or CT scan), and occasionally a biopsy is required. It is important to determine whether or not there is an underlying nutritional or metabolic disorder that needs to be treated. For mild sialadenosis no specific treatment of the gland is required, however if the enlargement is severe and is causing cosmetic concerns, part or all of the affected gland(s) may be removed.

Scroll to Top