MOUTH OR ORAL CANCER
Oral Cancer, also known as mouth cancer is a type of head and neck cancer and is any cancerous tissue growth located in the oral cavity.
The oral cavity includes the following:
- The front two thirds of the tongue.
- The gingiva (gums).
- The buccal mucosa (the lining of the inside of the cheeks).
- The floor (bottom) of the mouth under the tongue.
- The hard palate (the roof of the mouth).
- The retromolar trigone (the small area behind the wisdom teeth)
It may arise as a primary lesion originating in any of the tissues in the mouth, by metastasis from a distant site of origin, or by extension from a neighbouring anatomic structure, such as the nasal cavity. Alternatively, the oral cancers may originate in any of the tissues of the mouth, and may be of varied histologic types: teratoma, adenocarcinoma derived from a major or minor salivary gland, lymphoma from tonsillar or other lymphoid tissue, or melanoma from the pigment-producing cells of the oral mucosa. Oral or mouth cancer most commonly involves the tongue. It may also occur on the floor of the mouth, cheek lining, gingiva (gums), lips, or palate (roof of the mouth). Most oral cancers look very similar under the microscope and are called squamous cell carcinoma.
Oral Submucous Fibrosis (OSF)
It is condition which affects people who chew tobacco like Gutka, Paan masala, Areca nut or Supari. It is characterised by inability to open the mouth completely. This happens due progressive fibrosis of submucosal tissues and juxta-epithelial inflammatory reactions. It means inner cheek lining which is usually red or pink and stretchable turns into thick white hard like a parchment and become un-stretchable. In advanced stages there are fibrotic bands are formed which does not allow the mouth to open.
In the initial phase of the disease, the mucosa feels leathery with palpable fibrotic bands. In the advanced stage the oral mucosa loses its resiliency and becomes blanched and stiff. The disease is believed to begin in the posterior part of the oral cavity and gradually spread outward.
Certain symptoms of the disease include:
- Xerostomia(Dry Mouth)
- Recurrent ulceration
- Pain in the ear or deafness
- Nasal intonation of voice
- Restriction of the movement of the soft palate
- A budlike shrunken uvula
- Thinning and stiffening of the lips
- Pigmentation of the oral mucosa
- Burning sensation
- Decreased mouth opening and tongue protrusion
- Inability to eat normally as mouth does not open; there may be burning sensation in the mouth also.
- It is precancerous condition i.e. this lining has tendency to turn into cancer, symptoms one should be watchful of any ulcer which is to healing, pain during opening the mouth, pain in the ear or during eating. White or red patch can also develop.
- Stop tobacco– most important in early stages as changes can halt and might revert back, in other stages a least it will not further progress.
- Injection of local steroid with mouth opening exercise.
- If these do not work then surgery has to be done,Co2 LASER incision followed by mouth opening exercise, or putting a flap or piece of skin taken after the excision.
Important of Treatment
Our treatment is in accordance with the increased mouth opening. First and foremost thing is cessation of the habit and improve the lifestyle of the patient with a balanced and healthy diet.Physiotherapy for OSMF is a very important part of treatment as it helps in increasing mouth opening. Muscle stretching for the mouth may be helpful in preventing further limitation of mouth movement. If physiotherapy is used along with micronutrients, results are more favourable.
Tongue cancer is a type of oral cancer that forms in the front two-thirds of the tongue. Globally one person dies every six seconds due to tobacco use, which accounts for one in 10 adult deaths. This type of cancer usually develops in the squamous cells, the thin, flat cells that cover the surface of the tongue. Tongue cancer is also present as non-healing ulcer on the sides or tip of tongue. It can also cause pain in the ear also and difficulty in eating. It is usually affects people who consume tobacco in the form of smoking or chewing (Guthka, khaini, paan etc.) It can affect people with no tobacco habits also, especially ladies with sharp tooth causing longstanding tooth bite Cancer that forms in the back one third of the tongue is considered a type of head and neck cancer.
Common Tongue Cancer Symptoms
Symptoms of tongue cancer are very similar to symptoms of other types of oral cancer. It can often be mistaken for a cold that won’t go away, or a persistent sore in the mouth. Other tongue cancer symptoms and signs may include:
- Ulcer in the mouth which has not healed within 4weeks
- Development of white(Leucoplakia) and red patches(Erythroplakia) which are precancerous ( i.e. stages before development of cancer)
- Persistent heaviness or change in the voice.
- Persistent tongue and/or jaw pain
- A lump or thickening in the inside of the mouth
- A white or red patch on the gums, tongue, tonsil, or lining of the mouth
- A sore throat or feeling that something is caught in the throat that does not go away
- Difficulty swallowing or chewing
- Difficulty moving the jaw or tongue
Tongue Cancer can Occur
In the mouth, where it may be more likely to be seen and felt (oral tongue cancer). This type of tongue cancer tends to be diagnosed when the cancer is small and more easily removed through surgery.
In the throat, at the base of the tongue, where tongue cancer may develop with few signs and symptoms (hypopharyngeal tongue cancer). Base of tongue cancer is usually diagnosed at an advanced stage, when the tumor is larger and the cancer has spread into the lymph nodes in the neck.
Also base of tongue cancers are associated with human papillomavirus (HPV), which has a profound effect on the prognosis and treatment of the cancer.
Persistent difficulty in chewing or swallowing, speaking, or moving the jaw or tongue. The movements of the tongue can get affected with the cancer at advanced stage.
Endoscopic neck dissection (surgery) is a technically feasible and safe technique for treating early-stage oral cancer. Any incision in the neck gives a scar which is visible so technological advancement has led to more pragmatic and safe surgery by placing the incision behind the ear and along the hairline (retro auricular). Through this incision, endoscopic camera and instrument are put, surgery is performed and then incision is sutured. This operation is performed for doing thyroidectomy (thyroid removal operation), parathyroidectomy (parathyroid gland adenoma removal) and neck dissections for head neck cancer. The cosmetic outcome is very good with surgical removal of the tumor.
Treatment for advanced tongue cancers can impact your ability to speak and eat. Working with a skilled rehabilitation team can help you cope with changes that result from tongue cancer treatment.
Thyroid cancer is cancer that develops from the tissues of the thyroid gland. It is a disease in which cells grow abnormally and have the potential to spread to other parts of the body. Risk factors include radiation exposure at a young age, having an enlarged thyroid, and family history.
There are Four Main Types
- Papillary thyroid cancer
- Follicular thyroid cancer
- Medullary thyroid cancer
- Anaplastic thyroid cancer
Signs and Symptoms
- A nodule in the thyroid region of the neck
- An enlarged lymph node
- pain in the anterior region of the neck
Changes in voice due to an involvement of the recurrent laryngeal nerve
SCARLESS OR MINIMALLY INVASIVE THYROIDECTOMY:
This procedure is meant to perform half or total removal of thyroid gland by a technique which causes fewer scars in the neck or no visible scar in the neck.
There should be no previous surgeries in the same area of neck with nodule or thyroid size <=5cm, larger thyroid can also be removed with no visible scar but with combined approach (placing incision in the skin behind the ear and in the armpit)
Retroauricular approach in which incision is placed in area behind the ear and in the hairline so it is not visible, tunnel is created up to the thyroid lobe which is to be removed. The skin flap is held up with Chung’s retractor. Endoscope is introduced with for magnified view, specialised instruments are used to perform thyroidectomy (half or total removal of thyroid gland). Incision on other side may be required for removal of opposite thyroid. Special care is taken during surgery for identification of recurrent laryngeal nerve and its preservation, so that injury to this nerve is avoided. Parathyroid glands which are situated on the backside of thyroid lobe, control level of calcium in the body. These glands need to be preserved so that calcium levels are maintained in normal. For the utmost care during surgery we prefer ROBOTIC SURGERY (DAVINCI – XI) or ENDOSCOPIC SURGERY. Endoscopic surgery comes with the advantage of same approach with much decreased cost.
Risks of the Operation
There are three main risks for total thyroidectomy.
- Recurrent laryngeal nerve injury: This nerve controls your vocal cords and if injured you will have a hoarse voice. There is a 1% chance of permanent hoarseness and a 5% chance of temporary hoarseness (<6months).
- Low blood calcium: There are parathyroid glands that lie behind your thyroid gland that help to control your blood calcium levels. If they are injured or removed (can lie within the thyroid gland) during your operation, then your blood calcium can be too low. This would require you to take calcium and vitamin D supplementation. There is a 1% chance of permanent calcium supplementation and 5% chance of temporary calcium supplementation.
- Bleeding: There is a 1/300 risk of bleeding with your operation. This is the main reason you stay overnight in the hospital.
- Above risk factors can be surely eliminated with the adept expertise and supervision of the surgeon.
Admission in the hospital is for 1-2 days. Recovery time is 2weeks. Endoscopic neck dissection (surgery) is a technically feasible and safe technique for treating early-stage thyroid cancer.
CAROTID BODY TUMOR OR PARAGANGLIOMA
Carotid body tumors (CBTs) are rare neoplasms; although they represent about 65% of head and neck paragangliomas (These develop at various body sites including the head, neck, thorax and abdomen). These are located on the side of the neck, where the large carotid artery branches into smaller blood vessels to carry blood into the brain. The cluster of cells around that branching is called the carotid body, or carotid glomus. The tumors that develop there are not life-threatening, but they can grow quickly and press on nearby nerves and blood vessels, causing damage to those structures.
The carotid body, which originates in the neural crest, is important in the body’s acute adaptation to fluctuating concentrations of oxygen, carbon dioxide, and pH. The carotid body protects the organs from hypoxic damage by releasing neurotransmitters that increase the ventilatory rate when stimulated.These tumours arise from chemoreceptor zone present at the division of carotid artery (supplying arterial blood to face – external carotid artery and brain- internal carotid artery) into external and internal carotid artery as shown in the figure.
Usually presents as a painless neck mass, but larger tumors may affect cranial nerve , usually of the vagus nerve (leading to change or heaviness of voice) and hypoglossal (tilting or deviation of tongue towards the side of tumor) nerve. These are highly vascular tumors means have many small blood vessels around it.Individuals with malignant (cancerous) carotid body tumors may have higher blood pressure.
These are different types
- Familial : The familial (have genetic link) type (10-50%) is more common in younger patients.
- Sporadic : The sporadic (does not genetic link) form is the most common type, representing approximately 85% of carotid body tumors.
- Hyperplastic : The hyperplastic form is very common in patients living at a high altitude (> 5000 feet above sea level) due to decrease level of oxygen.
About 5% of carotid body tumors are present on both sides of neck and 5-10% can be cancerous also, but these rates are much higher in patients with inherited disease.
The test performed are ultrasonography with colour Doppler, CT scanning of the head and neck with contrast or CT Angiography is also helpful and typically reveals a hyper vascular tumor located between the external and internal carotid arteries.
MRI imaging may also be considered to be the criterion standard of carotid body tumors, and the tumor has a characteristic salt and pepper appearance on T1-weighted image.
Surgical excision is done by taking care of nearby vital structures and utmost care of internal carotid is observed.The process goes as under general anaesthesia, laterally inclined incision along the anterior border of the sternomastoid muscle is performed intraoperatively. After clear visualization of the anatomic structures such as the common carotid artery, the internal carotid vein, the cranial nerve, and the accessory nerve, then the common carotid artery and the internal and external carotid veins are sufficiently liberated for a good separation, and then the common carotid artery and the proximal end of the tumor artery are blocked, using blood vessel blocking bands for the convenient control of the blood flow, and finally they are carefully separated along the tumor body so that the blood vessels feeding the tumor could be radically removed. After the removal process, Reconstruction of the common carotid and the internal carotid artery are performed in patients undergoing resection of the internal carotid artery. Patient can be discharged in 1-2 days.
SALIVARY GLAND CANCER
Salivary gland cancer is a type of head and neck cancer. It is a rare disease in which malignant (cancer) cells form in the tissues of the salivary glands.Being exposed to certain types of radiation may increase the risk of salivary cancer.Signs of salivary gland cancer include a lump or trouble swallowing.
The salivary glands make saliva and release it into the mouth. Saliva has enzymes that help digest food and antibodies that help protect against infections of the mouth and throat. There are 3 pairs of major salivary glands:
- Parotid glands : These are the largest salivary glands and are found in front of and just below each ear. Most major salivary gland tumors begin in this gland.
- Sublingual glands : These glands are found under the tongue in the floor of the mouth.
- Submandibular glands : These glands are found below the jawbone.
Of all the above, PAROTID TUMOR is most common, In fact as many as 80% of salivary gland tumors begin in the parotid glands.
Parotid glands are salivary glands which are situated in the area in front of ear. It produces saliva to keep our mouth wet, if you see or think about delicious food it starts producing saliva and opens in the mouth via a duct, adjacent to upper 2 molar teeth or upper 2nd last tooth.
Parotid gland can get affected by tumors or lump which in 80% times is not cancerous. These Benign parotid tumors tend to grow but do not spread to other parts of the body. As they grow, they may push on the surrounding tissue or wrap around them; if the nerve is immediately next to the tumor then the nerve can in time be either pressed on or engulfed by the salivary gland tumor making surgery more difficult. The most common benign tumor of the parotid gland and the most common of which is Pleomorphic adenoma also called Benign Mixed Tumor. They will usually been seen as swelling which keeps on growing with time slowly and will usually not cause any pain. If there is pain or recently it has rapidly increased in size then we suggests cancerous conversion of the benign tumor.
To diagnose it one needle test is done called FNAC by which it is confirmed that swelling is cancerous or not cancerous. Surgeon will require CT scan or MRI for looking inside the nature of lump and likely any extension.
Surgery is challenging as there is nerve called Facial nerve which runs deep to the tumor so this nerve and its branches needs to be preserved. This nerve controls the facial expressions. Its damage during surgery leads to inability to close the eyelid and deviation or mouth to while smiling and in worst cases it may lead to permanent facial paralysis of the patient. In order to avoid this we take utmost care in identifying the facial nerve prior to the removal of Parotid Gland. Surgery is the only successful way by which it can be removed. Surgeon’s experience and use of adjunctive instruments like nerve stimulator to help in identifying the finer branches with large tumours are the key points of successful removal of tumor.
Patients are able to go home on same day or day after surgery, depending on the overall health and other parameters. After 1-2 weeks of surgery they are allowed to eat everything but forbidden from taking Pan Masala, Gutka and are also refrained from heavy lifting exercises.