The thyroid gland sits in front of the neck, above the collar bones and below the Adams apple, on either side of the wind pipe. It makes thyroid hormone, which is responsible for controlling the overall metabolic rate of the body. It can be over or under active. However the reason you would be referred to a head and neck surgeon would be if there was a lump in the thyroid gland, or if the gland had enlarged so much ( a goitre) so as to cause problems with the way it looks, or to cause problems with swallowing or breathing (particularly when lying flat). Lumps or nodules in the thyroid gland are not uncommon, and often no treatment is needed. However if the lumps get bigger, or if there is one lump only, then it may need to be removed. Most thyroid lumps are benign and are called thyroid adenomas. Thyroid cancers can occur however. Cancers are more common if you have been exposed to radiation (as in Chernobyl) or if there is a family history of thyroid cancers. Thyroid lumps in males, or in people younger than 20 or older than 45 can more often be cancer. Even in this group however, they are often benign.
The management of thyroid lumps involves an ultrasound scan, and a needle test (known as a Fine Needle Aspiration or FNA). This allows cells to be sent off to the laboratory to give more information about the nature of lump. A thryoid lump can appear suspicious of thyroid cancer on ultrasound or can look non cancerous (benign). The cells from the needle test (Fine Needle Aspiration or FNA) can look benign or cancerous. Clearly if there is the suspicion of cancer, then the surgeon will advise an operation to remove the thyroid gland (thyroidectomy). This is usually partial, only removing one side of the thryoid gland (that part with the thyroid lump in it) and is called a thyroidectomy.
Sometimes management of a thyroid lump can just be repeat ultrasound scanning, to check the lump does not grow much in size, or change in character.
Following surgery, if the lump is benign, then no further action need be taken. As only one half of the thyroid gland has been removed, you do not need thyroid hormone replacement. The remaining thyroid gland is more than enough to make enough thryoid hormone.
If however, after surgery, the lump is found to be malignant (cancerous) then further surgery is necessary. The other half of the thyroid gland needs to be removed, and sometimes some of the lymph nodes in the neck also need to be removed. After this completion thyroidectomy, further management is undertaken by the thyroid cancer doctors. This involves treatment called radio iodine treatment, and of course, ongoing monitoring.
Very occasionally the thyroid gland can be removed if it is overactive, and medicines have been inadequate to control this.
There are 6 main saliva glands in the mouth. They are the 2 parotid glands (those around the ear and just behind the jaw), the two submandibular glands (those under the jaw) and 2 smaller glands under the tongue (the sublingual glands). There are also many tiny salivary glands throughout the mouth.
This is quite a common in older patients, particularly those who are on several medications (as these can cause dry mouth). The best thing for this is to drink plenty of water, and often to carry a small water bottle with you. It is helpful to have some water by the bed also. There are saliva substitutes that can be prescribed by your doctor, but none are good as natural saliva and often they are little better than drinking water. If you are prone to dry mouth, it is important that you look after your teeth, as low saliva makes you more prone to dental problems. If you wear dentures, it is also very important to use a denture soak, to keep your mouth healthy.
Lumps in the Salivary Glands
The most common saliva gland affected by growths is the parotid gland. By far the vast majority of these (greater than 90%) are benign (non cancerous) and the majority of these are called pleomorphic adenomas. The management of lumps in the parotid gland is an ultrasound scan and a needle test (known as a Fine Needle Aspiration or FNA). This allows cells to be sent off to the laboratory to give more information about the nature of lump. Even though the majority of these lumps are benign, surgery to remove them is still considered the best treatment. This is because the lump does not go away with any other treatment, and if left will only slowly get bigger. Very very rarely these lumps can turn into cancer. If you do not have surgery, the parotid gland lump can be monitored with serial ultrasound scans. Removal of the parotid gland is called parotidectomy. Removal of the submandibular gland is also preformed commonly.
A face lift incision is now used to remove these lumps, so once the scar has healed it can be quite difficult to see. The main consideration with parotid surgery is that the nerve that controls the muscles of the face runs through the parotid gland. This means that the surgeon must be careful to dissect out this nerve and protect it during the operation. That is why quite a large incision (cut) is used (to allow good exposure) and is why the operation itself takes around 2 hours.
Lumps and Bumps in the Head and Neck
Lumps and bumps in the head in neck and enlarged lymph nodes in the neck are not always serious. They can be due to infection or inflammation. This is commonly seen when lymph nodes swell up at the angle of jaw, in children with tonsillitis. However lumps in the neck can be due to benign swellings as seen in sebaceous cysts and other cysts of the neck. Growths can form in the parotid and thyroid glands. These can be benign or malignant. Cancers that begin in the head or neck usually spread to lymph nodes in the neck before they spread elsewhere. For this reason, a lump in the neck that lasts more than one month, needs to be seen by a head & neck surgeon. Of course, not all lumps are cancer. But a lump (or lumps) in the neck can be the first sign of cancer of the mouth, throat, voice box (larynx), thyroid gland, or of certain lymphomas or blood cancers. Such lumps are generally painless and continue to enlarge steadily.
Management of lumps and bumps in the head and neck
History taking, the story about when the lump started, and what is making it worse or better
Examination of lump and potential sites the lump may have come from (potential primary sites)
- Blood Tests: This includes a full blood count, Glandular fever tests, Thyroid function tests, and sometimes Toxoplasmosis and HIV serology
- Fine Needle Aspiration Cytology (FNAC)
- CT or MRI
- Occasionally PET scanning if needed
- Panendoscopy and biopsy
If these lumps are caused by infection such as Tuberculosis or glandular fever, then this needs to be treated/managed. If the lump is likely to be a benign lump, such as a lipoma or sebaceous cyst, then this needs to be removed. If the lump is associated with another problem in the head and neck, such as cancer, then both the primary site and the neck lump need to be treated together.
Simple neck lumps such as a lipoma, may be able to removed under local anaesthesia. The tissue is always sent to the laboratory to check what it is.
Symptoms and signs
- Difficulty swallowing
- Painful swallowing
- Rapid growth of a mass in the neck/mouth &back of nose etc
- Weakness of surrounding muscles
- Generalised loss of weight
Risk factors include smoking and alcohol.
A complete history and examination, including checking the inside of the nose and throat with a flexible nasendoscope.
Investigations are likely to include a CT scan of the neck and chest, and an MRI scan of the neck. Sometimes another scan called a PET scan is also performed.
A biopsy of a lump needs to be obtained. It is often that this biopsy is done at the time of a panendoscopy.
There as several ways to treat throat cancers. These are:
- Laser treatment
- Photodynamic therapy (for oral cancers)
- Combinations of all of the above
Surgery for throat cancers varies depending on
- The size of the cancer
- What important structures the cancer is next too
- What surgery/treatment has previously been undertaken
All decisions regarding surgery for cancers are made as part of a Multidisciplinary team. This means that the patient is given the best opinion the hospital can based on the expertise of several consultants and the cancer team.
Treatment for my patients is discussed at the MDT (Multidisciplinary Team for Head & Neck Cancer) on Wednesday at Barts. Following this I would discuss treatment with the patient and the ‘patient pathway’ would be established.
Treatment often involves both surgery and radiotherapy, although sometimes just one treatment type is used. Photodymanic therapy can be used also in the mouth.
Patients are followed up closely in the first year after treatment
- Monthly in the first follow up year
- Every second month in the second post treatment year
- Every three months in the third post treatment year
- 6 monthly in the fourth post treatment year
Often the speech therapist is a very important person to work with, to try and optimize your rehabilitative treatment.
Skin lumps are very often benign (not malignant).
Common skin lumps are:
- Sebaceous cysts
Commonly they are slow growing and not painful. Occasionally they can get infected.
Treatment is surgical (an operation to remove it). Sometimes this can be performed under local anaesthetic.
Features that would suggest that a lump is not benign are:
- Rapid growth
- Weakness of muscles around the area of the lump
These features should alert you to see you GP promptly, to get a referral to a Head & Neck surgeon
Skin cancers are:
1. Basal cell carcinomas
2. Squamous cell carcinomas
The treatment of them is usually with surgery, although sometimes topical cream can be used such as 5FU. This is so particularly if there are some pre-cancerous changes on the face.
Treatment can be with simple excision. If lumps are larger they may need some grafting to repair the excision defect (from where the cancer has come from).
Sometimes a second operation is needed to re-excise the area, if the excision was not complete after the first operation.
3. The third type of skin cancer is Malignant melanoma.
These are a lot more aggressive that the other two types of skin cancers above. Surgery is again the best treatment. In this case a wide and deep margin of excision is required, as well as very close follow up.