For Caregivers

Welcome Caregivers. Your support means so much!

This section is dedicated to loved ones, friends, and children who participate in the care of a person with head and neck cancer.

When a loved one is diagnosed with cancer, the dynamics of relationships and families are impacted. Caregivers are forced sometimes to change roles, adjust schedules, change or drop out of activities. We hope to provide you with information, resources and support to help you cope and provide care.

Please visit our:

• Diagnosis and Procedures pages for more info on the condition
• Resources to assist you in providing more knowledgeable care
• Support Groups for Individuals with Head & Neck Cancer

If you are interested in a particular topic which is not represented, please email us.

Support Groups

An important part of the healing process!

Head and Neck Cancer Support GroupSupport groups have been proven to be an important component of wellness. In the last decade, research has shown that membership in groups improves overall quality of life. Psychological distress is reduced with ongoing participation. Groups provide in informal and supportive atmosphere in which to share common treatment experiences, coping strategies and feelings.

At the Dance Center there are two groups, each with a different focus. The groups seek to provide education and information about the disease along with a forum for open discussion. Patients may attend more than one group. Caregivers, family members, and significant others are welcome (and are encouraged) to attend.

The Patient & Family Support Group

The group is open to patients who have been diagnosed with cancer of the head and neck, their family members and significant others. The group is co-led by the Center's Social Worker and Head & Neck Rehabilitation Nurse in an effort to provide a supportive atmosphere in which to share feelings associated with your diagnosis. All meetings are held in the Physician's Pavilion East Conference Center on the third floor (main floor) of Physician's Pavilion East at the Greater Baltimore Medical Center. Dress is comfortable and casual, and beverages are served.

Meetings are the third Tuesday of every month from 7 p.m. to 8:30 p.m.



Cancer Survivor's Guide to Nutrition: Lecture Series

As cancer treatment continues or comes to an end, you may wonder what foods you should be eating. It may be time to develop new lifestyle behaviors in regard to nutrition and physical activity. Join in for a monthly lecture and discussion on the importance of nutrition and physical activity in cancer recovery and prevention. Each month, a new topic is discussed. Topics range from choosing whole foods, sugars and sweeteners, understanding food labels and nutrition claims, use of supplements, etc. This is a free patient service open to patients and family members of the Milton J. Dance, Jr. Head and Neck Center and the Sandra and Malcolm Berman Cancer Institute and Breast Center at GBMC. Light fare and refreshments are served and parking is complimentary. To reserve your spot, please call: Keri Ryniak, RD, CSO, CNSD at 443-849-8186. Learn more.

Nutrition

As cancer treatment continues or comes to an end, you may wonder what foods you should be eating. It may be time to develop new lifestyle behaviors in regard to nutrition and physical activity.





For more information call Keri Ryniak, RD, CSO, CNSD at 443-849-8186.



Nutrition Recommendations

Eating is essential to living. Calories from food supply the brain and body with energy. Protein keeps the muscles strong and fat provides energy and protects organs. Fluids, vitamins, and minerals allow the body to function at its best. Each person's unique caloric and nutritional needs may increase during times of growth, activity, stress and illness.



Head and neck cancer patients have specialized nutrition needs. The presence of a tumor may change the body's nutrition requirements and/or the way the body uses nutrients. These changes may also cause changes in appetite or eating patterns because of pain, difficulty chewing or swallowing.

Proper nutrition during cancer treatment is important to maximize functional status and quality of life. Research has suggested that patients who are malnourished and experience weight loss have a greater risk of hospitalizations, increased treatment side effects, and reduced quality of life. Maintaining an adequate intake will help prevent these negative effects of cancer treatment.

Nutrition Goals During Treatment

Goal 1: Consume adequate calories to maintain body weight.

Goal 2: Choose high protein foods such as eggs, beef, chicken, fish, cheese, beans and nuts.

Goal 3: Add snacks in between meals if needed to increase calorie intake.

Goal 4: Choose commercial liquid supplements, shakes, or smoothies as a meal replacement or snack.

Goal 5: Meet daily fluid needs - about 60-70 ounces each day.

If you cannot meet these recommendations or have further questions, please contact me for a personalized nutrition evaluation and consultation.

Newly Diagnosed?

If you have a diagnosis of cancer and you're not sure where to begin, let us help you.

A diagnosis of cancer or any other condition of the head and neck is often an intimidating experience. The aim of the website is to empower you with information. This site will give you more information on your condition, allow you to talk with professionals, and identify both print and electronic resources that will assist you in making treatment decisions. Be sure to visit all the areas of our website as they contain many resources to help you and your family. If you have questions about this site or want to speak directly with a professional, please call 443-849-2087 and ask for a head & neck professional or email us.

If you'd like to explore some of the issues and information surrounding your particular diagnosis or procedures, we have some helpful general information in our Diagnosis and Procedures section.

For Head & Neck Cancer Patients-Survivors

The Milton J. Dance, Jr. Head & Neck Center is a pioneer facility; the first ever to take an interdisciplinary approach to the treatment of head and neck cancer. Since our opening in 1980, we have continued to stay in the forefront of care, treating patients from all over the world.

Today, our comprehensive services address every physical and emotional need of patients with head and neck conditions -- from surgery to voice rehabilitation, dentistry to swallowing. Our integrated approach teams the patient and their primary care physician with specialists in the disciplines of:

• Surgery
• Medical Oncology
• Radiation Oncology
• Speech-Language Pathology
• Nursing
• Nutritional Services
• Occupational Therapy
• Physical Therapy
• Oncology Social Work
• Maxillofacial Prosthodontia
• Dentistry

Our expertise extends to patients in any stage of care -- from pre-operative to post-operative. The Center's Rehabilitation Services include:

• daily rounds on inpatients
• discharge planning and home health care coordination
• speech, voice and swallowing therapy
• outpatient follow-up
• patient and family counseling and support
• patient and family education
• patient assessment
• head and neck cancer tumor board and patient care conference

Head and neck conditions can be especially devastating for patients. In addition to medical concerns, these conditions can also have a tremendous psychological impact on patients' social lives and their interactions with the world. Oncology patients and their families participate together with a coordinated care team at the Center, whose services may include pre-treatment assessment and teaching, education, psychosocial evaluation and counseling services.

The Center also offers services for adult and pediatric patients with speech, language, voice, cognitive-communicative and swallowing disorders. We have sophisticated voice and dysphagia (swallowing) programs, incorporating state-of-the-art equipment including laryngeal stroboscopy, videofluoroscopy, (FEES) fiberoptic endoscopy, sEMG, transnasal esophagoscopy, Botox, Laryngeal EMG, and a swallowing workstation.

Our personnel are truly dedicated to providing excellent care by extending their commitment into the community with free oral cancer screenings, and by offering long-term follow-up programs to primary care physicians.

Diagnosis and Procedures

Types of Head and Neck Cancer

Below are some descriptions to help you better understand your (or your loved one's) diagnosis. While not all the information is covered, it will give you a general description and greater knowledge. If you still have questions take the opportunity to ask your doctor for further explanations.

Cancer of the Nasopharynx

• Sinus Cancer
• Nasal Cancer
• Mouth (Oral) Cancer
• Lip cancer
• Tongue Cancer
• Tonsillar Cancer
• Palatal Cancer
• Salivary Gland Cancer
• Floor of Mouth Cancer
• Cheek (buccal) Cancer

Neck Cancer

• Laryngeal Cancer
• Supraglottic
• Glottic
• Subglottic
• Other Cancers on the neck

Laryngeal Cancer:

The larynx is the area of the body from the hyoid bone to the epiglottis. It is critical to voice production, swallowing and breathing. Ninety-five percent of laryngeal cancers are SQUAMOUS CELL CARCIMONA. These tumors arise from the cells of the membranes lining the larynx. Less common tumors of the larynx include carcinosarcoma and verrucous carcinoma. In addition, some tumors that benign, or noncancerous also occur in the larynx. Although the Laryngeal Cancercause of cancer is unknown, there is a strong association between smoking and alcohol use and laryngeal cancers. More than 95% of laryngeal cancers occur in smokers. Continuing to smoke during and after treatment significantly increases your risk of recurrence.

Cancers of the larynx are classified by their site of origin. The larynx is commonly divided into three segments: 1) Supraglottic 2) Glottic and 3) Subglottic.

The Supraglottic Larynx is comprised of the epiglottis, the aryepiglottic folds, the ventricular folds and the laryngeal ventricles. Tumors in this area can cause hoarseness or airway obstruction and or swallowing problems. Tumors may be fairly large, before they are diagnosed. They are usually treated with surgery (partial laryngectomy or total) and radiation.

Glottic cancer refers to the vocal folds. Generally, hoarseness and airway obstruction are the first signs. If a tumor is confined to the larynx, it may be successfully treated with radiation and or laser cordectomy.

Subglottic tumors occur infrequently. They are in a less accessible area of the larynx and therefore often required a total laryngectomy. The surgeon may also have to remove all or part of the thyroid glands and adjacent lymph nodes.

In addition to these laryngeal tumors, cancers can directly involve the larynx from nearby sites. For example, a cancer on the tongue base may invade the epiglottic space.

Medical testing for cancer of the larynx may include chest x-ray, complete blood count, serum chemistry studies, pulmonary function studies, and MRI. Your doctor will perform a biopsy before proceeding with treatment of the tumor to confirm the diagnosis and often an endoscopy to determine the extent or stage of the tumor.

Treatment of laryngeal cancer traditionally includes surgery, radiation and chemotherapy. Treatment may consist of a single form, or be a combination of several modalities. The combination that is best suited for you is determined by multiple factors. Factors include: placement of tumor, size of tumor, patient's general health. Also of concern to is whether or not the cancer has invaded the LYMPH NODES or if it has METASTHESIZED. Your physician's primary concerns are eliminating the cancer and preserving function. Please ask your medical specialist for further information on the specific procedures relevant to your case.Soft Palate Cancer

Soft Palate Cancer

Cancer of the soft palate (or roof of mouth) is relatively rare. The soft palate anatomically divides the mouth from the nose. The overwhelming majority of tumors arise on the side facing the tongue. Although rare, these tumors are generally more readily visualized and thus are often identified earlier than other oral cancers. Larger tumors may create ulcerations or even perforation of the soft palate. Soft palate tumors tend to spread to the superior constrictor muscles and pterygoid fossa if left untreated.

Treatment of cancers in this region typically includes a combination of surgery and radiation. Radiation treatment is often the modality of choice for small lesions, as a full-thickness resection of the soft palate impairs speech production (Resonance- link to definition), and swallowing. In small lesions (less than one centimeter) surgery may be the primary form of treatment, because full closure of the tissue removed is possible. Large lesions that require both surgery and radiation typically also require the services of a Prosthodontist . This dental specialist, in conjunction with your speech and swallowing specialist will create a prosthesis to fill the area of removed tissue to restore function.

Supracricoid Partial Laryngectomies

The Supracricoid Partial Laryngectomies (SCPL) are a subset of surgical procedures that are available to the Head and Neck Surgeon for the management of selected cancers of the larynx. The SCPLs are a subset of conservation laryngeal operations.

SCPL refers to the resection of the diseased or affected part of the larynx that is removed at the time of operation. The defect in the larynx is then reconstructed at the time of operation with what is known as a crico-hyoidal impaction. The specific type of impaction is either a cricohyoidoepiglottopexy, a cricohyoidopexy, or a tracheocricohyoidoepiglottopexy. Exactly which reconstruction is used is determined by the location of the patient's cancer, the extent of involvement of the tumor and the patient's overall condition. The SCPLs are all alike in that the anterior component of the vocal cords is removed bilaterally in addition to the immediate area above and below the vocal cords. If the tumor then extends either above or below the actual vocal cords (or glottis), then either of the above reconstructions is performed. In addition, one of the arytenoids (the cartilage that controls the vocal cords) can also be removed.

The benefits of the SCPLs are that rather large tumors can be effectively removed from the larynx while still preserving swallowing, speech and the airway functions of the larynx. While the patient's voice will never be normal after any of the supracricoid partial laryngectomies, the patient is able to communicate readily without the aid of any prosthesis or electronic device, and most importantly, the vast majority of patients do not need a permanent tracheostomy. A tracheostomy is necessary in the immediate post-operative period, but we are usually able to remove this in the few days after surgery, before the patient even leaves the hospital. Then, as the surgery and tracheostomy sites heal, the patient relearns how to speak and swallow. Obviously then, if we can avoid the permanent hole in the neck needed with more traditional laryngeal surgeries, then the patient can lead a more normal and active life with fewer, if any, restrictions.

The SCPLs do, however, have some contraindications. Not everyone is a candidate for conservation laryngeal surgeries, and very specific criteria have to be met to be able to perform the resection and reconstruction while still removing the entire tumor. Obviously, the first goal of any cancer operation is to remove all of the cancer. In addition, pulmonary function must be assessed before performing any of the above surgeries. While patients recuperate from their surgery, there is often a moderate amount of aspiration of saliva and even diet into the airway. While the patient relearns to swallow in usually no more than seven to ten days, it is important that he have healthy lungs so that he can tolerate this small degree of aspiration. In addition, SCPLs do not give patients a normal voice. Patients are, however, able to communicate readily and without the use of any assisted devices.

Once a patient is found to have cancer of the larynx, it is then up to his treating surgeon to assess the extent of the disease and consider the patient's surgical options. If SCPL is an option, then we like to use it as we feel that not only is the patient's long-term function significantly improved as compared to traditional therapy but also long-term cancer control is not sacrificed.

Floor of Mouth Cancer/Buccal Cancer

The buccal cavity includes the inner surface of the lips. The Floor of mouth is the "U"-shaped lining over the hyoglossus and mylohyoid muscles. It is a deep area, extending all the way to the mandible (lower jaw). The buccal cavity (BC) and floor of mouth (FOM) are intimately connected. The move in synchrony with the tongue during to allow one to swallow. The major salivary glands empty secretions through the membranes that line the FOM and BC.

Over 97% of all cancers of this region are SQUAMOUS CELL CARCINOMA. Leukoplakia and erythroplasia often appear prior to a cancer diagnosis. Because of their interconnection with tongue and mandible, tumors in this region tend to spread locally. Distal metastasis is rare. The major risk factors in developing cancers in this region are alcohol and tobacco use. Other possible causes include, the Herpes Simplex 1 virus, and marginal oral hygiene. Chronic irritants, such as dentures are not strongly correlated with FOM/BC cancer.

The treatment for cancers of the FOM and BC is determined primarily from the stage of the lesion. The physician's primary goals in treatment are elimination of cancer and preservation of function/appearance. The two primary treatments are radiation, surgery, or a combination of both. Neck surgery may also be required if the cancer has spread to the lymph nodes. Techniques developed over the past decade have greatly improved quality of life for patients with FOM and BC cancer.

Tonsillar Cancer

Introduction

The tonsils are made of lymphoid tissue, which contains cells of the immune system that are involved in fighting infection. The palatine tonsils are what we commonly refer to as "the tonsil;" however, there is also a patch of lymphoid tissue at the base of tongue, called the lingual tonsil. Other lymphoid tissue occurs in the nasopharynx (high in the pharynx behind the nasal passages) and this is referred to as the adenoid. Together, the palatine tonsils, the lingual tonsil and the adenoid make up a ring of lymphoid tissue in the pharynx - Waldeyer's ring.

The most common cancers that occur in the tonsils are squamous cell carcinoma (SCCA). Lymphoma can also occur in the tonsil. The cancers that occur in the tonsil are similar to those that occur elsewhere in Waldeyer's ring. Lymphoepithelioma is an older term for a non-keratinizing undifferentiated SCCA.

Risk Factors

The risk factors for SCCA are smoking, drinking and in particular the combination of heavy smoking with heavy drinking. More recently viral infection has been implicated in the etiology of SCCA in the upper aerodigestive tract. Human papilloma virus (HPV) DNA has been found in SCCA of the tonsil. However, we do not know what role HPV plays in the development of cancer at this location. Risk factors notwithstanding, there are individuals who develop SCCA in the tonsil (and at other sites in the upper aerodigestive tract) without having any of the known risk factors. Currently, we have limited understanding of what factors may lead to development of SCCA of the tonsil in individuals who neither smoke nor drink. It may be that DNA viruses such as HPV may play a role in the process of carcinogenesis in these individuals.

Signs and Symptoms

Most tonsilar cancers are relatively quiet until they become very large or ulcerate. Most often, the first presenting symptom is that of a neck mass. Many tonsilar cancers have early spread to lymph nodes in the neck (cervical metastasis) and this is a common presenting feature of these cancers. The cervical metastases tend to be cystic and can be confused with a benign neck lump called a branchial cleft cyst. Because of the lack of symptoms in tonsilar SCCA, tonsilar asymmetry (one tonsil being larger than the other) in an adult is sufficient reason to perform a tonsillectomy to rule out cancer. In addition, if SCCA is diagnosed in the neck and the site of origin is not identified, a tonsillectomy is usually performed to rule out the tonsil as the source of the cancer. Fortunately, tonsilar SCCA does not have a high rate of early spread to distant sites such as the lung.

Staging

Tonsilar SCCA is staged according to size of the tumor and degree of involvement of bone and deep muscles. It is also important to evaluate the neck for metastatic spread of SCCA, which tends to occur rather early in the course of the disease. Distant spread is relatively infrequent and, in most cases, can be ruled out with a simple chest X-ray. In cases where there is extensive or bilateral neck disease a CT scan of the chest or a whole body PET scan may be obtained.

Treatment

Options for treatment depend on size of the tumor, whether adjacent structures (tongue, palate, bone) are involved, and degree of neck spread. Surgery followed by radiation therapy is the form of treatment that offers the best chance of cure. Surgery can sometimes be done through the mouth (transorally) as one would do a tonsillectomy in a child; however, this approach can only be done for the smaller tumors. Larger tumors usually require a different approach by splitting the mandible (mandibulotomy and mandible swing) or by entering the pharynx laterally (lateral pharyngotomy). A neck dissection with removal of lymph nodes structures is almost always performed because of the high rate of early tumor spread to the neck. Patients who have mandibulotomy or pharyngotomy as the approach for tumor removal require a temporary tracheostomy tube which in general stays in place for 4-14 days.

Combination chemotherapy and radiation therapy (chemoradiation) has also been used for these tumors. In these cases, neck dissection is performed afterward for any patient that initially presented with palpable neck disease. Combination chemoradiation is still in its early stages and we do not have complete information on tumor control with this modality, although the early results suggest cure rates that are comparable to those obtained with surgery. For smaller tumors, the results with surgery, both in terms of tumor control and functional outcome, are better with surgery followed by postoperative radiotherapy. The decision to choose one form of treatment over another has to be individualized. Factors that influence the choice of treatment are the size and location of the tumor, the experience of the treating team (surgeon, radiation oncologist, and medical oncologist), and the preference of the patient and his/her family.

Rehabilitation

Tumors of the tonsil, like most tumors of the upper aerodigestive tract, can affect speech and swallowing functions. The treatment of these tumors, whether it is surgery or radiation or chemotherapy, can also interfere with normal speech and swallowing. The process of rehabilitation involves prevention of complications and early intervention to maximize functional outcome. Dental care is quite important as is nutrition, swallowing ability and adequate social support.

Click here for details about surgical procedures.

Cancer Staging

A system of classifying and comparing tumors was developed. This information is included in this site for educational purposes and is not meant to suggest severity prognosis. Please contact your healthcare provider for specifics concerning your tumor.

Primary Tumor (t)

Tx

T0

TIS

T1

T2

T3

T4

No available information on primary tumor

No evidence of primary tumor

Carcinoma insitu

Greatest diameter of primary tumor less than 2 cm

Greatest diameter of primary tumor 2-4 cm

Greatest diameter of primary tumor more than 4 cm

Tumor greater than 4 cm with deep invasion

Nodal Involvement (n)

Nx

N0

N1

N2

N3

Nodes cannot be assessed

No clinically positive nodes

Single positive homolateral node less than 3 cm

Singe positive node 3-6 cm or...

Multiple clinically positive nodes, none over 6 cm

Homolateral node larger than 6 cm and, or bilateral nodes

Distant Metastasis (m)

MX

M0

M1

Not assessed

No known distant metastasis

Distant metastasis present (specify) _____________________________

Postsurgical treatment Residual Tumor (r)

R0

R1

R2

No residual tumor

Microscopic residual tumor

Macroscopic residual tumor (specify)

Histopathology Cell type-squamous cell carcinoma Tumor Grade (G)

G1

G2

G3-4

Well differentiated

Moderately well differentiated

Poorly differentiated

Surgical Procedures

Neck Dissection

What is a neck dissection?

Neck dissection is an operation done to remove groups of lymph nodes from the neck. It can be done on one or both sides of the neck. Lymph node groups in the neck are numbered I-V. Selective neck dissection is removal of only a few of the groups of lymph nodes on one side of the neck. Comprehensive neck dissection involves removal of all lymph node groups on one side of the neck (levels I, II, III, IV, and V).

What is a radical neck dissection?

"Radical Neck Dissection" is an operation in which the sternocleidomastoid muscle, the internal jugular vein, and the spinal accessory nerve are removed in addition to removing all of the lymph nodes in levels I-V. This operation is still sometimes performed to remove very extensive neck disease. Modified Radical Neck Dissection is performed more frequently. This operation entails removing all of the lymph node levels but sparing at least one of the 3 structures mentioned above: the muscle, the jugular vein, and/or the accessory nerve. The type of operation you have depends on the type of tumor, the location and size of the tumor, and on whether or not there is already evidence of tumor spread to the lymph nodes.

Why do I need to have a neck dissection?

A neck dissection is done for 3 basic reasons: 1) therapeutic, 2) preventive, 3) access .

Therapeutic reasons: in some instances, a neck dissection is done to remove lymph nodes known or suspected to contain cancer that has spread from other locations (e.g., skin, mouth, nose, throat, etc.) Preventive reasons: at times, even though there is no known spread of cancer to the lymph nodes, the chances are high that those lymph node contain cancer cells. In such instances, a neck dissection is done to properly stage the cancer and to determine whether further therapy (e.g., radiation) might be indicated. The lymph nodes are removed to determine whether or not the cancer has spread outside of its site of origin. Access reasons: the lymph nodes in the neck are contained amidst fatty tissue. There are times when the fatty tissue and lymph nodes are removed to better delineate the anatomical structures of the neck for the purpose of accessing vessels or nerves. In some cases, in order to reach certain tumors, a neck dissection is done so that these difficult to access areas can be approached in a safe manner.

What do the lymph nodes do and won't I miss them?

Lymph nodes filter the lymph system, which is fluid that leaks out of blood vessels. They can trap bacteria and cancer cells. However, there are thousands of lymph nodes throughout the body. Removal of all the groups of neck lymph nodes involved in a neck dissection will not impair your ability to fight infection. On the other hand, there are times when people experience more swelling in the affected body areas where the lymph nodes were removed (this is what is called lymphedema).

What is lymphedema?

Lymphedema is swelling that occurs in a body area drained by a group of lymph nodes that was surgically removed. Examples include women whose arms swell following removal of axillary lymph nodes for treatment of breast cancer. Lymphedema is not as common in the neck and face. However, it is more likely to occur in the following groups of patients: 1) persons who have undergone neck dissection on both sides of the neck, 2) those who have had additional surgery such as removal of some part of their pharynx/throat or larynx/voice box, 3) those who have had removal of both internal jugular veins, and 4) those who have received radiation therapy.

Can lymphedema be treated?

Yes. Therapy usually involves meeting with a physical therapist who specializes in lymphedema therapy and following a prescribed course of therapy. In addition, elevating the head of the bed can prevent some of the swelling that usually occurs following surgery.

How much pain will I have after surgery?

There is usually very little pain or discomfort following neck dissection. Most individuals find adequate relief with occasional Tylenol.

What pain relievers should I use?

You can use Tylenol (up to 2 extra strength Tylenol or acetaminophen every 6 hours). In addition, you can use whatever medication your doctor prescribed for you. Do not use the prescribed medication in addition to Tylenol without checking with your doctor. Many prescribed pain medications also contain Tylenol (e.g., Darvocet, Tylox, Percocet, etc.) and it is possible to overdose if you take these in addition to Tylenol. You should not use any pain reliever other than Tylenol or the medication prescribed without first consulting your doctor. In general, aspirin, ibuprofen and many other over the counter or prescription anti-inflammatory medications prescribed for pain or arthritis can cause bleeding and should not be taken for at least 2 weeks after surgery.

What can I expect after surgery?

Surgery is done under general anesthesia in the operating room. You will wake up in the recovery room (also called the post-anesthesia care area, or PACU) and after a period of 1-2 hours will be transferred to your room. Sore throat is not uncommon for a few days after surgery (usually the result of the endotracheal breathing tube used during surgery). Drainage tubes are usually left in place after surgery and they will be removed 2-5 days after surgery.

Numbness (i.e., lack of sensation or feeling) on the operated side of the neck is common. The area of numbness may shrink in size over time (3-6 months) but some numbness will always be present.

What are potential complications of this surgery?

Serious complications are rare. They can include any or all of the following:

• Bleeding and/or hematoma: bleeding may occur after surgery and require return to the operating room. In severe cases airway obstruction can occur.
• Infection and/or fistula: if infection occurs one can develop redness, pain, or drainage at the surgical site. In more serious cases, the wound can break down and require dressing changes for several weeks until healing is complete. Fistula can occur, particularly in cases where surgery was also performed on or around the larynx, mouth or pharynx. A fistula is an abnormal communication between the mouth, nose or throat and the skin. If this occurs, dressing changes will be required over several weeks until the fistula closes. Further surgical intervention can sometimes be required.
• Airway obstruction: bleeding or simply swelling of the tissues around the throat can make it difficult to breathe. In such cases, intubation with a breathing tube or an emergency tracheotomy may be required. If a person's airway becomes obstructed and an airway cannot be promptly established, hypoxia with severe brain damage or even death can occur.
• Nerve injury: many motor nerves are dissected and potentially at risk for injury during a neck dissection. The facial nerve can be injured, especially the marginal mandibular division, which would result in weakness or asymmetry in the lower corner of the mouth. Injury to the hypoglossal nerve would result in tongue paralysis and difficulty chewing and swallowing. If the vagus nerve is injured, one can have problems with hoarseness and severe swallowing difficulties including aspiration. The spinal accessory nerve helps with arm/shoulder elevation and injury to this nerve can make it difficult to elevate the arm above one's head. The phrenic nerve helps elevate the diaphragm for breathing. Injury to one phrenic nerve would paralyze one side of the diaphragm and make it harder to breathe and cough.
• Stroke: plaque from the carotid artery can be released during surgery around this artery. This rare complication can lead to stroke or even death. Patients with narrowing of the carotid arteries can also suffer stroke simply from having a slight reduction in blood pressure as a result of general anesthesia. Fortunately, this is also not a common complication.
• Blindness: loss of sight has been reported following neck dissection. This is a very rare complication but the risk is significant if both internal jugular veins are removed at the same time or if one is removed and the other happens to become occluded with clot after surgery.
• Heart attack : although not a direct complication of the surgery, myocardial infarction (or heart attack) can also occur especially in individuals with known risk factors for heart disease. Risk factors for heart disease are, among others, older age, smoking, high blood pressure, diabetes, and family history of heart disease or stroke.

Parotid Surgery

What is parotidectomy?

Parotidectomy is the surgical removal of the parotid gland.

What is a superficial parotidectomy?

Superficial, or lateral, parotidectomy refers to the removal of the portion of the gland which is to the side of the facial nerve. Total parotidectomy is the removal of the entire parotid gland, including that portion which is deep to the facial nerve.

Why do I need to have a parotidectomy?

Parotidectomy is done for the following reasons:

• To remove tumors (benign or malignant) of the parotid gland.
• To remove lymph nodes within the parotid gland that could contain cancer cells from elsewhere.
• To prevent recurrent infection or blockage of the parotid gland.

What does the parotid gland do and won't I miss it?

The parotid gland produces saliva (it's commonly called a "spit gland"). There are a total of 6 major saliva glands (3 on each side); therefore, loss of one or two glands does not usually result in any noticeable decrease in saliva production.

What is Frey's syndrome?

Gustatory sweating, or Frey's syndrome, refers to increased facial sweating during eating. Some degree of gustatory sweating is quite common after parotid surgery. It occurs because the nerves that normally go to the parotid gland to produce saliva during eating become confused by the loss of their target and go on to innervate the sweat glands of the face. Then, as the person eats, the signal to produce saliva is delivered to the sweat glands since the parotid is missing.

Can Frey's syndrome be treated?

Yes. Many people have very mild forms of this gustatory sweating and they are either unaware of it or simply not bothered by the phenomenon. For those who are bothered by this, Botulinum toxin (Botox) can be injected into the skin to reduce or eliminate the sweating. Some people prefer to use anti-perspirant cream rubbed on their face prior to eating a meal - this reduces the amount of facial sweating they experience during a meal.

How much pain will I have after surgery?

There is usually very little pain or discomfort following parotidectomy. Most individuals find adequate relief with occasional Tylenol.

What pain relievers should I use?

You can use Tylenol (up to 2 extra strength Tylenol or acetaminophen every 6 hours). In addition, you can use whatever medication your doctor prescribed for you. Do not use the prescribed medication in addition to Tylenol without checking with your doctor. Many prescribed pain medications also contain Tylenol (e.g., Darvocet, Tylox, Percocet, etc.) and it is possible to overdose if you take these in addition to Tylenol. You should not use any pain reliever other than Tylenol or the medication prescribed without first consulting your doctor. In general, aspirin, ibuprofen and many other over the counter or prescription anti-inflammatory medications prescribed for pain or arthritis can cause bleeding and should not be taken for at least 2 weeks after surgery.

What can I expect after surgery?

Surgery is done under general anesthesia in the operating room. You will wake up in the recovery room (also called the post-anesthesia care area, or PACU) and after a period of recovery you may go home. Sore throat is not uncommon for a few days after surgery (usually the result of the endotracheal breathing tube used during surgery). A drainage tubes may be left in place after surgery and if so it will be removed 1-3 days after surgery. A bandage dressing may be applied to hold pressure on the side of your face in order to prevent bleeding under the skin. If present, this bandage should be kept on for 24-48 hours and removed according to your doctor's instructions.

Numbness (i.e., lack of sensation or feeling) on the operated side of the face is common. The area of numbness may shrink in size over time (3-6 months) but some numbness will always be present. In general, the earlobe will remain numb permanently but the sensation on the remainder of the ear and face should return gradually over a period of 6 months.

Will my face be numb?

Numbness, or the lack of feeling, affects parts of the face, neck and ear of all persons who have undergone parotidectomy. Numbness should be distinguished from weakness, which is the inability to move a certain part of the body (in this case, the face). The area of numbness initially affects the ear, the face and the upper neck. However, over a period of 6 months, the area of numbness will gradually shrink in size. For most people, the earlobe (but little else) remains numb forever.

What about facial weakness?

The most feared complication of parotid surgery is facial nerve injury which, in the worst case, would result in complete facial paralysis and facial droop. Fortunately, this is very rare. However, some degree of temporary facial weakness is not uncommon after parotid surgery. The degree of weakness depends on the extent of facial nerve manipulation which itself depends on the size of the tumor and its location relative to the facial nerve.

If the facial nerve or one of its divisions is cut during surgery, the surgeon will try to sew it back together using very fine suture material. If a portion of the nerve has to be removed, a cable graft (using a donor nerve) can be performed to bridge the gap between the two ends of the cut nerve. Any time that a nerve repair (or neurorrhaphy) is performed, recovery takes several months (6-12 months). In such cases, recovery may also be less than complete.

Most people who have a "superficial" parotidectomy will have no facial weakness after surgery. Some will have mild weakness of the lower corner of the mouth (during smile) and this will resolve by about 3 months after surgery.

Most people who have a total parotidectomy will have complete facial weakness for a period of 4-6 months. But even in these cases, a full recovery is usually the norm.

If you have some weakness after surgery, you can start to get recovery at about 6 weeks but in many cases it will take 6 months or more for recovery to be complete. Recovery is usually complete but may be less than complete for older individuals (over 65), those who smoke, diabetics, and those who have radiation exposure.

What is facial reanimation or rehabilitation?

Several procedures can be done to minimize the impact of facial paralysis. A drooping brow can be lifted. An eyelid that does not close (thereby exposing the eye to injury) can be tightened and adjusted in order to achieve full closure. Other procedures can also be done to improve the appearance of the lower face (e.g., mouth corner). In general, these procedures are indicated for those in whom spontaneous recovery of function is not expected. In some instances, they can also be done for individuals in whom recovery is expected but known to take several months.

What are potential complications of this surgery?

Serious complications are rare. They can include any, or all, of the following:

• Bleeding and/or hematoma: bleeding may occur after surgery and require return to the operating room. In severe cases airway obstruction can occur.
• Infection and/or fistula: redness, pain, or drainage at the surgical site are signs of infection. In more serious cases, the wound can break down and require dressing changes for several weeks until healing is complete. Fistula can occur, particularly in cases where surgery was also performed on or around the larynx, mouth or pharynx. A fistula is an abnormal communication between the mouth, nose or throat and the skin. If this occurs, dressing changes will be required over several weeks until the fistula closes. Further surgery may be required. The most common type of fistula to occur after parotid surgery is leakage of saliva through the incision (not to be confused with Frey's syndrome). If this type of (sialocutaneous) fistula occurs, it is usually treated with pressure dressings, medications, and/or Botox. Further surgery is rarely required.
• Airway obstruction: bleeding or simply swelling of the tissues around the face, mouth, or throat can make it difficult to breathe. In such cases, assistance with breathing using a breathing tube or an emergency tracheotomy may be required. If a person's airway becomes obstructed and an airway cannot be promptly established, hypoxia with severe brain damage or even death can occur.
• Nerve injury: facial nerve injury (see above) can occur and result in either temporary or permanent inability to move the face (e.g., smile, frown, wink, etc.). The sensory nerves in this area (great auricular nerve) are almost always cut in order to remove the gland. This results in the loss of feeling in the face and ear.
• Stroke: plaque from the carotid artery can be released during surgery around this artery. This rare complication can lead to stroke or even death. Patients with narrowing of the carotid arteries can also suffer stroke simply from having a slight reduction in blood pressure as a result of general anesthesia. Fortunately, this is also not a common complication.
• Heart attack: although not a direct complication of the surgery, myocardial infarction (or heart attack) can also occur especially in individuals with known risk factors for heart disease. Risk factors for heart disease are, among others, older age, smoking, high blood pressure, diabetes, and family history of heart disease or stroke.

Self Exam

A quick and easy way to help you help yourself.

Finding oral cancer early is important so that it can be treated promptly. Some forms of oral cancer can be seen during monthly self-examinations. Warning signs of head and neck tumors include:

• A sore, lump or thickening in the mouth
• A white or red patch
• A sore throat that does not heal
• Difficulty chewing or swallowing
• Hoarseness that does not go away
• A feeling that something is stuck in the throat
• Difficulty moving the tongue or jaw
• A lump in the neck
• Numbness in the mouth, face or neck
• Seat yourself in front of a well-lit mirror. Remove any partials, dentures, or dental retainers that may be in your mouth.

If you have noted anything unusual during this exam, please contact your primary care physician, otolaryngologist, or other oral health specialist.

HPV

Resources

Periodical-on-line journals

Journal of the American Medical Association / www.jama.com

Oncology Issues / www.accc-cancer.org

Other Journal Information

Journal of Fluency Disorders / www.elsevier.com

Advocacy Sites

Tobacco Free - Education for people of all ages on smoking and tobacco use / www.tobaccofree.org

Cancer (General) Sites

American Cancer Society / www.cancer.org

Cancer Care. Source for information, resources, and services available to cancer patients. / www.cancercare.org

National Coalition for Cancer Survivorship (NCCS). Grassroots network of individuals and organizations working on behalf of people with all types of cancer. / www.canceradvocacy.org

Caregiver Sites

Caregiver Action Network / http://caregiveraction.org

Well Spouse Foundation. A site for well spouses who face the same problems of anger, guilt, fear, isolation, grief and financial threat, whether they are full-time caregivers or whether their partners have only moderately disabling illnesses. / www.wellspouse.org

Partnership for Caring: America's Voices for the Dying is a coalition of individual consumers, consumer organizations, health care professionals and health care organizations advocating for needed changes in professional and public policy and health care systems to improve care for dying persons and their families. / www.partnershipforcaring.org

Disability

Social Security. The official website of the social security administration. Information on disability, Medicare and how to apply for services. / www.ssa.gov/disability

Head and Neck Cancer Related Sites

American Academy of Otolaryngology-Head and Neck Surgery / www.entnet.org

American Brain Tumor Association: Learn about the latest treatments, research, support resources as well as ABTA events / www.abta.org

Cancer of the Larynx. Information, support and assistance for cancer of the larynx patients. / www.webwhispers.org

Cancer of the Larynx Information. This center provides information from the International Association of Laryngectomees (IAL). Includes resources for obtaining assistance and support from local organizations, where to find qualified speech pathologists and other events of interest. Has information on the association's listserv "web whispers". / www.theial.com

Thyroid Cancer. An excellent site for information on types of thyroid cancer and treatment. / www.endocrineweb.com

National Oral Cancer Awareness Program (NOCAP). A resource for professionals and the public. / www.oralcancerfoundation.org

Speech and Swallowing

The American Speech-Language Hearing / www.asha.org

Support Sites

WebWhispers Nu Voice Club - An active international Email-based online laryngectomee support group with a Newsletter and a Loaner Closet. / www.webwhispers.org

Support for People with Head and Neck Cancer. A patient directed self-help organization dedicated to meeting the needs of Oral and Head and Neck Cancer patients. / www.spohnc.org

Cancer Care - Source for information, resources, and services, online support groups. / www.cancercare.org

Head and Neck Cancer Presentations / Grand Rounds

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Esophageal Disorders - Continuing Education

This course consists of one presentation with supporting documents.

CEU Credits and Prices

• This course is offered for 0.2 ASHA CEUs (Intermediate Level; Professional area).
• You must complete presentation.
• You will receive a certificate of completion from BRS-S within three weeks of completing the application and submitting to BRS-S.
• Your ASHA CEU credits will be processed through the Specialty Board on Swallowing and Swallowing Disorders and submitted to ASHA three times per year in June, September, and January.
• The regular price for the course is $50.00

1. BRS-S members get a 25% discount - get the coupon code by logging onto your account at Swallowing Disorders.
2. Students get a 50% discount, contact Karen Schnieder karen@badgerbay.co This e-mail address is being protected from spambots. You need JavaScript enabled to view it for the coupon code.
3. Groups of four or more get a 50% discount, contact Karen Schnieder. This e-mail address is being protected from spambots. You need JavaScript enabled to view it for the coupon code.

Course Description

This two-hour session will include a discussion of the anatomy and physiology of the esophageal phase of deglutition. A review of the reflexes that may facilitate clinical symptomatology will be included. A discussion of the opening mechanism of upper esophageal sphincter during swallowing will be reviewed as well as current techniques used to evaluate, manage and treat disorders of the upper esophageal sphincter. A systematic classification of esophageal disorders with typical presenting symptoms will be included as well as a discussion of the latest technology used to diagnose esophageal disorders, possible management and treatment techniques used by the treating physician. CLICK HERE TO LEARN MORE