 |
 |
The General Otolaryngology Service deals with the medical and surgical treatment of a wide variety of head and neck disorders, including infectious, inflammatory, and neoplastic lesions. These can be broken down into several groups:
Thyroid surgery is typically performed for patients with thyroid nodules that are suspicious or proven to be thyroid cancer. In addition, patients with thyroid enlargement (goiter), as well as some patients with hyperthyroidism, are offered thyroid surgery. Although thyroid surgery is often uncomplicated, one of the risks of thyroid surgery involves vocal cord paralysis.
The recurrent laryngeal nerve, the nerve which brings electrical activity to the vocal cord, is situated just underneath the thyroid gland and is at risk during thyroid surgery. Gregory Randolph, M.D., director of the Massachusetts Eye and Ear Infirmary Thyroid Surgical Clinic, has developed a system of recurrent laryngeal monitoring to detect and avoid recurrent laryngeal nerve injury during thyroid surgery. This method represents a safe electrical intraoperative monitoring system. The rate of recurrent laryngeal nerve paralysis during thyroid and parathyroid surgery is zero at the Massachusetts Eye and Ear Infirmary.
Parathyroid surgery is performed when a patient's elevated calcium is shown to be due to enlargement and hyperfunction of the parathyroid glands. The enlarged parathyroid glands secrete abnormally high amounts of hormones (parathyroid hormone, PTH), which in turn elevates calcium levels. High calcium levels can result in a number of different abnormalities, including kidney stones, peptic ulcer disease, hypertension, and mood change. Typically, parathyroid surgery involved exploration on both sides of the neck and removal of all enlarged parathyroid glands.
Currently at Massachusetts Eye and Ear Infirmary, an intraoperative hormonal assay is available to measure during surgery the exact level of PTH hormone. When sufficient parathyroid tissue has been removed, the PTH levels falls during surgery. Gregory Randolph, M.D., director of the Massachusetts Eye and Ear Infirmary Thyroid and Parathyroid Surgical Clinic and colleagues have determined the exact criteria that need to be fulfilled during parathyroid surgery which correlate with surgical success. This allows the surgery to be more limited than would otherwise be possible, and also allows the avoidance of removal of excess tissue.
Much of the disease of the head and neck can be understood with a preliminary understanding of the complex anatomy of the head and neck.
The nasal cavity is divided left and right by the midline nasal septum. The nasal cavity starts anteriorly with the nasal openings (the nares) and ends posteriorly in the nasopharynx. The nasopharynx is where the eustachian tube arises, and extends up to the middle ear. Adenoidal hypertrophy centered in the nasopharynx, seen especially in children, can result in both nasal obstruction as well as eustachian tube dysfunction and middle ear problems. The nasal cavity is divided in the midline by the nasal septum. Septal deviations, congenital or through trauma, can result in nasal congestion.
The sinuses are air-filled bony hollows in the head, lined by moistened skin called mucosa. There are several individual sinuses. The frontal sinuses are near the eyebrows in the forehead. The ethmoid sinuses are between the eyes, deep to where eyeglasses rest on the nasal dorsum. The maxillary sinuses are in the cheek. The upper teeth insert into the floor of the maxillary sinuses, which explains why pain in the teeth can be felt during some types of sinusitis. The sphenoid sinus is more or less a deep extension of the ethmoid sinus in the posterior nasal cavity.
The nasal cavity and sinus works normally to warm and humidify the nasally inspired air, and produces mucus that normally drains into the throat. The upper nasal cavity is innervated by fibers of the olfactory nerve, allowing the sensation of smell and to a large degree the sensation of taste.
The oral cavity superiorly consists of the hard palate, the bone into which the upper teeth are inserted. Further back, the hard palate forms the soft palate. In the exact midline, the uvula hangs from the soft palate as a bag-like prominence. When the uvula and soft palate are especially long, patients may have snoring and even obstructive sleep apnea.
In the back of the oral cavity on the sides are the tonsils. The tonsils are really folds of lymphatic tissue. Debris can occasionally be caught within these folds and seen as whitish particulate debris on the surface of the tonsil. The throat is more or less behind the tongue between the tonsils. This is the area that hurts during the common cold and Strep throat.
As we go down, the throat continues into the lower neck, ultimately forming the esophagus, leading down to the stomach. Swallowing results from a complex series of muscular events of the oral cavity, tongue and throat, and ultimately the voice box/larynx. Lesions in these lower throat regions can be easily visualized during a complete ENT exam.
The voice box, or larynx, is the beginning of the airway, and rests on top of the trachea, which leads down to the lung. The voice box rests in the front portion of the lower throat. The two vocal cords are features within the voice box which move in to speak, and out to breathe.
The neck consists of, in the center, the swallowing and breathing tubes. On the side of the neck are the major muscles of the neck called the sternocleidomastoid muscles, which can be seen running from behind the ear to the sternal notch. Deep to these muscles run the carotid artery and jugular vein, the main blood vessels in the neck. On the side of the neck also are distributed a number of lymph nodes, which can swell both during infections of the throat, as well as in malignant conditions of the head and neck. Cysts can also occur both in the midline and the side of the neck.
The thyroid gland is a dumbbell-shaped endocrine gland which rests in the base of the neck. Nodules within the thyroid are very common in the adult population.
The sinuses were described previously as bony hollows in the head. When the lining of the nose and sinuses becomes swollen with allergies or infections, the sinuses can become obstructed. If they stay obstructed long enough, the puddled mucus in the sinuses can become infected. When this occurs, patients typically experience facial pain in the distribution of the sinuses, as well as thickened, often yellow or green, nasal discharge, as well as nasal congestion.
A variety of other symptoms can occur with sinusitis, including runny itchy eyes, cough, ear symptoms including fullness and discomfort, hoarseness, and a bad smell in the nose. In some patient, when sinus swelling occurs, it occurs focally and to a significant degree to the extent of the formation of nasal polyps. Nasal polyps, in turn, tend to obstruct sinuses and lead to sinusitis. Facial pain, in isolation, can be caused by a variety of other entities, including temporomandibular joint syndrome, dental disease, and non-sinus headache.
Since the sinuses, when infected, represent obstructed chambers, the medical management is initially not only antibiotics to fight infection, but also medicines to help encourage the sinuses to open and drain. Most typically, these include oral and/or topical decongestants. Other treatments may include steroid nasal sprays, antihistamines, as well as cessation of smoking.
In patients in whom medical management has failed, and who have significantly recurrent or chronic sinusitis, ENT evaluation is warranted. The initial evaluation includes a thorough history and physical exam, which involves often a rigid telescope exam of the nasal cavity. This allows the otolaryngologist detailed intranasal information regarding septal deviations, nasal turbinate abnormalities, and areas of abnormal drainage or polyp formation. CT scanning of the sinuses after medical management is often necessary in patients with chronic symptoms to allow documentation of chronic sinusitis, and allow for surgical planning.
Patients may require sinus surgery if all medical management has failed. The sinus surgery that is typically offered is endoscopic sinus surgery, which involves work in the nasal cavity under direct visualization with a nasal telescope, without external incisions.
Occasionally, at the Massachusetts Eye and Ear Infirmary, this surgery will be performed with a state-of-the-art CT guidance system, which allows the surgeons a whole new level of information for safe sinus surgery. The surgery is typically performed under general anesthesia, but can be performed under local anesthesia, and involves usually about 90 minutes of work. Patients may go home the same day, or may stay overnight and go home the next morning. Patients post-operatively will have generally mild pain, and a little bit of nasal congestion, and are asked to not strain for about a week or two after surgery.
There are one or two post-operative visits within the first two weeks after surgery, during which the nasal cavity and sinuses are cleaned. The endoscopic sinus surgery philosophy used at the Massachusetts Eye and Ear Infirmary is that limited surgery in key areas of the sinuses allows improved aeration and drainage, often giving dramatic improvement in widespread sinus regions. This sinus surgery is generally very well tolerated.
Snoring is often regarded humorously, but can be a difficult problem. Snoring is the sound that is made by the soft palate and uvula as one inspires at night with a relaxed throat during sleep. Although snoring does come from the mouth, it can be made worse with nasal obstruction, as this limits inward air flow. Patients are at risk if their oral cavity is small and crowded, if their uvula and palate is long, if they have large tonsils, or are obese. Snoring can be significantly disruptive to bed partners.
Depending on the amount of redundant tissue, the throat may actually close during sleep, rather than just reverberate with snoring. We call this obstructive sleep apnea. In obstructive sleep apnea, oxygen levels, which are meant to be maintained at a high level at all times, fall. This, in turn, can lead to significant strain on the lungs and heart, and may generate heart arrhythmias.
The evaluation of snoring an obstructive sleep apnea starts with a full office otolaryngology head and neck exam, looking at the upper aerodigestive tract in a comprehensive way. Usually then a formal sleep study is obtained. This study allows definitive diagnosis of obstructive sleep apnea and, importantly, quantification of its intensity.
The treatment of snoring and obstructive sleep apnea includes a variety of interventions. Weight loss is generally recommended. In addition, there are a variety of nasal and oral airflow devices (e.g. CPAP, BI-PAP masks). These masks basically allow a pneumatic stenting of the posterior throat during sleep, reducing obstruction.
There are a variety of surgical options for snoring and obstructive sleep apnea, all of which either scar or shorten the palate and uvula. These include radiofrequency treatment, CO2 laser palate and uvula treatment (LAUP), or standard surgical uvulopalatopharyngoplasty (UPP). Typically, during surgery for snoring and obstructive sleep apnea, any areas of nasal obstruction are corrected at the same time. In select patients, mandibular procedures may be included to increase the chance of surgical cure. Generally these procedures are well tolerated, but involve a sore throat that lasts for typically 7-10 days after surgery.
Nodules within the thyroid gland are very frequent in the adult population. Some studies suggest up to 50% of the adult population have thyroid nodules. Thyroid nodules commonly are benign, but may represent thyroid cancers. The risk of thyroid cancer is higher in an elderly age group, and is higher with a past history of radiation therapy. Also, the larger a thyroid nodule is, the higher the risk of malignancy for some nodules.
Thyroid nodules may be identified during routine physical exams by general medical physicians, or may be identified by the patient during a shower or during shaving. Thyroid nodules, when they are large enough, can also be sensed as a lump in the neck, especially noticeable during swallowing.
The evaluation of the thyroid nodule involves a complete history and head and neck physical exam, including evaluation of vocal cord function. The nerve to the vocal cord travels just deep to the thyroid and can occasionally be affected by thyroid nodules. This requires a vocal cord evaluation after a complete history and physical exam.
Testing is typically recommended, usually a blood test to assess the functioning of the thyroid and often a thyroid ultrasound to assess the exact nature and size of the thyroid nodule. This is a painless test which involves no radiation.
The central test for work-up of the thyroid nodule is a fine needle aspiration. Fine needle aspiration can be considered a microscopic needle biopsy. This often allows definitive diagnosis. Surgery is typically reserved for lesions that are identified as malignant or suspicious on fine needle aspiration. Other treatment options are available for lesions that are benign on fine needle aspiration.
For large thyroid masses/goiter, additional evaluation is often necessary, and may include CT scanning, MRI scanning, or barium swallow. The purpose of these tests is to assess the relationship of the thyroid mass to the adjacent swallowing tube (esophagus) and breathing tube (trachea).
Surgery of the thyroid and parathyroid glands at the Massachusetts Eye and Ear Infirmary is performed with recurrent laryngeal nerve monitoring. This new technology allows real-time vocal cord passive and evoked monitoring to help in identification and preservation of this important nerve during thyroid surgery. Such monitoring may decrease the rate of vocal cord nerve injury, and may reduce the incidence of voice and swallowing problems after thyroid surgery.
The evaluation of a neck lump, nodule, or mass is performed by the otolaryngologist. It is important to assess a history of smoking in a patient with a neck nodule. A complete head and neck exam is essential to view the entire upper aerodigestive tracts (breathing/swallowing passage).
During the ENT office exam, the location of the nodule can often given a clue as to its identity. CT and MRI scanning and other radiographic evaluation is sometimes necessary. Fine needle aspiration (please see thyroid nodule) is often a centrally important test in the work-up of a neck nodule and represents a microscopic biopsy that usually provides definitive diagnosis without surgery.
MEEI, 2nd Fl. 617-573-4115
Office hrs. Mon.-Fri 9 a.m.-5 p.m.
MEEI, 2nd Floor 617-573-3558
MEEI, 2nd Floor 617-573-3793
Office Hrs. Tues 8:30 a.m. – 5 p.m. Wed. 1 p.m. - 5 p.m.
MEEI, 2nd Floor. 617-573-4104
Office Hrs. Mon-Fri 9 a.m. – 5 p.m.
South Suburban Center
Edward Reardon, M.D.
John Lazor, M.D.
Wellesley
Robert H. Lofgren,M.D.
Victor E. Calcaterra, M.D.
H. Gregory Ota, M.D.
Kathryn A. Ryan, M.D.
 | We comply with the HONcode standard for
health trustworthy information: Verify here. |
|
|
|