Head and Neck/Skin Conditions

Head and Neck/Skin conditions treated by Dr Jae Park

What is skin cancer?

The skin is the largest organ in our body and is made up of two major layers (epidermis and dermis), as well as various types of cells. The top (or outer) layer of the skin, the epidermis, is composed of three types of cells: flat, scaly cells on the surface called squamous cells; round cells called basal cells; and melanocytes, cells that provide skin its colour and protect against skin damage.

The inner layer of the skin, the dermis, is the layer that contains the nerves, blood vessels, and sweat glands. Skin cancer is a disease in which cancerous (malignant) cells are found in the outer layers of your skin.

What Are the Symptoms of Skin Cancer?

Most skin cancers can be cured if diagnosed and treated early. Aside from protecting your skin from sun damage, it is important to recognize the early signs of skin cancer.

The ABCDEs of melanoma are a helpful guide: (A) Asymmetry; (B) Borders; (C) Colour; (D) Diameter; (E) Evolution. The symptoms of melanoma skin cancer include:

• (A) Moles that are different on one side (asymmetry)

• (B) Irregular borders of a mole

• (C) Color variation including shades of brown and black, which could be concerning

• (D) Diameter or the size—if the mole is larger than 6 mm, a doctor should evaluate it

• (E) Moles or lesions that are different than the rest, or change in size, shape, or color over time are concerning (evolution)

Symptoms of non-melanoma skin cancer include:

• Itchy patches of skin that may crust over or are very painful

• Bumps or skin spots that bleed easily or crust over frequently

• Nodules (aggregation or swelling or abnormal swelling) that do not go away. These may be clear, a pearl-like color, or even red, pink, or white.

• Skin sores that do not heal

• A scar-like bump that was not caused by injury or trauma

What Causes Skin Cancer?

Most skin cancers occur on sun-exposed areas of skin, and there is a lot of scientific evidence to support ultraviolet (UV) radiation as a causative factor in most types of skin cancer. Family history is also important, particularly in melanoma. The lighter your skin type, the more susceptible you are to UV damage and to skin cancer. You have a higher risk of developing skin cancer, and should be particularly careful about sun exposure, if you have any of these factors:

• Long-term sun exposure

• Fair skin (typically blonde or red hair with freckles) and lighter eye color

• Place of residence (increased risk in southern climates)

• Presence of moles, particularly if there are irregular edges, uneven coloring, or an increase in the size of the mole

• Family history of skin cancer, particularly melanoma

• Use of indoor tanning devices

• Severe sunburns as a child

• Non-healing ulcers or nodules in the skin

• History of organ transplant or other immune system suppression

What Are the Different Types of Skin Cancer?

There are several types of cancer that originate in the skin. The most common types are basal cell carcinoma and squamous cell carcinoma. These types are classified as non-melanoma skin cancer. Melanoma is the third type of skin cancer. It is less common than basal cell or squamous cell cancers, but potentially much more serious. Other types of skin cancer are rare.

Basal cell carcinoma is the most common type of skin cancer (70 percent of all skin cancers). It typically appears as a small raised bump that has a pearly appearance. It is most commonly seen on areas of the skin that have received excessive sun exposure. These cancers may spread to the skin surrounding them, but rarely spread to other parts of the body.

Squamous cell carcinoma (20 percent of all skin cancers) is also seen on the areas of the body that have been exposed to excessive sun (nose, lower lip, hands, and forehead). Often this cancer appears as a firm red bump or ulceration of the skin that does not heal. Squamous cell carcinomas can spread to lymph nodes in the area.

Melanoma is a skin cancer (malignancy) that arises from the melanocytes in the skin. This makes up five percent of skin cancers. Melanocytes are the cells that give colour to our skin. These cancers typically arise as pigmented (coloured) lesions in the skin with an irregular shape, irregular border, and multiple colours. It is the most harmful of all the skin cancers because it can spread to lymph nodes or other sites in the body. Fortunately, most melanomas have a very high cure rate when identified and treated early.

What Are the Treatment Options?

There are varieties of treatments available to treat skin cancer, including surgery, radiation therapy, and chemotherapy. Treatment for skin cancer depends on the type and size of cancer, your age, and your overall health.

Surgery is the most common form of treatment. It generally consists of an office or outpatient procedure to remove the lesion and check the edges, or margins, to make sure all the cancer was removed. For basal cell and squamous cell carcinomas, excision is frequently done using a specific technique called Mohs surgery, which gives the best chance to include all margins, while still minimizing the size of the defect. The site may then be repaired with simple stitches or skin from the same area or a different area of your body.

For melanoma treatment, your doctor might also recommend doing a biopsy of the lymph node with the highest chance of having tiny microscopic metastatic cancer cells called a sentinel lymph node biopsy.

Sometimes radiation may be used as definitive therapy or additional treatment after surgery. For non-melanoma skin cancers, chemotherapy is not used as primary therapy, and its use after surgery is controversial. For melanomas, chemotherapy and medications that modulate the immune system may be used in more advanced cases.

What is Sialadenitis?

Sialadenitis is inflammation and enlargement of one or more of the salivary glands. The salivary glands are responsible for producing and storing saliva.

The three major salivary glands are the “parotid” (on the sides of the face in front of the ears), “submandibular” (under the jaw), and “sublingual” glands (under the tongue). All of these glands empty saliva into the mouth through small tubes called ducts.

Sialadenitis can occur due to infection, salivary stones, or an underlying autoimmune disorder. It usually affects the parotid and submandibular glands and is most common among the elderly.

What Are the Symptoms of Sialadenitis?

The symptoms of sialadenitis can include:

• Swelling in the cheek and neck region, especially after eating

• Mouth or facial pain

• Dry mouth

• Foul taste or gritty feeling in the mouth

• Fever

• Chills

• Redness over the side of the face or upper neck

• Pus in the mouth

What Causes Sialadenitis?

Sialadenitis can be caused by a viral infection (such as mumps), bacterial infection, or an autoimmune disease such as Sjogren’s syndrome (see below). Bacterial infections can happen when the flow of saliva is blocked due to stones in the salivary duct or a narrowing of the duct. Dehydration can also cause bacterial infections by reducing saliva flow. Recent illness and the use of antihistamines, beta-blockers, or diuretics can lead to dehydration. Radioactive iodine (RAI), sometimes used for treatment after surgery of thyroid cancer, can also result in salivary gland scarring and sialadenitis because some of the radioactivity can be accumulated in the salivary glands.

Sjogren’s syndrome is an autoimmune disease which effects salivary glands and the “lacrimal” glands of the eyes. This chronic inflammatory disorder causes decreased saliva production in the mouth and decreased tear production in the eyes. In addition to dry mouth and eyes, there may be symptoms of fatigue, muscle aches, or rashes. In extreme cases, Sjogren’s syndrome may affect the lungs, kidneys, liver, and nervous system. People with Sjogren’s syndrome may also have swelling of the parotid or submandibular glands, as well as an unexplained increase in dental cavities or tooth decay.

What Are the Treatment Options?

Treatment for sialadenitis includes good oral hygiene, increasing fluid intake, massaging over the affected gland, applying a warm compress, and using candies or foods which increase saliva (such as lemon drops). In some cases, if the cause is bacterial, antibiotics may be prescribed. Antibiotics are not useful for viral infections.

Most salivary gland infections resolve or are cured with conservative treatment after one week. In rare cases of recurrent sialadenitis, surgery may be necessary to remove obstructive stone/s within the salivary duct (an endoscopic procedure) or remove part or all of the gland.

What is a neck lump or mass?

A neck mass is an abnormal lump in the neck. Neck lumps or masses can be any size—large enough to see and feel, or they can be very small.

A neck mass may be a sign of an infection, or it may indicate a serious medical condition. It does not necessarily mean you have cancer, but it does mean you may need additional evaluation to receive an accurate diagnosis.

What Are the Symptoms of a Neck Mass?

Common symptoms in patients with a neck mass at higher risk for cancer (see “What Causes a Neck Mass” below) include:

• The mass lasts longer than two to three weeks

• The mass gets larger

• The mass gets smaller but does not completely go away

• Voice change

• Trouble or pain with swallowing

• Trouble hearing or ear pain on the same side as the neck mass

• Neck or throat pain

• Unexplained weight loss

• Nasal blockage in one side of the nose

• Breathing difficulty

• Bleeding from nose and oral cavity

• Coughing up blood

• Skin lesion on the face or scalp that is growing or changing color

What Causes a Neck Mass?

Neck masses are common in adults and can occur for many reasons. You may develop a neck mass due to a viral or bacterial infection. Ear or sinus infection, dental infection, strep throat, mumps, or a goitre may cause a neck mass. If your neck mass is from an infection, it should go away completely when the infection goes away.

Your neck mass could also be caused by a noncancerous (benign) tumour or a cancerous (malignant) tumour. Cancerous neck masses in adults are most often due to head and neck squamous cell carcinoma (HNSCC). Other causes for a neck mass may be due to cancers such as lymphoma, thyroid or salivary gland cancer, skin cancer, or cancer that has spread from somewhere else in the body.

Long-term tobacco use (cigarettes, cigars, chewing tobacco, or snuff) and alcohol use are the two most common causes of cancers of the mouth, throat, voice box, and tongue. Another common risk factor for cancers of the neck, throat, and mouth is a human papilloma virus (HPV) infection. HPV infection is usually transmitted sexually. HPV found in the mouth and throat is called “oral HPV.” Some high-risk types of oral HPV infection can cause head and neck cancers.

HNSCC of the tonsil and base of the tongue has gone up because of the increase in HPV infections. HPV-related cancers often lack the common risk factors of tobacco and alcohol use and tend to affect younger adults. Patients with HPV-positive HNSCC may have some of the symptoms listed here, but many times a neck mass will be the only sign of this type of cancer.

When should I see a doctor?

See your doctor if the lump in your neck lasts longer than two to three weeks. This is a persistent neck mass, which means that the lump has not gone away. You should also see a doctor if you are not sure how long you have had the neck mass because your neck mass may mean that you have a serious medical problem. If you have any of the head and neck symptoms listed above, in addition to the neck mass, you should see your doctor right away. It may not be cancer, but you need to be evaluated. Your doctor will discuss any tests needed for diagnosing your neck mass and your follow-up care.

What Are the Diagnostic and Treatment Options?

Your doctor will ask about your medical history and examine your head and neck. They may perform (or recommend) an endoscopy, which is a procedure that inserts a small tube with an attached camera through your nose to look inside your throat, voice box, and the opening of your oesophagus. If a more detailed examination is required, the endoscopy will be performed in an operating room under anaesthesia.

In addition, your doctor may order tests to help diagnose your neck mass, such as a CT, MRI, or PET (positron emission tomography) scan (if needed) to get a more detailed picture of the neck mass than normal X-rays can provide as well as a biopsy.

A biopsy involves taking a sample of tissue from the neck mass to make a diagnosis. There are different types of biopsies based on your medical history and the location of your mass, including:

• Fine needle aspiration biopsy (FNA)—An FNA is the best initial test to diagnose a neck mass. A small needle is put into the mass and tissue is pulled out. An FNA is often done in your doctor’s office. It is well-tolerated by most patients. It can be done with or without ultrasound-guided needle biopsy.

• Core biopsy—A core biopsy is another way to diagnose a neck mass, typically performed if an FNA did not confirm a diagnosis. A core biopsy uses a slightly larger needle and gets a larger piece of tissue. It is well tolerated and has a low risk of complications.

• Open biopsy—An open biopsy should typically be done only after FNA and/or core biopsy have failed to make the diagnosis. It is the next step to diagnose a neck mass. It is a more invasive procedure. Open biopsy is done by a surgeon in the operating room and you will need anaesthesia. An open biopsy may remove only portion of the mass or the whole mass. Because open biopsies are more invasive, there is a somewhat higher risk for complications.

Your doctor will explain next steps and discuss a follow-up plan once a diagnosis has been made. If the neck mass is found to be cancerous, treatment options include surgery, radiation therapy with or without chemotherapy, or a combination of these treatments depending on the diagnosis and stage of the disease. Some neck masses may be thought to be benign (not cancerous) at first, but are later found to be cancer, which is why a follow-up plan is important.

What is HPV-related oropharyngeal cancer?

HPV, or human papillomavirus, is a sexually transmitted virus. It is not transmitted through casual contact. Many different subtypes of the virus exist, and it usually affects the throat or the reproductive tract.

HPV can cause cancer, but not all HPV infections lead to cancer. Most people contract HPV but then clear the virus from their body. In some people, however, HPV remains in the body causing genetic changes in tissue that can lead to cancer years later. The most commonly affected area by HPV-related cancer is the oropharynx, an area in the throat made up of the tonsils and the base of tongue. Oropharyngeal cancer can also occur unrelated to HPV, usually from smoking and drinking alcohol. HPV-related oropharyngeal cancer carries a better prognosis.

What are the Symptoms of HPV-related Cancer?

Signs and symptoms of HPV-related oropharyngeal cancer include:

• Lump or swelling in the neck

• Difficulty speaking

• Difficulty or pain when swallowing

• Noticeable sore in the back of the throat

• Earache

• Coughing or spitting up blood

• Weight loss

These symptoms are particularly concerning if they do not go away after a week or two. Early detection significantly improves the chances of a cure.

What Causes HPV-related Cancer?

In a small percentage of people, HPV is contracted through oral-genital contact and develops into oropharyngeal cancer. Infection usually occurs many years before symptoms appear. The risk of HPV-related oropharyngeal cancer can be significantly decreased with currently available vaccines. HPV and/or smoking and tobacco use can increase the risk of oropharyngeal cancer. Smoking or tobacco use with HPV-related oropharyngeal cancer decreases the chance of survival.

What Are the Treatment Options?

HPV-related oropharyngeal cancer can be treated with different types of therapy. Treatment options generally depend on how far the disease has progressed, the specific location and extent of disease, the patient’s health, availability of clinical expertise and equipment, and patient or physician preference.

The two main treatments are surgery and radiation therapy. Surgery can be done in different ways. The majority of these tumours can be removed successfully using surgical instruments through the mouth, including robotic and laser systems. Open surgery, known as a neck dissection, is also typically used to reach the lymph nodes in the neck because cancer cells often spread to these neck lymph nodes. Both sides of the neck often need to be treated.

Radiation therapy can be used as an alternative initial treatment, or as an additional treatment following surgery. Radiation therapy typically involves several weeks of treatment. If given as a primary treatment, it’s possible you may also need surgery later.

There are functional considerations as well as short- and long-term complications associated with both surgery and radiation. Chemotherapy can be used to make tumour cells more sensitive to radiation therapy, called a radiosensitizer, for advanced stages of the disease. This is generally only done when surgery or radiation therapy cannot be given or in a palliative setting and is not considered to be curative therapy when given by itself.

Each year, more than 5,200 Australians will develop cancer of the head and neck. Nearly 1,250 will die from cancer of the head and neck.

Head and neck cancers are curable if caught early. Fortunately, most of them produce early symptoms. You should know the potential warning signs so you can alert your physician as soon as possible. Successful treatment of head and neck cancer depends on early detection. Knowing and recognizing its signs can save your life.

What Are the Symptoms of Head and Neck Cancer?

Symptoms of head and neck cancer can include:

• A lump in the neck

• Change in the voice

• A growth in the mouth

• Bringing up blood

• Swallowing problems

• Changes in the skin

• Persistent earache

A lump in the neck—Cancers that begin in the head or neck usually spread to lymph nodes in the neck before they spread elsewhere. A lump in the neck that lasts more than two weeks should be seen by a physician as soon as possible. Of course, not all lumps are cancer. But a lump(s) in the neck can be the first sign of cancer of the mouth, throat, voice box (larynx), thyroid gland, salivary glands, or of certain lymphomas and blood cancers.

Change in the voice—Most cancers in the voice box cause a change in your voice. An ENT (ear, nose, and throat) specialist, or otolaryngologist, can examine your voice box easily and painlessly. If you are hoarse or notice voice changes for more than two weeks, see a physician.

A growth in the mouth—Most cancers of the mouth or tongue cause a sore or swelling that doesn’t go away. These may be painless, which can be misleading. Cancer is often painless. Bleeding may occur, but often not until late in the disease. If an ulcer or swelling is accompanied by lumps in the neck, you should be concerned. In addition, any sore or swelling in the mouth that does not go away after two weeks should be evaluated by a physician.

Bringing up blood—This is often caused by something other than cancer. However, tumours in the nose, mouth, throat, or lungs can cause bleeding. If blood appears in your saliva or phlegm for more than a few days, you should see a physician.

Swallowing problems—Cancer of the throat or oesophagus may make swallowing solid foods, and sometimes liquids, difficult. If you have trouble almost every time you try to swallow something, you should see a physician. A barium swallow X-ray or a direct examination of the swallowing tube with a scope, called an esophagoscopy, can help determine the cause.

Changes in the skin—The most common head and neck cancer is basal cell skin cancer. Fortunately, this is rarely serious if treated early. Basal cell cancers appear most often on sun-exposed areas like the forehead, face, and ears, but can occur almost anywhere on the skin. Basal cell cancer often begins as a small, pale patch that slowly grows, producing a central dimple and, eventually, an ulcer. Parts of the ulcer may heal, but the major portion remains ulcerated. Some basal cell cancers show colour changes.

Other kinds of cancer, including squamous cell cancer and malignant melanoma, also occur on the head and neck. Most squamous cell cancers occur on the lower lip and ear. They may look like basal cell cancers and are usually not dangerous if caught early and treated properly. If there is a sore on the lip, lower face, or ear that does not heal, see a physician. Malignant melanoma typically produces a blue-black or black discoloration of the skin. However, any mole or spot that changes size or colour, or begins to bleed, should be seen as soon as possible by your doctor.

Persistent earache—Constant pain in or around the ear when you swallow can be a sign of infection or tumour in the throat. This is particularly serious if you also have difficulty swallowing, a hoarse voice, or a lump in the neck, and should be evaluated by an ENT specialist.

What Causes Head and Neck Cancer?

Head and neck cancers occur due to prolonged exposure to specific risk factors, such as tobacco use (e.g., cigarettes, cigars, chewing tobacco, or snuff), excessive alcohol abuse, or exposure to HPV. Cancer of the lip may be caused by prolonged exposure to sunlight and is also a major cause of skin cancer.

What Are the Treatment Options?

Treatment options depend on several factors, such as the stage of disease, type and location of the tumour, and the patient’s overall health. Treatment options for cancer are best discussed in a multi-disciplinary setting involving the surgeon, radiation oncologist, oncologist, pathologist, radiologist, speech and swallowing experts, as well as the patient and caregivers. Treatment options may include:

Surgery—The goal of cancer surgery is to remove the cancerous tissue and a ring of normal tissue around it. The surgery may also include removing lymph nodes from the neck. Reconstructive plastic surgery may be needed if the cancer is widespread and requires extensive tissue removal. These may include surgery to the tongue, jawbone, facial skin, pharynx, or larynx. In cases such as this, tissue from other parts of the body, like the forearm or leg, can be transplanted to give patients the best possible cosmetic and functional outcomes.

Radiation therapy—High energy X-rays are used to stop the growth of and kill cancer cells. Depending on the type and stage of cancer, radiation can be used as a stand-alone treatment or given after surgery with or without chemotherapy. A commonly used form of radiation therapy is intensity-modulated radiation therapy (IMRT), which concentrates radiation beams to the tumour while minimizing damage to the surrounding healthy cells.

Systemic therapy—Chemotherapy is the most common type of systemic therapy and destroys cancer cells through the bloodstream using one drug or a combination of drugs. Chemotherapy is often used in combination with radiation therapy either concurrently as primary treatment or after surgery as supplemental treatment. These medications are given in fixed doses as determined by the medical oncologist who monitors the response to treatment and any potential adverse reactions.

Immunotherapy improves the body’s immune system and helps fight cancer cells. This rapidly growing area of treatment options has shown promise in patients with recurrent or widely spread (metastatic) cancers.