Question 1

In much of sub-Saharan Africa, PET-CT, contrast imaging and well-equipped laboratories are often available only in capital cities. In such resource-constrained settings, what should raise a doctor's suspicion of a head and neck cancer, and what should make that suspicion strong enough to refer the patient even when imaging and other investigations are unavailable?

Dr. Priyanka Raina · Accepted Answer

Clinical diagnosis is very important. In many countries, not only in Africa, patients present at an advanced stage, either because the diagnosis is made late or because they do not know they should see a doctor for the problem. For the general practitioner, and for the dentist, keeping the red flag signs in mind is essential, because a head and neck patient usually first comes with a persistent toothache, a mobile tooth, a foreign body sensation in the throat or constant ear pain. The common mistake is to treat the case as a simple infection and put the patient on a long course of antibiotics. That empirical treatment only prolongs the delay and lets an early stage become an advanced one. In the oral cavity, the warning signs are mobility of the teeth without another cause, a growth that does not heal with any ointment or medication, or ear pain with something at the base of the tongue. A Hopkins examination, or simply a glove and a torch, can identify these red flags, and that is the moment to refer to a specialist centre, because the journey from your clinic to that centre will itself take time. Do not waste that golden period. These signs remain the basis for triage even without imaging or advanced histopathology. Patients from Africa often reach us with advanced thyroid, oral or laryngeal disease, so the patient's symptoms and signs should be the main diagnostic tools when imaging is not available. Rely on your clinical skills: 20 to 30 years ago access to imaging was very difficult for all doctors, and a glove, a torch and a mirror were enough in head and neck cases.

Question 2

PET-CT is widely used for staging but is unavailable in most of these countries. Before deciding whether a patient can be treated locally or needs referral, what imaging should doctors use when only some modalities are available?

Dr. Priyanka Raina · Accepted Answer

Think of a hierarchy of what is available. Ultrasound is accessible almost everywhere, and CT is more widely available than MRI. For any lesion of the oral cavity, or wherever you suspect the mandible or the larynx is involved, CT should be the first modality of choice. If you suspect a thyroid problem, a thyroid function test and an ultrasound of the neck can take you close to the diagnosis. For a soft tissue lesion, MRI is very good if it is available. So three basic modalities, ultrasound of the neck, CT (contrast-enhanced, or plain CT if that is what is available, with an HRCT of the chest) and MRI, can be used according to the subsite.

Question 3

Some cancers, such as bladder cancer, progress quickly while others, such as early prostate cancer, progress slowly. Among the head and neck cancers, which are the most dangerous in terms of speed of progression and complexity of treatment?

Dr. Priyanka Raina · Accepted Answer

Many cancers elsewhere in the body take time to become symptomatic, but oral cavity and head and neck cancers show up: the patient becomes symptomatic very fast, often in a way the patient can see. For the larynx, any patient who has started developing breathing difficulty is an emergency; we cannot wait. For the thyroid, new difficulty in swallowing, a change in the breathing pattern or a change in the voice calls for immediate referral. For the oral cavity or tongue, drooling, bleeding, or an evidently large or rapidly increasing growth signals an emergency that needs emergent referral. Because doctors in these countries often find it difficult to prioritise which patient to send first, any patient with breathing difficulty, stridor or a rapidly increasing mass, whether of the oral cavity or the neck, should be referred immediately.

Question 4

International patients face a lead time before they can travel: visas, arranging money, and finding someone to accompany them. Setting emergencies aside, how should head and neck cancers be ranked by how urgently they need treatment?

Dr. Priyanka Raina · Accepted Answer

From most to least urgent: laryngeal and hypopharyngeal cancers need urgent attention because they quickly compromise the airway. Next come oral cavity cancers, because if the patient keeps waiting, an early cancer becomes locally advanced; then chemotherapy has to be given first and upfront surgery is no longer possible. After those come thyroid cancers and salivary gland cancers. That is the hierarchy to follow.

Question 5

A patient lost his voice after a laryngectomy for cancer. He is now cancer-free but does not want a surgical procedure for a voice device. Are there non-surgical options for him?

Dr. Priyanka Raina · Accepted Answer

We usually give every laryngectomy patient options. The surgical one is a voice prosthesis, placed at the time of the laryngectomy or as a secondary procedure. The second is an electrolarynx. The third is referral to a speech and swallowing specialist for training in oesophageal voice. For a patient who does not want any surgical method of voice rehabilitation, the choice is an electrolarynx, of which there are now various modifications on the market that are very patient-friendly, or speech and swallowing rehabilitation to train the patient in oesophageal voice.

Question 6

Are there screening tests to detect head and neck cancers?

Dr. Priyanka Raina · Accepted Answer

Screening starts with the history: select patients who chew or smoke tobacco or drink alcohol. In these countries it is better to start by spreading awareness of self-examination of the mouth and neck, as is already done for the breast. That is the first level of screening, done by the patient. Where that is not possible across the general population, general practitioners, dentists and ENT surgeons should be taught the clinical examination of the oral cavity and neck, with a Hopkins examination for the throat. Narrow band imaging is an advanced technique; the basic technique is clinical examination, first self-examination by the patient and then examination by the clinician.

Question 7

Can similar clinical screening be done for other types of cancer?

Dr. Priyanka Raina · Accepted Answer

Yes. In our awareness camps we teach women breast self-examination, alongside the head and neck examination. People with a family history of cancer, such as colon or oesophageal cancer, are told to watch for signs such as difficulty in eating or a change in bowel habits. For women we have been running a drive for Pap smear examination for cervical cancer and for breast examination, both self-examination and by clinicians. We also emphasise mammography, which, like ultrasound and chest X-rays, is available in most countries.

Question 8

How effective are voice prostheses after laryngectomy, and how well do these patients communicate?

Dr. Priyanka Raina · Accepted Answer

Consider the clinician and the patient. The latest generation of voice prostheses is very clinician-friendly: once the tracheo-oesophageal puncture has been made in theatre, the prosthesis can be placed very easily on an outpatient basis, in a minor theatre or even a dressing room. For the patient, we start teaching from the moment the device is placed; many patients learn immediately, and others need 2 to 3 sessions of speech therapy. Patients learn to clean, use and occlude the device themselves in front of a mirror. The challenges: the manufacturer's stated life of the prosthesis is only 6 months, although in many patients it easily lasts beyond 2 years, and for patients who have travelled far for cancer treatment, returning to change the prosthesis is costly and logistically difficult. We therefore explain both the benefits and the drawbacks before surgery, and the patient decides. Leakage is the other drawback. Most patients need postoperative radiotherapy, or have already been irradiated and need a flap; in those, where we feel the tissue may break down or a leak may develop, we generally avoid a voice prosthesis, because a leak is very troublesome to manage. Case selection is therefore very important. If the patient can remain in close follow-up with a practitioner who can manage the prosthesis, it is a good option; otherwise selection must be strict.

Question 9

How clear is the speech with a voice prosthesis?

Dr. Priyanka Raina · Accepted Answer

Very clear. An electrolarynx gives a mechanical, robotic voice, whereas the voice through a tracheo-oesophageal prosthesis is almost the same as the patient's natural voice. Speech efficiency with a voice prosthesis is very good.

Question 10

How soon might next-generation devices arrive that reproduce a patient's own voice?

Dr. Priyanka Raina · Accepted Answer

This is not only a dream; a lot of work is already under way, including trials of laryngeal transplantation, which are still at the experimental stage. In the last 4 years I have seen two new generations of voice prostheses arrive, so development is rapid, and I hope a device that is completely hands-free and leak-proof will come; designs with an extra seal against leakage are already in use. Advances have helped us cure the disease, but the real satisfaction for a surgeon is giving the patient the best quality of life: when the patient eats and speaks happily and feels no compromise in lifestyle.

Question 11

What has been your experience of postoperative sequelae after surgery for carotid body tumours?

Dr. Priyanka Raina · Accepted Answer

The carotid body tumours we have treated have all been benign; I have not come across a malignant carotid body tumour. We have operated on Shamblin III cases too, with the cardiothoracic and vascular surgeons in our team, and the results have been very good. In the case I showed, the patient needed only one day of postoperative ICU observation and was discharged after 3 to 4 days. If every preoperative step has been taken with adequate precautions, embolisation, a preoperative angiogram and assessment of the circle of Willis, and the assessment has been done properly, unwanted postoperative consequences can be avoided.

Question 12

How are you able to preserve the neurovascular bundles in most of your patients in these very complicated surgeries?

Dr. Priyanka Raina · Accepted Answer

In thyroid and parotid surgery, nerve monitoring has been very helpful. Surgical precision matters, and the most basic requirement is good surgical loupes: it may sound obvious, but in my practice very good loupes, combined with nerve monitoring devices and these techniques, have clearly improved results. In parotid surgery I have also been regularly applying steroids to the operated bed at the end of the operation, and the nerve's response has been very good, with better postoperative results, though I am still collecting the data on this. Good visibility, with either the microscope or surgical loupes, is the foundation for preserving the neurovascular bundle.

Live Discussion with Dr. Priyanka Raina