Head & Neck

Pacific ENT Medical Group specializes in the diagnosis and treatment of head and neck conditions .Such as thyroid, parathyroid, salivary gland, and neck masses.

Pacific ENT provides the following services:

Head and Neck

Thyroid nodules and surgery
Salivary gland disease (parotid, submandibular, sublingual)
Head and Neck Ultrasound
Obstruction, infection, enlargement, tumors
Sore throat
Mouth sores – canker sores
Tonsils and adenoids
Swallowing trouble (dysphagia)
Enlarged lymph nodes in the neck
Benign and malignant (cancerous) tumors
Bell’s Palsy – Sudden onset of weakness involving one side of the face. This condition is thought to be generally caused by a virus.
Tumors or growth of the mouth
Temporomandibular joint dysfunction

Symptoms of Head and Neck Cancer

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 (or lumps) in the neck can be the first sign of cancer of the mouth, throat, voicebox (larynx), thyroid gland, or of certain lymphomas or blood cancers. Such lumps are generally painless and continue to enlarge steadily.

Change in the voice – Most cancers in the larynx cause some change in voice. Any hoarseness or other voice change lasting more than two weeks should alert you to see your physician. An otolaryngologist is a head and neck specialist who can examine your vocal cords easily and painlessly. While most voice changes are not caused by cancer, you shouldn’t take chances. If you are hoarse more than two weeks, make sure you don’t have cancer of the larynx. See your doctor.

A growth in the mouth – Most cancers of the mouth or tongue cause a sore or swelling that doesn’t go away. These sores and swellings may be painless unless they become infected. Bleeding may occur, but often not until late in the disease. If an ulcer or swelling is accompanied by lumps in the neck, be very concerned. Your dentist or doctor can determine if a biopsy (tissue sample test) is needed and can refer you to a head and neck surgeon to perform this procedure.

Bringing up blood – This is often caused by something other than cancer. However, tumors 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 your physician.

Swallowing problems – Cancer of the throat or esophagus (swallowing tube) may make swallowing solid foods difficult. Sometimes liquids can also be troublesome. The food may “stick” at a certain point and then either go through to the stomach or come back up. If you have trouble almost every time you try to swallow something, you should be examined by a physician. Usually a barium swallow x-ray or an esophagoscopy (direct examination of the swallowing tube with a telescope) will be performed to find the cause.

Changes in the skin – The most common head and neck cancer is basal cell cancer of the skin. Fortunately, this is rarely a major problem if treated early. Basal cell cancers appear most often on sun-exposed areas like the forehead, face, and ears, although they can occur almost anywhere on the skin. Basal cell cancer often begins as a small, pale patch that enlarges slowly, 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 color changes. Other kinds of cancer, including squamous cell cancer and malignant melanoma, also occur on the skin of the head and neck. Most squamous cell cancers occur on the lower lip and ear. They may look like basal cell cancers and, if caught early and properly treated, usually are not much more dangerous. If there is a sore on the lip, lower face, or ear that does not heal, consult a physician. Malignant melanoma classically produces dense blue-black or black discolorations of the skin. However, any mole that changes size, color, or begins to bleed may be trouble. A black or blue-black spot on the face or neck, particularly if it changes size or shape, should be seen as soon as possible by a dermatologist or other physician.

Persistent Earache – Constant pain in or around the ear when you swallow can be a sign of infection or tumor growth in the throat. This is particularly serious if it is associated with difficulty in swallowing, hoarseness or a lump in the neck. These symptoms are best evaluated by an otolaryngologist.

Thyroid nodules

The thyroid gland is located in the front of the neck, below the Adam’s apple and above the collar bones. It is dumb-bell shaped with two lobes on each side, and a narrower isthmus that crosses the windpipe. The thyroid gland produces thyroid hormones that help regulate metabolism.

Thyroid lumps or nodules are relatively common, occurring in approximately 10% of the adult population. They are more commonly found in woman than men. Many nodules can be seen or felt in the neck; others are smaller or deeper and may be noted on ultrasound or imaging studies performed to evaluate other conditions in the neck.

Most nodules are asymptomatic. Some may cause pain, pressure, difficulty in swallowing or hoarseness. Nodules are more likely to be cancerous if you are less than 20 or older than 70 years old. They are more likely to be cancerous in males, than in females. Other risk factors are a history of external irradiation to the neck in childhood, other swollen lymph nodes in the neck, or symptoms of hoarseness, or difficulty in swallowing.

Fortunately, only 5-10% of thyroid nodules are cancerous. The benign nodules are most commonly adenomas, cysts, or Hashimoto’s thyroiditis; a form of inflammation of the thyroid gland. Of the cancerous nodules, most are differentiated and usually are curable with treatment. Papillary, follicular, and mixed papillary-follicular carcinoma account for at least 80% of thyroid cancers.

The evaluation of thyroid nodules includes laboratory (blood) studies to determine if the thyroid gland is functioning normally. Most thyroid nodules do not cause abnormalities in thyroid function.

An ultrasound examination of the gland is used to evaluate the size of the thyroid gland and nodule and whether the nodule is solid or cystic (fluid filled). Most cystic nodules are benign.

A fine needle aspiration (FNA) is performed to obtain a sample of the contents of the nodule. If the nodule is small or cannot be felt on examination of the neck, the ultrasound may be used to help locate the nodule during the biopsy. This procedure is performed in the office or radiology center and is performed under local anesthesia with a small needle. The results of the biopsy may be benign, suspicious, malignant, or non-diagnostic. Most biopsies are found to be benign. 5-10% may be non-diagnostic because there are not enough cells in the biopsy to evaluate. If non-diagnostic, the biopsy is usually repeated in order to obtain more cells. 10% of biopsies are suspicious. Of the suspicious biopsies, 25% are found to be cancerous when the entire nodule is removed. The remainder of the biopsies are either malignant, or contain follicular cells that cannot be interpreted as benign or malignant unless the entire nodule is removed. In some instances, other studies, such as a nuclear medicine scan, may be ordered to determine if the thyroid nodule is hot (producing thyroid hormone) or cold (not producing thyroid hormone). Most hot nodules are benign.

If the results of the fine needle aspiration biopsy are found to be malignant, suspicious, or indeterminate (follicular cells), it is often recommended that the entire nodule be removed. That entails removing the entire lobe of the thyroid that contains the nodule (thyroid lobectomy). If cancer is confirmed within the nodule, the entire thyroid gland and any enlarged lymph nodes adjacent to the thyroid gland may be removed.

Thyroid surgery is performed under general anesthesia. The procedure is performed through an incision in the front of the neck above the collar bones. Most patients may go home the same day of the surgery although others may be observed overnight in the hospital. The major risks of the surgery are bleeding, swelling, injury to the recurrent laryngeal nerve, temporary or permanent hoarseness, and damage to the parathyroid glands, which may result in hypocalcaemia (too low calcium levels). In the case of the latter, calcium supplementation would be necessary. These complications are infrequent and usually occur in less than 2% of thyroid procedures.

Most individuals can return to regular activity in 1-2 days but should not exercise vigorously for at least 10 days following their surgeries.

Salivary gland disease

There are three pairs of major salivary glands, the parotid, submandibular, and sublingual.

There are also hundreds of minor salivary glands lining the mouth. The function of salivary glands is to produce saliva to help with lubrication and taste of food, as well as the initial phases of digestion. Saliva also washes away bacteria, and is important for the health of teeth.

Salivary glands may become painful and swollen due to infection or inflammation. Infections may be caused by viruses, such as mumps, HIV or other viruses such as coxsackievirus-A, or echovirus. Bacteria such as staphylococcus aureus and anaerobes may cause infections as well. Granulomatous diseases such as sarcoidosis or tuberculosis also occur. Non-infectious inflammatory disorders may include Sjogren’s syndrome and sarcoidosis.

Swelling may be caused a sialolith or stone that lodges in the drainage duct of the gland. Swelling is usually worse at mealtime, especially when eating sweet or sour foods.

Treatment will depend on the cause of the inflammation. Increased fluid intake and moist heat, massage and use of sialogogues (sour lozenges) and in some instances, antibiotics are often helpful. Removal of the stone by opening of the drainage duct, or in some cases, removal of the salivary gland, will help those with sialoliths.

The parotid glands may also become painlessly enlarged because of underlying problems such as diabetes, malnutrition, alcoholism and bulimia.

Trauma may cause blockage of the drainage of the salivary glands resulting in mucoceles or ranulas. Mucus retention cysts (mucoceles) are relatively common on the lower lip because of trauma related to the adjacent teeth. Mucoceles are usually removed in the office under a local anesthetic.

Tumors may be benign or malignant (cancerous). The majority of tumors (70-80%) occur in the parotid gland, 10% in the submandibular gland, less than 1% in the sublingual gland and 10-20% in the minor salivary glands. Most tumors in the parotid gland are benign (80-90%). Malignant tumors increase with the other salivary glands, 50% of the submandibular gland, 75% in the sublingual gland.

The most common benign tumor is a pleomorphic adenoma or “mixed” tumor. They typically are slow growing, painless and lobular (bumpy). They may become large over time and there is a 2-10% rate of cancerous transformation in long-standing lesions. To ensure complete removal and prevent recurrence, they are treated with wide local excision. This may require removal of a portion or the entire salivary gland.

The next most common benign tumor is a Warthin tumor. This occurs most commonly in older men, may be present on both sides and is usually located behind the lower jaw bone. They are also treated with wide local excision of the tumor.

Cancerous salivary tumors may present with a painless lump. Symptoms of weight loss, facial weakness or numbness are more likely with cancerous lesions. The most common types of cancer include mucoepidermoid carcionoma, adenoid cystic, acinic cell, and adenocarcinoma. Cancer of the lymph nodes (lymphoma) may also occur in the salivary glands, especially the parotid gland.

Treatment depends on the type and extent of the cancerous growth. Surgery, to remove the gland, is often recommended. Radiation therapy is also recommended for certain tumors.

Upon diagnosis of a growth in a salivary gland, a biopsy with a small needle, under local anesthesia, is often recommended to determine what kind tumor is present. An imaging study, such as an MRI or CT scan may also be ordered. Further treatment is then recommended based on the results of those studies.

Head and neck ultrasound

We are now able to perform diagnostic ultrasound examinations and ultrasound guided biopsies of the head and neck region. Thyroid and parathyroid glands and lesions, enlarged lymph nodes and other head and neck masses can be evaluated by ultrasound. The procedure is highly accurate, noninvasive, and does not expose one to radiation. Ultrasonography is helpful in the diagnosis and differential diagnosis of any pathologic masses in the entire neck and prior to any surgical procedure. The procedure can be performed rapidly in the office reducing any delays in evaluating lesions or swelling in the head and neck region. There is no discomfort associated with the examination.

Dr. Davis has received certification of completing the American College of surgeons Ultrasound Course for Surgeons and Ultrasound Examination of the Thyroid and Parathyroid Glands.

Sore Throat

A sore throat, or pharyngitis, is a common reason why people visit their doctors. It is not a disease but is more often a symptom of another illness. It can occur with a variety of viral and bacterial illnesses. Most sore throats are caused by viruses, as seen in the common cold and flu. A smaller number are caused by bacterial infections.

Viruses that can cause a sore throat include: the common cold virus, influenza, mononucleosis, and other childhood diseases.
Bacteria that can cause a sore throat include: Streptococcus (“Strep throat”), diphtheria, Mycoplasma, and some sexually transmitted diseases.
Other common causes of sore throat include: allergies, dryness, pollution/irritants, reflux of stomach acid (heartburn).
Some things you can do to help ease your sore throat: increase your fluid intake, gargle with warm salt water, use honey and lemon in warm water/tea, suck on throat lozenges, humidify the air, avoid smoke/pollutants, and rest your voice.

BACTERIAL VS. VIRAL INFECTIONS

Bacteria and viruses cause many common infections, many that are seen here in our office. Bacteria and viruses are not the same: bacteria can be found both inside and outside the human body whereas viruses are smaller than bacteria and cannot long survive outside the body’s cells.

Antibiotics are medications that are used to treat bacterial infections. They do not work for any infections caused by viruses. If you have a viral infection, antibiotics will not help cure your infection, make you feel better or prevent you from spreading your infection.

It is difficult to tell if an illness is caused by a virus or bacteria. But here are some guidelines regarding common illnesses.

Colds and flu – These are caused by viruses. Children and adults should consider being vaccinated with the influenza vaccine before the flu season starts.
Cough or bronchitis – Viruses almost always cause these but if you have a problem with breathing or the illness lasts a long time, bacteria may be the cause.
Sore throat – Most sore throats are caused by viruses, however, strep throat is caused by bacteria. A throat swab is usually needed before the doctor prescribes an antibiotic for strep throat.
Ear infections – There are many types of ear infections caused by either bacteria, a virus or fungus.
Sinus infections – A runny nose and discolored mucus does not necessarily mean you need an antibiotic. It is normal for mucus to become thick and change color during a course of a viral infection. After physical exam, which may include using a scope to see inside your nose, or culturing the discharge, the doctor may decide to use an antibiotic.

Antibiotics are important medications that kill bacteria or stop them from growing. Antibiotic resistance happens when bacteria adapt or change in ways that makes a specific antibiotic less able to do their job. These “resistant” bacteria survive and multiply, causing more harm. One could have a longer or more severe illness, leading to more doctor visits or need for treatment with a more expensive and powerful antibiotic. Over time, more and more bacteria are becoming resistant to some of the commonly used antibiotics. In turn, fewer antibiotics are able to treat common, severe and even rare illnesses caused by bacteria. In order for this not to happen, available antibiotics must be used appropriately.

To help avoid antibiotic resistant infections: don’t demand an antibiotic when your healthcare provider determines that one is not appropriate; when given an antibiotic, take it exactly as instructed; do not save any antibiotics for the next time you are sick and never take someone else’s antibiotic.

Mouth Sores

There are various types of sores that can appear anywhere within the mouth, including the inner cheeks, gums, tongue, lips or palate.

Stomatitis: This is inflammation of the mucous lining of any of the structures in the mouth, which may involve the cheeks, gums, tongue, lips and roof or floor of the mouth. It can be caused by poor oral hygiene, poorly fitted dentures, mouth burns from hot foods/drinks, medications, allergic reactions or infections. Stomatitis is associated with redness, swelling and occasional bleeding as well as bad breath. Canker sores are a type of stomatitis.

Aphthous Ulcers (Canker Sores): These mouth sores are NOT contagious and can appear as a pale or yellow ulcer with a red outer ring. They can appear alone or in clusters. These are very painful and can last 5-10 days. The cause is not clear but may be related to: a virus; temporary weakness in the immune system (like a cold); hormonal changes; mechanical irritation; stress; or low levels of vitamins/minerals. The treatment does not provide a cure but is aimed towards relieving discomfort and prevention from infection. A topical corticosteroid such as Kenalog, may be prescribed.

Cold Sores: Also known as fever blisters, these sores are caused by the herpes simplex virus and are very contagious. This virus is usually dormant but can be activated by conditions such as stress, fever and trauma. Usually there is tenderness, tingling or burning before the sore actually appears. The sores begin as blisters and then crust over and last about 7-10 days. Although there is no cure, treatment includes using an antiviral ointment, such as acyclovir.

Oral Candidiasis (Thrush): Thrush is a yeast infection of the mucous membranes of the mouth and tongue and is caused by forms of a fungus called Candida. This is a normal organism that lives in your mouth and is kept in check by healthy organisms that also live there. When your resistance to infection is low, the fungus can grow, leading to the lesions in your mouth or on your tongue.

Taking antibiotics or steroid medications, being very old or young, poor health, having diabetes, being on chemotherapy or having HIV/AIDS can increase your chance of getting thrush. Thrush appears as whitish, velvety lesions in the mouth and on the tongue. Under the white there is red tissue that may bleed. There are antifungal mouthwashes or lozenges that can be used to treat this infection. The long term out-look for thrush is dependent on your immune status and cause of the immune deficit.

Oral Lichen Planus: This is an inflammatory condition that affects the lining of the mouth. It usually occurs on the inside of the cheeks but can affect the gums, tongue, lips and other parts of the mouth. This is not an infectious disease, and is not contagious, but may last weeks or months. There are often small, pale raised areas or bumps that form a lacy network on the tongue or inside the cheeks.

It may advance into a painful erosive lesion. The mouth may be sore, dry and have a metallic taste. The cause is not known but may be triggered by an allergic or immune reaction. There is no cure for oral lichen planus, so the treatment focuses on managing the symptoms.

Oral Cancer: Mouth cancer commonly involves the tissue of the lips or tongue but may also occur on the floor of the mouth, cheek lining, gums or roof of the mouth. Most oral cancers are called squamous cell carcinomas and may spread rapidly. Smoking cigarettes and other tobacco use is associated with 70-80% of oral cancer cases. Heavy alcohol use is another activity that increases one’s risk of developing oral cancer.

Oral cancer presents as a lump or ulcer, pale or dark in color and may be painless. Some individuals have tongue pain, swallowing difficulty, mouth sores or abnormal taste. A biopsy of the lesion confirms the diagnosis of cancer. Surgical excision is usually recommended. Radiation therapy and chemotherapy may be indicated when the tumor is larger or has spread to lymph nodes in the neck.

Keep your Mouth Healthy! Oral Self-Care

Practice good oral hygiene.
Limit alcohol consumption and don’t use tobacco products.
Adjust your diet.
Have regular oral examinations.

Dysphagia / Swallowing Disorders

Difficulty swallowing (dysphagia) may occur at any age but is more common in the elderly. An individual may have difficulty swallowing liquids, solid foods or both.

Symptoms of Swallowing Disorders:

A feeling that food or liquid is sticking in the throat
Discomfort in the throat or chest
Drooling
Sensation of a foreign body or “lump” in the throat
Weight loss and inadequate nutrition due to prolonged difficulty swallowing
Coughing or choking when eating
Drooling

Swallowing is a very complex process and any interruption in the swallowing process can lead to dysphagia. Some 50 pairs of muscles controlled by several nerves help an individual to swallow. There are 3 stages of swallowing:

Oral preparation –The food is chewed, mixed with saliva and the tongue collects the prepared food or liquid for swallowing.
Pharyngeal stage – The tongue pushes the food or liquid to the back of the mouth, triggering a swallowing reflex that pushes the food into the pharynx (throat). The voice box (larynx) closes tightly and breathing stops to prevent food or liquid from entering into the lungs.
Esophageal stage – The food or liquid passes into the esophagus and then into the stomach. It takes about 3 seconds for food to pass into the stomach.

Causes of Swallowing Disorders:

There are many causes. Any condition that weakens or damages the muscles and nerves used for swallowing may cause dysphagia. Examples of disease of the nervous system include patients with Parkinson’s disease, cerebral palsy or a history of stroke. Difficulty chewing food because of poor teeth or ill fitting dentures may cause dysphagia. An infection or irrigation of the esophagus, such as gastroesophageal reflux is another cause. Narrowing of the esophagus caused by a stricture or a tumor of the head, neck or chest, may also create swallowing problems.

How are Swallowing Disorders Evaluated:

Most problems with swallowing are temporary and not threatening. If your symptoms persist, then we recommend an evaluation by an Otolaryngologist, such as Dr. Davis. The initial evaluation includes an examination of the head and neck region, including the mouth and throat. Next, the back of the throat is examined with mirrors or a flexible lighted tube called a fiberoptic laryngoscope. Additional tests may be ordered, including an xray study called a barium swallow or esophagram, which examines a patient with xrays while swallowing.

A referral to a speech pathologist for a swallowing evaluation may also be ordered. The speech pathologist may perform a modified barium swallow with a radiologist to determine if there are problems with any of the four stages of swallowing, using different food consistencies.

You may be referred to a gastroenterologist to evaluate the esophagus or a neurologist to determine if there is a disorder of the nervous system.

How Are Swallowing Disordered Treated?

Many disorders of swallowing can be treated with medication, swallowing therapy or surgery.

Medications that reduce stomach acid production, muscle relaxants, and antacids may help patients with gastroesophageal relux disease.

Gastroesophageal reflux may be treated with lifestyle changes as well as medications. Some of those changes include:

Avoid alcohol, caffeinated beverages, nicotine and chocolate.
Eat small meals and avoid food within 3 hours of bedtime
Elevate the head of the bed at night
Avoid tight fitting clothes.
Reduce you weight.

Swallowing therapy is performed by the Speech Pathologist. Therapy consists of special exercises to strengthen weak swallowing muscles or to improve coordination. Some individuals may benefits from changing the consistency of their diet or to eat with their head turned to one side. Restimulating the nerves that trigger the swallow reflex may also be helpful.

Surgery is used to treat certain problems. If there is narrowing of the esophagus, the area may need to be stretched or dilated. If a muscle is too tight, it may need to be released surgically (myotomy). Surgical treatment may also be helpful if there is weakness of one of vocal cords of the voice box.