Head & Neck

Skin Cancer

The skin is the largest organ in the body so it is no surprise that skin cancer is the most common type of cancer. Fortunately most skin cancers are easily treated if caught early to do not spread to other parts of the body. Sun exposure is the most significant risk factor for almost all types of skin cancer. The face is the most common site for skin cancers since it is frequently exposed to sun. Development of a skin cancer on the face is scary for many people as treatment involves a highly visible area of the body. As specialists in head and neck cancer as well as facial plastic surgery we strive to maximize cure and aesthetic outcomes at the same time.

What are the different types of skin cancers?

Basal cell carcinoma – The most common (75%) and usually least aggressive type of skin cancer. This almost never spreads to other parts of the body.

Squamous cell carcinoma – The second most common (20%) type. These can be more aggressive and have the potential to spread to lymph nodes, nerves or other areas of the body if not treated early.

Melanoma – The most serious type of skin cancer which comes from the cells which give pigment and color to the skin (melanocytes). Although the cure rate is high when caught early, more advanced cancers have a low cure rate and can easily spread to many parts of the body.

How do I know if I have a skin cancer?

Warning signs of developing basal and squamous cell skin cancers include:

  1. Sores or ulcers that do not heal
  2. Bumps or nodules on the skin that are enlarging
  3. Crusting and bleeding areas that don’t improve

Melanomas usually appear different because almost all are colored. They usually are noticed by moles which are changing. Use the ABCDE’s to determine if your mole is concerning enough to have it looked at.

A – Asymmetry: Most normal moles are round or oval and symmetric
B – Border irregularity: Normal moles generally have a smooth regular border
C – Color: Variations or changes in color, particularly within the same mole are concerning
D – Diameter: Any mole over 6mm (more than ¼ inch)
E – Evolving: Common, benign most generally do not change in size, shape or elevation from the skin

What are the treatment options for skin cancer?

Surgery is the most common form of treatment and generally yields very high success rates (90-99%). For the face and neck specifically, it is important to minimize the normal skin removed so that the reconstruction is easier. Commonly this is done with Mohs surgery where small of skin are removed and examined immediately under the microscope to assure there is no cancer left. This is particularly useful for recurrent cancers or ones very close to the eye. The downside to Mohs surgery however is that because the goal is to take the smallest possible amount of tissue, frequently this can take a large part of a day and repeated injections for numbing. Additionally the area of removed skin still needs to be reconstructed which may be done after the removal of the cancer or on another day.

At Central Coast Otolaryngology we work closely with our board certified, dermatopathologists to maximize skin cancer cures and limit the amount of normal skin removed. Typically the skin cancer is removed in the office in a short amount of time the morning of your visit. The pathologist then looks comprehensively at the removed tissue to assure there is no cancer left. The area removed is covered with a small bandage. Usually the next day another short visit is scheduled for the reconstruction. Occasionally if there is a small amount of cancer left that was missed, a focal area is removed and sent immediately to the pathologist to assure all cancer is gone before the reconstruction. The results are usually available in about 20-30 minutes. For most skin cancers which are small and have not been treated before, this approach is a great option with very good cure rates and minimal time spent for the procedure.

In certain situations other treatments may be options instead of surgery. These include:

  1. Cryosurgery – Freezing with a liquid nitrogen spray destroys the tumor. The growth becomes scabbed and crusted and usually falls off within a few weeks. There may be some redness, swelling, or pigmentary changes to the skin. This can be a good treatment option for some pre-cancerous skin lesions or occasionally very superficial cancers, however the long-term cure rate is not nearly as good as surgical removal.
  2. Topical creams – Both 5-fluorouracil (Efudex) and Imiquimod (Aldara) are FDA-approved to treat actinic keratosis (pre-cancerous) and superficial basal cell carcinomas. 5-fluorouracil is a topical chemotherapy medication while Imiquimod stimulates the immune system to make interferon, a chemical which attacks cancerous and pre-cancerous cells.
  3. Radiation – A radiation doctor uses X-ray beams are used to kill cancer cells similarly to other cancers. Cure rates are around 85-95% and does not involve surgery, however treatment consists of approximately 4 weeks of daily radiation treatment. This may be an option for select patients who cannot undergo surgery or have tumors where excision would cause functionally or cosmetically unacceptable results.

Do I need thyroid surgery?

The thyroid gland sits low in the neck on top of the trachea (windpipe). It produces and releases thyroid hormone which regulates physiologic functions in the body primarily related to metabolism (heart rate, sweating, energy consumption etc.). Most thyroid disorders involve overactive or underactive thyroid gland. Problems like these are usually treated by your primary doctor or an endocrinologist and managed with medication. In some cases surgical removal of part or all of the thyroid (thyroidectomy) may be the best treatment. Most thyroid surgery now is performed by otolaryngologists (head and neck surgeons). Situations in which the thyroid may need to be removed are:

  1. Thyroid nodules – Small areas of growth in the thyroid called nodules can frequently occur, particularly in women. Most of these are benign (non-cancerous), however some are malignant (cancerous). Most nodules under 1 centimeter are not concerning but may be watched with ultrasound to make sure they are not growing rapidly. Nodules over 2 centimeters usually required a needle biopsy (FNA) to determine if there is a concern for cancer. Nodules between 1-2 centimeters may require biopsy depending on the clinical suspicion and ultrasound appearance.
  2. Thyroid cancer – The 8th most common cancer in the US, the number of thyroid cancers is one of the few that is actually rising. Fortunately for the most common types of thyroid cancers, if caught early cure rates are over 95%. Early thyroid cancers usually are found as a mass or nodule in the thyroid either by feeling or by ultrasound. More advanced cancers can present with hoarseness, enlarged lymph nodes, trouble swallowing or rarely trouble breathing. The primary treatment for thyroid cancer is removing part or all of the thyroid and sometimes lymph nodes. Occasionally for larger or more advanced cancers radioactive iodine is given after surgery.
  3. Goiters – A significantly enlarged thyroid (goiter) can produce symptoms of a lump in the throat, trouble swallowing, or difficulty breathing particularly when laying down. This occurs sooner if the thyroid grows down under the sternum (breastbone). Since many of these symptoms can occur without an enlarged thyroid, your surgeon will determine if your symptoms are likely due to the size of your thyroid.

What are parathyroid glands?

There are four parathyroid glands, smaller than the size of a pea, which usually sit behind the thyroid gland and regulate calcium levels in the body. They do this by breaking down the bones to dissolve the calcium into the blood, by increasing the calcium absorption from the gut and decreasing the calcium excreted into urine.

When do parathyroid glands need to be removed?

Parathyroidectomy, a procedure to removed one or more parathyroid glands is done to remove glands which are producing too much parathyroid hormone (PTH). Most commonly one gland grows large, called a parathyroid adenoma, producing excess PTH without the body’s normal physiologic control. This can cause a number of problems including:

  1. Osteoporosis – Decreased bone density developed as PTH breaks down bone to increase the calcium in the blood. This can lead to increased risk of fractures. A bone density scan (DEXA) is commonly used to identify bone loss.
  2. Kidney stones – Excess calcium in the blood is filtered through the kidney and often builds up as kidney stones.
  3. Constipation and abdominal discomfort – These symptoms are often seen for many other reasons, however symptoms may improve if PTH levels return to normal after surgery
  4. Psychiatric – Depression, fatigue, decreased memory among other mental health issues can significantly worsen with high calcium levels in the blood. Although resolution of these problems cannot be guaranteed, often people will feel much better after their calcium levels return to normal.

Today elevated calcium levels are often detected incidentally during blood tests for other reasons before it is severe enough to cause problems. If sigificantly elevated this usually requires additional lab work is done by an endocrinologist or your primary doctor. Your head and neck surgeon will determine if you are a candidate for parathyroidectomy. In general, people with higher calcium levels, lower bone density, and younger age are the ones who benefit most from surgery.

What is done in parathyroid surgery?

Before surgery imaging studies are used to help find which gland is diseased. A small incision is made in the lower neck and the thyroid gland is pulled forward to find the suspicious parathyroid gland(s). The enlarged gland(s) and removed and send to the pathologist. Usually the surgery itself takes less than 30 minutes however occasionally this can be longer if the parathyroid glands are not in a normal position. Most patients go home the same day. Success rates from surgery are over 90%. Generally complications rates are very low however there are small risks of wound problems, injury to the recurrent laryngeal nerve (controls vocal cord movement), or persistent calcium problems afterward.

Head and neck cancer

Over 55,000 Americans develop head and neck cancer each year and over 13,000 die from their cancer. By far the most common type of cancer in the head and neck is squamous cell carcinoma (SCCa). This affects the lips, mouth, throat, larynx (voicebox), tonsil, nose and sinuses.

What are the symptoms of head and neck cancer?

This depends on the location of the tumor. Concerning symptoms include:

  1. A lump in the neck – Particularly in adults, a firm mass in the neck is often one of the first signs of spread of head and neck cancer to the lymph nodes.
  2. Growth in the mouth or lip – Since most cancers come from the lining of the mouth and throat some can be seen. If there is an area which does not go away or continues to grow or bleed you should be evaluated by your doctor and biopsy may be taken.
  3. Voice changes – Persistent or progressive hoarseness are often the first symptom of laryngeal (voicebox) cancer.
  4. Ear pain – Constant ear pain particularly on only one side is a frequent symptom of an infection or growth in the throat. This is called referred pain as nerves in the ear and throat travel through similar pathways to the brain and the brain cannot tell where the pain is coming from. Particularly if present with other throat or neck symptoms this should be evaluated by an otolaryngologist early on if it does not go away.

What causes head and neck cancer?

The most common cause is still tobacco usage. Although smoking can affect many sites of the body including the lungs, mouth and throat, smokeless or spit tobacco is a significant risk factor for oral (mouth) cancer. Alcohol by itself is probably not major head and neck cancer risk factor for non-smokers. However in smokers this can dramatically increase cancer risk.

The number of head and neck cancers in non-smokers is increasing every year. Most of these cancers are believed to be due to human papilloma virus (HPV). This is the same virus that causes cervical cancer. HPV is a virus that most people have been exposed to during their lives and clear the virus without knowing they have it. However some people can develop a chronic infection which then develops into cancer. The most common sites of cancer start in the tonsil or back of the tongue and the first sign is usually a lump in the neck. Currently there are no good screening tests for head and neck cancer if you do not have symptoms.