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Head & Neck Cancer _ Your Questions Answered

Online Health Chat with Dr. Mumtaz Khan

April 16, 2012

Introduction

Cleveland_Clinic_Host: This year, more than 55,000 Americans will develop cancer of the head and neck (most of which is preventable) and nearly 13,000 of them will die.

As much as 90 percent of head and neck cancers arise after prolonged exposure to specific risk factors. Use of tobacco (cigarettes, cigars, chewing tobacco, or snuff) and alcoholic beverages are the most common cause of cancers of the mouth, throat, voice box, and tongue. In adults who do not smoke or drink, cancer of the throat can occur as a result of infection with the Human Papillomavirus (HPV).

Most head and neck cancer patients have the same fears; will they survive the cancer, and what problems might the treatment cause. Good news is that when head and neck cancers are detected early, they are highly curable, with few side effects.

Mumtaz Jamshed Khan, MD, is a Head and Neck Surgeon at the Head and Neck Institute. He is board-certified in otolaryngology, head and neck surgery. Dr. Khan’s specialty interests include head and neck tumors, laryngeal cancer, oral cancer, oropharyngeal cancer, paraganglioma, salivary gland tumors, thyroid cancer and minimally invasive surgical techniques.

A native of Pakistan, Dr. Khan received his medical degree from Aga Khan University in Karachi, Pakistan. He did his Research Fellowship in Otology/Neurotology, Internship and Residency in Otolaryngology at Henry Ford Hospital in Detroit, Michigan, followed by Fellowship in Head & Neck Oncology and Microvascular Reconstructive Surgery from Vanderbilt University in Nashville, Tennessee.

Dr. Khan is the past chief of Otolaryngology and the past Associate Dean of postgraduate education at Aga Khan University. He is a member of several professional societies including: American Academy of Otolaryngology Head & Neck Surgery, American Head & Neck Society and the American College of Surgeons.

Cleveland_Clinic_Host: To make an appointment with Mumtaz Khan, MD or any of the other specialists in our Head & Neck Institute at Cleveland Clinic, please call 216.444.8500 or call toll-free at 800.223.2273, ext. 48500. You can also visit us online at vanity clevelandclinic.org/voice.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Mumtaz Khan, MD. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


Complications after surgery

Piper: I had a tumor removed from the underside of my tongue 4 yrs ago followed by radiation treatment. Another operation 2 years ago has left me with an extremely swollen tongue and unable to eat in a normal way. I get all my nourishment through a gastric tube. I have lost weight, I am tired, and my tongue is constantly very painful. I am no longer able to swallow liquids except for very small amounts. What I do swallow often comes right back up. I cough a lot, especially during the night, and a major problem is that my mouth feels very dry. I don't have much saliva, but I do have an awful lot of heavy phlegm which distorts my speech. I need help in a bad way! Any advice you can provide will be greatly appreciated. Thanks.

Dr__Khan: Unfortunately, this is a known and common complication after radiation & surgery, but there are ways to improve the functions of the throat to some extent. This may involve something as simple as dilating the food pipe to some more involved procedures. Perhaps it is best to be evaluated by a head and neck surgeon and a swallowing therapist to find a reasonable solution.

Depression is also very common in patients dealing with this disease. We can also help assisting you to overcome such emotions.

nadia: After tongue cancer surgery, is therapy given to help a person speak normally again? Or, should I ask, “Will a person be able to speak normally again after part of their tongue has been removed?”

Dr__Khan: After removal of part of the tongue, speech therapy helps tremendously with regaining normal speech. If a larger portion of tongue is removed, then it is usually reconstructed with a free tissue transfer (free-flap) from the arm or forearm and that results in restoring both speech and swallowing function.

ask_me: Is it possible to have your epiglottis repaired? I lost 50% of mine during surgery.

Dr__Khan: Unfortunately, we are not able to repair or reconstruct the epiglottis surgically, but usually people are able to maintain normal function with partial resection (removal) of the epiglottis.


Medications

Piper: Is there any medication you can recommend to reduce the amount of phlegm? Are there any saliva substitutes that might help the dryness in my mouth?

Dr__Khan: There are certain medications like Salagen® (pilocarpine) or Evoxac® (cevimeline) that have been helpful in some people. You should ask your radiation therapist/oncologist if you would be a candidate for such treatments. As for the phlegm, increasing your water intake is the best solution, which I understand may be difficult in your case because of the swallowing issues.


Treatment options

confused: I have been given two different treatment options for my tonsil cancer. One doc says surgery and radiation; the other has said that chemo and radiation would work for the type of squamous cells that I have, with surgery as a later option if necessary. I have read that surgery and radiation is the better approach. However, if I would be okay without the surgery, I would prefer it. How does one pick the right approach?

Dr__Khan: Both treatment options are reasonable. The treatment of choice depends on the stage of the disease and also on the histologic type. Particularly for squamous cell tonsillar cancer, the HPV status of the tumor is also considered when determining the optimal treatment approach. For early stage tumors, surgery followed by radiation therapy is most of the time considered a better approach, particularly if we can prevent the need for chemotherapy. However, most of the time radiation & chemotherapy are essential and, since the outcomes are similar, the non-surgical approach is preferred. Speak to your physician to determine the best option in your case.

For larger tumors, or when radiation and/or chemotherapy are unsuccessful, then surgery becomes necessary. With proper reconstructive surgery, the functional outcomes after surgery are also very good.

requestor: Could you please explain which types of oral cancers are treated using the da Vinci Robotic surgery; which type of patients are good candidates for this surgery; how it compares with traditional surgery; and if there are any cautions related to post-surgery issues? Thank you.

Dr__Khan: A robot is essentially a tool that may be used in place of a laser, micro-instruments, or a knife (scalpel.) Over the past couple of years, robotic surgery has been approved by the FDA for treatment of oral cancers. The applications are limited primarily because of the limited exposure to the mouth and throat structures. The biggest advantage comparing it to laser or traditional endoscopic surgery is the advantage of acquiring adequate surgical exposure to areas such as the base of the tongue and the upper part of the larynx. It also depends on the body habitus (endomorphic or overweight individual) of the patient. The post-surgical issues are essentially the same as they are with other traditional surgical procedures.

plan_ahead: When given a diagnosis of tonsil cancer or any kind of cancer, and a recommended treatment plan, is it recommended to get a second opinion? Or, do you go by what your doctor says, if you trust them?

Dr__Khan

1_2_3: The doctors want to do a mandibular reconstruction of my father's jaw bone (osteo radio necrosis). Are there any other options available? What can be expected from this surgery?

Dr__Khan: Mandibular reconstruction for osteo radio necrosis is the treatment of choice. Best results are achieved with free tissue transfer, which may involve taking a piece of the fibula (leg bone) or scapula (shoulder blade) and transplanting it to replace the jaw bone. Surgical outcomes are very good with fine form (shape of the jawbone) and function.


Ethmoid cyst

Yram22: My 21-year-old daughter has had ongoing face pain and pressure, dry eyes, and left sided paresthesias for over a year now. The doctors did CT scan and MRI of her head and neck and only found an ethmoid cyst. The ENT doesn't think it is causing the pain, but do you think it could be causing her face pain? Also, is it possible that it is sinus cancer instead, and, if so, should we demand a biopsy? Thank you for your help.

Dr__Khan: I agree with the evaluation given to you. The ethmoid cyst may not be responsible for the pain & discomfort. In the absence of any significant finding on evaluation & on scans, the chances of a sinus cancer are very low. And a biopsy may not be warranted in the absence of a suspicious lesion. A neurologic evaluation for facial pain is often necessary and must be sought.


Mucoepidermoid carcinoma

mummy: My 12-year-old niece has been diagnosed with grade II mucoepidermoid carcinoma, grade II very recently. My sister hasn’t really been able to talk about it yet. My family would like to know what we can expect.

Dr__Khan: Mucoepidermoid carcinoma is a known entity (not uncommon) in children and is successfully treated surgically. Sometimes radiation afterward may be necessary. The outcomes are very good, and you should proceed with the suggested treatments as soon as possible.


Radiation issues

sell_it: I have been told I could lose teeth with radiation. If so, can I have implants, versus just having them removed or getting dentures (if need be)? If not, why not?

Dr__Khan: Radiation causes disruption of the blood supply to the bone which may result in dental infections and tooth loss. Implants are typically not done for several years after radiation therapy. If the teeth are not healthy, then they should be removed prior to radiation therapy to avoid subsequent problems. Dentures would be a reasonable substitute.

molloy: Any suggestions on reducing the redness/burning in face, neck and chest from the radiation/chemotherapy? The lotions I have been using don’t seem to help much.

Dr__Khan

suem: My friend is a 58-year-old male with tongue/head/neck cancer. This is the second time. The first time he was able to rid himself of the cancer using natural treatments and enzymes. It returned 3 years later, and this time he has started radiation and Eribetux® (cetuximab). Both treatments appear horrible. How will we know if they are destroying the cancer? It is so hard to tell with the acne spots and the red, burned skin.

Dr__Khan: You should ask your radiation oncologist and medical oncologist for their protocol in assessing treatment response. Typically, a clinical assessment is done during the course of treatments and afterward to look for a recurrence or persistent disease. Additionally, imaging of the head & neck is also obtained to look for treatment response once they have finished.

penny_wise: I had radiation and chemo for esophageal cancer 6 months ago. I am still in a lot of pain, especially my ears and throat. How long is normal for this pain to last?

Dr__Khan: This is a very common symptom after such treatments. Unfortunately, it is difficult to predict the duration of pain. The important thing is that if the pain worsens or is persistent, then you should be evaluated by your physician to rule out any potential problems.

mr_cass: What can you tell me about taste bud recovery after treatment? My wife is still having issues 7 weeks after treatment. Everything tastes sour or 'yucky' to her. Can you suggest things to eat that won’t taste so “yucky” to her until her taste returns? She has almost stopped eating.

Dr__Khan: I assume your wife had radiation treatments. Each case is different. The good news is that the taste buds will recover. Some people may take as long as 18 months to regain certain tastes. Typically, everything tastes bland. One suggestion is that since smell stimulates taste, this fact should be considered when deciding on a diet. A nutritionist should help with this.

Jmick: For surviving neck cancer patients who underwent radiation therapy, what is the overall impact on their life longevity?

Dr__Khan: If radiation therapy was successful, and there is no clinical evidence of recurrence of disease, then the survival rate is dependent on the stage of the cancer and areas that were involved.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialist Dr. Mumtaz Khan is now over. Thank you for taking the time to answer our questions today about Head and Neck Cancer.

Dr__Khan: Thank you very much for your questions. I hope I was able to answer your question. If I can be of any further assistance, please contact the Cleveland Clinic and I will be happy to see you.


More Information

To make an appointment with Mumtaz Khan, MD or any of the other specialists in our Head & Neck Institute at Cleveland Clinic, please call 216.444.8500 or call toll-free at 800.223.2273, ext. 48500. You can also visit us online at clevelandclinic.org/headandneckcancer.

A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit eclevelandclinic.org/myconsult.

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