What about its accuracy ?Itisabout90%accurateifdoneproperlybyatrainedorexperiencedpersonnel.Anymoreaccuratewouldneedanopenbiopsyandsendingthethree-dimensional tissue block to the pathologist. But beware the great disadvantage of the reason given just in the paragraph above.So what is the advantage of the surgeon doing the biopsy procedure ?Whilethisisnotcommon,asthespecialskillsneedtobeacquiredthoughfurtheradvancedtrainingandexperience.Heretheadvantageliesinthefactthat thesurgeonwhomyouhadconsultedhastheheads-upinknowingyourdiseasehistory,aclinicalexaminationofthemassbyinspectionandpalpation.A moreholisticapproachwouldbepossibleash/sheisabletocollateallthesedataandrelatetoyourultrasoundand/orbiopsyresults.Furthermore,thesame datawouldbeusefulforcorrelationshouldasurgerybeneededforthemassinthenearfuture.Hereweareafirmbelieverinthisholisticapproachof management.Is It painful ? Itisjustlikedrawingbloodfromyourveins,butnowtheneedleisaimedtowardsthemassofconcernintheheadandneckregioninstead.Togetabetter sample,sometimestheneedleisangledatmanydifferentanglesallaroundwithinthemassconcernedforawidercoveragetogetthemost representative/bestsample.Soatmost,theremaybeabitslightlymorediscomfortthanaroutinebloodtakingbutverytolerable.Anoptionofusinglocal anesthesia prior to the procedure is available upon request.
An open incisional biopsy (as the last resort)
Endosopic assessment of the nose and throat important
The truth about head and neck swellings:•Commonswellingsoriginatefromthelymphnodes,thyroidgland,salivary gland, skin•Most swellings are not cancerous. •Some will respond to medication, some will not.•Not all need surgery. Some will.•Beforeaswellingissurgicallyremoved,itisimportanttobestknowitscontent andnatureasitaffectssurgicalplanningandpatienttreatmentoutcome(‘ask, then shoot’ approach)•Ratherthan‘shoot,thenask’approach–cuttingintoaswellingasfirstline approach(whereapplicablewithfurtherclarificationbelow)thenfindoutwhat is the content
Hence, modern technology nowadays has allowed us to use minimally invasive techniques to understand a swelling before we plan our next move on its treatment. At the forefront of such studies of swelling are cytology and/biopsy studies using needles or fine biopsy instruments. To increase its accuracy, ‘live’ imaging equipment (commonly ultrasound) is used to guide its placement for the best possible sampling.What is the most important difference of using ultrasound and non-usage of ultrasound in performing the biopsies or cytology studies ?The usage of real-time imaging allows an accurate ‘live’ pinpoint of the mass you worry about. Theproblemis,inamasstheremaybeareaswhereitishard/solidorareaswherethefluidgather(cystic).Usuallythesolidparttendstobethepartthat harbours cancerous cells or has the potential to transform into a cancerous growth.Withoutanimagingguidancesystem,differentiatingitexternallybytheanydoctorlookingatit(inspection)orfeelingit(palpation)isratherimpossibletobe donewithgreataccuracy.Somanycombinationofthedifferentsolidandcysticmasscanexistinmanydifferentpartsofthemass(seepic).Evenifaneedleis insertedintothemassbythedoctorasinanon-imageguidedbiopsy,,howwouldheknowwhichcomponentisattheneedletip?Thepossibilitiesarethe different arrangement of structure types are many (The next paragraph further details the 2 main components ie. sold and cystic and their implications)AnotherrealadvantageofthisapproachIsthatevendeep-seatedswellingsnotvisiblefromtheoutside(meaningthenecklooksabsolutelynormal)butseenby ultrasound deep under the skin (maybe 2cm under the skin) can be sampled.Whileweacknowledgethatultrasoundguidancecostmore,theaccuracyandalltheotheradvantagesensuresthatitisaworthwhileprocedure/endeavor.The advantages (especially the ability to pinpoint the suspicious part of the mass) far outweigh the cost disadvantageWhat is the significance of the solid and cystic parts ?It is natural that most, if not all, patients worry about cancer changes. And those changes tend to happen way more commonly in the solid part of the mass.Theaddedbonusisthatoncethecysticpartispinpointed,thefluid,ifitiswatery/serousenoughtobedrainedthroughtheneedlepuncturingit,theswellingcan bedecompressed,shrinkingthemassasanaddedbonus(thinkofthatasanaddedbonusshouldyouneedto‘showoffanewneck’duringanimportantsocial function tomorrow !)The possibilities of the different combinations of the solid and cystic swellings in a gland are too many, as seen in the pictures below.
A thyroid gland swelling
A parotid salivary gland swelling
“Don’t shoot then ask !”
(graphic credit: www.historyisnowmagazine.com)
“Cant’ see well, can’t aim wellCan’t aim well, can’t get good results”
So what are the other advantages of ultrasound ?•UltrasoundusesNOradiationhenceitissafeinchildorevenpregnantladies.(thinkpregnantladieswiththeirregularantenatalultrasoundchecks. So there Is no denying that all of us would have had ultrasound done on us in our moms’ womb before we saw the light of this world !)•Ultrasound guidance allow a real-time ‘live’ assessment of the mass and its component•ItisareliableyetmuchcheapermodalityascomparedtoCTscan(whichalsohasamuchhigherdoseofradiation).Forthyroidswellings,theminute feature details are better seen on ultrasound rather than CT scan.•It is light-weight and hence a very portable system to move/lug around.•Notonlycanitdifferentiatethesolidandthecysticpart,italsoallowsthestudyofeachsolidandcysticparttofurthersuggestifeachcomponentis more likely to be cancerous or not, based on its ultrasound features/attributes.•Itcanbeappliedtoallheadandneckmasses(commonlythethyroid,salivaryandlymphnodes)andthenecessaryproceduresperformedegbiopsy, cytology studies, drainage, sclerotherapy etc.•This procedure is applicable in both children and adults. (though for uncooperative children, general anesthesia maybe needed)What if the mass studied is actually a cancerous mass ?The FNAC study has been proven to NOT increase the risk of any cancer spread (tumour seedling).Cuttingintothemasswithoutverifyingifitiscancerous,viaanopenincisionalbiopsyinfactcausetumourseedlingiethecancercellsspreadingalongthe openwoundintotheskinsurface.Thishasbeenproventoconferaworseprognosisieaworseoutcomeinthecancercure.Openbiopsyshouldonlybe used as a last resort or in some cases where the FNAC cannot confirm the true nature of the tumour. Inanyheadandneckmass,especiallyiftheswellingissuspectedtobealymphnode,itisImperativethattheentireear,noseandthroatsystembe scannedviaENTendoscopypriortoanyinvestigationofthesecondaryneckswelling.AnyinflammationortumoursoftheENTsystemcanpotentially spread to the neck lymph nodes.
Thepossiblevariationsaretoomany,beyondwhat the eyes can see and hands can feel
“Ask first (the nature of swelling), then shoot (treat/remove surgically if needed).”
DOWNLOAD OUR CONTACT DETAILS:
ENTdrvincenttan@gmail.com
+603-3377 7864+6012-3760 728
Vincent Ear, Nose, Throat, Head and Neck Surgery Specialist Clinic, Clinic Suite 210, Level 2,KPJ Klang Specialist HospitalNo.102, Persiaran Rajawali/KU 1,Bandar Baru Klang,41150 Klang,Selangor
What about its accuracy ?Itisabout90%accurateifdoneproperlybyatrainedor experiencedpersonnel.Anymoreaccuratewouldneedan openbiopsyandsendingthethree-dimensionaltissueblockto thepathologist.Butbewarethegreatdisadvantageofthe reason given just in the paragraph above.(open biopsy pic)Sowhatistheadvantageofthesurgeondoingthe biopsy procedure ?Whilethisisnotcommon,asthespecialskillsneedtobe acquiredthoughfurtheradvancedtrainingandexperience. Heretheadvantageliesinthefactthatthesurgeonwhomyou hadconsultedhastheheads-upinknowingyourdisease history,aclinicalexaminationofthemassbyinspectionand palpation.Amoreholisticapproachwouldbepossibleas h/sheisabletocollateallthesedataandrelatetoyour ultrasoundand/orbiopsyresults.Furthermore,thesamedata wouldbeusefulforcorrelationshouldasurgerybeneededfor themassinthenearfuture.Hereweareafirmbelieverinthis holistic approach of management.Is It painful ? Itisjustlikedrawingbloodfromyourveins,butnowthe needleisaimedtowardsthemassofconcernintheheadand neckregioninstead.Togetabettersample,sometimesthe needleisangledatmanydifferentanglesallaroundwithinthe massconcernedforawidercoveragetogetthemost representative/bestsample.Soatmost,theremaybeabit slightlymorediscomfortthanaroutinebloodtakingbutvery tolerable.Anoptionofusinglocalanesthesiapriortothe procedure is available upon request.
An open incisional biopsy (as the last resort)
Endosopic assessment of the nose and throat important
The truth about head and neck swellings:•Commonswellingsoriginatefromthelymphnodes, thyroid gland, salivary gland, skin•Most swellings are not cancerous. •Some will respond to medication, some will not.•Not all need surgery. Some will.•Beforeaswellingissurgicallyremoved,itisimportant tobestknowitscontentasitaffectssurgicalplanning andpatienttreatmentoutcome(‘ask,thenshoot’ approach)•Ratherthan‘shoot,thenask’approach–cuttingintoa swellingasfirstlineapproach(whereapplicablewith furtherclarificationbelow)thenfindoutwhatisthe content
Hence, modern technology nowadays has allowed us to use minimally invasive techniques to understand a swelling before we plan our next move on its treatment. At the forefront of such studies of swelling are cytology and/biopsy studies using needles or fine biopsy instruments. To increase its accuracy, imaging equipment (commonly ultrasound) is used to guide its placement for the best possible sampling.What is the most important difference of using ultrasound and non-usage of ultrasound in performing the biopsies or cytology studies ?Theusageofreal-timeimagingallowsanaccurate‘live’pinpoint of the mass you worry about. Theproblemis,inamasstheremaybeareaswhereitis hard/solidorareaswherethefluidgather(cystic).Usuallythe solidparttendstobethepartthatharbourscancerouscellsor has the potential to transform into a cancerous growth.Withoutanimagingguidancesystem,differentiatingitexternally bytheanydoctorlookingatit(inspection)orfeelingit (palpation)isratherimpossibletobedonewithgreataccuracy. Somanycombinationofthedifferentsolidandcysticmasscan existinmanydifferentpartsofthemass(seepic).Evenifa needleisinsertedintothemassbythedoctorasinanon-image guidedbiopsy,,howwouldheknowwhichcomponentisatthe needletip?Thepossibilitiesarethedifferentarrangementof structuretypesaremany(Thenextparagraphfurtherdetailsthe 2 main components ie. sold and cystic and their implications)AnotherrealadvantageofthisapproachIsthatevendeep-seatedswellingsnotvisiblefromtheoutside(meaningtheneck looksabsolutelynormal)butseenbyultrasounddeepunderthe skin (maybe 2cm under the skin) can be sampled.Whileweacknowledgethatultrasoundguidancecostmore,the accuracyandalltheotheradvantagesensuresthatitisa worthwhileprocedure/endeavor.Theadvantages(especiallythe abilitytopinpointthesuspiciouspartofthemass)faroutweigh the cost disadvantageWhat is the significance of the solid and cystic parts ?Itisnaturalthatmost,ifnotall,patientsworryaboutcancer changes.Andthosechangestendtohappenwaymore commonly in the solid part of the mass.Theaddedbonusisthatoncethecysticpartispinpointed,the fluid,ifitiswatery/serousenoughtobedrainedthroughthe needlepuncturingit,theswellingcanbedecompressed, shrinkingthemassasanaddedbonus(thinkofthatasan addedbonusshouldyouneedto‘showoffanewneck’during an important social function tomorrow !)Thepossibilitiesofthedifferentcombinationsofthesolidand cysticswellingsinaglandaretoomany,asseeninthepictures below.
A thyroid gland swelling
A parotid salivary gland swelling
“Don’t shoot then ask !”
(graphic credit: www.historyisnowmagazine.com)
“Cant’ see well, can’t aim wellCan’t aim well, can’t get good results”
So what are the other advantages of ultrasound ?•UltrasoundusesNOradiationhenceitissafeinchildor evenpregnantladies.(thinkpregnantladieswiththeir regularantenatalultrasoundchecks.SothereIsno denyingthatallofuswouldhavehadultrasounddone onusinourmoms’wombbeforewesawthelightof this world !)•Ultrasoundguidanceallowareal-time‘live’assessment of the mass and its component•Itisareliableyetmuchcheapermodalityascompared toCTscan(whichalsohasamuchhigherdoseof radiation).Forthyroidswellings,theminutefeature detailsarebetterseenonultrasoundratherthanCT scan.•Itislight-weightandhenceaveryportablesystemto move/lug around.•Notonlycanitdifferentiatethesolidandthecysticpart, italsoallowsthestudyofeachsolidandcysticpartto furthersuggestifeachcomponentismorelikelytobe cancerousornot,basedonitsultrasound features/attributes.•Itcanbeappliedtoallheadandneckmasses (commonlythethyroid,salivaryandlymphnodes)and thenecessaryproceduresperformedegbiopsy, cytology studies, drainage, sclerotherapy etc.•Thisprocedureisapplicableinbothchildrenandadults. (thoughforuncooperativechildren,generalanesthesia maybe needed)What if the mass studied is actually a cancerous mass ?TheFNACstudyhasbeenproventoNOTincreasetheriskof any cancer spread (tumour seedling).Cuttingintothemasswithoutverifyingifitiscancerous,viaan openincisionalbiopsyinfactcausetumourseedlingiethe cancercellsspreadingalongtheopenwoundintotheskin surface.Thishasbeenproventoconferaworseprognosisie aworseoutcomeinthecancercure.Openbiopsyshouldonly beusedasalastresortorinsomecaseswheretheFNAC cannot confirm the true nature of the tumour. Inanyheadandneckmass,especiallyiftheswellingis suspectedtobealymphnode,itisImperativethattheentire ear,noseandthroatsystembescannedviaENTendoscopy priortoanyinvestigationofthesecondaryneckswelling.Any inflammationortumoursoftheENTsystemcanpotentially spread to the neck lymph nodes.
Thepossiblevariationsaretoomany,beyondwhat the eyes can see and hands can feel
“Ask first (the nature of swelling), then shoot (treat/remove surgically if needed).”
DOWNLOAD OUR CONTACT DETAILS:
ENTdrvincenttan@gmail.com
+603-3377 7864+6012-3760 728
Vincent Ear, Nose, Throat, Head and Neck Surgery Specialist Clinic, Clinic Suite 210, Level 2,KPJ Klang Specialist HospitalNo.102, Persiaran Rajawali/KU 1,Bandar Baru Klang,41150 Klang,Selangor