HOARSENESS

Hoarseness is a symptom when there is change in the voice. The voice may become raspy, strained, unable to reach certain pitch or breathy. Hoarseness happens when there is an abnormality of the vocal cords. The vocal cords act like string instruments that come together and vibrates as we speak. During breathing the vocal cords come apart to allow air to enter the lungs.

CAUSES OF HOARSENESS

Laryngitis

The most common cause of hoarseness is laryngitis; which is inflammation of the vocal cords. It is usually temporary and related to the common cold or upper respiratory tract infection. However voice abuse during bouts of laryngitis can further strain and injure the vocal cords. If the hoarseness lasts for more than 2 weeks the patient should seek the advice of an ENT surgeon who would examine the larynx to confirm the cause. Persistent hoarseness can be an early sign of cancer.

Voice abuse

Excessive straining of the voice can also cause damage to the vocal cords. Habits of screaming, excessive use or shouting in noisy environment can also lead to hoarseness. Public speaking for prolonged periods without use of amplification is also voice abuse.

If the hoarseness happens suddenly after shouting then there is a possibility that the patient has developed vocal cord hemorrhage. This occurs when the sudden increased pressure on shouting causes a blood vessel to rupture at the surface of the vocal cord. An assessment by an ENT surgeon can determine this and treatment is strict voice rest.

Vocal cord lesions

Prolonged hoarseness of more than 2 week should be assessed by an ENT surgeon as it can be an early sign of cancer.

There are also other benign (non-cancerous) vocal cord lesions that can present with persistent hoarseness such as vocal cord polyp and nodules.

Laryngopharyngeal reflux

This is condition when there is stomach acid reflux which goes all the way up till the larynx or vocal cords. The acidic juice will cause inflammation of the vocal cords and result in hoarseness.

Smoking

Both primary and secondary smoking can cause hoarseness. Smokers also have a high risk of developing cancer of the larynx. Therefore they should not delay consulting an ENT surgeon if they develop hoarseness.

Vocal cord paralysis or palsy

Any impairment of the vocal cords movement can result in hoarseness. The vocal cords come in a pair and move synchronously to produce voice, pitch and volume. If one or both the vocal cords are unable to move then the patients will experience change in voice. Depending on the position of the vocal cords patients amy also have difficulty breathing or choking episodes on drinking fluids. Vocal cord palsy/paralysis can occur due to neurological conditions, trauma, thyroid disease and other rare causes such as muscle tension dysphonia or spasmodic dysphonia.

Treatment of hoarseness

The treatment of hoarseness depends on the underlying cause. Usually doctors would advice voice rest, taking lots of fluids, avoid smoking and spicy food. Occasionally the help of a speech therapist would be sought. The therapist is able to teach patients on proper voice usage and how to avoid voice abuse especially for professional voice users such as singers, teachers, telephonists and public speakers.

Vocal cord lesions or vocal cord paralysis often need surgical intervention.

When should patients seek ENT advice?

Since the most common cause of hoarseness is laryngitis then the initial treatment is given by the family doctor or general practitioner when patients come in for their common cold. However there are certain signs and symptoms which should prompt early referral to the ENT surgeon:

1. Persistent hoarseness of more than 2 weeks especially in smokers

2. When there is no associated upper respiratory tract infection

3. Professional voice users

4. Presence of neck swelling

5. When patients experience difficulty swallowing

6. When patients experience difficulty breathing

7. When there is cough with blood stained sputum

Voice hygiene

This term refers to maintaining the health of the vocal cords which is mainly avoiding voice abuse. These measures can be practiced:

• Quit smoking
• Avoid secondhand smoke
• Drink plenty of fluids
• Avoid caffeinated drinks and alcohol which can dehydrate the body
• Avoid spicy and oily food
• Try not to use the voice for too long or too loudly
• Humidify the home
• Use of amplification such as microphones when speaking to a crowd

Useful links:

Guide for Voice hygiene by Marshfield Clinic

BENGKAK LEHER (NECK LUMPS)

Gejala bengkak leher pasti akan membuat pesakit rasa gusar dan susah hati. Kebanyakan kes ia melibatkan bengkak kelenjar limfa yang berlaku apabila ada infeksi dan radang; dan ini bersifat sementara. Walaubagaimanapun ada beberapa gejala bengkak leher yang memerlukan rawatan selanjutnya dan pesakit harus peka dengan gejala-gejala lain yang merupakan tanda-tanda penyakit yang lebih serius.

Anatomi leher

Kedudukan kelenjar-kelenjar limfa di sekeling leher dan juga kelenjar air liur parotid di bahagian pipi dan kelenjar submandibular di bawah rahang.

Kelenjar limfa

Kelenjar limfa berperanan penting dalam sistem imunisasi badan. Cecair limfa mengalir dari organ dalaman manusia ke dalam system limfatik dan melalui kelenjar limfa. Sekiranya terdapat radang, infeksi, ketumbuhan atau kanser, kelenjar limfa boleh membengkak.

Selalunya radang dan infeksi merupakan penyebab utama bagi kelenjar limfa yang bengkak di bahagian leher. Contohnya seperti sakit kerongkong/tekak, tonsillitis, sakit gigi dan sebagainya. Dan kelenjar limfa yang bengkak ini akan surut apabila radang atau infeksi tersebut dirawat dengan antibiotik.

Kelenjar limfa leher yang terus membengkak melebihi tempoh 2 minggu dengan tanpa ada gejala lain berkaitan infeksi/radang sepatutnya diperiksa dengan lebih lanjut oleh doktor pakar ENT.

Sebab lain yang boleh menyebabkan kelenjar limfa leher yang bengkak adalah ketumbuhan/kanser pada bahagian dalam mulut, tekak dan hidung, tuberculosis, lymphoma (sejenis kanser sel darah) dan sebagainya.

Kelenjar air liur (Kelenjar submandibular dan parotid)

Kelenjar air liur juga boleh mengalami infeksi dan radang samada dari jangkitan bakteria atau sumbat saluran air liur disebabkan oleh batu karang. Jika begitu, pesakit akan mengadu rasa bengkak, sakit pada bahagian kelenjar dan mungkin demam. Jika terdapat batu karang selalunya kelenjar air liur tersebut akan lebih bengkak selepas makan dan surut sedikit beberapa jam kemudian.

Bengkak kelenjar air liur juga boleh disebabkan oleh ketumbuhan (tumor). Pesakit akan mengalami bengkak kelenjar air liur yang semakin membesar dan selalunya ia tidak merasa sakit. Kebanyakan ketumbuhan kelenjar air liur adalah jenis ketumbuhan ‘benign’ iaitu bukan kanser. Walaubagaimanapun sekiranya dibiarkan ia boleh berubah menjadi kanser.

Pakar ENT akan memeriksa punca sebenar bengkak kelenjar air liur. Sekiranya ia disebabkan oleh infeksi atau radang, pesakit perlu mengambil ubat antibiotik. Sekiranya ia disebabkan oleh batu karang atau ketumbuhan, pemeriksaan radiologi lanjutan seperti ‘ultrasound’ atau ‘CT scan’ perlu dijalankan sebagai persediaan untuk pembedahan.

Kelenjar tiroid

Kelenjar tiroid terletak di bahagian hadapan leher di bawah halkum (‘adam’s apple’). Kelenjar tiroid boleh membengkak ke bahagian tepi dan ke bawah. Selalunya kelenjar tiroid yang bengkak disebabkan oleh ‘multinodular goitre’ sejenis ketumbuhan yang ‘benign’. Tetapi ia juga boleh disebabkan oleh kanser tiroid seperti kanser tiroid papillary yang boleh berlaku pada mereka yang berusia muda. Oleh sebab itu mereka yang mengalami masalah bengkak kelenjar tiroid perlu pemeriksaan lanjutan oleh doktor pakar.

Cyst

Cyst merupakan bengkak yang terdiri daripada karung yang mengandungi cecair dan sel. Terdapat beberapa jenis cyst yang boleh terjadi di bahagian leher.

Thyroglossal cyst selalunya terjadi di bahagian tengah hadapan leher. Ia bergerak semasa pesakit menelan atau menjelirkan lidah. Kadangkala ia merasa sakit sekiranya berlaku infeksi di dalam cyst tersebut. Ia seeloknya dibedah kerana boleh dikaitkan dengan kejadian kanser.

Dermoid cyst juga terjadi di bahagian tengah hadapan leher tetapi ia tidak bergerak semasa pesakit menelan atau menjelirkan lidah. Ia selalunya berlaku pada kanak-kanak dan saiznya boleh membesar jika dibiarkan.

Branchial cyst pula merupakan bengkak di bahagian tepi leher dan berlaku pada pesakit remaja. Cyst ini hanya menjadi bengkak apabila berlaku infeksi dan ianya surut semula selepas infeksi tersebut reda.

Cystic higroma merupakan bengkak leher yang boleh terjadi pada bayi sejak lahir. Kadangkala saiznya menjadi sangat besar dan boleh menyukarkan pernafasan bayi tersebut. Rawatan cystic higroma selalunya melibatkan penggunaan suntikan ubat ke dalam karung (cyst) tersebut untuk mengecutkannya. Pembedahan pada cystic higroma selalunya adalah sukar kerana cystic higroma mempunyai ‘ekor-ekor’ yang meresap ke dalam tisu di sekelingnya.

Lain-lain punca bengkak leher

Kadangkala bengkak leher boleh berpunca dari bahagian lapisan kulit itu sendiri. Bengkak leher seperti ini terletak di bawah lapisan kulit dan senang dirasai dengan sentuhan jari. Bengkak dari lapisan kulit boleh terjadi disebabkan lipoma (ketumbuhan lemak), sebaceous cyst, dermoid cyst dan bisul.

Selain daripada itu, ada beberapa punca bengkak leher yang jarang berlaku. Contohnya seperti carotid body tumour, hemangioma, schwannoma, pharyngeal pouch dan sebagainya.

Bila bengkak leher perlu pemeriksaan pakar ENT

• Bengkak leher yang lebih dari 2 minggu walaupun setelah mendapat rawatan doktor klinik

• Saiz yang semakin membesar

• Terjadi beberapa bahagian bengkak leher

• Bengkak leher yang menganggu pernafasan, susah menelan atau perubahan suara

• Jika bengkak tersebut mengeluarkan nanah dan sakit (abscess; bisul yang besar)

• Sejarah keluarga untuk kanser

KANSER TEKAK

Kanser tekak lebih tepat dikenali sebagai kanser laring (larynx) dari segi istilah perubatan. Anatomi laring melibatkan kawasan peti suara yang juga berdekatan saluran pemakanan iaitu esofagus (esophagus).
Di dalam kajian National Cancer Registry tahun 2006 terdapat 1.1 kes per 100,000 populasi di Malaysia di mana kaum lelaki mencatatkan kekerapan lebih 5 kali ganda berbanding kaum wanita. Ia juga menunjukkan peningkatan kes bagi pesakit yang berumur 40 tahun ke atas dengan yang tertinggi di kalangan pesakit yang berumur 60-69 tahun.

Kawasan tekak (larynx) melibatkan khususnya organ peti suara (glottis), supraglottis dan subglottis

Gejala kanser tekak seringkali timbul sebagai perubahan suara, suara garau atau masalah menelan makanan dan minuman. Pesakit juga kadangkala berasa seperti ada 'sesuatu yang sangkut' di bahagian tekak. Perubahan suara kerapkali merupakan gejala sakit tekak biasa yang disebabkan oleh jangkitan kuman. Akan tetapi sekiranya perubahan suara itu berlarutan lebih dari 2 minggu, pesakit seharusnya mendapatkan pemeriksaan tekak yang lebih terperinci.

Gejala-gejala lain yang berkaitan kanser tekak adalah bengkak pada leher yang disebabkan oleh kelenjar limpa, batuk berdarah, sesak pernafasan atau pernafasan berbunyi terutamanya di kalangan mereka yang merokok.

PEMERIKSAAN KLINIKAL

Pesakit yang mempunyai gejala- gejala tersebut perlu diperiksa dengan lebih lanjut menggunakan peralatan endoskopi semasa sesi rawatan di dalam klinik pakar. Sekiranya pemeriksaan endoskopi menunjukkan ketumbuhan di kawasan tekak pesakit perlu menjalani pemeriksaan selanjutnya.

Ketumbuhan pada tekak boleh disebabkan oleh pelbagai penyakit seperti tuberkulosis (batuk kering), polip, granuloma selain dari kanser. Untuk mengenalpasti punca sebenar sedikit tisu perlu diambil dari ketumbuhan tersebut. Kerapkali ini melibatkan pembedahan kecil.

Pesakit juga perlu menjalani pemeriksaan CT scan (computed tomography) untuk mengetahui sejauh mana kanser tersebut telah merebak.

RISIKO KANSER TEKAK

Terdapat beberapa faktor yang merupakan risiko tinggi untuk kanser tekak:
Faktor umur- Risiko meningkat semakin pesakit berumur
Alkohol- Tabiat pengambilan alkohol atau minuman keras merupakan faktor risiko yang tinggi terutamanya jika pesakit juga mengamalkan tabiat merokok
Merokok- Perokok tegar yang bertahun-tahun lamanya mempunyai risiko yang amat tinggi
Pesakit kanser tekak di kalangan ahli keluarga terdekat terutamanya ibubapa atau adik-beradik
Human papillomavirus- Jangkitan virus ini juga meningkatkan risiko kanser tekak
Faktor lain seperti Asid reflux, pencemaran Bahan kimia, Diet yang kurang sihat

RAWATAN KANSER TEKAK

Pelan rawatan penyakit kanser perlu pertimbangan antara pesakit dan doktor pakar bedah bersama pakar onkologi. Rawatan kanser tekak yang disyorkan oleh doktor pakar bergantung kepada tahap kanser tersebut.

Sekiranya tahap penyakit kanser tekak masih di peringkat awal rawatan secara pembedahan atau radioterapi perlu dijalankan. Ketumbuhan kanser yang lebih besar terutamanya yang melibatkan kelenjar limpa perlu kedua-dua pembedahan dan radioterapi. Kadangkala kemoterapi juga diperlukan bagi tahap kanser tekak yang lebih lanjut. Pelan rawatan penyakit kanser adalah khusus bagi setiap pesakit setelah mengambil kira tahap kanser, keadaan kesihatan pesakit dan jenis sel kanser.

PERINGATAN
Peringatan yang paling penting ialah pesakit harus cepat mendapatkan pemeriksaan lanjutan sekiranya mengalami gejala-gejala di atas. Kerana pemeriksaan awal dapat mengesan ketumbuhan pada peringkat awal. Sekiranya kanser tersebut dapat dikenalpasti pada peringkat awal, sudah tentu rawatannya kurang rumit dan peratusan kebarangkalian sembuh adalah amat tinggi.

NASOPHARYNGEAL CARCINOMA

Nasopharyngeal carcinoma (NPC) is a tumour of the nasopharynx which is situated at the deep end of the nose. It has the highest incidence amongst the Chinese of Southeastern region and Hong Kong.  It is one of the top 5 cancers affecting both male and female in Malaysia apart from breast, colorectal (bowel), lung and cervical cancer. The Malaysian National Cancer Registry in 2006 noted an incidence of 7.5 per 100,000 for males and 2.4 per 100,000 for females. Chinese men had the highest incidence rate of 15.9 per 100,000. The age specific incidence increased after 30 years old. 

The nasopharynx is situated at the deep end of the nose which makes it a blind spot to normal clinical examination. Tumors or the nasopharynx also often present late because of this anatomical position.

This disease has a multifactorial origin and is a result of interplay between genetic susceptibility, environmental factors and Epstein Barr virus. There is evidence to suggest that abnormalities in specific chromosomes may play a role in the pathogenesis. Cultural factors linked to NPC which have been observed include consumption of dried salted fish in childhood.

CLINICAL FEATURES

The symptoms of NPC are usually non obvious and only apparent when the tumor has spread, due to the anatomical location of the nasopharynx. More commonly patients present with neck swelling in 50-70% of cases followed by unilateral ear block or tinnitus and nasal obstruction. Other less common symptoms include blood stained nasal discharge or saliva and headache. Advanced disease may present with cranial nerve palsies, altered conscious level or distant tumour spread.

DIAGNOSIS

The diagnosis of NPC requires visualization of the nasopharynx region using nasal endoscopy. This endoscopic facility is readily available as an outpatient procedure in ENT clinics. The neck is also palpated to assess for enlarged lymph nodes. Patients with neck swelling and unilateral ear symptoms coupled with high risk ethnicity should always be examined with nasal endoscopy. Endoscopic examination findings in NPC would show as a growth/mass, swelling or obliteration of the Fossa of Rosenmuller. The diagnosis of NPC is confirmed by biopsy and examination of the tissue in the histopathological laboratory. In rare instances, nasal endoscopy may be normal. In these highly suspicious cases the ENT surgeon may suggest examination under general anaesthesia with deep multiple biopsies.

TUMOR STAGING

When diagnosis is confirmed, the tumour is then staged by imaging studies. The rationale for tumour staging is to give a true picture of the tumour extension and its related prognosis. Imaging studies include computed tomography (CT) scan of the head and neck area, chest radiograph, abdominal ultrasound and bone scan.

TREATMENT

The mainstay of treatment for NPC is radiotherapy with without concurrent chemotherapy.  Early small tumours will do well with radiotherapy alone. Often the radiotherapy is combined with chemotherapy. The oncologist will devise the treatment plan after discussing with the patient.

Nowadays advanced forms of radiotherapy such as intensity modulated radiation therapy (IMRT) can better target the tumour volume thus reducing radiation exposure to normal tissues. The side effects that patients may experience with radiotherapy include skin pigmentation and desquamation, oral ulcers and dryness, tiredness, restricted mouth movements, taste disturbance and hearing changes. These side effects would gradually occur during the course of the treatment and will slowly get better. However some of the side effects such as dry mouth and hearing changes are long term.

FOLLOW UP AFTER TREATMENT

After completing the treatment for NPC, the patient is reassessed to ensure good response to the treatment given. Patient is again reviewed by medical history, physical examination along with nasal endoscopy and imaging studies are performed to make sure that the tumour has been eradicated. These clinic reviews are also important to assess for tumour recurrence (return of the tumour), metastasis (distant spread of the disease) and any ongoing problems that the patient may have following treatment. The follow up consultation may be frequent, 3-4 monthly, in the first 2 years and then becomes a 6-12 monthly visit after that.

Useful links

National Cancer Society Malaysia 

National Cancer Registry 2006 

HEALTHY EATING AFTER CANCER TREATMENT

As ENT doctors we often deal with cancers involving the head and neck area, commonly the oral cavity, throat and nose (nasopharynx). Treatment of these cancers entail either surgery, radiotherapy, chemotherapy or a combination of them. Because of the location of the cancer itself and the treatment, patient often have problems related to the head & neck area such as chewing and swallowing. And yet nutrition is an integral part of treatment to combat the disease.

During the course of the treatment patients should seek the doctor's advice before taking any supplements because it can interfere with the therapy. The doctor would also inform patients of the possible side effects of treatment and how best to prepare and deal with the problems. With the advent of new radiation technology there is less severe side effects such as those seen many years ago.

But what about after treatment? When follow-up examination and scans show that the cancer was successfully removed or had responded well to treatment, is it important to continue with a healthy diet?

An article published in the Harvard's Medical School's consumer health journal advocates healthy lifestyle as the key for cancer survivors to decrease the likelihood of recurrence. Their advice includes healthy eating with at least 5 servings of fruits and vegetables per day, exercise, maintaining body mass index between 20-25, eat fatty fish two to three times a week and having normal vitamin D levels.

The American Cancer Society has produced an informative booklet which provides nutrition advice during and after cancer treatment. The list below is taken from their booklet on tips of healthy eating after cancer treatment.

Tips on Healthy Eating after Cancer Treatment (American Cancer Society Nutrition Guide)

• Check with your doctor for any food or diet restrictions.
• Create healthy balance meals. Choose a variety of food.
• Eat at least 5 to 7 servings a day of fruits and vegetables, including citrus fruits and dark-green and deep-yellow vegetables.
• Eat plenty of high-fiber foods, like whole-grain breads and cereals.
• Decrease the amount of fat in your meals by baking or broiling foods.
• Limit your intake of red meat to no more than 3 to 4 servings a week.
• Avoid salt-cured, smoked, and pickled foods (including bacon, sausage, and deli meats).
• Choose low-fat milk and dairy products.
• If you choose to drink alcohol, limit the amount.
• Maintain a healthy weight.
• Exercise. Ask your doctor before starting any exercise regime.

USDA update pyramid 2005

Reference
Stephanie Meyers, 2009. Does diet affect cancer recurrence?
Healthy Eating. National Cancer Institute
American Cancer Society. Nutrition

Image credits:
http://www.flickr.com/photos/calliope/4206360542
http://www.flickr.com/photos/62116165@N00/2461157879