RELATED LINKS
Head & Neck Swellings
Thyroid Swelling
What about its accuracy ? It   is   about   90%   accurate   if   done   properly   by   a   trained   or   experienced   personnel.   Any   more   accurate   would   need   an   open   biopsy   and   sending   the   three- 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 ? While   this   is   not   common,   as   the   special   skills   need   to   be   acquired   though   further   advanced   training   and   experience.   Here   the   advantage   lies   in   the   fact   that the   surgeon   whom   you   had   consulted   has   the   heads-up   in   knowing   your   disease   history,   a   clinical   examination   of   the   mass   by   inspection   and   palpation.   A more   holistic   approach   would   be   possible   as   h/she   is   able   to   collate   all   these   data   and   relate   to   your   ultrasound   and/or   biopsy   results.   Furthermore,   the   same data   would   be   useful   for   correlation   should   a   surgery   be   needed   for   the   mass   in   the   near   future.   Here   we   are   a   firm   believer   in   this   holistic   approach   of management. Is It painful ? It   is   just   like   drawing   blood   from   your   veins,   but   now   the   needle   is   aimed   towards   the   mass   of   concern   in   the   head   and   neck   region   instead.   To   get   a   better sample,    sometimes    the    needle    is    angled    at    many    different    angles    all    around    within    the    mass    concerned    for    a    wider    coverage    to    get    the    most representative/best   sample.   So   at   most,   there   may   be   a   bit   slightly   more   discomfort   than   a   routine   blood   taking   but   very   tolerable.   An   option   of   using   local 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: Common   swellings   originate   from   the   lymph   nodes,   thyroid   gland,   salivary gland, skin Most swellings are not cancerous. Some will respond to medication, some will not. Not all need surgery. Some will. Before   a   swelling   is   surgically   removed,   it   is   important   to   best   know   its   content and   nature   as   it   affects   surgical   planning   and   patient   treatment   outcome   (‘ask, then shoot’ approach) Rather   than   ‘shoot,   then   ask’   approach   –   cutting   into   a   swelling   as   first   line approach   (where   applicable   with   further   clarification   below)   then   find   out   what 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. The   problem   is,   in   a   mass   there   may   be   areas   where   it   is   hard/solid   or   areas   where   the   fluid   gather   (cystic).   Usually   the   solid   part   tends   to   be   the   part   that harbours cancerous cells or has the potential to transform into a cancerous growth. Without   an   imaging   guidance   system,   differentiating   it   externally   by   the   any   doctor   looking   at   it   (inspection)   or   feeling   it   (palpation)   is   rather   impossible   to   be done   with   great   accuracy.   So   many   combination   of   the   different   solid   and   cystic   mass   can   exist   in   many   different   parts   of   the   mass   (see   pic).   Even   if   a   needle   is inserted   into   the   mass   by   the   doctor   as   in   a   non-image   guided   biopsy,,   how   would   he   know   which   component   is   at   the   needle   tip   ?   The   possibilities   are   the different arrangement of structure types are many (The next paragraph further details the 2 main components ie. sold and cystic and their implications) Another   real   advantage   of   this   approach   Is   that   even   deep-seated   swellings   not   visible   from   the   outside   (meaning   the   neck   looks   absolutely   normal)   but   seen   by ultrasound deep under the skin (maybe 2cm under the skin) can be sampled. While   we   acknowledge   that   ultrasound   guidance   cost   more,   the   accuracy   and   all   the   other   advantages   ensures   that   it   is   a   worthwhile   procedure/endeavor.   The advantages (especially the ability to pinpoint the suspicious part of the mass) far outweigh the cost disadvantage What 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. The   added   bonus   is   that   once   the   cystic   part   is   pinpointed,   the   fluid,   if   it   is   watery/serous   enough   to   be   drained   through   the   needle   puncturing   it,   the   swelling   can be   decompressed,   shrinking   the   mass   as   an   added   bonus   (think   of   that   as   an   added   bonus   should   you   need   to   ‘show   off   a   new   neck’   during   an   important   social 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 well
Can’t aim well, can’t get good results”
So what are the other advantages of ultrasound ? Ultrasound   uses   NO   radiation   hence   it   is   safe   in   child   or   even   pregnant   ladies.   (think   pregnant   ladies   with   their   regular   antenatal   ultrasound   checks. 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 It   is   a   reliable   yet   much   cheaper   modality   as   compared   to   CT   scan   (which   also   has   a   much   higher   dose   of   radiation).   For   thyroid   swellings,   the   minute 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. Not   only   can   it   differentiate   the   solid   and   the   cystic   part,   it   also   allows   the   study   of   each   solid   and   cystic   part   to   further   suggest   if   each   component   is more likely to be cancerous or not, based on its ultrasound features/attributes. It   can   be   applied   to   all   head   and   neck   masses   (commonly   the   thyroid,   salivary   and   lymph   nodes)   and   the   necessary   procedures   performed   eg   biopsy, 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). Cutting   into   the   mass   without   verifying   if   it   is   cancerous,   via   an   open   incisional   biopsy   in   fact   cause   tumour   seedling   ie   the   cancer   cells   spreading   along   the open   wound   into   the   skin   surface.   This   has   been   proven   to   confer   a   worse   prognosis   ie   a   worse   outcome   in   the   cancer   cure.   Open   biopsy   should   only   be used as a last resort or in some cases where the FNAC cannot confirm the true nature of the tumour. In   any   head   and   neck   mass,   especially   if   the   swelling   is   suspected   to   be   a   lymph   node,   it   is   Imperative   that   the   entire   ear,   nose   and   throat   system   be scanned   via   ENT   endoscopy   prior   to   any   investigation   of   the   secondary   neck   swelling.   Any   inflammation   or   tumours   of   the   ENT   system   can   potentially spread to the neck lymph nodes.
The   possible   variations   are   too   many,   beyond   what the eyes can see and hands can feel
“Ask first (the nature of swelling), then shoot (treat/remove surgically if needed).”
EDUCATIONAL
Ultrasound-based In-Clinic Procedures
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 Hospital No.102, Persiaran Rajawali/KU 1, Bandar Baru Klang, 41150 Klang, Selangor
Mon-Fri: 930am-5pm Sat: 9am-1230pm
vincentENTHNS
3.062578,101.46332 (Google Maps, Waze: KPJ Klang, Vincent ENT)
CONTACT US
CLINIC HOURS:
Vincent ENT Clinic
Bahasa/语文 :
vincententhns
VINCENT
Ear, Nose and Throat (ENT), Thyroid, Head and Neck Surgery
Specialist Clinic
Committed to YOUR Well-being
DR. VINCENT TAN Consultant Ear, Nose and Throat, Head and Neck Surgeon, KPJ Klang Specialist Hospital MD (UKM), MS ORL-HNS (UKM), DOHNS RCS Edinburgh (UK), MRCS Edinburgh (UK), Postgrad. Cert.in Allergy (UK), A.M. (Mal),  Fellowship in Rhinology (Singapore) Fellowship in Head and Neck Oncology & Surgery (Amsterdam)  +603-3377 7864 +6012-3760 728 ENTdrvincenttan@gmail.com www.vincentENTHNS.com www.entheadandneckspecialist.comt.com
Copyright Dr.Vincent Tan 2018
RELATED LINKS
Head & Neck Swellings
Thyroid Swelling
EDUCATIONAL
Ultrasound-based In-Clinic Procedures
What about its accuracy ? It    is    about    90%    accurate    if    done    properly    by    a    trained    or experienced    personnel.   Any    more    accurate    would    need    an open   biopsy   and   sending   the   three-dimensional   tissue   block   to the    pathologist.    But    beware    the    great    disadvantage    of    the reason given just in the paragraph above. (open biopsy pic) So   what   is   the   advantage   of   the   surgeon   doing   the biopsy procedure ? While   this   is   not   common,   as   the   special   skills   need   to   be acquired    though    further    advanced    training    and    experience. Here   the   advantage   lies   in   the   fact   that   the   surgeon   whom   you had    consulted    has    the    heads-up    in    knowing    your    disease history,   a   clinical   examination   of   the   mass   by   inspection   and palpation.    A    more    holistic    approach    would    be    possible    as h/she    is    able    to    collate    all    these    data    and    relate    to    your ultrasound   and/or   biopsy   results.   Furthermore,   the   same   data would   be   useful   for   correlation   should   a   surgery   be   needed   for the   mass   in   the   near   future.   Here   we   are   a   firm   believer   in   this holistic approach of management. Is It painful ? It    is    just    like    drawing    blood    from    your    veins,    but    now    the needle   is   aimed   towards   the   mass   of   concern   in   the   head   and neck   region   instead.   To   get   a   better   sample,   sometimes   the needle   is   angled   at   many   different   angles   all   around   within   the mass    concerned    for    a    wider    coverage    to    get    the    most representative/best   sample.   So   at   most,   there   may   be   a   bit slightly   more   discomfort   than   a   routine   blood   taking   but   very tolerable.   An    option    of    using    local    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: Common    swellings    originate    from    the    lymph    nodes, thyroid gland, salivary gland, skin Most swellings are not cancerous. Some will respond to medication, some will not. Not all need surgery. Some will. Before   a   swelling   is   surgically   removed,   it   is   important to   best   know   its   content   as   it   affects   surgical   planning and     patient     treatment     outcome     (‘ask,     then     shoot’ approach) Rather   than   ‘shoot,   then   ask’   approach   –   cutting   into   a swelling   as   first   line   approach   (where   applicable   with further    clarification    below)    then    find    out    what    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, 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. The    problem    is,    in    a    mass    there    may    be    areas    where    it    is hard/solid   or   areas   where   the   fluid   gather   (cystic).   Usually   the solid   part   tends   to   be   the   part   that   harbours   cancerous   cells   or has the potential to transform into a cancerous growth. Without   an   imaging   guidance   system,   differentiating   it   externally by    the    any    doctor    looking    at    it    (inspection)    or    feeling    it (palpation)   is   rather   impossible   to   be   done   with   great   accuracy. So   many   combination   of   the   different   solid   and   cystic   mass   can exist   in   many   different   parts   of   the   mass   (see   pic).   Even   if   a needle   is   inserted   into   the   mass   by   the   doctor   as   in   a   non-image guided   biopsy,,   how   would   he   know   which   component   is   at   the needle   tip   ?   The   possibilities   are   the   different   arrangement   of structure   types   are   many   (The   next   paragraph   further   details   the 2 main components ie. sold and cystic and their implications) Another   real   advantage   of   this   approach   Is   that   even   deep- seated   swellings   not   visible   from   the   outside   (meaning   the   neck looks   absolutely   normal)   but   seen   by   ultrasound   deep   under   the skin (maybe 2cm under the skin) can be sampled. While   we   acknowledge   that   ultrasound   guidance   cost   more,   the accuracy    and    all    the    other    advantages    ensures    that    it    is    a worthwhile   procedure/endeavor.   The   advantages   (especially   the ability   to   pinpoint   the   suspicious   part   of   the   mass)   far   outweigh the cost disadvantage What 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. The   added   bonus   is   that   once   the   cystic   part   is   pinpointed,   the fluid,   if   it   is   watery/serous   enough   to   be   drained   through   the needle    puncturing    it,    the    swelling    can    be    decompressed, shrinking   the   mass   as   an   added   bonus   (think   of   that   as   an added   bonus   should   you   need   to   ‘show   off   a   new   neck’   during an important social 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 well
Can’t aim well, can’t get good results”
So what are the other advantages of ultrasound ? Ultrasound   uses   NO   radiation   hence   it   is   safe   in   child   or even   pregnant   ladies.   (think   pregnant   ladies   with   their regular    antenatal    ultrasound    checks.    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 It   is   a   reliable   yet   much   cheaper   modality   as   compared to   CT   scan   (which   also   has   a   much   higher   dose   of radiation).    For    thyroid    swellings,    the    minute    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. Not   only   can   it   differentiate   the   solid   and   the   cystic   part, it   also   allows   the   study   of   each   solid   and   cystic   part   to further   suggest   if   each   component   is   more   likely   to   be cancerous      or      not,      based      on      its      ultrasound features/attributes. It    can    be    applied    to    all    head    and    neck    masses (commonly   the   thyroid,   salivary   and   lymph   nodes)   and the     necessary     procedures     performed     eg     biopsy, 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). Cutting   into   the   mass   without   verifying   if   it   is   cancerous,   via   an open   incisional   biopsy   in   fact   cause   tumour   seedling   ie   the cancer   cells   spreading   along   the   open   wound   into   the   skin surface.   This   has   been   proven   to   confer   a   worse   prognosis   ie a   worse   outcome   in   the   cancer   cure.   Open   biopsy   should   only be   used   as   a   last   resort   or   in   some   cases   where   the   FNAC cannot confirm the true nature of the tumour. In    any    head    and    neck    mass,    especially    if    the    swelling    is suspected   to   be   a   lymph   node,   it   is   Imperative   that   the   entire ear,   nose   and   throat   system   be   scanned   via   ENT   endoscopy prior   to   any   investigation   of   the   secondary   neck   swelling.   Any inflammation   or   tumours   of   the   ENT   system   can   potentially spread to the neck lymph nodes.
The   possible   variations   are   too   many,   beyond   what 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 Hospital No.102, Persiaran Rajawali/KU 1, Bandar Baru Klang, 41150 Klang, Selangor
vincentENTHNS
3.062578,101.46332 (Google Maps, Waze: KPJ Klang, Vincent ENT)
Mon-Fri: 930am-5pm Sat: 9am-1230pm
CONTACT US
CLINIC HOURS:
vincententhns
Bahasa/语文 :
Vincent ENT Clinic
APPOINTMENT:  +603-3377 7864 +6012-3760 728 VINCENT EAR, NOSE & THROAT, THYROID,  HEAD AND NECK SURGERY SPECIALIST CLINIC 
Copyright Dr.Vincent Tan 2018
VINCENT
Ear, Nose and Throat (ENT), Thyroid, Head and Neck Surgery
Specialist Clinic
Committed to YOUR Well-being