What Is FNA?

Fine needle aspiration (FNA), also called fine needle biopsy, is a technique that allows a biopsy of various bumps and lumps. It allows your otolaryngologist to retrieve enough tissue for microscopic analysis and thus make an accurate diagnosis of a number of problems, such as inflammation or even cancer.

FNA is used for diagnosis in:

  • Thyroid gland
  • Neck lymph nodes
  • Neck cysts
  • Salivary glands (i.e. parotid gland, submandibular gland)
  • Inside the mouth
  • Any lump that can be felt
  • Lumps that are found on imaging tests (such as ultrasound) even if they can’t be felt

Why Is FNA Important?

A mass or lump sometimes indicates a serious problem, such as a growth or cancer*. While this is not always the case, the presence of a mass may require FNA for diagnosis. Your age, sex and habits, such as smoking and drinking, are also important factors that help in the diagnosis of a mass. Symptoms of ear pain, increased difficulty swallowing, weight loss or a history of familial thyroid disorder or of previous skin cancer (squamous cell carcinoma) may be important as well.

* When found early, most cancers in the head and neck can be cured with relatively little difficulty. Cure rates for these cancers are greatly improved if people seek medical advice as soon as possible. So play it safe. If you have a lump in your head and neck area, see your otolaryngologist right away.

What are some areas that can be biopsied in this fashion?

FNA is generally used for diagnosis in areas such as neck lymph nodes or for cysts in the neck. FNA is the most commonly performed test to determine whether thyroid nodules are benign or suspicious for malignancy. The parotid gland (the mumps gland), submandibular gland, and other areas in the neck and inside the mouth or throat can be biopsied as well. Virtually any lump or bump that can be felt (palpated) or identified by ultrasound can be biopsied using the FNA technique. Tests for infection and certain chemical substances can also be done on the material that is obtained.

How Is FNA done?

Your doctor will insert a small needle into the mass. A small amount of tissue can be drawn back into the needle using negative pressure on the syringe. Under a microscope, this tissue can be identified leading to a diagnosis. This procedure is generally accurate and frequently prevents the patient from having an open, surgical biopsy, which is more painful and costly. Local anesthesia (numbing medicine) may be used but is frequently not required. If the mass is small or difficult to feel, an ultrasound device can be used to help direct the needle into the mass. FNA is about as painful as drawing blood from the arm for laboratory testing (venipuncture). In fact, the needle used for FNA is smaller than that used for venipuncture. Although not painless, any discomfort associated with FNA is usually minimal.

What are the complications of the FNA procedure?

No medical procedure is without risks. Due to the small size of the needle, the chance of spreading a cancer or finding cancer in the needle path is very small. Other complications are rare; the most common is bleeding. If bleeding occurs at all, it is generally seen as a small bruise. Patients who take aspirin, Advil®, or blood thinners, such as Coumadin®, are more at risk to bleed. However, the risk is minimal. Infection is rarely seen. Sometimes the results of an FNA are indeterminate, leading to the need to repeat the FNA or use alternative tissue sampling techniques.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Facial expressions allow us to interact and communicate with each other. Our appearance also has an impact on how others perceive us, so many people try to always put their “best face forward.”

Some individuals would like to improve certain aspects about their face. Others are born with facial abnormalities such as a cleft lip, a birthmark or other birth defects and desire correction. Many of us notice the effects of aging, sun damage or previous facial trauma on the face. Fortunately, many of these conditions can be corrected through procedures performed by a surgeon.

Why consider facial plastic surgery?

The range of conditions that otolaryngologists diagnose and treat are widely varied and can involve the whole face, nose, lips, ears and neck. Facial plastic surgery is a component of otolaryngology that can be divided into two categories – reconstructive and cosmetic.

Reconstructive plastic surgery is performed for patients with conditions that may be present from birth, such as birthmarks on the face, cleft lip and palate, protruding ears, and a crooked smile. Other conditions that are the result of accidents, trauma, burns or previous surgery are also corrected with this type of surgery. In addition, some reconstructive procedures are required to treat existing diseases like skin cancer.

Cosmetic facial plastic surgery is surgery performed to enhance visual appearance of the facial structures and features. Common procedures include facelifts, eye lifts, rhinoplasty, chin and cheek implants, liposuction and procedures to correct facial wrinkles. An otolaryngologist surgeon is well trained to address all of these problems.

What training is necessary?

An otolaryngologist can receive up to 15 years of college and post-graduate training in plastic surgery, concentrating on procedures that reconstruct the elements of the face.

Post-graduate training includes a year of general surgery, four years of residency in otolaryngology (disorders of the ears, nose and throat), and may also include one to two years in a fellowship dedicated to facial plastic surgery.

After passing a rigorous set of exams given by the American Board of Otolaryngology, otolaryngologists may become board-certified in the specialty of Otolaryngology – Head and Neck Surgery. Because they study the complex anatomy, physiology and pathology of the entire head and neck, these specialists (sometimes called ENTs) are uniquely qualified to perform the procedures that affect the whole face.

What kinds of problems are treated?

The following are examples of procedures:

Rhinoplasty/Septoplasty Surgery of the external and internal nose in which cartilage and bone are restructured and reshaped to improve the appearance and function of the nose.

Blepharoplasty Surgery of the upper and/or lower eyelids to improve the function and/or look of the eyes.

Rhytidectomy Surgery of the skin of the face and neck to tighten the skin and remove excess wrinkles.

Browlift Surgery to improve forehead wrinkles and droopy eyebrows.

Liposuction Surgery to remove excess fat under the chin or in the neck.

Facial implants Surgery to make certain structures of the face (cheek, lips, chin) more prominent and well defined.

Otoplasty Surgery to reshape the cartilage of the ears so they protrude less.

Skin surface procedures Surgery using lasers, chemical peels, or derma-abrasion to improve the smoothness of the skin.

Facial reconstruction Surgery to reconstruct defects in facial skin as a result of prior surgery, injury or disease. This includes reconstruction of defects resulting from cancer surgery, scar revision, repair of lacerations to the face from prior trauma, removal of birth marks, and correction of congenital abnormalities of the skull, palate or lips.

Non-surgical procedures Techniques such as chemical peels, microdermabrasion, and injectables. Injectables are medications that can be placed under the skin to improve the appearance of the face, such as BOTOX® Cosmetic, Dysport®, Restylane®, Juvéderm®, Radiesse®, Sculptra® and other fillers.

How do I find a surgeon?

The Academy can recommend a board-certified otolaryngologist in your area who has a specific interest in facial plastic surgery. A reputable surgeon will take a thorough patient history and advise you on the best procedure for you. Patients should also be cautious not to be swayed by doctors who have the latest equipment, but should instead focus on finding the provider who possesses the skills, expertise and experience necessary to choose the right treatment method for each individual.

What should you know prior to facial plastic surgery?

Your surgeon should discuss the procedure, risks, benefits, alternatives and recovery with you. Knowing what to expect will put you more at ease. You should ask how many of the particular type of procedures the surgeon has performed, and how often. You should also know what sort of preparation plans you need to make, how long the procedure will take, and any associated risks. Your surgeon should advise you about any medications you should avoid before your surgery.

Some risks might include: nausea, numbness, bleeding, blood clots, infection and adverse reactions to the anesthesia. Additionally, if you smoke, you should avoid doing so for two weeks before your surgery in order to optimize healing following your procedure.
You will also want to understand all associated costs and payment options before undergoing any procedure. Insurance will usually cover reconstructive plastic surgery, but check with your provider. If you will be paying for the procedure, find out what payment options are available and if there is a payment plan.

What will recovery be like?

Most plastic surgery will not require a long hospital stay. Depending on the extent of your surgery, some procedures can be completed on an outpatient basis, meaning you would not require a hospital stay. Other procedures may require a hospital stay overnight or for a day or two. Either way, before you are released from the hospital, your surgeon will discuss with you any special care to take while you’re recovering at home. You will be provided instructions regarding how to tend to your incision area. Permanent sutures and surgical staples will be removed in the office about a week after the procedure. Your surgeon should also explain any special diet you should follow, medications you should take or avoid, and any restriction on activities.

Following your surgery, you should generally:

  • Avoid aerobic exercise for two weeks.
  • Refrain from weight lifting and contact sports for one month.
  • Talk with your surgeon about medication to manage pain and swelling.
  • Avoid aspirin because it can cause bleeding and make bruising worse.

Most patients feel comfortable returning to work one to two weeks following their surgery, when swelling and bruising are reduced and their appearance has improved.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

The thyroid is a butterfly-shaped gland located at the base of the throat. It has two lobes joined in the middle by a strip of tissue (the isthmus). The thyroid secretes three main hormones: 1) Thyroxine, that contains iodine, needed for growth and metabolism; 2) Triiodothyronine, also contains iodine and similar in function to Thyroxine; and 3) Calcitonin, which decreases the concentration of calcium in the blood and increases calcium in the bones. All three of these hormones have an important role in your child’s growth.

Thyroid cancer is the third most common solid tumor malignancy and the most common endocrine malignancy in children. It occurs four times more often in females than males and has similar characteristics as adult thyroid cancer. Surgery is the preferred treatment for this cancer. Although the procedure is often uncomplicated, risks of thyroid surgery include vocal cord paralysis and hypocalcemia (low blood calcium). Consequently, an otolaryngologist – head and neck surgeon, one experienced with head and neck issues, should be consulted.

Types of thyroid cancer in children:

Papillary: This form of thyroid cancer occurs in cells that produce thyroid hormones containing iodine. This type, the most common form of thyroid cancer in children, grows very slowly. This form can spread to the lymph nodes via lymphatics in the neck and occasionally spreads to more distant sites.

Follicular: This type of thyroid cancer also develops in cells that produce thyroid hormones containing iodine. The disease afflicts a slightly older age group and is less common in children. This type of thyroid cancer is more likely to spread to the neck via blood vessels, causing the cancer to spread to other parts of the body, making the disease more difficult to control.

Medullary: This rare form of thyroid cancer develops in cells that produce calcitonin, a hormone that does not contain iodine. This cancer tends to spread to other parts of the body and constitutes about 5-10 percent of all thyroid malignancies. Medullary thyroid carcinoma (MTC) in the pediatric population is usually associated with specific inherited genetic conditions, such as multiple endocrine neoplasia type 2 (MEN2)

Anaplastic: This is the fastest growing of the thyroid cancers, with abnormal cells that grow and spread rapidly, especially locally in the neck. This form of cancer is not seen in children.

Symptoms: Symptoms of this disease vary. Your child may have a lump in the neck, persistent swollen lymph nodes, a tight or full feeling in the neck, trouble with breathing or swallowing, or hoarseness.

Diagnosis: If any of these symptoms occur, consult your child’s physician for an evaluation. The evaluation should consist of a head and neck examination to determine if unusual lumps are present. A blood test may be ordered to determine how the thyroid is functioning. Ultrasonography uses sound waves and a computer to create an image of the thyroid gland and neck contents such as lymph nodes. Other tests that may be warranted include a radioactive iodine scan, which provides information about the thyroid shape and function, identifying areas in the thyroid that do not absorb iodine in the normal way, or a fine needle biopsy of any abnormal lump in the thyroid or neck. Sometimes it is necessary to remove a part of the tumor or one of the lobes of the thyroid gland, known as a thyroid lobectomy, for analysis to help establish a diagnosis and plan for management.

Treatments for thyroid cancer:

If the tumor is found to be malignant, then surgery is recommended. Surgery may consist of a lobectomy, subtotal thyroidectomy (removal of at least one lobe and up to near-total removal of the thyroid gland), or a total thyroidectomy. In children with papillary or follicular thyroid cancer, total or near-total thyroidectomy is currently the standard of practice, as children typically have more extensive disease at presentation, have higher rates of spread, and it reduces the risk of recurrence. In children, there is an increased need for repeat surgery when less than a total thyroidectomy is performed. Lymph nodes in the neck may need to be removed as part of the treatment for thyroid cancer if there is suspicion of spread of cancer to the lymph nodes.

Surgery may be followed by radioactive iodine therapy, to destroy cancer cells that are left after surgery. Thyroid hormone therapy may need to be administered throughout your child’s life to replace normal hormones and slow the growth of any residual cancer cells.

If cancer has spread to other parts of the body, chemotherapy (treatment by chemical substances or drugs) may be given. This therapy interferes with the cancer cell’s ability to grow or reproduce. Different groups of drugs work in different ways to fight cancer cells and shrink tumors. Radiation treatment may also be required for treatment of some forms of thyroid cancer.

In general, treatment outcomes for this type of cancer in children tend to be excellent. The best outcomes are seen in teenage girls, papillary type cancer, and tumors localized to the thyroid gland.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

What is facial trauma?

The term facial trauma means any injury to the face or upper jaw bone. Facial traumas include injuries to the skin, underlying skeleton, neck, nose and sinuses, eye socket, or teeth and other parts of the mouth. Sometimes these types of injuries are called maxillofacial injury. Facial trauma is often recognized by swelling or lacerations (breaks in the skin). Signs of broken bones include bruising around the eyes, widening of the distance between the eyes, movement of the upper jaw when the head is stabilized, abnormal sensations on the face, and bleeding from the nose, mouth or ear.

In the U.S., about three million people are treated in emergency departments for facial trauma injuries each year. Of the pediatric patients, 5 percent have suffered facial fractures. In children under three years old, the primary cause of these fractures is falls. In children more than five years old, the primary cause for facial trauma is motor vehicle accidents. Fortunately, the correct use of seat belts, boosters and car seats can dramatically reduce the risk of facial trauma in children.

A number of activities put children at risk for facial injury, such as contact sports, cheerleading, gymnastics and cycling. Proper supervision and appropriate protective gear, such as bicycle helmets, shin guards, helmets, etc., should always be employed during these activities. But when accidents do happen, children’s facial injuries require special attention, as a child’s future growth plays a big role in treatment for facial trauma. So one of the most important issues for a caregiver is to follow a physician’s treatment plan as closely as possible until your child is fully recovered.

Why is facial trauma different in children than adults?

Facial trauma can range between minor injury to disfigurement that lasts a lifetime. The face is critical in communicating with others, so it is important to get the best treatment possible. Pediatric facial trauma differs from adult injury because the face is not fully formed and future growth will be a factor in how the child heals and recovers. Certain types of trauma may cause a delay in growth or further complicate recovery. Difficult cases require doctors or a team of doctors with special skills to make a repair that will grow with your child.

Types of facial trauma

New technology, such as advanced CT scans that can provide three-dimensional anatomic detail, has improved physicians’ ability to evaluate and manage facial trauma. In some cases, immediate surgery is needed to realign fractures before they heal incorrectly. Other injuries will have better outcomes if repairs are done after cuts and swelling have improved. Research has shown that even when an injury does not require surgery, it is important to a child’s health and welfare to continue to follow up with a physician’s care.

Soft tissue injuries

Injuries such as cuts (lacerations) may occur on the soft tissue of the face. In combination with suturing the wound, the provider should take care to inspect and treat any injures to the facial nerves, glands or ducts. In younger children, many lacerations require sedation or general anesthesia to achieve the best repair.

Bone injuries

When facial bone fractures occur, the treatment is similar to that of a fracture in other parts of the body. Some injuries may not need treatment, and others may require stabilization and fixation using wires, plates and screws. Factors influencing these treatment decisions are the location of the fracture, the severity of the fracture, and the age and general health of the patient. It is important during treatment of facial fractures to be careful that the patient’s facial appearance is minimally affected.

Injuries to the teeth and surrounding dental structures

Isolated injuries to teeth are quite common and may require the expertise of various dental specialists. Because of the specific needs of the dental structures, certain actions and precautions should be taken if a child has received an injury to his or her teeth or surrounding dental structures.

  • If a tooth is “knocked out” it should be placed in salt water or milk. The sooner the tooth is re-inserted into the dental socket, the better the chance it will survive, so the patient should see a dentist or oral surgeon as soon as possible.
  • Never attempt to “wipe the tooth off” since remnants of the ligament which hold the tooth in the jaw are attached and are vital to the success of replanting the tooth.

References:

Stewart MG, Chen AY. Factors predictive of poor compliance with follow-up after Facial trauma: A prospective study. Otolaryngology Head & Neck Surgery 1997: 117:72-75

Kim MK, Buchman R, Szeremeta. Penetrating neck trauma in children: An urban hospital’s experience. Otolaryngology Head & Neck Surgery 2000: 123: 439-43

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Your thyroid gland is one of the endocrine glands that makes hormones to regulate physiological functions in your body, like metabolism (heart rate, sweating, energy consumed). Other endocrine glands include the pituitary, adrenal and parathyroid glands and specialized cells within the pancreas.

The thyroid gland is located in the middle of the lower neck, below the larynx (voice box) and wraps around the front half of the trachea (windpipe). It is shaped like a bow tie, just above the collarbones, having two halves (lobes) joined by a small tissue bar (isthmus.). You can’t always feel a normal thyroid gland.

What is a thyroid disorder?

Diseases of the thyroid gland are very common, affecting millions of Americans. The most common thyroid problems are:

  • An overactive gland, called hyperthyroidism (e.g., Graves’ disease, toxic adenoma or toxic nodular goiter)
  • An underactive gland, called hypothyroidism (e.g., Hashimoto’s thyroiditis)
  • Thyroid enlargement due to overactivity (as in Graves’ disease) or from under-activity (as in hypothyroidism). An enlarged thyroid gland is often called a “goiter”.

Patients with a family history of thyroid cancer or who had radiation therapy to the head or neck as children for acne, adenoids or other reasons are more prone to develop thyroid malignancy.

If you develop significant swelling in your neck or difficulty breathing or swallowing, you should call your surgeon or be seen in the emergency room.

What treatment may be recommended?

Depending on the nature of your condition, treatment may include the following:

Hypothyroidism treatment:

  • Thyroid hormone replacement pills

Hyperthyroidism treatment:

  • Medication to block the effects of excessive production of thyroid hormone
  • Radioactive iodine to destroy the thyroid gland
  • Surgical removal of the thyroid gland

Goiters (lumps):

If you experience this condition, your doctor will propose a treatment plan based on the examination and your test results. He or she may recommend:

  • An imaging study to determine the size, location and characteristics of any nodules within the gland. Types of imaging studies include CT or CAT scans, ultrasound or MRIs.
  • A fine-needle aspiration biopsy – a safe, relatively painless procedure. With this procedure, a hypodermic needle is passed into the lump, and tissue fluid samples containing cells are taken. Several passes with the needle may be required. Sometimes ultrasound is used to guide the needle into the nodule. There is little pain afterward and very few complications from the procedure. This test gives the doctor more information on the nature of the lump in your thyroid gland and may help to differentiate a benign from a malignant or cancerous thyroid mass.

Thyroid surgery may be required when:

  • the fine needle aspiration is reported as suspicious or suggestive of cancer
  • imaging shows that nodules have worrisome characteristics or that nodules are getting bigger
  • the trachea (windpipe) or esophagus are compressed because one or both lobes are very large

Historically, some thyroid nodules, including some that are malignant, have shown a reduction in size with the administration of thyroid hormone. However, this treatment, known as medical “suppression” therapy, has proven to be an unreliable treatment method.

What is thyroid surgery?

Thyroid surgery is an operation to remove part or all of the thyroid gland. It is performed in the hospital, and general anesthesia is usually required. Typically, the operation removes the lobe of the thyroid gland containing the lump and possibly the isthmus. A frozen section (immediate microscopic reading) may be used to determine if the rest of the thyroid gland should be removed during the same surgery.

Sometimes, based on the result of the frozen section, the surgeon may decide not to remove any additional thyroid tissue, or proceed to remove the entire thyroid gland, and/or other tissue in the neck. This decision is usually made in the operating room by the surgeon, based on findings at the time of surgery. Your surgeon will discuss these options with you pre-operatively.

As an alternative, your surgeon may choose to remove only one lobe and await the final pathology report before deciding if the remaining lobe needs to be removed. There also may be times when the definite microscopic answer cannot be determined until several days after surgery. If a malignancy is identified in this way, your surgeon may recommend that the remaining lobe of the thyroid be removed at a second procedure. If you have specific questions about thyroid surgery, ask your otolaryngologist to answer them in detail.

What happens after thyroid surgery?

During the first 24 hours:

After surgery, you may have a drain (tiny piece of plastic tubing), which prevents fluid and blood from building up in the wound. This is removed after the fluid accumulation has stabilized, usually within 24 hours after surgery. Most patients are discharged later the same day or the next day. Complications are rare but may include:

  • Bleeding
  • Bleeding under the skin that rarely can cause shortness of breath, requiring immediate medical evaluation
  • A hoarse voice
  • Difficulty swallowing
  • Numbness of the skin on the neck
  • Vocal cord paralysis
  • Low blood calcium

At home:

Following the procedure, if it is determined that you need to take any medication your surgeon will discuss this with you prior to your discharge. Medications may include:

  • Thyroid hormone replacement
  • Calcium and/or vitamin D replacement

Some symptoms may not become evident for two or three days after surgery. If you experience any of the following, call your surgeon or seek medical attention:

  • Numbness and tingling around the lips and hands
  • Increasing pain
  • Fever
  • Swelling
  • Wound discharge
  • Shortness of breath

If a malignancy is identified, thyroid replacement medication may be withheld for several weeks. This allows a radioactive scan to better detect any remaining microscopic thyroid tissue, or spread of malignant cells to lymph nodes or other sites in the body.

How is a diagnosis made?

The diagnosis of a thyroid function abnormality or a thyroid mass is made by taking a medical history and a physical examination. In addition, blood tests and imaging studies or fine-needle aspiration may be required. As part of the exam, your doctor will examine your neck and ask you to lift up your chin to make your thyroid gland more prominent. You may be asked to swallow during the examination, which helps to feel the thyroid and any mass in it. Tests your doctor may order include:

  • Evaluation of the larynx/vocal cords with a mirror or a fiberoptic telescope
  • An ultrasound examination of your neck and thyroid
  • Blood tests of thyroid function
  • A radioactive thyroid scan
  • A fine-needle aspiration biopsy
  • A chest X-ray
  • A CT or MRI scan

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

What is Ménière’s disease?

Ménière’s disease describes a set of episodic symptoms including vertigo (attacks of a spinning sensation), hearing loss, tinnitus (a roaring, buzzing or ringing sound in the ear), and a sensation of fullness in the affected ear. Episodes typically last from 20 minutes up to 4 hours. Hearing loss is often intermittent, occurring mainly at the time of the attacks of vertigo. Loud sounds may seem distorted and cause discomfort. Usually, the hearing loss involves mainly the lower pitches, but over time this often affects tones of all pitches. After months or years of the disease, hearing loss often becomes permanent. Tinnitus and fullness of the ear may come and go with changes in hearing, occur during or just before attacks, or be constant.

Ménière’s disease is also called idiopathic endolymphatic hydrops and is one of the most common causes of dizziness originating in the inner ear. In most cases only one ear is involved, but both ears may be affected in about 15 percent of patients. Ménière’s disease typically starts between the ages of 20 and 50 years. Men and women are affected in equal numbers. Because Ménière’s disease affects each person differently, your doctor will suggest strategies to help reduce your symptoms and will help you choose the treatment that is best for you.

What are the causes?

Although the cause is unknown, Ménière’s disease probably results from an abnormality in the volume of fluid in the inner ear. Too much fluid may accumulate either due to excess production or inadequate absorption. In some individuals, especially those with involvement of both ears, allergies or autoimmune disorders may play a role in producing Ménière’s disease. In some cases, other conditions may cause symptoms similar to those of Ménière’s disease.

People with Ménière’s disease have a “sick” inner ear and are more sensitive to factors, such as fatigue and stress, that may influence the frequency of attacks.

How is a diagnosis made?

Your physician will take a history of the frequency, duration, severity and character of your attacks, the duration of hearing loss or whether it has been changing, and whether you have had tinnitus or fullness in either or both ears. When the history has been completed, diagnostic tests will check your hearing and balance functions. They may include:

For hearing

  • An audiometric examination (hearing test) typically indicates a sensory type of hearing loss in the affected ear. Speech discrimination (the patient’s ability to distinguish between words like “sit” and “fit”) is often diminished in the affected ear.

For balance

  • An ENG (electronystagmogram) may be performed to evaluate balance function. In a darkened room, eye movements are recorded as warm and cool water or air are gently introduced into each ear canal. Since the eyes and ears work in coordination through the nervous system, measurement of eye movements can be used to test the balance system. In about 50 percent of patients, the balance function is reduced in the affected ear.
    Rotational or balance platform testing may also be performed to evaluate the balance system.

Other tests

Electrocochleography (ECoG) may indicate increased inner ear fluid pressure in some cases of Ménière’s disease.
The auditory brain stem response (ABR), a computerized test of the hearing nerves and brain pathways, computed tomography (CT), or magnetic resonance imaging (MRI) may be needed to rule out a tumor occurring on the hearing and balance nerve. Such tumors are rare, but they can cause symptoms similar to Ménière’s disease.

What should I do during an attack of Ménière’s disease?

Lie flat and still and focus on an unmoving object. Often people fall asleep while lying down and feel better when they awaken.

How can I reduce the frequency of Ménière’s disease episodes?

Avoid stress and excess salt ingestion, caffeine, smoking and alcohol. Get regular sleep and eat properly. Remain physically active, but avoid excessive fatigue. Consult your otolaryngologist about other treatment options.

How is Ménière’s disease treated?

Although there is no cure for Ménière’s disease, the attacks of vertigo can be controlled in nearly all cases. Treatment may include:

  • A low salt diet and a diuretic (water pill)
  • Anti-vertigo medications
  • Intratympanic injection with either gentamicin or dexamethasone.
  • An air pressure pulse generator
  • Surgery

Your otolaryngologist will help you choose the treatment that is best for you, as each has advantages and drawbacks. In many people, careful control of salt in the diet and the use of diuretics can control symptoms satisfactorily.

Intratympanic injections involve injecting medication through the eardrum into the middle ear space where the ear bones reside. This treatment is done in the otolaryngologist’s office. The treatment includes either making a temporary opening in the eardrum or placing a tube in the eardrum. The drug may be administered once or several times. Medication injected may include gentamicin or corticosteroids. Gentamicin alleviates dizziness but also carries the possibility of increased hearing loss in the treated ear that may occur in some individuals. Corticosteroids do not cause worsening of hearing loss, but are less effective in alleviating the major dizzy spells.

An air pressure pulse generator is another option. This device is a mechanical pump that is applied to the person’s ear canal for five minutes, three times a day. A ventilating tube must be first inserted through the eardrum to allow the pressure produced by the air pressure pulse generator to be transmitted across the round window membrane and change the pressure in the inner ear. The success rate of this device has been variable.

When is surgery recommended?

Surgery is needed in only a small minority of patients with Ménière’s disease. If vertigo attacks are not controlled by conservative measures and are disabling, one of the following surgical procedures might be recommended:

  • Endolymphatic sac shunt or decompression procedure relieves attacks of vertigo in one-half to two-thirds of cases and the sensation of ear fullness is often improved. Control is often temporary. Endolymphatic sac surgery does not improve hearing, but only has a small risk of worsening it. Recovery time after this procedure is short compared to the other procedures.
  • Selective vestibular neurectomy is a procedure in which the balance nerve is cut as it leaves the inner ear and goes to the brain. While vertigo attacks are permanently cured in a high percentage of cases, patients may continue to experience imbalance. Similar to endolymphatic sac procedures, hearing function is usually preserved.
  • Labryrinthectomy and eighth nerve section are procedures in which the balance and hearing mechanism in the inner ear are destroyed on one side. This is considered when the patient with Ménière’s disease has poor hearing in the affected ear. Labryrinthectomy and eighth nerve section result in the highest rates for control of vertigo attacks.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Playing catch, shooting hoops, bicycling on a scenic path or just kicking around a soccer ball have more in common than you may think. On the up side, these activities are good exercise and are enjoyed by thousands of Americans. On the down side, they can result in a variety of injuries to the face.

Many injuries are preventable by wearing the proper protective gear, and your attitude toward safety can make a big difference. However, even the most careful person can get hurt. When an accident happens, it’s your response that can make the difference between a temporary inconvenience and permanent injury.

When Someone Gets Hurt:

What First Aid Supplies Should You Have on Hand in Case of An Emergency?

  • sterile cloth or pads
  • scissors
  • ice pack
  • tape
  • sterile bandages
  • cotton tipped swabs
  • hydrogen peroxide
  • nose drops
  • antibiotic ointment
  • eye pads
  • cotton balls
  • butterfly bandages

Ask “Are you all right?” Determine whether the injured person is breathing and knows who and where they are.

Be certain the person can see, hear and maintain balance. Watch for subtle changes in behavior or speech, such as slurring or stuttering. Any abnormal response requires medical attention.

Note weakness or loss of movement in the forehead, eyelids, cheeks and mouth.

Look at the eyes to make sure they move in the same direction and that both pupils are the same size.

If any doubts exist, seek immediate medical attention.

When Medical Attention Is Required, What Can You Do?

  • Call for medical assistance (911).
  • Do not move the victim, or remove helmets or protective gear.
  • Do not give food, drink or medication until the extent of the injury has been determined.
  • Remember HIV…be very careful around body fluids. In an emergency protect your hands with plastic bags.
  • Apply pressure to bleeding wounds with a clean cloth or pad, unless the eye or eyelid is affected or a loose bone can be felt in a head injury. In these cases, do not apply pressure but gently cover the wound with a clean cloth.
  • Apply ice or a cold pack to areas that have suffered a blow (such as a bump on the head) to help control swelling and pain.
  • Remember to advise your doctor if the patient has HIV or hepatitis.

Facial Fractures

Sports injuries can cause potentially serious broken bones or fractures of the face. Common symptoms of facial fractures include:

  • swelling and bruising, such as a black eye
  • pain or numbness in the face, cheeks or lips
  • double or blurred vision
  • nosebleeds
  • changes in teeth structure or ability to close mouth properly

It is important to pay attention to swelling because it may be masking a more serious injury. Applying ice packs and keeping the head elevated may reduce early swelling.

If any of these symptoms occur, be sure to visit the emergency room or the office of a facial plastic surgeon (such as an otolaryngologist – head and neck surgeon) where x-rays may be taken to determine if there is a fracture.

Upper Face

When you are hit in the upper face (by a ball for example) it can fracture the delicate bones around the sinuses, eye sockets, bridge of the nose or cheek bones. A direct blow to the eye may cause a fracture, as well as blurred or double vision. All eye injuries should be examined by an eye specialist (ophthalmologist).

Lower Face

When your jaw or lower face is injured, it may change the way your teeth fit together. To restore a normal bite, surgeries often can be performed from inside the mouth to prevent visible scarring of the face, and broken jaws often can be repaired without being wired shut for long periods. Your doctor will explain your treatment options and the latest treatment techniques.

Soft Tissue Injuries

Bruises, cuts and scrapes often result from high speed or contact sports, such as boxing, football, soccer, ice hockey, bicycling, skiing and snowmobiling. Most can be treated at home, but some require medical attention.

You should get immediate medical care when you have:

  • deep skin cuts
  • obvious deformity or fracture
  • loss of facial movement
  • persistent bleeding
  • change in vision
  • problems breathing and/or swallowing
  • alterations in consciousness or facial movement

Bruises

Also called contusions, bruises result from bleeding underneath the skin. Applying pressure, elevating the bruised area above the heart and using an ice pack for the first 24 to 48 hours minimizes discoloration and swelling. After two days, a heat pack or hot water bottle may help more. Most of the swelling and bruising should disappear in one to two weeks.

Cuts and Scrapes

The external bleeding that results from cuts and scrapes can be stopped by immediately applying pressure with gauze or a clean cloth. When the bleeding is uncontrollable, you should go to the emergency room.

Scrapes should be washed with soap and water to remove any foreign material that could cause infection and discoloration of the skin. Scrapes or abrasions can be treated at home by cleaning with 3% hydrogen peroxide and covering with an antibiotic ointment or cream until the skin is healed. Cuts or lacerations, unless very small, should be examined by a physician. Stitches may be necessary, and deeper cuts may have serious effects. Following stitches, cuts should be kept clean and free of scabs with hydrogen peroxide and antibiotic ointment. Bandages may be needed to protect the area from pressure or irritation from clothes. You may experience numbness around the cut for several months. Healing will continue for 6 to 12 months. The application of sunscreen is important during the healing process to prevent pigment changes. Scars that look too obvious after this time should be seen by a facial plastic surgeon.

Nasal Injuries

The nose is one of the most injured areas on the face. Early treatment of a nose injury consists of applying a cold compress and keeping the head higher than the rest of the body. You should seek medical attention in the case of:

  • breathing difficulties
  • deformity of the nose
  • persistent bleeding
  • cuts

Bleeding

Nosebleeds are common and usually short-lived. Often they can be controlled by squeezing the nose with constant pressure for 5 to 10 minutes. If bleeding persists, seek medical attention.
Bleeding also can occur underneath the surface of the nose. An otolaryngologist/facial plastic surgeon will examine the nose to determine if there is a clot or collection of blood beneath the mucus membrane of the septum (a septal hematoma) or any fracture. Hematomas should be drained so the pressure does not cause nose damage or infection.

Fractures

Some otolaryngologist – head and neck specialists set fractured bones right away before swelling develops, while others prefer to wait until the swelling is gone. These fractures can be repaired under local or general anesthesia, even weeks later.
Ultimately, treatment decisions will be made to restore proper function of the nasal air passages and normal appearance and structural support of the nose. Swelling and bruising of the nose may last for 10 days or more.

Neck Injuries

Whether seemingly minor or severe, all neck injuries should be thoroughly evaluated by an otolaryngologist – head and neck surgeon. Injuries may involve specific structures within the neck, such as the larynx (voice box), esophagus (food passage), or major blood vessels and nerves.

Throat Injuries

The larynx is a complex organ consisting of cartilage, nerves and muscles with a mucous membrane lining all encased in a protective tissue (cartilage) framework.

The cartilages can be fractured or dislocated and may cause severe swelling, which can result in airway obstruction. Hoarseness or difficulty breathing after a blow to the neck are warning signs of a serious injury and the injured person should receive immediate medical attention.

Prevention of Facial Sports Injuries

The best way to treat facial sports injuries is to prevent them. To insure a safe athletic environment, the following guidelines are suggested:

  • Be sure the playing areas are large enough that players will not run into walls or other obstructions.
  • Cover unremoveable goal posts and other structures with thick, protective padding.
  • Carefully check equipment to be sure it is functioning properly.
  • Require protective equipment – such as helmets and padding for football, bicycling and rollerblading; face masks, head and mouth guards for baseball; ear protectors for wrestlers; and eyeglass guards or goggles for racquetball and snowmobiling are just a few.
  • Prepare athletes with warm-up exercises before engaging in intense team activity.
  • In the case of sports involving fast-moving vehicles, for example, snowmobiles or dirt bikes – check the path of travel, making sure there are no obstructing fences, wires or other obstacles.
  • Enlist adequate adult supervision for all children’s competitive sports.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Insight into Bell’s palsy, including:

  • What is Bell’s palsy?
  • How is it treated?
  • What if I don’t fully recover?

What is Bell’s palsy?

Bell’s palsy is a fast change to one side of your face resulting in weakness or complete loss of movement. It happens because of damage to the facial nerve of unknown cause. This makes half of your face seem to droop. Although Bell’s palsy typically goes away on its own, facial droop or weakness may keep you from closing the affected eye, change how things taste, make your smile crooked, and sometimes may make you drool.

Bell’s palsy can affect anyone, but is most common in those 15-45 years old. There are some conditions that put you more at risk such as being overweight, having untreated high blood pressure, diabetes, or upper respiratory illness.

Most people with Bell’s palsy get better without medical attention within 2-3 weeks. Many recover completely within 3-4 months. Even without any treatment, 70 percent with this palsy get better within six months.

How does the facial nerve change facial expression?

While a virus may cause facial palsy, no one really knows how this works. It may be due to facial nerve swelling (inflammation). As the nerve travels through a narrow bony canal within the skull, the pressure of such swelling may lead to temporary or permanent facial nerve damage. The facial nerve not only carries nerve impulses to muscles of the face, but also to the tear glands, salivary glands, muscle of a tiny ear bone, and taste fibers of the tongue. This means that those with Bell’s palsy may have a dry eye or mouth, taste loss, and a sagging eyelid or mouth corner.

How is Bell’s palsy treated? What will my doctor do?

Facial weakness can be caused by many things. The determination of Bell’s palsy is made when the doctor finds no other cause of your facial weakness. The doctor will conduct a thorough history and examination, looking for any clear causes of the drooping. Be sure to tell your doctor about any change or discomfort you notice and when you first noticed a change. Unless a cause of the problem is found, your doctor is unlikely to do any additional tests, like laboratory testing or imaging. If your doctor does identify another cause of the facial weakness, then your condition is not Bell’s palsy.

For those 16 years and older, doctors may prescribe steroid medication to calm the swelling, helping the facial nerve to work better. Studies show that steroids are likely to be helpful. Antiviral treatment may also be of some help for Bell’s palsy when used in addition to steroids.

Protecting your eye

With Bell’s palsy you may have trouble shutting your eye. Not being able to close the eye will cause dryness and may cause pain or eye damage. So if you do, tell you doctor. He or she may suggest you use eye drops, ointment, or wear an eye patch while you heal.

What else can I do?

You will want to do everything you can to speed recovery, but so far doctors do not know if things like physical therapy or acupuncture help. Talk to your doctor about what else might help.

What if I don’t fully recover?

Most people with Bell’s palsy recover completely. For the small percentage of patients who do not fully recover the remaining problems can affect how you feel about yourself and being with others in your day-to-day life. Certain corrective procedures, such as weighting the eyelid or surgery to improve your smile may help your self-esteem and your appearance. Talk to your doctor about what might work for you.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

The skin is the largest organ in our body. It provides protection against heat, cold, light and infection. The skin is made up of two major layers (epidermis and dermis) as well as various types of cells. The top (or outer) layer of the skin – the epidermis – is composed of three types of cells: flat, scaly cells on the surface called squamous cells; round cells called basal cells; and melanocytes, cells that provide skin its color and protect against skin damage. The inner layer of the skin – the dermis – is the layer that contains the nerves, blood vessels and sweat glands.

What is skin cancer?

Skin cancer is a disease in which cancerous (malignant) cells are found in the outer layers of your skin. There are several types of cancer that originate in the skin. The most common types are basal cell carcinoma (70 percent of all skin cancers) and squamous cell carcinoma (20 percent). These types are classified as nonmelanoma skin cancer. Melanoma (5 percent of all skin cancers) is the third type of skin cancer. It is less common than basal cell or squamous cell cancers, but potentially much more serious. Other types of skin cancer are rare.

Basal cell carcinoma is the most common type of skin cancer. It typically appears as a small raised bump that has a pearly appearance. It is most commonly seen on areas of the skin that have received excessive sun exposure. These cancers may spread to the skin surrounding them, but rarely spread to other parts of the body.

Squamous cell carcinoma is also seen on the areas of the body that have been exposed to excessive sun (nose, lower lip, hands and forehead). Often this cancer appears as a firm red bump or ulceration of the skin that does not heal. Squamous cell carcinomas can spread to lymph nodes in the area.

Melanoma is a skin cancer (malignancy) that arises from the melanocytes in the skin. Melanocytes are the cells that give color to our skin. These cancers typically arise as pigmented (colored) lesions in the skin with an irregular shape, irregular border and multiple colors. It is the most harmful of all the skin cancers, because it can spread to lymph nodes or other sites in the body. Fortunately, most melanomas have a very high cure rate when identified and treated early.

What causes skin cancer?

Most skin cancers occur on sun-exposed areas of skin, and there is a lot of scientific evidence to support UV radiation as a causative factor in most types of skin cancer. Family history is also important, particularly in melanoma. The lighter your skin type, the more susceptible you are to UV damage and to skin cancer.

How is skin cancer diagnosed?

The vast majority of skin cancers can be cured if diagnosed and treated early. Aside from protecting your skin from sun damage, it is important to recognize the early signs of skin cancer.

  • Skin sores that do not heal,
  • Bumps or nodules in the skin that are enlarging, and
  • Changes in existing moles (size, texture, color).

If you notice any of the factors listed above, see your doctor right away. If you have a spot or lump on your skin, your doctor may remove the growth and examine the tissue under the microscope. This is called a biopsy. A biopsy can usually be done in the doctor’s office and usually involves numbing the skin with a local anesthetic. Examination of the biopsy under the microscope will tell the doctor if the skin lesion is a cancer (malignancy).

How is skin cancer treated?

There are varieties of treatments available to treat skin cancer, including surgery, radiation therapy and chemotherapy. Treatment for skin cancer depends on the type and size of cancer, your age and your overall health.

Surgery is the most common form of treatment. It generally consists of an office or outpatient procedure to remove the lesion and check edges to make sure all the cancer was removed. For basal cell and squamous cell carcinomas, excision is frequently done using a specific technique called Mohs surgery, which gives the best chance to include all margins, while still minimizing the size of the defect. In some cases, the site is then repaired with simple stitches. Depending on the size of the defect, your doctor may take some skin from somewhere else to cover the wound and promote healing. For melanoma treatment, your doctor might also recommend doing a biopsy of the lymph node with the highest chance of having tiny microscopic metastatic cancer cells. This is called a sentinel lymph node biopsy, and further removal of more lymph nodes might be needed if this biopsy is positive. Sometimes radiation may be used as definitive therapy or after surgery, depending on the situation. For non-melanoma skin cancers, chemotherapy is not needed as primary therapy, and its use after surgery is controversial. For melanomas, chemotherapy and medications that modulate the immune system may be used in more advanced cases.

Am I at risk for skin cancer?

People with any of the factors listed below have a higher risk of developing skin cancer and should be particularly careful about sun exposure.

  • Long-term sun exposure
  • Fair skin (typically blonde or red hair with freckles)
  • Place of residence (increased risk in southern climates)
  • Presence of moles, particularly if there are irregular edges, uneven coloring or an increase in the size of the mole
  • Family history of skin cancer, particularly melanoma
  • Use of indoor tanning devices
  • Severe sunburns as a child
  • Nonhealing ulcers or nodules in the skin.

How can I lower my risk of skin cancer?

The single most important thing you can do to lower your risk of skin cancer is to avoid direct sun exposure. Sunlight produces ultraviolet (UV) radiation that can directly damage the cells (DNA) of our skin. People who work outdoors are at the highest risk of developing skin cancer. The sun’s rays are the most powerful between 10 am and 2 pm, so be particularly careful during those hours. If you must be out during the day, wear clothing that covers as much of your skin as possible, including a wide-brimmed hat to block the sun from your face, scalp, neck and ears.

The use of sunscreen can provide protection against UV radiation. When selecting a sunscreen, choose one with a Sun Protection Factor (SPF) of 15 or more. For people who live in the Southern U.S., a SPF of 30 or greater should be used during summer and when prolonged exposure is anticipated. Sunscreen should be applied before exposure and when the skin is dry. If you will be sweating or swimming, most sunscreens need to be reapplied. Sunscreen products do not completely block the damaging rays, but they allow you to be in the sun longer without getting sunburn.

It is also critical to recognize early signs of skin trouble. The best time to do self-examination is after a shower in front of a full-length mirror. Note any moles, birthmarks and blemishes. Be on the alert for sores that do not heal or new nodules on the skin. Any mole that changes in size, color or texture should be carefully examined. If you notice anything new or unusual, see your physician right away. If you have a strong family history of skin cancer, particularly melanoma, an annual examination by a physician skilled at diagnosing skin cancer is recommended. Catching skin cancer early can save your life.

Ultraviolet index: What you need to know

The Ultraviolet (UV) index provides important information to help you plan your outdoor activities and avoid overexposure to the damaging rays of the sun. Developed by the National Weather Service and the Environmental Protection Agency, the UV index is issued daily as a national service.

The UV index gives the next day’s expected amount of exposure to UV rays. The index predicts UV levels on a 0 to 10+ scale (see chart).

Always take precautions against overexposure, and take special care when the UV index predicts exposure levels of moderate and above (5 to 10+).

Index Number: Exposure Level

l0 – 2: Minimal
3 – 4: Low
5 – 6: Moderate
7 – 9: High
10+ : Very High

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

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

Early detection of head and neck cancer

Tobacco use is the most preventable cause of these deaths. In the United States, up to 200,000 people die each year from smoking-related illnesses. The good news is that this figure has decreased due to the increasing number of Americans who have quit smoking. The bad news is that some of these smokers switched to smokeless or spit tobacco, assuming it is a safe alternative. This is untrue. By doing so, they are only changing the site of the cancer risk from their lungs to their mouths. While lung cancer cases are decreasing, cancers in the head and neck appear to be increasing, but they are curable if caught early. Fortunately, most head and neck cancers produce early symptoms. You should know the potential warning signs so you can alert your doctor as soon as possible. Remember – successful treatment of head and neck cancer depends on early detection. Knowing and recognizing its signs can save your life.

Symptoms of head and neck cancer

A lump in the neck. Cancers that begin in the head or neck usually spread to lymph nodes in the neck before they spread elsewhere. A lump in the neck that lasts more than two weeks should be seen by a physician as soon as possible. Of course, not all lumps are cancer. But a lump (or lumps) in the neck can be the first sign of cancer of the mouth, throat, voicebox (larynx), thyroid gland, or of certain lymphomas and blood cancers. Such lumps are generally painless and continue to enlarge steadily.

Change in the voice. Most cancers in the larynx cause some changes in voice. An otolaryngologist is a head and neck specialist who can examine your vocal cords easily and painlessly. While most voice changes are not caused by cancer, you shouldn’t take chances. If you are hoarse or notice voice changes for more than two weeks, see your doctor.

A growth in the mouth. Most cancers of the mouth or tongue cause a sore or swelling that doesn’t go away. These may be painless, which can be misleading. Bleeding may occur, but often not until late in the disease. If an ulcer or swelling is accompanied by lumps in the neck, you should be concerned. In addition, any sore or swelling in the mouth that does not go away after a week should be evaluated by a physician. Your dentist or doctor can determine if a biopsy (tissue sample test) is needed and can refer you to a head and neck surgeon who can perform this procedure.

Bringing up blood. This is often caused by something other than cancer. However, tumors in the nose, mouth, throat or lungs can cause bleeding. If blood appears in your saliva or phlegm for more than a few days, you should see your physician.

Swallowing problems. Cancer of the throat or esophagus (swallowing tube) may make swallowing solid foods – and sometimes liquids – difficult. The food may “stick” at a certain point and then either go through to the stomach or come back up. If you have trouble almost every time you try to swallow something, you should be examined by a physician. Usually a barium swallow x-ray or an esophagoscopy (direct examination of the swallowing tube with a scope) will be performed to find the cause.

Changes in the skin. The most common head and neck cancer is basal cell cancer of the skin. Fortunately, this is rarely serious if treated early. Basal cell cancers appear most often on sun-exposed areas like the forehead, face and ears, but can occur almost anywhere on the skin. Basal cell cancer often begins as a small, pale patch that enlarges slowly, producing a central “dimple” and eventually an ulcer. Parts of the ulcer may heal, but the major portion remains ulcerated. Some basal cell cancers show color changes. Other kinds of cancer, including squamous cell cancer and malignant melanoma, also occur on the head and neck. Most squamous cell cancers occur on the lower lip and ear. They may look like basal cell cancers, and if caught early and properly treated, usually are not dangerous. If there is a sore on the lip, lower face or ear that does not heal, consult a physician. Malignant melanoma typically produces a blue-black or black discoloration of the skin. However, any mole that changes size, color or begins to bleed may mean trouble. A black or blue-black spot on the face or neck, particularly if it changes size or shape, should be seen as soon as possible by a dermatologist or other physician.

Persistent earache. Constant pain in or around the ear when you swallow can be a sign of infection or tumor growth in the throat. This is particularly serious if it is associated with difficulty in swallowing, hoarseness or a lump in the neck. These symptoms should be evaluated by an otolaryngologist.

Identifying high risk of head and neck cancer

As many 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 papilloma virus (HPV). Prolonged exposure to sunlight is linked with cancer of the lip and is also established as a major cause of skin cancer.

What you should do.

All of the symptoms and signs described here can occur with no cancer present. In fact, many times complaints of this type are due to some other condition. But you can’t tell without an examination. So if they do occur, see your doctor to be sure.

Remember – when found early, most cancers in the head and neck can be cured with few side effects. Cure rates for these cancers could be greatly improved if people would seek medical advice as soon as possible. Play it safe. If you detect warning signs of head and neck cancer, see your doctor immediately. And practice health habits which help prevent these diseases.
© 2016 American Academy of Otolaryngology – Head and Neck Surgery