Otolaryngology

Otolaryngology

Adult & Pediatric Ear, Nose, Throat & Sinus
Facial Plastic Surgery

Facial Plastic Surgery

Eyelid Surgery, Facial Surgery, Facial Liposuction & Rhinoplasty
Head and Neck Surgery

Head and Neck Surgery

Thyroid, Parathyroid & Salivary Gland Disorders
Skin Rejuvenation

Skin Rejuvenation

Injectables, Peels, Skin Care & Microdermabrasion

Ear, Nose and Throat

Head & Neck Surgery

HotButton HeadNeck

Facial Plastic Surgery

HotButton FacialPlasticSurgery

Request More Info

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.

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.

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

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.

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