Oral Exam Using a Finger

For a good physical exam, physicians use their senses (eyes, ears, nose) to detect disease processes that may not necessarily be obvious to a lay person. Beyond these obvious senses, fingers and hands are also utilized to feel for unusual bumps or masses that may not be obvious to the naked eye.

Take a neck mass for example. Neck masses may not be necessarily visible, but by feeling the neck, may become obvious. To use an analogy, a bowling ball under a mattress may not necessarily be obvious, but if you lay on the bed, would become painfully obvious.

Physicians also use the hands/fingers to examine areas that may not be visible... such as the unpleasant digital rectal exam (inserting a finger up a bung-hole) which is done to detect blood in the stool, rectal/anal cancers, anal muscular incompetence, etc.

However, I find it odd that the mouth is a body area that is not often "felt" around... physicians included.

A finger can appreciate unusual mouth pathology that may not necessarily be appreciated by looking alone. Furthermore, just like the rectal exam, a finger can appreciate base of tongue pathology that cannot be visualized by having a patient go "ah".

I truly feel that actor Michael Douglas would have been diagnosed with his base of tongue cancer much earlier if only a doctor stuck a finger and swept that back area of the tongue. One can "feel" cancer as it is rock hard and very tender. True... it may cause a person to gag, but for a cancer test, it's dirt cheap, fast, and reliable.

However, it does not just have to be areas of the mouth that can not be seen. Even for those ulcerations and bumps of the mouth that one can clearly visualize (or not), it does help to touch it. Is it hard? Soft? Ulcerated? Tender? Grooved? Papillated? Fungating? Rubber-like? Blottable?

Each characteristic provides information to achieve a more accurate diagnosis.

To an ENT way of thinking, if a doctor regularly performs a digital rectal exam, than one can certainly do the same thing at the other end. It's less invasive and provides just as much information.

Say "ah"!!!

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Oral Sex Causes More Oral Cancer Than Smoking!

HPV may now be overtaking tobacco as the leading cause of oral cancers in America in people under age 50.

And HPV, otherwise known as Human Papilloma Virus responsible for gential warts and cervical cancer, finds it way into the mouth via oral sex.

The latest data suggest that 64% of oral cancers are caused by HPV, which is more than tobacco causes. Furthermore, as the number of partners on whom you have performed oral sex goes up, the risk of oral cancer goes up.

These findings were presented by scientists this past Sunday at the American Association for the Advancement of Science annual meeting.

Hopefully, these results will be formally published soon, but you can read the story on CNN for now here.

Read more about oral masses in general here.

Related References:
Human papillomavirus and oropharyngeal cancer. N Engl J Med. 2007 Sep 13;357(11):1157; author reply 1157-8

Human papillomaviruses in head and neck carcinomas. N Engl J Med. 2007 May 10;356(19):1993-5.

Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med. 2007 May 10;356(19):1944-56.

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New Anti-Snoring Device... aveoTSD

I received in the mail today a new device called aveoTSD anti-snoring aid by Glidewell Laboratories.

According to the literature, the way it works is by advancing the tongue forward thereby preventing the tongue from falling backward and vibrating against the throat's back wall causing snoring as well as obstructive sleep apnea.

The way the device moves the tongue forward is by literally suctioning the tongue tip into the device and holding it in place by vacuum seal.

The theory behind how this device works is sound and mimics what an oral appliance does as well as several surgical procedures including base of tongue reduction, hyoid advancement, and Repose procedure.

The one caveat I have with this device is that it only resolves snoring due to the tongue. It would not necessarily address snoring that comes from the nose or palate. There are other devices/surgeries that would address those areas (breath-rite strips, Pillar procedure, UPPP, septoplasty, etc).

I lied... there's another caveat... Will the suction vacuum hold all night for a patient??? It does come in several different sizes... but still...

Read more about the aveoTSD here.

Read more about snoring here.

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Link Between Oral Sex and Head & Neck Cancer

USA Today published a pretty accurate article regarding the rise of certain head & neck cancers with the increased popularity of oral sex and number of sexual partners.

The factor that creates this link is the HPV virus which is associated with tonsil and tongue cancer. Alcohol and tobacco use is more highly linked with such oral cancers, but HPV does appear to be an independent risk factor.

A 2007 study in the New England Journal of Medicine found that younger people with head and neck cancers who tested positive for oral HPV infection were more likely to have had multiple vaginal and oral sex partners in their lifetime. Having six or more oral sex partners over a lifetime was associated with a 3.4 times higher risk for oropharyngeal cancer; cancers of the base of the tongue, back of the throat, or tonsils. Having 26 or more vaginal-sex partners tripled the risk. The association continued to increase as the number of partners in either category increased.

Of greater concern is that "French" kissing may also potentially be a mode of transmission.

The good news (if one is a young, non-smoker diagnosed with HPV-positive tumors) is that about 85% of non-smoking people with HPV-positive tumors survive. That number drops to 45 or 50% in people who smoke and are HPV-negative.

Th take-home message here is that even if you are a non-smoker and non-drinker, you can STILL develop head and neck cancer. Oral HPV infection is strongly associated with oropharyngeal cancer among subjects with or without the established risk factors of tobacco and alcohol use and that oral HPV infection can occur through sexual activity.

Furthermore, it is possible that the HPV vaccine (ie, gardasil) may also be protective (studies pending) for both women AND men.

Read the USA Today article here.

References:
Human papillomavirus and oropharyngeal cancer. N Engl J Med. 2007 Sep 13;357(11):1157; author reply 1157-8

Human papillomaviruses in head and neck carcinomas. N Engl J Med. 2007 May 10;356(19):1993-5.

Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med. 2007 May 10;356(19):1944-56.

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ENT Robotic Surgery

There has been increasing interest in using robots to help the surgeon perform complex surgical procedures within small spaces thereby saving the patient more invasive incisions. Especially in the world of ENT, surgery that may have required large incisions to the face and/or neck can now be accomplished without any incisions by using robotics to perform the same surgery, but entirely through the mouth.

Such robotic surgery performed through the mouth is called Trans-Oral Robotic Surgery, or simply TORS. The DaVinci system is the robotics platform that is most commonly used in TORS.

Using TORS and other approaches, head and neck surgeons have been able to remove the thyroid gland through the armpit, perform base of tongue cancer surgical excision (same cancer that Michael Douglas had), voicebox removal (laryngectomy), vocal cord surgery, etc.

In many of these and other surgeries, any procedure performed through the mouth traditionally was limited to two hands. With the DaVinci system, one technically can fit as many as FOUR "hands" inside the mouth enabling greater surgical flexibility and ease in performing fine dissections that otherwise would be impossible.

There are some downsides however... namely, use of robotic surgery is not compensated by insurance and as such, major medical centers are the only locations where such high-tech equipment is available.

At this time, the otolaryngology department at Johns Hopkins University, George Washington University, and University of Virginia are the only locations in the mid-Atlantic region with access to such robotic technology and the otolaryngology-head and neck surgeons who know how to use it that I'm aware of.

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Robotic Surgery for Oral Cancer

I encountered these amazing pictures in the Archives of Otolaryngology-Head & Neck Surgery Dec 2010 edition in an article titled "Transoral Robotic-Assisted Surgery for Head and Neck Squamous Cell Carcinoma". This surgery was performed at Mayo Clinic as well as University of Alabama.

Of note, there are also some YouTube videos of robotic surgery for thyroidectomy you can watch below or here.

Reference:
Transoral Robotic-Assisted Surgery for Head and Neck Squamous Cell Carcinoma. Archives of Otolaryngol Head Neck Surg 136(12):1248-1252; 2010

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"Sinus Lift" Procedure - The Return of Intra-Oral Sinus Surgery

I saw a patient today who informed me that she underwent a "sinus lift" procedure in the past.

This statement made me realize that though ENTs are generally considered the sinus surgery experts, dentists and oral surgeons perform some sinus surgery as well like the "sinus lift" procedure. As far as I know, there is no ENT surgeon that does that specific sinus operation.

In essence, the "sinus lift" procedure is when the floor of the maxillary (cheek) sinus cavity is raised with bone graft material in order to accommodate a dental implant. Though there are many approaches to accomplish this task, most require entering into the maxillary sinus cavity. See image below:

It is somewhat strange when considering that back in the old days (like a few decades ago), ENTs routinely performed a similar intra-oral approach (Caldwell-Luc) in order to enter into the maxillary sinus cavity when performing sinus surgery for chronic sinus infections. However, with the advent of endoscopic techniques, this approach is now very rarely performed. Indeed, we try to avoid any incisions if at all possible.

So while ENTs have significantly decreased the use of intra-oral approaches for maxillary sinus surgery, the dental world has brought this approach back!

Who knows? Perhaps ENT and oral surgery will join forces at some point in the future in order to perform an endoscopic "sinus lift" procedure in order to avoid making any incisions in the mouth!

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Coffee Decreases Risk of Head & Neck Cancer

Researchers at University of Utah found that regular coffee drinkers who drank more than four cups of coffee a day had a 39 percent decreased risk of two types of head and neck cancer: oral cavity and pharynx cancers. In the study published in the journal of Cancer Epidemiology, Biomarkers & Prevention, they found however, that coffee did not decrease the risk of laryngeal cancer. Coffee contains over 1,000 different chemical compounds, including cancer-fighting antioxidants, and it’s those antioxidants that may provide a “plausible explanation” for reducing the cancer risk.

However, patients should not take this study as an excuse to increase their coffee intake specifically to counteract known cancer-causing behaviors including smoking, drinking alcohol, and chewing tobacco.

Read a CNN report on this here.

Reference:
Coffee and Tea Intake and Risk of Head and Neck Cancer: Pooled Analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer Epidemiol Biomarkers Prev, June 22, 2010; 1055-9965.

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CNN: Head & Neck Cancer Afflicting the Famous

CNN on 2/19/10 published a story portraying Roger Ebert (film critic) and George Karl (Denver Nuggets coach) diagnosed with head and neck cancer and the problems, suffering, disability associated with its treatment.

Read the story here.

Read an earlier story of Roger Ebert specifically here.

Here's another story in Esquire.

The picture portrays tongue cancer (stage 2 squamous cell carcinoma).

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Did you know that a few US Presidents also succumbed to head and neck cancer? Ulysses Grant had throat cancer (heavy drinker and smoker). Grover Cleveland had jaw cancer (also a heavy smoker and drinker).

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