The increase in HPV (Human Papilloma Virus) related cancers of the throat has resulted in much younger patients presenting to see me in the Head and Neck cancer clinics. These patients are often aged in their early 40s - 50s. There are certainly older age groups affected but it is certainly more intense dealing with a young patient who is far from retirement and often with a young family to boot.

The traditional methods of managing these patients are borrowed from the evidence based approach of treating cancers of the throat not caused by HPV but by smoking and alcohol related lifestyles. These treatments include chemotherapy and radiotherapy, in a combination that lasts six weeks should one intend to treat radically (i.e. with the intent to cure). Unfortunately, with radical treatment, especially chemotherapy, comes significant side effects. These side effects are classified into early and late onset effects. For younger patients, they can preclude timely return to work and thus, the ability to earn a living; Life changing consequences such as dental problems, deterioration in hearing, difficulty swallowing, etc. Nonetheless, oncologists find that the HPV related throat cancers (specifically those found in the tonsils and base of the tongue) respond brilliantly to this treatment The question is if this sledge hammer approach is indeed necessary. With this dilemma in mind, several studies have sprung up, the most popular (in the United Kingdom) of which is the PATHOS study. These studies exist to create a strict protocol under which young patients with HPV related disease can be randomised to have the usual treatment or to have the intensity of their treatment de-escalated. This means not giving them all chemotherapy and if at all, offering lower doses of chemotherapy and radiotherapy. The patients are followed up for several years and several analysis made. These include documenting tumour recurrences, post-treatment symptoms, quality of life, swallowing outcomes, survival without disease and overall survival.

One of the key elements of this trial is that patients are offered surgery first - Trans Oral Surgery. This means taking out the tumour in the throat through the mouth and also removing any spread (metastasis) in the neck. The Trans Oral Surgery may be done by LASER surgery or Robotic surgery.

Having a HPV related tumour in the throat can impact on one’s personal life. Patients are concerned they may pass the virus on to their partners and worry about sexual intercourse. Thankfully, the Throat Cancer Foundation have put together a leaflet entitled HPV & Throat Cancer which has answers to common questions which patients (and their relatives) may sometimes be embarrassed to ask. Click on the link below to find out more:

HPV & Throat Cancer

“A feeling of a lump in my throat …"

This is a very common problem that affects men and women of varying ages.

While most patients complain of a feeling of a lump in the throat, other symptoms are effortful swallow, throat clearing and voice concerns. Patients may already be on an anti-acid medication such as “Lanzoprazole” or “Omeprazole”. Some patients may have a history of reflux disease and may even complain of a cough, mucoid secretions, choking, etc. Some doctors may measure the severity of your symptoms using a questionnaire called the Reflux Symptom Index. A score >13 is indicative of a significant problem.

As doctors, we believe that “common things are common” and thus, the diagnosis of Silent Reflux or Laryngo-Pharyngeal Reflux (LPR) is often made as it is the most common cause of these symptoms. There may of course be other concerning features about your symptoms or the clinical examination findings that make your GP or ENT doctor arrive at an alternative diagnosis or request more investigations.

Causes of Silent Reflux

The symptoms of Silent Reflux occur as a result of stomach acid getting into the throat and in and around the voice box. While the gullet is well built to withstand acidic contents, the same cannot be said for the throat and voice box (or larynx). Thus, even the smallest amounts of acid in this area will cause an irritation/ inflammation of the lining of the throat and voice box… hence the symptoms we already mentioned above.

It follows then that anything that causes acid to come into the throat will precipitate and perpetuate Silent Reflux. These factors include:

1.Being overweight - This puts pressure on the stomach causing a squeezing effect and is a common cause of reflux.

Advice: Weight loss.

2. Lifestyle

Food and drink: Caffeine, chilli, fatty foods, carbonated drinks, acidic juices, alcohol (especially white wine and spirits) will also drive Silent Reflux symptoms.

Advice: Avoid these foods or reduce your daily intake; Eat your fruit rather than drink it; Increase your water intake.

Work: People who work fast paced jobs, variable and unsociable hours often develop these symptoms as they eat at irregular times of the day and do not allow time for the stomach to empty. Stress (whether at the work place or elsewhere) also contributes to the the symptoms of reflux.

Advice: Plan meal times as best possible; Allow at least 3 hours between your last meal and going to bed; If you work variable hours, have smaller portions more regularly rather than one large meal; Where client hospitality plays an important role in your job, organise meetings around lunch time and choose the healthier option whilst your clients indulge. You could also choose alternate days of the week to schedule these meetings to allow your body recover. Stress management at work and home is important.

3. Other factors: Smoking, other medical problems, medication, some home made remedies (for example, drinking vast quantities of lemon juice as a ‘cleanser’) will all aggravate Silent Reflux.

Advice: Quit smoking - there is a lot of help out there to assist you with this, most importantly, your GP; If you have a diagnosis of reflux already, have a hiatus hernia, obesity and/or significant symptoms then I will advice you sleep with 2 pillows or more to reduce the back flow of acid into the throat when you are asleep.

In general, Silent reflux symptoms can be managed by modifying ones’ lifestyle. It is however important to discuss matters with your General Practitioner. Concerning features will include weight loss and food actually getting stuck in the throat. These symptoms ought to be reported clearly to your GP.

Furthermore, your GP may want to commence you on medication for the Silent Reflux or increase the dose if you are already on some medicines. This may take the form of one of the class of drugs called a Proton-Pump Inhibitor (PPI) … one of the “…prazoles” and an Alginate such as Gaviscon Advance. The former is usually taken half an hour before food and the latter is taken after meals and/or last thing at night. Your GP will make the appropriate decisions about the dosages and frequency of the drugs. Medication should always be used along side lifestyle modification. If necessary, your GP may also refer you to an ENT specialist for further review. Patients with significant voice problems as a result of the Silent Reflux can also see a Speech Therapist to restore the hygiene and function of the voice box.

TRANS - NASAL OESOPHAGOSCOPY

This is currently my favourite new ENT technology. It is a fiberoptic camera that is put down the nose into the throat and into the gullet. It is an Out-Patient procedure that is done while the patient is awake. A small amount of local anaesthetic is sprayed in the nostrils and in the mouth to make the procedure pain free. It is very well tolerated and is a good way of determining if there is anything of concern in the throat, voice box and the gullet all at once. The procedure lasts about 5 mins and the patient can watch the entire procedure on a video screen.

See under the “What’s new in ENT” section for more on this technology and how it is used in practice. DP Medical is a medical solutions company that offers this technology.

Treating Human Papilloma Virus (HPV) Related Head & Neck Tumours.

"A feeling of a lump in my throat..."