Head and Neck Surgery

Each year more than 14 million new cases of malignant tumors are reported worldwide. Of these, the number of new cases of head and neck tumors is approximately 780,000. The very term “head and neck tumors” includes both benign and malignant tumors with different histopathological structures that are localized to the mucous membrane of the lips and mouth, larynx, pharynx, cervical esophagus, upper and lower jaw, large and small salivary glands, head and neck skin, thyroid gland, etc.

According to the Cancer Registry, every year up to 10 000 new cases of malignant tumors are registered in Georgia. It is an alarming fact that there is an inexorable increase in the number of new cancer cases every year, both globally and in Georgia.

The Mardaleishvili Medical Center provides surgical, medication, complex and combined treatment for head and neck tumors. Our clinic performs manipulations and surgeries of any complexity, from minimally invasive diagnostic procedures to advanced combined and reconstructive surgeries.

Our clinic carries out up to 3000 head and neck operations per year, including up to 1200 operations on patients with malignant tumors. Based on recent years’ statistics, 75-80% of the surgeries performed in Georgia for malignant head and neck tumors are performed at our institution.

In addition, about 150 surgical interventions are performed at our clinic during a year due to non-radical surgeries performed at other clinics.

The problem of thyroid cancer is particularly acute in contemporary oncology. According to the Georgian Cancer Registry, malignant thyroid tumors are second most common after breast cancer in women and fifth most common in the general population.

Over the last 30 years the number of malignant thyroid tumors has increased by 300%. The fact that the number of new cases of malignant thyroid tumors is increasing each year is alarming. At the same time there is a tendency for the disease to occur in younger patients.

The clinical course of thyroid tumors of differentiated forms, in contrast to many malignant tumors of other locations, is less aggressive, and the treatment results are correspondingly much better. The main symptom is a nodular mass in the thyroid gland, but in rare cases the disease may also present as metastatic nodules in the regional areas of the neck.

Thyroid tumors occur mainly in four forms. They are papillary, follicular, medullary and undifferentiated. Papillary tumors are the most common, and their treatment is much more effective than the other forms. Undifferentiated tumors have the worst prognosis.

Treatment

The main method of treatment for malignant tumors of the thyroid gland is surgery. In papillary and follicular tumors, depending on clinical and histological findings, radioiodine treatment may be necessary at a later stage.

Rehabilitation

Rehabilitation after surgery is usually quite easy and the patient quickly goes back to a normal pace of life. In the case of malignant tumors of the thyroid gland, the patient needs lifelong levothyroxine replacement therapy. In addition, patients need to be monitored for a certain period of time to detect a possible recurrence of the disease in good time.

At the Mardaleishvili Medical Center, if necessary, a neuromonitoring machine is used during the operation to visualize the innervated nerves, minimizing the risk of postoperative complications such as changes in voice timbre and breathing difficulties.

For maximum cosmetic effect after thyroid surgery at the Mardaleishvili Medical Center, minimal incisions are made and the wound is closed with non-traumatic sutures (subcutaneous sutures or special glue).

Our surgical team headed by Mr. Konstantin Mardaleishvili since 1984, consists of highly qualified endocrine surgeons. According to recent statistics, 75-80% of the operations done in Georgia due to malignant thyroid tumors are performed in our clinic.

In addition, Mardaleishvili Medical Center performs 100-120 repeated operations annually in connection with non-radical operations performed on the thyroid gland in other clinics in Georgia and abroad. This is due to the fact that in many cases the wrong treatment tactics and the scale of surgery are chosen in non-specialized facilities.

Both benign and malignant tumors can develop in the larynx. Clinical manifestations depend on the location of the tumor in the larynx, the most common being a change in voice quality, difficulty in breathing, a foreign body sensation in the throat and pain radiating to the ear – although in some cases the disease may be asymptomatic. Benign laryngeal tumors include fibroma, polyp, papilloma (juvenile, adult), hyperplastic laryngitis and others. Laryngeal cancer is the most common malignant tumor of the upper respiratory tract. Its causes are tobacco smoking (94-97% of patients are smokers) and chronic inflammatory processes, alcohol, prolonged breathing of polluted air, and the long-term presence of benign tumors. Early detection is crucial for the treatment of laryngeal cancer, which requires:

  • Initial examination of the patient: indirect laryngoscopy;
  • Fibrolaryngoscopy is one of the most informative examinations for laryngeal cancer. During this examination, not only can all parts of the larynx be examined in detail without harming the patient, but also a biopsy can be taken for further cytological and histomorphological examination of the material;
  • Larynx CT, which is important for assessing the spread of disease and invasion of the cartilaginous part of the larynx.
  • Neck ultrasound – to see the condition of the regional lymph collectors (to exclude their metastatic involvement);
  • If a lymph node is suspected of being metastatic, it should be biopsied with a fine needle, followed by cytology.

In case of laryngeal cancer the treatment at the Mardaleishvili Medical Center is done by a multidisciplinary team (surgeons, radiologists, clinical oncologists and radiotherapists).

Experienced and qualified specialists carry out surgeries of varying complexity in our clinic: from endolaryngeal (organ-sparing) laser microsurgery to total laryngeal excision along with the regional lymphatic system of the neck.

At the Mardaleishvili Medical Centre, radiation and chemotherapy treatments are also carried out by highly qualified specialists using state-of-the-art equipment and instrumentation.

The parotid gland’s main function is the production of saliva, which passes into the oral cavity through the Stensen’s duct. The saliva produced is mainly serous and contains important substances such as lysozyme,  amylase and IgA, which play an important role in improving oral cavity  lubrication, buffering and immunological properties and maintaining the mineral balance of the teeth. In addition, the parotid salivary gland provides lymphatic drainage of the soft tissues of the face and the corresponding half of the skull. Therefore, in practice we are confronted not only with diseases of the parotid  salivary gland, but also with the spread of malignant tumor metastases of the scalp, soft tissues of the upper face through the lymphatic channels.

The practice of head and neck surgeons of Mardaleishvili Medical Center cover the following diseases of the parotid gland: 1. Sialolithiasis (blockage of an excretory duct due to stone disease, which causes secondary inflammatory processes, development of sialadenitis), 2. Benign and malignant tumors of the parotid  gland:

  • Pleomorphic adenoma -60%
  • Mucoepidermoid carcinoma 20%
  • Monomorphic adenoma -10%
  • Adenocystic carcinoma -4%
  • Adenocarcinoma -4%
  • Undifferentiated carcinoma 1%
  • Metastatic carcinoma -1%.

The Department of Head and Neck Surgery at Mardaleishvili Medical Center treats parotid  gland cancers with great experience and success. Partial and complete parotid  gland excisions are performed in daily practice, depending on the nature and spread of the disease. The vast majority of such operations are carried out in our clinic with all branches of the facial nerve retained. This is the result of enormous experience gained over the years, a constant striving for modernity, a clear example of which is the use of state-of-the-art intraoperative neuromonitoring equipment in our clinic in daily practice, resulting in digital monitoring of facial nerve branches intraoperatively, in addition to visual monitoring, which ultimately enables patients to live a full life. In addition to the above, unfortunately, there are cases (mainly with malignant tumors) where the disease innervates one or more branches of the facial nerve. In this case, functional reconstructive surgeries are performed along with oncological surgery, when we reinnervate the damaged areas with the help of allograft  resulting in restoration of not only the action of facial mimic muscles, but also of vital functions.

The oral cavity is the initial part of the digestive tract where the primary chemical and mechanical processing of food takes place. It is lined with multi-layered squamous epithelium. The oral cavity is the integrity  of organs (tongue, lips, palate, teeth, salivary glands, periodontium, jaws), each of which is involved in food intake – grinding, biting and swallowing. If one of the above-mentioned organs does not perform its function properly, the other organs become functionally overloaded and this causes injury to them and leads to various kinds of diseases. The impairment of the function of the above organs can be caused by various reasons. For example: bad habits (smoking, biting the lips, chewing the tongue, etc.); wrongly positioned teeth, improperly made dentures and more.

One of the main risk factors for oral tumors is chronic trauma, excessive use of tobacco and alcohol. Papillomavirus is also an important risk factor. Most oral tumors are self-diagnosed by the patient, and most patients see a doctor afterwards. Mostly it is the dentist who refers the patient to a specialist clinic.

Self-examination,  occurrence of pain syndrome play a major role in the detection of oral tumors. Routine visits to the doctor and, if in doubt, referral to a specialist clinic play a major role. It is also important to study the morphology of the excised material in order to determine the genesis of the mass.

The National Cancer Institute (seer.cancer.gov) reports that oral cancer accounts for 2.9% of new cancer cases in the United States and the 5-year survival rate is 64.5%.

If a mass is found in the mouth, it is diagnostically advisable to perform cytology and morphology to determine the genesis of the mass. In the case of malignancy, additional examinations are carried out and the correct treatment is decided by a multidisciplinary team meeting based on international guidelines. As the oral cavity itself includes separate organs, its treatment is also different. Improper treatment leads to a recurrence of the disease and often death.

The Mardaleishvili Medical Center develops the right treatment strategy for patients with malignant oral tumors. In cases where a patient cannot be cured by conservative methods, various types of unique surgeries are performed to improve the patient’s quality of life and give them the chance to live without malignancy.

In everyday practice, we often deal with  facultative precancerous skin diseases such as keratomas, senile keratoses, keratoacanthomas, skin horns, lichen planus, atheromas, dermal and epidermal cysts and papillomas. They are treated according to current guidelines; depending on the size and anatomical location of the tumor, we use cryodestruction, close-focus radiation therapy, conservative surgical methods, and laser surgery.

Our medical practice is also associated with the detection of obligate  precancerous skin diseases, such as Dubreuil’s melanosis, lentigo melanocytic dysplasia, and nevi. Treatment is mainly surgical, after which patients are followed up on an outpatient basis. In people in their 5th, 6th and 7th decade of life, tumor diseases of the scalp and skin of  different localizations are common, most of which are basal cell carcinoma of the skin (also known as basalioma). We perform surgical treatment for this pathology in compliance with oncological principles. The surgery is radical, after which it is often necessary to close the tissue defect with local tissue, and we perform plasty with rotating or loose flaps. After the treatment the patients remain under outpatient observation, which allows us to dynamically monitor the wound condition, in case of recurrence of the disease, its early detection. Squamous cell skin cancer is often diagnosed, and in its early stages we treat it with close focused X-ray therapy or cryodestruction and with CO2 laser, available at our clinic. In case of large tumor radiotherapy or extensive surgical excision of the tumor is indicated. In cases of lymph node damage we perform lymphodissection of the corresponding lymphatic metastases.

Melanoma of the skin deserves special attention, as it is an aggressive tumor with a complex approach that involves radical excision of the disease through surgery and, if necessary, further treatment with radiation, chemotherapy or immunotherapy.

At the Mardaleishvili Medical Center the treatment of cancer patients is carried out in strict compliance with modern oncological principles and international recommendations. Thanks to many years of experience and professionalism, not only Georgian patients are treated in our clinic, but also a considerable flow of patients from other countries.

There are different types of jaw tumors (benign, malignant)  that can develop directly from bone tissue or from surrounding tissue (mucosa, dental tissue, etc.). Clinical manifestations of jaw tumors are pain, face and bone deformation, loose teeth, spreading of the tumor into the nasal cavity, upper jaw cavity, eye-pit, etc.

Causes of malignant tumors of the jaw include single or chronic trauma (injury to the gum mucous membrane by the edge of a decayed tooth, stones, tooth filling edge, a crown or a denture that has been incorrectly fitted), chronic inflammatory processes (periodontitis, sinusitis, actinomycosis, osteomyelitis of the jaw), and exposure to various chemical and physical factors (ionizing radiation, tobacco, alcohol, etc.). In addition, metastases of malignant tumors of different organs (breast, kidneys, thyroid, pituitary gland, etc.) can occur in the upper and lower jaw. Benign tumors of the jaw are: ameloblastoma, odontoma, cementoma, osteoma, osteoblastoclastoma, hemangioma as well as cystic neoplasms – the leading role in the treatment of all these formations belongs to surgery. In the case of malignant tumors (cancer, sarcoma) surgery is the leading treatment and in some cases the only option.

At the Mardaleishvili Medical Center surgical treatment of cancerous pathologies of the upper and lower jaw is performed by experienced and highly qualified specialists, using modern technology and materials, which in itself determines the effectiveness of the treatment. In addition to jaw cancer, skeletal anomalies of the jaw and teeth are surgically corrected at the Mardaleishvili Medical Center.

Saliva is secreted by three paired large salivary glands (submandibular salivary glands,   parotid salivary glands and sublingual  salivary glands) and scattered minor salivary glands located in the oral mucosa (lips, cheeks, tongue and palate). Minor salivary glands are a few millimeters in diameter. They are located in the submucosal layer of the oral mucosa. Both benign and malignant diseases can develop in the salivary glands.

The minor  salivary gland is a kind of ‘sac’ with one duct. Its inner surface is covered with salivary cells. Viscous saliva flows through the duct to the surface of the mucous membrane and moistens it. The most common disease of the minor salivary gland is a retention cyst of the minor salivary gland, because its weak point is the duct. It is microscopically small, so it is very easy to damage it even with a small trauma to the mucosa. For example, any mechanical trauma, burns, both thermal and chemical cause blockage of the secretory duct,  saliva can no longer be excreted in the mouth, but at the same time the gland itself continues to function and continues to actively produce saliva. Small retention cysts of the salivary glands are the most common and the only radical method of treatment is surgery. Self-treatment and unskilled medical careб such as mechanical impact on an existing mass and thermal irritation, may cause malignization (malignant transformation) of the disease, which drastically changes the tactics and scope of further treatment.

The submandibular salivary gland is located in the submandibular triangle and is easily palpated by hand, especially when enlarged. Its duct opens in the sublingual caruncles. The sublingual salivary gland is the smallest independent salivary gland. It has an elongated ovoid shape and is located at the base of the tongue, under the hyoid fold. The sublingual  gland has two types of ducts, the large sublingual  duct, which together with the duct of the submandibular gland opens into the sublingual caruncles, and the minor sublingual  ducts, which open in a single row along the entire length of the hyoid fold. Among the benign diseases of the submandibular and sublingual salivary glands, the most common is salivary gland stones, which cause blockage of the excretory duct and subsequently develop an inflammatory process in the salivary gland, which in turn leads to an increase in the salivary glands, swelling, pain, especially when eating, as the saliva cannot be excreted in the mouth. In these cases, surgical treatment is necessary, the maximum extent of which is extirpation of the salivary gland. With regard to malignant processes, the treatment tactic is determined according to the spread of the disease.

All possible algorithms for the treatment of benign and malignant diseases of small and large salivary glands have been implemented and tested for 20 years at the Mardaleishvili Medical Center. For benign processes, the maximum extent of treatment is limited to minimally invasive surgery while for malignant processes, depending on the spread of the disease, a combination of surgery, radiotherapy and medication (chemotherapy) and their different combinations is applied.

The highly qualified staff at the Mardaleishvili Medical Center, together with international colleagues and on the basis of recommendations provided by the US National Cancer Research Group (NCCN) through the board, selects the radical, correct and individual treatment tactics for a particular disease for each patient.

The Department of Head and Neck Diseases at Mardaleishvili Medical Center performs surgical interventions of varying complexity to treat metastatic lesions of the lymphatic collector  of the neck.

What is the lymphatic system?

The lymphatic system is a component of the body’s fluid environment. It includes lymphatic vessels in which lymph, an intercellular fluid, is constantly moving. It flows out of the organs and into the venous system. The movement of lymph in the lymphatic system helps maintain the balance of the tissue fluid in the body. Lymph is a nearly colorless, slightly yellowish fluid.

Lymph nodes

There are more than 150 groups of lymph nodes in the human body. The nodes are round or oval, mostly between 0.5 mm and 1 cm, but much larger nodes can also be found. Depending on the condition of the lymph nodes, infection or inflammation can be suspected. Normal lymph nodes do not cause any discomfort, but with inflammation or metastatic lesions they become painful and enlarged, which requires serious attention.

Function of the lymph nodes

  • Toxic substances are neutralized here.
  • Each lymph node or group of nodes collects and controls lymph in a specific part of the body
  • The lymph node is the body’s biological filter.
  • It has a barrier and protective function, destroys many microbes with the help of numerous macrophages
  • Participates in specific immune reactions

Cervical lymph nodes

Cervical lymph nodes protect against the spread of various kinds of tumors and inflammatory processes. Some are located deep in the tissues, while others are relatively superficial. The lymph nodes in the neck and back of the neck form a kind of chain and are the first signaling organs for certain inflammatory and malignant processes in the head and neck.

At the Mardaleishvili Medical Center, the diagnosis of altered (enlarged, painful) lymph nodes is carried out using modern technology. With the help of the latest computed tomography equipment, ultrasound imaging is done to visualize superficial or deep lymph nodes and then cytology is carried out to determine the underlying cause.

In malignant diseases of the head and neck, secondary damage (metastasis) occurs primarily in the lymph nodes in the neck. They are the first to react and have a protective function, preventing the spread of the disease. The lymph nodes retain (block) the malignant cells in their tissue, resulting in their (lymph nodes) degeneration (enlargement). Metastasized lymph nodes must be removed (in whole or partially).

At the Mardaleishvili Medical Center, under the direction of Professor Konstantin Mardaleishvili, highly qualified oncology surgeons perform radical surgical treatment on the lymphatic collection of the neck. Our clinic’s 20 years of experience, professionalism as well as the latest technology ensure the highest rates of patient recovery.