Hoarseness is a general term used to describe a change in the quality of one's voice. Voice disorders are important for two reasons: Firstly they can have a huge impact on the quality of your life. Communication with your family and friends may be difficult. Your livelihood may be jeopardised if you rely on your voice for your work. Secondly, voice change may be the first sign of a serious underlying medical condition, such as a cancer of the throat, or even a chest problem. Any voice change that lasts for more than 3 weeks should be investigated with an examination of your voice box. David is subspecialty trained in the diagnosis and treatment of voice disorders using the most up to date technology such as videostroboscopy. These voice disorders include: Nodules Polyp Cysts Reinke's oedema & Polypoid corditis Papilloma (Warts) Vocal process granuloma Carcinoma (Cancer) Atrophy Scar Web Sulcus vocalis Vascular lesions (Varix/Ectasia/Haemorrhage) Vocal cord paralysis Vocal cord paresis

Videostroboscopy is a specialised examination of the vocal folds (vocal cords) using an endoscope placed through the nose or mouth to examine the larynx (voice box) with a strobe light. This special light source allows assessment of the vibration of the vocal folds. The examination is recorded for detailed review and for following progress. David has a stroboscope in his consultation rooms and has extensive experience in the interpretation of this examination. David also performs videostroboscopy at the Voice Clinic at Auckland City Hospital and at North Shore Hospital.

If you find it difficult to pass food or liquid from your mouth to your stomach, you may have a swallowing disorder or dysphagia. Symptoms may include: a feeling that food is sticking in your throat, discomfort in your throat or chest, a sensation of a ‘lump’ in your throat, coughing or choking. A disorder may occur in any part of the swallowing process such as the mouth, pharynx (tube at the back of the throat that connects your mouth with your oesophagus), oesophagus (food pipe that takes food to your stomach) or stomach. Causes of dysphagia include: the common cold, gastro-oesophageal reflux, stroke or a tumour. Diagnosis may be by examination of a mucous sample or by viewing the pharynx, oesophagus and stomach using a small, flexible tube with a tiny camera on the end that is inserted down the back of your throat. Treatments for dysphagia depend on the causes, but may include: medication – antacids, muscle relaxants or medicine to slow down stomach acid production changes in diet and/or lifestyle surgery e.g. stretching or releasing a tightened muscle

Your tonsils are the oval-shaped lumps of tissue that lie on both sides of the back of the throat. Sometimes tonsils can become inflamed (red and swollen with white patches on them) as the result of a bacterial or viral infection; this is known as tonsillitis. If you have tonsillitis, you will have a very sore throat and maybe swollen glands on the side of your neck, a fever, headache or changes to your voice. In some cases, pus can be seen on the tonsils. Tonsillitis mostly occurs in young children and can be a recurrent condition (it keeps coming back). If the tonsillitis is caused by bacteria, antibiotics will be prescribed. If the tonsillitis is caused by a virus, treatment will usually consist of medications to relieve symptoms such as a pain killer. If tonsillitis occurs often over a period of two or more years, then surgical removal of the tonsils (tonsillectomy) may be considered.

Transoral Robotic Surgery (TORS) is a relatively new procedure to remove cancers from the throat, most commonly involving the tonsils or the base of tongue. TORS may also be used to remove cancers from other areas in the oropharynx (such as the soft palate and the posterior pharyngeal wall), as well as cancers in the hypopharynx (the lowest part of the throat) and in the larynx. During TORS, a team of two Head & Neck Surgeons operate through the mouth with the assistance of a surgical robot to remove cancers from the throat. The surgical robot has three arms that are placed inside the mouth of the patient. One arm holds a special camera (an endoscope) to visualize the throat, while the other two arms hold the surgical instruments used to grasp and cut tissue. The three arms of the robot are controlled by one of the surgeons sitting at a separate console away from the patient. The second surgeon sits at the head of the patient near the three arms to assist with the surgery. Using TORS, surgeons are able to access the throat to remove tumours that would otherwise require more involved and more invasive operations.

Head and neck cancer is a term used to describe a range of malignant tumours (cancers) that can occur in the throat, mouth, salivary glands, nose and sinuses. These cancers are classified and treated according to the location of the primary tumour, or where the cancer started in the head and neck. Head & neck cancers may spread from the primary site to the lymph nodes of the neck. Throat Cancer Throat cancers include cancers of the oropharynx (most commonly the tonsils and base of tongue), the larynx (the voice box), the nasopharynx (located behind the nasal cavities), and the hypopharynx (the lowest part of the throat adjacent to the oesophagus). Mouth Cancer Mouth cancer is also known as oral cancer. Oral cancers typically start as a white patch, a lump or an ulcer in the mouth. Salivary Gland Cancer Salivary gland cancers arise in the salivary glands in the head & neck. The salivary glands are classified as either major salivary glands: the parotid glands, the submandibular glands and the sublingual glands; or as minor salivary glands (in the mouth or throat). Sinonasal Cancer Sinonasal cancers are uncommon cancers that arise inside the nose (in the nasal cavities) or inside the paranasal sinuses (air-filled spaces in the head adjacent to the nasal cavities).

New Zealand has a very high rate of skin cancer, when compared to other countries. The most common forms of skin cancer usually appear on areas of skin that have been over-exposed to the sun. Risk factors for developing skin cancer are: prolonged exposure to the sun; people with fair skin; and possibly over-exposure to UV light from sun beds. There are three main types of skin cancers: basal cell carcinoma, squamous cell carcinoma and malignant melanoma. Basal Cell Carcinoma (BCC) This is the most common type and is found on skin surfaces that are exposed to sun. A BCC remains localised and does not usually spread to other areas of the body. Sometimes BCCs can ulcerate and scab so it is important not to mistake it for a sore. BCCs occur more commonly on the face, back of hands and back. They appear usually as small, red lumps that don’t heal and sometimes bleed or become itchy. They have the tendency to change in size and sometimes in colour. Treatment Often a BCC can be diagnosed just by its appearance. In other cases it will be removed totally and sent for examination and diagnosis, or a biopsy may be taken and just a sample sent for diagnosis. Removal of a BCC will require an appointment with a doctor or surgeon. It will be termed minor surgery and will require a local anaesthetic (numbing of the area) and possibly some stitches. A very small number of BCCs will require a general anaesthetic (you will sleep through the operation) for removal. Squamous Cell Carcinoma (SCC) This type of skin cancer also affects areas of the skin that have exposure to the sun. The most common area is the face, but an SCC can also affect other parts of the body and can spread to other parts of the body. The spreading (metastasizing) can potentially be fatal if not successfully treated. A SCC usually begins as a keratosis that looks like an area of thickened scaly skin, it may then develop into a raised, hard lump which enlarges. SCCs can sometimes be painful. Often the edges are irregular and it can appear wart like, the colour can be reddish brown. Sometimes it can appear like a recurring ulcer that does not heal. All SCCs will need to be removed, because of their potential for spread. The removal and diagnosis is the same as for a BCC. Malignant Melanoma This is the most serious form of skin cancer. It can spread to other parts of the body and people can die from this disease. A melanoma usually starts as a pigmented growth on normal skin. They often, but not always, occur on areas that have high sun exposure. In some cases, a melanoma may develop from existing pigmented moles. What to look for: • an existing mole that changes colour (it may be black, dark blue or even red and white) • the colour pigment may be uneven • the edges of the mole/freckle may be irregular and have a spreading edge • the surface of the mole/freckle may be flaky/crusted and raised • sudden growth of an existing or new mole/freckle • inflammation and or itchiness surrounding an existing or new mole/freckle. Treatment It is important that any suspect moles or freckles are checked by a GP or a dermatologist. The sooner a melanoma is treated, there is less chance of it spreading. A biopsy or removal will be carried out depending on the size of the cancer. Tissue samples will be sent for examination, as this will aid in diagnosis and help determine the type of treatment required. If the melanoma has spread more surgery may be required to take more of the affected skin. Samples from lymph nodes that are near to the cancer may be tested for spread, then chemotherapy or radiotherapy may be required to treat this spread. Once a melanoma has been diagnosed, a patient may be referred to an oncologist (a doctor who specialises in cancer). A melanoma that is in the early stages can be treated more successfully and cure rates are much higher than one that has spread.

Growths, lumps, tumours or masses on the head and neck can be benign (noncancerous) or cancerous and can form in the larynx, pharynx, thyroid gland, salivary gland, mouth, neck, face or skull. Tests to diagnose a mass may include: • Neurological examination – assesses eye movements, balance, hearing, sensation, coordination etc • MRI – magnetic resonance imaging uses magnetic fields and radio waves to give images of internal organs and body structures • CT Scan – computer tomography combines x-rays with computer technology to give cross-sectional images of the body • Biopsy – a sample of tissue is taken for examination under a microscope. Enlarged Lymph Nodes Lymph nodes in the neck often become swollen when the body is fighting an infection. Benign Lesions Noncancerous masses such as cysts are often removed surgically to prevent them from pressing on nerves and other structures in the head and neck. Cancer Cancerous masses spread to surrounding tissues and may be: • Primary – they arise in the head or neck. Mostly caused by tobacco or alcohol use • Secondary – they have spread from a primary tumour in another part of the body. Cancers may be treated by a combination of radiotherapy, chemotherapy and surgery.

Neck dissection is an operation in which the lymph nodes on one side of the neck are removed. This type of surgery is performed to treat cancer in the head & neck region.

There are three large pairs of glands (parotid, sublingual and submandibular) in your mouth that produce saliva which helps break down food as part of the digestion process. Salivary Gland Malfunction Salivary gland malfunction that results in a decrease in saliva production can be caused by conditions such as Parkinson’s disease, depression, HIV infection and chronic pain. Saliva production can also be decreased by certain medications such as some antidepressants, antihistamines and sedatives. Reduced saliva can lead to increased tooth decay and difficulty speaking and swallowing. Good dental care is important in this condition. In some cases, saliva substitutes can be helpful. Salivary Gland Swelling If the duct or tube carrying saliva from the gland to the mouth becomes blocked, the gland will swell. The glands can also swell as the result of mumps, bacterial infections and certain other diseases. If the duct is blocked by a stone, it can sometimes be squeezed or pulled out but may on occasion require surgery to remove it.

Parotidectomy: an incision (cut) is made in front of the ear and runs down below the jaw line. Part or all of the parotid gland is removed. Superficial Parotidectomy: an incision is made in front of the ear and runs down beneath the ear lobe. The superficial (top) lobe of the parotid gland is removed. Submandibular Gland Surgery: an incision is made just below the jaw bone and the submandibular gland removed.

When snoring is interrupted by episodes of totally obstructed breathing, it is known as obstructive sleep apnoea. The obstruction is caused by the relaxation of muscles that support the soft tissues at the back of the throat such as the uvula, soft palate, tongue and tonsils. These tissues then collapse and momentarily block the airway. Episodes may last 20 seconds or more and may occur hundreds of times per night. While you are not breathing, the levels of oxygen in your blood drop which causes your blood pressure to go up and adds strain to your cardiovascular system. In addition, you are likely to feel overly tired during the day and your work, driving and overall performance may be affected. The usual treatment for OSA is to wear a nasal mask that delivers pressurised air to keep the airways open while you sleep. This treatment is known as Continuous Positive Airway Pressure (CPAP).

Snoring is the harsh rattling noise made by some people when they sleep. Snoring occurs when the flow of air through the back of the mouth and nose becomes partially blocked and structures such as the tongue, soft palate (the back part of the roof of the mouth) and uvula (the tag that hangs at the back of the mouth) strike each other and vibrate. Causes of snoring include: nasal polyps; a bend in the nasal septum (the partition running down the middle of the nose), large tonsils or adenoids, obesity, smoking, excess alcohol. Surgical treatment of snoring involves the removal of excess loose tissue in the throat or soft palate.

In the facial bones surrounding your nose, there are four pairs of hollow air spaces known as sinuses or sinus cavities. These sinuses all open into your nose, allowing air to move into and out of the sinus and mucous to drain into the nose and the back of your throat. If the passage between the nose and sinus becomes swollen and blocked, then air and mucous can become trapped in the sinus cavity causing inflammation of the sinus membranes or linings. This is known as sinusitis. Sinusitis can be: acute - usually a bacterial (or sometimes viral) infection in the sinuses that follows a cold, or an allergic reaction. chronic - a long term condition that lasts for more than 3 weeks and may or may not be caused by an infection. Sinusitis can be a recurrent condition which means it may occur every time you get a cold. Symptoms of sinusitis include: facial pain or pressure nasal congestion (blocking) nasal discharge headaches fever. Treatment for bacterial sinusitis is antibiotics and for non-infective sinusitis may include steroid nasal sprays and nasal washes. If this treatment is unsuccessful, surgery may be considered. This is usually performed endoscopically; a tiny camera attached to a tube (endoscope) is inserted into your nose. Very small instruments can be passed through the endoscope and used to remove abnormal or obstructive tissue thus restoring movement of air and mucous between the nose and the sinus.

Rhinitis is the inflammation of the lining of the nose (nasal mucosa). The most common symptoms are a blocked, runny and itchy nose. Rhinitis can be: allergic – either seasonal (hay fever) caused by pollen allergies or perennial caused by e.g. house dust mite, pets. infectious – e.g. the common cold non-allergic, non-infectious – caused by irritants such as smoke, fumes, food additives In the case of allergic rhinitis, the specific allergen (the thing that you are allergic to) may be identified by skin prick tests. This involves placing a drop of the allergen on your skin and then scratching your skin through the drop. If you are allergic, your skin will become red and swollen at the site. Treatment of allergic rhinitis involves avoiding the allergen if possible, but if not possible then corticosteroid nasal sprays and antihistamines are the usual medications prescribed.

This is inflammation or infection of your middle ear (the space behind your eardrum) and is often associated with a build-up of fluid in your middle ear. Acute Otitis Media This is usually caused by a temporary malfunction of the Eustachian tube due to allergies, infections or trauma. The Eustachian tube connects the middle ear to the nose and allows air to enter the middle ear, thus making middle ear pressure the same as air pressure outside the head. Acute otitis media results in an infection in the middle ear causing pain, fever and a red, bulging eardrum (the thin, transparent membrane between the outer ear canal and the middle ear). This condition is usually seen in young children. The treatment may be antibiotics if it is suspected to be a bacterial, rather than viral, infection, or if there are repeated episodes, surgical insertion of grommets into the eardrums may be required. Grommets are tiny ventilation tubes that allow normal airflow into, and drainage out of, the middle ear until the Eustachian tube begins to work normally. The operation is done under general anaesthesia (the child is asleep) and takes 10-15 minutes. Most grommets fall out naturally after six to twelve months, by which time the Eustachian tubes are often working properly. Otitis Media with Effusion (Glue Ear) Like acute otitis media, glue ear is usually the result of a temporary malfunction of the Eustachian tube and may either follow an episode of acute otitis media or occur on its own. The condition is usually seen in children. Fluid is present in the middle ear and the ear is not usually painful, but the ear drum is not red and bulging and there is no fever. Glue ear may lead to hearing loss, which can result in speech delays, and balance problems. Treatment options include: a prolonged course of antibiotics; grommet insertion; or treatment with decongestants, antihistamines or steroids. Chronic Otitis Media If the Eustachian tube is blocked repeatedly over a period of several years, there may be changes to the tissues of the middle ear such as deformity of the ear drum and damage to the bones of the ear. These changes may result in hearing problems, balance problems, and persistent deep ear pain. If such long term damage has occurred, an operation called tympanomastoidectomy may be required. This involves making an incision (cut) behind or around the upper part of your ear, drilling through the mastoid bone and removing, and possibly repairing, damaged tissues.