Mouth ulcer
of mouth

Mouth ulcers are common and can usually be managed at home, without seeing your dentist or GP.



cheeks lips tongue

They can be white, red, yellow or grey in colour and swollen.

You may have more than one mouth ulcer at a time and they may spread or grow.

Mouth ulcers shouldn’t be confused with cold sores, which are small blisters that develop on the lips or around the mouth. Cold sores often begin with a tingling, itching or burning sensation around your mouth.

Causes

In many cases, the reason for mouth ulcers is unclear. Most single mouth ulcers are caused by damage to the lining inside of the mouth. For example:

accidentally biting the inside of your cheek or a sharp tooth poorly fitting dentures hard food a faulty filling

It’s not always clear what causes mouth ulcers that keep returning, but triggers are thought to include:

stress and anxiety hormonal changes – some women develop mouth ulcers during their monthly period eating certain foods – such as chocolate, spicy foods, coffee, peanuts, almonds, strawberries, cheese, tomatoes and wheat flour toothpaste containing sodium lauryl sulphate stopping smoking – when you first stop smoking, you may develop mouth ulcers

Your genes are also thought to have a role. Around 40% of people who keep getting mouth ulcers report that it runs in their family.

Medical conditions

Mouth ulcers can sometimes be caused by certain medical conditions, such as:

viral infections – including the cold sore virus, chickenpox, and hand, foot and mouth disease vitamin B12 or iron deficiency crohn’s disease – a long-term condition that causes inflammation of the lining of the digestive system coeliac disease – a common digestive condition where a person has an adverse reaction to gluten reactive arthritis – a condition that causes inflammation in various places in the body, usually as a reaction to an infection weakened immune system – for example, due to HIV or lupus behçet’s disease – a rare and poorly understood condition that also causes swelling of the blood vessels

Medications and treatments

Mouth ulcers can sometimes be caused by certain medications or treatments, such as:

non-steroidal anti-inflammatory drugs (NSAIDs) – such as ibuprofen nicorandil – a medication sometimes used to treat angina beta-blockers – used to treat conditions such as angina, high blood pressure and abnormal heart rhythms a side effect of chemotherapy or radiotherapy – this is known as mucositis

Is it mouth cancer?

In a few cases, a long-lasting mouth ulcer can be a sign of mouth cancer. If mouth cancer is detected early, the chances of a complete recovery are good. Regular dental check-ups are the best way to detect the early signs.

Treatments

Speak to a pharmacist if: you have a mouth ulcer They can give you advice and treatment.

If you have a dental problem you should always phone your dentist first. If you’re not registered with any dental practice then you should read our advice on dental emergencies.

Your pharmacist may advise that you see your GP or dentist if:

your mouth ulcer has lasted 3 weeks you keep getting mouth ulcers the mouth ulcer grows bigger than usual or is near the back of your throat your mouth ulcer becomes more painful or red – this could be a sign of a bacterial infection, which may need treatment with antibiotics

Mouth ulcers are also a possible symptom of hand, foot and mouth disease. Speak to your GP or phone 111 if you’re unsure.


Most mouth ulcers clear up by themselves within 1 to 2 weeks without treatment.

However, treatment can help to reduce swelling and ease any discomfort. This may help if you keep getting mouth ulcers or your mouth ulcer affects eating and drinking.

Self care

There are things you can do to speed up healing.

Do use a soft toothbrush to brush your teeth drink cool drinks through a straw eat softer foods get regular dental check-ups eat a healthy, balanced diet try to reduce stress and anxiety

Don’t do not eat very spicy, salty or acidic food do not eat rough, crunchy food, such as toast or crisps do not drink very hot or acidic drinks, such as fruit juice do not use chewing gum do not use toothpaste containing sodium lauryl sulphate

Pharmacy medicines

You can get several types of mouth ulcer treatment from a pharmacy. Speak to your pharmacist about the best treatment for you.

Treatment from a dentist or GP

A GP or dentist may prescribe stronger medicine to treat severe, persistent or infected mouth ulcers.

Possible treatments include:

steroid mouth spray or steroid tablets that dissolve in your mouth painkilling gels, ointments, sprays or tablets mouthwashes to kill or remove any germs in your mouth

Multiple myeloma
of cancer, cancer types in adults

Multiple myeloma, also known as myeloma, is a type of bone marrow cancer.

Bone marrow is the spongy tissue found at the centre of some bones. It produces the body’s blood cells. Multiple myeloma affects the plasma cells (a type of blood cell) inside the bone marrow.

Myeloma does not usually take the form of a lump or tumour. Instead, the myeloma cells divide and expand within the bone marrow, damaging the bones and affecting the production of healthy blood cells.

Myeloma often affects many places in the body, which is why it is called multiple myeloma. Commonly affected areas include the spine, skull, pelvis and ribs.

Symptoms

In the early stages, myeloma may not cause any symptoms. It’s often only suspected or diagnosed after a routine blood or urine test.

However, myeloma will eventually cause a wide range of problems, including:

a persistent dull ache or specific areas of tenderness in your bones weak bones that break (fracture) easily tiredness, weakness and shortness of breath (caused by anaemia) repeated infections less commonly, bruising and unusual bleeding – such as frequent nosebleeds, bleeding gums and heavy periods

Read more about the symptoms of multiple myeloma


In the early stages, multiple myeloma may not cause any symptoms or complications, and may only be diagnosed after a routine blood or urine test.

However, it will eventually cause a wide range of problems.


As well as the main treatments for multiple myeloma, you may also need treatment to help relieve some of the problems caused by the condition.

For example:

painkillers – may be given to reduce pain radiotherapy – may be used to relieve bone pain or help healing after a bone is surgically repaired bisphosphonate medication – either given as tablets or by injection, this may help prevent bone damage and reduce the levels of calcium in your blood blood transfusions or erythropoietin medication – may be used to increase your red blood cell count and treat anaemia surgery – may be carried out to repair or strengthen damaged bones, or treat compression of the spinal cord (the main column of nerves running down the back) dialysis – may be required if you develop kidney failure plasma exchange – treatment to remove and replace a blood component called plasma may be carried out if you have unusually thick blood (hyperviscosity)

These treatments can each cause side effects and complications, so make sure you discuss the potential risks and benefits with your treatment team beforehand.

Causes

In multiple myeloma, cells inside the bone marrow called plasma cells become cancerous.

Bone marrow is the spongy tissue found at the centre of some bones. It produces the body’s blood cells.

Plasma cells are normally produced in a controlled way. In cases of multiple myeloma, large numbers of abnormal plasma cells are produced. These fill up the bone marrow and interfere with the production of other cells, such as red and white blood cells.

The exact reason why this happens is unknown, but multiple myeloma is closely associated with a condition called monoclonal gammopathy of unknown significance (MGUS), and there are certain things that can increase your risk of developing it.

Diagnoses

Multiple myeloma can be difficult to diagnose because it’s an uncommon type of cancer that initially has few or no symptoms.

Your GP will examine you and ask about your symptoms, medical history and overall health. During the examination, your GP will look for things such as bleeding, signs of infection and specific areas of bone tenderness.

You may need urine and blood tests to check for certain types of antibodies and proteins (immunoglobulins).

If multiple myeloma is suspected, you will be referred to a haematologist (a doctor who specialises in conditions affecting the blood) for further tests and scans.


A number of blood tests are used to help diagnose multiple myeloma, and they may need to be repeated to monitor the condition.

These may include:

erythrocyte sedimentation rate (ESR) or plasma viscosity (PV) – if you have multiple myeloma, your ESR or PV will usually be raised tests to measure the type and number of abnormal antibodies produced by the cancerous plasma cells a full blood count (FBC) to check levels of different types of blood cells – your doctor will be looking for a low number of red blood cells and platelets liver and kidney function blood calcium level


A urine sample will be checked for the abnormal proteins produced by the cancerous plasma cells. The abnormal proteins are known as monoclonal light chains, or Bence Jones protein.

These proteins can damage your kidneys as they pass through them from your blood to your urine. You may be asked to collect your urine over a 24-hour period. This will be used to check the quantity of proteins being produced and how well your kidneys are working.

Treatments

Speak to your GP if you have any of these symptoms. While they’re unlikely to be caused by cancer, it’s best to get a proper diagnosis.

Your GP will examine you to check for bone tenderness, bleeding, signs of infection, and any other symptoms that suggest you may have myeloma.

They may also arrange blood and urine tests that can detect abnormal proteins produced by myeloma cells.

If myeloma is suspected, you will be referred to a consultant haematologist (a specialist in blood conditions) for further tests and treatment.

Read more about diagnosing multiple myeloma


There is currently no cure for multiple myeloma, but treatment can often help control it for several years.

Treatment will often involve:

a combination of anti-myeloma medications to destroy the myeloma cells medicines and procedures to prevent and treat problems caused by myeloma, such as bone pain, fractures and anaemia anti-myeloma medicines to control the cancer when it comes back (relapses)

As part of your treatment, you may be asked if you want to take part in a clinical trial to help researchers develop better treatments for multiple myeloma.

Read more about treating multiple myeloma


You should speak to your GP if you have symptoms of multiple myeloma. While they’re unlikely to be caused by cancer, it’s best to be sure by getting a proper diagnosis.

You should seek immediate medical help if you have symptoms of spinal cord compression, hypercalcaemia or kidney failure, as these are medical emergencies that need to be investigated and treated as soon as possible.

Read more about diagnosing multiple myeloma and treating multiple myeloma


If you have multiple myeloma, you will be cared for by a team, which is usually led by a consultant haematologist who specialises in myeloma.

The team will discuss your condition and recommend the best treatment for you. However, the final decision will be yours.

Before visiting hospital to discuss your treatment options, it may be useful to write a list of questions to ask the specialist. For example, you may want to find out the advantages and disadvantages of a particular treatment.

There are 2 main aims in treating multiple myeloma:

to bring the myeloma under control to prevent and treat problems associated with myeloma, such as anaemia and bone pain

While treatment can often control myeloma and improve quality of life, myeloma usually can’t be cured. This means additional treatment is needed when the cancer comes back (a relapse).

Not everyone diagnosed with myeloma will need immediate treatment if the condition is not causing any problems. This is sometimes referred to as asymptomatic, or smouldering myeloma.

If you don’t need treatment, you’ll be monitored for signs the cancer is beginning to cause problems. If you do need treatment, the following options are most commonly used.


Further treatment is needed if myeloma returns. Treatment for relapses is generally similar to initial treatment, although non-intensive treatment is often preferred to further intensive treatment.

Additional medications such as lenalidomide, pomalidomide and other chemotherapy medicines may be added, or used again as your haematologist feels is appropriate.

You may also be asked if you want to participate in clinical trial research into new treatments for multiple myeloma.

Lenalidomide and pomalidomide

Lenalidomide and pomalidomide are similar to thalidomide. They’re both taken by mouth, and both can have an effect on the cells produced by your bone marrow, which can cause:

increased risk of infection – as a result of a low number of white blood cells anaemia – caused by a low number of red blood cells bruising and bleeding – because of a low platelet count

They may also increase your risk of developing a blood clot and have other side effects similar to thalidomide.

Let your care team know if you experience any problems or unusual symptoms while taking lenalidomide or pomalidomide.


As well as the main treatments for multiple myeloma, you may also need treatment to help relieve some of the problems caused by the condition.

For example:

painkillers – may be given to reduce pain radiotherapy – may be used to relieve bone pain or help healing after a bone is surgically repaired bisphosphonate medication – either given as tablets or by injection, this may help prevent bone damage and reduce the levels of calcium in your blood blood transfusions or erythropoietin medication – may be used to increase your red blood cell count and treat anaemia surgery – may be carried out to repair or strengthen damaged bones, or treat compression of the spinal cord (the main column of nerves running down the back) dialysis – may be required if you develop kidney failure plasma exchange – treatment to remove and replace a blood component called plasma may be carried out if you have unusually thick blood (hyperviscosity)

These treatments can each cause side effects and complications, so make sure you discuss the potential risks and benefits with your treatment team beforehand.

Complications

As well as the main treatments for multiple myeloma, you may also need treatment to help relieve some of the problems caused by the condition.

For example:

painkillers – may be given to reduce pain radiotherapy – may be used to relieve bone pain or help healing after a bone is surgically repaired bisphosphonate medication – either given as tablets or by injection, this may help prevent bone damage and reduce the levels of calcium in your blood blood transfusions or erythropoietin medication – may be used to increase your red blood cell count and treat anaemia surgery – may be carried out to repair or strengthen damaged bones, or treat compression of the spinal cord (the main column of nerves running down the back) dialysis – may be required if you develop kidney failure plasma exchange – treatment to remove and replace a blood component called plasma may be carried out if you have unusually thick blood (hyperviscosity)

These treatments can each cause side effects and complications, so make sure you discuss the potential risks and benefits with your treatment team beforehand.

Multiple sclerosis (MS)
of brain nerves and spinal cord

It’s a lifelong condition that can sometimes cause serious disability. In many cases, it’s possible to treat symptoms. Average life expectancy is slightly reduced for people with MS.

MS Society estimates that there are more than 130,000 people diagnosed with MS in the UK.

It’s often diagnosed in people in their 20s and 30s, although it can develop at any age. It’s about two to three times more common in women than men.


MS Society estimates that there are more than 130,000 people diagnosed with MS in the UK.

It’s often diagnosed in people in their 20s and 30s, although it can develop at any age. It’s about two to three times more common in women than men.


It’s often diagnosed in people in their 20s and 30s, although it can develop at any age. It’s about two to three times more common in women than men.

Symptoms

Multiple sclerosis (MS) can cause a wide range of symptoms and can affect any part of the body. It affects everyone differently.

The symptoms are unpredictable. Some people’s symptoms develop and worsen over time, while for others, they come and go.

Periods when symptoms get worse are known as relapses. Periods when symptoms improve or disappear are known as remissions.

Some of the most common symptoms include:

Muscle spasms, stiffness and weakness MS can cause your muscles to: feel weak become stiff and resistant to movement (spasticity) contract tightly and painfully (spasm)

Vision problems In around 1 in 4 cases of MS, the first noticeable symptom is a problem with one of your eyes (optic neuritis). You may experience: some temporary loss of vision in the affected eye, usually lasting for days to weeks colour blindness  eye pain, which is usually worse when moving the eye flashes of light when moving the eye You might also experience double vision or involuntary eye movements, which can make it seem as though objects are jumping around.

Abnormal sensations You might have persistent numbness or tingling in different parts of your body which can last a few days to weeks.

Mobility problems MS can make walking and moving around difficult, particularly if you also have muscle weakness and spasticity. You may experience: clumsiness difficulty with balance and co-ordination (ataxia) shaking of the limbs (tremor) dizziness and vertigo, which can make it feel as though everything around you is spinning

Pain Some people with MS experience pain which can take two forms. Pain caused by MS itself (neuropathic pain) This is pain caused by damage to the nervous system, and can include: stabbing pains in the face stabbing sensations in the torso (body) and limbs feeling like you’re burning pins and needles feeling like you’re being hugged or squeezed Muscle spasms can sometimes be painful. Musculoskeletal pain This can be back, neck and joint pain particularly if you have problems walking or moving around.

Bladder problems Bladder problems are common in MS. They may include: having to pee more often having a sudden, urgent need to pee, which can lead to unintentionally passing urine (urge incontinence) difficulty emptying the bladder completely having to get up during the night to pee recurrent urinary tract infections These problems can also have a range of causes other than MS.

Bowel problems Many people with MS also have problems with their bowel function. Constipation is the most common problem. You may find passing stools (poo) difficult and pass them much less than normal. Bowel incontinence is less common, but is often linked to constipation. If a poo becomes stuck, it can irritate the wall of the bowel, causing it to produce more fluid and mucus that can leak out of your bottom. Some of these problems aren’t specific to MS and can be the result of medications.

Sexual problems MS can have an effect on sexual function. For women, problems include difficulty reaching orgasm. They might experience decreased vaginal lubrication and sensation. Men with MS might find it hard to get or maintain an erection (erectile dysfunction). They may also find it takes a lot longer to ejaculate when having sex or masturbating. They might lose the ability to ejaculate altogether. Both men and women with MS may find they’re less interested in sex than they were before. This could be directly related to MS, a mood disorder like depression, or it could be the result of living with the condition.

Speech and swallowing difficulties Some people with MS have difficulty chewing or swallowing (dysphagia) at some point. They might also slur their speech or be difficult to understand (dysarthria).

Fatigue Feeling fatigued is a common and troublesome symptom of MS. It can cause an overwhelming sense of exhaustion that means it’s a struggle to carry out simple tasks. Fatigue tends to get worse: towards the end of each day in hot weather after exercising during illness

Mental health issues Many people with MS experience periods of depression. It’s unclear if this is directly caused by MS, or is due to the stress of having to live with a long-term condition, or both. Anxiety can also be a problem for people with MS, possibly due to the unpredictable nature of the condition. In rare cases, people with MS can experience rapid and severe mood swings.

Problems with thinking, learning and planning Some people with MS have problems with thinking, learning and planning. This is known as cognitive dysfunction and can include: problems learning and remembering new things although long-term memory is usually unaffected slowness in processing lots of information or multi-tasking a shortened attention span getting stuck on words problems with understanding and processing visual information, such as reading a map difficulty with planning and problem solving – people often report that they know what they want to do, but can’t grasp how to do it problems with reasoning, such as mathematical laws or solving puzzles Many of these problems aren’t specific to MS. They can be caused by other conditions, including depression and anxiety or medication.

Speak to your GP if: you think you have symptoms of MS The symptoms can be similar to several other conditions, so they’re not necessarily caused by MS. 

Causes

Exactly why someone develops multiple sclerosis (MS) isn’t known. It’s not caused by anything you’ve done and it’s not clear if you can prevent it.

It’s likely to be partly caused by genes you inherit from your parents and partly by outside factors that may trigger the condition.

Some of the factors that might cause MS include:

Your genes MS isn’t directly inherited, but if you’re related to someone with the condition you’re more likely to develop it. The chance of a sibling or child of someone with MS also developing it is around 2-3%.

Lack of sunlight and vitamin D MS is more common in countries far from the equator. This could mean that a lack of sunlight and low vitamin D levels may play a role in the condition. It’s not clear whether vitamin D supplements can help prevent MS.

Smoking People who smoke are about twice as likely to develop MS compared to those who don’t smoke.

Viral infections Infections, particularly those caused by the Epstein-Barr virus, (responsible for glandular fever), might trigger the immune system, leading to MS in some people.

More research will help us understand why MS occurs and whether it can be prevented or not.

Diagnoses

It can be hard to tell if you have multiple sclerosis (MS) because some of the symptoms are like other conditions. You may need to rule out other possible causes of your symptoms first.

If your GP thinks you could have MS, you should see a neurologist (a specialist in conditions of the nervous system) for a specialist assessment.

Some of the tests you may need to confirm MS are:

neurological examination magnetic resonance imaging (MRI) scan lumbar puncture blood test

Types of MS

Once you have a diagnosis of MS, your neurologist might be able to identify which type of MS you have – either relapsing remitting MS or primary progressive MS.

This will largely be based on:

the pattern of your symptoms – like whether you experience periods when your symptoms get worse (relapses) then improve (remissions), or whether they get steadily worse (progress) the results of an MRI scan

It can take some time to find out which type of MS you have because the symptoms are so varied. It can take a few years to make an accurate diagnosis of progressive MS, as the condition usually worsens slowly.

Treatments

MS is an autoimmune condition. This means your immune system mistakes part of your body for a foreign substance and attacks it.

In the case of MS, it attacks the myelin sheath in the brain and/or spinal cord. This is the layer that surrounds your nerves, protecting them and helping electrical signals travel from the brain to the rest of the body.

The attacks cause the myelin sheath to become inflamed in small patches (plaques or lesions). This can be seen on a magnetic resonance imaging (MRI) scan.

These patches of inflammation can disrupt the messages travelling along the nerves. It can slow them down, jumble them, send them the wrong way, or stop them from getting through completely. This disruption leads to the symptoms and signs of MS.

When the inflammation goes away, it can leave behind scarring of the myelin sheath (sclerosis). These attacks, particularly if frequent and repeated, can lead to permanent damage.


Phone your specialist MS nurse or GP if: you think you’re having a relapse

Treatment with disease-modifying therapies

Although there isn’t a cure for MS, there are medicines that can help to reduce the number and severity of relapses in some people. These are called disease-modifying therapies or disease modifying drugs.

These reduce the amount of damage and scarring to the myelin sheath (layer surrounding your nerves), associated with MS relapses.

These treatments reduce the chances of developing progressive symptoms of MS. They might also help to slow worsening disability in MS.

Disease-modifying therapies are not suitable for everyone with MS. They’re only prescribed to those with either:

relapsing remitting MS secondary progressive MS who meet certain criteria, like the number of relapses they’ve had primary progressive MS who meet certain criteria like new lesions found by an MRI scan

People without relapses are less likely to benefit from the treatments and could still experience side effects from them.

Treatment of a relapse of MS

Sometimes an infection can cause a flare up of symptoms rather than a relapse, so your nurse or GP will check for other possible causes.

Treatment for a relapse might involve a five-day course of steroid tablets taken at home.

Steroids can help speed up your recovery from a relapse. They don’t prevent further relapses or stop MS getting worse over time.

Steroids are only given for a short period of time to avoid possible steroid side effects. The side effects could include infection, mood disturbance, stomach ulceration, osteoporosis (weak bones), weight gain and diabetes.

Not using steroids more than three times a year (if possible) will help to reduce the risk of side effects.

Treatment for MS symptoms

There are different treatments available for MS symptoms.

Fatigue Your healthcare professional should give you advice about ways to manage fatigue. This might include exercise, keeping healthy sleep patterns and energy-saving techniques. Your healthcare professional might suggest avoiding medications that can worsen fatigue. Specialist fatigue management courses or therapy, such as cognitive behavioural therapy (CBT), might also help.

Visual problems MS-related visual problems will often improve on their own, usually within a few weeks. If your symptoms are particularly severe, your healthcare professional might prescribe steroids. If you have problems with involuntary eye movements, medication like gabapentin can sometimes help. Some people with double vision need help from ophthalmologists (eye specialists).

Muscle spasms and stiffness Physiotherapy can help improve muscle spasms and stiffness. Techniques such as stretching exercises can help if your movement is restricted. If your muscle spasms are more severe, you may be prescribed a medicine that can relax your muscles. This will usually be either baclofen, gabapentin or tizanidine. These medicines all have side effects. You might experience dizziness, weakness, nausea and diarrhoea. Discuss which of these would be best for you with your specialist MS nurse.

Mobility problems Mobility problems are often the result of muscle spasms and spasticity. Muscle weakness, or problems with balance or dizziness can also cause mobility problems. If you have problems with mobility, your healthcare professional might suggest: an exercise programme supervised by a physiotherapist special exercises called vestibular rehabilitation, if you have problems with balance medication for dizziness or tremors mobility aids, such as a walking stick, or a wheelchair home adaptations such as stair lifts or railings An occupational therapist can carry out an assessment of your home and suggest adaptations.

Musculoskeletal pain Living with MS can cause stresses and strains to the muscles and joints in your body. A physiotherapist might be able to help with this pain by suggesting exercises or better seating positions. If your pain is more severe, you may be prescribed painkillers. Or, you might have a transcutaneous electrical nerve stimulation (TENS) machine that stimulates your nerves.

Neuropathic pain Neuropathic pain is caused by damage to your nerves and is usually sharp and stabbing. It can also occur in the form of extreme skin sensitivity, or a burning sensation. This type of pain can be treated using neuropathic painkillers.

Problems with thinking, learning and memory Your MS healthcare professionals can assess your thinking, learning and memory problems and suggest ways to manage them.

Emotional problems People with MS who have depression or anxiety can be treated with antidepressants or therapy, such as CBT. If you have emotional outbursts, such as laughing or crying for no clear reason, you should be assessed by a specialist. They may suggest treatment with an antidepressant.

Bladder problems Medication might help if you have an overactive bladder or need to pee frequently during the night. If you find it difficult to empty your bladder, advice from a continence nurse or physiotherapist can help. Hand-held external stimulators can help some people to start peeing or to empty the bladder. Sometimes a catheter can empty the bladder when needed. You might be taught how to do intermittent self catheterisation (ISC). In rare cases, people with MS may need a long-term catheter to keep the bladder emptying safely. You might be referred to a continence adviser or urologist, for specialist treatment and advice. Read more about treating urinary incontinence.

Bowel problems It might be possible to treat mild to moderate constipation by changing your diet or taking laxatives. More severe constipation may need to be treated with suppositories, which are inserted into your bottom, or an enema. During an enema, liquid medication is rinsed through your bottom and large bowel, which softens and flushes out your stools. Anti diarrhoea medication or pelvic floor exercises might help bowel incontinence.

Sexual problems If you experience problems with less interest in sex or difficulty reaching orgasm, relationship counselling or seeing a sex therapist might help. If you have MS and find it hard to get or maintain an erection (erectile dysfunction) you may be prescribed medication to increase the blood flow to the penis.

Speech and swallowing difficulties A speech and language therapist can help you find ways to overcome problems with speech and swallowing. For example, they can offer advice about foods that are easy to swallow. They might recommend exercises to strengthen the muscles used in speech and swallowing.

Complementary and alternative therapies for MS Some people with MS find that complementary therapies help them feel better. Complementary treatments and therapies claim to ease symptoms, although scientific evidence is often not clear about how effective they are. Many people think that complementary treatments have no harmful effects. However, people can experience problems. It’s not a good idea to use them as an alternative to medicines prescribed by your doctor. If you’re considering an alternative treatment, it’s important to let your doctor know.

Clinical trials Clinical trials have helped to improve the treatments available for MS. Speak to your care team if you’re interested in taking part in a clinical trial.

Mumps
of infections and poisoning

Mumps usually clears within 1 or 2 weeks.



Mumps causes painful swellings at the side of the face under the ears (the parotid glands). It gives a distinctive ‘hamster face’ appearance.

Other symptoms of mumps can include:

headaches joint pain feeling sick dry mouth mild stomach (abdominal) pain feeling tired loss of appetite a high temperature (fever) of 38°C (100.4°F), or above

These may develop a few days before the swelling of the parotid glands.

Sometimes, mumps doesn’t cause any noticeable symptoms.

Phone your GP if: you think you or your child might have mumps you’ve been in close contact with someone who has mumps and you’re pregnant, and haven’t been fully vaccinated

Mumps is not usually serious, but it has similar symptoms to more serious types of infection, such as glandular fever and tonsillitis.

You should phone your GP first before visiting. They can make arrangements to reduce the risk of spreading the infection to others.

Symptoms

The symptoms of mumps usually develop 14 to 25 days after you’re infected.

Mumps causes painful swellings at the side of the face under the ears (the parotid glands). It gives a distinctive ‘hamster face’ appearance.

Other symptoms of mumps can include:

headaches joint pain feeling sick dry mouth mild stomach (abdominal) pain feeling tired loss of appetite a high temperature (fever) of 38°C (100.4°F), or above

These may develop a few days before the swelling of the parotid glands.

Sometimes, mumps doesn’t cause any noticeable symptoms.

Phone your GP if: you think you or your child might have mumps you’ve been in close contact with someone who has mumps and you’re pregnant, and haven’t been fully vaccinated

Mumps is not usually serious, but it has similar symptoms to more serious types of infection, such as glandular fever and tonsillitis.

You should phone your GP first before visiting. They can make arrangements to reduce the risk of spreading the infection to others.

Diagnoses

Your GP can usually make a diagnosis after:

seeing and feeling the swelling looking at the position of the tonsils in the mouth checking your temperature to see if it’s higher than normal

If your GP suspects mumps, they should notify your local health protection team (HPT).

Treatments

There are things you can do to help relieve your symptoms.

Do get plenty of bed rest drink plenty of water to avoid dehydration use pain relief such as paracetamol or ibuprofen – aspirin shouldn’t be given to children under 16 apply a warm or cool compress to the swollen glands to help relieve pain eat foods that don’t need a lot of chewing, such as soup, mashed potatoes and scrambled eggs

Preventions

Mumps can be prevented by having the MMR vaccine.

This is given in 2 doses as part of the NHS childhood vaccination programme.

You can be vaccinated at any age if you haven’t been fully vaccinated before.

Complications

Mumps usually passes without causing serious damage to a person’s health. Serious complications are rare.

However, mumps can lead to viral meningitis if the virus moves into the outer layer of the brain. Other complications include swelling of the testicles in males or the ovaries in females if the affected person has gone through puberty.

About 1 in 20 cases of mumps lead to acute pancreatitis. This is usually mild, but you may be admitted to hospital so your body functions can be supported until your pancreas recovers.

About 1 in 20 people with mumps experience some temporary hearing loss, but permanent loss of hearing is rare.

Meniere’s disease
of ears nose and throat

Ménière’s disease is a rare disorder that affects the inner ear. It can cause vertigo, tinnitus, hearing loss, and a feeling of pressure deep inside the ear.

People with Ménière’s disease usually experience some or all of these symptoms during sudden attacks, which typically last around two to three hours, although it can take a day or two for the symptoms to disappear completely.

It’s worth noting, however, that the symptoms and severity of Ménière’s disease vary widely from person to person. Some people may experience frequent attacks of vertigo along with hearing loss, while others may have severe tinnitus with minor vertigo. Other symptoms include sensitivity to sound (hyperacusis) or distorted sound.

See your GP if you experience any of the symptoms of Ménière’s disease, so they can try to identify the problem and refer you to a specialist if necessary.

Read more about the symptoms and stages of Ménière’s disease and diagnosing Ménière’s disease

Symptoms

The symptoms of Ménière’s disease vary from person to person. They often begin as sudden attacks, lasting for a few hours. Some people may experience several attacks each week or they may be separated by weeks, months or even years.

See your GP if you experience any of the symptoms of Ménière’s disease, so they can try to identify the problem and refer you to a specialist, if necessary.


The main symptoms of Ménière’s disease are:

vertigo – the sensation that you, or the environment around you, is moving or spinning tinnitus – hearing sounds from inside your body, rather than from an outside source hearing loss, with a particular difficulty hearing deep or low sounds a sense of pressure or fullness deep inside the ear

These symptoms usually only affect one ear at first, but both ears often become affected over time.

Vertigo and tinnitus are described in more detail below.

Vertigo

Vertigo is one of the most common and noticeable symptoms of Ménière’s disease. 

As well as a sensation of spinning, you may also experience additional symptoms during an attack of vertigo, such as dizziness, feeling or being sick, and problems with balance. You may have difficulty standing or walking. Occasionally, you may have “drop attacks”, where you suddenly fall to the ground.

During a severe attack, you may also experience sweating, diarrhoea and rapid or irregular heartbeats.

Tinnitus

Tinnitus is usually more noticeable when you’re tired or when it’s quiet, as there’s less background noise to distract you from sounds coming from inside your body.

Examples of sounds you may hear include buzzing, humming, grinding, hissing and whistling.

Causes

The exact cause of Ménière’s disease is unknown, but it’s thought to be caused by a problem with pressure deep inside the ear.

Factors that can increase your risk of developing Ménière’s disease include a family history of the condition and a chemical imbalance in the fluid in your inner ear.

Read more about the causes of Ménière’s disease


The exact cause of Ménière’s disease isn’t clear, although it’s thought to be caused by a problem with the pressure in the inner ear.

The inner ear is made up of:

the cochlea – a coiled, spiral tube that contains two fluid-filled chambers and is responsible for hearing the vestibular apparatus – a complex set of tubes that help to control balance

The fluid inside the inner ear is called endolymph.

If the pressure of the endolymph fluid changes – for example, because there is too much fluid – it can result in symptoms such as vertigo and tinnitus.

It’s thought that this pressure change is responsible for Ménière’s disease, although it hasn’t been proven.

Diagnoses

There’s no single test for Ménière’s disease, and the condition can be difficult to distinguish from other conditions with similar symptoms.

For example, migraines and ear infections can also affect your balance and hearing. A viral infection of the balance nerve (vestibular neuronitis) or the inner ear (labyrinthitis) can also produce similar vertigo attacks.

Treatments

Treatments for Ménière’s disease can usually help people with the condition control their symptoms. However, current treatments aren’t able to cure the condition.

Possible treatments include:

medicines to treat the symptoms and prevent attacks changes to your eating habits, such as a low-salt diet balance training (vestibular rehabilitation) relaxation techniques surgery, in more severe cases

A number of different surgical procedures may be used to treat Ménières disease, depending on how severe the symptoms are and whether one or both ears are affected. However, the effectiveness of surgery is unclear and research is continuing.

Read more about the treatment of Ménière’s disease


Treatment can usually help to control the symptoms of Ménière’s disease, although there’s currently no cure.

Your ear, nose and throat (ENT) specialist and your GP can help you manage your symptoms. Possible treatments include:

dietary advice – particularly a low-salt diet medication to treat and prevent attacks treatment for tinnitus  treatment for hearing loss treatment called vestibular rehabilitation to cope with balance problems treatment for stress, anxiety and depression surgery

Your GP and ENT specialist should provide you with advice tailored to your individual needs, and should develop a plan to help you manage your symptoms.

In some cases, the treatment available may depend on what your local NHS Clinical Commissioning Group (CCG) can provide.


During an attack of Ménière’s disease, you may be prescribed medication to treat the symptoms of vertigo, nausea and vomiting.

This is usually prochlorperazine or an antihistamine. If these work, you may be given a supply to keep, so you can take them quickly during an attack.

Prochlorperazine

Prochlorperazine can cause side effects including tremors (shaking) and involuntary body or facial movements. It can also make some people feel sleepy.

Check the patient information leaflet that comes with your medicine for the full list of possible side effects, or read more about prochlorperazine.

If you experience vomiting during your attacks, you can take a type of prochlorperazine called Buccastem. This comes as a tablet that you place between your gums and your cheek, on the inside of your mouth. The tablet dissolves and is absorbed into your body.

Antihistamines

Antihistamines you may be prescribed include cinnarizine, cyclizine and promethazine teoclate.

Antihistamines can make you feel sleepy. Headaches and an upset stomach are also possible side effects. Check the patient information leaflet that comes with your medicine for the full list of possible side effects.

What to do during an attack

During an attack, take your medication as soon as possible and grab the nearest available support. Get into a position in which you feel most stable or comfortable, and keep as still as possible. If you need to move, do so slowly and carefully. Close your eyes or keep them fixed on objects in front of you, and don’t turn your head quickly.

Once your symptoms start to improve, it’s best to gradually try to move around, as this encourages your brain to use your vision and other senses to compensate for the problems in your inner ear.

Severe attacks

If you suffer severe vertigo, dizziness, nausea and vomiting during an attack of Ménière’s disease, you may need to be injected with prochlorperazine by your doctor.

If you suffer severe vertigo with or without nausea during an attack, your doctor may also prescribe you a tablet of Buccastem that dissolves very quickly in your mouth (see above).

In particularly severe cases, you may need to be admitted to hospital to receive intravenous fluids (through a vein) to keep you hydrated.


A number of different treatments can be used to treat tinnitus caused by Ménière’s disease. Some possibilities include:

Sound therapy – the effects of tinnitus are often more pronounced in quiet environments. The aim of sound therapy is to fill the silence with neutral, often repetitive sounds to distract you from the sound of tinnitus. Relaxation techniques – tinnitus can be a distressing and intrusive condition. Relaxing by practising yoga or special breathing techniques may help you to avoid stress and anxiety. Cognitive behavioural therapy (CBT) – this is a therapy based on the knowledge that Ménière’s symptoms can have a significant psychological effect, resulting in negative thoughts and changes in behaviour. This may aggravate your symptoms and create a vicious circle. CBT is given by a specially trained professional who aims to change the way you think and behave, to break this cycle.

Read more about treating tinnitus


You may experience permanent hearing loss if Ménière’s disease is in the middle or end stages. Ménière’s disease tends to make you more sensitive to loud sounds, and also makes it more difficult for you to distinguish low-pitched sounds.

There are a variety of hearing aids available. Hearing therapists and organisations, such as Action on Hearing Loss, can provide you with helpful advice for dealing with hearing loss.

Read more about treating hearing loss

Preventions

Your GP can prescribe a medication called betahistine to help reduce the frequency and severity of attacks of Ménière’s disease, or you may be advised to change your diet.

Special diets

Although it has not been proven to be consistently effective, following a diet without added salt can help some people to control their symptoms. It’s possible that this type of diet might alter the fluids in your inner ear.

Avoiding excessive caffeine, found in drinks such as tea and coffee, is also usually recommended.

Myasthenia gravis
of brain nerves and spinal cord

It’s a rare condition that commonly affects the muscles that control the eyes and eyelids. It can also affect the face, speaking, chewing, swallowing and other parts of the body.

It can affect people at any age, but is most often found in women under 40 and men over 60.

There are other rarer types of myasthenia which you can read about on myaware.

If you drive, you must inform the DVLA that you have myasthenia gravis.


It can affect people at any age, but is most often found in women under 40 and men over 60.

There are other rarer types of myasthenia which you can read about on myaware.

If you drive, you must inform the DVLA that you have myasthenia gravis.


There are other rarer types of myasthenia which you can read about on myaware.

If you drive, you must inform the DVLA that you have myasthenia gravis.

Symptoms

The first symptoms of myasthenia gravis are often droopy eyelids or double vision. It usually affects the eyes first and may spread to other parts of the body. It can take weeks, months or years for symptoms to develop in other parts of the body.

The severity of the symptoms is different for each person. It’s likely that your symptoms will tend to get worse when you’re tired. The symptoms might improve after resting.

Symptoms can include:

Eyes You might experience droopy eyelids affecting one or both eyes, and double vision. In some people, only the eye muscles are affected (ocular myasthenia). In most people, the symptoms will spread to affect other parts of the body over time.

Swallowing, speaking and breathing You might experience: slurred speech difficulty swallowing difficulty making facial expressions like smiling problems with chewing a change in your voice choking or accidentally inhaling food which can cause chest infections shortness of breath

Limbs and neck The muscle weakness might spread to other parts of the body like your arms, legs and neck. You might experience: weakness in your arms, legs, neck or other parts of your body difficulty holding your head up aching muscles problems with tasks like climbing stairs or washing your hair

Myasthenic crisis Some people can experience severe breathing and swallowing difficulties, which require immediate hospital treatment. This is called a myasthenic crisis. It’s possible for patients to experience a myasthenic crisis before they know they have myasthenia gravis.

Phone 999 for an ambulance if: you’re experiencing severe breathing or swallowing problems You might need emergency hospital treatment.

You should avoid activities that could become dangerous if you experience sudden weakness, like swimming alone.

Diagnoses

It can be difficult to diagnose myasthenia gravis. Your doctor will ask about your medical history and symptoms.

You might need several tests to rule out other causes of your symptoms before you can be diagnosed with myasthenia gravis.

Blood test A blood test will look for a high level of antibodies (made by your immune system) which might be causing myasthenia gravis. You might be offered another blood test at a later date if your initial blood test is normal but you continue to experience worsening symptoms.

Electromyography You might have electromyography (an EMG) to test your nerves and muscles. During electromyography, you’ll have small needles inserted into your muscles to measure their electric activity. These are usually inserted around your eyes, forehead or arms. The test will measure the signals from the nerves to the muscles. If the test detects a disruption in the signals, this might be a sign of myasthenia gravis.

Scans You might have a computerised tomography (CT) scan to check if the thymus gland in your chest is bigger than expected or has grown abnormally (a thymoma). The thymus gland is part of your immune system. Problems with the thymus gland like inflammation (swelling), can be linked to myasthenia gravis. An magnetic resonance imaging (MRI) scan might be used to check if your symptoms are being caused by an issue in your brain.

Treatments

There are treatments available that can help reduce the affects of your symptoms.

If your symptoms get worse following certain triggers, you should try to avoid those triggers as much as possible.

Triggers might include:

stress tiredness infections medicines surgery

Treatment might include: 

Medicine Pyridostigmine Sometimes myasthenia gravis can be treated with pyridostigmine alone. It works by temporarily improving the nerve to muscle transmission to help muscle strength. It can reduce muscle weakness and for some people this is the only medication they need to control the condition. It’s effects do not last long and it needs to be taken periodically throughout the day to give the best results. Side effects can include stomach upset, diarrhoea and drooling. Steroids You might be advised to take steroid tablets like prednisolone if pyridostigmine isn’t helping. Steroid tablets work by reducing the activity of your immune system to stop it attacking the communication between your nerves and muscles. It’s likely you’ll be advised to take the tablets every other day. You’re likely to start at a low dose which will be built up quickly. This might gradually be reduced once your symptoms are under control. It’s important that you do not stop your steroids suddenly, as this can make you very ill. Using steroids long term can cause side effects including osteoporosis (weak bones), weight gain, infection and diabetes. Read more about the side effects of steroids Immunosuppressants Immunosuppressants work by reducing the activity of your immune system. Your healthcare team might suggest taking immunosuppressants if: steroids aren’t controlling your symptoms you need a high dose of steroids to control your symptoms Commonly used immunosuppressants include azathioprine, mycophenolate mofetil and methotrexate. You’ll need to take the tablets every day and it can take at least 9 months to feel the full effect. You’ll be advised to take steroids at first. Immunosuppressants night cause side effects like: loss of appetite and tiredness feeling sick increased risk of infections You’ll have regular blood tests to check the the medicine isn’t causing any harm. You might be able to stop taking immunosuppressants if they keep your symptoms under control over a few years.

Surgery Your healthcare team might recommend surgery to remove the thymus gland (thymectomy). Symptoms should improve within the first few months after surgery and can continue to improve for up to 2 years. Surgery can reduce: the dose of steroids the need to take other immunosuppressants the chances of needing to go to hospital because of worsening symptoms Surgery might not help myasthenia symptoms in someone that has a thymoma. Your healthcare team might still recommend having your thymus gland removed because it can cause problems if it keeps growing. Your thymectomy will usually be carried out through keyhole surgery. The thymus is removed using surgical instruments inserted through small cuts (incisions) in the chest.

Plasma exchange and IVIG Plasma exchange and IVIG (intravenous immunoglobulin) can offer a quick improvement (within a few days) for people with myasthenia gravis who are particularly unwell or are having a myasthenic crisis. Plasma exchange is an emergency treatment that removes antibodies from your own blood. This treatment is given in hospital and the benefits can last around 6 weeks. IVIG treatment involves an injection of normal antibodies from donated blood to temporarily change the way your immune system works. The two treatments are similar and your healthcare team will decide which is the best option for you. Although the benefits only last a few weeks, it can give time for the longer term treatments to take effect and help improve symptoms.

You might find that, during pregnancy or after having a baby, your myasthenia gravis worsens. If you’re planning a pregnancy or become pregnant, you should speak to your healthcare team. Don’t stop taking your medications without first speaking to your healthcare professional.

Nasal and sinus cancer
of cancer, cancer types in adults

It’s a rare type of cancer that most often affects men aged 50 to 60.

Nasal and sinus cancer is different to cancer in the area where the nose and throat connect. This is called nasopharyngeal cancer.


Nasal and sinus cancer is different to cancer in the area where the nose and throat connect. This is called nasopharyngeal cancer.

Symptoms

The most common symptoms of nasal and sinus cancer are:

a persistent blocked nose, which usually only affects 1 side nosebleeds mucus draining from the nose, which may be blood-stained a decreased sense of smell

These symptoms can be similar to more common and less serious conditions, such as a cold or sinusitis.

At a later stage, symptoms can include:

pain or numbness in the face swollen glands in the neck partial loss of vision or double vision a bulging or persistently watering eye a lump or growth on your face, nose or roof of your mouth

Treatments

Speak to your GP if you notice any unusual or persistent symptoms. They’re very unlikely to be caused by nasal or sinus cancer, but are worth getting checked out.

If your GP thinks you might need some tests to determine what’s causing your symptoms, you’ll usually be referred to an ear, nose and throat (ENT) consultant in hospital.

Tests you may have include:

a nasal endoscopy – where a long, thin, flexible tube attached to a light source is inserted into your nose to examine the area a computerised tomography (CT) scan and a magnetic resonance imaging (MRI) scan a biopsy (where a small sample of tissue is removed and examined) – this may be done during an endoscopy or using a needle


The best treatment depends on several factors, including how far the cancer has spread and your general health.

Treatment may include:

surgery to remove a tumour – which can be performed using surgical incisions (open surgery) or as keyhole surgery through the nose (endoscopic microsurgery) radiotherapy – where high-energy radiation is used to kill the cancerous cells, shrink a tumour before surgery, or destroy small amounts of a tumour that may be left after surgery chemotherapy – where medicine is used to help shrink or slow down the growth of a tumour, or to reduce the risk of the cancer returning after surgery

Your treatment will be organised by a head and neck cancer multidisciplinary team (MDT), who will discuss the treatment options with you. A combination of treatments will often be recommended.

Nasopharyngeal cancer
of cancer, cancer types in adults

Nasopharyngeal cancer shouldn’t be confused with other types of cancer that also affect the throat, such as laryngeal cancer and oesophageal cancer.



Symptoms of nasopharyngeal cancer can include:

a lump in the neck hearing loss – usually only in 1 ear tinnitus – hearing sounds that come from inside the body rather than from an outside source a blocked or stuffy nose nosebleeds

Speak to your GP if you develop any worrying symptoms, particularly if they don’t improve after a few weeks. While they’re very unlikely to be caused by nasopharyngeal cancer, it’s best to get them checked out.

Symptoms

It’s often difficult to recognise nasopharyngeal cancer because the symptoms are similar to other, less serious conditions. Also, many people with nasopharyngeal cancer don’t have any symptoms until the cancer reaches an advanced stage.

Symptoms of nasopharyngeal cancer can include:

a lump in the neck hearing loss – usually only in 1 ear tinnitus – hearing sounds that come from inside the body rather than from an outside source a blocked or stuffy nose nosebleeds

Speak to your GP if you develop any worrying symptoms, particularly if they don’t improve after a few weeks. While they’re very unlikely to be caused by nasopharyngeal cancer, it’s best to get them checked out.

Causes

The exact cause of nasopharyngeal cancer is unknown, but a number of factors can increase your risk of developing the condition. These include:

being of south Chinese or north African descent having a diet very high in salt-cured meats and fish being exposed to the Epstein-Barr virus (EBV), a common virus that causes glandular fever having a job where you’re regularly exposed to hardwood dust having a first-degree relative, such as a parent, who’s had the condition

Being exposed to the human papilloma virus (HPV) may also increase your risk of developing certain types of nasopharyngeal cancer.

About 3 times as many men as women are affected by nasopharyngeal cancer. The average age at diagnosis is about 50.

Diagnoses

If you see your GP with symptoms that could indicate nasopharyngeal cancer, they’ll usually ask about your symptoms and carry out some examinations. This may involve examining your throat using a small mirror and a light.

If your GP thinks further tests are necessary, they’ll refer you to hospital. At hospital, a number of different tests may be carried out to check for nasopharyngeal cancer and rule out other conditions.

Some of the tests you may have include:

a nasendoscopy – where a thin, flexible telescope (endoscope) is inserted up your nose and passed down your throat to look for any abnormalities; it’s carried out while you’re awake, but local anaesthetic can be used to numb your nose and throat imaging scans – magnetic resonance imaging (MRI) scans or computerised tomography (CT) scans can be used to check for tumours and determine whether the cancer has spread a panendoscopy – a more detailed examination of your nose and throat carried out under general anaesthetic (where you’re unconscious) using a series of small, rigid telescopes connected together a biopsy – where a small tissue sample is removed during a panendoscopy so it can be examined in a laboratory

Once these tests are complete, your doctors will be able to confirm whether you have nasopharyngeal cancer. They’ll also be able to ‘stage’ the cancer, which means giving it a score to describe how large it is and how far it has spread.

The Cancer Research UK website has more information about the stages of nasopharyngeal cancer.

Treatments

If you’re diagnosed with nasopharyngeal cancer, you’ll be cared for by a team of different specialists who work together called a multidisciplinary team (MDT). Members of your MDT will discuss with you what they think the best treatment option is in your case.

The 2 main treatments for nasopharyngeal cancer are:

radiotherapy – where radiation is used to kill cancer cells chemotherapy – where medication is used to kill cancer cells

In most cases, a combination of radiotherapy and chemotherapy will be used.

Surgery isn’t usually used to treat nasopharyngeal cancer as it’s difficult for surgeons to access the affected area.

Neuroblastoma: Children
of cancer, cancer types in children

More children than ever are surviving childhood cancer. There are new and better drugs and treatments, and we can now also work to reduce the after-effects of having had cancer in the past.

It’s devastating to hear that your child has cancer. At times it can feel overwhelming, but there are many healthcare professionals and support organisations to help you through this difficult time.

Understanding more about the cancer your child has, and the treatments that may be used, can often help parents to cope. Your child’s specialist will give you more detailed information and, if you have any questions, it’s important to ask the specialist doctor or nurse who knows your child’s individual situation.

Neuroblastoma develops from the cells left behind from a baby’s development in the womb. The cells that it develops from are called neuroblasts.

‘Neuro’ means nerve ‘Blast’ means cells in early development ‘Oma’ means a group of cells, or a tumour

Neuroblastoma can occur anywhere in the body. The site of origin is either in 1 of the 2 adrenal glands situated in the abdomen (tummy) or in nerve tissue that runs alongside the spinal cord, in the neck, chest, abdomen or pelvis. The adrenal glands are specialised glands that are found above the right and left kidney. The adrenal glands normally release hormones to maintain blood pressure, and enable us to respond to stress. In some cases, neuroblastoma can spread to tissues beyond the original site such as the bone marrow, bone, lymph nodes, liver, and skin.


It’s devastating to hear that your child has cancer. At times it can feel overwhelming, but there are many healthcare professionals and support organisations to help you through this difficult time.

Understanding more about the cancer your child has, and the treatments that may be used, can often help parents to cope. Your child’s specialist will give you more detailed information and, if you have any questions, it’s important to ask the specialist doctor or nurse who knows your child’s individual situation.

Neuroblastoma develops from the cells left behind from a baby’s development in the womb. The cells that it develops from are called neuroblasts.

‘Neuro’ means nerve ‘Blast’ means cells in early development ‘Oma’ means a group of cells, or a tumour

Neuroblastoma can occur anywhere in the body. The site of origin is either in 1 of the 2 adrenal glands situated in the abdomen (tummy) or in nerve tissue that runs alongside the spinal cord, in the neck, chest, abdomen or pelvis. The adrenal glands are specialised glands that are found above the right and left kidney. The adrenal glands normally release hormones to maintain blood pressure, and enable us to respond to stress. In some cases, neuroblastoma can spread to tissues beyond the original site such as the bone marrow, bone, lymph nodes, liver, and skin.


Understanding more about the cancer your child has, and the treatments that may be used, can often help parents to cope. Your child’s specialist will give you more detailed information and, if you have any questions, it’s important to ask the specialist doctor or nurse who knows your child’s individual situation.

Neuroblastoma develops from the cells left behind from a baby’s development in the womb. The cells that it develops from are called neuroblasts.

‘Neuro’ means nerve ‘Blast’ means cells in early development ‘Oma’ means a group of cells, or a tumour

Neuroblastoma can occur anywhere in the body. The site of origin is either in 1 of the 2 adrenal glands situated in the abdomen (tummy) or in nerve tissue that runs alongside the spinal cord, in the neck, chest, abdomen or pelvis. The adrenal glands are specialised glands that are found above the right and left kidney. The adrenal glands normally release hormones to maintain blood pressure, and enable us to respond to stress. In some cases, neuroblastoma can spread to tissues beyond the original site such as the bone marrow, bone, lymph nodes, liver, and skin.

Symptoms

The symptoms vary, depending on where your child’s neuroblastoma tumour is:

if the tumour is in the abdomen, your child’s tummy may be swollen and they may complain of constipation or have difficulty passing urine (peeing) if the tumour affects the chest area, your child may be breathless and have difficulty swallowing if the tumour occurs in the neck, it’s often visible as a lump and occasionally affects breathing and swallowing occasionally, there are deposits of neuroblastoma in the skin that appear as small, blue-coloured lumps if the tumour is pressing on the spinal cord, children may have weakness in the legs and walk unsteadily – if your child is not yet walking, you may notice reduced leg movements; they may also have constipation or difficulty passing urine (peeing) your child may be found to have high blood pressure very rarely, children may have jerky eye and muscle movements, and general unsteadiness associated with the neuroblastoma

There are often symptoms of tiredness, being pale, loss of appetite, weight loss, bone pain and generalised discomfort.

Causes

As with most cancers, the cause of neuroblastoma is unknown. It is not infectious and cannot be passed on to other people.

Diagnoses

A variety of tests and investigations will be needed to diagnose neuroblastoma. These include a biopsy of the tumour, blood and bone marrow tests, X-rays, CT or MRI scans, and a special nuclear medicine scan called an MIBG scan. These tests are carried out to confirm the diagnosis of neuroblastoma, and to find the exact position of the original site of neuroblastoma within the body and to see whether it has spread. This process is known as staging.

A specific type of urine test will also be done. Nearly all children with neuroblastoma (9 out of 10) will have substances called vanillylmandelic acid (VMA), or homovanillic acid (HVA), in their urine. Measuring the VMA and HVA in the urine can help to confirm the diagnosis. Your child will also have their VMA and HVA levels checked during and after treatment. The levels of these substances will fall if the treatment is working. As these chemicals are produced by the tumour cells, and can be used to measure tumour activity, they are sometimes known as tumour markers.

Most children will have an MIBG (meta-iodo-benzyl guanidine) scan. MIBG is a substance that’s taken up by neuroblastoma cells. It’s given by injection into the blood stream. Attaching a small amount of radioactive iodine to the MIBG enables any neuroblastoma tissue to be seen by a radiation scanner. Sometimes MIBG can be used as a treatment.

Biopsy

A small sample of cells (a biopsy) is usually taken from the tumour during an operation under a general anaesthetic. These cells are then examined under a microscope. Other tests collectively referred to as tumour biology, look at the chromosomes and ‘biological markers’ in the tumour cells. One of these ‘markers’ is called MYCN. The presence of a certain amount of MYCN in the cells (known as MYCN amplification) can suggest that the neuroblastoma may be a more aggressive type. In this situation, the treatment needs to be more intensive.

Staging

The ‘stage’ of a cancer is a term used to describe its size and whether it has spread beyond its original site. Knowing the particular type and stage of the cancer helps the doctors to decide on the best treatment for your child.

Stage 1

The cancer is contained within 1 area of the body (localised) and there’s no evidence of it having spread. It can be completely removed by surgery, or there may be very small (microscopic) amounts of tumour left.

Stage 2A

The cancer is localised and has not begun to spread, but cannot be completely removed by surgery.

Stage 2B

The cancer is localised and has begun to spread into nearby lymph nodes.

Stage 3

The cancer has spread into surrounding organs and structures, but has not spread to distant areas of the body.

Stage 4

The cancer has spread to distant lymph nodes, bone, bone marrow, liver, skin or other organs.

Stage 4S (also called special neuroblastoma)

This stage of neuroblastoma is found in children under 1 year old. The cancer is localised (as in stage 1, 2A or 2B) and has begun to spread to the liver, skin or bone marrow.

A newer staging system has been developed by the International Neuroblastoma Risk Group (INRG). This system is now widely used. It looks at whether or not certain ‘image-defined risk factors’ are present in a neuroblastoma tumour before treatment. These risk factors can be detected by scans and help doctors understand the extent of the disease. Your doctor can explain more about this.

Stage L1

The tumour is localised and has not spread into important areas (vital structures) nearby. It can be removed by surgery.

Stage L2

The tumour is localised but has ‘image-defined risk factors’ and can’t be safely removed by surgery.

Stage M

The tumour has spread to other parts of the body.

Stage MS

The tumour has spread to the skin, liver and/or the bone marrow in children younger than 18 months old.

If the cancer has spread to distant parts of the body, this is known as secondary or metastatic cancer. If the cancer comes back after initial treatment, this is known as recurrent or relapsed cancer.

Treatments

The treatment of neuroblastoma depends on the age of the child, the size and position of the tumour, the tumour biology (including the MYCN status) and whether the neuroblastoma has spread.

Surgery

For tumours that have not spread (localised tumours), the treatment is usually surgery. If the tumour is at an early stage and there is no evidence that it has spread to the lymph nodes or any other parts of the body, an operation to remove the tumour, or as much of it as possible, will be undertaken. If the tumour is, at first, too large or in too difficult a position to remove safely, chemotherapy will be given to shrink it before surgery. A cure is usually possible for children with localised tumours. However, if a localised tumour is classed as ‘high-risk’, due to the tumour biology results, additional treatment with chemotherapy and usually radiotherapy will be needed.

Chemotherapy

If the tumour has already spread by the time of diagnosis, or is indicated as being high-risk by the tumour biology result, intensive chemotherapy is needed. Chemotherapy is the use of anti-cancer drugs to destroy cancer cells. It’s usually given as an infusion into a vein. Your child will have a semi-permanent cannula called a central venous line inserted under a general anaesthetic to minimise the distress caused by intravenous injections.

Your child’s specialist will discuss with you the type and amount of chemotherapy needed.

High-dose chemotherapy with stem cell rescue

If the neuroblastoma has spread to several parts of the body, or is high-risk with MYCN amplification, high dose chemotherapy with peripheral blood stem cell rescue is used after the initial courses of chemotherapy. High-dose chemotherapy will wipe out any remaining neuroblastoma cells but will also wipe out the body’s bone marrow, where blood cells are made. To prevent the problems this causes, stem cells (blood cells at their earliest stages of development) are collected from your child through a drip before the chemotherapy is given. These stem cells are then frozen and stored until required. After the high-dose chemotherapy, the stem cells are given back to your child through a drip. They make their way into the bone marrow, where they grow and develop into mature blood cells over a period of 14 to 21 days.

Monoclonal antibody treatment

Monoclonal antibodies can destroy some types of cancer cells while causing little harm to normal cells. In the UK, patients with high-risk neuroblastoma treated in the (SIOPEN) European high-risk clinical trial receive immunotherapy with a monoclonal antibody called anti-GD2 after their high dose therapy. There is good evidence from a clinical trial (research study) carried out in America, which was first reported on in 2009, that this may be a promising therapy when given alongside standard treatment for neuroblastoma. The anti GD2 is either given on its own or with cytokines. It is not yet a standard treatment for patients with neuroblastoma as it has very unpleasant side effects, the benefits need to be fully proven and the best way to administer it needs to be established. It is therefore currently only available to patients in the UK who are being treated within a clinical trial. Your child’s specialist will be able to tell you much more about this treatment.

Radiotherapy

External beam radiotherapy may be given if the neuroblastoma is high-risk, or has spread to several parts of the body. This uses high-energy rays to destroy the cancer cells, while doing as little harm as possible to normal cells. External beam radiotherapy is given from a machine outside the body. Internal radiotherapy may sometimes be given using radioactive MIBG. Radioactive MIBG is similar to the MIBG used in an investigation to diagnose neuroblastoma, but uses higher doses of radioactivity to kill the cancer cells.

Younger children

Children under 18 months old with neuroblastoma often have ‘low-risk’ tumours, and as long as there is no MYCN amplification, their outlook is excellent. Most children in this age group are cured.

Children with Stage 4S disease almost always get better with very little treatment or none at all. These tumours either regress spontaneously or after chemotherapy, which is only given if there are symptoms from the tumour. They disappear completely or develop into a non-cancerous (benign) tumour, called a ganglioneuroma. Many of these children, after their initial diagnostic tests and staging investigations, will just need careful monitoring for some years. Ganglioneuromas are usually harmless and will not cause any problems and do not need any treatment.

Side effects of chemotherapy treatment

Chemotherapy often causes side effects, and your child’s doctor will discuss this with you before the treatment starts. The side effects will depend upon the actual drugs being given. Immediate side effects can include:

feeling sick (nausea) and being sick (vomiting) diarrhoea weight loss hair loss increased risk of infection bruising and bleeding tiredness

Late side effects

A small number of children may develop late side effects, sometimes many years after treatment. These include a change in the way the heart and kidneys work, hearing problems, fertility problems, a possible reduction in bone growth if radiotherapy has been given, and a slightly increased risk of developing another cancer in later life. Your child’s doctor or nurse will talk to you about any possible late side effects.

Clinical trials

Many children have their treatment as part of a clinical research trial. Trials aim to improve our understanding of the best way to treat an illness, usually by comparing the standard treatment with a new or modified version. Specialist doctors organise many trials for children’s cancer. Children in the UK with neuroblastoma can take part in national and European studies. The European research group is called SIOPEN. If appropriate, your child’s medical team will talk to you about taking part in a clinical trial, and will answer any questions you have. Written information is provided to help explain things. Taking part in a research trial is completely voluntary, and you’ll be given plenty of time to decide if it’s right for your child.

Treatment guidelines

Sometimes, clinical trials are not available for your child’s tumour. This may be because a recent trial has just finished, or because the tumour is very rare. In these cases, you can expect your doctors and nurses to offer treatment which is agreed to be the most appropriate, using guidelines which have been prepared by experts across the country. The Children’s Cancer and Leukaemia Group (CCLG) is an important organisation which helps to produce these guidelines.

Follow-up care

Follow-up after treatment usually involves regular visits to the hospital outpatients department, with scans and urine tests as necessary. For children who have had chemotherapy and/or radiotherapy, more specialised tests may also be carried our. For example, hearing tests, kidney and heart function tests, and checking hormone levels. These will be repeated until your child is grown up. If you have specific concerns about your child’s condition and treatment, it’s best to discuss them with your child’s doctor, who knows their situation in detail.

Neuroendocrine tumours
of cancer, cancer types in adults

The neuroendocrine system consists of nerve and gland cells. It produces hormones and releases them into the bloodstream.

NETs are tumours (abnormal growths) that develop in the cells of the neuroendocrine system.

NETs can be malignant (cancerous) or benign (non-cancerous) and often – but not always – grow slowly. There are a number of different types of NET, depending on the specific cells affected.


NETs are tumours (abnormal growths) that develop in the cells of the neuroendocrine system.

NETs can be malignant (cancerous) or benign (non-cancerous) and often – but not always – grow slowly. There are a number of different types of NET, depending on the specific cells affected.


NETs can be malignant (cancerous) or benign (non-cancerous) and often – but not always – grow slowly. There are a number of different types of NET, depending on the specific cells affected.

Symptoms

The symptoms of a neuroendocrine tumour can vary depending on where it is and what hormones it produces.

For example, a tumour in the digestive system may cause diarrhoea, constipation or tummy pains. A tumour in the lung may cause wheezing or a persistent cough.

Some tumours (functioning tumours) may cause abnormally large amounts of hormones to be released into the bloodstream.

This can cause symptoms such as diarrhoea, flushing, cramps, wheezing, low blood sugar (hypoglycaemia), changes in blood pressure and heart problems.

Causes

What causes neuroendocrine tumours isn’t fully understood. However, your chance of developing a NET is increased if you have one of the following rare conditions or syndromes:

multiple endocrine neoplasia type 1 (MEN 1) – a rare inherited condition where tumours in the endocrine system develop, most commonly in the parathyroid glands, pituitary gland and the pancreas neurofibrmatosis type 1 – a group of genetic conditions that cause tumours to grow along your nerves Von Hippel-Lindau syndrome (VHL) – an inherited condition that causes blood vessels to grow abnormally

Research has also shown that your risk of developing a NET is slightly increased if one of your parents has had one in the past.

Diagnoses

There are many tests that can be used to diagnose NETs, including blood tests, urine tests, scans, and a biopsy (where a small tissue sample is taken for closer examination).

Different types of scans may also be used to identify or examine tumours. These include:

ultrasound scans – including echocardiograms and endoscopic ultrasound scans computerised tomography (CT) scans magnetic resonance imaging (MRI) scans positron emission tomography (PET) scans octreotide scans – where mild radioactive liquid is injected into your veins and a special camera is used to highlight any cancerous cells

Treatments

How a neuroendocrine tumour is treated will depend on your individual circumstances. For example, your treatment will depend on:

where the tumour is how advanced your condition is your overall health

Unfortunately, many people are only diagnosed after other parts of their body are affected. However, it may still be possible to surgically remove the tumour, even if it has spread to other parts of your body.

If surgery can’t be used to completely cure your condition, it may be used to help manage and reduce any symptoms that you have.

It may also be possible to shrink the tumour or stop further growth using treatments that block the blood supply to the tumour (embolisation), or chemotherapy, radiotherapy or radiofrequency ablation (where heat is used to destroy the cells).

The Cancer Research UK website has more information about neuroendocrine tumours (NETs).