The molecular characteristics of recurrent/metastatic HPV-positive head and neck squamous cell carcinoma: A systematic review of the literature.

OBJECTIVES: About 17% of patients with human papillomavirus (HPV)-positive head and neck squamous cell carcinoma (HNSCC), which is mainly comprised of oropharyngeal SCC (OPSCC), will experience disease recurrence, which is often considered incurable when manifested at a metastatic and/or recurrent stage. We conducted a critical qualitative systematic review. Our objectives were to provide an overview of the molecular landscape of recurrent/metastatic HPV-positive HNSCC as well as novel molecular biomarkers. DESIGN: A literature review was conducted to identify studies reporting on the molecular characteristics of recurrent/metastatic HPV-positive HNSCC, novel molecular biomarkers and treatment options. The reviews of abstracts, full articles, and revision of the included studies, followed by data extraction and quality assessment were performed by three independent assessors. All primary literature, such as retrospective, prospective, and clinical trials as well as basic research studies were considered, and the final search was conducted at the end of February 2023. The level of evidence was rated using the guidelines published by the Oxford Centre for Evidence-based Medicine and quality was assessed using the Newcastle-Ottawa Scale criteria. RESULTS AND CONCLUSIONS: The literature search resulted in the identification of 1991 articles. A total of 181 full articles were screened, and 66 articles were included in this analysis. Several studies reported that recurrent/metastatic HPV-positive HNSCC had higher rates of TP53 mutation and were genomically similar to HPV-negative HNSCC. The detection of circulating tumour tissue-modified HPV DNA (ctHPVDNA) as a specific biomarker has shown promising results for monitoring treatment response and recurrence in the subset of HPV-positive HNSCC. In addition, evidence for targeted therapy in recurrent/metastatic HPV-positive HNSCC has emerged, including agents that inhibit overexpressed EGFR. Studies of combination immunotherapy are also underway. Our review outlines the latest evidence on the distinct molecular profiles of recurrent/metastatic HPV-positive HNSCC as well as the clinical potential of ctHPVDNA testing in routine practice. More controlled and longitudinal studies are needed to identify additional molecular targets and to assess the performance and benefits of novel molecular biomarkers in clinical practice.

Outpatient parotidectomy with or without the use of a post-operative drain: A retrospective bi-institutional study.

OBJECTIVE: Parotid surgery is historically performed as an inpatient procedure and suctions drains are predominantly used during surgery. Recent literature provides evidence that outpatient parotid surgery is safe and effective. Our study aims to describe the results of drainless outpatient parotidectomy and outpatient parotidectomy with drain placement and compare their outcomes. DESIGN: Retrospective cohort study. SETTING: Bi-institutional retrospective cohort study. PARTICIPANTS: Patients that underwent outpatient drain-less parotidectomy and patients that underwent outpatient parotidectomy with post-operative drain placement. MAIN OUTCOME MEASURES: Complication rates, unplanned post-operative visits, unplanned prolonged stay. RESULTS: Three hundred eighty patients underwent outpatient parotidectomy with drain placement and 31 patients underwent outpatient drainless parotidectomy in two different hospitals. The incidence of haematoma (drain: 3.1% vs. drainless: 0%, p = 1), infection (drain: 14.3% vs. drainless: 13.8%, p = 1) and salivary fistula (drain: 5.6% vs. drainless: 3.4, p = 1) were comparable between both groups. Seroma or sialocele was more frequently seen in the drain-less group (27.6% vs. 6.2%, p < .001), but were all managed conservatively. Within 10 days after surgery, unplanned visits seemed more frequent in the drain group, although the difference was not statistically significant (14.9% vs. 3.4%, p = .16). CONCLUSIONS: Outpatient parotid surgery with or without the use of a post-operative drain is safe, practical and feasible. Same-day discharge with and without drain placement yield comparable outcomes. However, the results need to be interpreted cautiously as this study was limited by a small cohort of parotidectomies without drain placement. Future studies should further compare both approaches.

A UK based two-centre review of multifocality and its role in the treatment of papillary thyroid cancer.

INTRODUCTION: Multifocality is increasingly observed in papillary thyroid carcinoma (PTC) due to improvements in imaging and histopathological analysis. However, its significance in management, particularly as a sole risk-factor, remains controversial. This study aimed to investigate the prognostic value of multifocality in predicting recurrence following thyroid lobectomy in a contemporary group of PTC patients managed in the UK. METHODS: Patients with PTC in NHS Lothian (2009-19) and Guys and St Thomas NHS Foundation Trust (2012-19) were identified. Categorical variables were compared using Chi-squared or Fisher's exact test. Five-year recurrence free survival (RFS) were analysed using Kaplan-Meier method and compared using log-rank. RESULTS: Of 828 patients; 492 (59%) had unifocal and 336 (41%) multifocal disease on final pathology. A higher rate of pathological nodal disease (22%v36%,p < 0.001), total thyroidectomy (TT) (78%v92%,p < 0.001) and radioactive iodine (RAI) (57%v75%,p < 0.001) was demonstrated in patients with multifocality. With a median follow-up of 50 months, overall 5-year RFS was 96.5%; 96.5% for unifocal versus 96.6% for multifocal disease (p = 0.695). Recurrence was not shown to be associated with multifocality on either univariate or multivariate analysis. Amongst patients with T1/2N0M0 disease (n = 341), more patients were treated with TT and RAI with multifocal compared to unifocal disease (<0.001). Only two patients within this group recurred during follow up, both of whom had multifocal disease and were treated with TT and RAI (5yRFS100%v98.1%,p = 0.051). CONCLUSION: Multifocality is a common feature of PTC but does not appear to be an independent predictor of outcome. Therefore, treatment intensification on the basis of multifocality alone seems unwarranted.

Comparative evaluation of a low-cost solar powered otoscope with a traditional device among health care workers in Malawi.

OBJECTIVES: To comparatively evaluate a low-cost otoscope with a traditional device among health care workers in Malawi. METHODS: The study is a prospective, comparative, qualitative observational survey of health care worker's opinions using 5-point Likert rating scales and tick box categories in a 10-item survey questionnaire. Twenty-five mixed cadre health care workers from the Ear, Nose, and Throat Department of the Queen Elizabeth Hospital, Blantyre in Malawi were recruited. Outcomes measures used were ease of speculum attachment, handling, insertion, stability, the quality of view, color, build, brightness, overall ease of use, and their suitability for local work. RESULTS: The low-cost otoscope scored statistically higher in overall combined performance, as well as in the remaining four out of the nine attributes. Notably, 54.2% of users rated the low-cost device more suitable than the traditional device for use in low-middle income countries, 25% were equivocal, and 20.8% preferred the traditional device. CONCLUSION: This study found the Arclight otoscope to be an appropriate and practical substitute for more expensive traditional otoscopes for the delivery of ENT services in low resource settings. LEVEL OF EVIDENCE: N/A.

Outpatient (same-day discharge) versus inpatient parotidectomy: A systematic review and meta-analysis.

BACKGROUND: Parotidectomy is often performed as an inpatient procedure largely due to drain insertion; however, outpatient parotidectomy has increasingly become an attractive alternative for its shorter hospital stays and greater efficiency in cost-effectiveness. OBJECTIVE OF REVIEW: To assess the safety and feasibility of outpatient (or same-day discharge) parotidectomy compared with inpatient parotidectomy. TYPE OF REVIEW: Systematic review of the literature and meta-analysis, in accordance with the PRISMA guidelines. METHODS: Pubmed/Medline, Embase, CINAHL, Google Scholar, Web of Science, The Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL) were searched for articles published in English between 01/01/1990 and 05/10/2019. The Newcastle-Ottawa Scale was used for quality assessment and Review Manager 5.3 for meta-analyses. MAIN OUTCOME MEASURES: Primary outcomes assessed were postoperative complications including bleeding/haematoma, surgical site infection, seroma and facial weakness. Secondary outcome was readmission rate. RESULTS: Out of 445 studies identified, 6 were selected for systematic review. The overall quality of evidence was moderate. A total of 3664 patients were included (1646 in the outpatient group and 2018 in the inpatient group). Comparing the outpatient with inpatient cohorts, there were lower complications in outpatient groups though not statistically significant for haematoma (OR = 0.45; 95% CI = 0.11-1.92; P = .28), surgical site infection (OR = 0.88; 95% CI = 0.46-1.69; P = .70), seroma (0.79; 95% CI = 0.21-3.03; P = .74), facial nerve weakness (OR 0.39; 95% CI = 0.14-1.08; P = .07) and hospital readmission (OR 0.58; 95% CI = 0.33-1.04; P = .07). CONCLUSIONS: Outpatient parotidectomy appears to be safe and compares favourably to inpatient procedure in postoperative complication and readmission rates.

Endoscopic Sphenopalatine Artery Ligation: General Applicability in a Teaching Unit.

BACKGROUND:: Endoscopic sphenopalatine artery ligation (ESPAL) is the intervention of choice for refractory epistaxis in specialist ear, nose and throat (ENT)units and should be within the repertoire of competencies for all ENT trainees. Following its recent incorporation within the United Kingdom competency-based training syllabus as an explicit outcome standard, the ESPAL is not uncommonly being delivered by trainees under appropriate supervision. We assessed the efficacy and outcome of ESPAL in epistaxis management within our teaching hospitals. METHODS:: Retrospective, structured review of all ESPAL procedures performed for epistaxis between December 2005 and December 2013. The techniques of ligation, operator grade, and outcome were studied. RESULTS:: Sixty-five patients (41 male:24 female; average age of 58.2 years) were identified in whom 67 artery ligations were performed (63 unilateral; 2 bilateral). Overall, success rate of ESPAL was 92.3% (60/65), with 5 rebleed cases recorded within 30 days of the primary procedure. Sixteen (24.6%) underwent "clipping," 26 (40.0%) had diathermy ligation, 18 (27.7%) had both clipping and diathermy, and in 5 (7.7%) patients, the ligation technique was not recorded. In 31 (47.7%) of 65 cases, a consultant was the principal surgeon. The remaining 34 (52.3%) of 65 cases were performed by trainees with (24, 70.6%) or without (10, 29.4%) supervision. There was no correlation between rebleed and operators' grade, level of supervision, or ligation technique. CONCLUSION:: With appropriate training, ESPAL can achieve hemostasis in teams of varying grades of operators without significant reduction in outcome. To further enhance the technical learning curve, the utility of simulation-based training could offer continuous and longitudinal development of skills.

Recurrent respiratory distress and cardiopulmonary arrest caused by megaoesophagus secondary to achalasia.

INTRODUCTION: Respiratory distress and arrest from tracheal compression secondary to megaoesophagus are rare complications of achalasia. We present the case of a man with end-stage achalasia who required oesophagectomy to prevent recurrent life-threatening tracheal compression and respiratory arrest. A literature review is also presented. PRESENTATION OF CASE: A 40-year old man presented with post-prandial stridor which resolved spontaneously, later being diagnosed with achalasia. He underwent pneumatic dilatation year later, intended as definitive treatment. Despite intervention, the patient had developed megaoesophagus. One month later he presented with tracheal compression and cardiorespiratory arrest but was successfully resuscitated. He subsequently underwent elective oesophagectomy. DISCUSSION: Over 40 case reports of achalasia presenting with stridor have been published. However, only three cases (all female, age range, 35-79 years old) of cardiac, respiratory or cardiorespiratory arrest have been published. The definitive treatments received by these patients were botulinum toxin injections, open Heller cardiomyotomy with Dor fundoplication and pneumatic dilatation. None of these patients suffered recurrent respiratory distress following definitive treatment. The patient currently reported was unique as he suffered cardiorespiratory arrest following an intended definitive treatment, pneumatic dilatation. As such oesophagectomy was considered the greatest risk-reduction intervention. CONCLUSION: Oesophagectomy should be considered for patients with end-stage achalasia and mega-oesophagus causing respiratory compromise to avoid potential fatal complications such as tracheal compression and subsequent respiratory arrest.

Adult-onset laryngomalacia: case reports and review of management.

Laryngomalacia is a dynamic airway condition characterised by inward collapse of flaccid supraglottic structures during inspiration. Although the most common cause of stridor in the paediatric population, adult-onset laryngomalacia remains a rare entity and its management, challenging. Two cases of adult-onset laryngomalacia are reported. A review of the English literature is performed and additional publications identified by hand-searching relevant papers; 13 case reports/series comprising 28 cases of adult-onset laryngomalacia were identified, divided into two main groups: idiopathic (6/28) and acquired (22/28). The aetiology of the acquired form includes neurological, traumatic and iatrogenic. Reported therapeutic measures used are laser supraglottoplasty, epiglottopexy, partial epiglottidectomy, defunctioning tracheostomy and intubation whilst correcting the underlying cause. The majority of patients only required one therapeutic procedure (follow-up of 2-24 months). A strong index of suspicion is required to diagnose adult-onset laryngomalacia aided by in-office laryngoscopy. The rarity of this condition prevents management-based randomised controlled trials.