Immunotherapy in head and neck cancer: current practice and future possibilities.

The survival of patients with head and neck squamous cell carcinoma has changed little over the last 30 years. However, with recent advances in the fields of cellular and molecular immunology, there is renewed optimism with regards to the development of novel methods of early diagnosis, prognosis estimation and treatment improvement for patients with head and neck squamous cell carcinoma. Here, we present a critical review of the recent advances in tumour immunology, and of the current efforts to apply new immunotherapeutic techniques in the treatment of head and neck squamous cell carcinoma.

Head and neck tumour immunology: basic concepts and new clinical implications.

An understanding of the immune system and its modes of action is fundamental to understanding the causes, natural history, management and treatment of many diseases. As such, a grasp of the principles of immunology is essential for every physician.This paper represents a succinct overview of the immune system, discussing the major components in turn, in respect of structure, function and integrated organisation, in relation to head and neck cancer.

Genetic profile of head and neck squamous cell carcinoma: clinical implications.

The outcome for patients with head and neck squamous cell carcinoma remains poor, despite improvements in diagnosis and treatment over the past three decades. This has triggered great interest in the genetic events that underpin the aetiology and clinical behaviour of this group of cancers. As a result, the genetic profile for head and neck squamous cell carcinomas at different sub-sites has been relatively well characterised at the chromosomal level. Various studies have shown links between specific aberrations in head and neck squamous cell carcinoma and clinical outcome, e.g. loss of heterozygosity at 2q and 18q is commonly associated with poor prognosis, and loss of heterozygosity at 9p21 is associated with recurrence. However, there is as yet no significant clinical application of this genetic knowledge as regards the screening, diagnosis or treatment of head and neck squamous cell carcinoma. Here, we summarise the current state of knowledge, and highlight the most promising areas of research that may facilitate the translation of genetic data into clinical benefit.

The quality of operative note taking: an audit using the Royal College of Surgeons Guidelines as the gold standard.

To assess the quality of operative note keeping and compare the results with the Royal College of Surgeons (RCS) of England guidelines 'Good Surgical Practice' as the gold standard. ENT Department at Hull Royal Infirmary, University Hospital. A hundred consecutive operative notes were selected between November 2005 and January 2006. The documentation of the operative notes in each case was compared with the RCS of England guidelines. All surgeons were made aware of the results of the first cycle and the guidelines were made available in all ENT theatres in the form of a printed aide-memoir. A second audit cycle was then carried out prospectively between April and June 2006. The results demonstrated a change in practice in key areas. The 1st cycle results showed the documentation of patient identification (94%), name of surgeon (98%) and clearly written postoperative instructions (94%). However, surgeons performed suboptimally at recording the name of assistant (82%), operative diagnosis (46%), the incision type (87%) and the type of wound closure (83%). After introducing the aide-memoir, the second cycle demonstrated a change in practice with 100% documentation in most of the assessed parameters except that the time of surgery and the type of surgery (emergency or elective) were not adequately recorded. We recommend that all surgical departments should have the RCS guidelines as an aide-memoir in theatres to enhance the quality and standardise operative note recording.

Retroverted epiglottis presenting as a variant of globus pharyngeus.

We describe a series of four patients who presented with 'high globus pharyngeus', who all had an abnormally curled epiglottis tip touching and indenting the tongue base. The actual incidence of 'curling epiglottis', as well as the potential impact of this variation in persistent globus symptoms, is not known. We therefore describe for the first time a series of patients with this anatomical variant of the epiglottis, each of whom experienced unresolved globus symptoms despite receiving intensive medical treatment. In the literature, the success rate for improvement in symptoms following medical treatment ranges from 68 to 80 per cent. Following CO2 laser partial epiglottectomy, all four patients experienced complete relief of their symptoms. We advocate consideration of this treatment for high globus pharyngeus that fails to respond to conservative treatment, in cases with proven curled epiglottis on endoscopic examination.

Adult laryngeal rhabdomyosarcoma: report of a case and literature review.

Rhabdomyosarcoma is relatively seen in the pediatric age group with the head and neck region as the commonest site. To the best of our knowledge, few cases of laryngeal involvement in adult have been described in the literature. Biologically, rhabdomyosarcoma is different from squamous cell carcinoma, which is the commonest tumor of the larynx. A previously healthy non-smoker 77-year-old lady presented to the ENT outpatient with a six weeks history of intermittent alteration of voice quality. She had no history of sore throat, or any symptoms suggesting laryngo-pharyngeal reflux. Examination showed asymmetry of the left arytenoid cartilage and aryepiglottic fold. She subsequently had a direct laryngoscopy and biopsy. Histology and immunohistochemistry examination suggested the diagnosis of mesenchymal neoplasm. Following discussion at MDT she subsequently had a total laryngectomy. Histology confirmed a completely excised laryngeal rhabdomyosarcoma. Rhabdomyosarcoma of larynx in adult is a rare disease. Surgical treatment with or without adjuvant radiotherapy is currently the treatment of choice for this disease.

Otitis media and a neck lump--current diagnostic challenges for Paragonimus-like trematode infections.

A 29 year-old Nigerian studying in the UK presented with a neck lump and otitis media. Paragonimus-like trematode eggs were found in the neck lump aspirate. Morphologically these eggs resembled Paragonimus uterobilateralis or Achillurbainia congolensis. We favoured the diagnosis of achillurbainiasis over extrapulmonary paragonimiasis on the basis of clinical features and because we could not amplify DNA sequences using PCR primers specific for Paragonimus species. We discuss current diagnostic challenges for this rare parasitic infection.

Subglottic cysts in children: a 10-year review.

Subglottic cysts are associated with prematurity and periods of early neonatal intubation and are a rare cause of infant stridor. In this study we analyse our experience of this rare but important problem. We discuss the aetiology, diagnosis and management of subglottic cysts. We carried out a retrospective review of all cases of subglottic cysts presenting to the otorhinolaryngology department at the Leeds teaching hospitals trust during the period between 1995 and 2005. In total seven patients were identified. A retrospective review of the case notes of all patients proven to have subglottic cysts at direct laryngoscopy and bronchoscopy was undertaken. Seven patients were identified, four males and three females. Five were born premature (24-31 weeks). All were intubated with average intubation period of 20.6 days. Six of our patients' underwent endoscopic marsupialisation using cup forceps and one with a contact diode laser. Two patients had recurrence of the cyst and had a repeat of endoscopic marsupialisation. This study highlights the associated risk of neonatal intubation with the risk of formation of subglottic cysts, and the need for early diagnosis and appropriate treatment to avoid unnecessary morbidity.

Large B-cell non-Hodgkin's lymphoma presenting as a laryngeal cyst.

Cystic lesions of the larynx are most commonly benign. However, we report a case of non-Hodgkin's lymphoma (NHL) of the larynx which presented as a supraglottic cyst. This form of presentation has not been previously described in the medical literature.

Spontaneous rupture of the cervical oesophagus following nose blowing: a case report.

Spontaneous rupture of the oesophagus is a rare event. Most have been reported in association with oesophageal carcinoma, peptic ulceration and alcohol abuse followed by forceful episode of vomiting. We, however, report a case of spontaneous rupture of the oesophagus in an otherwise healthy individual with no history of alcohol intake, as a consequence of blowing of the nose.

Sudden sensorineural hearing loss following intracarotid injection of heroin.

A 26-year-old male presented with sudden right-sided sensorineural hearing loss after injection of heroin into the right neck. The hearing loss was found to be profound with no other associated abnormalities on examination or investigation. There was no change at 3-month follow-up. This was most probably due to arterial injection and is a previously unreported complication of heroin abuse.

Does thyroid subspecialization alter practice and outcome? A completed 4-year audit loop.

OBJECTIVE: To assess the effect of subspecialization on thyroid surgical practice and outcome. DESIGN: The multidisciplinary thyroid clinic was established in November 2000. A retrospective study of all thyroid surgery covering the period November 1998 to November 2000 was carried out. Best practice principles were implemented and prospective data were collected over a further 2 years to complete the audit loop. Practice and results were compared. SETTING: The project was carried out through the Hull and East Yorkshire Multidisciplinary Thyroid Clinic, a tertiary referral clinic for the management of thyroid disease. PARTICIPANTS: All patients who underwent thyroid surgery through the Department of Otolaryngology Head and Neck Surgery for 2 years before the establishment of the thyroid clinic (39 patients) and all patients who underwent thyroid surgery through the department for 2 years after the establishment of the clinic (108 patients) were included. MAIN OUTCOME MEASURES: Referral patterns, preoperative workup, types of surgery, histopathological diagnosis and complications rates were compared. RESULTS: The audit loop revealed that permanent vocal cord palsy rates had fallen from 8% to 0%, haematoma rates had fallen from 5% to 2% and permanent hypoparathyroidism rates had fallen from 8% to 2%. In addition, caseload had markedly increased, preoperative investigations were reduced and types of surgery standardized. CONCLUSION: It is clear that thyroid subspecialization is beneficial as far as overall outcome is concerned. However, this may lead to increased throughput which must be borne in mind for future activity planning.

Computerised tomography vs. pathological staging of laryngeal cancer: a 6-year completed audit cycle.

The aim of this audit was to examine the accuracy of computerised tomography (CT) staging of advanced laryngeal tumours. CT staging was evaluated against the T staging of laryngeal tumours as determined by pathological examination. Data from 38 patients, between 1996 and 2000 with laryngeal squamous cell cancer that fulfilled the audit criteria, were collected and compared. Subjects had to have a pre-operative CT scan of the larynx and a total laryngectomy specimen for pathological staging. The audit demonstrated that 45% of the patients were over staged and 10% were under staged using CT criteria as compared to pathological staging. Fourteen patients had been erroneously up staged to T4 on the basis of laryngeal cartilage invasion as judged by the radiological sign of cartilage sclerosis. While this radiological sign is used as a marker of neoplastic invasion in the literature, it was found to have a low sensitivity of 62% and low specificity of 42% in this study. Arytenoid cartilage sclerosis in isolation was no longer used as a radiological sign of neoplastic cartilage invasion. Following the change in practice, the CT staging of laryngeal cancer was re-evaluated in a second audit cycle. Correct CT staging of the tumour improved from 45 to 71%. Arytenoid cartilage sclerosis is no longer used as a sole CT criterion for predicting neoplastic cartilage invasion at our institution.

What happens to the lateral sinus following thrombosis? A case of failed recanalization.

Recanalization of the lateral sinus thrombosis is an expected outcome in patients who respond to treatment. We report a case of persistent lateral sinus thrombosis many years after treatment for peri-sinus infection.

Tuberculous osteitis of the cranium: a case report.

A 3-year old male presented with a 12-month history of painless scalp swellings associated with cough, fever and night sweats. Physical examination showed tender, fluctuant, pulsatile right frontotemporal and temporoparietal masses. Skull radiographs showed osteolytic skull lesions in the frontal and temporal bones. Microscopy of drained caseous material and histology of biopsies from the affected bone edges confirmed tuberculous osteitis. Though there was an initial response to antituberculous agents, the child died after 5 weeks from hepatic failure. Tuberculosis of the skull bones though rare, may become more common with the recent upsurge of tuberculosis worldwide. A high index of suspicion is necessary for early diagnosis and treatment.