Morbidity and Mortality Following Transoral Robotic Surgery, a Prospective Single Centre Study.

To review complications including mortality after transoral robotic surgery (TORS) for both benign and malignant pathologies. This is a prospective observational study. Postoperative haemorrhage (8.7%) was the most common complication and 2 (1.7%) mortality were seen in this study. Airway complications and tracheostomy (1.7%), aspiration pneumonia (1.7%), swallowing problems and nasogastric feeding (7%), intra-operative pharyngocutaneous fistula (0.9%) and transient nasal regurgitation (3.5%) were also seen. The more tissue is removed the more is the risk of complication. Complications were mainly seen in the first year of starting the service of TORS and it is a reflection of the learning curve. However, secondary haemorrhage did not follow any pattern in our series. The postoperative haemorrhage was more common in patients with T2 oropharyngeal carcinoma. The mortality was seen in 2 patients (1.7%) with T2 oropharyngeal carcinoma due to postoperative haemorrhage. Higher T stage of oropharyngeal squamous cell carcinoma (OPSCC) needs bigger resection with resultant increase in morbidity.

Laryngeal cancer: United Kingdom National Multidisciplinary guidelines.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. Significantly new data have been published on laryngeal cancer management since the last edition of the guidelines. This paper discusses the evidence base pertaining to the management of laryngeal cancer and provides updated recommendations on management for this group of patients receiving cancer care. Recommendations • Radiotherapy (RT) and transoral laser microsurgery (TLM) are accepted treatment options for T1a-T2a glottic carcinoma. (R) • Open partial surgery may have a role in the management of selected tumours. (R) • Radiotherapy, TLM and transoral robotic surgery are reasonable treatment options for T1-T2 supraglottic carcinoma. (R) • Supraglottic laryngectomy may have a role in the management of selected tumours. (R) • Most patients with T2b-T3 glottic cancers are suitable for non-surgical larynx preservation therapies. (R) • Concurrent chemoradiotherapy should be regarded as the standard of care for non-surgical management. (R) • Subject to the availability of appropriate surgical expertise and multi-disciplinary rehabilitation services, TLM or open partial surgical procedures ± post-operative RT, may be also be appropriate in selected cases. (R) • In the absence of clinical or radiological evidence of nodal disease, elective treatment (RT or surgery ± post-operative RT) is recommended to at least lymph node levels II, III and IV bilaterally. In node positive disease, it is recommended that lymph node levels II-V should be treated on the involved side. If level II nodes are involved, then elective irradiation of ipsilateral level Ib nodes may be considered. (R) • Most patients with T3 supraglottic cancers are suitable for non-surgical larynx preservation therapies. (R) • Concurrent chemoradiotherapy should be regarded as the standard of care for non-surgical management. (R) • Subject to the availability of appropriate surgical expertise and multi-disciplinary rehabilitation services, TLM or open partial surgical procedures ± post-operative RT, may also be appropriate in selected cases. (R) • In the absence of clinical or radiological evidence of nodal disease, elective treatment (RT or surgery ± post-operative RT) is recommended to at least lymph node levels II, III and IV bilaterally. In node positive disease, lymph node levels II-V should be treated on the involved side. (R) • As per the PET-Neck clinical trial, patients with N2 or N3 neck disease who undergo treatment with chemoradiotherapy to their laryngeal primary and experience a complete response with a subsequent negative post-treatment positron emission tomography combined with computed tomography (PET-CT) scan do not require an elective neck dissection. In contrast, patients who have a partial response to treatment or have increased uptake on a post-treatment PET-CT scan should have a neck dissection. (R) • Larynx preservation with concurrent chemoradiotherapy should be considered for T4 tumours, unless there is tumour invasion through cartilage into the soft tissues of the neck, in which case total laryngectomy yields better outcomes. (R) • In the absence of clinical or radiological evidence of nodal disease, elective treatment (RT or surgery ± post-operative RT) is recommended to bilateral lymph node levels II, III, IV, V and VI. (R).

The role of primary transoral laser microsurgery in laryngeal cancer: a retrospective study.

OBJECTIVE: To investigate the oncologic and survival outcomes of primary transoral laser microsurgery in laryngeal cancer. DESIGN: Retrospective analysis of a database of all patients undergoing primary transoral laser microsurgery with or without adjunctive therapy from June 2000 to October 2013. The median follow-up time was 33 months. SETTING: A teaching hospital. PARTICIPANTS: Two hundred and three patients underwent primary transoral laser microsurgery. Of these, 166 had glottic and 37 had supraglottic squamous cell carcinoma. MAIN OUTCOME MEASURES: Overall survival, disease-specific survival, local control and rate of salvage laryngectomy. RESULTS: Primary transoral laser microsurgery was performed exclusively in 149 (73%) patients, 16 (8%) had transoral laser microsurgery followed by postoperative (chemo)radiotherapy, 6 (3%) had transoral laser microsurgery with neck dissection, and 32 (16%) had transoral laser microsurgery in combination with neck dissection and postoperative (chemo)radiotherapy. In glottic cancer, the 5-year local control was 86%, 86% and 76% in carcinoma in situ (Tis), early-stage (T1, T2) and late-stage (T3, T4) disease, respectively. The 5-year disease-specific survival was 93% in Tis, 96% in early-stage and 65% at late-stage disease. In supraglottic cancer, the 5-year local control was 66% in early-stage and 88% in late-stage disease. The 5-year disease-specific survival was 80% and 75%, respectively. The rate of salvage laryngectomy was 9.9%. CONCLUSION: In carefully selected patients with laryngeal cancer, primary transoral laser microsurgery with or without adjunctive therapy can be organ preserving. It can provide a valid treatment option for patients.

Luc's abscess as an unlucky complication of mastoiditis.

Luc's abscess is a rare but important complication of acute otitis media (AOM), whereby infection spreads from the middle ear, resulting in a subperiosteal collection beneath the temporal muscle. Unlike other extracranial abscesses relating to AOM, Luc's abscess is not believed to involve the mastoid bone. We present the case of a patient with a Luc's abscess with mastoid involvement and discuss its successful management. We believe that patients presenting with a subperiosteal collection beneath the temporal muscle and mastoiditis may represent a different group of patients to those described originally by Luc. These individuals can be differentiated using computed tomography (CT) of the temporal bones. We advocate CT in patients with Luc's abscess and AOM; this aids preoperative surgical planning.

Outcomes following total laryngectomy for squamous cell carcinoma: one centre experience.

OBJECTIVES: To evaluate the clinical outcomes of total laryngectomy (TL), complications and factors affecting survival. DESIGN: Retrospective review of hospital electronic database for head and neck squamous cell carcinoma (SCCa). SETTING: Large district general hospital in England, United Kingdom. PARTICIPANTS: Patients who had TL between January 1994 and January 2008. MAIN OUTCOME MEASURES: 5-year disease specific survival (DSS) and disease-free survival (DFS). RESULTS AND CONCLUSIONS: Seventy-one patients were reviewed, of whom 38 (54%) had laryngeal SCCa and 33 (46%) hypopharyngeal SCCa. The overall mean survival period following TL was 42.4 months. The 5-year DSS and DFS was better for laryngeal SCCa compared to hypopharyngeal SCCa, although not statistically significant (P=0.090, P=0.54 respectively). Patients treated for laryngeal SCCa had a mean survival period of 47.5 months compared to 36.5 months for hypopharyngeal disease. Those who had laryngeal recurrence after primary radiotherapy (RT) demonstrated statistically better survival probability than those who had hypopharyngeal recurrence (P=0.011). Patients without cervical lymphadenopathy had statistically better survival (P=0.049). The most common early complication was related to the cardiorespiratory system. One fatal complication of erosion of the brachiocephalic artery due to the laryngectomy tube was noted. The most common late complication was neopharyngeal stenosis. The commonest cause of death was due to locoregional recurrence, followed by medical co-morbidities. Patients referred to specialised head and neck clinic had a better survival probability than those referred to a general ENT clinic (P=0.37). While there is increasing tendency towards laryngeal conservation, total laryngectomy remains a robust treatment option in selected patients.

Early outcomes after transoral CO2 laser resection of laryngeal and hypopharyngeal squamous cell carcinoma: one centre's experience.

OBJECTIVES: To review early oncological outcomes following transoral CO2 laser resection of laryngeal and hypopharyngeal squamous cell carcinoma. DESIGN: Retrospective review of hospital electronic database. SETTING: Large district general hospital in England, UK. MAIN OUTCOME MEASURES: Patients' three-year disease-specific survival and disease-free survival were evaluated, including post-operative complications, voice quality and swallowing status. RESULTS: Seventy-seven patients (16 women and 61 men) were identified. Transoral laser excision of squamous cell carcinoma of the larynx was undergone by 65 patients, and the same procedure in the hypopharynx by 12. Patients with laryngeal cancer had statistically better disease-specific survival than those with hypopharyngeal cancer (p = 0.021), although the cumulative disease-free survival probability was 0.71 for both larynx and hypopharynx groups. Patients who underwent laryngectomy following failed laser treatment or as a salvage procedure had poorer outcomes. CONCLUSIONS: The overall results of this study were comparable with those of other, larger studies. At three-year follow up, cumulative disease-specific survival probabilities were 0.92 and 0.71 for laryngeal and hypopharyngeal squamous cell carcinoma, respectively.

Effectiveness of X-ray and computed tomography screening for assessing pulmonary involvement in patients with head and neck squamous cell carcinoma.

OBJECTIVES: To evaluate the benefits of chest computed tomography and X-ray as screening tools in patients with newly diagnosed head and neck squamous cell carcinoma, to determine the incidence of lung metastases or synchronous pulmonary lesions, and to evaluate factors associated with positive radiological findings. DESIGN: Five-year, retrospective survey of all newly diagnosed cases of head and neck squamous cell carcinoma. RESULTS: We included 102 patients (63 men and 39 women), with a mean age of 67 years (range 33-91 years). The incidence of pulmonary involvement was 17 per cent. The sensitivity and specificity of computed tomography were 100 and 89.8 per cent, respectively. For chest X-ray, the sensitivity was 35.7 per cent and the specificity 92.7 per cent. The accuracy of computed tomography was 91.5 per cent and that of chest X-ray 83.1 per cent. There was a clear correlation between higher nodal stage and larger tumour with the development of distant metastases. In patients with a positive chest computed tomography scan, 86 per cent had T3 or T4 tumours, in contrast to 38 per cent of those with a negative chest scan (p < 0.05). In addition, 71 per cent of patients with positive findings had N2 or N3 nodal disease, compared with 29 per cent of those with negative findings (p < 0.05). CONCLUSION: There is currently no consensus on the use of chest X-ray and computer tomography for screening newly diagnosed cases of head and neck squamous cell carcinoma. We recommend routine scanning of high-staged head and neck squamous cell carcinoma. The National Institute of Health and Clinical Excellence guidelines should be reappraised.

Mucoepidermoid carcinoma of the tongue.

We report a 27-year-old Congolese man with mucoepidermoid carcinoma (MEC) of the tongue base, which presented as spontaneous intraoral bleeding. Optimal treatment of tongue base MEC is unknown. To our knowledge, this is the first reported case treated with transoral excision with carbon dioxide laser and selective neck dissection. Although immunohistochemical studies have revolutionised understanding of the disease, little else is known of the natural history of MEC. The majority of MEC is considered low-grade, with an indolent course without recurrence or metastasis. Nonetheless, MEC requires surgical management, postoperative radiotherapy and close long-term follow-up.

A completed audit cycle on post-tonsillectomy haemorrhage rate: coblation versus standard tonsillectomy.

CONCLUSION: A significant reduction in post-tonsillectomy secondary haemorrhage rate was observed after coblation tonsillectomy was abandoned in our department. OBJECTIVE: Comparison of the postoperative haemorrhage rate following coblation tonsillectomy and routine dissection tonsillectomy. PATIENTS AND METHODS: This was a retrospective study. In the first audit period, 441 sequential tonsillectomies between January and September 2002 were reviewed. Coblation was compared with cold steel and diathermy dissection with either ties and/or diathermy used for haemostasis. Coblation tonsillectomy was subsequently abandoned in our unit and, in the second audit period, all tonsillectomies (n=416) between July 2003 and August 2004 were included. Statistical analysis was performed using the chi2 test. RESULTS: The overall primary haemorrhage rate in the first audit cycle was 1.8% (8/441). In the second cycle with no coblation procedures, 1.4% of patients (6/416) suffered from primary haemorrhage (c.f. 8/441 (1.8%) in the first cycle, p=0.666). Secondary haemorrhage, was seen among 15.4% of patients (68/441) in the first audit cycle. In the second cycle, after coblation was discontinued, the secondary haemorrhage rate fell significantly (p<0.001) to 5.8% (24/416). A breakdown of the results of cold steel/diathermy and coblation techniques in both adults and children is also presented.

Prospective randomised single-blind controlled trial of glacial acetic acid versus glacial acetic acid, neomycin sulphate and dexamethasone spray in otitis externa and infected mastoid cavities.

OBJECTIVES: The literature reports the merits of antibacterial, antibiotic and steroid agents in treating otological infections but no controlled clinical trial has directly compared 2% glacial acetic acid (EarCalm; Stafford-Miller Ltd, Brentford, UK) against 2% glacial acetic acid, 0.1% dexamethasone and 3250 U/ml of neomycin sulphate (Otomize; Stafford-Miller Ltd) in the treatment of otitis externa and infected mastoid cavities. DESIGN: Prospective, single-blind randomised controlled trial. SETTING: Outpatients, Derby Royal Infirmary, Derby, UK. PATIENTS: Emergency and GP referrals with acute otitis externa (n = 53) and infected mastoid cavities (n = 56). MAIN OUTCOME MEASURES: Otoscopy was performed at initial randomisation and then at 2 and 4 weeks, the ear assessed for active and inactive disease. RESULTS: Patients with active otitis externa, 71% (15/21) resolved with glacial acetic acid, dexamethasone and of neomycin sulphate after 2 weeks, increasing to 86% (18/21) after 4 weeks treatment. Patients on glacial acetic acid had only 38% (12/32) resolution after 4 weeks (P < 0.0005). Two per cent glacial acetic acid, dexamethasone and neomycin sulphate resolved only 30% (8/27) of infected mastoid cavities compared to only 10% (3/29) on glacial acetic acid (P < 0.07). A further 2 weeks treatment this increased to 67%, (18/27) with glacial acetic acid, dexamethasone and neomycin sulphate and 48% (14/29) with glacial acetic acid. These results are not statistically significant. CONCLUSION: Glacial acetic acid, dexamethasone and neomycin sulphate is significantly more effective in treating otitis externa when compared with glacial acetic acid. This effect failed to be significant in the infected mastoid cavities group. We therefore recommend that in conjunction with aural toilet, antibiotic/steroid combination is more effective than an antibacterial agent for otitis externa. Larger numbers of infected mastoid cavities are required to be studied.

A prospective objective study of the cosmetic sequelae of nasal septal surgery.

CONCLUSIONS: Following nasal septal surgery, minor aesthetic changes may occur in up to 39.5% of patients and major changes in up to 4.5%. As part of the informed consent procedure, the potential for cosmetic changes should be discussed with all patients undergoing nasal septal surgery. OBJECTIVES: To objectively measure aesthetic changes following nasal septal surgery using pre- and post-operative photographic documentation and to highlight issues surrounding informed consent for nasal septal surgery. PATIENTS AND METHODS: The study population comprised 75 patients undergoing nasal septal surgery (septoplasty, submucous resection or revision nasal septal surgery). The main outcome measures were measurement of aesthetic changes (tip projection, supra-tip depression and columella retraction) using standardized pre- and post-operative photographic documentation examined by two independent observers. Patients' subjective perception of a change in shape of their nose was assessed using a visual analogue scale. The presence of any septal perforations was recorded at the follow-up visit (mean 15 months, range 8-13 months, standard deviation 4.2 months). RESULTS: The agreement between the two observers was very good when we considered a 1 mm difference as insignificant. Changes were arbitrarily defined as minor if < or =2 mm, and major, if > or =3 mm. With tip projection there was a minor change in 39.5% and major in 4.5% of patients. Supra-tip changes were minor in 6.7% and major in 1.3%. Minor columella changes occurred in 22% of patients, but there were no major changes. There was no statistically significant correlation between patients' subjective perception of changes in the shape of their nose with objectively measured changes. The septal perforation rate was 6.7%. Multivariate analyses (ANCOVA) showed no statistically significant influences of age, gender, grade of surgeon or type of nasal septal procedure.

Endoscopic dacryocystorhinostomy without silicone stenting.

Fifteen endoscopic dacryocystorhinostomies (DCRs) were performed without the use of silicone stents. These patients were followed up for an average of eight months. This procedure was successful in 87% of cases as measured by patients' relief of symptoms and endoscopic visualisation of a middle meatal ostium draining the lacrimal sac. Endoscopic DCR without silicone stenting compares favourably with other techniques described in the literature which use silicone stents. It does not have the disadvantage of complications associated with these stents.

Management of acute complicated sinusitis: a 5-year review.

Acute sinusitis is a relatively common problem; however, sinusitis associated with a complication is less frequent. Currently there is debate as to whether acute complicated sinusitis should be managed by frontal sinus trephine and sinus washout or by immediate frontoethmoidectomy/functional endoscopic sinus surgery. To assess the effectiveness of frontal sinus trephine in the management of acute complicated frontal sinusitis, we reviewed all patients admitted to Groote Schuur Hospital with acute pansinusitis (includes frontal, maxillary, and ethmoid) from 1989 to 1993. Eighty-seven patients were admitted, of whom 43 were treated medically and 44 were treated surgically. Of the surgical patients 38 had frontal trephines and management of associated complications. Thirty (80%) of the patients who received frontal trephines recovered without further surgery, and 8 required further sinus surgery for persistent disease. Frontal trephine with management of associated complications is an acceptable management option for patients with acute complicated pansinusitis. Frontoethmoidectomy or functional endoscopic sinus surgery can be held in reserve for those patients with persistent disease that does not resolve after the initial frontal trephine.

Complicated acute sinusitis and the computed tomography anatomy of the ostiomeatal unit in childhood.

The ostiomeatal unit is postulated to be a critical area in the pathogenesis of sinus disease and accurate assessment of this anatomical area has made possible by the coronal computed tomography (CT) scan. Data from the CT scans of 24 patients with complications of acute sinusitis were retrospectively reviewed and compared with a set of normative data of the infundibular length, and width and the uncinate angle in 196 scans of healthy children. In the patients with complicated sinusitis the infundibular length was found to be less and the infundibular width greater than the normative data. No difference in the mean uncinate angle of the two groups was shown. One, therefore, has to assume that the pathological process at the ostiomeatal unit is more likely to be mucosal than bony.