Transcervical pharyngeal pouch stapling.

BACKGROUND: Pharyngeal pouches are generally treated with surgery, via either an endoscopic or an external approach. Large pouches extending to the mediastinum carry an increased risk of post-operative mediastinitis in the event of a leak following external approach surgery, and may not always be amenable to endoscopic stapling. METHODS: Transcervical stapling is a newly described technique that uses the endoluminal stapling approach but in which the diverticuloscope is inserted into the pharynx via a neck incision. CONCLUSIONS: This technique has been used successfully on three patients with large pharyngeal pouches, where endoscopic stapling was not possible due to access limitations.

Malignancy rates and initial management of Thy3 thyroid nodules in a district general hospital: The 'Reading' experience.

BACKGROUND: Ultrasound-guided fine-needle aspiration cytology is the gold standard for investigating thyroid nodules. Stratifying the Thy3 thyroid nodule risk of malignancy is essential for clinical decision-making. According to the Royal College of Pathologists Guidance (2016), the rate of malignancy for Thy3a is 5-15% and for Thy3f 15-30%. Our aim was to investigate the malignancy rate and the initial management of Thy3 nodules in our institution. METHODS: A retrospective review was undertaken of 115 patients with Thy3 cytology results from thyroid fine-needle aspirations performed between January 2015 and June 2020 at a single centre. A total of 90 out of 115 patients underwent surgery. RESULTS: Of the 90 patients, we had a 40% malignant rate (36/90). Specifically, 14 of 34 (41.1%) Thy3a and 22 of 56 (39.2%) Thy3f nodules were malignant. Of the malignant lesions, 52.7% (19/36) were follicular thyroid carcinoma. 58.8% (10/17) of male patients and 35.6% (26/73) of female patients had a malignant histology. Eighteen patients eventually needed a completion thyroidectomy. CONCLUSION: Compared with national data, we showed a higher risk of malignancy in Thy3 nodules in our centre. Our study should encourage other centres to audit their own data. We propose setting up a national Thy3 registry as a basis to promote research in improving preoperative diagnosis of indeterminate thyroid nodules.

Relation of a hypoxia metagene derived from head and neck cancer to prognosis of multiple cancers.

Affymetrix U133plus2 GeneChips were used to profile 59 head and neck squamous cell cancers. A hypoxia metagene was obtained by analysis of genes whose in vivo expression clustered with the expression of 10 well-known hypoxia-regulated genes (e.g., CA9, GLUT1, and VEGF). To minimize random aggregation, strongly correlated up-regulated genes appearing in >50% of clusters defined a signature comprising 99 genes, of which 27% were previously known to be hypoxia associated. The median RNA expression of the 99 genes in the signature was an independent prognostic factor for recurrence-free survival in a publicly available head and neck cancer data set, outdoing the original intrinsic classifier. In a published breast cancer series, the hypoxia signature was a significant prognostic factor for overall survival independent of clinicopathologic risk factors and a trained profile. The work highlights the validity and potential of using data from analysis of in vitro stress pathways for deriving a biological metagene/gene signature in vivo.

Relation of erythropoietin and erythropoietin receptor expression to hypoxia and anemia in head and neck squamous cell carcinoma.

PURPOSE: The use of erythropoietin in head and neck squamous cell carcinoma (HNSCC) has been associated with poor survival. This study examines the protein and mRNA expression of erythropoietin and erythropoietin receptor in HNSCC and their relation to hypoxia, hemoglobin (Hb), and clinical outcome. EXPERIMENTAL DESIGN: The immunohistochemical expression of erythropoietin and erythropoietin receptor was assessed in 151 cases of HNSCC. Expression was compared with the hypoxia-dependent proteins hypoxia-inducible factor-1alpha (HIF-1alpha) and carbonic anhydrase-9 (CA-9) and correlated with clinical outcome. The mRNA expression of erythropoietin and erythropoietin receptor was measured in paired samples of HNSCC. RESULTS: Erythropoietin and erythropoietin receptor were expressed in 95% and 99% of tumors, respectively. Using a weighed expression score, there was a positive correlation between erythropoietin and erythropoietin receptor expression (r = 0.18, P = 0.03). HIF-1alpha (r = 0.38, P < 0.01) and CA-9 (r = 0.26, P = 0.002) correlated with erythropoietin expression, but there was no correlation with erythropoietin receptor. No correlation was found between Hb and erythropoietin (r = 0.07, P = 0.36) or erythropoietin receptor (r = -0.02, P = 0.8), and no survival difference between high and low erythropoietin or erythropoietin receptor expression (P = 0.59 and P = 0.98, respectively). The mRNA expression of erythropoietin (P = 0.03) but not erythropoietin receptor (P = 0.62) was significantly increased in 11 paired samples of HNSCC. CONCLUSION: In vivo, the HIF pathway regulates erythropoietin at the mRNA level but not erythropoietin receptor expression in HNSCC. Anemia does not seem to influence the hypoxic microenvironment of tumors sufficiently to alter the expression of erythropoietin. The effects of exogenous erythropoietin may be acting via receptors expressed on tumor cells in vivo, or on vascular cells, which also express the pathway.

Granulomatosis with polyangiitis affecting the skull base and manifesting as spontaneous skull base osteomyelitis.

A 53-year-old woman presented with right-sided otalgia radiating to the temporal region, angle of the mandible and upper neck. Otoscopy was unremarkable on examination and there were no signs of otitis externa. MRI revealed an infiltrative soft tissue mass to the right lateral aspect of the clivus. Transnasal and CT-guided biopsies were performed, however, these showed either inconclusive or benign tissue. Following multidisciplinary team assessment a diagnosis of spontaneous skull base osteomyelitis was made and treatment with intravenous antibiotics started. Failure to respond to antimicrobials and the development of cranial nerve palsies raised the possibility of a vasculitis. Subsequently, a clinical diagnosis of granulomatosis with polyangiitis (GPA) was made. Remission has now been maintained with cyclophosphamide and prednisolone. We discuss the rare presentation of GPA mimicking that of spontaneous skull base osteomyelitis as well as its management and related primary otolaryngological manifestations.

Opportunistic hearing screening in elderly inpatients.

OBJECTIVE: To determine the prevalence of occult hearing loss in elderly inpatients, to evaluate feasibility of opportunistic hearing screening and to determine subsequent provision of hearing aids. MATERIALS AND METHODS: Subjects (>65 years) were recruited from five elderly care wards. Hearing loss was detected by a ward-based hearing screen comprising patient-reported assessment of hearing disability and a whisper test. Subjects failing the whisper test or reporting hearing difficulties were offered formal audiological assessment. RESULTS: Screening was performed on 51 patients aged between 70 and 95 years. Of the patients, 21 (41%) reported hearing loss and 16 (31%) failed the whisper test. A total of 37 patients (73%) were referred for audiological assessment with 17 (33%) found to have aidable hearing loss and 11 were fitted with hearing aids (22%). DISCUSSION: This study highlights the high prevalence of occult hearing loss in elderly inpatients. Easy two-step screening can accurately identify patients with undiagnosed deafness resulting in significant proportions receiving hearing aids. KEY SENTENCES: Approximately 14% of the elderly population use hearing aids despite a reported prevalence of deafness in up to 55%.The use of hearing aids is associated with an improvement in physical, emotional, mental and social well-being.An easy screening test for hearing loss consists of patient-reported hearing loss and a whisper test.Opportunistic screening of elderly inpatients resulted in referral of 73% of screened patients for formal audiology.Of the screened patients, 22% were provided with hearing aids.

Pharyngeal pouch surgery: a combined open and endoscopic approach.

Pharyngeal pouches are common, particularly in the elderly population, in whom they can cause significant morbidity. The advanced age of many patients and existing comorbidities mean that in some cases neither open nor endoscopic pouch stapling is possible. We present a technique of combined open and endoscopic pharyngeal pouch surgery, which may be used when other therapeutic options are limited.

hsa-mir-210 is a marker of tumor hypoxia and a prognostic factor in head and neck cancer.

BACKGROUND: Hypoxia is an important mechanism of treatment resistance in head and neck squamous cell carcinoma (HNSCC). MicroRNAs are short noncoding RNAs that regulate multiple mRNAs and are frequently dysregulated in cancer. The authors have investigated the role of 3 microRNAs, including the hypoxia-induced hsa-miR-210, as potential markers of hypoxia or prognosis. METHODS: Three hypoxia-related microRNAs, hsa-miR-210, hsa-miR-21, and hsa-miR-10b, were measured in 46 samples from patients with HNSCC. Expression levels were correlated with clinicopathological variables and other markers of hypoxia: a published 99-gene hypoxia metagene, individual hypoxia-related genes such as TWIST1, and immunohistochemical expression of hypoxia-inducible factor 1 and its target gene carbonic anhydrase 9. We then performed survival analyses to investigate the prognostic significance of these microRNAs. RESULTS: Only the level of hsa-miR-210 was significantly correlated with other markers of hypoxia, including the 99-gene hypoxia metagene (rho = 0.67, P < .001). We found no association between hsa-miR-210, hsa-miR-21, or hsa-miR-10b and clinicopathological variables such as tumor size, differentiation, and stage. However, high levels of hsa-miR-210 were associated with locoregional disease recurrence (P = .001) and short overall survival (P = .008). hsa-miR-21 and hsa-miR-10b had no prognostic significance. CONCLUSIONS: Expression of hsa-miR-210 in head and neck cancer correlates with other approaches for assessing hypoxia and is associated with prognosis. This warrants further study as a classification marker of patients for therapies involving modulation of hypoxia.

Outcomes in squamous cell carcinoma with advanced neck disease.

INTRODUCTION: Treatment of advanced neck disease (N2c/N3) in head and neck squamous cell carcinoma is contentious. The aim of this study was to review the survival outcome following surgical excision of neck disease and the complications of this surgery. PATIENTS AND METHODS: A retrospective review of the case notes of 39 patients treated at the Oxford Radcliffe Infirmary Head and Neck Unit with squamous cell carcinoma and advanced neck metastases confirmed as either pN2c or pN3 on histological examination was performed. Patients were treated with surgery and, in some cases, with adjunctive postoperative radiotherapy at the centre between August 1996 and November 2004. The study sought to establish the demographics, UICC staging/pathology, method of treatment, complications, recurrence and survival. Kaplan-Meier curves were used for statistical analysis of survival. Comparisons were then made between the cohort and historical control groups. RESULTS: All patients were UICC stage IV disease. The 2- and 5-year overall survival in patients with resectable disease was 63% and 52%, respectively. DISCUSSION: Patients with advanced neck disease have traditionally been thought to have terrible prognosis and, therefore, treatment is controversial. In treating advanced head and neck cancer, there has been a recent trend away from surgery towards chemotherapy and/or radiotherapy. CONCLUSIONS: Comparing this study group to historical controls that include chemotherapy and/or radiotherapy, the outcomes appear favourable. The use of a combination of radiotherapy and surgery is advocated; it is suggested that advanced neck disease can have an acceptable prognosis and morbidity and that local disease control may be achieved.

How well equipped are ENT wards for airway emergencies?

INTRODUCTION: With increased cross cover of specialities at night and more direct triaging of casualty patients to ENT wards, there is an increased need to ensure that there is adequate provision of emergency airway management. There are currently no national guidelines on what equipment should be available on ENT wards, and the authors have devised a portable airway box with all equipment deemed necessary to manage an acute airway. We believe that all junior doctors covering ENT should have airway training and access to an airway box. The aim of this study was to determine the provision of on-ward airway equipment and training on ENT wards in England. MATERIALS AND METHODS: A telephone survey of all English hospitals with in-patient ENT services. RESULTS: A total of 103 departments were contacted with 98% response rate. Most wards were covered by a combination of ENT and other specialties. Results indicated that only 18% of departments had an airway box and 28% had some training in airway management. CONCLUSIONS: Results suggest poor provision of emergency airway equipment and training on wards. We recommend the use of an airway box, and list of minimal equipment required.

The relation between hypoxia-inducible factor (HIF)-1alpha and HIF-2alpha expression with anemia and outcome in surgically treated head and neck cancer.

BACKGROUND: Hypoxia promotes tumorigenesis through the hypoxia-inducible factor (HIF) pathway. There are 2 main homologues of the regulatory proteins, HIF-1alpha and HIF-2alpha, which have different effects in genetic knock-out experiments. Anemia may contribute to hypoxia by reducing oxygen delivery, but it is not known whether this influences HIF-alpha expression in tumors. METHODS: The expression of HIF-1alpha, HIF-2alpha, carbonic anhydrase-9 (CA-9), and peripheral hemoglobin (Hb) levels in 151 patients who underwent surgery for head and neck squamous cell carcinoma (HNSCC) were analyzed and related to outcome. RESULTS: High HIF-1alpha was expressed in 45 of 140 tumors (30%), HIF-2alpha was expressed in 21 of 139 tumors (14%), and CA-9 was expressed in 56 of 149 tumors (62%). There was a positive correlation between HIF-1alpha expression and HIF-2alpha expression (P =.0001). HIF-1alpha alone was associated with a worse disease-specific survival (DSS) (P =.05) and disease-free survival (DFS) (P = .03) in multivariate analyses. Nine percent of tumors expressed both high HIF-1alpha and high HIF-2alpha. High HIF-1alpha/high HIF-2alpha expression was an independent prognostic factors in DSS (P = .04) and DFS (P =.005) in multivariate analyses. There was no correlation noted between Hb and HIF-1alpha, HIF-2alpha, or CA-9. CONCLUSIONS: HIF-1alpha alone was correlated with DSS and DFS. The additive effect of HIF-2alpha on poor prognosis suggested that different pathways may be regulated by HIF-2alph. Anemia that was not related to HIF-alpha expression suggests that tumor intrinsic factors regulate HIF-alpha therefore, anemia may be a surrogate marker for other factors that affect outcome.