A multidisciplinary audit of head and neck referrals: considerations for patients' timelines and outcomes.

The Rapid Diagnostic Clinic (RDC) was introduced to comply with NICE recommendations for improving head and neck cancer services (National Institute of Clinical Excellence 2004 Improving outcomes in head and neck cancer: the manual. NICE, London). It provides multi-modality specialist assessment for new referrals, with on-site sonography and cytology. We have critically appraised the efficacy of our RDC, with respect to its impact on patients' timelines and outcomes. A retrospective audit of new referrals to the head and neck clinic during a 6-month period was conducted (pre-RDC period); areas in delay in patients reaching a definitive outcome were identified. Following implementation of the RDC, a second cycle, prospective audit was performed and its impact on timelines for patients' journey and outcomes determined. One hundred and ninety-seven patients were seen during the pre-RDC period. The average time from referral to being seen was 11 days for 2-week wait (2WW) referrals and 34 days for other sources. During the RDC period, 299 patients were seen in total. The average waiting time was reduced to 9 days for 2WW referrals and 23 days for other referrals. During the RDC period, over one-third of patients utilised the provision of ultrasound ± FNAC, and consequently, the majority reached a definitive outcome (discharged or scheduled for surgery) following their first consultation. This was a significant improvement compared to the pre-RDC period, where the main outcome was referral for an investigation, with consequently longer waiting time for surgery. We report the first study to consider the effect of a 'one-stop' clinic on patients' journey timelines and outcomes. Our study has shown that the RDC provides an efficient and effective system, which facilitates the patients' pathway to a definitive management plan.

Free jejunum reconstruction of upper esophageal defects.

The free jejunum has become an important method for reconstructing extensive oncologic defects of the upper esophagus and pharynx. The advantages of a single-staged reconstruction with a low incidence of morbidity have generally outweighed criticisms such as the requirement for a laparotomy and poor voice quality. The aim of the study was to present the technique and outcomes of free jejunal reconstruction of the upper esophagus in 31 consecutive cases. We reviewed our experience of free jejunal flaps undertaken over a 6-year period. Our surgical approach, complications, and results of swallow and speech restoration are described. A functional swallow was achieved by 27/31 patients. However, satisfactory voice restoration was seen in only a small proportion of patients. Complications at the donor site occurred in just one patient. The current review confirms the jejunal flap as a reliable reconstructive option with minimal donor site morbidity.

Preoperative and postoperative optimisation of patients undergoing thyroid surgery: a multicentre quality improvement project at Barts Health NHS Trust.

Hypocalcaemia following thyroid surgery can occur in up to 38% of patients. With over 7100 thyroid surgeries performed in 2018 in the UK, this is a common postoperative complication. Undertreated hypocalcaemia can result in cardiac arrhythmias and death. Preventing adverse events from hypocalcaemia requires preoperative identification and treatment of at-risk patients with vitamin D deficiency, timely recognition of postoperative hypocalcaemia and prompt appropriate treatment with calcium supplementation. This project aimed to design and implement a perioperative protocol for prevention, detection and management of post-thyroidectomy hypocalcaemia. A retrospective audit of thyroid surgeries (n=67; October 2017 to June 2018) was undertaken to establish baseline practice of (1) preoperative vitamin D levels assessment, (2) postoperative calcium checks and incidence of postoperative hypocalcaemia and (3) management of postoperative hypocalcaemia. A multidisciplinary team approach following quality improvement principles was then used to design a perioperative management protocol with all relevant stakeholders involved. After dissemination and implementation, the above measures were reassessed prospectively (n=23; April-July 2019). The percentage of patients having their preoperative vitamin D measured increased from 40.3% to 65.2%. Postoperative day-of-surgery calcium checks increased from 76.1% to 87.0%. Hypocalcaemia was detected in 26.8% of patients before and 30.43% of patients after protocol implementation. The postoperative component of the protocol was followed in 78.3% of patients. Limitations include low number of patients which precluded from analysis of the impact of the protocol on length of stay. Our protocol provides a foundation for preoperative risk stratification and prevention, early detection and subsequent management of hypocalcaemia in thyroidectomy patients. This aligns with enhanced recovery protocols. Moreover, we offer suggestions for others to build on this quality improvement project with the aim to further advance the perioperative care of thyroidectomy patients.

The impact of mixing surgical subspecialty patients on wound infection rates.

To investigate the impact of mixing surgical subspecialty patients on post-operative wound infections. A retrospective analysis of post-operative wound infections in head and neck surgery patients before and after mixing them with urology patients. We selected two periods that are identical in duration and seasonal spread. The first was from March 2005 to November 2005 and the second was from March 2006 to November 2006. 1,381 patients underwent head and neck surgery at our institution in the two periods; 705 in the first and 676 in the second. Excluding MRSA positive swabs, the rate of positive swabs or "episodes" was 4% in the first group (2005) and 10% in the second group (2006). The monthly breakdown showed a significant increase in the second group (2006) (p = 0.024). Uro-genital microorganisms were the main factor contributing to the increase in wound infection rates in the second period (p = 0.008). Other organisms like MRSA, remained statistically unchanged (p = 0.464). It is recommend that head and neck surgery patients are better managed on separate wards. Clinicians should have a low threshold of suspecting a broader range of microorganisms when other specialty patients are on the same ward.

Primary Immunoglobulin G4-Related Laryngeal Disease: A Case Series and Review of Literature.

OBJECTIVE: Immunoglobulin G4-related disease (IgG4-RD) is an increasingly recognised cause of various systemic fibro-inflammatory conditions. However, laryngeal involvement as a primary feature is extremely rare. We aimed to report on a case series of such patients and examine the global literature relating to laryngeal involvement. METHODS: Having previously reported a case of IgG4-RD laryngeal pseudotumour, we describe a case series of further 4 patients with primary laryngeal IgG4-RD managed by our UK quaternary airway service and provide a brief overview of laryngeal IgG4-RD. RESULTS: Including our cases, 14 cases of primary laryngeal IgG4-RD have been reported. Vocal cord involvement is relatively uncommon. Repeat biopsies may be required to achieve histological diagnosis. Remission is achievable by commencement of immunomodulatory treatment, following which laryngeal reconstruction may be necessary. CONCLUSION: Laryngeal involvement is a rare presentation of IgG4-RD, itself a rare and difficult-to-diagnose condition. A high and prolonged index of suspicion is necessary from both surgical and pathological specialists for correct diagnosis and management.

Atypical 18F-FDG PET-CT uptake in the head and neck; a case-based pictorial review.

Positron emission tomography - computed tomography (PET-CT) with fluorine-18-fluorodeoxy-d-glucose (18F-FDG) has an increasing role in head and neck imaging. Interpretation of 18F-FDG-tracer uptake in the head and neck requires an understanding of normal physiological patterns of tracer uptake, as well as knowledge of potential pitfalls and atypical patterns. This article presents a select series of unusual patterns of 18F-FDG uptake on PET-CT imaging of the head and neck.

Outcome of endoscopic treatment of adult postintubation tracheal stenosis.

OBJECTIVES/HYPOTHESIS: To assess the results of primary endoscopic treatment of adult postintubation tracheal stenosis, to identify predictors of a successful outcome, and better define the scope and limitations of minimally-invasive surgery for this condition. METHODS: Sixty-two consecutive patients treated between April 2003 and 2006 with initial endoscopic surgery were prospectively studied. Patient and lesion characteristics, treatment details, complications, decannulation, and open surgery rates were recorded. Actuarial analysis and Cox regression were used to identify predictors of decannulation and freedom from external surgery. RESULTS: There were 34 male patients and the average age was 45 +/- 16 years. The average stenosis height was 18 mm (range: 5-55 mm), and 82% of lesions were Myer-Cotton grades III or IV. Lesion height and intubation-to-treatment latency independently predicted success of endoscopic surgery. Ninety-six percent of patients with lesions <30 mm in height were treated endoscopically, but the success rate fell to 20% for lesions longer than 30 mm. Patients with recalcitrant lesions underwent airway augmentation (n = 11) or resection (n = 3), with a 79% success rate. All patients were decannulated, but some, predominantly morbidly obese patients, required long-term stents for dynamic airway compromise. Ninety-eight percent of re-interventions occurred within 6 months. CONCLUSIONS: Minimally invasive treatment is effective in postintubation airway stenosis and obviates the need for open cervicomediastinal surgery in most patients. Patients with old and long lesions are less likely to be cured endoscopically. For most patients in this subgroup, endoscopic surgery makes airway augmentation a viable, less invasive alternative to resection. Patients were unlikely to require further therapy after 6 months of symptom-free follow-up.

Massive lipoma of the posterior neck.

Giant lipomas are a rare, benign cause of painless neck mass. We describe the case of a 63-year-old man with a giant lipoma of the left posterior neck, which presented with intermittent upper limb paraesthesia. Surgical excision confirmed the diagnosis of spindle-cell lipoma and resulted in complete resolution of neurological symptoms.

Conjunctival melanoma: the role of conservative surgery and radiotherapy in regional metastatic disease.

OBJECTIVE: To evaluate prognostic factors and determine the role of conservative surgery and radiotherapy in managing metastatic conjunctival malignant melanoma (MM) involving preauricular/submandibular lymph nodes. METHOD: A retrospective analysis (1990-2003) of clinical and histopathologic data from 12 patients presenting with regional metastases after failed local treatment for conjunctival MM. Patients received a common, multispecialty, conservative management approach: wide local excision, topical cryotherapy or radiotherapy to conjunctival MM (orbital exenteration for more advanced local disease), lumpectomy, and adjuvant "ring" radiotherapy of regional metastases, with chemotherapy for distant metastases. RESULTS: Median age at primary diagnosis was 51 (range 28-86) years with equal sex predilection. Six of the 12 patients had primary tumors of the bulbar conjunctiva; the remainder arose in the palpebral conjunctiva, the caruncle, or the fornix. Of 11 originating in primary acquired melanosis (PAM), 2 were amelanotic. Epithelioid tumor cells were noted histologically in seven of eight specimens in which cell type could be determined. Eight tumors metastasised to preauricular nodes, three to submandibular and one to both, with a median interval of 23 (range 12-108) months after primary diagnosis. After conservative surgery and "ring irradiation," 7 of 12 patients remained free of regional nodal relapse at median interval of 16 (range 3-126) months. Five patients developed regional nodal recurrence at median interval of 11 (range 6-13) months, 3 of whom were within radiotherapy portals. Eight patients developed distant metastasis at median interval of 44 (range 22-138) months. Eleven patients had tumor-related death. The mean Kaplan-Meier adjusted survival time after primary diagnosis was 76 months with death ensuing postregional metastasis within a median 18 (range 4-127) months. The sole survivor's follow-up duration was 56 months. CONCLUSION: Locoregional metastasis after treatment for conjunctival MM is associated with a poor prognosis. Both epithelioid tumor cells and PAM are associated with disseminating disease and poorer outcome. Literature review has failed to demonstrate advantages of mutilating radical surgery over a conservative approach in this rare disease.

Operative training in otolaryngology in the United Kingdom: a specialist registrar survey.

OBJECTIVE: To assess the current status of operative training for otolaryngology specialist registrars in the United Kingdom. DESIGN: Web-based questionnaire survey. PARTICIPANTS: All otolaryngology specialist registrars in the United Kingdom. MAIN OUTCOME MEASURES: The overall satisfaction with operative training was assessed as well as the number of operations performed and level of competency in stage-specific procedures, as defined by the Joint Committee for Higher Specialist Training. RESULTS: Otolaryngology specialist registrars are generally satisfied with the quality of their operative training. The most important predictive factor of satisfaction with operative training was the number of theatre sessions per week. The vast majority of registrars (92 per cent by the end of year one, 73 per cent at the end of years two to four) appear to attain all the stage-appropriate surgical competencies during the first four years. However, with respect to the last two years of registrar training, only 26 per cent can perform all the designated (complex) procedures. There are no significant differences between deaneries or geographic regions in the overall satisfaction rates, number of operative sessions, number of operations performed or operative competencies attained. CONCLUSION: It appears that the Specialist Advisory Committee (SAC) is generally successful in maintaining common operative training standards and providing a homogenous training environment. During the first four years registrars attain an appropriate level of general training while the last two years are mainly devoted to subspecialty interests.

Endoscopic CO2 laser management of laryngocele.

OBJECTIVE: To report on the management of laryngoceles by CO2 laser-assisted endoscopic excision. STUDY DESIGN: A 15-year retrospective study of 12 adult patients (7 men and 5 women) who presented with a laryngocele. Nine patients had an internal laryngocele, one patient had an external laryngocele, and two patients had combined internal-external components. Two laryngoceles were right-sided, six were left-sided, and four were bilateral. METHODS: An endoscopic examination of the laryngocele was carried out for both diagnostic and therapeutic purposes. Once identified the air- or mucus-filled cyst (extending from the laryngeal ventricle into the paraglottic space and beyond the thyrohyoid membrane in some cases), the laryngocele was excised in toto, with its surrounding capsule, via endoscopic approach using the CO2 laser. RESULTS: The main presenting symptom was dysphonia in seven patients, visible or palpable mass in the neck in three, and upper airway obstruction in the remaining two. All laryngoceles were treated with endoscopic laser excision of the internal and external components when required. The average postoperative stay in hospital was 1.8 days. Only two of the patients treated had a tracheotomy; both cases presented elsewhere with an emergency airway obstruction, which necessitated tracheotomy. In these two cases, decannulation was subsequently performed. There were no significant complications. The follow-up ranged from 6 months to 5 years. CONCLUSION: CO2 laser-assisted endoscopic excision of a laryngocele is a quick, precise, and safe alternative to an external approach excision (lateral thyroidotomy, laryngofissure) with fewer complications than its external counterparts, resulting in speedier rehabilitation of both the patient and his or her voice.

Pseudosarcomatous fibrovascular proliferative tissue masquerading as a primary subglottic angiosarcoma.

A unique case of pseudosarcomatous fibrovascular proliferative tissue causing biphasic stridor and simulating a primary subglottic angiosarcoma is reported. The patient presented with a wheeze and was diagnosed initially with asthma. He subsequently developed worsening biphasic stridor. Flexible nasendoscopy revealed a subglottic mass obstructing the airway. The mass was removed with a carbon dioxide laser and the patient's condition improved dramatically. The specimen was difficult to interpret histologically and was thought at first to be a novel case of a primary subglottic angiosarcoma. However, the slides were reviewed by expert soft tissue pathologists in the UK and USA, and a final diagnosis of a pseudosarcomatous fibrovascular proliferative lesion was made. This case highlights the important principle of seeking additional opinions before making a malignant diagnosis in an atypical site. Our report also emphasizes the importance of good clinico-pathological liaison, especially in difficult cases.

Feasibility of a synthetic temporal bone for training in mastoidectomy: face, content, and concurrent validity.

OBJECTIVE: To investigate the face, content, and concurrent validity of the synthetic Pettigrew temporal bone (PTB) for mastoidectomy training as compared with cadaveric temporal bone (CTB). STUDY DESIGN: A prospective evaluation study. METHODS: Participants were invited to perform a step-by-step modified radical mastoidectomy using both bones and complete a 22-item, 5-point Likert scale questionnaire. The questionnaire is divided into 4 domains: face validity (FV), global content (GC), task-specific content (TSC), and curriculum recommendation (CR). RESULTS: Thirty-six experts and 89 trainees completed all tasks, 63 using CTB and 62 using PTB. The PTB median FV was 4 (IQR: 4-5), GC of 4 (IQR: 4-5), TSC of 4 (IQR: 3-4), and CR of 4 (IQR: 4-5). The CTB was rated significantly higher than PTB by both groups in all domains; CTB FV: 5 (IQR: 4-5), GC: 5 (IQR: 4-5), TSC: 5 (IQR: 4-5), and CR: 5 (IQR: 5-5), p < 0.001 for each. Trainees rated PTB significantly higher than experts in all domains. There was no statistically significant difference between experts and trainees in rating the CTB in all domains. PTB gives similar haptic feedback to CTB, allows the use of suction and irrigation, has the important landmarks painted for identification, and contains articulating ossicles. The facial nerve anatomy was found to be inaccurate around the region of the second genu. CONCLUSION: Participants found PTB to be valid for teaching some, yet not all, aspects of mastoid surgery, and experts agreed that it could improve global transferrable otologic skills. It is essential that the facial nerve anatomy is addressed before recommending this model.

Branchiootic syndrome--a clinical case report and review of the literature.

Branchiootoic syndrome is part of the spectrum of brachiootorenal disorders. Brachiootorenal disorder is a rare autosomal dominant condition, characterized by malformations of the outer, middle, and inner ear, which are associated with branchial and renal anomalies. We describe a case of bilateral branchiootoic syndrome and discuss the anatomy of second branchial cleft fistulae and the surgical management of this uncommon condition. We report the case of a 6-year-old girl referred to our department with bilateral intermittently discharging neck swellings. Clinical examination revealed bilateral branchial fistulae and preauricular sinuses, on a background of a positive family history of branchial fistulae. A magnetic resonance imaging scan confirmed the diagnosis of bilateral second branchial cleft fistulae. In view of her symptoms, she underwent bilateral branchial fistula excision and tonsillectomy with an uneventful postoperative recovery.

Outcome of treating airway compromise due to bronchial stenosis with intralesional corticosteroids and cutting-balloon bronchoplasty.

OBJECTIVES: To determine the feasibility, safety, and efficacy of treating benign bronchial stenosis with laryngoscopy, jet ventilation, intralesional corticosteroids, and cutting-balloon bronchoplasty. STUDY DESIGN: Case series with planned data collection. SETTING: National airway unit. SUBJECTS AND METHODS: Ten adult patients with bronchial stenosis caused by Wegener's granulomatosis (n = 6), tuberculosis (n = 2), intubation (n = 1), and photodynamic therapy (n = 1) who underwent bronchoplasty using cutting-balloon dilation via suspension laryngoscopy in 2009. Information about patient demography, etiology, lesion characteristics, and details of the interventions were recorded. Patients underwent spirometry before surgery and at last follow-up. Chest infection rate in the 6 months before bronchoplasty and from bronchoplasty to the last follow-up was ascertained. RESULTS: There were 3 men and 7 women. Mean age at bronchoplasty was 46 ± 20 years. Length of stay was 1 day in all cases, and no treatment-related complications occurred. One patient required a second bronchoplasty at 55 days. Mean follow-up was 7 ± 2.3 months. Forced expiratory volume in 1 second increased from a prebronchoplasty mean of 1.6 ± 0.6 to 2.2 ± 0.5 at last follow-up (P < .0001; paired Student t test). Forced vital capacity rose from 2.7 ± 0.6 to 3.1 ± 0.6 (P = .02), and peak expiratory flow rate increased from 3.7 ± 0.8 to 5.0 ± 0.8 (P < .0001). Chest infection rate fell from an average of 0.7 ± 0.3 infections per month to 0.2 ± 0.2 (P < .003; paired Student t test). CONCLUSION: Cutting-balloon bronchoplasty via suspension laryngoscopy is an effective treatment for benign bronchial stenosis. It is safer than airway stenting and is less invasive than thoracotomy. The authors propose its use as first-line treatment for this condition.