Methodology for the development of National Multidisciplinary Management Recommendations using a multi-stage meta-consensus initiative.

BACKGROUND: Methods for developing national recommendations vary widely. The successful adoption of new guidance into routine practice is dependent on buy-in from the clinicians delivering day-to-day patient care and must be considerate of existing resource constraints, as well as being aspirational in its scope. This initiative aimed to produce guidelines for the management of head and neck squamous cell carcinoma of unknown primary (HNSCCUP) using a novel methodology to maximise the likelihood of national adoption. METHODS: A voluntary steering committee oversaw 3 phases of development: 1) clarification of topic areas, data collection and assimilation, including systematic reviews and a National Audit of Practice; 2) a National Consensus Day, presenting data from the above to generate candidate consensus statements for indicative voting by attendees; and 3) a National Delphi Exercise seeking agreement on the candidate consensus statements, including representatives from all 58 UK Head and Neck Multidisciplinary Teams (MDT). Methodology was published online in advance of the Consensus Day and Delphi exercise. RESULTS: Four topic areas were identified to frame guideline development. The National Consensus Day was attended by 227 participants (54 in-person and 173 virtual). Results from 7 new systematic reviews were presented, alongside 7 expert stakeholder presentations and interim data from the National Audit and from relevant ongoing Clinical Trials. This resulted in the generation of 35 statements for indicative voting by attendees which, following steering committee ratification, led to 30 statements entering the National Delphi exercise. After 3 rounds (with a further statement added after round 1), 27 statements had reached 'strong agreement' (n = 25, 2, 0 for each round, respectively), a single statement achieved 'agreement' only (round 3), and 'no agreement' could be reached for 3 statements (response rate 98% for each round). Subsequently, 28 statements were adopted into the National MDT Guidelines for HNSCCUP. CONCLUSIONS: The described methodology demonstrated an effective multi-phase strategy for the development of national practice recommendations. It may serve as a cost-effective model for future guideline development for controversial or rare conditions where there is a paucity of available evidence or where there is significant variability in management practices across a healthcare service.

Fascia lata graft closure of an enlarged tracheoesophageal puncture (TEP) after laryngectomy/laryngopharyngectomy.

Enlargement of tracheoesophageal puncture (TEP) is seen in 1-29% of laryngectomee/laryngopharyngectomee using tracheoesophageal voice. It predisposes patient for recurrent aspiration pneumonia. Surgical closure of TEP is required in 30-67% of patients not responding to conservative measures. Surgical closure of an enlarged TEP using a flap may be time consuming, complex, and logistically challenging to organize. A novel technique of Fascia lata graft closure of an enlarged TEP is presented here. This technique can be useful in carefully selected patients with an enlarged TEP.

Vocal process granulomas: a systematic review of treatment.

OBJECTIVES: Vocal process granulomas (VPGs) are benign laryngeal lesions with controversial treatment and a tendency to recur. There are several treatment options with unpredictable results, high recurrence rates, and disappointing long-term outcome. The aims of this article are to focus on evidence-based current treatment strategies for primary lesions and recurrences. DATA SOURCES: The data came from a systematic review of the literature. METHODS: Main outcome measures were recurrence rate, reduction, and/or complete resolution. Inclusion criteria included English literature, randomized and nonrandomized trials, prospective and retrospective studies, and primary and recurrent cases. Exclusion criteria included case reports, teaching reviews, and papers not focusing on treatment. RESULTS: The time frame of the included studies was from 1997 to 2012. There are 6 different treatment options (single or combined) for VPG. Antireflux medication is the mainstay treatment and when combined with lifestyle changes and voice therapy results in the lowest recurrence rate. "Bloodless" in-office or in-theater laser techniques appear to have lower recurrence rates when compared to traditional cold steel microlaryngoscopy techniques, especially for recurrences. CONCLUSIONS: There is level 2A evidence that antireflux treatment is the main treatment strategy for vocal process granulomas with surgery reserved only for failures of medical treatment or airway obstruction or when diagnosis is in doubt.

Radiologically-guided balloon sialoplasty for benign salivary duct obstruction: a 7-year UK service evaluation.

Obstructive sialadenitis is the most common cause of non-malignant salivary gland disorders, with salivary gland strictures being responsible for approximately 23% of all benign obstructive disease. Significant advances in minimally invasive techniques, including radiologically-guided balloon sialoplasty, offer the potential for successful treatment with reduced complications. At present there is a paucity of follow-up data regarding patient outcomes and repeat interventions in those undergoing the procedure. Patients with parotid or submandibular gland sialadenitis secondary to gland stricture were identified and underwent radiologically-guided balloon sialoplasty at Queen Alexandra Hospital, Portsmouth, UK between 2015 and 2022. Patient outcomes, complications and reintervention rates were recorded prospectively over the seven-year period and analysed retrospectively. A total of 44 patients underwent radiologically-guided balloon sialoplasty. Forty (89%) underwent sialoplasty for parotid gland disease, with a minority (n = 5) receiving an intervention for submandibular gland strictures. A total of 37 (84%) had their obstruction successfully treated (82% of parotid gland obstructions and 100% of submandibular gland obstructions). Five patients (11%) required a repeat intervention. Seventeen successfully treated patients (85%) who attended follow-up clinic appointments described complete resolution of their symptoms, with the remaining three (15%) describing a partial response. Radiologically-guided balloon sialoplasty for the treatment of benign obstructive sialadenitis secondary to a gland stricture is a safe and effective method of eliminating the obstruction and relieving patients' symptoms. Most patients were symptom free at short-term follow up, with a minority requiring a second sialoplastic intervention.

Manipulation of nasal fractures under local anaesthetic: a convenient method for the Emergency Department and ENT clinic.

BACKGROUND: Nasal fractures are the commonest facial fracture. They can cause morbidity in terms of nasal obstruction and cosmesis. They can be treated by simple external digital manipulation, provided they are seen and assessed in a timely fashion. This manipulation is commonly done under general anaesthetic (GA), which utilises precious resources and may cause delays in treatment. SUMMARY OF EVIDENCE FOR PROPOSED METHOD: A recent comprehensive systematic review has shown local anaesthetic (LA) to be comparable to GA in terms of cosmesis, airway patency and patient acceptability. The experience for the patient is akin to that of a dental filling, and can be made more painless with the use of topical anaesthesia. PROPOSED METHOD: In the current age of evidence-based medicine and drive for cost-effective management decisions, it is thought that LA manipulation may offer a superior option to GA. A simple method for manipulation under LA is presented that can be done in the Emergency Department.

A survey of postoperative nasal packing among UK ENT surgeons.

Packing of the nasal cavity following routine nasal surgery is a common but controversial practice. We aimed to evaluate nasal packing practices among UK ENT consultants for common nasal operations. A questionnaire was sent to 648 consultant ENT surgeons regarding their packing practice in patients undergoing nasal surgery. Data were collected regarding rhinology subspecialty interest, number of nasal operations performed per year, likelihood of packing for six common nasal procedures, and types of pack used. In all, 282 (43.5%) replies were received. Fifty-four (78.3%) rhinologists claimed to perform >100 nasal operations per year versus 64 (31.8%) non-rhinologists (P < 0.005). For specific operations, there was a universal trend towards less routine packing (>70% frequency) in the rhinologist group (P < 0.005). Surgeons who specified a subspecialty interest in rhinology packed significantly less often than the non-rhinologists for common nasal operations. There was great variation in the type of pack favoured by different surgeons.

Impact of social deprivation on the outcome of major head and neck cancer surgery in England: A national analysis.

BACKGROUND: Socioeconomic status plays an important role in the incidence and prognosis of many cancers. We examined the relationship between social deprivation and clinical outcomes in patients undergoing major surgery for head and neck cancer. METHODS: A retrospective population-based observational study was performed. Patients undergoing head and neck surgical procedures in England between 2002 and 2012 were identified. This totaled 5051 patients in the less socially deprived (LSD) and 7282 in the more socially deprived (MSD) group. RESULTS: MSD patients were younger (61 vs 63) and were more likely to present with hypopharyngeal-laryngeal cancers (41% vs 30%). They had higher burdens of morbidity and more frequently required emergency surgery (odds ratio [OR] 1.74 [95% CI 1.52-1.99]). Following surgery, MSD patients had higher lengths of inpatient stay (OR 1.72 [95% CI 1.57-1.88]) and higher proportions of both inpatient (OR 1.47 [95% CI 1.19-1.82]) and overall mortality (OR 1.34 [95% CI 1.24-1.45]). CONCLUSION: Increasing socioeconomic deprivation is associated with poor health outcomes in patients with head and neck cancer.

Timing of neck dissection in association with transoral surgery: A systematic review.

BACKGROUND: The purpose of this study was to present our evaluation of the importance of timing (early vs synchronous vs delayed) in conjunction with transoral laser surgery for head and neck squamous cell carcinoma (HNSCC). METHODS: Articles addressing surgical management via transoral laser surgery for HNSCC were included for review. RESULTS: Twenty-six articles fulfilled our criteria. The overall 5-year disease-specific survival (DSS) was 75.6% (95% confidence interval [CI], 67.3-83.9) and locoregional control was 87.3% (95% CI, 82.3-92.1), respectively. In the synchronous neck dissection group, the mean locoregional control was 89.9% (95% CI, 84.8-95.1) versus 84.5% (95% CI, 56.2-112.7) for the delayed neck dissection group. From studies in which complications were explicitly given, a bleeding rate of 5.3% (95% CI, 3.6-6.9) was established. There were 11.1% of patients who underwent a tracheostomy. CONCLUSION: There is no evidence to indicate that timing of neck dissection after transoral laser surgery for HNSCC has any effect on overall survival (OS). © 2016 Wiley Periodicals, Inc. Head Neck, 2016 © 2016 Wiley Periodicals, Inc. Head Neck 39: 1020-1032, 2017.

Primary Intestinal-Type Adenocarcinoma of Tongue: A Case Report with Immunohistochemical and Molecular Profiles and Review of the Literature.

Primary lingual intestinal-type adenocarcinomas are extremely rare with only a few cases described. A case with immunohistochemical expression of Androgen Receptor (AR) which was treated solely by chemo-radiotherapy is reported herein. A 54-year-old male was referred with symptoms of fullness in his tongue. Clinical examination showed an asymmetry of the tongue with a hard mass palpable within the middle of the tongue. Biopsy showed intestinal-type adenocarcinoma. The tumour showed positive staining with cytokeratin 7, cytokeratin 20, CDX2, AR, ß-catenin and was mismatch repair proteins (MMR) proficient. The molecular analysis did not show mutations in the KRAS, NRAS, BRAF and PIK3CA genes. The patient was treated with radiochemotherapy and is in remission 3.5 years after the diagnosis. This is the first case of intestinal-type tongue adenocarcinoma which showed AR expression and was treated solely with radical chemoradiotherapy.

Patients' understanding of words used to describe lumps: a cross-sectional study.

OBJECTIVES: To explore the interpretation of words commonly used to describe lumps. Specific words were explored to assess their understandability and implication of threat to the patient. METHODS: A cross-sectional, questionnaire-based study was undertaken. Age, gender, level of education, employment and socio-economic group were determined. The questionnaire explored the following words: malignant, tumour, carcinoma, lymphoma, sarcoma, lipoma, lymph node, nodule, ganglion, benign, cyst and gland. Participants comprised 204 consecutive adult patients attending the ENT out-patient clinic at a Bristol teaching hospital. RESULTS: Patients found 'malignant' and 'tumour' the most threatening words and were most unsure of the meaning of 'sarcoma' and 'lipoma'. Nineteen per cent (n = 37) thought a 'benign' lump was a cancer. Results did not significantly differ between demographic groups. CONCLUSIONS: A significant misunderstanding of some words commonly used to describe lumps was found. This study provides important guidance on which terms to use and which to avoid in consultations with patients.

Sigmoid sinus thrombosis secondary to Lemierre's syndrome.

Lemierre's syndrome, a rare and almost forgotten cause of internal jugular vein thrombosis, is usually caused by an anaerobic head and neck infection. Left untreated, it can result in the release of septic emboli. We describe the case of a 42-year-old man who presented with fever and a tender, swollen neck mass. Computed tomography revealed an edematous parapharyngeal area and a compressed internal jugular vein. Despite antibiotic treatment, the patient's condition worsened, and a parapharyngeal fluid collection was drained 4 days later. Six weeks later, the patient returned to the outpatient department complaining of headaches, and he was found to have a tender, firm neck. He was readmitted, and magnetic resonance venography revealed a right internal jugular vein thrombosis that extended intracranially to the sigmoid sinus. He was anticoagulated for 6 months, and he remained well during outpatient follow-up. We examine the controversial roles that anticoagulation and thrombolysis play in Lemierre's syndrome and sigmoid sinus thrombosis, and we review the diagnostic options.

Is there a relationship between weather conditions and aortic dissection?

BACKGROUND: Bleeding and rupture of blood vessels has been correlated with weather conditions in the past. This is the first study in the world literature with the aim of investigating the relationship between atmospheric pressure and temperature with the presentation of aortic dissection. METHODS: The dates of all emergency aortic dissection repairs from 1996-2002 in a regional cardiothoracic unit at Blackpool Victoria Hospital were obtained. Hourly temperature and pressure data from a regional weather station for this time period was supplied by the Meteorological Office. The mean and standard deviation of hourly temperature and pressure data for that month were compared to the mean and standard deviation of the data 24 and 48 hours prior to the aortic dissection. RESULTS: 26 patients were found to have been operated on during the time period studied. There was no statistically significant correlation between temperature or atmospheric pressure readings, and the incidence of aortic dissection, using a Bonferonni-corrected significance p-value of 0.005 CONCLUSION: This study is the first to examine the relationship between atmospheric pressure, temperature and dissecting thoracic aorta. No statistically significant relationship was demonstrable.

Referral letters: are we prioritizing consistently?

OBJECTIVES: To determine the levels of intra- and inter-grade variability of the vetting of general practice (GP) letters as well as the intra-rater reliability of letter prioritization. DESIGN: Prospective assessment of letter vetting and questionnaire survey. SETTING: Three otolaryngology secondary referral centres in Bristol and Bath, UK. PARTICIPANTS: Twelve consultants, nine registrars, four staff and associate specialists (SAS) and 16 senior house officers (SHOs) in otolaryngology. METHODS: Fifty GP letters (not including 'fast-track' referrals) addressed to one of the ENT departments were chosen sequentially. These were anonymized, photocopied and included in the questionnaire to all participating staff. Participants were asked to vet the letters as 'urgent', 'soon' or 'routine' according to supplied waiting time criteria. The same letters were sent out again six weeks later. RESULTS: There was no significant difference between grades for the mean number of letters vetted into each category. Intra-grade variability was high; the number of letters vetted urgent varied from one out of 50 to 15 out of 50 for the consultants. The intra-rater reliability was high. CONCLUSION: The grade of trainee seems to make little difference with regard to ability to prioritize referrals, but within grades there is little agreement on what constitutes an urgent referral. We suggest further research, looking at the final outcome of patients, needs to be done to try to establish evidence-based guidelines to assist with letter vetting.

Preservation of greater auricular nerve during parotidectomy: sensation, quality of life, and morbidity issues. A systematic review.

BACKGROUND: Our objectives were to assess the evidence of preservation of the greater auricular nerve in parotidectomy with regard to morbidity and quality of life. METHODS: This was a systematic review. Inclusion criteria were: English literature, prospective and retrospective studies. Exclusion criteria were: single case reports, "teaching" reviews. Outcome measures were: tactile sensation, pain, thermal sensitivity, and quality of life. RESULTS: Although quality of life does not seem to be adversely affected when the greater auricular nerve is sacrificed, preservation of the posterior branch was recommended in 8 studies. When preserving the nerve, the incremental operative time increase is no more than 10 to 5 minutes after a rapid learning curve. CONCLUSIONS: There is level Ib evidence that preservation of the greater auricular nerve minimizes the postoperative sensory disturbance and should be considered whenever tumor clearance is not compromised. There is no evidence that overall quality of life is affected when the greater auricular nerve is sacrificed.

Manipulation of nasal fractures with local anaesthetic: a 'how to do it' with online video tutorial.

Nasal fractures are the most common facial fractures and displaced fractures may cause considerable cosmetic concern. Traditionally, displaced nasal fractures have been manipulated under general anaesthesia (GA) performed within 2 weeks of the injury. Despite evidence for the benefit of local anaesthesia (LA), nasal fractures are still most commonly reduced under GA. We have presented a method of reduction of simple nasal fractures under LA in an outpatient setting. This has the advantage of being painless, simple to attempt and cost-effective. If reduction is inadequate then a general anaesthetic reduction is still possible. A recent comprehensive systematic review of all the available evidence did not show any significant difference (in terms of cosmesis, pain or nasal obstruction) between using LA and GA methods and highlighted the evidence base to support LA. We describe our method of assessment and treatment of displaced nasal fractures and provide an online tutorial (http://sciencestage.com/v/22194/local-anaesthetic-nasal-fracture-reduction.html). It is important to keep in mind that any concerns should be referred to an otolaryngology specialist for further management and that practitioners attempting this technique should first receive training from an otolaryngologist.

Epithelial-myoepithelial carcinoma of the tongue base: a case for the case-report and review of the literature.

A 60 year old lady was referred to the Princess Alexandra Hospital (Brisbane, Queensland, Australia) tertiary Otolaryngology, Head and Neck Unit from a peripheral hospital for investigation and management of a tumour at the base of the tongue. Biopsy of the tumour revealed it to be an epithelial-myoepithelial carcinoma of the base of the tongue. This is an extremely rare tumour in this location with only 2 other case reports in the world literature: the patients were treated with chemo-radiotherapy and surgery respectively. Our patient was made aware of the world literature and was able to make a fully informed decision on her choice of treatment modality and was treated with radiotherapy. Increasingly journals are limiting publication of case reports to "world firsts" only. We present a case where such a policy would have denied patient choice and possibly led to detrimental treatment.We review the world literature of tongue base epithelial-myoepithelial carcinoma of the tongue.

Transoral laser microsurgery for early laryngeal cancer.

The decision to treat patients suffering from glottic cancer with either radiotherapy or surgery is both complex and controversial. Transoral laser microsurgery is a surgical technique that offers an attractive alternative therapy for laryngeal cancer. In addition to excellent oncologic outcomes and organ preservation, the benefits of transoral laser microsurgery include low morbidity and mortality, shorter periods of hospitalization and exceptional functional results. As the evidence base for the effectiveness of laser surgery grows, transoral laser microsurgery has become established as a valid surgical option for the treatment of early laryngeal cancer. In this article we examine the surgical technique and discuss the oncologic and functional outcomes of transoral laser microsurgery. Furthermore, we offer a vision of the future of endoscopic laser surgery for the management of cancer of the larynx and the upper aerodigestive tract.

Role of microbiological studies in management of peritonsillar abscess.

INTRODUCTION: Peritonsillar abscess (quinsy) is one of the most common ENT emergencies. A 2002 UK audit of quinsy management revealed that an average ENT department treated 29 cases annually; the most common treatment was needle aspiration with intravenous antibiotics, and culture of the aspirate was often performed routinely. The aims of our study were to evaluate the value of routine culture of quinsy aspirates, and to establish whether the information thus gained was clinically useful. METHODS: We examined the notes of patients admitted with quinsy to two hospitals in south-west England, from January 1998 to January 2004 in one hospital and from January 1995 to January 2005 in the other. A total of 577 cases was found. Aspirated pus had been sent for culture in 119 (21 per cent). These cases were examined in more detail. RESULTS: Of the 119 patients, 78.2 per cent (93/119) were treated with either a cephalosporin or penicillin, plus metronidazole. Streptococcal species were cultured in 43.7 per cent (52/119) and anaerobes in 23.5 per cent (28/119; of these cultures, 5.9 per cent (7/119) were pure anaerobes only). All the anaerobes were sensitive to metronidazole. One of the 119 cultures, growing aerobic bacteria, was resistant to penicillin; however, this patient improved clinically on a combination of penicillin and metronidazole. No patients had their treatment changed because of culture results. CONCLUSIONS: There appears to be no need to routinely culture quinsy aspirates, based upon our findings (of 16 hospital years) and previous studies (which found no recorded episodes of treatment change as a result of culture sensitivities). The combination of penicillin or a cephalosporin, plus metronidazole appeared to be theoretically effective in 99.2 per cent (118/119) of our specimens; this finding is supported by other studies. However, the rare but potentially life-threatening complications of quinsy must be recognised.