Triaging algorithm for head & neck oncology follow-up patients in COVID-19 climate.

The current climate is one of uncertainty and immeasurable tragedy for people afflicted by the pandemic of SARS-CoV-2 virus infection. As professionals, we have a duty of care towards all patients especially the vulnerable and those suffering with life-threatening illnesses such as oral cancer. We present a safe & objective triaging method for afflicted with this disease in the prevailing morbid situation.

Non-Pulmonary Tuberculosis--A Case Report: Importance and Pitfalls of Diagnosis.

A case of tuberculosis presenting as a neck lump is highlighted. Tuberculosis is on the increase. There are national and international strategies to improve the management of tuberculosis in the United Kingdom, and raising clinical awareness of tuberculosis is an important part of that strategy. Neck lumps can present in the dental setting and the differential diagnosis should include tuberculosis, with referral to an appropriate multidisciplinary team. Special tests to aid diagnosis are helpful but not completely discriminating. Tuberculosis is a notifiable disease and it must be treated by a designated specialist medical team. CPD/Clinical Relevance: Tuberculosis is a differential diagnosis for a persistent neck lump and clinicians should understand the problems of diagnosis and the importance of appropriate referral for treatment in the national and international strategy to reduce this disease.

A guide to skin cancer of the face for the dental team.

UNLABELLED: The incidence of skin cancer in the United Kingdom is increasing and is associated with an ageing population and increasing lifetime exposure to sunlight. The three most common types of skin cancer are basal cell carcinoma, squamous cell carcinoma and malignant melanoma, all three of which may present on the skin of the face. The dental team are, therefore, well-placed to recognize suspicious lesions and arrange for further advice or assessment. This paper outlines the epidemiology, important clinical features and principles of modern management of facial skin cancers to aid dental practitioners in the recognition of suspicious lesions. In addition, some of these treatments have side-effects which have the potential to affect a patient's oral health or its management and these aspects are also discussed. CLINICAL RELEVANCE: The dental surgeon is ideally placed to recognize malignant or potentially malignant lesions on patients'faces and to advise on seeking further advice or refer for assessment, as appropriate. Dental practitioners will increasingly encounter patients who have undergone surgical or non-surgical management of facial skin cancer and should understand the potential oro-facial side-effects of such treatment.

Estimating quality-adjusted life expectancy (QALE) for local authorities in Great Britain and its association with indicators of the inclusive economy: a cross-sectional study.

OBJECTIVES: Quantifying area-level inequalities in population health can help to inform policy responses. We describe an approach for estimating quality-adjusted life expectancy (QALE), a comprehensive health expectancy measure, for local authorities (LAs) in Great Britain (GB). To identify potential factors accounting for LA-level QALE inequalities, we examined the association between inclusive economy indicators and QALE. SETTING: 361/363 LAs in GB (lower tier/district level) within the period 2018-2020. DATA AND METHODS: We estimated life tables for LAs using official statistics and utility scores from an area-level linkage of the Understanding Society survey. Using the Sullivan method, we estimated QALE at birth in years with corresponding 80% CIs. To examine the association between inclusive economy indicators and QALE, we used an open access data set operationalising the inclusive economy, created by the System Science in Public Health and Health Economics Research consortium. RESULTS: Population-weighted QALE estimates across LAs in GB were lowest in Scotland (females/males: 65.1 years/64.9 years) and Wales (65.0 years/65.2 years), while they were highest in England (67.5 years/67.6 years). The range across LAs for females was from 56.3 years (80% CI 45.6 to 67.1) in Mansfield to 77.7 years (80% CI 65.11 to 90.2) in Runnymede. QALE for males ranged from 57.5 years (80% CI 40.2 to 74.7) in Merthyr Tydfil to 77.2 years (80% CI 65.4 to 89.1) in Runnymede. Indicators of the inclusive economy accounted for more than half of the variation in QALE at the LA level (adjusted R2 females/males: 50%/57%). Although more inclusivity was generally associated with higher levels of QALE at the LA level, this association was not consistent across all 13 inclusive economy indicators. CONCLUSIONS: QALE can be estimated for LAs in GB, enabling further research into area-level health inequalities. The associations we identified between inclusive economy indicators and QALE highlight potential policy priorities for improving population health and reducing health inequalities.

Presentation of intramuscular myxoma as an unusual neck lump.

Intramuscular myxoma (IM) has a distinct diagnostic identity among soft tissue myxomas. IMs have an approximate incidence of 1 per million of the population per year, with a female-to-male ratio of 14:3. The age range for presentation is 40 to 70 years, and the thigh is affected most frequently. IMs most commonly affect larger muscle groups, making the head and neck a rare site. To the authors' knowledge, there is 1 previous report of an IM presenting in the sternocleidomastoid muscle. In addition, IMs usually present as slow-growing asymptomatic swellings. Although abnormal gag reflexes have been reported in cases of glossopharyngeal schwannoma and neurofibroma in patients with neurofibromatosis-1, a gag reflex has not been reported previously as a complication of IM in the head and neck. A case of IM in the left sternocleidomastoid muscle, presenting with an intense gag reflex on palpation, in a 70-year-old woman is presented.

Slow to heal or slow to diagnose cancer?

There are around 8,500 new cases of oral squamous cell carcinoma (SCC) diagnosed in the UK each year and the incidence appears to be increasing. Although surgical and non-surgical treatment options have improved significantly in the last few decades, five-year survival has not, with an average five-year survival of 56% in the UK. Providing patients have access, there are frequent opportunities for oral cancer screening by their general dental practitioner. We present two cases of SCC managed in our department, both of whom were referred following a protracted period of review in general dental practice, where the initial 'benign diagnoses' were not re-evaluated during this time. This delay can considerably impact on patient outcomes, including survival. We outline each patient's clinical course, and key learning points to help dental practitioners detect lesions that require prompt referral to the oral and maxillofacial service for urgent investigation.

GABA, noise and gain in human visual cortex.

High levels of GABA (gamma-aminobutyric acid, the brain's primary inhibitory neurotransmitter) are associated with enhanced cognitive and perceptual performance. It has been proposed that these effects result from GABA reducing neural noise or variability, but the precise mechanisms remain unknown. We have measured how individual differences in GABA concentration in the visual cortex are related to performance on a visual contrast discrimination task. Our results reveal that the facilitatory strength of the typical "dipper" function elicited by this task is strongly correlated with GABA concentration. A simple, biologically plausible, network model comprising excitatory and suppressive neural populations accounts for the data well and indicates that the strength of suppression increases as GABA concentration increases. Inter-individual variations in GABA were correlated both with the inhibition strength of the model (mimicking the effect of GABA) and, inversely, with the magnitude of the response criterion. This enhanced suppression has the dual effect of suppressing noise and reducing the gain of the neural response. Our findings thus suggest that the changes in performance conferred by high GABA concentration are mediated by both a reduction of noise and, paradoxically, a reduction in neural, but not perceptual, sensitivity.

The SIPHER Consortium: Introducing the new UK hub for systems science in public health and health economic research.

The conditions in which we are born, grow, live, work and age are key drivers of health and inequalities in life chances. To maximise health and wellbeing across the whole population, we need well-coordinated action across government sectors, in areas including economic, education, welfare, labour market and housing policy. Current research struggles to offer effective decision support on the cross-sector strategic alignment of policies, and to generate evidence that gives budget holders the confidence to change the way major investment decisions are made. This open letter introduces a new research initiative in this space. The SIPHER ( Systems Science in Public Health and Health Economics Research) Consortium brings together a multi-disciplinary group of scientists from across six universities, three government partners at local, regional and national level, and ten practice partner organisations. The Consortium's vision is a shift from health policy to healthy public policy, where the wellbeing impacts of policies are a core consideration across government sectors. Researchers and policy makers will jointly tackle fundamental questions about: a) the complex causal relationships between upstream policies and wellbeing, economic and equality outcomes; b) the multi-sectoral appraisal of costs and benefits of alternative investment options; c) public values and preferences for different outcomes, and how necessary trade-offs can be negotiated; and d) creating the conditions for intelligence-led adaptive policy design that maximises progress against economic, social and health goals. Whilst our methods will be adaptable across policy topics and jurisdictions, we will initially focus on four policy areas: Inclusive Economic Growth, Adverse Childhood Experiences, Mental Wellbeing and Housing.

The proximal tibia donor site in cleft alveolar bone grafting: experience of 75 consecutive cases.

BACKGROUND: The optimum donor site for cleft alveolar bone grafting is still debated. Donor site morbidity is an important factor in deciding the site for harvest of cancellous bone. Use of the proximal tibia as donor site is associated with few complications. The occurrence of a proximal tibia fracture following cancellous bone harvest from this site, prompted a review of the last 75 consecutive cases carried out at our unit. MATERIAL AND METHOD: The medical notes of 75 consecutive patients undergoing cleft alveolar bone graft were reviewed and postal questionnaires were sent to patient's parents and family physicians. The review focused on donor site morbidity. RESULTS: Fracture of the proximal tibia, a hitherto unreported complication, occurred in two out of 75 cases (2.7%) within our series. Post-operative mobilization was achieved rapidly with normal joint function and donor site healing progressed satisfactorily in all cases. In 1 out of 75 cases the graft was repeated at a later date due to recipient site infection. The incidence of other morbidity was low with most representing local complications only. Length of hospital stay was 3 days (range 2-5 days). CONCLUSION: Based on our findings we feel that the proximal tibia offers a reliable site for harvest of sufficient quantities of good quality cancellous bone. Recommendations are made as to the technique of bone harvest, to minimize the fracture risk.

Quadhelix appliance therapy resulting in pyogenic granuloma of the tongue.

This paper describes the examination, diagnosis and treatment of a rapidly enlarging tongue mass presenting in a healthy 12-year-old girl. This mass caused distress to both the patient and her parents and diagnostic uncertainty for her general medical and dental practitioners. The lesion was in fact caused by an orthodontic quadhelix appliance and responded to simple treatment.

Transcervical repair of tracheal diverticulum.

Tracheal diverticula are rare congenital or acquired abnormalities of the posterior tracheal wall. They are usually asymptomatic, and therefore treatment has not been widely reported. We describe the entity and surgical management of a symptomatic tracheal diverticulum.

Recurrent Langerhans cell histiocytosis of the mandible.

We report a case of Langerhans cell histiocytosis with a restricted presentation (eosinophilic granuloma of the mandible) complicated by multiple reactivations.

Replacing tracheostomy with overnight intubation to manage the airway in head and neck oncology patients: towards an improved recovery.

In maxillofacial head and neck oncology, tracheostomy is often used to secure the airway, but not without risk. This study compared the existing practice of two units: one where tracheostomy was routinely done with one where overnight intubation was used. From both units we retrospectively analysed 50 consecutive patients who had intraoral resection, neck dissection, and microvascular reconstruction for head and neck cancer. When compared with tracheostomy, overnight intubation resulted in a shorter mean stay in the intensive therapy unit (ITU) (1.4 compared with 3.7 days), a shorter overall hospital stay (12.9 compared with 18.0 days), less time to first oral intake (8.9 compared with 12.8 days), and a lower rate of lower respiratory tract infection (LRTI) (10% compared with 38%). This study supports the discontinuation of routine tracheostomy and the adoption of a more selective practice to improve recovery.

Angiolymphoid hyperplasia with eosinophilia successfully treated with oral steroids.

Angiolymphoid hyperplasia with eosinophilia is a rare benign vascular lesion most commonly affecting the head and neck region. This article reports a case of a 26-year-old white woman with rapidly enlarging nodules of the upper lip and cheek treated successfully with oral corticosteroids and cetirizine. Morbidity and cosmetic deformity associated with radical surgery to the face and possible consequences of radiation treatment were avoided. There were no long-term complications.

Minor salivary gland squamous cell carcinoma of the lower lip demonstrating striking perineural invasion.

Squamous cell carcinomas (SCC) of minor salivary gland origin are extremely rare. We present an unusual case of a 29-year-old female patient who presented with a well-differentiated SCC of minor salivary gland origin arising in the lower lip. Wedge resections of the lip, including bilateral mental nerve excision, were required to clear the tumor because of striking pathological evidence of perineural invasion distant from the primary tumor site.

Accuracy of positron emission tomography in the evaluation of patients treated with chemoradiotherapy for mucosal head and neck cancer.

BACKGROUND: The aim of this study was to evaluate the accuracy of positron emission tomography (PET) in assessing the patients treated with primary chemoradiotherapy for mucosal carcinoma of the head and neck. METHODS: A retrospective review of patients with biopsy-proven cancer of mucosal head and neck sites receiving chemoradiotherapy with curative intent was undertaken. RESULTS: Seventy-eight patients met the study criteria. Staging PET identified unsuspected distant metastatic disease in 11% of patients. Sixty-one patients (78%) had a complete metabolic response on PET, with 17 showing residual disease. Sensitivity of PET was 82% (positive predictive value: 82%) and specificity was 95% (negative predictive value: 95%). Accuracy of PET response was significantly better than clinical assessment and conventional imaging (p < .002, p < .001, respectively). CONCLUSION: PET has been found to be significantly better than clinical examination or conventional imaging in restaging patients after chemoradiotherapy. Patients with a complete response on posttreatment PET have a significant survival advantage and can be safely observed.