Telephone triage for 2-week-wait cancer clinics: a viable alternative to face-to-face clinics?

INTRODUCTION: Head and neck cancer services have had to adapt to reduce the risk of exposure to patients and staff during the pandemic. Telephone consultations as a first point contact have been adopted in some centres. It is important that this does not lead to delays in diagnosis. Our hospital adopted a telephone triage service and we aim to describe the implications of this structure. METHODS: Data were collected from all new patients referred to the head and neck 2-week-wait (2ww) pathway from June to September of 2019 and 2020. Days between first clinic appointment and cancer or noncancer diagnosis were calculated. Statistical tests were performed between years. RESULTS: A total of 215 patients in 2019, and 165 in 2020 were included; 23 (6.8%) cancer diagnoses were identified across 2019 and 2020 groups. The cancer group had a mean time from first consultation to date of diagnosis of 16.33 days in 2019 and 12.81 days in 2020. There was no significant difference in days until diagnosis between 2019 and 2020 (p=0.05). In the noncancer group there was no significant difference in days until noncancer diagnosis (p=0.05). In 2020 26.1% (n=43) patients did not need to be seen face-to-face (f2f) under the 2ww pathway after telephone triage. CONCLUSIONS: No difference in diagnosis timing was observed between cancer and noncancer patents in 2019 and 2020. Telephone clinics reduce the total number of f2f appointments required. Reduction in the number of f2f appointments may have other benefits in saving time and environmental costs.

Thy 3F and 3a malignancy rate, a multisite regional retrospective case series.

Introduction The aim of this study was to ascertain the incidence of thyroid cancer for patients categorised as Thy3, 3a or 3f across four tertiary thyroid multidisciplinary centres in the UK. Material and methods This is a retrospective case series examining patients who presented with a thyroid nodule and diagnosed as Thy3, 3a or 3f according to the Royal College of Pathologists modified British Thyroid Association and Royal College of Physicians Thy system. Results In total, 395 patients were included in this study. Of these, 136 turned out to have benign thyroid disease and 24 had micropapillary thyroid carcinomas. The overall rate of thyroid malignancy was 28.8%. For each subcategory, the rate of malignancy was Thy3 24.7.7%, Thy3a 30.4% and Thy3f 29.2. However, the incidence of thyroid malignancy varied considerably between the four centres (Thy 3f 18-54%). Discussion The diagnosis of thyroid cancer is evolving but detection for malignancy for indeterminate nodules remains below 50% for most centres around the world. In 2014, the British Thyroid Association subdivided the original Thy3 category into Thy3a and Thy3f and recommended a more conservative approach to management for Thy3a nodules. Despite this, only two centres yielded a higher conversion rate of malignancy in the new higher graded Thy3f group compared with Thy3a. Conclusion It is debateable whether the new 'Thy3' subcategories are more useful than the original. Local thyroid malignancy rates may also be more useful than national averages to inform treatment decisions.

Level 5 Lymphadenopathy Warrants Heightened Suspicion for Clinically Significant Pathology.

We conclude that patients presenting with level 5 lymphadenopathy should be investigated with heightened clinical vigilance. Our results suggest that up to 80 % will harbour clinically significant pathology requiring further medical treatment, three quarters of which will be malignancy. We report an observational study of histological outcomes of level 5 lymph node biopsies from a regional histopathology department across 5 years. 184 subjects were identified as having a biopsy of a lymph node from the level 5 region within the study period. One hundred and fifty six cases (84.8 %) had clinically significant pathology on final histology requiring further medical treatment. Lymphoma accounted for the highest number of cases (n = 72, 39.1 %), followed by metastatic carcinoma (n = 65, 35.3 %) and granulomatous change (n = 17, 9.2 %). Gender and laterality were not shown to be independent predictors of pathology significance (p > 0.05).

The great mimicker: a rare case of head and neck inflammatory pseudotumour in the presence of human immunodeficiency virus.

BACKGROUND: Inflammatory pseudotumours of the head and neck are rare. A connection has been made between inflammatory pseudotumours and human immunodeficiency virus positivity. CASE REPORT: This paper reports a case of an inflammatory pseudotumour presenting with a lesion in the left tonsil and left cervical lymph node in a 49-year-old human immunodeficiency virus positive patient. A histological diagnosis was obtained after biopsy and serial radiological imaging. CONCLUSION: Diagnostic uncertainties can lead to unnecessary surgery. It is important to recognise the clinical, radiological and histological indicators of an inflammatory pseudotumour to enable a timely diagnosis and arrange appropriate treatment. In patients with co-morbidities causing immunocompromise, the potential diagnosis of an inflammatory pseudotumour should be considered. This is especially the case in human immunodeficiency virus patients, as inflammatory pseudotumours have been associated with immune reconstitution inflammatory syndrome, which can manifest up to several years after the initiation of, or change in, antiretroviral therapies.

Video-assisted thoracoscopic surgery for large Zenker's diverticulum: report of two cases.

INTRODUCTION: Zenker's diverticulum is a propulsion diverticulum in the pharynx. Current practice for the management of symptomatic pharyngeal pouches includes endoscopic pharyngeal stapling, performed trans-orally, and external approaches via a cervical incision. There is no published recommendation on how to approach diverticula with extension into the mediastinum, which may not be adequately treated with the above methods. CASES: We describe two cases in which thoracoscopic mobilisation of Zenker's diverticulum was performed using video-assisted thoracoscopic surgery together with traditional transcervical mobilisation and excision of the pouch. This allowed safe surgical access to the inferior limit of the pouch, and delivery of the sac into the neck incision following division of any inferior adhesions (to the great vessels in one case). DISCUSSION: In the first report of this technique, we describe a thorough, safe method of dissecting large diverticula that extend into the mediastinum, which minimises the risk to mediastinal structures.

The perils of paint-balling.

While paint-balling a 15-year-old boy was shot on the front of his face guard causing him to hyperextend his neck. Over the next few days he developed neck stiffness and a large painful swelling over his upper left sternocleidomastoid muscle. CT confirmed this to be a haematoma abscess and at operation it was found to originate from the parapharyngeal vessels, extending from the skull base and tracking inferiorly along the carotid sheath, compressing (and partially thrombosing) the internal jugular vein (IJV). After surgical decompression, double-dose low molecular weight heparin and antibiotics, the patient made an uneventful recovery, including recanalisation of his IJV. Delayed cervical haematoma can result in neck space infection and potential airway compromise. Early CT scanning optimises timely intervention, consisting of airway protection, broad-spectrum antibiotics and surgical drainage.

Sublingual grass pollen immunotherapy is associated with increases in sublingual Foxp3-expressing cells and elevated allergen-specific immunoglobulin G4, immunoglobulin A and serum inhibitory activity for immunoglobulin E-facilitated allergen binding to B cells.

BACKGROUND: The mechanisms of sublingual immunotherapy (SLIT) are less well understood than those of subcutaneous immunotherapy (SCIT). OBJECTIVES: To determine the effects of grass-pollen SLIT on oral mucosal immune cells, local regulatory cytokines, serum allergen-specific antibody subclasses and B cell IgE-facilitated allergen binding (IgE-FAB). METHODS: Biopsies from the sublingual mucosa of up to 14 SLIT-treated atopics, nine placebo-treated atopics and eight normal controls were examined for myeloid dendritic cells (mDCs) (CD1c), plasmacytoid dendritic cells (CD303), mast cells (AA1), T cells (CD3) and Foxp3 using immunofluorescence microscopy. IL-10 and TGF-beta mRNA expression were identified by in situ hybridization. Allergen-specific IgG and IgA subclasses and serum inhibitory activity for binding of allergen-IgE complexes to B cells (IgE-FAB) were measured before, during and on the completion of SLIT. RESULTS: Foxp3(+) cells were increased in the oral epithelium of SLIT- vs. placebo-treated atopics (P=0.04). Greater numbers of subepithelial mDCs were present in placebo-treated, but not in SLIT-treated, atopics compared with normal controls (P=0.05). There were fewer subepithelial mast cells and greater epithelial T cells in SLIT- compared with placebo-treated atopics (P=0.1 for both). IgG(1) and IgG(4) were increased following SLIT (P<0.001). Peak seasonal IgA(1) and IgA(2) were increased during SLIT (P<0.05). There was a time-dependent increase in serum inhibitory activity for IgE-FAB in SLIT-treated atopics. CONCLUSIONS: SLIT with grass pollen extract is associated with increased Foxp3(+) cells in the sublingual epithelium and systemic humoral changes as observed previously for SCIT.

Expression of CC chemokine receptor 7 in tonsillar cancer predicts cervical nodal metastasis, systemic relapse and survival.

The aim of this study was to evaluate the expression of CC chemokine receptor 7 (CCR7) in squamous cell cancer of the tonsil with respect to patterns of spread, relapse-free, overall and disease-specific survival. Eighty-four patients with squamous cell cancer of the tonsil were identified. There was a male predominance of 3 : 1 and the median age at diagnosis was 53 (range 35-86) years. The median duration of follow-up was 33 (range 2-124) months. There was a significant association between CCR7 immunopositivity and synchronous cervical nodal metastasis in patients with tonsillar cancer (Spearman's correlation coefficient 0.564; P<0.001). Relapse-free (P=0.0175), overall (P=0.0136) and disease-specific (P=0.0062) survival rates were significantly lower in patients whose tumours expressed high levels of CCR7. On multivariate analysis, high-level CCR7 staining predicted relapse-free (hazard ratio 3.0, 95% confidence intervals 1.1-8.0, P=0.026) and disease-specific (hazard ratio 10.2, 95% confidence intervals 2.1-48.6, P=0.004) survival. Fifteen percent of patients with the highest level of tumour CCR7 immunopositivity relapsed with systemic metastases. These data demonstrated that CCR7 expression was associated with cervical nodal and systemic metastases from tonsillar cancers. High levels of CCR7 expression predicted a poor prognosis.

An effortless way of inserting a Montgomery T-tube stent in a closed neck.

We describe a simple technique of replacement Montgomery T-tube insertion in a closed neck under general anaesthetic.

Solitary infantile myofibroma compromising the airway.

Infantile myofibromatosis is an uncommon and benign condition presenting in the neonatal period. It is self-limiting disease that may present as a localised or generalised process. Various examples of this entity have been reported in the literature. This report describes a neonate with a rapidly growing oropharyngeal lesion obstructing the airway that had the typical histological features of an infantile myofibroma. This case report highlights that a solitary myofibroma may be incredibly extensive making complete excision impossible and can be particularly challenging to manage in terms of airway stabilisation.

Grass pollen sublingual immunotherapy for seasonal rhinoconjunctivitis: a randomized controlled trial.

BACKGROUND: Previous studies suggest that sublingual immunotherapy (SLIT) represents a safer alternative to injection immunotherapy but equivalent efficacy is yet to be confirmed. OBJECTIVE: To evaluate the efficacy and safety of SLIT in grass pollen-induced seasonal rhinoconjunctivitis. METHODS: A randomized, placebo-controlled trial in 56 adults over 18 months. Outcome measures included diary scores of seasonal symptoms and medication use, overall assessments, conjunctival and intradermal provocation tests and serum antibody measurements. To investigate possible mechanisms, sublingual biopsies were taken for measurement of local T cells, antigen-presenting cells and IL-12 mRNA expression. RESULTS: There were no significant differences between the immunotherapy (IT) and placebo groups for diary symptom scores (P = 0.48) or rescue medication (P = 0.19). The patients' overall assessment of hayfever severity compared with previous years showed a highly significant improvement in favour of the IT group (P < 0.02). After treatment the late skin response was smaller (P = 0.003) and the ratio of serum allergen-specific IgG4/IgE was higher (P = 0.05) in the IT group. Both of these variables correlated with the clinical response to SLIT. There were no differences between groups in either the sublingual epithelium or lamina propria for numbers of CD3+ cells (epithelium: P = 0.9, lamina propria: P = 0.2), CD1a+ cells (P = 0.3, P = 0.25), CD68+ cells (P = 0.9, P = 1.0) or IL-12 mRNA+ cells (P = 0.6, P = 0.4). Local side-effects were minor and there were no serious treatment-related adverse events. CONCLUSION: Grass pollen sublingual immunotherapy was well tolerated. Although there was no significant change in diary scores, the improvement in overall assessments, which correlated with inhibition of the late skin response and increases in serum IgG4 : IgE ratio, indicates the need for larger, dose-ranging studies.