Radiological imaging of the neck for initial decision-making in oral squamous cell carcinomas--a questionnaire survey in the Nordic countries.

BACKGROUND: Fast and accurate work-up is crucial to ensure the best possible treatment and prognosis for patients with head and neck cancer. The presence or absence of neck lymph node metastases is important for the prognosis and the choice of treatment. Clinical lymph node (N)-staging is done by palpation and diagnostic imaging of the neck. We investigated the current practice of the initial radiological work-up of patients with oral squamous cell carcinomas (OSCC) in the Nordic countries. METHODS: A questionnaire regarding the availability and use of guidelines and imaging modalities for radiological N-staging in OSCC was distributed to 21 Head and Neck centres in Denmark (n = 4), Finland (n = 5), Iceland (n = 1), Norway (n = 4) and Sweden (n = 7). We also asked for a description of the radiological criteria for determining the lymph nodes as clinical positive (cN+) or negative (cN0). RESULTS: All 21 Head and Neck centres responded to the questionnaire. Denmark and Finland have national guidelines, while Norway and Sweden have local or regional guidelines. Seventeen of the 19 centres with available guidelines recommended computed tomography (CT) of the cN0 neck. The waiting time may influence the imaging modalities used. Lymph node size was the most commonly used criteria for radiological cN+, but the cut-off measures vary from 0.8 to 2.0 cm. CONCLUSION: Overall, CT is the most commonly recommended and used imaging modality for OSCC. Despite availability of national guidelines the type and number of radiological examinations vary between centres within a country, but the implementation of a fast-track programme may facilitate fast access to imaging. The absence of uniform criteria for determining the lymph nodes of the neck as cN+ complicates the comparison of the accuracy of the imaging modalities. Well-defined radiological strategies and criteria are needed to optimise the radiological work-up in OSCC.

Reduction in waiting time for diagnosis and treatment of head and neck cancer - a fast track study.

UNLABELLED: Acceleration of diagnosis and initiation of treatment for head and neck cancer requires optimal organization and multidisciplinary collaboration. A project at the Head and Neck Oncology Centre, Aarhus University Hospital aimed at accelerating patient flow. MATERIAL AND METHODS: Initiatives were implemented throughout the year 2007. Focus was on optimizing logistics for all patients referred to the center with suspected head and neck cancer. Initiatives included a full-time case manager, pre-booked slots for clinical work-up and weekly tumor-boards. Key-dates were registered and relevant intervals were quantitatively evaluated and compared to a reference-group from 2006. RESULTS: We registered 446 patients. Waiting times for first clinical examination on ENT department were reduced from median eight to median two days through 2007 (p < 0.0001). Time from first clinical examination and until referral for treatment was reduced from median 21 to median nine days (p < 0.0001). Time from referral to treatment and until initiation of treatment was reduced from median 26 to median 15 days (p < 0.001). The net result of these reductions was a reduced overall time from median 57 days ultimo 2006 to median 29 days ultimo 2007 (p < 0.0001). CONCLUSION: The current project has shown that it is possible to reduce waiting times in head and neck cancer. Through logistic changes, employment of a full-time case manager, strengthening the multidisciplinary tumor board and giving higher priority for head and neck cancer patients, the overall time from first suspicion of cancer until treatment start was reduced from 57 calendar days to 29 calendar days.

Late swallowing dysfunction and dysphagia after radiotherapy for pharynx cancer: frequency, intensity and correlation with dose and volume parameters.

BACKGROUND AND PURPOSE: Dysphagia and swallowing problems are common in pharynx cancer patients treated with radiotherapy. Dysfunction of the upper aerodigestive tract may lead to reduced quality of life, malnutrition and aspiration pneumonia. The aim of the current study was to describe swallowing function after radiotherapy and examine its correlation with irradiated volume and dose. PATIENTS AND METHODS: All recurrence free patients treated for pharynx cancer with radical radiotherapy at our institution, between 1998 and 2002, were invited to participate, 35 (55% of eligible) agreed. Patients were examined with EORTC quality of life questionnaires and functional endoscopic evaluation of swallowing. Organs at risk were delineated on planning CT scans, available for 25 patients. RESULTS: Eighty-three percent of patients had some degree of dysphagia. Reduced sensitivity was observed in 94%, residues in 88%, penetration in 59% and aspiration in 18% of patients. Several significant correlations were found between both subjective and objective swallowing problems and DVH parameters of the upper aerodigestive tract. Doses less than 60 Gy to the supraglottic region, the larynx and upper esophageal sphincter resulted in a low risk of aspiration. DISCUSSION: Both subjective and objective swallowing problems were frequent and severe after radiotherapy for pharynx cancer. Swallowing dysfunction was correlated with dose and volume parameters of the upper aerodigestive tract.

[Congenital anosmia]. / Kongenit anosmi.

A 72-year-old woman with congenital familiar lack of smell is described. General ENT and otoneurological examination were normal. The ability to smell was totally absent. By MR scan normal conditions were found in the nose, paranasal sinuses, the cribriform plate in the anterior cranial fossa and in the brain especially in the olfactory bulbs. Microscopic examinations of biopsy specimens from the olfactory region showed no signs of olfactory epithelium.

Salivary gland carcinoma in Denmark 1990-2005: outcome and prognostic factors. Results of the Danish Head and Neck Cancer Group (DAHANCA).

To describe outcome and prognostic factors in a national Danish series of patients treated for salivary gland carcinoma. From three Danish nation-wide registries and supplementary patient records, 871 patients diagnosed with primary major or minor salivary gland carcinoma in the period from 1990 to 2005 were identified. A total of 796 (91%) histological specimens were revised according to the WHO 2005 classification. The median follow-up time was 78 months. Three hundred and thirty-four patients (38%) experienced recurrence. Crude survival, disease-specific survival and recurrence-free survival after 5 and 10 years were 66%, 76%, 64% and 51%, 69%, 58%, respectively. In multivariate analysis age, latency, stage, microscopic margins, vascular invasion and histological grade were all independent prognostic factors with regards to crude and disease-specific survival. Stage, microscopic margins, vascular invasion and histological grade were independent prognostic factors for recurrence-free survival. Age over 61 years, latency under 8 months, stage 3+4 disease, involved or close microscopic margins, vascular invasion and high histological grade are all independent prognostic factors with a negative impact on survival in salivary gland carcinoma patients. This knowledge can be helpful in guiding clinicians in daily work and choice of treatment across the large variety of salivary gland carcinoma subtypes.

Salivary gland carcinoma in Denmark 1990-2005: a national study of incidence, site and histology. Results of the Danish Head and Neck Cancer Group (DAHANCA).

To describe the incidence, site and histology (WHO 2005) of salivary gland carcinomas in Denmark. Nine hundred and eighty-three patients diagnosed from 1990 to 2005 were identified from three nation-wide registries. The associated clinical data were retrospectively retrieved from patient medical records. Histological revision was performed in 886 cases (90%). Based on histological revision, 31 patients (3%) were excluded from the study leaving 952 for epidemiological analysis. The mean crude incidence in Denmark was 1.1/100,000/year. The male vs. female ratio was 0.97 and the median age was 62 years. The parotid gland was the most common site (52.5%) followed by the minor salivary glands of the oral cavity (26.3%). The most frequent histological subtypes were adenoid cystic carcinoma (25.2%), mucoepidermoid carcinoma (16.9%), adenocarcinoma NOS (12.2%) and acinic cell carcinoma (10.2%). The revision process changed the histological diagnosis in 121 out of 886 cases (14%). The incidence of salivary gland carcinoma in Denmark is higher than previously reported. More than half of salivary gland carcinomas are located in the parotid gland with adenoid cystic carcinoma being the most frequent subtype. Histological classification of salivary gland carcinomas is difficult and evaluation by dedicated pathology specialists might be essential for optimal diagnosis and treatment.

Necrotizing fasciitis of the head and neck.

BACKGROUND: Necrotizing fasciitis of the head and neck is a rapidly progressing and life-threatening condition. The purpose of this study was to describe the patients with a focus on clinical presentation, microbiology, treatment, and prognosis. PATIENTS AND RESULTS: Seventeen patients (10 men; median age, 54 years) were included. Nine patients underwent minor head and neck surgery immediately prior to necrotizing fasciitis. The typical course was a quickly spreading erythema, pronounced tenderness, and severe pain. Imaging demonstrated diffuse swelling of the soft tissue, poorly differentiated dilated fat layers, and subcutaneous gas. All patients underwent surgical debridement within 2 days, and received broad-spectrum antibiotics and hemodynamic support, hyperbaric oxygen, and immunoglobulin. All patients survived, although 12 of 17 suffered sequelae. CONCLUSIONS: Early diagnosis is of utmost importance. Quickly spreading erythema and extreme pain in the affected area serve as red flags. With the current intensive multimodality regimen, the mortality was zero, although 70% suffered sequelae.

Common adder bite to the tongue causing life threatening toxicity from airway compromise.

We illustrate the acute phase and development of symptoms in a 24-year-old man following a European Common Viper bite to the tongue.

[Accelerated diagnosis and treatment initiation for head and neck cancer patients]. / Accelererede udrednings- og behandlingsforløb for patienter med hoved-hals-kraeft.

INTRODUCTION: Acceleration of diagnosis and initiation of treatment for head and neck cancer requires optimal organisation and multidisciplinary collaboration. A project at the Head and Neck Oncology Centre, Aarhus University Hospital aimed at accelerating patient flow. MATERIALS AND METHODS: The initiatives were implemented throughout 2007. Focus was on optimizing logistics for all patients referred to the centre with suspected head and neck cancer. Initiatives included a full-time coordinator, pre-booked slots for clinical work-up and weekly tumour boards. Key dates were registered and relevant intervals were quantitatively evaluated and compared to a reference group from 2006. RESULTS: We registered 446 patients. Waiting times for first clinical examination at the ENT department were reduced from medially eight to two days through 2007 (p < 0.0001). Time from first clinical examination to referral for treatment was reduced from medially 21 to nine days (p < 0.0001). Time from referral to treatment to initiation of treatment was reduced from medially 26 to 15 days (p < 0,001). The net result of these reductions was a reduced overall median time (from primary referral to initiation of treatment) from medially 57 days by end of 2006 to medially 29 days by end of 2007 (p < 0,0001). CONCLUSION: Logistic changes and especially introduction of a full-time coordinator, a multidisciplinary tumour board and a generally higher priority for head and neck cancer patients resulted in a significant acceleration regarding diagnosis and start of treatment from 2006 to 2007.

[Reconstruction of the maxilla with pedicled temporalis muscle after maxillectomy]. / Maksilrekonstruktion med stilket temporalislap efter maksillektomi.

INTRODUCTION: Removal of the maxilla requires adequate restoration of the maxillary structure to replace form and functions, especially vocal and eating functions. A host of reconstructive options are available to restore the maxilla, most of which include free-flap reconstruction. The aim of this study was to clinically evaluate the use of pedicled temporalis flap for reconstruction of the maxilla and to assess patient quality of life. MATERIAL AND METHODS: In the period 2000-2007, a total of 32 patients with malignant tumours of the maxilla were operated with immediate reconstruction of the maxilla using pedicle temporalis muscle flap at the ENT department, Aarhus University Hospital. Follow-up was implemented in 2007. Twenty-seven of 28 patients alive at the time of the follow-up participated in the study. The patients were evaluated objectively as well as subjectively by answering the EORTC's standard questionnaire concerning quality of life and functional results. RESULTS: Few patients had complaints and these where mostly minor functional deficits. The most common complaints were slightly impaired mouth opening. One temporalis muscle flap necrotized and was removed. Three patients developed oro-nasal/antral fistula, witch were later closed using local flaps. CONCLUSION: The follow-up study of the 27 patients showed a most satisfactory result evaluated objectively as well as subjectively using the EORTC questionnaire.

Patient assessed symptoms are poor predictors of objective findings. Results from a cross sectional study in patients treated with radiotherapy for pharyngeal cancer.

INTRODUCTION: The aim of the study was to assess the value of the EORTC questionnaires C30 and H&N35, as an instrument for the study of side effects. PATIENTS AND METHODS: We invited all recurrence free patients, treated with radical radiotherapy for pharyngeal cancer between 1998 and 2002 at our institution, to participate in the study. Data was retrieved using questionnaires, functional endoscopic evaluation of swallowing, dental examination with orthopantomography and saliva flow measurements. Thirty-five (55% of invited) participated. RESULTS: Side effects were omnipresent and often severe. The value of patient assessed symptom scores to predict equivalent objective changes was varied: We found a sensitivity of 0.59-0.93, specificity of 0.40-0.81, positive predictive value of 0.28-0.81 and a negative predictive value of 0.46-0.94. CONCLUSION: The questionnaire should be used to retrieve information on subjective side effects and objective examination should be used for objective changes. One cannot conclude from one to the other.