Aerosol-generating procedures in head and neck surgery - can we improve practice after COVID-19?

The COVID-19 pandemic has had a dramatic impact on international medicine practice. The propensity for head and neck surgery to generate aerosols needs special consideration over and above simply adopting personal protective equipment. This study sought to interrogate the literature and evaluate whether which additional measures might provide benefit if routinely adopted in minimising viral transmission.

Sentinel lymph node biopsy for oral squamous cell carcinoma. Where are we now?

Recent data have confirmed that elective surgical management of the cN0 neck improves survival in patients with early (T1-T2) oral squamous cell carcinoma (SCC), and is better than watchful waiting. However, elective neck dissection (END) may not always be necessary. Sentinel node biopsy (SNB), which is a reliable staging test for patients with early disease and a radiologically N0 neck, can detect occult metastases with a sensitivity of 86%-94%. Patients with no sign of metastases on SNB could avoid neck dissection, and individual treatment should reduce both morbidity and cost. Currently, SNB for oral SCC is available at a limited number of centres in the UK, but this is likely to change as national guidelines have recommended that it is incorporated into the standard treatment pathway. It is therefore important to understand the current evidence that supports its use, its limitations and related controversies, and to plan for a validated training programme.

Transoral laser microsurgery versus radiation therapy in the management of T1 and T2 laryngeal glottic carcinoma: which modality is cost-effective within the UK?

OBJECTIVES: To identify the most cost-effective treatment strategy in patients with early stage (T1 and T2) cancers of the laryngeal glottis. DESIGN: A Markov decision model populated using data from updated systematic reviews and meta-analyses, with attributable costs from NHS sources. Data on local control and mortality were obtained from updates of existing systematic reviews conducted for the NICE guideline on cancer of the upper aerodigestive tract. Procedure costs were sourced from NHS reference costs 2013/14 by applying tariffs associated with the appropriate health resource group code SETTING: The UK National Health Service. POPULATION: Patients with early stage (T1 and T2) cancers of the laryngeal glottis. INTERVENTIONS: Transoral laser microsurgery (TLM) and radiation therapy (RT). MAIN OUTCOME MEASURES: Total costs, incremental costs and quality adjusted life years (QALYs) over a 10-year time horizon. RESULTS: Radiation therapy as the initial treatment strategy was found to be more expensive (£2654 versus £623) and less effective (QALY reduction of 0.141 and 0.04 in T1a and T1b-T2 laryngeal cancers, respectively) than TLM. The dominance of TLM for T1a cancers was unchanged in most scenarios modelled in sensitivity analysis. For T1b-T2 laryngeal cancers, the result changed in numerous scenarios. In probabilistic sensitivity analysis, TLM was found to have a 71% and 58% probability of being cost-effective in T1a and T1b-T2 laryngeal cancers, respectively. CONCLUSIONS: Transoral laser microsurgery is a cost-effective strategy to adopt in the management of T1a laryngeal cancers. Uncertainty remains over the optimal strategy to adopt in T1b-T2 laryngeal cancers.

Oral cavity and lip cancer: United Kingdom National Multidisciplinary Guidelines.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. It provides recommendations on the assessment and management of patients with cancer of the oral cavity and the lip. Recommendations • Surgery remains the mainstay of management for oral cavity tumours. (R) • Tumour resection should be performed with a clinical clearance of 1 cm vital structures permitting. (R) • Elective neck treatment should be offered for all oral cavity tumours. (R) • Adjuvant radiochemotherapy in the presence of advanced neck disease or positive margins improves control rates. (R) • Early stage lip cancer can be treated equally well by surgery or radiation therapy. (R).

Nose and paranasal sinus tumours: United Kingdom National Multidisciplinary Guidelines.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. With only limited high-level evidence for management of nasal and paranasal sinus cancers owing to low incidence and diverse histology, this paper provides recommendations on the work up and management based on the existing evidence base. Recommendations • Sinonasal tumours are best treated de novo and unusual polyps should be imaged and biopsied prior to definitive surgery. (G) • Treatment of sinonasal malignancy should be carefully planned and discussed at a specialist skull base multidisciplinary team meeting with all relevant expertise. (G) • Complete surgical resection is the mainstay of treatment for inverted papilloma and juvenile angiofibroma. (R) • Essential equipment is necessary and must be available prior to commencing endonasal resection of skull base malignancy. (G) • Endoscopic skull base surgery may be facilitated by two surgeons working simultaneously, utilising both sides of the nose. (G) • To ensure the optimum oncological results, the primary tumour must be completely removed and margins checked by frozen section if necessary. (G) • The most common management approach is surgery followed by post-operative radiotherapy, ideally within six weeks. (R) • Radiation is given first if a response to radiation may lead to organ preservation. (G) • Radiotherapy should be delivered within an accredited department using megavoltage photons from a linear accelerator (typical energies 4-6 MV) as an unbroken course. (R).

Survey of UK practice for management of breast cancer metastases to the neck.

INTRODUCTION: Cervical metastases from breast carcinoma are rare and their management is controversial. Between 1987 and 2002 the American Joint Committee on Cancer (AJCC) staged patients with supraclavicular fossa nodal disease as M1 but the subsequent demonstration that patients with regional stage IV disease had better outcomes than visceral stage IV disease led to a reclassification of the former to stage IIIC in 2003. The literature remains inconsistent regarding the fate of these patients. Despite the attendant morbidity of treatment and lack of knowledge regarding long-term survival, we hypothesised that current practice varies in the UK and a unified approach does not exist. The aim of this study was therefore to determine current practice and opinion of both head and neck specialists and breast cancer clinicians in the UK. METHODS: Questionnaires were disseminated to 185 head and neck surgeons, breast surgeons and their oncology counterparts. These outlined a clinical scenario of a patient with a history of T3 primary breast cancer presenting with cervical and supraclavicular nodal metastases, with opinion being sought regarding the significance of this status and the individual's practical approach to the problem. The extent of any proposed neck dissection was also explored. RESULTS: Of the 117 respondents, a noticeable variation in opinion was evident. Contrary to the current AJCC staging, 61% of clinicians felt that both level V and III metastases represented stage IV disease. There was a tendency towards aggressive surgical treatment with a third recommending comprehensive neck dissection despite a lack of evidence base. A disparity was noted between adjuvant treatments offered and the final pN stage. CONCLUSIONS: This study suggests that at present there is widespread inconsistency in the management of breast carcinoma cervical metastases in the UK. There is a need to unify practice with an evidence base in order to improve informed multidisciplinary decision making and, ultimately, patient care. This study goes some way to supporting multicentre collaboration in order to achieve that aim.

Complications of head and neck cancer surgery - prevention and management.

Surgery continues to retain a pivotal role in head and neck cancer in terms of the management of both the index tumour and potential or proven cervical disease. This review considers the specific complications of surgery in this anatomical region and, on the basis of the available evidence, describes both their management and prevention.

Spontaneous sensory recovery in non-innervated radial forearm flaps used for head and neck reconstruction.

Although several studies have reported the use of reinnervated microvascular free flaps for oro-pharyngeal reconstruction, it has been known for some time that non-innervated flaps demonstrate spontaneous sensory recovery. This study sought to evaluate the degree of such spontaneous recovery in 50 radial forearm flaps used for mucosal reconstruction of head and neck ablative defects. The recovery of sensation to pinprick, light touch and temperature was tested a mean of 38 months (range 15-71) after surgical insetting. Two-point discrimination was also sought. Although 18 flaps (36%) remained anaesthetic, partial recovery in one or more modalities was present in 28 patients (56%). A recovery in all modalities of sensation in at least two-thirds of the flap area was recorded in 4 patients (8%). The mean 2-point static discrimination for fascio-cutaneous flaps was 18.9mm.

Sensory deficit in the donor hand after harvest of radial forearm free flaps.

Fifty patients undergoing radial forearm free flap reconstruction of head and neck defects were examined to find out the extent of sensory defect at the donor site. Flaps (mean length 6 cm, range 4-9) and mean width 4.7 cm (range 3.5-7) were raised. Of the 50 patients 38 (76%) were aware of some sensory loss over the radial distribution in the donor hand. There was objective evidence of a reduction in at least one sensory function in 32 of these patients (84%). The mean affected area was 44.3 cm(2) (range 6-125). The mean length of the affected area was 11.3 cm (range 4.3-12.1) and the mean width 5.1cm (range 2.1-8.4). Of the 12 patients (24%) who reported no feeling of sensory loss all modalities of sensation were preserved in 11 (92%).

Management of drooling by transposition of the submandibular ducts and excision of the sublingual glands.

STATEMENT OF THE PROBLEM: Persistent drooling is common in patients with neurological impairments such as cerebral palsy. Although it may be induced by an excess of saliva, it usually results from incontinence secondary to impaired cerebral control of orofacial function. Various techniques, both medical and surgical, exist to combat the problem. The patient should have a course of conservative management initially (head position, education and training, suction aids, bio-feedback and support). Non-surgical managements and medical treatment should start as early as possible. Surgery has a place, when conservative and medical treatments (drugs/botulinum toxin) have failed. PURPOSE OF THE STUDY: Patients subjected to some of the more radical surgical methods may develop complications of the procedures themselves, it is important therefore that any intervention is based on sound principles. Physiology predicts that the most benefit would be derived from diversion of submandibular rather than parotid salivary flow (Fig. 1). MATERIALS AND METHODS: To assess the effect of bilateral transposition of the submandibular ducts combined with excision of the sublingual glands as a treatment for drooling, a retrospective survey of 21 patients was undertaken by contacting their carers and reviewing the clinical notes. RESULTS: Sixteen out of 21 patients had good to excellent control of their drooling with minimal side-effects and low morbidity. CONCLUSION: Drooling should be managed with a team approach using non-surgical management in the first instance. Surgery has a place and can be beneficial with few long-term side effects. Patients require long-term paedontic/dental follow up to maintain a healthy oral cavity.

Effects of repeated drill use on temperature of bone during preparation for osteosynthesis self-tapping screws.

Drills used during preparation for osteosynthesis with self-tapping screws are often used repeatedly until they become blunt and ineffective. Because the sharpness of the drill is one of the most important factors in its cutting efficiency, blunt drills may require the application of extra force, which in turn may contribute to excessive frictional heat produced during preparation of screw holes. Large rises in temperature can impair bony regeneration around screws and contribute to failure of internal fixation. In an attempt to quantify the potential increase in temperature produced by blunt drills, we devised an in vitro experiment to simulate preparation for osteosynthesis by using drills with different degrees of wear. Three drills were used: one was new, one had drilled 600 holes, and the third drill had been in use in theatre for several months. The mean (range) rise in temperature for the three drills were: new drill 7.5 degrees C (0.6-20.5 degrees C); drill after 600 holes 13.4 degrees C (5.7-28.3 degrees C); and drill from theatre 25.4 degrees C (12.4-41.3 degrees C). There was a highly significant difference in the temperatures generated by the three drills, and the changes in temperature were related to the amount of wear. The cost of drills is low, and as their repeated use can compromise the results of the operation they must be discarded after single use.

Can monocortical miniplates provide bony compression?. An experimental model.

Some maxillofacial surgeons advocate that screws in monocortical plate systems be placed eccentrically in an attempt to provide compression between bony ends. We sought to quantify the degree of displacement and compressive forces made possible by such eccentric placement in an experimental model using five miniplates and Perspex blocks to simulate mandibular fractures. The maximum displacement obtained was 0.67 mm and the maximal compressive force 5.2N (SEM=0.9, range=2.7-7.1). This demonstrates that eccentric placement of screws can achieve some compression and displacement at the fracture interface and that the forces obtained are close to those predictable from the dimensions of the burr, screw, and miniplate.

Palmar arch backflow following radial forearm free flap harvest.

BACKGROUND: Most surgeons advocate an Allen test (for occlusion of the radial or ulnar artery) and Doppler ultrasound examination before harvesting a forearm flap. In this study we attempted to correlate the results of these tests with intraoperative measurement of backflow pressure in the radial artery stump. METHOD: Stump pressures were measured in 30 patients after the flap had been harvested and were compared with preoperative assessment and intraoperative measurements of mean arterial pressure (MAP). RESULTS: Mean arterial backflow pressure (MABP) in the arterial stump varied from 27 to 55mm Hg (mean 40.5). The ratio of this value to the mean arterial pressure ranged from 0.39 to 0.89 (mean 0.59) and exceeding 0.5 in 21 patients (70%). There was no correlation between this ratio and the preoperative assessment. CONCLUSIONS: These findings suggest that in the presence of a satisfactory Allen test and Doppler examination, there is adequate pressure in the palmar system to maintain vascular integrity of the donor hand after sacrifice of the radial artery. Despite the possibility of anatomical variants, the routine use of more invasive imaging is unnecessary.

Prospective randomised trial of the benefits of a sternocleidomastoid flap after superficial parotidectomy.

Parotid surgery can cause postoperative facial nerve dysfunction, cosmetic impairment, and Frey's syndrome. Thirty-six patients listed for superficial parotidectomy were entered into a prospective randomised trial to find out if the use of a sternocleidomastoid flap could reduce the incidence of these complications. Partial facial nerve paresis was seen at 3 months in five patients in whom flaps were raised compared with six among those who did not have flaps (P=0.025). There was no difference between the two groups at 1 year. The flap was not associated with an improvement in either subjective (P=0.13) or objective (P=0.12) appearance measured on visual analogue scales. Eight patients in whom flaps were raised described symptoms suggestive of Frey's syndrome, compared with nine patients in whom a flap was not raised (P=0.31). Overall 19 of those who had a flap and 11 of those who did not had a positive starch-iodine test (P=0.21).