Unmet needs, quality of life and psychological distress: insights regarding head and neck cancer patients in a rural setting.

OBJECTIVE: This study aimed to evaluate the perceived quality of life, unmet needs and psychological distress in patients with head and neck cancer in a rural setting in New Zealand. METHOD: Patients presenting with head and neck cancer in Northland, New Zealand, were asked to complete questionnaires on quality of life, unmet needs, and anxiety or depression together with a free-text option. RESULTS: About one quarter of respondents (27 per cent) scored high in the anxiety and depression scale, with corresponding diminished quality of life scores and increased needs. Over half of respondents (54 per cent) found it challenging to travel for treatment. Financial difficulties were encountered more frequently with indigenous patients. Rurality alone does not lead to significant differences in quality of life or needs. CONCLUSION: After treatment for head and neck cancer, it is important to monitor and manage patients' psychological distress and ease of access to health services to improve quality of life.

Utility of transcervical management of Zenker's diverticulum.

OBJECTIVE: To evaluate our results in treating Zenker's diverticulum via the transcervical approach, and to compare our experiences with a recent systematic review of both open and endoscopic approaches to the pharyngeal pouch. METHOD: An audit yielded 41 consecutive cases of Zenker's diverticulum treated between 2003 and 2013. RESULTS: All 41 patients underwent transcervical cricopharyngeal myotomy; 29 sacs also required 'inversion'. The median and mean length of hospital stay was 1 night and 2.5 nights respectively. The recurrence rate was 2.4 per cent and the complication rate was 9.8 per cent. CONCLUSION: When compared to reported endoscopic techniques, transcervical cricopharyngeal myotomy (with or without inversion) in our unit resulted in: shorter hospital stay, a comparable complication rate and fewer recurrences.

Diagnostic difficulties of plunging ranula: case series.

OBJECTIVES: To evaluate common pitfalls in diagnosing complicated plunging ranula, either due to misidentification of plunging ranula or alternative pathology (i.e. false negatives or false positives, respectively). METHODS: A review of cases of plunging ranula seen in Middlemore Hospital, New Zealand, was performed. Diagnostically uncertain cases were identified and reviewed, taking particular note of clinical, radiological and surgical findings. RESULTS: From our database, 12 cases were found to have had a complicated diagnosis of plunging ranula. Ten cases were false negatives: four were treated as abscesses, four as simple cysts, one as a thyroglossal cyst and one as a cystic hygroma. Two cases were false positives: one was found to be a thyroglossal cyst and the other a lipoma. CONCLUSION: The diagnosis of plunging ranula is usually straightforward, with simple surgical management. Misdiagnosis can lead to recurrence of symptoms and inappropriate management, with the associated risks, complications and frustrations of surgery.

Risk of bleeding after thyroid surgery: matched pairs analysis.

OBJECTIVE: To identify those patients most at risk of developing a compressive post-operative haematoma following thyroid surgery. METHOD: Retrospective analysis of patients undergoing thyroid surgery. Factors associated with the group of patients who developed a post-operative haematoma were examined using a matched pairs, case-control design. RESULTS: Following 355 thyroid operations, seven patients developed a post-operative haematoma requiring return to the operating theatre for bleeding control. A post-operative systolic blood pressure of greater than 150 mmHg, in the post-anaesthetic care unit, was the major significant factor identified by regression analysis (p = 0.002). Current smoking status was also a significant factor (p = 0.04). CONCLUSION: In our facility, a post-anaesthetic systolic blood pressure in excess of 150 mmHg was associated with an increased risk of haemorrhage following thyroid surgery.

Outcome and relative cost of transoral removal of submandibular calculi.

OBJECTIVE: To examine the outcomes and treatment cost of transoral removal of submandibular calculi, and to compare the outcomes and costs of other reported techniques. METHOD: Retrospective review of 60 consecutive patients undergoing transoral removal of submandibular calculi. All clinical, operative, post-operative and follow-up data were collated and outcomes analysed. RESULTS: A total of 61 submandibular glands were treated by the transoral approach. Patients with multiple stones (p = 0.034) and stones in the proximal submandibular duct (p = 0.0028) were at greater risk of requiring submandibular gland excision, compared with patients with single stones and stones in the distal duct, respectively. There was a significant difference between the gland preservation rate during the first versus the second half of the study (p = 0.028). Larger calculi were significantly more likely to be seen in the proximal duct (p < 0.001). The mean operating time (28 minutes) and length of hospital stay for transoral removal of submandibular calculi was much less than those for other treatment techniques.

Quality of life and functional outcomes in the management of early glottic carcinoma: a systematic review of studies comparing radiotherapy and transoral laser microsurgery.

BACKGROUND: Early glottic carcinoma can be managed by radiotherapy and transoral laser microsurgery with similar control and survival rates. The functional and quality of life outcomes of these interventions are therefore important to guide management. OBJECTIVE OF REVIEW: To compare the different treatment modalities for early glottic carcinoma with respect to quality of life, post-treatment voice character and swallowing outcomes. TYPE OF REVIEW: A systematic review of the literature with defined search strategy. SEARCH STRATEGY: Searches of EBM databases, and literature databases using key words: glotti*, laryn*, neoplasm, radiotherapy and laser surgery from 1970 to November 2009. Articles were screened for relevance using pre-determined inclusion and exclusion criteria. EVALUATION METHOD: Articles reviewed by authors and data compiled in tables for analysis. RESULTS: No randomised controlled trials were identified. There were 15 studies reporting vocal outcomes, and perception of voice disability was measured in eight studies; numbers were low in all the papers. Cumulatively, results for 880 patients were included, 448 had trans-oral laser microsurgery and 442 had radiotherapy. For vocal outcomes, 12 studies found no significant difference between radiotherapy and laser surgery, three reported superior outcomes for radiotherapy, whereas for the perception of voice disability, five reported no difference between treatment groups, while the remaining three reported conflicting results. Nine studies reported quality of life outcomes; seven of these reported no difference between the treatment groups in overall scores although some report differences in subsets of questions. CONCLUSIONS: The evidence base to date demonstrates comparable vocal and quality of life outcomes for radiotherapy and transoral laser surgery for early glottic carcinoma. There is a need for consensus on which measures of vocal quality and life satisfaction to be used in research trials to allow comparison between studies.

The association of psycho-social factors and survival in head and neck cancer.

OBJECTIVE: Update a previous review examining associations between psycho-social factors and survival in head and neck cancer patients. DATA SOURCES: Searched Cochrane, Psych info and Embase for the period from 1 January 1995 to 1 June 2007, as well as personal and article reference lists and article archives. STUDY SELECTION: Identified articles assessed by consensus for eligibility using following criteria: survival as outcome measure; psycho-social factors as prognostic indicators; results specifically for head and neck cancer patients, not including oesophageal or thyroid cancer. Seven of 64 articles fulfilled criteria. DATA EXTRACTION: Data abstracted independently by two reviewers using pre-determined proformas. Quality also rated using Scottish Intercollegiate Guidelines Network 50 tool. DATA SYNTHESIS: At baseline, expression of intense psycho-social complaints, higher self-perceived physical ability and self-reported high physical functioning were significantly associated with increased survival. Uncertainty about the diagnosis and treatment was found to be a negative prognostic indicator, as was being single, poor cognitive function, baseline fatigue and alcoholism. Overall quality of life and head and neck pain 12 months after date of diagnosis were found to be significantly associated with survival in one study. However, overall quality of life and depression at the time of diagnosis were not. CONCLUSIONS: There appears to be some association between selected psycho-social factors and long-term survival from head and neck cancer. However this relationship is currently neither strong nor proven, requiring examination by multi centred trials with standardisation of research definitions and methodologies, and examination of post-treatment psycho-social factors.

Is electrogustometry useful for screening abnormalities of taste?

BACKGROUND: Electrogustometry is an accurate and increasingly popular method used to examine taste. However, its usefulness as a screening test is unknown. METHODS: We asked 114 subjects, some healthy but most with medical conditions possibly affecting taste, to rate their overall taste ability, on a scale of zero to 10. Those who had current symptoms related to taste- and who rated their taste as five or worse - were defined as 'aberrant tasters'. We recorded automated electrogustometry thresholds, and visual analogue scale intensity ratings, for solutions of the four basic tastes (sweet, sour, salty and bitter). A visual analogue scale score of 50 was used as a cut-off point to identify 'poor tasters'. RESULTS: The sensitivity and specificity of electrogustometry in identifying abnormal taste function were low. CONCLUSIONS: We conclude that automated electrogustometry is not a useful clinical screening method for taste disturbance in a population such as ours.

Anatomical and surgical considerations of the external branch of the superior laryngeal nerve: a systematic review.

The anatomical course of the external branch of the superior laryngeal nerve (EBSLN) is variable, and a consistent approach to its preservation during thyroid surgery is needed to reduce risk of post-operative voice impairment. Despite agreement that careful dissection in the region of the superior thyroid pole is required, there is no accepted 'best' approach, nor any universal acknowledgement that location of the EBSLN is actually necessary. The popular cernea classification of EBSLN has limitations, including its decreased reliability with increased thyroid size and its irrelevance in cases of 'buried' variants. * Recent work has identified factors such as ethnicity and stature in the prevalence of EBSLN variants. Consistent approaches to the post-operative detection of EBSLN injury are needed to build an accurate picture of the incidence of surgical nerve injury. Then a standardised approach to EBSLN preservation may emerge.

Patients' views on the utility of quality of life questionnaires in head and neck cancer: a randomised trial.

OBJECTIVES: (i) To evaluate head and neck cancer patient perspectives regarding the usefulness of quality of life questionnaires in communicating their health problems to clinicians and (ii) to identify the quality of life questionnaire that head and neck cancer patients find most useful. DESIGN: Randomised questionnaire study. Patients completed all four validated head and neck cancer quality of life questionnaires - European Organisation for Research and Treatment of Cancer (EORTC), Functional Assessment of Cancer Therapy Scale (FACT) HN35, Washington quality of life questionnaire, Auckland quality of life questionnaire. Order of questionnaire presentation was randomised to counterbalance order effects. SETTING: Tertiary referral head and neck cancer centre. PARTICIPANTS: Eighty patients diagnosed and treated for head and neck cancer. EXCLUSION CRITERIA: blindness, learning difficulties or inability to understand or read English. MAIN OUTCOME MEASURES: Patient ratings of perceived usefulness and preferences of studied questionnaires. RESULTS: Patients reported high relevance to their problems and high ease of understanding of all questionnaires, with FACT scoring highest (79% and 89%, respectively); 58% of participants (67% respondents) would like to complete a questionnaire in clinic, as it would help them describe their health problems to their doctors; 28% of participants did not. Almost half preferred a particular quality of life questionnaire, FACT being most preferred. Length of questionnaire did not affect reported usefulness, but most would prefer a short questionnaire (<20 items). CONCLUSIONS: Patients report that head and neck cancer quality of life questionnaires effectively describe their health concerns. Most are in favour of completing quality of life questionnaires in clinic, as an aid for describing health problems to clinicians. There appears to be a difference between clinicians and patients regarding the perceived usefulness of quality of life questionnaires in the clinic setting, which needs to be highlighted to clinicians.

Deterioration in quality-of-life of late (10-year) survivors of head and neck cancer.

OBJECTIVES: To determine 10-year quality-of-life (QOL) in head and neck cancer patients and to examine the potential predictors of late QOL. DESIGN: Prospective 10-year (QOL) assessment in a cohort of head and neck cancer patients. SETTING: Tertiary referral head and neck cancer centre in Auckland, New Zealand. PARTICIPANTS: Two hundred patients diagnosed and were treated for head and neck cancer. Exclusion criteria were blindness, learning difficulties or inability to understand or read English. MAIN OUTCOME MEASURES: Quality-of-life at 10 years measured by Auckland QOL questionnaire, and analysed for associations with the following co-variates: age, gender; co-morbidities (alcohol intake and smoking), type and stage of disease; treatment modality; and QOL measures. RESULTS: At 10 years following diagnosis, overall QOL (life satisfaction), decreased significantly by an average of 11% (95% CI: -5, -17) compared with before treatment, and by 15% when compared with years 1 and 2. Pre-treatment QOL significantly predicted late QOL, whilst QOL 1 year after treatment did not. None of the socio-demographic, disease- or treatment-related factors predicted long-term QOL on univariate analysis, but this may be due to the small sample size. CONCLUSIONS: This observed, late drop in the QOL of head and neck cancer patients requires further corroboration and investigation. Due to small sample sizes associated with long-term studies in head and neck cancer cohorts, studies of predictors of long-term QOL will only be likely to succeed if done as multi-centre studies. As there is some evidence to suggest that psychosocial interventions improve the QOL of head and neck cancer patients, it may be appropriate to consider screening for risk of a late deterioration in QOL in order to plan appropriate psycho-social intervention.

Why are head and neck cancer clinicians not measuring quality of life?

AIM: To quantify and qualify the use of quality of life (QOL) measures by head and neck cancer clinicians and to identify any impediments to the use of these measures. METHODS: Questionnaire survey of members of the Australia and New Zealand Head and Neck Society. RESULTS: One hundred and twenty-eight of 187 (68.5 per cent) responded. Only 43 (34 per cent) had ever used a QOL questionnaire (QLQ), and only 17 (13 per cent) were currently using one. Impediments to QLQ use included clinicians' perceptions that QLQs were too time-consuming and conferred no proven benefit for clinical management. Nevertheless, 113 (88 per cent) respondents indicated willingness to use a minimum core QLQ--for routine clinical use and for research--but indicated a preference for a short (10-15 questions), quick (less than 10 minutes) questionnaire. CONCLUSIONS: Most head and neck cancer clinicians did not use a QOL measure routinely, with impediments to routine use being mainly clinician-based. Most respondents would use a minimum core QOL measure, especially if it were a short, quick consensus questionnaire.

TN/TN glottic carcinoma: a comparison of two fractionation schedules.

The aim of this paper is the retrospective comparison of accelerated/hypofractionated radiotherapy regimen (AHFX) with standard fractionation regimen (SFX) for patients with early glottic carcinoma. One hundred and forty-five patients with T(1)-T(2) glottic cancer between 1986 and 1998 were eligible. Before 1992, patients received 60-66 Gy in 30-33 fractions over 6-6.5 weeks (SFX) with (60)Co and 6-MV beams. After 1992, patients received 52.5-55 Gy in 20 fractions over 4 weeks (AHFX) using 6-MV beams. The end-points were overall survival, laryngectomy-free survival (LFS), loco-regional control and toxicity. One hundred and two were stage T(1)N(0); 43 were stage T(2)N(0). Median follow up was 4.9 years. The 5-year overall survival was 78%. Five-year loco-regional control in T(1)N(0) patients was higher in AHFX than in SFX group (95 vs 75%, P = 0.002). Loco-regional control in T(2)N(0) patients was similar for AHFX and SFX (81 vs 80%, P = 0.813). Overall LFS was 88%. T(1)N(0) AHFX patients had 5-year LFS of 95% compared with 75% for SFX (P = 0.003). For T(2)N(0) AHFX patients, overall LFS was 92% compared with 80% for the SFX group (P = 0.291). No grade 4 or 5 late toxicity occurred. One AHFX patient developed grade 3 toxicity; two of 51 SFX patients developed grade 2 toxicity versus five of 94 AHFX patients. AHFX using 6-MV beams for treatment of early glottic cancer resulted in equivalent LFS and toxicity when compared with SFX.

A 12 country field study of the EORTC QLQ-C30 (version 3.0) and the head and neck cancer specific module (EORTC QLQ-H&N35) in head and neck patients. EORTC Quality of Life Group.

This study tests the reliability and validity of the European Organization for Research and Treatment of Cancer (EORTC) head and neck cancer module (QLQ-H&N35) and version 3.0 of the EORTC Core Questionnaire (QLQ-C30) in 622 head and neck cancer patients from 12 countries. The patients completed the QLQ-C30, the QLQ-H&N35 and a debriefing questionnaire before antineoplastic treatment or at a follow-up. 232 patients receiving treatment completed a second questionnaire after treatment. Compliance was high and the questionnaire was well accepted by the patients. Multitrait scaling analysis confirmed the proposed scale structure of the QLQ-H&N35. The QLQ-H&N35 was responsive to differences between disease status, site and patients with different Karnofsky performance status, and to changes over time. The new physical functioning scale (with a four-point response format) of version 3.0 of the QLQ-C30 was shown to be more reliable than previous versions. Thus, the QLQ-H&N35, in conjunction with the QLQ-C30, appears to be reliable, valid and applicable to broad multicultural samples of head and neck cancer patients.

Presumed laryngo-pharyngeal reflux: investigate or treat?

A review of a combined gastroenterology and laryngology clinic was conducted to determine the effectiveness of treatment and the predictive value of clinical findings and investigations. Data were collected prospectively. Investigations were performed according to clinical criteria. Patients with symptoms suspected to be due to laryngopharyngeal reflux (based on a positive oesophageal pH test and/or changes on videolaryngoscopy consistent with posterior laryngitis) were treated with omeprazole for at least two to three months. There were 87 patients; the most common symptoms were cough (38 per cent) and hoarseness (36 per cent); 77 per cent had some symptoms suggestive of gastro-oesophageal reflux. Sixty-seven patients were given omeprazole. A good response to laryngo-pharyngeal symptoms was seen in 37 patients (55 per cent). The presence of reflux symptoms was not a predictor of a good response. Increasing severity of oesophageal acid exposure over the 24 hours of pH testing was associated with a better symptom response (Spearman rank correlation, p = 0.01). Posterior laryngitis was not associated with the response to treatment, although there was a trend towards an association between improvement in laryngitis (after treatment) and improvement in symptoms (p = 0.08). The response to proton pump inhibitors was lower than other published results. Oesophageal pH monitoring may have a role in predicting which patients will respond to proton pump inhibitors. This study does not support the decision to treat with anti-secretory therapy, based only on the presence of posterior laryngitis.