Novel use of a supraclavicular transverse cervical artery customised perforator flap: a paediatric emergency.

Perforation of the piriform fossa is a rare, potentially life-threatening paediatric emergency. Prompt diagnosis and early operative intervention is key to patient survival, yet restoring aerodigestive continuity can pose a significant reconstructive challenge. A seven-month old baby girl presented to an emergency department acutely unwell with a twenty-four-hour history of haemoptysis, cough and worsening respiratory distress. A contrast swallow demonstrated extension of contrast into the retropharyngeal region necessitating immediate surgical intervention. A 3.0 cm×1.0 cm perforation within the left posterolateral piriform fossa was identified. The defect was repaired with a supraclavicular transverse cervical artery customised perforator flap. This was inset into the piriform fossa luminal defect as a life-saving procedure. Following a stormy post-operative course, the child was discharged home on day 28 of admission and admitted electively 6 weeks later for division of flap pedicle. This case highlights the novel use of this fasciocutaneous island flap to reconstruct an extensive, potentially fatal, piriform fossa defect in an acute paediatric setting. This simple flap design offers timely mobilisation, reliable blood supply, adequate tenuity and surface area, to reconstruct this extensive defect as a life-saving intervention in a profoundly septic child.

Ectopic olfactory neuroblastoma: report of four cases and a review of the literature.

Our objective is to present a short series of four rare cases of ectopic olfactory neuroblastoma. Our methods present four case reports of ectopic olfactory neuroblastoma and a review of the literature for management and treatment of this disease. The results indicate short case series reports of ectopic olfactory neuroblastoma arising from the anterior ethmoidal sinuses, the nasopharynx, the lateral nasal wall and the floor of the nose. The discussion focuses on likely origins of ectopic olfactory neuroblastoma, its clinical features and management. We conclude that ectopic olfactory neuroblastoma is a rare disease. Treatment principles are the same for non-ectopic disease and guided by extension into adjacent structures such as the orbit or anterior cranial fossa and usually involves surgery with or without adjuvant radiotherapy.

Challenging the use of the lymphocyte to white cell count ratio in the diagnosis of infectious mononucleosis by analysis of a large cohort of Monospot test results.

OBJECTIVE: We investigated the hypothesis that a lymphocyte/white cell count ratio should be used as a diagnostic indicator of infectious mononucleosis. DESIGN: Retrospective study to compare lymphocyte counts and white blood cell counts, against the criterion standard, the mononucleosis spot test. SETTING: Department of Otolaryngology, Mater Misericordiae University Hospital, Dublin, Ireland. PARTICIPANTS: We reviewed 1000 patients who had Monospot assays, 500 positive and 500 negative. MAIN OUTCOME MEASURES: The lymphocyte counts and white blood cell ratio was calculated and compared with the monospot result to calculate the sensitivity and specificity at various ratios. RESULTS: The lymphocyte counts and white blood cell ratio was significantly different in the positive and negative monospot groups (P < 0.05). The mean lymphocyte counts and white blood cell ratio in the positive group was 0.49 and the mean lymphocyte to white cell count ratio in the monospot negative group was 0.29.A ratio of 0.35 had a specificity of 72% and a sensitivity of 84% for the detection of glandular fever. A higher ratio will give a greater specificity, but a lower sensitivity, and vice versa. CONCLUSIONS: The mean lymphocyte to white cell count ratio is not sufficient to diagnose or exclude infectious mononucleosis. Thus, this study does not confirm the conclusions of earlier studies.

Prospective, blinded trial of whole-body magnetic resonance imaging versus computed tomography positron emission tomography in staging primary and recurrent cancer of the head and neck.

OBJECTIVES: To compare the use of computed tomography - positron emission tomography and whole-body magnetic resonance imaging for the staging of head and neck cancer. PATIENTS AND METHODS: From January to July 2009, 15 consecutive head and neck cancer patients (11 men and four women; mean age 59 years; age range 19 to 81 years) underwent computed tomography - positron emission tomography and whole-body magnetic resonance imaging for pre-therapeutic evaluation. All scans were staged, as per the American Joint Committee on Cancer tumour-node-metastasis classification, by two blinded consultant radiologists, in two sittings. Diagnoses were confirmed by histopathological examination of endoscopic biopsies, and in some cases whole surgical specimens. RESULTS: Tumour staging showed a 74 per cent concordance, node staging an 80 per cent concordance and metastasis staging a 100 per cent concordance, comparing the two imaging modalities. CONCLUSION: This study found radiological staging discordance between the two imaging modalities. Whole-body magnetic resonance imaging is an emerging staging modality with superior visualisation of metastatic disease, which does not require exposure to ionising radiation.

Complementary medicine use in patients with head and neck cancer in Ireland.

The objectives of the study were: first, to determine the prevalence of traditional medicine (TM) and complementary and alternative medicine (CAM) use in head and neck cancer patients in Ireland; second, to educate ourselves on the plethora of CAM/TM options available to patients outside the dominion of conventional medicine. The study design consisted of a cross-sectional survey carried out in three head and neck cancer centres. Self-administered questionnaires were distributed to 110 head and neck cancer patients attending the three cancer centres and data were collected for statistical analysis. A total of 106 patients completed the questionnaire; 21.7% of the participants used CAM/TM since their diagnosis with head and neck cancer. CAM/TM usage was higher in female (34.3%) than in male patients (16.2%). CAM/TM use was more common in the 41-50-year age group, in patients with higher educational levels and those holding strong religious beliefs, and also in married than single patients. The most common types of CAM/TM used were spiritual and laying on of hands. The most common reasons reported for using CAM/TM were to counteract the ill effects of treatment and increase the body's ability to fight cancer. Sources of information on CAM/TM were friends (65%), family (48%) and media (21%). This survey reveals a high prevalence of CAM/TM use in head and neck cancer patients, hence emphasising the need for otolaryngologists to educate themselves on the various therapies available to be able to provide informative advice. There is an urgent need for evidence-based investigation of various CAM/TM therapies currently offered to patients.

Sentinel lymph node biopsy in node-negative squamous cell carcinoma of the oral cavity and oropharynx.

OBJECTIVES: Considerable controversy exists regarding the merits of elective neck dissection in patients with early stage oral cavity and oropharyngeal squamous cell carcinoma. It is highly desirable to have a method of identifying those patients who would benefit from further treatment of the neck when they are clinically node-negative. The purpose of the present study was to examine the use of sentinel lymph node biopsy in identifying occult neck disease in a cohort of patients with node-negative oral cavity and oropharyngeal squamous cell carcinoma. DESIGN: We evaluated a total of 13 patients with oral cavity and oropharyngeal cancer who were clinically and radiologically node-negative. RESULTS: A sentinel lymph node was found in all 13 patients, revealing metastatic disease in five patients, four of whom had one or more positive sentinel lymph nodes. There was one false negative result, in which the sentinel lymph node was negative for tumour whereas histological examination of the neck dissection specimen showed occult disease. CONCLUSION: In view of these findings, we would recommend the use of sentinel lymph node biopsy in cases of oral cavity and oropharyngeal squamous cell carcinoma, in order to aid the differentiation of those patients whose necks are harbouring occult disease and who require further treatment.

Does the addition of sublingual gland excision to submandibular duct relocation give better overall results in drooling control?

UNLABELLED: Submandibular duct relocation plus or minus excision of the sublingual glands are relatively simple procedures with low morbidity. Between 1981 and 2005, 71 submandibular duct relocation and 29 submandibular duct relocation plus excision of the sublingual glands procedures were conducted. OBJECTIVES: To compare both procedures including operative time, length of hospital stay, postoperative complications, drooling scores and parental satisfaction. STUDY DESIGN: Prospective study. SETTING: Paediatric tertiary referral centre. PARTICIPANTS: Patients referred with excessive drooling after failure of conservative methods. EXCLUSION CRITERIA: patients with recurrent aspiration pneumonias or dental caries. Two patients were lost to follow up and excluded from the study. RESULTS: Operative time and length of hospital stay were increased in the submandibular duct relocation plus sublingual gland excision group. Drooling scores and parental satisfaction results were excellent, 93% of parents in the submandibular duct relocation group and 89% of parents in the duct relocation plus sublingual glands excision were satisfied and would recommend the procedure. There was no statistical difference (P = 0.643) in drooling scores between the two procedures. Postoperative morbidity was higher with the addition of sublingual gland excision, with postoperative haemorrhage occurring in 13.7% and 36% of parents expressing concern over postoperative pain, compared with 3% postoperative haemorrhage rate with submandibular duct relocation and only 12% of parents expressing the same concerns. CONCLUSION: We conclude that both procedures are effective in drooling control, but the addition of sublingual gland excision increases morbidity and we are no longer excising these glands with submandibular duct relocation.

A comparative analysis of anterior versus posterior squamous cell carcinoma of the tongue: a 10-year review.

INTRODUCTION: The study sought to compare and contrast squamous cell carcinoma (SCC) of the anterior mobile tongue with SCC of the tongue base, with emphasis on clinical presentation, management and outcome. METHODS: This was a retrospective, comparative analysis of patients treated for SCC of the tongue over a 10-year period. Cox's regression model was used to assess the effect of tumour site on survival. RESULTS: The study included 142 patients, of whom 86 were treated for SCC of the anterior tongue and 56 for tongue base lesions. Patients with carcinoma of the anterior tongue tended to present with a visible lump or ulceration of the tongue, whereas the majority of patients with tongue base SCC presented with pain. Sixty per cent of anterior tongue lesions were early stage (I or II) at initial presentation as compared with 21 per cent of tongue base lesions. CONCLUSION: Patients with anterior tongue lesions had a better prognosis, but this was not statistically significant when adjusted for stage.

Parotid masses in patients with previous ear surgery.

This paper describes three cases of patients presenting with lumps in their parotid gland, the origin of which was difficult to define. In each case the past medical history revealed that the patients had undergone previous ipsilateral middle ear surgery. We highlight the fact that where there has been previous incisions in the skin about the ear, there is a risk of epidermal inclusion cysts in the parotid gland. These cysts can occur many years after the initial surgery and therefore may not be identified as an obvious origin to lumps in the parotid gland. Rarely as this series highlights there may also be extension of a cholesteatoma (a collection of keratin which arises from the eardrum and extends into the middle ear space) from the mastoid bone to the parotid gland. We recommend formal ear examination where there is a history of previous ear surgery and an ipsilateral parotid gland lump is present.

Cost and morbidity of MRSA in head and neck cancer patients: what are the consequences?

Methicillin resistant Staphylococcus aureus (MRSA) has become a prevalent nosocomial pathogen worldwide. The objectives of this study were to assess the morbidity and cost associated with the treatment of head and neck cancer patients who become colonized or infected with MRSA following major surgical procedures. We present a retrospective review of patients who underwent major surgery for head and neck cancer over a one year period and who then became MRSA positive in the post-operative period. MRSA affected 25/55 (45 per cent) patients who underwent major head and neck procedures during the period studied. The mean time of diagnosis was 13 days post-surgery. Morbidity included cellulitis, osteomyelitis and MRSA pneumonia. Thirteen of the patients who became MRSA positive (52 per cent of the MRSA group) required further surgery including plate removal, new flap formation and wound debridement as a result of the infection. Average in-hospital stay was almost three times more prolonged for patients who became MRSA positive compared to those who did not have MRSA. The costs of the first hospital stay were over three times more in the MRSA-positive group of patients. Antibiotic costs were increased by pound 2470 per patient because of MRSA. The extra stay in hospital, together with extra days in intensive care, extra medical and nursing care and additional costly antibiotic treatment, led to major cost implications and loss of health service resources in the unit. MRSA infection is a serious cause of morbidity in any surgical group of patients and this study focuses on the consequences for treatment of head and neck cancer patients in particular.

Endolaryngeal cysts presenting with acute respiratory distress.

This is a retrospective review of benign cysts of the adult endolarynx that presented as airway emergencies in four teaching hospitals of Dublin, Ireland, over 2 years. During that period nine patients with endolaryngeal cysts necessitating emergency airway intervention were managed. All cases were treated by endoscopic microlaryngeal marsupialization after securing the airway either at the same time or as a staged procedure. Four of these patients required tracheostomies, one performed under local anaesthesia and the others after initial endotracheal intubation. Definitive treatment was carried out in six cases at initial endoscopic diagnosis. Three of the tracheostomized patients had a staged management, two because of their medical status and one for further investigations. On the basis of our findings we suggest that all benign cysts around the endolarynx should simply be called 'endolaryngeal cysts' instead of the current practice of trying to classify them into various histological and morphological types with no prognostic or management differences. Benign cysts of the endolarynx presenting with airway obstruction would appear to be more frequent than is generally maintained in the literature.

Effect of tumour thickness and other factors on the risk of regional disease and treatment of the N0 neck in early oral squamous carcinoma.

A high occult metastatic rate and a high regional recurrence rate are reported among patients with early oral squamous carcinoma; however, considerable controversy exists regarding the merits of elective neck dissection in this group. The purpose of the present study was to examine the influence of various histological factors on the risk of occult neck disease, neck conversion and recurrence among 63 patients with stage I and II oral cancer. Tumour thickness (P = 0.0175) and size (P = 0.023) were both significantly predictive of outcome. Among tumours of a given thickness, those with infiltrative margins also showed a tendency towards a poorer outcome; however, this was not significant (P = 0.0768). Patients undergoing elective neck dissection with pathological evidence of cervical metastases or with subsequent neck recurrence had a better 3-year survival (55%) than those developing neck conversion after primary neck observation (20%). Our data would suggest considering tumours greater than 5 mm in thickness or with infiltrative margins as potential candidates for elective neck treatment.

Secondary primary malignancies in head and neck squamous cell carcinoma.

Second primary malignancies pose a significant clinical challenge to the head and neck oncologist. The prognosis for these patients is poor and therefore early detection of these tumours is essential. There are considerable differences in the reported cohorts of patients and the biological behaviour of these tumours throughout the world literature. This is particularly marked when there is considerable demographic variation present. The behaviour of second primary malignancies in 425 Irish patients with head and neck cancer was reviewed retrospectively. The overall incidence of second cancers was 8.5 per cent. There were a higher proportion of oral cancer patients 47 per cent, the second cancers overall presented with a more advanced T stage, and the overall five-year survival was much lower than that of the index tumour.

Pleomorphic adenoma involving the stylomastoid foramen.

A rare case of an intratemporal pleomorphic adenoma is presented and the management of such a tumour is discussed. Some anatomical aspects of the facial nerve, pertinent to the pathophysiology of facial paralysis are outlined. This case demonstrates that tumour extension into the temporal bone can be resected successfully at initial surgery with excellent facial nerve functional outcome. We advocate exploration of the fallopian canal to be carried out at primary surgery and be performed by a surgeon familiar with the surgical anatomy of the intratemporal segment of the facial nerve. This approach will reduce the risk of facial nerve injury and palsy both at surgery and subsequently.

Head and neck schwannomas--a 10 year review.

Schwannomas of the head and neck are uncommon tumours that arise from any peripheral, cranial or autonomic nerve. Twenty-five to 45 per cent of extracranial schwannomas occur in the head and neck region and thus are usually in the domain of the otolaryngologist. They usually present insidiously and thus are often diagnosed incorrectly or after lengthy delays, however, better imaging and cytological techniques have lessened this to some degree more recently. For benign lesions conservative surgical excision is the treatment of choice bearing in mind possible vagal or sympathetic chain injury. Malignant schwannomas are best treated with wide excision where possible. The role of adjuvant therapy remains uncertain and irrespective of treatment modality prognosis is poor with an overall survival of 15 per cent. However, recent advances in ras oncogene inhibitors may hold hope for the future.

Recurrent pleomorphic adenoma: uninodular versus multinodular disease.

BACKGROUND: While treatment of previously untreated pleomorphic adenoma is relatively straightforward, recurrent pleomorphic adenoma presents a management problem with increased risk of injury to the facial nerve and an increased risk of malignant transformation in recurrent disease. AIMS: The objectives of this study were to review the management of recurrent pleomorphic adenoma in our unit to identify factors that might help treatment of future cases. METHODS: We reviewed the management of pleomorphic adenoma at our department over an eight-year period from 1990-1998 and present our experience of recurrent pleomorphic adenoma of the parotid gland and parapharyngeal space. RESULTS: Twelve patients were treated with recurrent pleomorphic adenoma. In 10 of these, the site of recurrence was in the parotid gland with the remainder occurring in the parapharyngeal space. Type of recurrence was uninodular or multinodular, the former being easier to treat. Three patients required adjuvant radiotherapy. None of our patients had permanent facial nerve damage. CONCLUSIONS: In order to prevent recurrence of pleomorphic adenoma of the parotid gland, we recommend formal superficial parotidectomy for first time surgery.