The risk and interval to malignancy of patients with laryngeal dysplasia; a systematic review of case series and meta-analysis.

BACKGROUND: Laryngeal dysplasia is a pre-malignant condition with wide variability in rates of malignant transformation reported in the literature. The management and follow-up strategies of these lesions vary widely. OBJECTIVES: To assess the risk of and interval to malignant transformation in patients with laryngeal dysplasia, the effect of different treatment modalities on malignant transformation and the effects that risk factors such as smoking, excessive alcohol intake and histological grade may have on this. TYPE OF REVIEW: Systematic of observational studies with attempted meta-analysis. SEARCH STRATEGY: A structured search of Medline (1966 to January 2010), EMBASE (1980 to January 2010), CINAHL (1981 to January 2010) and Cochrane databases (CENTRAL, Cochrane Library, 1995 to January 2010). RESULTS: Nine hundred and forty cases from nine studies were included in the analysis. Overall malignant transformation rate was 14% (confidence interval 8, 22) and mean time to malignant transformation was 5.8 years. The malignant transformation rate is higher with increased severity of dysplasia grade - severe/CIS 30.4%versus mild/moderate 10.6% (P < 0.0002). Treatment modality did not show significant effects. CONCLUSIONS: Laryngeal dysplasia carries a significant risk of malignant transformation. This risk triples with increasing severity of dysplasia. Transformation often occurs late and is not related to the grade of dysplasia. There is little evidence, therefore, to support the early discharge of patients with mild/moderate dysplasia, which is practised by some clinicians.

A systematic review and meta-analysis of the role of positron emission tomography in the follow up of head and neck squamous cell carcinoma following radiotherapy or chemoradiotherapy.

OBJECTIVES: This review examines the effectiveness of positron emission tomography (PET) in the detection of recurrent or persistent head and neck squamous cell carcinoma after radiotherapy or chemoradiotherapy. DESIGN: A systematic review and meta-analysis of trials of PET for detecting residual/recurrent head and neck squamous cell carcinoma treated by radiotherapy or chemoradiotherapy. Trials were quality assessed using the Quality Assessment of Diagnostic Accuracy Studies tool for assessing diagnostic accuracy studies. Quantitative data were extracted and a bivariate random effects model used to calculate pooled sensitivity and specificity. SETTING: Tertiary referral head and neck centre. PARTICIPANTS: Prospective and retrospective studies, excluding reviews, which included patients with head and neck squamous cell carcinoma who had fluorodeoxyglucose PET in the post-treatment phase following primary treatment by radiotherapy or chemoradiotherapy. MAIN OUTCOMES MEASURES: Quality assessment, sensitivity, specificity, false positive rates, false negative rates, positive and negative predictive values. RESULTS: Twenty-seven of 1871 identified studies were eligible for inclusion. The pooled sensitivity and specificity of PET for detecting residual or recurrent head and neck squamous cell carcinoma were 94% [95% confidence interval (CI), 87-97%] and 82% (95% CI, 76-86%) respectively. Positive and negative predictive values were 75% (95% CI, 68-82%), and 95% (95% CI, 92-97%) respectively. Sensitivity was greater for scans performed 10 weeks or more after treatment. CONCLUSIONS: Positron emission tomography is highly accurate in this role. However it is less sensitive early after treatment and has poor anatomical detail. PET may reduce the requirement for check endoscopies and planned neck dissections. A protocol for its use in post-treatment surveillance is proposed.

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.

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.

National audit of the management of peritonsillar abscess.

An anonymous postal survey of 200 consultants was used to audit the current prevalent practices in the management of quinsy in the UK; 101 responded. The findings reveal that on average an otolaryngology department treats 29 cases per year, the vast majority (94%) on an inpatient basis. The main initial treatment was needle aspiration combined with intravenous antibiotics. Interestingly, those departments treating more than 20 cases a year are more likely to use needle aspiration, while departments in England and Wales use significantly more incision and drainage than those in Scotland. Incision and drainage (52%) was the most common form of treatment of non-resolving patients. The median hospital stay was two days.

The case of the missing carotid artery--a well aimed knife!

A 20-year-old male presented with a small stab wound to the neck and with haemodynamic signs of significant haemorrhage, but no signs of local bleeding. On exploration, an intact vagus nerve and internal jugular vein were found, but the common carotid artery was not immediately apparent. Careful dissection confirmed a completely transected common carotid artery with the two ends contracted and retracted. A primary repair was performed and post-operatively the patient recovered completely and had no neurological deficit.