Socioeconomic Inequality in the Head and Neck Cancer Referral System: Redressing the Balance.

INTRODUCTION: Socioeconomic deprivation is a known risk factor for head and neck cancer (HNC). Despite this, there is no current way to acknowledge this in two-week wait (2WW) referrals. 2WW HNC referrals have continually risen, and a self-reporting questionnaire was trialled with referrals to the ear, nose and throat (ENT) department with suspected HNC, allowing additional triage information not included in referrals to be obtained. METHODS: Patients referred through the 2WW pathway for HNC between February 2021 and March 2022 were asked to complete an electronic self-reporting symptom questionnaire. The vetting process resulted in the referral being accepted or regraded to less urgent referral streams. Scottish Index of Multiple Deprivation (SIMD) quintiles were derived using the online postcode checker tool. RESULTS: A total of 984 2WW referrals were retrospectively reviewed. The questionnaire was completed by 717 (72.9%) patients. Regrading of urgency resulted in 292 (29.7%) 2WW appointments not required. Of those regraded, 264 (90.4%) patients completed the questionnaire. A significantly greater number of patients (p = 0.03) from SIMD 4 and SIMD 5 were regraded (33.3%) compared to SIMD 1 and SIMD 2 (26.4%). Patients who did not complete the questionnaire had a higher median age (61.0 years, range: 17-96, IQR: 25.0) compared to those who completed the questionnaire (56.0 years, range: 17-88, IQR: 23.5, p < 0.001). CONCLUSION: A self-reported symptom questionnaire can help rebalance urgent appointments to those with genuine red flag symptoms. This in turn reduces social inequality in 2WW referrals and reduces the number of inappropriate 2WW appointments.

Diagnostic accuracy outcomes of office-based (outpatient) biopsies in patients with laryngopharyngeal lesions: A systematic review.

BACKGROUND: In-office biopsies (IOB) using local anaesthetic for laryngopharyngeal tumours has become an increasingly popular approach since the advent of distal chip endoscopes. Although a wide range of studies advocate use in clinical practice, the widespread application of the procedure is hampered by concerns regarding diagnostic accuracy. OBJECTIVE: To assess the diagnostic accuracy of IOB performed via flexible endoscopy. In addition, to analyse modifiable factors that may affect diagnostic accuracy of IOB. DESIGN: A systematic review following the PRISMA guidelines was conducted. PubMed, EMBASE, the Cochrane Library, Web of Science and CINAHL were used in the literature database search. Quality assessment of included studies was perfomed using the Newcastle-Ottawa Scale. RESULTS: A total of 875 studies were identified, 16 of which were included into the systematic review; 1572 successful biopsies were performed using flexible endoscopy; 1283 cases were accurately diagnosed in the outpatient setting (81.6%) and 289 samples did not provide an accurate diagnosis (18.4%). The median sensitivity of IOB was 73%, and the specificity was 96.7%. Analysis of variable factors did not show any significant differences in method of approach, size of equipment (forceps) and additional lighting system or learning curve. CONCLUSION: IOB are a viable tool for diagnostic workup of laryngopharyngeal tumours. Clinicians should be wary of reported limitations of IOB when benign or pre-malignant diagnoses are made. In cases suspicious of malignancy, confirmatory investigation should be conducted.

An open structure questionnaire on reasons for delay in presentation: a study of patients attending clinic with red flag symptoms of head and neck cancer.

PURPOSE: Reasons for delayed presentation in cancer are reported as patient or professional delays. Studies have examined patient demographic factors associated with presentation delay, but it is currently unknown why patients feel they delayed presenting. METHODS: Questionnaire study of consecutive patients attending an urgent suspicion of cancer clinic at a tertiary referral centre in Glasgow over a 3-month period. RESULTS: 395 patients were included. 53 (13%) patients waited 0-7 days, 164 (41%) patients 1-4 weeks, 139 (35%) 1-12 months and 31 (8%) waited longer than 12 months, before presenting. 8 (3%) did not state length of time before presentation. 123 (31%) patients were not worried about their symptoms. 5 of the 13(38%) patients diagnosed with head and neck cancer, waited up to 12 months. 5 (38%) cancer patients delayed presentation because they were not worried about symptoms. CONCLUSION: Patients with head and neck cancer are not worried about their symptoms and delay their presentation, possibly contributing towards later stage diagnosis.

Total thyroidectomy for Graves' disease-what do our patients think? A qualitative cohort study to evaluate the surgical management of Graves' disease.

INTRODUCTION: Total thyroidectomy for Grave's disease has been covered extensively in literature. There are established risks and side effects of the procedure, but in experienced hands, this is minimised. Studies show the physical complication rate of total thyroidectomy, but not a holistic view. The authors pose the question, "what do our patients really think"? Has there been a significant improvement in quality of life by doing this surgery? METHODS: A cohort of patients who underwent total thyroidectomy for Graves' disease between the dates 2015-2018. A total of 95 patients were identified. The Glasgow Benefit Inventory (GBI) was used to ascertain patient's opinions on their surgery. RESULTS: There were 54 responders, 46 female and 8 male. Average age was 41, with a range 20-81. Average GBI scores were 13.35 (SD 30.16). A general subset had an average score of 19.21 (SD = 32.59), a social subset average was 9.57 (SD = 25.61), and a physical subset was average -6.79 (SD = 37.40). Patients' feedback included positive and negative statements on their feelings surrounding pre-operative communication and post-operative side effects. CONCLUSION: Overall, the GBI scores are positive, thereby showing an improvement in quality of life since having total thyroidectomy for Graves. Pre-operative communication was of paramount importance. It should be made clear to patients that they will require medication after surgery. The majority of patients stated they would prefer to know about "minor" post -operative side effects like weight gain or mood change post op. This highlights the importance of the consenting process- Montgomery Ruling-that clinicians explain the risks involved with surgery according to what the patient would deem a risk. In addition, they must be informed of the non-surgical options available, therefore, surgeons should be able to discuss risks and benefits of radio-iodine and anti-thyroid drugs too.

Primary thyroid squamous cell carcinoma - a Scottish National Case Series.

AIM: To present our national case series on primary thyroid squamous cell carcinoma (PTSCC) and add to the current literature about this rare and aggressive disease. METHODS: Scottish pathology departments were contacted and asked to provide details of patients with the diagnosis of PTSCC from the last 10 years. Three patients were included. RESULTS: Patients 1, 2 and 3 underwent surgical resection. Patients 1 and 3 went on to receive chemoradiotherapy. Patient 1 received nivolumab. Patient 1 died 10 months following diagnosis. Patient 2 and 3 are currently living with no recurrence, over two years post-diagnosis. CONCLUSION: This case series has demonstrated an unusually good set of outcomes for a classically rapidly progressing disease with poor survival rates. This raises the question whether there is a subgroup of PTSCC associated with better outcomes and lower mortality. A patient-centred approach will give optimal patient management.

Prediction of general hospital admission in people with dementia: cohort study.

BACKGROUND: People with dementia are extremely vulnerable in hospital and unscheduled admissions should be avoided if possible. AIMS: To identify any predictors of general hospital admission in people with dementia in a well-characterised national prospective cohort study. METHOD: A cohort of 730 persons with dementia was drawn from the Scottish Dementia Research Interest Register (47.8% female; mean age 76.3 years, s.d. = 8.2, range 50-94), with a mean follow-up period of 1.2 years. RESULTS: In the age- and gender-adjusted multivariable model (n = 681; 251 admitted), Neuropsychiatric Inventory score (hazard ratio per s.d. disadvantage 1.21, 95% CI 1.08-1.36) was identified as an independent predictor of admission to hospital. CONCLUSIONS: Neuropsychiatric symptoms in dementia, measured using the Neuropsychiatric Inventory, predict non-psychiatric hospital admission of people with dementia. Further studies are merited to test whether interventions to reduce such symptoms might reduce unscheduled admissions to acute hospitals.

National survey sampling exercise on current practice in channelled local anaesthetic biopsy in suspected head and neck cancer.

OBJECTIVE: Out-patient channelled endoscopic local anaesthetic biopsy reduces the time to diagnosis and wider use may improve cancer pathway times. This study aimed to assess the practice of ENT surgeons using channelled local anaesthetic biopsy. METHOD: A survey was distributed nationally, containing questions about out-patient local anaesthetic biopsy. RESULTS: In total, 58 responses were returned; only 12 per cent of respondents (n = 7) used general anaesthetic biopsy. The advantages of local anaesthetic biopsy were: the avoidance of general anaesthetic for patients with poor performance scores (95 per cent, n = 55) and faster cancer pathway times (91 per cent, n = 53). Disadvantages were: clinics running late (29 per cent, n = 17) and complications (24 per cent, n = 14). The main barrier to using local anaesthetic was access to channelled flexible endoscopy (38 per cent, n = 22), with 43 per cent (n = 25) reporting they were not using out-patient channelled endoscopes but would be interested in using them. CONCLUSION: Surgeons are interested in using channelled endoscopic local anaesthetic biopsy, but they are limited by access to equipment. Increased use of channelled endoscopes may improve national cancer pathway times and avoid challenging general anaesthetics.

Prospective cohort study assessing patient satisfaction and diagnostic accuracy in channeled endoscope local anesthetic biopsy in the investigation of head and neck cancer.

BACKGROUND: There are delays in the head and neck Urgent Suspicion of Cancer (USOC) pathway. Local anesthetic (LA) biopsy with channeled endoscopes in outpatients can reduce time to diagnosis. METHODS: Questionnaire-based prospective study of LA or general anesthetic (GA) biopsy for investigation of cancer from September 2021 to July 2022. RESULTS: 100% (n = 48) were very satisfied or satisfied with their overall experience. 71% (n = 20) of LA patients reported they would prefer to have a biopsy under LA. LA biopsy was 68% sensitive and 100% specific for cancer diagnosis. 28.6% (8) and 10% (2) of LA and GA patients had palliative MDT outcomes. Median time to diagnosis was 44.5 and 49.0 days for LA and GA biopsy, respectively. CONCLUSION: LA biopsy had a high satisfaction rate and is sensitive for diagnosing cancer. LA biopsy can expedite treatment pathways. LA biopsy should be considered as an option for first line investigation.

Low-Grade Chondrosarcoma of the Posterior Cricoid Plate.

This case report presents an unusual case of chondrosarcoma arising from the cricoid cartilage of the larynx. Although these are commonly low-grade malignancies, this patient attended an outpatient respiratory clinic with acute airway obstruction, and went on to require a total laryngectomy due to the size of their tumour.