Finnish Version of the Eating Assessment Tool (F-EAT-10): A Valid and Reliable Patient-reported Outcome Measure for Dysphagia Evaluation.

Our aim was to validate a Finnish version of the Eating Assessment Tool (F-EAT-10) for clinical use and to test its reliability and validity in a multicenter nationwide study. Normative data were acquired from 180 non-dysphagic participants (median age 57.0 years, 62.2% female). Dysphagia patients (n = 117, median age 69.7 years, 53.0% female) referred to fiberoptic endoscopic evaluation of swallowing (FEES) completed F-EAT-10 before the examination and after 2 weeks. Patients underwent the 100-ml water swallow test (WST) and FEES was evaluated using the following three scales: the Yale Pharyngeal Residue Severity Rating Scale, Penetration-Aspiration Scale, and the Dysphagia Outcome Severity Scale. An operative cohort of 19 patients (median age 75.8 years, 57.9% female) underwent an endoscopic operation on Zenker's diverticulum, tight cricopharyngeal muscle diagnosed in videofluorography, or both. Patients completed the F-EAT-10 preoperatively and 3 months postoperatively. The cut-off score for controls was < 3 (sensitivity 94.0%, specificity 96.1%) suggesting that ≥ 3 is abnormal. Re-questionnaires for test-retest reliability analysis were available from 92 FEES patients and 123 controls. The intraclass correlation coefficient was excellent for the total F-EAT-10 score (0.93, 95% confidence interval 0.91-0.95). Pearson correlation coefficients were strong (p < 0.001) for each of the questions and the total score. Internal consistency as assessed by Cronbach's alpha was excellent (0.95). Some correlations between findings in FEES and 100-ml WST with F-EAT-10 were observed. The change in subjective symptoms of operative patients paralleled the change in F-EAT-10. F-EAT-10 is a reliable, valid, and symptom-specific patient-reported outcome measure for assessing dysphagia among Finnish speakers.

Olfactory and gustatory functions after free flap reconstruction and radiotherapy for oral and pharyngeal cancer: a prospective follow-up study.

BACKGROUND: The senses of smell and taste can be adversely affected by both tumour- and treatment-related factors amongst head and neck cancer patients. The consequences may negatively impact nutritional status as well as quality of life in this patient population. PATIENTS AND METHODS: This prospective longitudinal follow-up study is consisted of 44 patients treated for oral cavity, oropharyngeal or hypopharyngeal cancer with tumour resection and microvascular free tissue transfer reconstruction at the Helsinki University Hospital, Helsinki, Finland. Thirty-nine (89%) of them also received radiotherapy. The senses of smell (odour detection, identification and threshold test) and taste (electrogustometry) and quality of life (UW-QOL) were evaluated preoperatively, and at 6 weeks, 3 months, 6 months and 12 months, postoperatively. RESULTS: There were higher scores in the odour detection values in the 6-week and 3-month tests compared with preoperative values for the tumour side. Other detection scores did not differ statistically from the preoperative values neither in the tumour nor the contralateral side. However, in the odour identification test, all posttreatment values were statistically significantly higher than pretreatment ones. In the olfactory threshold test, no statistically significant differences were found between pre- and posttreatment values. Electrogustometry values for the taste on the tumour side were statistically significantly impaired at 6 weeks (p < 0.05) and at 3 months (p < 0.01) compared with the pretreatment results. They were also impaired at 6 months and at 12 months, although the differences were not statistically significant. The quality of life was impaired after treatment in this patient series. However, the correlation between quality of life and sense of taste was found only at one time point (3 months) and only with contralateral side measurements. CONCLUSIONS: We conclude that in oral and pharyngeal cancer patients the postoperative taste problems are related to the impairment on the taste sensation in the tongue but not with the sense of smell. Moreover, the impairment in the quality of life is not clearly related to the impaired sense of taste.

Work-up of globus: assessing the benefits of neck ultrasound and videofluorography.

Globus patients with normal ear, nose, and throat (ENT) status are a diagnostic challenge. The symptom may be long lasting and cause concern about malignancy, leading to possibly unnecessary further investigation. The aim of the study was to assess whether radiological examinations are useful in globus diagnostics, how often patients suffer from persistent globus, and whether globus patients with normal ENT status develop a malignancy during a follow-up. We reviewed medical records of all 76 globus patients referred to Helsinki University Hospital, Department of Otorhinolaryngology-Head and Neck Surgery in 2009. Patient history and findings in physical and radiological examinations were registered. A questionnaire concerning patients' present pharyngeal symptoms was sent 3 and 6 years after their initial visit. Data from the Finnish Cancer Registry revealed whether patients developed malignancies within a 3-year follow-up. Based on medical records, neck ultrasound was performed for 37 (49 %) and videofluorography for 22 patients (29 %), with nonsignificant findings. After a 3- and 6-year follow-up, half patients indicated that they were asymptomatic or had fewer symptoms, whereas the rest had persistent symptoms. The Finnish Cancer Registry data confirmed that globus patients developed no head and neck malignancies during a 3-year follow-up. In the present study, neck ultrasound and videofluorography showed no additional benefit to evaluate the globus etiology in patients whose ENT status was normal. Half the globus patients suffered from persistent symptoms after a 3- and 6-year follow-up, indicating that globus may cause discomfort chronically. However, no patients developed malignancies during a 3-year follow-up.

[Development of a child's eating and urge for suckling]. / Lapsen syömisen kehitys ja imemisen tarve.

A child's oral-motor movement models develop from coarse and all-embracing generalized reflexive patterns towards separate, voluntary muscle functions. Development of the oral-motor sensory system begins already during fetal life. Suckling, dealing with and swallowing of food are rhythmic functions that are programmed from foci formed by neural networks of the brainstem. As breast feeding does not seem to completely satisfy children's need for suckling, a pacifier has been offered to bring additional satisfaction. To ensure safe swallowing, the separate stages of eating should be neurologically coordinated with breathing.

De-escalation of post-treatment surveillance in oropharyngeal cancer.

BACKGROUND: The majority of new oropharyngeal squamous cell carcinoma (OPSCC) cases are associated with human papillomavirus and favorable prognosis. Post-treatment follow-up should be targeted to patients at greatest risk for disease recurrence. METHODS: To assess the benefits of routine clinical surveillance in OPSCC, we reviewed all follow-up visits conducted in 2014 at Helsinki University Hospital Department of Otorhinolaryngology. RESULTS: Of 366 visits, 26 (7%) were from patients presenting with a new symptom, and disease recurrence was detected in four. The presence of a new symptom was significantly associated with disease recurrence (P < 0.001). Of 366 visits, 340 (93%) were from patients presenting without new symptoms, and not a single recurrence was found during these visits. CONCLUSIONS: Based on our findings, and previous studies assessing the prognosis and pattern of recurrent OPSCC, we concluded that the number of routine post-treatment visits can be reduced. Follow-up should rather focus on symptom-directed examinations.

Transoral Robotic Surgery in the Nordic Countries: Current Status and Perspectives.

Background: The five Nordic countries with a population of 27 M people form a rather homogenous region in terms of health care. The management of head and neck cancer is centralized to the 21 university hospitals in these countries. Our aim was to gain an overview of the volume and role of transoral robotic surgery (TORS) and to evaluate the need to centralize it in this area as the field is rapidly developing. Materials and Methods: A structured questionnaire was sent to all 10 Departments of Otorhinolaryngology-Head and Neck Surgery in the Nordic countries having an active programme for TORS in December 2017. Results: The total cumulative number of performed robotic surgeries at these 10 Nordic centers was 528 and varied between 5 and 240 per center. The median annual number of robotic surgeries was 38 (range, 5-60). The observed number of annually operated cases remained fairly low (<25) at most of the centers. Conclusions: The present results showing a limited volume of performed surgeries call for considerations to further centralize TORS in the Nordic countries.

Cyclooxygenase-2 expression in squamous cell carcinoma of the oral cavity and pharynx: association to p53 and clinical outcome.

Cyclooxygenase-2 (COX-2) expression is up-regulated in transformed cells and in malignant tissues, including tumours of the head and neck, and it has prognostic significance in many types of cancer. COX-2 expression is suppressed by the wild-type but not by the mutant tumour suppressor gene TP53. The purpose of this study was to investigate the association between the expression of COX-2 and the clinical outcome in patients with oral and pharyngeal squamous cell carcinoma (SCC), and to examine its relationship to p53. Immunohistochemistry showed an elevated COX-2 expression in 88% (n = 57; strong 38, weak 19) of the 65 tumour samples. The staining intensity was not associated with patient or tumour characteristics, nor with the immuhistochemical expression of p53. Kaplan-Meier analysis showed no significant correlation between COX-2 expression and recurrence-free or overall survival, but a strong p53 expression was associated with a poor recurrence-free (p = 0.001, log-rank) and overall survival (p = 0.003). We conclude that, unlike strong p53 expression, COX-2 expression does not have prognostic significance in advanced oral and pharyngeal SCCs.

Swallowing after free-flap reconstruction in patients with oral and pharyngeal cancer.

Swallowing and intraoral sensation outcome were investigated prospectively after microvascular free-flap reconstruction. Forty-one patients with a large oral or oropharyngeal carcinoma underwent free-flap surgery usually combined with radiotherapy. The patients completed modified barium swallow, self-rating of swallowing, and 2-point moving discrimination preoperatively and at four time points during the 12-month follow-up period, and a plain chest X-ray one year after operation. Swallowing was impaired with respect to an objective and subjective measure after therapy. Rates for nonsilent and silent aspiration increased during the follow-up. Intraoral sensation deteriorated. Swallowing outcome was not related to sensation. One year after surgery, 86% of the patients ate regular masticated or soft food. Microvascular transfers offer a reasonable option for oral reconstruction. This study does not support the need for sensate flaps. Swallowing problems should be routinely sought and patients rehabilitated during a sufficiently long follow-up with videofluorography regardless of the patient's perception of swallowing.

Changes in articulatory proficiency following microvascular reconstruction in oral or oropharyngeal cancer.

Articulatory proficiency of /r/ and /s/ sounds, voice quality and resonance, speech intelligibility, and intraoral sensation were examined prospectively before operation, and at four time points during a 1-year follow-up after microvascular transfer. Forty-one patients with a large oral or oropharyngeal carcinoma undergoing tumor resection and free-flap reconstruction usually combined with radiotherapy participated in the study. Articulation, voice, and resonance were investigated both live and from recorded speech samples by two trained linguistic examiners. The patients completed a self-rating of their speech intelligibility and were assessed for anterior intraoral surface sensation by means of 2-point moving discrimination. Misarticulations of /r/ and /s/ increased significantly after the therapy. Voice quality and resonance remained essentially normal. Speech intelligibility deteriorated significantly. Intraoral sensation decreased postoperatively but was not related to speech outcome. Sensate flaps did not prove to be superior in relation to speech tasks. A multidisciplinary approach is advocated in assessment of speech outcome after cancer surgery. Speech therapy is strongly recommended, even in the absence of a gross articulatory handicap.

Dysphagia and malignancy: A three-year follow-up and survey of National Cancer Registry data.

OBJECTIVES/HYPOTHESIS: Dysphagia may cause concern about malignancy. Symptoms are often unspecific; thus, it is essential to identify those requiring further investigations. STUDY DESIGN: Retrospective study combined with patient survey. METHODS: Case records of the 303 dysphagia patients referred in 2009 to Helsinki University Hospital, Department of Otorhinolaryngology-Head and Neck Surgery were surveyed. Based on clinical data, the main cause of symptoms divided patients into five groups. Alarming signs were food sticking in the throat or in the esophagus, weight loss, and progressive dysphagia symptoms. A questionnaire sent 3 years after the primary visit concerned the present symptoms. To investigate whether dysphagia could have been early symptom of malignancy, we surveyed the Finnish Cancer Registry database until the end of 2012. RESULTS: Most diagnoses remained descriptive: unspecific dysphagia (167, 55%). Five (0.02%) had malignant disease, for all of whom the suspicion of malignancy was evident. Finnish Cancer Registry data indicated that unspecific dysphagia did not develop into malignancy during a 3-year follow-up. Returned questionnaires numbered 154 (62%), of which 30 (19%) were asymptomatic patients; relieved symptoms in 36 (23%), fluctuating or unchanged symptoms in 43 (28%), and worse symptoms in 12 (8%). The remaining patients (33, 21%) had not answered that question or the answer was uninterpretable. CONCLUSION: Further investigations to reveal malignancy seemed unnecessary if alarming clinical signs or findings were lacking. After 3 years, almost half the patients were asymptomatic or had milder symptoms revealing the condition's potential for spontaneous recovery. LEVEL OF EVIDENCE: N/A. Laryngoscope, 126:2073-2078, 2016.

Developing a Registry for Complications in Otorhinolaryngologic Surgery: Tonsil Surgery as a Pilot Cohort.

OBJECTIVE: To find a suitable method to prospectively register all tonsil surgery-related complications. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary care center. SUBJECTS AND METHODS: From September 2011 to February 2012, patients undergoing tonsillectomy or tonsillotomy were enrolled. A wide range of demographic and clinical data including incidents of postoperative complications was recorded prospectively, and patient records were reviewed 9 months after the end of study period. We evaluated the coverage of prospective data recording, analyzed the complication rates, and assessed the process of registration. RESULTS: A total of 573 patients were recruited. The study registry including 57 variables required the completion of missing data before analysis. Of all 79 patients with a complication, 69.6% were captured prospectively at the emergency department, and the rest were found when reviewing the patient records. The proportion of prospectively captured complications was highest for the most common complications (eg, 81.1% for secondary hemorrhage). The overall complication rate was 13.8%. Secondary hemorrhage was the most common complication, with the incidence of 9.6%. CONCLUSION: We have demonstrated the initial feasibility of a prospective complication registry for otorhinolaryngology procedures, and the results can be applied accordingly. We also present 5 practical recommendations when initiating a functional registry. Particular attention should be paid to recognition and registration of both rare and serious events. Regular analysis of the results is required in order to respond to possible changes in the incidence or nature of complications.

Tenascin-C expression and its prognostic significance in oral and pharyngeal squamous cell carcinoma.

BACKGROUND: Tenascin-C (Tn-C) is an extracellular matrix protein with growth-, invasion- and angiogenesis-promoting activities. It is up-regulated in tumorigenesis and has been suggested to correlate with prognosis in various carcinomas, but its significance in squamous cell carcinoma of the head and neck remains unknown. The purpose of this study was to examine the prognostic significance of Tn-C expression in oral and pharyngeal squamous cell carcinomas. PATIENTS AND METHODS: Tn-C expression was determined by immunohistochemistry in 65 consecutive tumors from patients with primary oral and pharyngeal squamous cell carcinoma. Based on staining intensity, both the stroma and invasion border were separately classified into two groups and the results correlated with overall survival (OS) and disease-free survival (DFS). RESULTS: The tumor stroma showed strong Tn-C expression in 56 (86%) samples, and weak Tn-C expression in 9 (14%). At the invasion border, Tn-C expression was strong in 38 (58%) samples and weak in 27 (42%). Tn-C expression was not a statistically significant predictor of survival and there was no correlation between Tn-C expression and tumor or patient characteristics. CONCLUSION: Tn-C protein was overexpressed in the majority of our oral and pharyngeal squamous cell carcinoma samples. The presence of TnC did not appear to predict for OS or DFS.

Percutaneous endoscopic gastrostomy tube placement by otorhinolaryngologist-head and neck surgeons.

CONCLUSION: Percutaneous endoscopic gastrostomy (PEG) tube placement by an otorhinolaryngologist-head and neck surgeon is a feasible procedure with logistical advantages for the patient. Patient selection, co-morbidities, and the prognosis of the underlying disease are factors determining the outcome. Patient evaluation by a multidisciplinary team, with a gastroenterologist surgeon as a technical adviser, is proposed. OBJECTIVE: PEG tube placement offers an alternative to enteral nutrition. We aimed to analyze complication rates after PEG tube placement in order to evaluate the changed management policy. METHODS: This was a retrospective review of complication rates in two patient cohorts with consecutive PEG tube placement at the Departments of Otorhinolaryngology - Head and Neck Surgery (group I, n = 120) and Surgery (group II, n = 172) at Helsinki University Central Hospital, Helsinki, Finland. Data were collected on the patients' age, sex, preoperative condition, tumor site and stage, preoperative laboratory parameters, coexisting medical diagnoses, indication and date for PEG tube placement, complications, time of PEG use, follow-up time, and clinical status at the last follow-up. RESULTS: The only baseline differences between the cohorts were a higher ASA classification and fewer prophylactic PEG tubes in group II. The rate of major complications was 7.5% in group I and 13.9% in group II; in group I the rate of minor complications was 25%, compared with 15% in group II; and the procedure-related mortality rate was 0.8% in group I and 0.5% in group II. The differences were not significant (p = 0.105-0.795).

Bilateral Basal cell adenocarcinoma of the parotid gland: in a recipient of kidney transplant.

We report a rare case of bilateral basal cell adenocarcinoma (BcAC) of the parotid gland in a male patient 30 years after kidney transplantation and continuous administration of immunosuppressive therapy. BcAC is a salivary gland malignancy first recognized as a distinct neoplastic entity in WHO classification of salivary gland tumours in 1991. Over 90% of BcACs are detected in the parotid gland. The most important differential diagnosis is basal cell adenoma. Infiltrative growth is the distinguishing feature of BcAC. Administration of immunosuppressive medication to this patient for three decades may have contributed to development of this rare neoplasia. To our knowledge, similar cases of BcAC have not been reported previously.

Quality of life after free-flap reconstruction in patients with oral and pharyngeal cancer.

BACKGROUND: Our aim was to investigate quality of life and outcome after microvascular free-flap reconstruction after oncologic surgery. METHODS: Forty-four patients with a large carcinoma in the oral cavity, oral pharynx, or hypopharynx underwent free-flap surgery with or without radiotherapy. Patients completed the University of Washington Quality-of-Life Questionnaire preoperatively and four times during the 12 postoperative months. Survival rates and complications were analyzed. RESULTS: Postoperative composite quality-of-life scores were significantly lower than before treatment with no significant overall improvement during the follow-up. The scores for disfigurement, chewing, speech, and shoulder function remained significantly below the preoperative level throughout the follow-up. Sociodemographic factors predicted quality of life. Heavy drinking and unemployment caused a 2.4-fold and a 4.4-fold increase in risk of death, respectively. The rates for overall survival, tumor recurrence, flap success, and surgical complications were consistent with previous literature. CONCLUSION: Sociodemographic variables affect quality of life and patient survival in patients with oral cancer treated with microvascular free-flap reconstruction.

Speech aerodynamics and nasalance in oral cancer patients treated with microvascular transfers.

The purpose of the current study was to assess speech aerodynamics and nasal acoustic energy during a follow-up period of 12 months in patients having undergone microvascular free flap reconstruction after tumor ablation from the oral cavity or oropharynx, usually followed by radiotherapy. Velopharyngeal function was assessed in terms of velopharyngeal orifice size by a pressure-flow measurement technique as well as by determining the instrumental correlate of perceived nasality (i.e., nasalance) during speech production. Velopharyngeal closure and nasalance were estimated to be adequate before operation both in oral cavity and oropharyngeal cancer patients. After the operation, at the group level, the oral cavity patients showed adequate velopharyngeal closure and nasalance. In contrast, the postoperative velopharynx orifice size was significantly bigger in the oropharyngeal cancer patients as compared with the oral cavity patients 6 months after operation. However, based on average aerodynamic as well as the nasalance data, the impairment of velopharyngeal function was not regarded clinically significant at the group level in either group of patients. The present treatment protocol served to maintain the prerequisites for normal or close to normal speech physiology.