Evaluation of hypoparathyroidism following laryngectomy.

BACKGROUND: Hypoparathyroidism is a recognised complication following laryngectomy; it is associated with significant short-and long-term morbidity. This study aimed to further characterise this condition, identify risk factors and describe preventative and management strategies in a large cohort. MATERIALS AND METHODS: This was a retrospective study at a tertiary referral centre for head and neck cancers. All consecutive patients who had total laryngectomy over an eight-year period were included. RESULTS: A total of 140 patients were included. Rates of transient and long-term hypoparathyroidism were 14.3% and 10.1%, respectively. The following factors were significantly associated with transient post-surgical hypocalcaemia or hypoparathyroidism: total thyroidectomy (relative risk, RR, 4.33; 95% confidence interval, CI, 1.86-10.10), oesophagectomy (RR 6.05; 95% CI 2.92-12.53) and female sex (RR 3.23; 95% CI 1.45-7.19). In addition, total thyroidectomy (RR 5.89; 95% CI 1.94-17.86), central neck dissection (RR 3.97; 95% CI 1.42-11.10), oesophagectomy (RR 9.38; 95% CI 4.13-21.3), pharyngectomy (RR 7.14; 95% CI 2.08-24.39) and female sex (RR 5.52; 95% CI 1.95-15.63) were risk factors for long-term hypoparathyroidism. There was variability in the use of preventative measures, monitoring and management of hypocalcaemia and hypoparathyroidism following total laryngectomy. CONCLUSIONS: Transient hypocalcaemia and long-term hypoparathyroidism occur in a significant proportion of patients after laryngectomy. A standard protocol is required to improve care.

The formulation of an enhanced recovery programme for patients undergoing laryngectomy.

OBJECTIVE: Enhanced recovery programmes have been widely adopted in other surgical disciplines but are not commonplace in head and neck surgery. The authors of this study created a pathway for post-operative laryngectomy patients. METHOD: A multidisciplinary working group reviewed the literature and agreed standards of care. A retrospective audit was conducted to measure current practice against our new pathway; after programme implementation our performance was reaudited in two prospective cycles, with an education programme and review after the first prospective cycle. RESULTS: Statistically significant improvement in performance was realised in catheter and surgical drain removal, opiate analgesia use, mobilisation, and timeliness of swallow assessment. The rate of hospital acquired pneumonia reduced from 23.1 to 9.5 per cent and length of stay reduced by a median of 5.2 days to 14.8 days (non-significant). CONCLUSION: The programme improved consistency of patient care across most areas that were measured. Improving patient stoma training needs to be prioritised.

Ultrasound core biopsies of neck lumps: an experience from a tertiary head and neck cancer unit.

BACKGROUND: Traditionally, fine needle aspiration cytology was the primary diagnostic investigation for head and neck lumps; however, ultrasound-guided core biopsy offers the advantage of preserving tissue architecture with increased tissue yield. This study reviews the diagnostic utility of ultrasound-guided core biopsy for investigating head and neck lumps. METHODS: Overall, 287 ultrasound-guided core biopsies were reviewed between May 2017 and April 2019 at a single tertiary site for head and neck cancer. RESULTS: On initial ultrasound-guided core biopsy, a diagnostic sample was obtained in 94.4 per cent of patients and in 83.7 per cent of patients with lymphoma. Where the initial ultrasound-guided core biopsy was non-diagnostic, 50 per cent of samples were diagnostic on repeat ultrasound-guided core biopsy. Overall, five complications were seen related to ultrasound-guided core biopsy, and all were managed conservatively. No cases of disease recurrence were identified at the biopsy site. CONCLUSION: Ultrasound-guided core biopsy is a safe procedure with a high diagnostic yield when investigating head and neck lumps. Patients whose ultrasound-guided core biopsies were non-diagnostic should be considered for excisional biopsy over repeat ultrasound-guided core biopsy.

Atypical facial presentation of subcutaneous fat necrosis of the newborn.

Subcutaneous fat necrosis of the newborn (SCFN) is a rare self-limiting panniculitis. It is thought to be associated with perinatal hypoxia and therapeutic hypothermia. It is characterised by firm subcutaneous nodules on the back, shoulder and arms. We present a rare facial presentation of SCFN in a 4-week-old infant with no history of therapeutic cooling. She presented with a discrete right cheek mass with no overlying skin changes. We present the diagnostic challenge and undertake a review of the literature. SCFN is an important differential diagnosis in a neonate with subcutaneous facial lesions. SCFN can be complicated by metabolic derangements including hypercalcaemia.

Soft tissue head and neck sarcoma: experience of a tertiary referral centre over a 15-year period.

BACKGROUND: Head and neck soft tissue sarcoma is uncommon. It is both histologically and clinically heterogeneous, ranging from an indolent, locally destructive tumour, to a locally aggressive neoplasm with metastatic potential. METHODS: A retrospective review was conducted of all adult head and neck soft tissue sarcomas, including cases of malignant soft tissue sarcoma and all intermediate type tumours, diagnosed between 1997 and 2012. RESULTS: Sixty-eight cases were identified in this series from the sarcoma multidisciplinary team. Seventeen different histological subtypes of sarcoma were identified. Neither age, gender nor tumour size were significant prognostic indicators for survival in this series. CONCLUSION: Prognosis is dependent on histological subtype, underscoring the importance of histological classification. Some histological subtypes occur only once or twice in a decade, even within a large regional referral centre. An accumulation of evidence from relatively small case series is key in the long-term development of treatment strategies.

YouTube™ as a source of information for patients undergoing laryngectomy: a thematic analysis.

PURPOSE: Total laryngectomy and end tracheal stoma formation are often required to treat advanced laryngeal cancer. Resources on the internet are commonly accessed by patients as a source of healthcare information. YouTube™, the most popular video-hosting website, is one such resource. The aims of this study were to assess the thematic content of the most viewed YouTube™ videos concerning laryngectomy for laryngeal cancer and to evaluate user response to these videos. METHOD: A search of YouTube™ was performed and data were extracted from videos with > 100 views. Upload source, number of views, likes, dislikes and comments were collected and the content of comments was analysed. User response was compared between upload sources using Kruskal-Wallis testing. Inductive thematic analysis of video content was performed to identify overarching themes and subthemes. RESULTS: A total of 96 videos were identified, 16 uploaded by patients, 24 by individual healthcare professionals and 56 by professional healthcare institutions. There were 1214,503 views and no significant differences in the number of views, likes or dislikes between upload sources. Three overarching themes and 17 subthemes were identified. Comments were most frequently characterised as offering praise. CONCLUSION: YouTube™ has been shown to be a popular platform for sharing information about laryngectomy for laryngeal cancer. There is a lack of data concerning the quality of this information, however, and future work should focus on assessing this. Trusted institutions could make use of this medium to disseminate high-quality information to their patients, and to the wider public.

Aetiology and risk factors for head and neck cancer: United Kingdom National Multidisciplinary Guidelines.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. It discusses the aetiology and risk factors for head and neck cancer and the recommended interventions appropriate for each risk factor. Recommendations • Recent evidence synthesis from National Institute for Health and Care Excellence suggests that the following brief interventions for smoking cessation work should be used: ○ Ask smokers how interested they are in quitting (R) ○ If they want to stop, refer them to an intensive support service such as National Health Service Stop Smoking Services (R) ○ If they are unwilling or unable to accept a referral, offer a stop smoking aid, e.g. pharmacotherapy. (R) • Brief interventions are effective for hazardous and harmful drinking. (R) • Specialist interventions are effective in people with alcohol dependence. (R) • Most people with alcohol dependence can undergo medically assisted withdrawal safely at home, after risk assessment. (R) • Management of leukoplakia is not informed by high-level evidence but consensus supports targeted use of biopsy and histopathological assessment. (R) • The management of biopsy proven dysplastic lesions favours: ○ advice to reduce known environmental carcinogens such as tobacco and alcohol (R) ○ surgical excision when the size of the lesions and the patient's function allows (R) ○ long-term surveillance. (R) • Fanconi anaemia patients should: ○ be followed up in a multidisciplinary specialist Fanconi anaemia clinic (G) ○ have quarterly screening for head and neck squamous cell carcinoma and an aggressive biopsy policy (G) ○ receive prophylactic vaccination against high risk human papilloma virus (G) ○ receive treatment for head and neck squamous cell carcinoma with surgery alone where possible. (G).

Routine non-thyroid head and neck cytology in a large UK centre: clinical utility and pitfalls.

OBJECTIVE: This study aimed to examine the performance of head and neck cytology at Nottingham University Hospitals between 2009 and 2010. METHODS: Cases were extracted from the Winpath pathology reporting system and correlations were investigated between results and the histological and clinical outcomes. Specimen adequacy and the sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy of the cytology tests were calculated. RESULTS: In all, 19.7 per cent of aspirates were judged to be inadequate. The absolute and relative sensitivities of head and neck cytology were 87.0 per cent and 89.0 per cent, respectively, and the absolute and relative specificities were 99.0 per cent and 97.0 per cent, respectively. The positive predictive values were 99.0 per cent and 96.0 per cent and the negative predictive values were 92.0 per cent and 92.0 per cent for a diagnostic accuracy of 94.5 per cent and 93.0 per cent. The performance was consistent with previous reports and superior to that of a recent UK series. The high rate of inadequate samples is, however, a concern. CONCLUSION: Head and neck cytology is a robust technique at our institution, although there are certain problem areas. There is room for improvement in the technical quality of fine needle aspiration.

A decade of experience of thyroglossal cyst excision.

INTRODUCTION: We report our ten-year experience of thyroglossal cyst excision at Queen's Medical Centre, Nottingham, comparing outcomes, practice and technique. METHODS: Retrospective case note analysis was conducted alongside surgical histopathology review for all thyroglossal cyst excisions performed between 2000 and 2010. This yielded 108 patients with histopathology results confirming a thyroglossal cyst. RESULTS: The mean patient age was 21 years (range: 1 week - 76 years). Over half the patients (n=59, 55%) were less than 18 years of age. Fifty-five patients (51%) were male and fifty-three (49%) were female. Seventy cases (63%) were operated on by ear, nose and throat (ENT) surgeons. The rest were performed by paediatric surgeons (n=35, 32%), maxillofacial surgeons (n=2, 2%) and general surgeons (n=1, 1%). Paediatric surgeons undertook 35 (69%) of the 59 paediatric cases, with ENT surgeons operating on the rest (n=24, 41%). The primary surgeon was a consultant in 59 operations (55%) while in 49 cases (45%) it was a registrar. Thyroglossal cysts were ruptured in 21 operations (19%) during removal. The central portion of the hyoid bone was not excised in seven cases (6%). Twelve patients (11%) suffered postoperative complications, six of which were recurrences. CONCLUSIONS: There was a combined recurrence rate of 6% across all specialties for the Sistrunk procedure. This is in keeping with commonly reported recurrence rates. However, we found that central compartment neck dissection, as a modification of the original Sistrunk procedure, provides a highly effective method for permanently excising a thyroglossal cyst and, in our experience, it eliminates recurrence.

Changing trends in intracranial abscesses secondary to ear and sinus disease.

OBJECTIVES: To review the management, causative organisms, morbidity and mortality of intracranial abscesses secondary to sinus and ear disease. STUDY DESIGN AND SETTING: Retrospective, case note review of suppurative intracranial complications of ear and sinus disease in patients admitted to a regional neurosurgical centre between 1980 and 2004. These data were compared with published material from the same region from 1950-1979. RESULTS: There was a marked reduction in the mortality rate and the number of intracranial abscesses secondary to chronic ear disease, comparing the two time periods. However, there was little change in the percentage of sinus-related abscesses treated and in their symptoms, signs, abscess location and long term morbidity. Microbiology results showed that streptococcal species predominated as causative organisms, with a high percentage of anaerobic bacteria in otogenic abscesses. CONCLUSION: Despite improved outcomes, a high index of suspicion for intracranial complications of ear or sinus disease should be maintained in the presence of appropriate signs and symptoms.

Foreign body reaction mimicking a second primary tumour of the oesophagus.

OBJECTIVE: To present a significant complication of pharyngolaryngeal reconstruction, which resulted in diagnostic confusion as it mimicked a second primary tumour of the head and neck. METHODS: Case report and review of the world literature. CASE REPORT: A 61-year-old man developed a granulomatous foreign body reaction, mimicking a second primary tumour, at the distal end of a salivary bypass tube, following pharyngolaryngectomy and reconstruction using a tubed anterolateral thigh flap. Clinically and radiologically, this was felt to represent a second primary tumour of the oesophagus, but biopsies revealed full thickness inflammation of the mucosa and granulation tissue. Repeat oesophagoscopy two weeks after removal of the tube showed complete resolution. CONCLUSION: No record of an oesophageal foreign body reaction to a Montgomery salivary bypass tube has previously been reported in the world literature. This report highlights the potential for such a lesion to cause diagnostic confusion with a second primary tumour.

How we do it: improving the success of endoscopic pharyngeal pouch stapling.

A simple technique to improve the success rate of endoscopic stapling diverticulotomy of pharyngeal pouches is described. Equipment used is readily available. This technique can be used in difficult cases when the pouch cannot be visualised using a Weerda diverticuloscope. It reduces the need for conversion to an open surgical procedure with associated increased risk of complications.

Tonsillitis to mediastinitis.

Parapharyngeal abscess secondary to quinsy is a well understood complication; however, its incidence has significantly declined following early use of effective antibiotics. Tracking of infection from the parapharyngeal space through the anatomical planes to cause mediastinitis has a significant mortality rate and requires early detection and aggressive management. A case of quinsy leading to mediastinitis, pericarditis and pleural effusions is presented. It highlights the potentially life-threatening complications of a commonly encountered ENT problem.

The FOXP1 winged helix transcription factor is a novel candidate tumor suppressor gene on chromosome 3p.

The JC12 monoclonal antibody recognizes a previously unknown nuclear protein that showed a restricted distribution in normal tonsil and was also overexpressed in a subset of diffuse large B-cell lymphomas. Using this reagent, we expression cloned cDNAs encoding its antigenic target and identified this protein as a novel putative transcription factor, FOXP1. The FOXP1 protein sequence contains predicted domains characteristic of transcription factors, including a winged helix DNA-binding motif, a second potential DNA-binding motif, a C(2)H(2) zinc finger, nuclear localization signals, coiled-coil regions, PEST sequences, and potential transactivation domains. The FOXP1 gene has been mapped to chromosome 3p14.1, a region that commonly shows loss of heterozygosity in a wide range of tumors and which is reported to contain a tumor suppressor gene(s). Using tissue arrays and immunohistochemistry, we demonstrate that both the FOXP1 mRNA and protein are widely expressed in normal tissues. The levels of FOXP1 mRNA were compared in paired normal and tumor tissues (from the same patient) using a tissue array containing cDNAs extracted from 68 samples taken from kidney, breast, prostate, uterus, ovary, cervix, colon, lung, stomach, rectum, small intestine, and from nine cancer cell lines. Differences in FOXP1 mRNA expression between normal and tumor samples were observed in 51% of cases. Most striking was the comparative loss of expression in 73% of colon tumors and comparative overexpression of FOXP1 mRNA in 75% of stomach tumors. Analysis of the FOXP1 mRNA expression in normal tissues (not taken from cancer patients) indicated that loss of FOXP1 expression may occur in some histologically normal tissues adjacent to tumors. Immunohistochemical analysis of FOXP1 protein expression was performed on 128 solid tumors, including 16 renal, 9 breast, 12 lung, 20 colon, 21 stomach, 10 head and neck, 35 prostate, and 5 pancreatic cases. Complete loss of expression, increased expression, and cytoplasmic mislocalization of the predominantly nuclear FOXP1 protein were frequently observed in neoplastic cells. Our study identifies FOXP1 as a new candidate tumor suppressor gene localized to the chromosome 3p14.1 region.

Carbonic anhydrase IX, an endogenous hypoxia marker, expression in head and neck squamous cell carcinoma and its relationship to hypoxia, necrosis, and microvessel density.

Carbonic anhydrase IX (CA IX) is a transmembrane glycoprotein with an active extracellular enzyme site. We have shown previously that it was hypoxia inducible and may therefore be an endogenous marker of hypoxia. It is overexpressed in some tumors, particularly renal cell carcinoma. The aim of this study was to examine the expression and localization of CA IX in head and neck squamous cell carcinoma (HNSCC) and relate this to the location of tumor microvessels, angiogenesis, necrosis, and stage. Expression of CA IX was determined by immunoblotting in three HNSCC cell lines grown in normoxia and hypoxia (pO(2) 0.1%) and three paired tumor and normal tissue samples of HNSCC. Archived paraffin sections (79) of HNSCC were immunostained with antibodies to CA IX and CD34 to determine microvessel density (MVD). By double staining sections with CA IX and CD34, the distance between blood vessels and the start of CA IX expression and necrosis was calculated. CA IX was induced by hypoxia in all three HNSCC cell lines and overexpressed in HNSCC tumor tissue. Overexpression was localized to the perinecrotic area of the tumor on immunostaining, and the percentage area of the tumor expressing CA IX was significantly higher with more tumor necrosis (P = 0.001), a high MVD (P = 0.02), and advanced stage (P = 0.033) on univariate analysis and necrosis (P = 0.0003) and MVD (P = 0.0019) on multivariate analysis. The median distance between a blood vessel and the start of CA IX expression was 80 microm (range, 40-140 microm). CA IX is overexpressed in HNSCC because of hypoxia and is a potential biomarker for hypoxia in this tumor. Overexpression may help to maintain the intracellular pH, giving tumor cells a survival advantage and enhancing resistance to radiotherapy and chemotherapy. CA IX is a potential target for future therapy in HNSCC.

Cause of death in patients with well-differentiated thyroid carcinoma.

OBJECTIVES: The aim of this study is to examine in detail patients dying of well-differentiated thyroid carcinoma. STUDY DESIGN: A retrospective chart review with follow-up. METHODS: Data were collected from 522 consecutive cases of differentiated thyroid carcinoma treated by one endocrinologist and four surgeons at Mount Sinai Hospital, Toronto, Ontario, Canada, from 1964 to 1999. RESULTS: Ten patients died as a direct result of thyroid carcinoma; 19 other deaths were unrelated. Five of 102 patients were men (5%) and 5 of 420 were women (1%); the median age at diagnosis was 68.5 years (range, 49-82 y). No cases were stage I; three, stage II; two, stage III; and five, stage IV. Pathologically papillary carcinoma was found in six of the patients who died, follicular carcinoma in three patients, and Hurtle cell carcinoma in one patient. The causes of death were local invasion or compression of the trachea in two cases and distant metastases in eight patients. Median survival was 3.5 years (range, 1 mo-20 y). CONCLUSIONS: All patients dying of well-differentiated thyroid carcinoma had neck nodes, extrathyroidal spread, or distant metastases at presentation and were older than 49 years of age. Many presented because of their distant metastases. Death resulting from local disease was unusual, with most patients dying of distant metastases.

Expression of the hypoxia-inducible and tumor-associated carbonic anhydrases in ductal carcinoma in situ of the breast.

Carbonic anhydrases (CA) influence intra- and extracellular pH and ion transport in varied biological processes. We recently identified CA9 and CA12 as hypoxia-inducible genes. In this study we examined the expression of these tumor-associated CAs by immunohistochemistry in relation to necrosis and early breast tumor progression in 68 cases of ductal carcinoma in situ (DCIS) (39 pure DCIS and 29 DCIS associated with invasive carcinoma). CA IX expression was rare in normal epithelium and benign lesions, but was present focally in DCIS (50% of cases) and in associated invasive carcinomas (29%). In comparison, CA XII was frequently expressed in normal breast tissues (89%), in DCIS (84%), and in invasive breast lesions (71%). In DCIS, CA IX was associated with necrosis (P: = 0.0053) and high grade (P: = 0.012). In contrast, CA XII was associated with the absence of necrosis (P: = 0.036) and low grade (P: = 0.012). Despite this, augmented CA XII expression was occasionally observed adjacent to necrosis within high-grade lesions. Neither CA IX nor CA XII expression was associated with regional or overall proliferation as determined by MIB1 staining. Assessment of mammographic calcification showed that CA XII expression was associated with the absence of calcification (n = 43, P: = 0.0083). Our results demonstrate that induction of CA IX and CA XII occurs in regions adjacent to necrosis in DCIS. Furthermore, these data suggest that proliferation status does not influence expression of either CA in breast tissues, that hypoxia may be a dominant factor in the regulation of CA IX, and that factors related to differentiation, as determined by tumor grade, dominate the regulation of CA XII. The existence of differential regulation and associations with an aggressive phenotype may be important in the development of selective inhibitors of CAs, because the latter have recently been shown to prevent tumor invasion.

The impact of weekly iron supplementation on the iron status and growth of adolescent girls in Tanzania.

We evaluated the effect of weekly doses of 400 mg of ferrous sulphate for 4 months on the iron status of adolescent girls in a controlled trial in Tanga, Tanzania. Supplementation led to a significantly greater increase in serum ferritin compared with the control group (+ 15.6 microg/l vs. 8.6 microg/l) (P = 0.002) but there was no significant difference in change in haemoglobin. Children given iron showed a significantly greater weight gain than controls (+ 2.4 kg vs. + 1.4 kg) (P = 0.03). Weekly iron supplementation may be an effective means of increasing iron stores and growth in children vulnerable to iron deficiency.

The health of enrolled and non enrolled children of school age in Tanga, Tanzania.

The health of 227 children enrolled at primary school was compared with that of 214 non enrolled children living in rural Tanga, Tanzania. No consistent difference was observed with respect to prevalence and intensity of parasitic infection (hookworm, T. trichiura, A. lumbricoides, S. haematobium and P. falciparum). Since enrolled children were as commonly and as heavily infected as non enrolled children, treatment of enrolled children would be effective in reducing transmission throughout the total population. Non enrolled children were more stunted (P=0.0001) and wasted (P=0.0001) than enrolled children and also tended to be more anaemic (P=0.080) showing that poor nutrition is not only associated with delayed enrolment but continues to be associated with non enrolment throughout the school age years. Given that treatment has the greatest impact on the most malnourished children, additional measures to extend treatment to non enrolled children would be justified.