Impact of the method and success of pharyngeal reconstruction on the outcome of treating laryngeal and hypopharyngeal cancers with pharyngolaryngectomy: A national analysis.

BACKGROUND: Surgical treatment of cancers that arise from or invade the hypopharynx presents major reconstructive challenges. Reconstructive failure exposes the airway and neck vessels to digestive contents. METHODS: We performed a national N = near-all analysis of the administrative dataset to identify pharyngolaryngectomies in England between 2002 and 2012. Information about morbidity, pharyngeal closure method and post-operative complications was derived. RESULTS: There were 1589 predominantly male (78%) patients whose mean age at surgery was 62 years. The commonest morbidities were hypertension (24%) and ischemic heart disease (11%). For 232 (15%) patients, pharyngolaryngectomy was performed during an emergency admission. The pharynx was closed primarily in 551 patients, with skin or muscle free or pedicled flaps in 755 patients and with jejunum and gastric pull-up in 123 and 160 patients, respectively. In-hospital mortality rate was 6% and was significantly higher in the gastric pull-up group (11%). Reconstructive failure had an odds ratio of 6.2 [95% confidence interval (CI) 2.4-16.1] for in-hospital death. The five-year survival was 57% and age, morbidities, emergency surgery, gastric pull-up, major acute cardiovascular events, renal failure and reconstructive failure independently worsened prognosis. Patients who underwent pharyngeal reconstruction with radial forearm or anterolateral thigh flaps had lower mortality rates than patients who had jejunum flap reconstruction (hazard ratio = 1.50 [95% CI 1.03-2.19]) or gastric pull-up (hazard ratio = 1.92 [95% CI 1.32-2.80]). CONCLUSIONS: Pharyngolaryngectomy carries a high degree of risk of morbidity and mortality. Reconstructive failure worsens short- and long-term prognosis, and the use of cutaneous free flaps appears to improve survival.

A stratified analysis of the perioperative outcome of 17623 patients undergoing major head and neck cancer surgery in England over 10 years: Towards an Informatics-based Outcomes Surveillance Framework.

OBJECTIVES: To perform a national analysis of the perioperative outcome of major head and neck cancer surgery to develop a stratification strategy and outcomes assessment framework using hospital administrative data. DESIGN: A Hospital Episode Statistics N = near-all analysis. SETTINGS: The English National Health Service. MAIN OUTCOME MEASURES: Local audit data were used to assess and triangulate the quality of the administrative dataset. Within the national dataset, cancer sites, morbidities, social deprivation, treatment, complications, and in-hospital mortality were recorded. RESULTS: Within local audit datasets, the accuracy of assigning newly-derived Cancer Site Strata and Resection Strata were 92.3% and 94.2%, respectively. Accuracy of morbidities assignment was 97%. Within the national dataset, we identified 17 623 major head and neck cancer resections between 2002 and 2012. There were 12 413 males and mean age at surgery was 63 ± 12 years. The commonest cancer site strata were oral cavity (42%) and larynx-hypopharynx (32%). The commonest resection site was the larynx (n = 4217), and 13 211 and 11 841 patients had neck dissection and flap-based reconstruction, respectively. There were prognostically significant baseline differences between patients with oromandibular and pharyngolaryngeal malignancy. Patients with pharyngolaryngeal malignancies had a greater burden of morbidities, lower socio-economic status, fewer primary resections, and a sixfold increased risk of undergoing their major resection during an emergency hospital admission. Mean length of stay was 25 days and each complication linearly increased it by 9.6 days. There were 609 (3.5%) in-hospital deaths and a basket of seven medical and three surgical complications significantly increased the risk of in-hospital death. At least one potentially lethal complication occurred in 26% of patients. The risk of in-hospital death in a patient with no potentially lethal complication was 1.1% and this increased to 6% with one potentially lethal complication, and to 15.1% if two potentially lethal complications occurred in one patient. Complex oral-pharyngeal resections and pharyngolaryngectomies had the highest risks of complications and mortality. CONCLUSION: Mortality following head and neck cancer surgery shows variation across different resection strata. We propose an Informatics-based Framework for Outcomes Surveillance (IFOS) in Head and Neck Surgery for perpetual quality assurance, using the local hospital coding data or its collated destination, the national administrative dataset.

The follow-up of patients with head and neck cancer: an analysis of 1,039 patients.

In all cancer specialities, there has been much debate about the best follow-up regime. The provision of a service that meets high standards whilst being cost-effective is increasingly pertinent. The objectives of the study were to examine: whether routine follow-up facilitates early diagnosis and recurrence; whether there is a cohort of patients who require a more intensive follow-up regime; whether follow-up should be customised to individual patients. A total of 1,039 consecutive outpatient consultations were prospectively analysed in a multicentre study. All adult patients who had undergone multidisciplinary, multimodality management for head and neck cancer were included. The case mix was representative of all head and neck tumour sites and stages. Suspicion of recurrence was noted in 10% (n = 96/951) of patients seen routinely. This rose to 68% (n = 60/88) for the subset of patients who had requested an appointment. Most recurrences were found within the first follow-up year (n = 64/156, 54%). Only 0.3% (n = 3/1,039) of asymptomatic patients attending routine appointments were suspected of having a recurrence, and two (0.2%) were found to have an actual recurrence following investigation. Of the total number of patients reporting a new suspicious symptom, recurrence was suspected in 56% (n = 152/270). Patients thus had a 98.1% sensitivity to raising suspicion for a recurrence based on the reporting of new symptoms with a 99.6% negative predictive value. Our data show that the efficiency of the current follow-up regime at detecting suspected recurrence of head and neck cancer is low, suggesting the need for a customised, more focused follow-up regime, tailored to individual cases. Patient education and close relationships with clinicians and allied health-care professionals are essential for early diagnosis and management of cancer recurrence. Follow-up regimes within the first year should be most intensive as recurrence is most likely within this time, and it serves to alleviate patient anxiety in the early post-treatment period. More research needs to be carried out to investigate the role of patient self-reporting and surveillance of cancer recurrence.

Novel use of ultrasound-guided endo-cavitary probe to evaluate an impalpable parapharyngeal mass.

AIM: We present a novel, previously undescribed technique of obtaining a biopsy from an inaccessible parapharyngeal space mass. METHOD: A modified endo-cavitary ultrasound probe was utilised to obtain an intra-oral, image-guided core biopsy of a parapharyngeal tumour. The parapharyngeal mass was not accessible to percutaneous ultrasound-guided biopsy due to its anatomical location. CONCLUSION: To our knowledge, this is the first such modification of the conventional endo-cavitary probe technique described in the literature. The technique permits accurate, well controlled biopsy of lesions located high in the parapharyngeal space, under general anaesthesia.

Use of botulinum toxin in voice restoration after laryngectomy.

BACKGROUND: Following laryngectomy, a distinct population of patients fails to achieve successful tracheoesophageal voice. These patients' voices range from strained and effortful to none at all. Such patients may present with severe hypertonicity or spasm of the pharyngoesophageal segment. Botulinum toxin has been used to chemically denervate the pharyngeal musculature, and is an alternative to invasive surgical procedures. The aim of this article is to review the evidence for using botulinum toxin to achieve an improvement in post-laryngectomy voice. METHODS: A Medline literature review (1966 to January 2009) and a search of the Cochrane database were performed. Foreign language articles and those not pertaining to post-laryngectomy voice restoration were excluded. RESULTS: Nine articles reporting a total of 134 patients were identified. Although there were differences in the outcome measures used, objective improvement in voice production occurred in between 70 and 100 per cent of cases. CONCLUSION: Botulinum toxin can be used as a safe and cost-effective treatment in patients with confirmed pharyngoesophageal segment hypertonicity and/or spasm following laryngectomy, to obtain an improvement in voice quality.

Head and neck cancer in the UK: what is expected of cytopathology?

OBJECTIVE: This review highlights the role of cytopathology in cancer management within UK Head and Neck Cancer Networks and informs on the issues raised by recent UK Department of Health documents and other UK professional guidance. UK guidance requires the formal involvement of cytopathologists within multidisciplinary cancer teams, with medical and non-medical cytopathology staff setting up and running rapid access lump clinics, and support for image-guided fine needle aspiration cytology (FNAC) services. UK guidance also makes recommendations for training, resources and quality control. This review also highlights the resource gap between best practice evidence-based guidance for head and neck (HN) cancer services and existing UK provision for cytopathology, as evidenced by lack of availability of experienced staff and adequacy of training and quality control (QC). Finally, it stresses the importance in the UK of the Royal College of Pathologists' guidance, which defines the need for training, the experience needed for new consultants, the requirements for audit and QC. The implications for the additional resources required for HN cancer cytopathology services are discussed. Recent professional guidance specifying the provision of HN cancer services in the UK includes a cytopathology service for cancer networks, such as rapid access FNAC clinics. Although these clinics already operate in some institutions, there are many institutions where they do not and where the provision of cytopathology services would have to be restructured. This would need the support of local cancer networks and their acceptance of the detailed requirements for cytopathology, including resources, training and QC. The standards are not defined locally, as Strategic Health Authorities and Primary Care Trusts have been instructed by the Department of Health to support, invest and implement them.

A multicentre audit of single-use surgical instruments (SUSI) for tonsillectomy and adenoidectomy.

INTRODUCTION: Prions are resistant to conventional sterilisation procedures and, therefore, could be transmitted iatrogenically through re-usable adenoid and tonsil surgical instruments. Using disposable instruments would avoid the risk of transmission. We present the results of a complete audit loop using BBraun single-use surgical instruments (SUSI). PATIENTS AND METHODS: This was a prospective multicentre audit. Surgeons were asked to fill in a standardised questionnaire recording details including postoperative complications, and evaluation of each piece of equipment compared with their own experience of conventional re-usable instruments. In the first cycle, constructive criticisms of the instruments were noted and the manufacturers modified the instruments accordingly. A second cycle of audit was subsequently undertaken. RESULTS: A total of 86 patients were audited in the first cycle and 97 in the second cycle. Postoperative haemorrhage rate for both cycles was well within acceptable range. In the first audit cycle, surgeons generally found the Draffin rods, Boyle-Davis gag and bipolar diathermy forceps of poor quality and difficult to use. These were redesigned and, on repeat evaluation during the second audit cycle, were found to be just as good, if not better, than the re-usable instruments. CONCLUSIONS: This study suggests that SUSI may be just as good as re-usable instruments. Furthermore, they may be more cost effective.

Parapharyngeal granular cell tumour: a unique surgical challenge.

A granular cell tumour is a rare lesion of probable nerve sheath origin. It is typically benign but up to seven per cent may be malignant. Since its original description in the tongue in 1926, the tumour has been reported to occur at many other sites in the body. The authors report a case of a 49-year-old African woman with an oro-naso-parapharyngeal granular cell neoplasm causing mild dysphagia. The location of this tumour, which has not been reported previously, posed a unique surgical challenge. An initial attempt to remove the lesion transorally was only partially successful because it was too tough and adherent for conventional surgical dissecting instruments. Complete resection, however, was achieved with a carbon dioxide laser via the same approach. This information may be helpful in the management of other similar cases in the future.

Management of posterior epistaxis by endoscopic clipping of the sphenopalatine artery.

Posterior epistaxis poses a challenge to the otolaryngologist as the bleeding point itself cannot easily be identified. Haemostasis by conventional means is usually nasal packing and this results in repeated/persistent haemorrhage, morbidity and prolonged bed occupancy. In recent years the increased availability of rigid endoscopes and a better understanding of the anatomy of the nasal cavity have facilitated a direct approach to the sphenopalatine artery. Using a 0 degrees or 30 degrees rigid nasendoscope the sphenopalatine artery-the main blood supply to the nose-can be clearly identified and treated. Over the last 12 months we have employed endoscopic intranasal clipping of the said artery under a general anaesthetic to control persistent posterior nasal bleeding. Twelve patients have undergone 14 procedures within 48 h of failure of their conservative management. In all the epistaxis was controlled no complications were noted. The average follow-up period in our series was nine months. We believe that intranasal endoscopic clipping of the sphenopalatine artery is effective and less traumatic than either any other site of arterial ligation technique or repeated packing. In this series we employed only clipping of the artery and not diathermy/electrocautery to reduce the theoretical risk to adjacent structures

The management of dysphasia in skeletal hyperostosis.

Diffuse idiopathic skeletal hyperostosis (DISH), or Forestier's disease, is an ossifying condition frequently encountered in otolaryngology as it affects 12-28 per cent of the adult population. This form of hyperostosis can manifest clinically with dysphagia, food impaction, hoarseness, stridor, myelopathies and other neurological problems. Judicious management of severe dysphagia proves challenging. The failure of conservative care often leaves surgery as the only option. In this report an anterolateral transcervical surgical approach to the confluent osteophytes is discussed and the value of videofluoroscopic swallow highlighted.

Effect of caffeine on the vocal folds: a pilot study.

Caffeine is considered to be a dehydrating agent with detrimental effects on the quality of voice of persons ingesting it. This has led medical personnel dealing with voice disorders, especially in the case of professional voice users, to give advice against the use of caffeine. Yet this is an anecdotal truth as an extensive Medline literature search did not reveal any scientific evidence of caffeine being proven to have adverse effects on the vocal folds. We, therefore, initiated this pilot study to ascertain the connection between caffeine and voice quality on a laboratory basis. Two hundred and fifty mg of caffeine were provided to eight volunteers in tablet form, and blood levels along with laryngograph readings were recorded to document the changes produced. Analysing the irregularities of frequencies in a) free speech b) a reading passage and c) singing 'Happy Birthday', substantial changes were seen to authenticate the fact that caffeine does produce alterations in voice quality but these alterations have considerable intra-subject variability. A full study with wider parameters is to be performed on this subject as we consider it to be of importance in the management of voice disorders.

Dercum's disease (adiposis dolorosa).

Dercum's disease (adiposis dolorosa) is a rare condition characterized by progressively painful fatty deposits, usually, in menopausal women with obesity, asthenia and mental phenomena. We report a case of a 48-year-old woman with recurrent neck swelling and pain in the neck and parotid region, and a review of management of this uncommon problem.

Access to the traumatized vertebral artery: an unusual approach.

Although injuries to the vertebral arteries are relatively uncommon, there are several different methods used to gain access to these vessels, and to control any bleeding arising from them. We describe a case of torrential oropharyngeal bleeding following a stab wound to the neck in which rapid access to the vertebral artery was gained using a paramedian mandibulotomy; this approach has not previously been documented. The other approaches are discussed.

Effective securing of a drain.

The importance of effective anchoring of drains cannot be over emphasized. In this paper, we describe a safe and effective method of drain fixation used in 118 cases between January 1998-99 in our department. This useful technique has the advantage of minimizing inadvertent drain displacement with its consequent complications.

Acute on-chronic middle ear disease.

The discharging ear is a common presenting symptom to GPs and otologists. The commonest causes are otitis externa and otitis media. Less common is cholesteatoma, which presents with a chronic offensive mucopurulent discharge and deafness. Acute mastoiditis as a presenting symptom of cholesteatoma is rare and, with the introduction of antibiotics, the incidence has declined even further. We present three cases of cholesteatoma presenting as mastoiditis.

Oncocytomas of the upper jaw.

BACKGROUND: Oncocytomas are rare tumors; they occur most often in the parotid gland and here behave in a benign fashion. Few of these tumours have been described arising from tissues of the upper jaw. The reviews of the literature in these cases often appear incomplete. It has been suggested that outside the major salivary glands oncocytomas should be considered to be low-grade adenocarcinomas. METHODS: We present a case of a 78-year-old woman with a frankly malignant oncocytoma of the lateral nasal wall, treated with radical local excision. A search of the world literature was undertaken and a review conducted. RESULTS: We found a total of 19 cases affecting the upper jaw, in a wide age distribution, 10 male and 9 female. Thirteen cases were malignant, 3 with metastases. CONCLUSIONS: When affecting the upper jaw, these tumors must be considered malignant. Radical surgical excision is the treatment most often employed.

Acoustic rhinometry: validation of volume changes following intra-nasal polypectomy.

Acoustic rhinometry measures nasal cavity geometry by analysis of reflected acoustic impulses. Previously, the technique has been applied to normals, patients with septal deviations and rhinitis and to monitor the medical treatment of nasal polyps. To date, no study has been published to validate the application of this technique where nasal polyps are present. In this study, acoustic rhinometry has been used to assess the change in nasal cavity volume following intra-nasal polypectomy in 20 subjects. The volumes of the polyps removed surgically were measured by displacement and compared with the volume change recorded by acoustic rhinometry. A correlation of r = 0.59 (P = < 0.01) has been obtained. Therefore, it is possible to apply acoustic rhinometry as a method of assessing non-surgical treatment of nasal polyps given certain conditions.