Complications and predisposing factors from a decade of total laryngectomy.

BACKGROUND: Total laryngectomy is often utilised to manage squamous cell carcinoma of the larynx or hypopharynx. This study reports on surgical trends and outcomes over a 10-year period. METHOD: A retrospective review of patients undergoing total laryngectomy for squamous cell carcinoma was performed (n = 173), dividing patients into primary and salvage total laryngectomy cohorts. RESULTS: A shift towards organ-sparing management was observed. Primary total laryngectomy was performed for locoregionally advanced disease and utilised reconstruction less than salvage total laryngectomy. Overall, 11 per cent of patients developed pharyngocutaneous fistulae (primary: 6 per cent; salvage: 20 per cent) and 11 per cent neopharyngeal stenosis (primary: 9 per cent; salvage: 15 per cent). Pharyngocutaneous fistulae rates were higher in the reconstructed primary total laryngectomy group (24 per cent; 4 of 17), compared with primary closure (3 per cent; 3 of 90) (p = 0.02). Patients were significantly more likely to develop neopharyngeal stenosis following pharyngocutaneous fistulae in salvage total laryngectomy (p = 0.01) and reconstruction in primary total laryngectomy (p = 0.02). Pre-operative haemoglobin level and adjuvant treatment failed to predict pharyngocutaneous fistulae development. CONCLUSION: Complications remain hard to predict and there are continuing causes of morbidity. Additionally, prior treatment continues to affect surgical outcomes.

Ten years of ENT Scotland meetings: an appraisal of the publication rates of trainee-presented scientific papers.

OBJECTIVE: The ENT Scotland society (formerly known as the Scottish Otolaryngological Society) has two meetings a year and accepts oral presentations from trainees. This study aimed to identify publication rates from these meetings. METHODS: Abstracts of the presentations are published in The Journal of Laryngology and Otology. A structured search on PubMed and Google Scholar was undertaken to identify which presentations from the 2005 to 2014 meetings have been published. RESULTS: Of the 145 abstracts found, 60.7 per cent were presenting clinical research and 44.1 per cent were related to the head and neck subspecialty. Seventy-three abstracts (50.3 per cent) were associated with publication as a peer-reviewed article; otology papers were more likely to be published than those focusing on other subspecialties (64.3 per cent, p = 0.036). No correlation was found between publication and other factors. CONCLUSION: Presentations at the ENT Scotland meetings undergo unbiased peer review and are as likely to be published as those of other conferences.

Surgical management of primary thyroid tumours.

The majority of patients who present with well differentiated thyroid cancer will require surgery, but decisions on the appropriate primary procedure will depend on information relating to patient, tumour and surgical factors. As the incidence of thyroid cancer continues to rise, it is critical that clinicians involved in the management of these cases understand the factors which underpin surgical decision making for individual patients. Reporting outcomes in well differentiated thyroid cancer (WDTC) has always been challenging due to the low recurrence and mortality rate of the disease. Although early data supported total thyroidectomy for all patients with >1 cm WDTC, more recent evidence has supported lobectomy in selected, low risk patients. As a result we have seen a change in the approach of international guidelines from a blanket statement that total thyroidectomy should be the treatment for all patients towards a more selective approach to therapy. When selecting the most appropriate surgical approach to WDTC, the primary aim is to minimize the chance of death from disease or further recurrence. Additionally the impact of potential side effects of treatment (laryngeal nerve injury and hypocalcaemia) must also be weighed in the balance. In this review of surgical management of WDTC we aim to present a historical perspective on this subject and explore the arguments for and against total thyroidectomy and thyroid lobectomy in the low-risk patient group.

Differentiated and Medullary Thyroid Cancer: Surgical Management of Cervical Lymph Nodes.

Thyroid cancer metastasises to the central and lateral compartments of the neck frequently and early. The impact of nodal metastases on outcome is affected by the histological subtype of the primary tumour and the patient's age, as well as the size, number and location of those metastases. The impact of extranodal extension has recently been highlighted as an important prognosticating factor. Although clinically evident nodal disease in the lateral neck compartments has a significant impact on both survival and recurrence, microscopic metastases to the central or the lateral neck in well-differentiated thyroid cancer do not significantly affect outcome. Here we discuss the surgical management of neck metastases in well-differentiated and medullary thyroid carcinoma.

Incidence of neoplasia in patients with clinically suspicious nasal lesions and the value of computed tomography imaging in diagnosis.

BACKGROUND: There is no consensus as to whether all routine bilateral polypectomy specimens should be sent for formal histopathological diagnosis to exclude underlying neoplastic pathology. This study assessed the necessity for histopathological investigation as routine practice in cases of bilateral and unilateral nasal lesions by estimating the incidence of unexpected pathologies. It also evaluated the ability of computed tomography to predict histopathological diagnosis in patients with unilateral nasal lesions. METHODS: A retrospective analysis was conducted of 98 patients undergoing nasal polypectomy over a 12-month period. RESULTS: Five of 23 patients with a unilateral lesion on nasendoscopy had inverted papillomas on histopathological examination. None of the 75 patients with clinically bilateral lesions on nasendoscopy showed evidence of neoplasia on histopathological examination. Patients with inverted papillomas had significantly lower total Lund-Mackay scores than those with bilateral polyps. Asymmetry scores of inverted papilloma patients were significantly higher compared to both bilateral and unilateral polyps patients. CONCLUSION: The results suggest that histopathological diagnosis is only necessary in unilateral lesion patients as no unexpected histopathological diagnoses were made in bilateral lesion patients. Computed tomography imaging may have a role in predicting histopathological diagnosis by demonstrating asymmetry and less overall sinus opacification in patients with neoplastic lesions.

A case-based discussion on a patient with non-otogenic fungal skull base osteomyelitis: pitfalls in diagnosis.

OBJECTIVE: To discuss the diagnostic pitfalls and limitations of imaging investigations in non-otogenic skull base osteomyelitis. CASE REPORT: This paper reports a fatal case of non-otogenic fungal skull base osteomyelitis in an immunosuppressed patient. The patient initially presented with headache and later diplopia during multiple hospital admissions. A retrospective review of the initial imaging studies of his skull base revealed subtle signs of early infection at the inferior portion of the nasopharynx. Biopsies were taken from the posterior nasopharyngeal wall. Fungal cultures isolated Aspergillus fumigatus and mucor species. CONCLUSION: The insidious onset of the clinical features and the limitations of the currently available investigations make early diagnosis of skull base osteomyelitis difficult. This case highlights that skull base osteomyelitis should be suspected in immunocompromised patients with subtle radiological abnormalities on initial imaging. There is still controversy regarding the

Changes in quality of life in people with Parkinson's disease left untreated at diagnosis.

BACKGROUND: The issue of whether to adopt a "wait and watch" strategy or to initiate drug therapy soon after diagnosis in Parkinson's disease (PD) has been the subject of some debate. A recent observational study supported early treatment by demonstrating deterioration in self-reported health status in those left untreated, but not those who received therapy. We aimed to replicate this observation. METHODS: People with PD from a prospective incidence study underwent follow-up with yearly clinical assessment of parkinsonian impairment (Unified Parkinson's Disease Rating Scale (UPDRS)) and self-reported health status (Parkinson's Disease Questionnaire (PDQ-39)). Two year outcomes were compared with those who started treatment within 1 year of diagnosis and those left untreated. RESULTS: 42 patients with PD were followed-up for 2 years, of whom 26 started treatment during the first year and 16 remained untreated. Those receiving treatment had significantly higher UPDRS and PDQ-39 scores at baseline. There was no significant deterioration in PDQ-39 score in either group (median change untreated 0.8 vs treated 4.0; p = 0.47), despite a significant difference in the change in motor UPDRS scores (untreated 6.0 vs treated -6.0; p = 0.03). CONCLUSION: Given the lack of significant deterioration in the PDQ-39 in untreated patients, we believe a "wait and watch" strategy for the treatment of newly diagnosed PD remains a credible approach unless randomised trials prove otherwise.

Phenylephrine induced aortic vasoconstriction is attenuated in hyperthyroid rats.

BACKGROUND: Abnormal vascular responsiveness to vasoconstrictors may play an important role in peripheral vascular resistance in hyperthyroidism. The aim of the present study was to evaluate whether the vascular response to potassium chloride and phenylephrine is abnormal in a rat model of thyroxine-induced cardiac hypertrophy. METHODS: Left ventricular hypertrophy was induced in Wistar rats by subcutaneous administration of L-thyroxine for two weeks ("THYR"), n=17. Animals treated with normal saline served as controls, ("NORM"), n=20. The thoracic aorta was dissected and cut into rings that were suspended in an isolated organ bath with Krebs-Henseleit buffer. Maximal tension, Tmax, in g was measured in response to KCl and PE at the highest concentration in rings with endothelium (+E) and without endothelium (-E) in both groups. Relaxation response (Relax percent) to acetylcholine administration was expressed as percent of the maximal tension induced by phenylephrine. RESULTS: Left ventricular weight was 0.9 (SEM, 0.04) g for THYR group vs 0.7 (0.02) g for the NORM group, p<0.05. With KCl, Tmax was not different between the THYR and NORM groups with and without endothelium. With PE, there was a difference in Tmax between THYR+E and NORM+E, 1.2 (0.05) g vs 1.5 (0.09) g, p<0.05. Tmax was also different between THYR-E and NORM-E, 1.5 (0.08) g vs 1.7 (0.07) g, p<0.05. Relax percent was not significantly different between THYR+E and NORM+E (45.9 percent vs 42.8 percent, p>0.05). CONCLUSIONS: We conclude that: a) Vascular tension of the thoracic aorta in response to PE is lower in thyroxine-treated rats as compared to controls, probably due to enhanced PE-induced vasorelaxation at high concentration. b) Relaxation response of the thoracic aorta to acetylcholine is not different between THYR and NORM groups.