Quality of life outcomes comparing primary Transoral Robotic Surgery (TORS) with primary radiotherapy for early-stage oropharyngeal squamous cell carcinoma: A systematic review and meta-analysis.

BACKGROUND: Transoral Robotic Surgery (TORS) and radiotherapy are considered oncologically equivalent primary treatment options for early-stage HPV-positive oropharyngeal squamous cell carcinoma (OPSCC). Quality of Life (QoL) and Patient Reported Outcome Measures (PROMs) are therefore imperative in supporting clinical decision-making and optimising patient-centred care. The aim of this article is to evaluate how these primary treatment modalities compare in terms of QoL. MATERIALS AND METHODS: Systematic review and meta-analysis of studies comparing primary TORS and primary radiotherapy for OPSCC using validated QoL tools. Swallowing and global QoL were the primary endpoints with secondary endpoints including all other QoL domains. An inverse variance random-effects model was employed to calculate the weighted estimate of the treatment effects across trials. RESULTS: A total of six studies collectively reporting on 555 patients were included (n = 236 TORS and n = 319 radiotherapy). Meta-analysis showed no significant difference for swallowing (mean difference = -0.24, p = 0.89) and global QoL (mean difference = 4.55, p = 0.14). For the remaining QoL domains (neck/shoulder impairment, neurotoxicity, voice, xerostomia, speech, and distress), the scarcity of data did not permit meta-analysis. However, the existing data showed no significant difference for any except for xerostomia where TORS appears favourable in the sole study reporting on this. CONCLUSIONS: TORS and radiotherapy appear to be comparable primary treatment options for early stage OPSCC when it comes to QoL. However, a substantial proportion of patients in the TORS group received adjuvant (chemo)radiotherapy rendering it difficult to establish the 'true' QoL outcomes following surgery alone. There are also minimal studies reporting QoL outcomes beyond swallowing and global QoL. Further research is therefore needed, including more randomised trials adequately powered to detect differences in QoL outcomes.

Patient-perceived dysphagia and voice change post thyroid surgery: a telephone questionnaire.

OBJECTIVE: This study analyses the incidence of subjectively experienced dysphagia and voice change in post-thyroidectomy and parathyroidectomy patients without recurrent laryngeal nerve palsy. METHODS: A total of 400 patients were invited to participate in a telephone questionnaire based on the Dysphagia Handicap Index and Voice Handicap Index. At 6-24 months following surgery, participants were divided into: post-thyroid surgery (total, hemi-, parathyroidectomy) groups and controls (other ENT procedures). A total of 254 responses were received (127 following thyroid surgery, 127 controls). RESULTS: Twenty-two per cent of post-thyroidectomy patients had a Voice Handicap Index score of more than 3, compared to 15 per cent of parathyroid patients and 4 per cent of controls. The mean Dysphagia Handicap Index score for patients post thyroidectomy and hemi-thyroidectomy was 2.0. Parathyroidectomy patients had a mean Dysphagia Handicap Index score of 1.3, higher than controls at 1.0. CONCLUSION: Dysphagia and voice alteration are common following thyroid surgery, even in the absence of recurrent laryngeal nerve injury. Both deficits occur more frequently following thyroid surgery than parathyroid surgery.

Synchronous mucoepidermoid carcinoma and papillary microcarcinomas of the thyroid gland.

Thyroid mucoepidermoid carcinoma (MEC) is a rare thyroid malignancy first documented in 1977. The majority of thyroid MECs are indolent, low-grade tumours with excellent prognosis. A woman in her 60s presented with an ongoing sensation of a lump in the left neck. There were no swallowing, voice or airway concerns. Ultrasound of the neck showed an enlarged thyroid with U5 and U3 features on the right and left lobes, respectively. Right fine needle aspiration cytology (FNAC) demonstrated certain features of Hurthle cell or anaplastic carcinoma (Thy5). Left FNAC showed Hurthle cell changes with atypical cells and prominent nucleoli (Thy3a). Following total thyroidectomy, histopathology revealed synchronous right low-grade MEC and left papillary thyroid microcarcinomas (pT2(m) N0 M0) on a background of Hashimoto's thyroiditis. This case adds to the literature and details the key histopathological features for a rare but important differential in patients with thyroid carcinoma due to synchronous histological types.

Evaluating the role of the self-assembling topical haemostat PuraBond® in Transoral Robotic Surgery (TORS) for oropharyngeal cancer: A case series.

Background: Transoral Robotic Surgery (TORS) has been increasingly employed in head and neck surgery for the assessment and treatment of malignancies over the last two decades. PuraBond® is a self-assembling viscous solution that forms a transparent hydrogel 3-D matrix to promote local haemostasis. This study aimed to assess the utility of PuraBond® in patients undergoing TORS for Human Papilloma Virus (HPV) positive oropharyngeal squamous cell carcinoma (OPSCC). Methods: All patients who underwent TORS with PuraBond® between October 2021-May 2022 at a single tertiary university hospital in the United Kingdom were included. Primary outcome measures included post-operative haemorrhage rate (primary; within 24hrs of surgery, secondary; 1-30 days post-surgery). Secondary outcome measures included, Length Of hospital Stay (LOS), swallowing complications, hospital re-admission, and surgeon-reported ease of PuraBond® application. Results: Twelve patients were included (13 procedures due to one second look and re-resection case). No patients developed primary or secondary post-operative haemorrhage. There were no re-attendances within 30 days. Average LOS was 2.78 days (range: 1.54-4.31 days). No patient required feeding tube insertion or tracheostomy. In all procedures, the use of PuraBond® was reported as 'easy'. Conclusion: This is the first study to evaluate the role of PuraBond® in TORS. The wide range of favourable outcomes reported support its safety and efficacy. The current findings mandate the need for larger, prospective, controlled studies to better define whether the known haemostatic and regenerative properties of PuraBond® may translate into direct patient benefit in the expanding field of TORS for HPV-mediated OPSCC.

Novel Strategies for Managing Retropharyngeal Lymph Node Metastases in Head and Neck and Thyroid Cancer with Transoral Robotic Surgery (TORS).

Retropharyngeal metastases are encountered in a variety of head and neck malignancies, imposing significant surgical challenges owing to their distinct location and proximity to neurovascular structures. Radiotherapy is the recommended treatment in most cases owing to its oncological efficacy. However, retropharyngeal irradiation affects the superior pharyngeal constrictor muscles and parotid glands, with the potential for long-term dysphagia and xerostomia. A younger oropharyngeal and thyroid cancer patient demographic is trending, fueling interest in treatment de-escalation strategies. Consequently, reducing radiotoxicity and its long-term effects is of special relevance in modern head and neck oncology practice. Through its unique ability to safely extirpate these traditionally difficult-to-access retropharyngeal lymph nodes via a natural orifice, TransOral Robotic Surgery (TORS) can considerably lower the surgical morbidity of retropharyngeal lymph node dissection (RPLND), compared with current existing approaches. This review summarizes the latest developments in the field, exposing current research gaps and discusses specific clinical settings where TORS could enable treatment de-escalation. In early-stage node-negative oropharyngeal cancer, single-modality surgical treatment with TORS RPLND may improve risk stratification of metastasis and recurrence in this region. TORS RPLND is also a potentially viable treatment option in salvage of an isolated retropharyngeal node recurrence or in the primary setting of a thyroid malignancy with a single positive retropharyngeal node. In time, TORS RPLND may provide an alternative de-escalation strategy in these three scenarios. However, with the reported morbidities, further prospective trials with long-term follow-up data are required to prove oncological safety and functional benefits over existing strategies.

Infections and foreign bodies in ENT.

Infections of the ear, nose and throat are common. The majority of these infections are managed by the primary care physicians and they settle with conservative and medical management. However, a small group can progress to become troublesome and develop complications to the extent that they may require surgical intervention. Some of the infections can lead to life-threatening complications therefore awareness and correct diagnosis along with appropriate management is paramount. Foreign bodies in the ear, nose and throat are commonly encountered. The location and type of foreign body can have an implication on the urgency of action and the possible complications. In this article the common ENT infections and foreign bodies and their management are discussed.

Multipathogenic necrotising supraglottitis in an immunocompetent patient.

Supraglottitis is a potentially life-threatening condition. It is now uncommon due to the Haemophilus influenzae type B vaccination and is more recently caused by Streptococcus pneumoniae, S. pyogenes, H. influenzae non-type B, H. parainfluenzae, Staphylococcus aureus and Pasteurella multocida Very rarely, it can cause necrotising supraglottitis/epiglottitis, and this has been reported in immunocompromised individuals. We present a unique case of multipathogenic supraglottitis causing laryngeal fibrinoid necrosis in an immunocompetent patient. During his admission, the patient was critically unwell and required surgical intervention and tracheostomy. However, he made a full recovery with no persisting morbidity. We believe that this was owed to the aggressive antimicrobial therapy, timely surgical management of the disease process and the patient’s immunocompetency.

High Removal of Effluent-borne Nitrogen with Multiple External Electron Donors in the Engineered Drainfield of an Advanced Septic System.

Septic systems can be a major source of nitrogen (N) in shallow groundwater. We designed an in situ engineered drainfield with aerobic-anaerobic (sand-woodchips) and anaerobic (elemental sulfur-oyster shell) media to remove N in the vadose zone and reduce N transport to groundwater. Effluent was dispersed on top of the engineered drainfield (3.72 m infiltrative surface) and then infiltrated through the aerobic-anaerobic and anaerobic media before reaching natural soil. Water samples were collected over 64 sampling events (May 2012-December 2013) from three parts of the drainfield: (i) a suction cup lysimeter installed at the sand-woodchips interface, (ii) a pipe after effluent passed through the aerobic-anaerobic media, and (iii) a tank containing anaerobic media. In the effluent, most of the total N (66 mg L) was present as NH-N (88.8%), whereas at the sand-woodchips interface the dominant N form was NO-N (31 mg L; 85% of total N). As the effluent passed through the aerobic-anaerobic media in the drainfield, heterotrophic denitrification reduced NO-N to 5.4 mg L. In the tank containing anaerobic media, autotrophic denitrification, facilitated by elemental sulfur, further reduced NO-N to 1 mg L. Overall, 90% of total added N was removed as the effluent passed through the aerobic-anaerobic and anaerobic media within the engineered drainfield. We conclude that the use of multiple electron donors from external media (sand-woodchips and elemental sulfur-oyster shell) was effective at removing N in the engineered drainfield and will reduce the risk of groundwater N contamination from septic systems in areas with shallow groundwater.

Mass Balance of Water and Nitrogen in the Mounded Drainfield of a Drip-Dispersal Septic System.

Quantitative assessment of nitrogen (N) loading from septic systems is needed to protect groundwater contamination. We determined the mass balance of water and N in the mounded drainfield of a drip-dispersal septic system. Three lysimeters (152.4 cm long, 91.4 cm wide, 91.4 cm high, with 1:1 side slope) were constructed using pressure-treated wood to mimic mounded drainfields. Of total water inputs, septic tank effluent (STE) added 57% water and natural rainfall added 43% water from January 2013 to January 2014. Outputs included leached water (46%) from the lysimeters over 67 sampling events ( = 15 daily and = 52 weekly flow-weighted), potential evapotranspiration (28%), and water stored in the drainfields (26%). Over 13 mo, each drainfield received 227 g of total N (STE, 99%; rainfall, 1%), of which 33% leached, 23% accumulated in the drainfield, and 6% was taken up by grass, with the remainder (38%) estimated to be gaseous N loss. Using these data, the leaching of water from 2.5 million drip-dispersal drainfields in the state of Florida was estimated to be 2.29 × 10 L yr, which would transport 2.4 × 10 kg of total N yr from the drainfields to shallow groundwater. Further reduction of N below drainfields in the soil profile could be expected before STE reaches groundwater. Our results provide quantitative information on the water and N loading and can be used to optimize drainfield conditions to attenuate N and protect groundwater quality.

Patient attitudes to tonsillectomy.

Introduction. Recent changes to primary care trusts' Procedures of Limited Clinical Value (PLCV) policy mean that otolaryngologists must now follow policy rather than exercising clinical judgment when listing patients for tonsillectomy. Objectives. To gauge perception within the general public of when tonsillectomy is acceptable and to compare this to the current policy. Method. All patients or their parents attending the adult and paediatric outpatient ENT departments were asked to anonymously complete questionnaires. Results. One hundred and twenty-five completed questionnaires were collected. Thirty-one percent of respondents thought tonsillectomy should be offered solely on patient request, 19% after one to three bouts, and 35% after four to six bouts of tonsillitis. Only 9% thought the current guidelines were reasonable. Patients who had suffered recurrent tonsillitis or had undergone previous tonsillectomy generally thought tonsillectomy advisable after more bouts of tonsillitis than those who had not. Fourteen patients fulfilled the SIGN guidelines for tonsillectomy for recurrent tonsillitis. Of these, 13 (93%) felt that suffering 4-6 bouts of tonsillitis was reasonable before tonsillectomy. Conclusion. All patients we surveyed who meet the current PLCV and SIGN guidelines regarding the appropriateness of tonsillectomy for recurrent tonsillitis perceive that they are excessive, believing that 4-6 bouts of recurrent tonsillitis are adequate to justify tonsillectomy.

Diphtheria: the patch remains.

This study analysed the number of patients admitted with diphtheria to a teaching hospital in the state of Assam in India over a period of five years and compared the disease characteristics and management with outcomes and incidences of diphtheria reported in the literature. It was a retrospective analysis of data elicited from clinical records of patients admitted to hospital. A total of 101 admissions were recorded during a five-year period between March 1997 to March 2002, mostly with pharyngeal diphtheria (90 per cent). The majority of patients had no history of immunization (70 per cent). Significant presenting features were a tonsillar patch, sore throat, respiratory distress and fever. All patients were treated with anti-diphtheritic serum and intravenous antibiotics. Steroids were given to 81 per cent of patients and tracheostomy was carried out in 10 per cent of cases. The mortality was 16 per cent. Diphtheria of the respiratory tract remains a potentially fatal disease commonly presenting with membranous pharyngitis. Early diagnosis and treatment with anti-diphtheritic serum and antibiotics remain the cornerstone of treatment. Inadequate immunization cover is deemed responsible for the continued menace of diphtheria.

Outcomes of submandibular duct relocation: a 15-year experience.

Drooling is common in patients with neurological disability and a major factor affecting quality of life. Management of this problem is best carried out by a team approach using surgical and non-surgical methods. Submandibular duct relocation is a commonly performed procedure with low complication rate. This procedure has been carried out in 56 patients over the last 14 years at the Belfast City Hospital by the senior author. All the patients underwent physiotherapy for six months before they were selected for surgery. All the patients were over five years of age and most had severe neurological impairment. For the purposes of this study, all the patients were followed by a questionnaire regarding symptomatic improvement, parent satisfaction and complication rate. All case notes were also reviewed retrospectively. Parental satisfaction was high and drooling was significantly reduced in 49 cases. The main complication was ranula formation seen in five cases. The most significant area of parental concern was post-operative pain. It is important to counsel the parents regarding the post-operative pain relief as well as failure rate of the procedure. It can be concluded that this procedure is a safe and highly successful procedure, which significantly improves the quality of life.