Clinical and psychosocial factors associated with quality of life in patients with head and neck cancer: an analytical cross-sectional study from a lower-middle-income country.

INTRODUCTION: The disease course of head and neck (H&N) cancer can severely impair patients' quality of life (QoL). In Pakistan, a South Asian lower-middle-income country (LMIC), psychosocial factors may impact QoL. We aimed to assess QoL and associated factors amongst patients with H&N cancer in Pakistan. METHODS: An analytical cross-sectional study was conducted amongst adult (≥ 18 years) patients with H&N cancer who were ≥ 4 weeks post-initiation of treatment. The survey assessed QoL (European Organization for Research and Treatment of Cancer Quality of Life Questionnaires), anxiety and depression (Hospital Anxiety and Depression Scale), and social support (Enriched Social Support Instrument). Multivariable linear regression was performed for analysis. RESULTS: A total of 250 patients (mean age: 51.6 years) were included. The majority of patients were married (87%) and living with multigenerational/extended family households (53%). On multivariable linear regression, ongoing cancer treatment (beta coefficient: -13.93), having a tracheostomy (-10.02), and receiving adjuvant chemoradiotherapy (-8.17) were significantly associated with poorer global QoL. Additionally, poorer QoL was associated with depression (-24.37) and anxiety (-13.34). However, having more household family members was associated with better global QoL (0.34). CONCLUSION: The QoL of patients with H&N cancer in Pakistan is affected by both the nature of cancer treatment as well as sociocultural factors such the number of household family members. Given that poorer QoL is associated with worse mental health outcomes, there is a need to develop and implement psychosocial interventions to improve the QoL of patients with H&N cancer in Pakistan, particularly during active treatment.

Successful management of a difficult airway in a case of advanced thyroid cancer.

Papillary thyroid carcinoma is the most prevalent endocrine malignancy of the head and neck region. It makes up to 80% of all thyroid cancers, and has a 10-year survival rate of up to 95%. Differentiated thyroid carcinomas have good prognosis after a complete surgical extirpation as long as it is not associated with invasion of the surrounding structures. The advanced papillary thyroid carcinoma can invade the neighbouring structures of the thyroid gland, such as strap muscles, recurrent laryngeal nerve, trachea, oesophagus, larynx, pharynx, and carotids. Whenever papillary thyroid carcinoma is associated with invasion of aerodigestive tract it is difficult to excise the tumour. We report a patient with stage IV invasive papillary thyroid carcinomas as per Shin Staging system. The surgery was deferred from several hospitals considering the advanced stage of the disease with tracheal extension making it a problematic airway for both the anaesthesiologist and the operating surgeon. The patient underwent total thyroidectomy, modified radical neck dissection, tracheal resection, and primary anastomosis. Successful intubation was done with video laryngoscopy. Intermittent apnoea technique was used for ventilation during the repair of posterior tracheal wall. The patient was extubated on the table and shifted to the recovery room. The histopathologic diagnosis was reported as papillary thyroid carcinoma classic variant with tracheal invasion.

Frequency of Thyroid Gland Invasion by Laryngeal Squamous Cell Carcinoma: The Role of Subglottic Extension

Abstract Introduction Management of the thyroid gland during laryngectomy has been controversial. The primary tumor may invade the thyroid gland by direct invasion or lymphovascular spread. Hypothyroidism and hypoparathyroidism are potential risks when lobectomy or total thyroidectomy are performed simultaneously. Objective To report the frequency of thyroid gland involvement by primary laryngeal squamous cell carcinoma in patients undergoing laryngectomy and to identify possible risk factors for thyroid gland involvement so that judicious excision of thyroid gland can be attained. Methods We performed a retrospective review of 9 years. Data was collected from medical records of patients dated from December 2009 to October 2018. All patients with laryngeal cancer who underwent laryngectomy with lobectomy or total thyroidectomy were included in the present study. Results We reviewed 151 laryngectomy records. A total of 130 surgeries included the thyroid gland with the excised specimen and were available for analysis. There were 124 males and 6 females. The mean age was 59.4 years old. The glottis was the most common subsite involved, in 70 patients, followed by 38 transglottic, 16 supraglottic and 03 subglottic tumors. On histology, 12 out of 130 excised thyroid glands were involved by squamous cell carcinoma. Only subglottic involvement (p = 0.01) was significantly associated with thyroid gland invasion (TGI). Type of laryngectomy, subsite of the primary tumor, thyroid cartilage involvement, neck nodal metastases, and perineural and lymphatic invasion by the primary tumor were not associated with TGI. Conclusion Only subglottic involvement is associated with TGI; therefore, preoperative and intraoperative assessment is necessary prior to considering excision of the thyroid gland.

Fibroepithelial Polyp: A Rare Presentation In Sinonasal Cavity.

A fibroepithelial polyp is a benign polypoidal lesion of mesodermal origin. It can present in any area of the body with an epithelial surface. These are relatively more common in skin and genitourinary tract and has been reported very rarely in head and neck region. We report here a rare presentation of fibroepithelial polyp in sinonasal cavity presenting with the symptoms of unilateral nasal obstruction. The patient underwent endoscopic surgical excision and recovered completely. In patients with unilateral sinonasal growing masses fibroepithelial polyp should be considered as one of the possible diagnoses. Sinonasal fibroepithelial polyps have good prognosis after being treated surgically.

Frequency of Thyroid Gland Invasion by Laryngeal Squamous Cell Carcinoma: The Role of Subglottic Extension.

Introduction Management of the thyroid gland during laryngectomy has been controversial. The primary tumor may invade the thyroid gland by direct invasion or lymphovascular spread. Hypothyroidism and hypoparathyroidism are potential risks when lobectomy or total thyroidectomy are performed simultaneously. Objective To report the frequency of thyroid gland involvement by primary laryngeal squamous cell carcinoma in patients undergoing laryngectomy and to identify possible risk factors for thyroid gland involvement so that judicious excision of thyroid gland can be attained. Methods We performed a retrospective review of 9 years. Data was collected from medical records of patients dated from December 2009 to October 2018. All patients with laryngeal cancer who underwent laryngectomy with lobectomy or total thyroidectomy were included in the present study. Results We reviewed 151 laryngectomy records. A total of 130 surgeries included the thyroid gland with the excised specimen and were available for analysis. There were 124 males and 6 females. The mean age was 59.4 years old. The glottis was the most common subsite involved, in 70 patients, followed by 38 transglottic, 16 supraglottic and 03 subglottic tumors. On histology, 12 out of 130 excised thyroid glands were involved by squamous cell carcinoma. Only subglottic involvement ( p = 0.01) was significantly associated with thyroid gland invasion (TGI). Type of laryngectomy, subsite of the primary tumor, thyroid cartilage involvement, neck nodal metastases, and perineural and lymphatic invasion by the primary tumor were not associated with TGI. Conclusion Only subglottic involvement is associated with TGI; therefore, preoperative and intraoperative assessment is necessary prior to considering excision of the thyroid gland.

Psychometric properties of the Urdu version of the EORTC QLQ-H&N35 (European organization for research and treatment of cancer head and neck module) quality of life tool.

BACKGROUND: We translated and validated the Urdu version of the European Organization for Research and Treatment of Cancer Quality of Life (QoL) Questionnaire's Head and Neck (H&N) Cancer Module (EORTC QLQ-H&N35) and assessed its convergent and discriminant validity by examining correlations of QoL with depression, anxiety, and resilience. METHODS: We translated the EORTC QLQ-H&N35 according to EORTC instructions. Patients at a tertiary care hospital in Pakistan completed a survey consisting of Urdu versions of EORTC QLQ-C30 (core QoL tool), QLQ-H&N35, Hospital Anxiety and Depression Scale, and Wagnild and Young Resilience Scale (RS-14). Content validity, convergent validity, discriminant validity, and reliability (using Cronbach's alpha) of the EORTC QLQ-H&N35 were assessed. RESULTS: Our sample comprised 250 patients with H&N cancer, most commonly oral (82%). The Urdu translations were comprehensible for all patients. The Cronbach alpha for QLQ-H&N35 multi-item domains ranged from 0.75 to 0.98 (acceptable to excellent), barring "Senses Problems", which was less than the generally acceptable level (0.50). The patient-reported content validity index (CVI) scores for relevance and clarity of the Urdu version of the QLQ-H&N35 were 0.93 and 0.92, respectively (both excellent). Our results revealed weak bidirectional correlations of the QLQ-H&N35 with resilience, depression, and anxiety, showing good discriminant validity. A weak-to-moderate but significant negative correlation (r: - 0.185 to - 0.613; p < 0.01) was seen between the QLQ-H&N35 and the global QoL measure of the QLQ-30. CONCLUSION: Our Urdu translation of the EORTC QLQ-H&N35 demonstrated validity comparable to previous studies, with good discriminant construct validity when measured against resilience, depression, and anxiety. An issue of concern is the poor internal consistency of the "Senses Problems" domain. Nevertheless, the Urdu translation produced in this study serves as a valid and reliable measure to measure QoL in H&N cancer in clinical or research settings in Pakistan.

Low-carbon alcohol fuels for decarbonizing the road transportation industry: a bibliometric analysis 2000-2021.

The application of low-carbon alcohols (LCA fuels) in internal combustion engines has become one of the most important topics in road transport decarbonization. This paper aims to identify the trends and characteristics of LCA combustion research for the period 2000-2021 through bibliometric analysis. Citation analysis is used to evaluate the influence of most productive journals, countries/regions, authors, institutions, and relevant literature, while collaborative network between various authors, countries/regions, institutions, and the co-occurrences among different keywords are discussed. A dataset of 2250 publications was extracted from the Web of Science Core database and analyzed with CiteSpace and Biblioshiny. The extracted documents involve 429 journals of publications by 4782 authors from 1434 institutions across 83 countries/regions. The results reveal that the research output in this field has undergone three main stages of development, i.e., initial development (2000-2007), slow development (2008-2015), and rapid development (2016-2021). Currently, the research field is growing at an annual growth rate of 9.24%, with most of the contributions by authors and institutions originating from China. The analysis from relevant keywords and literature suggests that the core of this research field centers on the combustion, performance, and emission characteristics of LCA-fueled engines. The current study helps keep the scientific community informed of the latest paradigms in the LCA combustion research field.

Depth of Invasion as a Predictor of Cervical Nodal Metastasis of Oral Tongue Squamous Cell Carcinoma: Findings From a Tertiary Care Center in Pakistan.

Background and objective Cervical lymph node metastasis has a significant impact on the survival of patients with oral cavity tumors. The rate of occult neck node metastasis is reported to range from 20 to 40%. The depth of invasion (DOI) has been incorporated in the eighth edition of the American Joint Commission on Cancer (AJCC) staging manual and is an important predictor of cervical lymph node metastasis. In this study, we aimed to identify the occult neck node metastasis rate in early oral tongue squamous cell carcinoma (OTSCC) and correlate it with the DOI. Methods A retrospective review of all patients presenting to our facility with early-stage OTSCC was performed. Patients with tumor size of ≤4 cm and who underwent elective neck dissection at the time of surgery were included. The study outcomes were the rates of occult neck metastases in T1 and T2 OTSCC and their correlation with the DOI. Results There were 80 patients in total. Occult neck node metastases were seen in 29 (36.25%) patients. Patients with a DOI >5 mm were 1.41 times more likely to have occult neck node metastasis than those with a DOI ≤5 mm. Conclusion Occult neck node metastasis is significantly associated with the DOI. The risk of neck metastasis is higher in patients with a DOI >5 mm.

Resilience and its associated factors in head and neck cancer patients in Pakistan: an analytical cross-sectional study.

INTRODUCTION: The study aimed to assess resilience and its associated factors in head and neck cancer patients, post-treatment in a low middle income country (LMIC) such as Pakistan. METHODS: An analytical cross-sectional study was conducted from November 2019 to May 2020 among head and neck cancer patients aged at least 18 years at the largest private tertiary care hospital, in Karachi, Pakistan. Information regarding their resilience scores was collected through Wagnild and Young's Resilience scale that comprises of 14 items (RS-14). Moreover, depression and anxiety were also assessed via Hospital Anxiety and Depression Scale (HADS) and social support was assessed by Enriched Social Support Instrument (ESSI). RESULTS: The data was analyzed by linear regression modeling. Unadjusted and adjusted beta coefficients with 95% CI were reported. A total of 250 head and neck cancer patients were recruited, 79% of them were males. Mean age of the patients was 51.59 years with 93% having high social support and only 8% having severe depression and 3% having severe anxiety. After adjusting for the covariates in multivariable analysis resilience was associated with severe depression (- 17[- 20.98,-12.93]) or borderline depression (- 4[- 8.41,-0.39]), severe anxiety (- 11 [- 17.88,-4.18]), low social support (- 6[- 9.62,-1.71]), having family members of > 6 in the household (- 2[- 4.31,-0.29), smokeless tobacco users post- treatment (10[5.79, 14.45]), and those who underwent tracheotomy (- 4[- 7.67,-0.21]). There was a significant interaction between education and role in the family (decision maker). CONCLUSION: In Pakistan, a South Asian LMIC, collectivist culture prevails, family ties are greatly promoted thus resilience and social support is highly prevalent in head and neck cancer patients resulting in lower prevalence of depression and anxiety. Our study highlights that higher resilience is prevalent among small families less than six members, as the welfare of the individual is prioritized over multiple needs of the family. Formal Education and role in household/decision making power are effect modifiers in our study, demonstrating its protective effect on the mental health of head and neck cancer patients. High resilience scores were reported among current smokeless tobacco users as compared to quitters post treatment. Resilience-building interventions should be formulated to aid head and neck cancer patients to cope with the disease and its sequel.

Synchronous primary diffuse large B-cell lymphoma and papillary thyroid carcinoma: A case report highlighting "Lymphoma first approach".

Papillary thyroid carcinoma (PTC) is the most common type of all thyroid carcinomas and accounts for up to 90% of all thyroid malignancies. It is the most indolent form of the disease and has an excellent prognosis. On the other hand, Primary thyroid lymphoma (PTL) is a rare entity accounting for only about 1% to 5% of all thyroid malignancies and only 2% of extranodal lymphomas. Synchronous PTC and PTL is a very rare condition and only a few cases have been reported in the literature up till now. We report one such case in a 52-year-old lady who was referred to us with goiter and progressively increasing difficulty in breathing.

Prevalence of allergic fungal sinusitis among patients with nasal polyposis.

OBJECTIVE: To determine the frequency of allergic fungal sinusitis among patients with nasal polyps, and to compare Lund-Mackay scores of patients with and without allergic fungal sinusitis. METHODS: The cross-sectional longitudinal study was conducted at a tertiary healthcare centre in Karachi, Pakistan, from December 2016 to November 2018, and comprised patients with sinonasal polyposis undergoing surgery. The patients were categorised as having allergic fungal sinusitis when histopathology showed allergic mucin with fungal hyphae and culture was positive for fungal growth. Lund-Mackay scoring of each patient was noted and mean scores of allergic fungal sinusitis and non-allergic fungal sinusitis patients were compared. Data was analysed using SPSS 25. RESULTS: Of the 114 patients, 61(53.5%) were males. The overall mean age was 37.3±15.3 years. Of the total, 27(23.7%) patients had allergic fungal sinusitis. There was a significant relationship between asthma and allergic fungal sinusitis (p=0.03). The mean Lund-Mackay score was significantly higher for allergic fungal sinusitis patients (p<0.01). Recurrence was seen in 11(9.6%) cases. CONCLUSIONS: About one-fourth of patients with nasal polyps had allergic fungal sinusitis, and such patients showed significantly high mean Lund-Mackay score.

Optimum Degree of Head Elevation/Reverse Trendelenburg Position for Sinus Surgery: Systematic Review.

BACKGROUND: This review aims to evaluate the effect of Reverse Trendelenburg Position (RTP) on bleeding and Boezaart score and to determine the optimum degree of head elevation through a systematic review and meta-analysis.Methodology: We conducted a systematic review according to PRISMA guidelines and a literature search was performed on PubMed, Web of Science, Cochrane, Dental and Oral Science, Google scholar and Clinicaltrials.gov and included randomized controlled trials (RCTs) in English language only. We extracted all relevant data and conducted quality assessment using Cochrane risk of Bias tool (Version 2). We also performed quality assessment of the outcomes using GRADE. Meta-analysis for all the outcomes using conducted on RevMan version 5.3. RESULTS: The search identified 629 articles and three RCTs that met our inclusion criteria. Two were included in the meta-analysis. A total of 124 patients were assessed for bleeding during sinus surgery and there was a significant reduction in total blood loss in RTP (10-15°) when compared to horizontal position by 134 ml (Mean Difference (MD): -134.23; 95% confidence interval (CI): -184.13 to -67.27). RTP also had a significant reduction in bleeding per minute by 1.07 ml/min (MD: -1.07; 95%CI: (-1.69 to -0.44), while the Boezaart score was significantly lower in the RTP group (MD: -0.69; 95%CI: -0.94 to -0.43) when compared to horizontal position. CONCLUSION: Though with limited evidence RTP for ESS reduces total blood loss, blood loss per minute and improves visualization. Further studies are needed to assess the actual impact and optimal degree of head elevation.

Prognostic factors in patients with salivary gland malignancy: a retrospective cohort study.

Our objective was to determine the factors affecting the prognosis in patients with major salivary gland malignancy presenting to Aga Khan University Hospital in Karachi. Retrospective cohort study was carried out at our center on patients diagnosed and treated for salivary gland cancers. Presentation and treatment offered was reviewed from medical charts. Telephonic interviews were conducted to assess the survival of patients who were lost to follow-up. Log rank test was used to compare the mean survival times. A total of 36 patients were included in the study. The mean age was 45.1 +/- 14.6 years. Majority were male 21 (58.3%). The most common malignancy was mucoepidermoid carcinoma (36.1%) followed by adenoid cystic carcinoma (22.2%). Node positivity, grade of tumor, radiotherapy and chemotherapy were a significant indication of survival times on log rank test.

Non-recurrent laryngeal nerve: a case report and review of literature.

Right recurrent laryngeal nerve can take a "Non-Recurrent" course and can present as a Non Recurrent Laryngeal nerve which is a rare entity. Such anomalies can lead to difficulty in locating the laryngeal nerve during thyroid surgeries and there are higher chances of it being injured. Therefore, surgeons should be mindful of this entity. We report the case of a 53-year-old lady who underwent thyroid surgery and a right Non Recurrent Laryngeal Nerve was identified intra-operatively.

Dual spinal accessory nerve: caution during neck dissection.

Preserving the spinal accessory nerve (SAN) is an important step in the modern-day neck dissection to avoid postoperative functional morbidity in patients. This goal can become technically difficult, especially, when rare anatomical variations are encountered. We present a case of dual SAN in a patient undergoing selective neck dissection for oral squamous cell carcinoma. Both SANs were preserved and patient had no shoulder dysfunction postoperatively. We take this opportunity to emphasise that meticulous dissection is the only proven way to preserve the nerve. And that surgeons should be aware of this anatomical variation. SAN should be subjected to minimal traction during neck dissection to avoid tension neuropraxia and long-term shoulder dysfunction.

Successful Airway Management Using Awake Videolaryngoscopy for a Rare Thyroid Cancer with Grade III Goitre and Intra-Tracheal Invasion.

In the present report, we described a case of anticipated difficult intubation in which the access to airway was limited due to external and internal factors. Our patient presented with a large goitre, shortness of breath and mild stridor. A clinical examination and investigations were performed. An intra-tracheal subglottic mass visible on a positron emission tomography scan was nearly occluding the lumen. The clinical diagnosis was thyroid cancer with intra-tracheal invasion. For patients with a large thyroid cancer, airway management can be complicated, using both regional invasion and intrathoracic extension, due to the effect of the mass on the airway and major vessels. This approach has a great potential for leading to complete airway obstruction after the induction of general anaesthesia. Here, we aimed to discuss the meticulous planning and preparation for the intubation of a conscious patient using different procedures of airway management, especially when the fibreoptic intubation failed and awake videolaryngoscopy salvaged the situation.

Glomangiopericytoma: A rare tumour of sinonasal cavity.

The history of glomangiopericytoma began in 1924 when it was initially diagnosed by Stout and Murray. It is a rare tumour of the respiratory mucosa, with a prevalence of less than 0.5% among all sinonasal tumours. Literature shows female predominance among patients who develop glomangiopericytoma. So far, no accurate aetiology has been discovered, but there are certain risk factors, including trauma, use of corticosteroids and high blood pressure, which are believed to cause glomangiopericytoma. Patients usually present with a history of epistaxis or nasal blockage, though symptoms can get worse if the tumour is not resected timely and can lead to visual disturbance, chronic sinusitis and headache. It has reddish polypoidal appearance on examination. The best modality for the treatment of glomangiopericytoma is endoscopic surgical resection via trans-nasal approach. We present the case of a 70-year-old man, with nasal blockage and epistaxis who underwent endoscopic sinus surgery for this condition.

Prostate Cancer Metastasis To Cervical Node Chain-An Unusual Clinic-Pathological Finding.

Prostate carcinoma is one of the most common cancers in males all around the world. Head and neck squamous cell carcinoma is amongst the leading carcinoma (HNSCC) in men especially in the sub-continent. There are around 150 lymph nodes on either side in the neck and cervical lymph nodes are a common site for head and neck malignancies to metastasize however carcinoma of prostate may in rare cases metastasize to cervical chain, therefore warranting a neck dissection. In case of unknown primary of head and neck extensive work up is required to find the primary site. Our case provided a similar picture with a single enlarged node which on biopsy to our surprise revealed adenocarcinoma of prostate.