Postoperative serum C-reactive protein dynamics after pharyngolaryngectomy with jejunal free-flap reconstruction.

INTRODUCTION: Pharyngolaryngectomy with jejunal free-flap (JFF) reconstruction can be offered for locally advanced hypopharyngeal cancer. However, the procedure carries significant morbidity. Postoperative serial serum C-reactive protein (CRP) has been shown to be a marker predicting postoperative complications, and the aim of this study was to describe the dynamics and value of CRP in this patient group. METHODS: Retrospective analysis of pharyngolaryngectomies with JFF reconstruction was performed in our institution. Daily postoperative CRP values were analysed within the first 14 days, as were complications. RESULTS: Twenty-one cases were included. Total morbidity was 57.1% including 14.3% (temporary) anastomotic leaks and 14.3% flap failures. Patients in the normal group showed peak CRP levels around postoperative day 2 (2.2). Increased CRP levels on or after day 4 were associated with complications (p<0.01) with a sensitivity of 83.3% and specificity of 77.8%. In keeping with CRP kinetics from other surgical studies, peak CRP values on day 2 or 3 are expected, followed by a decline. Peaks in CRP on day 4 or later raise the suspicion of complications. CRP is not specific for any one complication but rather can help guide early appropriate clinical assessment and management. CONCLUSIONS: The natural postoperative CRP response peaks around postoperative day 2 (2.2) and declines thereafter. Rising CRP levels after postoperative day 3 are suspicious of surgical complications (p<0.01) with positive and negative predictive values of 83.3% and 77.8%, respectively. Therefore, serial postoperative CRP can be used as an adjunct to monitor outcomes in this group.

Management of neck metastases in 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. A rational plan to manage the neck is necessary for all head and neck primaries. With the emergence of new level 1 evidence across several domains of neck metastases, this guideline will identify the evidence-based recommendations for management. Recommendations • Computed tomographic or magnetic resonance imaging is mandatory for staging neck disease, with choice of modality dependant on imaging modality used for the primary site, local availability and expertise. (R) • Patients with a clinically N0 neck, with more than 15-20 per cent risk of occult nodal metastases, should be offered prophylactic treatment of the neck. (R) • The treatment choice of for the N0 and N+ neck should be guided by the treatment to the primary site. (G) • If observation is planned for the N0 neck, this should be supplemented by regular ultrasonograms to ensure early detection. (R) • All patients with T1 and T2 oral cavity cancer and N0 neck should receive prophylactic neck treatment. (R) • Selective neck dissection (SND) is as effective as modified radical neck dissection for controlling regional disease in N0 necks for all primary sites. (R) • SND alone is adequate treatment for pN1 neck disease without adverse histological features. (R) • Post-operative radiation for adverse histologic features following SND confers control rates comparable with more extensive procedures. (R) • Adjuvant radiation following surgery for patients with adverse histological features improves regional control rates. (R) • Post-operative chemoradiation improves regional control in patients with extracapsular spread and/or microscopically involved surgical margins. (R) • Following chemoradiation therapy, complete responders who do not show evidence of active disease on co-registered positron emission tomography-computed tomography (PET-CT) scans performed at 10-12 weeks, do not need salvage neck dissection. (R) • Salvage surgery should be considered for those with incomplete or equivocal response of nodal disease on PET-CT. (R).

Rapid on-site assessment of specimens by biomedical scientists improves the quality of head and neck fine needle aspiration cytology.

OBJECTIVE: Immediate rapid on-site assessment (ROSA) of fine needle aspiration cytology (FNAC) specimens by biomedical scientists (BMS), the UK equivalent of cytotechnologists, or by pathologists may improve specimen quality and cellular adequacy rates for lymph node, head and neck and thyroid FNAC. The aim of this study was to evaluate the effect of introducing ROSA by BMS in an outpatient clinic setting. METHODS: The adequacy rate and sensitivity of histological diagnosis for lymph node, thyroid and salivary gland FNAC samples were determined before and after the introduction of BMS ROSA. The additional financial costs and time required to perform this service were also estimated. RESULTS: Thirty-one patients underwent ultrasound (US)-guided FNAC with ROSA and 151 without. ROSA reduced the number of FNAC insufficient in quality for diagnosis from 43% to 19% (P = 0.0194). The estimated additional cost for pathology per patient for ROSA was between £52.05 and £70.74, equivalent to €65.40/US $83.90 and €88.89/US $114.0, respectively, an increase of between 28% and 49% from the original cost. ROSA necessitated an additional 6 minutes clinic time per patient, reducing the number of patients that could be seen in an average clinic from 13 to 10 as well as requiring increased laboratory time for FNAC slide assessment. CONCLUSION: ROSA by suitably trained biomedical scientists and with appropriate consultant pathologist support can improve the quality of FNAC sampling for head and neck lesions. Although ROSA resulted in both additional financial and time costs, these are more than likely to be offset by a reduction in patients returning to clinic for repeat FNAC or undergoing unnecessary surgery.

A false aneurysm.

OBJECTIVE: We report a case of a remaining hemi-thyroid following laryngectomy, which was misinterpreted as a pseudoaneurysm. METHODS: Case report and comment on this understandable error which is easily avoidable. RESULTS: A 59-year-old man had undergone salvage laryngectomy for recurrent squamous cell carcinoma of the larynx, which had previously been treated with radiotherapy. Three months after his laryngectomy, he presented with a sore neck and subcutaneous collections. Computed tomography revealed a unilateral mass with high signal contrast uptake anterior to the left common carotid artery, which was thought initially to be a carotid pseudoaneurysm. Further investigation, including ultrasonography and a review by the senior head and neck radiologist, demonstrated that this mass was actually the remnant hemi-thyroid preserved at laryngectomy (which is often misshapen compared with a normal hemi-thyroid). The collections were found to be recurrent tumour, and unnecessary further interventions were avoided. CONCLUSION: Ultrasonography easily distinguishes between a thyroid remnant and a pseudoaneurysm. Furthermore, the opinion of an experienced head and neck radiologist may be vital when interpreting complex post-surgical head and neck radiology.

A low-cost, endoscopic, digital, still and video photography system for ENT clinics.

Image capture systems that display and record endoscopic images are important for documentation and teaching. We have modified a universal serial bus microscope to couple with most clinical endoscopes used in our practice. This very economical device produces images suitable for teaching, and potentially for clinical use. The implications of this could be significant for teaching, patient education, documentation and the developing world.

Local anaesthesia for manipulation of nasal fractures: systematic review.

OBJECTIVE: To determine the most effective local anaesthetic method for manipulation of nasal fractures, and to compare the efficacy of local anaesthesia with that of general anaesthesia. METHOD: Systematic review and meta-analysis. DATABASES: Medline, Embase, Cochrane Library, National Research Register and metaRegister of Controlled Trials. INCLUDED STUDIES: We included randomised, controlled trials comparing general anaesthesia with local anaesthesia or comparing different local anaesthetic techniques. Non-randomised studies were also systematically reviewed and appraised. No language restrictions were applied. RESULTS: Five randomised, controlled trials were included, three comparing general anaesthesia versus local anaesthesia and two comparing different local anaesthetic methods. No significant differences were found between local anaesthesia and general anaesthesia as regards pain, cosmesis or nasal patency. The least painful local anaesthetic method was topical tetracaine gel applied to the nasal dorsum together with topical intranasal cocaine solution. Minimal adverse events were reported with local anaesthesia. CONCLUSIONS: Local anaesthesia appears to be a safe and effective alternative to general anaesthesia for pain relief during nasal fracture manipulation, with no evidence of inferior outcomes. The least uncomfortable local anaesthetic method included topical tetracaine gel.

How we do it: analysing GP referral priorities: the unforeseen effect of 'Choose and Book'.

The introduction of Choose and Book may have a significant effect on the proportion of urgent referrals seen by ENT surgeons. Much of the responsibility for prioritisation will be transferred to the GP. Patients who are considered urgent by the ENT surgeon will be added to those considered urgent by the GP. Our results show that there was little agreement between GPs and ENT surgeon on what constitutes an urgent referral. The combined effect of joint prioritisation and the removal of the 'soon' category resulted in a 270% increase in 'urgent' referrals in our sample. This potentially unforeseen consequence of the Choose and Book system should be taken into consideration by ENT departments to allow for an expansion of the 'urgent' category.

How much do healthcare professionals know about informed consent? A bristol experience.

BACKGROUND: It is important that healthcare professionals have a thorough knowledge of consent practice. The purpose of this study was to compare understanding against the agreed standards found in consent guidelines and UK case law. METHOD: Twelve 'true or false' questions testing knowledge of the consent process were completed by 118 healthcare professionals from the United Bristol Healthcare NHS Trust. The questions addressed areas of fundamental importance, difficult clinical situations, and common consent dilemmas. The answers were marked against pre-validated answers determined using published guidelines and case law. Results were analysed for differences between pre-determined population sub-groups. RESULTS: A 100% response rate was achieved. Significant areas of weakness were identified including the role of consent forms, Gillick competence and mentally-ill patients. Performance was generally better by medical staff, those in surgical specialties, and more junior doctors. For example, 30.9% of doctors versus 62% of non-doctors (p=0.05) thought, incorrectly, that if an adult is unable to provide consent for an emergency procedure, the patient's next of kin must sign the consent form. Doctors also demonstrated a greater understanding of Gillick case law and scored significantly higher than non-doctors (68% vs. 48.5%, p=0.027). CONCLUSIONS: National guidelines and case law provide the gold standard for ideal consent practice. Many healthcare professionals have either not read these documents or are unable to reliably recall them. Improvements in knowledge and practice could be possible with further education, particularly targeting those most closely involved in the consent process