Primary versus secondary tracheoesophageal puncture: systematic review and meta-analysis.

BACKGROUND: Tracheoesophageal puncture represents the 'gold standard' for voice restoration following laryngectomy. Tracheoesophageal puncture can be undertaken primarily during laryngectomy or in a separate secondary procedure. There is no current consensus on which approach is superior. The current evidence comparing primary and secondary tracheoesophageal puncture was assessed. METHODS: A systematic review and meta-analysis of articles comparing outcomes for primary and secondary tracheoesophageal puncture after laryngectomy were conducted. Outcome measures were: voice success, overall complication rate and pharyngocutaneous fistula rate. RESULTS: Eleven case series met the inclusion criteria, two prospective and nine retrospective. Meta-analysis did not demonstrate statistically significant differences in overall complication rate or voice outcomes, though it suggested a significantly increased risk of pharyngocutaneous fistula in primary compared to secondary tracheoesophageal puncture. CONCLUSION: Primary tracheoesophageal puncture is a safe and efficient approach for voice rehabilitation. However, secondary tracheoesophageal puncture should be preferred where there is a higher risk of pharyngocutaneous fistula.

Palliative and supportive care 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. It provides recommendations on the assessments and interventions for this group of patients receiving palliative and supportive care. Recommendations • Palliative and supportive care must be multidisciplinary. (G) • All core team members should have training in advanced communication skills. (G) • Palliative surgery should be considered in selected cases. (R) • Hypofractionated or short course radiotherapy should be considered for local pain control and for painful bony metastases. (R) • All palliative patients should have a functional endoscopic evaluation of swallowing (FEES) assessment of swallow to assess for risk of aspiration. (G) • Pain relief should be based on the World Health Organization pain ladder. (R) • Specialist pain management service involvement should be considered early for those with refractory pain. (G) • Constipation should be avoided by the judicious use of prophylactic laxatives and the correction of systemic causes such as dehydration, hypercalcaemia and hypothyroidism. (G) • Organic causes of confusion should be identified and corrected where appropriate, failing this, treatment with benzodiazepines or antipsychotics should be considered. (G) • Patients with symptoms suggestive of spinal metastases or metastatic cord compression must be managed in accordance with the National Institute for Health and Care Excellence guidance. (R) • Cardiopulmonary resuscitation is inappropriate in the palliative dying patient. (R) • 'Do not attempt cardiopulmonary resuscitation' orders should be completed and discussed with the patient and/or the family unless good reasons exist not to do so where appropriate. This is absolutely necessary when a patient's care is to be managed at home. (G).

Organisation and provision of head and neck cancer surgical services in the United Kingdom: United Kingdom National Multidisciplinary Guidelines.

This is the official guideline endorsed by the surgical specialty associations involved in the care of head and neck cancer patients in the UK. This paper summarises the current state of play in the organisation and provision of head and neck cancer surgical services in the UK.

Emergency presentations of head and neck cancer: a modern perspective.

BACKGROUND: Head and neck cancer emergency presentations are uncommon but persistent. However, there is little published literature on this aspect of cancer and patient demographics. This study aimed to assess the incidence, patient profile, tumour site and stage of emergency cancer presentations in our region. METHOD: Retrospective review of regional cancer database over a five-year period. RESULTS: Emergency presentations accounted for 7 per cent of all cases. There was no difference in patient age and risk factors between the emergency and non-emergency presentations. The emergency presentation group showed a greater proportion of female patients compared to the non-emergency presentation group (30 vs 15 per cent). In all emergency presentations, the cancer was at advanced stages. Oropharyngeal cancer was the commonest emergency presentation of cancer, but the third commonest in the non-emergency group. CONCLUSION: Emergency presentations are increasing annually. Female patients and oropharyngeal cancer showed greater representation compared to male patients and laryngeal cancer.

Evidenced-based management of haemoptysis by otolaryngologists.

BACKGROUND: Haemoptysis is an uncommon presenting symptom to the ENT clinic and ward, but has potentially sinister aetiology. This article aims to provide a systematic and evidence-based method of managing patients with haemoptysis. METHODS: The data in this article are based on a literature search performed using PubMed in August 2013. The keywords used included 'haemoptysis' in combination with 'otolaryngology', 'ENT', 'head & neck', 'diagnosis', 'management', 'investigations' and 'treatment'. RESULTS: The majority of published literature on the subject is level IV evidence. However, this can guide ENT specialists in assessing, investigating and managing presentations of haemoptysis. CONCLUSION: Understanding the different causes of haemoptysis is important for the otolaryngologist. The main concern is the detection of a malignant lesion in the upper aerodigestive tract or tracheobronchial tree. A thorough history and systematic examination can aid diagnosis.

Enhanced recovery programmes in head and neck surgery: systematic review.

OBJECTIVE: To review the literature on enhanced recovery programmes in head and neck surgery. METHOD: A systematic review was performed in May 2013. RESULTS: Thirteen articles discussing enhanced recovery after laryngectomy, neck dissection, major ablative surgery and microvascular reconstruction were identified. Articles on general pre-operative preparation and post-operative care were also reviewed. CONCLUSION: Considerable evidence is available supporting enhanced recovery in head and neck surgery that could be of benefit to patients and which surgeons should be aware of.

The case for mistletoe in the treatment of laryngeal cancer.

INTRODUCTION: Complementary and alternative medicine usage, though rising, remains largely devoid of a sound scientific basis; however, there is increasing evidence to support its use in cancer therapy. AIM: To present the case of a patient with laryngeal carcinoma who made a full recovery following mistletoe therapy, despite failing to respond to chemoradiotherapy and salvage laryngectomy. DESIGN: Case report with relevant literature review. RESULTS: The patient developed extensive, unresectable stomal recurrence, and it was deemed appropriate to supply palliative care only. Following treatment with mistletoe extract injections after palliative radiotherapy, he recovered fully and was eventually discharged from care. CONCLUSION: The benefit of mistletoe in laryngeal cancer treatment requires further investigation, and might be considered in selected patients, as an adjunct or when other conventional therapies have failed.

Trans-oral resection of large parapharyngeal space tumours.

The aim of this study is to describe minimally invasive trans-oral approach for resection of parapharyngeal space (PPS) tumours and to demonstrate surgical technique, resection, repair and outcomes. Five cases were prospectively included in the study. The data collected include age, sex, site, size, pathology, radiological investigations, surgical excision, complications and outcomes. Three females and two male patients underwent trans-oral resection of PPS tumours sized 4-8 cm. The pathology included two deep lobe parotid tumours, one schwannoma, one hibernoma and one primary adenocarcinoma arising form the minor salivary gland. All tumours were resected completely without any technical difficulty. The healing was quick and by primary intention. Patients resumed oral feeding on recovery from general anaesthesia and did not require any significant analgesia beyond the first 2 days. Patient with adenocarcinoma received postoperative radiotherapy and remained disease-free during 4 years post-treatment. No recurrences were observed in patients with benign tumours. No neurovascular injury occurred during surgery and no secondary bleeding was observed. We have demonstrated successful and safe execution of trans-oral resection of large PPS tumours. There were no intra and post-operative complications and there has been no recurrence during the follow-up period. In our experience, it appears to be efficient, safe and minimally invasive compared to the established techniques.

Neck abscess and vocal cord paresis: delayed complications of a self-extruded long fishbone stuck in throat.

A 57-year-old Caucasian man, otherwise fit and well, presented with a 2-week history of dysphagia, odynophagia. Two weeks prior to the presentation, he had felt a fishbone stuck in his throat which was self-extruded after 3 days. Subsequently he developed a right anterior neck swelling and hoarseness. Transnasal endoscopic examination of larynx revealed an injected and oedematous right hemilarynx with right vocal cord paresis. An ultrasound examination of the neck confirmed a collection in the neck on the right side, and frank pus was aspirated from the neck abscess and he responded well to conservative management. Subsequent examination in follow-up had shown complete recovery of vocal cord movement. The patient did not seek medical attention immediately after getting a 5 cm fishbone extruded from the throat which resulted in significant morbidity. All patients should be alerted to the possibility of delayed complications and they should be encouraged to seek urgent medical attention.

Variation in practice: an analysis of Scottish Surgical Profiles ENT data.

BACKGROUND: Variation in otolaryngology intervention rates is reported in the Scottish Surgical Profiles Project. Tonsillectomy is one of the selected key indicator procedures. The variation in practice was discussed nationally at the Scottish Otolaryngology Society summer meetings in 2009 and 2010. NHS Grampian had a significantly higher tonsillectomy rate compared with other Scottish NHS boards. AIMS: To determine the accuracy of NHS Grampian data reported by the Information Service Division (ISD) and to record the appropriateness of listing of patients for tonsillectomy with reference to the Scottish Intercollegiate Guidelines Network (SIGN). METHODS: Retrospective review of case notes and surgical records of patients who had undergone tonsillectomy between March 2007 and March 2008 in NHS Grampian. RESULTS: Between March 2007 and March 2008, 509 tonsillectomy cases were performed in NHS Grampian. This corresponded to the data received from ISD. 87% of tonsillectomies performed were compliant with SIGN guidelines. CONCLUSION: The Scottish otolaryngology clinicians have found the reporting of the intervention rates stimulating and challenging. Discussion of the surgical profile project regularly at national specialty meetings resulted in a preliminary detailed targeted audit of those who were persistent outliers for tonsillectomy. This refuted the presumed reasons for this variation, namely inaccurate figures from ISD and inappropriate listings by clinicians.

Revision nasal surgery after septoplasty: trainees versus trainers.

Otolaryngology trainees are expected to be able to successfully perform septoplasty early in their career. An important parameter to assess the success of an operation is to look at the revision surgery rate. This study aimed to investigate the revision nasal surgery rate after septoplasty based on the grade of the primary surgeon. Retrospective review of hospital records of all patients who underwent septoplasty with or without inferior turbinate reduction over 12 years (1998-2010) in a tertiary referral centre in North-East Scotland. Patients were identified from theatre log books and were excluded if they underwent any other simultaneous nasal procedure. Data were collected on demographics, type of primary and revision surgery, grade of surgeon and duration of hospital stay. 2,168 eligible patients (70 % male, 30 % female) with a mean age of 39 years were investigated. Surgeons were divided into four categories: junior trainee (Group A), senior trainee (Group B), staff grade (Group C) and consultant (Group D). There were 753, 644, 298 and 473 patients in Groups A, B, C and D, respectively. The revision rate in Group A was 4.4 % compared to 3.2 % for Group D and this difference was not statistically significant. For their operation, patients in Group A stayed for 1.54 nights compared to 1.47 nights in Group D, the difference being insignificant. Grade of the surgeon does not appear to strongly affect the need for revision nasal surgery and our patients do not appear to be disadvantaged if operated on by trainees.

A case of a 'lost' nasogastric tube.

OBJECTIVES: To present the case of a 'lost' nasogastric tube and to highlight the importance of imaging and/or chest X-ray after nasogastric tube insertion, especially in unreliable patients. CASE REPORT: A 50-year-old man, undergoing radiotherapy treatment for squamous cell carcinoma of the tongue base, was admitted for pain control and nasogastric tube feeding. This patient required multiple nasogastric tubes over a two-week period. The patient repeatedly denied pulling the nasogastric tube out and we were unable to establish the exact mode of nasogastric tube removal. On one such occasion another tube was inserted and a check X-ray showed two feeding tubes; the latest one was lying in the left main bronchus and the old nasogastric tube was observed in the oesophagus, with its upper end jutting above the hypopharynx. It was apparent that the patient had somehow cut the tube and swallowed it. CONCLUSION: This case not only illustrates the importance of flexible nasendoscopy and/or chest X-ray for checking the position of the nasogastric tube, but also highlights that some patients are not tolerant of nasogastric tubes. The use of nasogastric tubes should be avoided in these patients to prevent any self-inflicted injury.

Facial paralysis during air travel: case series and literature review.

OBJECTIVE: We report three cases of recurrent, unilateral facial palsy associated with air travel. METHOD: The three cases are presented, along with a brief literature review concerning barotrauma and its association with air travel and facial palsy. RESULTS: All three patients experienced unilateral facial paralysis during air travel, accompanied by additional symptoms which varied between cases. Symptoms resolved spontaneously in all cases. Two patients received ventilation tube insertion to prevent further recurrence. Computed tomography scanning revealed no bony defect in two patients, while the third exhibited dehiscence of the facial canal which may have contributed to the condition. CONCLUSION: Available evidence suggests that eustachian tube dysfunction can contribute to increased pressure within the middle ear, leading to neuropraxia of the facial nerve. Cases of facial paralysis associated with air travel are under-reported. Since there is no evidence-based management protocol for this condition, further investigation of its pathology is encouraged in order to improve our understanding.

Wegener's granulomatosis presenting as meningitis.

BACKGROUND: Wegener's granulomatosis is a rare but well recognised autoimmune necrotising vasculitis. Presentation of disease in the head and neck is common and mostly consists of nasal crusting, blockage and bloody discharge. Neurological presentation is very uncommon. METHODS: We report a patient who presented to the medical emergency services with signs and symptoms of meningitis, but who was eventually diagnosed with Wegener's granulomatosis. A literature search on this topic was carried out using Medline and Embase (1996 to 2011), searching for 'Wegener's granulomatosis' and 'meningitis'. RESULTS: After thorough neurological and medical investigation, a combination of brain computed tomography, lumbar puncture, nasal biopsy and laboratory results refuted the diagnosis of meningitis and confirmed the diagnosis of Wegener's granulomatosis. CONCLUSION: To the best of our knowledge, this is the first English-language case report of a patient with Wegener's granulomatosis presenting with symptoms of meningitis unconfirmed on computed tomography and lumbar puncture.

Routine clotting screen has no role in the management of epistaxis: reiterating the point.

Objective of the study is to investigate the role of clotting screen in adult patients presenting with epistaxis. The study is a prospective case series done in a teaching hospital in the Northeast of Scotland. Prospective data was collected for 100 consecutive patients with epistaxis admitted to the Department of Otolaryngology over 1 year (2006-2007 August). The demographics, co-morbidities, long-term medications and blood test results were noted for these patients. A retrospective audit of all patients attending the Emergency Department (ED) with epistaxis during the same study period was also performed. The following were measured: frequency of clotting screen performed in patients with epistaxis; the treatment modifying effect of clotting screen results. Of the 100 admitted patients, 45 were male and 55 were female. The majority of them had more than two co-morbidities such as hypertension, ischaemic heart disease and atrial fibrillation. Forty-seven patients were on aspirin, 19 on warfarin and 12 patients on clopidogrel. A clotting screen was done for 80 patients but only 2 patients (2.5%) had an abnormal INR. A total of 356 patients presented to the ED with epistaxis. Of 356 patients, 138 (39%) had their clotting screen checked. Of 138 patients, 42 (30%) were on warfarin. Only 7 patients (7/138 = 5%) had an abnormal result. Our data suggests that routine clotting screen check does not alter the epistaxis management in patients with no risk factors or with stable warfarin dosage. Therefore, routine clotting screen in patients with epistaxis without relevant risk factors is not an evidence-based practice.

Epistaxis: prospective evaluation of bleeding site and its impact on patient outcome.

OBJECTIVES: To assess impact of site of idiopathic epistaxis on adult patient management and its association with patient demographics and co-morbidities. METHOD: The site of epistaxis, patient data, their management and outcomes prior to discharge was recorded prospectively for 100 consecutive eligible adult patients. RESULT: Fifty three patients had anterior and 47 patients had a posterior site of bleeding. The site of epistaxis was not related to the patient s age, medical condition or medication. CONCLUSION: Most patients with epistaxis can be controlled with nasal cauterisation. However, patients with posterior epistaxis are more likely to need hospital admission, are twice as likely to require nasal packing, and stay in hospital longer. There appears to be no link between the site of epistaxis and patient factors.

Stapled closed technique for laryngectomy and pharyngeal repair.

BACKGROUND AND AIMS: Total laryngectomy is a recognised treatment for advanced laryngeal carcinoma. Traditionally, pharyngeal repair is performed with layered sutures. We describe our experience with a technique of closed pharyngoplasty using a linear stapler device. MATERIAL AND METHODS: Ten total laryngectomies were performed from July 2002 to July 2004, using an Ethicon TLC 75 linear stapler for pharyngeal closure. Data collected included age, sex, staging, endoscopic assessment, surgical margins and post-operative course (including complications and swallowing). RESULTS: Patients comprised eight men and two women. The mean age was 55.4 years. Six patients had stage T4 endolaryngeal carcinoma and four had stage T3. Four patients underwent pre-operative radiotherapy. Clear surgical margins were achieved in all patients. One patient developed a pharyngocutaneous fistula. Patients resumed oral intake at 48 hours, or at 72 hours if they had undergone pre-operative radiotherapy. Patients' mean hospital stay was seven days. CONCLUSION: This stapled closed technique for pharyngoplasty is efficient and eliminates the risk of wound contamination, thus theoretically reducing the risk of tumour seeding. In addition, we were able to commence patients on oral fluids at a mean of 48 hours after surgery. The mean hospital stay was seven days. We recommend this technique as an alternative for repairing the pharynx in patients undergoing total laryngectomy for endolaryngeal carcinoma.