Impact of patient and professional diagnostic delays on the risk of recurrence in laryngeal carcinoma.

OBJECTIVES: To evaluate the impact of patient and professional diagnostic delays on the risk of recurrence in laryngeal squamocellular carcinoma (LSCC). DESIGN: Retrospective study using primary health care records completed before the diagnosis of malignancy. SETTING: One primary health care district (onset of symptoms), one tertiary centre (final diagnosis). PARTICIPANTS: A population-based sample of 99 patients, of which 66 fulfilled the entry criteria, with LSCC diagnosed in northern Finland in 1990-1995. MAIN OUTCOME MEASURES: Impact of patient delay (interval between the onset of symptoms and the first visit to a physician) and professional delay (interval between the first medical visit and histologically verified diagnosis) on the risk of local, neck and distant recurrence in LSCC. RESULTS: Professional delay of 1 year or longer was an independent predictor of both local [adjusted relative hazard (HR) 4.62, P = 0.02] and neck (HR 9.5, P = 0.015) recurrence. Longer professional delay was associated with the risk of recurrence particularly among patients with early stage (stages I-II) disease. Professional delay was almost exclusively because of a delay in referring patients from primary care to an ENT centre. CONCLUSIONS: Lengthened professional diagnostic delay is an independent predictor of an increased risk of local and neck recurrence in early stage LSCC. These patients could benefit from more aggressive primary treatment or more meticulous follow-up.

Experience of climacteric symptoms among 42-46 and 52-56-year-old women.

OBJECTIVE: The intensity of climacteric symptoms and their connection with sociodemographic background data were assessed among women who are or will soon be menopausal. METHODS: A sample of 5510 Finnish women who were 42-46 or 52-56-years-old was selected to this 'Quality of Life among Middle-aged Women' Study and received a menopause-specific questionnaire. RESULTS: Only 5% of the older and 36% of the younger women were totally asymptomatic. Altogether, 2% of the younger and 11% of the older women had severe climacteric symptoms. In the younger age group, a high symptom intensity was associated with living in town, having a low level of professional education, and being unemployed/laid off, whereas in the older age group, the experience of severe symptoms was associated with those having a couple relationship. CONCLUSION: Altogether 95% of women in the productive working age (52-56-years-old) surprisingly suffer from mild, moderate, or severe climacteric symptoms. Further even up to 64% of the younger women (42-46-years-old) suffered from similar symptoms.

The impact of patient and professional diagnostic delays on survival in pharyngeal cancer.

BACKGROUND: Cancers of the head and neck still are detected mostly at an advanced stage, especially pharyngeal cancers. METHODS: To study the impact of patient and professional delay on survival, the authors collected the data from 84 patients with pharyngeal cancer. In addition to clinical data from the tertiary care center, the authors evaluated the data from the first medical visit in primary care before the diagnosis of malignancy had been made. RESULTS: The patients who had a patient delay of 2 months or more had a significantly higher relative hazard of death (HR; HR, 2.5; 95% confidence interval (CI), 1.39-4.38) compared with the patients with less than 2 months of patient delay. This risk was significant among the patients with oropharyngeal (P = 0.008) and nasopharyngeal cancer (P = 0.03), but not in those with hypopharyngeal cancer (P = 0.56). In contrast, there was no relation between professional diagnostic delay and prognosis. Advanced stage (International Union Against Cancer [UICC] TNM; Stage IV vs. Stage I-III; HR, 3.19; CI, 1.61-6.35) and age (> or = 65 vs. < 65 years; HR, 2.47; CI, 1.32-4.62) also were associated with an impaired prognosis. CONCLUSIONS: Shortening of patient delay would substantially improve survival in pharyngeal cancer, but this goal seems difficult to attain because symptoms emerge late in pharyngeal cancer, and no specific symptoms or patient characteristics were related to a long patient delay. Professional delay does not have an impact on survival in pharyngeal cancer.

The common cold in patients with a history of recurrent sinusitis: increased symptoms and radiologic sinusitislike findings.

BACKGROUND: We evaluated whether the symptoms and signs and radiologic findings during a common cold are similar in patients who have and have not suffered from recurrent sinusitis. METHODS: We recruited 2 series of volunteer cases from February 1, 1996, to December 31, 1996. Twenty-three adults who claimed to have suffered from recurrent sinusitis and 25 who had never had sinusitis were examined during the period of a self-diagnosed cold of 48 to 96 hours' duration and again after 21 days. Symptom scores were recorded, nasoendoscopy and computed tomography scans were performed, and viral and bacterial specimens were taken. RESULTS: The patients with a history of sinusitis had significantly higher symptom scores than the control patients (P=.04) and had radiologic sinusitislike changes more often (65% [15] vs 36% [9]; difference 29% [95% confidence interval, 2%-56%]; P=.04). The viral etiology of the common cold (verified in 67% of the episodes) was similar in both groups. Pathogenic bacteria were isolated from the middle meatus in 24% (6) of the control patients and only 9% (2) of the sinusitis-prone patients (P=.15). On the basis of the symptomatology, radiologic findings, and bacterial cultures only 2 patients in the sinusitis-prone group should have been treated with antimicrobials. CONCLUSIONS: Some patients are susceptible to both sinusitislike symptoms and radiologic findings during viral common colds. This may cause them to consult their physicians earlier and more often during viral colds, which may result in unnecessary antibiotic treatments. Nasopharyngeal bacteriological cultures may prove to be useful in ruling out bacterial sinusitis.

Detection of tongue cancer in primary care.

BACKGROUND: The incidence of tongue cancer is increasing, and survival has not improved since the majority of patients present at an advanced stage. Patient delay has remained the same over the years and is difficult to influence. Much less is known about the delay in diagnosis caused by physicians and dentists. AIM: To investigate the detection of tongue cancer in primary care in Northern Finland and to examine the consultation prevalence of oral symptoms in primary care in Finland. STUDY: Analysis of data from medical records of tongue cancer patients kept between 1 January 1974 and 31 December 1994 for the general health insurance scheme. SETTING: The two northernmost provinces of Finland (population of 700,000). METHOD: Data were collected on demographic and clinical variables and on the first medical visit on 75 tongue cancer patients. In addition, primary care physicians recorded all patient visits during four weeks in 25 health centres randomly selected throughout Finland in 1996. RESULTS: At the initial visit, the tongue cancer patient was correctly referred for further examinations in 49 (65%) cases. In 12 (16%) of cases the patient was not referred but was scheduled for a follow-up visit, and was neither referred nor followed-up in 14 (19%). When compared with the referred patients the median professional delay was somewhat longer for the unreferred patients but increased dramatically if no follow-up was arranged (0.6 months [range = 0.1-2.4] versus 1.2 [range = 0.3-2.2] versus 5.2 [range = 0.7-18.2], P < 0.001). Compared with the referred patients the adjusted relative hazard of death for the non-referred followed-up patients was 1.4 (95% confidence interval [CI] = 0.31-6.5) and that for the non-referred/not followed-up patients 6.3 (95% CI = 1.7-22.9). The high-risk patients included those who sought an early professional evaluation, those who made the appointment for a completely different reason and only mentioned the symptom suggestive of cancer incidentally, those that had a small ulcerative lesion, and blue-collar workers. Oral symptoms were a rare cause of visits (0.55% of all visits) in primary care in Finland. CONCLUSION: Misdiagnosis of tongue cancer at the initial professional evaluation often leads to a fatal delay if the patient is left without any follow-up.

Decreasing incidence and improved survival of laryngeal cancer in Finland.

The decreasing incidence rate and improvement in survival of laryngeal cancer patients in Finland are exceptions among western countries. A descriptive study of these trends was conducted including both nationwide population-based cancer registry data with 5 766 patients diagnosed in 1956-1995 and regional hospital-based data from Northern Finland, allowing classification into supraglottic and glottic cancers, with 353 patients diagnosed in 1976-1995. In Finland, the age-adjusted incidence rate among males decreased from 6.5 per 100 000 in 1956-1965 to 3.5 in 1986-1995, while in females the rate remained around 0.3 per 100 000. The rates in Northern Finland were slightly higher and the supraglottic to glottic incidence ratio diminished from 1.4:1 in 1976-1985 to 0.5:1 in 1986-1995. The 5-year relative survival rate improved in both Northern Finland and the whole country, most noticeably among males and the elderly. In the data from Northern Finland, the survival rate was more favourable in glottic (80%) than in supraglottic cancer (64%). Considering the marked decrease in the incidence of the less favourable supraglottic disease, the observed improvement in survival was small.

Lip cancer in Northern Finland: changing incidence and clinical characteristics.

A population-based survey was conducted in 35 municipalities in Northern Finland to assess the incidence of lip cancer as well as the patient and tumour characteristics in cases diagnosed between 1983 and 1997. A total of 96 new patients emerged. The age-standardised incidence (per 100,000 years) of lip cancer in men decreased from 4.8 in 1983-1987 to 1.4 in 1993-1997. The incidences in women were 0.30 to 0.36, respectively. The median age of the patients increased from 66 to 73 years through the years. Overall, 90% of the patients had at least one of the known risk factors, namely rural domicile, outdoor occupation or smoking. The median duration of symptoms also remained the same, as did the median size and location of the tumour at diagnosis. In contrast, spread to regional lymph nodes became rare during the period.

Prognostic factors in tongue cancer - relative importance of demographic, clinical and histopathological factors.

The incidence of and mortality from squamous cell carcinoma (SCC) of the tongue have increased during the recent decades in the Western world. Much effort has been made to predict tumour behaviour, but we still lack specific prognostic indicators. The aim of our study was to evaluate the relative importance of the known demographic, clinical and histological factors in a homogeneous population-based group of patients with SCC of the mobile tongue. The demographic and clinical factors were reviewed retrospectively from primary and tertiary care patient files. Histological prognostic factors were determined from pre-treatment biopsies. The TNM stage was found to be the most important prognostic factor. In particular, local spread outside the tongue rather than spread to regional lymph nodes was related to poor prognosis. Several demographic and histopathological factors were closely related to TNM stage. When the cases were divided into stage I-II carcinomas and stage III-IV carcinomas, it appeared that the patient's older age (> 65 years), a high malignancy score and an absence of overexpressed p53 protein were associated with a poorer prognosis in stage I-II carcinomas. Such cases may require more aggressive treatment. Among patients with stage III-IV carcinomas, heavy use of alcohol was significantly associated with a poor disease-specific survival time.

The storage life of packed shredded Iceberg lettuce dipped in glycine betaine solutions.

The effects of glycine betaine dip, packaging method, and storage time on the sensory quality of shredded Iceberg lettuce were first modeled using a statistical experimental design, followed by a second storage test verifying the effect of the glycine betaine treatment. Shredded lettuce was dipped in 0 to 100 mg/liter active chlorine solution and then in 0 to 1.0 mol/liter glycine betaine solution, packed in 25 microm oriented polypropylene film, 250 g per package, and stored at 5 degrees C for 8 days. Models with good predictability were created suggesting that the glycine betaine dip helped retain sensory quality, especially appearance (P < 0.05). The models also suggested that washing periods over 60 s were not needed and that the microperforation of packages should not exceed 0.31 mm2 per package. The modeled positive effect on sensory quality was verified in the second storage test (P < 0.05). The optimum glycine betaine concentration was 0.2 mol/liter. Chlorination of the first dip particularly retained appearance of packed lettuce.

Acute epiglottitis in northern Finland today--still a potential emergency situation.

To examine patient characteristics related to airway intervention in acute epiglottitis and how the intervention affected the further course of the disease, 46 pediatric and 49 adult cases were retrospectively evaluated. All three airway management approaches, namely observation, nasotracheal intubation and tracheotomy were needed in both the children and adults. Five out of every six children needed an artificial airway, while observation was sufficient in three out of every five adults. H influenzae type b bacteremia in children, a short duration of the symptoms in adults and most important, respiratory distress in both were the best predictors of the need for an artificial airway. Nasotracheal intubation may be a successful means of implementing an artificial airway, but it is a technically demanding procedure and complications are frequent. Despite the recent changes in the occurrence of acute epiglottitis it remains a potential emergency situation both in children and adults.

Trends in chronic maxillary sinusitis that require surgical treatment in northern Finland.

To examine trends in the incidence of chronic maxillary sinusitis that require surgical treatment in northern Finland, a retrospective population-based survey from 1974 through 1995 was conducted. Data on surgical cases and on various demographic factors and on variables describing medical care in the area were collected for every third year. The overall crude incidence rate (per 100,000 person-years) of chronic maxillary sinusitis requiring surgical therapy was 44 for children and 76 for adults. The age-standardized incidence rate dropped by 78% in children, and by 66% in adults during the period. The changes found to have taken place in the population and in medical care and which could have promoted the decrease were higher educational level and mean income, smaller families, improved level of hygiene, a higher number of physicians and an expanded use of broader-spectrum antibiotics. In conclusion, the most serious forms of chronic maxillary sinusitis, that require operative treatment, are decreasing in both children and adults in northern Finland.

Cancer of the mobile tongue in Finland--increasing incidence, but improved survival.

A population-based descriptive study was conducted to describe incidence and survival of cancer of the mobile tongue in Finland between 1953 and 1994. The study included 1504 patients, drawn from the Finnish Cancer Registry, with first primary mobile tongue cancer diagnosed between 1953 and 1994. Incidence and relative survival were determined. The age-standardized overall incidence rate was 0.6 per 100000 years in 1953-1994. At the time of diagnosis 78% of the patients had either localized or regional disease. The age-standardized incidence rate decreased after the mid-1960s, but increased in the 1990s. The 5-year relative survival rate increased gradually from 40% in 1953 1959 to 58% in 1988-1994. Disease stage at the time of the diagnosis strongly affected the survival rate. Survival increased especially in regional disease. Cancer of the mobile tongue is increasing in Finland, but survival has increased particularly in regional disease, probably because of improved treatment. Early diagnosis is emphasized for a good prognosis.

Chronic suppurative otitis media and cholesteatoma. Vanishing diseases among Western populations?

A population-based survey of patients who had undergone surgery for chronic ear disease over the past 30 years in northern Finland revealed that the number of new surgical cases of both chronic suppurative otitis media and cholesteatoma has declined sharply after a peak in 1971-1974 and is now almost non-existent in contrast to the number of patients being operated on for chronic dry perforations, which has remained more or less the same. Most of the patients with chronic suppurative otitis media and cholesteatoma had had chronic ear trouble as early as the 1940s or 1950s. Moreover, if an active chronic otitis media developed in these cases, it started at a younger age than in cases with an onset after the 1950s. These facts may indicate that the decrease seen in this population is in close connection with the introduction of antimicrobials in the treatment of acute otitis media in the mid-1950s in the area.

Direct microscopy of effusions obtained from peritonsillar abscesses as a complement to bacterial culturing.

Effusion material was aspirated from 51 consecutive peritonsillar abscesses (34 male, 17 female; age range eight to 46 years) and subjected to direct microscopy after staining with acridine orange. Bacteria were counted per ml effusion material and their morphology was analyzed. In addition, aerobic and anaerobic bacterial culturing was performed. Effusions containing beta-haemolytic streptococci Group A, which appeared as a single species contained fewer bacteria (8 x 10(6) per ml, median value) than effusions harbouring a mixed flora (7 x 10(8) bacteria per ml, median value). Direct microscopy of effusions obtained from peritonsillar abscesses makes possible rapid identification of a single or mixed flora, which is of importance for the antibiotic treatment of the disease.

The growth rate of osteomas of the paranasal sinuses.

Paranasal sinus osteomas are benign tumours, occasionally known to cause complications. They have a tendency to grow slowly, but the growth rate has never been evaluated previously. We retrospectively studied 44 patients with paranasal sinus osteomas. In 13 out of the 23 patients who underwent at least two sinus radiographs at different times some growth was seen. The mean growth rate of these 13 osteomas was 1.61 mm/yr, range 0.44 to 6.0 mm/yr. The endoscopic technique is a good method for the removal of osteomas and obliteration of the frontal sinus does not seem to be necessary. Two patients having osteomas with intracranial expansion are described.

Snoring children: factors predicting sleep apnea.

Many snoring children present obstructive symptoms according to their parents. The seriousness of the symptoms and the possibility of the obstructive sleep apnea syndrome (OSAS) in these children may be difficult to judge on the basis of the clinical findings and the patient's history only. In order to evaluate snoring children's relative risk (RR) to have OSAS, their symptoms and signs, as reported by the parents, and clinical findings were compared with the results of overnight polysomnography (PSG). An obstructive apnea index (AI) > or = 1 in PSG was regarded as the criterion for OSAS. The mean AI was 1.55 (range 0-15), and 29 children had a pathological AI, while 49 had a normal PSG recording. Apneic episodes every night detected by the parents was the most important single risk factor for OSAS (RR 3.6, 95% confidence interval (CI) 1.7-7.7). The RR ratio decreased when apneas appeared less frequently, but any detected apnea was still a single risk factor (RR 1.4, CI 1.2-1.8). The other risk factors of night-time symptoms were constant snoring (RR 1.5, CI 1.0-2.1) and restless sleep (RR 2.1, CI 1.1-4.0). Of the daytime symptoms, absence of excessive sleepiness was a protective factor against OSAS (RR 0.3, CI 0.1-1.0). Previous adenoidectomy was found to be a risk factor (RR 1.7, CI 1.1-2.7), as was tonsillar enlargement (RR 1.4, CI 1.1-1.8). These two findings suggest that the epipharyngeal space does not play a central role in the development of OSAS in children. OSAS cannot be reliably diagnosed without PSG, which is the most important examination for snoring children with obstructive symptoms. For clinical decisions, the consideration of risk factors is essential.

Carcinoma of the oral tongue in northern Finland: trends in overall incidence and patient and tumour characteristics.

A population-based survey was conducted in the two northernmost provinces of Finland to describe the incidence of tongue cancer as well as patient and tumour characteristics in cases diagnosed between 1974 and 1994. A total of 105 new patients with cancer of the oral tongue were included in the 21-year study period. The age-standardised incidence (per 100,000 years) of the carcinoma in men increased from 0.6 in the first 7-year period (1974-1980) to 1.0 in the last period (1988-1994). The incidences in women were 0.7 to 1.4, respectively. The average patient profile remained much the same through the years. The median duration of symptoms also remained the same over the 2 decades, as did the median size and location of the tumour at diagnosis. In conclusion, the incidence of carcinoma of the tongue about doubled in both the male and the female population from 1974 to 1994. However, the patient and tumour characteristics remained about the same, the tumours being relatively large at the time of diagnosis in spite of well-developed community health and dental care.

Perforation in hypopharynx and deep cervical emphysema caused by blunt external trauma.

We present a case in which a blunt external trauma caused a perforating wound in the hypopharynx without any superficial damage on the skin of the neck. Deep cervical emphysema and general signs of systemic infection followed. The wound was sutured through an endoscope and the patient recovered uneventfully. The importance of the early diagnosis is emphasized.

Acute epiglottitis and infant conjugate Haemophilus influenzae type b vaccination in northern Finland.

OBJECTIVE: To determine the incidence and characteristics of acute epiglottitis among children (< or = 19 years of age) and adults (> or = 20 years of age) before and after widespread conjugate Haemophilus influenzae type b vaccination for infants. DESIGN: A retrospective population-based survey over a 27-year period from 1967 through 1993 in 35 communities in a northern province of Finland with a population of approximately 300,000. SETTING: An academic tertiary referral center. MAIN OUTCOME MEASURES: All acute epiglottitis cases in the area identified from the hospital discharge register and the regional autopsy register. RESULTS: The average incidence rate for children was 1.8 cases per 100,000 individuals per year (95% confidence interval [CI], 1.3 to 2.5). As no vaccine failures emerged, the incidence rate for children aged 0 to 4 years declined sharply once the vaccination started in 1986 from 7.6 (95% CI, 5.3 to 10.4) to 0 (95% CI, 0 to 3.3) cases per 100,000 individuals per year. By contrast, a fourfold increase in adult acute epiglottitis (incidence rate ratio, 4.6; 95% CI, 2.7 to 7.9) was detected after vaccination of the children, the average incidence rate for the whole period being 1.0 cases per 100,000 individuals per year (95% CI, 0.8 to 1.3). No marked change in the adult patient profile was found during this increase, however. CONCLUSION: Acute epiglottitis practically vanished among young children in this population after conjugate H influenzae vaccination, but adult cases increased, the patient profile remaining the same.