Lateral cystic neck masses in adults: a ten-year series and comparative analysis of diagnostic modalities.

BACKGROUND: In adults, the solitary lateral cystic neck mass remains a diagnostic challenge with little solid material to target for cytology and few clues on imaging modalities to suggest underlying malignancy. METHOD: This study was a retrospective review of patients presenting with a lateral cystic neck mass to a tertiary academic head and neck centre over a 10-year period. RESULTS: A total of 25 of 157 cystic lesions were subsequently malignant on paraffin section histopathology, with the youngest patient being 42 years. In the age cohort over 40 years, 30 per cent of males and 10 per cent of females were diagnosed with malignancy. The ipsilateral palatine tonsil was the most common primary site (50 per cent). A total of 85 per cent of cases demonstrated integrated human papillomavirus infection. Age, male sex and alcohol were significant risk factors on univariate analysis. Ultrasound-guided fine needle aspiration cytology and magnetic resonance imaging represented the most accurate pre-open biopsy tests. CONCLUSION: The authors of this study advocate for a risk-stratified, evidence-based workup in patients with solitary lateral cystic neck mass in order to optimise timely diagnosis.

The management of vacuum neck drains in head and neck surgery and the comparison of two different practice protocols for drain removal.

Introduction The management of vacuum neck drains in head and neck surgery is varied. We aimed to improve early drain removal and therefore patient discharge in a safe and effective manner. Methods The postoperative management of head and neck surgical patients with vacuum neck drains was reviewed retrospectively. A new policy was then implemented to measure drainage three times daily (midnight, 6am, midday). The decision for drain removal was based on the most recent drainage period (at <3ml per hour). A further patient cohort was subsequently assessed prospectively. The length of hospital stay was compared between the cohorts. Results The retrospective audit included 51 patients while the prospective audit included 47. The latter saw 16 patients (33%) discharged at least one day earlier than they would have been under the previous policy. No adverse effects were noted from earlier drain removal. Conclusions Measuring drainage volumes three times daily allows for more accurate assessment of wound drainage, and this can lead to earlier removal of neck drains and safe discharge.

Transoral laser resection versus lip-split mandibulotomy in the management of oropharyngeal squamous cell carcinoma (OPSCC): a case match study.

The objective of this study was to compare transoral laser microsurgery (TLM) with lip-split mandibulotomy (LSM) and radial forearm free-flap reconstruction, for the resection of squamous cell carcinoma of the oropharynx (SCCOP). This study is designed as a case-control study matching 24 patients treated with TLM for SCCOP with those treated with LSM. Patients were matched by age (in 5-year epochs), sex, TNM stage, tumour sub site and type of neck dissection. Each group comprised 20 males and 4 females (mean age 56 years). Seven patients treated with TLM had an elective tracheostomy compared with all patients undergoing LSM. Moreover, the time for decanulation was reduced in patients undergoing tracheostomy for TLM. Although similar rates of patients were able to swallow to some degree on discharge, 29% of patients having LSM were discharged requiring enterostomy feeding compared with 4% of patients treated using TLM. Of those able to swallow on discharge, patients who had TLM resumed swallowing in half the time taken for those having LSM. Moreover, those treated with TLM remained in hospital for half the length of time than those treated with LSM. Due to these factors, overall cost for TLM is reduced in comparison with LSM. In comparison with LSM, TLM for the treatment of SCCOP results in fewer tracheostomies and shorter time to decanulation; a quicker recovery of swallowing function and a reduced length of hospital stay. As a result of this, treatment with TLM is on average cheaper. These factors should be considered when deciding on the surgical treatment of a patient with SCCOP.

Accuracy of magnetic resonance imaging in diagnosing thyroid cartilage and thyroid gland invasion by squamous cell carcinoma in laryngectomy patients.

OBJECTIVES: We examined the accuracy of magnetic resonance imaging in assessing thyroid cartilage and thyroid gland invasion in patients undergoing total laryngectomy for squamous cell carcinoma, by comparing histopathology results with imaging findings. STUDY DESIGN: A retrospective study reviewed histology and magnetic resonance scan results for all total laryngectomies performed between 1998-2008 at University Hospital Aintree, Liverpool. METHODS: Pre-operative magnetic resonance images were reviewed independently by two consultant head and neck radiologists masked to the histology; their opinions were then compared with histology findings. RESULTS: Eighty-one magnetic resonance scans were reviewed. There were 22 laryngectomy patients with histologically verified thyroid cartilage invasion and one patient with thyroid gland invasion. There were 31 patients with apparent radiological thyroid cartilage invasion pre-operatively (with 17 false positives), giving sensitivity, specificity, and positive and negative predictive values of 64, 71, 45 and 84 per cent, respectively. On assessing thyroid gland invasion, there were nine false positive scans and no false negative scans, giving sensitivity, specificity, and positive and negative predictive values of 100, 89, 10 and 100 per cent, respectively. CONCLUSION: Magnetic resonance scanning over-predicts thyroid cartilage and gland invasion in patients undergoing total laryngectomy. Magnetic resonance scans have limited effectiveness in predicting thyroid cartilage invasion by squamous cell carcinoma in laryngectomy patients.

Acoustic analysis in asthmatics and the influence of inhaled corticosteroid therapy.

The impact of sustained inhaled corticosteroid (ICS) therapy on the larynx and pharynx was assessed using a prospective, cross-sectional, and investigator-blinded study conducted at the University Hospital Aintree, Liverpool, UK. Forty-six adults recruited from two local general practices and from general ENT clinics at our University hospital were investigated for the study. Patients were allocated to three groups according to ICS use. Laryngeal effects were measured by correlating the results of a vocal performance questionnaire, a respiratory symptom questionnaire, and measurements obtained by computerized speech analysis. Sustained vowels and connected speech were analyzed in normal and asthmatic subjects. Acoustic analysis was correlated with cellular markers of inflammation after biopsy. Regular ICS users had significantly more pharyngeal inflammation and throat discomfort (P<0.0001). Vocal performance was also worse in this group (P<0.0001). They were more likely to have hoarseness, weakness of voice, aphonia, sore throat, throat irritation, and cough (P<0.0001). All these variables were directly related to one another (P<0.0001). Multiple linear regression analysis showed that jitter was a good objective measure of hoarseness (P<0.05). Regular ICS users were significantly more likely to have abnormal jitter, shimmer, and closed-phase quotient scores (P<0.0001). There was no difference between the groups in the observed parameters of inflammation (P>0.01). A higher pharyngitis score did not correlate with any of the histological markers of inflammation (P>0.01). Local side effects are more common in asthmatics that use ICS regularly. Measures of laryngeal function are significantly worse in regular ICS users. However, histological markers and oropharyngeal redness are not reliable measures of inflammation.

Prospective, randomized cross-over trial to assess the ability of a dry-powder inhaler to reverse the local side effects of pressurized metered-dose inhalers.

OBJECTIVES: To determine whether a corticosteroid dry-powder inhaler could reverse the pharyngeal and laryngeal side effects produced by a corticosteroid pressurised metered-dose inhaler. DESIGN: Prospective, randomized, controlled, cross-over, evaluator-blinded study. SETTING: University Hospital Aintree, Liverpool, United Kingdom. PATIENTS: Thirty-seven adults recruited over a 12-month period from Ear, Nose and Throat clinics at our University hospital. Patients were randomized into three groups using a computer-generated random number list and sealed opaque envelopes. MAIN OUTCOME MEASURES: Scores were achieved on respiratory symptom and vocal performance questionnaires. Acoustic analysis was performed followed by a standardized biopsy of the posterior pharyngeal wall. Histological markers of inflammation were correlated with pharyngitis. The data were tested for normality using the Kalmogorov-Smirnov test. The Kruskal-Wallis analysis of variance was used to investigate differences between medians and ranges. The data were further investigated for correlations using the Spearman test. Discriminant analysis was used to examine the effect of the three groups on each variable. RESULTS: Discomfort scores (median and range) were significantly lower after dry-powder inhaler use than with either a spacer or water gargle (p < 0.01). These worsened after restoring pressurized metered-dose inhaler therapy. The reduction in pharyngitis in each of the three groups was not significant. Vocal performance scores improved with dry-powder inhaler use. Jitter, shimmer, and closed-phase quotient scores improved with dry-powder inhaler use (p < 0.01). Shimmer scores deteriorated once the pressurized metered-dose inhaler was restored (p < 0.01). There was no significant difference between the groups in most observed parameters of inflammation (p > 0.01). CONCLUSION: A dry-powder inhaler may alleviate the local side effects produced by a pressurized metered-dose inhaler. Laryngeal dysfunction appears to be particularly responsive to the absence of propellant. More observational and randomized controlled trials are necessary to examine existing inhalers and specifically, how and why they cause local side effects.

Prevalence of pharyngeal and laryngeal complications in adult asthmatics using inhaled corticosteroids.

OBJECTIVES: To investigate the prevalence in adults of pharyngeal and laryngeal symptoms associated with the use of inhaled corticosteroids. DESIGN: Prospective, observational and based on a structured, specifically designed postal questionnaire. SETTING: University Hospital Aintree, Liverpool, UK. PARTICIPANTS: The questionnaire was distributed to 190 patients on the basis of current inhaled corticosteroid use. Recruitment was from the databases of two local general practices. Individuals were classified as mild, moderate or severe asthmatics, using the guidelines of the British Thoracic Society. MAIN OUTCOME MEASURES: Demographic data, including smoking history, were recorded. The number, type, strength, dosing regime and duration of individual inhaler use were recorded. Specific pharyngeal and laryngeal side effects were enquired about. Co-morbidities and preventive measures were also recorded. Results were analysed using univariate and multivariate statistical tests. RESULTS: There was a 75.8 per cent response rate (144/190 questionnaires); 63 (43.8 per cent) of respondents were male and 81 (56.2 per cent) were female. The majority of our patients were either mild or moderate asthmatics. Longer use of an inhaled corticosteroid predisposed to weak voice (p = 0.0016), hoarseness (p = 0.0001) and throat irritation (p = 0.008). Hoarseness, throat irritation, sore throat and cough were observed much more frequently than anticipated. Severe asthmatics were more likely to use a spacer device compliantly (p = 0.0487; odds ratio 1.53). Side effects were more prevalent as asthma severity worsened (p = 0.0049; odds ratio 1.87). CONCLUSIONS: Inhaled corticosteroids cause sore throats, throat irritation, hoarseness and cough. Further research in this area is required in order to elucidate the mechanism of inflammation. Only then can effective preventive measures be introduced and implemented.

The inflammation produced by corticosteroid inhalers in the pharynx in asthmatics.

OBJECTIVES: To investigate inflammation of the pharyngeal mucosa caused by inhaled corticosteroids. DESIGN: Prospective, cross-sectional, single-blinded study. SETTING: University Hospital Aintree, Liverpool, UK. PATIENTS: Fifty adults were recruited from two local general practices and from general ENT clinics at our University hospital. Patients were allocated to one of four groups according to use of inhaled corticosteroids and the presence of adverse local side effects. MAIN OUTCOME MEASURES: Scores achieved on a respiratory symptom questionnaire. Histological markers of inflammation and their correlation with pharyngitis. Statistical modelling included univariate and multivariate analyses, which included multiple linear and logistic regression, and discriminant analysis. RESULTS: The regular use of inhaled corticosteroids predisposed subjects to hoarseness, weakness of voice, sore throat and throat irritation (P < 0.0001). Pharyngitis was significantly different between the groups (P < 0.0001). Furthermore, those not using an inhaled corticosteroid regularly had little or no clinically apparent pharyngitis, whereas those using an inhaled corticosteroid regularly had significantly higher pharyngitis scores (P = 0.0204). Similarly, weakness of voice (P = 0.0234), hoarseness (P < 0.001) and sore throat (P < 0.001) were also more common in those patients that used an inhaled corticosteroid on a regular basis. To our surprise, however, cellular markers of inflammation did not corroborate the appearances of clinical examination. We found that the five most important discriminators, between those that were using inhaled corticosteroid therapy regularly and those that were not, to be intra-epithelial inflammatory cells (scdf -1.2939); age (scdf 0.8389); use of a spacer device (scdf 0.5456); sore throat (scdf 0.4230) and throat irritation (scdf 0.4015). The groups were significantly different (P < 0.0001). The statistical model used, classified 68% of the cases correctly into their respective groups. CONCLUSIONS: Inhaled corticosteroids predispose to pharyngitis and an inflammatory infiltrate. However, the clinical diagnosis of pharyngitis does not correlate well with cellular inflammatory infiltrate and is therefore, not a reliable measure of underlying inflammation. We advocate caution in the use of pharyngeal erythema as a measure of underlying inflammation.

Head and neck cancer waiting times.

The guidelines for treating cancer changed in December 2005 to no longer than 62 days from urgent referral to treatment, or 31 days from diagnosis to treatment. The use, by general practitioners, of suspected head and neck cancer proformas has reduced the time taken from referral to first outpatient appointment from 15 days in 2003 to 5.5 days in 2005. The introduction of specific radiology request forms for suspected malignancy has allowed easier identification of requests for imaging and subsequently a shorter waiting time for radiological investigations from 23 days in 2003 to 10 days in 2005. The appointment of a new dedicated head and neck cancer consultant at Aintree and the provision of another linear accelerator have reduced the waiting time for surgery from 68 days in 2003 to 39 days in 2005 and radiotherapy from 86 days in 2003 to 52.6 days in 2005. Patients not referred as suspected cancer patients who subsequently receive primary radiotherapy for a head and neck cancer fall outside the 62 day rule, being treated on average 70 days after referral.

Look before you pack: key point in epistaxis management.

We report a patient with epistaxis who used cotton wool to pack his nose before reaching the hospital, and underwent further packing in the accident and emergency department, which probably pushed the cottonwool further back. This led to the formation of foreign body granuloma inside the nasal cavity. It is difficult to examine the nose without proper equipment and experience, and the examination is more difficult in the presence of active bleeding to find a foreign body such as cotton wool. Hence, it is important to ask the patient about any temporary pack they have used in the nose and to look for and remove it before inserting a proper pack. It is also important for trainees to have a better understanding of the different levels of management of epistaxis. Hence, we propose the term "epistaxis management ladder" for easy understanding of the treatment of epistaxis.

Myringoplasty using a subcutaneous soft tissue graft.

A retrospective study was performed on patients who underwent myringoplasty using an autologous subcutaneous soft tissue graft over a 5-year period. Details including age, site and size of perforation, grade of surgeon, surgical approach, postoperative dressings, overnight stay, complications and outcome were recorded and analysed. Fifty-two patients underwent myringoplasty using a subcutaneous soft tissue graft. Their ages ranged from 4 to 78 years (median = 36 years). The mean follow-up period was 19 months. Successful closure to give an intact tympanic membrane was obtained in 82.7% of patients. Thresholds improved on pure tone audiometry in 57.1% and deteriorated in only one patient. There was no case of dead ear as a result of surgery. Subcutaneous tissue graft has comparable outcomes with temporalis fascia graft with additional advantages of a smaller incision, minimum dissection and a lower risk of bleeding.

Airway intervention in adult supraglottitis.

BACKGROUND: The timing of aggressive airway intervention in adult epiglottitis is controversial. AIMS: To correlate Friedman's staging of epiglottitis on admission with the airway interventions undertaken. METHODS: A retrospective study of 23 adult patients, mean age 51 years (range 29-81 years), who had been admitted with acute supraglottitis between March 1988 and December 2000 was undertaken. RESULTS: Three patients (13%) had airway interventions; two with tracheostomy and one with tracheal intubation. All were Friedman stage III and had rapid symptom progression during the 24 hours prior to admission. Three other stage III patients with symptom progression longer than 24 hours and all the remaining patients (stage II or less) were managed with observation and intravenous therapy. CONCLUSIONS: Friedman originally advocated airway intervention in any patient stage II or worse, but this intubation threshold should probably be lowered to those patients with rapid-onset stage Ill (moderate respiratory distress, stridor, respiratory rate > 30 per minute, pCO2 > 45mmHg) disease.

Day-case myringoplasty: five years' experience.

A retrospective study of patients who underwent myringoplasty as a day-case procedure in two freestanding day-surgery units during a five-year period was carried out. Their case notes were identified and details including age, site and size of perforation, grade of surgeon, surgical approach, graft material, post-operative dressings, overnight stay, complications, and outcome were noted and analysed. The total number of patients including both children and adults who had myringoplasty as a day case was 144. Of these, 125 patients with 143 procedures were included in this study. Their ages ranged from four to 74 years (mean = 31 years). The perforation size was small in 40 cases, medium in 61 cases, and large/subtotal in 42 cases. The overnight stay rate was 2.7 per cent and this was for immediate post-operative problems such as nausea and bleeding from the wound. The readmission rate for post-operative complications was 2.1 per cent. The follow-up ranged from six months to five years (mean = 19 months). The success rate was 83.3 per cent and thresholds on pure tone audiometry improved in 69.2 per cent of cases. The age of the patient, grade of the surgeon, and graft material did not influence the surgical outcome. There was no case of dead ear as a result of surgery. Myringoplasty can be safely performed in both adults and children as a day-case procedure with low overnight stay and readmission rates. Success rates are comparable to when the procedure is performed on an in-patient basis.

Hearing loss due to mannosidosis and otitis media with effusion. A case report and review of audiological assessments in children with otitis media with effusion.

A case of a child with mannosidosis and bilateral otitis media with effusion (OME) is reported here along with some discussion of relevant literature to emphasize the need for age appropriate audiometric assessment before and after insertion of grommets for glue ear (OME). There is a need for multidisciplinary teamwork in the management of children with hearing loss. If OME is treated surgically, age-appropriate hearing assessment is required before and after insertion of grommets. The need for audiological assessments will be relevant even if children had passed the newborn hearing screening test.

Foreign body reaction to calcium alginate fibre mimicking recurrent tumour of the submandibular salivary gland.

A 50-year-old woman was referred after the discovery of adenoid cystic carcinoma in an excised left submandibular gland. Treatment involved clearance of the left submandibular fossa, and bilateral levels II and III selective neck dissections. A left-sided submandibular haematoma developed during the immediate postoperative period. After removal of the clot, there was a persistent, low volume capillary ooze from the left submandibular fossa and a calcium alginate fibre pack (Kaltostat) was left in place to control the bleeding. After an extended period of time the pack excited a foreign body reaction which, on a computed tomogram, mimicked a recurrence of the tumour. We review the role of Kaltostat in this setting and its potential for foreign body reaction, which may mimic serious disease.

Waiting times during the management of head and neck tumours.

The waiting times incurred during the management of 75 consecutive head and neck oncology patients attending for post-treatment follow-up were reviewed. Data were gleaned from general practitioner (GP) referral letters, patient case-notes as well as radiology and histology reports. The mean time for GP referral to ENT was 5.1 weeks. From ENT to endoscopy was 3.1 weeks, to histology 3.5 weeks, to computed tomography (CT) scan 5.6 weeks, to magnetic resonance scan (MR) 4.1 weeks, to primary radiotherapy 10.3 weeks and to surgery 5.5 weeks. The mean symptom duration prior to referral was 4.9 months. Our results compare unfavourably with the standards recommended by the BAO-HNS. Local modifiations may improve matters, but significant increases in funding, manpower and equipment are required to achieve the stipulated standards. Moreover, criteria for referral have to be re-emphasized and patient education has to be addressed as these appear to contribute the longest delay in the diagnosis of head and neck tumours.

Observer error in the assessment of nodal disease in head and neck cancer.

BACKGROUND: There is no previously published information on clinicians' abilities to accurately differentiate between different stages of node positive disease in head and neck cancer. METHODS: Forty-two surgeons examined standardized nodes in a model neck and estimated nodal size. Each recorded their confidence in their ability to perform the task using a visual analogue scale. Reference nodes of known size were provided for comparison during a second examination of each node. The study was repeated after 1 month. RESULTS: Accuracy was poor and was not dependent on experience or confidence. There was a tendency to underestimate the size of smaller nodes. Estimates were strongly influenced by volume independent of largest diameter (p <.001). Reference nodes aided accuracy (p =.031). Subjects were not consistent on repeated testing (p <.001). CONCLUSIONS: Both trainees and specialists are poor at accurately staging nodal disease using palpation alone.