Robotic lateral oropharyngectomy following diagnostic tonsillectomy is oncologically safe in patients with human papillomavirus-related squamous cell cancer: Long-term results.

INTRODUCTION: To report the long-term oncological and functional outcomes of en bloc TORS lateral oropharyngectomy to address the close/involved margin following diagnostic tonsillectomy in HPV-related SCC of unknown primary. MATERIAL AND METHODS: A single tertiary center observational cohort over a 4-year period. Primary outcome measures were disease-specific survival (DSS), overall survival (OS), and PSS NOD (Performance Status Scale-Normalcy of Diet) scores. RESULTS: TORS specimens did not evidence residual carcinoma in 93% of patients. Of 14 patients, 50% received surgery alone (median follow-up 57 months; range 46-96), the remainder surgery and adjuvant therapy (median follow-up of 58 months; range 51-69) with 100% DSS, OS and no deterioration of PSS NOD scores. CONCLUSIONS: Long-term oncological outcomes confirm TORS lateral oropharyngectomy alone is an oncologically safe treatment. Due consideration of this approach is warranted to mitigate against the morbidity of adjuvant radiotherapy treatment in this group of patients.

Quality of life comparison in thyroxine hormone withdrawal versus triiodothyronine supplementation prior to radioiodine ablation in differentiated thyroid carcinoma: a prospective cohort study in the Indian population.

BACKGROUND: Thyroid withdrawal in preparation for radioiodine ablation (RIA) may have a profound impact on health-related quality of life (HRQL). Cost implications and scheduling limit the use of recombinant TSH and triiodothyronine (T3) with its shorter half-life is a conceptually attractive alternative. METHODS: Prospective cohort study design with patients having withdrawal of thyroxine (n = 37) or T3 supplementation (n = 33). HRQL was assessed using EORTC QLQ-C30, QLQ-H&N35 and modified Billewicz questionnaires. Time interval to achieve optimal TSH levels (at least 30 mIU/ml) prior to RIA was determined. RESULTS: With the exception of emotional domain (QLQ-C30 p = 0.045), LT3 supplementation did not confer significant benefit when compared to LT4 withdrawal. Target serum TSH levels was achieved in 95% of patients by week 4 post thyroidectomy. CONCLUSIONS: LT3 supplementation delivered equivocal benefit and therefore the alternate strategies to minimize the impact on HRQL of reduction in the duration of hypothyroidism in T4 withdrawal are suggested.

Recognition and Management of Button Battery Ingestion Amongst Emergency Practitioners.

Introduction Button battery ingestion (BBI) carries a significant risk of morbidity and mortality. We conducted a regional analysis following an NHS England national patient safety alert to evaluate the knowledge base in the emergency management of BBI amongst emergency practitioners. Methods A ten-point questionnaire was distributed electronically and in hardcopy formats to emergency departments across 15 hospitals within the West Midlands, United Kingdom. The questionnaire assessed participants' knowledge of emergency management of BBI. The effect of clinician grade and previous otorhinolaryngology experience on knowledge scores was evaluated. Results A total of 176 responses were received from 11 hospitals. A small proportion (18%) were aware of a local department protocol. The majority of participants (70%) routinely screened for a button battery in their history taking. Our findings highlighted a lack of awareness of the timeframe for mucosal injury, potential complications, radiological signs, and the necessity for immediate retrieval. The median knowledge score was 18.8% (IQR=12.5-31.3%). Both registrars and consultants scored the highest (median 25%). Previous otorhinolaryngology experience was associated with a higher median score (P=0.002). Conclusion Our multi-center regional emergency medicine analysis demonstrated knowledge deficiency in the initial assessment and management of BBI. A high index of suspicion for button battery ingestion is needed. In view of the time-critical nature of button battery impaction in the esophagus, a "golden hour" concept should be integrated into acute management pathways with the early involvement of otorhinolaryngologists.

Outcomes of Tumour Control from Primary Treatment of Hypopharyngeal Cancer.

Hypopharynx cancer continues to pose a clinically challenging head and neck subsite, driven not only by the unique set of patient, anatomic and disease factors but also by the paucity of robust clinical data to guide clinical decision making. The standard of care of radical surgery (pharyngolaryngectomy) in combination with postoperative radiotherapy was the previously accepted norm in the setting of advanced hypopharynx cancer, but this was often at the expense of significant morbidity. In the absence of survival benefit for advanced staged disease with radical surgical approaches, over the last 2 decades, the philosophy of quality of life in survivors has driven the agenda for new therapeutic approaches. The adoption of functional larynx preservation strategies has seen a paradigm shift in the treatment of this subsite since the 1990s with the advent of chemoradiation and intensity-modulated radiotherapy, thereby introducing a reducing trend for radical surgery. However, radical surgery (pharyngolaryngectomy) has a role in the non-functioning larynx (either pre- or post-treatment), in advanced volume disease and the more technically challenging salvage setting because of residual or recurrent disease. In earlier stage disease, transoral laser microsurgery and robotic surgery have shown good oncological benefits. Crucially, determining appropriate personalised treatment decisions in this challenging cohort of patients requires discussion within a multidisciplinary team framework.

Transoral tongue base mucosectomy for the identification of the primary site in the work-up of cancers of unknown origin: Systematic review and meta-analysis.

BACKGROUND: The use of transoral robotic surgery (TORS) and laser microsurgery (TLM) in the diagnosis and identification of the site of the unknown primary has become increasingly common. This systematic review and meta-analysis aims to assess the use and efficacy of TORS and TLM for this indication. METHOD: Systematic review and meta-analysis of studies employing TORS or TLM in diagnosis of the unknown primary tumor site in patients with cervical nodal metastases of squamous cell origin. MEDLINE, EMBASE and CINHAL were searched from inception to July 2018 for all studies that used TORS and or TLM in identifying the unknown primary. RESULTS: 251 studies were identified, of which 21 were eligible for inclusion. The primary tumour was identified by TORS/TLM in 78% of patients (433 out of 556). Tongue base mucosectomy (TBM) identified the primary in 222 of 427 cases (53%). In patients with negative physical examination, diagnostic imaging and PETCT, TBM identified the primary in 64% (95% CI 50, 79) cases. In patients who had negative CT/MRI imaging, negative PETCT and negative EUA and tonsillectomy, TBM identified a tongue base primary in 78% (95% CI 41, 92) cases. Haemorrhage, the commonest complication, was reported in 4.9% cases. Mean length of stay varied between 1.4 and 6.3 days. CONCLUSION: Tongue base mucosectomy, performed by TORS or TLM, is highly efficacious in identifying the unknown primary in the head and neck region.

Robotic lateral oropharyngectomy following diagnostic tonsillectomy is oncologically safe in patients with high risk human papillomavirus related squamous cell cancer.

PURPOSE: Diagnostic tonsillectomy is rarely an oncologic operation owing to close or positive margins. The standard of care is for further treatment to the primary site, typically with adjuvant radiotherapy. METHODS: 14 patients with close or positive margins following a diagnostic tonsillectomy underwent transoral robotic surgery (TORS) and lateral oropharyngectomy; five patients with the longest follow-up had their excision specimens examined with a step serial sectioning technique (SSS). RESULTS: Conventional histopathological examination of the TORS resection specimens did not demonstrate residual carcinoma in 13 patients, confirmed by examination using SSS in 5 patients. There were no post-operative complications or long-term functional deficit. Seven patients received surgery alone with 100% overall and disease specific survival, respectively (median follow-up 27.5 months; range 5.2-50.4). CONCLUSIONS: This prospective study suggests that TORS lateral oropharyngectomy alone is an oncologically safe treatment when close or positive margins are identified on diagnostic tonsillectomy in HPV-positive SCC.

Neck stoma patients: is vital information displayed at the bedside?

Tracheostomies are common procedures in head and neck and critical care practice, with 50% of airway-related deaths attributable to complications such as occlusion or displacement. The National Tracheostomy Safety Project (NTSP) published guidance regarding emergency management of neck stoma patients. A prospective multicentre regional audit of all neck stoma inpatients (ward and intensive care unit (ICU) settings) was conducted. Bed spaces were assessed for tracheostomy care bundles and essential stoma information, as recommended by the NTSP guidelines. The results demonstrate inadequate ward compliance across all three trusts, with ICU compliance greater in comparison to a ward environment. Of note, crucial information regarding the nature of stoma and whom to contact in the event of an emergency, was not displayed in the majority of cases. A greater awareness of the NTSP guidance and implementation of vital information is a necessity across all disciplines in order to reduce stoma complication-related morbidity and mortality.

Fifteen-minute consultation: investigation and management of childhood epistaxis.

Recurrent epistaxis is very common in children, and the majority of cases are self-limiting with simple first aid measures. However, recurrent episodes are a source of distress and anxiety for child and parent alike, and commonly result in hospital referral. We present a structured approach highlighting initial assessment, examination and management including when to refer to ear, nose and throat (ENT) surgery.