Rethinking the 'one-stop' neck lump clinic: a novel pathway beyond coronavirus disease 2019.

OBJECTIVES: UK guidelines advocate 'one-stop' neck lump assessment for cancer referrals. This paper reports the pilot of a novel pre-clinic ultrasound pathway, presents outcomes, and discusses strengths and limitations in the context of the coronavirus disease 2019 pandemic. METHODS: Two-week-wait cancer referral patients with a neck lump were allocated a pre-clinic ultrasound scan followed by a clinic appointment. Demographic, patient journey and outcome data were collected and analysed. RESULTS: Ninety-nine patients underwent ultrasound assessment with or without biopsy on average 8 days following referral. Patients were followed up on average 14.1 days (range, 2-26 days) after initial referral. At the first clinic appointment, 45 patients were discharged, 10 were scheduled for surgery, 12 were diagnosed with cancer, 6 were referred to another specialty and cancer was excluded in 19 patients. Retrospectively, four ultrasounds were performed unnecessarily. CONCLUSION: Pre-clinic ultrasound scanning is an alternative to the one-stop neck lump pathway. This study demonstrates fewer clinic visits, faster diagnosis and a low proportion of unnecessary scans, whilst minimising face-to-face consultations and aerosol-generating procedures.

Postoperative monitoring of the free jejunal flap: use of colour duplex and systematic review of available techniques.

Introduction The free jejunal flap represents the gold standard for circumferential defects in upper digestive tract reconstruction. It is a technically demanding procedure with significant failure rates. Unrecognised failure leads to flap necrosis and potentially fatal sequelae, including sepsis and carotid artery bleed. Despite these catastrophic consequences, however, there remains no consensus on an optimum method for postoperative flap monitoring. Our unit has pioneered the use of external colour duplex ultrasound to monitor flap vascularity. We describe this technique and systematically review other published monitoring systems. Materials and methods A patient underwent oesophageal reconstruction using a jejunal free flap. Monitoring commenced immediately via external application of a colour duplex probe over the flap's vascular pedicle to facilitate flow volume assessment. Further bi-daily assessments were successfully used to monitor the postoperative viability of the flap. The systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results Six alternative monitoring techniques were identified: exteriorised jejunal segment, implantable Doppler probe, watch window, microdialysis, microendoscopy and reflectance photoplethysmography. Discussion Exteriorised jejunal segment and implantable Doppler probe are most commonly described, yet both are associated with high false positive rates, which is particularly significant in a patient demographic facing increased general anaesthetic risk. Most other techniques remain experimental. External colour Doppler ultrasound provides the surgeon with immediate reassurance following the reconstruction, requires minimal training to use, and eliminates the need for revisional procedures. Conclusion Our initial experience suggests that external colour Doppler ultrasound has exciting potential as an efficient and noninvasive technique for monitoring the free jejunal flap.

Do demographics and tumour-related factors affect nodal yield at neck dissection? A retrospective cohort study.

BACKGROUND: Nodal metastasis is an important prognostic factor in head and neck squamous cell carcinoma. This study aimed to determine the average nodal basin yield per level of neck dissection, and to investigate if age, gender, body mass index, tumour size, depth of tumour invasion and p16 status influence nodal yield. METHOD: A retrospective review of 185 patients with head and neck squamous cell carcinoma generated 240 neck dissection specimens. RESULTS: The respective mean nodal yields for levels I, II, III, IV and V were 5.27, 9.43, 8.49, 7.43 and 9.02 in non-cutaneous squamous cell carcinoma patients, and 4.2, 7.57, 9.65, 4.33 and 12.29 in cutaneous squamous cell carcinoma patients. Multiple regression analysis revealed that p16-positive patients with mucosal squamous cell carcinoma yielded, on average, 2.4 more nodes than their p16-negative peers (p = 0.04, 95 per cent confidence interval = 0.116 to 4.693). This figure was 3.84 (p = 0.008, 95 per cent confidence interval = 1.070 to 6.605) for p16-positive patients with oral cavity squamous cell carcinoma. CONCLUSION: In mucosal squamous cell carcinoma, p16-positive status significantly influenced nodal yield, with the impact being more pronounced in oral cavity squamous cell carcinoma patients.

Assessment and management of presumed branchial cleft cysts: our experience.

Assessment and management of presumed branchial cleft cysts: our experience. OBJECTIVES: The aim was to assess the accuracy of diagnosis and management of presumed branchial cleft cysts in our centre. METHODOLOGY: Retrospective review of patients with a clinical diagnosis of branchial cleft cyst at B arts Health NHS Trust from 2009 to 2015. RESULTS: 67 patients underwent surgical excision for presumed branchial cysts. Ninety per cent were histologically confirmed, 7% demonstrated cystic metastatic squamous cell carcinoma, and 3% lymph node metastases from papillary thyroid cancer. No patient had pre-operative Multi-Disciplinary Team (MDT) discussion. Pre-operative FNA had a positive predictive value of 90% (95% Cl 0.82-0.95). Age >40 years (p=0.02) and presence of lymph nodes (p=0.02) carried a higher risk of malignancy. CONCLUSIONS: Patients >40 years with or without multiple lymph nod 'es on imaging should be treated as presumed meta- static cancer. Consideration should be given to concurrent panendoscopy and intra-operative frozen section +/- selective neck dissection after discussion at the Head & Neck MDT.

Psychological status in female carriers of premutation FMR1 allele showing a complex relationship with the size of CGG expansion.

We utilized a sample of 299 adult females aged between 19 and 86 years, carrying fragile X mental retardation (FMR1) alleles with small CCG expansions ranging from 50 to 141 repeats to analyse the relationships between psychological symptoms as assessed by the Symptom Checklist-90-Revised (SCL-90-R) and the size of the CGG repeat in the FMR1 gene. There were highly significant (negative) correlations between the size of the CGG repeat and a great majority of SCL-90-R subscale scores and all the global indices, suggesting that carriers of premutations in the mid-size CGG repeat range may be at greatest risk for the development of psychiatric disorder.

Middle-ear involvement in type I Gaucher's disease - a unique case.

OBJECTIVE: Gaucher's disease is a rare autosomal recessive lysosomal storage disease. We describe a unique case of middle-ear involvement presenting with hearing loss. CASE REPORT: A five-year-old boy with known Gaucher's disease presented with bilateral hearing impairment and conductive hearing loss on pure tone audiometry with flat tympanometry traces. INTERVENTION: Exploratory Tympanomastoidectomy revealed inflammatory material filling the mastoid and the middle ear. Histological analysis confirmed Gaucher cell infiltrates. CONCLUSION: This is the first detailed report in the english language literature of Gaucher's disease affecting the middle ear and the mastoid. We discuss the disease process and suggest future management options.

Ear, nose and throat day-case surgery at a district general hospital.

INTRODUCTION: In 2000, The NHS Plan in the UK set a target of 75% for all surgical activity to be performed as day-cases. We aim to assess day-case turnover for ENT procedures and, in particular, day-case rates for adult and paediatric otological procedures together with re-admissions within 72 h as a proxy measure of safety. PATIENTS AND METHODS: Retrospective collection of data (procedure and length of stay) from the computerised theatre system (Galaxy) and Patient Information Management System (PIMS) of all elective patients operated over one calendar year. The setting was a district general hospital ENT department in South East England. All ENT operations are performed with the exception of oncological head and neck procedures and complex skull-base surgery. RESULTS: Overall, 2538 elective operations were performed during the study period. A total of 1535 elective adult procedures were performed with 74% (1137 of 1535) performed as day-cases. Of 1003 paediatric operations, 73% (730 of 1003) were day-cases. Concerning otological procedures, 93.4% (311 of 333) of paediatric procedures were day-cases. For adults, we divided the procedures into major and minor, achieving day-case rates of 88% (93 of 101) and 91% (85 of 93), respectively. The overall day-case rate for otological procedures was 91% (528 of 580). Re-admission rates overall were 0.7% (11 of 1535) for adults and 0.9% (9 of 1003) for paediatric procedures. The most common procedure for re-admission was tonsillectomy accounting for 56% of all adult re-admissions and 78% of paediatric re-admissions. The were no deaths following day-case procedures. DISCUSSION: ENT surgery is well-suited to a day-case approach. UK Government targets are attainable when considering routine ENT surgery. Day-case rates for otology in excess of targets are possible even when considering major ear surgery.