Recurrent acute otitis media detracts from health-related quality of life.

OBJECTIVE: Acute otitis media causes discomfort to children and inconvenience to their parents. This study evaluated the quality of life in children with recurrent acute otitis media aged less than 24 months. METHODS: Quality of life was evaluated in 149 children aged 10 to 24 months who were referred to the Oulu University Hospital on account of recurrent acute otitis media. The children were treated with or without surgery. Age-matched controls were selected randomly from the general child population. Parents completed the Child Health Questionnaire. RESULTS: The children with recurrent acute otitis media had a significantly poorer quality of life than control children. The control children with a history of a few acute otitis media episodes had a significantly poorer quality of life than those without any such history. The quality of life of the children with recurrent acute otitis media improved during the one-year follow up, regardless of the treatment, but did not reach the same level as healthy children. CONCLUSION: Acute otitis media detracted from quality of life when a generic measure was used. The mode of treatment used to prevent further recurrences of acute otitis media did not influence quality of life improvement.

Predictive Factors for Medical Consultation for Sore Throat in Adults with Recurrent Pharyngotonsillitis.

Objects. To seek patient- and episode-related factors that associate with medical consultation for acute sore throat because these factors may affect the patient being referred to specialist care and tonsillectomy for recurrent pharyngotonsillitis. Methods. In a secondary analysis of two prior randomised controlled trials, sore throat episodes and medical visits were explored among 156 adult patients referred for tonsillectomy because of recurrent pharyngotonsillitis. Results. The 156 patients (104 females, mean age of 26 years) suffered from 208 acute pharyngotonsillitis episodes during 5-6 months of follow-up. Forty (25%) patients visited a physician, and female gender (adjusted hazard ratio, HR, 3.3; 95% confidence interval 1.4-8.0) and finding of chronically infected tonsils (HR 2.7; 1.2-6.1) were associated with medical consultation. Thirty-six (17%) episodes led to medical consultation during the first 7 days of symptoms. Presence of severe throat pain was related to medical visit (HR 4.3; 1.0-18.5). Conclusions. Even among patients with recurrent pharyngotonsillitis, the acute sore throat episodes were usually mild and only few resulted in medical consultation, with female gender, chronically infected tonsils, and having severe throat pain increasing the consultation rate.

Use of real patients in teaching ENT diseases to undergraduate students and its effects on patient satisfaction: cross-sectional survey.

OBJECTIVES: To describe a method of using real patients in teaching ENT to undergraduates and to examine whether being a case patient affected patient satisfaction. METHODS: In a cross-sectional study, 68 teaching-involved patients (case patients) with a suspected common ENT illness and 68 matched (in terms of age, sex and region of complaint) control patients evaluated the health service and their encounter with the physician. The students saw the case patients first independently and then saw the patient with the teacher physician. The controls were treated in a normal way. RESULTS: Fifty-eight case patients (84 per cent) and 65 control patients (95 per cent) answered the questionnaire. The median duration of the visit was significantly longer for the case patients than the controls (115 vs 60 minutes). Almost all patients in both groups graded the overall quality of the health service, and the variables describing various aspects of the setting and the encounter with the physician, as either good or excellent. CONCLUSION: Patients who took part in the undergraduate teaching of ENT diseases were equally content with their primary visit as the control patients, even though their visit took a markedly longer time.

Predictive factors for quality of life after tonsillectomy among adults with recurrent pharyngitis: a prospective cohort study.

OBJECTIVES: To assess health-related quality of life (QoL) and clinical factors predicting it after tonsillectomy among adult patients with recurrent pharyngitis. DESIGN: Prospective cohort design. SETTING: Tertiary referral centre. PARTICIPANTS: Adults (n = 153) who underwent tonsillectomy for recurrent pharyngitis. MAIN OUTCOME MEASURES: QoL 6 months after tonsillectomy measured by the Glasgow Benefit Inventory (GBI). Factors predicting high postoperative QoL were sought using multiple linear regression analysis. RESULTS: Of the 142 patients (93% of all eligible) responding to the GBI questionnaire, 94 (66%) were female; median age was 26 years (range 14-65). GBI Total Scores varied markedly (range -19 to +69), but on average showed improvement (median +27, interquartile range 18-36), most evidently in the GBI Physical Health Score (median +83), after tonsillectomy. Among routinely recorded clinical characteristics, the number of prior pharyngitis episodes, frequent throat pain, untreated dental caries and chronically infected tonsils made up the optimal subset of factors for predicting the GBI Total Score. However, in a random sample of patients (n = 56) for whom preoperative diary-based data were also available, somewhat better predictive ability was achieved based on just two diary items: number of days with throat pain and with fever during the preceding few months (correlation coefficient, r, between observed and fitted scores improved from 0.39 to 0.55). Yet, the precision of even these predictions was still quite low. CONCLUSIONS: Adult patients with recurrent pharyngitis were on average satisfied after tonsillectomy, regardless of the aetiology of the episodes. Clinical factors rather modestly predicted which patients benefited most from the operation.

Patient-recorded outcomes and quality of life in evidence-based medicine databases on most common ear, throat and nose procedures: a systematic review.

BACKGROUND: The Cochrane database of systematic reviews is an evidence-based medicine (EBM) database that provides the highest quality evidence of the effect of various treatments. Quality of life (QoL) is an important aspect when treatment effect is considered. OBJECTIVE: To assess how often patient-reported outcome measures (PROM), and specifically the quality of life aspect, were evaluated in the randomised controlled trial projects (RCTs) included in the Cochrane database of systematic reviews of the most common ear, throat and nose operations. Also, to explore the same in ongoing trials registered in ClinicalTrials.gov. METHODS: Structured literature search. SEARCH STRATEGY AND EVALUATION METHOD: The Cochrane database of systematic reviews that evaluated the effects of ventilation tube insertion, adenoidectomy, tonsillectomy and endoscopic sinus surgery was assessed. The RCTs on which the reviews' conclusions were based were explored, and the outcome variables were recorded. A similar search was carried out in the ClinicalTrials.gov trial register. RESULTS: In the Cochrane database, we identified seven systematic reviews with 30 RCT projects. Fourteen (49%) collected some sort of PROM and of those, three (10%) used a validated QoL instrument. After the year 2000, the respective figures were 12 of 15 (80%) and 3 of 15 (20%). In ClinicalTrials.gov, we found 500 ongoing studies on the most common ENT operations, nine being RCTs relevant to this review. Five (55%) and three (30%) of the ongoing RCTs in ClinicalTrial.gov assess PROM and QoL topics in ENT surgery, respectively. CONCLUSIONS: Since the introduction of QoL instruments in the 1990s, their use has gradually increased, but validated QoL instruments have been used in only one of 10 RCTs included in EBM databases. Ongoing RCTs consider QoL only slightly more often.

Addendum to 'Continuous assessment of nasal airflow resistance by adaptive modeling'.

This addendum adds to the analysis of 'Continuous assessment of nasal airflow resistance by adaptive modeling' (Seppänen et al 2009 Physiol. Meas. 30 1197­209). The technical repeatability tests of the new nasal resistance measurement system presented here show that the resistance values remained very stable during two successive measurements indicating excellent repeatability.

Continuous assessment of nasal airflow resistance by adaptive modeling.

A method to assess nasal airflow resistance is presented that provides a continuous resistance value and applies a novel minimally obtrusive measurement technique. Instead of calculating the resistance once for each breathing cycle conventionally, it is calculated for each signal sample at any sampling frequency. The continuous pressure recording is produced with a nasopharyngeal catheter inserted 8 cm deep along the floor of the other nasal cavity and the flow recording is produced with respiratory effort bands. A least-mean-square (LMS) extension for the resistance model of Broms is developed that dynamically adapts to the time-varying characteristics of the nasal functioning and produces the continuous resistance values. Experimental results are shown that demonstrate the uniqueness and applicability of the new technique in assessing quickly changing resistance in a histamine/xylometatsolin challenges, the differences between normal and symptomatic patients, and the effect of nasal treatment of patients.

Factors affecting quality-of-life impact of adult tonsillectomy.

OBJECTIVE: To assess the quality of life of adult patients with recurrent tonsillitis after tonsillectomy, and to determine predictive factors for patient satisfaction. METHODS: In a prospective cohort study, a Glasgow benefit inventory questionnaire was posted to 70 adult patients six months after tonsillectomy for recurrent tonsillitis. Data were obtained on patient characteristics, risk factors, tonsillitis history, and clinical and operative findings. The patients were also assessed using self-completed diary data collection regarding acute symptoms (i.e. fever, throat pain, cough and rhinitis), tonsillitis episodes and visits to a doctor, either three to six months before tonsillectomy or six months after tonsillectomy. Predictive factors were sought for inclusion in the worst 30th percentile of patients (i.e. Glasgow benefit inventory score under 18), regarding post-operative change in quality of life. RESULTS: Sixty-two patients (40 females, 22 males; age range 15-46 years) returned the questionnaire (response rate 89 per cent). The mean total Glasgow benefit inventory score after tonsillectomy was +26 (standard deviation 14). The mean scores for Glasgow benefit inventory subscales were: general health +25 (standard deviation 18), social functioning +5 (standard deviation 14) and physical functioning +55 (standard deviation 23). The only factors associated with low patient satisfaction were a small number of tonsillitis episodes (diary-based data) and days with fever before tonsillectomy. CONCLUSIONS: Adult patients with recurrent tonsillitis seemed to be generally pleased with their tonsillectomy. The more symptoms they had prior to surgery, the greater was their improvement in quality of life. No other patient- or disease-related factors were associated with patient satisfaction.

Diagnostic delays in vestibular schwannoma.

OBJECTIVES: The literature on delays in vestibular schwannoma diagnosis is from the era before the routine use of magnetic resonance imaging. We evaluated such diagnostic delays and their impact on tumour size and on pre- and post-treatment morbidity, in a relatively recent patient series. STUDY DESIGN: Retrospective review. METHODS: A two-centre study was conducted, including 91 consecutive vestibular schwannoma patients diagnosed between 1992 and 2006. Data on the presenting symptom and the initial medical visit were obtained from primary care records completed at the time of the initial visit; data on the tumour and the clinical course were obtained from review of the hospital chart. Data on diagnostic delays were available for 59 patients. RESULTS: The median patient, professional and total diagnostic delays were three, four and 14 months, respectively. Unilateral hearing loss as the presenting symptom predicted an lengthened total diagnostic delay. Diagnostic delay had no impact on the tumour size at time of diagnosis or on the pre- and post-treatment morbidity. CONCLUSIONS: Delays in the diagnosis of vestibular schwannoma have shortened since the introduction of magnetic resonance imaging. Longer diagnostic delays do not seem to have significant consequences.

Relative importance of diagnostic delays in different head and neck cancers.

OBJECTIVES: Clinical stage at the time of diagnosis is the most important determinant of prognosis in head and neck cancer. Previously, longer diagnostic delay has been shown to worsen prognosis in cancer of tongue, pharynx and larynx. The aim of this study was to evaluate the relative importance of patient and professional diagnostic delays in the prognosis of these head and neck cancers. DESIGN: Population-based retrospective cohort study. SETTING: Oulu University Hospital (tertiary referral centre) district, Northern Finland. PARTICIPANTS: Population-based cohort of 221 patients with tongue, pharyngeal or laryngeal cancer diagnosed in 1986-1996. MAIN OUTCOME MEASURES: Patient and professional diagnostic delays, overall survival. RESULTS: Delays were significantly longer in laryngeal cancer. Moreover, longer diagnostic delays worsened survival markedly only in laryngeal cancer. Cut-off points at which the delays showed significant adverse impact in prognosis of laryngeal cancer were >or=3 months in patient delay and >or=6 months in professional delay. If mirror laryngoscopy was not performed at the initial visit, professional delay in laryngeal cancer turned out to be significantly longer. CONCLUSIONS: Diagnostic delays are longer and have a more significant impact on survival in laryngeal cancer than in lingual or pharyngeal cancer. Thus, patients with symptoms suggestive of laryngeal process should always be examined properly at the initial visit in order to shorten the professional diagnostic delay in laryngeal cancer.

Nasopharyngeal dimensions in magnetic resonance imaging and the risk of acute otitis media.

BACKGROUND: We have previously found by lateral cephalometry an association between nasopharyngeal anatomy and the risk of acute otitis media (AOM). We evaluate here the association of nasopharyngeal dimensions in magnetic resonance imaging (MRI) with the occurrence of AOM in otherwise healthy children. METHODS: Sixty-one healthy children (mean age 5.7 years, range 3.9-6.9) were recruited from child care centres. The parents filled in a questionnaire on the child's history of ear infections and adenoidectomy. MRI was performed with a 4 mm slice thickness during an upper respiratory infection. Five dimensions and two angles expressing the structure of the bony nasopharynx were measured in sagittal images. RESULTS: The dimension from the caudal edge of the septum to the midpoint of the sella, reflecting the height of the nasopharynx, was on average 2.2 mm smaller in the children who had had AOM attacks during the last 12 months than those without attacks (95% confidence interval (CI) 0.9 to 3.4, p=0.001) and the nasal base angle was on average 2.1 degrees smaller (95% CI 0.7 to 3.5, p=0.004). These differences remained significant after adjustment for age, sex and previous adenoidectomy in the logistic modelling. A history of adenoidectomy did not have any effect on the dimensions. CONCLUSIONS: The nasopharynx was smaller in the children with AOM attacks during the last year. The value of this finding for predicting susceptibility to recurrent AOM and directing preventive procedures should be evaluated.

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.

Nasal mucosa in natural colds: effects of allergic rhinitis and susceptibility to recurrent sinusitis.

The mechanisms of virus-induced airway hyperresponsiveness in asthma and allergy and the failure of host defence in patients suffering from secondary airway infections are still largely unknown. The aim of this study was to examine whether the presence of allergic rhinitis or susceptibility to recurrent sinusitis affects the structural and cellular changes in nasal mucosa during natural colds and convalescence. We compared the mucosal changes in biopsy samples during acute natural colds (days 2-4 of illness) and convalescence (3 weeks later) in patients with allergic rhinitis (n = 9), patients with susceptibility to sinusitis (n = 19) and healthy controls (n = 20). We saw similarly increased numbers of mucosal T and B lymphocytes and mast cells and increased vascular density during the acute colds compared to convalescence in all the three groups. The allergic subjects had elevated levels of eosinophils in the acute phase (P = 0.03), and the allergic and sinusitis-prone subjects had elevated levels of epithelial T cells (P = 0.04) and low levels of mast cells (P = 0.005) in convalescence compared to the control group. The sinusitis-prone subjects lacked intraepithelial cytotoxic cells in convalescence. In the allergic subjects, the reticular basement membrane was thicker in the acute phase compared to the convalescence (P = 0.05). These results suggest that various cells of the airways, including inflammatory and structural cells, are involved during viral respiratory infections in subjects with allergic rhinitis. The small numbers of mast cells and cytotoxic lymphocytes in the sinusitis-prone subjects may be related to their susceptibility to bacterial complications.

Subjects with allergic rhinitis show signs of more severely impaired paranasal sinus functioning during viral colds than nonallergic subjects.

BACKGROUND: Viral cold is thought to be the major contributing factor in the pathogenesis of sinusitis, as it causes ostiomeatal obstruction. The aim was to evaluate whether paranasal sinus functioning during viral colds is similar in subjects with and without allergic rhinitis. METHODS: Forty-eight volunteers were examined during an early (2-4 days) natural cold and again 3 weeks later. The examinations included computed tomography (CT) scans, nasal mucosal biopsies, and viral and bacterial specimens. Subjects with positive skin prick tests and persistent or intermittent rhinitis were considered to have allergic immunoglobulin E (IgE)-mediated rhinitis. In addition, specific IgE antibodies to staphylococcal enterotoxin B (SEB) were measured. RESULTS: Nine subjects (19%) had allergic rhinitis. The allergic subjects were significantly more often IgE sensitized to SEB than the nonallergic subjects (33%vs 3%, P = 0.02). Viral etiology of the cold was identified in 32 (67%) subjects. The subjects with allergic rhinitis had significantly higher CT scores compared with nonallergic subjects during the colds (median (range) scores 16 (6-22) vs 6 (0-17), P = 0.004). In both groups, the median scores declined markedly during convalescence, but the difference remained significant (P = 0.009). Among the allergic subjects, those who were IgE sensitized to SEB tended to have the highest CT scores [median (range) 16 (16-22)]. Total serum IgE and the nasal subepithelial eosinophil counts correlated with the CT scores during the cold (rs = 0.38, P = 0.008 and rs = 0.46, P = 0.001, respectively). CONCLUSIONS: Subjects with allergic IgE-mediated rhinitis had more severe paranasal sinus changes in CT scans than nonallergic subjects during viral colds. These changes indicate impaired sinus functioning and may increase the risk of bacterial sinusitis.

Cross-sectional survey of paranasal sinus magnetic resonance imaging findings in schoolchildren.

AIM: Sinus image abnormalities are common among children examined for indications other than sinus disease. The purpose of this study was to determine the frequency of sinus abnormalities among otherwise healthy children attending school. METHODS: Magnetic resonance imaging (MRI) was performed on 24 children aged 8-9 y, 18 of whom were re-examined after 6-7 mo. RESULTS: Sinus abnormalities were common. An abnormality was seen in 12 of the children [50%, 95% confidence interval (95% CI) 29-71%], and 9 (38%, 95% CI 19-59%) had abnormalities in the maxillary sinuses. As many as 8 (42%, 95% CI 20-67%) of the asymptomatic children (lacking clinical symptoms or findings) had abnormalities in the maxillary or ethmoidal sinuses. The follow-up examination showed that about half of the abnormal sinus MRI findings had resolved or improved without any intervention. CONCLUSION: Abnormal sinus MRI findings are common both among otherwise healthy children attending school and in totally asymptomatic children. As incidental findings, these should be interpreted as normal and do not indicate any need for treatment in children imaged for purposes other than sinus disease.

Lymphocyte and mast cell counts are increased in the nasal mucosa in symptomatic natural colds.

Knowledge of the virus-induced immune response is important in understanding the pathophysiology of respiratory virus infections. Data on the cellular immune response is still limited and based mainly on experimental studies. Natural colds may differ in their pathophysiology from experimentally induced ones. To evaluate the inflammatory cell responses in the upper respiratory tract during natural colds we counted the number of lymphocytes, mast cells and macrophages in the nasal mucosa. Nasal biopsies were taken from 22 adult volunteers during the acute (2-4 days of symptoms) and convalescent phases (day 21) of the cold, and the numbers of cells were counted with immunohistochemical methods. Viral aetiology was identified in 14 (64%) subjects by using viral isolation, antigen detection and rhino-polymerase chain reaction assays. The number of T lymphocytes was increased in the nasal epithelium and that of T and B lymphocytes and mast cells in the subepithelial layer in the acute phase compared to the convalescent phase. Intraepithelial T lymphocyte counts were significantly higher in the subjects who had a proven viral infection or a finding of pathogenic bacteria in the nasopharynx compared to the subjects without such findings (P = 0.005 and P = 0.04, respectively). Contrary to the earlier experimental studies, we found that viruses cause accumulation of T and B lymphocytes and mast cells during the first days of a symptomatic naturally acquired respiratory infection.

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.

Surfactant protein-A gene locus associated with recurrent otitis media.

Surfactant protein-A, which plays a role in innate host defense in the lung, is also expressed in the Eustachian tube. We report that the frequency of specific surfactant protein-A haplotypes and genotypes differs between children with recurrent otitis media compared with a control population.

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.