Accuracy of the sleep clinical record for the diagnosis of pediatric moderate-to-severe obstructive sleep apnea syndrome.

PURPOSE: The sleep clinical record (SCR) has been used to diagnose obstructive sleep apnea syndrome (OSAS) in children when access to polysomnography (PSG) is limited. Our aim was to determine the best SCR score that could facilitate diagnosis of moderate-to-severe OSAS in children with snoring. METHODS: Healthy children with history of snoring, who were referred for PSG, were prospectively recruited. The SCR score was calculated. Receiver operating characteristic curves (ROCs) were plotted to determine the area under curve (AUC), and the optimum SCR cutoff value was determined using the Youden index (J). RESULTS: Two hundred and seventy-three children were recruited (mean age 6.3 ± 2.5 years; median obstructive apnea-hypopnea index 1.5 episodes/h; range 0-61.1). The mean SCR score was 6.9 ± 3.6. Forty-six children had moderate-to-severe OSAS. Subjects with moderate-to-severe OSAS had a significantly higher mean SCR score (10.2 ± 2.9) than those with mild OSAS (6.2 ± 3.3; P < 0.001). Based on the plotted ROC, the AUC was 0.811 (95% confidence interval: 0.747-0.876; P < 0.001). Calculation of J, based on its ROC coordinates, indicated that the optimum cutoff SCR score to predict moderate-to-severe OSAS was 8.25, corresponding to a sensitivity of 83% and a specificity of 70%. CONCLUSION: Among children with history of snoring, an SCR score above 8.25 can identify those with moderate-to-severe OSAS.

Microorganisms involved in deep neck infection (DNIs) in Greece: detection, identification and susceptibility to antimicrobials.

BACKGROUND: To determine, from October 2010 to October 2018, the epidemiology of Deep Neck Infections (DNIs), regarding the detection, the identification and the susceptibility to antimicrobials of causative microorganisms, in Thessaly-Central Greece. METHODS: An analysis of data from a prospective database was conducted on 610 consecutive patients with DNIs treated in the Otolaryngology / Head & Neck Surgery Department of University Hospital of Larissa. Demographics, clinical features and microbiological data were analyzed. RESULTS: Among the 610 patients (1,9/1 male to female ratio, mean age: 39,24 ± 17,25) with DNIs, 579 had a single space (94,9%), while the remaining 31 had a multi-space (5,1%) DNI. The most common areas affected were the peritonsillar space (84,6%) followed by the submandibular space (6,5%). Clinical samples were obtained from 462 patients, and were tested by culture and by the application of 16S rRNA PCR. Two hundred fifty-five samples (55,2%) gave positive cultures, in which Streptococcus pyogenes and Staphylococcus aureus were predominant. The application of the 16S rRNA PCR revealed that 183 samples (39,6%) were positive for bacterial DNA; 22 of them, culture negative, were found to be positive for anaerobic (Fusobacterium necrophorum, Actinomyces israellii etc) and for fastidious microorganisms (Brucella mellitensis, Mycobacterium avium). CONCLUSION: DNIs represent a medical and surgical emergency and evidence-guided empirical treatment with intravenous infusion of antibiotics at the time of diagnosis is mandatory, highlighting the importance of epidemiological studies regarding the causative microorganisms. Although, in our study, the predominant pathogens were S. pyogenes and S. aureus, the combination of culture and molecular assay revealed that anaerobic bacteria play also a significant role in the pathogenesis of DNIs. Based on the local epidemiology, we propose as empirical therapy the intravenous use of a beta-lactam /beta-lactamase inhibitor; metronidazole or clindamycin can be added only in specific cases such as in immunocompromised patients.

The sino-nasal outcome test (SNOT)-22: validation for Greek patients.

The aim of this study was to perform translation, cross-cultural adaptation, and validation of the sinonasal outcome test 22 (SNOT-22) in the Greek language. SNOT-22 was translated into Greek. A prospective study was conducted on adult patients with chronic rhinosinusitis (CRS) according to rhinosinusitis and nasal polyps (EPOS) criteria. Test-retest evaluation of the patients was carried out. Internal consistency was assessed with Cronbach's alpha test, and test-retest reliability with Pearson's test (parametric correlation coefficient), kappa (reproducibility) and Bland-Altman plot (extent of agreement). Validity was assessed by comparing scores between a control group of volunteers without CRS and the CRS group using Mann-Whitney test. Responsiveness was assessed on CRS patients who underwent surgery, by comparing preoperative to 3 months postoperative scores with paired t test. Furthermore the magnitude of surgery effect was evaluated. Test-retest evaluation was accepted in 64 patients. Cronbach's alpha was 0.84 and 0.89 at test and retest, respectively, suggesting good internal consistency. Pearson's correlation coefficient was 0.91 (p < 0.001), revealing good correlation between initial and retest scores. Mean kappa value was 0.65, indicating a high level of reproducibility, while in Bland-Altman plot the differences were located between agreement thresholds. The control group consisted of 120 volunteers. Mann-Whitney test showed a statistically significant lower score for the control group (p < 0.0001). 32 CRS patients underwent surgical treatment. Postoperative scores were significantly lower than preoperative (p < 0.0001) while the magnitude of surgery effect was considered high. Greek SNOT-22 is a valid instrument with good internal consistency, reliability, reproducibility, validity and responsiveness.

Does perioperative dexamethasone affect voice-related quality of life after thyroidectomy?

The objective of this study is to assess the impact of perioperative dexamethasone on post-thyroidectomy voice outcomes. This study is a retrospective review of prospectively collected data in a tertiary referral center. This is a retrospective analysis of prospectively collected data on adult patients undergoing total thyroidectomy. Exclusion criteria were: previous neck surgery, thyroid lobectomy, neck dissection or other procedure together with thyroidectomy, pathological findings on laryngeal examination, preoperative or postoperative steroid therapy, diabetes mellitus, pregnancy, and postoperative recurrent laryngeal nerve palsy. In all patients, flexible laryngoscopy was performed and Voice Handicap Index (VHI) scores were obtained the day before, 48 h and 1 month after surgery. Patients' medical records were reviewed to find the patients who had received dexamethasone by the anesthesiologist as nausea and vomiting prophylaxis or analgesia. Thus, two groups of patients were formed: dexamethasone (D) group and non-steroid (NS) group. Mann-Whitney test used to compare VHI between the two groups. 122 patients fulfilled the criteria. D group consisted of 50 patients (44 females; mean age 53.16 ± 17.61), in which a single IV dose of 8 mg dexamethasone had been administered perioperative, and NS group consisted of 72 patients (58 females; mean age 50.53 ± 13.60), where no steroids had been administered. No significant difference was noticed between D and NS groups for preoperative VHI score, VHI scores 48 h and 1 month after surgery. In our study, a single perioperative IV dose of 8 mg dexamethasone did not seem to add any benefit on voice-related quality of life after thyroid surgery.

Endoscopic Management of Glomus Tympanicum Tumor: Report of Three Cases and Review of the Literature.

Glomus tympanicum are benign tumors of vascular origin, arising from the neural crest cells and located on promontory. The treatment of choice is surgical excision of the lesion. Traditionally, it is performed under microscopic observation. With the introduction of endoscopes in the field of ear surgeries, an endoscopic approach has also evolved. Herein, we present case reports of three patients diagnosed with glomus tympanicum tumors who were operated on using an endoscopic approach. A review of the literature is also performed. The mass was completely excised in all patients, and there were no signs of recurrence at the follow-up at least a year later. Endoscopic ear surgery is a safe and effective method of managing glomus tympanicum tumors. Its main limitation is the tumor size; however, in most cases, tumors of stages I to II as per the Glasscock-Jackson classification and types A1 to B1 according to the modified Fisch-Mattox classification can be completely removed endoscopically. Careful preoperative selection of patients warrants the best outcomes.

A large thyroglossal duct cyst and its management: a case report.

Thyroglossal duct cysts (TGDC) are congenital neck cysts, formed as a result of the failure of the thyroglossal duct to involute during embryogenesis and their mean size is 1.5-2.4 cm. We present a case of a 44-year-old male who presented with a history of a large anterior neck mass measuring 8.7x6x6.4 cm and causing dysphagia and mild dyspnea. After being mistaken for a goiter, a clinical diagnosis of TGDC was made based on history, clinical and radiographic findings. The patient was treated with Sistrunk's procedure. No recurrence was noted on follow-up. Thyroglossal duct cysts are generally well-defined small lesions, but even bigger ones are not linked with severe symptomatology. The larger size at presentation may increase the list of potential diagnoses and lead to diagnostic dilemmas. Every effort should be made to rule out malignancy before surgery. Sistrunk's procedure with dissection of the posterior hyoid space should be the standard of care.

TNFRSF13B/TACI Mutations in Patients with Chronic Rhinosinusitis with Nasal Polyps.

BACKGROUND: The pathogenesis of Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) remains still inconclusive. Recent studies identified an increased expression of BAFF (a B cell-activating factor) and its receptor TACI (Transmembrane Activator and cAML Interactor) in nasal polyp samples, while TNFRSF13B/TACI mutations have been found in patients with benign lymphoproliferative disorders and primary antibody deficiencies. OBJECTIVE: The aim of our study was to evaluate the possible contribution of TNFRSF13B/TACI mutations in CRSwNP pathogenesis. METHODS: Forty-four (44) patients with CRSwNP (male/female: 33/11, mean age: 52.5 years, range: 16-83) were analyzed for TNFRSF13B/TACI mutations by PCR-sequencing. RESULTS: No pathogenic TNFRSF13B/TACI mutations were identified in our cohort study of CRSwNP patients. We detected two common missense mutations (p.P251L and p.V220A), along with other common silent mutations and intronic polymorphisms in an identical prevalence to healthy control population. CONCLUSION: TNFRSF13B/TACI mutations might not play a role in the pathogenesis of CRSwNP.

Sino-nasal outcome test tool assessment in patients with chronic rhinosinusitis and obstructive sleep apnea.

OBJECTIVE: The Sino-Nasal Outcome Test (SNOT-20) is a rhinosinusitis quality of life instrument. Nonrhinologic illnesses like obstructive sleep apnea (OSA) may elevate SNOT-20 scores. We compared SNOT-20 outcomes in patients with chronic rhinosinusitis (CRS) to those in patients with OSA. METHODS: We analyzed prospectively collected data of patients with CRS and OSA. Pretreatment SNOT-20 and Lund-Kennedy endoscopy scores were obtained. Scores and patterns of SNOT-20 symptom distribution were compared. RESULTS: Fifty-seven patients had CRS and 65 patients had OSA. Both groups had elevated mean total SNOT-20 scores (28 ± 12.2 and 29 ± 10.7, respectively). Higher scores were noticed for OSA patients on the wellness section of the SNOT-20 and for CRS patients on the sinonasal section of the SNOT-20 (p < 0.001). CONCLUSIONS: CRS and OSA patients present with elevated total SNOT-20 scores but differ in their symptom distribution pattern. This study demonstrates that other disorders can elevate SNOT-20 scores and confirms the need for additional objective data to confirm CRS diagnosis.

Sinonasal Lobular Capillary Hemangioma After Continuous Self-tests for COVID-19: A Case Report and Review of the Literature.

Sinonasal lobular capillary hemangiomas (LCH) are rare benign vascular lesions commonly arising from the nasal septum. Nasopharyngeal, nasal mid-turbinate, and anterior nasal swabbing is the preferred method of screening for coronavirus disease-2019 (COVID-19). Herein, we present a case of a sinonasal LCH in a child after continuous self-tests for COVID-19, with an anterior nasal swab. The child presented with a well-defined red mass in the anterior part of the nasal septum, which was removed endoscopically. Histopathology revealed a LCH. This is the first report of a complication other than epistaxis with the use of an anterior nasal swab. Our literature review identified 32 studies reporting complications of COVID-19 screening. Cerebrospinal fluid leaks and foreign body retention are the most common ones. A proper specimen collection technique and a quick patient history with an emphasis on risk factors are the best practices to prevent complications from COVID-19 screening.

Double Coin Mimicking a Button Battery: a Rare Radiological Entity of an Esophageal Foreign Body.

Ingestion of foreign bodies is a common entity in emergency clinical practice, especially in the pediatric population. Personal history is rather challenging in these patients, while it is important to accurately define the ingested foreign body. Therefore, the history of a caregiver/eyewitness, physical examination and radiographic findings are taken under consideration. Coins - in various places and alignments - are among the most common foreign bodies of the upper digestive tract, while a history or radiological findings of button batteries are indicating the need for immediate removal. We report a rare case of a seven-year-old boy with an esophageal foreign body, whose radiographic findings were intriguing, as they were suggesting a button battery digestion, while urgent esophagoscopy revealed a double coin ingestion perfectly aligned in the same place, opposing each other.

Bilateral Vocal Cord Palsy as the Only Symptom of Thymoma Associated-Myasthenia Gravis.

Bilateral vocal cord paresis is a rare phenomenon caused by different underlying etiologies. Myasthenia gravis is included in this long differential diagnosis. Usually, it happens as part of a serious clinical state of a patient, that also suffers from generalized muscle weakness, diplopia, dysphagia, eyelid ptosis. In our case, a 58-year-old woman presented in the emergency room with solely dyspnea, caused by bilateral cord palsy, and that appeared to be the only symptom of thymoma associated-myasthenia gravis. Another interesting fact about this case is the quick recovery and no need for tracheostomy and intubation in the first hours of her admission to hospital.

Cross-Cultural Adaptation and Validation of the Greek SPOT-25 Quality of Life Questionnaire in Patients with Otosclerosis.

Objective: To translate, adapt and validate in Greek the stapesplasty outcome test (SPOT)-25 quality of life questionnaire for patients with otosclerosis. Materials and methods:SPOT-25 was translated to Greek and completed by otosclerosis patients on the day of diagnosis, the day before surgery and three months postoperatively. Fifty controls without any otological history, symptom or finding also completed the questionnaire. Pure-tone average was obtained both preoperatively and three months postoperatively. Results:Test-retest evaluation on 56 patients was accepted. The Greek-SPOT-25 had an excellent internal consistency. All its items and subscales were significantly correlated between test and retest evaluation. Controls had significant lower SPOT-25 scores, and the postoperative scores were significantly lower than preoperative ones. Pure-tone average of four frequencies (PTA4) was significantly correlated to preoperative SPOT-25 total and subscales scores (P<0.001) before surgery and significantly correlated only with the "hearing function" subscale (p<0.05) postoperatively.

Doctors Spreading SARS-CoV-2 Infection to Their Patients and Health Workers. What is the Likelihood of This Scenario?

Aims: In this particular study, we report our experience of eight doctors infected with SARS-CoV-2 and discuss the probability of in-hospital virus transmission to patients or the rest of the hospital personnel. The importance of PPEs is highlighted. Materials and methods:We explore the data of eight doctors who were tested positive for SARS-CoV-2 after returning from their summer vacation. More specific, we evaluated the time they spent working before they got tested after their return, the symptoms they developed and the results of their tracking through their patients and the rest of hospital workers. Results:All doctors followed their working schedule, ranging from 2-4 days after their summertime off, without knowledge of being infected. They had been keeping all suggested protection precautions, while no further virus transmission to patients and/or other healthcare workers occurred, even though they had close contact and cooperation with many of them. Conclusions:Our experience suggests that, if healthcare workers conform to established safety procedures, the likelihood of further transmission both to patients and their colleagues, even in asymptomatic state, appears to be minimal.

Erythropoietin levels in children with obstructive sleep apnea.

OBJECTIVE: High serum erythropoietin (EPO) levels have been reported in adult patients with obstructive sleep apnea (OSA), however there is a lack of related literature in children with OSA. The main objective of this study was to explore the potential use of EPO as a pediatric OSA biomarker by exploring the relationship between serum EPO levels and the presence of pediatric OSA. METHODS AND MATERIALS: A prospective study was conducted on children (4-12 years old) referred for overnight PSG. Thirty (30) consecutive children with mild. 30 consecutives with moderate, and 30 consecutives with severe OSA (OSA group), as well as 30 consecutive children with AHI≤1 (non-OSA group) were recruited. Morning blood specimens after PSG studies were obtained in order to compare EPO levels. RESULTS: Finally, 115 children included for analysis. Non-OSA group consisted of 29 children (mean age: 6.93 ± 2.10) and OSA-group of 86 children (mean age: 6.78 ± 2.53). Mean EPO values for the non-OSA and OSA groups were 5.46 ± 2.29 mIU/ml and 8.33 ± 4.10 mIU/ml respectively. OSA-group had significant higher EPO levels than non-OSA (P: 0.01) while EPO levels were significantly correlated with AHI (p < 0.001). CONCLUSION: Our study showed that serum EPO levels of children with OSA are significantly higher than those without OSA and correlate significantly with AHI. These results suggest that EPO may be considered as a biomarker candidate for pediatric OSA. Since this may be the first study on the topic further research is needed.

Do smoking and human papilloma virus have a synergistic role in the development of head and neck cancer? A systematic review and meta-analysis.

PURPOSE: Head and neck squamous cell carcinoma (HNSCC), arising from the squamous epithelium, is the most common head and neck cancer (HNC). Smoking and alcohol are well known risk factors for HNSCC, while some high-risk human papilloma virus (HPV) subtypes were specifically identified as a high-risk factors for developing oropharyngeal squamous cell carcinoma (OPSCC). In this study, we have conducted a systematic review and meta-analysis in order to investigate the possible synergistic role of smoking and HPV in the development of HNSCC. METHODS: We conducted a systematic search in two online databases PubMed and Cochrane Library, searching for studies published between 2010-2018. Sixteen studies met the inclusion criteria; a total of 2161 patients were included, comprising 1470 HPV-negative and 691 HPV-positive, respectively. RESULTS: The number of smokers between HPV-positive HNSCC patients (group A) and HPV-negative HNSCC patients (group B) was compared. We have found that smokers in HPV-positive group were statistically significantly less than smokers in HPV-negative group (OR=0.33 with 95% CI 0.18, 0.61). The test for overall effect was Z =3.61 (p=0.0003). CONCLUSION: Smoking is less common in HPV positive group than in HPV negative group, and so probably smoking does not play a major role in the pathogenesis of HPV-positive HNSCC as in the pathogenesis of HPV-negative HNSCC.

Real-world experience of extracranial carotid artery interventions for atherosclerotic disease during a 10-year period.

BACKGROUND: The aim of this study was to assess the long-term outcome of carotid disease treatment with endarterectomy or stenting (CEA or CAS) in a real-world setting during a 10-year period. METHODS: A single center retrospective study with prospectively collected data including patients (symptomatic or asymptomatic) being treated with CEA or CAS. Survival, restenosis, stroke and major adverse cardiac events (MACE) were the outcomes. RESULTS: A total of 413 patients (mean age of 69±3.5 years; 80%, 333/413 males) were treated with CEA (83.7%, 346/413) or CAS (16.3%, 67/413). Most of the patients were asymptomatic (60%, 248/413). The incidence of in-hospital stroke and death was 0.5% (2/413) and 0.7% (3/413), respectively. The survival rate at 1, 3 and 5 years was 98%, 94.7% and 90.6%, respectively. The freedom of re-stenosis at 1, 3 and 5 years was 99%, 98% and 90.5%, respectively. The freedom of any stroke at 1, 3 and 5 years was 99%, 97% and 94.8%, respectively. The freedom of MACE at 1, 3 and 5 years was 97.6%, 91.5% and 86.3%, respectively. Symptomatic presentation was associated with higher rates of restenosis after CEA and higher rate of mortality (P=0.025) and MACE (P=0.022) after CAS. CONCLUSIONS: Carotid interventions remain durable treatment methods of carotid disease. Long-term outcomes regarding mortality, restenosis, and risk of stroke or MACE are similar between CAS and CEA for asymptomatic patients. Symptomatic presentation may be associated with higher rates of restenosis after CEA and higher rate of mortality and MACE after CAS, however larger studies are needed to clarify this issue.

Urine concentrations changes of cysteinyl leukotrienes in non-obese children with obstructive sleep apnea undergoing adenotonsillectomy.

OBJECTIVE: The main objective of the study was to compare preoperative to postoperative levels of urine-Cysteinyl leukotrienes (uCysLT) in children undergoing adenotonsillectomy (AT) for obstructive sleep apnea (OSA) in order to investigate whether exaggerated leukotriene activity is the cause or consequence of OSA. METHODS AND MATERIALS: A prospective study was conducted on non-obese children (4-10 years old) referred for overnight PSG. Children with moderate/severe OSA treated with AT were included. A second PSG study performed 2 months postoperatively to confirm OSA resolution, and those with residual OSA were excluded. Morning urine specimens after both PSG studies were obtained and pre-operative uCysLT levels were compared to postoperative levels. RESULTS: 27 children fulfilled the criteria and underwent a post-operative PSG study with three exclusions for residual OSA (postop-AHI>2), so the study group consisted of 24 children (mean age: 5.7 ±â€¯2.1 years). Mean preoperative and postoperative AHI was 10.96 ±â€¯5.93 and 1.44 ±â€¯0.56 respectively. Mean preop-uCysLT were 21.14 ±â€¯4.65, while after AT they significantly reduced to 12.62 ±â€¯2.67 (P < 0.01). CONCLUSION: uCysLT levels are significantly reduced after AT in non-obese children with moderate/severe OSA, suggesting that exaggerated leukotriene activity is mainly a consequence of OSA.

Patterns in the management of superficial vein thrombosis.

Objective To highlight current practice patterns in management of superficial vein thrombosis. Methods An electronic survey was conducted using the mailing lists of the Mediterranean League of Angiology and Vascular Surgery and European Venous Forum regarding superficial vein thrombosis diagnosis, investigation, and treatment. Results The response rate was 41% (175/430) and the majority of the participants were vascular surgeons practicing in a hospital. More experienced physicians considered superficial vein thrombosis as a medical issue of moderate seriousness and performed duplex ultrasound for confirmation of diagnosis. Elastic stockings were recommended by 87% of the physicians, while 57% prescribed nonsteroidal anti-inflammatory drugs. Eighty six percent advised anticoagulation, although a large disparity was shown regarding regime, dose, and duration. Thrombophilia test was regularly suggested by 19% of the physicians. Ligation of the saphenofemoral junction was the treatment of choice by those who suggested intervention in the acute phase of superficial vein thrombosis. Conclusions A great disparity exists in the management of superficial vein thrombosis. Current guidelines have not been adopted by physicians; more focused training is needed for those involved in the management of venous diseases.

A survey on the status of the management of diabetic foot in the Mediterranean region.

BACKGROUND: We conducted a survey in order to highlight the current trends in the management of diabetic foot among vascular specialists practicing in the Mediterranean region. METHODS: A survey Monkey was conducted from December 2013 to November 2014, including 10 main questions on the management of diabetic foot patients. The questionnaire was sent to vascular specialists included in the current mailing list of the Mediterranean League of Angiology and Vascular Surgery. Spearman's correlation analysis was used for statistical analysis. RESULTS: The response rate was 37.5% (150/400) and 52.6% of them were practicing in a Tertiary hospital service. The diabetic foot patient management and most of the amputations were performed in Tertiary hospitals. Most responders were experienced vascular specialists (55.3%). In general specialists with high work volume performed more major amputations in diabetic patients as compared to PAD patients and adopted equally all types of interventions (open, endovascular and hybrid). In particular the most experienced specialists required more diagnostic investigations, performed more minor amputations and used endovascular approach as first line treatment in diabetic patients. A lack of multidisciplinary approach was demonstrated as referral to other specialties was suboptimal. CONCLUSIONS: In the Mediterranean region, patients with diabetic foot are managed by the most experienced vascular physicians in Tertiary centers. Endovascular first approach seems to be the preferred strategy, but services were able to provide open as well as hybrid procedures. Finally, the multidisciplinary team approach has not been adopted as part of the standard care even in tertiary centers.

Intraoperative radiation therapy (IORT) in head and neck cancer: A systematic review.

BACKGROUND: Multimodality therapy constitutes the standard treatment of advanced and recurrent head and neck cancer. Since locoregional recurrence comprises a major obstacle in attaining cure, the role of intraoperative radiation therapy (IORT) as an add-on in improving survival and local control of the disease has been investigated. IORT allows delivery of a single tumoricidal dose of radiation to areas of potential residual microscopic disease while minimizing doses to normal tissues. Advantages of IORT include the conformal delivery of a large dose of radiation in an exposed and precisely defined tumor bed, minimizing the risk of a geographic miss creating the potential for subsequent dose reduction of external beam radiation therapy (EBRT). This strategy allows for shortening overall treatment time and dose escalation. The aim of this review is to summarize recent published work on the use of IORT as an adjuvant modality to treat common head and neck cancer in the primary or recurrent setting. METHODS: We searched the Medline, Scopus, Ovid, Cochrane, Embase, and ISI Web of Science databases for articles published from 1980 up to March 2016. RESULTS: Based on relevant publications it appears that including IORT in the multimodal treatment may contribute to improved local control. However, the benefit in overall survival is not so clear. CONCLUSION: IORT seems to be a safe, promising adjunct in the management of head and neck cancer and yet further well organized clinical trials are required to determine its role more precisely.