Outcomes of elective head and neck confirmed or suspected cancer surgery during the COVID-19 pandemic.

PURPOSE: To analyse the complication outcomes of COVID-19 negative patients undergoing elective head and neck surgery during the COVID-19 pandemic. METHODS: This was a retrospective case review of all patients undergoing elective head and neck surgery for confirmed or suspected head and neck cancer. RESULTS: There were no mortalities recorded in the cohort of patients analysed. At 30 days, pulmonary complications had occurred in 4 patients (9%). None of these were related to COVID infection. CONCLUSION: With careful pre-operative screening of patients for COVID-19 and post-operative care in a COVID-19 clean ward, head and neck surgery can proceed safely during the epidemic. This data could help to minimise delay in treatment by allowing a greater number of elective head and neck cancer operations to proceed.

Unilateral aberrant anatomy of the hypoglossal nerve.

PURPOSE: Neck dissection is often performed in patients with oral cancer to both treat and reduce the risk of subsequent neck metastases. Injury to the hypoglossal nerve may result in dysarthria, dysphagia, and profound difficulty with upper airway control. Although surgical landmarks facilitate intra-operative identification of vital structures to be preserved, they should not be an absolute measure, due to anatomical variants. We present a rare case of unilateral aberrant anatomy of the hypoglossal nerve, passing superficial to the internal jugular vein. METHODS: A 70-year-old female presented to the emergency department with an indurated and ulcerated floor of mouth lesion, later confirmed to be a squamous cell carcinoma. She was treated with wide local excision, bilateral selective neck dissection of levels I to III, surgical tracheostomy, anterior mandibulectomy and reconstruction with a left composite radial forearm free flap. RESULTS: A nerve-like structure was identified crossing superficially and perpendicular to the internal jugular vein within the left neck, which was later determined to be an anatomical variant of the hypoglossal nerve. This was carefully dissected and preserved, and the remainder of the surgery completed uneventfully. On the right, the hypoglossal nerve followed its normal anatomical course. The patient made a good recovery and suffered no neurological complications. CONCLUSION: Identification, meticulous dissection and preservation of the hypoglossal nerve is essential in lymphadenectomy involving levels I and II. Detailed knowledge of both normal and variant anatomy is fundamental for surgeons, which will allow for identification and protection of important neurovascular structures, thereby minimising surgical morbidity.

Cystic Squamous Cell Carcinomas of the Jaws: Twelve Cases Highlighting Histopathological Pitfalls.

Cystic squamous cell carcinomas (SCCs) of the jaws, including carcinoma cuniculatum, are rare, slow growing, and relentlessly invasive. The aim of this article is to present 12 cases, 4 of which were designated as carcinoma cuniculatum on the basis of deeply endophytic, anastomosing channels of cystic stratified squamous epithelium and keratin microabscesses. The other 8 were also cystic, but more heterogeneous morphologically and were diagnosed as well differentiated SCCs. Six patients were female, 6 were male (mean age = 74.0 years, range = 50-94 years). Six tumors affected the mandible, 6 the maxillary alveolus with or without extension into the hard palate. All patients underwent primary resection with neck dissection and were staged as T4a N0 M0. In 4 patients, diagnosis was delayed as a result of superficial biopsies and/or confusing histopathology. Cystic SCCs of the jaws can be difficult to diagnose and clinicoradiological correlation is essential. Long-term follow-up is mandatory.

A needle free system for cervical lymphatic mapping and sentinel node biopsy in oral squamous cell carcinoma.

The techniques of lymphatic mapping and sentinel node biopsy are finding increasing utility in the management of the loco-regional lymphatics in many areas of oncology. Our unit is currently investigating their feasibility in relation to the management of the clinically node negative neck in oral squamous cell carcinoma. In order to reduce patient discomfort, and to remove the possibility of sharps injury, particularly in the high-risk patient, we report the use of a needle free device for the intra-oral delivery of the radiopharmaceutical. We believe that this is the first report using such a device in the oral cavity for the purpose of lymphoscintigraphy, and that it has significant advantages over the conventional hypodermic needle in certain patient groups.

Metastasising clear cell odontogenic carcinoma: a case report and review of the literature.

Primary odontogenic carcinomas are rare and examples which have metastasised are even more uncommon. We describe the first reported case of a clear cell odontogenic carcinoma which metastasised to distant bones, namely the 5th lumbar vertebra and hip, 3 years after initial diagnosis. The initial incisional biopsy was thought to represent a calcifying epithelial odontogenic tumour, but in the subsequent resection the tumour showed a prominent clear cell component admixed with squamous cells showing peripheral palisading, widespread infiltration and necrosis indicating a malignant neoplasm. Radiologically guided biopsy revealed a metastatic lesion in L5 vertebrae and left hip, confirmed by immunohistochemistry. The metastatic lesion had similar appearances to the first biopsy, and diagnosis was confirmed by comparison of histological features, immunohistochemistry and exclusion of a second primary lesion by clinical examination and imaging. The diagnosis of clear cell odontogenic carcinoma is a difficult one to make. The behaviour of these tumours is unpredictable. This case confirms that clear cell odontogenic carcinomas have the potential for distant metastasis and require long-term follow up.

How serious are oral infections?

Life-threatening conditions following dental infections have been rare since antibiotics were introduced into the world of medicine. However, infections spreading through the soft tissues of the head and neck are encountered occasionally and mortality is still reported as a result of sepsis or airway embarrassment. A case of Ludwig's angina from odontogenic infection that progressed into mediastinitis and pericarditis is presented. The steps adopted in the management of this case highlight the significance of early recognition and diagnosis of the source of deep cervical infections, the importance of securing the airway, effecting surgical drainage and aggressive intravenous antibiotic therapy.

Does the method of resection affect the margins of tumours in the oral cavity? Prospective controlled study in pigs.

It is important to obtain tumour-free resection margins in patients with oral cancer. Pathological processing is known to cause tissue to shrink, which affects the reported margins, and it is postulated that the method of resection also has an effect. We marked standardised simulated lesions on the tongues of 15 live anaesthetised pigs and divided each lesion into four equal sections. They were resected each with a margin of 10mm using cutting diathermy, coagulative diathermy, Harmonic scalpel, and a conventional scalpel. After processing, the excision margins were measured. With cutting diathermy and coagulative diathermy, shrinkage of the soft tissues was minimal relative to the margin of the simulated lesion compared with the Harmonic scalpel (p=0.001) and conventional scalpel (p=0.001). Cutting diathermy and coagulative diathermy caused significant thermal damage (p=0.001). The method of resection affects the surgical margin. Diathermy resulted in thermal injury and denaturing of the underlying muscle, but there was less tissue contraction than when the Harmonic scalpel and conventional scalpel were used. The ethics committee approved the study, which was undertaken in a registered European Scientific Institute in Hamburg.

Decreased levels of alternative co-stimulatory receptors OX40 and 4-1BB characterise T cells from head and neck cancer patients.

BACKGROUND AND AIM: Head and neck cancers (HNC) are aggressive tumours. Tumour-specific T cells are frequently identified in patients with cancer, although they fail to control tumour progression. A family of proteins called co-stimulatory receptors regulate the function of T cells and may account for T cell dysfunction in cancer. Our aim was to characterise co-stimulatory receptors on T cells in HNC patients to identify novel targets for immunotherapy. METHODS: Peripheral blood mononuclear cells were isolated from HNC patients and healthy controls and the expression of co-stimulatory (OX40, 4-1BB, ICOS) and co-inhibitory (CTLA-4, PD1) receptors was analysed on CD4(+) and CD8(+) T cells using flow cytometry. RESULTS: We found that the levels of co-stimulatory receptors OX40 and 4-1BB were significantly lower on CD4(+) T cells from HNC patients. This was more pronounced in locally advanced tumours (T3/T4) compared to early carcinomas (T1/T2). PD-1 levels were higher on CD8(+) T cells in HNC patients compared to controls. Human papilloma virus (HPV)-specific CD8(+) T cells appeared to be more affected than Influenza-specific T cells. CONCLUSIONS: Our results indicate that expression of co-stimulatory receptors on T cells from HNC patients is imbalanced with a preponderance of inhibitory signals, and reduction of stimulatory signals, especially in advanced disease. Restoring this balance could improve T cell therapy outcomes in HNC.

Impact of colour digital photography on pathologists' orientation of resected specimens: a prospective pilot study.

Accurate orientation of surgical resection specimens is a prerequisite for the correct histopathological study of the extent of disease and for a complete clinico-pathological interpretation. This pilot study demonstrates how the pathologists understanding of specimen orientation may be enhanced by the sending of a digital image with the pathology request form.

Endoscopic removal of a supernumerary tooth from the nasal cavity in an adult.

Eruption of a tooth into the nasal cavity is a rare event. However it is important to identify such a condition as it has the potential to cause significant morbidity. We report a unique case of intranasal supernumerary tooth erupted into nasal causing significant nasal symptoms in an otherwise healthy patient which was removed endoscopically.