The prevalence of oropharyngeal squamous cell carcinoma in patients admitted with symptoms of peritonsillar abscess or cellulitis: A retrospective multicentre study.

OBJECTIVES: Anecdotal evidence suggests that oropharyngeal squamous cell carcinoma (OPSCC) should be suspected in patients presenting with symptoms of peritonsillar abscess (PTA) or cellulitis (PTC). The aim of this study was to estimate the prevalence of OPSCC in patients presenting with symptoms of PTA/PTC. METHOD, SETTING AND PARTICIPANTS: We retrospectively identified all adults with a coded diagnosis of PTA or PTC who presented between 2012 and 2016 inclusive, across six ENT units in Merseyside. Records were compared to that of the centralised regional head and neck cancer database. The clinical records of a subset of patients were reviewed for the purposes of data validation. RESULTS: A total of 1975 patients with PTA/PTC were identified. Three patients were subsequently diagnosed with OPSCC. None of the three actually had an objective underlying diagnosis of PTA/PTC on the same side. The prevalence of OPSCC in patients admitted with symptoms of PTA/PTC was 0.15% or approximately 1:650 admissions. The records of 510 patients who presented over a one-year period (2016) were reviewed in even greater detail. There were 298 patients with PTA (59.4%) and 151 with PTC (29.1%) and 61 had an alternative diagnosis (11.9%). High-risk features (age ≥40, tonsillar asymmetry or tonsillar lesion) were present in 106 patients (24%). Urgent follow-up was expedited for 77 patients (73%). CONCLUSION: This study estimates the risk of OPSCC in patients with peritonsillar symptoms. The prevalence is low, even in a region with a relatively heavy disease burden. Clinicians should, however, retain a high level of suspicion in patients with persistent symptoms.

A prospective multicentre external validation study of the Liverpool Peritonsillar abscess Score (LPS) with a no-examination COVID-19 modification.

OBJECTIVES: Our primary aim was to validate the Liverpool Peritonsillar abscess Score (LPS) externally in a new patient cohort. Our secondary aim was to modify the LPS in the light of the COVID-19 pandemic to produce a no-examination variant for use in this instance. DESIGN: Prospective multicentre external validation study. SETTING: Six different secondary care institutions across the United Kingdom. PARTICIPANTS: Patients over 16 years old who were referred to ENT with any uncomplicated sore throat such a tonsillitis or peritonsillar abscess (PTA). MAIN OUTCOME MEASURES: Sensitivity, specificity, positive predictive value and negative predictive value for both the original LPS model and the modified model for COVID-19. RESULTS: The LPS model had sensitivity and specificity calculated at 98% and 79%, respectively. The LPS has a high negative predictive value (NPV) of 99%. The positive predictive value (PPV) was slightly lower at 63%. Receiver operating characteristic (ROC) curve, including the area under the curve (AUROC), was 0.888 which indicates very good accuracy. CONCLUSIONS: External validation of the LPS against an independent geographically diverse population yields high NPV. This may support non-specialist colleagues who may have concerns about mis-diagnosing a PTA. The COVID-19 modification of the LPS has a similar NPV, which may be of use where routine oral examination is to be avoided during the COVID-19 pandemic.

The effect of fibrin sealant tissue glue in reducing post-operative collections following parotidectomy.

PURPOSE: Seroma/sialocele and haematoma formations following parotidectomy are common complications. Fibrin-sealant tissue glue (FSTG) applied to the surgical bed prior to closure has been used widely to reduce such complications at other surgical sites. We sought to evaluate a potential role in parotidectomy, examining outcomes before and after the use of FSTG was introduced in our department. METHODS: Outcomes were studied retrospectively for 1 year prior to the introduction of FSTG (group A, n = 31), and prospectively for 1 year subsequently (group B, n = 29). Primary outcome measures were seroma/sialocele and haematoma rates. Secondary outcome measures of interest included the use of a surgical drain and the duration of hospital stay. Chi-squared statistics and Mann-Whitney U tests were used to compare the outcomes between groups as appropriate. RESULTS: Seroma/sialocele rates were significantly lower in group B than in group A (n = 2 [6.9%] versus n = 8 [25.8%], p = 0.01) (Fig. 1), with an absolute risk reduction of 18.9%, a relative risk reduction of 26.7%, and a number needed to treat of 5.3. Haematoma rates were similar between groups (n = 0 [0%] versus n = 1 [3.2%], p = 0.36) (Fig. 2). In group A, a surgical drain was used in 24 cases (77.4%), while no cases in group B were drained.Fig. 1Seroma ratesFig. 2Haematoma rates CONCLUSION: The use of FSTG appears to significantly reduce the risk of post-parotidectomy seroma/sialocele formation and facilitates safe, drain-free daycase surgery. We hope this report will prompt other departments to consider using this technique and that our findings will help foster further appraisal in larger, prospective studies going forward.

Is OperaVOX a clinically useful tool for the assessment of voice in a general ENT clinic?

BACKGROUND: Objective acoustic analysis is a key component of multidimensional voice assessment. OperaVOX is an iOS app which has been shown to be comparable to Multi Dimensional Voice Program for most principal measures of vocal function. As a relatively cheap, portable and easily accessible form of acoustic analysis, OperaVOX may be more clinically useful than laboratory-based software in many situations. This study aims to determine whether correlation exists between acoustic measurements obtained using OperaVOX, and perceptual evaluation of voice. METHODS: Forty-four voices from the multidisciplinary voice clinic were examined. Each voice was assessed blindly by a single experienced voice therapist using the GRBAS scale, and analysed using OperaVOX. The Spearman rank correlation co-efficient was calculated between each element of the GRBAS scale and acoustic measurements obtained by OperaVOX. RESULTS: Significant correlations were identified between GRBAS scores and OperaVOX parameters. Grade correlated significantly with jitter (ρ = 0.495, p < 0.05), shimmer (ρ = 0.385, p < 0.05), noise-to-harmonic ratio (NHR; ρ = 0.526, p < 0.05) and maximum phonation time (MPT; ρ = -0.415, p < 0.05). Roughness did not correlate with any of the measured variables. Breathiness correlated significantly with jitter (ρ = 0.342, p < 0.05), NHR (ρ = 0.344, p < 0.05) and MPT (ρ = -0.336, p < 0.05). Aesthenia correlated with NHR (ρ = 0.413, p < 0.05) and MPT (ρ = -0.399, p < 0.05). Strain correlated with Jitter (ρ = 0.560, p < 0.05), NHR (ρ = 0.600, p < 0.05) and MPT (ρ = -0.356, p < 0.05). CONCLUSIONS: OperaVOX provides objective acoustic analysis which has shown statistically significant correlation to perceptual evaluation using the GRBAS scale. The accessibility of the software package makes it possible for a wide range of health practitioners, e.g. general ENT surgeons, vascular surgeons, thyroid surgeons and cardiothoracic surgeons to objectively monitor outcomes and complications of surgical procedures that may affect vocal function. Given the increasing requirement for surgeons to monitor their outcomes as part of the move towards 'surgeon reported outcomes' this may become an invaluable tool towards that goal.

Bone-anchored hearing aids in conductive and mixed hearing losses: why do patients reject them?

This study aimed to report the bone-anchored hearing aid uptake rate and the reasons for their rejection by patients with conductive and mixed hearing losses. A retrospective review was performed of 113 consecutive patients with unilateral or bilateral conductive or mixed hearing loss referred to the Greater Manchester bone-anchored hearing aid (BAHA) programme between September 2008 and August 2011. 98 (86.7 %) patients were deemed audiologically suitable for BAHA implantation. Of these, 38 (38.8 %) had BAHA implanted; 60 (61.2 %) patients declined. Of those who declined, 27 (45 %) cited anxiety over surgery, 18 (30 %) cited cosmetic reasons, 16 (26.7 %) perceived limited benefit from the device and six (10 %) preferred conventional hearing aids. Our study highlights a 38.8 % BAHA uptake rate in audiologically suitable patients. The main reasons cited for rejection of BAHA were anxiety over surgery and cosmetic concerns. It is important that clinicians address these early during consultation with prospective BAHA recipients and avoid rushing to implant these patients with a bone-anchored hearing aid.

Management of penetrating neck injuries at a London trauma centre.

Penetrating neck injuries (PNIs) are uncommon in the UK. The majority of guidelines are from the USA or South Africa. No UK national guidelines exist. Increasing urban violence in the UK has lead to an increase in PNIs. There is a need to develop a PNI guideline that reflects the pathology and experience in the UK. A retrospective review of all PNIs managed at St George's Hospital over an 18 month period was undertaken. Data collected included patient demographics, mechanism of injury, investigations, multidisciplinary team involvement and management. Clinical activity data was correlated to current worldwide literature and a flow-chart style clinical guideline was produced. 25 neck wounds were managed over an 18 month period. 68 % were male, 32 % female with a mean age of 36 years. The mechanism of injury included deliberate self-harm (48 %), stab wounds (32 %), gunshot wounds (4 %), shotgun wounds (4 %) and other accidental causes (12 %). 52 % of wounds were superficial to platysma. 58 % of deep wounds had CT. 42 % of patients with deep wounds also had panendoscopy. Interventional radiology was used in one case (8 %) and a single case was managed jointly with the vascular team (8 %). UK ENT surgeons have limited exposure to neck trauma and dedicated head and neck out-of-hours cover is uncommon. There is a need for UK PNI guidelines that reflect local pathology and experience. The St George's PNI guideline can be used to facilitate assessment, documentation and management of a relatively infrequent emergency presentation.

The assessment and management of globus pharyngeus.

Globus is the sensation of a foreign body in the throat. Investigation and management of patients with globus is widely variable. Most investigations yield negative results yet incur varying patient morbidity and healthcare costs, while malignancy is vanishingly rare in the absence of red flag symptoms and ear, nose and throat examination findings. History taking is key and can help to identify possible causative pathology, directing further investigations and management if necessary. Treatment of globus mainly centres on patient reassurance and counselling, and may include reflux management, neuromodulation, or speech therapy in selected cases, and treatment of any identified cause.

Importance of serum calcium in spontaneous neck haematoma.

We present an unusual case of spontaneous cervical haemorrhage secondary to extra-capsular bleeding from a parathyroid adenoma. Signs and symptoms on presentation included sore throat, dysphagia and anterior chest ecchymosis. While CT confirmed active cervical haemorrhage, elevated serum calcium and parathyroid hormone raised suspicion of possible parathyroid pathology. This case report and literature review highlight the diagnostic value of serum calcium in presentations of acute spontaneous neck haematoma. This should be considered especially in the acute phase, where imaging may not identify the source of haemorrhage. Initial observation and deferred surgery is the treatment of choice, with emergency operative management reserved for respiratory distress and worsening compressive symptoms.

Surgery results in complete cure of Lambert-Eaton myasthenic syndrome in a patient with metastatic Merkel cell carcinoma.

Lambert-Eaton myasthenic syndrome is a paraneoplastic phenomenon associated with neuroendocrine tumours, most frequently small cell lung carcinoma. Merkel cell carcinoma is a rare cause of Lambert-Eaton myasthenic syndrome. A 70-year old gentleman was referred with metastatic axillary nodal disease from a previously resected Merkel cell carcinoma of the left arm. Pre-operatively, the patient was wheelchair-bound from Lambert-Eaton myasthenic syndrome. Level I-III left axillary node clearance was performed and within 6 months, he had experienced full recovery of muscle power and mobility. We describe a case of complete cure of Lambert-Eaton myasthenic syndrome following axillary nodal clearance in a patient with metastatic Merkel cell carcinoma.