A. R. Welch

The 2-week rule for suspected head and neck cancer in the United Kingdom : Referral patterns, diagnostic efficacy of the guidelines and compliance

A retrospective audit of 1079 2-week referrals between 1 January 2004 and 31 December 2006 was undertaken. The aims of this audit were to assess compliance of referrals with Department of Health (DoH) guidelines; the effectiveness of the 2-week referral route in detecting head and neck cancers, and to determine whether this route identified more early stage cancers. Of 1079 2-week referrals, 71.5% conformed to DoH criteria. DoH guidelines were found to have a high sensitivity of 83.9% (75.5-89.7%, 95% CI) for head and neck cancer, but a low positive predictive value of 12.8% (10.5-15.3%) and a specificity of 30.0% (27.2-33.1%). Only 10.9% of 2-week referrals were diagnosed with a head and neck cancer. The cancer detection rate was higher amongst referrals that conformed to DoH guidelines (12.8%) compared to those that did not 6.2%. This was statistically significant (Chi square, p<0.01). The guidelines had a positive likelihood ratio of 1.20 (1.1-1.3), suggesting that there is a minimal increase in the likelihood of head and neck cancer when DoH guidelines are correctly applied. The diagnostic odds ratio (DOR) of the DoH referral criteria is 2.21. Most head and neck cancers were diagnosed via routine referral routes, 2-week referrals contributing to only 21.4% of all head and neck cancers diagnosed during the study period. The 2-week referral route did not identify more early stage cancers.

Occupational rhinitis: possible mechanisms of pathogenesis

Occupational rhinitis has been a prescribed industrial disease in the UK since 1907. It has only relatively recently received significant attention from otorhinolaryngologists although numerous studies have been performed in the past by occupational and industrial health physicians. At the present time the precise mechanisms of pathogenesis are unclear and would appear to be multiple. Recently interest has arisen because of compensation claims. Diagnosis made on the basis of the clinical history is subject to two problems: firstly, there is difficulty in differentiating between occupational and nonoccupational rhinitis, and secondly, clinical histories can easily be feigned. Physical signs would be a more reliable indicator of occupational damage to the nasal mucosa if they differ from the signs normally found in allergic or vasomotor rhinitis. In a series of 100 shipyard workers dry atrophic nasal mucosa was found in 66 and septal ulceration in two. From their clinical histories 78 individuals complained of nasal obstruction, 28 of epistaxis, 42 of hyposmia, 10 of anosmia and 90 of rhinorrhoea. Possible pathogenesis is described.

Basal cell adenocarcinoma of the parotid gland

A case of basal cell adenocarcinoma of the parotid gland is reported. Histologically it is to be distinguished from basal cell adenoma and adenoid cystic carcinoma. Clinically the presentation may appear benign. Surgical excision is the treatment of choice. The prognosis is uncertain because of lack of follow-up data.

Late development of a squamous carcinoma in a reconstructed pharynx

We report a case in which a squamous cell carcinoma was found to have arisen from a delto-pectoral skin flap used in pharyngeal reconstruction. The flap had been forming a neo-pharynx for 24 years. No other signs of recurrent disease had developed in this period. This raises the possibility of tumour induction in heterotopic skin used for oropharyngeal reconstruction.

Voice outcomes after concurrent chemoradiotherapy for advanced nonlaryngeal head and neck cancer: a prospective study.

The voice impact of treatment for nonlaryngeal head and neck primary sites remains unknown.

Thyroid gland invasion in total laryngectomy and total laryngopharyngectomy: a systematic review and meta-analysis of the English literature.

Advanced laryngeal and hypopharyngeal squamous cell carcinomas carry an inherent risk of invading thyroid parenchyma leading to the incorporation of a hemithyroidectomy or total thyroidectomy as part of a total laryngectomy. In some centres, thyroid gland removal occurs routinely during surgery for T3 and T4 laryngopharyngeal carcinoma. However, the incidence of invasion is low, and therefore, thyroid‐sparing surgery must be considered for select cases.

Surgical treatment of chronic parotid sialadenitis

OBJECTIVE To review the results of surgical management of chronic parotid sialadenitis refractory to medical therapy, with particular respect to long-term symptom resolution and development of post-operative complications. METHODS A retrospective review of parotidectomies performed for chronic intractable parotid sialadenitis. Information was collected about presentation, pre-operative investigations, surgical treatment, post-operative complications and outcome. RESULTS 36 parotidectomies were performed for chronic sialadenitis between 1991 and 2002. Age at presentation was 56+/-9.6 years, with median symptom duration of 2.3 years. For patients with non-specific presentations, magnetic resonance imaging (MRI) was the most useful pre-operative investigation. Superficial parotidectomy with duct preservation was the main treatment with a 94 per cent success rate, and near-total parotidectomy was reserved for patients with extensive deep-lobe involvement. Duct ligation significantly increased the risk of transient facial palsy. There was a 56 per cent and 22 per cent incidence of temporary facial paresis and Freys syndrome, respectively. CONCLUSIONS Controversies exist regarding the optimal pre-operative investigation and surgical treatment of chronic parotid sialadenitis. We advocate magnetic resonance image (MRI) scanning for patients with non-specific symptoms of sialadenitis, and sialography in the presence of reasonable clinical suspicion. We propose superficial parotidectomy without parotid duct ligation as the standard of care, with near-total parotidectomy reserved for extensive deep-lobe disease.

Factors affecting duration of gastrostomy tube retention in survivors following treatment for head and neck cancer

BACKGROUND Many patients treated for head and neck cancer require nutritional support, which is often delivered using a gastrostomy tube. It is difficult to predict which patients will retain their gastrostomy tube in the long term. This study aimed to identify the factors which affect the duration of gastrostomy tube retention. METHOD In this retrospective study, 151 consecutive patients from one centre were audited. All patients had a mucosal tumour of the head and neck, and underwent gastrostomy tube insertion between 2003 and 2007. RESULTS There were near-complete data sets for 132 patients. The gastrostomy tube was retained in survivors (n = 66) for a mean of 21.3 months and in non-survivors (n = 66) for 11.9 months. Univariate analysis showed that co-morbidity was the only factor which significantly increased duration of gastrostomy tube retention in survivors (p = 0.041). CONCLUSION Co-morbidity alone was associated with a significant increase in gastrostomy tube retention. It is suggested that co-morbidity be included as a variable in future relevant research. Co-morbidity should also be considered when counselling patients about their long-term function following cancer treatment. Gastrostomy tube retention is likely to be affected by many factors, with few single variables having importance independently.

Inflammatory myofibroblastic tumours of the respiratory tract: paediatric case series with varying clinical presentations.

OBJECTIVES To highlight the clinical importance of inflammatory myofibroblastic tumours of the respiratory tract in children, and to present a case series of three children which illustrates this tumours variable clinical presentation. CASE HISTORY The series includes: a nine-year-old girl with a diagnosis of juvenile idiopathic arthritis, who presented with finger clubbing and was found to have an inflammatory myofibroblastic tumour in her right upper lobe; a 15-year-old adolescent with a left main stem bronchial inflammatory myofibroblastic tumour, who presented with breathlessness and chest pain; and a 12-year-old girl with a tracheal inflammatory myofibroblastic tumour who presented with stridor. In each case, the tumour was resected surgically. CONCLUSION Inflammatory myofibroblastic tumour are a rare but clinically important and pathologically distinct lesion of the respiratory tract in children. The cases in this series highlight some of the varied clinical presentations of inflammatory myofibroblastic tumours, and illustrate some of this tumours different anatomical locations within the paediatric respiratory tract.

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

Sir, I welcome the thoughtful and excellent letter from Mr Moorthy regarding Post-CCT Fellowships, which extends the debate and for raises important points. Like all surgery, ORL training is experiencing sweeping change. It is important that such change should be questioned, particularly by those it most affects. Thus, a lively debate was held prior to the announcement of the first posts in which the real concerns of trainees (expressed correctly, with particular eloquence by Mr Moorthy) were heard and digested. As a result, only those programmes which demonstrated clearly that there were no knock-on effects on the training of others were approved. There were more posts applied for than advertised, and this criterion was a major factor in the choice of applications. Post-CCT positions will not affect the training of years 1–3 StR’s in any case, as they are aimed at the acquisition of skills beyond those required by ISCP, and there is precious little time in present training to achieve ISCP goals, let alone supplementary ones. Mr Moorthy is correct to say that there were political imperatives involved in these awards. However, he is mistaken in believing that these represented the prime purpose. The Post-CCT paradigm was developed by surgeons, for surgeons and, despite the efforts of PMETB and others, will be run and monitored by surgeons, with funding administered by the Royal College of Surgeons of England. Yet, the programme would not have got off the ground were it not for the leverage applied to the DoH to release the funds on the grounds of (a) reducing postCCT unemployment and (b) improving competitiveness of the workforce. Whilst this might be considered ‘sleeping with the enemy’, the funds were identified quickly. Thus, we have some of the posts we require to take our specialty to the next level of development. All this is not to say that we have not had problems: the main one was the small time window for potential applicants to have gained their CCT in order to be eligible. As a result, the potential pool was small, and many potentially excellent candidates have been forced to wait for the second and subsequent rounds in order to apply. Furthermore, only the trainees in this ‘political window’ were circulated with the advertisement (to my knowledge), resulting in confusion for trainees and trainers alike. The English College is working to correct both of these problems. We should establish a mechanism whereby the brightest and the best of our young surgeons have a training platform which will equip them for the demands of the tertiary referral services of the future. To resist such opportunities in the interests of protecting the rights of the remainder is to deliver a speciality driven by medicocrity, waiting for innovation to be imposed from outside. I propose that post-CCT Fellowships, for all the pain of their birth, are a key part in keeping ORL at the forefront of quality and innovation in surgery.