Guy Rees

Sentinel node biopsy in squamous cell cancer of the oral cavity and oral pharynx: A diagnostic meta-analysis†

The sentinel node biopsy concept has been gaining support in the head and neck cancer literature during only the last few years, and several pilot studies have been published. This procedure aims to avoid unnecessary treatment to the clinically negative neck by identifying the patients with occult neck disease.

The Effect of β-Blocker Premedication on the Surgical Field During Endoscopic Sinus Surgery

Objectives/Hypothesis: A number of previous studies have tried to assess the effects of hypotension on the surgical field during endoscopic sinus surgery. These studies have been limited by inadequate sample sizes, lack of a control group, and limited data collection. The aim of the present study was to determine whether the routine use of β‐blockers as a pre‐medication could improve the operative field in endoscopic sinus surgery.

An evaluation of effect of pterygopalatine fossa injection with local anesthetic and adrenalin in the control of nasal bleeding during endoscopic sinus surgery

Background The aim of this study was to determine the effect of pterygopalatine fossa infiltration with lidocaine and adrenalin on bleeding in the surgical field during endoscopic sinus surgery. Methods A prospective blind randomized controlled trial was performed. Fifty-five patients were randomized to receive a unilateral transoral infiltration of the pterygopalatine fossa with 2 mL of 2% lidocaine and 1:80,000 adrenalin. The operating surgeon was blinded as to which side had been infiltrated at the start of surgery. The surgical field was graded on a previously validated surgical field grading scale every 15 minutes with the side being operated on alternated every 30 minutes. The pulse, mean arterial blood pressure, and end-tidal CO2 concentration were monitored with each surgical field observation. Results At each individual time point from 30 minutes to 3.5 hours there was a significant difference in surgical grade between injected and noninjected sides in favor of the injected side (p = 0.01). The difference between surgical grades averaged across all time points was slight but significant. The injected side had an overall mean of 2.59 (SE, 0.22) compared with 2.99 (SE, 0.23) for the noninjected side. Heart rate also was found to correlate independently to surgical grade. Conclusion Injection of the pterygopalatine fossa resulted in an improved surgical field during endoscopic sinus surgery.

Human papillomavirus modifies the prognostic significance of T stage and possibly N stage in tonsillar cancer

BACKGROUND Despite the association with more advanced nodal stage, patients with human papillomavirus (HPV) positive oropharyngeal cancers have better outcomes. We examined whether the HPV can modify the effect of known prognostic factors in tonsillar cancer. PATIENTS AND METHODS A total of 489 patients from 10 centres were followed up for recurrence or death for a median of 3.2 years. Determinants of the rate of locoregional recurrence, death from tonsillar cancer and overall survival were modelled using Cox regression. RESULTS The prognostic value of T and N stages were modified by HPV as indicated by statistically significant interaction terms. After adjusting for age, gender and treatment, T stage appeared relevant only for HPV-positive cancers (where a higher T stage was associated with worse outcomes). There was some evidence that N stage was a more relevant prognostic factor for HPV-negative than -positive cancers. There was no evidence that the HPV modifies the effect of age, gender or grade on outcomes. CONCLUSIONS This study suggests that the prognostic significance of the conventional staging system in tonsillar cancer is modified by HPV.

DISSECTION OF THE SUBMUSCULAR RECESS (SUBLEVEL IIB) IN SQUAMOUS CELL CANCER OF THE UPPER AERODIGESTIVE TRACT: PROSPECTIVE STUDY AND SYSTEMATIC REVIEW OF THE LITERATURE

Selective neck dissection is commonly used to clear occult neck metastases in the N0 neck. The aim of this study was to identify the incidence of occult metastases in lymph nodes of sublevel IIb (submuscular recess; SMR) in upper aerodigestive tract squamous cell carcinoma in the setting of clinically and radiologically staged N0 necks and to perform a systematic review of the literature on the incidence of metastases in this setting.

Nasopharyngeal pH Monitoring in Chronic Sinusitis Patients Using a Novel Four Channel Probe

Objective: To determine the prevalence of acid reflux into the nasopharynx in patients with chronic sinusitis.

The influence of the size of the maxillary sinus ostium on the nasal and sinus nitric oxide levels

Background Nitric oxide (NO) is produced in significant quantities in the nasal sinuses and is thought to have a beneficial effect on the mucociliary transport of the sinuses and nose and to have significant antibacterial properties that contribute to the health of the sinuses. Recently, the concept of “mini-functional endoscopic sinus surgery” has been introduced where the uncinate is removed without enlargement of the maxillary ostium. Although no scientific evidence has been published, enlargement of the ostium is thought to possibly disrupt the mucociliary pathway and decrease the concentration of NO in the nose and sinuses. The aim of this study was to establish the effect of enlargement of the maxillary ostium on sinus and nasal NO. Methods Twenty-nine patients who were post-endoscopic sinus surgery were included with 52 who were maxillary sinus ostia cannulated. There were 22 large maxillary sinus ostia and 30 small ostia. Smoking, allergy status, and topical steroid use were recorded. NO levels were measured in the nose and maxillary sinus after decongestion with patients mouth breathing and breath holding. Results This study shows that enlargement of the maxillary sinus ostium above its normal size (20 mm2) produces a significant decrease in both the maxillary sinus and the nasal cavity NO levels. In addition, the size of the ostium showed a significant correlation to the sinus NO level. Use of topical nasal steroid sprays and topical decongestants were shown to effect NO levels in the sinuses and nasal cavity. The lowered levels of NO were found irrespective of the technique of measurement of the NO. Conclusions The effect of this lowered NO level on the susceptibility of the maxillary sinuses to recurrent infection is yet to be determined.

Human papillomavirus, smoking status and outcomes in tonsillar squamous cell carcinoma

It is now clear that the two separate entitles of tonsillar cancer, HPV induced and non‐HPV induced (smoking induced), have significantly different presenting stage and outcomes. A significant proportion of patients with human papillomavirus positive tonsillar cancer have had exposure to smoking. We examined the combined effect of human papillomavirus and smoking on the outcomes and determined whether smoking can modify the beneficial effect of human papillomavirus. A total of 403 patients from nine centers were followed up for recurrence or death for a median of 38 months. Determinants of the rate of loco‐regional recurrence, death from tonsillar cancer and overall survival were modeled using Cox regression. Smoking status was a significant predictor of overall survival (p = 0.04). There were nonstatistically significant trends favoring never smokers for loco‐regional recurrence and disease specific survival. In addition, there was no statistically significant interactions between smoking and human papillomavirus (p‐values for the interaction were 0.26 for loco‐regional recurrence, 0.97 for disease specific survival and 0.73 for overall survival). The effect of smoking on loco‐regional recurrence and disease specific survival outcomes was not statistically significant, nor was there significant evidence that the effect of smoking status on these outcomes was modified by HPV status. Irrespective of HPV status, however, smokers did have poorer overall survival than never‐smokers, presumably due to effects of smoking that are unrelated to the primary cancer.

Multiplanar reconstructed computed tomography images improves depiction and understanding of the anatomy of the frontal sinus and recess.

Aims The use of multiplanar reconstructed computed tomography (CT) images of frontal recess and sinuses was assessed with regard to depiction and understanding of anatomy and effect on surgical approach. Materials and Methods Three otorhinolaryngologists and one radiologist read CT scans of 43 patients referred for routine paranasal sinus scans. Spiral (helical) CT scans were obtained and coronal and parasagittal reconstructions were imaged. Three hundred forty-two readings were analyzed. The scans were assessed in the coronal plane and then in the parasagittal plane. The images were assessed for (i) Bent and Kuhn classification of frontal ethmoidal sinus air cells, (ii) size of frontal sinus ostium (assessed as unsure, normal, small, or large), (iii) use of parasagittal scans regarding additional understanding of the anatomy with particular reference as to how the agger nasi cell and frontal ethmoidal cells were arranged in a three-dimensional space, and (iv) if the parasagittal scan and subsequent three-dimensional picture created altered the surgical approach. The first two criteria were assessed in the coronal plane and then in the parasagittal plane. Results There was no statistically significant difference between the Bent and Kuhn classification of frontoethmoidal cells on coronal and reconstructed parasagittal images (t-test; p < 0.05). The parasagittal scans were significantly better than the coronal scans for identifying and assessing the size of the frontal sinus ostium (p > 0.001; chi-square test). Assuming an intraobserver change rate (repeat error) of 10% on CT scan observations, an exact binomial test was performed on S-PLUS, which showed that there was a significant (p < 0.001) proportion of observers who changed their rating after looking at the parasagittal scan. There also was significant improvement in observers’ abilities to identify and classify the size of the frontal ostium as reflected by the number of observers who changed from being unsure on the coronal scans to sure on the parasagittal scans. Observers felt that the parasagittal scans improved their three-dimensional understanding of the anatomy of the frontal recess by 58% on a 10-point Lickert scale. In 55% of these observations, the surgical plan was altered by a mean of 70.2% on a 10-point Lickert scale based on additional information obtained by viewing the parasagittal scans. Conclusions The three-dimensional understanding of the frontal recess is improved greatly by using both coronal and parasagittal reconstructed images as compared with coronal images alone. This had important implications on the planning of the surgery in the frontal recess.

Gastroesophageal reflux disease and chronic sinusitis: In search of an esophageal-nasal reflex

Background This study was performed to explore whether or not a neural reflex linking the esophagus and the nasal airway exists, as a pathogenic mechanism accounting for the association between gastroesophageal reflux (GER) disease and chronic rhinosinusitis (CRS). A prospective trial of healthy human volunteers was performed. Methods Ten healthy volunteers without GER or sinonasal disease were investigated using an acid infusion challenge test. Normal saline and hydrochloric acid were infused into the lower esophagus through an esophageal manometry catheter. Nasal responses in symptom score, nasal inspiratory peak flow, and mucus production were analyzed after the esophageal challenge. Results A tendency for an increase in nasal mucus production was observed after esophageal stimulation with both normal saline and HCl. This returned to baseline level 45 minutes after the acid infusion. A similar trend was also observed with the measurements of nasal symptom scores and, to a lesser extent, nasal inspiratory peak flow. Conclusion These results support the possibility that a neural reflex exists between the esophagus and the paranasal sinuses via the vagus nerve. If indeed present, the reflex-mediated rhinitis derived from this neuropathic inflammation may contribute to the development of CRS in patients with GER. Further study is required to define the relationship between GER and CRS.