Joacim Stalfors

Quality assessment of a multidisciplinary tumour meeting for patients with head and neck cancer

Head and neck oncology MDT meetings are held in our region to establish a correct diagnosis and an appropriate treatment plan for each reviewed patient. The quality of these MDT meetings was assessed based on the following factors: How often can a diagnosis, a TNM-classification and a treatment plan be successfully established from the workup presented at the patients first MDT meeting? And what are the reasons for failure? Further, how often are the TNM-classification altered at treatment start? All patients (n=329) presented at MDT meetings during one year were included prospectively and data were collected in a protocol. As telemedicine recently was introduced to reduce travel, any eventual impact on quality on decisions with regard to telemedicine were also studied. A diagnosis and a treatment plan could be established for 236 (73%) of 324 patients at the first MDT meeting. TNM classification was revised in four patients (1.4%) before treatment. In conclusion, the validity of decisions made at the MDT meeting is satisfactory, but improvements regarding the quality of workups are possible. The mode of presentation of patients at the MDT meeting was not decisive for the quality of decisions regarding diagnosis and treatment plans.

Reduced risk of primary postoperative hemorrhage after tonsil surgery in Sweden: Results from the national tonsil surgery register in Sweden covering more than 10 years and 54,696 operations

To analyze the incidence of primary bleeding following tonsil surgery and to evaluate risk factors.

Tumour boards/multidisciplinary head and neck cancer meetings: are they of value to patients, treating staff or a political additional drain on healthcare resources?

Purpose of reviewThis article reviews the literature on the management of head and neck cancer using multidisciplinary team meetings as well as addressing the question of whether or not this organization is of benefit to the patients and treating staff and if it is cost efficient. Recent findingsThe multidisciplinary team has developed because of the complexity of clinical workup and treatment of head and neck cancer for which no single physician can claim to master all the training and skills necessary to treat the patients. The multidisciplinary team ensures that the professional efforts are coordinated and timely, thus ensuring the best results for patients. The multidisciplinary team usually involves a centralization of care with specialization, which benefits the outcome of treatment as well as enabling the development of clinical pathways to minimize complications, and improving on cost effectiveness. SummaryThe multidisciplinary team has become more and more an integral part of the clinical pathway for a patient with head and neck cancer in many European countries. This is cost effective and benefits patient outcomes.

Acute mastoiditis in children aged 0-16 years—A national study of 678 cases in Sweden comparing different age groups

OBJECTIVE To compare the characteristics of acute mastoiditis in children in different age groups in order to identify risk groups and risk factors for acute mastoiditis. METHODS Records for all children aged 0-16 years treated for acute mastoiditis during 1993-2007 at 33 Ear, Nose and Throat departments in Sweden were reviewed retrospectively according to defined criteria for acute mastoiditis. RESULTS A total of 678 cases fulfilled the inclusion criteria. Acute mastoiditis was most common in children younger than two years of age and this group was characterized by less prior history of other diseases and ear diseases, fewer visits to health care centers and less antibiotic treatment before admission, shorter duration of symptoms before admission, hospitalization for fewer days and lower frequency of complications and mastoidectomies. These children also showed a higher incidence of clinical findings, increased inflammatory markers such as fever and heightened counts of C-reactive protein and white blood cells compared with older children. They also tested positive for significantly more samples of Streptococcus pneumoniae while the older children more often exhibited growth of Streptococcus pyogenes or Pseudomonas aeruginosa or no microbial growth. CONCLUSIONS The characteristics of pediatric acute mastoiditis differed significantly between age groups. Acute mastoiditis was most common in children younger than two years of age. They showed more rapid progress of symptoms and more distinct signs of acute mastoiditis. This is probably the reason why parents rapidly seek medical care for small children and hospital treatment thus starts earlier in the youngest children, which may in turn explain the excellent outcome. This study showed that younger children have neither more severe acute mastoiditis nor more complications than older ones. The differences between age groups suggest that there are distinctions in the pathophysiology behind the onset and course of acute mastoiditis in younger and older children.

Deep Neck Space Infections Remain a Surgical Challenge. A Study of 72 Patients

Objective—The treatment of deep neck space infections (DNSIs) remains a clinical challenge and these infections are associated with significant risks of mortality. Material and Methods—We analyzed records over a 4.5-year period for all patients with DNSIs who required hospitalization. We recorded age, previous disease, delay in diagnosis, body temperature at admission, C-reactive protein level, X-ray results, location of DNSIs, origin of the infection, spread of infection, use of antibiotics, bacteriology, surgery and outcome. Results—A total of 72 patients (average age 45 years) were included. The locations and spread of DNSIs were described in detail. The commonest origins of DNSIs were dental (n=35) or salivary gland infections (n=15). Conclusion—Continuous assessment of the patient using CT scans, fine-needle aspiration and physical examinations will determine if and when surgery is necessary. As a large number of DNSIs are of dental origin, it is of great importance that diagnosis and treatment be performed in close cooperation with dental surgeons.

A cost analysis of participation via personal attendance versus telemedicine at a head and neck oncology multidisciplinary team meeting

Multidisciplinary team (MDT) meetings are used for establishing diagnosis, for tumour, node, metastasis (TNM) classification and for treatment in head and neck tumour patients in the western region of Sweden. Because of the distances, telemedicine was introduced to link the regional hospital to two of the three district general hospitals (DGHs). We evaluated the costs of presenting patients face to face (FTF) versus via telemedicine. Cost analyses were based on questionnaires completed by patients presented at the MDT meeting. A total of 39 patients were included in the FTF group and 45 patients in the telemedicine group. The cost analysis showed that FTF presentation cost SEK 2267 versus SEK 2036 by telemedicine (difference not significant). The small difference was explained by the fact that the responsible physician accompanied only six of 39 patients when presented FTF, but when presented via telemedicine the DGH physician always participated. A sensitivity analysis revealed that if the responsible physician always accompanied his/her patient for presentation FTF, the cost would be SEK 5366 per patient. This study shows that costs may be saved by carrying out MDT meetings by means of telemedicine instead of FTF.

Tonsil surgery efficiently relieves symptoms: analysis of 54 696 patients in the National Tonsil Surgery Register in Sweden

Abstract Conclusion: Patients operated with tonsillar surgery report a high degree of symptom relief 6 months after surgery. Objective: The purpose of this study was to analyze symptom relief 6 months after tonsil surgery in relation to age, indication, surgical procedure, primary bleeding and unplanned postoperative visits. The National Tonsil Surgery Register in Sweden offers data from 54 696 patients registered during 1997–2008. Methods: This was a prospective assessment by questionnaire. Data were collected using three questionnaires, two completed by professionals and one 6 months postoperatively by the parents/patients. Results: Among 54 696 patients, the most common surgical indications were obstruction (49.7%), followed by recurrent tonsillitis (35.2%). Symptom relief 6 months after surgery was high in all indication groups (>92%), and highest for patients operated on the indication peritonsillitis (>98%). The indications obstruction, recurrent tonsillitis or chronic tonsillitis reported a high degree (>96%) of symptom relief. Of the patients who underwent tonsillectomy with adenoidectomy, 97.5% were symptom-free compared to 96% of patients who had tonsillectomy alone and 96.1% who underwent tonsillotomy (p < 0.0001). In all, 13.9% of patients required an unplanned visit to the clinic postoperatively. Only 148 of 54 696 patients reported worsening of symptoms after surgery.

Post-tonsillectomy haemorrhage rates are related to technique for dissection and for haemostasis. An analysis of 15734 patients in the National Tonsil Surgery Register in Sweden

To analyse post‐tonsillectomy haemorrhage (PTH) rates related to technique for dissection and haemostasis.

Titanium-bone-anchored penile epithesis: Preoperative planning and immediate postoperative results

Abstract The principle of osseointegration is accepted and used in reconstructive surgery. This study presents the first series of five patients where titanium implants have been implanted into the pubic bones of female-to-male (FTM) transsexual patients, in order to attach a “bone-anchored” penile epithesis. Following patient selection based on patients’ wishes, pubic bones of 10 FTM transsexuals were analysed by CT-scan and a virtual planning was made. A surgical plan was also developed. To date, five FTM transsexuals have undergone the two-stage surgery. During stage-1, two titanium implants (“fixtures”) are implanted onto the pubic bone. Four weeks postop, a new CT scan is performed to analyze osseointegration and the final implant position. During stage-2, the soft tissue of the pubic area is reduced; abutments are inserted and passed through the skin. A few weeks after stage 2 surgery, a penile epithesis is connected to the skin-penetrating titanium implants. Two out of 10 patients who received preoperative CT scan presented with smaller pubic bones, not able to accommodate the fixtures as chosen originally. Preoperative virtual planning is crucial for the selection of the appropriate implants size. The stage-1 and stage-2 surgery occurred uneventfully in all five patients. One patient presented with a wound infection 1 week after stage-2 surgery. Postoperative CT scan demonstrates implant osseointegration in all cases. This experimental clinical study demonstrates that titanium osseointegration is feasible onto the pubic bone. This new approach for penile reconstruction constitutes another alternative for both transsexual patients and cases following genital development disorders, post-trauma and surgery.

Trends and changes in paediatric tonsil surgery in Sweden 1987–2013: a population-based cohort study

Objectives The objective of this study was to longitudinally describe the history of tonsil surgery in Swedish children and adolescents regarding incidence, indications for surgery, surgical methods and the age and gender distributions. Setting A retrospective longitudinal population-based cohort study based on register data from the Swedish National Patient Register (NPR) and population data from Statistics Sweden. Participants All Swedish children 1–<18 years registered in the NPR with a tonsil surgery procedure 1987–2013. Results 167 894 tonsil surgeries were registered in the NPR 1987–2013. An increase in the total incidence rate was observed, from 22/10 000 person years in 1987 to 47/10 000 in 2013. The most marked increase was noted in children 1–3 years of age, increasing from 17 to 73/10 000 person years over the period. The proportion children with obstructive/sleep disordered breathing (SDB) indications increased from 42.4% in 1987 to 73.6% in 2013. Partial tonsillectomy, tonsillotomy (TT), increased since 1996 and in 2013 55.1% of all tonsil procedures were TTs. Conclusions There have been considerable changes in clinical practice for tonsil surgery in Swedish children over the past few decades. Overall, a doubling in the total incidence rate was observed. This increase consisted mainly of an increase in surgical procedures due to obstructive/SDB indications, particularly among the youngest age group (1–3 years old). TT has gradually replaced tonsillectomy as the predominant method for tonsil surgery.