P. H. Rhys Evans

Tracheo-oesophageal puncture: a review of problems and complications

Tracheo-oesophageal puncture now has a well established role and in several units is now the principal means of speech rehabilitation following laryngectomy. Although not a difficult procedure, there are a number of problems and complications that may be encountered. With proper management these can usually be overcome and a useful voice achieved. This study looks at those problems in a series of 119 patients and discusses their management.

Wegener's granulomatosis, subglottic stenosis and antineutrophil cytoplasm antibodies.

Wegeners granulomatosis is difficult to diagnose, especially when the presentation is unusual, restricted to an isolated region. We report four cases of recurrent subglottic stenosis posing difficulty in diagnosis. In each case the finding of anti-neutrophil cytoplasm antibodies (ANCA) strongly suggested an underlying vasculitic pathology, Wegeners granulomatosis. We discuss reasons for the difficulty in diagnosis in the past, the possible role of the ANCA assay in such patients, and suggest it should be more widely used in the future.

Quality of life outcome measures following partial glossectomy: Assessment using the UW-QOL scale

BACKGROUND The consequences of a diagnosis of head and neck cancer and the impact of treatment have a clear and direct influence on well-being and associated quality of life (QOL) in these patients. AIMS To determine the QOL in head and neck cancer patients following a partial glossectomy operation. DESIGN AND SETTING Cross-sectional cohort study; Head and Neck Oncology Unit, tertiary referral center. MATERIALS AND METHODS 38 patients with partial glossectomy were assessed with the University of Washington head and neck quality of life (UW-QOL) scale, version 4. STATISTICAL ANALYSIS Statistical analysis was performed using the Statistical Package for Social Sciences 10.0 (SPSS Inc, Chicago version III). Information from the scale was correlated using the Mann Whitney test. A P value less than/equal to 0.05 was considered as significant. RESULTS The mean (sd) composite score of the QOL in our series was 73.6 (16.1). The majority (71.8%) quoted their QOL as good or very good. Swallowing (n = 16, 47.1%), speech (n = 15, 44.1%) and saliva (n = 15, 44.1%) were most commonly cited issues over the last 7 days. On the other hand, the groups with reconstruction, neck dissection, complications and radiotherapy demonstrated a significant reduction of quality of life scores (Mann Whitney test, P < 0.005). CONCLUSION The composite score and overall QOL as assessed using the UW-QOL scale (version 4) were modestly high in our series of partial glossectomy patients. Swallowing, speech, and saliva are regarded as the most important issues. Stage of the disease, neck dissection, reconstruction, complications, radiotherapy and time since operation were seen to significantly affect domain scores.

Secretory otitis media--evidence for an inherited aetiology.

In a study to determine whether or not there is a familial or hereditary predisposition to develop secretory otitis media (SOM), the parents of 73 children with persistent SOM and 35 controls were examined clinically, and abnormalities of the tympanic membrane (TM) noted. Analysis of the findings suggests that heredity plays a large part in determining a childs likelihood of developing SOM.

Expression of CC chemokine receptor 7 in tonsillar cancer predicts cervical nodal metastasis, systemic relapse and survival

The aim of this study was to evaluate the expression of CC chemokine receptor 7 (CCR7) in squamous cell cancer of the tonsil with respect to patterns of spread, relapse-free, overall and disease-specific survival. Eighty-four patients with squamous cell cancer of the tonsil were identified. There was a male predominance of 3 : 1 and the median age at diagnosis was 53 (range 35–86) years. The median duration of follow-up was 33 (range 2–124) months. There was a significant association between CCR7 immunopositivity and synchronous cervical nodal metastasis in patients with tonsillar cancer (Spearmans correlation coefficient 0.564; P<0.001). Relapse-free (P=0.0175), overall (P=0.0136) and disease-specific (P=0.0062) survival rates were significantly lower in patients whose tumours expressed high levels of CCR7. On multivariate analysis, high-level CCR7 staining predicted relapse-free (hazard ratio 3.0, 95% confidence intervals 1.1–8.0, P=0.026) and disease-specific (hazard ratio 10.2, 95% confidence intervals 2.1–48.6, P=0.004) survival. Fifteen percent of patients with the highest level of tumour CCR7 immunopositivity relapsed with systemic metastases. These data demonstrated that CCR7 expression was associated with cervical nodal and systemic metastases from tonsillar cancers. High levels of CCR7 expression predicted a poor prognosis.

Complications in head and neck surgery and how to avoid trouble.

Increasing litigation in recent years has made it more and more necessary for the surgeon to be aware of the problems, pitfalls and complications which may arise as a result of surgery. The risks are compounded in the head and neck not only because of its complex anatomy but also because of additional difficulties relating to surgery of the upper aero-digestive tract. Some problems are unavoidable. The potential risks of surgery and its complications should be carefully weighed against the natural history of the pathological process and a realistic expectation of the surgical outcome compared with alternative treatments. Other problems may result from genuine mistakes, but a number of complications are caused through actions or omissions which are avoidable and which in certain circumstances may be construed as professional negligence. Some of the more common pitfalls and complications in head and neck surgery are discussed with particular reference to their causation and possible avoidance.

Preservation of neck dissection for histological study

Dissection of lymphatic nodes in the neck--whether radical or partial, functional or prophylactic--forms an integral part of the surgical management of cancer of the head and neck. Accurate orientation and fixation of the surgical specimen is a prerequisite for correct histopathological study of the extent of the disease and for a complete clinicopathological interpretation, which is of significant therapeutic and prognostic importance.

Isolated intrathyroid metastasis from undifferentiated and squamous carcinoma of the head and neck: the case for surgery and re-irradiation

Metastasis to the thyroid gland is rare, with fewer than 450 cases reported in the literature. Furthermore, intrathyroid metastasis from head and neck squamous cell carcinoma (HNSCC) is even more unusual, with only nine previously documented cases. This study details the cases of three patients (from one centre) who presented with intrathyroid metastasis from HNSCC and who were treated with a combination of surgery and radiotherapy. Although previous reports have suggested that this pattern of spread is associated with a poor outcome, we are able to show that appropriately selected patients benefit from a combination of both radical surgery and adjuvant radiation therapy, even when this entails some areas of re-irradiation.

Asymptomatic oropharyngeal lipoma complicating intubation.

Oropharyngeal lipomas are rare tumours. We present the case of a young man with an asymptomatic lipoma almost completely occluding his supraglottic airway, found on magnetic resonance imaging (MRI) for a separate oral cavity lesion. Pre-operative anaesthetic assessment was undertaken because of the risk of airway obstruction at induction of general anaesthesia. We discuss the awake fibre-optic technique used for induction, as well as the treatment and follow-up of these tumours. This case highlights the need for formal anaesthetic assessment, in such cases, to avoid total airway obstruction at induction of general anaesthesia. It also emphasizes the extent of supraglottic obstruction that can be present without giving rise to any symptoms.

Mesenchymal chondrosarcoma of the vagus nerve

Mesenchymal chondrosarcoma is a rare, aggressive, malignant neoplasm, which arises from extraskeletal sites in 30-40 per cent of cases. It is extremely rare in children. We present a novel case of childhood mesenchymal chondsarcoma arising from the vagus nerve in the neck, resulting in paralysis of the right vocal fold. The clinicopathologic features and management of this case are described along with a brief discussion on the aetiology of vocal fold paralysis in this age group. Current literature on extraskeletal presentation of mesenchymal chondrosarcoma is reviewed.