Objectives
To assess how type and number of symptoms are related to survival in head and neck cancer patients.
Methods
Patients from the Scottish Audit of Head and Neck Cancer (a national cohort of head and neck cancer patients in Scotland, 1999 to 2001) were followed up for over 10 years. Median survival was measured in relation to patients’ presenting symptoms.
Results
The study comprised 1146 males (72 per cent) and 443 females (28 per cent), with a mean age at diagnosis of 64 years (range, 13–95 years). Median survival was 5.3 years in those with one symptom, versus 1.1 years in those with three symptoms. Patients who presented with weight loss had a median survival of 0.8 years, compared to 4.2 years in those with no weight loss (p < 0.001). Patients who presented with hoarseness had a median survival of 5.9 years, compared to 2.6 years in those without (p < 0.001). There was no significant difference in long-term survival for patients who presented with an ulcer, compared to those who did not (p = 0.105).
Conclusions
This study highlights the importance of patients’ presenting symptoms. It provides valuable information regarding highlighting appropriate ‘red flag’ symptoms, and subsequent treatment planning and prognosis.
Introduction
Epistaxis is the commonest ENT emergency. Nevertheless, little is known about the effect of socio-economic status on epistaxis outcomes.
Aim
To investigate the effect of the Scottish Index of Multiple Deprivation on epistaxis data, including: number of hospital admissions, gender, number of bed days and one-year mortality.
Methods
Univariate analysis of epistaxis patients’ demographic and clinical information, obtained from Information Services Division Scotland for the period 1995 to 2015, was conducted.
Results
Epistaxis admission numbers remained stable, with an average of 2600 new admissions per year. Males were more likely to require in-patient care (p = 0.001). Length of hospital stay has reduced significantly over the 21-year period (1 in-patient day reduction, p < 0.001). Patients from socio-economically deprived areas were more likely to require hospital admission (p < 0.001). The total one-year mortality rate was 9.5 per cent.
Conclusions
Scotland has shown a reduction in hospital length of stay for epistaxis. Socio-economic deprivation was linked with a higher number of admissions.
Introduction
Microlaryngoscopy is a routinely performed procedure. At times, the intra-operative view of the larynx is suboptimal. The Laryngoscore is a validated tool designed to predict difficult laryngeal exposure.
Aim
To evaluate the accuracy of the Laryngoscore in predicting difficult laryngeal exposure in our centre.
Methods
A prospective cohort study was conducted. All patients undergoing elective microlaryngoscopy over one year were assessed pre-operatively using the Laryngoscore. They were categorised into four classes based on anterior commissure visualisation, where classes I–II were identified to have good laryngeal exposure and classes III–IV had difficult laryngeal exposure.
Results
A total of 170 patients were evaluated. When the Laryngoscore was less than 5, good laryngeal exposure was observed in 87 per cent of our cohort. When the score was 5 or more, difficult laryngeal exposure was detected in 79 per cent of the cohort. Prominent or normal dentition, and body mass index of more than 25 kg/m2, provided the best clinical predictors for difficult laryngeal exposure.
Conclusions
The Laryngoscore is a good predictor for difficult laryngeal exposure. It can help identify the patients at risk of undergoing failed transoral laser laryngeal surgery.
Introduction
Otitis media with effusion (OME) is very common in children with cleft palate (with or without cleft lip), occurring in 97 per cent by two years. Hearing loss associated with OME can lead to problems with speech and language development.
Aim
To assess if audiology results at three years correlate with speech outcomes at five years for this cohort.
Methods
A retrospective case note review was conducted of children born between January 2003 and December 2009 with a cleft palate (with or without cleft lip). Each child underwent a five-year ‘Cleft Audit Protocol for Speech – Augmented’ speech assessment and had formal hearing tests at three years.
Results
Sixty patients were included (30 male, 30 female). Abnormal tympanograms were present in 70.9 per cent of cases. Twenty-two of these patients (36.7 per cent) had acceptable speech outcomes at five years, despite nearly two-thirds (65 per cent) having normal hearing assessments at three years. Lower socio-economic class and larger defects were also associated with poorer speech outcomes.
Conclusion
Hearing and speech are linked. For the best outcomes in conditions such as cleft lip (with or without cleft palate), hearing should be given as much emphasis as speech.
Introduction
Laser microsurgery can be used to treat benign and malignant conditions of the larynx. The National Institute for Health and Care Excellence recommends that patients with tumour stage T1–2 squamous cell carcinoma of the glottic larynx be offered laser microsurgery or radiotherapy.
Methods
We audited our practice, and identified 25 patients from 2014 to 2017 who had undergone laser microsurgery, 8 of whom had early malignancy.
Results
Ventilation was applied via a tubeless field or flexometallic endotracheal tube in all cases. In the malignant cases, 88 per cent had a second procedure (mean of 6.57 months), 75 per cent had a third (5.33 months) and 25 per cent had a fourth (3 months). Eighteen procedures (78 per cent) were carried out as a day case. Two cases proceeded to radiotherapy as the lesions were unsuitable for laser resection. No recurrence was identified in any case on recent follow up.
Conclusion
Our data suggest that laser microsurgery for early laryngeal cancer is an effective treatment modality; it decreases radiotherapy workload and is ultimately more cost effective.
Introduction
Post-tonsillectomy haemorrhage has been studied extensively in the literature. The National Prospective Tonsillectomy Audit identified a primary haemorrhage rate (i.e. within 24 hours) of 0.6 per cent, and a secondary haemorrhage rate of 3 per cent, with ‘hot’ surgical techniques and trainee surgeon operators associated with a greater risk of haemorrhage. This audit aimed to establish the cause of high tonsillectomy morbidity noted in NHS Greater Glasgow and Clyde.
Methods
All adult patients undergoing tonsillectomy between 1 October 2015 and 30 September 2016 were identified for inclusion. All patients with post-tonsillectomy haemorrhage re-admitted to the centralised ENT department in Queen Elizabeth University Hospital were identified, through a retrospective electronic clinical record review.
Results
Tonsillectomy was performed in 526 patients during the study period. Primary haemorrhage occurred in 12 patients (2.3 per cent) and secondary haemorrhage occurred in 88 patients (16.7 per cent). A return to the operating theatre for haemorrhage control was necessary in 23 patients (4.4 per cent). The sole factor associated with an increased risk of haemorrhage was male gender (χ2 = 6.15, degrees of freedom = 1, p = 0.013), with age, surgeon seniority, dissection technique, indication for surgery and years of recurrent tonsillitis showing no statistical association.
Conclusion
This audit highlighted a high post-tonsillectomy haemorrhage rate in NHS Greater Glasgow and Clyde, with no clear causative factor. Haemorrhage rates may have been heightened because of the non-paediatric population studied. However, tonsillectomy indication and years of recurrent tonsillitis were both non-significant outcomes. Given the centralisation of ENT emergency care in Glasgow, and the comprehensive data capture for the year, the authors postulate whether data collection has been suitably robust in previous studies.
Introduction
Tonsillar crypts are a reservoir for group A streptococcus bacteria, which can cause potentially life-threatening invasive infections. The incidence of these infections in England has been on the rise, whilst tonsillectomy rates have decreased.
Aim
To determine if there is a relationship between tonsillectomy rates and invasive group A streptococcus infection in England.
Methods
Data on elective tonsillectomies, admissions for tonsillitis and incidence of invasive group A streptococcus infections between 1991 and 2014, extracted from the Hospital Episodes Statistics database and Public Health England, were analysed to identify age-related trends.
Results
There was a strong positive correlation between admissions for tonsillitis and invasive group A streptococcus incidence (Pearson's coefficients = 0.69–0.92), and a negative correlation between tonsillectomy rates and invasive group A streptococcus incidence (Pearson's coefficients = 0.53–0.79).
Conclusion
Our study does not allow us to infer causation, and the increasing incidence of invasive group A streptococcus will have a multifactorial aetiology. Further research is required to assess the benefit of early tonsillectomy.
Introduction
Immediate discharge letters are sent out to allow relevant information to be conveyed promptly to general practitioners. There are six important points to mention in the context of epistaxis: site, treatment, medication changes, haemoglobin, transfusion and medications prescribed.
Aim
To improve the quality of our immediate discharge letters by auditing current practice and implementing guidelines.
Method
A closed-loop audit was conducted (over eight-month periods) following the implementation of an epistaxis immediate discharge letter proforma.
Results
Immediate discharge letters were found to be of poor quality in terms of their content. Many letters failed to include details of: site, antiplatelet or anticoagulant medications (and when to restart), haemoglobin levels, and whether blood transfusions had been carried out. The introduction of an epistaxis immediate discharge letter proforma produced more complete and concise immediate discharge letters.
Conclusion
Awareness of the purpose of immediate discharge letters and their use by general practitioners prompted us to produce a proforma, in order to generate better quality immediate discharge letters for patients admitted with epistaxis.
Introduction
We investigated the implementation of ultrasound reporting standards set out by the British Thyroid Association guidelines published in July 2014.
Aims
To identify initial compliance to guidelines, and to educate and engage the relevant departments regarding use of the British Thyroid Association guidelines.
Methods
A closed-loop audit was conducted on compliance with thyroid ultrasound scan reporting guidelines. The first loop results were presented, and a general consensus on the changes required was decided by the radiology department. A second loop was initiated following an interval.
Results
Sixty-five reports were reviewed in the first loop and 50 reports were reviewed in the second loop. The key guideline of ultrasound 1–5 grading system usage improved from 19 per cent in the first loop to 57 per cent in the second loop.
Conclusions
The British Thyroid Association guidelines are a useful tool for standardising ultrasound scan reporting, to facilitate and standardise interpretation and management decisions. Our compliance with the reporting standards has improved.
Introduction
Undergraduate otolaryngology in the UK is highly variable. It would therefore be advantageous to identify key components to include within a curriculum.
Aim
To establish what doctors feel a medical student should learn about otolaryngology.
Method
A national questionnaire survey was undertaken. The survey was devised from an analysis of current UK otolaryngology curricula, a literature review and expert panel opinion.
Results
A total of 308 responses were received. Respondents indicated that students should be competent in examination skills. Common and life-threatening conditions were deemed most important. Results showed that competence in managing the majority of otolaryngology conditions was not required. Many topics identified by doctors are not currently included in undergraduate otolaryngology curricula.
Conclusions
At an undergraduate level, emphasis should be on examination skills and acute conditions. A general knowledge of ENT conditions is required, but competence in their management is not necessary for the majority.
Introduction
There is currently no ‘gold standard’ in the management of the shared airway in subglottic stenosis. Transnasal humidified rapid-insufflation ventilatory exchange (‘THRIVE’) is a technique that allows for prolonged apnoeic oxygenation with a tubeless field, which can be advantageous for the ENT surgeon.
Aim
To establish the effectiveness of transnasal humidified rapid-insufflation ventilatory exchange in patients undergoing endoscopic balloon dilatation for subglottic stenosis.
Method
A prospective review was conducted of 17 subglottic stenosis patients undergoing endoscopic balloon dilatation with transnasal humidified rapid-insufflation ventilatory exchange at St John's Hospital, Livingston.
Results
Transnasal humidified rapid-insufflation ventilatory exchange maintained the oxygen saturation in all cases, and only two patients had oxygen desaturation during the procedure. Transnasal humidified rapid-insufflation ventilatory exchange was discontinued in one patient after 25 minutes. The median apnoea time was 18 minutes (range, 10–27 minutes). There were no reported complications.
Conclusions
Transnasal humidified rapid-insufflation ventilatory exchange can be an effective technique in the shared airway in subglottic stenosis. It can result in better surgical access and visualisation, with less airway trauma and interruption compared to alternative ventilation techniques.
Introduction
The pectoralis major flap is a widely used regional pedicled myocutaneous flap in head and neck cancer reconstruction. Its use has been limited following improvement in microsurgical techniques for free flaps and their associated success. However, it still remains the frontrunner when it comes to pedicled flaps. Its robust pedicled supply and its proximity to the neck make it an ideal choice for managing head and neck cancers that are within its reach for reconstruction.
Method
A retrospective case review was conducted of all patients undergoing pectoralis major flap reconstruction from January 2012 to January 2017.
Results
The study comprised 31 patients (with limited data for 3 included patients). There were 27 males and 4 females, with an average age of 63 years (range, 29–82 years). There were 34 pectoralis major flaps, as 3 patients had bilateral pectoralis major flap reconstruction. The indications were tumour stage T2–4 head and neck malignancies, which included 15 hypopharyngeal, 12 laryngeal, 3 oropharyngeal and 1 parotid primary area of cancer requiring reconstruction. Fourteen of these patients had salvage procedures. Eight patients required adjuvant treatment. There was only one patient with flap failure (3.5 per cent). Six patients had a post-operative fistula (21 per cent). Twenty-two (78.5 per cent) of 28 patients with complete data had good established oral intake. Two patients had recurrence and one patient had pulmonary metastasis. No significant post-operative pain was reported.
Conclusion
Our experience shows that the pectoralis major flap is still a safe, reliable and robust flap. The very high success rate of this flap in our study indicates that it should be one of the primary flaps used in head and neck reconstructive surgery, when indicated.
