A Systematic Review and Meta-Analysis of 29 Studies Predicting Diagnostic Accuracy of CT, MRI, PET, and USG in Detecting Extracapsular Spread in Head and Neck Cancers.

BACKGROUND: Extracapsular spread (ECS) is the extension of cancer cells beyond the lymph node capsule and is a significant prognostic factor in head and neck cancers. This meta-analysis compared the diagnostic accuracy of CT, MRI, PET, and USG in detecting ECS in head and neck cancers. METHODOLOGY: The authors conducted a systematic review and meta-analysis of studies that compared the diagnostic accuracy of CT, MRI, PET, and USG in detecting ECS in head and neck cancers. They included studies that were published between 1990 and December 2023 and that used histopathology as the reference standard for ECS. RESULTS: The pooled sensitivity and specificity of CT scan were 0.63 (95% CI = 0.53-0.73) and 0.85 (95% CI = 0.74-0.91), respectively. The pooled sensitivity and specificity of MRI were 0.83 (95% CI = 0.71-0.90) and 0.85 (95% CI = 0.73-0.92), respectively. The pooled sensitivity and specificity of PET were 0.80 (95% CI = 0.74-0.85) and 0.93 (95% CI = 0.92-0.94), respectively. The pooled sensitivity and specificity of USG were 0.80 (95% CI = 0.68-0.88) and 0.84 (95% CI = 0.74-0.91), respectively. MRI had significantly higher sensitivity than CT scan (p-0.05). The specificity of CT and MRI was not significantly different (p-0.99). PET scan had the highest specificity among all imaging modalities. CONCLUSION: MRI is the most accurate imaging modality for detecting ECS in head and neck cancers. CT scan is a reasonable alternative, but PET scan may be considered when high specificity is required. USG may not add any further benefit in detecting ECS.

Comparison of side effects and patient perceptions towards Rapid Rhino and Merocel packs in epistaxis.

OBJECTIVE: Non-dissolvable nasal packs (Rapid Rhino and Merocel) are widely used in secondary healthcare centres for the control of epistaxis, with some side effects. METHODS: A prospective, observational cohort study was conducted of adults who required Rapid Rhino or Merocel packing for acute epistaxis management in a large healthcare centre between March 2020 and 2021. A validated modified version of the 22-item Sino-Nasal Outcome Test was used. RESULTS: A total of 80 adults requiring non-dissolvable packs were recruited. Seventy per cent of patients had Rapid Rhino packs inserted. Embarrassment was greater in patients who used Rapid Rhino than Merocel. Merocel packs had a significantly higher mean pain score on removal compared to Rapid Rhino. There was no correlation between rebleed rate and type of nasal pack used. CONCLUSION: Non-dissolvable Rapid Rhino and Merocel nasal packs have similar efficacy in controlling epistaxis. Rapid Rhino packs are more embarrassing for patients in comparison to Merocel packs, but are less painful to remove.

Incidence of synchronous contralateral tonsillar malignancy in a known case of unilateral tonsillar carcinoma.

OBJECTIVE: The literature is divided with regards to contralateral tonsillectomy in a known/suspected case of ipsilateral tonsillar malignancy. In this study, we evaluate the incidence of indolent synchronous contralateral tonsillar malignancy (SCTC) in patients with known ipsilateral tonsillar malignancy. METHODS: All patients diagnosed with ipsilateral tonsillar carcinoma (TC) at a tertiary teaching center between January 2016 and December 2019 were screened. None of the patients were suspected to have bilateral TC. All patients underwent appropriate imaging in the form of Magnetic resonance imaging and computed tomography of head and neck region and then underwent bilateral tonsillectomy. The prevalence of bilateral tonsillar malignancy and the factors predicting them were analyzed. RESULTS: In all 59 patients were included in the study. The mean and median age of the patient population was 60.8 and 59 years, respectively, with a male to female ratio of 3.2:1. The incidence of bilateral tonsillar malignancy in carcinoma of unknown primary (CUP) was 3/10 (33.3%). Among the remaining 49 patients, incidence of synchronous contralateral tonsillar carcinoma (SCTC) was 2/49 (4.08%). Overall, 5/59 (8.5%) patients had synchronous bilateral tonsillar malignancy. Furthermore, dysplasia was found in the contralateral tonsil in 4/10 (40%) CUP patients. Among the remaining 49 patients, dysplasia was seen in the contralateral tonsil in 20/49 (40.8%) patients. The absence of p16 expression predicted higher probability of SCTC. Factors like gender, T stage, nodal status or smoking did not predict SCTC. CONCLUSION: We recommend bilateral tonsillectomy in all patients with suspected or proven TC (unilateral or bilateral) and CUP as it helps identify indolent SCTC and it does not add any significant morbidity to the patients. LEVEL OF EVIDENCE: III.

Comparison of PET-CT, CT and MRI scan in initial staging and management of head and neck cancers.

BACKGROUND: To evaluate the utility of positron-emission tomography (FDG PET) in initial staging and management of head and neck cancers. METHODS: This is a retrospective study of 99 treatment naïve head and neck cancer patients treated between January 2017 and December 2020 at a tertiary teaching centre. Change in initial staging and management was noted based on PET scan compared to cross-sectional imaging (CT and MRI). RESULTS: There were 73 (73.7%) males and 26 (26.2%) females with male-to-female ratio of 2.8:1.Overall, change in management was seen in 36/99 (36.4%) patients due to PET scan. With regards to initial staging, T, N and M stage was changed in 14/99 (14.1%), 19/99 (19.1%) and 3/99 (3%) patients, respectively. These changes were significantly higher in patients with unknown primary (63.3%, p value -0.001) and N3 (41%, p -0.045) nodal disease. CONCLUSION: PET-CT plays an important role in appropriate initial staging and subsequent treatment planning of head and neck cancers. ADVANCES IN KNOWLEDGE: Initial staging PETCT changes management in 36.4% cases. Accuracy of various different imaging modalities have been compared.

SARS-Cov2: a meta-analysis of symptom distribution by continent in 7310 adult COVID-19 infected patients.

There is recent evidence that suggests that there are multiple strains of coronavirus in different parts of the world. Moreover, scientist have noted multiple mutations and postulated that these changes might increase the infective rate of the virus. However literature on varying severity of disease based on these strains is absent. In this meta-analysis, we have made an attempt to correlate the symptoms in different continents with respect to various studied strains of virus. We searched three databases, PubMed, EMBASE and EMCARE to identify studies reporting symptoms of COVID-19. All articles published between December 2019 and May 2020 was included in this meta-analysis. A total of 56 studies consisted of 7310 patients were included in the meta-analysis. Mean age of patients varied from 22 to 69.8 years. The pooled proportion of male patients was 52%. Highest incidence of fever (76%) and cough (56%) was noted in Chinese population. Sore throat (29%) was most common in Asian population. Upper respiratory tract symptom like Rhinorrhoea, Anosmia and dysgeusia (32%, 47% and 39%) were well documented in European population as compared to the other continents. Nausea and diarrhoea were more common in European (17%, 19%) and Australian (12%, 16%) population. Dyspnoea and fatigue were consistently similar in all the continents. We postulate that different mutations in COVID-19 virus may vary its pathogenicity and screening symptoms across all the continents should be not be generalised but continent-specific. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s13337-021-00699-y.

COVID-19 Cross-Infection Rate After Surgical Procedures: Incidence and Outcome.

OBJECTIVES/HYPOTHESIS: Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) is transmitted by droplet as well as airborne infection. Surgical patients are vulnerable to the infection during their hospital admission. Some surgical procedures are classified as aerosol generating (AGP). STUDY DESIGN: Retrospective observational study of four specialties associates with known AGP's during the 4 months of the first wave of UK COVID-19 epidermic to identify post-surgical cross-infection with SARSCoV-2 within 14 days of a procedure. METHODS: Retrospective observational study in a tertiary healthcare center of four specialties associates with known AGP's during the 4 months of the first wave of UK COVID-19 epidermic to identify post-surgical cross-infection with SARSCoV-2 within 14 days of a procedure. RESULTS: There were 3,410 procedures reported during this period. The overall cross-infection rate from tested patients was 1.3% (4 patients), that is, 0.11% of all operations over 4 months. Ear, nose, and throat carried slightly higher rate of infection (0.4%) than gastroenterology (0.08%). The mortality rate was 0.3% (one gastroenterology patient from 304 positive cases) compared to 0% if surgery performed after recovery from SARSCoV-2 and 37.5% when surgery was conducted during the incubation period of the disease. Routine preoperative rapid screening tests and self-isolation are crucial to avoid the risk of cross-infection. Patients with underlying malignancy or receiving chemotherapy were more prone to pulmonary complications and mortality. CONCLUSION: The risk of SARS-COV-2 cross-infection after surgical procedure is very low. Preoperative screening and self-isolation together with personal protective measures should be in place to minimize the cross-infection. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2749-E2754, 2021.

A systematic review and meta-analysis comparing the diagnostic accuracy of initial RT-PCR and CT scan in suspected COVID-19 patients.

OBJECTIVE: To perform a systematic review and meta-analysis to compare the diagnostic accuracy of CT and initial reverse transcriptase polymerase chain reaction (RT-PCR) for detecting COVID-19 infection. METHODS: We searched three databases, PubMed, EMBASE, and EMCARE, to identify studies reporting diagnostic accuracy of both CT and RT-PCR in detecting COVID-19 infection between December 2019 and May 2020. For accurate comparison, only those studies that had patients undergoing both CT and RT-PCR were included. Pooled diagnostic accuracy of both the tests was calculated by using a bivariate random effects model. RESULTS: Based on inclusion criteria, only 11 studies consisting of 1834 patients were included in the final analysis that reported diagnostic accuracy of both CT and RT-PCR, in the same set of patients. Sensitivity estimates for CT scan ranged from 0.69 to 1.00 and for RT-PCR varied ranging from 0.47 to 1.00. The pooled estimates of sensitivity for CT and RT-PCR were 0.91 [95% CI (0.84-0.97)] and 0.84 [95% CI (0.71-0.94)], respectively. On subgroup analysis, pooled sensitivity of CT and RT-PCR was 0.95 [95% CI (0.88-0.98)] and 0.91 [95% CI (0.80-0.96), p = o.ooo1]. The pooled specificity of CT and RT-PCR was 0.31 [95% CI (0.035-0.84)] and 1.00 [95% CI (0.96-1.00)]. CONCLUSION: CT is more sensitive than RT-PCR in detecting COVID-19 infection, but has a very low specificity. ADVANCES IN KNOWLEDGE: Since the results of a CT scan are available quickly, it can be used as an adjunctive initial diagnostic test for patients with a history of positive contact or epidemiological history.

A Meta-Analysis of 67 Studies with Presenting Symptoms and Laboratory Tests of COVID-19 Patients.

OBJECTIVES/HYPOTHESIS: The objective of this meta-analysis was to look at the pooled prevalence of symptoms, laboratory tests, and imaging of all COVID-19 infected patients. This will allow better identification of potential COVID-19 patients and take appropriate precautions. STUDY DESIGN: Meta analysis. METHODS: We searched three databases, PubMed, EMBASE, and Ovid to identify studies published between Dec-2019 and May-2020. All studies reporting upper-aerodigestive symptoms of COVID-19 infection were included. The meta-analysis was conducted following meta-analyses of observational studies in epidemiology (MOOSE) guidelines, which have evaluated the pooled prevalence of 14 symptoms and nine laboratory investigations. RESULTS: Based on inclusion criteria, 67 publications consisting of 8302 patients were included. Among adults, the pooled proportion of hypertensive and diabetic patients was 18% and 7%. Cough (53% [0.46-0.61]), anosmia (38% [0.19-0.58]), loss/distortion of taste (31% [0.17-0.45]), and nasal obstruction (26% [0.12-0.39]) were the most common ear, nose & throat (ENT) symptoms. Fever (69% [0.62-0.76]) and fatigue (31% [0.26-0.37]) were the commonest generalized symptoms. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were raised in 56% (0.41-0.71) and 49% (0.21-0.77), respectively. Interestingly, lymphopenia (41% [0.30-0.53]) and leucopenia (22% [0.16-0.29]) were more common than lymphocytosis (33% [0.02-0.64]) and leucocytosis (12% [0.09-0.16]). Fever (69% vs. 44%), cough (53% vs. 33%), and dyspnea (20% vs. 4%) were more common in adults as compared to the pediatric population. Diarrhea was more common among the pediatric cases (12%) versus (9%). The pooled estimate of fatality was 4%. CONCLUSIONS: The most commonly experienced ENT symptom was cough followed by anosmia and dysguesia. Raised ESR and CRP with leukopenia and lymphopenia are common laboratory findings. Majority of the infected patients had abnormal computed tomography findings. COVID infection is less severe in pediatric patients. Laryngoscope, 131:1254-1265, 2021.

Isolated submandibular lymph node metastasis in pancreatic adenocarcinoma.

Pancreatic adenocarcinoma is a highly aggressive malignancy that usually presents at a late stage. Common sites of metastasis include the liver, lung and adjacent lymph nodes. Cervical lymph node involvement has been reported previously but there are no documented cases of submandibular lymph node metastasis in the available literature. We describe a case of pancreatic adenocarcinoma metastasis to the left submandibular lymph node with no confirmed concurrent sites of metastasis.

Follicular thyroid carcinoma presenting with pathological fracture of the humerus at initial diagnosis.

Differentiated carcinomas of the thyroid gland usually have a good prognosis with prognosis often discussed in terms of 20 year survival. Nevertheless its 10-year-survival rate decreases when accompanied by distant metastasis. Follicular thyroid cancer (FTC) is the second most common thyroid cancer and usually presents with a solitary thyroid nodule with or without cervical lymphadenopathy. Distance metastasis at initial diagnosis is seldom observed with incidence range from 1 to 9%. In cases of bone metastasis, the incidence is only 2-3% and weight-bearing skeleton is preferentially affected. In our case, we present a patient with FTC that metastasized to the upper limb causing severe pain and pathological fracture at the initial presentation.

Nasopharyngeal tuberculosis presenting with auditory symptoms.

We present an unusual case of a 54-year-old Chinese lady presenting to the ears, nose and throat clinic after family members noticed that her hearing had progressively deteriorated over the preceding weeks. She also complained of tinnitus. Examination of the ears, nose and throat was unremarkable. Flexible nasoendoscopy demonstrated swelling in the postnasal space, which, following biopsy, was shown to be pathognomonic of tuberculosis. This was successfully treated with multidisciplinary input and the patient made a complete recovery.

A frog in the throat? An expansile mass presenting in the neck with dysphonia.

A neck mass, which rapidly increases in size over several weeks, is concerning for all involved. When accompanied by other symptoms suggesting sinister underlying pathology, efficient management and rapid diagnosis are vital. The causes may include primary or metastatic carcinoma, or lymphoreticular malignancy. Other non-sinister pathology may account for the swelling such as reactive lymph nodes or benign neoplasms. A benign neoplasm of the lymphatic system known as a lymphangioma may rarely be the cause of a mass in the neck in adults. More commonly found in infants, with approximately 40% found at birth, they are seldom encountered in adults. In children, they have the propensity to infiltrate into and around muscles and neurovascular structures, occasionally leading to difficult surgical excision. The authors present an unusual case of an adult patient with an expansile mass in the supraclavicular fossa of insidious onset. It was associated with dysphagia and hoarseness of voice.

Junior doctors' ability to interpret lateral soft tissue neck X-rays: is there a training issue?

In light of the introduction of the European Working Time Directive and Modernising Medical Careers initiative, this article reports the results of a study to see whether junior doctors possess adequate skills to correctly interpret lateral soft tissue neck X-rays and if they receive adequate training.

Use of tissue sealant for day surgery parotidectomy.

OBJECTIVES: To evaluate the use of tissue sealant in facilitating day surgery parotidectomy without the use of surgical drains and to consider the potential economic benefit using this technique. STUDY DESIGN AND SETTING: Prospective cohort study of 21 patients undergoing parotidectomy for nonmalignant disease in a university hospital. Surgery as a day procedure without the use of surgical drains was planned. The costs associated with parotidectomy, including the use of tissue sealant and its delivery system, versus in-patient admission with a drain were calculated and compared. METHODS AND OUTCOME MEASURES: Parotidectomy was undertaken by one surgeon. Prior to wound closure, the skin flap and wound bed were approximated using Tisseel tissue sealant (Baxter Corp., Mississauga, ON). Data regarding the costs of the tissue sealant, the delivery system, and hospital in-patient stay were obtained to enable an economic comparison. Patients were followed to assess surgical outcome and document any complications. RESULTS: There were no major surgical complications. One patient required admission for control of postoperative nausea. None of the patients felt that discharge had been premature. The estimated cost advantage of this technique applied to institutions in Canada was $1,775 per case. CONCLUSIONS: Parotidectomy can be undertaken safely in a day surgery setting without the need for surgical drains. The increased cost associated with the use of tissue sealant compared with surgical drains is greatly overshadowed by the economic advantage of undertaking day surgery. There is a significant potential cost saving to the health care system.