Malignant salivary gland tumours: treatment outcomes from a tertiary referral centre in the UK.

Salivary gland malignant tumours are a complex and highly variable pathological group. Their diagnosis can be challenging, and management is guided by multidisciplinary teams. This project aimed to establish clinicopathological and sociodemographic features that significantly impacted overall disease-free or progression-free survival in patients diagnosed with malignant salivary gland disease between 2010 and 2019 in a tertiary referral centre. In total, 86 patients were included for analysis, with a female:male gender ratio of 1.3:1. Mean age at diagnosis was 57.7 years. Mucoepidermoid carcinomas constituted almost 25% (n = 20) of all cases, with adenoid cystic carcinomas (20%, n = 17) and acinic cell carcinomas (17.5%, n = 15) being the next most frequently diagnosed. The parotid gland was the most frequently affected site (80.2%, n = 69). Perineural and lymphovascular invasion, and a maximum tumour dimension of ≥4 cm were highly associated with the decision to provide a neck dissection as part of treatment. Involved margins, extracapsular spread, and lymphovascular and perineural invasion were associated with the need for adjuvant treatment. However, no factors remained statistically significant on multivariate analysis. This retrospective service evaluation demonstrates the difficulty of predicting treatment outcomes for patients diagnosed with malignant salivary gland disease.

Outcomes of anastomotic venous flow couplers in head and neck free flap reconstruction - five-year experience in a single centre.

Flow couplers for venous anastomosis, which enable the invasive monitoring of free flaps during the postoperative period with a continuous venous signal audible immediately after completion of the anastomosis, have been reported to be reliable, sensitive, and specific as anastomotic flap monitoring adjuncts. The purpose of this study was to evaluate the reliability, sensitivity, specificity, and outcomes of surgical exploration, and the impact on free-flap survival of the venous anastomotic flow coupler for microvascular head and neck reconstruction in a consecutive series of patients. This is a retrospective review of consecutive patients treated in the department of oral and maxillofacial surgery who underwent reconstruction of a head and neck defect using venous anastomosis with a flow coupler-vascularised free flap between October 2015 and December 2020. A total of 189 patients had free-flap reconstruction of head and neck defects. We compared the venous flow coupler group (n = 72) with patients who had free flaps with hand-sewn anastomoses over the same period (n = 117). There were no false positive/negatives associated with the flow coupler as an implantable flap monitor. The flow coupler cohort had a significantly higher flap salvage rate compared with free flaps that were monitored clinically (p = 0.04). The venous flow coupler has been shown to be a reliable microvascular anastomotic and invasive flap monitor that enables accurate and timely detection of flap compromise and prompt, successful free-flap salvage.

BAOMS QOMS: findings from the pilot phase and lessons learned in the feasibility evaluation of a national quality improvement initiative.

The BAOMS QOMS pilot was developed and run in six England OMFS units between December 2019 - April 2020. The aims of this pilot project were: to evaluate feasibility of the questionnaires developed for the audit and how effective they were with regards to quality improvement, to test the processes associated with the data collection system and finally, to provide baseline data to support patient data collection without the requirement of prospective consent. The pilot included a series of six audits (oral and dentoalveolar [ODA], oncology, orthognathic, reconstruction, trauma, and skin). Data entry was clinician-led in five OMFS units and in one unit (EKHU), it was additionally supported by members of the clinical coding team. One hundred and twenty-eight REDCap account user details were issued and of these, 45 (35%) completed registration and 22 (17%) were active users who participated in the pilot data entry. Disproportionate focus on individual audits within QOMS was seen, though not all units offered the full range of service audited. Users suggest the skin and ODA audits were sufficiently clear, but improvement is required in the oncology and reconstruction questionnaire particularly. The pilot was successful in aiding the project team identify areas of weaknesses and strength in the design of the REDCap registry and implementation of the next phase of the initiative. The information and experience gained has to date enabled a successful application for section 251 approval from the HRA and progress for the next phase of national data collection.

Impacts of lockdown during the SARS-CoV-2 pandemic on patients presenting with cervicofacial infection of odontogenic origin: a comparative study.

The SARS-CoV-2 pandemic caused unprecedented disruption to primary and secondary healthcare services. Our aim was to explore whether the pandemic had had any impact on patients presenting with cervicofacial infections (CFI) of odontogenic origin to secondary care and management. Comparative analysis was carried out evaluating prospective and retrospective consecutively admitted patients with a diagnosis of CFI of odontogenic origin in the COVID-19 lockdown period from 15 March to 15 June 2020 and pre-COVID-19 during the same period of the previous year. Data included patients' demographics, comorbidities, systemic inflammatory response syndrome (SIRS) status on admission, clinical features, prior treatment in primary care, source of referral, SARS-COV-2 antigen status, treatment received in secondary care, intraoperative findings, and whether escalation of the level of care was required. Across both cohorts there were one hundred and twenty-five (125) patients admitted with CFI of odontogenic origin, with a 33% reduction (n=75 (2019) vs n=50 (2020)) in number of patients admitted during COVID-19 lockdown. There was no difference between the cohorts in terms of age (p=0.192), gender (p=0.609) or major comorbidities (p=0.654). Proportionally more patients in the COVID-19 group presented with SIRS (p=0.004). This group of patients persisted with symptoms for longer before presenting to secondary care (p=0.003), more delay from hospital admission to surgical intervention (p<0.005) and had longer hospital stays (p=0.001). More patients required extraoral surgical drainage during COVID-19 (p=0.056). This study suggests that the COVID-19 lockdown has had adverse effects on the presentation of CFI of odontogenic origin and its management within a Regional Acute Maxillofacial Service. Commissioners and clinicians should endeavour to plan for adequate primary and secondary care provision during any future local lockdowns to ensure that patient care is optimised.

Results of flap reconstruction: categorisation to reflect outcomes and process in the management of head and neck defects.

The reporting of the outcomes of flap reconstruction is often based on numerical success rates. Whilst this remains a useful variable with which to measure success, it is limited in its ability to reflect the complex processes involved. The lack of consistency in the categorisation of outcomes of flap reconstruction in the head and neck could potentially lead us to lose the opportunity to fully capture the implications of its success or failure, or both. We propose a classification that moves away from primarily reporting the results of its binary nature, and focuses more on the process of reconstruction, particularly in the head and neck.

Adults with autism are less proficient in identifying biological motion actions portrayed with point-light displays.

BACKGROUND: Whether individuals with autism spectrum disorder (ASD) have impairments with biological motion perception has been debated. The present study examined the ability to identify point-light-displayed (PLD) human actions in neurotypical (NT) adults and adults with ASD. METHOD: Twenty-seven adults with ASD (mean age = 28.36) and 30 NT adults (mean age = 22.45) were tested. Both groups viewed 10 different biological motion actions contacting an object/tool and 10 without making contact. Each action was presented twice, and participant's naming responses and reaction times were recorded. RESULTS: The ASD group had a significantly lower total number of correct items (M = 29.30 ± 5.08 out of 40) and longer response time (M = 4550 ± 1442 ms) than NT group (M = 32.77 ± 2.78; M = 3556 ± 1148 ms). Both groups were better at naming the actions without objects (ASD group: 17.33 ± 2.30, NT group: 18.67 ± 1.30) than those with objects (ASD group: 11.96 ± 3.57, NT group: 14.10 ± 1.97). Correlation analyses showed that individuals with higher Autism-spectrum Quotient scale scores tended to make more errors and responded more slowly. CONCLUSION: Adults with ASD were able to identify human point-light display biological motion actions much better than chance; however, they were less proficient compared with NT adults in terms of accuracy and speed, regardless of action type.

Recruitment of patients into head and neck clinical trials: acceptability of studies to patients from perspective of the research team.

We reviewed longitudinal recruitment data to assess recruitment into head and neck cancer trials, and to identify factors that could influence this and affect their acceptability to patients. We retrieved data from the prospective computerised database (2009-2016) to measure acceptability to patients using the recruitment:screening ratio, and compared observational with interventional studies, single specialty (or site) with multispecialty (or site) studies, and "step-up" randomisation with "non-inferiority" randomisation designs. A total of 1283 patients were screened and 583 recruited. The recruitment:screening ratio for all National Institute for Health Research (NIHR) portfolio studies combined was 0.47 (486/1133). Studies that involved treatment by several specialties or at several sites had a significantly adverse impact on acceptability (p=0.01). Recruitment into non-inferiority randomised controlled studies was lower than that into step-up randomised studies (p=0.06). The complexity of a study's design did not compromise recruitment. Treatment across several specialties or several sites and perceived non-inferiority designs, reduced the acceptability of some trials.

An automated quantitative DNA image cytometry system detects abnormal cells in cervical cytology with high sensitivity.

OBJECTIVE: To evaluate the performance of an automated DNA-image-cytometry system as a tool to detect cervical carcinoma. METHODS: Of 384 liquid-based cervical cytology samples with available biopsy follow-up were analyzed by both the Imager System and a high-risk HPV test (Cobas). RESULTS: The sensitivity and specificity of Imager System for detecting biopsy proven high-grade squamous intraepithelial lesion (HSIL, cervical intraepithelial neoplasia [CIN]2-3) and carcinoma were 89.58% and 56.25%, respectively, compared to 97.22% and 23.33% of HPV test but additional HPV 16/18 genotyping increased the specificity to 69.58%. The sensitivity and specificity of the Imager System for predicting HSIL+ (CIN2-3+) lesions among atypical squamous cells of undetermined significance samples were 80.00% and 70.53%, respectively, compared to 100% and 11.58% of HPV test whilst the HPV 16/18 genotyping increased the specificity to 77.89%. Among atypical squamous cells-cannot exclude HSIL, the sensitivity and specificity of Imager System for predicting HSIL+ (CIN2-3+) lesions upon follow up were 82.86% and 33.33%%, respectively, compared to 97.14% and 4.76% of HPV test and the HPV 16/18 genotyping increased the specificity to 19.05%. Among low-grade squamous intraepithelial lesion cases, the sensitivity and specificity of the Imager System for predicting HSIL+ (CIN2-3+) lesions were 66.67% and 35.71%%, respectively, compared to 66.67% and 29.76% of HPV test while HPV 16/18 genotyping increased the specificity to 79.76%. The overall results of imager and high-risk HPV test agreed in 69.43% (268) of all samples. CONCLUSIONS: The automated imager system and HPV 16/18 genotyping can enhance the specificity of detecting HSIL+ (CIN2-3+) lesions.

Current thinking about the management of recurrent pleomorphic adenoma of the parotid: a structured review.

Pleomorphic adenoma is the most common tumour of the parotid gland, and can recur after excision. Recurrent pleomorphic adenoma can be a challenge to treat, and has variable outcomes. The aim of this review was to summarise current thinking in its management, which may be helpful to clinical teams and could improve patients' health-related quality of life. We searched several online databases using the key terms pleomorphic adenoma, recurrent pleomorphic adenoma, parotid gland tumours, parotid surgery, radiotherapy and parotid pleomorphic adenoma, and parotid surgery outcomes. Information collected included sample size, recurrence rate, condition of the facial nerve, type of operation, adjuvant treatments associated with recurrence, and clinical outcome. We screened 2301 papers, of which 49 were eligible. There was no consensus among authors about management. There are few if any randomised studies, and so conclusions in most papers were based on coherent arguments. Pleomorphic adenomas of the parotid tend to recur after long intervals, with a propensity towards multifocal disease, and the risk of recurrence (which depends on the initial surgical technique) is higher when the initial operation was done at a young age, after enucleation, and if the initial margins were invaded. Published conclusions suggest that the accepted management varies from observation in selected cases to total parotidectomy with or without postoperative radiotherapy.

Genomic analysis to assess disease progression and recurrence in patients with oral squamous cell carcinoma: - a preliminary study.

We studied the progression from dysplasia to invasive carcinoma and subsequent second primaries or locoregional recurrences in 11 patients with recurrent squamous cell carcinoma (SCC). Between one and six samples were sequenced/patient. DNA samples were prepared, and libraries multiplexed to between 40 and 80 samples/lane of an Illumina HiSeq 3000 and sequenced with 2×100bp paired end sequencing. Copy number data were generated by CNAnorm (Bioconductor package). Samples of recurrent SCC showed unique patterns of descent when compared with earlier samples from the primary tumour, and three main patterns emerged. In four patients there was convincing evidence that the later lesion was descended directly from cells from the first, and in a further four there were no detectable genomic events between the two lesions. Three patients had some shared events between the early and later lesions, but although there were enough differences to deduce that the two lesions had a shared ancestor, they were not directly descended from each other. We present the patients' characteristics in detail, including the overall survival in each group. There was a distinct genomic pattern after a second episode of SCC in all the groups. A larger study that uses similar methods and a longer duration could provide reliable conclusions with respect to survival. With the use of new techniques, genomic data can be available to clinical teams during the planning of treatment.

Refining the indications for scapula tip in mandibular reconstruction.

Mandibular reconstruction in osteoradionecrosis or salvage surgery can often be complicated by the lack of suitable recipient vessels in the ipsilateral neck and the associated requirement for significant extraoral skin reconstruction. The scapula tip with its long vascular pedicle and option of a chimeric soft tissue component offers a versatile reconstructive solution in such cases. This article reports four consecutive cases of mandibular reconstruction with poor ipsilateral vascular options and additional soft tissue requirements in which the scapula tip was justified and preferred. The blood supply to the lateral scapula through the circumflex scapular system is well established in the literature and this would be the preferred reconstruction in class I mandibular defects associated with a significant soft tissue requirement. The scapula tip would suit cases where the ipsilateral recipient vessels are compromised, and so justify the potential for mandibular reconstruction with inferior bone stock.

The management of vacuum neck drains in head and neck surgery and the comparison of two different practice protocols for drain removal.

Introduction The management of vacuum neck drains in head and neck surgery is varied. We aimed to improve early drain removal and therefore patient discharge in a safe and effective manner. Methods The postoperative management of head and neck surgical patients with vacuum neck drains was reviewed retrospectively. A new policy was then implemented to measure drainage three times daily (midnight, 6am, midday). The decision for drain removal was based on the most recent drainage period (at <3ml per hour). A further patient cohort was subsequently assessed prospectively. The length of hospital stay was compared between the cohorts. Results The retrospective audit included 51 patients while the prospective audit included 47. The latter saw 16 patients (33%) discharged at least one day earlier than they would have been under the previous policy. No adverse effects were noted from earlier drain removal. Conclusions Measuring drainage volumes three times daily allows for more accurate assessment of wound drainage, and this can lead to earlier removal of neck drains and safe discharge.

Thoracodorsal artery perforator - scapular flap in oromandibular reconstruction with associated large facial skin defects.

The reconstruction of oromandibular defects associated with extensive loss of external skin is surgically challenging. We describe 2 cases where such defects were reconstructed with a chimeric thoracodorsal artery perforator and scapular (TDAP-Scap) free flap based on the subscapular system. The flap is a reliable option in the reconstruction of through-and-through oromandibular defects.