Increasing incidence of oral cancer amongst young persons: what is the aetiology?

The reasons for an increasing incidence of oral cancer, particularly amongst younger persons is unclear. It has been hypothesised either to be a result of an increase in exposure to known risk factors amongst certain groups in the community, or to be due to new aetiological agents. Prior to conducting large expensive population-based studies, it seems appropriate to conduct initial smaller-scale surveys to assess evidence for each of these two hypotheses. This survey of young persons with oral cancer suggest that most are exposed to traditional risk factors of tobacco smoking, drinking alcohol and a low consumption of fruit and vegetables.

Hyalinizing clear cell carcinoma of the oral cavity and of the parotid gland.

Hyalinizing clear cell carcinoma (HCCC) is a rare, recently described tumor of salivary gland origin. Differential diagnosis includes benign lesions as clear cell change in a pleomorphic adenoma or in oncocytoma and malignant tumors - i.e. epithelial-myoepithelial carcinoma, polymorphous low-grade adenocarcinoma, mucoepidermoid carcinoma, clear cell acinic carcinoma, clear cell squamous carcinoma, clear cell malignant melanoma, clear cell odontogenic carcinoma, clear cell rhabdomyosarcoma, sebaceous carcinoma and metastasis of renal carcinoma. A favorable prognosis after wide local excision has been evidenced. Three new cases of HCCC (2 in the oral cavity and 1 in the parotid gland) are presented.

Local research ethics committee approval for a national study in Scotland.

The handling of research proposals by different ethics committees has been reported as varying widely from one district to another. Multicentre research projects are particularly liable to delay when dealing with several individual committees. We recently performed a nation-wide postal questionnaire study in Scotland on young patients with oral or oropharyngeal cancer. Our experience indicates that despite calls for standardization of the processes involved wide variations still exist between committees. Fifteen out of 19 committees approached had unique application forms, the number of copies of forms and other documentation required ranged from one to 20, and the time to final approval ranged from 39 to 182 days (mean of 90 days). Improved training and a standardized constitution of committee members is required. A uniform national application form and improved co-operation between neighbouring committees is needed.

Trends in randomized controlled trials in ENT: a 30-year review.

There is a growth in the demand for clinical practice to be evidence based. Recent years have seen a rise in the number of randomized controlled clinical trials (RCTS). Such trials while acknowledged as the gold standard for evidence can be difficult to perform in surgical specialities. We have recently identified a low proportion of RCTS in the otolaryngology literature. Our aim was to identify any trend in the number of published RCTS within the ENT literature over a 30-year period and to identify which areas of our speciality lend themselves to this form of study design. A Medline search of 10 prominent journals published between 1966 and 1995 was performed. Two hundred and ninety-six RCTS were identified. Only five were published before 1980. Two hundred (71 per cent) of RCTS were in the areas of otology and rhinology. An encouraging trend is seen in RCTS within ENT literature.

Is there an evidence base for the practice of ENT surgery?

In order to assess the strength of the 'evidence base' for the practice of otolaryngology a review of recent journal articles was undertaken. A review of all articles published during the period 1990-1994 in five major general otolaryngology journals was performed. The articles were classified according to a standardized scheme from the abstract or, if necessary, the full paper. Papers were grouped into observational studies (descriptive or analytical, hypothesis-testing), controlled trials, randomized controlled trials, audits, non-clinical and others. One true meta-analysis was found. Randomized controlled trials comprised 0.7%-4% of articles across the journals studied; other controlled trials comprised 0.8-2%; and other analytical studies 7.6-21.9%. Very few true audits were seen. Descriptive studies were by far the commonest type of paper seen. This literature review suggests there is a poor evidence base for our specialty if one regards randomized controlled trials as the gold standard.

Wegener's granulomatosis presenting as major salivary gland enlargement.

Salivary gland involvement is rare in Wegener's granulomatosis. We report the first case of widespread major salivary gland enlargement as part of the presentation of this disease. A review of the few reported cases in the literature suggests that salivary gland involvement may be associated with a limited form of the disease and an improved prognosis. The anti-neutrophil cytoplasmic antibody (c-ANCA) assay remains the gold standard of diagnosis but care should be exercised in the interpretation of results. This patient responded well to current immunosuppressive therapy.

The function of free jejunal autografts in the pharyngo-oesophageal segment.

Eight patients were studied 6 weeks to 16 months following pharyngo-oesophageal reconstruction using a free jejunal interposition graft. Ambulatory manometry was carried out using an intraluminal strain gauge assembly linked to a portable microprocessor. In one patient, the assembly could not be passed because of a redundant jejunal loop. In four subjects, the jejunal interposition appeared to function as a passive conduit with very little manometric activity. In the remaining three patients, however, there was evidence of both propagated peristaltic waves within the graft and regular contractile activity, characteristic of Phase III of the intestinal Migrating Motor Complex (MMC). The presence of MMC activity at only 7 weeks following surgery confirms its independence of extrinsic intestinal innervation. Spontaneous contractile activity, however, was not interrupted by propagated water swallows and may contribute to post-operative dysphagia in some individuals.

Swallowing performance in patients with vocal fold motion impairment.

Twenty-seven patients with vocal fold motion impairment underwent detailed pharyngoesophagel manometry with a strain gauge assembly linked to a computer recorder. Nine were known to have lesions of the central vagal trunk or nucleus, 9 had recurrent laryngeal nerve (RLN) palsy, and the remainder were idiopathic. The site of the lesion was a more important determinant of subjective swallowing performance than the position of the involved cord at laryngoscopy. Patients with central lesions had lower tonic and contraction upper esophageal sphincter (UES) pressures than 25 age-matched controls, suggesting that high cervical branches of the lower cranial nerves are important in UES excitatory innervation. RLN palsy patients showed significantly increased pharyngeal contraction amplitude and reduced pharyngoesophageal wave durations. The results suggest that the dysphagia associated with vocal fold motion impairment is not simply due to the disruption of laryngeal deglutitive kinetics, but to independent effects on pharyngeal function.

A prospective analysis of incidental paranasal sinus abnormalities on CT head scans.

A prospective analysis of the incidence of paranasal sinus opacification in 100 patients referred for cranial computerized tomography (CT) for non-sinus related problems is described. The findings were correlated with symptomatic assessment. Twenty-seven per cent of asymptomatic patients had sinus opacification. The study illustrates the importance of careful clinical correlation when interpreting CT scans of the paranasal sinuses.

Nasoantral window assessment by acoustic rhinometry.

Twenty-five patients who had each had inferior meatal antrostomies performed were endoscopically examined and assessed with acoustic rhinometry six weeks and six months after surgery. No significant increase in nasal cross-sectional area could be demonstrated at the site of the antrostomy in the post-operative cases, although the nasoantral window was found to be patent in 44 of the 50 nasal cavities.

Endoscopic sinus surgery.

Endoscopic nasal surgery has become the single major advance in the specialty of otolaryngology since the introduction of the operating microscope and middle ear surgery. The value of improved assessment of nasal and sinus pathology using the endoscope diagnostically cannot be overstated. Once pathology is better evaluated, therapy will at least be more appropriate. It is now possible to carry out such nasal surgery as polypectomy, antrostomy and turbinoplasty more accurately and more safely, as well as provide better postoperative care. The use of the endoscope has afforded a useful sub-cranial route for the repair of at least small cerebrospinal fluid leaks, while it is likely that such procedures as dacrocystorhinostomy will eventually be mostly performed using the nasal endoscope. Some orbital decompressions will also be suitable for medial orbitotomy via the endoscope. Additionally, assessment of the extent of extrusion of orbital contents after blow-out injury has been invaluable, as is evaluation of the posterior wall of the frontal sinus after frontal bone trauma. Functional endoscopic sinus surgery (FESS) has an undoubted place in the surgery of frontoethmoidal mucocoeles. While few oncologists would be sanguine about its use in the surgery of nasal tumors, it is still of great value in evaluation and biopsy. Although FESS confined to the osteomeatal complex in the presence of early sinus disease is almost certainly an advance, what is still not proven, is the place of endoscopic sphenoethmoidectomy in the treatment of chronic rhinosinusitis.

Women in surgery in Scotland. A Working Party of the Royal College of Surgeons of Edinburgh.

Despite the fact that 50% of medical undergraduates are female, women comprise fewer than 1% of consultant general surgeons. The possible reasons for this were addressed by a working party of the Royal College of Surgeons of Edinburgh, which now reports the results of a survey of 35 women surgeons of SHO 3 grade and above working in Scotland. Findings were compared with those of 12 anaesthetists and 10 house officers. Surgeons had had an accurate perception of the work patterns their job would entail but no preparation for the lifestyle implications. The experience of gender discrimination was similar in all three groups but perceived discrimination was much more prevalent among surgeons/ophthalmologists. In contrast to the other groups surveyed, the surgical cohort was not deterred by training length, but rather discouraged by the lack of responsibility offered. Other factors which seem to contribute to the underrepresentation of women among surgeons may be the lack (1) of time for child rearing and (2) of same-sex role models.

Otolaryngological indicator operations: one year's experience.

One year's experience of otolaryngological indicator operations is presented. Of 59 myringoplasties, 47 (79%) were successful; trainees performed 44 (74%) of the procedures. Seventy patients undergoing septal surgery reported significant improvements in nasal obstruction (P < 0.001), catarrh and facial pain (P < 0.005). Seventeen laryngectomies were performed for stage III and IV disease. The median operative time of 3.1 h rose to 5.1 h with a concomitant neck dissection. Eleven complications ensued, and the median stay for an uncomplicated laryngectomy was 16 days and 30 days following complications. Forty-one parotidectomies, 19 submandibular gland excisions and 10 ductal procedures were performed with 5 wound complications and 5 minor temporary facial nerve weaknesses. We have established a baseline for comparison of our practice with others and concluded that septal surgery gives good symptomatic relief, trainees perform reasonable numbers of myringoplasties, and improvements remain to be made in our outpatient septal surgery data collection.

Epidermal growth factor receptors and oestrogen receptors in the head and neck.

We report a pilot study of the levels of epidermal growth factor receptors (EGFR) in normal and neoplastic tissues of the head and neck. Specimens from 20 consecutive patients undergoing major head and neck surgery showed that squamous cell carcinomas had detectable but widely varying levels of EGFR. EGFR expression was greater in normal salivary gland tissue than in benign salivary neoplasms. Oestrogen receptors were not detected in clinically significant amounts in any of the tumours assayed.

The nature of the head and neck cancer.

Squamous cell carcinoma of the head and neck is a disease predominantly of males and is due to a variety of known environmental irritants, notably cigarette smoke. Dietary, viral and immunological factors may also be relevant. Head and neck squamous cancers express epidermal growth factor receptors and some show weak levels of oestrogen receptor activity, but a reliable serum marker of tumour burden remains to be identified. The prognosis is found to be less favourable in females, in those with advanced T stage, in association with multiple node involvement, especially where extracapsular spread is present and where the T4/T8 ratio is elevated. Administration of heterologous blood during therapy may also have an adverse effect on prognosis. Interested clinicians must remember that most cases are preventable.

The quantitative analysis of dysphonia.

A clinical method of measuring 'hoarseness' is presented. Its value is assessed in 3 different types of vocal cord lesion and compared against normal values. There are shown to be significant differences between the normal and the abnormal voice and also differences between each type of vocal cord lesion. We feel that this quantification of hoarseness is useful in the treatment of patients as well as in monitoring their progress under therapy.