Dysphagia presentation and management following COVID-19: an acute care tertiary centre experience.

OBJECTIVES: As the pathophysiology of COVID-19 emerges, this paper describes dysphagia as a sequela of the disease, including its diagnosis and management, hypothesised causes, symptomatology in relation to viral progression, and concurrent variables such as intubation, tracheostomy and delirium, at a tertiary UK hospital. RESULTS: During the first wave of the COVID-19 pandemic, 208 out of 736 patients (28.9 per cent) admitted to our institution with SARS-CoV-2 were referred for swallow assessment. Of the 208 patients, 102 were admitted to the intensive treatment unit for mechanical ventilation support, of which 82 were tracheostomised. The majority of patients regained near normal swallow function prior to discharge, regardless of intubation duration or tracheostomy status. CONCLUSION: Dysphagia is prevalent in patients admitted either to the intensive treatment unit or the ward with COVID-19 related respiratory issues. This paper describes the crucial role of intensive swallow rehabilitation to manage dysphagia associated with this disease, including therapeutic respiratory weaning for those with a tracheostomy.

Rehabilitation following open partial laryngeal surgery: key issues and recommendations from the UK evidence based meeting on laryngeal cancer.

BACKGROUND: It is recognised that a limited cohort of patients receive open partial laryngeal surgery in specific centres within the UK, so sharing information around key clinical issues and recommendations for practice is necessary to improve outcomes. METHODS: This position statement provides practice recommendations based on a synthesis of the available evidence presented at the 12th Evidence Based Management day on 'Laryngeal Cancer' and the ensuing discussions. Literature searches and critical analysis of available evidence were undertaken and triangulated with the clinical experience of the authors to develop these recommendations.Results and conclusionThis paper presents a comprehensive overview of challenges that the multidisciplinary team may encounter. It provides recommendations for swallow and speech rehabilitation after open partial laryngectomy, and suggests practical ways that these issues may be addressed pre- and post-operatively.

Hypopharyngeal cancer: United Kingdom National Multidisciplinary Guidelines.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. With an age standardised incidence rate of 0.63 per 100 000 population, hypopharynx cancers account for a small proportion of the head and neck cancer workload in the UK, and thus suffer from the lack of high level evidence. This paper discusses the evidence base pertaining to the management of hypopharyngeal cancer and provides recommendations on management for this group of patients receiving cancer care. Recommendations • Cross-sectional imaging with computed tomography of the head, neck and chest is necessary for all patients; magnetic resonance imaging of the primary site is useful particularly in advanced disease; and computed tomography and positron emission tomography to look for distant disease. (R) • Careful evaluation of the upper and lower extents of the disease is necessary, which may require contrast swallow or computed tomography and positron emission tomography imaging. (R) • Formal rigid endoscopic assessment under general anaesthetic should be performed. (R) • Nutritional status should be proactively managed. (R) • Full and unbiased discussion of treatment options should take place to allow informed patient choice. (G) • Early stage disease can be treated equally effectively with surgery or radiotherapy. (R) • Endoscopic resection can be considered for early well localised lesions. (R) • Bulky advanced tumours require circumferential or non-circumferential resection with wide margins to account for submucosal spread. (R) • Offer primary surgical treatment in the setting of a compromised larynx or significant dysphagia. (R) • Midline lesions require bilateral neck dissections. (R) • Consider management of silent nodal areas usually not addressed for other primary sites. (G) • Reconstruction needs to be individualised to the patients' needs and based on the experience of the unit with different reconstructive techniques. (G) • Consider tumour bulk reduction with induction chemotherapy prior to definitive radiotherapy. (R) • Consider intensity modulated radiation therapy where possible to limit the consequences of wide field irradiation to a large volume. (R) • Use concomitant chemotherapy in patients who are fit enough and consider epidermal growth factor receptor blockers for those who are less fit. (R).

Follow-up after treatment for head and neck cancer: United Kingdom National Multidisciplinary Guidelines.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. In the absence of high-level evidence base for follow-up practices, the duration and frequency are often at the discretion of local centres. By reviewing the existing literature and collating experience from varying practices across the UK, this paper provides recommendations on the work up and management of lateral skull base cancer based on the existing evidence base for this rare condition. Recommendations • Patients should be followed up to a minimum of five years with a prolonged follow-up for selected patients. (G) • Patients should be followed up at least two monthly in the first two years and three to six monthly in the subsequent years. (G) • Patients should be seen in dedicated multidisciplinary head and neck oncology clinics. (G) • Patients should be followed up by dedicated multidisciplinary clinical teams. (G) • The multidisciplinary follow-up team should include clinical nurse specialists, speech and language therapists, dietitians and other allied health professionals in the role of key workers. (G) • Clinical assessment should include adequate clinical examination including fibre-optic rigid or flexible nasopharyngolaryngoscopy. (R) • Magnetic resonance imaging and positron emission tomography combined with computed tomography imaging should be used when recurrence is suspected. (R) • Narrow band imaging can be used in the follow-up in selected sites. (R) • Second primary tumours should be part of rationale of follow-up and therefore adequate screening strategies should be used to detect them. (G) • Patients should be educated with regard to the appearance and detection of recurrences. (G) • Patients with persistent pain should be investigated to exclude recurrent disease. (R) • Patients should be offered support with tobacco and alcohol cessation services. (R).

Refining the head and neck cancer referral guidelines: a two-centre analysis of 4715 referrals.

OBJECTIVES: To identify the set of referral criteria that will offer optimal diagnostic efficacy in patients suspected to have head and neck cancer (HNC) in the primary care setting. DESIGN: Statistical analysis of referral criteria and outcomes. SETTING: Two tertiary care cancer centres in the United Kingdom. PARTICIPANTS: 4715 patients who were referred via the fast-track system with a suspected HNC between 2007 and 2010. MAIN OUTCOME MEASURES: Parameters of diagnostic efficacy, multivariate regression model to calculate estimated probability of HNC and area under the receiver operating characteristic curve (AUROC). RESULTS: The majority of referring symptoms had a positive predictive value higher than the 3% cut-off point stated to be significant for HNC detection in the 2015 NICE recommendations. Nevertheless, our multivariate analysis identified nine symptoms to be linked with HNC. Of these, only four are included in the latest NICE guidelines. The best fit predictive model for this data set included the following symptoms: hoarseness >3 weeks, dysphagia >3 weeks, odynophagia, unexplained neck mass, oral swelling >3 weeks, oral ulcer >3 weeks, prolonged otalgia with normal otoscopy, the presence of blood in mouth with concurrent sensation of lump in throat and the presence of otalgia with concurrent lump in throat sensation. Intermittent hoarseness and sensation of lump in throat were negatively associated with HNC. The AUROC demonstrated that our model had a higher predictive value (0.77) compared to those generated using the NICE 2005 (0.69) and 2015 (0.68) referral criteria (P < 0.0001). An online risk calculator based on this study is available at http://www.orlhealth.com/risk-calculator.html. CONCLUSIONS: This study presents a significantly refined version of referral guidelines which demonstrate greater diagnostic efficacy than the current NICE guidelines. We recommend that further iterative refinements of referral criteria be considered when referring patients with suspected HNC.

The anterolateral fasciocutaneous thigh flap for circumferential pharyngeal defects--can it really replace the jejunum?

Free jejunal transfer has been used in pharyngeal reconstruction for many years, but many have criticised it as being unreliable, poorly tolerant of radiotherapy, and susceptible to stenosis and dysphagia. Recently, the trend has been to use the anterolateral thigh (ALT) flap to overcome these problems, and many authors have reported good results. At the University of Birmingham we used the jejunal free flap for pharyngeal reconstruction for many years, but in view of recent reports we changed to the ALT flap. We retrospectively analysed all patients who had pharyngeal reconstruction with an ALT flap in our unit since changing from the jejunal flap. Only circumferential defects were included. Six patients had pharyngeal resection and required reconstruction of a circumferential defect between 2007 and 2010. All the defects were reconstructed with a tubed ALT flap. No flaps failed and there was no partial necrosis. However, stricturing still occurred and the diet of many patients was restricted. Three patients required the flap to be replaced with a jejunal free flap. Although no flaps failed, we have not been able to replicate the results of other surgeons and have therefore abandoned use of the ALT flap and returned to use of the jejunal free flap for the reconstruction of circumferential pharyngeal defects.

Hypofractionated accelerated radiotherapy with concurrent carboplatin for locally advanced squamous cell carcinoma of the head and neck.

AIMS: Hypofractionated accelerated radiotherapy with concurrent carboplatin utilises both advantages of altered fractionation and synchronous chemotherapy to maximise local control in locally advanced head and neck cancer. Such fractionation schedules are increasingly used in the intensity-modulated radiotherapy era and the aim of this study was to determine the outcome of hypofractionated accelerated radiotherapy with carboplatin. MATERIALS AND METHODS: One hundred and fifty consecutive patients with squamous cell carcinoma of the larynx, oropharynx, oral cavity and hypopharynx (International Union Against Cancer [IUAC] stage II-IV) treated with 55Gy in 20 fractions over 25 days with concurrent carboplatin were analysed. Outcome measures were 2 year overall survival, local control and disease-free survival. RESULTS: The median follow-up in surviving patients was 25 months. IUAC stages: II n=15; III n=42; IV n=93. Two year overall survival for all patients was 74.9% (95% confidence interval 66.0-81.7%). Two year local control was 78.3% (95% confidence interval 69.6-84.8%). Two year disease-free survival was 67.2% (95% confidence interval 58.3-74.7%). There were 135 patients with stage III and IV disease. For these patients, the 2 year overall survival, local control and disease-free survival were 74.3% (95% confidence interval 64.7-81.6%), 79.1% (95% confidence interval 69.8-85.9%) and 67.6% (95% confidence interval 58.0-75.4%), respectively. Prolonged grade 3 and 4 mucositis seen at ≥4 weeks were present in 9 and 0.7%, respectively. Late feeding dysfunction (determined by dependence on a feeding tube at 1 year) was seen in 13% of the surviving patients at 1 year. CONCLUSION: Hypofractionated accelerated radiotherapy with concurrent carboplatin achieves a high local control. This regimen should be considered for a radiotherapy dose-escalation study using intensity-modulated radiotherapy.

Current trends in the follow-up of head and neck cancer patients in the UK.

AIMS: The follow-up of patients with head and neck cancer is an essential aspect of their management. Follow-up provides support and reassurance for patients and will allow early detection of recurrence and second primary tumours. However, there is little evidence of a survival benefit from follow-up. With prolonged follow-up periods, multidisciplinary teams may be under increasing pressure to see more patients and this could have a negative effect on the time and quality of consultations given to individual patients. The aim of the present study was to analyse the current trends in the follow-up of head and neck cancer patients after treatment with curative intent in the UK. MATERIALS AND METHODS: A postal questionnaire was sent to all members of the British Association of Head and Neck Oncologists. RESULTS: Three hundred and twenty-seven questionnaires were sent and 214 were returned, making a response rate of 65.4%. One hundred and ninety-eight (61%) of these were deemed appropriate for evaluation and of these 111 (56%) clinicians followed up patients for a minimum of 5 years with 25 (13%) following patients for 10 years and 44 (22%) for life. Within the set of clinicians following patients for 5 years, 24 (12%) followed up patients with salivary gland and thyroid malignancies for a longer period of time. All clinicians concurred that the reasons for follow-up are to support patients, to detect local recurrences or metastases, second primary tumours and to monitor and manage the complications of treatment. CONCLUSIONS: Most of the clinicians followed up their patients up to a minimum of 5 years, with a significant minority who followed up the patients treated for cancers of the head and neck for longer periods. More studies are needed to elucidate the rationale and evidence for follow-up and to determine the adequate period of surveillance.

Consensus statement on management in the UK: transoral laser assisted microsurgical resection of early glottic cancer.

BACKGROUND: Transoral laser assisted microsurgical resection of early glottic laryngeal cancer is a relatively new treatment modality that is practised in many centres across the UK. In the absence of the results from randomised clinical trials, clinicians may be guided by an expert panel consensus statement on transoral laser assisted microsurgical resection of early squamous cell cancer of the larynx. OBJECTIVE: To provide consensus recommendations on the various aspects of transoral laser assisted microsurgical resection for early glottic cancer. EVALUATION METHOD: Nine centres across the UK were invited to describe current practice and outcomes for transoral laser assisted microsurgical resection of early glottic cancer. Four working groups were created to draw consensus on standard of care, surgical procedures, outcomes measures and training/certification. The feedback from these groups was integrated into the consensus statement. CONCLUSIONS: The consensus meeting confirmed the stablished and widespread use of transoral laser assisted microsurgical resection for early glottic cancer throughout the UK. The common experience gained allowed a full discussion of all aspects of the management with consensus achieved in key areas of standards of care, surgery, histopathologic reporting, outcomes assessment and training. This consensus statement will result in closer auditing of management and dissemination of results.

Laryngeal reconstruction following shrapnel injury in a British soldier: case report.

INTRODUCTION: Laryngeal injuries are uncommon but result in high mortality and morbidity rates when they do occur. We report a case of laryngeal fracture due to penetrating shrapnel injury, repaired with miniplates. CASE REPORT: A 26-year-old soldier was involved in an explosion and sustained a shrapnel wound to his right neck. After immediate airway management at the field hospital he was transferred to the UK, where he underwent a neck exploration, laryngofissure and repair of the thyroid cartilage using miniplates. An endolaryngeal stent was placed, which was removed at a second operation seven days later. Post-operatively, the patient recovered well and his voice improved rapidly. Six months post-operatively, he returned to work. DISCUSSION: The cause and nature of laryngeal injury differs between wartime and peacetime. The methods of diagnosis and management strategies are reviewed. The early recognition of injury and protection of the airway are of paramount importance when dealing with laryngeal injury. Delayed laryngeal reconstruction using miniplates can give a good functional result.

The effect of operating time on surgeon's hand tremor.

The objective of this prospective study, performed at two tertiary referral centers in the West Midlands, was to determine if operating has an effect on a surgeon's baseline tremor. A total of 10 head and neck surgery consultants, 2 ENT registrars and 19 normal controls participated in the study. The interventions were preoperative and postoperative tremor measurements for surgeons and pre and post-days' desk work for controls, with the main outcomes measure being the percentage change in tremor. No difference in baseline tremor was determined between consultants and registrars. Operating led to an increase in hand tremor in all subjects. Tremor increases in all subjects were directly proportional to the length of the time spent in operating. Operating compared to a normal day's desk work increased tremor by a factor of 8.4. In conclusion, surgeons should be aware that their tremor will increase as an operation progresses. More complex parts should be performed as early in the day as possible, or, in the case of a very long operation, a change of surgeons may occasionally be necessary.

Recurrent facial paraesthesia secondary to maxillary antral cyst and dehiscent infraorbital canal: case report.

OBJECTIVES: To report a rare presentation of dehiscent infraorbital canal associated with a maxillary antral cyst. CASE REPORT: A 26-year-old woman presented with symptoms of right infraorbital nerve dysfunction experienced while travelling by aeroplane. She was subsequently diagnosed with dehiscent infraorbital canal and large maxillary antral cyst on computed tomography scanning. The cyst was removed by endoscopic sinus surgery, and the patient's symptoms resolved. DISCUSSION: The effects of barotrauma on the ears and paranasal sinuses are reviewed. This is the first report of infraorbital nerve dysfunction caused by altered atmospheric pressure in the presence of dehiscent infraorbital canal and maxillary antral cyst. Endoscopic sinus surgery was successful in relieving the symptoms in this case.

Bilateral medialization thyroplasty: an effective approach to severe, chronic aspiration.

AIMS: To demonstrate the efficacy of bilateral medialization thyroplasty as a treatment for severe, chronic aspiration. To review the literature on surgical options available in the treatment of severe aspiration. MATERIALS AND METHODS: Three cases that underwent bilateral medialization thyroplasty are described. The technique used was the standard medialization thyroplasty described by Isshiki as a unilateral procedure. The assessment and rehabilitation of these patients is discussed. RESULTS: All patients stopped aspirating following surgery. One patient returned to a normal diet and one patient returned to a solid diet. All patients required a permanent tracheostomy. CONCLUSION: Bilateral medialization thyroplasty offers an effective surgical option in the treatment of severe, chronic aspiration. It maintains good voice, with a possible return to oral diet. The operation is easily reversible if the patient's condition alters.

Patient autonomy in physical restraint.

Despite initiatives to raise the awareness of patient autonomy among healthcare providers, the use of physical restraints on frail or confused older patients continues to be a common practice in many healthcare settings. This paper examines the relationship between patient autonomy and the use of physical restraints by drawing on the literature contradicting its efficacy and the assumption that its use is necessary to protect the welfare of patients. It argues that the paternalistic use of physical restraints without patient's informed consent is morally unjustified and is an unequivocal violation of their autonomy. The duty to respect individual autonomy should be extended to a duty to respect the autonomy of older people who are being restrained. Only in this way can their human dignity and quality of life be enhanced.

Diagrammatic recording of head and neck tumours.

The increasing demands of clinical audit have resulted in the need for accurate data collection. The use of tumour maps allows standardization of the records of patients with head and neck cancer, which facilitates collation of data in multicentre studies and makes interdepartmental comparisons more meaningful. The aim of this study was to develop an improved standard set of tumour maps for recording the stage of head and neck tumours. A review of the existing tumour diagrams was performed to identify those anatomical areas that are not adequately represented or where ambiguity exists. The areas where improvements could be made were identified as: (1). the anterior commissure of the larynx; (2). axial and sagittal views of the larynx; (3). the pyriform fossa and cervical oesophagus; (4). the oropharynx and vallecula; (5). the nasal cavity and paranasal sinuses; and (6). cervical nodal involvement. A new set of tumour maps is presented in an attempt to correct some of the limitations of the existing diagrams.

The use of a lymphatic bridge in the management of head and neck lymphoedema.

Severe progressive lymphoedema of the whole of the head and neck is almost always due to the combined effects of surgery and radiotherapy, compounded by repeated infections or recurrent tumour. The condition is difficult to control, and manual lymphatic drainage is the mainstay of management. We present a case of progressive lymphoedema following treatment for an occult squamous carcinoma of the head and neck, and describe the use of a lymphatic bridge to drain the facial tissue.

Sensory deprivation as a consequence of severe head and neck lymphoedema.

We report a case of sensory deprivation that occurred as a consequence of progressive head and neck lymphoedema, following combined surgery and radiotherapy for squamous cell carcinoma. The management of head and neck lymphoedema is discussed and measures are suggested for improving the sensory deprivation experienced by the worst affected patients.

An assessment of the value of the preoperative computed tomography scans prior to otoendoscopic 'second look' in intact canal wall mastoid surgery.

'Second look' surgery following primary intact canal wall mastoid surgery for cholesteatoma is considered mandatory for most cases in modern otological practice. The morbidity of the second look can be reduced by the use of the rigid otoendoscope. Forty-three patients undergoing 'second look' surgery were studied with an average age of 24.7 years. Prior to surgery a computed tomography (CT) scan was performed to assess the anatomy and pneumatisation of the cavity. The mean interval between primary and secondary surgery was 16 months and in all cases CT scans were performed within 6 months of 'second look' surgery. The presence of an opaque mastoid did not correlate with residual or recurrent cholesteatoma. The sensitivity of CT in diagnosing residual or recurrent cholesteatoma was 42.9% with a specificity of 48.3% and a predictive value of 28.6%. These results are explained by the fact that it is radiologically impossible to differentiate between recurrence, scar tissue or fluid with a CT scan. Nevertheless it was possible to inspect the cavity with the otoendoscope even in the presence of an opaque mastoid whether due to scar tissue or residual/recurrent cholesteatoma.