Pharyngeal angiosarcoma following multimodal treatment for oropharyngeal squamous cell carcinoma.

It is well established that angiosarcoma can develop following radiotherapy. We present an unusual case of angiosarcoma of the pharynx that developed three years after treatment with surgery and adjuvant chemoradiotherapy for a T2N2bM0 squamous cell carcinoma of the oropharynx. The patient was tumour free until developing dysphagia, which was found to be caused by an angiosarcoma. The patient underwent surgery of the pharyngeal angiosarcoma by laryngopharyngectomy, tongue base resection, selective neck dissection and radial forearm microvascular free flap reconstruction. Angiosarcoma following head and neck malignancy is rare but must be considered as part of the differential diagnosis in patients with new symptoms after radiotherapy.

Laryngeal cancer management in a small, rural, multidisciplinary team setting: 15-year review.

BACKGROUND: The Cumberland Infirmary, Carlisle, serves a largely remote, rural population of 330 000. The aim of this study was to report the treatment and survival figures for patients treated for laryngeal cancer at this centre. METHODS: The study included 209 consecutive patients with squamous cell carcinoma of the larynx diagnosed between 1996 and 2010 at the Cumberland Infirmary. RESULTS: Disease-specific survival was 100 per cent for stage one, 76 per cent for stage two, 87 per cent for stage three and 46 per cent for stage four. In total, 76 patients (36 per cent) had a laryngectomy, either as primary treatment or as a salvage procedure. CONCLUSION: Our tumour-specific survival rate was very high, and this success may be due in part to high rates of surgical intervention. Survival data compared favourably with other centres, despite less radical radiotherapy regimes. Laryngeal cancer can be managed effectively in a small, relatively remote, multidisciplinary team setting.

Can head and neck cancer patients be discharged after three years?

BACKGROUND: Follow-up surveillance of head and neck cancer patients varies throughout the UK. The heterogeneity of these patients limits the applicability of a standardised protocol. Improvements in our understanding of the natural history of the disease may assist in the tailoring of resources to patients. METHOD: Prospective data collected at the Cumberland Infirmary over a 13-year period were analysed, primarily focusing upon recurrence rates and time to recurrence. RESULTS: In keeping with other studies, recurrence of head and neck squamous cell carcinoma was found to be maximal within the first three years of treatment, regardless of subsite. CONCLUSION: Hospital-based surveillance may be safely discontinued after three years for some patients. Laryngeal carcinoma may require further surveillance due to possible delayed recurrence of a second primary formation. Emphasis must be placed on patient education, accessibility to head and neck services, and the existence of a robust system to facilitate urgent referrals.

Audit of handover in an ENT unit.

OBJECTIVES: To analyse the completeness and accuracy of the written handover in our ENT department, in line with Royal College of Surgeons of England guidance, and to improve standards. SETTING: University Hospital, Cumberland Infirmary, Carlisle, UK. METHODS AND RESULTS: We prospectively analysed the written handover over two periods (of 30 and 18 days each). In the first period, the morning handover was present and complete on 77 per cent of days, present but incomplete or illegible on 6 per cent of days, and absent on 17 per cent of days; the evening handover was present and complete on 30 per cent of days, and absent on 67 per cent of days. To improve standards, we emphasised the importance of accurate handover to the ENT team and to junior doctors who cross-covered ENT. A reminder of the Royal College of Surgeons of England guidance was included in the handover book, and junior doctors received regular feedback. CONCLUSION: We demonstrated a substantial improvement in the quality and completeness of written handover, comparing the second and first audit periods.

Epiphora: an evidence based approach to the 12 minute consultation.

BACKGROUND: Epiphora is the presence of a watering eye which may be due to reflex tearing or defective drainage of tears. Whilst most cases present to the ophthalmologist the otolaryngologist has a key role to play in both assessment and management of these patients. METHODS: This review was based on a literature search last performed on 21st October 2009. MEDLINE and Cochrane databases were searched using the subject headings 'epiphora' or 'functional epiphora' in combination with diagnosis, investigation, management, treatment, intervention and surgery. Results were limited to English language articles. The personal biographies of the senior authors were also used. CONCLUSION: An accurate assessment of the site and degree of obstruction is important to ensure the correct management is undertaken. Medical treatment with nasal steroid spray may be effective but the majority of obstructed cases will require surgical intervention in the form of dacryocystorhinostomy (DCR). There is increasing evidence that powered endoscopic DCR has outcomes comparable with the 'gold standard' procedure of external DCR.

Magnetic resonance imaging of branchial cleft abnormalities: illustrated cases and literature review.

OBJECTIVE: We report two cases of branchial cleft abnormalities investigated using magnetic resonance imaging. BACKGROUND: There appears to be no clear imaging technique that is universally recommended for imaging branchial cleft abnormalities. Options include fistulography, computed tomography, magnetic resonance imaging and ultrasonography. METHOD: Case reports and literature review. CASE REPORTS: Two cases, although not unusual in themselves, are described to illustrate the use of magnetic resonance imaging to define the anatomy and to assist surgical planning. CONCLUSION: Magnetic resonance imaging is able to accurately depict the extent and course of branchial cleft abnormalities, and in the current cases could have been relied upon to determine the necessary surgical procedure. Branchial cleft abnormalities are sufficiently rare for magnetic resonance imaging to be recommended as the first-line imaging modality.

Endoscopic 'cold steel' versus laser dacryocystorhinostomy: completing the audit cycle.

INTRODUCTION: Dacryocystorhinostomy via an endonasal route has been adopted in our department. This audit study describes and compares our results for external, laser endonasal and 'cold steel' endonasal techniques. Success was defined as a subjective report of eye watering being 'better' or 'cured'. Data were obtained from a retrospective review of the medical records of all patients undergoing primary dacryocystorhinostomy in our department. 'Gold standard': External dacryocystorhinostomy performed by a consultant ophthalmologist was taken as our gold standard. In our study, the success rate for external dacryocystorhinostomy was 94 per cent. First cycle - laser-assisted endonasal dacryocystorhinostomy: Our initial results for endonasal laser-assisted dacryocystorhinostomy produced a success rate of 64 per cent, which was significantly worse than that for external dacryocystorhinostomy. These results have been previously published. CHANGE IN PRACTICE: Evidence suggested that cold steel endonasal dacryocystorhinostomy was more effective, and we adopted this as our technique of choice. Second cycle - cold steel endonasal dacryocystorhinostomy: Over a four-year period, 57 cases completed a full nine months' follow up. 93 per cent were completed as day cases and 39 per cent were performed under local anaesthetic. The success rate was 79 per cent (45/57). There was no difference in success rates when this procedure was compared with external dacryocystorhinostomy (p = 0.55). The type of anaesthetic used (i.e. local vs general) made no difference to the success rate (p = 0.93). CHANGE IN PRACTICE: Cold steel endonasal dacryocystorhinostomy was as effective as the gold standard, i.e. external dacryocystorhinostomy. Laser-assisted dacryocystorhinostomy was significantly less successful than external dacryocystorhinostomy. Due to the benefits of decreased operating time, lower morbidity and success under local anaesthetic, we recommend cold steel endonasal dacryocystorhinostomy as our procedure of choice for the treatment of epiphora.

Cost-efficiency of endoscopic and external dacryocystorhinostomy.

BACKGROUND: In most centres in the United Kingdom, endoscopic dacryocystorhinostomy is currently undertaken as a joint operation between ophthalmologists and otolaryngologists. The addition of an extra surgeon, the use of endoscopic equipment and the relatively lower success rate of this procedure made us compare endoscopic dacryocystorhinostomy and external dacryocystorhinostomy with regards to costs and income for our hospital. METHODS: All 38 primary endoscopic dacryocystorhinostomy cases performed in our centre in 2001-2003 were retrospectively compared with the 49 external dacryocystorhinostomy cases performed in 1993-2000. Cost-income calculations were made based on: rate of local anaesthesia, success rate, rate of day case admission, hospital reference cost for dacryocystorhinostomy, and the income per case extracted from national tariffs (based on the Health Resources Group). Also, the average number of cases per session was used to calculate the income gained per session for each method. RESULTS: The following rates between the endoscopic and the external dacryocystorhinostomy were found: local anaesthesia, 29 vs 6 per cent, respectively; day-case operation, 95 vs 12 per cent, respectively; and success rate, 87 vs 94 per cent, respectively. The average number of endoscopic dacryocystorhinostomy cases conducted in a single theatre session was twice that of external dacryocystorhinostomy cases. Endoscopic dacryocystorhinostomy generated approximately twice the income of external dacryocystorhinostomy (6585 pounds vs 3292 pounds, respectively). CONCLUSION: Endoscopic dacryocystorhinostomy is more cost-effective than external dacryocystorhinostomy, despite having a lower success rate and greater usage of resources, as the endoscopic procedure generates more income. This is mainly due to the higher number of cases per session and the higher rates of local anaesthesia and day case operations possible.

Lesson plans in surgical training.

Lesson plans in surgery enable trainers and trainees to agree on goals that balance training needs with service commitments. Lesson plans are individualised to the trainee and encourage ownership of learning. They are based on SMART criteria and therefore have a sound educational footing. Most of the work in creating a lesson plan falls to the trainee. The total time for creation of each plan is approximately 20 min. Our use of lesson plans for surgical training has been met with favourable response from both trainer and trainees.

Silicone septal button in the management of a large tracheo-oesophageal fistula following primary puncture in a laryngectomee.

We describe the use of a silicone septal button in the management of a patient who developed a large tracheo-oesophageal fistula following primary puncture as part of a total laryngectomy. The button was easily inserted, well tolerated and prevented leakage of solids into the trachea, allowing the patient to eat.

A retrospective comparison of endonasal KTP laser dacryocystorhinostomy versus external dacryocystorhinostomy.

We retrospectively reviewed all primary external dacryocystorhinostomies (DCRs) and endonasal KTP laser DCRs performed for epiphora as a result of nasolacrimal duct obstruction in our unit between 1993 and 2000. Forty-nine patients underwent an external approach and 76 endonasal laser procedures were performed. The success rate of the external group was 94% with a mean follow-up of 9 months. In contrast, the endonasal group's success rate was 64% with a mean follow-up of 12 months. This difference reached statistical significance (P = 0.0002). However, when including revision procedures, the success rate in the endonasal group increased from 64% to 82%. The success rate in the endonasal group improved from 50% in the first 38 cases to 79% in the last 38 cases (P = 0.0084), thereby demonstrating a learning curve. Our study confirms external DCR as the 'gold standard' for a successful outcome. However, the endonasal technique has significant advantages, including being a quicker procedure with less morbidity, no cutaneous scar, and being more amenable to a bilateral procedure, daycase surgery and local anaesthetic. We are persisting with the endonasal technique because of its advantages but have moved towards more 'cold steel' techniques in an effort to improve results and emulate other series. In conclusion, for nasolacrimal duct obstruction, the endonasal technique is our approach of choice, with revision surgery if necessary, and the external technique is held in reserve.

Role of computerized tomography (CT) scan of the chest in patients with newly diagnosed head and neck cancers.

Chest metastases and second primaries are not uncommon in patients with head and neck cancer. Early detection of a second site of malignant disease may alter prognosis and management. This study assessed the diagnostic yield of chest radiographs compared with computerized tomography (CT) in a series of patients with head and neck cancer. Forty-four consecutive patients with a head and neck squamous cell carcinoma (SCC) attending the head and neck surgery department of Cumberland Infirmary, Carlisle, between January 2000 and December 2000 were included in this prospective study. Patients with lymphomas and localized cancers of the skin and lip were excluded. Thirty men and 14 women, with a mean age of 67 years, were assessed. All had chest radiographs and chest CT at the same time as the CT scan of the primary site. Only one patient had a true positive finding on chest radiograph. Five patients had an abnormal chest CT. Of these, two had multiple lung metastases, and another patient had biopsy-proved bronchogenic carcinoma and underwent surgical excision. The sensitivity and specificity of CT scan was 100% and 95%, as opposed to 33% and 97% for chest radiograph.

The development of a General Nasal Patient Inventory.

Most available clinical outcome measures for rhinology patients relate to specific nasal disease or general quality of life. Fairley's validated 12-item questionnaire measures general nasal symptoms, but is a 'physician-derived' clinical tool and may not reflect all the problems that rhinology patients experience. Our aims were to develop a patient-orientated questionnaire, representing the concerns of a large number of rhinology patients, called the General Nasal Patient Inventory (GNPI) and compare this with the Fairley nasal questionnaire (FNQ). The GNPI was developed from the open-ended problem lists of 211 rhinology patients, from the 45 most frequent complaints. Both questionnaires were then administered to 153 general rhinology patients and the results compared. The highest-ranking items for each questionnaire were different, but the total scores were highly correlated (r = 0.79, P < 0.0001). Factor analysis showed six factors to account for 75% of FNQ variance and 18 factors for 78% of GNPI variance. The 45-item GNPI, the first patient-derived, comprehensive nasal questionnaire could be a time-saving tool in rhinology clinics and more sensitive to change after intervention than other available measures.

The fish hook retractor.

We describe a simple and easily adjustable method of retracting skin flaps during head and neck surgery. It involves the use of a modified fish hook and rubber band. The retractor is easily applied and adjusted, and inexpensive to manufacture.

Endoscopic laser dacryocystorhinostomy. An unusual post-operative finding: re-opening of the nasolacrimal duct.

Endoscopic laser dacryocystorhinostomy (DCR) is a recognized technique for the surgical treatment of epiphora. Nasolacrimal duct obstruction is surgically bypassed by creating a passage from the lacrimal sac to the nasal cavity (rhinostomy). Some patients have undergone endonasal laser-assisted DCR, and were found to have an obstructed rhinostomy at follow-up. However, they reported a subjective improvement in their symptoms. Five such patients, at six months follow-up, were found to have a non-functioning rhinostomy with fluorescein dye emerging from under the inferior turbinate. These five patients along with four controls had post-operative macrodacryocystograms (MDCG) to delineate the anatomical passage by which tears were entering the nasal cavity. In the control group, clear passage of contrast into the middle meatus was demonstrated in three of the four subjects. In the study group, passage of dye to the inferior meatus, via the nasolacrimal duct was demonstrated in four of the five subjects. It is well recognized that a proportion of patients suffering from epiphora will have a natural resolution of their symptoms. Our results demonstrate that the resolution of epiphora in some operated patients was due to a re-opening of the nasolacrimal duct, and not because of a patent rhinostomy.

Epiphora: the role of rhinitis.

Inflammation in the nasal mucosa may lead to epiphora by causing edema around the orifice of the nasolacrimal duct. We present and discuss three cases where simple treatment of rhinitis led to the resolution of the presenting symptom of epiphora, avoiding the need for surgery. A randomized prospective trial of topical nasal corticosteroids in the management of epiphora associated with rhinitis is in progress.

Validation of the combined olfactory test.

A new test of olfactory function, the combined olfactory test, has been designed to assess odours easily recognizable by the test population. The test consists of an odour recognition test of nine odours, where an odour in a bottle is chosen from a list of four possible odours in a forced choice manner. This is followed by a threshold test using a series of three-fold dilutions of 1-butanol. The mean of the two scores is the combined olfactory score. The test was subjected to a validation study. It was performed on 133 participants with a normal sense of smell and a normal rhinological examination and on 94 participants who said that they did not have a sense of smell. There was a highly significant difference between the combined olfactory score in the normal and 'anosmic' groups (P < 0.001). This significant difference was the same between the two groups for the threshold and odour recognition arms of the test. There was a highly significant difference (P < 0.001) between the two subgroups of 'completely anosmic' and 'almost anosmic' participants, indicating that the test could grade the degree of olfactory dysfunction.