Operative technique in laryngeal paraganglioma: A case series and literature review.

Background: Laryngeal paragangliomas (LP) comprise a rare subset of head and neck neoplasms and are an important differential in the patient with a submucosal laryngeal mass. Methods: We discuss an operative technique using coblation assisted excision via laryngofissure in the cases of four confirmed LPs and discuss the current literature with respect to diagnosis and management of these patients. Results: Our case series of four patients demonstrate the laryngofissure approach for LP is safe, provides oncological cure and preserves laryngeal function. This technique with coblation has not been previously discussed in the surgical management of LPs. Patient-reported postoperative voice and swallowing outcomes were excellent in all patients. Whole body imaging techniques were utilized in all patients, with octreotide scintigraphy demonstrating synchronous lesions in two of the four patients-one had a retroperitoneal lesion, whilst another patient had multiple lesions in the skull base, paravertebral region, liver, and adrenal gland. Conclusions: Our cases also highlight the changing clinical paradigms in the diagnostic approach of LPs and an emerging role for octreotide scintigraphy in the workup of these patients. Coblation assisted excision via laryngofissure is efficient and effective in the surgical resection of LP. In patients with multicentric forms of LP, the size, side, and anatomic location of synchronous lesions should be considered in surgical planning to determine feasibility and safety of operative management. Level of Evidence: IV.

A web-based comprehensive head and neck cancer patient education and support needs program: Usability testing.

Background: With increasing accessibility of the World Wide Web, patients are using it to obtain patient education materials (PEM). With this in mind, our group (surgeons, radiation oncologists, medical oncologists, nursing, allied health professionals and academic researchers) developed a comprehensive information resource for patients with head and neck cancer (HNC), the Head and Neck Cancer Australia, formerly Beyond Five website. The aim of this study was to determine patient usability of the Head and Neck Cancer Australia website. Methods: Usability testing (Cognitive walkthrough & Think-Aloud) in 18 patients treated for HNC was undertaken at a Cancer centre (anonymous for reviewers). Results: The tasks rated easiest by patients were finding information on psychological well-being (mean time spent: 66 s, range: 10-565), health and well-being effecting quality of life (mean time spent: 36 s, range 9-117) and carer information (mean time spent: 10 s, range 3-35). Patients indicated the website contained a lot of information, covers most topics, was a trusted source of information and a springboard to other information. Conclusions: The Head and Neck Cancer Australia website provides a wide range of information and support in multiple formats available to HNC patients. Further refinements in design, navigation and website instructions are needed to allow effective patient interaction.

A Multidisciplinary Approach to Secondary Tracheoesophageal Puncture for Voice Prosthesis Insertion Using Flexible Esophagoscopy.

BACKGROUND: Tracheoesophageal puncture (TEP) with voice prosthesis (VP) insertion is the gold standard of surgical voice restoration in postlaryngectomy patients. The conventional technique involves rigid esophagoscopes and trocar performed by ENT surgeons alone, with technical limitations encountered in patients with cervical abnormalities - in particular those with free or rotational flap reconstructions and postradiotherapy strictures. We report our technique using flexible endoscopy which we show to be feasible and without major safety events, as a possible consideration in the anticipated difficult TEP. METHODS: Our study describes a multidisciplinary approach to secondary TEP involving a combined upper gastrointestinal (UGI) and (Ear, Nose, and Throat) ENT procedure, under the guidance of flexible esophagoscopy, with intraoperative involvement of the speech pathologist to guide VP insertion and placement. The procedure was performed with ease without major complications. RESULTS: We identified nine postlaryngectomy and laryngopharyngectomy patients in our institution who underwent secondary TEP with VP insertion using flexible esophagoscopy and multidisciplinary intra-operative involvement. All patients had pharyngeal reconstruction, including radial forearm free flap (n = 4), pectoralis major rotational flap (n = 3), and anterolateral thigh flap (n = 2). Eight out of nine patients underwent adjuvant radiotherapy. The technique was successfully performed in all patients. There were three cases of early TEP displacement in two patients, of which one patient had a successful repeat procedure. We found the technique advantageous in terms of feasibility and practicality compared to the conventional approach, and without intraoperative difficulties encountered in achieving the desired field of views or navigating the challenging anatomy in a free flap and post-radiotherapy patients. This includes distorted cervical anatomy, the presence of bulky and hair-bearing flap skin, and stricture formation. Minor complications in our cohort included pharyngo-esophageal spasm, TEP displacement, granulation tissue, and peri-prosthetic leaks. CONCLUSION: Our multidisciplinary approach to secondary TEP was performed with flexible esophagoscopy without major related complications. The technique is advantageous in the surgical approach to VP insertion in postlaryngectomy and laryngopharyngectomy patients who have had radiotherapy or pharyngeal reconstruction. It allows for safe anatomical insertion and thorough evaluation of the upper aerodigestive tract for comorbid benign or malignant esophageal pathology.

Combination Immunosuppressive Therapy in Primary Autoimmune Inner Ear Disease in Pregnancy.

Objective: Autoimmune inner ear disease (AIED) is a rare disorder characterized by rapidly progressive, sensorineural hearing loss that demonstrates good responsiveness to corticosteroid and immunosuppressive therapy. The pathophysiology is likely driven by chronic trafficking of immune cells into the inner ear, targeting inner ear proteins to coordinate inflammation. Suppression or modulation of the immune response can minimize cochleitis allowing for potential recovery of hearing. It is an otologic emergency requiring a multidisciplinary approach to management to commence immunosuppressive therapy. This can be achieved using steroids, immunomodulators, plasmapheresis, intravenous immunoglobulin, or biologic agents. Treatment decisions are further complicated in pregnancy and require supervision by an obstetrician and maternal-fetal medicine (MFM) specialist. Concerns include safe dosing of steroids and potential for transplacental migration of immune complexes. We provide the first comprehensive literature review on AIED and its implications in pregnancy. We frame our discussion in the context of the second reported case of primary AIED in pregnancy and the first to show excellent response to immunosuppressive therapy. Methods: We reviewed the presented case and literature on AIED. Results: A 27-year-old, pregnant, HSP-70 positive woman was diagnosed with AIED and had excellent recovery of hearing and balance following a combination of steroid treatment, augmented by oral immunomodulators, plasmapheresis, and IVIG. Conclusion: AIED is a diagnostic challenge, and treatment considerations are complex when encountered in pregnancy. Management requires multidisciplinary involvement between otolaryngologists, immunologists, and obstetricians to balance maternal and fetal health outcomes.

Lump at the back of my tongue. The lingual thyroid-A case report and narrative review of literature.

Although the ectopic thyroid in adults is rarely symptomatic, biochemistry and imaging workup are essential. Treatment modality of choice is dependent on patient factors, institution factors and surgeon factors. The mainstay treatment involves hormone suppression treatment with exogenous thyroid hormone. If medical management is unsuccessful, surgical excision requires an experienced team including an anaesthetist and otolaryngologist. Anaesthetic considerations are important because intubation may be a potentially difficult procedure secondary to potential serious obstruction of the upper airway. We present a case report and narrative review of the literature regarding lingual thyroid workup and management.

Assessment of an evidence-based laryngeal cancer fact sheet: A mixed methods study.

To evaluate perceptions of a laryngeal cancer fact sheet amongst people with direct experience of the disease and its treatment. A mixed methods study (questionnaire and interview) evaluating the information resource was conducted across two institutions. In total 20 participants responded to the questionnaire. Overall participants reported the information resource was detailed and understandable. Insufficient information was provided on: impact on family in eight participants (40%); impact on work in six (33%); and, second opinions and long-term side effects in five (25%). The majority (67%) wanted a large amount of information with the preferred source being one-on-one meetings with their doctor. The thematic analysis identified three main themes: preferences for information, self-management; and, information sources. People with direct experience of laryngeal cancer and its treatments reported the information resource was comprehensive and clear. There were some gaps in the information provided, particularly related to survivorship issues.

Burkitt Leukemia Presenting as Acute Appendicitis: A Case Report and Literature Review.

BACKGROUND Appendicitis is the most common cause of an acute abdomen. Approximately 1% of appendicectomies will have an incidental finding of an appendiceal neoplasm. A primary appendiceal lymphoma is extremely rare, and is found in 0.015% of all appendiceal specimens. Burkitt lymphoma is an aggressive B cell lymphoma characterized by translocation and dysregulation of the c-Myc gene. Burkitt leukemia is considered to be an alternative manifestation of the same pathology, and is defined by the presence of >25% Burkitt blasts within the bone marrow. The treatment approaches for Burkitt leukemia/lymphoma are similar. CASE REPORT A 6-year old girl presented with a history, examination, and radiological imaging consistent with acute appendicitis. An inflamed, edematous appendix was identified intraoperatively, and a cecectomy was performed. Histopathological investigations demonstrated Burkitt leukemia with isolated extra-nodal involvement of the appendix. The patient was subsequently started on a multi-agent steroid and chemotherapy regimen. A literature review was performed, identifying cases of Burkitt leukemia/lymphoma presenting as appendicitis. CONCLUSIONS This case highlights the importance of clinical vigilance and routine specimen histopathology review, and explores key management considerations associated with the incidental diagnosis of Burkitt leukemia/lymphoma.

Glottic Obstruction from Fibroepithelial Polyp.

BACKGROUND Fibroepithelial polyps are benign lesions of mesodermal origin, which have been reported in the head and neck area. The aim of this study is to describe the management of an oropharyngeal fibroepithelial polyp causing stridor. CASE REPORT A 39-year-old male presented with 24 hours of stridor and dysphagia. Flexible laryngoscopy revealed a pedunculated sessile polyp on the posterior oropharynx. The mass was excised using bipolar diathermy and histopathology revealed a fibroepithelial polyp. The differential diagnoses for stridor are extensive. Although uncommon, a fibroepithelial polyp should be considered. CONCLUSIONS We present a rare case of a fibroepithelial polyp causing stridor and imminent airway obstruction. We recommend the use of SponTaneous Respiration using IntraVEnous anaesthesia and High-flow nasal oxygen (STRIVE Hi) for general anaesthesia and resection of pharyngeal polyps.

A Case of Pneumomediastinum Due to Blunt Neck Trauma in a 23-Year-Old Male Rugby Player.

BACKGROUND Pneumomediastinum is an uncommon clinical condition that usually occurs spontaneously, or is caused by blunt thoracic or abdominal trauma. This report is of a rare case of pneumomediastinum caused by blunt neck trauma in an adult and describes the clinical and radiological features and the principles of clinical management. CASE REPORT A 23-year-old man presented with increased neck swelling, dysphonia and pain on swallowing (odynophagia) after blunt neck trauma during a rugby game. Chest X-ray and computed tomography (CT) showed features that were consistent with pneumomediastinum, including extensive subcutaneous emphysema. The patient was intubated and monitored in the intensive care unit (ICU) and managed with early stabilization of the airway and with conservative methods. He had no complications on clinical follow-up following hospital discharge. CONCLUSIONS Although pneumomediastinum is an uncommon condition, the complications can be fatal. This case highlights the importance of thoroughly investigating cases of subcutaneous emphysema and the importance of early stabilization of the airway.

The relationship between role preferences in decision-making and level of psychological distress in patients with head and neck cancer.

OBJECTIVE: Is there a relationship between decision-making preferences and psychological distress? METHODS: Patients who had received treatment for head and neck cancer (HNC) at four institutions within NSW, Australia were invited to complete a single questionnaire. RESULTS: Five hundred and ninety-seven patients completed the questionnaire. The majority of patients (308, 54%) preferred shared decision making. Significant predictors of a preference towards active decision making were education level (OR 2.1 for tertiary, p < 0.001), primary cancer site (OR 1.9 for thyroid compared to salivary gland, p = 0.024) and gender (OR 1.4 for female, p = 0.028). Mean psychological distress score on Kessler 6 (K6) was 9 (Range: 0-28). Significant predictors of psychological distress were age (p < 0.001), gender (p < 0.001), primary site (p < 0.01), and decision preference (p < 0.01). CONCLUSION: HNC patients who are either tertiary educated or female are more likely to prefer active involvement in decision-making. Psychological distress is more likely in patients actively involved in decision making, younger patients, and in females. PRACTICE IMPLICATIONS: Patients experienced paternalistic decision-making, but most preferred active or a shared approached. Clinicians need to be aware of potential for psychological distress in active decision-makers and refer patients for psychosocial support.

Examining clinicians' perceptions of head and neck cancer (HNC) information.

BACKGROUND: Providing appropriate educational resources to patients with head and neck cancer (HNC) is important but challenging. The aim of this study was to determine Australian clinicians' perceptions of currently used HNC information resources. METHODS: A purpose-designed questionnaire was disseminated electronically to clinician members of the Australian and New Zealand Head and Neck Cancer Society (ANZHNCS) and The Australian Society of Otolaryngology Head and Neck Surgery (ASOHNS). RESULTS: Of the 648 clinicians invited, 112 responded to the survey (17.3% response rate). Overall, 85% utilized written information as their primary mode of patient education and 49% received information on treatment details. Areas for improvement include information provision, pain management, emerging risk factors, survivorship and side effects. The majority (66%) of clinicians had a preference for internet patient education materials. CONCLUSIONS: Clinicians predominantly utilized written HNC information rather than multimedia or interactive resources. However, they expressed the desire to be able to deliver HNC information resources via an internet-based platform covering the psychosocial effects of treatment.

Trans-oral robotic surgery in oropharyngeal carcinoma - A guide for general practitioners and patients.

BACKGROUND: Trans-oral robotic surgery (TORS) is emerging as a minimally invasive alternative to open surgery, or trans-oral laser surgery, for the treatment of some head and neck pathologies, particularly oropharyngeal carcinoma, which is rapidly increasing in incidence. OBJECTIVE: In this article we review current evidence regarding the use of TORS in head and neck surgery in a manner relevant to general practice. This information may be used to facilitate discussion with patients. DISCUSSION: Compared with open surgery or trans-oral laser surgery, TORS has numerous advantages, including no scarring, less blood loss, fewer complications, lower rates of admission to the intensive care unit, and reduced length of hospitalisation. The availability of TORS in Australia is currently limited and, therefore, public awareness about TORS is lacking. Details regarding the role of TORS and reliable, up-to-date, patient-friendly information sources are discussed in this article.

Education and support needs in patients with head and neck cancer: A multi-institutional survey.

BACKGROUND: Head and neck cancer (HNC) encompasses a diverse group of tumors, and thus providing appropriate and tailored information to patients before, during, and after treatment is a challenge. The objective of the current study was to characterize the experience and unmet needs of patients with HNC with regard to information and support provision. METHODS: A 28-question, cross-sectional survey was completed by patients treated for HNC at 1 of 4 institutions in New South Wales, Australia (Chris O'Brien Lifehouse and Liverpool, Westmead, and Wollongong hospitals). It consisted of the adapted Kessler Psychological Distress Scale and questions assessing information quality, quantity, and format. RESULTS: A total of 597 patients responded. The mean age of the patients was 58 years (range, 21-94 years) with 284 men and 313 women (1:1.1). The majority of patients reported information concerning the disease process (76%), prognosis (67%), and treatment (77%) was sufficient, and approximately 50% reporting having received little or no information regarding coping with stress and anxiety. A substantial percentage of patients reported receiving minimal information concerning psychosexual health (56%) or the availability of patient support groups (56%). The majority of patients preferred access to multiple modes of information delivery (72%), with the preferred modality being one-on-one meetings with a health educator (37%) followed by internet-based written information (19%). CONCLUSIONS: Patients with HNC are a diverse group, with complex educational and support needs. Patients appear to be given information regarding survivorship topics such as psychological well-being, patient support groups, and psychosexual health less frequently than information concerning disease and treatment. Verbal communication needs to be reinforced by accessible, well-constructed, written and multimedia resources appropriate to the patient's educational level. Cancer 2017;123:1949-1957. © 2017 American Cancer Society.

Oropharyngeal cancer and human papilloma virus: evolving diagnostic and management paradigms.

The significant increase in human papilloma virus (HPV)-associated oropharyngeal carcinoma (OPC) over recent years has lead to a surge in research and an improved understanding of the disease. Most patients with HPV-associated OPC present with cystic nodal metastases with a small primary tumour, and respond well to all treatment modalities including primary surgery and primary chemoradiotherapy. Current research is evaluating treatment de-escalation to reduce long-term treatment-associated morbidities. Transoral robotic surgery (TORS) is particularly relevant as the transoral approach allows small primary tumours to be removed with lower morbidity than traditional surgical approaches. The current American Joint Committee on Cancer staging system for oropharyngeal cancer does not appropriately stratify HPV-associated OPC; hence, alternative risk stratification and staging classifications are being proposed.