Indications for oropharyngeal biopsy in head and neck squamous cell carcinoma of unknown primary: A systematic review (HNSCCUP).

INTRODUCTION: Patients presenting with head and neck squamous cell carcinoma of unknown primary (HNSCCUP) remain challenging clinical scenarios as large variation exists in practices used to locate the primary. OBJECTIVE: The objective of this systematic review is to review of the literature and offer recommendations for oropharyngeal biopsies in HNSCCUP. METHOD: Pubmed, Medline and Embase were searched to identify studies from inception to October 2021. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. RESULTS: A total of 483 articles were included and screened, 41 studies met the inclusion criteria, including over 3400 patients from the original articles (122 of these patients were reported on in two sequential articles by a single author - table 1) and 4 large metaanalyses including 1852 patients. The primary site identification rate following random biopsies or deep tissue biopsies is less than 5% in most studies. The mean detection rate following ipsilateral tonsillectomy is 34%; two pooled analyses indicate that the mean detection rate following tongue base mucosectomy is 64%, with this figure rising when the tonsils are negative. CONCLUSIONS: High level evidence is lacking, with heterogeneity in the reported studies. Published meta-analyses are based on retrospective data. There is little evidence supporting the practice of random/non-directed oropharyngeal biopsies. Available evidence supports palatine tonsillectomy and tongue base mucosectomy compared to deep tissue biopsies.

Drainless, day-case lateral neck dissection with Artiss™ fibrin sealant: A prospective cohort study.

OBJECTIVE: Lateral neck dissection (LND) is performed for staging/treatment of head and neck lesions. This traditionally includes placement of a drain and inpatient admission. Drainless, day-case head and neck surgery is attractive due to cost-effectiveness and reduced length of stay, but evidence is lacking in LND. We aim to investigate Artiss™ as an alternative to drain placement, facilitating day-case LND. METHODS: A prospective review was conducted of patients who underwent LND in a UK hospital over a 22-month period. RESULTS: Thirty-nine patients were identified (27 Artiss™ only; 12 Artiss™ with a drain). Eight Artiss™ only patients were day-case. All drains were removed by post-operative day 2. There was no statistically significant difference in the number of complications between the two groups. CONCLUSION: This observational study demonstrates that for selected patients, Artiss™ could facilitate drainless, day-case LND. Further controlled studies with matched groups and larger numbers are required to validate this.

Methodology for the development of National Multidisciplinary Management Recommendations using a multi-stage meta-consensus initiative.

BACKGROUND: Methods for developing national recommendations vary widely. The successful adoption of new guidance into routine practice is dependent on buy-in from the clinicians delivering day-to-day patient care and must be considerate of existing resource constraints, as well as being aspirational in its scope. This initiative aimed to produce guidelines for the management of head and neck squamous cell carcinoma of unknown primary (HNSCCUP) using a novel methodology to maximise the likelihood of national adoption. METHODS: A voluntary steering committee oversaw 3 phases of development: 1) clarification of topic areas, data collection and assimilation, including systematic reviews and a National Audit of Practice; 2) a National Consensus Day, presenting data from the above to generate candidate consensus statements for indicative voting by attendees; and 3) a National Delphi Exercise seeking agreement on the candidate consensus statements, including representatives from all 58 UK Head and Neck Multidisciplinary Teams (MDT). Methodology was published online in advance of the Consensus Day and Delphi exercise. RESULTS: Four topic areas were identified to frame guideline development. The National Consensus Day was attended by 227 participants (54 in-person and 173 virtual). Results from 7 new systematic reviews were presented, alongside 7 expert stakeholder presentations and interim data from the National Audit and from relevant ongoing Clinical Trials. This resulted in the generation of 35 statements for indicative voting by attendees which, following steering committee ratification, led to 30 statements entering the National Delphi exercise. After 3 rounds (with a further statement added after round 1), 27 statements had reached 'strong agreement' (n = 25, 2, 0 for each round, respectively), a single statement achieved 'agreement' only (round 3), and 'no agreement' could be reached for 3 statements (response rate 98% for each round). Subsequently, 28 statements were adopted into the National MDT Guidelines for HNSCCUP. CONCLUSIONS: The described methodology demonstrated an effective multi-phase strategy for the development of national practice recommendations. It may serve as a cost-effective model for future guideline development for controversial or rare conditions where there is a paucity of available evidence or where there is significant variability in management practices across a healthcare service.

Transoral robotic surgical excision of hypopharyngeal ectopic parathyroid adenoma causing primary hyperparathyroidism.

Ectopic parathyroid adenomas are a rare congenital anomaly despite the complex migration parathyroid glands undergo during development. Rarer still, these can be found in the hypopharynx, become adenomas and be the cause of primary hyperparathyroidism. We present a case of a woman in her 50s who underwent transoral robotic surgery (TORS) to remove her hypopharyngeal ectopic parathyroid adenoma and cure her primary hyperparathyroidism without complication. This is a radical change in practice compared with traditional open, transverse cervical approaches. We demonstrate the efficacy of using TORS for this unusual case, highlighting its versatility and the need to continue to search for opportunities to best use this advancing technology, especially when it can improve patient outcomes.

Laryngeal leishmaniasis: case report of a rare infection.

BACKGROUND: We report a case of laryngeal leishmaniasis in a United Kingdom (UK) resident who lived in Spain for 5 years. METHODS AND RESULTS: The patient presented with a history of hoarseness. He had returned to the UK after spending 5 years in Spain as a retiree. His past medical history includes chronic obstructive pulmonary disease (COPD). Histology of a vocal cord biopsy was suggestive of leishmaniasis and polymerase chain reaction (PCR) test was positive for Leishmania donovani. His use of steroid inhaler probably contributed to his acquiring this extremely unusual infection. He was successfully treated with intravenous amphotericin. CONCLUSIONS: Laryngeal leishmaniasis is an extremely rare infection and is rarely reported in the UK. The ease of travel ensures that many tropical infections may present to UK clinicians.