How applicable is the TNM 8 staging for human papillomavirus (HPV) related oropharyngeal squamous cell carcinoma (OPSCC) to a UK population of 106 patients? : A cohort comparison of the TNM 7 and TNM8 staging systems for HPV positive oropharyngeal cancer in a UK population.

PURPOSE: TNM8 introduced a new staging system for HPV positive oropharyngeal squamous cell carcinoma (OPSCC). This study aimed to investigate whether the changes made in TNM8 offer the perceived benefit in prognostication when compared to TNM7 in a specific patient population in the North East of England. METHODS: A retrospective cohort comparison study of all patients with HPV positive OPSCC (n = 106) through the Newcastle Head and Neck MDT between January 2012 to December 2014. Overall survival (OS) and Disease specific survival (DSS) data at 3 years was gathered for both TNM7 and TNM8. Log rank test was used to compare survival curves. Harrell's C-index adjusted for age and smoking status was used to assess prognostic ability of the two staging methods. RESULTS: TNM8 downstages disease (TNM7 stage IV patients n = 74, TNM8 stage IV patients n = 2) but gives a more even distribution of patients across disease stages. Survival for TNM8 stage II and III is similar. In our small cohort, the log-rank test detected differences in OS between stages for both scoring methods (TNM7 p = 0.006, TNM8 p < 0.001) and similarly for DSS (TNM7 p = 0.001, TNM8 p < 0.001). Harrell's C-index was similar for both models for OS (TNM7 0.71, TNM8 0.71) and DSS (TNM7 0.74, TNM8 0.70). CONCLUSION: TNM8 downstages disease and prognosticates well for stage I disease but does not differentiate between stage II and III disease when compared to TNM7. Further adaptation is required to address this to make TNM8 a more accurate prognostic tool.

Trans-oral robotic assisted tongue base mucosectomy for investigation of cancer of unknown primary in the head and neck region. The UK experience.

OBJECTIVES: The diagnosis of cancer of unknown primary (CUP) in head and neck occurs when the treating clinicians have utilised all available diagnostic tests and failed to identify the origin of the disease. There is no agreed consensus on which diagnostic investigations to use, or the order in which to use them in, although broad recommendations exist. Small tumours arising in the tongue base can be below the limits of resolution of conventional diagnostic techniques. Given the difficulty in targeting the tongue base, current practice involves blind random biopsies, which leads to a variable detection rate. Robotically assisted surgical removal of the tongue base, tongue base mucosectomy (TBM) has been shown to improve diagnostic yield. This study reports the diagnostic hit rate for tongue base primaries using this technique. DESIGN: Retrospective case review. SETTING: UK Head and Neck Centres. PARTICIPANTS: Patients presenting as an unknown primary, investigated with clinical examination, PET-CT and palatine tonsillectomy. MAIN OUTCOME MEASURES: The detection of a primary site of head and neck cancer in the otherwise unknown primary tumour. RESULTS: The primary tumour site was identified in the tongue base in 53% (n=17) of patients. In 15 patients the tumour was in the ipsliateral tongue base (88%) while in two cases (12%) the tumour was located in contra lateral tongue base. CONCLUSIONS: Trans-oral robotic assisted TBM raises the possibility of identifying over 50% of tumours that would otherwise be classified as CUP. Identifying these in the contralateral tongue base has implications for treatment planning and outcome.

Baseline swallowing measures predict recovery at 6 weeks after transoral robotic surgery for head and neck cancer.

OBJECTIVES: To explore whether pre-treatment swallowing measures predict swallowing recovery at 6 weeks after transoral robotic surgery (TORS). DESIGN: Prospective cohort study. SETTING: Tertiary care cancer centre in the United Kingdom. PARTICIPANTS: Fifty-one consecutive patients undergoing TORS for head and neck cancer, between April 2013 and February 2015. MAIN OUTCOME MEASURES: Swallowing function assessed by Performance Status Scale (PSS) Normalcy of Diet, timed water swallow test capacity scores (WST) and duration of tube feeding. RESULTS: The primary site distribution was as follows: 21 oropharynx, 8 larynx, 6 mucosectomy and 6 hypopharynx. T stages included 7 staged Tx, 21 T1-T2 tumours and 1 T3 tumour. Moderate-to-severe comorbidity was found in 45/51 patients. Mean PSS score was 83 (sd 27.54); mean WST score was 11.14 (sd 7.97). Most patients (73%) required tube feeding post-operatively, with mean tube feed duration of 18.08 days (sd 17.91); 76% resumed oral intake by 6 weeks. Pre-treatment swallow tests showed moderate negative correlation with tube feeding duration: PSS (rho 0-.430, P = .003); WST (rho 0-.503, P = 0.002). CONCLUSIONS: The majority of TORS patients resume oral intake by 6 weeks. This study shows that impaired swallowing prior to surgery correlates with post-operative duration of tube feeding and strengthens the evidence for the utility of these measures in this clinical setting.

Thyroid gland invasion in total laryngectomy and total laryngopharyngectomy: a systematic review and meta-analysis of the English literature.

BACKGROUND: Advanced laryngeal and hypopharyngeal squamous cell carcinomas carry an inherent risk of invading thyroid parenchyma leading to the incorporation of a hemithyroidectomy or total thyroidectomy as part of a total laryngectomy. In some centres, thyroid gland removal occurs routinely during surgery for T3 and T4 laryngopharyngeal carcinoma. However, the incidence of invasion is low, and therefore, thyroid-sparing surgery must be considered for select cases. OBJECTIVE OF REVIEW: The primary goal of the review is to assess the true incidence of thyroid gland invasion in laryngopharyngeal carcinoma. Utilising this data we aim to identify risk factors and clinical predictors of thyroid gland invasion to facilitate in a more targeted approach in the surgical management of advanced laryngopharyngeal carcinoma. TYPE OF REVIEW: A systematic review and meta-analysis of all published data and review of case series at Newcastle upon Tyne Hospitals (NuTH). SEARCH STRATEGY: MEDLINE (1946-2012) and EMBASE (1980-2012) were searched. EVALUATION METHOD: A single reviewer conducted the systematic review with a follow-up ancestry search. Studies publishing case series of T3 and T4 laryngeal and hypopharyngeal carcinoma treated by total laryngectomy or laryngopharyngectomy and partial or total thyroidectomy, with pathological assessment for thyroid gland invasion rates were selected. Articles published prior to 1977 were excluded due to the advent of whole organ sectioning. RESULTS: The literature search identified 16 studies suitable for inclusion, with 1180 cases. The NuTH case series identified 107 patients. The overall pooled incidence of thyroid gland invasion in 1287 patients is 10.7% (95% CI 7.6-14.2). Patients with primary subglottic tumours (relative risk 7.5; 95% CI 4.3-13.0) and disease extension into the subglottis (relative risk 4.3; 95% CI 2.5-7.2) have a significantly higher relative risk of thyroid gland invasion. Radiorecurrent tumours and hypopharyngeal tumours did not have an increased risk of thyroid gland invasion. CONCLUSION: Advanced laryngeal and hypopharyngeal carcinomas involving the subglottis carry a significantly elevated risk of thyroid gland invasion compared with those that spare this subsite. The overall incidence of thyroid gland invasion is low, and therefore, thyroidectomy should be reserved for cases considered to be at risk as opposed to a being a routine measure for all total laryngectomies.

The 2-week rule for suspected head and neck cancer in the United Kingdom: referral patterns, diagnostic efficacy of the guidelines and compliance.

A retrospective audit of 1079 2-week referrals between 1 January 2004 and 31 December 2006 was undertaken. The aims of this audit were to assess compliance of referrals with Department of Health (DoH) guidelines; the effectiveness of the 2-week referral route in detecting head and neck cancers, and to determine whether this route identified more early stage cancers. Of 1079 2-week referrals, 71.5% conformed to DoH criteria. DoH guidelines were found to have a high sensitivity of 83.9% (75.5-89.7%, 95% CI) for head and neck cancer, but a low positive predictive value of 12.8% (10.5-15.3%) and a specificity of 30.0% (27.2-33.1%). Only 10.9% of 2-week referrals were diagnosed with a head and neck cancer. The cancer detection rate was higher amongst referrals that conformed to DoH guidelines (12.8%) compared to those that did not 6.2%. This was statistically significant (Chi square, p<0.01). The guidelines had a positive likelihood ratio of 1.20 (1.1-1.3), suggesting that there is a minimal increase in the likelihood of head and neck cancer when DoH guidelines are correctly applied. The diagnostic odds ratio (DOR) of the DoH referral criteria is 2.21. Most head and neck cancers were diagnosed via routine referral routes, 2-week referrals contributing to only 21.4% of all head and neck cancers diagnosed during the study period. The 2-week referral route did not identify more early stage cancers.

T-cell lymphoma presenting as acute mastoiditis with a facial palsy.

Isolated T-cell lymphomas affecting only the mastoid are extremely rare. Presentation with oto-neurological signs prior to systemic involvement of a lymphoproliferative disease is also unusual. This is the youngest reported patient with a peripheral T-cell lymphoma with disease isolated only in the mastoid who presented with acute mastoiditis and a complete seventh cranial nerve palsy.

Optimizing the assessment of quality of life after laryngeal cancer treatment.

Reports of the impact of larynx cancer treatment modality on quality of life are conflicting, in part due to varying study methodology. The aims of this study were to (1) provide preliminary comparisons of quality of life following radiotherapy or combination therapy; (2) evaluate a number of measures of quality of life and thereby (3) inform future prospective studies. Thirty-six laryngeal cancer patients, 24 following radiotherapy, 12 following radiotherapy and laryngectomy completed the Functional Assessment of Cancer Therapy (FACT) - General/Head and Neck subscale; Nottingham Health Profile (NHP); and the Hospital Anxiety and Depression scale (HAD), three to 12 months post-treatment. Results showed trends towards a less good quality of life in the combined therapy group over a wide range of outcomes, significant for the disease specific FACT head and neck subscale, NHP emotion (p = 0.04) and isolation (p = 0.027). To the authors' knowledge, however, this is the first demonstration of greater impact of laryngeal cancer on quality of life in younger subjects, who had lower scores among others on emotional wellbeing (p = 0.015) and anxiety (p = 0.035). Younger patients thus appear more likely to need more intensive support through treatment. Many of the physical and psychosocial domains derived from the three tools used were highly correlated. In other words, given the known high morbidity of the disease and its treatment, the selection of tools for head and neck quality of life assessment may be much less important than their universal application.

Tracheostomy, lingular tonsillectomy and sleep-related breathing disorders.

Laser resection of lingual tonsils and formal closure of a tracheostomy improved the airway in a 14-yr-old patient with Down's syndrome. Non-invasive airway support to treat obstructive sleep apnoea was postponed with this treatment. During the anaesthetic a laryngeal mask airway was used to support the airway after lingual tonsillectomy, to assess the suitability of defunctioning the tracheostomy. Laryngeal mask airways assist management of lingual tonsils. Lingual tonsillar hypertrophy can lead to obstructive sleep disorders.

Maternal nutrition and reproduction of daughters in wild house mice (Mus musculus).

Food deprivation after weaning often has greater effects on the reproductive success of females than of males. However, if animals are deprived prenatally (that is, through food deprivation of the mother during gestation), the reproductive success of males may be more adversely affected than that of females because of a disruption in the organizational effects of testosterone in neonatal male mice. The hypotheses that daughters of female mice deprived of food during gestation would have lower reproductive success than control daughters, but that the impact of maternal food deprivation would be lower for daughters than it would be for sons, was tested. There was no difference in the proportion of daughters of food-deprived and control mothers that produced one or two litters. However, the mean number of pups weaned in the second litters by daughters of control females (5.9 +/- 0.57 SEM) was greater than the number of pups weaned by daughters of food-deprived females (4.5 +/- 0.65 SEM). There were no differences in the mean birth or weaning body weights of offspring. Therefore, maternal food deprivation in mice may have a small but significant effect on the reproductive success of daughters. However, studies of sons born to females that were subjected to the same food deprivation protocol indicate that maternal food deprivation may have a much greater effect on the reproduction of sons than on that of daughters.

Bone-anchored hearing aid quality of life assessed by Glasgow Benefit Inventory.

OBJECTIVE/HYPOTHESIS: The bone-anchored hearing aid (BAHA) is a well established mode of treatment and many studies show the audiological benefit, but none has assessed the benefit to the quality of life of patients. This study uses the validated Glasgow Benefit Inventory to quantify the changes in quality of life. STUDY DESIGN: Retrospective questionnaire study. METHODS: Sixty consecutive patients receiving treatment with BAHA were enrolled in the study. The male/female ratio was 1.26 to 1; mean patient age was 45 years. The most common indication was hearing loss secondary to mastoid disease and surgery followed by congenital atresia and chronic discharge from the ear. RESULTS: The response rate was 85%, which is high and adds weight to the results. The general benefit score was +34 (range, +27-+48), which is comparable to middle ear surgery but just below benefit from cochlear implantation. The social benefit was +21 (range, +12-+37) with only +10 (range, +2-+26) for the physical score. This pattern mirrors that reported for other ear interventions. Maximum benefit was noted in patients with congenital atresias followed by discharging mastoid cavities. CONCLUSION: This study is the first to demonstrate significant quality of life benefit from BAHA surgical intervention as measured by the Glasgow Benefit Inventory.

Adenoid cystic carcinoma of the head and neck.

Adenoid cystic carcinoma (ACC) is a rare malignant tumour believed to arise from the epithelial cells of mucous-secreting glands. It is a slow-growing but aggressive tumour with a propensity for perineural invasion. A 10 year review of 45 patients (19 males and 26 females with a median age of 56 years) treated for ACC at a single institution between 1989 and 1999 was performed to analyse factors involved in treatment failure, local control, treatment-related morbidity and mortality. The data collected were treated for survival curves according to the Kaplan-Meier method and the log-rank test was used to assess the statistical significance of the various groups. The overall survivals at 3 years and 5 years were 71% and 65%, respectively, while the disease-free survivals at 3 years and 5 years were 73% and 63% respectively. Out of the 45 patients, only six had local recurrences, yielding an 87% locoregional freedom from relapse; 16 patients (35.6%) developed distant metastases, with the lung (8/16) being the commonest site. Patients treated for tumours of the nose and paranasal sinuses experienced more morbidity than those with tumours at other sites. Positive margins, perineural invasion and solid histology of ACC were associated with increased morbidity and treatment failure. Patients treated with combined therapy did better than those who underwent a single treatment modality.

Social dominance rank and accessory sex glands in wild adult male house mice born to food-deprived mothers.

Food deprivation after weaning often has greater effects on the reproduction of females than males. However, if animals are deprived prenatally (i.e., through deprivation of the mother during gestation), the reproduction of males may be more negatively impacted because it may decrease their ability to compete with other males and their attractiveness to females. We tested the predictions that adult sons of females that are food-deprived during gestation would tend to lose agonistic encounters with sons of well-nourished (control) females and would have smaller accessory sex glands as well. Sons of control mothers were more frequently dominant to sons of deprived mothers. They also had heavier vesicular-coagulating gland complexes and tended to have heavier preputial glands. However, among males that had not been tested for social dominance rank, there were no such differences in accessory gland weights. These data indicate that maternal food deprivation affects sons only if they engage in agonistic encounters. These effects may be due to a disruption of the organizational effects of testosterone that occur in neonatal male mice and they are likely to have a strong negative impact on the reproduction of the sons of deprived mothers.

Bone-anchored hearing aid: quality of life assess by glasgow benefit inventory

INTRODUCTION: The bone-anchored hearing aid (BAHA) uses the system of osseointegration described by Branemark. It is a well-established mode of treatment and many studies show the audiological benefit, but none have assessed the benefit to the quality of life of patients who underwent this surgical intervention. This study uses the validated Glasgow Benefit Inventory (GBI) to quantify the changes in quality of life. The GBI is a specific patient-orientated questionnaire designed to look at the changes in health status secondary to an ORL intervention.1 The GBI gives an overll scorek, but also subscores of general, social and physical benefits. METHOD: Sixty consecutive BAHA patients were enrolled in the study. The male: female ratio was 1 : 26, with a mean age of 45 years. The most common indication was hearing loss secondary to mastoid disease/surgery followed by congenital atresia and chronically discharging ear. The mean bone conduction of the better ear was 19 dB and the mean conductive loss across the speech frequencies was 58 dB. Only patients who were fitted with the classic model were included in the study. RESULTS: The response rate was > 70%, which is high and adds weight to the results. The general benefit score was + 40 which is comparable to middle ear surgery, but just below benefit from chochlear implantation. The social benefit was + 27 with only + 10 for the physical score. This pattern mirrors that reported for other ear interventions. CONCLUSION: This paper is the first to demonstrate that there is significant quality of life benefit from BAHA surgical intervention as measured by the GBI.

Leiomyomatous hamartoma of the posterior tongue: a case report.

A case of a rare leiomyomatous hamartoma arising in the posterior tongue of a sixteen-month-old male is reported. There has been no recurrence following simple excision and presenting symptoms of choking on swallowing have resolved. Most other leiomyomatous hamartomas in the upper aerodigestive tract have been reported in Japanese patients and have involved the maxillary gingiva and hard palate.

Premating and gestational effects of maternal nutrition on secondary sex ratio in house mice.

Pregnant female house mice maintained on a consistent low-food diet give birth to a lower proportion of males than do control females fed ad libitum. Because house mice may experience daily fluctuations in food availability, we tested whether intermittent feeding during gestation influences the sex ratio of the offspring. In addition, we tested whether intermittent feeding has asymmetrical effects on the masses of adult male and female offspring. Females deprived of food every other day one week before mating and those deprived every third day during gestation produced a lower proportion of males than did control (fed ad libitum) females. Males born to females that were deprived of food during gestation had the same body mass at birth as males born to control females, but as adults their mass was lower than that of control males. There were no differences in the birth or adult body masses of female offspring. Because males of low body mass may have relatively low lifetime reproduction, our results support the Trivers-Willard model of sex ratio variation.

A study of haemostasis following tonsillectomy comparing ligatures with diathermy.

The use of diathermy to achieve haemostasis after tonsillectomy remains controversial. We have reviewed the English language literature, and found no convicting evidence that diathermy is any more likely to cause post-operative haemorrhage than the use of ligatures. The results of a prospective, randomized study of 1036 consecutive tonsillectomies are presented. No significant difference was found in post-operative haemorrhage rates when either diathermy or ligatures were used. Diathermy was found to reduce operating time compared to ligatures. The possibilities for day-case tonsillectomy are discussed.