Impact of the COVID-19 pandemic on acute otolaryngology inpatient activity at a tertiary referral centre: A retrospective analysis.

OBJECTIVE: To determine the impact of the COVID-19 pandemic on acute admissions and inpatient activity at a tertiary referral centre. DESIGN: Retrospective review of coding-based inpatient electronic records. SETTING: An otolaryngology and head and neck surgery department at a major UK trauma and tertiary referral centre. PARTICIPANTS: Otolaryngology patients admitted as an emergency over a period of 10 months pre-COVID19 (01/04/2019-23/01/2020) and 10 months post-COVID19 (01/04/2020-23/01/2021). MAIN OUTCOME MEASURES: Baseline characteristics, admission rates, length of stay (LoS), overall mortality and 30-day mortality. RESULTS: A total of 1620 records were reviewed; (1066 pre-COVID19, 554 post-COVID19). Admissions across all age groups were reduced, with an increase in mean age from 39.88 to 47.4 years (p = .018). LoS remained unchanged (3.85 vs 3.82 days, p = .160). Infection remained the most common presentation, followed secondly by epistaxis which entailed an increased LoS compared to the pre-COVID19 cohort. GP referrals reduced from 18.3% to 4.2% (n = 195 vs n = 23, p < .001) and ED referrals proportionally increased from 71.9% to 85.9% (n = 766 vs n = 476, p < .001). Critical care admissions were higher in the post-COVID19 cohort (OR 1.78 (1.07-2.98) [95% CI], p = .027). There was no significant difference in overall mortality between groups (n = 60, 5.6% vs. n = 33, 6.0%; p = .844). Thirty-day mortality increased from 0.9% (n = 12) pre-COVID19 to 2.3% (n = 13) post-COVID19 (p = .039). CONCLUSIONS: This study demonstrates significant changes and a reduction in acute otolaryngology presentations. Our findings may suggest that sicker, frailer patients were admitted during the pandemic. This study reports the observational effect that the pandemic has had on acute otolaryngology admissions, which may be relevant in addressing unmet care needs in the post-pandemic period.

Importance of the immune system in head and neck cancer.

Head and neck squamous cell carcinoma (HNSCC) are a heterogeneous group of tumors, mainly caused by exposure to cigarette smoke and/or alcohol. In recent years, a virally driven subset of cancers driven by human papillomavirus subtype 16 [HPV-16]) has emerged. Our own data and data from other groups have demonstrated the favorable clinical outcome of HPV-driven oropharyngeal tumors and in both HPV+ and HPV- cancers the importance of a high density of tumor-associated lymphocytes for survival. These data underpin manipulation and activation of the patients' immune system by treatment, and as a result immunotherapy is rapidly taking its place in the management of HNSCC. Here we review the role the immune system in relation to HNSCC and consider the implications these have for HNSCC immunotherapy. Studies to quantify survival benefits and treatment-associated toxicities are ongoing.

Impact of social deprivation on the outcome of major head and neck cancer surgery in England: A national analysis.

BACKGROUND: Socioeconomic status plays an important role in the incidence and prognosis of many cancers. We examined the relationship between social deprivation and clinical outcomes in patients undergoing major surgery for head and neck cancer. METHODS: A retrospective population-based observational study was performed. Patients undergoing head and neck surgical procedures in England between 2002 and 2012 were identified. This totaled 5051 patients in the less socially deprived (LSD) and 7282 in the more socially deprived (MSD) group. RESULTS: MSD patients were younger (61 vs 63) and were more likely to present with hypopharyngeal-laryngeal cancers (41% vs 30%). They had higher burdens of morbidity and more frequently required emergency surgery (odds ratio [OR] 1.74 [95% CI 1.52-1.99]). Following surgery, MSD patients had higher lengths of inpatient stay (OR 1.72 [95% CI 1.57-1.88]) and higher proportions of both inpatient (OR 1.47 [95% CI 1.19-1.82]) and overall mortality (OR 1.34 [95% CI 1.24-1.45]). CONCLUSION: Increasing socioeconomic deprivation is associated with poor health outcomes in patients with head and neck cancer.

Head and Neck Squamous Cell Carcinomas Are Characterized by a Stable Immune Signature Within the Primary Tumor Over Time and Space.

Purpose: Genetic and morphologic heterogeneity is well-documented in solid cancers. Immune cells are also variably distributed within the tumor; this heterogeneity is difficult to assess in small biopsies, and may confound our understanding of the determinants of successful immunotherapy. We examined the transcriptomic variability of the immunologic signature in head and neck squamous cell carcinoma (HNSCC) within individual tumors using transcriptomic and IHC assessments.Experimental Design: Forty-four tumor biopsies from 16 HNSCC patients, taken at diagnosis and later at resection, were analyzed using RNA-sequencing. Variance filtering was used to identify the top 4,000 most variable genes. Principal component analysis, hierarchical clustering, and correlation analysis were performed. Gene expression of CD8A was correlated to IHC analysis.Results: Analysis of immunologic gene expression was highly consistent in replicates from the same cancer. Across the cohort, samples from the same patient were most similar to each other, both spatially (at diagnosis) and, notably, over time (diagnostic biopsy compared with resection); comparison of global gene expression by hierarchical clustering (P ≤ 0.0001) and correlation analysis [median intrapatient r = 0.82; median interpatient r = 0.63]. CD8A gene transcript counts were highly correlated with CD8 T-cell counts by IHC (r = 0.82).Conclusions: Our data demonstrate that in HNSCC the global tumor and adaptive immune signatures are stable between discrete parts of the same tumor and also at different timepoints. This suggests that immunologic heterogeneity may not be a key reason for failure of immunotherapy and underpins the use of transcriptomics for immunologic evaluation of novel agents in HNSCC patients. Clin Cancer Res; 23(24); 7641-9. ©2017 AACR.

Timing of neck dissection in association with transoral surgery: A systematic review.

BACKGROUND: The purpose of this study was to present our evaluation of the importance of timing (early vs synchronous vs delayed) in conjunction with transoral laser surgery for head and neck squamous cell carcinoma (HNSCC). METHODS: Articles addressing surgical management via transoral laser surgery for HNSCC were included for review. RESULTS: Twenty-six articles fulfilled our criteria. The overall 5-year disease-specific survival (DSS) was 75.6% (95% confidence interval [CI], 67.3-83.9) and locoregional control was 87.3% (95% CI, 82.3-92.1), respectively. In the synchronous neck dissection group, the mean locoregional control was 89.9% (95% CI, 84.8-95.1) versus 84.5% (95% CI, 56.2-112.7) for the delayed neck dissection group. From studies in which complications were explicitly given, a bleeding rate of 5.3% (95% CI, 3.6-6.9) was established. There were 11.1% of patients who underwent a tracheostomy. CONCLUSION: There is no evidence to indicate that timing of neck dissection after transoral laser surgery for HNSCC has any effect on overall survival (OS). © 2016 Wiley Periodicals, Inc. Head Neck, 2016 © 2016 Wiley Periodicals, Inc. Head Neck 39: 1020-1032, 2017.

Removal of foreign bodies from children's ears: a nurse-led clinic.

This article presents an account of the rationale for and the introduction of a change in practice. The successful removal of foreign bodies from children's ears requires appropriate skills and experience. While traditionally a role for junior doctors, removal of foreign bodies from children's ears at the ear, nose and throat outpatient clinic at Birmingham Children's Hospital was associated with a low success rate. Therefore, it was proposed that an experienced advanced nurse practitioner would carry out this task in an attempt to improve patient outcomes. A database of outcomes was maintained and compared with those from a doctor-led clinic at Nottingham University Hospitals NHS Trust. The results highlight the benefits of nurse-led removal of foreign bodies from children's ears.