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BackgroundDelays to timely admission from emergency departments (EDs) are known to harm patients.ObjectiveTo assess and quantify the increased risk of death resulting from delays to inpatient admission from EDs, using Hospital Episode Statistics and Office of National Statistics data in England.MethodsA cross-sectional, retrospective observational study was carried out of patients admitted from every type 1 (major) ED in England between April 2016 and March 2018. The primary outcome was death from all causes within 30 days of admission. Observed mortality was compared with expected mortality, as calculated using a logistic regression model to adjust for sex, age, deprivation, comorbidities, hour of day, month, previous ED attendances/emergency admissions and crowding in the department at the time of the attendance.ResultsBetween April 2016 and March 2018, 26 738 514 people attended an ED, with 7 472 480 patients admitted relating to 5 249 891 individual patients, who constituted the study’s dataset. A total of 433 962 deaths occurred within 30 days. The overall crude 30-day mortality rate was 8.71% (95% CI 8.69% to 8.74%). A statistically significant linear increase in mortality was found from 5 hours after time of arrival at the ED up to 12 hours (when accurate data collection ceased) (pConclusionsDelays to hospital inpatient admission for patients in excess of 5 hours from time of arrival at the ED are associated with an increase in all-cause 30-day mortality. Between 5 and 12 hours, delays cause a predictable dose–response effect. For every 82 admitted patients whose time to inpatient bed transfer is delayed beyond 6 to 8 hours from time of arrival at the ED, there is one extra death.

The COVID‐19 pandemic has disproportionately affected more vulnerable populations, including those living with dementia. Over 50 million individuals worldwide are living with Alzheimer's disease (AD) or other dementia, and it is crucial to continue the fight against the condition during the global pandemic. Since the start of mandated lockdowns in March 2020, charity and non‐profit organizations that fund AD and related dementia research continue to respond to the needs of the AD research community, ensuring the momentum continues and accelerates. Members of the International Alzheimer's and Related Dementia Research Funder Consortium, a group of nearly 40 funding organizations that informally convene throughout the year to share updates and information, have taken a number of steps to ensure the continued support of the research community. Even during times of uncertainty, it is essential that the field moves forward to uncover preventions, diagnoses, and treatments for these diseases that affect many millions globally.

ObjectiveThe coronavirus disease 2019 pandemic resulted in the cessation of elective surgery. The continued provision of complex head and neck cancer surgery was extremely variable, with some UK centres not performing any cancer surgery. During the pandemic, Guy's and St Thomas’ NHS Foundation Trust received high numbers of coronavirus disease 2019 admissions. This paper presents our experience of elective complex major head and neck cancer surgery throughout the pandemic.MethodsA head and neck cancer surgery hub was set up that provided a co-ordinated managed care pathway for cancer patients during the pandemic; the Guy's Cancer Centre provided a separate, self-enclosed coronavirus-free environment within the hospital campus.ResultsSixty-nine head and neck cancer patients were operated on in two months, and 13 patients had a microvascular free tissue transfer. Nosocomial infection with coronavirus disease 2019 was detected in two cases (3 per cent), neither required critical care unit admission. Both patients made a complete recovery and were discharged home. There were no deaths.ConclusionPerforming major head and neck surgery, including free flap surgery, is possible during the pandemic; however, significant changes to conventional practice are required to achieve desirable patient outcomes.

Purpose To evaluate whether the 8th staging system is a better discriminator of overall survival (OS) than the 7th edition for oropharyngeal cancer patients after definitive (chemo)radiotherapy (CRT). Material and methods Data from oropharyngeal cancer patients treated with CRT with curative intent between 2010 and 2016 at Guy’s and St Thomas’ Hospitals were reviewed. Human papillomavirus (HPV) status was ascertained in all cases. Patients were staged using the 7th edition and the 8th edition TNM staging system. Demographics, tumor characteristics and treatment response data were included in univariate and multivariate analysis for OS. OS and disease-free survival (DFS) were estimated using the Kaplan-Meier method. In addition, a multivariate survival Cox regression analysis of several clinical variables was performed. Results A total of 273 patients were included. The median follow-up was 4.7 years. Overall 63 patients died. In multivariate analysis, HPV status, complete response at 3 months and ≤21 units/week alcohol were prognostic for OS. For the entire cohort, the 5-year OS and DFS rates were 78.1% (95% confidence interval CI 0.719–0.831) and 73.9% (95% CI 0.677–0.792), respectively. Better stratification of OS and DFS was recorded by 8th edition for the entire cohort. In HPV-positive cases, risk stratification based on tobacco smoking and nodal stage resulted in statistically higher discrimination in OS rates (5-year OS 90.7% in low risk patients and 84.6% in intermediate risk, p = 0.05) and DFS rates (5-year DFS 91.5% in low risk and 76.1% in intermediate risk, p = 0.001). Conclusion The 8th edition TNM staging system provides better OS stratification in oropharyngeal cancer after definitive CRT compared with the 7th edition. Other clinical variables, such as complete response at 3 months, alcohol and tobacco smoking, should also be considered in future classifications as they provide additional risk stratification information in both HPV-positive and HPV-negative disease.

Objectives: To validate the use of neck dissection as part of the management of parotid carcinoma. Design, setting, participants: Retrospective pathological and clinical data were retrieved from the Guy’s and St Thomas’ Hospital Head and Neck pathology archive for all primary parotid carcinoma resected at the centre between 1992 and 2014. Main outcome measure: The main outcome measure was the incidence of metastatic disease. Results: 54 of the 82 cases identified underwent a neck dissection. Nodal metastases were detected in 10 cases of carcinomas ex-pleomorphic adenoma (high grade, invasive), 2 salivary duct carcinomas, 1 adenocarinoma not otherwise specified (NOS) (high grade), 1 adenoid cystic carcinoma and 1 acinic cell carcinoma (high grade). No metastases were found in cases of acinic cell carcinoma (low grade), mucoepidermoid carcinoma (low grade), epithelial-myoepithelial carcinoma and non-invasive carcinoma ex-pleomorphic adenoma. Conclusions: The findings of this study support the use of routine neck dissection in treating carcinoma ex-pleomorphic adenoma (high grade, invasive), salivary duct carcinoma, adenocarcinoma NOS (high grade), adenoid cystic carcinoma and acinic cell carcinoma (high grade).

OBJECTIVE Management of recurrent laryngeal cancer presents a major challenge, and salvage laryngectomy is complicated by previous oncologic treatments. Thyroidectomy as part of salvage laryngectomy adds a nonnegligible degree of morbidity. The purpose of this study is to assess the rate of thyroid gland invasion in patients undergoing salvage laryngectomy to determine relevant predictive factors. STUDY DESIGN Case series with chart review. SETTING Department of Otorhinolaryngology, Head and Neck Surgery, Guy's Hospital, London, United Kingdom. METHODS A retrospective review of patients undergoing salvage laryngectomy between 2009 and 2019 was undertaken. Preoperative cross-sectional imaging and histopathological analysis were performed to define evidence and predictors of thyroid gland invasion (TGI). RESULTS Fifty-one patients had salvage laryngectomy. Histological evidence of TGI was found in 4 patients (7.8%). No significant relationship was found between histological TGI and subsite of primary carcinoma, degree of differentiation, T staging, or radiological TGI. Preoperative computed tomography had a high negative predictive value for TGI. CONCLUSION Thyroidectomy should be carefully considered in patients undergoing salvage laryngectomy, and its extent should be defined on an individual basis. Total thyroidectomy should not routinely be performed in salvage laryngectomy or pharyngolaryngectomy in patients with no preoperative radiological evidence of TGI on cross-sectional imaging, unless there is intraoperative evidence of TGI.

Oncocytic sialolipoma is a very rare tumor of which only three cases have been reported. This entity is considered to be a variant of sialolipoma which harbours oncocytic nodules within a well-circumscribed lipomatous mass. We report a parotid mass in 73-year-old female that was difficult to diagnose in imaging and on biopsy. Ultrasonography and MRI demonstrated a mass with features thought to be consistent with lipoma. Twice needle core biopsies were performed. Both were indefinite for diagnosis. The first report favoured a lipoma and the second report suggested the lesion represented oncocytic hyperplasia or an oncocytoma. The microscopic examination of the excised surgical specimen demonstrated typical features of oncocytic sialolipoma, characterized by a predominately lipomatous component, sparse normal-appearing salivary gland tissue and multiple oncocytic nodules. This is the second case of oncocytic sialolipoma reported to occur in the parotid gland.

Objective:To describe the approach and outcomes from two cancer centres in Southern and Northern Europe during the first wave of coronavirus disease 2019 (COVID-19) of patients with head and neck cancer (HNC).Methods:Data collection was performed on a retrospective cohort of patients surgically treated for primary HNC between March and May 2020, using data from two tertiary hospitals: the European Institute of Oncology (Milan) and Guy’s & St Thomas’ NHS Foundation Trust (London).Results:We included 77 patients with HNC. More patients with COVID-19 were taking angiotensin-converting enzyme (ACE) inhibitors and had Clavien-Dindo Classification grade I compared to negative patients, respectively (60% vs 22% [ p = 0.058] and 40% vs 8% [ p = 0.025]). Multivariate logistic regression analyses confirmed our data ( p = 0.05 and 0.03, respectively). Sex and age were statistically significantly different ( p = 0.05 and 63 years: 69.44% vs 29.27%).Conclusions:This study presents a large cohort of patients with HNC with nasopharyngeal swab during the first peak of the COVID-19 pandemic in Europe. Patients with HNC with COVID-19 appeared more likely to develop postsurgical complications and to be taking ACE inhibitors. The preventive measures adopted guaranteed the continuation of therapeutic surgical intervention.

Head and neck squamous cell carcinoma (HNSCC) has a significant impact on patients' quality of life and treatment can be associated with severe morbidity. Following completion of treatment, patients are followed up in order to detect potentially salvageable recurrences and to manage long-term toxicities. In recent years, a growing interest has been given to risk stratified follow-up interventions to prevent and detect recurrences and manage treatment toxicities in other tumour sites as well as to transfer some of that care to community services. We review the literature for HNSCC and propose a risk stratified follow up protocol to address these issues and assist clinicians in decision making. A shift in patterns of care is suggested in order to provide a basis to improve care for HNSCC patients after complete response to primary treatment.

Summary Background Due to supply chain disruption, the COVID-19 pandemic has caused severe shortages in personal protective equipment for health care professionals. Local fabrication based on 3D printing is one way to address this challenge, particularly in the case of products such as protective face shields. No clear path exists, however, for introducing a locally fabricated product into a clinical setting. Methods We describe a research protocol under Institutional Review Board supervision that allowed clinicians to participate in an iterative design process followed by real-world testing in an emergency department. All designs, materials used, testing protocols, and survey results are reported in full to facilitate similar efforts in other clinical settings. Findings Clinical testing allowed the incident command team at a major academic medical center to introduce the locally fabricated face shield into general use in a rapid but well-controlled manner. Unlike standard hospital face shields, the locally fabricated design was intended to be reusable. We discuss the design and testing process and provide an overview of regulatory considerations associated with fabrication and testing of personal protective equipment, such as face shields. Conclusions Our work serves as a case study for robust, local responses to pandemic-related disruption of medical supply chains with implications for health care professionals, hospital administrators, regulatory agencies, and concerned citizens in the COVID-19 and future health care emergencies. Funding : This work was supported by the Harvard MIT Center for Regulatory Sciences, NIH/NCI grants U54-CA225088 and T32-GM007753, and the Harvard Ludwig Center. M.-J.A. is a Friends of McGovern Graduate Fellow., Context and Significance The COVID-19 pandemic has disrupted medical device supply chains and caused severe shortages in personal protective equipment needed for infection control. To mitigate these shortages, local companies and maker communities have come together to use 3D printing and public domain designs to fabricate protective equipment, such as face shields. However, using unapproved versions of regulated protective equipment in hospitals is problematic. The authors describe the use of a research protocol supervised by an ethical review panel to test a 3D-printed face shield in the emergency department of a major academic medical center and deploy the face shield widely. They make available designs, materials, testing protocols, and provider surveys so that others can reproduce their efforts and make pandemic response more resilient., Graphical Abstract, Highlights An investigational medical device protocol was used to test a 3D-printed face shield Health care providers preferred our design over hospital-supplied face shields The face shield is reusable, making it ideal for use in COVID-19 response Designs and protocols are provided for others to use at their own institutions, In response to pandemic-related shortages in medical supplies, the authors use an institutional review board-supervised research protocol to clinically test a 3D-printed face shield in a hospital emergency department. This allowed a major academic medical center to incorporate locally manufactured personal protective equipment into the care of COVID-19 patients.

ObjectiveThe global coronavirus disease 2019 (COVID-19) pandemic has necessitated rapid alterations to diagnostic pathways for head and neck cancer patients that aim to reduce risk to patients (exposure to the hospital environment) and staff (aerosol-generating procedures). Transoral fine needle aspiration cytology offers a low-risk means of rapidly diagnosing patients with oral cavity or oropharyngeal lesions. The technique was utilised in selected patients at our institution during the pandemic. The outcomes are considered in this study.MethodDiagnostic outcomes were retrospectively evaluated for a series of patients undergoing transoral fine needle aspiration cytology of oral cavity and oropharyngeal lesions during the COVID-19 pandemic.ResultsFive patients underwent transoral fine needle aspiration cytology, yielding lesional material in 100 per cent, with cell blocks providing additional information. In one case, excision biopsy of a lymphoproliferative lesion was required for final diagnosis.ConclusionTransoral fine needle aspiration cytology can provide rapid diagnosis in patients with oral cavity and oropharyngeal lesions. Whilst limitations exist (including tolerability and lesion location), the technique offers significant advantages pertinent to the COVID-19 era, and could be employed in the future to obviate diagnostic surgery in selected patients.

Introduction Treating locally advanced laryngeal squamous cell carcinoma (LSCC) with primary chemoradiotherapy (CRT) can preserve the larynx without compromising survival. However, whether this is associated with good functional outcomes remains up for debate. The aim of this study was to evaluate survival and functional outcomes in patients with locally advanced LSCC treated with primary CRT. Methods We retrospectively analysed data from all consecutive patients with stage III-IV (M0) disease treated with primary CRT between April 2010 and December 2017. Study endpoints were overall survival (OS), disease free survival (DFS), laryngectomy free survival (LFS), laryngo-oesophageal dysfunction free survival (LEDFS) and functional preservation rates. Prognostic factors were assessed by univariate and multivariate analysis. Results 69 consecutive patients treated with primary CRT were analysed. All patients were treated with Intensity Modulated Radiotherapy (IMRT). 29 patients received induction chemotherapy prior to CRT. 60 patients (87%) received concomitant platinum-based chemotherapy, and 9 (13%) concomitant Cetuximab. The median follow-up was 57 months (range 4-96). The completion rate for prescribed RT was 98.5%. The 2- and 5 year OS rates were 81.1% and 52.1%. For patients with T3 disease, the 2- and 5 year OS rates were 82.4% and 61.6%. Positive nodal status, N2b-N3 nodal staging, or stage IV disease were associated with poor OS on univariate, but not multivariate, analysis. Functional preservation was 69.1% at 2 years in all patients alive (68.1% in T3 patients). The 2-year LEDFS rate was 52%. The 2- and 5-year LFS rates was 72.4% and 43.3% respectively. There was no significant difference in LFS rate between primary tumour localization, baseline laryngeal fixation or cartilage invasion. Conclusion Our study illustrates survival and functional outcomes in line with contemporary studies. The survival and function preservation rates suggest that carefully selected patients with locally advanced LSCC can successfully be treated with larynx-preserving primary CRT.

Due to supply chain disruption, the COVID-19 pandemic has caused severe shortages in personal protective equipment (PPE) for health care professionals. Local fabrication based on 3D printing is one way to address this challenge, particularly in the case of simple products such as protective face shields. As a consequence, many public domain designs for face shields have become available. No clear path exists, however, for introducing a locally fabricated and unapproved product into a clinical setting. In a US health care setting, face shields are regulated by the Food and Drug Administration (FDA); similar policies exist in other countries. We describe a research protocol under which rapid iteration on an existing design, coupled with clinical feedback and real-world testing in an emergency department, allowed a face shield to be implemented by the members of the incident command team at a major academic medical center. We describe our design and testing process and provide an overview of regulatory considerations associated with fabrication and testing of face shields and related products. All designs, materials used, testing protocols, and survey results are reported in full to facilitate the execution of similar face shield efforts in other clinical settings. Our work serves as a case study for development of a robust local response to pandemics and other health care emergencies, with implications for healthcare professionals, hospital administrators, regulatory agencies and concerned citizens.

Objectives Very little is known about those who receive a negative (benign) result after referral for suspected cancer, including their risk for future cancer. This service evaluation aimed to track the occurrence of cancer (of any type) in the 5 years after an appointment for suspected head and neck cancer (HNC) and compare to those referred to hospital for routine ear nose and throat reasons. Materials & methods Patient identifiers of referrals to one hospital Trust with either a) suspected HNC cancer on a two week wait (TWW) pathway, or b) routine ear, nose & throat problems, were linked with the National Cancer Registry data to determine the occurrence, site and stage of subsequent cancer. Results 10,314 patients were referred between 2009 and 2011. Cancer occurrence in the 5 years after their appointment for those who had initially received a negative diagnosis, was 4.0% for those referred via TWW and 2.1% for those routinely referred. Lung cancer was the most common subsequent cancer site in the TWW group. Those in higher age groups, those with previous cancer, and those referred via the TWW pathway were significantly more likely be diagnosed with subsequent cancer. Conclusion Given the increased risk of subsequent cancer, it could be beneficial to improve the service provision (e.g. advice on screening attendance, ways to reduce risk, advice on timely help-seeking for symptoms of cancer) at the point of a negative diagnosis on the TWW pathway, especially in older patients and those with a previous diagnosis of cancer. Objectives: Very little is known about those who receive a negative (benign) result after referral for suspected cancer, including their risk for future cancer. This service evaluation aimed to track the occurrence of cancer (of any type) in the 5 years after an appointment for suspected head and neck cancer (HNC) and compare to those referred to hospital for routine ear nose and throat reasons. Materials & methods: Patient identifiers of referrals to one hospital Trust with either a) suspected HNC cancer on a two week wait (TWW) pathway, or b) routine ear, nose & throat problems, were linked with the National Cancer Registry data to determine the occurrence, site and stage of subsequent cancer. Results: 10,314 patients were referred between 2009 and 2011. Cancer occurrence in the 5 years after their appointment for those who had initially received a negative diagnosis, was 4.0% for those referred via TWW and 2.1% for those routinely referred. Lung cancer was the most common subsequent cancer site in the TWW group. Those in higher age groups, those with previous cancer, and those referred via the TWW pathway were significantly more likely be diagnosed with subsequent cancer. Conclusion: Given the increased risk of subsequent cancer, it could be beneficial to improve the service provision (e.g. advice on screening attendance, ways to reduce risk, advice on timely help-seeking for symptoms of cancer) at the point of a negative diagnosis on the TWW pathway, especially in older patients and those with a previous diagnosis of cancer.

Few studies examine techniques of surgical resection for scalp malignancies to ensure clear margins. We present a case series utilizing outer cortex removal in patients without evidence of bony or pericranial invasion. A retrospective casenote review is presented of three cases treated in a tertiary Head and Neck Cancer Centre. An outer table removal approach was utilized based on the absence of bony involvement either on pre-operative imaging or from intra-operative findings. All cases underwent an outer table drilldown procedure. Tumour histology included high grade carcinoma of unknown origin, malignant cylindroma and squamous cell carcinoma. Complete excisions with adequate deep margins were achieved in 100% cases. Overall disease-free survival was 66.6% and local control rate was 100%. This technique allows a high degree of local control, notably at the deep margin. There is little morbidity and it avoids the complications associated with full thickness calvarial resection.

The purpose of this study was to review our recent experience of salvage surgery, comparing larynx and oropharynx recurrence patterns. A single centre, retrospective review of salvage surgery for recurrent head and neck cancer including patients between 2008 and 2016. 61 patients were identified, 36 underwent salvage laryngectomy and 25 received oropharyngeal resections. The median overall survival of oropharyngeal recurrent tumors was 26 months (95% CI 15–118 months) and for laryngeal tumors was 23 months (95% CI 11–38 months), p = 0.1008. There was a significant overall survival benefit in patients with negative resection margin. The median survival in the negative margin group was 38 months (95% CI 25–108 months) compared to the positive margin group, 9 months (95% CI 5–15 months), p

The tumours of the parotid accessory lobe may present with significant challenges to the clinicians due to their rarity, presenting with diagnostic difficulties as well as difficult decision-making in terms of surgical approach. We retrospectively analysed 8 cases of accessory parotid lobe tumours treated in our unit. The presenting symptom was a mass in all cases present in the peri-parotid region with duration ranging from 6 weeks to 2 years. All cases were investigated with ultrasound-guided fine needle aspiration cytology (FNAC). Various surgical approaches were adopted that included standard cervico-facial (n = 4), trans-oral (n = 3) and cervical (n = 1) incision approach. The rate of early post-operative facial nerve weakness was 37.5% (n = 3). There were no cases of tumour recurrence. Any lump not typical of a parotid lump but close to the parotid region should be treated with a high degree of suspicion to exclude an accessory lobe tumour. A full work up with US-guided FNAC is recommended prior to definitive treatment. Although a standard cervico-facial incision approach is recommended in most cases, other direct approaches may also be considered depending on the location of the tumour. We present our experience of these tumours providing practical tips on diagnosis and surgical management.

Background:Sarcoma of the head and neck is a rare condition that poses significant challenges in management and often requires radical multimodality treatment.Objectives:This study aimed to analyse current clinical presentation, evaluation, management dilemmas and oncological outcomes.Methods:Computer records and case notes were analysed, and 39 patients were identified. Variables were compared using Pearson's chi-square test and the log-rank test, while survival outcomes were calculated using the Kaplan–Meier method.Results:The histopathological diagnosis was Kaposi sarcoma in 20.5 per cent of cases, chondrosarcoma in 15.3 per cent and osteosarcoma in 10.2 per cent. A range of other sarcomas were diagnosed in the remaining patients. The site of disease was most commonly sinonasal, followed by the oral cavity and larynx.Conclusion:Wide local excision with clear resection margins is essential to achieve local control and long-term survival. There is a need for cross-specialty collaboration in order to accrue the evidence which will be necessary to improve long-term outcomes.

Objectives To analyze clinical features, dosimetric parameters, and outcomes of osteoradionecrosis (ORN). Study Design Thirty-six patients with ORN who had been previously treated with radiotherapy (RT) were retrospectively identified between January 2009 and April 2014. ORN volumes were contoured on planning computed tomography (CT) scans. Near maximum dose (D2%), minimum dose (Dmin), mean dose (Dmean), and percentage of bone volume receiving 50 Gy (V50) were examined. Clinical and dosimetric variables were considered to compare ORN resolution versus ORN persistence. Results Median interval time from end of RT to development of ORN was 6 months. Of the ORN cases, 61% were located in the mandible. Dmean to affected bone was 57.6 Gy, and 44% had a D2% 65 Gy or greater. Smoking was associated with ORN persistence on univariate analysis, but no factors were found to impact ORN resolution or progression on logistic regression. Conclusions Prevention strategies for ORN development should be prioritized. Dose-volume parameters could have a role in preventing ORN.

Summary We present the case of unanticipated airway ignition during hard palate biopsy. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) and monopolar diathermy were utilised for the procedure, during which an arc arose from the diathermy tip to a titanium implant, causing a brief ignition on the monopolar diathermy grip. This case highlights the need for maintained awareness of fire risk when using diathermy in the presence of THRIVE during airway surgery.

AIM: To analyse the maximum standardised uptake value (SUVmax) ratio between tonsils in patients with and without tonsillar carcinoma to determine useful diagnostic thresholds.MATERIALS AND METHODS: Positron-emission tomography (PET)/computed tomography (CT) examinations of patients with suspected head and neck squamous cell carcinoma (SCC) and controls from April 2013 to September 2016 were reviewed retrospectively. Tonsillar SUVmax ratios (ipsilateral/contralateral for malignant tonsils, maximum/minimum for patients without [controls]) were calculated and used to construct a receiver operating characteristic (ROC) curve.RESULTS: Twenty-five patients had tonsillar carcinoma (mean SUVmax ratio of 2, range 0.89-5.4) and 86 patients acted as controls (mean SUVmax ratio of 1.1, range 1-1.5). Using the ROC, the most accurate SUVmax ratio for identifying malignancy was >1.2 (77% sensitivity, 86% specificity). A potentially more clinically useful SUVmax ratio is ≥1.6 with 62% sensitivity and 100% specificity.CONCLUSION: An SUVmax ratio between tonsils of ≥1.6 is highly suspicious for SCC and could be used to direct site of biopsy. Some malignant tonsils had normal FDG uptake; therefore, PET/CT should not be used to exclude tonsillar cancer. Minor asymmetrical uptake is frequently seen in non-malignant tonsils and does not necessarily require further investigation. Due to the single centre nature of this study and the recognised variation in SUV measurements between PET scans, other centres may need to develop their own cut-offs.

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BACKGROUND Mucoceles occur as a result of accumulation and retention of mucous secretions in a paranasal sinus and are uncommon in the pediatric age group. Persistent or intermittent closure of its ostium through a variety of causes, including previous surgery, is implicated in etiology. The authors report 2 cases of frontoethmoidal mucocele that followed box osteotomies for the treatment of orbital dystopia, with medical literature review and discussion of possible causal factors and events. METHODS Case histories and radiological imaging are presented on 2 patients presenting with frontoethmoidal mucoceles following craniofacial surgery. Both had transcranial craniofacial techniques where all orbital walls and globe are moved en bloc as a "box." RESULTS Patient 1, a 12-year-old male patient with Crouzon syndrome, developed mucoceles within 18 months of monobloc distraction surgery and box osteotomies. This was successfully marsupialized with a combined external and endoscopic surgical approach. The second patient, a 15-year-old boy with previously corrected right-sided facial cleft, developed mucocele 9 years following box osteotomies; this was successfully managed by endoscopic drainage. Of 3 other patients having similar box osteotomies in our unit, no other mucoceles were noted as complications. CONCLUSIONS Mucoceles are a rare complication of craniofacial surgery, and literature review confirms a paucity of reports. Only 1 case has previously been alluded to of mucocele complicating box osteotomy for orbital dystopia. Our 2 cases illustrate and highlight a successful management approach in a multidisciplinary craniofacial unit.

OBJECTIVES To analyse survival and toxicity outcomes in patients treated with primary intensity-modulated radiotherapy (IMRT) for oropharyngeal squamous cell carcinoma (OPSCC) in the era of routine human papilloma virus (HPV) testing. DESIGN Single-institution case series. SETTING Tertiary Head and Neck Cancer Unit. PARTICIPANTS A total of 186 patients received IMRT (+/- chemotherapy) for radical primary treatment of OPSCC between March 2010 and December 2013. HPV status was available for 88% of cases. Median radiation dose was 65 Gy in 30 daily fractions. 90% of stage III/IV patients received concurrent chemotherapy or cetuximab. MAIN OUTCOME MEASURES Overall, disease-free and disease-specific survival; rates of late xerostomia and dysphagia. RESULTS A total of 177 patients completed treatment (Stage I/II: 23; Stage III/IV: 154), with median follow-up of 26 months. Estimated 3-year overall survival (OS), disease-free survival (DFS) and disease-specific survival (DSS) rates were 77.2% (70.5-83.9), 72.3% (65.4-79.2) and 80.2% (74.1-86.3). Estimated 3-year OS, DFS and DSS for HPV-positive patients were 90.9% (85.2-96.6), 87.9% (81.4-94.4) and 91.8% (86.3-97.3). A previously identified risk stratification method was validated, showing improved OS for low-risk over high-risk patients (HR 0.09, P < 0.001). The 2-year feeding tube retention rate was 6%, and 2-year grade ≥2 xerostomia rate was 38% (23% if mean contralateral parotid dose

Background:The prevalence of occult neck metastasis in patients undergoing salvage total laryngectomy remains unclear, and there is controversy regarding whether elective neck dissection should routinely be performed.Method:A retrospective case note review of 32 consecutive patients undergoing salvage total laryngectomy in a tertiary centre was performed, in order to correlate pre-operative radiological staging with histopathological staging.Results:The median patient age was 61 years (range, 43–84 years). With regard to lymph node metastasis, 28 patients were pre-operatively clinically staged (following primary radiotherapy or chemoradiotherapy) as node-negative, 1 patient was staged as N1, two patients as N2c and one patient as N3. Fifty-two elective and seven therapeutic neck dissections were performed. Pathological analysis up-staged two patients from clinically node-negative (following primary radiotherapy or chemoradiotherapy) to pathologically node-positive (post-surgery). No clinically node-positive patients were down-staged. More than half of the patients suffered a post-operative fistula.Conclusion:Pre-operative neck staging had a negative predictive value of 96 per cent. Given the increased complications associated with neck dissection in the salvage setting, consideration should be given to conservative management of the neck in clinically node-negative patients (staged following primary radiotherapy or chemoradiotherapy).

Carcinoma of unknown primary of the neck (CUP) is a metastasis presenting in one or more cervical lymph nodes, with no primary mucosal site identified. Retrospective case notes review of 25 consecutive patients (median age 55, 72% males) diagnosed as CUP who underwent neck dissection in a UK tertiary referral comprehensive cancer centre between 2000 and 2011. Median follow-up was 33 months. Nineteen patients underwent comprehensive neck dissections (six extended), six patients had selective neck dissection. Five year disease specific survival and regional recurrence free survival were 76 and 80% respectively. The overall rate of occult disease (disease not identified on preoperative evaluation, but found on histopathologic examination) was 8%, with rates of 0% in level I and 6% in level V. Our study suggests that in patients without preoperative evidence of disease in levels I or V selective neck dissection might be considered as an option, to facilitate preservation of the submandibular gland and accessory nerve without compromising oncological outcome. Larger studies should be performed before a change in practice can be advised.

The success of high pressure source ventilation is entirely dependent upon upper airway patency to facilitate passive expiration and prevent increasing intrathoracic pressure and its associated deleterious sequelae. Distortions in airway anatomy may make passive expiration inadequate or impossible in some patients.

Pre-operative tracheostomy (POT) to secure a critical airway up to several weeks before definitive laryngectomy in patients with laryngeal cancer has been proposed as a risk factor for poor oncologic outcome. Few modern papers, however, examine this question. The aim of this study is therefore to determine whether POT affects oncologic outcome with an emphasis on stomal/peristomal recurrence. This is a retrospective case note review of 60 consecutive patients undergoing curative primary total laryngectomy (TL) for advanced laryngeal squamous cell carcinoma (SCC). Demographic, staging, treatment and outcome data were collected. 27/60 (45 %) patients had POT and 33/60 did not. No patient underwent laser debulking. Median age was 62 years (39-90 years) and median follow-up of survivors was 31 months. 5-year overall survival (OS), disease-specific survival (DSS) and local recurrence-free survival (LRFS) of patients undergoing POT versus no POT was 28 versus 39 % (p = 0.947), 55 versus 46 % (p = 0.201) and 96 versus 88 % (p = 0.324) respectively. No statistically significant difference in OS, DSS and LRFS was found between patients undergoing POT and those not. Despite the relatively small case series, this evidence should reassure surgeons without the ability to perform trans-oral debulking that they should not hesitate to perform tracheostomy on a patient with airway obstruction due to laryngeal cancer. Appropriate definitive treatment meant that POT was not a risk factor for poor oncological outcome in our series.

The safety of high pressure source ventilation (jet ventilation) is dependent upon upper airway patency to facilitate adequate passive expiration and prevent increasing intrathoracic pressure and its associated deleterious sequelae. Distortions in airway anatomy may make passive expiration inadequate or impossible in some patients. We report the elective use of the Ventrain device to provide ventilation in a clinical setting of upper airway obstruction in a patient with post radiation fibrosis that had previously prevented passive expiration during attempted high pressure source ventilation.

To evaluate the use of 18F-FDG PET/CT as the principal investigation to assess tumour response, to determine the need for further surgery and to guide follow-up following radical chemoradiotherapy for stage III/IV oropharyngeal squamous cell carcinoma (OPSCC). A retrospective analysis was undertaken in 146 patients treated at our centre with radical chemoradiotherapy for OPSCC and who had a PET/CT scan to assess response. According to the PET/CT findings, patients were divided into four groups and recommendations: (1) complete metabolic response (enter clinical follow-up); (2) low-level uptake only (follow-up PET/CT scan in 12 weeks); (3) residual uptake suspicious for residual disease (further investigation with or without neck dissection); and (4) new diagnosis of distant metastatic disease (palliative treatment options). The initial PET/CT scan was performed at a median of 12.4 weeks (range 4.3 – 21.7 weeks) following treatment. Overall sensitivity and specificity rates were 92.0 % (74.0 – 99.0 %) and 85 % (77.5 – 90.9 %). Of the 146 patients, 90 (62 %) had a complete response and had estimated 3-year overall and disease-free survival rates of 91.9 % (85.6 – 98.2 %) and 85.6 % (78.0 – 93.2 %), respectively, 17 (12 %) had residual low-level uptake only (with two having confirmed residual disease on subsequent PET/CT, both surgically salvaged), 30 (21 %) had suspicious residual uptake (12 proceeded to neck dissection; true positive rate at surgery 33 %). HPV-positive patients with reassuring PET/CT findings had an estimated 3-year progression-free survival rate of 91.7 % (85.2 – 98.2 %), compared with 66.2 % (41.5 – 90.9 %) of HPV-negative patients. A strategy of using PET/CT results alongside clinical examination to help select patients for salvage surgery appears successful. Despite a complete response on the 12-week PET/CT scan, HPV-negative patients have a significant risk of disease relapse in the following 2 years and further studies to assess whether surveillance imaging in this group could improve outcomes are warranted.

Differentiated thyroid cancer (DTC) accounts for over 90 % of thyroid malignancies, and is frequently associated with central neck compartment nodal metastasis that requires a therapeutic central compartment neck dissection (CCND) for clinically evident nodes. Current knowledge on the expected lymph node yield from a CCND is limited, compared with data on the lateral neck. The aim of our study was to accurately quantify nodal yield from the cadaveric central neck compartment. Twenty-eight cadaveric necks were dissected and the central neck compartment was subdivided into four regions: pre-laryngeal (delphian), pre-tracheal, right and left para-tracheal regions. Each cadaver had a thyroid gland, which was also removed, and the CCND tissue in each compartment was processed and examined by a consultant histopathologist. Only lymphoid tissue with a defined microscopic fibrous capsule and subcapsular sinus was included in the node count. The median total lymph node count per cadaver was four (range 1-16), with a median of one node detectable in each para-tracheal region (range 0-7) and the pre-tracheal region (range 0-8). The median pre-laryngeal node count was 0 (range 0- 2). The average lymph node size across all compartments was 2.9 mm. This is the first European study to assess cadaveric central neck lymph nodes and establish baseline counts for nodal yield. If a prophylactic or therapeutic CCND is required during thyroid surgery, those involved in DTC management must recognise that there is a wide range, and low median yield of central neck compartment lymph nodes.

The enzyme 3-deoxy-D-arabinoheptulosonate-7-phosphate (DAHP) synthase catalyses the first step in aromatic amino acid biosynthesis in prokaryotes, plants and fungi. Cells of Saccharomyces cerevisiae contain two catalytically redundant DAHP synthases, encoded by the genes ARO3 and ARO4, whose activities are feedback-inhibited by phenylalanine and tyrosine, respectively. ARO3/4 gene transcription is controlled by GCN4. The authors previously cloned an ARO3 gene orthologue from Candida albicans and found that: (1) it can complement an aro3 aro4 double mutation in S. cerevisiae, an effect inhibited by excess phenylalanine, and (2) a homozygous aro3-deletion mutant of C. albicans is phenotypically Aro+, suggesting the existence of another isozyme(s). They now report the identification and functional characterization of the C. albicans orthologue of S. cerevisiae Aro4p. The two Aro4p enzymes share 68% amino acid identity. Phylogenetic analysis places the fungal DAHP synthases in a cluster separate from prokaryotic orthologues and suggests that ARO3 and ARO4 arose from a single gene via a gene duplication event early in fungal evolution. C. albicans ARO4 mRNA is elevated upon amino acid starvation, consistent with the presence of three putative Gcn4p-responsive elements (GCREs) in the gene promoter sequence. C. albicans ARO4 complements an aro3 aro4 double mutation in S. cerevisiae, an effect inhibited by excess tyrosine. The authors engineered Δaro3/Δaro3 Δaro4/MET3p::ARO4 cells of C. albicans (with one wild-type copy of ARO4 placed under control of the repressible MET3 promoter) and found that they fail to grow in the absence of aromatic amino acids when ARO4 expression is repressed, and that this growth defect can be partially rescued by aromatic amino acids and certain aromatic amino acid pathway intermediates. It is concluded that, like S. cerevisiae, C. albicans contains two DAHP synthases required for the first step in the aromatic amino acid biosynthetic pathway.

Objectives:Prolonged tracheostomy is associated with morbidity, mortality, and length of stay. Otolaryngologists are called upon to diagnose and manage patients who have failed to achieve decannula...