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This article discusses the challenges in managing head neck squamous cell cancer from an unknown primary (HSCCUP) due to a lack of contemporary evidence and evolving understanding of the role of human papillomavirus (HPV) in head and neck cancer. Despite these limitations, various organizations have produced guidelines for managing HSCCUP using different methodologies. The article presents the results of a consensus process involving multiple stakeholders and centers, which led to the publication of consensus statements in the United Kingdom National Multidisciplinary Guidelines. The authors of the document, Vinidh Paleri, John Hardman, Tom Roques, and Ben O'Leary, made significant contributions to the work and have no conflicts of interest to report. The peer review history of the article is available for further reference. [Extracted from the article]

Introduction: To investigate factors influencing survival in head and neck squamous cell carcinoma of unknown primary (HNSCCUP). Methods: A retrospective observational cohort study was conducted, over 5 years from January 2015, in UK Head and Neck centres, of consecutive adults undergoing 18F‐Fluorodeoxyglucose‐PET‐CT within 3 months of diagnosis with metastatic cervical squamous cell carcinoma. Patients treated as HNSCCUP underwent survival analysis, stratified by neck dissection and/or radiotherapy to the ipsilateral neck, and by HPV status. Results: Data were received from 57 centres for 965 patients, of whom 482 started treatment for HNSCCUP (65.7% HPV‐positive, n = 282/429). Five‐year overall survival (OS) for HPV‐positive patients was 85.0% (95% CI 78.4–92.3) and 43.5% (95% CI 32.9–57.5) for HPV‐negative. HPV‐negative status was associated with worse OS, disease‐free (DFS), and disease‐specific (DSS) survival (all p <.0001 on log‐rank test) but not local control (LC) (p =.16). Unilateral HPV‐positive disease treated with surgery alone was associated with significantly worse DFS (p <.0001) and LC (p <.0001) compared to radiotherapy alone or combined modalities (5‐year DFS: 24.9%, 82.3% and 94.3%; 5‐year LC: 41.8%, 98.8% and 98.6%). OS was not significantly different (p =.16). Unilateral HPV‐negative disease treated with surgery alone was associated with significantly worse LC (p =.017) (5‐year LC: estimate unavailable, 93.3% and 96.6%, respectively). Small numbers with bilateral disease precluded meaningful sub‐group analysis. Conclusions: HPV status is associated with variable management and outcomes in HNSCCUP. Unilateral neck disease is treated variably and associated with poorer outcomes when managed with surgery alone. The impact of diagnostic oropharyngeal surgery on primary site emergence, survival and functional outcomes is unestablished. [ABSTRACT FROM AUTHOR]

Objective: Salvage laryngectomy is more predisposed to complications than primary operations, with pharyngocutaneous fistula (PCF) being among the most challenging to manage. Vascularized flaps are increasingly employed during salvage laryngectomy, with a previous review finding a PCF incidence of 31.2% and 22.2% after primary and flap‐assisted closure respectively. We aim to better define the role of vascularized flaps after salvage laryngectomy by performing an updated review comparing the rate of PCF in those undergoing primary or vascularized flap‐assisted closure. Data Sources: Pubmed/Medline, CINAHL, and CENTRAL. Review Methods: An updated literature review was conducted of English language literature from 2003 to 2023. A random effects and network meta‐analysis of odds ratios (OR) and pooled proportions were conducted. Results: Literature search found 31 studies, including seven from the previous review. Overall random effects pooled PCF rate was 25% (95% CI 0.21; 0.30, I2 = 72%, p = <0.01), whereas incidence in primary closure was 37% (95% CI 0.32; 0.43, I2 = 60%, p = <0.01) and 19% (95% CI 0.12; 0.20, I2 = 47%, p = <0.01) after flap closure. Pooled OR was 0.39 (95% CI 0.28; 0.55, I2 = 36%, p = 0.04) in favor of vascularized tissues. The number needed to treat was 6.5. The rate of PCF was lower after free and pedicled flaps, and on‐lay and patch closure compared to primary closure techniques. Network meta‐analysis found all combinations of closure techniques and vascularized tissue were superior to primary closure. Conclusion: The updated analysis has demonstrated a widening in the rates of PCF between primary and vascularized flap‐assisted closure. Surgeons should strongly consider the use of free or pedicled flaps in any salvage laryngectomy procedure. Laryngoscope, 134:2991–3002, 2024 [ABSTRACT FROM AUTHOR]

The water vapor transport associated with latent heat flux (LE) in the planetary boundary layer (PBL) is critical for the atmospheric hydrological cycle, radiation balance, and cloud formation. The spatiotemporal variability of LE and water vapor mixing ratio (rv) are poorly understood due to the scale‐dependent and nonlinear atmospheric transport responses to land surface heterogeneity. Here, airborne in situ measurements with the wavelet technique are utilized to investigate scale‐dependent relationships among LE, vertical velocity (w) variance (σw2 ${\sigma }_{w}^{2}$), and rv variance (σH2O2 ${\sigma }_{\mathrm{H}2\mathrm{O}}^{2}$) over a heterogeneous surface during the Chequamegon Heterogeneous Ecosystem Energy‐balance Study Enabled by a High‐density Extensive Array of Detectors 2019 (CHEESEHEAD19) field campaign. Our findings reveal distinct scale distributions of LE, σw2 ${\sigma }_{w}^{2}$, and σH2O2 ${\sigma }_{\mathrm{H}2\mathrm{O}}^{2}$ at 100 m height, with a majority scale range of 120 m–4 km in LE, 32 m–2 km in σw2 ${\sigma }_{w}^{2}$, and 200 m–8 km in σH2O2 ${\sigma }_{\mathrm{H}2\mathrm{O}}^{2}$. The scales are classified into three scale ranges, the turbulent scale (8–200 m), large‐eddy scale (200 m–2 km), and mesoscale (2–8 km) to evaluate scale‐resolved LE contributed by σw2 ${\sigma }_{w}^{2}$ and σH2O2 ${\sigma }_{\mathrm{H}2\mathrm{O}}^{2}$. The large‐eddy scale in PBL contributes over 70% of the monthly mean total LE with equal parts (50%) of contributions from σw2 ${\sigma }_{w}^{2}$ and σH2O2 ${\sigma }_{\mathrm{H}2\mathrm{O}}^{2}$. The monthly temporal variations mainly come from the first two major contributing classified scales in LE, σw2 ${\sigma }_{w}^{2}$, and σH2O2 ${\sigma }_{\mathrm{H}2\mathrm{O}}^{2}$. These results confirm the dominant role of the large‐eddy scale in the PBL in the vertical moisture transport from the surface to the PBL, while the mesoscale is shown to contribute an additional ∼20%. This analysis complements published scale‐dependent LE variations, which lack detailed scale‐dependent vertical velocity and moisture information. Plain Language Summary: The vertical water vapor transport in the planetary boundary layer (PBL), and the associated latent heat flux (LE), are critical for the atmospheric hydrological cycle, radiation balance, and cloud formation. However, the vertical moisture transport varies nonlinearly at multiple scales due to the land surface heterogeneity across multiple properties. This study investigates the scale‐resolved impact of water vapor and vertical velocity on LE, using data collected aboard an atmospheric research aircraft flying low above the surface in summer over northern Wisconsin during the CHEESEHEAD19 campaign. This study finds that LE and water vapor variance is largest at the large‐eddy scale in PBL and at the mesoscale. In contrast, vertical velocity variance is primarily present in turbulent and large‐eddy scales in PBL. This study confirms the significant role of the large‐eddy scale in PBL in contributing to the majority of the vertical moisture transport from the surface to the PBL top. These findings provide better insight into the factors influencing LE at different scales. Key Points: The scale‐dependent distribution of latent heat flux, vertical velocity variance, and water vapor variance at 100 m over a heterogeneous surface is describedIn the large‐eddy scale, 70% of total latent heat flux is contributed by 50% of total vertical velocity variance and 50% of total water vapor varianceThe large‐eddy scale contributes most of the vertical moisture transport from the surface to the Planetary Boundary Layer [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to determine the feasibility of the novel technique of intra‐cavitary saline‐aided ultrasound (US) guided transoral biopsy or excision of retropharyngeal nodes. Methods: We followed the IDEAL 2a framework to develop this technique. Procedures were performed between July 2020 and July 2022 at a tertiary head and neck center. Results: Five patients in total underwent an ultrasound‐guided biopsy of a retropharyngeal node. They underwent seven procedures between them: three transoral robotic surgery (TORS) procedures, three fine needle aspirations (FNA) and/or core biopsy procedures, and one US assessment under general anesthetic. The six patients with histology taken (three TORS and three FNA/core biopsies) all had diagnostically adequate samples enabling appropriate treatment planning. There were no significant complications from the procedure. Conclusion: Saline‐aided US‐guided biopsy of a retropharyngeal node is a safe and useful tool enabling accurate tissue sampling and tumor excision and ongoing appropriate treatment planning. [ABSTRACT FROM AUTHOR]

Background: Excessive flexion of the neck and upper back from severe kyphosis of the thoracic spine may limit treatment options for head and neck cancer (HNC). Methods: We describe an innovative approach to transoral robotic surgery (TORS) in a patient with severe thoracic kyphosis and oropharyngeal squamous cell carcinoma (OPSCC) who was unsuitable for definitive radiotherapy. Results: Detailed discussion of management pathway, perioperative considerations, and surgical challenges is presented. TORS lateral oropharyngectomy was successfully performed with the robotic system docked from the caudal end in a modified Trendelenburg position. Conclusions: With appropriate surgical and anesthetic planning, TORS for patients with severe thoracic kyphosis is a feasible and suitable treatment. [ABSTRACT FROM AUTHOR]

Although the Climate Forecast System version‐2 model simulates an overall dry bias in boreal summer mean rainfall over Indian land, the deficiency is particularly prominent over northwest India. The prevailing dryness limits the interannual prediction skill of the Indian summer monsoon rainfall and its subseasonal variability because of poor representation of latent heating due to weak moist convection and the resulting circulation. Here, we show that land‐surface vegetation plays a crucial role in determining the dry bias in the Climate Forecast System version‐2 model. We replaced the land‐surface model's existing vegetation type over India with that derived from recent satellite‐based observations. The modifications helped improve the seasonal mean rainfall over northwest India by 6%. The improvements are especially noticeable during the monsoon season's onset (14%) and withdrawal (10%) phases. Simulations with modified vegetation advanced the onset dates over Kerala, central India, and northwest India closer to that observed. This improvement in the mean onset dates is most prominent over northwest India. Such an improvement was possible owing to a substantial reduction of long rainfall hiatus after onset over Kerala in the simulation with modified vegetation. The modification makes the spatial orientation of monsoon onset isochrones more realistic. We found that although the vertically integrated moisture flux is eastward over most of the Indian monsoon region during its onset phase, its intraseasonal components are westward. In other words, at the intraseasonal time‐scale, moisture propagates against the prevailing low‐level westerlies. This intraseasonal eddy moisture transport advances onset from the Bay of Bengal toward the far northwest parts of the Indian land. The representation of such intraseasonal moisture seepage in the model updated with satellite‐derived vegetation types was improved. Our study indicates the necessity of greater attention to land‐surface representations for improved predictions of onset dates. [ABSTRACT FROM AUTHOR]

The Earth's surface is heterogeneous at multiple scales owing to spatial variability in various properties. The atmospheric responses to these heterogeneities through fluxes of energy, water, carbon, and other scalars are scale‐dependent and nonlinear. Although these exchanges can be measured using the eddy covariance technique, widely used tower‐based measurement approaches suffer from spectral losses in lower frequencies when using typical averaging times. However, spatially resolved measurements such as airborne eddy covariance measurements can detect such larger scale (meso‐β, meso‐γ) transport. To evaluate the prevalence and magnitude of these flux contributions, we applied wavelet analysis to airborne flux measurements over a heterogeneous mid‐latitude forested landscape, interspersed with open water bodies and wetlands. The measurements were made during the Chequamegon Heterogeneous Ecosystem Energy‐balance Study Enabled by a High‐density Extensive Array of Detectors intensive field campaign. We ask, how do spatial scales of surface‐atmosphere fluxes vary over heterogeneous surfaces across the day and across seasons? Measured fluxes were separated into smaller‐scale turbulent and larger‐scale mesoscale contributions. We found significant mesoscale contributions to sensible and latent heat fluxes through summer to autumn which would not be resolved in single‐point tower measurements through traditional time‐domain half‐hourly Reynolds decomposition. We report scale‐resolved flux transitions associated with seasonal and diurnal changes of the heterogeneous study domain. This study adds to our understanding of surface‐atmospheric interactions over unstructured heterogeneities and can help inform multi‐scale model‐data integration of weather and climate models at a sub‐grid scale. Plain Language Summary: Accurate and reliable knowledge of the surface‐atmospheric transport of mass and energy is essential to inform our theories and models of Earth system processes. Conventionally, such transport has been measured by tower‐mounted weather instruments that make high‐frequency measurements. However, experimental and simulation studies over the last couple of decades have shown that there is an imbalance between incoming, available energy and outgoing transport as observed from tower‐mounted setups. A dominant hypothesis addressing this imbalance issue postulates that there exists significant larger landscape scale transport (of the order of 10–100 km) over the course of a day. Single‐point tower measurements would not be able to include such transports in their conventional process flows. We use airborne data collected over a mid‐latitude temperate forest in Northern‐Wisconsin, USA to quantify large‐scale transport over the forested domain. Observations were made over the course of single days in July, August, and September to include seasonal landscape transitions. The measured surface‐atmospheric exchange is resolved into smaller and larger scale contributions using a space‐frequency analysis framework that has been in use for aircraft measured atmospheric data. We report substantial large‐scale contributions with daily, seasonal and spatial characteristics. Key Points: Substantial, persistent mesoscale surface‐atmospheric fluxes were measured across a heterogeneous mid‐latitude forested domainMeasured fluxes show distinct seasonal and diurnal variationsMeasured mesoscale fractions of sensible and latent heat fluxes do not behave similarly [ABSTRACT FROM AUTHOR]

Long‐running eddy covariance flux towers provide insights into how the terrestrial carbon cycle operates over multiple timescales. Here, we evaluated variation in net ecosystem exchange (NEE) of carbon dioxide (CO2) across the Chequamegon Ecosystem‐Atmosphere Study AmeriFlux core site cluster in the upper Great Lakes region of the USA from 1997 to 2020. The tower network included two mature hardwood forests with differing management regimes (US‐WCr and US‐Syv), two fen wetlands with varying levels of canopy sheltering and vegetation (US‐Los and US‐ALQ), and a very tall (400 m) landscape‐level tower (US‐PFa). Together, they provided over 70 site‐years of observations. The 19‐tower Chequamegon Heterogenous Ecosystem Energy‐balance Study Enabled by a High‐density Extensive Array of Detectors 2019 campaign centered around US‐PFa provided additional information on the spatial variation of NEE. Decadal variability was present in all long‐term sites, but cross‐site coherence in interannual NEE in the earlier part of the record became weaker with time as non‐climatic factors such as local disturbances likely dominated flux time series. Average decadal NEE at the tall tower transitioned from carbon source to sink to near neutral over 24 years. Respiration had a greater effect than photosynthesis on driving variations in NEE at all sites. Declining snowfall offset potential increases in assimilation from warmer springs, as less‐insulated soils delayed start of spring green‐up. Higher CO2 increased maximum net assimilation parameters but not total gross primary productivity. Stand‐scale sites were larger net sinks than the landscape tower. Clustered, long‐term carbon flux observations provide value for understanding the diverse links between carbon and climate and the challenges of upscaling these responses across space. Plain Language Summary: The terrestrial biosphere features the largest global sources and sinks of atmospheric carbon. Changes in growing season length, disturbance frequency, human management, increasing atmospheric carbon dioxide (CO2) concentrations, amount and timing of precipitation, and warmer air temperature all influence the carbon cycle. Observations from the global eddy covariance flux tower network have been key for diagnosing these changes. However, data from most sites are limited in length. Here, we explore how multi‐decadal carbon flux measurements from a cluster of flux towers in forests and wetlands in the upper Midwest USA respond to environmental change. Despite the proximity of the sites, year‐to‐year variation in carbon fluxes was rarely similar between sites. Surprisingly, warmer winters promoting earlier snowmelt led to later spring green‐up because soil temperature was colder. Impacts of higher CO2 and warmer temperature on annual carbon fluxes were limited but did influence factors linking carbon flux sensitivity to climate. Differences in flux magnitudes from a very tall tower flux to the network show that the whole does not seem to be simply a sum of its measured parts. More elaborate approaches may be needed to understand the processes that control carbon fluxes across large landscapes. Key Points: Multi‐decadal eddy covariance flux tower site cluster provides insight into variation of regional carbon cyclingVariation of carbon exchange in two forests, two wetlands, and a tall tower responded differently to weather, phenology, and disturbanceChallenges in upscaling fluxes indicate need for advances in aquatic observations, disturbance mapping, and flux footprint decomposition [ABSTRACT FROM AUTHOR]

Introduction: To report the long‐term oncological and functional outcomes of en bloc TORS lateral oropharyngectomy to address the close/involved margin following diagnostic tonsillectomy in HPV‐related SCC of unknown primary. Material and methods: A single tertiary center observational cohort over a 4‐year period. Primary outcome measures were disease‐specific survival (DSS), overall survival (OS), and PSS NOD (Performance Status Scale‐Normalcy of Diet) scores. Results: TORS specimens did not evidence residual carcinoma in 93% of patients. Of 14 patients, 50% received surgery alone (median follow‐up 57 months; range 46–96), the remainder surgery and adjuvant therapy (median follow‐up of 58 months; range 51–69) with 100% DSS, OS and no deterioration of PSS NOD scores. Conclusions: Long‐term oncological outcomes confirm TORS lateral oropharyngectomy alone is an oncologically safe treatment. Due consideration of this approach is warranted to mitigate against the morbidity of adjuvant radiotherapy treatment in this group of patients. [ABSTRACT FROM AUTHOR]

The highly interactive and variable nature of scales of space and time featured in components of the Earth system imparts enormous complexity to land‐atmosphere interactions. Here, we introduce an open special collection on Advances in Scaling and Modeling of Land‐Atmosphere Interactions that features articles in JGR: Biogeosciences, JGR: Atmospheres, Journal of Advances in the Modeling of Earth Systems, and Earth & Space Science. Collectively, these articles identify interactions across multiple processes, in field experiments, long‐term observations, and numerical simulations, which are then used to advance theories of scale interaction to improve predictive models. Plain Language Summary: Scale refers to the patterns in space and oscillations in time of features in our universe. The Earth system features a wide range of scales. Understanding the processes that explain the size, shape, regularity, and changes in those scales looms large in our science. Land‐atmosphere interaction refers to the ways that organisms and elements of the land surface influence the structure and evolution of the atmosphere and in turn, how weather and climate processes influence the ground. Numerous studies through coordinated field experiments and computer simulations have helped us advance understanding of how scale influences land‐atmosphere interaction. We introduce a special collection that documents many of those. Key Points: Scaling in space and time is an essential foundation for understanding land‐atmosphere interactionsA series of papers in this collection demonstrate scale‐related advances in a number of areasCoordination of research across disciplines is needed [ABSTRACT FROM AUTHOR]

We report on the first clinical experience with the robotic‐assisted extended "Sistrunk" approach (RESA) for access to constrained spaces of the upper aerodigestive tract. This prospective case cohort study include six patients that underwent RESA if transoral exposure could not be achieved. Three patients received previous radiation. Patients were postoperatively followed until week 16 for perioperative complications, surgical margins, and functional outcomes. In all patients RESA allowed adequate exposure and resection with negative margins. Three patients who underwent salvage surgery experienced a minor or intermediate grade postoperative bleeding. No patient developed a pharyngocutaneous fistula. Three patients recovered their swallowing to their preoperative status and the remaining three experienced an improvement. All patients experienced complete recovery of their voice. RESA has the potential to provide a new organ preservation approach for head and neck cancer (HNC) not amenable to transoral exposure and thus warrants further prospective clinical studies. [ABSTRACT FROM AUTHOR]

Objectives: To report the incidence of locoregional recurrence in head and neck cancer (HNC) patients under surveillance following treatment undergoing symptom‐based remote assessment. Design: A 16‐week multicentre prospective cohort study. Setting: UK ENT departments. Participants: HNC patients under surveillance following treatment undergoing symptom‐based telephone assessment. Main outcome measures: Incidence of locoregional recurrent HNC after minimum 6‐month follow‐up. Results: Data for 1078 cases were submitted by 16 centres, with follow‐up data completed in 98.9% (n = 1066). Following telephone consultation, 83.7% of referrals had their face‐to‐face appointments deferred (n = 897/1072). New symptoms were reported by 11.6% (n = 124/1072) at telephone assessment; 72.6% (n = 90/124) of this group were called for urgent assessments, of whom 48.9% (n = 44/90) came directly for imaging without preceding clinical review. The sensitivity and specificity for new symptoms as an indicator of cancer recurrence were 35.3% and 89.4%, respectively, with a negative predictive value of 99.7% (p =.002). Locoregional cancer identification rates after a minimum of 6 months of further monitoring, when correlated with time since treatment, were 6.0% (n = 14/233) <1 year; 2.1% (n = 16/747) between 1 and 5 years; and 4.3% (n = 4/92) for those >5 years since treatment. Conclusions: Telephone assessment, using patient‐reported symptoms, to identify recurrent locoregional HNC was widely adopted during the initial peak of the COVID‐19 pandemic in the United Kingdom. The majority of patients had no face‐to‐face reviews or investigations. New symptoms were significantly associated with the identification of locoregional recurrent cancers with a high specificity, but a low sensitivity may limit symptom assessment being used as the sole surveillance method. [ABSTRACT FROM AUTHOR]

Unprecedented times call for extraordinary measures. While surgeons across the globe try to comprehend the evolving facade of the COVID‐19 pandemic and improvise surgical practice to the best of their ability, the psychological impact of the stress on their own mental health and well‐being has been underestimated. This paper aims to review the indirect and overt factors that may affect the mental health of a surgeon in the present circumstances. Furthermore, it will aim to highlight key coping mechanisms at an individual and institutional level, so as to mitigate the negative psychological impact on surgeons. [ABSTRACT FROM AUTHOR]

There has been increased interest in the use of transoral surgery (TOS) for the treatment of oropharyngeal cancer (OPC). This systematic review summarizes the available evidence for validated functional outcomes following TOS for OPC, within the early postoperative period. Key databases were searched. Primary TOS resections of human subjects were included. Validated functional outcomes extracted included instrumental assessment, clinician rated, and patient reported measures. Database searches yielded 7186 titles between 1990 and December 2020. Full‐text articles were obtained for 296 eligible studies, which were screened and a resulting 14 studies, comprising 665 participants were included in the review. Oropharyngeal dysfunction following TOS was observed across all three categories of outcome measures (OMs) reported and was dependent on pretreatment function, T‐classification, and tumor volume. Future investigations should include optimal OMs to be used in the postoperative setting to allow for conclusive comparisons. [ABSTRACT FROM AUTHOR]

Background: Remote triage for suspected head and neck cancer (HNC) referrals was adopted by many institutions during the initial peak of the coronavirus disease 2019 pandemic. Its safety in this population has not been established.Methods: A 16-week, prospective, multicenter national service evaluation was started on March 23, 2020. Suspected HNC referrals undergoing remote triage in UK secondary care centers were identified and followed up for a minimum of 6 months to record the cancer status. Triage was supported by risk stratification using a validated calculator.Results: Data for 4568 cases were submitted by 41 centers serving a population of approximately 26 million. These represented 14.1% of the predicted maximum referrals for this population outside of pandemic times, and this gave the study a margin of error of 1.34% at 95% confidence. Completed 6-month follow-up data were available for 99.8% with an overall cancer rate of 5.6% (254 of 4557). The rates of triage were as follows: urgent imaging investigation, 25.4% (n = 1156); urgent face-to-face review, 27.8%; (n = 1268); assessment deferral, 30.3% (n = 1382); and discharge, 16.4% (n = 749). The corresponding missed cancers rates were 0.5% (5 of 1048), 0.3% (3 of 1149), 0.9% (12 of 1382), and 0.9% (7 of 747; P = .15). The negative predictive value for a nonurgent triage outcome and no cancer diagnosis was 99.1%. Overall harm was reported in 0.24% (11 of 4557) and was highest for deferred assessments (0.58%; 8 of 1382).Conclusions: Remote triage, incorporating risk stratification, may facilitate targeted investigations for higher risk patients and prevent unnecessary hospital attendance for lower risk patients. The risk of harm is low and may be reduced further with appropriate safety netting of deferred appointments.Lay Summary: This large national study observed the widespread adoption of telephone assessment (supported by a risk calculator) of patients referred to hospital specialists with suspected head and neck cancer during the initial peak of the coronavirus disease 2019 pandemic. The authors identified 4568 patients from 41 UK centers (serving a population of more than 26 million people) who were followed up for a minimum of 6 months. Late cancers were identified, whether reviewed or investigated urgently (0.4%) or nonurgently (0.9%), but the overall rate of harm was low (0.2%), with the highest rate being seen with deferred appointments (0.6%). [ABSTRACT FROM AUTHOR]

Introduction: The advent of immunotherapy has impacted both the management and, to a lesser extent, the outcomes for patients with head and neck mucosal melanoma. As a consequence, one might expect that the role of the surgeon would be limited to the diagnostic work‐up and that systemic therapies would be the mainstay of treatment. Methods and Results: Here, we present the surgical aspects of the recently published United Kingdom Head and Neck Mucosal Melanoma Guideline to highlight the continued role of surgeons in the management of this disease. We highlight key areas where surgeons remain the lead clinician and reinforce the multidisciplinary requirement for exemplary patient care. Conclusions: Despite the advent of immunotherapy, surgeons continue to have a key role to play in this disease. When indicated, it is essential that appropriate surgery is offered by a suitably experienced team. [ABSTRACT FROM AUTHOR]

Surface‐atmosphere fluxes and their drivers vary across space and time. A growing area of interest is in downscaling, localizing, and/or resolving sub‐grid scale energy, water, and carbon fluxes and drivers. Existing downscaling methods require inputs of land surface properties at relatively high spatial (e.g., sub‐kilometer) and temporal (e.g., hourly) resolutions, but many observed land surface drivers are not continuously available at these resolutions. We evaluate an approach to overcome this challenge for land surface temperature (LST), a World Meteorological Organization Essential Climate Variable and a key driver for surface heat fluxes. The Chequamegon Heterogenous Ecosystem Energy‐balance Study Enabled by a High‐density Extensive Array of Detectors (CHEESEHEAD19) field experiment provided a scalable testbed. We downscaled LST from satellites (GOES‐16 and ECOsystem Spaceborne Thermal Radiometer Experiment on Space Station [ECOSTRESS]) with further refinement using airborne hyperspectral imagery. Temporally and spatially downscaled LST compared well to independent observations from a network of 20 micrometeorological towers and piloted aircrafts in addition to Landsat‐based LST retrieval and drone‐based LST observed at one tower site. The downscaled 50‐m hourly LST showed good relationships with tower (r2 = 0.79, RMSE = 3.5 K) and airborne (r2 = 0.75, RMSE = 2.4 K) observations over space and time, with precision lower over wetlands and lakes, and some improvement for capturing spatio‐temporal variation compared to a geostationary satellite. Further downscaling to 10 m using hyperspectral imagery resolved hot and cold spots across the landscape as evidenced by independent drone LST, with significant reduction in RMSE by 1.3 K. These results demonstrate a simple pathway for multi‐sensor retrieval of high space and time resolution LST. Plain Language Summary: The temperature of the Earth's surface over land—land surface temperature (LST)—is an important variable to observe and forecast. Variation in LST over space and time at scales of meters and hours influence processes in the atmosphere, soils, vegetation, and water. For the worldwide coverage of LST, we rely on Earth‐observing satellites. However, there are trade offs in how finely LST can be observed over space versus how often LST can be observed over time, given the characteristics of any one satellite's orbit, not to mention the obscuring effect of clouds. Therefore, methods are needed that enable data from multiple satellites as well as aircraft and towers if we want to observe LST at high space and time resolution. Here, we develop such an approach and test its accuracy over a test bed of extensive LST observations made by towers, drones, and aircraft during a field experiment in Northern Wisconsin USA. Key Points: Fusion of satellites with models for high space and time resolution land surface temperature needed for many surface‐atmosphere studiesDeveloped an approach that evaluates well across array of towers and aircraft observations from an intensive field experimentAdditional downscaling with airborne hyperspectral imagery further refines the identification of hot spots as evaluated with drone observations [ABSTRACT FROM AUTHOR]

Objectives: To analyse the oncological outcomes following primary Transoral Robotic Surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC). Design: Observational case series. Setting: Tertiary centre; first TORS practice to commence in the UK. Participants: All consecutive patients undergoing primary TORS with curative intent, with or without adjuvant treatment. Main outcome measures: Descriptive analysis of patient and tumour pathology variables. Survival outcomes: Overall, Disease‐Specific, Progression‐Free and Locoregional control. Results: The cohort comprised of 120 patients undergoing TORS with minimum 12‐month follow‐up data and the following characteristics: mean age 58 years, 91 males (76%), 78 tonsil (65%) and 34 base of tongue primaries (28%), 89% HPV‐related OPSCC. The surgical pathology revealed 14 (12%) with positive margins, 19 (16%) had close margins <2mm and 31% with extranodal extension. The treatment was as follows: 39 (33%) treated with TORS alone, 50 (42%) received adjuvant radiotherapy and 31 (26%) received adjuvant radiotherapy with chemotherapy. There were 15 recurrences. Estimated survival for all patients at 3 years (95% CI): overall 85% (78‐92), disease‐specific 90% (85‐96), progression‐free 86% (79‐92) and locoregional control 90% (84‐96). The equivalent survival figures for the HPV‐related cases alone were as follows: overall 88% (82‐94), disease‐specific 93% (87‐98), progression‐free 88% (81‐95) and locoregional control 92% (87‐98). Conclusions: Whilst TORS has become a common practice in the management of OPSCC in the UK, these are the first reported oncological outcomes. For selected patients, TORS with or without adjuvant therapy is an appropriate treatment modality. [ABSTRACT FROM AUTHOR]

Background: Chest keloids are a difficult sub‐group of scars to treat, likely secondary to the high wound tension in the area that promotes excessive fibroblast proliferation and collagen deposition. Excision and adjuvant radiotherapy has been demonstrated as an efficacious treatment for keloids in general, but no meta‐analysis exists to support the claims for chest keloids. This study aims to identify the rate of recurrence after surgical resection and radiotherapy on patients with chest keloids. Methods: A search was performed using Embase, MEDLINE, Pubmed and Cochrane database on 22 December 2018 for terms 'radiotherapy', 'keloid' and 'chest'. Papers included met a prospectively designed inclusion criteria assessed by multiple investigators. Results: Twelve studies, including 1 randomized controlled trial, were included for a total of 400 patients with a chest keloid scar managed with surgical excision and adjuvant radiotherapy. Overall pooled‐estimate of recurrence rate was 22% (95% CI 12–32%). Meta‐regression did not demonstrate a significant effect for method of wound closure, type of radiotherapy, radiotherapy dose (BED10) and study type. Conclusion: Excision and adjuvant radiotherapy represents an effective method of treatment for chest keloids, however sufficient prospective data, including randomized controlled trials, did not yet exist to support these findings. Further studies with sufficient sub‐group analysis for keloid location are required to add to the pool of literature that can be added to this meta‐analysis. [ABSTRACT FROM AUTHOR]

Background: In the wake of the coronavirus disease 2019 (COVID‐19) pandemic, access to surgical care for patients with head and neck cancer (HNC) is limited and unpredictable. Determining which patients should be prioritized is inherently subjective and difficult to assess. The authors have proposed an algorithm to fairly and consistently triage patients and mitigate the risk of adverse outcomes. Methods: Two separate expert panels, a consensus panel (11 participants) and a validation panel (15 participants), were constructed among international HNC surgeons. Using a modified Delphi process and RAND Corporation/University of California at Los Angeles methodology with 4 consensus rounds and 2 meetings, groupings of high‐priority, intermediate‐priority, and low‐priority indications for surgery were established and subdivided. A point‐based scoring algorithm was developed, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN‐HN). Agreement was measured during consensus and for algorithm scoring using the Krippendorff alpha. Rankings from the algorithm were compared with expert rankings of 12 case vignettes using the Spearman rank correlation coefficient. Results: A total of 62 indications for surgical priority were rated. Weights for each indication ranged from −4 to +4 (scale range; −17 to 20). The response rate for the validation exercise was 100%. The SPARTAN‐HN demonstrated excellent agreement and correlation with expert rankings (Krippendorff alpha,.91 [95% CI, 0.88‐0.93]; and rho, 0.81 [95% CI, 0.45‐0.95]). Conclusions: The SPARTAN‐HN surgical prioritization algorithm consistently stratifies patients requiring HNC surgical care in the COVID‐19 era. Formal evaluation and implementation are required. Lay Summary: Many countries have enacted strict rules regarding the use of hospital resources during the coronavirus disease 2019 (COVID‐19) pandemic. Facing delays in surgery, patients may experience worse functional outcomes, stage migration, and eventual inoperability.Treatment prioritization tools have shown benefit in helping to triage patients equitably with minimal provider cognitive burden.The current study sought to develop what to the authors' knowledge is the first cancer–specific surgical prioritization tool for use in the COVID‐19 era, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN‐HN). This algorithm consistently stratifies patients requiring head and neck cancer surgery in the COVID‐19 era and provides evidence for the initial uptake of the SPARTAN‐HN. To the authors' knowledge, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN‐HN) is the first cancer surgery–specific prioritization tool for use during the coronavirus disease 2019 (COVID‐19) pandemic. The SPARTAN‐HN algorithm is reliable and valid for the stratification of patients with head and neck cancer who require urgent cancer care in resource‐restricted practice environments. [ABSTRACT FROM AUTHOR]

Under the INCOMPASS project, state of the art eddy‐covariance based surface flux measurement systems were installed at eight locations across India. These sites cover different climatic conditions, land use and land cover, and water management practices. Here we present the initial analysis of the measurements taken at seven sites mainly focusing on the year 2017, quantifying for the first time the remarkable contrasts in evaporative fraction across the seasons, climate zones and land management practices of the Indian subcontinent. With the exception of Jaisalmer which is the driest of the places studied, all the sites maintain values of evaporative fraction above 0.5 after the monsoon through to November. By contrast, for those sites with natural vegetation or rain‐fed agriculture, evaporative fraction remains below 0.3 for the dry January–May period. In the middle Gangetic Plain area, irrigation and pre‐monsoon showers together maintain evaporative fraction above 0.5 between January and June. It is also observed that different variables exhibit different intraseasonal variation characteristics even at one site. Except for Samastipur which is situated in the middle Indo‐Gangetic Plains, wind speed shows spectral peak at a smaller time‐scale compared to sensible and latent heat fluxes. [ABSTRACT FROM AUTHOR]

Background: Outpatient telemedicine consultations are being adopted to triage patients for head and neck cancer. However, there is currently no established structure to frame this consultation. Methods: For suspected referrals with cancer, we adapted the Head and Neck Cancer Risk Calculator (HaNC‐RC)‐V.2, generated from 10 244 referrals with the following diagnostic efficacy metrics: 85% sensitivity, 98.6% negative predictive value, and area under the curve of 0.89. For follow‐up patients, a symptom inventory generated from 5123 follow‐up consultations was used. A customized Excel Data Tool was created, trialed across professional groups and made freely available for download at www.entintegrate.co.uk/entuk2wwtt, alongside a user guide, protocol, and registration link for the project. Stakeholder support was obtained from national bodies. Results: No remote consultations were refused by patients. Preliminary data from 511 triaging episodes at 13 centers show that 77.1% of patients were discharged directly or have had their appointments deferred. Discussion: Significant reduction in footfall can be achieved using a structured triaging system. Further refinement of HaNC‐RC‐V.2 is feasible and the authors welcome international collaboration. [ABSTRACT FROM AUTHOR]

The 2019 novel coronavirus disease (COVID‐19) is a highly contagious zoonosis produced by SARS‐CoV‐2 that is spread human‐to‐human by respiratory secretions. It was declared by the WHO as a public health emergency. The most susceptible populations, needing mechanical ventilation, are the elderly and people with associated comorbidities. There is an important risk of contagion for anesthetists, dentists, head and neck surgeons, maxillofacial surgeons, ophthalmologists, and otolaryngologists. Health workers represent between 3.8% and 20% of the infected population; some 15% will develop severe complaints and among them, many will lose their lives. A large number of patients do not have overt signs and symptoms (fever/respiratory), yet pose a real risk to surgeons (who should know this fact and must therefore apply respiratory protective strategies for all patients they encounter). All interventions that have the potential to aerosolize aerodigestive secretions should be avoided or used only when mandatory. Health workers who are: pregnant, over 55 to 65 years of age, with a history of chronic diseases (uncontrolled hypertension, diabetes mellitus, chronic obstructive pulmonary diseases, and all clinical scenarios where immunosuppression is feasible, including that induced to treat chronic inflammatory conditions and organ transplants) should avoid the clinical attention of a potentially infected patient. Health care facilities should prioritize urgent and emergency visits and procedures until the present condition stabilizes; truly elective care should cease and discussed on a case‐by‐case basis for patients with cancer. For those who are working with COVID‐19 infected patients' isolation is compulsory in the following settings: (a) unprotected close contact with COVID‐19 pneumonia patients; (b) onset of fever, cough, shortness of breath, and other symptoms (gastrointestinal complaints, anosmia, and dysgeusia have been reported in a minority of cases). For any care or intervention in the upper aerodigestive tract region, irrespective of the setting and a confirmed diagnosis (eg, rhinoscopy or flexible laryngoscopy in the outpatient setting and tracheostomy or rigid endoscopy under anesthesia), it is strongly recommended that all health care personnel wear personal protective equipment such as N95, gown, cap, eye protection, and gloves. The procedures described are essential in trying to maintain safety of health care workers during COVID‐19 pandemic. In particular, otolaryngologists, head and neck, and maxillofacial surgeons are per se exposed to the greatest risk of infection while caring for COVID‐19 positive subjects, and their protection should be considered a priority in the present circumstances. [ABSTRACT FROM AUTHOR]

Objectives: Head and neck cancer (HNC) diagnosis through the 2‐week wait, urgent suspicion of cancer (USOC) pathway has failed to increase early cancer detection rates in the UK. A head and neck cancer risk calculator (HaNC‐RC) has previously been designed to aid referral of high‐risk patients to USOC clinics (predictive power: 77%). Our aim was to refine the HaNC‐RC to increase its prediction potential. Design: Following sample size calculation, prospective data collection and statistical analysis of referral criteria and outcomes. Setting: Large tertiary care cancer centre in Scotland. Participants: 3531 new patients seen in routine, urgent and USOC head and neck (HaN) clinics. Main outcome measures: Data collected were as follows: demographics, social history, presenting symptoms and signs and HNC diagnosis. Univariate and multivariate regression analysis were performed to identify significant predictors of HNC. Internal validation was performed using 1000 sample bootstrapping to estimate model diagnostics included the area under the receiver operator curve (AUC), sensitivity and specificity. Results: The updated version of the risk calculator (HaNC‐RC v.2) includes age, gender, unintentional weight loss, smoking, alcohol, positive and negative symptoms and signs of HNC. It has achieved an AUC of 88.6% with two recommended triage referral cut‐offs to USOC (cut‐off: 7.1%; sensitivity: 85%, specificity: 78.3%) or urgent clinics (cut‐off: 2.2%; sensitivity: 97.1%; specificity of 52.9%). This could redistribute cancer detection through USOC clinics from the current 60.9%–85.2%, without affecting total numbers seen in each clinical setting. Conclusions: The use of the HaNC‐RC v.2 has a significant potential in both identifying patients at high risk of HNC early thought USOC clinics but also improving health service delivery practices by reducing the number of inappropriately urgent referrals. [ABSTRACT FROM AUTHOR]

Background: Transoral robotic surgery (TORS) for recurrent head and neck (H&N) cancer is an emerging but relatively infrequent procedure. Methods: Systematic review and meta‐analysis of studies reporting survival data and functional outcomes for patients undergoing TORS for previously treated H&N cancers. Results: Eight hundred seventy‐eight records were identified, of which eight were eligible for inclusion, covering 161 cases (range 1‐64). The pooled rates were as follows: 2‐year overall survival 73.8% (4 studies, range 70.6‐75.0, 95% confidence intervals (CI) 65.4 to 81.5, [I2 0.0%, P = 1.0]); 2‐year disease‐free survival 74.8% (4 studies, range 56.2‐92.0, 95% CI 63.3 to 84.8, [I2 36.9%, P =.2]); postoperative hemorrhage 9.3% (4 studies, range 3.3‐13.3, 95% CI 4.7 to 15.1, [I2 0.0%, P =.5]). Conclusions: Functional and oncological outcomes are favorable, although the follow‐up is limited in the literature. Larger cohorts with longer follow‐up are needed for definitive conclusions to be drawn. [ABSTRACT FROM AUTHOR]

Long-term swallowing outcomes following transoral surgery and adjuvant radiotherapy vs adjuvant chemoradiotherapy for oropharyngeal carcinoma: Our experience in 37 patients Approximately 75% of patients are recommended adjuvant oncological treatment after transoral surgery (TOS) for oropharyngeal squamous cell carcinoma. Pre-treatment MDADI scores were high in both adjuvant RT and CRT groups at 93.3 (9.7) and 94.6(9.8), respectively, and both declined at long-term follow-up with a greater decline of 19.9 in the CRT group compared to RT group (10.7). There were also variations in radiotherapy treatment with some patients receiving conformal 3D radiotherapy and others intensity modulated RT. [Extracted from the article]

Background: Approximately 30% of nonsurgically treated patients with laryngeal squamous cell carcinoma will suffer recurrence, and many will be clinically N0; the indication for elective neck dissection (END) remains uncertain. We aimed to determine whether END is indicated during salvage laryngectomy. Methods: Systematic review and meta‐analysis. Results: A total of 1141 patients were identified from 17 studies. Occult nodal positivity was 13.7% (106/775) confidence interval (CI) 11.3%‐16.1%; higher in supraglottic than glottic disease (17.8%, CI 10.3%‐25.3% vs 12%, CI 7.1%‐16.9%, P = .18). No significant difference existed between END vs observation in 5‐year disease free survival (odds ratio [OR] = 0.76, CI = 0.49‐1.17, P = .21, I2 = 10%) and overall survival (OS; OR = 0.96, CI = 0.65‐1.41, P = .82, I2 = 54%). Conclusions: No significant survival advantage was found for END vs observation. Individual studies trended towards improved survival with END in supraglottic and locally advanced tumors. These factors should be considered when deciding on END in salvage laryngectomy. [ABSTRACT FROM AUTHOR]

The objective of this article was to review the indications for transoral robotic surgery (TORS) in head and neck malignancies. The role of imaging in patient selection will be specifically reviewed. TORS is a recently developed technique that allows minimally invasive surgeries to be performed in the head and neck. TORS has a role in the de‐escalation of oropharyngeal cancers, which allows for lower doses of chemoradiation therapy (this is a technique currently in clinical trials). Additionally, this technique allows for less invasive surgery and decreases associated complications. TORS can also be performed at other subsites. Cross‐sectional imaging has a prominent role to help identify suitable candidates for this type of surgery. This article will review important anatomy and staging related to TORS. Additionally, the key imaging features for patient selection (indications and contraindications) will be presented along with case illustrations. [ABSTRACT FROM AUTHOR]

Background: Hemorrhage remains a major potential risk when performing any form of transoral surgery. This is the first study to focus on the location of the facial artery "bulb" (FaB) and its tonsillar branches within the parapharyngeal space (PPS) from the perspective of the transoral surgeon. Method: A total of 44 hemi‐sections were dissected via the transoral approach with endoscopic assistance: 26 from fresh‐frozen specimens and 18 formalin‐fixed hemi‐sections. The distance from the superior apex of the FaB to the pterygoid hamulus (PH) was recorded, and the arterial branching variations described. Results: The average distance from the PH to the FaB was 4.17 ± 0.4 cm. In 90.9% of cases, the two tonsillar artery branches passed between styloglossus muscle (SGM) and stylopharyngeus muscle (SPM). Conclusion: Understanding the FaB location and its branching patterns offers the surgeon confidence dissecting in the PPS transorally. [ABSTRACT FROM AUTHOR]

Introduction: Patients with severe aortic stenosis (AS) require multi-detector computed tomography (MDCT) when considered for transcatheter aortic valve implantation (TAVI). Incidental findings on MDCT are common given the age group and region imaged. Our aim was to evaluate the frequency and outcome of incidental findings (IF) identified on MDCT and the impact on survival.Methods: This single-centre analysis retrospectively reviewed severe AS patients who underwent MDCT during TAVI workup. MDCT reports were reviewed for any IF and defined into three categories: IF of no relevant clinical significance (IF-NoCS), IF of non-immediate clinical significance (IF-NICS) and IF of immediate clinical significance (IF-ICS). Demographics, follow-up of IF and survival were calculated from MDCT date.Results: Two hundred and sixty-five patients underwent MDCT for TAVI suitability (mean age 83 ± 6 years, 52% male). The majority proceeded to TAVI (65%). Renal lesions (25%) and lung nodules (18%) were the most common IF. Fifty-nine patients (22%) had IF-NICS; 39% (23/59) were benign, 59% were not further investigated and one patient had suspected lung cancer. Six patients (2.3%) had IF-ICS and all were diagnosed with lung cancer. During a median follow-up of 272 days, there was no survival difference between patients with IF-ICS or IF-NICS versus patients without IF or IF-NoCS in the overall cohort (P = 0.44) or in TAVI patients (P = 0.88).Conclusion: Incidental findings on MDCT are common with one-quarter having IF-ICS or IF-NCIS. Most patients with IF-NICS did not undergo further investigation. Standardized reporting of MDCT may assist in clarifying the need for further investigation which will in turn influence decision and timing to proceed with TAVI. [ABSTRACT FROM AUTHOR]

Objective: To compare clinical and functional outcomes of regional and urban patients after transcatheter aortic valve implantation for severe aortic stenosis. Methods: Data were collected at patient follow‐up post‐transcatheter aortic valve implantation at 30 days and 12 months. Patients were stratified by residential postcodes into remoteness areas using the Australian Statistical Geography Standard. Design: Retrospective cohort study. Setting: Single‐centre tertiary referral hospital. Participants: Patients undergoing transcatheter aortic valve implantation (n = 142) from 2009 to 2018 were analysed, with 77 patients (54.2%) residing in regional Victoria and New South Wales. Main outcome measures: Procedural success, adverse event rates, readmission rates, mortality rates, loss to follow‐up and functional improvement. Results: Patients residing in regional areas had a lower mean age (81.8 vs 83.7 years) and proportion of Stage 4 or 5 chronic kidney disease (1.3% vs 9.2%), compared with urban patients. Procedural characteristics and immediate post‐procedural outcomes were similar between both groups. There was no statistically significant difference in mortality, readmission rates or loss to follow‐up between the two cohorts. Regional patients demonstrated poorer rates of functional improvement at 30 days (50.7% vs 67.7%); however, this difference was not sustained at 12 months (79.2% vs 71.0%). Frailty was demonstrated to be an independent predictor of poor 30‐day functional improvement. Conclusion: Regional patients treated with transcatheter aortic valve implantation for severe aortic stenosis have non‐inferior 30‐day and 12‐month outcomes, when compared with urban patients. Frailty is a predictor of poor functional improvement post‐transcatheter aortic valve implantation. [ABSTRACT FROM AUTHOR]

Background: Clinicians have recognised the role of narrow band imaging (NBI) in the management of head and neck cancer in several studies. However, a recent systematic review was unable to pool the data on diagnostic efficacy in this setting owing to the heterogeneity in the published data. Methods: Secondary analysis of data, utilising Bayes' theorem, from meta‐analyses and randomised trials. Results: In patients with a histological diagnosis of mild dysplasia who show no abnormalities on NBI, the post‐test probability of malignancy is estimated to be 2.3%, compared to 10.3% with conventional white light imaging (WLI). For severe dysplasia, similar post‐test probabilities after NBI and WLI are estimated to be 8.0% and 29.7%, respectively. Post‐test probabilities in this setting indicate the chance of missing malignancy following a negative NBI or WLI in patients who undergo no further intervention. This study also provides a nomogram designed for use in this setting. Conclusions: This study identifies the evidence base for use of NBI in the follow‐up for laryngeal dysplasia. [ABSTRACT FROM AUTHOR]

Background: The long‐term effect of concurrent chemoradiation on voice outcomes in the context of non‐laryngeal head and neck cancer is not established. Methods: A prospective, observational study to evaluate the voice quality in disease‐free patients receiving concurrent chemoradiation for advanced non‐laryngeal squamous cell carcinoma of the upper aerodigestive tract. Voice assessment occurred at four distinct time‐points: pretreatment, 3, 12 and 92.6 months (mean) post‐treatment in 34, 21 and nine patients, respectively. The authors used a combination of subjective (VoiSS questionnaire), expert rater‐assessed (GRBAS scale) and acoustic analysis of the fundamental frequency to assess voice outcomes. Ethical approval was obtained from the United Kingdom National Research Ethics Service. Results: Both the VoiSS impairment and GRBAS domains continued to deteriorate over time from pre‐treatment to 92.6 months post‐treatment (P = 0.03). There was a strong correlation between increase in total VoiSS and GRBAS scores (r = 0.93). Acoustic analysis demonstrated no statistically significant variation in fundamental frequency. Conclusion: Radiation therapy for advanced non‐laryngeal head and neck has a significant, deleterious effect on voice, which is apparent up to eight years post‐treatment. [ABSTRACT FROM AUTHOR]

The article discusses the validation of head and neck cancer (HNC) risk calculator of patients suspected with HNC in Scotland. Topics mentioned include the study on the hospital patients from June 2015-May 2016, the referral criteria for urgent cancer suspicion, and the comparison to National Institute for Health and Care Excellence (NICE) guidelines in Grat Britain in relation to its predictive ability, sensitivity and specificity.

Abstract: Background: The purpose of this study was to identify the role of transoral robotic surgery (TORS) in the management of residual and recurrent oropharyngeal cancer. Methods: IDEAL (Idea, Development, Exploration, Assessment, Long‐term Follow‐up) 2a framework. Results: Of 26 patients assessed for TORS, 21 underwent the procedure, 5 underwent open resection (4 due to unsuitable anatomy/tumor extent and 1 on the basis of patient choice). Three patients underwent intraoperative ultrasound‐assisted robotic resection, and 3 received robotic‐assisted free flap inset. A technical refinement for TORS of residual and recurrent oropharyngeal cancer of the tongue base is described. Actuarial plots showed estimated overall survival of 48.2%, local control of 76.6%, and disease‐specific survival of 77.1% at 42.6 months. Conclusion: TORS is a valid management option for residual and recurrent oropharyngeal cancer. Oncologic outcomes are comparable to open surgery and transoral laser microsurgery, with the added advantages of en bloc resections, facility for intraoperative ultrasound imaging, and inset of free flaps without mandibular split. [ABSTRACT FROM AUTHOR]

Design: Time trade‐off choice experiment. Setting: Two large head and neck cancer centres. Participants: Patients who have received treatment for head and neck cancer and members of the head and neck cancer multidisciplinary team. Main outcome measures: Participants were asked to rank the outcome scenarios, assign utility values using time trade‐off and rate the importance of survival on treatment choice. Results: A total of 49 patients with head and neck cancer and 73 staff members were recruited. Chemoradiotherapy (CRT) optimal outcome was the most preferred health state (34 of 49, 69% patients, and 50 of 73, 68% staff), and CRT with complications was least preferred (27 of 49, 55% patients, and 51 of 73, 70% staff). Using time trade‐off, mean utility values were calculated for CRT optimal outcome (0.73 for patients, 0.77 for staff), total laryngectomy (TL) optimal outcome (0.67 for patients, 0.69 for staff), TL outcome with complications (0.46 for patients, 0.51 for staff) and CRT with complications (0.36 for patients, 0.49 for staff). The average survival advantage required for a participant to change their preferred choice was 2.6 years. Conclusions: We have demonstrated that a significant proportion of patients with head and neck cancer and staff members would not choose CRT to manage locally advanced laryngeal cancer. Staff members rated the health states associated with laryngeal cancer treatment higher than patients who have experienced them, and this is particularly evident when considering the poorer outcomes. The head and neck cancer community should develop methods of practice and decision‐making which incorporate elicitation and reporting of patient values as a central principle. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objectives There is currently no consensus on the optimal feeding route for an oropharyngeal squamous cell cancer (OPSCC) patient without pre-existing dysphagia undergoing chemoradiotherapy. This study aimed to compare the swallowing outcomes for OPSCC patients fed via either prophylactic RIG (pRIG) or reactive nasogastric tube (rNGT). Design A prospective cohort study. Setting Four head and neck cancer centres in the North of England Cancer Network. Participants Fifty-three participants with OPSCC, on a normal diet pre-(chemo) radiotherapy. Main outcome measure Swallowing outcomes for patients with rNGT and pRIG were compared using the following outcome measures administered prospectively at pre-treatment, three and 12 months post-treatment: MD Anderson Dysphagia Inventory (MDADI), Performance Status Scales (Normalcy of Diet), timed water swallow test. Results Twenty-three patients received pRIG while 30 were planned for a rNGT. No differences in demographics were found between the groups. The rNGT group had a clinically significant higher score on MDADI at 12 months post-treatment. No significant difference was found on a timed water swallow test or diet texture scale. Conclusions There is no statistical difference for swallowing outcomes in either group. However, patients' in the rNGT group reported a clinically meaningful difference at 1 year, with a trend for them to do better across all measures. Neither group returned to their baseline swallowing function. Further research with a larger sample size is indicated. [ABSTRACT FROM AUTHOR]

Objective Gastro-oesophageal reflux disease is thought to be a risk factor for head and neck malignancies. Bile acids are one of the principle components of gastric refluxate and have previously been implicated in the development of oesophageal and bowel malignancies. There is clear evidence that bile acids reflux into the laryngopharynx. Despite this, the carcinogenic properties of bile acids in this area are yet to be fully identified. We therefore investigated the potential role of bile acids in pharyngeal malignancy, through the highly conserved process of epithelial-mesenchymal transition ( EMT). EMT occurs in invasion and metastasis and is a central process in the development of epithelial carcinoma. Design Translational research study. Methods Human hypopharyngeal squamous carcinoma FaDu cells were challenged with primary (cholic or chenodeoxycholic) and secondary (deoxycholic or lithocholic) bile acids. EMT-relevant proteins TGF- β1 and MMP-9 were measured in the cell culture supernates at 48 h via ELISA. Cell viability was confirmed >95% via CellTiter-Blue assay. Results Significantly greater concentrations of TGF- β1 were measured in the culture supernates of cells treated with cholic acid, deoxycholic acid and chenodeoxycholic acid. MMP-9 levels were increased in deoxycholic acid and lithocolic acid stimulations when compared to control ( P < 0.05). Conclusion This is the first demonstration that bile acids induce TGF- β1 and MMP-9 in pharyngeal cells. TGF- β1 is considered a master switch for EMT, while MMP-9 is a part of the EMT proteome which degrades basement membranes. This implies a potential role for bile acids in pharyngeal carcinogenesis through the mechanism of EMT and suggests potential novel therapeutic targets. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objectives To identify the most cost-effective treatment strategy in patients with early stage (T1 and T2) cancers of the laryngeal glottis. Design A Markov decision model populated using data from updated systematic reviews and meta-analyses, with attributable costs from NHS sources. Data on local control and mortality were obtained from updates of existing systematic reviews conducted for the NICE guideline on cancer of the upper aerodigestive tract. Procedure costs were sourced from NHS reference costs 2013/14 by applying tariffs associated with the appropriate health resource group code Setting The UK National Health Service. Population Patients with early stage (T1 and T2) cancers of the laryngeal glottis. Interventions Transoral laser microsurgery ( TLM) and radiation therapy ( RT). Main outcome measures Total costs, incremental costs and quality adjusted life years ( QALYs) over a 10-year time horizon. Results Radiation therapy as the initial treatment strategy was found to be more expensive (£2654 versus £623) and less effective ( QALY reduction of 0.141 and 0.04 in T1a and T1b-T2 laryngeal cancers, respectively) than TLM. The dominance of TLM for T1a cancers was unchanged in most scenarios modelled in sensitivity analysis. For T1b-T2 laryngeal cancers, the result changed in numerous scenarios. In probabilistic sensitivity analysis, TLM was found to have a 71% and 58% probability of being cost-effective in T1a and T1b-T2 laryngeal cancers, respectively. Conclusions Transoral laser microsurgery is a cost-effective strategy to adopt in the management of T1a laryngeal cancers. Uncertainty remains over the optimal strategy to adopt in T1b-T2 laryngeal cancers. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Mucosal melanoma of the upper aerodigestive tract (MM-UADT) occurs in a complex anatomic region. It represents a small number of tumors of the head and neck and a small number of melanoma cases. Methods Search strategies initially identified 600, 11 of which were included in this study. Results All studies involved surgery and radiotherapy. None were randomized, and all were assessed as having a high risk of selection and performance bias. No studies reported quality of life, treatment-related mortality, or morbidity. The results indicate that the addition of radiotherapy to surgery reduces the rate of locoregional recurrence (hazard ratio [HR], 0.60; 95% confidence interval [CI], 0.42-0.87). There was no statistically significant difference in overall survival (HR, 1.16; 95% CI, 0.98-1.37). Conclusion Surgical resection with postoperative radiotherapy remains the optimal treatment strategy for locoregional control. More robust studies and the use of molecular targeted therapies need to be undertaken to improve overall survival. © 2016 Wiley Periodicals, Inc. Head Neck 39: 819-825, 2017 [ABSTRACT FROM AUTHOR]

The article provides guidelines for the cancers of the upper aerodigestive tract (CUADT) including the oral cavity, oropharynx, nasopharynx, hypopharynx, larynx and paranasal sinus by the National Institute for Health and Care Excellence. Topics discussed include ultrasound guidance to fine-needle aspiration cytology, fluorodeoxyglucose positron emission tomography, and surgical management of the neck.

Background Treatment of recurrent oropharyngeal cancer is widely thought to have poor outcomes. Justification for treatment, especially in advanced cases, can be difficult. Methods A systematic search of MEDLINE, Embase, and Cochrane databases was conducted. Included studies reported specific recurrent oropharyngeal cancer survival data. Results Twenty-two retrospective studies were included. Pooled 3-year overall survival (OS) was 26% (95% confidence interval [CI] = 22% to 29%; I squared = 40.7%; p = .057). Pooled 5-year OS was 23% (95% CI = 20% to 27%; I squared = 73.9%; p = .000). Surgical treatment was superior to radiation (5-year OS 26% vs 16%, respectively; p < .001). The 5-year OS improved over time: 18% in the pre-2000 cohort; 35% in the mixed pre-2000 and post-2000 group; and 51% in the post-2000 cohort ( p < .001). Conclusion Outcomes have improved considerably over the last 2 decades, resulting in approximately 50% overall 5-year survival. Human papillomavirus (HPV) status, patient selection, and improvements in care may explain this. © 2016 The Authors Head & Neck Published by Wiley Periodicals, Inc. Head Neck, 2016 © 2016 Wiley Periodicals, Inc. Head Neck 38: 1855-1861, 2016 [ABSTRACT FROM AUTHOR]

Narrow band imaging (NBI) is reported to improve the diagnostic accuracy of head and neck cancers. The purpose of this review was to evaluate the diagnostic accuracy of NBI in the literature. A systematic review was performed in PubMed, Web of Knowledge, and the Cochrane Library until March 2015. Two reviewers independently assessed articles and extracted data. Meta-analyses were performed in MetaDisc 1.6. Five hundred seventeen studies were identified and 17 were included in this study. Combined use of NBI and white light imaging (WLI) showed high diagnostic accuracies for primary, recurrent, and nasopharyngeal lesions. Methodological heterogeneity exists and meta-analyses were only appropriate for cancers of unknown primary (CUP) in which NBI performed on 115 patients across 4 studies demonstrated high sensitivity (74.1%; 95% confidence interval [CI] = 52.5% to 100%) and specificity (94.1%; 95% CI = 23.7% to 100%). NBI may further help identify lesions in CUP not seen by positron emission tomography (PET)-CT. NBI offers a high level of diagnostic accuracy for head and neck cancers. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2358-E2367, 2016 [ABSTRACT FROM AUTHOR]

ABSTRACT Background The purpose of this study was to use time trade-off to assess the factors influencing patients' decisions in advanced laryngeal cancer. Time trade-off is a well-established method of assessing how individuals value a particular health state. Methods We developed vignettes depicting life after chemoradiotherapy or laryngectomy. One hundred fourteen participants ranked them, assigned utility values, and rated the importance of survival on treatment choice. Results Chemoradiotherapy was preferred by 62% and laryngectomy by 38%. Chemoradiotherapy optimal outcome had the highest mean utility value (0.64) followed by total laryngectomy optimal outcome (0.56). Total laryngectomy poor outcome (0.33) was equivalent to chemoradiotherapy poor outcome (0.32).The average survival advantage required for a participant to change their preferred choice was 2.1 years. Conclusion The functional treatment outcome had a greater effect on health state utility values than treatment modality. In many individuals, larynx conservation may not be the primary consideration in treatment preference. © 2015 Wiley Periodicals, Inc. Head Neck 38: E631-E637, 2016 [ABSTRACT FROM AUTHOR]

Background There are variations in the proportions of head and neck cancers caused by the human papillomavirus (HPV) between countries and regions. It is unclear if these are true variations or due to different study designs and assays. Methods We tested formalin-fixed paraffin-embedded diagnostic biopsies for p16 immunohistochemistry and HPV-DNA (by polymerase chain reaction [PCR] and in situ hybridization [ISH]) using validated protocols on samples from 801 patients with head and neck cancer recruited prospectively between 2006 and 2011 in 4 randomized controlled trials (RCTs). Results Twenty-one percent of patients (170 of 801) showed both HPV-DNA and p16-positivity, detected almost exclusively in oropharyngeal cancer (55%; 15 of 302); and only 1% of the patients (5 of 499) with nonoropharyngeal cancer were HPV positive. HPV-positive oropharyngeal cancer differed between Western and Eastern Europe (37%, 155 of 422 vs 6%, 8 of 144; p < .0001) and between Western Europe and Asia (37% vs 2%; 4 of 217; p < .0001). Other independent determinants of HPV positivity were tumor site and smoking. Conclusion This is the first study to establish geographic variability as an independent risk factor in HPV-positive oropharyngeal cancer prevalence, with higher prevalence in Western Europe. © 2016 The Authors Head & Neck Published by Wiley Periodicals, Inc. Head Neck 38: E1863-E1869, 2016 [ABSTRACT FROM AUTHOR]

Objectives To identify the set of referral criteria that will offer optimal diagnostic efficacy in patients suspected to have head and neck cancer ( HNC) in the primary care setting. Design Statistical analysis of referral criteria and outcomes. Setting Two tertiary care cancer centres in the United Kingdom. Participants 4715 patients who were referred via the fast-track system with a suspected HNC between 2007 and 2010. Main outcome measures Parameters of diagnostic efficacy, multivariate regression model to calculate estimated probability of HNC and area under the receiver operating characteristic curve ( AUROC). Results The majority of referring symptoms had a positive predictive value higher than the 3% cut-off point stated to be significant for HNC detection in the 2015 NICE recommendations. Nevertheless, our multivariate analysis identified nine symptoms to be linked with HNC. Of these, only four are included in the latest NICE guidelines. The best fit predictive model for this data set included the following symptoms: hoarseness >3 weeks, dysphagia >3 weeks, odynophagia, unexplained neck mass, oral swelling >3 weeks, oral ulcer >3 weeks, prolonged otalgia with normal otoscopy, the presence of blood in mouth with concurrent sensation of lump in throat and the presence of otalgia with concurrent lump in throat sensation. Intermittent hoarseness and sensation of lump in throat were negatively associated with HNC. The AUROC demonstrated that our model had a higher predictive value (0.77) compared to those generated using the NICE 2005 (0.69) and 2015 (0.68) referral criteria ( P < 0.0001). An online risk calculator based on this study is available at . Conclusions This study presents a significantly refined version of referral guidelines which demonstrate greater diagnostic efficacy than the current NICE guidelines. We recommend that further iterative refinements of referral criteria be considered when referring patients with suspected HNC. [ABSTRACT FROM AUTHOR]