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Background Diffuse large B-cell lymphoma, NOS (DLBCL NOS) is the commonest extranodal non-Hodgkin lymphoma diagnosed in the oral and maxillofacial region. However, few studies are currently available and its prognostic determinants remain undefined. Purpose To analyse the available data on oral DLBCL NOS and to describe its clinicopathological features, identifying potential prognostic factors. Methods An electronic systematic search was performed using multiple databases with a specific search strategy in April 2018. All reports describing DLBCL NOS involving the oral cavity and jaw bones with sufficient clinicopathological information were assessed. Results Sixty-three publications were included in the study, comprising 122 cases. Oral DLBCL NOS was found predominantly in elderly males (61.5%), and most often presented as an asymptomatic swelling of the gingiva. Patients commonly were HIV-negative (36.1%), with few reports describing EBV-positive cases (four cases/3.3%). Only eight cases presented B symptoms and most cases were classified as stage I or II (48.4%). CHOP therapy was the main treatment option (24.5%) and the overall 5-year survival rate achieved 83%. Males and advanced Ann Arbor stage patients presented significantly lower survival rates in the univariate analysis, but no significance was found in the multivariate model. Conclusion Oral DLBCL NOS is an aggressive malignancy, but with a high survival rate.

Introduction The Intercollegiate Membership of the Royal College of Surgeons (MRCS) is a mandatory examination to enter higher surgical specialty training in the UK. It is designed to help to ensure that successful candidates are competent to practice as higher surgical trainees. The annual review of competence progression (ARCP) assesses trainees’ competence to progress to the next level of training and can be interpreted as a measure of ‘on-the-job’ performance. We investigated the relationship between MRCS performance and ARCP outcomes. Materials and methods All UK medical graduates who passed MRCS (Parts A and B) from 2007 to 2016 were included. MRCS scores, attempts and sociodemographics for each candidate were crosslinked with ARCP outcomes (satisfactory, unsatisfactory and insufficient evidence). Multinomial logistic regression was used to identify potential independent predictors of ARCP outcomes. Results A total of 2570 trainees underwent 11,064 ARCPs; 1589 (61.8%) had only satisfactory outcomes recorded throughout training; 510 (19.9%) had at least one unsatisfactory outcome; and 471 (18.3%) supplied insufficient evidence. After adjusting for age, gender, first language and Part A performance, ethnicity (non-white vs white, OR 1.36, 95% CI 1.08 to 1.71), Part B passing score (OR 0.98, 95% CI 0.98 to 1.00) and number of attempts at Part B (two or more attempts vs one attempt, OR 1.50, 95% CI 1.16 to 1.94) were found to be independent predictors of an unsatisfactory ARCP outcome. Conclusions This is the first study to identify predictors of ARCP outcomes during higher surgical specialty training in the UK and provides further evidence of the predictive validity of the MRCS examination.

Introduction The Intercollegiate Membership of the Royal College of Surgeons (MRCS, Parts A and B) is designed to safeguard patients and ensure high standards for trainees wishing to pursue a surgical career. We investigated which factors predict Part A and B success. Methods UK graduates who had attempted both parts of MRCS from September 2007 to February 2016 were included. Pearson correlation coefficients were used to examine the linear relationship between each part of MRCS and logistic regression analysis to identify potential independent predictors of MRCS pass/fail outcome. Results A positive correlation between Part A and B score was identified (r = 0.41, P < 0.01). In Part A, males had higher pass rates than females (odds ratio, OR, 2.78, 95% confidence interval, CI, 1.83–4.19), white candidates were more likely to pass than black minority and ethnic doctors (OR 1.70, 95% CI 1.52–1.89), foundation year 1 doctors had higher pass rates than all other grades (e.g. core surgical year 2 trainees vs. foundation year 1 doctors, OR 0.50, 95% CI 0.32–0.77) and younger graduates were more likely to pass than older graduates (OR 2.60, 95% CI 1.81–3.63). In addition to ethnicity and stage of training, Part A performance (number of attempts and score) was an independent predictor for Part B. Conclusions Part A performance is related to Part B score. Many independent predictors of MRCS success were identified, but only stage of training and ethnicity were found to be common predictors of both parts. This article summarises the findings of our most recent MRCS study which was published in The Surgeon (online) in October 2017. 1

BACKGROUND We have evaluated the rationale of existing grading and staging schemes of oral submucous fibrosis (OSMF) based on how they are categorized. A novel classification and staging scheme is proposed. METHODS A total of 300 OSMF patients were evaluated for agreement between functional, clinical, and histopathological staging. Bilateral biopsies were assessed in 25 patients to evaluate for any differences in histopathological staging of OSMF in the same mouth. Extent of clinician agreement for categorized staging data was evaluated using Cohen's weighted kappa analysis. Cross-tabulation was performed on categorical grading data to understand the intercorrelation, and the unweighted kappa analysis was used to assess the bilateral grade agreement. Probabilities of less than 0.05 were considered significant. Data were analyzed using SPSS Statistics (version 25.0, IBM, USA). RESULTS A low agreement was found between all the stages depicting the independent nature of trismus, clinical features, and histopathological components (K = 0.312, 0.167, 0.152) in OSMF. Following analysis, a three-component classification scheme (TFM classification) was developed that describes the severity of each independently, grouping them using a novel three-tier staging scheme as a guide to the treatment plan. CONCLUSION The proposed classification and staging could be useful for effective communication, categorization, and for recording data and prognosis, and for guiding treatment plans. Furthermore, the classification considers OSMF malignant transformation in detail.

A significant cause of mistakes in healthcare and which are potentially harmful or fatal to patients can result from both individual clinicians and their employing organisations. The understanding and recognition of the role of human error within the healthcare setting is improving, but we still have much to learn when compared with other high-risk organisations such as aviation where such errors can be devastating at a much larger scale. The importance of both organisational issues and human factor issues at a more personal level including tiredness, the effect of emotions and the role of situational awareness, needs to be understood by all those involved in healthcare. Potential mistakes can be reduced with simple measures which need to be recognised by, emphasised and embedded in both teams and individuals. In this review, we address the need for greater awareness of human factors, assessing the path to error and how this can be reduced to minimum levels in clinical practice.

This review summarises all orthognathic and related papers published between January 2011 and December 2012 in the British Journal of Oral and Maxillofacial Surgery (BJOMS). A total of 36 articles were published, a high proportion of which (78%) were full-length papers. The remainder consisted of short communications and technical notes. The topics included operative planning and postoperative outcomes, and there was a strong focus on distraction osteogenesis. There were fewer orthognathic articles published in BJOMS than articles on other subspecialties such as trauma or head and neck oncology. Only 8 (29%) of the full-length articles were prospective studies or randomised trials, which highlights a need for well-designed clinical studies in orthognathic research.

Item does not contain fulltext Oral submucous fibrosis (OSMF) is a devastating disease commonly seen in the Asian subcontinent that results in significant functional morbidity for patients and has a high potential for malignant transformation. Over the last three decades, different diagnostic methods have been described to quantify and grade OSMF severity. Some methods have been used with perceived favorable outcomes although recurrence and malignant transformation remains a problem in many cases, and OSMF presents a major therapeutic challenge. We present a simple, noninvasive and less time-consuming diagnostic method which measures the severity of OSMF, helping to predict its malignant transformation and monitoring the effect of medical therapy on this disease.

Carcinoid tumours are usually slow-growing, neuroendocrine neoplasms that primarily affect the gastrointestinal tract and bronchial tree. Although relatively rare, isolated, single metastasis to the head and neck has been reported. We present a unique case of 6 metachronous carcinoid metastases to both parotid glands, the left submandibular gland, upper lip, and thyroid, over 3 years. To our knowledge, this widespread presentation in the head and neck has not previously been reported.

Carcinomas of the lacrimal drainage apparatus are rare and due to their aggressive behavior, they usually require extensive surgical treatment. We report a unique case of a 60-year-old man presenting with proptosis found to have a mass in the lacrimal drainage system on magnetic resonance imaging. Histology revealed a high-grade carcinoma with morphologic features of salivary gland duct carcinoma. Immunohistochemistry showed an extensive positive staining to androgen receptor. This is the first report of salivary gland-like duct carcinoma of the lacrimal drainage apparatus. Androgen receptor should be included in the immunohistochemical panel for the diagnostic work-up of lacrimal drainage system carcinomas, which resemble salivary gland duct carcinoma. This finding could have important diagnostic and therapeutic implications.

Background Spindle cell hemangioma (SCH) is an uncommon benign vascular tumor that rarely occurs in the mouth. Methods and Results We present an SCH arising in the tongue of a 52-year-old otherwise healthy woman. SCH should be considered in the differential diagnosis of vascular tumors in the oral cavity and not misinterpreted as a more aggressive vascular tumor. We describe the clinical presentation, investigation, differential diagnosis and management of this condition and a literature search showing published case reports. Conclusion Although SCH rarely presents in the oral cavity it needs to be considered in the differential diagnosis of oral cavity tumors.

Anatomical variants that affect both the anterior and posterior digastric muscles are well described, and include duplications and variable origin or sites of insertion. Although agenesis or atrophy of the anterior digastric occurs in up to 40% of patients with hemifacial microsomia, to our knowledge, it has been reported only rarely in those without this syndrome. To minimise observer bias and to establish the incidence of anomalies and atrophy of this muscle, a prospective 6-year study was conducted by an experienced consultant radiologist in all patients referred for ultrasound of the head and neck. Unilateral atrophy or absence of the anterior digastric muscle was seen in 3 of 1484 patients (0.2%). All 3 were female, and they had no symptoms or clinical signs related to the finding. One subsequently had a magnetic resonance scan. Non-syndromic absence or atrophy of the anterior digastric muscle is rare, and seems to be a unilateral phenomenon. Recognition of this variant could be important before operations in which it may be used as a landmark, or during procedures in which it is used, for example, for reanimation of a static lip or during reconstruction with a submental island flap.

Background Osteoradionecrosis of the mandible is the most common serious complication of radiotherapy for head and neck malignancy. For decades, hyperbaric oxygen has been employed in efforts to prevent those cases of osteoradionecrosis that are precipitated by dental extractions or implant placement. The evidence for using hyperbaric oxygen remains poor and current clinical practice varies greatly. We describe a protocol for a clinical trial to assess the benefit of hyperbaric oxygen in the prevention of osteoradionecrosis during surgery on the irradiated mandible. Methods/design The HOPON trial is a phase III, randomised controlled, multi-centre trial. It employs an unblinded trial design, but the assessment of the primary endpoint, i.e. the diagnosis of osteoradionecrosis, is assessed on anonymised clinical photographs and radiographs by a blinded expert panel. Eligibility is through the need for a high-risk dental procedure in the mandible where at least 50-Gy radiotherapy has been received. Patients are randomised 1:1 to hyperbaric oxygen arm (Marx protocol) : control arm, but both groups receive antibiotics and chlorhexidine mouthwash. The primary endpoint is the presence of osteoradionecrosis at 6 months following surgery, but secondary endpoints include other time points, acute symptoms and pain, quality of life, and where implants are placed, their successful retention. Discussion The protocol presented has evolved through feasibility stages and through analysis of interim data. The classification of osteoradionecrosis has undergone technical refinement to ensure that robust definitions are employed. The HOPON trial is the only multi-centre RCT conducted in this clinical setting despite decades of use of hyperbaric oxygen for the prevention of osteoradionecrosis. Trial registration European Clinical Trials Database, ID: EudraCT200700622527. First registered on 5 November 2007. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2376-7) contains supplementary material, which is available to authorized users.

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Introduction Evidence supports the efficacy of incorporating select recognized aviation practices and procedures into healthcare. Incident analysis, debrief, safety brief, and crew resource management (CRM) have all been assessed for implementation within the UK healthcare system, a world leader in aviation-based patient safety initiatives. Mindful application, in which aviation practices are specifically tailored to the unique healthcare setting, show promise in terms of acceptance and long-term sustainment. Methods In order to establish British healthcare applications of aviation practices, a PubMed search of UK authored manuscripts published between 2005-2016 was undertaken using search terms 'aviation,' 'healthcare,' 'checklist,' and 'CRM.' A convenience sample of UK-authored aviation medical conference presentations and UK-authored patient safety manuscripts were also reviewed. Results A total of 11 of 94 papers with UK academic affiliations published between 2005-2016 and relevant to aviation modeled healthcare delivery were found. The debrief process, incident analysis, and CRM are the primary practices incorporated into UK healthcare, with success dependent on cultural acceptance and mindful application. CRM training has gained significant acceptance in UK healthcare environments. Discussion Aviation modeled incident analysis, debrief, safety brief, and CRM training are increasingly undertaken within the UK healthcare system. Nuanced application, in which the unique aspects of the healthcare setting are addressed as part of a comprehensive safety approach, shows promise for long-term success. The patient safety brief and aviation modeled incident analysis are in earlier phases of implementation, and warrant further analysis.Powell-Dunford N, Brennan PA, Peerally MF, Kapur N, Hynes JM, Hodkinson PD. Mindful application of aviation practices in healthcare. Aerosp Med Hum Perform. 2017; 88(12):1107-1116.

Loss of an already established airway causing stridor is a common condition seen in busy oncology centres of India and other third world countries. Patients attend with acute respiratory distress, and are unable to reinsert the tracheostomy tube, sometimes days after having successfully mastered the technique. We have therefore developed a simple nonsurgical technique to widen simple tracheostomies to establish an emergency airway. In our opinion, since this is an easy non surgical procedure to perform and, can be performed rapidly without the need for any specialized types of equipment. This article is protected by copyright. All rights reserved.

Objective Androgen receptor (AR) is a diagnostic immunohistochemical marker for salivary gland duct carcinoma (SDC), but other nonsquamous cell head and neck carcinomas (NSCCs) may also express it. The aim of this preliminary study was to investigate the immunohistochemical expression of AR in rare head and neck NSCCs. Study Design Retrospective analysis of histologic records. Setting A large community hospital. Subjects and Methods Twenty-seven patients with NSCC were selected (21 men, 6 women; average age, 69 years). Exclusion criteria were histologically confirmed primary and metastatic head and neck squamous cell carcinomas and thyroid carcinomas. AR immunohistochemistry was done on formalin-fixed, paraffin-embedded tissue blocks. Results Variable AR expression was found in 5 of 27 (25%) cases of NSCC. All 7 patients with SDC showed intense and extensive positive immunoreactivity. Of 27 NSCC tumors, 15 (56%) had negative staining. Conclusion In the head and neck, expression of AR is not limited to SDCs; other NSCCs also express it. When surgery or radiotherapy is not appropriate for recurrent or metastatic head and neck NSCC, palliative chemotherapy offers poor results. Antiandrogen therapy is well tolerated and is much less toxic than chemotherapy. Since androgen deprivation therapy has been used against SDCs, this therapy may theoretically be used in a small subset of head and neck NSCCs.

Item does not contain fulltext Over the last 40 years, many theories linking oral submucous fibrosis (OSMF) to various risk factors have been proposed. Spicy, pungent foods and irritants such as supari (areca nut), paan (betel leaves), tobacco (through chewing or smoking)-the common Asian habits of chewing the aforementioned agents-have all been incriminated as causative agents. Systemic factors such as nutritional deficiency, genetic predisposition and autoimmunity have also been proposed in the pathogenesis of OSMF. However, the precise aetiology of OSMF is still unknown, and no conclusive evidence has been found despite many extensive investigations on implicated factors. Most of the ideas proposed have been derived from the existing clinical and epidemiological data. We present a comprehensive review of the various theories regarding the pathogenesis of the condition, but have not concentrated on malignant transformation in this article.

Head and neck hard tissue sarcomas form a rare group of mesenchymal-derived tumours that comprise less than 1% of all head and neck neoplasms. Hard tissue sarcomas account for 20% of head and neck sarcomas and they form a heterogeneous group with a diverse origin. Unlike head and neck soft-tissue sarcomas, they have lower recurrence and mortality rates. In this study, we review the current management of head and neck hard tissue sarcomas.

We review papers on diseases of the salivary glands published in journals relating to the head and neck, which are commonly read by members of our specialty. Most of the papers focus on the investigation and treatment of diseases of the parotid gland, which reflects the relative prevalence of parotid lesions among salivary gland diseases. Minimally invasive surgery is increasingly of interest. There is a lack of clinical trials that address the many controversies concerning salivary gland surgery, and much of the evidence for treatment is based on small case series and expert opinion, partly because of the relative rarity of salivary disease and the disparate groups that treat it. This problem could be addressed if regional and national oral and maxillofacial surgery (OMFS) units, and possibly other specialties, could collaborate more closely and combine data.

Galanin is a pleiotropic neuropeptide widely expressed in the nervous system. It plays a role in many diverse physiological functions - including nociception, cognition and metabolism regulation - and acts as neurotrophic/neuroprotective factor for several neuronal populations. In this article we sought to determine the role of galanin on neural stem cell function and its contribution to the plasticity of the nervous system. Here we show that galanin and its receptors are expressed in neural progenitor cells (NPCs) isolated from the developing striatum. Stimulation with galanin results in upregulation of Bcl-Xl, Bcl-2, Mash-1 and Olig-2 that are part of well known pro-survival/pro-neuronal signalling pathways. Accordingly, treatment with galanin increases the number of neurons upon differentiation from these progenitors. We then show that these effects are recapitulated in NPCs isolated from the adult subventricular zone (SVZ), where galanin increases the total number of neurons and the number of newly-generated neurons upon differentiation in vitro. The significance of these findings is highlighted in the adult brain where loss of galanin leads to a marked decrease in the rate of adult SVZ neurogenesis and a reduction in the number of newly generated cells in the olfactory bulb. Interestingly, Gal-KO mice display normal performances in simple tasks of olfactory detection and discrimination, which points to the existence of a certain degree of redundancy in SVZ neurogenesis. Our findings establish the role of galanin as a modulator of neural stem cell function and support the importance of galanin for brain plasticity and repair.

Osteoradionecrosis (ORN) is potentially a debilitating and serious consequence of radiotherapy to the head and neck. Although it is often defined as an area of exposed bone that does not heal, it can also exist without breaching the mucosa or the skin. Currently, 3 classifications of ORN are in use, but they depend on the use of hyperbaric oxygen or are too complicated to be used as a simple aide-mémoire, and include features that do not necessarily influence its clinical management. We propose a new classification to cover these shortcomings and to take into account the increasingly widespread use of antifibrotic medical treatment. We classified a series of 85 patients with varying severities of ORN into 4 groups. An analysis of the outcomes of the series showed that the classification staged the severity of the condition simply and that the stage was relevant to both treatment and outcome. The new classification was therefore verified by the series presented.

Purpose Osteonecrosis of the jaws is a potential complication of bisphosphonate (BP) therapy. The underlying mechanisms remain unclear. Although most research has concentrated on the effects of BPs on osteoclast and osteoblast functions, the disease is diagnosed and classified based on of mucosal breakdown, suggesting that oral soft tissues may be involved in its pathogenesis. The aim of this study was to determine the effect of 3 different BP drugs (alendronate, zoledronate, and clodronate) on the function of oral keratinocytes and fibroblasts. Materials and Methods Human oral keratinocytes (OKF6) and fetal foreskin fibroblasts (HFFF2) were exposed to each drug at several concentrations and the effect on cell proliferation was assessed by counting the viable cells after different lengths of treatment. The effect on cell migration was examined using Transwell migration assays. An organotypic coculture model using keratinocytes and fibroblasts, which recapitulated the morphology of the oral mucosa, was used to assess the effect of the drugs on epithelial stratification and differentiation. Results The 3 BPs affected the viability and proliferation of OKF6 and HFFF2 cells at concentrations in keeping with their known relative in vitro potencies. There was no effect on cell migration or tissue architecture in organotypic cultures at subtoxic concentrations. Conclusion The lack of effect of these drugs on cell migration below concentrations known to affect cell viability suggests that BP-related osteonecrosis is not caused through suppression of keratinocyte or fibroblast motility.

Empowering doctors to speak up when they have concerns is essential to making our NHS safer, say Peter Brennan and Mike Davidson

We aimed to investigate the concentration of copper ions in drinking water and to assess whether copper has a role in the pathogenesis of oral submucous fibrosis (OSMF). We studied 50 patients with clinically and histologically diagnosed OSMF from the Yadgir district of Karnataka in India. Fifty healthy people matched for age and sex were used as controls. In both groups concentrations of copper ions in serum, saliva, and home drinking water were measured using atomic absorption spectroscopy and intelligent nephelometry technology. Serum ceruloplasmin concentrations were also estimated in both groups. The mean (SD) concentration of copper in the home drinking water of patients with OSMF was significantly higher (764.3 (445.9)μmol/L) than in the controls (305.7 (318.5)μmol/L) (p

The role that human factors have in contributing to air crashes is well known and is included as an essential part of training. Awareness of human factors in surgery is increasingly being recognised but surprisingly few papers have come from head and neck specialties. We circulated a questionnaire on human factors based on an aviation model to 140 head and neck medical and ancillary staff who work in operating theatres in 3 large UK hospitals. Most positive responses were found in the consultant group followed by trainee doctors and support staff. A significant difference was found in the subcategories of Unsafe Supervision ( p = 0.002) and Preconditions to Unsafe Acts ( p = 0.001). This work will help to identify multi-system deficiencies that can be corrected, and highlights aspects that may yield the greatest reduction in surgical errors.

Facial paralysis can have a profound effect on the patient from both an aesthetic and functional point of view. The symptoms depend on which branch of the nerve has been damaged and the severity of the injury. The purpose of this paper is to review currently available treatments for dynamic reanimation of a damaged facial nerve, and the goals are a symmetrical and coordinated smile. Careful selection of patients and use of the appropriate surgical technique can have excellent results.

Purpose Central giant cell granuloma is a benign entity that commonly occurs in the mandible and maxilla. It is usually treated by surgical excision, varying from curettage to en bloc resection. Because the entity is more common in diseases such as neurofibromatosis, a genetic element may be involved in its pathogenesis. Cytogenetic studies of central giant cell granuloma affecting bone are rare, and to the authors' knowledge, there are none reported in the literature for central giant cell granuloma of the mandible. Materials and Methods The authors investigated the cytogenetic profile of a case occurring in the mandible. Fresh biopsy tissue was minced and cultured in RPMI-1640 medium. Cells were fixed and stained, and cytogenetic analysis was performed according to standard procedures. Results A clone with t(1;17;18) and other random numerical chromosomal changes was found. Conclusions The significance of these findings in diagnosis and prognosis is currently unclear and further karyotyping studies are needed to more fully understand this tumor.

Suspicious malignant supraclavicular lymphadenopathy provides a challenge for diagnosis and treatment. The wide variety of primary tumours that metastasise to this region should alert the clinician to look beyond the head and neck, particularly if it is the only site in the neck with suspected disease. As metastatic spread to these nodes from primaries not in the head and neck often indicates wide spread disease, neck dissection is controversial. In this article we review the lymphatic anatomy and discuss the investigation of supraclavicular lymphadenopathy. We discuss the evidence for the management of the neck in patients with subclavicular primary cancers (excluding lymphoma and melanoma) and the role of neck dissection.

We describe an enzyme-based electroanalysis system for real-time analysis of a clinical microdialysis sampling stream during surgery. Free flap tissue transfer is used widely in reconstructive surgery after resection of tumours or in other situations such as following major trauma. However, there is a risk of flap failure, due to thrombosis in the flap pedicle, leading to tissue ischaemia. Conventional clinical assessment is particularly difficult in such ‘buried’ flaps where access to the tissue is limited. Rapid sampling microdialysis (rsMD) is an enzyme-based electrochemical detection method, which is particularly suited to monitoring metabolism. This online flow injection system analyses a dialysate flow stream from an implanted microdialysis probe every 30 s for levels of glucose and lactate. Here, we report its first use in the monitoring of free flap reconstructive surgery, from flap detachment to re-vascularisation and overnight in the intensive care unit. The on-set of ischaemia by both arterial clamping and failure of venous drainage was seen as an increase in lactate and decrease in glucose levels. Glucose levels returned to normal within 10 min of successful arterial anastomosis, whilst lactate took longer to clear. The use of the lactate/glucose ratio provides a clear predictor of ischaemia on-set and subsequent recovery, as it is insensitive to changes in blood flow such as those caused by topical vasodilators, like papaverine. The use of storage tubing to preserve the time course of dialysate, when technical difficulties arise, until offline analysis can occur, is also shown. The potential use of rsMD in free flap surgery and tissue monitoring is highly promising. Figure Free flap surgery timeline: The flap is raised and MD probe inserted. Glucose and lactate levels were monitored at 1 minute intervals throughout flap removal and the reconstruction of the tongue. Grey lines indicate key events as communicated by the surgeons in real time.

Head and neck hard tissue sarcomas form a rare group of mesenchymal-derived tumours that comprise less than 1% of all head and neck neoplasms. Hard tissue sarcomas account for 20% of head and neck sarcomas and they form a heterogeneous group with a diverse origin. Unlike head and neck soft-tissue sarcomas, they have lower recurrence and mortality rates. In this study, we review the current management of head and neck hard tissue sarcomas.

An 80-year-old fit male with known long-standing stable chronic lymphatic leukaemia (CLL) presented with a rapidly enlarging left neck mass. The mass invaded the neck skin and began to fungate reaching to 10 cm in less than 3 weeks. Whilst head and neck skin SCC can metastasise to the regional lymph nodes (including to the contra-lateral side) rapid growth as occurred in this case is exceptionally rare and to our knowledge has not been previously reported.

Spindle-cell lipoma (SCL) is a variant of lipoma, usually presenting in the neck or trunk. SCL of the oral cavity is rare. Some cases of oral SCL have been reported; however, the clinico-pathologic characteristics of oral SCL are still unknown. Here we report on 2 cases and review 33 cases of oral SCL published in the literature. The patients were 23 men and 12 women, with a mean age of 55 years (range 23 - 88 years); there were no children. Tumor sites included: tongue (n = 13), cheek/buccal mucosa (n = 11), floor of mouth (n = 5), lip (n = 2), hard palate (n = 2), alveolar ridge (n = 1), and maxilla (n = 1). The mean tumor size was 20.87 mm (range 3 - 50 mm), smaller than extra-oral lesions. Thirty-three patients (94%) presented with a single lesion that was circumscribed and composed of mature adipocytes admixed with bland spindle cells. The spindle cells were strongly immunoreactive for CD34, whereas the adipocytes were negative. The main differential diagnosis is atypical lipoma/well-differentiated liposarcoma. All lesions underwent local excision and recurrences are rare. Oral SCL do not seem to differ from their extra-oral counterpart, which are much more common and larger in size. SCL should be included in the differential diagnosis of oral cavity mesenchymal tumors.

Primary melanoma arising from the nasolacrimal sac is a rare form of mucosal melanoma, with only 30 cases previously reported in the literature and none reporting cervical metastatic disease. Given the extremely rare nature of this disease, specific guidelines for staging and intervention are impractical and do not exist. As such, case presentations have formed the basis for management. This report describes the only case to the authors' knowledge of primary nasolacrimal sac mucosal melanoma with cervical metastatic disease at the time of diagnosis, which was detected only with positron emission tomographic computer tomography, and briefly reviews the existing published cases to help assist in the development of a general algorithm for patient care.