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IntroductionTonsillectomy is now only indicated in the UK when specific criteria are met, as outlined by the Scottish Intercollegiate Guidelines Network (SIGN) and The National Institute for Health and Care Excellence (NICE). As a result, fewer numbers of tonsillectomy are being performed. Tonsillectomy is the primary treatment for recurrent tonsillitis; therefore, we hypothesise that acute admissions to hospital with tonsillitis and infective complications will have risen since criteria were introduced. Our aim was to assess the rates of acute hospital admissions with tonsillitis in children and the factors associated with this.MethodsData were provided by Information Service Division for all under 16s in Scotland between 1996/1997 and 2016/2017. Socioeconomic background was determined from the Scottish Index of Multiple Deprivation (SIMD) score. Poisson regression analysis was used to model predictors of surgery and correlation analysis to study the relationship between tonsillitis and other factors.Results60 456 tonsillectomies were performed. The number of tonsillectomies dropped significantly following the introduction of SIGN guidelines, and the rates of tonsillitis increased; however, admissions with tonsillitis were already on an upward trajectory. Children from the most deprived areas were 72.0% (95% CI 60% to 85%, pConclusionTonsillectomy and tonsillitis rates are highest in the most deprived; postulated reasons include antibiotic stewardship and difficulty accessing primary care. Current guidelines on tonsillectomy may be disproportionately harmful in children from deprived households.

Background Reconstruction of mandibular bone defects is a surgical challenge, and microvascular reconstruction is the current gold standard. The field of tissue bioengineering has been providing an increasing number of alternative strategies for bone reconstruction.Methods In this preclinical study, the performance of two bioengineered scaffolds, an hydrogel made of polyethylene glycol-chitosan (HyCh) and an hybrid core-shell combination of poly(L-lactic acid)/poly(\(\epsilon\)-caprolactone) and HyCh (PLA-PCL-HyCh), seeded with different concentrations of human mesenchymal stem cells (hMSCs) (i.e. 1000, 2000, and 3000 cells/mm3), has been explored in non-critical size mandibular defects in a rabbit model. The bone regenerative properties of the bioengineered scaffolds were analyzed by in vivo radiological examinations and ex vivo radiological, histomorphological, and immunohistochemical analyses.Results The relative density increase (RDI) was significantly more pronounced in defects where a scaffold was placed, particularly if seeded with hMSCs (2000 and 3000 cells/mm3). The immunohistochemical profile showed significantly higher expression of both VEGF-A, in defects reconstructed with a PLA-PCL-HyCh, and osteopontin, in defects reconstructed with both scaffolds. Native microarchitectural characteristics were not demonstrated in any experimental group.Conclusions Herein, we demonstrate that bone regeneration can be boosted by scaffold- and seeded scaffold-reconstruction, achieving, respectively, 50% and 70% restoration of presurgical bone density in 120 days, compared to 40% restoration seen in spontaneous regeneration. Although optimization of the regenerative performance is needed, these results will help to establish a baseline reference for future experiments.

Each year, there are 11 900 new diagnoses of head and neck cancers in the UK, with around 4000 deaths. Survival rates are higher for those diagnosed earlier, however, patients are often diagnosed later, with 20% palliative at the time of diagnosis. There is a scarcity of head and neck cancer palliative care literature available. This review article aims to discuss the unique challenges of head and neck cancer palliation. It specifically focusses on the challenges of pain management, airway obstruction, dysphagia, haemorrhage and the psychology of palliative head and neck cancer management. This article explores the advantages and disadvantages of many of the different treatment options available. It is hoped that this article will highlight the unique difficulties encountered by patients with head and neck cancer towards the end of their life and offer insights and suggestions to improve patients’ quality of life in their final weeks and months.

There appears to be reduced symptom burden in those waiting for tonsillectomy during the COVID-19 pandemic. Despite the reduced symptom burden, most patients wished to go ahead with elective tonsillectomy. COVID-19 infection does not appear to be a factor in those patients no longer wishing to have a tonsillectomy. Patients should be reassessed during long waiting times to see if symptom burden has improved and if tonsillectomy is still required. Due to long waiting times, it is important to ensure information given can be repeated to allow adequate informed consent given the morbidity of tonsillectomy.

Reasons for delayed presentation in cancer are reported as patient or professional delays. Studies have examined patient demographic factors associated with presentation delay, but it is currently unknown why patients feel they delayed presenting. Questionnaire study of consecutive patients attending an urgent suspicion of cancer clinic at a tertiary referral centre in Glasgow over a 3-month period. 395 patients were included. 53 (13%) patients waited 0–7 days, 164 (41%) patients 1–4 weeks, 139 (35%) 1–12 months and 31 (8%) waited longer than 12 months, before presenting. 8 (3%) did not state length of time before presentation. 123 (31%) patients were not worried about their symptoms. 5 of the 13(38%) patients diagnosed with head and neck cancer, waited up to 12 months. 5 (38%) cancer patients delayed presentation because they were not worried about symptoms. Patients with head and neck cancer are not worried about their symptoms and delay their presentation, possibly contributing towards later stage diagnosis.

Importance Skull base surgery requires precise preoperative assessment and intraoperative management of the patient. Surgical navigation is routinely used for complex skull base cases; however, the image guidance is commonly based on preoperative scans alone. Objective The primary objective of this study was to assess the image quality of intraoperative cone-beam computed tomography (CBCT) within anatomical landmarks used in sinus and skull base surgery. The secondary objective was to assess the registration error of a surgical navigation system based on intraoperative CBCT. Design Present study is a retrospective case series of image quality after intraoperative cone beam CT. Setting The study was conducted at Toronto General Hospital and Princess Margaret Cancer Centre, University Health Network, Toronto. Participants A total of 46 intraoperative scans (34 patients, 21 skull base, 13 head and neck) were studied. Main Outcome and Measures Thirty anatomical landmarks (vascular, soft tissue, and bony) within the sinuses and anterior skull base were evaluated for general image quality characteristics: (1) bony detail visualization; (2) soft-tissue visualization; (3) vascular visualization; and (4) freedom from artifacts (e.g., metal). Levels of intravenous (IV) contrast enhancement were quantified in Hounsfield's units (HU). Standard paired-point registration between imaging and tracker coordinates was performed using 6 to 8 skin fiducial markers and the corresponding fiducial registration error (FRE) was measured. Results Median score for bony detail on CBCT was 5, remaining at 5 after administration of IV contrast. Median soft-tissue score was 2 for both pre- and postcontrast. Median vascular score was 1 precontrast and 3 postcontrast. Median score for artifacts on CBCT were 2 for both pre-and postcontrast, and metal objects were noted to be the most significant source of artifact. Intraoperative CBCT allowed preresection images and immediate postresection images to be available to the skull base surgeon. There was a significant improvement in mean (standard deviation [SD]) CT intensity in the left carotid artery postcontrast 334 HU (67 HU) (p Conclusion Intraoperative CBCT in complex skull base procedures provides high-resolution bony detail allowing immediate assessment of complex resections. The use of IV contrast with CBCT improves the visualization of vasculature. Image-guidance based on CBCT yields registration errors consistent with standard techniques.

The incidence of differentiated thyroid cancer has increased significantly during the last several decades. Surgical resection is the primary treatment for thyroid cancer and is highly effective, resulting in 5-year survival rates greater than 98%. However, surgical resection can result in short- and long-term treatment-related morbidities. Additionally, as this malignancy often affects women less than 40 years of age, there is interest in more conservative treatment approaches and, an unmet need for therapeutic options that minimize the risk of surgery-related morbidities while simultaneously providing an effective cancer treatment. Photodynamic therapy (PDT) has the potential to reduce treatment-related side effects by decreasing invasiveness and limiting toxicity. Owing to multiple advantageous properties of the porphyrin-HDL nanoparticle (PLP) as a PDT agent, including preferential accumulation in tumor, biodegradability and unprecedented photosensitizer packing, we evaluate PLP-mediated PDT as a minimally invasive, tumor-specific treatment for thyroid cancer. On both a biologically relevant human papillary thyroid cancer (K1) mouse model and an anatomically relevant rabbit squamous carcinoma (VX2)-implanted rabbit thyroid model, the intrinsic fluorescence of PLP enabled tracking of tumor preferential accumulation and guided PDT. This resulted in significant and specific apoptosis in tumor tissue, but not surrounding normal tissues including trachea and recurrent laryngeal nerve (RLN). A long-term survival study further demonstrated that PLP-PDT enabled complete ablation of tumor tissue while sparing both the normal thyroid tissue and RLN from damage, thus providing a safe, minimally invasive, and effective alternative to thyroidectomy for thyroid cancer therapies.

Background Monitoring circulating tumor DNA (ctDNA) and circulating tumor cells (CTCs), known as liquid biopsies, continue to be developed as diagnostic and prognostic markers for a wide variety of cancer indications, mainly due to their minimally invasive nature and ability to offer a wide range of phenotypic and genetic information. While liquid biopsies maintain significant promising benefits, there is still limited information regarding the kinetics of ctDNA and CTCs following radiation therapy which remains a vital treatment modality in head and neck cancers. This study aims to describe the kinetics of ctDNA and CTCs following radiation exposure in a preclinical rabbit model with VX2 induced buccal carcinoma. Methods Seven rabbits were inoculated with VX2 cells in the buccal mucosa and subjected to radiation. At selected time points, blood sampling was performed to monitor differing levels of ctDNA and CTC. Plasma ctDNA was measured with quantitative PCR for papillomavirus E6 while CTCs were quantified using an immunomagnetic nanoparticles within a microfluidic device. Comparisons of CTC detection with EpCAM compared to multiple surface markers (EGFR, HER2 and PSMA) was evaluated and correlated with the tumor size. Results Plasma ctDNA reflects the overall tumor burden within the animal model. Analysis of correlations between ctDNA with tumor and lymph node volumes showed a positive correlation (R = 0.452 and R = 0.433 [p Conclusion This study demonstrates the utility of ctDNA and CTCs detection in response to radiation treatment in a preclinical head and neck model, allowing for better understanding of liquid biopsy applications in both clinical practice and research development.

BackgroundPublic awareness of ‘red flag’ symptoms for head and neck cancer is low. There is a lack of evidence regarding patient concerns and expectations in consultations for cancer assessment.MethodThis prospective questionnaire study examined the symptoms, concerns and expectations of 250 consecutive patients attending an ‘urgent suspicion of cancer’ clinic at a tertiary referral centre.ResultsThe patients’ most frequent responses regarding their concerns were ‘no concerns’ (n = 72, 29 per cent); ‘all symptoms’ were a cause for concern (n = 65, 26 per cent) and ‘neck lump’ was a symptom causing concern (n = 37, 17 per cent). The expectations of patients attending clinic were that they would find out what was wrong with them, followed by having no expectations at all. Overall patient knowledge of red flag symptoms was lacking and their expectations were low.ConclusionPatients with non-cancer symptoms are frequently referred with suspected cancer. Patients with red flag symptoms are not aware of their significance and they have low expectations of healthcare.

BACKGROUND The image-guided operating room (OR) is an emerging standard for dealing with complex cases in many surgical disciplines including neurosurgery, thoracic surgery, maxillofacial trauma, and orthopedic surgery. Its use in head and neck oncological surgery is not well established. The primary aim of this study was to assess the image quality of cone-beam CT (CBCT) under real clinical conditions. The secondary aim was to assess the effect on surgical performance and decision making. METHODS Intraoperative 3D imaging was performed using a CBCT capable C-Arm mounted on a multi-axis robot (Siemens Zeego) in the image-guided OR. All patients had immediate preoperative imaging taken with further intraoperative imaging performed as required. Ten initial patients, comprising 28 intraoperative scans, were used for questionnaire-based image reviews conducted with experienced head and neck clinicians. Scans were assessed for aspects of both image quality and clinical utility, on separate 5-point Likert scales (1-5). RESULTS The median rating for bony detail was 4 out of 5. Vascular detail was increased (P < 10-8 ) from 1 to 3 with the use of IV contrast (region of interest CT# was 284 HU [SD, 47 HU]). Images were rated as 4 for freedom from artifact. Soft tissue definition was 2, with no significant improvement (P = .2) with the addition of IV iodinated contrast. Surgeons rated the greatest clinical utility (4) for the CBCT when assessing postreconstruction imaging of a complex case. CONCLUSIONS The image quality of CBCT in the image-guided OR is good for bony detail and complex oncological reconstructions in the head and neck setting but probably has limited benefit for intraoperative soft tissue delineation. Future studies must also focus on clinical outcomes to help demonstrate the value of the image-guided OR.

ObjectiveEpistaxis is the most common ENT emergency. This study aimed to assess one-year mortality rates in patients admitted to a large teaching hospital.MethodThis study was a retrospective case note analysis of all patients admitted to the Queen Elizabeth University Hospital in Glasgow with epistaxis over a 12-month period.ResultsThe one-year overall mortality for a patient admitted with epistaxis was 9.8 per cent. The patients who died were older (mean age 77.2 vs 68.8 years; p = 0.002), had a higher Cumulative Illness Rating Scale-Geriatric score (9.9 vs 6.7; p < 0.001) and had a higher performance status score (2 or higher vs less than 2; p < 0.001). Other risk factors were a low admission haemoglobin level (less than 128 g/dl vs 128 g/dl or higher; p = 0.025), abnormal coagulation (p = 0.004), low albumin (less than 36 g/l vs more than 36 g/l; p < 0.001) and longer length of stay (p = 0.046).ConclusionThere are a number of risk factors associated with increased mortality after admission with epistaxis. This information could help with risk stratification of patients at admission and enable the appropriate patient support to be arranged.

Introduction Primary care patients with a suspected head and neck cancer are referred through the urgent suspicion of cancer referral pathway. Rates of cancer detection through this pathway are low. Evidence surrounding the pathway of these patients is lacking. This study aimed to determine the outcome of urgent suspicion of cancer referrals for head and neck cancer. Methods and methods All head and neck cancer urgent suspicion of cancer referrals in NHS Greater Glasgow and Clyde between June 2015 and May 2016 were analysed in regard to their clinical pathway. Results There were 2116 urgent suspicion of cancer referrals in the one-year period. The overall cancer rate was 235 (11.8%), compared with 152 (7.6%) that resulted in a primary head and neck cancer diagnosis. Of the total, 851 (42.6%) were reassured and discharged after one clinic appointment; 536 (26.8%) were followed up for suspected benign pathology and 436 (21.8%) were actively investigated for cancer. Conclusion A significant proportion of patients attending urgent suspicion of cancer clinic appointments can be seen and discharged in one clinic appointment, provided there is same day imaging available. Cancer identification rates through urgent suspicion of cancer pathways remain low.

Background: We investigated long‐term survival from head and neck cancer (HNC) using different survival approaches. Methods: Patients were followed‐up from the Scottish Audit of Head and Neck Cancer. Overall survival and disease‐specific survival were calculated using the Kaplan–Meier method. Net survival was calculated by the Pohar‐Perme method. Mutually adjusted Cox proportional hazards models were used to determine the predictors of survival. Results: A total of 1820 patients were included in the analyses. Overall survival at 12 years was 26.3% (24.3%, 28.3%). Disease‐specific survival at 12 years was 56.9% (54.3%, 59.4%). Net survival at 12 years was 41.4% (37.6%, 45.1%). Conclusion: Determinants associated with long‐term survival included age, stage, treatment modality, WHO performance status, alcohol consumption, smoking behavior, and anatomical site. We recommend that net survival is used for long‐term outcomes for HNC patients—it disentangles other causes of death, which are overestimated in overall survival and underestimated in disease‐specific survival.

An integrated augmented reality (AR) surgical navigation system that potentially improves intra-operative visualization of concealed anatomical structures. Integration of real-time tracking technology with a laser pico-projector allows the surgical surface to be augmented by projecting virtual images of lesions and critical structures created by multimodality imaging. We aim to quantitatively and qualitatively evaluate the performance of a prototype interactive AR surgical navigation system through a series of pre-clinical studies. Four pre-clinical animal studies using xenograft mouse models were conducted to investigate system performance. A combination of CT, PET, SPECT, and MRI images were used to augment the mouse body during image-guided procedures to assess feasibility. A phantom with machined features was employed to quantitatively estimate the system accuracy. All the image-guided procedures were successfully performed. The tracked pico-projector correctly and reliably depicted virtual images on the animal body, highlighting the location of tumour and anatomical structures. The phantom study demonstrates the system was accurate to 0.55 ± 0.33mm. This paper presents a prototype real-time tracking AR surgical navigation system that improves visualization of underlying critical structures by overlaying virtual images onto the surgical site. This proof-of-concept pre-clinical study demonstrated both the clinical applicability and high precision of the system which was noted to be accurate to

Objectives Tonsillectomy, grommet insertion and adenoidectomy are only permissible in the UK when specific criteria are met. , Children from deprived backgrounds are more likely to require tonsillectomy. Our aim was to assess correlation between tonsillectomy and deprivation plus tonsillectomy and related infections. Design Retrospective observational study of data provided by Information Service Division between 1996/7 and 2016/17. Socio-economic background was determined by Scottish Index of Multiple Deprivation (SIMD) score. Setting and Participants Complete national data for all patients under 16 years old admitted to Scottish NHS hospitals. Main outcome measures Admission to hospital for ENT procedures and ENT-related infections. Results 60,456 tonsillectomies were performed during the study period, significantly fewer following the introduction of SIGN guidelines. Children from the most deprived areas were 72.0% more likely to receive tonsillectomy than the least deprived. Significantly increased rates of tonsillitis were observed following the introduction of SIGN guidelines. The most deprived children were 59% more likely to be admitted with quinsy than the least deprived. Conclusion Tonsillectomy rates are highest in the most deprived. Complications of throat infection appear to be increasing following the introduction of SIGN and NICE guidelines.

Introduction Flexible nasendoscopy (FNE) is the principal assessment method for vocal cord movement. Because the procedure is inherently subjective it may not be possible for clinicians to grade the degree of vocal cord movement reliably. The aim of this study was to assess the accuracy and consistency of grading vocal cord movement as viewed via FNE. Methods Thirty FNE videos, without sound or clinical information, were assessed by six consultant head and neck surgeons. The surgeons were asked to assess and grade right and left vocal cord movement independently, based on a five-category scale. This process was repeated three times on separate occasions. Agreement and reliability were assessed. Results Mean overall observed inter-rater agreement was 67.7% (sd 1.9) with the five-category scale, increasing to 91.4% (sd 1.9) when a three-category scale was derived. Mean overall observed intra-rater agreement was 78.3% (sd 9.7) for five categories, increasing to 93.1% (sd 3.3) for three categories. Discriminating vocal cord motion was less reliable using the five-category scale (k = 0.52) than with the three-category scale (k = 0.68). Conclusions This study demonstrates quantitatively that it is challenging to accurately and consistently grade subtle differences in vocal cord movement, as proven by the reduced agreement and reliability when using a five-point scale instead of a three-point scale. The study highlights the need for an objective measure to help in the assessment of vocal cord movement.

Background Current UK referral criteria stipulate that hoarseness should be persistent to merit 2 week wait (2WW) or urgent suspicion of cancer (USOC) referral. This study delineates patterns of hoarseness presentation with a view to assisting referral pathways, and whereby reassurance could be provided. Methods A pre-existing database of patients referred with hoarseness under the urgent suspicion of cancer (USOC) category was analysed. Univariate and multivariate analyses were performed on a variety of demographic and comorbid features to produce odds ratios (OR) of features either related or not related to laryngeal cancer. Results Of 698 consecutive hoarseness referrals were studied. In these referrals there were 506(73%) with persistent hoarseness and 192(27%) with intermittent hoarseness. The most significant patient variables related to laryngeal cancer were persistent hoarseness (OR 4.97), recreational drug use (OR 4.94), male gender (OR 4.01) and weight loss (OR 3.75). Significant patient variables present not related to laryngeal cancer diagnosis were intermittent hoarseness (OR 0.2), the presence of cough (OR 0.2), globus sensation (OR 0.25) and recent viral infection (OR 0.29). Conclusion The strongest association with cancer is seen in patients that are persistently hoarse. Patients with fluctuating hoarseness do not need an "urgent suspicion of cancer" referral. Additional demographic referral information could help to streamline the referral of these patients, and reassure others.

This study evaluates a long-acting liposomal fluorescence / CT dual-modality contrast agent (CF800) in head and neck cancer to enhance intraoperative tumor demarcation with fluorescence imaging and cone-beam computed tomography (CBCT). CF800 was administered to 12 buccal cancer-bearing rabbits. Imaging was acquired at regular time points to quantify time-dependent contrast enhancement. Surgery was performed 5-7 days after, with intraoperative near-infrared fluorescence endoscopy and CBCT, followed by histological and ex-vivo fluorescence assessment. Tumor enhancement on CT was significant at 24, 96 and 120 hours. Volumetric analysis of tumor segmentation showed high correlation between CBCT and micro-CT. Fluorescence signal was apparent in both ex-vivo and in-vivo imaging. Histological correlation showed [100%] specificity for primary tumor. Sensitivity and specificity of CF800 in detecting nodal involvement require further investigation.CF800 is long acting and has dual function for CT and fluorescence contrast, making it an excellent candidate for image-guided surgery.

Background Current sentinel lymph node biopsy (SLNB) techniques, including use of radioisotopes, have disadvantages including the use of a radioactive tracer. Indocyanine green (ICG) based near-infrared (NIR) fluorescence imaging and cone beam CT (CBCT) have advantages for intraoperative use. However, limited literature exists regarding their use in head and neck cancer SLNB. Methods This was a prospective, non-randomized study using a rabbit oral cavity VX2 squamous cell carcinoma model (n = 10) which develops lymph node metastasis. Pre-operatively, images were acquired by MicroCT. During surgery, CBCT and NIR fluorescence imaging of ICG was used to map and guide the SLNB resection. Results Intraoperative use of ICG to guide fluorescence resection resulted in identification of all lymph nodes identified by pre-operative CT. CBCT was useful for near real time intraoperative imaging and 3D reconstruction. Conclusions This pre-clinical study further demonstrates the technical feasibility, limitations and advantages of intraoperative NIR-guided ICG imaging for SLN identification as a complementary method during head and neck surgery.

One of the largest geometric uncertainties in designing radiotherapy treatment plans for squamous cell cancers of the head and neck is contouring the gross tumor volume. We have previously described a method of projecting mucosal disease contours, visible on endoscopy, to volumetrically reconstructed planning computed tomography (CT) datasets, using electromagnetic (EM) tracking of a flexible endoscope, enabling rigid registration between endoscopic and CT images. However, to achieve better accuracy for radiotherapy planning, we propose refining this initial registration with image-based registration methods. In this paper, several types of cost functions are evaluated based on accuracy and robustness. Three phantoms and eight clinical cases are used to test each cost function, with initial registration of endoscopy to CT provided by the pose of the flexible endoscope recovered from EM tracking. Cost function classes include: cross correlation, mutual information and gradient methods. For each test case, a ground truth virtual camera pose was first defined by manual registration of anatomical features visible in both real and virtual endoscope images. A new set of evenly spaced fiducial points and a sample contour were created and projected onto the CT image to be used in assessing image registration quality. A new set of 5000 displaced poses was generated by random sampling displacements along each translational and rotational dimension. At each pose, fiducial and contour points in the real image were again projected on the CT image. The cost function, fiducial registration error and contouring error values were then calculated. While all cost functions performed well in select cases, only the normalized gradient field function consistently had registration errors less than 2 mm, which is the accuracy needed if this application of registering mucosal disease identified on optical image to CT images is to be used in the clinical practice of radiation treatment planning. (Registration: ClinicalTrials.gov NCT02704169)

BACKGROUND The treatment of head and neck cancer (HNC) may cause significant financial toxicity to patients. Herein, the authors have presented the development and validation of the Financial Index of Toxicity (FIT) instrument. METHODS Items were generated using literature review and were based on expert opinion. In item reduction, items with factor loadings of a magnitude

AIM To determine the accuracy of contrast-enhanced computed tomography (CECT) for nodal extracapsular spread (ECS) and identify predictive radiological signs and clinicopathological features for ECS in unknown-primary head and neck squamous cell cancer (UPHNSCC). MATERIALS AND METHODS The CECT imaging of patients who underwent primary neck dissection for UPHNSCC during 2011–2015 was analysed. The largest pathological-looking node at each radiologically involved level was evaluated in consensus by two head and neck radiologists. Parameters included longest diameter, margin sharpness, haziness in adjacent fat, necrosis, and loss of fat plane with adjacent structures. Independent assessment was also made regarding the presence/absence of ECS. Findings and clinicopathological parameters were correlated with histopathology. RESULTS Thirty-one patients with 39 neck levels had metastatic nodal involvement determined on CECT. Confirmed ECS was found at 26 levels in 23 patients. Sensitivity of radiological assessment for ECS by nodal level was 81–85% (95% confidence interval [CI]=65–93%) and specificity 46–54% (95% CI=19−81%); kappa 0.87. On univariate analysis based on the largest involved node per patient, longest diameter being ≥30 mm (p=0.007), haziness in adjacent fat (p=0.023), increasing age (p=0.006), and more advanced pathological nodal status (p=0.027) were statistically significantly associated with ECS. Haziness and increasing age were independent predictors on multivariate analysis (odds ratio [OR]=26.4 and 1.24). CONCLUSION Expert assessment of ECS on CECT had good sensitivity with excellent interobserver agreement. A longest nodal diameter of ≥30 mm, haziness in the surrounding fat on CECT, advanced pathological nodal status, and advancing patient age were significantly associated with ECS in UPHNSCC patients, findings not previously reported.

Current intraoperative methods to assess tumor invasion depth in mucosal oral cancer provide limited real-time information. The advent of targeted fluorescence contrast agents for head and neck cancer is a promising innovation, but surgical imaging systems typically provide only two-dimensional views. Here, we investigate the use of an image-guided fluorescence tomography (igFT) system to estimate the depth of tumor invasion in tissue-simulating oral cancer phantoms. Implementation of non-contact diffuse optical tomography using finite-element software (NIRFAST) is enabled with geometric data from intraoperative cone-beam CT (CBCT) imaging and surgical navigation. The tissue phantoms used gelatin for the background (5% for fat, 10% for muscle) and 2% agar for palpable, tumor-like inclusions. Standard agents were used for absorption (hemoglobin), scattering (Intralipid), fluorescence (indocyanine green), and CT contrast (iohexol). The agar inclusions were formed using 3D printed molds, and positioned at the surface of the gelatin background to mimic mucosal tumor invasion (an “iceberg” model). Simulations and phantom experiments characterize fluorescence tomography performance across a range of tumor invasion depths. To aid surgical visualization, the fluorescence volume is converted to a colored surface indicating tumor depth, and overlaid on the navigated endoscopic video. Clinical studies are necessary to assess in vivo performance and intraoperative workflow.

BACKGROUND Epistaxis affects most people over their lifetime. It is the commonest ear, nose and throat emergency. Hospital admission and socio-economic deprivation have been associated with mental health disorders, respiratory illness and with emergency hospital admissions. Low socio-economic status has never previously been associated with epistaxis, a common reason for admission to ear, nose and throat departments throughout the UK. METHODS Demographics from Information Services Division Scotland were analysed over a period of 20 years. This focused on gender, number of admissions, number of bed days, socio-economic deprivation (Scottish Index of Multiple Deprivation) and mortality within 1 year. RESULTS Data from 54 501 patients were assessed. Admission numbers and length of stay have significantly decreased (P < 0.0001). Males are more frequently affected (P = 0.001). Admission numbers were higher for patients in more deprived areas (P < 0.001). Mean duration of stay has decreased by 1 bed day. Surgical intervention of epistaxis has increased significantly (P < 0.001). There is an associated 1-year mortality rate of 9.8% following epistaxis. CONCLUSION There has been a significant decrease in hospital admissions and length of hospital stay in patients admitted with epistaxis over the past 20 years. There is a significant association with deprivation and epistaxis admission.

Aim To examine deprivation measured by the Scottish index of multiple deprivation (SIMD) and its relation to urgent suspicion of head and neck cancer referrals. A secondary aim was to examine the symptomatology generating urgent suspicion of cancer (USOC) referrals by SIMD category. Methods All "urgent suspicion of cancer" referrals to the GGC ENT department over a one-year period, between 2015 and 2016, were reviewed. Information was recorded anonymously and included demographics and red flag referral symptoms. Results A total of 1998 patients were assessed, 43.4% (n = 867) were male. A total of 171 (8.6%) patients had primary head and neck cancer. A total of 61 patients had other types of cancer, giving an all cause cancer rate of 11.6%. About 71.3% of primary patients with head and neck cancer (HNC) were male. The most common SIMD category observed was SIMD1, the most common SIMD category yielding a primary head and neck cancer diagnosis was SIMD1. Neck lump was the commonest symptom amongst all SIMD categories. Conclusion A link between deprivation and USOC referrals has been established. A difference in gender distribution between referrals and HNC was observed, more females are referred but a significantly higher number of patients with HNC are males. Neck lump is a very strong referral indicator for HNC and intermittent hoarseness is not. The findings from this analysis could be used to refine local referral patterns and priority of referral.

Background The aim of this study was to report outcomes and late toxicity following hypofractionated accelerated radiotherapy for T2 glottic cancers. We highlight the importance of hypofractionated treatments with shorter overall treatment times, in improving outcomes for T2 glottic cancers. We also compare the biologically effective dose of hypofractionated regimes, with conventional fractionation. Methods One hundred twelve patients with T2 glottic cancer were treated between January 1999 and December 2005. All patients were prescribed a hypofractionated accelerated radiotherapy dose of 52.5 Gray in 3.28 Gray per fraction, delivered over 22 days. Radiobiological calculations were used to assess the relationship of fraction size and overall treatment time on local control outcomes and late toxicity. Results The 5-year overall survival was 67%, the 5-year local control was 82%, and the 5-year disease-specific survival was 90%. The respective 5-year local control for T2a and T2b disease was 88.8 and 70.8% (p = 0.032). Severe late toxicity occurred in two patients (1.8%). Radiobiological calculations showed an increase in local control of nearly 12%, with a 10 Gray increase in biologically effective dose. Conclusion This study has demonstrated that accelerated hypofractionated regimes have improved local control and similar late toxicity compared with conventional fractionation schedules. This supports the use of hypofractionated regimes as the standard of care for early glottic laryngeal cancers.

Reasons for delayed presentation in cancer are reported as patient or professional delays. Studies have examined patient demographic factors associated with presentation delay, but it is currently unknown why patients feel they delayed presenting.Questionnaire study of consecutive patients attending an urgent suspicion of cancer clinic at a tertiary referral centre in Glasgow over a 3-month period.395 patients were included. 53 (13%) patients waited 0-7 days, 164 (41%) patients 1-4 weeks, 139 (35%) 1-12 months and 31 (8%) waited longer than 12 months, before presenting. 8 (3%) did not state length of time before presentation. 123 (31%) patients were not worried about their symptoms. 5 of the 13(38%) patients diagnosed with head and neck cancer, waited up to 12 months. 5 (38%) cancer patients delayed presentation because they were not worried about symptoms.Patients with head and neck cancer are not worried about their symptoms and delay their presentation, possibly contributing towards later stage diagnosis.

Purpose The risk of developing head and neck squamous cell carcinoma (HNSCC) in patients with graft versus host disease (GVHD) after bone marrow transplant (BMT) is well established but large series reporting outcomes are sparse. Methods Retrospective, single institution, study of patients with GVHD and HNSCC after BMT, between January 1, 1968, and June 30, 2016. Results In total, 25 patients were studied, of which 21 (84%) were male and 4 (16%) were female. Mean age for BMT was 41 (18-65) years. All patients developed GVHD, most common site was oral cavity (19 patients, 76%). Mean age for diagnosis of HNSCC was 52 (28-76) years. Mean time between BMT and diagnosis of HNSCC was 12 (2-13) years. The 2-year progression-free survival (PFS) was 61.4%, 5-year PFS was 56.7%. The 2-year overall survival (OS) was 82.8%, 5-year OS was 68.7%. Conclusion HNSCC can develop many years after BMT in patients without the classic risk factors for head and neck cancer. The majority were seen with oral cancer and with early-stage disease likely due to active surveillance and early detection in this patient population.

BackgroundThere is little consensus on how best to manage head and neck cancer with palliative intent. Predicting outcome is difficult and reported survival varies. The present study sought to delineate local practice and outcomes in patients treated with palliative intent.MethodsThe clinical records of all head and neck cancer patients treated with palliative intent presenting between 2015 and 2016 to our multidisciplinary team were reviewed.ResultsEighty-four patients (21.5 per cent) were treated with palliative intent. All had squamous cell carcinoma. Mean survival time was 151 days (standard deviation = 121.1; range, 8–536 days). Of the patients, 83.3 per cent had a palliative care referral; 74.1 per cent had a hospice referral. Patients received a variety of interventions, and there was an associated complication in 8.2 per cent. The mean number of days spent in hospital for interventions was 11.9 days (standard deviation = 12.5; range, 0–41 days).ConclusionDifferent interventions are used to manage head and neck cancer patients with palliative intent, and these may be associated with significant morbidity. Survival time is variable, often several months; thus, any treatment must take into account morbidity in conjunction with the patient's wishes.

Background: Socioeconomic inequalities impact on the survival of head and neck cancer (HNC) patients, but there is limited understanding of the explanations of the inequality, particularly in long-term survival.\ud \ud Methods: Patients were recruited from the Scottish Audit of Head and Neck Cancer between 1999 and 2001 and were linked to mortality data as at 30th September 2013. Socioeconomic status was determined using the area-based Carstairs 2001 index. Overall and disease-specific survival were calculated using the Kaplan-Meier method with 95% confidence intervals (CI's) at 1-, 5-, and 12-years. Net survival at 1-, 5-, and 12-years was also computed with 95% CIs. Cox proportional hazard models with 95% CIs were used to determine the explanations for the inequality in survival by all-cause mortality and disease-specific mortality with 95% CIs.\ud \ud Results: Most patients were from the most deprived group, and were more likely to smoke, drink, have cancer of a higher stage and have a lower WHO Performance Status. A clear gradient across Carstairs fifths for unadjusted overall and disease-specific survival was observed at 1-, 5-, and 12-years for patients with HNC. Following the adjustment for multiple patient, tumor and treatment factors, the inequality in survival for patients with HNC had attenuated and was no longer statistically significant at 1-, 5-, and 12-years.\ud \ud Conclusion: A clear gradient across Carstairs fifths for unadjusted overall, disease-specific and net survival was observed at 1-, 5-, and 12-years for HNC patients in Scotland from 1999 to 2001. This study concludes that explanations for the inequality in the survival of patients with HNC are not straightforward, and that many factors including various patient, tumor and treatment factors play a part in the inequality in the survival of patients with HNC.

Objectives To demonstrate and quantify, in a preclinical setting, the benefit of three-dimensional (3D) navigation guidance for margin delineation during ablative open surgery for advanced sinonasal cancer. Materials and methods Seven tumor models were created. 3D images were acquired with cone beam computed tomography, and 3D tumor segmentations were contoured. Eight surgeons with variable experience were recruited for the simulation of osteotomies. Three simulations were performed: 1) Unguided, 2) Guided using real-time tool tracking with 3D tumor segmentation (tumor-guided), and 3) Guided by 3D visualization of both the tumor and 1-cm margin segmentations (margin-guided). Analysis of cutting planes was performed and distance from the tumor surface was classified as follows: “intratumoral” when 0 mm or negative, “close” when greater than 0 mm and less than or equal to 5 mm, “adequate” when greater than 5 mm and less than or equal to 15 mm, and “excessive” over 15 mm. The three techniques (unguided, tumor-guided, margin-guided) were statistically compared. Results The use of 3D navigation for margin delineation significantly improved control of margins: unguided cuts had 18.1% intratumoral cuts compared to 0% intratumoral cuts with 3D navigation (p Conclusion This preclinical study has demonstrated the significant benefit of navigation-guided osteotomies for sinonasal tumors. Translation into the clinical setting – with rigorous assessment of oncological outcomes – would be the proposed next step.

Objective:In Scotland, patients with suspected head and neck cancer are referred on the basis of the Scottish Referral Guidelines for Suspected Cancer, rather than the National Institute for Health and Care Excellence guidelines. A chest X-ray should be requested by the general practitioner at the same time as referral for persistent hoarseness. The evidence for this is level 4.Methods:This audit identified adherence to this recommendation and X-ray results. All ‘urgent suspicion of cancer’ referrals to the ENT department in the National Health Service Greater Glasgow and Clyde for 2015–2016 were audited.Results:Persistent hoarseness for more than 3 weeks instigated referral in 318 patients (15.7 per cent). Chest X-ray was performed in 120 patients (38 per cent), which showed: no abnormality in 116 (96.7 per cent), features of infection in 2 (1.7 per cent) and something else in 2 patients (1.7 per cent). No chest X-ray altered the management of a patient.Conclusion:Performance of chest X-ray does not alter management and its removal from the Scottish Referral Guidelines for Suspected Cancer is recommended.

Objectives To assess how type and number of symptoms are related to survival in patients with head and neck cancer. Design Patients were followed up for over 10 years from the Scottish Audit of Head and Neck Cancer (national cohort of head and neck cancer patients in Scotland 1999‐2001). September 2013, cohort was linked to national mortality data. First, second and third presenting symptoms were recorded at diagnosis. Setting National prospective audit—Scotland. Participants A subset of 1589 patients, from the original cohort of 1895, who had cancer arising from one of the four main subsites; larynx, oropharynx, oral cavity and hypopharynx. Main outcome measures Median survival in relation to patients’ presenting symptoms. Results A total of 1146 (72%) males and 443 (28%) females, mean age at diagnosis 64 years (13‐95). There was a significant difference in survival in relation to the number of the patient's presenting symptoms; one symptom had a median survival of 5.3 years compared with 1.1 years for three symptoms. Patients who presented with weight loss had a median survival of 0.8 years, compared to 4.2 years if they did not (P < .001). Patients who presented with hoarseness had a median survival of 5.9 years compared to 2.6 years without (P < .001). There was no significant difference in long‐term survival for patients who presented with an ulcer, compared to those that did not (P = .105). Conclusions This study highlights the importance of patients’ presenting symptoms, giving valuable information in highlighting appropriate “red flag” symptoms and subsequent treatment planning and prognosis.

Background\ud \ud Tonsillitis is a common condition with an incidence in UK general practice of 37 per 1000 population a year.1 Recurrent tonsillitis results in significant morbidity and impacts on individuals’ quality of life. This study assesses the morbidity and quality of life of adults with recurrent tonsillitis, and the impact of surgical intervention on their health state.\ud Objectives\ud \ud To describe disease-specific and global quality of life for adults with recurrent tonsillitis 6 months after tonsillectomy, using two instruments: the health impact of throat problems (HITP) and EuroQol-visual analogue scale questionnaire. To assess the overall health benefit from tonsillectomy as an intervention using the Glasgow Benefit Inventory (GBI). To assess potential predictors of tonsillectomy benefit.\ud Design\ud \ud A prospective, observational cohort audit of patients who have fulfilled Scottish Intercollegiate Guideline Network (SIGN) criteria for tonsillectomy.2\ud Setting\ud \ud Secondary care, teaching hospital.\ud Participants\ud \ud Seventy patients (57 female), median age 20 years (range 13-41).\ud Results\ud \ud Median preoperative HITP was 47 (range 15-67), compared to 4 (0-72), (P

Background:There has been a surge in the popularity of loom bands amongst children in recent months. These small rubber bands, which can be woven together to make colourful bracelets and necklaces, have become the world's most popular toy. Foreign bodies in paediatric nasal and aural cavities are a common presentation to ENT units across the country. Whilst most are removed without incident, foreign bodies in nasal passages represent a potential risk for inhalation, leading to airway obstruction.Method:This paper reports a case series of four paediatric patients who presented with a loom band associated foreign body in the nose over a 7-day period at a district general hospital in Scotland.Conclusion:Although the four cases presented were resolved without the need for general anaesthetic, the ever-soaring prevalence and popularity of loom bands necessitates a degree of caution and vigilance from parents, retailers and manufacturers alike. We believe there is an urgent need for greater public awareness of their potential hazards.

Background:The electroglottogram approximate entropy value is a numerical variable which gives an overall measure of voice quality. It is derived by analysing the complexity of the electroglottogram waveform using regulatory statistics.Aims:(1) To use electroglottogram approximate entropy to measure voice quality in patients with glottic pathology and in normal subjects, to ascertain whether this parameter can distinguish between pathological and normal voices. (2) To ascertain whether electroglottogram approximate entropy can measure voice change over time within individual subjects. (3) To determine any correlation between electroglottogram approximate entropy and the grade–roughness–breathiness–asthenia–strain scale.Methods:One hundred and forty-one normal volunteers were recruited to characterise electroglottogram approximate entropy in the normal voice. One hundred and eighty-six patients with glottic squamous cell carcinoma underwent electroglottogram approximate entropy measurement prior to radiotherapy and then three to six months and one year after treatment. Subjects’ voices were categorised by a speech therapist using the grade–roughness–breathiness–asthenia–strain scale.Results:The mean electroglottogram approximate entropy of the normal volunteers was 0.302 (range 0.05–0.42). The mean electroglottogram approximate entropy of the glottic squamous cell carcinoma patients was significantly lower prior to treatment, at 0.227 (range 0.001–0.397;p Conclusion:Electroglottogram approximate entropy can be used to assess change in voice quality resulting from glottic morphological abnormality. Electroglottogram approximate entropy values improve as voice quality improves after treatment. Electroglottogram approximate entropy values correlate significantly with grade–roughness–breathiness–asthenia–strain scale results.