Paediatric Laryngeal Synovial Sarcoma: Dilemmas and Decision-Making

Primary laryngeal synovial sarcoma is a rare head and neck cancer. We describe a case of synovial sarcoma of the larynx in a previously well 9-year-old boy with a one-month history of a progressively enlarging neck lump. He was referred to our institution after incomplete surgical excision of the then undifferentiated neck mass. A partial laryngectomy including wide local excision of the residual mass was performed. An ipsilateral level I-III neck dissection was also performed concurrently. Clear re-excision margins were achieved. The neck nodes were all negative for metastatic disease. Adjuvant local radiotherapy treatment was administered to reduce the probability of local recurrence. Four years following treatment completion, the patient remains in remission with no signs of treatment-related morbidity. A review of the published literature on laryngeal synovial sarcoma was undertaken. This case represents the youngest patient to be diagnosed with the condition. Surgical excision represents the mainstay of treatment of laryngeal synovial sarcoma. At more common sites of disease, adjuvant radiotherapy has been associated with lower rates of recurrence. However, there is the potential for significant morbidity from irradiating the neck of a paediatric patient. This case report explores the challenges in treating young patients with aggressive head and neck cancers when faced with little available evidence to guide decision-making.

Systematic review of head and neck lymphedema assessment

Head and neck lymphedema (HNL) is an increasingly recognized complication of head and neck cancer and its treatment. However, no consensus exists on the "gold-standard" assessment tool for the purposes of diagnosis, classification, or monitoring of HNL. We conducted a systematic review of the literature regarding HNL assessment to determine the optimal method/s of assessment for patients with HNL. A review of publications between January 2000 and September 2021 was undertaken on four electronic databases. Studies were excluded if no clear assessment method of HNL was documented. Sixty-seven articles were included in the study. A wide range of assessment methods for HNL have been reported in the literature. For the purposes of diagnosis and classification of physical findings, computed tomography (CT) appears the most promising tool available for both external and internal HNL. In terms of monitoring, ultrasound appears optimal for external HNL, while a clinician-reported rating scale on laryngoscopy is the gold standard for internal HNL. Patient-reported assessment must be considered alongside objective methods to classify symptom burden and monitor improvement with treatment.

Timing of Ansa Cervicalis-to-recurrent Laryngeal Nerve Reinnervation: A Systematic Review

BACKGROUND

Ansa cervicalis-to-recurrent laryngeal nerve anastomosis (ARA) is an established technique for the treatment of recurrent laryngeal nerve (RLN) injury after head and neck surgery. However, the optimal timing of ARA remains unclear, and the evidence bases for ARA performed at each timepoint after RLN injury have not previously been clearly distinguished. We conducted a systematic review of the literature to evaluate the efficacy of ARA performed at different timepoints on postoperative voice outcomes.

METHODS

A review of English-language journal articles published in the last 20 years was undertaken on three electronic databases: Ovid MEDLINE, PubMed and Embase. Studies with a focus on paediatric RLN injury, bilateral RLN injury, ansa cervicalis anatomy and non-ARA techniques alone were excluded.

RESULTS

Twenty eight articles were included in the review. ARA was performed as a delayed surgery in 16/28 studies (57%), while immediate ARA was utilized in 14/28 studies (50%). On qualitative synthesis, delayed ARA was shown to be effective in improving patient-reported, subjective observer-reported and objective observer-reported voice outcomes. Likewise, a substantial body of evidence was identified demonstrating postoperative voice improvement with immediate ARA. On direct comparison of timepoints, some benefit was shown for early delayed ARA relative to late delayed operations, while no comparative data for immediate versus delayed repair were available in the literature.

CONCLUSIONS

ARA at both delayed and immediate timepoints is effective in the treatment of patients with RLN injury after head and neck surgery. The timing of ARA may have some influence on its efficacy, with early delayed repair potentially associated with superior outcomes to late delayed operations, and immediate ARA offering several practical advantages relative to delayed repair. Further comparative studies are required to better characterize the optimal timing of ARA after RLN injury.

Tranexamic acid in otorhinolaryngology - A contemporary review

Tranexamic acid (TXA) is an anti-fibrinolytic agent which has been proven beneficial in multiple surgical specialties where significant bleeding can occur. Whilst it has been widely available for over 40 years its use within Otorhinolaryngology is still limited. Operations in Otorhinolaryngology are particularly varied with some such as tonsillectomy having the potential for significant life threatening bleeding. Other operations are performed within small confined surgical fields and even small amounts of bleeding can significantly detriment surgical field and increase technical difficulty and operative time. This review evaluated the current literature on the benefits of tranexamic acid within the field of Otorhinolaryngology and Head and Neck Surgery. Overall TXA was demonstrated to be a safe drug with no major adverse effects including thromboembolic events reported in any study. It has been shown to be of particular benefit in rhinology by improving surgical field, reducing operative time and reducing postoperative swelling and ecchymosis. The benefit in tonsillectomy is less clear and further studies are required to evaluate its potential use in the reduction of post tonsillectomy haemorrhage rates.

Meta-analysis on the rate of pharyngocutaneous fistula in early oral feeding in laryngectomy patients

BACKGROUND

Laryngectomy remains a common operation in head and neck units. The operation holds significant risk of post-operative morbidity including swallowing dysfunction. The most significant post-operative concern is the formation of a pharyngocutaneous fistula [PCF], the reported incidence of which is between 3% and 65%. The purpose of this systematic review and meta-analysis was to assess the safety of initiating early oral feeding following laryngectomy and the risk of PCF formation.

METHODS

A literature search was conducted through online databases: MEDLINE, EMBASE and PubMed. Eligible studies were included which contained cohorts of patients who had undergone laryngectomy, with early oral feeding commencing within seven days compared to late oral feeding. The primary outcome assessed was the incidence of PCF. Studies were excluded if cohorts had not included laryngectomy or if no comment was made on PCF formation. Meta-analysis was used to examine associations between oral feeding and PCF formation using Fixed Effect models.

RESULTS

Twelve studies and 1883 patients were included after systematic review. Six studies were non-interventional whereas the remaining were randomized clinical trials. Exposure included those with early oral feeding (before seven days) or late feeding oral feeding (after seven days) and the outcome assessed was the risk of PCF formation. Results from observational studies showed a higher risk of PCF formation for early feeders compared to late feeders [RR = 1.56, 95% CI: 1.15, 2.11]. Higher risk was also observed for RCT but was not significant [RR = 1.40, 95% CI: 0.85, 2.30]. Overall, there was a 50% greater risk of PCF formation for early oral feeding compared to late oral feeding [RR = 1.51, 95% CI: 1.17, 1.96].

CONCLUSION

While early oral feeding can reduce post-laryngectomy patients' hospital stay and improve psychological wellbeing, there is a significant relative risk of PCF development within this group. However, this must be taken in context of the significant heterogeneity that exists within the literature.

Acinic cell carcinoma of the salivary gland in the adult and paediatric population: a survival analysis

BACKGROUND

Acinic cell carcinoma (AcCC) is a rare malignant neoplasm of the salivary glands and generally considered to be a low-grade tumour. Surgical treatment is often curative, but a more aggressive high-grade variant has been associated with poorer survival and propensity for distant metastasis. No standard treatment guidelines exist and the approach to treatment is varied in the published series. The aim of this study is to present the experience of three major hospitals in Sydney, Australia, in treating AcCC of the salivary gland, with a focus on clinico-pathological features of disease and their associations with survival outcomes.

METHODS

Adult and paediatric cases of AcCC of the salivary gland during the time period 1979-2018 were retrospectively included. Demographic, clinico-pathological, treatment and survival outcome data were extracted. Survival analysis was undertaken to assess the effect of clinical and pathological variables on overall and disease-free survival.

RESULTS

Thirty-two cases were reviewed (29 adult and three paediatric). Thirty tumours (93.8%) were parotid gland primary tumours. Mean overall and disease-free survival was 17.0 ± 0.7 and 16.0 ± 0.9 years, respectively. Features associated with poorer survival were cT staging >1, presence of preoperative clinical facial nerve deficit and local recurrence. Positive margins were associated with recurrence.

CONCLUSION

These data suggest that disease-free and overall survival in AcCC of the salivary gland is excellent with surgery as the first-line treatment. Poor survival outcomes are uncommon and may be associated with locally advanced disease in the presence of other well-established high-risk features.

Systematic review of laryngocele and pyolaryngocele management in the age of robotic surgery

OBJECTIVE

A laryngocele is a space that develops as a result of pathological dilatation of the laryngeal saccule. However, the reported management of laryngoceles varies. We conducted a systematic review of the literature regarding the surgical management of laryngoceles and pyolaryngoceles, to understand the evolving nature of treatment for this rare condition.

METHODS

We searched for publications in the PubMed, Cochrane Library, JBI Library of Systematic Reviews, and Ovid databases using the terms "laryngocele", "pyolaryngocele", and "laryngopyocele", and reviewed the identified articles.

RESULTS

After removal of repeated studies and filtering for relevance and studies written in English, a total of 227 studies were included in this review. No meta-analyses or randomized controlled trials have been published. The identified studies have been summarized in 14 reviews conducted since 1946. The meta-analysis determined that endoscopy was the preferred approach for internal laryngoceles, while combined laryngoceles benefited from both internal and external surgical approaches.

CONCLUSIONS

Laryngocele management has progressed since its initial description, from open surgery to an endoscopic approach, and more recently to a robotic-assisted surgical approach. The uptake of robotic surgery as a possible treatment modality over the last decade shows much promise for the treatment of these conditions.

Operative team checklist for aerosol generating procedures to minimise exposure of healthcare workers to SARS-CoV-2

OBJECTIVES

In many countries around the world, the COVID-19 pandemic has resulted in health services being diverted to manage patients with the condition. There are situations however that still require the undertaking of aerosol generating procedures (AGP) with potentially high exposure of healthcare workers to SARS-CoV-2 transmission through droplet, contact and possibly airborne routes. The objective of this paper is to explore a structured way for the operative team to approach AGP to reduce aerosolisation of secretions, decrease open airway time and minimise staff exposure.

METHODS

The authors (otolaryngologists, anaesthetists and nursing staff) created a unified operative team checklist based on collation of national and international specialty society statements, local state government recommendations, hospital policies and literature review. Simulation was undertaken and the checklist was refined after performing AGP on patients with unknown (presumed positive) COVID-19 status.

RESULTS

An 8 step operative team checklist is provided describing details for the immediate pre-operative, intra-operative and post-operative journey of the patient to encourage healthcare workers to reflect upon and modify usual practice during AGP to mitigate exposure to SARS-CoV-2. The example of paediatric laryngo-bronchoscopy for diagnostic purposes or retrieval of an inhaled airway foreign body is used to illustrate the steps however the checklist structure is modifiable for other AGP and adaptable for local needs.

CONCLUSIONS

At a time of overwhelming and changing information and recommendations, an operative team checklist may provide some structure to healthcare workers undertaking AGP to reduce anxiety, maintain focus, prompt consideration of alternatives and potentially reduce risk.

Laryngeal Synovial Sarcoma: A Systematic Review of the Last 40 Years of Reported Cases

Primary laryngeal synovial sarcoma is an extremely rare tumor predominantly affecting young adults. There are currently no well-defined guidelines to direct investigation and management, and treatment is largely based on what is known for synovial sarcoma of the upper and lower limbs. This PROSPERO-registered study aims to review the diagnostic methods, treatment regimens, and survival outcomes for patients with synovial sarcoma of the larynx. A systematic search of databases Medline, Embase, SCOPUS, and Web of Science was undertaken in December 2017. The literature search identified 1031 potentially relevant studies, and after the deletion of duplicates and excluded papers, 98 full-text articles were screened. A total of 39 cases were reviewed from 32 studies in the data extraction. The average age at the time of laryngeal synovial sarcoma diagnosis was 32 years (range, 11-79 years). In all cases (n = 39), patients underwent wide surgical excision, with 20 patients requiring a partial or total laryngectomy. A total of 18 patients received adjuvant and 3 received neoadjuvant radiotherapy. Chemotherapy was used in 10 cases, with ifosfamide the most frequently used agent. There was considerable variability in the order and combinations of the abovementioned treatments. No clinicopathologic factors or treatment regimens were associated with improved overall survival or lower rate of recurrence. There is a paucity of literature and heterogeneity in clinical approaches to this highly aggressive sarcoma. Reporting of cases must be standardized and formal guidelines must be established to guide clinical management.

B cell activating factor (BAFF) in the natural history of chronic hepatitis C virus liver disease and mixed cryoglobulinaemia

B cell activating factor (BAFF) plays a crucial role in the process of development, maturation and activation of B lymphocytes. Chronic hepatitis C virus (HCV) infection is characterized by multiple B cell disorders. It is a major cause of type II mixed cryoglobulinaemia (MC). We measured serum BAFF levels in several clinical situations to elucidate the potential role of BAFF in chronic HCV infection. We used a commercially available solid phase enzyme-linked immunosorbent assay. We estimated serum BAFF in stored sera from uninfected controls (n = 8), patients with chronic hepatitis B virus infection HBV (n = 5) and chronic HCV infection with (n = 16) and without mixed cryoglobulinaemia (n = 14). In two patients with HCV and MC we correlated BAFF with HCV RNA after pegylated interferon (peg-I). We correlated serum BAFF levels at baseline and at 12 weeks with treatment response: sustained virological response SVR (n = 5), non-responders (n = 6) and relapsers (n = 2). Finally, we estimated BAFF levels after complete depletion of B cells with rituximab in patients with chronic HCV with MC (n = 3). Serum levels of BAFF were increased in chronic HCV with MC, but not in chronic HBV infection, suggesting an association between BAFF and cryoglobulinaemia. Peg-I increased BAFF levels in serum and this paralleled HCV RNA very closely. Serum BAFF levels at week 12 of therapy with peg-I and R were significantly higher in responders than non-responders. Finally, B cell depletion was associated with markedly increased levels of BAFF.

Absolute and relative contraindications to pegylated-interferon or ribavirin in the US general patient population with chronic hepatitis C: results from a US database of over 45 000 HCV-infected, evaluated patients

BACKGROUND

Chronic hepatitis C (HCV) treatment with pegylated-interferon (PEG-IFN)/ribavirin (RBV) is often limited by preexisting medical, psychiatric and psychosocial contraindications. However, limited data exist in general patient populations.

AIM

To evaluate the percentage of HCV-infected patients in the general US population who may have contraindications to PEG-IFN/RBV.

METHODS

The General Electric (GE) Centricity dataset was used to screen the US population between 2004 and 2009 for HCV infection and contraindications to PEG-IFN/RBV. HCV diagnosis and contraindications were identified using ICD-9-CM codes or laboratory values. Only patients with an encounter 180 days prior to HCV diagnosis were included. Demographic differences were calculated using Pearson's chi-squared test. Frequencies and percentages for absolute and relative contraindications to PEG-IFN and/or RBV were determined and proportions and rates/1000 person-months were calculated.

RESULTS

A total of 15 561 021 patients were screened, and 45 690 (0.3%) were HCV-positive and were evaluated. Those with contraindications were significantly younger, female, White, not currently married and receiving Medicare or Medicaid coverage (all P < 0.0001). 17.3% had at least one contraindication to PEG-IFN/RBV (5.5 events/1000 person-months); bipolar disorder (6.5%), anaemia (Hgb < 10 g/dL; 5.9%), pregnancy (1.9%) and neutropenia (neutrophils <750 cells/mm(3) ; 1.2%) were most frequently cited.

CONCLUSIONS

Approximately, 17% of HCV-infected patients in the general US population had at least one contraindication to PEG-IFN/RBV. Most contraindications were relative and potentially modifiable. Clinical assessment of contraindications as relative and/or modifiable should be considered and used to determine if patients could benefit from current PEG-IFN-containing triple therapy or future PEG-IFN- or RBV-free regimens.

Injuries among Swedish female elite football players: a prospective population study

Injury occurrence in all 12 female elite senior football teams in premiere league was registered during 1 year. Of 269 players, 129 (48%) sustained 237 injuries. The total injury incidence was 4.6/1000 h of football. The injury incidence during practice was 2.7 and during the game time was 13.9/1000 h. The highest injury incidence during practice was to the knee (0.8/1000 h) and thigh (0.5/1000 h), and during game time was to the knee (4.4/1000 h) and head (2.2/1000 h). In total, the location for the highest injury incidence was the knee with 1.5 injuries/1000 h of football. The majority of injuries (82%) were localized to the lower extremities. Sixty-six injuries (28%) were re-occurring injuries (re-injuries). The incidence of traumatic injuries was 3.3/1000 h of football and for overuse injuries 1.3/1000 h. Overuse injuries occurred mainly during the preseason and at the beginning of the spring season. Thirty-nine percent of the injuries were slight or minor causing absence from practice or game time of less than 1 week, 39% were moderate (absence 7-28 days) and 22% were major (absence more than 28 days). The major injuries occurred often owing to trauma and were mainly to the knee.

Optimisation and validation of a medium-throughput electrophysiology-based hERG assay using IonWorks™ HT

INTRODUCTION

Regulatory and competitive pressure to reduce the QT interval prolongation risk of potential new drugs has led to focus on methods to test for inhibition of the human ether-a-go-go-related gene (hERG)-encoded K+ channel, the primary molecular target underlying this safety issue. Here we describe the validation of a method that combines medium-throughput with direct assessment of channel function.

METHODS

The electrophysiological and pharmacological properties of hERG were compared using two methods: conventional, low-throughput electrophysiology and planar-array-based, medium-throughput electrophysiology (IonWorks HT). A pharmacological comparison was also made between IonWorks HT and an indirect assay (Rb+ efflux).

RESULTS

Basic electrophysiological properties of hERG were similar whether recorded conventionally (HEK cells) or using IonWorks HT (CHO cells): for example, tail current V1/2 -12.1+/-5.0 mV (32) for conventional and -9.5+/-6.0 mV (46) for IonWorks HT (mean+/-S.D. (n)). A key finding was that as the number of cells per well was increased in IonWorks HT, the potency reported for a given compound decreased. Using the lowest possible cell concentration (250,000 cells/ml) and 89 compounds spanning a broad potency range, the pIC50 values from IonWorks HT (CHO-hERG) were found to correlate well with those obtained using conventional methodology (HEK-hERG)(r=0.90; p<0.001). Further validation using CHO-hERG cells with both methods confirmed the correlation (r=0.94; p<0.001). In contrast, a comparison of IonWorks HT and Rb+ efflux data with 649 compounds using CHO-hERG cells showed that the indirect assay consistently reported compounds as being, on average, 6-fold less potent, though the differences varied depending on chemical series.

DISCUSSION

The main finding of this work is that providing a relatively low cell concentration is used in IonWorks HT, the potency information generated correlates well with that determined using conventional electrophysiology. The effect on potency of increasing cell concentration may relate to a reduced free concentration of test compound owing to partitioning into cell membranes. In summary, the IonWorks HT hERG assay can generate pIC50 values based on a direct assessment of channel function in a timeframe short enough to influence chemical design.

Analysis of the formed track in solid state materials using atomic force microscopy

The track formation in solid state materials, from the theoretical point of view, is still under study. One way to understand the track formation mechanisms and radiation damage of the charged particles in some materials such as polymers, glasses and minerals, is to analyse the surface topography effects. In this work, the track formation analysis in polycarbonate material is presented using an atomic force microscope (AFM) to characterise the evolution of the track on the material surface and beyond a thin layer of the surface material. The AFM is very useful to obtain valuable information at the level of the atomic structure of the materials and of the nuclear tracks, due to its high resolution and very easy operation involving also a simple sample preparation. The results show the development of the formed track by means of induced surface effects after being exposed to ionising radiation and chemical etching.

Chronic oesophagitis in the cat

BACKGROUND

Our understanding of the pathophysiology of gastro-oesophageal reflux disease (GERD) in man is limited. The aim of the present study was to establish a long-term (>1 year) animal model for reflux oesophagitis which would allow us to study various aspects of the development of chronic reflux oesophagitis.

METHODS

Myotomy was carried out in the gastro-oesophageal junction in eight cats; seven other cats were sham-operated. Before the operation, and every 2 months thereafter, oesophagoscopy was carried out, biopsies were taken for histology, and manometry was performed to determine the lower oesophageal sphincter pressure (LESP). The cats were killed 1 year after the operation.

RESULTS

The myotomy operation resulted in a significantly decreased LESP. In oesophageal biopsies from these cats, there was a varying degree of oesophagitis starting already 2 months after surgery. In six of the eight myotomized cats there was hyperplasia of the stratum basale, and cardiac type metaplasia was observed in two cats. The control cats showed no significant changes in LESP or in the histology of the oesophagus.

CONCLUSIONS

In cats followed for more than a year, myotomy in the gastro-oesophageal junction results in reflux oesophagitis similar to that seen in patients with chronic gastro-oesophageal reflux.

Screening of ion channel receptor agonists using capillary electrophoresis-patch clamp detection with resensitized detector cells

Efficient techniques for identifying endogenous and synthetic ligands of ion channels are important in understanding neuronal communication and for screening drug libraries. This paper describes a technique based on capillary electrophoresis (CE) separation coupled to patch-clamp (PC) detection where a pulsed-flow superfusion scheme was implemented for improved detection. The nicotinic acetylcholine receptor (nAChr) agonists acetylcholine, carbachol, and (-)-nicotine were fractionated and detected by patch-clamped pheochromcytoma detector cells. The high-conductance state of the nAChr during CE-PC detection was maintained and repetitively resensitized using pulsed-flow superfusion with agonist-free buffer. In this way, each agonist evoked an ensemble of peak currents that reflected the spatiotemporal distribution for the ligand at the cell surface. The technique takes advantage of the intrinsic high selectivity and sensitivity of membrane-expressed receptors and allowed for resolution and identification of closely migrating ligands. The method was employed for determination of acetylcholine content in cell lysates.

Management of interferon relapsers

Relapse in patients who have evidenced an initial response to a course of interferon monotherapy for chronic hepatitis C virus (HCV) infection has been a major frustration. At least 70% of responders will relapse after a 6-month course of treatment and more than 50% will relapse after a 12-month course of treatment, usually within the first 3 to 6 months after treatment discontinuation. At most, half of patients relapsing after an initial 6-month course will have a sustained response to a second, 12-month course of interferon monotherapy. A more promising second-line regimen is the combination of interferon plus ribavirin. A recent multicenter international trial has shown that this regimen results in a sustained virologic response rate of nearly 50%, fully 10-fold higher than the sustained response rate observed with a second 6-month course of interferon alone (49% vs 5%, respectively). In patients with non-1 genotype and viral levels no greater than 2 million copies/mL, the likelihood of sustained response to the second course of combination therapy was 100%. Biochemical and virologic responses (normalization of liver enzymes and disappearance of HCV RNA from the serum) were frequently accompanied by histologic improvement. HCV-RNA levels < or = 2 million copies/mL and non-1 viral genotype predicted treatment response, whereas age, gender, body weight, source of infection, type of interferon used for the first round of treatment, and elapsed time since first treatment had no effect. Based on these data, combination therapy with interferon and ribavirin is now considered the treatment of choice for relapsers. It is not clear whether 12 months of combination therapy might have produced even better rates of viral eradication in relapsed patients.