Epidemiology and management of oral cavity squamous cell carcinoma in Ireland

INTRODUCTION

The epidemiology and management of oral cavity cancer have changed considerably in recent decades. This study examines epidemiological and management trends in oral cavity squamous cell carcinoma (OCSCC).

METHODS

A retrospective cohort study of data from the National Cancer Registry of Ireland between 1994 and 2014.

RESULTS

A total of 2725 patients were identified. The most common subsites were the tongue (34 %, n = 1025), lip (19 %, n = 575), floor of mouth (FOM) (18 %, n = 550), and retromolar trigone (RMT) (6 %, n = 189). The incidence of OCSCC remained largely unchanged (3.14 cases/100000/year) during the study period. 5-year disease-specific survival (DSS) was 58.6 % overall, varying between subsites (lip 85 %, RMT 62.9 %, tongue 54.7 %, and FOM 47.3 %). DSS improved over the study period (p = 0.03), in particular for tongue primaries (p = 0.007). Primary surgery significantly improved DSS versus radiotherapy (HR 0.28, p < 0.0001). Survival of T4 disease managed surgically was superior to that of T1 disease managed with radiotherapy. In node positive patients, chemotherapy improved overall survival (HR 0.8 p = 0.038) but not DSS (HR 0.87 p = 0.215).

CONCLUSION

Primary surgery remains the standard of care in the management of OCSCC. Prognosis has improved in line with an increase in the use of primary surgery in the same time frame, though the incidence remains unchanged.

The role of surgery for anaplastic thyroid carcinoma in the era of targeted therapeutics: A scoping review

Background

Questions exist regarding patient selection for surgery in anaplastic thyroid carcinoma (ATC), particularly with the advent of neoadjuvant-targeted therapeutics. The present scoping review sought to evaluate what extent of surgical resection should be performed in ATC.

Methods

A scoping review was carried out in accordance with Joanna Briggs Institute and the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) protocols. Included studies were required to provide clear description of the surgery performed for ATC.

Results

The final search identified 6901 articles. Ultimately only 15 articles including 1484 patients met inclusion criteria. A total of 765 patients (51.5%) underwent attempted curative intent surgery. The approach to resection of adjacent tissues varied between studies. Eight studies considered laryngeal ± pharyngeal resection (8/15, 53.3%), eight studies (53.3%) considered tracheal resection and again eight studies (53.3%) considered esophageal resection. More extensive resections increased morbidity without improving overall survival (OS) (<9 months in the 12 studies using a combination of surgery and chemoradiotherapy). In the three studies utilizing targeted therapy in addition to surgery, OS was notably improved while surgical resection following neoadjuvant therapy was less extensive.

Conclusions

There is no clear agreement in the literature regarding the limits of surgical resection in locoregionally advanced ATC. A definition of surgically resectable disease will be required to guide surgical decision making in ATC, particularly with the potential to reduce tumor burden using neoadjuvant targeted treatment in suitable patients.

Level of evidence

III.

Factors affecting Naseptin treatment success - A prospective cohort study

OBJECTIVE

To assess patient factors to predict treatment success of Naseptin for recurrent paediatric epistaxis.

METHODS

This prospective cohort study of paediatric patients referred to a tertiary paediatric otolaryngology clinic with recurrent epistaxis treated with Naseptin cream and education. Patients with red flag symptoms and bleeding diathesis were omitted, along with patients with concurrent otolaryngology complaints. Statistical analysis included logistic regression analysis to assess for predictive factors contributing to treatment success.

RESULTS

125 of 210 patients on the waiting list met the inclusion criteria and were given a complete trial of Naseptin. 80.8% (n = 101) of patients found that the frequency and severity of epistaxis had reduced, with the remaining 19.2% (n = 24) reporting that the episodes of epistaxis remained the same and required further management (i.e., silver nitrate cautery). Five patients (4%) reported minor side effects (skin irritation etc.) with no significant adverse events reported.

CONCLUSION

We found that Naseptin is a safe, well-tolerated treatment that should be trialled in most cases of recurrent paediatric epistaxis. Most children will benefit from it with complete epistaxis cessation or at least reduced frequency and severity.

A multi-disciplinary team approach to pediatric malignant mandibular tumors

OBJECTIVE

Mandibular tumors in the pediatric population are rare. These malignancies are variable in their histology, and combined with their rarity, has made it difficult to describe their clinical course, and treatment guidelines. The aim of this paper is to describe the experience of Boston Children's Hospital, a pediatric tertiary referral center, with treating malignant mandibular malignancies, as well as provide multi-disciplinary team approach in managing this clinical entity.

METHODS

A retrospective search was performed for mandibular malignancies in pediatric patients between 1995 and 2020 via the pathological database at Boston Children's Hospital. Only patients with malignant solid mandibular neoplasms were included, leaving 15 patients for final analysis.

RESULTS

The median age at presentation was 10.1 ± 10.3 years. Nine of 15 patients (60%) presented with jaw mass which was the most common clinical presentation. The most commonly identified histological diagnosis was rhabdomayosarcoma and osteosarcoma (n = 4, 26% each). A mandibulectomy was performed in 12 (80%) cases. Reconstruction of the mandible was performed using a fibular free flap in 6 (40%) cases, and a plate in 3 (20%) cases. Mean follow-up was 4.6 ± 4.9 years.

CONCLUSION

Malignant tumors most commonly present with a jaw mass, however asymptomatic and incidental presentations follow closely and pathologies can vary greatly. Surgical resection and reconstruction is often indicated, multidisciplinary tumor board review is required to determine when children are best treated with neo-/adjuvant treatment with chemo- and radiotherapy.

Pattern of nodal metastasis of cutaneous squamous cell carcinoma involving the temporal bone

Objective

The objective of this study was to explore the pattern of lymph-node spread of SCCs involving the temporal bone.

Methods

We retrospectively reviewed all cutaneous SCCs involving the temporal bone over a 20-year time-period. Forty-one patients were eligible.

Results

Mean age was 72.8 years. The diagnosis was cutaneous SCC in all cases.All patients underwent a temporal bone resection, 70.7% had a neck-dissection and 78.0% a parotidectomy.Level 2 was the most common area of neck metastasis, and occurred in 12.2%. The parotid had disease in 34.1%. 51.2% of patients underwent free-flap reconstruction.Mean overall survival of the cohort was 4.2 years.

Conclusions

Overall, the rate of cervical nodal metastasis was 22.0% and 13.5% in the occult setting. The parotid was involved in 34.1% and 10.0% in the occult setting. Results from the present study support consideration for performing a parotidectomy at the time of temporal bone resection, while a neck dissection can be performed for adequate staging of the nodal basin.

Level of Evidence

3.

Supporting the use of adjuvant radiotherapy in recurrent pleomorphic adenoma of the parotid

BACKGROUND

The use of adjuvant radiotherapy remains controversial in the treatment of recurrent pleomorphic adenomas.

AIMS/OBJECTIVES

The aim of this study was to provide the highest level of evidence possible by performing a systematic review and meta-analysis of the literature.

MATERIAL AND METHODS

We searched the English-language literature between 1985 and 2019.Inclusion criteria included any study on the treatment and outcome of recurrent pleomorphic adenomas. Exclusion criteria included the use of radiotherapy for residual tumors, case reports, and pleomorphic adenomas not arising from the parotid.

RESULTS

A total of 522 abstracts were studied, data analyzed from 14 studies, on a total of 697 patients. When the data werepooled, the overall risk of further recurrence was 21%. In studies where surgery alone was undertaken this increased to 26% and decreased to 10% in those receiving adjuvant radiotherapy (p = .000). There were 21 recurrences in 159 patients in the radiotherapy group, and 151 recurrences out of 538 patients in the surgery group (p < .0001).

CONCLUSIONS

These data support the use of radiotherapy to decrease the risk of re-recurrence in recurrent pleomorphic adenoma.

SIGNIFICANCE

This study is the highest level of evidence currently available in guiding management of recurrent pleomorphic adenoma.

Impact of the COVID-19 Pandemic on Pelvic and Acetabular Trauma: Experiences From a National Tertiary Referral Centre

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on daily life. Restrictions imposed to help minimise virus transmission have limited both population movement and employment, as well as altering the potential mechanisms of high-energy trauma. The objective of this study was to assess the impact of the COVID-19 pandemic on pelvic and acetabular trauma.

Materials and methods

A retrospective observational study of the incidence, causality, patient profile, fracture morphology, and treatment strategy of pelvic and acetabular trauma managed in a national tertiary referral specialist pelvic and acetabular centre between the 1^st of March and 1^st of August 2020 was undertaken and compared to corresponding time periods in the two preceding years.

Results

A total of 78 patients were referred for management following pelvic and acetabular trauma during the study period with a mean age of 52 years (SD +/- 24.2). Overall, 45% and 42% of patients were referred following isolated pelvic or acetabular fractures respectively. The most frequent mechanism of injury was a fall from height (>1m) (42%), with 53% of patients suffering from concomitant injuries and 32% requiring surgical management. While there was a statistically significant difference in mechanism of injury (P=0.026), there was no significant difference in overall incidence, fracture types, incidence of concomitant injuries, or overall proportion requiring surgical intervention during the study period when compared to previous years.

Conclusion

While some variation in the mechanisms of injury have been observed, the overall incidence, patient, fracture, and injury profiles associated with pelvic and acetabular trauma appear to have remained consistent during the COVID-19 pandemic. Additionally, the number and proportion of those requiring surgical treatment of these fractures have remained stable. Understanding the continued burden of these potentially severe injuries may help guide injury prevention, treatment, and resource allocation as the pandemic continues.

Differences in patient satisfaction with virtual telephone clinics in a tertiary referral centre for otolaryngology during and after lockdown measures during the SARS-Cov2 pandemic

Introduction

The SARS-Cov2 pandemic has caused considerable disruption to provision of routine outpatient care. This pandemic has necessitated a more modern and innovative approach to clinics, which could potentially change outpatient organisation and improve efficiency in the long term. Telephone clinics are the most practical way to deliver healthcare at a distance.

Aim

The purpose of the present study was to assess patient satisfaction with a virtual telephone clinic in a tertiary referral centre for otolaryngology first during the height of the SARS-Cov2 pandemic, and subsequently at a physical follow-up appointment after easing of “lockdown” measures.

Methods

Patients were enrolled prospectively via a telephone interview over a 1-week period during the height of the “lockdown” measures, and subsequently at a physical appointment when measures eased.

Results

Overall, patients responded very positively in the anonymised questionnaire at the time of their virtual appointment. However, at a subsequent physical appointment, there was a reduction in overall favourable responses from patients. While patients still thought virtual clinics were a good idea and convenient in the context of SARS-Cov2, we noted a reduction in satisfaction in other key aspects of their care. Notably, patients were less likely to think that virtual clinics were able to properly address their condition.

Conclusion

While virtual clinics remain a useful tool during the height of lockdown measures during the SARS-Cov2 pandemic, we did note a significant reduction in favourable responses to virtual appointments over physical ones upon easing of lockdown measures. Patients remained cautious in suggesting that outpatient appointments may be replaced by virtual clinics.

Tracheostomy stomal seeding following oral cavity resection

BACKGROUND

Tracheal stoma recurrence following oral cavity surgery is exceedingly rare. Although several different mechanisms for this have been described, the pathogenesis still remains uncertain.

METHODS

We present the case of a gentleman who presented 6-months following oral cavity SCC resection with a large fungating mass at his previous tracheostomy site, and also review the reported literature on this rare phenomenon.

RESULTS

Four weeks after diagnosis of his recurrence he underwent a total laryngectomy, wide-local skin excision and reconstruction with a pectoralis major pedicled flap. He recovered well initially following his operation, however unfortunately contracted nosocomial SARS-Cov2 and succumbed from respiratory complications during his post-operative recovery.

CONCLUSION

Stomal recurrence after temporary tracheostomy for oral cavity malignancies are very rare. Previously reported management of these can vary from surgical to palliative treatment. Methods to prevent these include delaying tracheostomy until after surgical resection, packing the pharynx during resection and adjuvant radiotherapy.

Mortality risk in post-operative head and neck cancer patients during the SARS-Cov2 pandemic: early experiences

PURPOSE

The objective of this report is to outline our early experience with head and neck cancer patients in a tertiary referral center, during the SARS-Cov2 pandemic, and to describe the poor outcomes of patients who acquired the infection.

METHODS

In this case series from a single-center, national tertiary referral center for head and neck cancer we describe three consecutive head and neck cancer patients who contracted SARS-Cov2 during their inpatient stay.

RESULTS

Of the three patients described in our case series that contracted SARS-Cov2, two patients died from SARS-Cov2 related illness.

CONCLUSION

We have demonstrated the significant implications that SARS-Cov2 has on head and neck cancer patients, with 3 patients acquiring SARS-Cov2 in hospital, and 2 deaths in our that cohort. We propose a complete separation in the location of where these patients are being managed, and also dedicated non-SARS-Cov2 staff for their peri-operative management.

LEVEL OF EVIDENCE

IV.

Computed Tomography Data to Generate a Reproducible, Anatomically Accurate Hemilaryngeal Model

Objective

The study aims to demonstrate the reproducibility and feasibility of creating a hemilaryngeal model with a medialized vocal fold (VF) using 3-dimensional (3D) modeling techniques in both healthy larynges and those affected by cancer.

Study Design

Three-dimensional modeling of human larynges.

Setting

Tertiary academic referral center and regenerative medicine laboratory.

Subjects and Methods

Computed tomography (CT) scans from 10 healthy control and 10 patients with laryngeal cancer were segmented and imported into 3D modeling software. The larynx was cut sagittally to create a hemilaryngeal model and the vocal fold medialized. Measurements were taken from the CT and 3D model data and compared.

Results

All control modeling data closely matched the CT data and were not statistically different from each other. There was a significant correlation between subglottic anteroposterior diameter and VF length ( r2 = 0.78, P = .0008), and it may be a valuable tool to infer true VF dimension in cases where disruption has occurred. The modeling data from patients with cancer did not show statistical difference to the control data, showing that accurate modeling can also be achieved in patients with laryngeal cancer.

Conclusion

CT scan-based 3D modeling of the larynx and VF is possible and reproducible. The results closely match those previously reported in the literature and can also be replicated in cases with laryngeal cancer. This study paves the way for future de novo fabricated laryngeal scaffolds that can be synthesized using 3D printers and tailored to meet surgical demands.

The impact of repetitive hyperbaric exposure during SCUBA diving on cochlear implants

OBJECTIVES/HYPOTHESIS

Complications during or after cochlear implantation are relatively rare. They occur more frequently in patients who partake in activities that can potentially lead to local trauma. No formal recommendations exist for participation in self-contained underwater breathing apparatus (SCUBA) activities. We describe three patients with a combined five cochlear implants and extensive diving experience, the largest case series to date, and highlight some of the difficulties faced. We also review the literature on previously described SCUBA-diving patients with cochlear implants.

STUDY DESIGN

Retrospective case series and literature review.

METHODS

A review of the known SCUBA divers in the National Hearing Implant and Research Centre in Ireland was conducted, and a review of the literature was carried out using PubMed and Google Scholar.

RESULTS

Of the three SCUBA divers with cochlear implants, two required reimplantation, the first due to nonauditory stimulation, and the second due to extrusion of the electrode through the tympanic membrane following repetitive SCUBA dives. The third patient remains without complications after 80 dives.

CONCLUSIONS

Patients with cochlear implants can have complications relating to the implant itself, with device failure a theoretical risk. The cochleostomy can lead to perilymphatic extravasation, as well as inner ear barotrauma, decompression sickness, and formation of air bubbles along the electrode. A combination of deafness, vestibulopathy with abrupt perilymph leak, and loss of proprioception can lead to disorientation and blue dome syndrome. Based on our experience with cochlear implants in SCUBA divers, along with those reported in the literature, we recommend caution in patients with cochlear implants who SCUBA dive regularly and strict adherence to the recommended safety limits.

LEVEL OF EVIDENCE

4 129:2760-2764, 2019.

Development of xeno-free epithelial differentiation media for adherent, non-expanded adipose stromal vascular cell cultures

INTRODUCTION

Reconstruction of respiratory epithelium is critical for the fabrication of bioengineered airway implants. Epithelial differentiation is typically achieved using bovine pituitary extract (BPE). Due to the xenogenic nature and undefined composition of BPE, an alternative for human clinical applications, devoid of BPE, must be developed. The goal of this study was to develop two different BPE-free media, with and without select pituitary hormone (PH), which could initiate epithelial differentiation for use in human implantation.

METHODS

The ability of the two BPE-free media to initiate epithelial differentiation of adherent, non-expanded stromal-vascular cells grown on porcine small intestinal submucosa was compared to traditional BPE-containing media (M1). Nanostring^® was used to measure differences in gene expression of stemness (MSC), basal cell (basal), and ciliated markers (muco-cil), and staining was performed support the gene data.

RESULTS

Compared to baseline, both BPE-free media upregulated epithelial and stemness genes, however this was to a lower degree than BPE-containing media. In general, the expression of basal cell markers (COL17A1, DSG3, ITGA6, KRT6A, LOXL2) and secreted mucous proteins (PLUNC, MUC5B, SCGB2A1) was upregulated. The gene expression of ciliated markers C9orf24, TUBA3 and DNCL2B but not of the key transcription factor for cilagenesis FOXJ1 were upregulated, indicating that mucus-secreting cell differentiation occurs more rapidly than ciliogenesis. The ability of the adherent stromal vascular cells to upregulate gene expression of both epithelial and stemness markers suggests maintenance of the self-renewal capacity of undifferentiated and/or basal cell-like cells contributing to proliferation and ensuring a persisting source of cells for regenerative medicine applications.

CONCLUSION

This study provides the initial step to defining a BPE-free epithelial differentiation medium for clinical translation. Thus, either of the proposed BPE-free medium are viable alternatives to BPE-containing medium for partial epithelial differentiation for human translational applications.

Strengthening the case for gender-neutral and the nonavalent HPV vaccine

PURPOSE

The purpose of this review is to highlight the benefits of gender-neutral and the nonavalent human papillomavirus vaccination. Human papillomavirus infection is the most commonly sexually transmitted disease and is known to cause several types of cancers, including cervical, vulvar, vaginal, penile, oropharyngeal, anal, and rectal. 5% of cancers every year are attributable to human papillomavirus infection, with cervical cancer the most common and oropharyngeal cancer estimated to surpass the incidence of cervical cancer by 2020.

METHODS

PubMed and MEDLINE were searched using the following search terms: [(human papillomavirus OR HPV) AND (vaccine OR vaccination)] AND [(gardasil OR gardasil9 OR cervarix OR quadrivalent OR nonavalent OR ninevalent) OR (gender neutral OR male)].

RESULTS

There are currently three different types of human papillomavirus vaccinations and range in cover from four to nine different strains known to cause human disease. Most countries currently only supply vaccination to females; however, recent data point towards both a personal benefit as well as a cost-effective population-based benefit with gender-neutral vaccination. Data from female vaccination only have shown the vaccine to be effective in preventing premalignant cervical lesions, and are believed to have the same effect for other human papillomavirus cancers. Male vaccination not only provides personal benefit but also has a "herd effect" for females by preventing the propagation of the virus.

CONCLUSION

Gender-neutral vaccination provides significant cost-effective benefits for preventing human papillomavirus-related diseases, and this effect is further enhanced by the use of the nonavalent vaccine.

Paratesticular myositis ossificans of the spermatic cord

A 56-year-old man presented with a painless scrotal lump, enlarging over the preceding 1 month. The lump was roughly 1 cm in size, and located in his left hemiscrotum and separate from the testis. An ultrasound revealed an echogenic focus with dystrophic tissue calcification. Subsequent surgical excision and histopathological analysis revealed it to be late-stage myositis ossificans, a benign, extraosseous formation of the bone or cartilage. We report of only the second described case of myositis ossificans of the spermatic cord in the literature to date.

Tracheal decellularization using a combination of chemical, physical and bioreactor methods

INTRODUCTION

The purpose of this study was to compare different decellularization protocols with the conventional detergent enzymatic method (DEM) using continuous agitation.

METHODS

The first experiment compared conventional DEM with sonication and lyophilization+freeze-thaw cycles. A second experiment was carried out to compare time-adjusted DEM (2-hour instead of 4-hour incubations with 4% deoxycholate) to decellularization in a bioreactor. Cellularity was determined by DNA-quantitation, H&E-staining and immunostaining for major histocompatibility complex-1 (MHC-1).

RESULTS

Compared to untreated trachea, DNA content significantly decreased after 2 cycles in all groups in the first experiment and dropped below the minimal criteria for efficient decellularization (<50 ng dsDNA/mg dry weight) after 4 cycles. However, nuclei were seen in the cartilage and MCH-1 staining was detected in some submucosal areas, indicating presence of chondrocytes and cellular residues that may render the scaffold immunogenic. In the second experiment DNA content significantly decreased after 1 cycle in both groups; however, even after 4 cycles, DNA content was above the minimal criteria for efficient decellularization. While collagen-levels remained stable, glycosaminoglycans diminished significantly after the initial cycles.

CONCLUSIONS

Efficient decellularization can be achieved after only 4 cycles of DEM compared to the 17 cycles previously reported. The use of a bioreactor can preserve the integrity of the extracellular matrix.

Spasmodic Dysphonia: A Review. Part 1: Pathogenic Factors

Objective The purpose of this review is to describe the recent advances in identifying possible factors involved in the pathogenesis of spasmodic dysphonia. Spasmodic dysphonia is a task-specific focal laryngeal dystonia characterized by irregular and uncontrolled voice breaks. Pathogenesis of the disorder is poorly understood. Data Sources PubMed, Google Scholar, and Cochrane Library. Review Methods The data sources were searched using the following search terms: ( spasmodic dysphonia or laryngeal dystonia) and ( etiology, aetiology, diagnosis, pathogenesis, or pathophysiology). Conclusions Several potential etiological factors have been proposed by epidemiological, genetic, and neuropathological studies. Spasmodic dysphonia is a rare disorder primarily affecting females beginning in their 40s. Vocal tremor co-occurs in 30% to 60%. Large cohort studies identified risk factors such as a family history of neurological disorders including dystonia and tremor, recent viral illness, and heavy voice use. As none are rare events, a complex interactive process may contribute to pathogenesis in a small proportion of those at risk. Consequences to pathogenesis are neurological processes found in spasmodic dysphonia: loss of cortical inhibition, sensory processing disturbances, and neuroanatomical and physiological differences in the laryngeal motor control system. Implications for Practice Diagnosis of spasmodic dysphonia usually includes speech and laryngoscopic assessment. However, as diagnosis is sometimes problematic, measurement of neurophysiological abnormalities may contribute useful adjuncts for the diagnosis of spasmodic dysphonia in the future.

Spasmodic Dysphonia: A Review. Part 2: Characterization of Pathophysiology

Objective

The purpose of this review is to describe the recent advances in characterizing spasmodic dysphonia. Spasmodic dysphonia is a task-specific focal laryngeal dystonia characterized by irregular and uncontrolled voice breaks. The pathophysiology is poorly understood, and there are diagnostic difficulties.

Data Sources

PubMed, Google Scholar, and Cochrane Library.

Review Methods

The data sources were searched using the following search terms: ( spasmodic dysphonia or laryngeal dystonia) and ( etiology, aetiology, diagnosis, pathogenesis, or pathophysiology).

Conclusion

The diagnosis of spasmodic dysphonia can be difficult due to the lack of a scientific consensus on diagnostic criteria and the fact that other voice disorders may present similarly. Confusion can arise between spasmodic dysphonia and muscle tension dysphonia. Spasmodic dysphonia symptoms are tied to particular speech sounds, whereas muscle tension dysphonia is not. With the advent of more widespread use of high-speed laryngoscopy and videokymography, measures of the disruptions in phonation and delays in the onset of vocal fold vibration after vocal fold closure can be quantified. Recent technological developments have expanded our understanding of the pathophysiology of spasmodic dysphonia.

Implications for Practice

A 3-tiered approach, involving a questionnaire, followed by speech assessment and nasolaryngoscopy is the most widely accepted method for making the diagnosis in most cases. More experimental and invasive techniques such as electromyography and neuroimaging have been explored to further characterize spasmodic dysphonia and aid in diagnosing difficult cases.

Sarcoidosis Presenting as Bilateral Vocal Fold Immobility

Bilateral true vocal fold paralysis is rarely attributable to inflammatory diseases. Sarcoidosis is a rare but important etiology of bilateral true vocal fold paralysis by compressive lymphadenopathy, granulomatous infiltration, and neural involvement. We describe the first reported case of sarcoidosis presenting as bilateral vocal fold immobility caused by direct fixation by granulomatous infiltration severe enough to necessitate tracheostomy insertion. In addition, we discuss the presentation, the pathophysiology, and the treatment of this disease with a review of the literature of previously reported cases of sarcoidosis-related vocal fold immobility. Sarcoidosis should therefore be an important consideration for the otolaryngologist's differential diagnosis of true vocal fold immobility.

Distant melanoma causing small bowel obstruction

Small bowel obstructions (SBOs) are common. Adhesions make up the majority of cases at 84.9%, followed by abdominal herniae and malignancies. A 71-year-old female presented with total constipation, abdominal distension, on a background of resected cutaneous melanoma nine years prior. A CT-scan showed small bowel intussusception and disseminated mucosal-enhancing lesions consistent with metastases. She was brought to the operating theatre where six areas of intussusception were identified and manually reduced. Biopsies confirmed the diagnosis of melanoma. Melanoma of the gastrointestinal tract (GIT) is rare, with most cases occurring as metastasis from cutaneous lesions. Melanomas of the GIT are usually asymptomatic in their early stages, and are often diagnosed when complications, such as obstruction or perforation occur. Management of such cases consists mainly of surgical intervention to resolve the complication. In people who present with SBO without previous surgeries or herniae, a malignant cause must be considered.