Management of neck metastases in head and neck cancer:United Kingdom National Multidisciplinary Guidelines

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. A rational plan to manage the neck is necessary for all head and neck primaries. With the emergence of new level 1 evidence across several domains of neck metastases, this guideline will identify the evidence-based recommendations for management. RECOMMENDATIONS: • Computed tomographic or magnetic resonance imaging is mandatory for staging neck disease, with choice of modality dependant on imaging modality used for the primary site, local availability and expertise. (R) • Patients with a clinically N0 neck, with more than 15–20 per cent risk of occult nodal metastases, should be offered prophylactic treatment of the neck. (R) • The treatment choice of for the N0 and N+ neck should be guided by the treatment to the primary site. (G) • If observation is planned for the N0 neck, this should be supplemented by regular ultrasonograms to ensure early detection. (R) • All patients with T1 and T2 oral cavity cancer and N0 neck should receive prophylactic neck treatment. (R) • Selective neck dissection (SND) is as effective as modified radical neck dissection for controlling regional disease in N0 necks for all primary sites. (R) • SND alone is adequate treatment for pN1 neck disease without adverse histological features. (R) • Post-operative radiation for adverse histologic features following SND confers control rates comparable with more extensive procedures. (R) • Adjuvant radiation following surgery for patients with adverse histological features improves regional control rates. (R) • Post-operative chemoradiation improves regional control in patients with extracapsular spread and/or microscopically involved surgical margins. (R) • Following chemoradiation therapy, complete responders who do not show evidence of active disease on co-registered positron emission tomography–computed tomography (PET–CT) scans performed at 10–12 weeks, do not need salvage neck dissection. (R) • Salvage surgery should be considered for those with incomplete or equivocal response of nodal disease on PET–CT. (R

A false aneurysm

AbstractObjective: We report a case of a remaining hemi-thyroid following laryngectomy, which was misinterpreted as a pseudoaneurysm.Methods: Case report and comment on this understandable error which is easily avoidable.Results: A 59-year-old man had undergone salvage laryngectomy for recurrent squamous cell carcinoma of the larynx, which had previously been treated with radiotherapy. Three months after his laryngectomy, he presented with a sore neck and subcutaneous collections. Computed tomography revealed a unilateral mass with high signal contrast uptake anterior to the left common carotid artery, which was thought initially to be a carotid pseudoaneurysm. Further investigation, including ultrasonography and a review by the senior head and neck radiologist, demonstrated that this mass was actually the remnant hemi-thyroid preserved at laryngectomy (which is often misshapen compared with a normal hemi-thyroid). The collections were found to be recurrent tumour, and unnecessary further interventions were avoided.Conclusion: Ultrasonography easily distinguishes between a thyroid remnant and a pseudoaneurysm. Furthermore, the opinion of an experienced head and neck radiologist may be vital when interpreting complex post-surgical head and neck radiology

Singing Exercises Improve Sleepiness and Frequency of Snoring among Snorers—A Randomised Controlled Trial

Objectives: To assess the effectiveness of regular singing exercises in reducing symptoms of snoring and sleep apnoea. Methods: A prospective single blinded randomised controlled trial was conducted in the otolaryngology department of a UK teaching hospital (Exeter). 127 adult patients with a history of simple snoring or sleep apnoea were recruited. 93 patients completed the study. Patients were excluded because of severe sleep apnoea (apnoea index > 40), or morbid obesity (BMI > 40). The study group completed a self-guided treatment programme of singing exercises contained on a 3CD box set, performed for 20 minutes daily. Outcome measures included the Epworth Sleepiness Scale, the SF-36 generic quality of life assessment tool, visual analogue scales (VAS range 0-10) of snoring loudness and frequency, and visual analogue scale of compliance (for intervention group). Results: The Epworth scale improved significantly in the experimental group compared to the control group (difference -2.5 units; 95% CI -3.8 to -1.1; p = 0.000). Frequency of snoring reduced significantly in the experimental group (difference -1.5; 95% CI -2.6 to -0.4; p = 0.01), and loudness of snoring showed a trend to improvement which was non-significant (difference -0.8; 95% CI -1.7 to 0.1; p = 0.08). Compliance with exercises was good; median 6.6 (quartiles = 4.1, 8.3). Conclusions: Improving the tone and strength of pharyngeal muscles with a 3 months programme of daily singing exercises reduces the severity, frequency and loudness of snoring, and improves symptoms of mild to moderate sleep apnoea.The article is available via Open Access. Click on the 'Additional link' above to access the full-text.Published version, accepted version, submitted versio

Methodology for the development of National Multidisciplinary Management Recommendations using a multi-stage meta-consensus initiative.

BACKGROUND: Methods for developing national recommendations vary widely. The successful adoption of new guidance into routine practice is dependent on buy-in from the clinicians delivering day-to-day patient care and must be considerate of existing resource constraints, as well as being aspirational in its scope. This initiative aimed to produce guidelines for the management of head and neck squamous cell carcinoma of unknown primary (HNSCCUP) using a novel methodology to maximise the likelihood of national adoption. METHODS: A voluntary steering committee oversaw 3 phases of development: 1) clarification of topic areas, data collection and assimilation, including systematic reviews and a National Audit of Practice; 2) a National Consensus Day, presenting data from the above to generate candidate consensus statements for indicative voting by attendees; and 3) a National Delphi Exercise seeking agreement on the candidate consensus statements, including representatives from all 58 UK Head and Neck Multidisciplinary Teams (MDT). Methodology was published online in advance of the Consensus Day and Delphi exercise. RESULTS: Four topic areas were identified to frame guideline development. The National Consensus Day was attended by 227 participants (54 in-person and 173 virtual). Results from 7 new systematic reviews were presented, alongside 7 expert stakeholder presentations and interim data from the National Audit and from relevant ongoing Clinical Trials. This resulted in the generation of 35 statements for indicative voting by attendees which, following steering committee ratification, led to 30 statements entering the National Delphi exercise. After 3 rounds (with a further statement added after round 1), 27 statements had reached 'strong agreement' (n = 25, 2, 0 for each round, respectively), a single statement achieved 'agreement' only (round 3), and 'no agreement' could be reached for 3 statements (response rate 98% for each round). Subsequently, 28 statements were adopted into the National MDT Guidelines for HNSCCUP. CONCLUSIONS: The described methodology demonstrated an effective multi-phase strategy for the development of national practice recommendations. It may serve as a cost-effective model for future guideline development for controversial or rare conditions where there is a paucity of available evidence or where there is significant variability in management practices across a healthcare service