A comparison of the efficacy of narrow band imaging and contact endoscopy in an early diagnosis of squamous malignancies of the upper aerodigestive tract

Background

This study aims to compare the efficacy of narrow band imaging (NBI) endoscopy and contact endoscopy in early diagnosis of squamous malignancies of upper aerodigestive tract.

Methods

This study was of 18 months duration, sample size 50, and carried out at tertiary care hospital. The patients were subjected initially to NBI endoscopy followed by contact endoscopy. Thereafter, the lesion was biopsied and subjected to histopathological examination as is done routinely. The images obtained were analyzed based on criteria proposed by earlier studies and compared with histopathological examination as gold standard.

Results

The sensitivity, specificity, and negative predictive values of NBI in early diagnosis of squamous malignancies of upper aerodigestive tract were high and better than contact endoscopy.

Conclusion

Endoscopic NBI is a noninvasive and promising tool used for in vivo differentiation between malignant and nonmalignant lesions of upper aerodigestive tract by using morphology of mucosal capillaries and is more efficacious than contact endoscopy. It can be employed as part of routine ENT examination in outpatient departments; however, it has got a learning curve associated with it.

COVID-VU - ENT-UK national survey of flexible nasendoscopy in the upper aerodigestive tract amidst the COVID-19 pandemic

Background

Flexible nasendoscopy (FNE) is an invaluable multi-disciplinary tool for upper aerodigestive tract (UADT) examination. During the COVID-19 pandemic concerns were raised that FNE had the potential of generating aerosols resulting in human cross-contamination when performed on SARS-COV2 carriers. In the UK, and other European countries, national guidelines were issued restricting FNE to essential cases. We surveyed ENT-UK members and Royal College of Speech and Language Therapists (RCSLT) members to determine the impact of the COVID-19 pandemic (first peak) on FNE practice in the UK.

Methods

An observational internet-based survey constructed in accordance to the CHERRIES checklist and setup in SurveyMonkey of FNE practice amongst UK-based ENT surgeons and speech and language therapists in community clinics, the outpatient department, inpatient wards, ICU, emergency department and operating theatres (through the NHS and private sector) prior to, during and following the first COVID-19 wave in the UK.

Results

314 responses collected (24% response rate), 82% from ENT clinicians, 17% from SLTs and 1% from other allied healthcare professionals. Overall, there has been a large reduction in the volume and indications for FNE during the first peak of the COVID-19 pandemic with limited recovery by mid-August 2020. Cancer and airway assessments were impacted less. A wide range of FNE protocols influenced by local factors are reported, varying in endoscope preference, Personal Protective Equipment (PPE) and sterilization methods. Where dedicated Aerosol Generating Procedure (AGP) rooms were unavailable, clinicians resorted to window opening and variable room “down-time” between patients. Endoscope preference reflected availability and user familiarity, ENT trainees favoring the use of single-use video endoscopes.

Conclusion

Despite national guidance, local practice of FNE remains interrupted and highly variable in the UK. A collaborative inter-disciplinary approach is required to re-introduce FNE safely in volume across healthcare settings, re-establishing timely endoscopic diagnosis and pre-pandemic levels of patient care.

Learning Curve of Upper Aerodigestive Tract Foreign Body Management for Otorhinolaryngology Residents

INTRODUCTION

Foreign body ingestion is the most common reason for otolaryngology specialist consultations in emergency departments. Among the different types of foreign bodies, fish bones are the most common, particularly in Asian populations. In Taiwan, upper aerodigestive tract foreign bodies (UADT-FBs) are mostly managed by residents in the otorhinolaryngology (ORL) department. Considering the learning curve required for all procedures, different management types between residents, and possible resulting safety issues, this study explored the outcomes of UADT-FB management by residents in different years of ORL training.

MATERIALS AND METHODS

The medical records of 2,283 patients who visited Kaohsiung Veterans General Hospital's Emergency Department for UADT-FB during June 2013-August 2019 were retrospectively reviewed. The reviewed data included the demographic data of enrolled patients, outcomes of foreign body management, and follow-up chart records of the patients.

RESULTS

Among the 2,283 patients, 1,324 (58%) were found to be negative for foreign bodies, and foreign bodies in 951 (41.7%) were removed immediately. In the negative finding (NF) group, 2 (4.9%) patients were later found to be positive for foreign bodies during follow-up in the outpatient department. One (2.4%) patient developed a deep neck infection and esophageal perforation. The percentage of NFs decreased from 62.58% in residents in the first half of their first year (R1a) to 54% for third-year residents (R3). Comparing R1a with R3, the number needed to harm for retained UADT-FBs after patients visited the emergency department was 12.2.

DISCUSSION/CONCLUSION

This study provides data from 1 referral center regarding the management of UADT-FBs. With increasing resident training, the percentage of NFs declined from 62.58 to 54%. Young residents, especially those in the first 6 months of their training, should have senior residents perform a second examination if UADT-FBs are not found in suspected cases.

Clinical impact of lymphatic spread in patients with limited-stage upper aerodigestive tract NK/T cell lymphoma

Background

We investigated whether distance_max, that is, the degree of distance between the upper aerodigestive tract (UAT) mass and the farthest pathologic lymph node, was significantly associated with survival in patients with limited-stage UAT natural killer/T cell lymphoma (NKTCL).

Methods

A total of 157 patients who received chemotherapy (CTx) with/without radiotherapy (RTx) were enrolled.

Results

In the survival analysis, an elevated lactate dehydrogenase level [progression-free survival (PFS) hazard ratio (HR), 2.948; 95% confidence interval (CI), 1.606‒5.404; P<0.001; overall survival (OS) HR, 2.619; 95% CI, 1.594‒4.822; P=0.003], short distance_max (PFS HR, 0.170; 95% CI, 0.071‒0.410; P<0.001; OS HR, 0.142; 95% CI, 0.050‒0.402; P< 0.001), and CTx combined with RTx (HR, 0.168; 95%CI, 0.079‒0.380; P<0.001; OS HR, 0.193; 95% CI, 0.087‒0.429; P<0.001) had an independent predictive value for PFS and OS.

Conclusion

The evaluation of the degree of lymphatic spread and local control by CTx combined with RTx is essential in patients with limited-stage UAT NKTCL.

Anaplastic extraosseous (extramedullary) plasmacytoma in the right nostril

Extraosseous (extramedullary) plasmacytomas are rare plasma cell neoplasms that can result in an erroneous and/or delayed diagnosis as often they are not considered in the differential diagnosis due to their rarity. Furthermore, the anaplastic type is one of the most difficult to recognize in biopsies. We report the case of a patient with an extraosseous plasmacytoma occluded in the right nostril. Its prompt and accurate diagnosis resulted in early treatment and a good outcome, despite the tumour being anaplastic with the risk of progressing into a plasma cell myeloma. The patient shows no recurrence or disease progression after 10 years of follow-up. Our case highlights the clinical and pathological characteristics of this rare disorder that should be considered in order to improve diagnostic criteria and thus early treatment. We also reviewed the pertinent literature.

Well-Differentiated/Dedifferentiated Liposarcoma Arising in the Upper Aerodigestive Tract: 8 Cases Mimicking Non-adipocytic Lesions

Well-differentiated (WDL) and dedifferentiated liposarcomas (DL) of the pharynx, larynx and oral cavity are rare, often mimicking benign lipomatous neoplasms or non-lipogenic mesenchymal tumors. Cases of WDL/DL arising in the upper aerodigestive tract, exclusive of the cervical esophagus, were reviewed. Morphologic features, ancillary studies, including fluorescence in situ hybridization (FISH) studies for CPM/MDM2, and clinical data was catalogued. Eight WDL/DL (4 WDL, 4 DL); were identified in patients ranging from 32 to 77 years (median 52.5 years; 6 males, 2 females) with sites of origin including hypopharynx (5 cases), larynx (2 cases) and oral cavity (1 case). Six of the 8 cases were received for expert consultation, and the remaining 2 cases were initially misdiagnosed as benign lymphangiomatous or fibroepithelial polyps. Morphologically, 4 tumors had areas mimicking various non-lipomatous soft tissue tumors including nodular fasciitis, mammary-type myofibroblastoma, low-grade myofibroblastic sarcoma and undifferentiated pleomorphic sarcoma, 2 cases simulated benign hypopharyngeal polyps, and 1 lesion was notable for a dense lymphoplasmacytic infiltrate suggestive of hematolymphoid neoplasm or IgG4-related sclerosing disease. FISH showed amplification of CPM/MDM2 (8/8 cases). All cases (4/4) with longer than 1-year of follow-up recurred (45-118 months) with 1 tumor showing progression to DL. WDL/DL presenting in the upper aerodigestive tract are rare and diagnostically challenging. Awareness of the morphologic spectrum of WDL/DL coupled with appropriate use of MDM2 FISH is essential for accurate classification and management, as these tumors appear to have a high risk for local recurrence and eventual dedifferentiation in these anatomical locations.

Acute Epstein-Barr virus-positive cytotoxic T cell lymphoid hyperplasia in the upper aerodigestive tract, mimicking extranodal natural killer/T cell lymphoma, nasal type

To describe the clinicopathological features of nine patients with acute Epstein-Barr virus (EBV)-positive cytotoxic T cell lymphoid hyperplasia (EBV+TLH) in the upper aerodigestive tract, in which initial findings led to a preliminary misdiagnosis of extranodal NK/T cell lymphoma, nasal type (ENKTL). A series of nine cases of EBV+TLH in one Chinese institution over a 9-year interval was retrospectively analyzed. Median age was 16 years (range 5-29 years) with a M:F ratio of 5:4. All patients were previously healthy with an acute onset period of < 1 month. Six patients (66%) presented with masses or polypoid protrusions in the upper aerodigestive tract. Nasopharyngeal symptoms, cervical lymphadenopathy, and fever were found in 89%, 78%, and 56% of patients, respectively. In seven cases, morphology mainly showed small-sized irregular cells and in two cases medium-to-large cells. In all cases, the cells diffusely expressed cytoplasmic CD3 and at least one marker for cytotoxic granules, but were negative for CD56. CD5 expression was detected in eight cases (8/9, 89%). In all cases, double staining for CD3 and EBER indicated that most T cells were infected with EBV. T cell receptor gene rearrangement was performed in five cases and all showed polyclonal results. All patients achieved complete remission within 1 month after diagnosis without any chemoradiotherapy and were followed up 19-124 months without recurrent disease. EBV+TLH in the upper aerodigestive tract is occasionally observed in China. The histopathologic features of EBV+TLH can mimic ENKTL. EBV+TLH should be taken into consideration as a potential diagnosis when the disease duration is short, spontaneous remission is achieved without intervention, and when histology shows infiltration with EBV-infected T lymphocytes.

Topical Anesthesia for Endoscopic Office-based Procedures of the Upper Aerodigestive Tract

OBJECTIVE

Over the last two decades, an increase in office-based procedures under topical anesthesia in laryngology and head and neck oncology has occurred. Adequate anesthesia in the nasal cavity, pharynx, and larynx is essential for successful performance of these procedures. Our goal is to provide an objective summary on the available local anesthetics, methods of application, local secondary effects, efficacy, and complications.

MATERIAL AND METHODS

A descriptive review of literature on topical anesthesia for office-based procedures in laryngology and head and neck oncology was performed.

RESULTS

Lidocaine is the most applied and investigated topical anesthetic. Topical anesthesia results in decreased sensory function without impairing motor function of the pharynx and larynx. For the nasal cavity, cotton pledgets soaked in anesthetic spray and decongestant, or anesthetic gel, are effective. For the pharynx, anesthetic spray is the most frequently used and effective method. For the larynx, applying local anesthesia through a catheter through the working channel of the endoscope or anesthetic injection through the cricothyroid membrane is effective. Studies comparing the most effective application methods for each anatomical site are lacking. Complications of topical lidocaine administration are rare.

CONCLUSIONS

By properly applying topical anesthesia to the upper aerodigestive tract, several surgical procedures in laryngology and head and neck oncology can be performed in the outpatient clinic under topical anesthesia instead of the operating room under general anesthesia. Lidocaine is the most investigated anesthetic, with adequate efficacy and few complications. Studies that determine the most effective application methods are still wanting.

Papillary squamous cell carcinoma of the palatine tonsil: a rare cancer of the head and neck

Papillary squamous neoplasms of the upper respiratory tract are rare variants of squamous cell carcinomas. They are characterised by an exophytic, papillary growth and generally have favourable prognosis. The tumour has been described in the upper aerodigestive tract. In this context, most common sites of involvement are the larynx and hypopharynx, and rarely the oral cavity and oropharynx. The limited studies and small number of published cases of papillary squamous cell carcinoma of the palatine tonsil led us to make a complete analysis of this tumour by analysing the clinical, histological, radiological, virological and therapeutic aspects that are not always present in the literature. A case of papillary squamous cell carcinoma of the palatine tonsil is reported. The lesion (T2N0M0) was located into the left palatine tonsil that hung towards the oral cavity. Both HPV 16 DNA and E6/E7 mRNA were detected in the lesion. The clinicopathological profile of the neoplasm is presented and a comprehensive review of recent literature was made by analysing all aspects of interest of this neoplasm.

Fishbones in the Upper Aerodigestive Tract: A Review of 24 Cases of Adult Patients

INTRODUCTION

We present a retrospective study series and discussion of the current literature to discuss the management of fishbones in the upper aerodigestive tract.

MATERIALS AND METHODS

From January 2013 to July 2016, all patients referred to our referral center because of a fishbone in the upper aerodigestive tract were analysed.

RESULTS

Of the 24 patients, 95% of them reported discomfort in the throat. It was noted that 58% of physical examinations and nasofibroscopy results were normal. Ten fishbones were found in the upper aerodigestive tract. They were removed by foreign body forceps or by endoscopy depending on the location. Foreign body-related complications were not observed. Ten patients with no identifiable fishbone had no symptoms after 48 hours. Other patients, including the 10 patients with the fishbone removed, were asymptomatic after 10 days.

CONCLUSION

From our experience, we recommend a systematic nasofibroscopy. If it is normal, the patient is assessed at 48h. The complementary investigation by CT scan and/or oesophagoscopy must be reserved in cases of suspicion of oesophageal localization or complication. Otherwise, rigid or flexible endoscopy may be performed when laryngoscopy is unsuccessful or for the treatment of foreign bodies lodged below this area.

Day-care unit for rigid panendoscopy of the upper aerodigestive tract: A study of 436 procedures

OBJECTIVES

To assess the role of day-care management of upper aerodigestive tract (UADT) panendoscopy and to study criteria for conventional hospital admission and reasons for conversion.

PATIENTS AND METHODS

Retrospective study, from January 2011 to May 2013. Inclusion criteria UADT panendoscopy for carcinoma assessment. Study variables, age, gender, tumor location, reason for panendoscopy, TNM stage, previous external radiotherapy, home-to-hospital distance and Apfel, Detsky and ASA scores. A day-care and a conventional admission group were compared using Fisher's test for ASA score, student's test for age and Pearson's chi² test for the other variables.

RESULTS

Four hundred and thirty-six panendoscopies were performed: 252 in day-care, including 4 cases of conversion and 184 with conventional admission. There were no significant differences between groups for age, gender, tumor location, TNM stage, reason for panendoscopy, previous external radiotherapy, home-to-hospital distance or Apfel score. A significant difference was observed for ASA score (P<0.0001) and Detsky score (P=0.03). In 39% of cases, the reason for hospital admission without criteria defined by the French Society of Anesthesia and Intensive Care Medicine (SFAR) and French Health Authority (HAS) was the patient's refusal of day care. In 10% of conventional admissions, day-care was not implemented because of psychosocial factors.

CONCLUSION

Day-care management is appropriate for UADT panendoscopy in selected patients. The reasons for the high rate of patient refusal should be studied.

Nonkeratinizing Squamous Cell Carcinoma In Situ of the Upper Aerodigestive Tract: An HPV-Related Entity

The clinical and pathologic characteristics of human papillomavirus (HPV)-related premalignant lesions in the upper aerodigestive tract have not been adequately studied. There are a few reports of oral cavity HPV-related severe dysplasia with unique morphology (prominent apoptosis/karyorrhexis imparting a 'bowenoid' appearance) and a single case report of HPV-related squamous cell carcinoma in situ with nonkeratinizing histology distinct from the 'bowenoid' pattern that extensively involved the upper aerodigestive tract. The aim of this study was to characterize the morphologic and clinical features of HPV-related severe dysplasia/carcinoma in situ. All cases of upper aerodigestive tract severe dysplasia/carcinoma in situ (111 cases from 98 patients) at Washington University from July 2012 to March 2015 were categorized into histologic types: keratinizing, nonkeratinizing, mixed or 'bowenoid'. There were 83 (85 %) patients with keratinizing, 3 (3 %) nonkeratinizing and 12 (12 %) mixed patterns. The previously reported 'bowenoid' morphology was not identified. All 3 (100 %) nonkeratinizing and 6 (50 %) mixed cases were p16 and HPV RNA in situ hybridization (RNA ISH) positive (100 % concordance between p16 and RNA ISH). Only 2 of 73 keratinizing cases were p16 positive, 1 of which was also HPV RNA ISH positive (1.4 % of keratinizing cases HPV-related). Thus, nonkeratinizing morphology was a strong predictor of transcriptionally-active HPV in severe dysplasia/carcinoma in situ. HPV-related cases most commonly occurred in the floor of mouth and were frequently extensive (≥4 cm) or unresectable.

The transnasal VideoPanendoscopy (ViP): diagnostics of the upper aerodigestive tract using an anatomically correct model from the model to the patient

Endoscopy of the upper aerodigestive tract (UADT) develops rapidly. New endoscopes in combination with special imaging techniques allow complete examinations of the UADT in an ambulatory setting. Therefore, it is necessary to educate and train young physicians in a standardized protocol. A special anatomical training model has been designed to allow a stepwise endoscopy training course. It can be used by specialists who would like to take advantage of transnasal VideoPanendoscopy for examination of suitable candidate patients. This method offers advantages for ENT doctors, gastroenterologists as well as endoscopic surgeons.

Respiratory epithelial adenomatoid hamartoma: a review

Respiratory epithelial adenomatoid hamartoma (REAH) is an uncommon lesion of the upper aerodigestive tract first described by Wenig and Heffner in 1995 as prominent glandular proliferations lined by ciliated respiratory epithelium originating from the surface epithelium. The entity is seen most often in male adults. Clinically the lesion presents as a polypoid mass, often in one or both nasal cavities, though other locations have been described. While REAH is benign, awareness and recognition of the lesion is important because it can be easily confused grossly and microscopically with more threatening tumors such as inverted papilloma and sinonasal carcinoma. The literature of REAH is reviewed with detail paid to the histologic diagnosis. The clinical presentation, radiologic findings, and differential diagnosis are also described.