Risk factors and healing factors for pharyngocutaneous fistula after total laryngectomy for laryngeal cancer: An epidemiological study

To analyse the risk factors and healing factors of pharyngocutaneous fistula (PCF) in patients with laryngeal cancer after total laryngectomy, and to explore the relevant epidemiology. A retrospective analysis was conducted on laryngeal cancer patients who underwent total laryngectomy in our hospital from January 2010 to December 2022. The 349 patients included in the study were divided into a PCF group of 79 and a non-PCF group of 270. Perform one-way analysis of variance and multivariate logistic analysis on various data of patients included in the statistics, and analyse the risk factors and healing factors of PCF. Smoking, history of radiation therapy for laryngeal cancer, history of chemotherapy for laryngeal cancer, tumour location (larynx, pharynx, oesophagus), preoperative albumin, postoperative proteinaemia, <99 haemoglobin, postoperative haemoglobin, postoperative C-reactive protein (CRP) level are the risk factors for PCF. Also, radiation therapy and postoperative proteinaemia were the main reasons for preventing PCF healing. Smoking history, laryngeal cancer, radiation therapy, albumin, haemoglobin and CRP are risk factors for postoperative PCF after total laryngectomy, while radiation therapy and postoperative hypoalbuminaemia are key factors affecting PCF healing.

Novel techniques for prevention of post-operative pharyngocutaneous fistula in locally advanced laryngeal and hypopharyngeal cancers

BACKGROUND

Pharyngocutaneous fistula is one of the most common complications following total laryngectomy. It increases hospital stay and the financial burden on patients, and prolongs nasogastric feeding. This paper presents novel techniques for prevention of pharyngocutaneous fistula.

METHOD

A retrospective study was conducted at a tertiary referral centre to assess the effectiveness of continuous extramucosal pharyngeal suturing and the hydrogen peroxide leak test in prevention of pharyngocutaneous fistula in 59 patients who had undergone total laryngectomy with or without partial pharyngectomy for locally advanced cancers of the larynx and hypopharynx.

RESULTS

The incidence of pharyngocutaneous fistula in our study was 6.8 per cent, which is considerably lower than the incidence reported in various previous studies.

CONCLUSION

The continuous extramucosal suturing technique provides watertight closure of the neopharynx and can be recommended as a reliable method for neopharyngeal closure post total laryngectomy to reduce the occurrence of pharyngocutaneous fistula.

Correlation between the presence of tonsilloliths and the bone defects by periodontitis on imaging analysis: a pilot study

BACKGROUND

Very recently, a significant relationship between tonsilloliths and dental plaque-related pathologies was reported using digital panoramic radiographs. Their dynamics over time suggest that tonsilloliths may be in a permanently active phase that functions to remove foreign matter. The aim of the study was to evaluate the relationship between the occurrence of tonsilloliths and the extent of periodontitis.

METHODS

A total of 608 patients who underwent both CT and panoramic radiographs were included in the study. Both of two imaging were retrospectively and independently assessed with respect to the presence of tonsilloliths detected on CT and panoramic radiographs, and bone defects caused by periodontitis detected on panoramic radiographs. The type of retrospective study is case-control. Then, the differences between age groups were evaluated with respect to the degree of bone resorption and its correlation with the presence of tonsilloliths. The relationships between categorical variables were assessed using Pearson's correlation coefficient or Spearman's correlation coefficient.

RESULTS

There was a significant relationship between tonsilloliths on CT and the extent of the bone defect on panoramic radiographs (Spearman's correlation coefficient, r = 0.648, p = 0.043). In addition, there was a significant difference in the extent of the bone defect caused by periodontitis between subjects with and without tonsilloliths in the 60 to 69-year-old group (Mann-Whitney U test, p = 0.025), 70 to 79-year-old group (Mann-Whitney U test, p = 0.002), and 80 to 89-year-old group (Mann-Whitney U test, p = 0.022), but not in other age groups (Mann-Whitney U test: under 9-year-old group, p = 1.000; 10 to 19-year-old group, p = 1.000; 20 to 29-year-old group, p = 0.854; 30 to 39-year-old group, p = 0.191, 40 to 49-year-old group, p = 0.749; 50 to 59-year-old group, p = 0.627; ≥90-year-old group, p = 1.000).

CONCLUSIONS

The presence of tonsilloliths was related to the extent of periodontitis because the structures were responding dynamically.

Vitamin D Deficiency in Advanced Laryngeal Cancer and its Association with Pharyngocutaneous Fistula Following Total Laryngectomy

BACKGROUND

Nutritional factors in developing some malignancies have been investigated recently.

OBJECTIVE

In this study, we evaluated the role of vitamin D in advanced laryngeal cancer and its association with the development of pharyngocutaneous fistula (PCF) following total laryngectomy.

STUDY DESIGN

A cross-sectional, case-control study was conducted.

METHODS

Fifty-five patients with advanced laryngeal cancer referred for total laryngectomy were included. We also considered 55 healthy individuals after matching age and sex as a control group. Serum levels of 25(OH)D3 were measured using a commercially available enzyme-linked immunosorbent assay (ELISA) kit. The association of serum 25(OH)D3 with PCF following total laryngectomy was also determined.

RESULTS

Vitamin D was significantly lower in patients with advanced laryngeal cancer than in the control group (p < 0.001). Moreover, our results showed that a mean serum concentration of 25(OH)D3 in patients with PCF was significantly lower than in patients without PCF (p < 0.001).

CONCLUSION

Vitamin D deficiency is highly prevalent in advanced laryngeal cancer, most pronounced in those who develop a PFC following total laryngectomy.

Early detection of pharyngocutaneous fistulae after total laryngectomy by cytokine in drainage: A pilot study (DEFILAC)

BACKGROUND

The determination of cytokines in the postoperative drainage (POD) fluid could be a method for early detection of the development of a pharyngocutaneous fistula (PCF).

MATERIALS AND METHODS

We conducted a prospective two-center study involving 28 patients. PODs were collected on Day 1 (D1) and Day 2 (D2) postoperatively for determination of a cytokine panel and cytobacteriological examination.

RESULTS

Eleven (39%) patients presented with PCF on average 13 ± 5.5 days after surgery. Patients with PCF had higher IL-10 (121 vs. 40.3, p = 0.04, effect size (ES) = 0.98 [0.16, 1.79]) and TNFα level (21.2 vs. 2.2, p = 0.02, ES = 0.83 [0.03, 1.63]) on D2. An IL-10 threshold of 72 pg/mL on D2 was diagnostic of the occurrence of PCF with a sensibility of 70%, specificity of 88%.

CONCLUSION

The determination of cytokines in POD fluid on D2 is a reliable tool for predicting the development of a PCF after total laryngectomy.

Water soluble swallow for leak detection after total laryngectomy post radiotherapy

AIM

Pharyngeal leak (PL) and pharyngocutaneous fistula (PCF) are serious complications following total laryngectomy and their incidence is higher in the salvage setting. The aim of this study is to describe the accuracy of water soluble swallow (WSS) to rule out salivary postoperative leak after salvage total laryngectomy (STL) to expedite start of oral intake.

MATERIAL AND METHODS

Retrospective study including patients undergoing STL between 2008 and 2021 at Guy's Hospital. WSS was routinely performed within 15 days post operation.

RESULTS

Sixty-six patients underwent STL. Nine developed clinically diagnosed PCF; one died before having WSS. Fifty-six patients underwent WSS post STL. WSS was performed within 15 days after STL when no postoperative complications occurred (76.8%). Among patients undergoing WSS with no clinical suspicion for fistula (56), PL was identified in 15 cases (26.8%). They were managed conservatively; PCF was avoided in 7(46.7%) cases. Three patients (7.3%) developed PCF after having started oral intake with a negative WSS. These three cases were further analysed, 2 cases where recorded at the beginning of the studied period when less experience was available possibly leading to incorrect results. Sensitivity and negative predictive value (NPV) for fistula prediction were 72.7% and 92.7%, respectively.

CONCLUSION

Taking into account the high NPV of WSS, it is safe to start oral intake after negative WSS. Further studies to evaluate its accuracy earlier on after SLT are justified taking into account the results and the impact that delayed feeding has on patient's quality of life.

Pharyngeal Gonorrhea in Heterosexual Male and Female Sex Partners of Persons With Gonorrhea

BACKGROUND

Current guidance from the US Centers for Disease Control and Prevention recommends empiric treatment for persons exposed to sexually transmitted infections, including Neisseria gonorrhoeae ( NG ). As an antimicrobial stewardship measure, some clinics now recommend a test and treat strategy, but reliance on urogenital testing only may miss cases.

METHODS

We conducted a descriptive analysis of pharyngeal NG infection in men who have sex with women (MSW) and women seeking care at a sexual health clinic in Seattle, WA, from February 2017 to July 2021 because of sexual contact to a partner diagnosed with gonorrhea. We also explored behavioral factors associated with pharyngeal NG positivity (by culture or nucleic acid amplification test by χ2 analysis.

RESULTS

Among 352 NG contacts tested for urogenital or pharyngeal infection, 34% were positive for NG at ≥1 anatomic site (27% for MSW and 40% for women). Among 161 NG contacts tested at the pharynx, 30% (n = 48) were positive: 20% of 54 MSW (n = 11) and 35% (n = 37) of 107 women. If only urogenital testing were performed, 36% of MSW NG infections (n = 5) and 19% of female NG infections (n = 9) would have remained unidentified.

CONCLUSIONS

Pharyngeal NG is relatively common among MSW and women who have been exposed to NG, and likely represents an underdiagnosed reservoir of NG infection. If empiric treatment is abandoned in favor of testing and treating, testing the throats of heterosexuals will be necessary.

Factors predicting pharyngocutaneous fistula in patients after salvage laryngectomy for laryngeal malignancy - A multicenter collaborative cohort study

OBJECTIVES

Pharyngocutaneous fistula (PCF) is a major morbidity of salvage total laryngectomy (TL). Understanding the factors predicting PCF is fundamental to managing laryngeal cancer. We aim to assess factors associated with PCF following salvage TL in a multicenter, international retrospective cohort study of academic centers in the US and Canada.

RESULTS

In total, 550 patients post-salvage TL were identified (mean [SD; range] age, 64 [10.4; 32-90] years; 465 [85 %] male and 84 [15 %] female) between 2000 and 2014. Rate of PCF was 23 % (n = 127) with median time to PCF of 2.9 weeks. Surgical management of PCF was required in 43 % (n = 54) while 57 % (n = 73) required wound care alone. Rates of PCF differed by primary treatment modality [radiation, 20 % (n = 76); chemoradiation, 27 % (n = 40); not available (n = 6)] and use of vascularized tissue in pharyngeal closure [free/regional flap, 18 % (n = 25); no vascularized tissue/primary closure, 24 % (n = 98); not available (n = 4)]. There was no statistically significant association between PCF and treatment with chemoradiation (HR, 1.32; 95 % CI, 0.91-1.93, p = 0.14) or lack of vascularized tissue reconstruction (HR, 1.41, 95 % CI 0.91-2.18, p = 0.12). Significant association between PCF and advanced stage (T3 or T4), positive margin, close margin (<5mm), lymphovascular invasion and pre-operative tracheostomy were identified on univariable analysis. Positive surgical margin (HR, 1.91; 95 % CI, 1.11 to 3.29) was the only significant association on multivariable analysis.

CONCLUSION

We highlight positive surgical margin as the only variable significantly associated with increased risk of PCF following salvage TL on multivariable analysis in a large cohort across several major head and neck oncology centers.

Radiographic Detection of the Relationship between Tonsilloliths and Dental Plaque-Related Pathologies in a Series of Digital Panoramic Radiographs

OBJECTIVE

The purpose of this study was to analyse the prevalence of tonsilloliths and to determine radiographically whether there is a relationship between tonsilloliths and dental plaque-related pathologies in a series of digital panoramic radiographs.

MATERIALS AND METHODS

This retrospective study included digital panoramic radiographs of 859 patients admitted for routine dental examination. The panoramic images were examined for both the presence of tonsilloliths and the number of decayed, missing, restored teeth and apical periodontitis. Periodontal bone loss was also measured in thirds of optimal bone height according to the root length and a percentage of bone loss was obtained for each panoramic radiograph evaluated.

RESULTS

Tonsilloliths were observed in 141 (16.4%) of all individuals. While there was no significant difference regarding the number of decayed teeth and restored teeth between tonsillolith cases (TT) and cases without tonsillolith (TC), the number of missing teeth and apical periodontitis in TT was significantly higher than TC (p: 0.004, p: 0.030, respectively). There was a significant difference between the groups in terms of the mean percentage of bone loss (p: 0.001; p < 0.05). In addition, cases showing bone loss between one-third and two-thirds of the optimal bone height in the TT group (52.5%) were significantly higher than those in TC (45.5%) (p: 0.035; p < 0.05).

CONCLUSION

The relationship between dental plaque-related pathologies and tonsilloliths observed in this retrospective study should be confirmed by computed tomography studies and randomized, prospective, clinical trials conducted in a multidisciplinary manner.

Low skeletal muscle mass assessed directly from the 3rd cervical vertebra can predict pharyngocutaneous fistula risk after total laryngectomy in the male population

Purpose

Skeletal muscle mass (SMM) loss and sarcopenia have been identified as risk factors for postoperative complications. The aim of this study was to investigate the relationship between pharyngocutaneous fistula (PCF) formation after total laryngectomy (TL) and SMM assessed from a computed tomography image of the 3rd cervical vertebra (C3).

Methods

Retrospective study of 86 male patients who underwent TL between 2013 and 2019 in a single institution. We excluded women from the analysis due to our limited sample. SMM was determined from cross-sectional muscle area (CSMA) measurement at C3 using the ImageJ software. Results were compared with those for the skeletal muscle mass index (SMMI) calculated from the estimated measure at 3rd lumbar vertebra (L3).

Results

PCF formation occurred in 21/86 patients. According to the CSMA at a C3 cut-off of 35.5cm2, of 18 patients (20.9%) with low SMM, 9 developed PCFs (50.0%). Among patients with normal SMM (n = 68, 79.1%), 12 developed PCFs (17.6%). The CSMA at C3 was the only variable significantly associated with PCF risk, which was 4.7 times greater in patients with low SMM (p = 0.007). Sarcopenia was more frequent in underweight patients (p = 0.0001), patients undergoing extended surgeries (p = 0.003), or presenting preoperative anaemia (p = 0.009) or hypoalbuminemia (p = 0.027).

Conclusion

Measuring the CSMA at C3 obtained results equivalent to those obtained by calculating the SMMI at L3, suggesting that direct SMM assessment from C3 is a useful approach to evaluating PCF formation risk after TL.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00405-021-07127-3.

Major head and neck surgeries in the elderly population, a match-control study

BACKGROUND AND OBJECTIVES

To investigate complication rates in elderly cancer patients undergoing major head and neck surgeries.

METHODS

A retrospective, matched-control, analysis. For each elderly (≥70 years) patient, a younger, (<70 years) patients were matched based on sex, tumor location, disease stage, and operation time. Post-operative complication and survival analyses were performed.

RESULTS

Of 225 patients, 75 (33.3%) were elderly (mean age 76.2 (70-88) years) and compared with a match control group (53.2 (23-69) years). A higher rate of cardio-vascular comorbidity was noted in the elderly group (70.6% vs. 34%, respectively, P < 0.001). The majority (62.7%) of elderly patients required reconstruction with 24% receiving vascularized flap reconstruction. Total postoperative complication rate was 49.9% in the study versus 42.3% in the control group, with a major complication rate of 22.5% in the elderly versus 11.9% in the control group (P = 0.154). Mean follow-up was 41 (0-144) months. Five-year disease-specific (67.1% vs. 80.7%, P < 0.001) and overall survival rates (48.6% vs. 75.4%, P < 0.001) were significantly lower among elderly patients.

CONCLUSIONS

Major head and neck surgery in the elderly population does not entail higher complication rate, compared with younger patients, and should be allowed when curative intent is feasible and patient's general condition allows.

Early versus late oral feeding following total (pharyngo)laryngectomy: Systematic review and meta-analysis

Timing of oral feeding following total laryngectomy is a contentious issue with highly varied practices. Multiple database search was performed to identify studies comparing outcomes of early (≤5 days) versus late (>5 days) oral feeding. Bias assessment was carried out using Cochrane bias tool. Random-effects meta-analysis was used. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The rate of pharyngocutaneous fistula (PCF) in randomized control trials (RCTs) in early versus late feeding was 15.2% versus 11.7% (RR 1.35, 95%CI [0.68-2.7], p = 0.40). The rate of PCF in the cohort studies was 14.1% versus 20.5% (RR 1.0, 95%CI [0.76-1.3], p = 0.98). The length of hospital stay was significantly shorter in the early feeding group (mean difference (days) -4.68 (-6.2 to -3.1, p < 0.0001). Early oral feeding appears to be safe and is associated with shorter hospital stay. However, the quality of evidence is low and the patient characteristics are not representative of current practices.

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.

Prevalence of Human Papillomavirus Infection in the Head and Neck Area of Patients After Kidney Transplantation Treated With Immunosuppressive Therapy

The introduction of new and stronger immunosuppressive agents has significantly improved the overall survival rate of patients with transplanted organs; however, prolonged use of immunosuppressive agents has led to severe complications, such as the development of de novo malignant cancers. The incidence of malignant tumors is 3 to 5 times greater among renal transplant recipients than that of the overall population. Traditional neoplasms of the head and neck region are associated with the addiction to smoking and drinking alcohol. However, recent studies indicate that cancers of the throat, tongue, and tonsils are primarily associated with the human papillomavirus (HPV) infection. At present, approximately 25% of the head and neck squamous cell carcinomas are associated with HPV infection. Therefore, we aimed to determine the incidence of oropharyngeal HPV infection in recipients with kidney transplants treated with immunosuppressive therapy and to determine the factors that may favor the contraction of infectious diseases. Furthermore, we considered the purpose of vaccination against HPV among transplant recipients. A total of 32 recipients with kidney transplants were included in this study. Medical history was obtained and a throat swab was collected from each patient. The presence of the HPV DNA in the throat was determined using the GP5+/GP6+ primers. According to our results, 28% of the recipients with kidney transplants were positive for oropharyngeal HPV infection. In addition, among the investigated risk factors, early commencement of the sexual life (below the age of 16 years) was significantly correlated with the development of oropharyngeal HPV infection.

Correlations of chlamydia and gonorrhoea among pharyngeal, rectal and urethral sites among Thai men who have sex with men: multicentre community-led test and treat cohort in Thailand

OBJECTIVE

Routine screening for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections in sexually exposed anatomical sites may be challenging in resource-limited settings. The objective of this study was to determine the proportion of missed CT/NG diagnoses if a single anatomical site screening was performed among men who have sex with men (MSM) by examining the pattern of anatomical sites of CT/NG infections.

METHODS

Thai MSM were enrolled to the community-led test and treat cohort. Screening for CT/NG infections was performed from pharyngeal swab, rectal swab and urine using nucleic acid amplification testing. The correlations of CT/NG among the three anatomical sites were analysed.

RESULTS

Among 1610 MSM included in the analysis, 21.7% had CT and 15.5% had NG infection at any anatomical site. Among those tested negative for CT or NG infection at either pharyngeal, rectal or urethral site, 8%-19% had CT infection and 7%-12% had NG infection at the remaining two sites. Of the total 349 CT infections, 85.9%, 30.6% and 67.8% would have been missed if only pharyngeal, rectal or urethral screening was performed, respectively. Of the total 249 NG infection, 55.7%, 39.6% and 77.4% would have been missed if only pharyngeal, rectal or urethral screening was performed, respectively. The majority of each anatomical site of CT/NG infection was isolated to their respective site, with rectal site having the highest proportion of isolation: 78.9% of rectal CT and 62.7% of rectal NG infection.

CONCLUSIONS

A high proportion of CT/NG infections would be missed if single anatomical site screening was performed among MSM. All-site screening is highly recommended, but if not feasible, rectal screening provides the highest yield of CT/NG diagnoses. Effort in lowering the cost of the CT/NG screening test or developing affordable molecular technologies for CT/NG detection is needed for MSM in resource-limited settings.

TRIAL REGISTRATION NUMBER

NCT03580512; Results.

Risk factor of pharyngocutaneous fistula

INTRODUCTION

Pharyngocutaneous fistula is the most frequent complication of primary and secondary laryngectomy and pharyngolaryngectomy. It has an important impact on the patient, his entourage and the healthcare team. The risk factors for pharyngostoma are multiple and its treatment is not codified.

AIM

To identify the various factors that may predispose to this complication and to describe the different therapeutic means to control it.

METHODS

This retrospective study examined 68 cases of laryngeal cancer treated by total laryngectomy or pharyngolaryngectomy at Salah Azaїez's head and neck oncologic surgery department between 2015 and 2017.

RESULTS

Most of our patients were male (97%) who were major consumer of tobacco and alcohol. The most common stage were T4aN0M0 (34%) and T4aN1M0 (22%). Regarding treatment, we found that 73.5% of patients were operated on by total laryngectomy, 17.7% of patients were operated on by total pharyngolaryngectomy and 8.8% of patients were operated on by square laryngectomy. Pharyngostoma was diagnosed in 20.5% of cases within an average of 15 days. Among the risk factors studied, those that were statistically correlated with the occurrence of CPF in univariate studies were pre-laryngeal infiltration (p = 0.006), postoperative CRP level (p= 0.017), extension to piriform recess (p = 0.009), TNM stage (p=0.039), an associated thyroid surgery (p = 0.020) and pharyngeal closure under tension (p=0.000). In multivariate studies, five of the risk factors identified in the univariate analysis were found. This testifies to their major role as a risk factor for pharyngostoma. These factors were pre-laryngeal infiltration (p=0.001), postoperative CRP level (p=0.000), piriform recess involvement (p=0.004) Associated thyroid surgery (p=0.012) and pharyngeal closure under tension (p = 0.000).

CONCLUSION

By identifying predictive factors for pharyngostoma, we can identify patients in which this complication may occur and manage the medical care means to prevent it more efficiently.

Extragenital Gonorrhoea in Men Who Have Sex with Men: A Retrospective Study in a STI Clinic in Lisbon, Portugal

INTRODUCTION

Recent studies worldwide reveal a significant prevalence of extragenital infections by Neisseria gonorrhoeae among men who have sex with men. We aimed to analyse the frequency and characteristics of extragenital gonococcal infections diagnosed in men who have sex with men in a walk-in Sexually Transmitted Infection clinic in Lisbon, Portugal.

MATERIAL AND METHODS

We conducted a cross-sectional, retrospective study of the anorectal and/or oropharyngeal Neisseria gonorrhoeae infections in men who have sex with men, diagnosed in our Sexually Transmitted Infection clinic between January 2014 and December 2016.

RESULTS

We found extragenital infection in 87 cases of gonorrhoea identified in men who have sex with men in this period, including: 49 cases of anorectal disease, 9 of oropharyngeal disease, 13 cases of infection at both extragenital sites, and 16 of simultaneous extragenital and urogenital gonorrhoea. Patients' ages ranged from 17 to 64 years (median: 28 years). Forty-seven (54%) of the patients did not present with any extragenital symptoms. Thirty (35%) were human immunodeficiency virus-1-positive.

DISCUSSION

Since most extragenital Neisseria gonorrhoeae infections are asymptomatic, they may be missed and go untreated unless actively investigated. Current international guidelines recommend the screening of gonorrhoea at extragenital sites in men who have sex with men because anorectal and oropharyngeal infections constitute a potential disease reservoir, and may facilitate transmission and/or acquisition of human immunodeficiency virus infection.

CONCLUSION

Our results highlight the relevance of testing men who have sex with men for Neisseria gonorrhoeae at extragenital sites, regardless of the existence of local complaints. The implementation of adequate screening programmes in Portugal should be considered. We also reinforce the need to raise awareness in the population regarding the adoption of prophylactic measures against transmission of sexually transmitted infections during anal and/or oral sexual exposure.

Association of Nasopharyngeal and Laryngopharyngeal Reflux with Postnasal Drip Symptomatology in Patients with and without Rhinosinusitis

Background

Patients often report postnasal drip (PND), but objective rhinosinusitis and allergy findings are frequently absent. In this study, we evaluate the association between PND and pharyngeal reflux.

Methods

Sixty-eight participants underwent 24-hour pH testing, including chronic rhinosinusitis (CRS) patients persistently symptomatic after endoscopic sinus surgery, CRS patients successfully treated by endoscopic sinus surgery, and volunteers without a CRS history. The pH probes contained nasopharyngeal (NP), laryngopharyngeal (LP), and distal esophageal sensors. Participants completed the Sinonasal Outcome Test-20 (SNOT-20) and Modified Reflux Symptom Index (MRSI) questionnaires. Survey items addressing PND symptomatology were compared with NP reflux (NPR) below pH 4 and pH 5 (defined as ≥1 event), and LP reflux (LPR; defined as ≥7 events or reflux area index <6.3).

Results

Pearson analyses revealed a positive correlation of r = 0.87 between SNOT-20 and MRSI PND items. For NPR < pH 4, no significant difference existed between participants with and without reflux on the SNOT-20 or MRSI (p < 0.05). However, for NPR < pH 5, reflux-positive participants exhibited significantly more PND symptoms on the SNOT-20 (p = 0.030) and the MRSI (p = 0.018) compared with participants without reflux. Finally, participants with LPR had significantly more PND symptomatology on the SNOT-20 (p = 0.010) versus those without LPR. A borderline significant difference existed on the MRSI PND item between participants positive and negative for LPR (p = 0.055).

Conclusion

Objective evidence of NPR and LPR exists in patients reporting PND. Reflux treatment may reduce PND complaints.

Tonsillectomy increases the risk of retropharyngeal and parapharyngeal abscesses in adults, but not in children: A national cohort study

Objectives

The purpose of this study is to evaluate the risk of retropharyngeal and parapharyngeal abscesses (deep neck infection) after tonsillectomy in Koreans using national cohort data.

Methods

Using the national cohort study from the Korean Health Insurance Review and Assessment Service, participants who had undergone a tonsillectomy (5,299) and control participants (21,196) were selected and matched 1:4 (for age, sex, income, region of residence, and pre-operative upper respiratory infection visits). The Cox-proportional hazard model was used. A crude model and an adjusted model for age, sex, income, region of residence, hypertension, diabetes, and dyslipidemia were used in this analysis. For the subgroup analyses, the participants were divided into 2 groups: children (≤ 14 years old) and adolescents and adults (≥ 15 years old).

Results

The adjusted hazard ratio of deep neck infection after tonsillectomy was 1.43 (95% confidence interval, CI = 1.18–1.72, P < 0.001). In subgroup analysis, this ratio was 1.12 (95% CI = 0.86–1.47, P = 0.390) in children and 1.87 (95% CI = 1.43–2.45, P < 0.001) in adolescents and adults. The crude hazard ratios were almost the same as the adjusted ratios.

Conclusion

The risk of deep neck infection was higher in the tonsillectomy group. The subgroup analysis showed a similar finding in the adolescent and adult group but not in the child group.

BAHNG score: predictive model for detection of subjects with the oropharynx colonized by uncommon microorganisms

OBJECTIVE

Pneumonia is most frequently produced by the microaspiration of flora that colonizes the oropharynx. Etiological diagnosis of pneumonia is infrequent in clinical practise and empirical treatment should be prescribed. The aims of the present study were to determine the factors associated with oropharynx colonization by uncommon microorganisms (UM) and to develop a predictive model.

METHODS

A cross-sectional study that included all pa-tients living in one long-term care facilities was developed. Demographic, comorbidities, basal functional status and clinical data were collected. To determinate the oropharyngeal colonization, a single sample of pharynx was obtained for each subject using a cotton swab.

RESULTS

A total of 221 subjects were included, mean age 86.27 (SD 8.05) years and 157 (71%) were female. In 32 (14.5%) subjects UM flora was isolated, Gram-negative bacilli in 16 (7.2%) residents, and Staphylococcus aureus in 16 (7.2%). The predictive model included the presence of hypertension, neuromuscular disease, Barthel <90 and use of PEG. The BAHNG score (BArthel, Hypertension, Neuromuscular, Gastrostomy), showed an area under the curve of 0.731 (CI 95% 0.643-0.820; p<0.001). We have classified patients according to this score in low (0-2 points), intermediate (3-5 points) and high risk (≥ 6). The probability of UM colonization in the oropharyngeal based on this classification is 4.1%, 15.8% and 57.1% for low, intermediate and high risk, respectively.

CONCLUSIONS

The BAHNG score could help in the identifications of elderly patients with high risk of colonization by UM. In case of pneumonia the evaluation of the subject through this score could help in the initial decisions concerning antibiotic treatment.

Oral Human Papillomavirus Infection: Differences in Prevalence Between Sexes and Concordance With Genital Human Papillomavirus Infection, NHANES 2011 to 2014

BACKGROUND

The burden of human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) is disproportionately high among men, yet empirical evidence regarding the difference in prevalence of oral HPV infection between men and women is limited. Concordance of oral and genital HPV infection among men is unknown.

OBJECTIVE

To determine the prevalence of oral HPV infection, as well as the concordance of oral and genital HPV infection, among U.S. men and women.

DESIGN

Nationally representative survey.

SETTING

Civilian noninstitutionalized population.

PARTICIPANTS

Adults aged 18 to 69 years from NHANES (National Health and Nutrition Examination Survey), 2011 to 2014.

MEASUREMENTS

Oral rinse, penile swab, and vaginal swab specimens were evaluated by polymerase chain reaction followed by type-specific hybridization.

RESULTS

The overall prevalence of oral HPV infection was 11.5% (95% CI, 9.8% to 13.1%) in men and 3.2% (CI, 2.7% to 3.8%) in women (equating to 11 million men and 3.2 million women nationwide). High-risk oral HPV infection was more prevalent among men (7.3% [CI, 6.0% to 8.6%]) than women (1.4% [CI, 1.0% to 1.8%]). Oral HPV 16 was 6 times more common in men (1.8% [CI, 1.3% to 2.2%]) than women (0.3% [CI, 0.1% to 0.5%]) (1.7 million men vs. 0.27 million women). Among men and women who reported having same-sex partners, the prevalence of high-risk HPV infection was 12.7% (CI, 7.0% to 18.4%) and 3.6% (CI, 1.4% to 5.9%), respectively. Among men who reported having 2 or more same-sex oral sex partners, the prevalence of high-risk HPV infection was 22.2% (CI, 9.6% to 34.8%). Oral HPV prevalence among men with concurrent genital HPV infection was 4-fold greater (19.3%) than among those without it (4.4%). Men had 5.4% (CI, 5.1% to 5.8%) greater predicted probability of high-risk oral HPV infection than women. The predicted probability of high-risk oral HPV infection was greatest among black participants, those who smoked more than 20 cigarettes daily, current marijuana users, and those who reported 16 or more lifetime vaginal or oral sex partners.

LIMITATION

Sexual behaviors were self-reported.

CONCLUSION

Oral HPV infection is common among U.S. men. This study's findings provide several policy implications to guide future OPSCC prevention efforts to combat this disease.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Factors related to pediatric obstructive sleep apnea-hypopnea syndrome in children with attention deficit hyperactivity disorder in different age groups

This study aimed to retrospectively investigate the factors related to pediatric obstructive sleep apnea-hypopnea syndrome (OSAHS) with attention deficit hyperactivity disorder (ADHD) in children younger than 6 years and those older than 6 years.A total of 437 children who were hospitalized due to OSAHS between January 2014 and December 2014 were retrospectively reviewed. The children were further divided into OSAHS group and OSAHS + ADHD group. The general characteristics, OSA-18 quality of life, intention-hyperactivity score, and polysomnographic parameters (apnea-hypopnea index and the lowest oxygen saturation) were collected and compared between groups.There were 298 boys and 139 girls with the male to female ratio of 2.14:1. ADHD was found in 146 children including 105 boys and 41 girls with the male to female ratio of 2.56:1. Of these children, 31.62% and 35.46% had concomitant ADHD in children aged 4 to 5 years and those aged 6 to 11 years, respectively. In children aged 4 to 5 years, the incidence of allergic rhinitis was significantly higher (P = .016) and the adenoid hypertrophy was more severe (P = .001) in those with concomitant ADHD. In children aged 6 to 11 years, the tonsil hypertrophy was more severe in those with concomitant ADHD (P = .019). In children with concomitant ADHD, OSA-18 score was higher than in those with OSAHS alone (P < .001). Higher frequency of respiratory events (P < .001) and more severe hypoxia (P < .001) were found in children with concomitant ADHD than in those with OSAHS alone.As high as 30% of OSAHS children have concomitant ADHD, and the incidence of ADHD in OSAHS children is increasing over age. Boys are more likely to develop OSAHS and incidence of ADHD in OSAHS boys is higher than in OSAHS girls. In addition, risk factors of ADHD also vary between age groups. The ADHD is related to the severity of allergic rhinitis and adenoid hypertrophy in children aged 4 to 5 years, and to the severity of tonsil hypertrophy in children aged 6 to 11 years. Hypoxia may be an important factor causing ADHD. OSAHS should be treated as early as possible to reduce the incidence of ADHD in children.

Do salivary bypass tubes lower the incidence of pharyngocutaneous fistula following total laryngectomy? A retrospective analysis of predictive factors using multivariate analysis

Salivary bypass tubes (SBT) are increasingly used to prevent pharyngocutaneous fistula (PCF) following laryngectomy and pharyngolaryngectomy. There is minimal evidence as to their efficacy and literature is limited. The aim of the study was to determine if SBT prevent PCF. The study was a multicentre retrospective case control series (level of evidence 3b). Patients who underwent laryngectomy or pharyngolaryngectomy for cancer or following cancer treatment between 2011 and 2014 were included in the study. The primary outcome was development of a PCF. Other variables recorded were age, sex, prior radiotherapy or chemoradiotherapy, prior tracheostomy, type of procedure, concurrent neck dissection, use of flap reconstruction, use of prophylactic antibiotics, the suture material used for the anastomosis, tumour T stage, histological margins, day one post-operative haemoglobin and whether a salivary bypass tube was used. Univariate and multivariate analysis were performed. A total of 199 patients were included and 24 received salivary bypass tubes. Fistula rates were 8.3% in the SBT group (2/24) and 24.6% in the control group (43/175). This was not statistically significant on univariate (p value 0.115) or multivariate analysis (p value 0.076). In addition, no other co-variables were found to be significant. No group has proven a benefit of salivary bypass tubes on multivariate analysis. The study was limited by a small case group, variations in tube duration and subjects given a tube may have been identified as high risk of fistula. Further prospective studies are warranted prior to recommendation of salivary bypass tubes following laryngectomy.

[Clinical Characteristics of Pediatric Deep Neck Abscesses]

Pediatric deep neck abscesses are a relatively rare and can lead to critical or life-threatening situations. However, the clinical characteristics of pediatric deep neck abscesses are not fully understood in Japan. We conducted a retrospective study of the clinical characteristics of children presenting with pediatric deep neck abscesses at our hospital. All pediatric patients were diagnosed with deep neck abscesses on the basis of the clinical findings and computed tomography (CT) scanning of the neck between April 2009 and March 2014. The incidence, initial examining department, sex, age, presenting signs and symptoms, physical findings, duration between onset and admission, timing of CT scanning, abscess location, causative organism, and method of treatment were determined from the medical records. 　We identified a total of 20 pediatric patients with deep neck abscesses, with a mean incidence of 4.0±1.9 cases per year. Pediatric deep neck abscesses were more common during winter and spring. Most patients initially presented to the pediatric department before consulting an otolaryngologist. Fourteen (70%) patients were male and six (30%) were female, with no obvious peak age of onset. The mean duration between onset and admission was 7.2±3.9 days. The mean timing of CT scanning was 8.1±3.6 days after onset. The most commonly involved area was the retropharyngeal space in nine (45%) and the retro-cervical space in eight (40%) patients. The most frequent causative organism was Staphylococcus aureus (20%), with no cases of antibiotic-resistant bacteria infection observed. Majority of the children were initially managed with conservative treatment. Five patients who failed to improve within 48 h of treatment subsequently underwent surgical drainage. No significant complications such as descending mediastinitis and septic shock were observed in any of the patients.

Why do geriatric patients visit otorhinolaryngology?

The number and proportion of people more than 65 years old in the population are increasing with the rise in life expectancy. This study was designed to investigate the otolarygologic needs and visits of geriatric patients. We conducted a retrospective study that included all patients ≥65 years of age who visited the otolaryngology department between 8 a.m. and 4 p.m. during 1 year. Age, gender, main complaint, and clinical diagnosis were noted on a chart and analyzed. In 2012, a total of 19,875 patients attended the otolaryngology department between 8 a.m. and 4 p.m., of whom 418 (2.1%) were aged ≥65 years. The most common complaints were ear and hearing disorders (24.2%), epistaxis(15.3%), balance disorders (15.1%), pharyngotonsillar pathologies (14.8%), and head and facial trauma (9.6%). This study shows that the changing patient population will change the type and frequencies of pathologies seen in general otolaryngology practices. Geriatric patients need a targeted approach to their diseases because they have special issues unique to their population.

Postlaryngectomy Pharyngocutaneous Fistula: Incidence, Predisposing Factors, and Therapy

OBJECTIVE: The pharyngocutaneous fistula (PCF) is a serious complication after total laryngectomy, and its etiology is not well understood yet. The aim of our study was to evaluate predisposing factors, incidence, and management of this complication.

STUDY DESIGN AND SETTING: This was a retrospective study of 268 patients who underwent total laryngectomy in our clinic (January 1990-December 2001). A number of factors potentially predisposing to PCF formation were evaluated.

RESULTS: A PCF was observed in 16% of patients. Systemic diseases, previous radiotherapy, supraglottic origin of tumor, and concurrent radical neck dissection were significantly associated with PCF. Spontaneous closure was noted in 28 patients, whereas a surgical closure was necessary in 15 patients.

CONCLUSIONS: In presence of a specific risk factor, PCF can be expected; nevertheless, its prevention remains very difficult. Moreover, given the high percentage of spontaneous closure, we suggest the “wait and see” approach for 28 days before proceeding with a surgical approach.

Increased incidence of head and neck abscesses in children

Objective

To describe increasing incidence and changing microbiology of head and neck abscesses in children admitted to the hospital during the first quarters of 2000 through 2003.

Study Design and Setting

Retrospective data warehouse review identified 89 children less than 19 years of age admitted to a tertiary care pediatric hospital during the first quarters of 2000 through 2003 for suspicion of head and neck abscess involving the neck, face, and peritonsillar, retropharyngeal, and parapharyngeal spaces; and for orbital and intracranial complications of acute sinusitis.

Outcome Measures

Outcome measures included the incidence of infection admissions and description of infection location and microbiology, calculated by χ2 technique.

Results

The incidence of infections increased in 2003. The greatest increase was in neck abscesses and complications of acute sinusitis.

Conclusions

The increase in group A strep infections may be related to its biologic properties.

Significance

Group A strep remains a significant cause of head and neck infections in children.

Branchial cleft and pouch anomalies in childhood: a report of 50 surgical cases

BACKGROUND AND AIMS

Branchial abnormalities occur when there is disturbance in the maturation of the branchial apparatus during fetal development. Branchial anomalies are congenital lesions usually present in childhood, even if they can be diagnosed later for enlargement or infection. A correct diagnosis will lead to proper management: complete surgical excision is the treatment of choice. The purpose of this article is to present clinical features, diagnostic methods and surgical treatment of branchial anomalies in childhood, based on a series of 50 patients.

METHODS

We conducted a retrospective analysis of a total of 50 pediatric patients operated from June 2005 to June 2014 for the presence of branchial cleft anomalies.

RESULTS

27 cases (54 %) presented a second branchial cleft fistula and 11 cases (22 %) a second branchial cleft cyst and one case (2 %) presented both cyst and sinus of the second branchial cleft; four cases (8 %) presented first branchial cleft cyst whereas four cases (8 %) a first branchial cleft sinus and two cases (4 %) a first branchial cleft fistula; one case (2 %) presented a piriform sinus fistula (third branchial cleft). None of our patients presented anomalies of the fourth branchial cleft. All patients underwent surgical treatment and lesions have been removed by excision or fistulectomy. No post-surgical complication occurred. The rate of recurrence was 4 %.

CONCLUSIONS

Pre-operative diagnosis supplies important information to the surgeon for a proper therapy: a complete excision of the lesion without inflammatory signs is essential to avoid re-intervention and to achieve a good outcome.

Recorded gonorrhoea rates in Denmark, 1900-2010: the impact of clinical testing activity and laboratory diagnostic procedures

OBJECTIVES

Assessment of the relations between recorded gonorrhoea rates and clinical testing activity and disposable diagnostic tests.

METHODS

In Denmark, two sources of information on the epidemiology of gonorrhoea are available: (1) a mandatory clinical notification system (since 1867) comprising summary information about geographic distribution, season, age group and gender; in 1994, more detailed anonymous individualised epidemiological information was included; (2) a voluntary countrywide laboratory surveillance system for culture-confirmed cases (since 1957) comprising information about patient's age and gender, infected anatomical sites and medical setting attended.

RESULTS

Both surveillance systems showed marked simultaneous changes in gonorrhoea rates, although periodically considerable under-reporting or under-diagnosing was demonstrated. The annual incidence of notified cases peaked in 1919 (474/100,000), in 1944 (583/100,000) and in 1972 (344/100,000). Since 1995, the incidence has been at a low endemic level (1.5-10/100,000) and the total male/female incidence ratios were from 3 to 7 times higher than previously recorded. Among approximately 2 million persons tested during 1974-1988 78,213 men and 63,143 women with culture-confirmed gonorrhoea were identified. During this period, pharyngeal sampling was performed in 36% of men and 25% of women with gonorrhoea; pharyngeal gonorrhoea was found in 10% and 16%, respectively; 40% and 30% of these patients had no concomitant urogenital gonorrhoea. Among men with gonorrhoea, 34% were sampled from the rectum; 9% had rectal gonorrhoea, among whom the rectum was the only infected site in 67%.

CONCLUSIONS

Crucial factors for case finding are clinical sampling tradition and appropriate laboratory diagnostic facilities. When case finding is insufficient, a reservoir of asymptomatic rectal or pharyngeal gonorrhoea remains unrecognised.

Characterization of patients' requests and pharmacists' professional practice in oropharyngeal condition in Spain

BACKGROUND

A sore throat is the reason behind 4 million visits to health care services per year in Spain. The management of these ailments is usually associated with an inappropriate use of medicines. Community pharmacists are often the first point of contact for patients under the healthcare system and play a major role in the management of minor ailments.

OBJECTIVE

To characterize the pharmacists' professional practice in oropharyngeal condition in terms of patients' requests and pharmacists' interventions performed.

SETTING

Community pharmacies throughout Spanish territory.

METHOD

Cross-sectional multicenter observational study, undertaken between November 2012 and March 2013. Patients were recruited consecutively in the participant pharmacies. Eligible patients were those making a consultation related to an oropharyngeal condition or requesting treatment for an oropharyngeal condition. A univariate descriptive analysis showing the frequency of occurrence of the different variables was performed. This was completed with a multivariate statistical analysis through a multiple correspondence method, in order to analyze the potential association between the pharmacist profile and the intervention provided.

MAIN OUTCOME MEASURE

Professional Pharmacy Service requested (dispensing/counselling/medication review with follow-up), reason for consultation, source of the recommendation, Pharmacist's intervention and reason for referral.

RESULTS

710 pharmacies and 3,547 patients participated in the study. The most frequently requested service was dispensing (44.7 %), followed by counselling (31.8 %). Regarding dispensing, the majority of patients requested a throat preparation, mostly antiseptics. Symptoms associated with the pharmacy consultation were mainly throat symptoms (70.8 %), voice symptoms (24.9 %), and mouth/tongue/lip symptoms (10.1 %). The most common pharmacist intervention was "selection of pharmacological treatment", followed by "dispensing the requested medicine"; 6.51 % of the patients were referred to a general practitioner, mainly due to fever and other symptoms associated with infection. No relationship between the pharmacist profile and the intervention performed was found.

CONCLUSION

The most frequently requested professional service was the dispensing service, mainly for treating throat symptoms. Community pharmacists play a major role in managing patients with an oropharyngeal condition. They can keep them out of general practice or act as referral agents when a more severe disease is identified.

Pharyngo-cutaneous fistula complicating laryngectomy in the chemo-radiotherapy organ-preservation epoch

Pharyngo-cutaneous fistula is a serious complication of laryngectomy, with a significant associated morbidity and mortality. The oncologic success of organ-preservation protocols with radiotherapy or chemo-radiotherapy for laryngeal carcinoma means laryngectomy is increasingly reserved for surgical salvage in the event of persistent or recurrent disease. A retrospective review of fistula incidence after laryngectomy in 171 patients in a UK tertiary referral centre over the last decade was conducted to identify trends in this complication in the epoch of non-surgical organ preservation. The overall fistula incidence following laryngectomy is 29.2% (50/171). Fistula incidence following salvage total laryngectomy is significantly higher than after primary total laryngectomy [19/51 (37.3%) vs. 8/47 (17.0%), χ2 = 5.02, p = 0.03]. There is no significant effect of prior treatment on fistula incidence following laryngo-pharyngectomy or pharyngo-laryngo-oesophagectomy [14/39 (35.9%) vs. 9/27 (33.3%), χ2 = 0.05, p = 0.83]. Prophylactic vascularised tissue flaps to reinforce the pharyngeal suture line may reduce fistula incidence and fistula severity in salvage total laryngectomy.

Pharyngocutaneous fistulae after total laryngectomy: analysis of the risk factors and treatment approaches

OBJECTIVES

To investigate the incidence and predisposing factors in the development of postoperative pharyngocutaneous fistula (PCF) after total laryngectomy.

METHODOLOGY

A total of 166 patients with complete medical records who underwent total laryngectomy (TL) due to laryngeal cancer were analysed retrospectively. The mean age of the patients was 57.4 (+ 19.6) years. This study looked at a total of 32 different parameters considered to be effective in the development of pharyngocutaneous fistula after total laryngectomy.

RESULTS

Thirty-two patients (19.2%) had a pharyngocutaneous fistula. Aged over 61 years (p = 0.003), Diabetes Mellitus (DM) (p = 0.002), alcohol use (p = 0.006), history of preoperative radiotherapy (p = 0.001), preoperative tracheotomy (p = 0.017), postoperative low levels of haemoglobin (Hb) (p = 0.029), low levels of preoperative albumin (p = 0.001), total protein and a low alb/glb (albumin/globulin) ratio (p = 0.001), serum prealbumin levels on the third and seventh postoperative days (p = 0.001), high postoperative CRP levels (p = 0.002), T4 stage (extralaryngeal) and presence of transglottic lesion (p = 0.003), presence of stage IV (p = 0.012) lesion, primary surgery accompanied by bilateral neck dissection (p = 0.047), T-shaped oesophagus suture, postoperative bleeding (p = 0.07), presence of postoperative fever (p = 0.001), presence of skin defect in the anterior neck (p = 0.001) and presence of postoperative depression (p = 0.001) were found to be statistically significant factors in the development of PCF.

CONCLUSIONS

Our study found many parameters associated with an increased risk of the development of PCF. According to the multivariate regression analysis, aged over 61 years, DM, preoperative RT, preoperative tracheostomy, postoperative Hb under 10 g/dl, prealbumin under 17 mg/dl on the third postoperative day, and a postoperative fever of 38.3 degrees C and above were found be associated with a higher risk of the development of fistulae more than the other risk factors.

Stapler suture of the pharynx after total laryngectomy

The use of a stapler for pharyngeal closure during total laryngectomy was first described in 1971. It provides rapid watertight closure without surgical field contamination. The objective of our study was to compare the incidence of pharyngocutaneous fistula after total laryngectomy with manual and mechanical closures of the pharynx. This was a non-randomised, prospective clinical study conducted at two tertiary medical centres from 1996 to 2011 including consecutive patients with laryngeal tumours who underwent total laryngectomy. We compared the incidence of pharyngocutaneous fistula between two groups of patients: in 20 patients, 75 mm linear stapler closure was applied, whereas in 67 patients a manual suture was used. Clinical data were compared between groups. The groups were statistically similar in terms of gender, age, diabetes mellitus, smoking and alcohol consumption and tumour site. The group of patients who underwent stapler-assisted pharyngeal closure had a higher number of patients with previous tracheotomy (p < 0.001) and previous chemoradiation (p < 0.001). The incidence of pharyngocutaneous fistula was 30% in the mechanical closure group and 20.9% in the manual suture group (p = 0.42). In conclusion the use of the stapler does not increase the rate of fistulae.

How reliable is self-testing for gonorrhea and chlamydia among men who have sex with men?

BACKGROUND

Recent studies have demonstrated a high prevalence of pharyngeal (P) and rectal (R) Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) infections among men who have sex with men (MSM). Guidelines by the Centers for Disease Control and Prevention recommend testing at least annually. But surveys of medical providers suggest that adherence to these guidelines is minimal as a result of limited time and staff. Because of these concerns, we evaluated the feasibility and accuracy of patient self-testing.

METHODS

Three-hundred seventy-four patients at a Washington, DC clinic who identified themselves as MSM and requested testing for sexually transmitted infections (STIs) participated in the study. Patients performed self-screening using the Gen-Probe APTIMA Combo 2 (AC2) kit after viewing written and pictorial instructions. Trained providers also screened patients. We randomized the order in which patients or providers performed testing.

RESULTS

Among those receiving specific tests, 8% of patients tested positive for R-GC, 9.3% for P-GC, 12.7% for R-CT, and 1.3% for P-CT. We performed McNemar tests, stratified by infection type and anatomic site to evaluate concordance. Self-administered testing was significantly better at identifying P-GC (discordant: 3%) and R-GC (discordant: 2.9%) (P ≤.01), and had results similar to provider- administered testing for P-CT (discordant: 0.5%) and R-CT (discordant: 1.1%) detection.

CONCLUSIONS

The equivalent or better detection rates for rectal and oral gonorrhea and chlamydia among patients suggest that patients are capable of performing their own screening for STIs, which may increase infection detection and treatment.

Human myiasis in Fars Province, Iran

We evaluated the prevalence and consequences of human myiasis among people involved in animal husbandry and butchers among 6 counties in Fars Province, Iran using a descriptive cross sectional survey. A semi-structured questionnaire was used to evaluate knowledge, community perceptions and practices. Three hundred two herders shepherds and butchers were included in the study. Eighty-eight point three percent of subjects had experienced myiasis during their job experiences. Seventy-one point five percent had become infected in barns. Pharyngeal myiasis was reported by 87% of subjects. The most likely cause of myiasis in subjects was the sheep botfly, Oestrus ovis (Diptera: Oestridae). Age and job experiences did not have an effect on the knowledge and practice regarding myiasis of subjects. Academic educational level had no significant effect on knowledge but did have a significant effect on practices. A myiasis education program needs to be created to better control and prevent this problem.

Postlaryngectomy pharyngocutaneous fistula: determining the risk of preoperative tracheostomy and primary tracheoesophageal puncture

BACKGROUND

This article considers whether preoperative tracheostomy and primary tracheoesophageal puncture (TEP) contribute as independent risk factors to the development of pharyngocutaneous fistula (PCF), as well as discusses the significant factors related to the perioperative management of these patients.

METHODS

Retrospective data were collected on 145 patients treated with total laryngectomy/pharyngolaryngectomy between January 2003 and July 2010 at the Victoria Hospital in London, Ontario, including whether preoperative tracheostomy or primary TEP was performed.

RESULTS

One in four (25%) patients developed a postoperative PCF. No increase in PCF rates was observed with either preoperative tracheostomy or primary TEP. Salvage surgery PCFs achieved lower rates of spontaneous closure compared to those undergoing primary surgery (p  =  .002).

CONCLUSIONS

Neither preoperative tracheostomy nor primary TEP was associated with the development of PCF. Surgical closure of PCF is more likely to be required in the setting of salvage surgery.

Three years audit of the emergency patients in the department of ENT of a rural medical college

Surgical audit is a systematic, critical analysis of the quality of surgical care provided, with the aims of improving quality of care, continuing education for surgeons, and guiding appropriate use of health resources. Emergency service is an integral part of any discipline of clinical medicine and it is considered as an indicator of quality of healthcare system. A three years record based, retrospective, cross-sectional study was carried out in the department of ear, nose and throat (ENT) of Midnapore Medical College, Paschim Medinipur,West Bengal to identify the total attendance of various emergency patients, diagnosis made thereafter, the mode of interference and outcome and the potential problems in the quality of care provided to the community. A total of 9051 patients had been admitted/attended in the ENT emergency from January 2008 to December 2010 who were included in this audit. Detailed statistical analysis of the data showed male: female (2.38:1) with the peak in the first decade of life. Majority of the patients were from Medinipur sadar (58.43%). The total otological cases were maximum (42.41%) in comparison to nose (28.98%) and throat (28.60%). The most common ear emergencies were earache due to impacted wax, acute suppurative otitis media, foreign body ear and the trauma/injury. Chronic suppurative otitis media with complications were the least. Amongst the sinonasal emergency, the most common aetiology was the epistaxis and foreign body nose in children. The different types of foreign body impaction in the throat and the inflammatory condition of throat or the inspiratory stridor due to upper airway obstruction were the main emergency situation recorded. Some cases were fatal. The overall mortality was 0.44%.

[Urumqi 11 689 secondary school teachers of throat disease investigation]

OBJECTIVE

To investigate the prevalence of throat disease in secondary school teachers of Urumqi.

METHOD

Use Stage-Two random sampling at 11689 teachers from 109 secondary schools in Urumqi; Draw 3 217 from 11689 teachers in 109 secondary schools to accept voice self-assessment questionnaire survey and routine examination of throat, and the one who were confirmed abnormal in routine inspection would be underway stroboscopic laryngoscopy.

RESULT

The total illness prevalence rate of throat disease in secondary school teachers of Urumqi is 28.23%; there is no statistic difference of illness prevalence rate between male and female teachers (P > 0.05). However, results showed statistical significance of illness prevalence rate in teachers of different racial-groups with different years of teaching experience (P < 0.05). Teachers who have 5 to 15 years of teaching experience suffer a high incidence of throat diseases. Among eight racial groups involved in investigation, Kazak teachers are in the highest illness prevalence rate. The results of assessment for voice disorder index between teachers with and without throat diseases showed statistical difference in total score TVH (P < 0.05), which is shown significant in the physical and emotional areas (P < 0.05), while there is no statistical difference in function. Diseases of pharyngeal portion are mainly chronic pharyngitis and hyperplastic tonsil in tongue root; Diseases of laryngeal portion are mainly chronic laryngitis and vocal nodule for female, while mainly chronic laryngitis and vocal polypus for male.

CONCLUSION

There is no significant difference in illness prevalence rate of throat disease for secondary school teachers in Urumqi between genders; the highest prevalence rate is in teachers who have 5 to 15 years teaching experience; among different racial groups, Kazak teachers are of the highest illness prevalence rate; the illness prevalence of throat diseases is related with voice disorder index.

Nose and throat complications associated with passive smoking among Congolese school children

OBJECTIVE

To assess associations between nose-throat (NT) diseases and passive smoking prevalence among school children.

METHODS

A cross-sectional survey was carried out on a randomized multistage sample of 381 school children (50.9% males, aged 9.8 ± 3.5 years) from Kinshasa town. Parents and children were asked to fill in a questionnaire detailing their smoking habits. The NT symptoms and diseases were assessed by the survey NT specialist.

RESULTS

The prevalence of passive smoking was 38.6% (n = 147). Residence in peripheral areas, catholic school system, elementary level, exposure of family to passive smoking, history of NT surgery, medicines and menthol inhaling, headache, nasal pain, dysphagia, odynophagia, dysosmia, dysphonia, pharyngeal irritation, dry throat, snooze, and chronic pharyngitis were more reported by passive smokers. After adjusting for confounding factors, passive smoking (OR = 16.7 95%CI 3.3-83.3), catholic system(OR = 2 95%CI 1.2-3.2), and elementary degree(OR = 1.4 95%, CI 1.1-2.1) were identified as independent determinants of chronic pharyngitis.

CONCLUSION

Parents should not smoke in the same room used by their children.

Contemporary profile of oral manifestations of HIV/AIDS and associated risk factors in a Southeastern US clinic

BACKGROUND

Introduction of highly active antiretroviral therapy (HAART) has resulted in a significant decrease of oral manifestations (OMs). The profile and risk factors for OM in those individuals initiating HAART remain understudied in the Southeast of the United States, region of increasing HIV prevalence.

OBJECTIVE

To determine clinical, socio-demographic, and laboratory characteristics associated with the presence of OM among patients initiating HAART.

METHODS

Retrospective review of electronically captured data from patients initiating HAART at a Southeastern US clinic. Prevalence was determined, and risk factors for overall OM, oropharyngeal candidiasis (OPC), and all other OM were evaluated using logistic regression.

RESULTS

In our sample (n = 744), majority of individuals were males (75 percent), African-American (50 percent), mean age of 39 years, 42 percent of which reported sex with men (MSM). Two hundred sixty-six had some type of OM. Compared with those without any OM, patients with OM had a lower mean baseline CD4+ T cells count (CD4 count) (331 ± 260 versus 179 ± 244 CD4 cells/mm(3) ) and higher mean baseline HIV-1 RNA viral load (4.0 ± 1.34 log(10) versus 4.6 ± 1.30 log(10) ) (P < 0.01). In the logistic regression models seeking to determine factors associated with an increased risk of OM and OPC, the only characteristic associated with the outcome was baseline CD4 value. Being male, African-American, and heterosexual showed a protective role for OM other than OPC.

CONCLUSION

OM continues to be common despite HAART. General OM and OPC were closely associated with a low baseline CD4 count. Knowledge of risk factors for OM can potentially help clinicians target oral evaluation of HIV-positive individuals.

Serum albumin concentration and surgical site identify surgical risk for major post-operative complications in advanced head and neck patients

INTRODUCTION

To determine the relationship between peri-operative predictors of morbidity and mortality in advanced head and neck cancer patients.

METHODS

The records of 37 consecutive patients who underwent major surgery for advanced head and neck cancer were reviewed. We evaluated factors potentially predisposing to major complications after major surgery for treating advanced head and neck cancer.

RESULTS

Twenty-seven men and ten women with a median age of 59 years were included. Eighteen of the thirty-seven had an albumin level < 3.5 g/dl. All the post-operative complications occurred in hypoalbuminemic patients (p = 0.001). The fatal complication appeared in the patient with a albumin level < 0.5 g/dl. The definitive model with logistic regression analysis showed that peri-operative albumin level and the site of origin of the tumour involved a five- and twofold increase respectively in the risk of major complications after major surgery in advanced head and neck patients.

CONCLUSION

The results suggest that hypoalbuminemia is common among head and neck patients. Hypoalbuminemia, as the site of origin of the tumour, is associated with an increased risk of morbidity and mortality in head and neck patients who receive surgical treatment.

[The influence of application of the assisted reproductive technologies on the state of ENT organs in children]

The objective of the present study was to estimate the state of ENT organs in the children born after assisted reproductive technologies (ART). A group of 208 children at the age from 1 to 3 years enrolled in the study included 97 ones born following application of the assisted reproductive technologies. It is concluded that the use of the assisted reproductive technologies has no appreciable effect on the extent and the structure of ENT organ morbidity in the children.

Retropharyngeal and parapharyngeal abscess in children--epidemiology, clinical features and treatment

OBJECTIVE

To describe the clinical presentation, diagnosis, management and complications of children with retropharyngeal abscesses (RPAs) and parapharyngeal abscesses (PPAs).

METHODS

A retrospective chart review was conducted at two tertiary care, pediatric hospitals in Israel. The medical records of all children <18 years who had been admitted with a diagnosis of RPA or PPA during an 11-year period (January 1997 to February 2008) were reviewed. Data on demographics, presenting symptoms, physical examination findings, imaging studies and interpretation, laboratory results, hospital course, medical treatment and surgical interventions were retrieved.

RESULTS

A total of 39 children were diagnosed as having RPA (n=26, 67%) or PPA (n=13, 33%). There was a predominance of boys (61.5%). The mean age of all the children at diagnosis was 4 years. The annual incidence increased over the 11-year period. The most common symptoms at presentation included fever (n=27, 70%) and neck pain (n=24, 62%). The physical examination revealed cervical lymphadenopathy in 30 children (77%), limitation of neck movements in 25 (64%), torticollis in 21 (54%), drooling in three (8%), and stridor in two (5%). Computerized tomographic (CT) scanning with contrast was performed in 37 patients (95%), of whom 17 underwent surgical drainage. Thirteen children were positively diagnosed as having an abscess by the finding of pus at surgery, of whom 12 had been found to have an abscess on their CT scan. All the patients received intravenous antibiotics. There was no significant difference in the duration of hospital stay between those who underwent surgery and those who were treated with antibiotics alone. There were no treatment failures and no complications in either of the two groups.

CONCLUSION

Children with RPA most commonly present with restricted neck movements, fever and cervical lymphadenopathy, and rarely with respiratory distress or stridor. Many patients with RPA and PPA can be treated successfully without surgery. CT scans are helpful in diagnosing and assessing the extent of the infection, but they are not always accurate.

Tularaemia outbreaks in Sakarya, Turkey: case-control and environmental studies

INTRODUCTION

Tularaemia is an important zoonotic disease that leads to outbreaks. This study aimed to compare the epidemiological characteristics of two tularaemia outbreaks that occurred in the Sakarya region of Turkey, analyse the risk factors for the development of outbreaks and identify Francisella (F.) tularensis in the water samples.

METHODS

Two tularaemia outbreaks occurred in the Kocadongel village in 2005 and 2006. A field investigation and a case-control study with 47 cases and 47 healthy households were performed during the second outbreak. Clinical samples from the patients and filtrated water samples were analysed for F. tularensis via real-time polymerase chain reaction.

RESULTS

From the two outbreaks, a total of 58 patients were diagnosed with oropharyngeal tularaemia based on their clinical and serological results. Both outbreaks occurred between the months of January and April, and the number of patients peaked in February. Logistic regression analysis revealed that the consumption of natural spring water was the only significant risk factor for tularaemia infection (odds ratio 3.5, confidence interval 1.23-10.07). F. tularensis was detected in eight clinical samples and in the filtrated natural spring water.

CONCLUSION

This study is the first report of tularaemia from this region. The results show that both tularaemia outbreaks were related to the consumption of untreated natural spring water. To prevent waterborne tularaemia, community water supplies should be treated and checked periodically.

Retrospective analysis of cellulitis of the floor of the mouth

OBJECTIVES

To analyze clinical data of patients treated for mouth floor cellulitis during 2003-2006 years at the Department of Maxillofacial Surgery, Vilnius University Hospital Zalgiris Clinic and to compare the results with existing data.

MATERIAL AND METHODS

Patient's gender, age, social insurance, demographic profile, preference of first visit, previous treatment, origin of inflammation, symptoms of disease, treatment protocol and outcomes were evaluated from 240 clinical records.

RESULTS

The male-female ratio was 1.3:1. The mean age of patients was 43.18+/-7.56 years. 65% of patients were from urban. 47% of patients were employed, 15% retirees, 22% unemployed, 10% children, 2% students and 4% handicapped people. In 65% of cases primary diagnosis was incorrect. Majority of patients appealed to doctor on the first five days from the beginning of the disease. 93.7% of mouth floor cellulites were odontogenic origin. In 32.9% of the patients at the time of first examination the extension of inflammation into parapharyngeal, pterygomandibular spaces or neck together with mouth floor cellulitis was diagnosed. In 1.7% (in 4 out of 240) of cases infection extended into the neck and parapharyngeal spaces despite treatment. In 2% (in 5 out of 240) of cases infection extended to mediastinum.

CONCLUSIONS

Despite the aggressive treatment serious complications still are possible. Delayed treatment procedures might determine poor prognosis.

[Fistula following total laryngectomy. Retrospective study and bibliographical review]

BACKGROUND

The pharyngocutaneous fistulae is troublesome and the most common complication following total laryngectomy. Our objective was to determine the incidence of pharingocutaneous fistulae after the total laryngectomy in our serie and to make review of the medical literature.

METHODS

We made a retrospective study of a serie of 81 consecutive cases of laryngeal carcinoma treated between 1995 and 2008 in our section. Total laryngectomy was performed in 29 cases and 52 patients treated with organ preservation approach, were excluded. In 14 cases, the procedure was combined with radical neck dissection, pharyngeal resection or myocutanenous flaps. Nasogastric tube for feeding in the postoperative period was used in all patients and surgical gastrostomy was performed in 5 cases.

RESULTS

Our incidence of fistulas when total laryngectomy was the alone procedure is 20 % and 34.5 % when simultaneous surgical proceedings were associated. Spontaneous closure was noted in 80 % of the cases and the mean hospitalization time was 23 days.

CONCLUSIONS

Most of the fistulas can be managed with conservative treatment. Pectoralis major myocutanenous flap is appropriate when conservative treatment has failed. In small fistulas, nasogastric or gastrostomy tube for feeding can be successfully managed in the ambulatory follow up. The cost-benefit relation must be better analyzed.

Abnormal Sensorimotor Integrative Function of the Larynx in Congenital Laryngomalacia: A New Theory of Etiology

OBJECTIVES/HYPOTHESIS

Laryngomalacia is an enigmatic disease in which laryngeal tone is weak, resulting in dynamic prolapse of tissue into the larynx. Sensorimotor integrative function of the brainstem and peripheral reflexes are responsible for laryngeal tone and airway patency. The goal of this study was to elucidate the etiology of decreased laryngeal tone through evaluating the sensorimotor integrative function of the larynx. The secondary goal was to evaluate factors and medical comorbidities that contribute to the wide spectrum of symptoms and outcomes.

STUDY DESIGN

Prospective and retrospective collection of evaluative data on infants with congenital laryngomalacia at two tertiary care pediatric referral centers.

METHODS

Two hundred one infants with laryngomalacia were divided into three groups on the basis of disease severity (mild, moderate, severe). Patients were followed prospectively every 8 to 12 weeks until symptom resolution or loss to follow-up. Sensorimotor integrative function of the larynx was evaluated in 134 infants by laryngopharyngeal sensory testing (LPST) of the laryngeal adductor reflex (LAR) by delivering a duration- (50 ms) and intensity- (2.5-10 mm Hg) controlled air pulse to the aryepiglottic fold to induce the LAR. Medical records were retrospectively reviewed for medical comorbidities.

RESULTS

The initial LPST was higher (P < .001) in infants with moderate (6.8 mm Hg) and severe disease (7.4 mm Hg) compared with those with mild disease (4.1 mm Hg). At 1, 3, and 6 months, infants with moderate and severe disease continued to have a higher LPST compared with those with mild disease. At 9 months, the LPST decreased in all subjects (3.1-3.5 mm Hg, P = .14), which also correlated with symptom resolution. Neurologic, genetic, and cardiac diseases were more common in infants with severe disease (P < .001). Gastroesophageal reflux disease (GERD) and feeding problems more common in those with moderate and severe disease (P < .001). Apgar scores were lower in those with severe disease (P < .001). Most symptoms resolved within 12 months of presentation. Those with GERD benefited from treatment. Supraglottoplasty resulted in few complications. Multiple comorbidities (>3) influenced the need for tracheotomy.

CONCLUSIONS

Laryngeal tone and sensorimotor integrative function of the larynx is altered. The degree of alteration correlated with disease severity, indicating that factors that alter the peripheral and central reflexes of the LAR have a role in the etiology of signs and symptoms of laryngomalacia. GERD, neurologic disease, and low Apgar scores influenced disease severity and clinical course, explaining the spectrum of disease symptoms and outcomes. Sensorimotor integrative function improved as symptoms resolved.