Neck Service Research Articles

Head & neck surgical oncology: Success in private practice.

Due to its complexity and multimodality treatment needs, traditional delivery of head and neck cancer care often occurs in a multidisciplinary cancer center, frequently in a university-based program in an urban setting. Fellowship training opportunities for subspecialty-focused head and neck surgeons have increased over recent years. There is a persistent concern that the number of newly minted Head & Neck Surgeons graduating each year outpaces the number of university-based employment opportunities, and that the workforce does not match the job opportunities. Recent publications examine this potential mismatch to better understand career choices, with a 2021 survey revealing that nearly 90% of fellowship graduates were employed by a university or academic institution and only 10% reported being in "private practice". However, it should not be an automatic assumption that academic practice is somehow superior to private practice. Moreover, not every patient can access university-based care, creating a societal mismatch between disease incidence, resources, and access to high quality care. The well-trained Head & Neck Surgeon may be able to deliver excellent care in a satisfying practice setting without an academic affiliation. Two Head & Neck Surgeons who have practiced in both Academic and Community-based ("private") subspecialty settings offer practical and actionable tips to provide high level evidence-based head and neck surgical care without the trappings of a university, and with a focus on patient-centered care as well as career satisfaction. Further, since graduates of comprehensive otolaryngology training programs receive a robust amount of head and neck surgery training in residency, understanding these practical tips will potentially assist the Comprehensive Otolaryngologist in private practice to expand head and neck services within their practice. 1) Review recently published survey-based reports of practice patterns and career satisfaction of recent HNS fellowship graduates, recognizing self-reported rates of practice settings, academic versus non-university-based ("private practice"). 2) Analyze and report practice structure of HNS graduates over the years 2015 to 2021 to determine rates of practice structure change from academic to private or vice versa, using Public Use Files combined with Google search. 3) Outline tips and pearls for a successful Head & Neck Surgery practice in a non-university-based setting, with 11 practical and actionable items that will allow high level subspecialty care without the traditional attributes of academic employment. Graduates of head & neck surgery fellowships in recent years may perceive a paucity of academic job opportunities. This article reviews practice patterns of recent graduates, and presents practical tips to achieve a satisfying Head & Neck Surgery career in a private practice setting.

Applying the British Association of Oral and Maxillofacial Surgeons quality outcomes metrics to a regional Australian oncology and reconstructive service: benchmarking the data to audit clinical outcomes in emerging, regional, and small-volume centres

The traditional model of centralisation of care, whilst having many advantages, also requires adaptation and upscaling to meet the requirements of both regional areas and the increasing urban sprawl. However, to ensure comparable outcomes with current major centres, this transition, when required, must be delivered in a safe and effective manner. Our project, which utilised the British Association of Oral and Maxillofacial Surgeons (BAOMS) recently published outcome data from the Quality and Outcomes in Oral and Maxillofacial Surgery (QOMS) project to benchmark data prospectively collected from a small-volume, emerging centre in Northern Queensland, was the first of its kind in terms of validation studies. As expected, the small volume of our centre impacted the ability to derive powerful statistical models and comparators, an intrinsic limitation for small-volume centres whilst they are developing services. However, during this evolution project, the use of comparison metrics allowed for the detection of alert and alarm levels, which are invaluable to ensure patient safety and quality of outcome.Our paper demonstrated that, irrespective of size or volume, the utilisation of quality assurance metrics (national or international) provides for the safe and transparent upscaling of head and neck services in emerging, regional, and small-volume centres.

Impact of primary care triage using the Head and Neck Cancer Risk Calculator version 2 on tertiary head and neck services in the post-coronavirus disease 2019 period.

This study investigates the impact of primary care utilisation of a symptom-based head and neck cancer risk calculator (Head and Neck Cancer Risk Calculator version 2) in the post-coronavirus disease 2019 period on the number of primary care referrals and cancer diagnoses. The number of referrals from April 2019 to August 2019 and from April 2020 to July 2020 (pre-calculator) was compared with the number from the period January 2021 to August 2022 (post-calculator) using the chi-square test. The patients' characteristics, referral urgency, triage outcome, Head and Neck Cancer Risk Calculator version 2 score and cancer diagnosis were recorded. In total, 1110 referrals from the pre-calculator period were compared with 1559 from the post-calculator period. Patient characteristics were comparable for both cohorts. More patients were referred on the cancer pathway in the post-calculator cohort (pre-calculator patients 51.1 per cent vs post-calculator 64.0 per cent). The cancer diagnosis rate increased from 2.7 per cent in the pre-calculator cohort to 3.3 per cent in the post-calculator cohort. A lower rate of cancer diagnosis in the non-cancer pathway occurred in the cohort managed using the Head and Neck Cancer Risk Calculator version 2 (10 per cent vs 23 per cent, p = 0.10). Head and Neck Cancer Risk Calculator version 2 demonstrated high sensitivity in cancer diagnosis. Further studies are required to improve the predictive strength of the calculator.

664 Rapid-Access Head and Neck Lump Imaging Clinics Improve Compliance to the NHS Faster Diagnosis Standard, With Reduction of Head and Neck Cancer Diagnosis Times

Abstract Aim The NHS “Faster Diagnosis Standard” (FDS) recommends patients referred for suspected cancer to be diagnosed or have cancer ruled out within 28 days. Reducing time to diagnosis and treatment in head and neck cancer is associated with improved patient outcomes. Our aim was to improve compliance to the 28-day standard in a large tertiary head and neck department, by introducing a rapid-access clinic for head and neck lumps including same day ultrasound-scanning with biopsy. Method Data was collected in two rounds: 3 months before and after introduction of the rapid-access clinic in September-2022. Data collected included referral reason, time from referral to specialist review, to ultrasound, and to diagnosis. Patients not fitting agreed criteria for the clinic were excluded. Results In the first round 39 patients had a diagnosis at time of analysis; as had 13 in the second round: Initial compliance to the 28-day FDS was 33%, this increased to 85% in the second round. Median time to diagnosis was 36 days, decreasing to 12 in the second round (p-value <0.001). Median time to ultrasound was 28.5 days in the first round, decreasing to 9 in the second round (p-value <0.001). Conclusions Preliminary data shows a 53% improvement in compliance to the 28-day FDS, after introduction of the rapid-access clinic. This suggests the model could significantly improve compliance to national standards for diagnosing head and neck cancer presenting via neck lumps. This should encourage other tertiary head and neck services that creating rapid-access clinics can reduce delays in cancer diagnosis and treatment.

797 Short-Term Review of the Presentations and Outcomes of Vocal Fold Palsy Cases Identified at a Large DGH

Abstract Aim Due to the convoluted course of the recurrent laryngeal nerves, vocal cord palsy can be a manifestation of pathologies that cross multiple surgical and medical specialties. The primary role of the vocal folds is that of airway protection. Therefore, it is important that all relevant clinicians understand this clinical scenario in order to prevent aspiration pneumonia in their patients. Method We reviewed eight months of referrals and diagnoses of patients with vocal cord paresis or palsy. This was in the setting of a tertiary Head & Neck service within a large DGH. We assessed the aetiology, management, and outcome of these cases. Results Eleven new cases were identified over the course of eight months. One was due to intrathoracic vascular pathology; one breast cancer; two from head & neck cancer; one bilateral palsy due to upper-GI cancer surgery; four from thyroid-related pathology; one lung cancer; and one idiopathic. To date, ten of eleven cases appear permanent in nature. One patient underwent in-clinic injection laryngoplasty. Two patients (18%) died within six months of diagnosis, both predictable deaths based on baseline pathology. Conclusions Our experience demonstrated the relevance of ENT (Head & Neck), Vascular, Breast, Upper-GI and Thoracic surgeons as well as medical colleagues in Endocrinology, Respiratory Medicine, and Rheumatology. We present diagnostic and management strategies to help surgical trainees across the specialties identify, manage, and refer patients to prevent complication, improve quality of life and provide access to relatively novel procedures such as awake (local anaesthetic) injection laryngoplasty.

CONVENTIONAL SQUAMOUS CELL CARCINOMA COEXISTING WITH A VERRUCOUS CARCINOMA: A HYBRID NEOPLASM

Verrucous carcinoma (VC) is a low-grade variant of squamous cell carcinoma (SCC) that lacks the cytological features of malignancy and does not metastasize, differently from the conventional SCC. Oral hybrid verrucous carcinoma is a rare neoplasm comprised of VC and conventional SCC. This study presents a case report of this hybrid neoplasm in an 81-year-old male former smoker. In the intraoral examination, the patient exhibited a white lesion with a verrucous surface in the maxillary alveolar ridge. Under clinical hypothesis of VC or conventional SCC, an incisional biopsy was performed. Microscopically, the tumor showed an endophytic proliferation of hyperkeratinized squamous epithelium with parakeratin plugging and bulbous rete ridges extending in depth. Areas of infiltration by trabeculae and islands of well-differentiated SCC were also observed. The final diagnosis was SCC coexisting with a hybrid verrucous carcinoma (VC). The patient was referred to a head and neck service and is undergoing treatment. Verrucous carcinoma (VC) is a low-grade variant of squamous cell carcinoma (SCC) that lacks the cytological features of malignancy and does not metastasize, differently from the conventional SCC. Oral hybrid verrucous carcinoma is a rare neoplasm comprised of VC and conventional SCC. This study presents a case report of this hybrid neoplasm in an 81-year-old male former smoker. In the intraoral examination, the patient exhibited a white lesion with a verrucous surface in the maxillary alveolar ridge. Under clinical hypothesis of VC or conventional SCC, an incisional biopsy was performed. Microscopically, the tumor showed an endophytic proliferation of hyperkeratinized squamous epithelium with parakeratin plugging and bulbous rete ridges extending in depth. Areas of infiltration by trabeculae and islands of well-differentiated SCC were also observed. The final diagnosis was SCC coexisting with a hybrid verrucous carcinoma (VC). The patient was referred to a head and neck service and is undergoing treatment.

Comparative Assessment of Total Versus Hemi Glossectomy Defects Reconstructed With Anterolateral Thigh Free Flap

Free tissue transfers for reconstruction following tongue resection has become standard practice. This study sought to evaluate volume shrinkage of the anterolateral thigh free (ALTF) reconstructing tongue defects at 6months postoperative. The aim was to estimate a shrinkage factor for ALTF reconstructing hemi and total glossectomy. This was an IRB-approved retrospective cohort study conducted at the head and neck service at the University of Florida, College of Medicine, Jacksonville (FL). This study targeted patients with tongue cancer from January 2018 to April 2022. patients with tongue squamous cell carcinoma (SCC) who were surgically treated by either hemi or total glossectomy and reconstructed with ALTF. Patients had to have a postoperative computer tomography scans at 1 and 6months post-surgery. Patients with constant body mass index during 6months postreconstruction. Additionally, the patients were to have been treated with adjuvant radiotherapy. patients with recurrent tongue cancer and those who weren't reconstructed or managed with other treatment modalities. Type of tongue resection hemi versus total glossectomy for treatment of tongue SCC. Shrinkage percentage of ALTF reconstructing tongue defects at 6months postoperatively. Age and gender. Paired t-test and student t-test with level of significance P≤.05 were used to statistically analyze ALTF volume changes at 1 and 6months postoperatively and ALTF shrinkage percentage at 6months postreconstruction, respectively. We identified 85 patients who were treated for tongue SCC during the time period of study. Out of the 85 patients, 11 patients were reconstructed with an ALTF. Eight males and 3 females with a mean age of 62.3years old. Six patients had total glossectomy and 5 had hemi glossectomy. Patients with hemi glossectomy had a significant difference in mean average flap shrinkage of 39.6%, while in those with total glossectomy had 17.7% (P=.004). According to our results, we recommend that the flap size should be larger than the defect to adjust for volume shrinkage (1.4 times and 1.2 times for cases of hemi and total glossectomy, respectively).

Smell-related quality of life changes after total laryngectomy: a multi-centre study

PurposeA total laryngectomy creates an alternate airway for gas exchange that bypasses the upper aerodigestive tract. The subsequent reduction in nasal airflow, and therefore, reduction in deposition of particles to the olfactory neuroepithelium leads to hyposmia or anosmia. The aim of this study was to assess the quality of life impairment conferred by anosmia following laryngectomy and identify any specific patient-related risk factors that are associated with poorer outcomes.MethodsConsecutive patients with a total laryngectomy presenting for review at three tertiary head and neck services (in Australia, the United Kingdom and India) over a 12-month period were recruited. Patient demographic and clinical data were collected, and each subject completed the validated assessment of self-reported olfactory functioning and olfaction-related quality of life questionnaire (ASOF). Dichotomous comparisons were performed using the student's unpaired t-test for continuous variables (SRP), a chi-squared test for categorical variables, and a Kendall's tau-b for ordinal variables (SOC) to assess for a correlation with poorer questionnaire scores.ResultsA total of 66 laryngectomees (13.4% female; age 65.7 ± 8.6 years) were included in the study. The mean SRP score of the cohort was found to be 15.6 ± 7.4, while the mean ORQ score was noted to be 16.4 ± 8.1. No other specific risk factors associated with poorer quality of life were identified.ConclusionA significant quality of life detriment from hyposmia is conferred following laryngectomy. Further research to assess treatment options and the patient population that would best benefit from these interventions is required.

Barriers to head and neck cancer care in high-income and low- and middle-income countries: a scoping review

Identify patient-perceived barriers to head and neck cancer care and compare differences in barriers by country income status. Of the 37 articles, 51% ( n = 19) were from low- and middle-income countries (LMICs), while 49% ( n = 18) were from high-income countries. Of the papers from high-income countries, unspecified head and neck cancer (HNC) subtype (67%, n = 12) were the most common cancer type, while upper aerodigestive tract mucosal malignancies (58%, n = 11) were more common in LMICs ( P = 0.02). Based on World Health Organization barriers, level of education ( P = < 0.01) and alternative medicine use ( P = 0.04) were greater barriers in LMICs compared to high-income countries. At least 50% of articles listed barriers at all three 'Three Delays' timepoints. There were no significant differences by country income status for the 'Three Delays' timepoints of deciding to seek care ( P = 0.23), reaching the healthcare facility ( P = 0.75), or receiving care ( P = 1.00). Patients face barriers to care for head and neck cancer regardless of country income status. There is overlap in several barriers and a need for systemic improvement in access. The differences in education and alternative medicine may guide region-specific interventions to improve the provision of head and neck services.

Primary care triaging of head and neck cancer referrals using the head and neck cancer risk calculator version 2: impact on a tertiary head and neck service.

This study aimed to investigate the use of the head and neck cancer risk calculator version 2 in a primary care setting and to evaluate the impact of the risk calculator on the number of referrals stratified by urgency and cancer yield. Referrals between April 2019 and August 2019, April 2020 and July 2020 (pre-risk calculator) and August 2020 and July 2021 (post-risk calculator) were analysed. Referral urgency, head and neck cancer risk calculator version 2 score, cancer diagnosis, cancer type and further investigations were recorded. The 2023 patient encounters were analysed; there were 1110 (55 per cent) referrals before head and neck cancer risk calculator version 2 use and 913 (45 per cent) after head and neck cancer risk calculator version 2 use. A higher proportion of older (p < 0.001) and male (p < 0.013) patients were seen post-head and neck cancer risk calculator version 2 use. All cancer cases were seen on the urgent suspicion of cancer pathway post-head and neck cancer risk calculator version 2 use; however, a higher proportion of patients were seen as urgent suspicion of cancer (51.1 vs 83.5 per cent; p < 0.001). Overall, the cancer diagnosis rate increased from 2.7 to 4.1 per cent. The head and neck cancer risk calculator version 2 had high sensitivity in cancer diagnosis. More studies are required to optimise the predicted versus actual cancer probability gap.

Improving access to neck ultrasound referral and using guidance as a means of reducing demand on neck lump specialist assessment clinics

Background: As with many services across the NHS, specialist clinics for the assessment of neck lumps are under increasing pressure. These clinics are ideally reserved for urgent suspected cancer (USC) referrals. However, confirmation of normal anatomy or benign pathology contributes to a considerable proportion of clinical resources. Neck ultrasound (NUS) is the primary imaging modality in assessment. In NHS Grampian, referral for NUS has historically not been widely publicised to general practitioners (GPs), with patients typically referred via the head and neck (H&N) service. This study aimed to reduce patient footfall to H&N clinics by improving GP direct access to NUS. This could reduce the number of patient hospital attendances; with a single NUS appointment replacing a clinic attendance, an NUS appointment and a clinic review for discussion of results and management.

Head and Neck Injuries Observed in Violence against Women

Gender-based violence is a public health problem according to the WHO, especially among women. Head and Neck injuries during this type of violence are multiple, responsible for physical and psychological damage that can alter the social and professional life of the woman. The aim of this study was to map the Head and Neck injuries observed during domestic, marital or family violence against women. Our retrospective and prospective study conducted from 2018 to 2020 in the ENT, Head and Neck service at reference health center of the commune I of Bamako in Mali, allowed us to collect 30 files of female patients who were victims of violence. The prevalence of violence was identified in 24% of cases out of 125 cases of trauma in women. The average age was 26 years with extremes of 12 to 48 years. Female students represented 33.33% of the cases. Married women represented 66.67%. The perpetrator was the spouse or partner in 73.33% of the cases. The mode of aggression was slapping in 76.67% and punching in 23.33%. The predominant functional and physical signs were respectively otalgia, hearing loss (30% each) and tympanic perforation (50%). 13.33% had a type 1 tympanoplasty. Residual perforations with conductive hearing loss were noted in 13.33% at 45 dB. These traumas affect a population of varied socioeconomic level, relatively young, posing a problem of psychological care and integration of women within the socio-professional activities vector of economic independence.

Blood transfusion demands in a tertiary otolaryngology, head and neck centre: A 5-year retrospective cohort study.

To retrospectively analyse and report the utilisation of red blood cell (RBC) transfusion in a tertiary otolaryngology, head and neck centre in the United Kingdom. Twenty-seven per cent of RBC transfusions were for surgical indications in a 2014 England and North Wales survey. Currently, there is limited literature on RBC transfusions in Otolaryngology. All inpatients admitted primarily under the care of the Otolaryngology, Head and Neck service between January 2015 and December 2019 were analysed. The primary outcomes of interest were number of units of RBC transfused over 5 years and distribution across clinical indications. Secondary outcome measure was cost of RBC transfusions over the same time period. Most patients receiving transfusions are aged in their sixth and seventh decades. Epistaxis patients utilised 105 RBC units over the 5 years (56% of total RBC units) with emergency epistaxis accounting for 78% of use. Post-operative Head & Neck Cancer surgery with and without reconstruction required 47 RBC units over 5 years (25% of total RBC units). The mean cost incurred by the department over the 5-year period was £6171.49 (SD 1460.25). The cost has fallen by over £2000 over the 5-year period. Blood transfusion use has fluctuated over the last 5 years. Epistaxis and post-operative Head and Neck cancer cases account for significant use compared with other patient groups. Prehabilitation strategies will add value towards mitigating future consumption of RBC.

P-239 The Impact of the Introduction of a Triage Risk Calculator to the NHS Lothian (Scotland) Head and Neck Service

P-239 The Impact of the Introduction of a Triage Risk Calculator to the NHS Lothian (Scotland) Head and Neck Service

The Diagnostic Yield of Excisional Biopsy in Cervical Lymphadenopathy: A Retrospective Analysis of 158 Biopsies in Adults.

Cervical lymph nodes are the most common site of peripheral lymphadenopathy. The underlying etiologies are usually benign and self-limiting but may include malignancies or other severe life-threatening diseases. The aim of the current study was to investigate the various underlying pathologies of cervical lymphadenopathy as assessed by the diagnostic yield of excisional lymph node biopsies of the neck in a tertiary adult practice. The evaluation was performed in light of previous literature and regional epidemiological patterns. Retrospective analysis of hospital charts of 158 adult patients who underwent an excisional biopsy for suspected cervical lymphadenopathy at a tertiary referral head and neck service between January 2017 and December 2019. The most common underlying pathology was unspecific and/or reactive lymphadenitis in 44.5% of specimens, followed by malignant disease in 38.6% of cases. An age above 40 years was significantly correlated with an increased likelihood of malignant disease. Lower jugular and posterior triangle lymph nodes showed higher malignancy rates than other groups (100% and 66.7%, respectively). The overall surgical complication rate was 2.5%. The results of the current study serve as an indicator of the variety of etiologies causing cervical lymphadenopathy. In particular, given the increasing incidence of malignant diseases in recent decades, the findings should alert physicians to the importance of lymph node biopsy for excluding malignancy in persistent cervical lymphadenopathy especially in older adults. The findings emphasize the value of excisional lymph node biopsy of the neck as a useful diagnostic tool in adult patients with peripheral lymphadenopathy.

Demographic profile of subjects undergoing sphenoidotomy for sphenoid sinusitis, in a tertiary care centre of Punjab- analysis of 75 subjects

Background: The demographic profile of patients with Sphenoiditis undergoing surgical intervention, in the state of Punjab was studied. The emphasis was on the age, gender and clinical presentation in this prospective study.Methods: There were 75 patients of sphenoethmoidal recess pathology with sphenoditis, who were selected from the Rhinology clinics of Otorhinolaryngology and head Neck services of Dayanand Medical College and Hospital Ludhiana , in a period one and a half years (November 2002 to October 2004). All patients were taken up for Functional endoscopic sinus surgery of the sphenoid sinus surgery with sphenoidotomy.Results: The age range of subjects with sphenoiditis was between 12 years to 70 years. The mean age was 38.13 years. The maximum number of patients were in 19-30 years age group and the minimum in 31-40 years age group. Males outnumbered the females by a ratio of 1.7:1. The most common was posterior nasal drip (69.33% cases) behind the Eustachian tube and the least common complaint was diplopia (5.33% cases. Ocular involvement was observed in 32%. The right eye was more frequently involved (17.33%) as compared to the left (12%).Conclusions: Patients with Sphenoid sinusitis were seen in the broad age range from 19 to 30 years with a male predominance. Posterior nasal discharge behind the Eustachian tube, rather than the typical occipital ache was the primary complaint .Right sided eye involvement with ptosis and lateral rectus palsy were commonly noted.

Case study of the integration of electronic patient-reported outcomes as standard of care in a head and neck oncology practice: Obstacles and opportunities.

Patient-reported outcomes (PROs) allow for the direct measurement of functional and psychosocial effects related to treatment. However, technological barriers, survey fatigue, and clinician adoption have hindered the meaningful integration of PROs into clinical care. The objective of the authors was to develop an electronic PROs (ePROs) program that meets a range of clinical needs across a head and neck multidisciplinary disease management team. The authors developed the ePROs module using literature review and stakeholder input in collaboration with health informatics. They designed an ePROs platform that was integrated as the standard of care for personalized survey delivery by diagnosis across the disease management team. Tableau software was used to create dashboards for data visualization and monitoring at the clinical enterprise, disease subsite, and patient levels. All patients who were treated for head and neck cancer were eligible for ePROs assessment as part of the standard of care. A descriptive analysis of ePROs program implementation is presented herein. The Head and Neck Service at Memorial Sloan Kettering Cancer Center has integrated ePROs into clinical care. Surveys are delivered via the patient portal at the time of diagnosis and longitudinally through care. From August 1, 2018, to February 1, 2020, a total of 4154 patients completed ePROs surveys. The average patient participation rate was 69%, with a median time for completion of 5 minutes. Integration of the head and neck ePROs program as part of clinical care is feasible and could be used to assess value and counsel patients in the future. Continued qualitative assessments of stakeholders and workflow will refine content and enhance the health informatics platform. Patients with head and neck cancer experience significant changes in their quality of life after treatment. Measuring and integrating patient-reported outcomes as a part of clinical care have been challenging given the multimodal treatment options, vast subsites, and unique domains affected. The authors present a case study of the successful integration of electronic patient-reported outcomes into a high-volume head and neck cancer practice.

Standard operating procedures for re-establishing dental services in an acute NHS trust following COVID-19

As consultants in restorative dentistry working within an acute NHS trust, our role primarily involves working as part of a multidisciplinary head and neck service alongside our orthodontics and maxillofacial colleagues to provide treatment for patients with head and neck cancer, cleft lip and palate, hypodontia, and dentoalveolar and facial trauma. In March 2020, the provision of these essential services was brought to an abrupt halt; with the exception of urgent head and neck cancer care, due to the COVID-19 pandemic. This virus not only impacted how we lived our lives but how we provided key services in hospital dentistry. This article provides clear guidance on personal protective equipment (PPE), infection prevention and control guidance; the role of amber cleans and the integration of laboratory services into safe working environments. We understand that the standard operating procedures in this article are accurate at the time of publication but may be subject to change due to updated government guidelines. Managing risks and alleviating concern: new protocols for patient and staff safety.

Head and neck/maxillofacial nurse-led clinical activity during COVID-19 Pandemic — experience of one unit

COVID-19 infection has changed the practice in the primary and secondary healthcare services worldwide.1Holmes S. Bhatti N. Bhandari R. et al.Toward a consensus view in the management of acute injuries during the Covid-19 pandemic.Br J Oral Maxillofac Surg. 2020; 58: 571-576Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 2Barca I. Cordaro R. Kallaverja E. et al.Management in Oral and Maxillofacial Surgery During the Covid-19 Pandemic: Our Experience.Br J Oral Maxillofac Surg. 2020; 27 (30177-7)Google Scholar Virtual clinics in the form of telephone or video consultation have become the new normal. Microsoft Teams is now used to conduct professional meetings and interdepartmental teaching. Nonetheless, there are certain steps in the patient journey which cannot be done on the virtual basis, and require face-to-face consultation. The most important of this is wound care and this essential activity generally falls into nurse-led clinics. Prior to the COVID-19 outbreak, there was reasonable support for suture removal, dressing changes and wound care in the primary care settings. During the pandemic, the workload in the nurse-led clinic has substantially increased due to the temporary closure of the primary settings. Furthermore, during the pandemic most of the NHS resources were channelled towards treating patients with COVID-19 infections and expanding intensive care units. The resources available to the nurse-led clinics, particularly the head and neck, have been put on the back burners. This has resulted in physical and psychological stress to the dedicated group of nurses. We carried out an audit of activity within the nurse-led clinics in head and neck/maxillofacial specialty and compared the results between 3 months prior to the pandemic and 3 months during the pandemic (Fig. 1). The results clearly indicate that during the pandemic there has been an increase in demand in this service. Due to the increased demand, there has been delay in patients obtaining regular and emergency wound care. The numbers are high and complications have increased. The increase in the complication rate is most likely multifactorial and can be affected by the general comorbidity of the patients, delay in receiving care in timely manner, COVID-19 infections, and challenges related to Personal Protection Equipment (PPE). Nurse-led dressing clinic is an important step in the patient journey when they are undergoing head and neck procedures. This specialised service was not easily available in the primary setting prior to COVID and has become depleted during the pandemic. This audit proves the need for development of this nurse-led service in the primary setting with funding and necessary training. Hospital-based tissue viability nurses input is minuscule and their expertise towards head and neck service is also questionable. Overall, there is a clear requirement for extra funding and increased resources. It is essential that this small subgroup of nurses get the recognition they deserve, as they are an essential part of patients' head and neck pathway. We have no conflicts of interest. Not required.

Evaluation of a novel database for quality assurance at a head and neck service in New Zealand: an audit of free flap head and neck reconstruction.

Clinical audit is a critical quality improvement exercise, yet efficient audit tools are lacking. The main objective of this study was to evaluate a recently deployed database in facilitating the process of clinical audit, and the secondary objective was to evaluate the outcomes of free flap reconstruction of the head and neck at our centre. A head and neck cancer-specific database was customized to suit the needs of our head and neck multidisciplinary team. Data has been entered prospectively into this database since March of 2018. An audit of free flap reconstruction of the head and neck over a 12-month period was performed using the database and analysed as a case study to examine its efficacy as a clinical audit tool. Additionally, the outcomes of free flap reconstruction at our centre were compared to those reported in the international literature. The database allows flexible and specific queries, analysis and export of data, and can provide immediate results. However, issues with data quality and completeness were identified. In this audit, the overall 30-day complication rate and 30-day mortality in patients undergoing free flap reconstruction of the head and neck were 58% and 3%, respectively. The database is fit for its intended purpose as an audit tool. Outcomes of free flap reconstruction of the head and neck at our centre are comparable to those of institutions overseas.