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DR JUN KWON Jun is a non training registrar at Wellington Hospital. SALINE VERSUS ANTIBIOTIC EAR DROPS FOR PREVENTION OF EARLY COMPLICATIONS OF VENTILATION TUBE INSERTION HJ Kwon1, X Lin1, K Baguley1.
1. Department of Otolaryngology, Head and Neck Surgery, Capital and Coast District Health Board
Introduction:
Early complications of grommet insertion include otorrhoea (16%), lumen obstruction (7%) and early extrusion (3.9%). Post operative antibiotics and steroid drops decrease otorrhoea and prevent blockage of the tube, but have a cost and potential ototoxic risk associated with them.
Aim:
Compare saline and antibiotic drops in reducing rates of post operative otorrhoea and lumen blockage for patients with non-infective middle ear effusions.
Method:
Retrospective review of consecutive grommet insertions from May 2014 to 30 April 2015. Ears with active infection or no effusion intraoperatively were excluded. Incomplete follow up or follow up after 10 weeks postoperatively were also excluded.
Results:
Of 591 ears in 310 patients in the time period, 334 ears were included for final analysis. Average age was 5.9 years, 39.2% were female. Previous grommets had been inserted in 35.9%. Concomitant adenoidectomy occurred in 42.5%. Indications for operating were otitis media with effusion (78.4%) and acute otitis media (21.6%). Intraoperative saline irrigation occurred in 37.1% and with antibiotic/steroid ear drops in 30.1%. Patients continued the saline at home for 3 days in 32.3% of patients, and antibiotics/steroid ear drops in 16.2%. Mean follow up interval was 38 days.
Overall, 12.6% had otorrhoea, and of these 79% had a course of antibiotics from the general practitioner. Twelve patients (3.6%) had blocked ventilation tubes and thirteen (3.9%) were actively discharging on follow up review.
Rates of otorrhoea were significantly higher in the saline cohort compared to antibiotic/steroid drops, regardless of whether it was in theatre (18.5% vs 5.9%, p=0.0091) or at home (p=0.0256). Rates of blockage and late discharge were comparable.
Conclusion:
Our study shows increased rates of discharge with saline compared to antibiotic drops, but raises other options, such as a single intraoperative treatment, which needs to be studied further.
HJ Kwon1, N Lilic1, C Baguley1
1. Department of Otolaryngology Head and Neck Surgery, Hutt Valley District Health Board
Case presentation
A 70 year old Maori male prisoner presented with a 6 month history of increasing unilateral nasal obstruction and discharge. Examination revealed a vascular, polypoid mass arising from the anterior nasal septum with further mucosal change on the lateral wall. Biopsies were taken which revealed a granulomatous lesion negative for fungal and acid fast bacilli. A CT scan showed no bone destruction. Other initial tests were negative (CXR, urine, ACE level, ANCA) with positive low titre ANA.
Larger biopsies sent from theatre cultured Mycobacterium turberculosis (TB). Anti-tuberculosis therapy was commenced 14 weeks after initial presentation.
Discussion
TB is reducing in incidence in NZ with approximately 300 new cases being reported annually. Eighty percent of cases occur in patients born outside of New Zealand. Other risk factors include immunosuppressant therapy and socioeconomic deprivation. Prisoners are at 6-fold higher risk
In New Zealand extra-pulmonary TB occurs in 45% of cases, primarily affecting lymph nodes, pleura or abdomen. Primary nasal tuberculosis is a rare presentation. It is thought to arise from inhaled particles or from digital innoculation. The septum is the most commonly involved site, followed by the inferior turbinate.
The appearance of a friable mass may lead to repeated biopsies to exclude malignancy, hence delaying the true diagnosis. The differential diagnosis includes granulomatous conditions such as sarcoidosis, syphilis, fungal infection and granulomatosis with polyangiitis. Treatment of nasal tuberculosis follows much the same guidelines as pulmonary TB. In New Zealand, 88% of cultured TB is sensitive to standard treatment, but the incidence of resistance is rising rapidly worldwide.
Conclusion
Despite New Zealand having a low incidence of TB, it needs to be remembered in the differential diagnosis for granulomatous lesions of the head and neck. It has a wide range of presentations, including primary nasal tuberculosis.
THE ECONOMIC BURDEN OF ACUTE DENTAL ABSCESS AND COMPLICATIONS.
HJ Kwon1, C Pears1, R Garland1.
1. Department of Otolaryngology, Head and Neck Surgery, Capital and Coast District Health Board.
Introduction
ORL-HNS surgeons often care for complications of dental disease, especially in centres without a dedicated maxillofacial department. These complications may be life threatening, with significant economic impacts, which disproportionately burden socioeeconomically debrived subgroups. On literature review, the economic impact of dental abscess has only previously been quantified in the United States.
Aim
Profile acute dental abscesses and complications in the Wellington and Hutt Valley region.
Estimate the economic burden of acute dental abscesses to our District Health Boards.
Method
Retrospective review of consecutive acute admissions of periapical abscess, local and distant complications to Wellington Regional Hospital and Hutt Valley Hospital between 1 January 2009 to 31 December 2014. Revenue calculated according to Ministry of Health costweight algorithms. Cost of admissions of Wellington Regional Hospital were recorded prospectively.
Results
Two-hundred-seventy-two admissions were included. The average age was 37.1 years. Smokers (41.5%), Maori (22.4%) and Pacific Islanders (13.6%), and those living in the two most deprived socio-economic deciles (29.4%) were disproportionately represented in the study population.
Fifty-six patients developed a complication, such as deep space neck infections, intracranial abscess and mediastinitis. Fourty-four patients underwent surgery, fourteen patients were admitted to ICU and 137 had inpatient dental extraction.
Microbiology was available in only 12.1% of cases, with Streptococcus being the most common organism (36.3%). Around two thirds of patients were prescribed a combination of Augmentin, amoxicillin and/or metronidazole.
From revenue analysis, we estimate the total cost of admissions of our study to be close to $2 million.
Conclusion
Our study shows that acute dental abscesses and their complications have a significant economic cost to the district health boards. We have not measured the wider economic (time off work, loss in productivity) and quality of life impacts. There is an ethnic and socioeconomic disparity in presentation for dental abscesses.
CUTANEOUS METASTASES OF PAPILLARY THYROID CANCER.
HJ Kwon1, AJ Lindford1, C Davis1
1. Department of Plastics and Reconstructive Surgery, Hutt Valley District Health Board
Case presentation
A 67 year old lady presented with a 2 year history of an occipital skin lesion with intermittent bleeding. She had previously undergone multiple excisions of squamous and basal cell carcinomas, the last of which had been excised 3 years earlier. On examination, she had a round, raised, smooth, red soft lesion which clinically resembled an epidermal cyst. This lesion was excised 4 months later under local anaesthesia and subsequently the histology was reported as metastatic papillary thyroid carcinoma. On further questioning, the patient had undergone total thyroidectomy for a multifocal papillary carcinoma 12 years prior. CT scanning revealed multiple pulmonary nodules suggestive of metastatic disease. The patient has commenced radioactive iodine therapy.
Discussion
Thyroid cancer is the most common endocrine malignancy. The most common subtype is papillary carcinoma, followed by follicular carcinoma. Both subtypes tend to have a good prognosis, but can typically spread to the lymph nodes in the neck. Rarely, they spread haematogenously, to involve the lung, liver, bone and occasionally brain. Whilst anaplastic cancer is a rare and aggressive tumour that can metastasise to skin as well as diffusely to the rest of the body, cutaneous spread by differentiated thyroid carcinoma is very rare. Dahl et al reviewed the English literature from 1964 to 1997 and found only 43 cases of thyroid carcinoma with skin metastases. They found highest rates in papillary (41%), followed by follicular (28%), anaplastic (15%) and medullary (15%) carcinomas. Approximately two thirds of lesions presented on the scalp.
Conclusion
While skin metastases from differentiated thyroid cancer is uncommon, the presence of a fleshy skin nodule with a background of thyroid cancer should raise concern and expedite resection.
PART 1: CHANGES IN INCIDENCE AND CHARACTERISTICS OF HPV-RELATED OROPHARYNGEAL CANCER IN THE GREATER WELLINGTON REGION 1994-2014.
HJ Kwon1, HD Brasch2,3, S Benison3, R Marsh2, T Itinteang2, GW Titchener1, J Evans4, ST Tan2,5
1. Department of Otolaryngology, Head and Neck Surgery, Capital and Coast District Health Board
2. Gillies McIndoe Research Institute, Wellington
3. Department of Anatomic Pathology, Hutt Valley District Health Board
4. Department of Radiation Oncology, Capital and Coast District Health Board
5. Wellington Regional Plastics, Maxillofacial and Burns Unit, Hutt Valley District Health Board
Introduction
Oropharyngeal cancer (OPC) incidence has been increasing globally, including New Zealand, where it has increased 11.9% per annum between 2005 and 2010.
In the context of lower smoking and alcohol abuse rates, this has been attributed to increasing prevalence of OPC associated with the human papillomavirus (HPV). Reported proportions of HPV associated OPC vary from 0% in China to 84% in Sweden.
It is unknown whether increasing rates of OPC in New Zealand are attributable to increasing HPV prevalence.
Aim
Quantify changes in prevalence and profile patients with OPC in greater Wellington over 20 years.
Method
All OPC diagnosed in the greater Wellington region (Wellington, Hutt Valley and Wairarapa) between 1/1/1994 and 30/11/ 2014 identified via New Zealand Cancer Registry. Formalin-fixed, paraffin-imbedded tissue retrieved for p16 immunohistochemistry testing. p16 status assessed independently by two blinded consultant pathologists. Data collected from clinical records, New Zealand Death Registry and New Zealand Census.
Results
One hundred and sixty-one patients were included, 81.4% were male. Average age was 60.1 years (range: 28-88). Ethnicity distribution was European (84.5%), then Māori (9.3%), Asian (4.3%) and Pacific (1.9%).
Incidence of OPC in our population increased from 0.97 to 1.83 per 100,000 person years between 1994-1999, and 2009-2014 (p<0.0001).
p16 immunohistochemistry was performed in 125 patients (77.6%). There was 100% concordance between the two pathologists, and between retrospective and prospective testing. The proportion of OPC staining positive for p16 increased from 23.8% to 75.6% betwee 1994-1999, and 2009-2014 (p<0.0001).
PART 2: HPV RELATED OROPHARYNGEAL CANCER HAS DIFFERENT OUTCOMES AND CHARACTERISTICS. GREATER WELLINGTON STUDY, 1994-2014.
HJ KWON1, HD BRASCH2,3, S BENISON3, R MARSH2, T ITINTEANG2, GW TITCHENER1, J EVANS4, ST TAN2,5
1. Department of Otolaryngology, Head and Neck Surgery, Capital and Coast District Health Board
2. Gillies McIndoe Research Institute, Wellington
3. Department of Anatomic Pathology, Hutt Valley District Health Board
4. Department of Radiation Oncology, Capital and Coast District Health Board
5. Wellington Regional Plastics, Maxillofacial and Burns Unit, Hutt Valley District Health Board
Introduction
Human papillomavirus (HPV) related oropharyngeal cancer (OPC) is epidemiologically and clinically distinct, presenting in younger patients with more frequent nodal metastases but favourable survival outcomes after treatment.
Characteristics and outcomes of HPV related OPC have not been quantified in New Zealand. It is unclear whether overseas data can be extrapolated to our unique multi-ethnic population, Maori and Pacific heritage, and medical system. Information specific to New Zealanders is invaluable in counselling patients.
Method
All OPC diagnosed in the greater Wellington region (Wellington, Hutt Valley and Wairarapa) between 1/1/1994 and 30/11/ 2014 identified via New Zealand Cancer Registry. Formalin-fixed, paraffin-imbedded tissue retrieved for p16 immunohistochemistry testing. p16 status assessed independently by two blinded consultant pathologists. Data collected from clinical records, New Zealand Death Registry and New Zealand Census.
Results
Of 161 patients, 125 cases (77.6%) were tested for p16. p16+ve patients were younger (56.01 vs 66.23 years, p<0.01), less comorbid (Charlson Comorbidity Index: 2.447 vs 2.921, p=0.01), less likely to smoke (69.7% vs 89.5%, p=0.035) or abuse alcohol (15.8% vs 34.2%, p=0.042).
p16+ve tumours were located exclusively on lymphoid tissue (palatine tonsils and tongue base), significantly higher than p16-ve tumours (100% vs 64.9%, p<0.0001). p16+ve tumours were more commonly poorly differentiated (56.5% vs 24.1%, p=0.0192), with nodal metastases (89.7% vs 53.8%, p=0.0002).
Radiotherapy was the mainstay of treatment for both, though p16+ve cases were more likely to receive concomitant chemotherapy (p<0.01). Though rates of mucositis, skin reaction and trismus during radiotherapy were similar, p16+ve patients had higher rates of nasogastric or gastrostomy feeding (p=0.0193).
5-year all-cause survival rate was twice as high in p16+ve patients (75.3% vs 34.1%, p=0.0001). Though interestingly, the p16+ve patients died at a much younger age overall than their p16-ve counterparts.
Conclusion
p16 status is a significant predictor of patient characteristics and outcomes in the greater Wellington region.
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