Sialorrhea is a common and uncomfortable adverse effect of clozapine, and its severity varies between patients. The aim of the study was to select broadly genes related to the regulation of salivation and study associations between sialorrhea and dry mouth and polymorphisms in the selected genes.

The study population consists of 237 clozapine-treated patients, of which 172 were genotyped. Associations between sialorrhea and dry mouth with age, sex, BMI, smoking, clozapine dose, clozapine and norclozapine serum levels, and other comedication were studied. Genetic associations were analyzed with linear and logistic regression models explaining sialorrhea and dry mouth with each SNP added separately to the model as coefficients.

Clozapine dose, clozapine or norclozapine concentration and their ratio were not associated with sialorrhea or dryness of mouth. Valproate use (p = 0.013) and use of other antipsychotics (p = 0.015) combined with clozapine were associated with excessive salivation. No associations were found between studied polymorphisms and sialorrhea. In analyses explaining dry mouth with logistic regression with age and sex as coefficients, two proxy-SNPs were associated with dry mouth: epidermal growth factor receptor 4 (ERBB4) rs3942465 (adjusted p = 0.025) and tachykinin receptor 1 (TACR1) rs58933792 (adjusted p = 0.029).

Use of valproate or antipsychotic polypharmacy may increase the risk of sialorrhea. Genetic variations in ERBB4 and TACR1 might contribute to experienced dryness of mouth among patients treated with clozapine.

Poor oral health is increasingly recognised as an important comorbidity in people with psychiatric illness. One risk factor is psychotropic-induced dry mouth.

To perform a systematic review of the severity of dry mouth due to psychotropic drugs in adults (CRD42021239725). Study quality was assessed using the Cochrane risk of bias tool.

We searched the following databases: PubMed, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, CINAHL and Web of Science. We included randomised controlled trials (RCTs) measuring the severity of drug-induced hyposalivation and xerostomia.

Eighteen RCTs with 605 participants were included. Severity of drug-induced dry mouth was compared among eight drug classes and/or against placebo. All studies were published 20 to 40 years ago and included tricyclic antidepressants (TCAs), serotonin specific reuptake inhibitors (SSRIs) and other drug classes. Meta-analysis was not feasible owing to design heterogeneity. TCAs caused more severe dry mouth, both objectively and subjectively, than placebo or other drug classes. SSRIs were generally associated with less severe symptoms. However, there was no information on antipsychotics or more recently available antidepressants, and there was minimal information on mood stabilisers. Most studies were on healthy subjects, limiting the generalisability of findings. Only one study measured both objective and subjective dry mouth, which have different clinical implications.

Psychotropic-induced dry mouth is a poorly researched area, and well-designed RCTs of newer psychotropic drugs using standardised objective and subjective measures are indicated. Given the ongoing use of TCAs for treatment-resistant depression, prescribers need to remain vigilant for xerostomia.

Cervical metastasis from an unknown primary site invariably results in pan-mucosal irradiation if a primary tumour is not identified. Transoral robotic and laser-assisted mucosectomy are valid techniques to increase diagnostic rates, but these remain restricted to certain centres. This paper describes, in detail, a technique in which mucosectomy is performed via endoscopic electrocautery.

Patients were prospectively recruited between May 2017 and June 2018. Inclusion criteria stipulated biopsy-proven metastatic cervical squamous cell carcinoma, with negative findings on magnetic resonance imaging and positron emission tomography/computed tomography, in addition to examination under anaesthetic, tonsillectomy and ‘blind’ tongue base biopsies without tumour identification, prior to mucosectomy.

Of nine patients, a mucosal primary was identified in four (44.4 per cent), for which ipsilateral intensity-modulated radiotherapy was advocated in three and completion tongue base resection in the fourth. Dysplasia was demonstrated in two further patients, which provided information relevant to radiotherapy fields and post-treatment surveillance. No surgical complications were identified.

Tongue base mucosectomy using electrocautery and conventional tonsillectomy equipment is a safe, effective technique in the identification of cervical metastasis from an unknown primary site. It expands the potential breadth of use, quickens prolonged diagnostic pathways and obviates the necessity for pan-mucosal irradiation.

Accupuncture-like transcutaneous electrical nerve stimulation (ALTENS) therapy has been shown in prospective studies to be effective in the treatment of radiation-induced xerostomia. Those studies treated patients within 27 months from end of radiation with ALTENS delivered in the clinic using a Codetron unit. However, that unit is no longer produced and there is limited data on success of ALTENS when delivered at home.

A 50-year old man with xerostomia, 8 years post-radiation for T4N1 squamous cell carcinoma of the tonsillar fossa, was given ALTENS with a currently commercially available unit from Girish Surgical. He used the unit at home, 20 minutes daily for 8 weeks.

After 8 weeks of ALTENS therapy the patient saw a reduction in the Self-Reported University of Michigan Xerostomia-Related Quality of Life Scale from 20 to 1.

This case report demonstrates (1) the Girish Surgical unit is effective, (2) self-administration of ALTENS in patients who cannot come to clinic regularly may be practical and (3) ALTENS can still offer durable benefit to patients even 8 years after chemoradiation therapy.

Salivary gland transfer surgery can reduce xerostomia in oropharyngeal squamous cell carcinoma patients undergoing primary chemoradiation. A potential drawback of salivary gland transfer is the treatment delay associated with the surgery, and its complications. This study aimed to determine whether the treatment delay affects patient survival and to evaluate patient quality of life after salivary gland transfer.

A retrospective analysis of 138 patients (salivary gland transfer group, n = 58; non-salivary gland transfer group, n = 80) was performed. Patient survival was compared between these groups using multivariate analysis. Salivary gland transfer patients were further evaluated for surgical complications and for quality of life using the head and neck module of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire.

Salivary gland transfer and non-salivary gland transfer patients had comparable baseline clinical characteristics. Salivary gland transfer patients experienced a median treatment delay of 16.5 days before chemoradiation (p = 0.035). Multivariate analysis showed that this did not, however, correspond to a survival disadvantage (p = 0.24 and p = 0.97 for disease-free and disease-specific survival, respectively). A very low complication rate was reported for the salivary gland transfer group (1.7 per cent). Questionnaire scores for the item ‘xerostomia’ were very low in salivary gland transfer patients.

The treatment delay associated with salivary gland transfer surgery does not negatively affect patient survival. Oropharyngeal squamous cell patients have an excellent quality of life after salivary gland transfer.

Symptom experiences and their interference with life are not well-researched in head and neck cancer patients. The aim of the study was to explore and understand the experience of receiving treatment for head and neck cancer with particular focus on symptom experiences over a one year period from diagnosis.

A qualitative study design was used with a heterogeneous sample of 16 patients with head and neck cancer. Interviews, conducted at four time points over 12 months, provided a total of 50 interview datasets.

Key themes derived include nutritional concerns, tiredness, and experiences related to the radiotherapy mask and regaining normality. These data highlight issues of importance in the first year of living with head and neck cancer: impact of nutritional changes on the lives of patients, including weight loss, dysphagia, xerostomia and taste changes; debilitation from ongoing fatigue; unpreparedness for and distress from the radiotherapy mask; and attempts to maintain a normal life amidst the interference of symptoms.

Multitude of symptoms impact the patients' life, particularly nutritional symptoms and fatigue, and interfere with the patients' survivorship and quality of life. The changing nature of symptoms over the first year from diagnosis in head and neck cancer patients and the identified issues in the attempt to normalize their lives need to be incorporated more fully into the supportive care of head and neck cancer patients in order to improve their experience and enhance their survivorship.

This study aimed to evaluate the incidence of submandibular gland metastases in cases of oral cavity squamous cell carcinoma.

Sixty-nine patients treated between 1 January 2004 and 30 June 2009 were retrospectively reviewed. Patients were treated with wide local excision of the primary tumour, plus simultaneous neck dissection and reconstruction if required.

Of 69 submandibular glands from 46 men and 23 women (mean age, 58 years), 43 (62.3 per cent) had advanced, tumour stage three or four lesions. Histopathological reappraisal of all submandibular glands demonstrated an absence of metastatic spread. Only 2/69 (2.9 per cent) submandibular glands demonstrated ipsilateral contiguous tumour involvement.

This study demonstrated an absence of metastasis to the submandibular gland from oral cavity squamous cell carcinoma. Patients with early stage oral cavity squamous cell carcinoma and with a pre-operative node stage zero neck may be candidates for preservation of the submandibular gland during neck dissection.

To investigate the incidence of metastasis to the submandibular gland in patients with head and neck squamous cell carcinoma.

We retrospectively evaluated histological reports of neck dissections for upper respiratory tract carcinoma (performed 2002–2009), recording: primary tumour site, tumour–node–metastasis stage, level Ib involvement, previous radiotherapy, perineural invasion, lymphovascular invasion, extracapsular spread, and the presence of malignant disease in the submandibular gland.

We evaluated 107 cases. The most common primary site was the oral cavity (49 per cent) followed by the supraglottis (21 per cent), glottis (14 per cent), oropharynx (9 per cent) and hypopharynx (6 per cent). Forty-eight per cent of patients had advanced local disease, with 21 per cent at tumour stage 3 and 27 per cent at tumour stage 4. Fifty-six per cent had cervical lymph node metastasis, and 8 per cent received pre-operative radiotherapy. Forty-eight per cent had perineural invasion, 46 per cent lymphovascular spread, 27 per cent extracapsular spread and 8 per cent level Ib metastasis. Only one patient had submandibular gland involvement, due to direct spread (a case with prior radiotherapy and macroscopic submandibular gland involvement evident peri-operatively).

Submandibular gland metastasis from head and neck primary squamous cell carcinoma is extremely rare. Preservation of the ipsilateral submandibular gland during neck dissection is oncologically safe, except in patients with prior surgery or radiotherapy, or a primary tumour in close relation to the gland.