Management of retraction pockets: historic and novel approaches.

BACKGROUND: Retraction pockets are collapsed segments of the tympanic membrane. Their formation is associated with a disruption in middle-ear ventilation pathways, leading to the loss of organised collagen of the tympanic membrane. There are several approaches in treating retraction pockets, which aim either to improve ventilation or repair the retraction pockets themselves. METHODS: A review of the literature regarding the classification and associated management of retraction pockets was conducted, using Medline and Cochrane Library databases, with the addition of our institution's experience in undertaking novel techniques. RESULTS: All the current classification systems fail to guide treatment or prognosticate the disease. Commonly, an initial conservative approach is suggested for early stages, with no clear indication regarding when a surgical solution should be offered. There are conflicting data concerning the effectiveness of these treatments in terms of disease prevention, recurrence and hearing outcomes. CONCLUSION: Minimally invasive approaches utilising novel techniques may be key to reducing peri-operative morbidity and improving the overall patient experience.

What still presents urgently to ENT during a pandemic? Experience of an ENT rapid access clinic during the coronavirus disease 2019 pandemic.

OBJECTIVES: This study sought to determine the conditions that still present to ENT despite government advice to avoid unnecessary travel. It also assessed the impact of social distancing on pathologies presenting to ENT and reviewed the usefulness of telephone consultations in semi-urgent presentations. METHOD: A retrospective review was conducted of 97 instances of patient care carried out in the rapid access ENT clinic at a large district general hospital. RESULTS: Otitis externa and foreign bodies represented 25 per cent and 13 per cent of consultations respectively. Tonsillitis and peritonsillar abscess were uncommon, representing 6 per cent of total consultations. Telephone appointments represented only 28 per cent of total consultations; however, they appeared to reduce the number of physical appointments required. CONCLUSION: Otitis externa and foreign bodies continue to be common during the pandemic. Social distancing measures reduced the number of tonsillitis and quinsy presentations. Telephone consultations are effective for certain urgent presentations to ENT, most noticeably nasal trauma and follow up of non-serious pathologies.

One year on: assessing the impact of coronavirus disease 2019 on demand for semi-urgent ENT services.

OBJECTIVE: This study investigated how the coronavirus disease 2019 pandemic has impacted on presentations to ENT first-on-call services. METHODS: All appointments to a rapid access triage clinic from 1 June to 31 August in 2019 and 2020 were reviewed retrospectively and their reasons for consultation classified. A binomial proportion test was used to determine whether the proportions of consultations per presentation differed significantly between years. This analysis was repeated with the number of unique patients per presenting complaint. RESULTS: The proportions of nine reasons for consultation differed significantly between 2019 and 2020, including an increase in otitis media and nasal trauma presentations, and a decrease in otitis externa and tonsillitis presentations. Reattendances caused some variation in the frequency of certain diagnoses. CONCLUSION: Our data suggest a shift in the presentations to first-on-call services, which may be a result of changes in patient behaviour and access to healthcare services.

Investigation of the influence of ambient temperature, atmospheric pressure and water vapour pressure on epistaxis admission rate.

BACKGROUND: To investigate the relationship between weather variables (atmospheric pressure, temperature, water vapour pressure) and epistaxis admission rates at Derriford Hospital, Plymouth, United Kingdom. METHODOLOGY: Retrospective observational study using hospital inpatient information databases to identify all patients admitted with epistaxis from April 1999 to March 2009 inclusive. Meteorological data for the same period was retrieved from the University of Plymouth Meteorological Archive. Epistaxis admissions were investigated for correlation with weather variables using Pearson correlation, and stepwise multiple regression analysis was performed. RESULTS: During the study period there were 1071 admissions (978 patients) (501 males (mean age 64 years) and 477 females (mean age 72 years)). Less than 10% of the variance in epistaxis admissions is explained by the maximum temperature only. Temperature and water vapour pressure demonstrated statistically significant association with epistaxis admission rates. CONCLUSIONS: Though there is statistical significance in the association of some weather variables and epistaxis admission rates, the findings are not practically relevant (<10% variance). The results of this study do not indicate a need for revision of current healthcare resource allocation.

Failed voice restoration: closure of the tracheo-oesophageal fistula.

Tracheo-oesophageal fistula and voice prosthesis have revolutionised voice rehabilitation, but are not without their complications. The most significant problem is widening of the tracheo-oesophageal fistula relative to the voice prosthesis and subsequent leaking. Three-layer surgical closure is a means of permanently closing a problematic fistula. Use of an interposition in situ muscle graft as a second layer provides an adequate, well vascularised barrier to prevent fistula reformation. Our technique provides a safe, effective method of closing a problematic tracheo-oesophageal fistula. We report a five case series in which 100% of patients acquired satisfactory closure of their fistulae and resolution of their symptoms.

Air rifle pellet injury to the middle ear, a very rare occurence.

INTRODUCTION: Air rifle pellet injuries are relatively common. These injuries often involve the brain, eyes chest or abdomen. It is rare for ENT surgeons to be involved in the care of these patients. CASE REPORT: We present the case of a 38 year old man with a history of an air rifle pellet injury to the left ear. Presenting symptoms included bleeding per ear, otoalgia, hearing loss and tinnitus. Imaging and surgical exploration demonstrated a metallic pellet in the left petrous temporal bone, within the middle ear and a fracture of the anterior wall of the external auditory meatus with associated tiny metallic fragments. A further surgical exploration was required to remove a bony sequestrum of the anterior canal wall. CONCLUSION: The onset of pain and discharge a few months after the injury may imply the formation of a delayed sequestrum. The possibility of an implantation cholesteatoma should also be considered.

Endoscopic ultrasound in esophageal carcinoma: comparison with multislice computed tomography and importance in the clinical decision making process.

AIM: As resective surgery for oesophageal carcinoma is only appropriate for a selected cohort of patients, preoperative staging plays an important role in the management of these patients. This study assessed the accuracy of endoscopic ultrasound (EUS) staging in comparison with computerised tomography (CT) staging and the impact of EUS in management of patients with oesophageal carcinoma undergoing gastro-esophagectomy. METHODS: Ninety-six consecutive patients with oesophageal carcinoma underwent preoperative staging with multislice CT and EUS. Of these, 50 patients underwent gastro-esophagectomy, allowing preoperative staging data from these imaging modalities to be compared to postoperative histopathological staging, classified according to the TNM system. Management plans for these patients made without use of EUS were then compared to those following EUS staging. RESULTS: The overall accuracy rate of EUS for T staging was 64%, showing good agreement with postoperative histopathological staging of the resected specimen (weighted k=0.42, 95%CI= 0.32-0.52). In terms of clinical decision making, the T stage accuracy rose to 90% when differentiating T1 from T2/3 lesions. In terms of N staging, the overall accuracy was 72% (weighted k=0.44, 95% CI=0.34-0.54). In comparison, N staging by CT was significantly less accurate (62% vs 72%, P<0.01, chi squared) and showed poor agreement with postoperative histopathological nodal staging (weighted k=0.24, 95%CI =0.11-0.37). Importantly, in 56% of patients, staging information obtained from EUS instigated change in management compared to that configured without EUS. CONCLUSION: EUS enhances preoperative staging of oesophageal cancer and is important in preoperative clinical decision making process, especially with increasing use of neoadjuvant chemotherapy.

The persistence and degradation of chlorothalonil and chlorpyrifos in a cranberry bog.

The effect of a spray-tank adjuvant on the persistence, distribution, and degradation of two pesticides, chlorothalonil and chlorpyrifos, was studied in a commercial cranberry bog. Pesticides were applied according to label instructions to cranberry plants in paired plot studies. Dislodgeable foliar and whole fruit residues of both pesticides and several degradation products were assessed over a growing season. Residues were also assessed in soil samples collected at fruit harvest. Adjuvant increased both fruit and foliar residues but did not significantly alter the dissipation rate or metabolism of either pesticide. The dissipation of dislodgeable foliar chlorothalonil and chlorpyrifos residues followed first-order kinetics, with estimated half-lives of 12.7 and 3.5 d, respectively. All residue levels on harvested fruit were well below the current U.S. EPA tolerances for fresh cranberries. Chlorothalonil (58%) was the major residue in fruit at harvest (76 d post-chlorothalonil application), with 4-hydroxy-2,5,6-trichloroisophthalonitrile and 1,3-dicarbamoyl-2,4,5,6-tetrachlorobenzene accounting for 26% and 6% of the total residues, respectively. Degradation products accounted for 88% of the total chlorothalonil residues in soil at fruit harvest. The products 1,3-dicarbamoyl-2,4,5,6-tetrachlorobenzene, 1-carbamoyl-3-cyano-4-hydroxy-2,5,6-trichlorobenzene, 2,5,6-trichloro-4-methylthioisophthalonitrile, and 2,4,5-trichloroisophthalonitrile have not been previously identified in cranberry bog environments. Chlorpyrifos was detected in fruit at harvest (62 d post-chlorpyrifos application), but no metabolites were found. Chlorpyrifos-oxon and 3,5,6-trichloro-2-pyridinol, however, were detected in earlier fruit samples and in foliage and soil samples.

Vitellogenesis in male Fundulus heteroclitus (killifish) induced by selected estrogenic compounds.

The response of male Fundulus heteroclitus to estrogenic compounds was assessed in anticipation of using this species in endocrine disrupter field studies in the Chesapeake Bay. Measurements of plasma vitellogenin, gonadosomatic (GSI) and hepatosomatic (HSI) indices, and an assessment of changes in gonadal histology were made. Of the parameters assessed, vitellogenin was found to be the most sensitive biomarker. Plasma vitellogenin production occurred in a dose-dependent manner in males exposed to 4-nonylphenol, 4-(tert-octyl)phenol, bisphenol-A, and 17beta-estradiol. There was some indication that the effect on GSI may be influenced by the season in which the experiments are carried out. Two time course experiments revealed that vitellogenin is a fairly long-lived biomarker in male F. heteroclitus. There was also evidence that fish from two moderately contaminated areas injected with 4-nonylphenol or bisphenol-A produced less vitellogenin than those collected from a more pristine habitat. Production of vitellogenin in male F. heteroclitus appeared similar to two other species dosed with the same compounds.

Fatal cutaneous anthrax in a heroin user.

BACKGROUND AND OBJECTIVE: Cutaneous anthrax usually has a mortality rate of less than 1 per cent. However, since December 2009 there have been more than 13 deaths in the UK due to anthrax-contaminated heroin. We therefore wish to raise clinical awareness of this treatable disease. CASE REPORT: We describe the case of a heroin user with an equivocal presentation of cellulitis in the neck. Within 36 hours, this led to death due to cutaneous anthrax. CONCLUSION: Whilst cutaneous anthrax remains rare, this case report aims to raise awareness of the fact that the symptoms and signs of this condition in intravenous drug users may not always fit the typical picture.

A decade of experience of thyroglossal cyst excision.

INTRODUCTION: We report our ten-year experience of thyroglossal cyst excision at Queen's Medical Centre, Nottingham, comparing outcomes, practice and technique. METHODS: Retrospective case note analysis was conducted alongside surgical histopathology review for all thyroglossal cyst excisions performed between 2000 and 2010. This yielded 108 patients with histopathology results confirming a thyroglossal cyst. RESULTS: The mean patient age was 21 years (range: 1 week - 76 years). Over half the patients (n=59, 55%) were less than 18 years of age. Fifty-five patients (51%) were male and fifty-three (49%) were female. Seventy cases (63%) were operated on by ear, nose and throat (ENT) surgeons. The rest were performed by paediatric surgeons (n=35, 32%), maxillofacial surgeons (n=2, 2%) and general surgeons (n=1, 1%). Paediatric surgeons undertook 35 (69%) of the 59 paediatric cases, with ENT surgeons operating on the rest (n=24, 41%). The primary surgeon was a consultant in 59 operations (55%) while in 49 cases (45%) it was a registrar. Thyroglossal cysts were ruptured in 21 operations (19%) during removal. The central portion of the hyoid bone was not excised in seven cases (6%). Twelve patients (11%) suffered postoperative complications, six of which were recurrences. CONCLUSIONS: There was a combined recurrence rate of 6% across all specialties for the Sistrunk procedure. This is in keeping with commonly reported recurrence rates. However, we found that central compartment neck dissection, as a modification of the original Sistrunk procedure, provides a highly effective method for permanently excising a thyroglossal cyst and, in our experience, it eliminates recurrence.

Plastic bronchitis requiring bronchoscopy.

OBJECTIVE: We report two cases of plastic bronchitis presenting with acute respiratory failure and mimicking foreign body inhalation. METHOD: The clinical findings, differential diagnoses and radiological investigation are discussed. RESULTS: Plastic bronchitis is an uncommon condition, particularly in children. The condition may present to otolaryngologists with symptoms mimicking foreign body inhalation. It is important to consider plastic bronchitis as a differential diagnosis, based on its clinical and radiological signs. Early intervention, in the form of bronchoscopy, can be both diagnostic and therapeutic. CONCLUSION: Plastic bronchitis is uncommon and its clinical and radiological features are non-specific. The recommended management is early bronchoscopy to establish the diagnosis and enable therapeutic intervention.

Spontaneous pneumomediastinum: benefits of contrast computed tomography imaging.

OBJECTIVE: We report a case of spontaneous pneumomediastinum presenting with chest and anterior neck pain. METHOD: The clinical findings, differential diagnosis and selection of radiological investigations are discussed. RESULTS: Spontaneous pneumomediastinum is an uncommon condition usually presenting in young patients. Presentation to the otolaryngology department occurs due to the presence of symptoms such as neck pain. Differential diagnoses must be considered and excluded, using the clinical features and the results of radiological investigation. Once the diagnosis is confirmed, conservative management is undertaken. CONCLUSION: Spontaneous pneumomediastinum is uncommon and the clinical features are variable. The recommended investigation is a computed tomography scan with orally administered, water soluble contrast to exclude important differential diagnoses and thus enable definitive diagnosis.

An unusual presentation of vertigo: is head titubation the key to diagnosis?

Objective. Discuss complex interplay of pathophysiological effects of cerebellar space occupying lesions on the vestibular pathway. Discuss challenges of diagnosis and referral along with differential and final diagnosis of unusual presentation. Case Report. We describe the case of a patient with vertiginous symptoms complicated by neurological features, namely, head titubation and tremor. The patient also had signs of oscillopsia and possible impairment of the vestibulo-ocular reflex. The resulting symptom and sign complex made for a difficult diagnosis, as the interplay of the pathophysiology of these signs, were unusual. Conclusion. The discussion has revealed that the cerebellar lesions themselves may have simultaneously caused head tremor and an inability for the vestibulo-ocular reflex to compensate, resulting in vertigo. However, whether the vertigo was a result of an oscillopsia, nystagmus, or central cause, the referral route should initially be via a general physician to rule out such a life threatening cause as a tumour.

A survey of indicators for reproductive endocrine disruption in Fundulus heteroclitus (killifish) at selected sites in the Chesapeake Bay.

Plasma vitellogenin and related parameters in the killifish Fundulus heteroclitus were measured at selected sites in the Chesapeake Bay. In males, vitellogenin was above the detection limit 14% of the time, and detections did not differ between sites or seasons. Few differences in plasma vitellogenin levels were found between sites during fall in either male or female F. heteroclitus, the time of natural gonadal regression for this species. There was some variation in the ratio of male to female F. heteroclitus, but was not consistent at most sites. Significant negative correlations were found between reported sediment polycyclic aromatic hydrocarbons (PAHs) and GSI, and PAHs and plasma vitellogenin in females in both Spring 1999 and Spring 2000. Gonadal anomalies in F. heteroclitus included slight reductions in certain tissue types. Overall, reproductive endocrine disruption in the killifish F. heteroclitus at the sites sampled in the Chesapeake Bay appeared somewhat minimal.