Unilateral tonsil enlargement in children and adults: is routine histology tonsillectomy warranted? A multi-centre series of 323 patients.

BACKGROUND: This study aimed to establish whether histology tonsillectomy is justified for unilateral tonsil enlargement. METHODS: A retrospective review was conducted of histology tonsillectomies in three health organisations over five years, with strict exclusion criteria, focusing on benign-appearing unilateral tonsil enlargement. RESULTS: Ninety paediatric and 233 adult cases were included. No paediatric cases and five adult cases of malignancy were detected. All malignant cases presented with other symptoms. Using binary logistic regression, a history of rapid unilateral tonsil enlargement was the only factor found to be significantly associated with malignant outcome. Thirty-three per cent of subjectively larger tonsils were smaller on post-operative histological measurement. Of the cases, 12.1 per cent re-presented with post-tonsillectomy bleeding. CONCLUSION: The authors recommend avoiding histology tonsillectomy for unilateral tonsil enlargement unless 'red flag' signs of malignancy are present, with particular attention to rapid unilateral tonsil enlargement. This study demonstrated discrepancy between clinical examination findings and true tonsil asymmetry; there may be a role for cross-sectional imaging prior to histology tonsillectomy in high-risk patients.

Hypocalcaemia following laryngectomy: prevalence and risk factors.

OBJECTIVES: To establish the prevalence of hypocalcaemia following laryngectomy and demonstrate that total thyroidectomy is a risk factor. METHODS: A retrospective cohort study was conducted that included all patients who underwent total laryngectomy from 1st January 2006 to 1st August 2017. Exclusion criteria were: pre-operative calcium derangement, previous thyroid or parathyroid surgery, concurrent glossectomy, pharyngectomy, or oesophagectomy. RESULTS: Ninety patients were included. Sixteen patients had early hypocalcaemia (18 per cent), seven had protracted hypocalcaemia (8 per cent) and six had permanent hypocalcaemia (10 per cent). Exact logistic regression values for hypocalcaemia following total thyroidectomy compared to other patients were: early hypocalcaemia, odds ratio = 15.5 (95 per cent confidence interval = 2.2-181.9; model p = 0.002); protracted hypocalcaemia, odds ratio = 13.3 (95 per cent confidence interval = 1.5-117.1; model p = 0.01); and permanent hypocalcaemia, odds ratio = 22.7 (95 per cent confidence interval = 1.9-376.5; model p = 0.005). CONCLUSION: This is the largest study to investigate the prevalence of hypocalcaemia following laryngectomy and the first to include follow up of longer than three months. Total thyroidectomy significantly increased the risk of hypocalcaemia at all time frames and independent of other variables.

The role of transnasal oesophagoscopy in the management of globus pharyngeus and non-progressive dysphagia.

Introduction Transnasal oesophagoscopy is a relatively new method of examining the upper aerodigestive tract via the nasal passage as an outpatient procedure without the need for sedation. It has been shown to be a well tolerated, safe and accurate technique, that can therefore be used in the investigation of patients thought to have globus pharyngeus and other non sinister causes of dysphagia. Methods A total of 150 consecutive patients undergoing transnasal oesophagoscopy were analysed retrospectively. Results The main indications for this procedure were non-progressive dysphagia (n=68, 45%) and globus pharyngeus (n=60, 40%). Transnasal oesophagoscopy was normal in 65% of patients and 42% of patients were discharged from clinic at the same appointment with no further investigation. The most common positive findings were laryngeal erythema (13%) and oesophagitis (10%). Conclusions Transnasal oesophagoscopy is a useful adjunct to the management of patients with the symptoms of globus pharyngeus and non-progressive dysphagia.

Successful treatment of a rare metastatic malignant carotid body tumour in a young adult, with conservative surgery and local radiotherapy.

OBJECTIVE: We report a patient with a malignant carotid body paraganglioma treated with surgery and adjuvant radiotherapy. We discuss her treatment and outcome in the light of the published literature. CASE REPORT: A 26-year-old woman presented with a 12-month history of a painless, left-sided neck lump. Ultrasound, computed tomography and magnetic resonance imaging revealed a carotid body tumour, which at surgical excision was found to be adherent to the vagus and hypoglossal cranial nerves (X and XII). The tumour was resected from the surrounding structures. Two local lymph nodes were removed to allow access. The internal carotid artery was also involved and had to be repaired with a synthetic graft. Histology and immunohistochemistry confirmed malignant carotid body paraganglioma. There were positive resection margins, and cervical lymph node metastasis was reported in one of the two nodes. Post-operatively, she had left Horner's syndrome, left vocal fold palsy and right upper limb weakness, all of which resolved spontaneously. She underwent adjuvant radiotherapy and remained recurrence free after 30 months. CONCLUSION: Malignant carotid body paraganglioma can affect young adults, with an insidious onset of symptoms. In this patient, local excision (without neck dissection) and adjuvant radiotherapy were well tolerated and resulted in satisfactory local disease control.

Quality of life after treatment of laryngeal carcinoma: a single centre cross-sectional study.

INTRODUCTION: Laryngeal cancer treatment inherently affects life's most basic functions and significantly affects quality of life (QOL). We aimed to identify which aspects of QOL and which patients are most affected by the various treatment options. METHODS: The University of Washington Quality of Life (UW-QOL) questionnaire was administered to all patients with laryngeal cancer treated at a single institution over a seven-year period (2003-2010). RESULTS: In total, 41 patients responded. All had been treated for squamous cell carcinoma of the larynx. Questionnaires were completed at a median of 18.5 months after treatment. The overall quality of life was 81.1/100 as assessed by the UW-QOL scale, with only 4.9% reporting 'poor' or worse QOL. Neither patient age nor time after treatment significantly affected any aspect of QOL. Patients undergoing primary radiotherapy reported the best QOL. Those undergoing chemoradiotherapy or combined surgical treatment and chemoradiotherapy reported the worst QOL, particularly in terms of social eating, taste and saliva production. Patients with a T stage ≥2 and those with nodal metastases reported a significantly worse QOL. CONCLUSIONS: Overall, QOL in our patients was good. This study highlights the aspects of QOL most affected by various treatments for laryngeal cancer and identifies areas in which therapeutic intervention may be focused. It also provides information to guide clinicians when assisting patients to make informed decisions regarding treatment of their head and neck cancer.

Calculi and intracellular ochronosis in the submandibular tissues from a patient with alkaptonuria.

Alkaptonuria (AKU) is a rare autosomal recessive condition caused by deficiency of the enzyme homogentisate 1,2 dioxygenase, resulting in widespread deposition of oxidised homogentisic acid (HGA) polymer, primarily in joint tissues but also in other connective tissues. Macroscopic pigmentation of connective tissues in AKU is well documented and is the end point of a process that is not understood. Deposition in less common regions may provide clues to the pigment formation process. This is the first report of detection of ochronotic pigment in acinar cells and lumina in the submandibular gland of a patient with AKU. Deposition was noted in the apical region of the cells. A lobar duct presented a large calculus with unusual deposits possibly associated with calcium salts. This report highlights the effect that local and intracellular factors may have on converting HGA into polymeric derivatives in the absence of an extracellular matrix.

Laryngopharyngeal reflux: A literature review.

Laryngopharyngeal reflux (LPR) is a common condition encountered in otolaryngological practice in the United Kingdom. It is one of the most important aetiological factors for many inflammatory disorders of the upper aerodigestive tract. The presentations are diverse and include chronic hoarseness, sensation of a foreign body in the throat, sore throat, dysphagia, postnasal drip, excessive throat mucous, chronic cough and throat clearing. LPR patients may not complain of heartburn. Although LPR is common, its diagnosis may not be easy, as its symptoms are non specific and the laryngeal findings are not always associated with symptom severity. This article discusses an overall view of LPR in terms of pathophysiology, clinical presentation, diagnosis and treatment

Reliability of a tympanic thermometer in measuring temperatures in children after minor ear surgery.

AIM: To evaluate the reliability of infrared tympanic thermometry in children who have undergone myringotomy with grommet insertion. METHOD: Forty children who had undergone myringotomy with at least one grommet insertion had the tympanic temperature of each ear and the axillary temperature measured on admission and 30 minutes post-operatively. RESULT: No difference was found between the pre- and post-operative temperatures measured by either method (p > 0.05, paired t-test, hypothesized difference of 0). CONCLUSION: Infrared tympanic thermometry is reliable in monitoring body temperature in children who have had minor ear surgery.

Wegener's granulomatosis: a rare, chronic and multisystem disease.

Wegener's granulomatosis (WG) is an autoimmune disease which has a clinical predilection for the upper airways, lungs and kidneys. It is a necrotising granulomatous vasculitis which is associated with a distinct autoantibody--the antineutrophil cytoplasmic antibody (ANCA). A heightened index of suspicion by clinicians is needed in the diagnosis of this complex and rare condition. A multidisciplinary approach should then be used to treat this chronic multisystem disease. Treatment involves the use of various regimens of corticosteroids and immunosuppressive medication. Mortality due to WG has been significantly decreased by this therapy. In this article, we focus on clinical manifestations and review the salient histologic, laboratory and serologic features and treatment.

Improving patient care and quality of life after laryngectomy/glossectomy.

Patients undergoing total laryngectomy/glossectomy are left without a voice at least temporarily in the early postoperative stage, since their larynx and/or tongue has been removed. Those patients rendered permanently speechless usually acquire a form of mechanical speech through electronic devices. However, the life-changing nature of this surgery should not be underrated as effectively these people have lost their normal voice. It can be argued that this patient group is also without a voice in a political sense - theirs seems to be a forgotten cancer, as other forms of cancer appear to attract greater attention for research priorities and funding. In some ways this research attempts to redress the balance through exploring the patient experience postoperatively, in particular the issues related to communication for this patient group. The results also highlight the emotional trauma experienced by patients and the mechanisms healthcare staff employ to support these patients. This research is multidisciplinary, involving patients and all those health workers that come into contact with them on the ward. The patient experience forms a major part of this article, allowing their stories to form much of the content. The results draw attention to deficiencies in service delivery that, as a direct result of this research, have been and are being addressed so that patients' care is improved and their quality of life is restored. Such change has been driven by patient comment such as: 'But then when you wake up after that operation that's the pits when you are laying there and you think "I'm dead". And then when you wake up properly that's the bit I always say you wish you were dead. That's when you wish you had died.'

Slow-release 5-fluorouracil and triamcinolone reduces subglottic stenosis in a rabbit model.

A previous pilot study suggested that a sustained-release conjugate that provided a slow release of 5-fluorouracil and triamcinolone acetonide injected into the tracheal and paratracheal tissues of rabbits at the time of subglottic surgery reduced the formation of subglottic stenosis. Our study was undertaken to confirm the effect. Ten milligrams of the compound suspended in hyaluronic acid was injected at the time of injury via a laryngofissure approach. The results showed that the control group had a mean stenosis of 52%, whereas the treated group had a mean stenosis of 32%. There was a significant difference between the treated and untreated groups (p = .003). It is hoped that this co-drug ultimately can be used in humans to reduce stenosis formation after laryngotracheal surgery and in other forms of otorhinolaryngological surgery.

Laryngocele: an anatomical variant.

It is commonly believed that external laryngoceles always penetrate the thyrohyoid membrane at the site of penetration of the neurovascular bundle. We present a case where the site of penetration was posterosuperior to this. Careful dissection of the neck of a laryngocele sac is important to prevent damage to the neurovascular bundle.

Endoscopic sinus surgery: are junior doctors being properly trained?

Endoscopic sinus surgery (ESS) is a technique which carries great potential benefits for the treatment of many nasal conditions. However, it also carries substantial risks. The key to safe surgery lies with adequate training. A survey carried out as part of a North (East) Thames Region audit of higher surgical trainees revealed large discrepancies in their training and in their subsequent clinical practice. Almost half the trainees had started ESS without having been on a training course or performed any cadaver dissections. Despite the potential hazards of ESS, audit of complications and outcome received a low priority. The trainees made several suggestions for improving training, including better provision of courses, regional training programmes and improved access to cadavers for dissection. Other surgical specialties are being forced to examine the prospect of specific accreditation for minimally invasive techniques and otorhinolaryngology may have to follow suit.

Sinus surgery: does mitomycin C reduce stenosis?

This experimental study investigates the effect of mitomycin C (MMC) on sinus mucosal healing. MMC has an antiproliferative action on fibroblasts. It is used in glaucoma surgery to prevent restenosis of fistulas. Antrostomies were drilled in rabbit maxillary sinuses. One side was used as a control and the other treated with MMC at a concentration of 0.04, 0.4, or 1 mg/mL. Two animals from each group were sacrificed at 1, 2, 4, and 12 weeks. The antrostomies in the control and 0.04-mg/mL groups had closed by 1 week; in the 0.4-mg/mL group by 4 weeks, and in the 1.0-mg/mL group by 12 weeks. Ciliary function was initially impaired but normalized within 1 week. Both light and scanning electron microscopy showed no permanent damage to the cilia. These results suggest that MMC can be used to delay closure of antrostomies in sinus surgery.

Does slow-release 5-fluorouracil and triamcinolone reduce subglottic stenosis?

The surgical management of subglottic stenosis may be complicated by reformation of strictures. A slow-release combination of 5-fluorouracil, which has an antiproliferative effect on fibroblasts, and the corticosteroid triamcinolone acetonide has been used experimentally to control scar production in ophthalmic operations. This study was performed to determine if this material also can be used to reduce formation of subglottic stenosis. Subglottic stenosis was induced in rabbits by means of injury to the subglottic mucosa and submucosa. A suspension of the compound at a concentration of 2.5 mg/ml or 12.5 mg/ml was injected into the adjacent soft tissues. A control group of rabbits received the same volume of the suspension fluid but no compound. Two rabbits from each group were killed 1, 2, and 12 weeks postoperatively. No stenosis was seen at 1 or 2 weeks, but at 12 weeks the rate of formation of subglottic stenosis was decreased to a mean of 15.20% in the experimental groups compared with 47.37% in the control group. There were no indications of local or systemic toxicity. The promising results from this preliminary study suggest that use of this compound may reduce restenosis among patients treated surgically for subglottic stenosis. Further studies are being conducted.

Acute pulmonary oedema complicating laryngospasm.

Pulmonary oedema is an uncommon but important complication of laryngeal spasm which in turn occurs more commonly in ENT practice than in most other surgical specialties. A case is reported and the literature reviewed, with particular reference to the proposed pathophysiological mechanism of this phenomenon.

Autofluorescence characteristics of oral mucosa.

BACKGROUND: The fluorescence characteristics of tissues depend upon their biochemical composition and histomorphological architecture, both of which undergo a change during malignant transformation. These changes are detectable as an alteration in the fluorescence spectral profile of the tissues. METHODS: Biopsy specimens from clinically suspicious lesions and normal-appearing oral mucosa were obtained from patients. Fluorescence spectroscopic measurements were obtained to study the differences between normal and dysplastic tissues and to determine the most appropriate excitation wavelength(s) for exploiting these differences. RESULTS: Fluorescence spectra from a total of 12 histologically normal (healthy mucosa or benign lesions) and ten abnormal (dysplastic or malignant) tissue samples were compared. Significant spectral differences were seen between the two groups. These differences were most marked at the excitation wavelength of 410 nm. Using this wavelength, fluorescence correctly diagnosed 20 of 22 samples studied. CONCLUSIONS: This technique accurately differentiates normal from abnormal tissues in vitro and has the potential applications for in vivo use as a noninvasive diagnostic tool.