Disseminated tuberculosis caused by Mycobacterium bovis presenting as a tongue base mass.

An 80-year-old woman presented with dysphagia, odynophagia and progressive weight loss. Initial investigations suggested a large base of tongue squamous cell carcinoma. At panendoscopy, biopsies were taken which revealed granulomatous inflammation with multinucleated giant cells and areas of caseous necrosis. Acid-fast bacilli were identified on Ziehl-Neelsen stain and the appearances were consistent with Mycobacterium bovis Closer inspection of the patient's medical history revealed that she had previously undergone right hemicolectomy for an ascending colon stricture. The histology had shown granulomatous inflammation consistent with intestinal tuberculosis but no systemic treatment had been instigated at the time. This case highlights the importance of taking a detailed clinical history as well as the need to be cognisant of tuberculosis masquerading as cancer in the head and neck.

Rare glomangiosarcoma of the tongue.

The glomus tumour is a rare neoplasm derived from the glomus apparatus. Subungual sites are most common with only three published cases involving the dorsal tongue. To our knowledge, this is the first case of an intraoral malignant glomus tumour (glomangiosarcoma) to be published in English literature. We report a case of a single glomus tumour located on the posterior dorsal tongue of a middle-aged man, which was surgically excised. Immunohistological features were indicative of a glomus tumour; however, in this case, malignant features were also discovered, warranting re-excision.

Is it safe to inject local anaesthetic with adrenaline into the pinna and external nose?

Adrenaline containing lidocaine preparations such as lignospan are routinely used in ear, nose and throat (ENT) care. Despite this, textbooks and internet resources warn against their use in peripheries, including the nose and ear. As a result, they are commonly avoided by other specialties, such as emergency medicine. This article reports on the findings of a review undertaken to assess the evidence of harm associated with using lignospan in the pinna and external nose. A literature search was carried out, and retrospective data were collected on all elective facial skin lesion surgery in the ENT department at the Great Western Hospital in Swindon between 2005 and 2015. Cases using lignospan in the pinna and nose were included. The literature search revealed no reports of ischaemic complications of the pinna or nose following use of lignospan, or similar preparation. Of the 1,409 cases collected, no ischaemic complications were recorded. The article concludes that adrenaline containing lidocaine preparations such as lignospan are safe for use in the pinna and nose, and should be considered for use in emergency departments.

Bilateral isolated submandibular gland mumps.

Isolated submandibular swellings pose a diagnostic challenge to the practising otolaryngologist. We report an unusual case of mumps isolated to bilateral submandibular glands. We discuss the case and the literature surrounding this condition and remind clinicians that mumps should be considered as a diagnosis in the presence of submandibular gland swelling in the absence of typical parotid swelling associated with mumps. Early consideration of this differential diagnosis, serological testing and a multidisciplinary approach may help to clinch the diagnosis earlier and prevent spread of the virus.

A case of bilateral sensorineural hearing loss from Langerhans cell histiocytosis.

Langerhans cell histiocytosis is a rare disorder, with resultant bilateral sensorineural hearing loss unreported in adults. A 42-year-old man presented with 4 months of right-sided tinnitus and hearing loss treated initially as otitis media with effusion. He re-presented 5 months later with progressive bilateral hearing loss--sensorineural (>100 dB) on pure tone audiogram. CT showed bilateral petrous temporal bone and calvarial lesions. Biopsy confirmed diagnosis of Langerhans cell histiocytosis and chemotherapy was started. Though uncommon, Langerhans cell histiocytosis should be considered among the differentials of persistent otological symptoms, as its progressive nature can cause bilateral irreversible sensorineural hearing loss.

A case of persistent hemifacial weakness.

Hemifacial weakness, or palsy, results from disruption of communication between cortical motor centres and the facial musculature along the course of the facial nerve. Bell's palsy has a typical presentation of sudden onset, mild otalgia, altered facial sensation and/or taste, with no obvious prodrome. It represents over half of hemifacial weakness cases in primary care. However, as a diagnosis of exclusion, there are a number of key clinical features of more sinister diagnoses that must be considered. Acute hemifacial weakness secondary to isolated facial nerve palsy must be differentiated from acute cerebrovascular accident. The latter results in sparing of the brow musculature due to the bilateral innervation of the frontalis. Altered facial sensation and mild otalgia are common in Bell's palsy, however severe pain is suggestive of Ramsay Hunt syndrome. Recent facial or head trauma and surgery should also be excluded in causation. Patients with the following conditions should be referred: lagophthalmos if the weakness persists beyond a few days or ocular damage is suspected; Ramsay Hunt syndrome (immunocompromised patients, those with significant pain, and where intraoral vesicles prohibit oral intake); and palsy secondary to trauma or surgery. A parotid mass with facial palsy implies malignant change and must be referred within the two-week wait pathway. A history of progressive hearing loss and tinnitus with palsy also requires urgent referral to neuro-otology for assessment of cerebellopontine angle tumours. All cases of facial palsy associated with infective otological symptoms should be discussed with ENT.

Postviral vagal neuropathy.

OBJECTIVES: Postviral vagal neuropathy (PVVN) is a clinical diagnosis characterized by laryngeal complaints initiated by an upper respiratory tract infection (URI). Little is known about the natural history of this disease, and only small case series have been reported. We describe the clinical presentation, symptoms, patient demographics, and natural history of PVVN. METHODS: A cross-sectional survey of all patients with a diagnosis of PVVN from January 1, 2006, to December 31, 2006, was prospectively administered, detailing disease onset, type and duration of symptoms, demographics, and previous treatment. The Reflux Symptom Index, Voice Handicap Index, and laryngoscopic findings were collected for each patient. RESULTS: Forty-four patients with PVVN were identified. The mean age (+/-SD) was 48 +/- 13 years, and 73% of the patients were female. The most common initial URI symptoms were cough (89%), nasal congestion (75%), and rhinorrhea (64%). Fifty-nine percent of the patients took antibiotics, and the mean time between symptom onset and presentation to the laryngologist was 83 +/- 127 weeks. The most common persistent symptoms were cough (52%), throat clearing (48%), dysphonia (41.5%), and vocal fatigue (43%). Fifty-seven percent of the patients consulted 3 or more physicians for their symptoms. The mean Voice Handicap Index was 13.4 +/- 10.3, and the mean Reflux Symptom Index was 17.7 +/- 11. Forty-nine percent of the patients had evidence of vocal fold paresis on strobovideolaryngoscopy. CONCLUSIONS: PVVN is a clinical entity characterized by a complex of laryngeal symptoms that begin after a URI. The symptoms include chronic cough, excessive throat clearing, dysphonia, and vocal fatigue. Affected individuals are typically in their fifth decade of life and appear more likely to be women. Most patients have seen multiple physicians, and the time to laryngologist referral is often delayed.

Alcohol misuse in the Royal Navy.

BACKGROUND: Evidence suggests that military personnel consume considerable amounts of alcohol which may have both medical and occupational implications. AIM: To compare alcohol consumption and misuse within the Royal Navy (RN) to that in the civilian population. METHODS: The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire is a short measure of alcohol use disorders. It was administered to 1333 male RN personnel from operational naval units. 'Heavy' drinking was defined as consuming >21 units/week, 'very heavy' as >42 units/week, binge drinking as >8 units in one session and 'problem' drinkers as those advised to cut down in the last year. The study also measured psychological health using the General Health Questionnaire (GHQ)-12 and post-traumatic stress disorder checklist for civilians (PCL-C). RESULTS: The response rate was 70%. The majority (92%) scored as hazardous drinkers on the AUDIT-C, 40% met the criteria for heavy drinking, 27% for very heavy drinking, 48% reported binge drinking at least once a week and 15% were classed as problem drinkers. Heavy drinking was associated with younger age, lower rank and higher scores for both PCL and GHQ. All results were substantially higher than in age-matched civilian samples. CONCLUSIONS: Excessive alcohol consumption, especially binge drinking, is significantly more prevalent in the RN than in the general population. Such high levels of drinking are likely to impact upon occupational efficiency and have both short-term and long-term health effects. We suggest that more needs to be done to deter excessive levels of consumption in order to avoid long-term health consequences.

Peer responses to perceived stress in the Royal Navy.

BACKGROUND: Various organizations, including the Armed Forces, regularly place their personnel into potentially traumatic environments. Exposure to such events can lead to the development of psychological distress and organizational inefficiencies. It follows that the Armed Forces need to consider how best to address and prevent trauma-related problems both from duty of care and organizational effectiveness viewpoints. AIM: To investigate how Royal Navy personnel report they would deal with distress including the possibility of Deliberate Self-Harm (DSH) in peers. METHODS: In total, 142 interview transcripts were examined to see how military personnel would respond to a vignette which was concerned with how they would help a distressed peer. Interviews were analysed using content analysis and inclusive inductive categorization. RESULTS: The majority of individuals would interact positively with a peer who appeared to be 'under stress', and refer them on if problems did not resolve. Most respondents reported they would take positive action regarding immediate management of DSH, referring to either medical or management staff. The majority thought that reporting ideas of DSH would impact upon the potential harmer's career. Lower ranked personnel were more likely to report a negative impact. CONCLUSIONS: The results are generally encouraging; the majority of those interviewed would actively involve themselves in the care of their peers and refer them on appropriately if the situation deteriorated. Most individuals interviewed saw DSH as a real, predominately medical problem that required immediate active intervention. However, many felt that help seeking could be detrimental to one's career within the services.