Stapes surgery under local anaesthesia.

In the UK, stapes surgery is performed almost universally under general anaesthesia. In 1984 there was consensus that local anaesthesia should be the technique of choice in stapes surgery. Despite reports of successful use of local anaesthesia for middle ear surgery, this is still not widely accepted practice in the UK. We describe the senior author's technique for local anaesthetic stapes surgery and present the hearing results for a series of 100 consecutive cases.

Gold weight implants in the management of lagophthalmos in facial palsy.

The otolaryngologist plays an essential role in the diagnosis and management of a facial palsy. We present one of the largest cohort prospective studies in the UK of 22 patients with gold weight implants, including ancillary oculoplastic techniques, and their outcomes. Facial paralysis places the eye at risk and protection and lubrication of the eye is paramount in the management of these patients. If recovery of facial function is likely to be delayed or negligible, gold weight loading of the upper lid has been shown to be effective in providing a dynamic solution to lagophthalmos. Following surgery, complete eye closure was possible in the upright position in 18 patients (82%). Two patients had their weights removed secondary to infection (9%). At long-term follow up, four patients judged their vision to have deteriorated (29%). Two of these, after investigation by the ophthalmologists, were found to have pressure astigmatism and removal corrected the visual problems. Overall patient satisfaction with the procedure is high and all reported improvement in eye closure following the operation. An algorithm for the management of the eye in patients with facial palsy is outlined.

Dysphonia associated with inhaled steroids.

The use of inhaled steroids in the treatment of asthma is not without its complications. In some studies up to 50% of such patients complain of oropharyngeal and voice problems. We present the findings in 22 patients complaining of dysphonia who underwent videostrobolaryngoscopy (VSL) and computerized speech analysis. A number of abnormalities were identified. On VSL, these included mucosal changes (noted in 58%), apposition abnormalities (noted in 43%), and supraglottic hyperfunction (noted in 40%). On speech analysis, cycle-to-cycle irregularity was frequently noted (mean of 39%). Maximum phonation time was reduced in 73%. Our findings did not confirm the widely held views that steroid dysphonia is due primarily to a fungal infection or a steroid-induced adductor myasthenia of the larynx. A larger-scale prospective study is indicated.

Sudden onset deafness: two cases associated with pregnancy.

Sudden onset sensorineural deafness is an otological emergency; subsequent recovery of hearing has been shown to correlate with early treatment. There have been few documented reports of this occurring in pregnancy, although the increased thrombogenic risk of the pregnant state is a proposed aetiological factor. The wide variation in outcome is demonstrated by these two cases, which are presented to raise awareness of this condition.

Tuberculosis presenting as a laryngeal tumour.

As the prevalence of tuberculosis in the U.K. increases, uncommon clinical presentations of the disease may be encountered by the otolaryngologist. We describe just such a case, where a caucasian patient presented with laryngeal lesion, considered to be highly suspicious of a neoplastic process rather than an infective one. We discuss the pathogenesis of tuberculous laryngitis, and review the differential diagnosis and management of the condition.

Post-tonsillectomy pain: the difference between younger and older patients.

In a prospective study of 50 patients undergoing tonsillectomy the pain scores over the first 14 days were recorded. The scores for those patients 10 years or younger were compared with those older than 10. The results showed a significant difference between the distribution of pain over the course of time between the two groups. The mean pain scores on day 1 were similar in the two groups but in the older group the level of pain recorded daily remained fairly constant until day 9 when it fell to around half the initial score. In the younger children the pain scores peaked at day 2 but thereafter fell to approximately half the peak score by day 6. The analgesic intake in each group mirrored these findings.

A prospective randomized controlled study of 4% lignocaine solution in Merocel nasal pack removal.

Packing of the nasal cavity following intranasal surgery is still widely practised. The removal of this packing is invariably associated with a significant amount of pain. We designed a prospective randomised case-controlled study to look at the efficacy of 4% lignocaine solution as a potential analgesic in the removal of Merocel nasal packs. Each patient had bilateral packs and acted as his or her own control with one pack being rehydrated with lignocaine and the other with saline. We found that there was a reduction in the level of discomfort experienced on the side rehydrated with lignocaine, although this reduction did not reach significance. We emphasize the importance of rehydration of these packs prior to removal.

First aid treatment of epistaxis--are the patients well informed?

OBJECTIVE: To investigate the level of lay knowledge of first aid measures for epistaxis, and to determine the effectiveness of an ENT department policy of providing an advice sheet of first aid measures. METHODS: 50 patients presenting with epistaxis were questioned on the accuracy and level of their knowledge of the four basic procedures used to combat a nose-bleed. The results were correlated with the source of referral, previous treatment, and advice. RESULTS: A large proportion of patients who had previously been treated for epistaxis by their general practitioners and other non-ENT trained medical or nursing staff were unable to recall being given any first aid advice. For those who remembered being given advice, very few described all the steps correctly. In contrast, patients who had previously been seen by the ENT staff scored full points in every aspect. CONCLUSIONS: The results are a reflection of the departmental policy of supplying information sheets outlining the first aid measures to all patients presenting with epistaxis.

Outpatient clinic review after arterial reconstruction: is it necessary?

After arterial reconstruction, patients have traditionally been followed up in clinic in the long term. We have pursued a policy of limited clinic follow-up, with an 'open access' service for suspected graft failure (and latterly duplex scanning surveillance for vein grafts). This policy was assessed by measurement of the success of self-referral, graft patency and patient satisfaction after operation for lower limb ischaemia in 173 patients. At median follow-up of 50 months, 61 (35%) patients had died and 45 (25%) had required amputation. Of those with salvaged limbs and available for follow-up, 55 (86%) patients reported continuing symptomatic improvement with a graft patency rate of 80%. During the review period, 27 (42%) patients had presented themselves on suspicion of graft occlusion and 14 (52%) of these had required surgical intervention. Of the patients, 45 (70%) found a single postoperative clinic visit helpful, and the majority thought that further visits would not have been helpful to them. Limited clinic appointments seem especially desirable for elderly patients for whom journeys are an imposition, as well as reducing travel costs, and giving surgeons more time to deal with new referrals. These results suggest that properly educated patients present themselves when signs of graft occlusion occur, and there is little to be gained by regular long-term clinic follow-up in vascular surgical practice.