Posterior nasal neurectomy for intractable rhinitis: A systematic review of the literature.

BACKGROUND: Rhinitis affects up to 40% of the population worldwide and can significantly reduce quality of life. Some patients remain symptomatic despite maximal medical therapy. In refractory cases, posterior nasal neurectomy (PNN-the endoscopic division of the intranasal nerve branches containing postganglionic parasympathetic fibres) is postulated to reduce symptom burden. OBJECTIVES OF REVIEW: To establish whether PNN is effective and safe in the management of allergic and non-allergic rhinitis. TYPE OF REVIEW: Systematic review. METHODS: A comprehensive literature search was undertaken using PubMed, EMBASE, MEDLINE, and Cochrane. The inclusion criteria were: studies published in English, studies where PNN was performed either with or without additional procedures, and where measures of objective/subjective outcomes and/or complications were reported. Extracted data included study type, sample size, surgical technique, study population characteristics, follow-up period, outcome measures, complications of surgery, and symptom outcomes. RESULTS: A total of 23 articles satisfied the inclusion criteria studying in total 2282 patients. Sample size ranged from 8 to 1056. There were 3 randomised controlled trials, 3 case-control studies, and the remaining 17 were case series using both objective and subjective outcome measures. All but one study found improved patient-reported outcomes following PNN. Complications were reported in 14 studies-epistaxis was the most common complication and was observed in 30 patients (1.5% of subjects). CONCLUSIONS: PNN had a low rate of complications. Although most studies reported significant symptomatic improvement, their heterogeneity, level of evidence, study design, and/or quality was not sufficient to draw any firm conclusions on the effectiveness of the procedure. Larger, well-designed studies are needed to clarify its role in the management of difficult-to-treat rhinitis.

Bony orbital changes in allergic fungal sinusitis are reversible after treatment.

Allergic fungal sinusitis (AFS) arises from a host hypersensitivity reaction to fungi residing within the sino-nasal tract. Computed tomography imaging may show heterogenous sinus opacification with bony erosion and expansion into the orbits. With advanced orbital involvement there is a risk of optic neuropathy and irreversible vision loss. We present a patient with AFS who presented with bilateral proptosis and early optic neuropathy. Radiologically, there was evidence of bony erosion and orbital wall compression. Following oral corticosteroids and full-house endoscopic sinus surgery, these changes reversed considerably. This case shows that bony and anatomical orbital changes from AFS are reversible with adequate surgical treatment.

Does the pre-operative serum phosphate level predict early hypocalcaemia following parathyroidectomy for primary hyperparathyroidism?

BACKGROUND AND OBJECTIVES: Hypocalcaemia is a significant post-operative complication following parathyroidectomy. Early identification of risk factors can help pre-empt hypocalcaemia and avoid serious sequelae. It can also help identify those patients that are not suitable for day-case surgery. The aim of this study was to analyse the predictive value of the pre-operative serum phosphate level as an indicator for developing hypocalcaemia post-operatively in patients undergoing parathyroidectomy for primary hyperparathyroidism. METHODS: We performed a retrospective review of all patients who underwent parathyroidectomy between 2008 and 2010 at the Southern General Hospital in Glasgow. Data collected included the number of parathyroid glands excised and their histology, pre-operative adjusted calcium (aCa) and phosphate levels, post-operative aCa at 6 and 24 h following surgery, and the fall in aCa levels in the first 6 h and 24 h following surgery. Minitab Statistical Analysis (Version 15) was used for data analysis. RESULTS: Fifty-six patients underwent parathyroidectomy in the study period. Twelve patients were excluded for various reasons including incomplete records and secondary hyperparathyroidism. Patients given calcium or Vitamin D supplements immediately post-operatively were also excluded. Statistical analysis showed no significant correlation between the pre-operative phosphate level and the post-operative decline in aCa level 6 h or 24 h following surgery. CONCLUSIONS: Patients with a lower phosphate level pre-operatively were not at risk of a more drastic fall in calcium levels following parathyroidectomy. The pre-operative phosphate level was not found to be predictive of post-operative hypocalcaemia in our study.

Head drop syndrome secondary to multimodality treatments for head and neck cancer.

Five patients under follow-up for head and neck squamous cell carcinoma (SCC) at Southern General Hospital Glasgow presented with a fixed flexion deformity of the neck. These cases are characterized by the onset of severe weakness and atrophy of the neck extensor muscles and anterior fibrosis forcing the mandible to the chest wall. This causes considerable morbidity with communication, feeding, and appearance. This is a rare complication with no curative treatments that has not been reported previously by a UK center and is likely to become important with the increased use of multimodality treatments for head and neck SCC.