Smell and taste disorders, a study of 750 patients from the University of Pennsylvania Smell and Taste Center.

Smell and taste disorders are common in the general population, yet little is known about their nature or cause. This article describes a study of 750 patients with complaints of abnormal smell or taste perception from the University of Pennsylvania Smell and Taste Center, Philadelphia. Major findings suggest that: chemosensory dysfunction influences quality of life; complaints of taste loss usually reflect loss of smell function; upper respiratory infection, head trauma, and chronic nasal and paranasal sinus disease are the most common causes of the diminution of the sense of smell, with head trauma having the greatest loss; depression frequently accompanies chemosensory distortion; low body weight accompanies burning mouth syndrome; estrogens protect against loss of the sense of smell in postmenopausal women; zinc therapy may provide no benefit to patients with chemosensory dysfunction; and thyroid hormone function is associated with oral sensory distortion. The findings are discussed in relation to management of patients with chemosensory disturbances.

External nasal nerve division: a treatment for post-traumatic neuralgia.

We present four patients complaining of neuralgic pains across the nasal bridge following trauma, who were successfully treated by division of the external nasal nerve. We believe it is a useful treatment in selected cases.

Topical bupivacaine in paediatric day-case tonsillectomy: a prospective randomized controlled trial.

Post-operative pain and delayed oral intake are common reasons for failure of discharge in day-case tonsillectomy. A double blind prospective randomized study was devised to investigate the effectiveness of topical bupivacaine in reducing post-operative pain in paediatric day-case tonsillectomy. Ninety-nine patients aged between three and 16 years were recruited into the study. One group received bupivacaine soaked swabs tightly packed in their tonsillar fossae while the control group received saline-soaked swabs. The bupivacaine group was found to drink (p < 0.001) and eat (p = 0.006) earlier than the control group. The pain scores at one (p < 0.001), three (p < 0.001) and six (p < 0.001) hours post-operatively were also found to be lower in the bupivacaine group than the control group. We conclude that topical bupivacaine has a role in facilitating recovery in day-case tonsillectomy in children.

Subtle diagnostic markers of orbital floor blow-out fracture on coronal CT scan.

The sagittal plane, computerized tomography (CT) scan has been proposed as the most important radiological view in the diagnosis of orbital floor blow-out fractures. This view however is impractical and unnecessary. Direct, coronal plane CT scan with careful attention paid to the shape of the inferior rectus muscle and antral roof will successfully diagnose this traumatic condition, as in our reported case in which no other radiological abnormalities were present.

Kaposi's sarcoma masquerading as pyogenic granuloma of the nasal mucosa.

Kaposi's sarcoma (KS) is a neoplastic vascular disorder characterized by multiple reddish blue nodules which, according to the original description (Kaposi, 1872), usually present on the skin of the upper and lower extremities. It is not until the disease progresses that nodules appear on the skin of the head and neck, on mucosal membranes and as visceral lesions. However, with the large increase in the incidence of this tumour associated with the acquired immune deficiency syndrome (AIDS) epidemic, there have been increasing numbers of cases of Kaposi's sarcoma presenting primarily on the skin or mucosa of the head and neck. The most common sites reported are within the oral cavity, particularly on the palate. Other mucosal sites are rare. We present an unusual case where the primary manifestation of the Kaposi's sarcoma was in the nasal mucosa and stress the importance of this diagnosis not being overlooked.

Combined forceps and catheter extraction of an oesophageal foreign body.

The extraction of impacted foreign bodies from the oesophagus is frequently performed using forceps under endoscopic guidance. We report the case of a 23-year-old prisoner who ingested a lump of cannabis resin which could not be removed from the upper oesophagus with forceps alone. We recommend the use of a Fogarty balloon catheter in conjunction with toothed forceps in such cases.

Ventilatory monitoring during microlaryngeal surgery using jet insufflation anaesthesia.

We describe a method for continuous measurement of end-tidal carbon dioxide concentration during jet insufflation anaesthesia for microlaryngeal surgery. This increases the safety of the technique by allowing closer monitoring of inspired and expired gases during anaesthesia.

Pseudomonal supraglottitis occurring in a patient with profound neutropenia secondary to virus-associated haemophagocytic syndrome.

We present a case of virus-associated haemophagocytic syndrome following Epstein-Barr virus infection in which a fulminant pseudomonal supraglottitis developed. Increasingly, unusual pathogens have been found in immunocompromised patients. This is the first reported case of pseudomonal supraglottitis.

Constipation: what does the patient mean?

Constipation is a very common complaint but, in the absence of a universally accepted definition, misunderstandings may result between doctor and patient. Two hundred and eighty-seven patients attending this hospital completed a questionnaire which attempted to establish what patients themselves mean by the term. Almost half considered constipation purely in terms of frequency of bowel action, without considering difficulty or pain on defaecation. Women were more likely to have infrequent bowel actions than men, and men more likely to consider such infrequency harmful. A quarter of respondents believed in the benefits of regular purgation, surprisingly with no difference in attitude between age groups, but men were much less likely to have heeded their own advice.

The nose after laryngectomy.

Previous studies of nasal function after laryngectomy have suggested that patients must accept complete and irreversible anosmia as an inevitable consequence of the operation, and that this is due to interruption of a poorly defined neuronal interaction between larynx and nose. In this study nasal function was investigated in 23 laryngectomees and 10 patients about to undergo laryngectomy. Scanning electron microscopy showed a more densely ciliated nasal epithelium in the laryngectomees compared with the preoperative controls, and nasal mucociliary transport, measured by saccharine clearance, was significantly faster (P less than 0.01) in laryngectomees. Olfactory acuity, as determined by the threshold for detection of insufflated pyridine vapour, was normal in laryngectomees. Some laryngectomees did have a relatively normal sense of smell; these were shown to be those who had discovered a technique of sniffing using buccopharyngeal rather than respiratory musculature. These findings have obvious implications for the rehabilitation of laryngectomees, many of whom may otherwise have to contend with distressing anosmia as well as the other physical and psychological consequences of the operation.

Chaperones in ENT out-patients; the patients' perspective.

Chaperones are used in order to avoid misunderstandings that can lead to false accusations. Consultations and examinations may be a minefield especially if the doctors are accused of sexual misconduct. The allegations may have irreparable effects on their reputation and may lead to removal from the medical register and to criminal charges being brought. We present the results of a questionnaire from 85 patients, exploring patient experience in ENT out-patients particularly with respect to examination of the ear under the microscope. This procedure necessitates close contact between the patient and doctor for several minutes and there may be inadvertent contact with intimate areas on the patient. Up to 30 per cent of patients expressed a preference for a chaperone during the ENT consultation. There was noticeably a greater proportion of men than women patients stating a preference for a chaperone during the consultation. Interestingly, there was a strong positive correlation between the presence of friends/relatives and the preference for a chaperone. Patients should be given the freedom to choose for or against the presence of a chaperone in clinic consultations. The most commonly predicted scenario requiring a chaperone is with the male doctor and female patient. This study shows that based on patient feedback, this scenario, although common is not the exclusive area in which chaperones should be used.

A prospective comparative study to examine the effects of oral diazepam on blood pressure and anxiety levels in patients with acute epistaxis.

OBJECTIVE: To examine the effects of oral diazepam on blood pressure and anxiety in patients with acute epistaxis. STUDY DESIGN AND SETTING: A prospective comparative study in an otorhinolaryngology tertiary referral centre. PARTICIPANTS: Patients with acute epistaxis requiring hospital admission. INTERVENTION: Oral diazepam. MAIN OUTCOME MEASURES: Anxiety and blood pressure levels. RESULTS: 32 patients received diazepam and 45 did not (control). On average, patients were hypertensive on admission (mean [standard deviation (SD)] systolic blood pressure diazepam group=157 mmHg [26], control=152 mmHg [23]; diastolic blood pressure diazepam group=87 mmHg [16], control=87 mmHg [18]). Both groups showed significant blood pressure reduction on discharge (p<0.0001) but the difference in mean blood pressure reduction between the two groups was insignificant (systolic blood pressure p=0.16, 95% confidence interval [CI]=-5 to +19 mmHg; diastolic blood pressure p=0.43, 95% CI=-8 to +10 mmHg). Anxiety was significantly lower on discharge (p<0.0001) but the difference in mean fall in anxiety scores between the two groups was insignificant (p=0.08, 95% CI=0 to +2). There was no significant correlation between total diazepam and changes in blood pressure (systolic blood pressure p=0.32; diastolic blood pressure p=0.65) or anxiety (p=0.73), nor between blood pressure and anxiety on admission (systolic blood pressure p=0.45; diastolic blood pressure p=0.72). CONCLUSIONS: Elevated blood pressure and anxiety in acute epistaxis patients reduced on epistaxis resolution irrespective of oral diazepam use. The elevated blood pressure does not appear to be directly related to anxiety.

Handedness and the side on which pharyngeal pouches occur.

Pharyngeal pouches present far more commonly on the left side of the neck than the right. Sixty one patients with a history of pharyngeal pouch were questioned about their handedness and about whether they had had symptoms or signs predominantly on one side of the neck before receiving treatment. There was a highly significant association between handedness and pharyngeal pouches on the opposite side of the neck. It is suggested that this is the reason for the rarity of right sided pouches.

Destructive noninvasive paranasal sinus aspergillosis: component of a spectrum of disease.

A chronic, destructive form of paranasal sinus aspergillosis may exist without evidence of tissue fungal invasion. In this state, the pathogen results in progressive, chronic inflammation intermediate between previously described saprophytic and invasive states. We report three such cases. This variety of aspergillosis and an analysis of the clinical and histopathologic findings of previously reported cases support the concept that infection with the organism may produce a spectrum of pathologic changes and is akin to the range of aspergillosis disease states described affecting the lung. We classify paranasal and nasal aspergillosis as (1) noninvasive, either an aspergilloma or allergic type, (2) destructive, noninvasive, and (3) invasive, either slowly progressive or fulminant. Any form may progress to, or be associated with, more aggressive disease.

High frequency oscillations improve nasal mucociliary transport.

The saccharin clearance time technique was used to determine the effect upon nasal mucociliary transport of sine wave oscillations. Nasal air was oscillated at 8 Hz, 14 Hz, and 20 Hz by a loudspeaker attached to a nasal mask. Mucociliary transport was significantly increased at all frequencies with an overall mean rise of 161%. Because sine waves have zero mean pressure and flow, the improvement is more likely to be caused by changes in mucus viscoelasticity or ciliary function rather than by a direct physical effect on mucus velocity. This simple and comfortable technique may have practical application in patients with overproduction or retention of mucus within the nasal passages or intrathoracic airways.

Balloon dilatation of the pharynx.

Balloon dilatation has become a widely accepted technique in the management of oesophageal and other gastrointestinal strictures. The use of this procedure in the pharynx has rarely been reported. We have performed 55 balloon dilatations on 13 patients with pharyngeal strictures. In three patients all symptoms were permanently abolished after one dilatation. Seven patients were successfully managed with repeated, regular dilatations. Two patients had a good initial response but this was not maintained and one patient had no relief of symptoms. Balloon dilatation is minimally invasive, less traumatic than rigid pharyngoscopy with dilatation, and well tolerated. It may be frequently repeated, and has successfully relieved dysphagia caused by benign and malignant strictures of the pharynx, including instances where previous rigid bouginage had failed.

Day case adenoidectomy.

The Audit Commission recommends that more day surgery be undertaken in the Health Service. In a prospective study of 62 children undergoing adenoidectomy one major complication commenced within 2 hours of surgery. Of 15 minor complications, 78% occurred within 6 hours of surgery; they did not herald later major complications. Day adenoidectomy can safely be performed if patients remain in hospital for 6-8 hours post-operatively and then fulfil the following discharge criteria: they are apyrexial, eating, drinking and with no signs of haemorrhage. This will not result in a significant increase in workload for general practitioners. Day adenoidectomy for medically and socially appropriate patients increases our day surgery figures by 74% to 43% of the routine paediatric ENT caseload. There are immediate benefits to patients but the potential economic benefits to the Health Service will not be felt unless these children are treated in a designated Day Case Unit.