Functional Laryngeal Assessment in Patients with Tracheostomy Following COVID-19 a Prospective Cohort Study.

To explore laryngeal function of tracheostomised patients with COVID-19 in the acute phase, to identify ways teams may facilitate and expedite tracheostomy weaning and rehabilitation of upper airway function. Consecutive tracheostomised patients underwent laryngeal examination during mechanical ventilation weaning. Primary outcomes included prevalence of upper aerodigestive oedema and airway protection during swallow, tracheostomy duration, ICU frailty scores, and oral intake type. Analyses included bivariate associations and exploratory multivariable regressions. 48 consecutive patients who underwent tracheostomy insertion as part of their respiratory wean following invasive ventilation in a single UK tertiary hospital were included. 21 (43.8%) had impaired airway protection on swallow (PAS ≥ 3) with 32 (66.7%) having marked airway oedema in at least one laryngeal area. Impaired airway protection was associated with longer total artificial airway duration (p = 0.008), longer tracheostomy tube duration (p = 0.007), multiple intubations (p = 0.006) and was associated with persistent ICU acquired weakness at ICU discharge (p = 0.03). Impaired airway protection was also an independent predictor for longer tracheostomy tube duration (p = 0.02, Beta 0.38, 95% CI 2.36 to 27.16). The majority of our study patients presented with complex laryngeal findings which were associated with impaired airway protection. We suggest a proactive standardized scoring and review protocol to manage this complex group of patients in order to maximize health outcomes and ICU resources. Early laryngeal assessment may facilitate weaning from invasive mechanical ventilation and liberation from tracheostomy, as well as practical and objective risk stratification for patients regarding decannulation and feeding.

Duplication of internal jugular vein and relation to the spinal accessory nerve.

We report a case of duplication of the internal jugular vein in which the duplication was incomplete and the accessory nerve lay deep to the vein.

Childhood pseudohypacusis.

Pseudohypacusis is a condition in which a hearing loss is exhibited in the absence of any organic disease. The mainstay of diagnosis is a lack of consistency in audiological testing. It is usually easier to diagnose in children than in adults, as children are less able to produce consistently erroneous results on repeated testing. In spite of this, the diagnosis is often missed in children, probably due to a lack of awareness of the condition. We present the findings in ten children seen in the past year. Initially they had average pure tone thresholds of 51.3 db in the right ear and 51.4 db in the left ear. All of the children underwent repeat pure tone audiometry and speech audiometry. In nine cases the speech audiograms confirmed the diagnosis. In one child the speech audiogram was consistent with a mild hearing loss subsequently confirmed as a 30-40 db low frequency sensorineural hearing loss. Following a programme of close follow up and support, the pure tone thresholds returned to within normal limits in nine children and to a level consistent with the clinical impression in the child with a sensorineural loss. None of the children required brain stem evoked response audiograms to confirm the diagnosis.

Acute pneumonitis caused by low density barium sulphate aspiration.

The aspiration of contrast medium during the investigation of swallowing disorders is a well recognized hazard. It is therefore essential that the contrast medium administered is non-irritant to the lungs. A case is presented to illustrate the problems associated with the aspiration of a relatively non-irritant contrast medium.

Management of laryngeal amyloidosis.

Amyloidosis of the upper aerodigestive tract is rare. However, the larynx is the commonest site within the upper airways to be affected. Three cases of uncomplicated primary amyloidosis of the larynx and one case of laryngeal amyloidosis with more generalized dissemination throughout the head and neck are presented. In this article the different presentations of laryngeal amyloidosis and principles of management of this condition at that site are highlighted.

Management of retraction pockets of the pars tensa in children by excision and ventilation tube insertion.

Retraction pockets of the pars tensa in children can result in erosion of the ossicles leading to hearing loss and eventually cholesteatoma formation. Several different types of treatment for the more severe grades of retraction pocket have been described. The aim of this pilot study was to assess the outcome following simple excision and ventilation tube insertion of grade II, III and IV retraction pockets of the pars tensa. The eardrums were graded according to Sadé's classification (1979). There were seven grade II and four grade III retractions. Ten eardrums healed completely in a mean time of 3.6 months (mean follow-up 16 months) and there was one residual perforation. Two retractions recurred and both of these were only grade I. Clinically, an improvement in hearing was reported in seven children (eight ears) and the average air conduction threshold gain for these patients was 16 dB. A larger prospective study is currently underway.

Nasal teeth.

Ectopic and supernumerary teeth occur in a wide variety of sites. Those that have been reported include the mandibular condyle, coronoid process, orbit, palate, nasal cavity and the maxillary antrum. Eruption of teeth into these sites is rare, and easily overlooked. We present two cases in which eruption of teeth into the nose and paranasal sinuses was associated with significant morbidity and show how this was relieved by appropriate surgery.

Angioedema secondary to angiotensin-converting enzyme inhibitors.

Angioedema secondary to angiotensin-converting enzyme (ACE) inhibitors is rare, but it is a side effect which is likely to be seen more frequently because of the increased use of these drugs to treat cardiac failure and hypertension. Presentation is variable and the diagnosis may go unrecognized for many months or years. The cases reported illustrate problems both in the diagnosis and management of this life-threatening condition.

Feasibility study of magnetic resonance imaging-guided intranasal flexible microendoscopy.

Interventional magnetic resonance imaging (MRI) offers potential advantages over conventional interventional modalities such as X-ray fluoroscopy, ultrasonography, and computed tomography (CT). In particular, it does not use ionizing radiation, can provide high-quality images, and allows acquisition of oblique sections. We have carried out a feasibility study on the use of interventional MRI to track a flexible microendoscope in the paranasal sinuses. In this cadaver study, high-speed MRI was used to track a passive marker attached to the end of the endoscope. Automatic image registration algorithms were used to transfer the coordinates of the endoscope tip into the preoperative MRI and CT images, enabling us to display the position of the endoscope in reformatted orthogonal views or in a rendered view of the preoperative images. The endoscope video images were digitized and could be displayed alongside an approximately aligned, rendered preoperative image. Intraoperative display was provided in the scanner room by means of an liquid crystal display (LCD) projector. We estimate the accuracy of the endoscope tracking to be approximately 2 mm.

The whys and wherefores of getting patients to give up smoking.

Smoking-related diseases are responsible for the majority of premature deaths in industrialized societies. It is 50 years since the link between smoking and lung cancer was first established, since when a gradually increasing number of smoking-related illnesses have been identified. The treatment of patients suffering smoking-related illnesses consumes a large proportion of health care budgets. The ever-increasing costs of health care, in part due to the advent of new therapeutic techniques, could be offset by a concerted effort to reduce the number of people smoking. Various strategies, particularly if used in combination, have been shown to produce acceptable smoking cessation rates. At present there appears to be a reluctance on the part of governments to fund a concerted, co-ordinated programme to encourage and assist people to stop smoking. In the absence of such support it is important for all health professionals to provide sensible advice and support to help their patients to stop smoking.

Treatment of lymphangiomas of the head and neck in children by intralesional injection of OK-432 (Picibanil).

The treatments previously used for lymphangiomas of the head and neck in children-surgery and intralesional injection of sclerosants-are associated with significant morbidity. A new treatment-intralesional injection of OK-432-was used for lymphangiomas of the head and neck in 11 children. The results were total shrinkage in two, marked shrinkage in two, slight shrinkage in five and no response in two. The results were not affected by previous surgery nor by whether aspiration prior to injection was possible. There were no recurrences in those children in whom shrinkage occurred and no child had subsequent surgery following injection. The results of this series support those of previous series showing that OK-432 injection is an effective and safe treatment for lymphangiomas of the head and neck in children.

Localized tracheomalacia as a complication of the Cole tracheal tube.

The Cole tracheal tube is designed for use in neonates. Subglottic stenosis is a recognized complication of prolonged use of the tube. We report a case of tracheomalacia as a further complication of prolonged use of the tube. A 4-month-old infant with a history of repeated failed extubation and multiple medical problems was found to have an unusual region of severe inspiratory collapse localized to the upper 1 cm of the trachea. This was felt to be the result of pressure from the shoulder of the Cole tube which had been used for prolonged intubation. A tracheostomy was performed to bypass the collapse, but the infant subsequently died due to other medical problems.

Bomb blast injuries to the ear: the London Bridge incident series.

Twelve patients who were treated for ear injuries at Guy's Hospital following the London Bridge bomb blast in February 1992 were reviewed. Among three there were four perforated eardrums, two of which closed spontaneously (50%). All three patients had a persistent mixed hearing loss. The remaining nine patients had acute sensorineural hearing loss and/or tinnitus only. Four of these had resolved completely by 4h, another one by 48h, and two by 4 weeks. Two patients had a residual high frequency hearing loss. In total, five patients (42%) have a persistent hearing loss. None of the patients suffered from balance problems. In summary, the ear is very susceptible to bomb blast injury, but there is a high rate of spontaneous closure of perforations and improvement of sensorineural hearing loss and tinnitus.

The comparative anatomy of the pig middle ear cavity: a model for middle ear inflammation in the human?

This study was undertaken to develop a functional model of otitis media with effusion (OME) in the pig (Sus scrofa), with the purpose of investigating the origin of lymphocytes populating the middle ear during the course of an inflammatory process. The relevance of the model to the human condition of OME is to a large extent dependent on the anatomical and physiological similarities between the middle ear cavity and the pharyngeal lymphoid tissue of the pig and man. Anatomical specimens were collected from 7 young Large White pigs to determine the gross anatomy of the middle ear cavity and the histological characteristics of the middle ear mucosa. It was found that the anatomy of the 3 parts of the middle ear cavity in man and in the pig is broadly similar, although some minor differences were observed. The porcine eustachian tube was seen to be cartilaginous throughout its length in contrast to the part osseous, part cartilaginous structure found in man; the porcine ossicles were slightly different in shape to those of man and the air cell system was situated inferior to the tympanic cavity in the pig as opposed to posteriorly in man. This paper describes the structure and morphology of the pig middle ear cavity and compares and contrasts it with that of man. The minor differences observed are of anatomical importance but do not diminish the usefulness of the pig middle ear cleft as a potential model for human middle ear disorders.