Learning curve of medialization thyroplasty using a Montgomery™ implant.

UNLABELLED: Type I thyroplasty--also called medialization thyroplasty (MT)--is considered as an effective treatment for glottic incompetence in general and for abductor vocal fold palsy in particular. In the past there have been some concerns about the experience a laryngeal framework surgeon should have in order achieve an acceptable voice outcome. To assess the learning curve of MT performed using the Montgomery(®) hard silicone implant. A retrospective study involving 36 patients divided into three consecutive groups (1, 2, 3) of 12 MT patients or six consecutive groups (1a, 1b, 2a, 2b, 3a, 3b) of six MT patients. OUTCOME MEASURES: acoustic and aerodynamic outcome improvements (δ) compared to the duration of intervention [operative times (OT)]. Data were analysed by Anova, Kuskal Wallis and χ (2) statistical tests, according to data distributions. OT decreased significantly between groups 1, 2 and 3 with a mean OT of 90.5', 71.5' and 56' (p < 0.001), respectively. Objective δ such as maximum phonation time (MPT) (p 0.376), Estimated Sub-Glottic Pressure (ESPG) (p: 0.675) Shimmer (p: 0.543) and Jitter (p: 0.709) did not show significant improvement. Only the voice handicap index (VHI) δ of group 2 showed significant improvement (p 0.005) compared with the two other groups 1 and 3. Surgeon experience decreases the OT significantly. On the other hand, our study did not show a correlation between surgeon experience and voice outcome measures improvemnts (MPT, ESGP, Shimmer, Jitter).

Megaesophagus associated with Myasthenia Gravis: a rare condition in humans.

We present the case of a 79 year-old patient with megaesophagus and aphagia, who required percutaneous endoscopic gastrostomy (PEG) feeding. Megaesophagus was considered the sole cause of aphagia by the referring secondary hospital. Solid state sensor videofluoromanometry (VFM) showed a substantial decrease in manometric values within the hypopharynx along with good relaxation of the upper-esophageal sphincter (UES). This led to electromyography (EMG), which showed features compatible with the diagnosis of Myasthenia Gravis (MG). The diagnosis of MG was confirmed by an intravenous injection of edrophonium chloride, performed under VFM monitoring. The co-existence of MG and megaesophagus rarely occurs in humans; although, most small animals, such as dogs, cats, and rodents, present with megaesophagus as an initial symptom of MG.

Magnetic resonance imaging findings in patients with idiopathic olfactory dysfunction and normal findings on nasoendoscopy.

OBJECTIVE: In presentations of anosmia or dysosmia, magnetic resonance imaging may be required to screen for intracranial pathology such as olfactory neuroblastomas and other intracranial masses impacting on the olfactory pathway. This study aimed to establish positive magnetic resonance imaging findings of anosmia or dysosmia for scans performed before the coronavirus disease 2019 pandemic. METHODS: The study examined the outcome of patients who presented with isolated olfactory dysfunction and who underwent magnetic resonance imaging between 2015 and 2019. RESULTS: Of the 131 patients, 41 (31.3 per cent) had normal scan findings, 50 (38.2 per cent) had insignificant paranasal mucosal disease and 6 (4.6 per cent) had mucosal thickening significant enough to require additional intervention. These interventions included repeat nasoendoscopy or commencement of intranasal or oral steroids. No patients had olfactory neuroblastoma. CONCLUSION: Only 4.6 per cent of the magnetic resonance imaging scans revealed abnormal findings related to anosmia or dysosmia, and none required ENT surgical intervention. None of the magnetic resonance imaging scans identified an olfactory neuroblastoma or intracranial masses impacting on the olfactory pathway.

A case series and literature review on patients with rhinological complications secondary to the use of cocaine and levamisole.

BACKGROUND: Levamisole is an increasingly common cutting agent used with cocaine. Both cocaine and levamisole can have local and systemic effects on patients. METHODS: A retrospective case series was conducted of patients with a cocaine-induced midline destructive lesion or levamisole-induced vasculitis, who presented to a Dundee hospital or the practice of a single surgeon in Paisley, from April 2016 to April 2019. A literature review on the topic was also carried out. RESULTS: Nine patients from the two centres were identified. One patient appeared to have levamisole-induced vasculitis, with raised proteinase 3, perinuclear antineutrophil cytoplasmic antibodies positivity and arthralgia which improved on systemic steroids. The other eight patients had features of a cocaine-induced midline destructive lesion. CONCLUSION: As the use of cocaine increases, ENT surgeons will see more of the complications associated with it. This paper highlights some of the diagnostic issues and proposes a management strategy as a guide to this complex patient group. Often, multidisciplinary management is needed.

Large retropharyngeal abscess: a case of mistaken identity.

We report an unusual case of nasopharyngeal carcinoma (NPC), presenting initially as a retropharyngeal collection. We discuss the investigation, diagnosis and management of NPC and furthermore review the literature of NPC, emphasising the varied presentation. A 44-year-old Caucasian male ex-smoker presented with a 10-day history of a painless left-sided neck lump; progressive dysphagia and unintentional weight loss. Examination demonstrated a large left posterior pharyngeal swelling with soft palatal effacement, confirmed on nasoendoscopy. A CT scan revealed a fluid collection in the retropharyngeal space, which partially occluded the nasopharynx, and numerous satellite lesions were identified along with cervical lymphadenopathy. The suspected abscess was drained in theatre and nasopharyngeal biopsies were taken. These revealed Epstein-Barr virus-positive NPC. Staging investigations revealed a T4N2M0l carcinoma. Treatment consisted of radical chemoradiation therapy with curative intent. NPC is known for its varied and late presentation, and is an important condition to be aware of when considering a differential diagnosis of pharyngeal masses.

Potential airway compromise secondary to impacted Wharton's duct calculus: a noteworthy phenomenon.

OBJECTIVES: This case report describes a patient who suffered an acute, severe complication of unilateral submandibular sialolithiasis, the disease process and management of these patients. CASE REPORT: A 70-year-old woman was under investigation for a recurrent, painful right submandibular swelling and subsequently presented with an acute exacerbation. She exhibited symptoms of acute submandibular sialadenitis, and also reported breathing difficulty and a change in voice quality. Computed tomography imaging showed that this was caused by a submandibular gland duct sialolith, with inflammation extending to the ipsilateral supraglottis. She was treated medically and the stone was removed when the inflammation had stabilised. CONCLUSION: This case highlights the need to thoroughly assess patients with neck swellings, especially when symptoms are atypical, to avoid life-threatening complications.

Adenovirus-mediated in vivo gene transfer in guinea pig middle ear mucosa.

This article describes a study designed to assess the feasibility of using recombinant adenovirus for delivering therapeutic peptides in vivo in the guinea pig middle ear cleft. A recombinant adenoviral vector AdCMVsp1 LacZ containing the Escherichia coli beta-galactosidase was injected into the middle ear space. Qualitative assessment of cell middle ear transfection was performed on day 2 by light microscopy study, after injecting a multiplicity of infection (MOI) ranging from 0 to 1000. At an MOI of 30, 30% of the promontory area epithelial cells were stained. An MOI of 50 stained 60% of the cells and an MOI of 100 or more stained more than 90% of the cells. The duration of cell transfection was studied after injecting an MOI of 50. The percentage of stained cells was 60% on day 2, 10% on day 7, and 0% on day 14. Middle ear mucosal inflammation, consisting of a granulocytic infiltrate, was observed when an MOI above 50 was used. Even at a high MOI (500), no staining could be found in the cochlea, in the facial nerve, in the brain, or in visceral organs. These data suggest that recombinant adenovirus vectors can be used to transfer genes in the middle ear. This method appears to be safe, and may be envisaged as a short-duration treatment to transfer genes in vivo in the treatment of middle ear diseases.

Malignant B cell non-Hodgkin's lymphoma of the larynx in children with Wiskott Aldrich syndrome.

A 15 years old male with a primary diagnosis of Wiskott Aldrich syndrome presented a laryngeal B cell lymphoma associated with Epstein-Barr virus. A chemotherapy and a radiotherapy were started in association with an endoscopic debulking of the tumor. The child died of respiratory failure secondary to a lung infection. The incidence of NHL (non-Hodgkin's lymphoma) of laryngeal origin in infants is extremely low and to our knowledge it has never been found in Wiskott Aldrich syndrome.

Maxillary sinus mucocoeles--10 cases--8 treated endoscopically.

Maxillary sinus mucocoeles are rare, but may cause significant problems outside the sinus including diplopia and cheek swelling. We present 9 patients suffering from maxillary sinus mucocoele, including one patient with bilateral involvement, representing 10 involved sinuses. Eight sinuses were treated endoscopically and followed-up for 3 to more than 6 years; one of these developed a recurrence. Two sinuses were treated using a classical external approach (Caldwell-Luc), one at the beginning of our series, and one as the endoscopic technique was difficult to perform due to loss of anatomical landmarks. One of these two sinuses developed a recurrence and was then successfully treated endoscopically. We discuss the aetiology, pathogenesis and appropriate treatment of this unusual condition. Endoscopic treatment appears to be effective and leads to minimal recurrence. The aim is to perform a wide removal of the medial wall of the maxillary sinus including most of the inferior turbinate, immediately posterior to the lachrymal duct leaving intact the sinus mucosa. In some cases, however, the endoscopic technique can be difficult to perform due to loss of essential anatomical landmarks and in these cases recourse to an external approach may be necessary.

Endoscopic surgical treatment of sinonasal polyposis-medium term outcomes (mean follow-up of 5 years).

BACKGROUND: Between 30 and 50% of patients with sinonasal polyposis (SNP) will require surgical treatment. OBJECTIVE: To determine the medium term risks and benefits of endonasal ethmoidectomy in SNP. METHOD: 132 cases of SNP have been retrospectively studied before and after endoscopic nasal surgery with a mean follow-up of 5 years. Functional symptoms and appearances on endoscopic examination were recorded on graded scales. Non-parametric statistical analyses for matched series were used in the assessment of data. RESULTS: Post-operative normalisation of nasal function was obtained in 62% of cases. Each of the four main nasal symptoms (nasal obstruction, rhinorrhoea, facial pain and anosmia) was improved (p = 0.001). Patients with associated asthma or ASA triad had higher scores for nasal obstruction and rhinorrhoea (Fisher's exact test; p < 0.02). The pre-operative clinical stage of SNP correlated neither with recurrence nor with functional outcomes (Fisher's exact test; p > 0.05). The requirement for steroid treatment of concurrent asthma was also reduced post-operatively (p = 0.001). The association with asthma and its level of treatment was not related to the frequency of recurrence of SNP (Chi2; p > 0.6). CONCLUSIONS: Functional outcomes for patients with SNP and asthma were significantly improved by endoscopic surgical treatment, even if the appearance of the nasal mucosa did not always return to normal.

Effects of leukotriene receptor antagonist therapy in patients with chronic rhinosinusitis in a real life rhinology clinic setting.

Although there is evidence from randomised controlled trials that leukotriene receptor antagonists are efficacious in chronic rhinosinusitis there are still little data on their use in everyday real life clinical practice. We report on a pragmatic case series of 32 patients referred from primary care with uncontrolled chronic rhinosinusitis (allergic or non-allergic) who have been treated with montelukast in our joint medical/surgical rhinology clinic. Patients' symptoms were scored according to "facial pain", "headache", "nasal blockage", "nasal discharge", "sense of smell" and "daily activity", and measurements of peak inspiratory nasal flow were made, before and after the introduction of montelukast 10 mg/day. There were significant (p < 0.05) improvements in subjective scoring for headache, nasal discharge & blockage, sense of smell and daily activity but not for facial pain, when montelukast was added along with other alterations in chronic rhinosinusitis medication (all receiving intra-nasal corticosteroids). Subgroup analysis of 10 patients, were the addition of montelukast was the only change to medical therapy, showed significant (p < 0.05) improvements in headache, nasal discharge and blockage and their daily activity. There was no significant improvements in nasal peak inspiratory flow or spirometry. In conclusion, montelukast may be a useful therapeutic option in addition to standard therapy (i.e. intra-nasal corticosteroids or anti-histamines) when treating patients with chronic rhinosinusitis in a real life clinical setting.

Evaluation of the importance of head and probe stabilisation in acoustic rhinometry.

As yet there is no established procedure to ensure the repeatability of acoustic rhinometry measurements although anecdotal evidence suggests that instrument fixation improves repeatability. The aim of this study is to validate the methodology of acoustic rhinometry and determine whether instrument fixation and head stabilisation is necessary. Four methods were compared in fifteen healthy volunteers, after nasal decongestion: A) Patient holding the probe (patient-held), B) Probe fixed in a probe stand (probe-stand), C) Probe fixed in stand and head stabilised in head rest (head-rest), D) Examiner holding the probe (examiner-performed). The two minimum cross-sectional areas and volume between 0 and 5 cm were recorded. The examiner-performed and probe-stand methods were consistently less variable than the other methods. With examiner-performed method, this was significant (p < 0.05) versus head-rest and patient-held methods for both measures of minimum cross-sectional area. For nasal volume the examiner-performed method was significantly (p < 0.05) less variable than the head-rest method. In conclusion, examiner-performed acoustic rhinometry is more repeatable than combined head stabilisation and instrument fixation and therefore the use of a head-rest may be unnecessary. Instrument fixation or examiner performed test is also preferable to allowing the patient to position the probe. The repeatability of the probe-stand method was similar to the examiner-performed method.

Myxoma of the larynx: a case report and a review of the literature.

Laryngeal myxomas are rare benign mesenchymal tumours in contrast to myxomatous degeneration in laryngeal polyps which occurs frequently. A correct diagnosis of myxoma is usually not difficult to reach if the possibility of myxomatous degeneration in laryngeal polyps is excluded and strict pathological criteria are adhered to. We report a myxoma arising from the left vocal fold in a 64-year-old male who presented with a four-year history of intermittent dysphonia. Although excision was microscopically incomplete, there is no evidence of recurrence macroscopically 18 months later and the patient remains asymptomatic.

Factors that inform the career choice of medical students: implications for otolaryngology.

Knowledge of the factors that inform the career choice of medical students may help plan the workforce for medical specialties. To determine which factors inform the career choice of medical students we carried out a survey of medical students at the start of their educational block in Otolaryngology. Of 202 questionnaires handed out 169 were returned (84 per cent). Students were asked to rank factors according to their importance in their career choice. The single most important factor was career progression. Other factors include on-call commitment, teachers as role models, and the interest for a particular subject. At the present time progression from senior house officer grade to specialist registrar grade in Otolaryngology is delayed. If this issue is not addressed the influx of applicants into Otolaryngology training programmes will be reduced, limiting the pool from which candidates can be chosen for a career in Otolaryngology.

Day-stay myringoplasty.

Grafting of the tympanic membrane (myringoplasty) has traditionally been performed as an in-patient procedure in the UK. We have performed day-stay myringoplasty on 21 consecutive patients (15 adults and six children) under general anaesthesia using an underlay temporalis fascia graft. In 18 cases there was complete healing of the tympanic membrane and in three cases the patients developed perforations at four weeks. This success rate is consistent with previously reported studies. All patients were discharged on the day of admission with no major complications. We have compared the results with a group of patients having the same operation as an in-patient and have concluded that day-stay myringoplasty under general anaesthesia is as safe and effective as in-patient surgery for the majority of patients.

The 'Darling' elbow rest--an aid to a stable operating position in endoscopic sinus surgery.

The 'Darling' elbow rest provides a compact, easily manoeuvrable platform for the surgeon's elbow during endoscopic sinus surgery, stabilizing the endoscope and increasing operative safety.

An animal model for training in endoscopic nasal and sinus surgery.

An animal model has been devised to allow trainees in nasal and sinus endoscopy to develop basic instrument handling and psychomotor skills, without risk to patients. The sheep's head obtained from the abattoir was modified slightly to simulate more closely the human situation. The model permits nasendoscopy, foreign body removal, septoplasty, turbinate reduction, frontal and maxillary sinoscopy, antrostomy and an epistaxis exercise. To date the tissues have been used freshly thawed, and must be used on the day of preparation.

A randomized control trial of post-operative care following endoscopic sinus surgery: debridement versus no debridement.

Endoscopic sinus surgery (ESS) has undergone exponential growth worldwide in the last decade. It is now accepted as a safe and effective means of treating sinonasal disease. The purpose of this study was to determine whether post-operative debridement is necessary after ESS. Seventeen patients undergoing bilateral primary ESS were randomized to receive debridement of either the left or right ethmoid cavity. All patients included in the study had symmetrical disease. Saline douches and all other concomitant treatments were delivered bilaterally. Outcome measures were based on regular symptom scores and surgeons' semi-quantitative assessment of the debrided and non-debrided cavities, over a three-month period. Analysis of adhesion rates, healing and symptom scores showed no statistically significant difference between the two groups. In conclusion, this study did not demonstrate significant benefit from post-operative ESS cavity debridement, at least with regard to cavity healing. This should be considered a pilot study and therefore limited conclusions can be drawn. Further work is needed to determine the optimum post-operative care for ESS.

Treatment of head and neck cancer with photodynamic therapy: results after one year.

Photodynamic therapy (PDT) is a new and promising treatment modality for the treatment of malignant disease. This paper reports the preliminary experience of our group in the use of this therapy for the treatment of tumours arising in the head and neck. The majority of treatments in these cases have used a second generation systemic photosensitizer, meta-tetrahydroxyphenylchlorin (m-THPC). Two other cases were treated with either Photofrin 2 (a first generation systemic sensitizer) or with the topical photosensitizer, delta-aminolaevulinic acid (delta-ALA). The initial results have been encouraging with good clinical responses evident in patients presenting with a variety of differing tumour types. We feel there is now sufficient evident of the efficacy of this treatment to warrant a multicentre prospective study into the treatment of early head and neck cancer with PDT.