Use of bilateral suture lateralisation technique in severe paradoxical vocal fold movement, allowing removal of long-term tracheostomy: case report.

OBJECTIVE: We report a novel bilateral suture lateralisation technique that allowed permanent tracheostomy decannulation in a patient with severe paradoxical vocal fold movement. CASE REPORT: A 45-year-old woman presented to the accident and emergency department with worsening shortness of breath. Flexible nasoendoscopy revealed limited vocal fold abduction and an emergency tracheostomy was sited; this was subsequently changed to a long-term Silver Negus tube. Her tracheostomy care was complicated by discomfort and dislodgement. The diagnosis of paradoxical vocal fold movement was only made when the patient presented to our department. Cognitive behaviour therapy and botulinum toxin injection were tried without success. A right vocal fold lateralisation procedure was performed, which enabled temporary tracheostomy decannulation. A left vocal fold lateralisation procedure was subsequently performed and the patient was successfully decannulated, with significant improvement in quality of life. CONCLUSION: Paradoxical vocal fold movement is a rare condition that is most commonly managed by biofeedback sessions, relaxation manoeuvres or botulinum toxin injection. However, in cases similar to ours in which these treatments are unsuccessful, we suggest a 'last resort' technique to manage this rare condition.

Out-patient management of patients with a peritonsillar abscess.

In the United Kingdom, patients with a peritonsillar abscess are usually managed as inpatients. However, studies in other countries have shown successful management of these patients as outpatients. We designed an evidence based protocol for the management of patients with a peritonsillar abscess. Diagnosis was by aspiration of pus. Initial treatment was with analgesia, 1.2 g co-amoxiclav and 4 mg dexamethasone intravenously. Data were collected prospectively over 11 months on the management of all patients who had been confirmed by aspiration of pus to have a peritonsillar abscess. Four of the 46 patients (9%) treated as per the protocol required admission, two immediately and two later on. Of the 44 patients initially treated as outpatients, 41 said they were happy to have been treated as outpatients and not admitted to hospital (93%). Patients with a peritonsillar abscess can be managed successfully as outpatients with a high degree of patient satisfaction.

An anatomical comparison of Blair and facelift incisions for parotid surgery.

BACKGROUND: The rhytidectomy approach for parotidectomy allows the incision to be hidden, and post-operative scarring minimised. Furthermore, separate elevation of the Superficial Musculo-Aponeurotic System (SMAS) reduces the incidence of Frey's syndrome, and provides vascularized soft tissue for contour reconstruction. The technique has gained popularity particularly with plastic surgeons, but concerns persist that with this approach, particularly with lesions located anteriorly, access to the gland may be inadequate, and facial nerve identification may be compromised. MATERIALS AND METHODS: We undertook an anatomical study to quantitatively compare the surgical access achieved using the facelift approach with the conventional Blair incision, by comparing the distances between the parotid edge and the retracted flaps. RESULTS: Despite reduced tissue elasticity due to formaldehyde fixation, it proved possible to demonstrate all regions of the parotid gland to the operating surgeon with either approach. There were no significant differences in the distance between the parotid edge and the retracted skin flaps (P > 0.1; paired t-test). CONCLUSIONS: The facelift approach provides at least equal access to all regions of the parotid gland when compared to a Blair's incision. It is a superior approach aesthetically and its more widespread use in parotid surgery is advocated.