Practical use of povidone-iodine antiseptic in the maintenance of oral health and in the prevention and treatment of common oropharyngeal infections.

AIMS: To better inform medical practitioners on the role of antiseptics in oropharyngeal health and disease, this article focuses on povidone-iodine (PVP-I), an established and widely-available antiseptic agent. METHODOLOGY: Review of the anti-infective profile, efficacy and safety of PVP-I in managing common upper respiratory tract infections such as the common cold, influenza and tonsillo-pharyngitis, as well as oral complications resulting from cancer treatment (oral mucositis), and dental conditions (periodontitis, caries). RESULTS: Antiseptics with broad-spectrum anti-infective activity and low resistance potential offer an attractive option in both infection control and prevention. While there is some evidence of benefit of antiseptics in a variety of clinical settings that include dental and oral hygiene, dermatology, oncology, and pulmonology, there appears to be discordance between the evidence-base and practice. This is especially apparent in the management and prevention of oropharyngeal infections, for which the use of antiseptics varies considerably between clinical practices, and is in marked contrast to their dermal application, where they are extensively used as both a prophylaxis and a treatment of skin and wound infections, thus minimising the use of antibiotics. CONCLUSION: The link between oral and oropharyngeal health status and susceptibility to infection has long been recognised. The high rates of antibiotic misuse and subsequent development of bacterial resistance (e.g. increasing vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA)) in large parts of the world, especially across Asia Pacific, highlight the need for identifying alternative antimicrobials that would minimise the use of these medications. This, together with recent large-scale outbreaks of, for example, avian and swine influenza virus, further underline the importance of an increasing armamentarium for infection prevention and control.

Bacteriology of deep neck abscesses: a retrospective review of 96 consecutive cases.

INTRODUCTION: This study aimed to review the microbiology of deep neck abscesses and identify the factors that influence their occurrence. METHODS: A retrospective chart review was done of patients diagnosed with deep neck abscesses at the Department of Otorhinolaryngology, Tan Tock Seng Hospital, Singapore between 2004 and 2009. The data of 131 deep neck abscess patients were reviewed, and those with positive pus culture were included in the study. Logistic regression was applied to analyse and compare the incidence of common organisms in various conditions (age, gender, aetiology and effects of diabetes mellitus). RESULTS: Of the 96 patients recruited, 18 had polymicrobial cultures. The leading pathogens cultured were Klebsiella (K.) pneumoniae (27.1 percent), Streptococcus milleri group (SMG) bacteria (21.9 percent) and anaerobic bacteria-not otherwise specified (NOS) (20.8 percent). K. pneumoniae (50.0 percent) was over-represented in the diabetic group. SMG bacteria (68.8 percent) and anaerobic bacteria-NOS (43.8 percent) were most commonly isolated in patients with odontogenic infections. K. pneumoniae was found more commonly among female patients (39.3 percent). The distribution of the three leading pathogens between patients aged below 50 years and those 50 years and above was comparable. K. pneumoniae was the commonest organism cultured in parapharyngeal space abscesses, while the submandibular space and parotid space most commonly isolated SMG bacteria and Staphylococcus aureus, respectively. CONCLUSION: Broad-spectrum antibiotics are recommended for treating deep neck abscesses. Empirical antibiotic coverage against K. pneumoniae infection in diabetic patients, and SMG and anaerobic bacteria in patients with an odontogenic infection, is advocated. Routine antibiotic coverage against Gram-negative bacteria is not paramount.

Vertebral artery dissection after direct laryngoscopy: case report and literature review.

OBJECTIVE: We report a case of vertebral artery dissection following direct laryngoscopy, and we provide an update on current knowledge regarding this condition and its relationship to movements of the neck. METHOD: A case report and review of the world literature are presented. RESULTS: Vertebral artery dissection is an uncommon event leading to stroke. It has been associated with many risk factors, particularly extreme movement of the cervical spine. The pathogenesis of the condition and the true aetiological significance of neck movement are not known. CONCLUSION: To our knowledge, we present the first case of vertebral artery dissection following direct laryngoscopy. We highlight the need for caution when considering neck pain in patients after direct laryngoscopy.

Quality of life following total laryngectomy: assessment using the UW-QOL scale.

OBJECTIVES: To determine the quality of life (QOL) in patients using valved speech following total laryngectomy with a validated patient self-report scale. STUDY DESIGN: Cross-sectional cohort study. PATIENTS: 63 patients following total laryngectomy using valved speech. INTERVENTION: University of Washington Quality of Life (UW-QOL) questionnaire. MAIN OUTCOME MEASURES: Patient perception of the QOL over the last 7 days following total laryngectomy in response to specific questions and correlated with sociodemographic and treatment factors. RESULTS: Responses were received from 44 males and 11 females (response rate: 87.3%) with a median age of 66 years (range: 40-84). The mean (SD) composite score of the QOL in our series of patients with total laryngectomy was 81.3 (10.9). As regards the overall QOL, 80% of our patients cited it as very good (45.5%) to good (34.5%). Patients identified speech, appearance, and activity as the most important issues following total laryngectomy. Only age and pharyngo-oesophageal segment closure were significant predictors of QOL scores (Student t test, p < 0.05) and not other demographic and treatment variables. CONCLUSIONS: The composite score and overall QOL were high in our series of total laryngectomy patients and this possibly reflects adequate multidisciplinary management. We strongly urge the use of prospective longitudinal studies that will adequately identify any QOL changes over time. Although the UW-QOL questionnaire is a simple and brief scale, it has limitations that can curtail its effective use in laryngectomy patients and we advise supplementing it with the use of domain-specific questionnaires.

Long-term outcomes of laser-assisted uvulopalatoplasty in 168 patients with snoring.

Laser-assisted uvulopalatoplasty (LAUP) is an established treatment for snoring. Our institution has been using a modification of the Kamami technique since 1995. Between January 1995 and December 2001, 469 patients underwent LAUP for snoring. A telephone survey of these patients and their partners was conducted retrospectively. One hundred and sixty-eight patients and their partners were interviewed and the findings analysed.Of the 168 patients, 122 had LAUP alone, 42 had LAUP and tonsillectomy and four had LAUP and septoplasty. The median follow-up time was 59 months (range 19 to 98 months).Seventy-four per cent reported improvement at six weeks, 69 per cent reported improvement at nine months and 55 per cent reported improvement at the time of interview. To assess the degree of improvement, patients and their partners were asked to grade any improvement in percentage terms. The mean subjective improvement scores were 57 per cent at six weeks (95 per cent confidence interval (CI) 50-64 per cent), 45 per cent at nine months (95 per cent CI 38-59 per cent) and 30 per cent at the time of interview (95 per cent CI 23-35 per cent). Patients who reported weight gain since surgery did not have a poorer outcome than those who reported no weight change or weight loss. Neither did weight loss predict a better outcome. The procedure was generally well tolerated, with only 30 patients (18 per cent) reporting complications (mainly minor). The benefits of LAUP wane with time and the results are best in the first 12 months following surgery. Our study suggests that 55 per cent of patients selected after sleep studies and sleep nasendoscopy will enjoy long-term benefit.

A randomized trial of Rapid Rhino Riemann and Telfa nasal packs following endoscopic sinus surgery.

OBJECTIVES: To compare Telfa with the Rapid Rhino Riemann nasal pack for use following endoscopic sinus surgery. DESIGN: Prospective, randomized, double-blind, paired trial. SETTING: Tertiary otolaryngology hospital. PARTICIPANTS: Forty-five adult patients undergoing bilateral endoscopic sinus surgery for either chronic rhinosinusitis or nasal polyps. MAIN OUTCOME MEASURES: A visual analogue scale was used to assess discomfort caused by the presence of the packs in the nose and by their removal. The amount of bleeding was noted with the packs in place and following their removal. Crusting and adhesions were assessed 2 and 6 weeks following surgery. RESULTS: Both packs performed well giving good haemostasis and causing little bleeding on removal. Both packs caused only mild discomfort while in the nose. On the visual analogue scale of 0-10 cm the mean visual analogue score for Rapid Rhino Riemann pack was 1.7 and for Telfa 2.0 (P = 0.371). The Rapid Rhino Riemann pack caused significantly less pain on removal compared with the Telfa pack with a mean visual analogue score of 2.0 in comparison with 3.7 for Telfa (P = 0.001). There were less adhesions with the Rapid Rhino Riemann than Telfa pack but this was not statistically significant (P = 0.102). CONCLUSIONS: Both Telfa and Rapid Rhino Riemann packs can be recommended as packs that control postoperative haemorrhage, do not cause bleeding on removal and cause little discomfort while in the nose. The Rapid Rhino Riemann pack has the advantage of causing significantly less pain on removal.

Upper neck spinal accessory nerve identification during neck dissection.

Iatrogenic injury to the spinal accessory nerve (SAN) during neck dissection may result in significant and avoidable morbidity in the form of 'shoulder syndrome'. The authors describe a simple method, based on the anatomy of the sternocleidomastoid muscle (SCM), which allows consistent and rapid identification of the SAN in the upper neck during dissection, thereby facilitating its preservation.

New world mucosal and cutaneous leishmaniasis: an emerging health problem among British travellers.

BACKGROUND: Mucosal leishmaniasis (ML) is an important complication of new world cutaneous leishmaniasis (CL) caused by species of the Leishmania Viannia subgenus. Previous reports of ML among travellers to Latin America are few. AIMS: To determine the annual number of cases of CL due to L. Viannia species diagnosed at this institution and to correlate this with changing patterns of travel. Secondly, to document the clinical presentation, diagnosis, treatment and outcome of ML at this institution. DESIGN: Retrospective observational study. METHODS: Data were collected from a clinical database, laboratory records, patient case notes and an international passenger survey. RESULTS: Between 1995 and 2003, the annual number of cases of CL (total 79) steadily increased from 4 per year to 18 per year; the estimated number of travellers from the UK to Latin America increased 3.5-fold. Six cases of ML were diagnosed among British travellers in 1995 (1), 1997 (1) and 2002 (4). These infections were acquired in Bolivia (3), Colombia (2) and Belize (1). Nasopharyngeal symptoms developed 0-15 months after returning to the UK. Four patients had concurrent CL at diagnosis. Diagnosis of ML was delayed up to 6 months from the onset of symptoms. Mucosal biopsies from all 6 patients were PCR-positive for L. (Viannia) DNA; microscopy and culture were less sensitive. ML relapsed in one patient following treatment. DISCUSSION: Increasing travel to Latin America from the UK was associated with an increasing number of diagnoses of L. Viannia CL. ML is likely to emerge as a more frequently imported infection among such travellers. Familiarity with these diseases is important for prompt diagnosis and optimal management.

A new technique for the management of inaccessible anterior glottic lesions.

We describe a new technique for removing anterior vocal fold lesions, which cannot be visualized with conventional suspension laryngoscopy. These situations are rare and the only alternative surgeons have had previously is an open laryngeal procedure. The technique we describe involves the use of a laryngeal mask airway (LMA), a flexible bronchoscope with biopsy channel, a 400 microm laser fibre and KTP/532 nm laser. This method was used to treat two patients in whom conventional suspension laryngoscopy had previously been attempted and abandoned.

The disinfection of flexible fibre-optic nasendoscopes out-of-hours: confidential telephone survey of ENT units in England.

We present the results of a confidential telephone survey of ENT units in England on the disinfection of flexible fibre-optic nasendoscopes out-of-hours. The on-call residents of 124 units were contacted and questioned. In 35.1 per cent of units surveyed, the on-call resident was primarily responsible for cleaning the scopes after use. Only 46 per cent of these junior doctors had access to a chemical sterilant to allow for high-level disinfection of these scopes. Provision for disinfection of scopes was poorer in teaching hospitals and in units that served inner city populations. Only 12.1 per cent of Senior House Officers (SHOs) received any training in disinfection techniques and only 25.5 per cent of units kept a register of patients nasendoscoped out-of-hours for purposes of contact tracing.

Swimmer's view: a diagnostic adjunct for oesophageal foreign bodies.

We describe the use of a common radiographic view of the lower cervical skeleton, 'Swimmer's View', to aid the diagnosis of foreign bodies in the upper oesophagus, which may be obscured by the clavicles. We further recommend this view when there is uncertainty over the nature of an impacted food bolus in this location, and luminal air is the only visible sign on a plain soft-tissue cervical radiograph.

Rhabdomyosarcoma of the adult nasopharynx.

Rhabdomyosarcoma of the adult head and neck is rare, particularly beyond 40 years of age. In this region, the nasopharynx is an unusual site. Most nasopharyngeal rhabdomyosarcomas are of an alveolar variety. We report a case of embryonal or spindle cell rhabdomyosarcoma in the nasopharynx of a 47-year-old man. The histology of this tumour revealed clear cells that have not been described in embryonal rhabdomyosarcomas occurring in the head and neck. The pathology is discussed and current literature reviewed.