KTP laser treatment of suprastomal obstruction prior to decannulation in paediatric tracheostomy.

OBJECTIVE: Decannulation following tracheostomy in the paediatric patient is often complicated by the development of secondary suprastomal obstruction. We describe the technique of bronchoscopic KTP laser therapy in the management of such conditions, and have audited the results of this treatment with 12 children treated with this modality before attempted decannulation over the last 2 years at Great Ormond Street Hospital for Children (GOSH). METHOD: Via a retrospective record review. RESULTS: Eight (67%) were successfully decannulated, with four being unsuccessful. All children with less than 50% suprastomal obstruction were successfully decannulated following bronchoscopic KTP laser treatment. CONCLUSIONS: Bronchoscopic KTP laser therapy is a useful tool in the abolition of suprastomal obstruction prior to decannulation following paediatric tracheostomy. Children with greater than 50% obstruction are likely to require an open procedure.

Epistaxis and oral anticoagulant therapy.

Epistaxis in the anticoagulated patient poses a complicated management problem, which requires interdisciplinary collaboration. The aetiology of the majority of cases of epistaxis remains idiopathic, but an ageing population and the prevalence of ischaemic heart disease and peripheral vascular disease has meant that there are increasing numbers of patients on long term oral anticoagulant therapy. This has led to a concomitant increase in the incidence of complications experienced. We have reviewed the available relevant literature and guidelines in the current management practice in this scenario. In light of this, we propose a more standardised algorithm for the management of epistaxis in this challenging group of patients.

Current practice in pharyngeal pouch surgery in England and Wales.

A survey of the current surgical practice for patients with a pharyngeal pouch was conducted among general surgeons, otolaryngologists and cardiothoracic surgeons in England and Wales. Our results show that while pouch excision remains the most common method used, endoscopic stapling diverticulotomy is rapidly being adopted. The reasons why this recently introduced technique is likely to become the definitive treatment of pharyngeal pouch are discussed.

Long-term results of laser-assisted uvulopalatoplasty for snoring.

We present the ongoing results of the series of 53 consecutive patients who underwent laser-assisted uvulopalatoplasty (LAUP) for snoring at the Kent and Canterbury Hospital. Twenty-nine patients (55 per cent) were completely satisfied with their surgery 18 to 24 months following LAUP when previously questioned via telephone questionnaire. We have followed up the 29 patients with a previously successful result at between 70 and 79 months following surgery. They underwent an average of 1.6 procedures. Twelve patients (22 per cent) continue to be completely satisfied at this late stage, and a further 12 (22 per cent) have some ongoing improvement in their snoring. Only three patients have indicated that a previously successful result has failed since the previous survey. The failure rate of LAUP in the treatment of snoring is seen predominantly in the first two years following surgery, but some long-term subjective recurrence of snoring does occur.

A technique to control persistent haemorrhage following curettage adenoidectomy.

We describe a modification of an instrument readily available on a standard basic ENT instrument set that can be utilized for the cessation of troublesome haemorrhage following curettage adenoidectomy.

Combined approach intranasal endoscopic and external Lothrop procedure in chronic frontal sinus disease.

The endoscopic approach to the fronto-ethmoidal recess (FER) in the treatment of chronic frontal sinus disease is now widely accepted. The Lothrop procedure was first described in 1914, but was largely replaced with more invasive open frontal sinus procedures until the advent of the rigid Hopkins' rod, since when it has enjoyed renewed popularity. We describe a modification of this technique which allows both transnasal endoscopic and external direct visualization of the FER and frontal sinus and a direct approach to the anterior buttress (or "nasofrontal beak") which allows its quick and simple removal.

The Canterbury technique for canalplasty via an endaural approach in the surgical management of chronic refractory otitis externa.

We describe an endaural technique for soft tissue and bony meatoplasty and canalplasty in the surgical management of chronic otitis externa unresponsive to medical treatment and out-patient microsuction. Following analysis of the surgical outcome via a retrospective review of patient records, we would recommend this surgical treatment in this patient group.

Neonatal stridor in association with herpes simplex infection of the larynx.

Herpes simplex virus (HSV) infection in the neonatal period may be confined to the eyes, skin and upper aerodigestive tract or may be widely disseminated to other organs, with particular recognition of involvement of the central nervous system (CNS) causing herpes encephalitis (Whitley et al., 1980a, b; Andersen, 1987). Primary laryngeal HSV infection is extremely uncommon. We present a case of acute neonatal stridor secondary to such localized disease and discuss its management.

Bulbar presentations of myasthenia gravis in the elderly patient.

We report on three cases of patients whose primary symptoms of myasthenia gravis were related to the upper aerodigestive tract. Symptoms had been present unrecognized in all patients for up to three years, and one patient subsequently developed a myasthenic crisis. We highlight the clinical features of myasthenia gravis to allow its prompt recognition in patients presenting to the ENT surgeon or physician.

Endoscopic ligation or diathermy of the sphenopalatine artery in persistent epistaxis.

Conventional methods of arterial ligation in persistent epistaxis often involve significant surgical morbidity, as well as failure due to arterial anastomosis. We have performed endoscopic intranasal end ligation or diathermy of 11 sphenopalatine arteries in 10 patients with no complications and with no further episodes of epistaxis, with an average follow-up period of nine months.

Computer imaging and patient satisfaction in rhinoplasty surgery.

The measurement and achievement of improved patient benefit following a particular medical or surgical intervention has become an increasingly relevant part of the provision of effective healthcare. We have retrospectively analysed patient satisfaction in 56 patients following rhinoplasty via the Glasgow Benefit Inventory (GBI), 25 of whom underwent pre-operative computer imaging planning. We have also audited patient reaction to this technique via a concurrent questionnaire in those subjects who underwent imaging, and correlated this with overall patient outcome. Patient satisfaction with cosmetic rhinoplasty following computer imaging was significantly improved compared to those patients who did not receive imaging.

Malakoplakia of the oropharynx.

We present a case of malakoplakia presenting as a lesion in the oropharynx of an elderly smoker. In this case a clinical diagnosis of carcinoma of the pharynx was made, biopsy revealed the nature of the lesion and management was radically altered.

Nasal septal cyst: a rare phenomenon.

INTRODUCTION: Well-recognized complications of nasal septal surgery i.e. septoplasty or submucous resection (SMR), include septal haematoma, infection, septal perforation and external nasal deformity. Nasal septal cysts are extremely rare in rhinology. OBJECTIVES: To discuss the underlying aetiological theories, management and strategies for prevention of this very rare complication of a commonly performed rhinological procedure such as SMR. CASE REPORT: We describe a case of a nasal septal cyst several years after an SMR had been performed, which was excised using an open rhinoplasty approach that has not previously been described for this purpose. CONCLUSION: Entrapment of free nasal mucosal remnants or inward folding of incised septal mucosa in the submucosal space is postulated as the cause of this phenomenon, leading to the development of this type of "inclusion" cyst. Postoperative nasal packing, especially if traumatic, may exacerbate this. We recommend that anterior nasal packing should be used only if necessary, and packs inserted with care, possibly under endoscopic guidance.

A review of sinonasal outcome scoring systems - which is best?

* In patients undergoing endoscopic sinus surgery for chronic rhinosinusitis, there is a lack of a universally accepted system for the evaluation of outcome. * This makes critical comparison between results less meaningful. * To determine the most suitable sinonasal outcome scoring system for use in our own practice, we reviewed the available literature and known systems in existence. * We analysed 15 known disease-specific sinonasal outcome indices with emphasis on reliability, validity and responsiveness. * We concluded by choosing one quality of life outcome tool for our departmental use, the Sinonasal Outcome Test-22, due to its reliability, validity, responsiveness and ease of use. * It has been validated to distinguish between disease-affected patient groups and those without rhinosinusitis, demonstrate a worse score if the condition gets worse and show an appropriateness of items and scales in the questionnaire. This has been demonstrated in 3128 British patients.

Major complications and consent prior to endoscopic sinus surgery.

The endonasal endoscopic approach to the paranasal sinuses is no longer exclusively practised by a small number of dedicated super-specialists and has gained widespread acceptance in the UK. We have audited the practice of the Consultant members of the BAO-HNS via a confidential postal questionnaire with regards to the consent of their patients prior to surgery, and to the complications they have experienced. The overall rate of complications following endoscopic sinus surgery (ESS) was 0.69%, with the incidence of major complications 0.25% and of minor complications 0.44%. Wide variations in the practice of informed consent were found to exist, and this is discussed with reference to a suggested template for preoperative discussion with the patient.

The outcome of endoscopic sinus surgery: correlation with computerized tomography score and systemic disease.

We have prospectively analysed the outcome of patients undergoing endoscopic sinus surgery for chronic rhinosinusitis in relation to the Lund and Mackay system of scoring the preoperative computerized tomography scan for extent of disease, and also investigated the possible links of outcome to the presence or absence of systemic respiratory tract conditions which may relate to the pathogenesis of chronic rhinosinusitis. Statistical analysis of the data by chi 2 test, unpaired t-test and logistic regression analysis has shown significant correlation between outcome at 2 years and preoperative computerized tomography scan score, but that the most statistically significant factor determining the success or failure of surgery is the presence of a systemic disease known to predispose to chronic rhinosinusitis.