Lessons learnt from an audit of 95 cases of major nasal reconstruction.

BACKGROUND: Several texts detail the possible complications of nasal reconstruction but few critically describe a series. We present an audit of the complications of 95 major nasal reconstructions. METHODS: This is a retrospective analysis of 95 consecutive major nasal reconstructions (49 male, 46 female, aged between 4 and 92 years) over a 16-year period treated in a tertiary refer-ral centre. RESULTS: Fifty-eight patients in our series required nasal reconstruction after Moh's Micrographic surgery for a morpheiform basal cell or a squamous cell carcinoma. Eight patients had further removal using frozen section to determine the margins, as the disease was very extensive. Minor procedures with local random flaps or full thickness skin grafts were excluded. Ninety-five patients underwent major reconstructive procedures and had an average of 2.8 operations. SUMMARY: The main problem was the suboptimal contouring of the alar margin in 6 of 54 patients who had a full thickness defect repaired. Other complications included telangectasia or hair growth requiring laser ablation (13), stenosis of the nasal valve area (2), ectropion after a cheek advancement flap, donor site haematoma of the pinna, and neuropathic pain.

The presence of ovarian hormone receptors in the nasal mucosa and their relationship to nasal symptoms.

BACKGROUND: There is evidence in the literature showing a link between ovarian hormones and changes to nasal physiology. OBJECTIVES: The aim of this pilot study was to identify and quantify female hormone receptor positive cells in the nasal mucosa and to establish if there is a correlation with rhinitic symptoms. METHODS: Twenty-five adult patients attending a university hospital for routine, elective nonrhinological ENT procedures under general anaesthetic (mainly tonsillectomy) were recruited pre-operatively. Background information about each participant was recorded. Biopsies were taken from the inferior turbinates. These were analysed using immunohistochemistry techniques to assess for the presence of Progesterone, Oestrogen-alpha (ERalpha) and Oestrogen-beta (ERbeta) receptors. The mean number of cells positive for the receptors in each biopsy was deduced using a stratified random sampling technique. RESULTS: All nasal biopsies were negative for progesterone and ERalpha receptors. ERbeta receptors were present in the mucosal glands in 24 out of the 25 biopsies. Using unpaired t-tests to compare the sexes, smoking status and atopic history no statistical difference was shown between any of these groups (p > 0.05). However, the rhinitis quality of life questionnaire score and the mean number of ERbeta receptor positive cells per biopsy showed a positive correlation (Pearson correlation of 0.4, p < 0.05). CONCLUSIONS: The number of oestrogen receptor positive cells appears unaffected by sex, smoking history, hormone status, age or atopy. However, there is a significant positive relationship between the mean number of ERbeta positive cells and nasal symptoms. Pharmacological downregulation of ERbeta positive cells may reduce rhinitic symptoms and is the subject of further research.

Reduction of nasal fractures under local anaesthesia: an acceptable practice?

Nasal fractures are among the most common bony injuries and are among the most frequent reasons for referral to Otorhinolaryngology departments resulting in significant pressure on clinical resources. We present our experience of a Nasal Fracture Clinic dedicated to the assessment of nasal injuries. A prospective study has been undertaken using questionnaires regarding patient satisfaction and acceptability of manipulation under a local anaesthetic (LA). During our three-month study period 91 new patients with nasal injuries were seen; 43 patients were diagnosed to have a displaced nasal fracture requiring reduction. Reduction of the nasal fracture under LA was performed in 37 patients. We found that manipulation under LA was preferred by 94% of patients over the age of 14 years. We achieved a high patient satisfaction rate (80% after three months). The discomfort associated with reduction under LA did not exceed that of a minor dental procedure. No significant complications were encountered during the study period. We conclude that reduction of nasal fractures under LA is a safe and attractive alternative to reduction under a general anaesthetic (GA) and frees-up valuable clinical resources.

Bacterial colonization of laryngectomy stomas.

Infections with organisms resistant to conventional antibiotics are of increasing concern. This observational study investigates the bacterial colonization of the peristomal area of laryngectomy patients. Thirty-two consecutive patients who had previously undergone laryngectomy were recruited from the Head and Neck Clinic of a teaching hospital. Swabs were taken from the laryngectomy stoma site, the mouth and both nasal cavities. Microbiological culture and isolation were performed following standard procedures. Despite no clinical sign of infection, 27 patients were found to be carriers of one or more organism (84.4 per cent). Staphylococcus aureus was detected in the peristomal area of 15 patients (46.9 per cent). Methicillin-resistant Staphylococcus aureus (MRSA) was isolated in seven (21.9 per cent) cases. In this series the authors found a high incidence of colonization with potentially pathogenic bacteria in laryngectomy stomas with no clinical signs of infection. In a significant number of patients, Gram positive organisms were identified that could potentially cause cellulitis or wound infections.

Treatment of epistaxis in Accident and Emergency departments in the UK.

This study aims to investigate the facilities available in Accident and Emergency (A&E) departments and the education of casualty officers in the treatment of epistaxis in the UK. Fifty departments were chosen at random and a telephone survey undertaken. The results show a paucity of facilities and inadequate training of A&E officers in a majority of departments. Recommendations for treatment standards are made.

Does hormone replacement therapy in post-menopausal women have any effect upon nasal physiology?

BACKGROUND: Previous studies have suggested that the female menstrual cycle, pregnancy and the oral contraceptive pill have an effect upon nasal physiology. OBJECTIVES: This study aimed to assess the effects upon nasal physiology of female hormone replacement therapy in post-menopausal women. This has not been previously studied. METHODS: Twenty post-menopausal women (age range 36 to 70 years; mean age 57.0 years) underwent measurements of the nasal airway, including anterior rhinoscopy, peak nasal inspiratory flow rate, acoustic rhinometry, anterior rhinomanometry, mucociliary clearance time and rhinitis quality of life questionnaire. Measurements of nasal patency were recorded prior to commencing hormone replacement therapy and at a time point 77-195 days (mean 101.9 days) following commencement. RESULTS: There was no statistical difference found for any of the variables, using the paired t-test (p > 0.05 for all). CONCLUSIONS: Female hormone replacement therapy has no discernable effect upon nasal physiology and should not be considered a cause of rhinitic symptoms.

Safe magnetic resonance scanning of patients with metallic middle ear implants.

OBJECTIVE: To determine the MR scanning risk to patients with otologic implants. DESIGN: We used a repeated-measures study with an additional control measure to assess two aspects of risk; (i) movement of the device in the magnetic field, and (ii) absorption of energy leading to local heating. We used an ex vivo test method that met with international standards. We measured the effects in a Philips Intera Achieva 3 Tesla (T) MR scanner using a Sense Head 8 channel RF coil. SETTING: University-based magnetic resonance research facility. MAIN OUTCOME MEASURES: Heating or displacement of the stapedectomy pistons. RESULTS: No evidence of displacement or heating was found. CONCLUSION: Complying with the ex vivo standard testing protocols, the Schuknecht and McGee wire pistons (device product numbers 140106 and 140108, respectively) were found to be safe in a 3 T MR scanner. These conclusions can be extrapolated to the in vivo case.

How we do it: improving the success of endoscopic pharyngeal pouch stapling.

A simple technique to improve the success rate of endoscopic stapling diverticulotomy of pharyngeal pouches is described. Equipment used is readily available. This technique can be used in difficult cases when the pouch cannot be visualised using a Weerda diverticuloscope. It reduces the need for conversion to an open surgical procedure with associated increased risk of complications.

Noise-induced hearing loss is exacerbated by long-term smoking.

OBJECTIVE: To analyse the influence of long-term smoking on the hearing threshold of individuals subjected to occupational noise exposure. DESIGN: Prospective observational cohort study. SETTING: Occupational health examination of noise-exposed employees in the brick manufacturing industry. PARTICIPANTS: A study group of long-term smokers (n = 30) and a control group of non-smokers (n = 58) were identified from a population of 227 male noise-exposed employees. Individuals of both groups were employed for 10 years or more at a single brick manufacturing plant. Data on noise exposure, smoking habits, medical and otological history were collected and standard pure tone audiometry was obtained. Exclusion criteria included asymmetrical or conductive hearing loss, uncontrolled systemic illnesses, history of head injury, chronic middle ear pathology or major ear operations. MAIN OUTCOME MEASURE: Pure tone audiometry. RESULTS: Both groups had similar mean age and total duration of occupational noise exposure. The median age-corrected hearing thresholds at 3 and 4 kHz in the smokers group were significantly higher (approximately 7dB) than those in the non-smokers group. No statistical difference in the hearing thresholds between both groups was found in any other tested frequency (0.5, 1, 2, 6 and 8 kHz). CONCLUSION: Long-term smokers with occupational noise exposure may, on the basis of this limited study, have a higher risk of developing permanent hearing loss at 3 and 4 kHz when compared with non-smokers with a similar occupational history.

A double-blinded randomized controlled trial of coblation versus conventional dissection tonsillectomy on post-operative symptoms.

OBJECTIVES: The aim of this study was to compare postoperative symptoms following coblation tonsillectomy with those experienced following a traditional cold dissection. DESIGN: A prospective randomized controlled trial. SETTING: Secondary otorhinolaryngology care. PARTICIPANTS: Ninety-two adult patients with recurrent tonsillitis meriting tonsillectomy were recruited and randomly allocated into either coblation or cold dissection tonsillectomy groups. MAIN OUTCOME MEASURES: Primary outcomes were post-operative pain, otalgia, swallowing and analgesia use at 6-8 hours, 1, 3, 7 and 14 days post-operative. Secondary outcomes were post-operative day returned to eating and returned to normal activities/work. RESULTS: No significant differences between the two groups (P >or= 0.1) were found in any of the above primary outcomes, apart from swallowing at 6-8 hrs post-operatively where the cold dissection group had less pain. This group also returned earlier to normal eating (P = 0.03). The power of the study was sufficient to show a difference in the visual analogue scores of 2 between groups. CONCLUSIONS: The use of coblation to perform tonsillectomy does not confer any symptomatic benefits to the patient over conventional cold dissection tonsillectomy.

Myringitis bullosa haemorrhagica associated with meningo-encephalitis.

An unusual case of a patient presenting with myringitis bullosa haemorrhagica (MBH), who subsequently developed acute otitis media and meningo-encephalitis, is described. The aetiology of MBH is discussed, and recommendations for the management of patients with acute otitis are made.

Sublingual packing as an useful adjunct to submandibular gland excision.

We describe a simple preoperative procedure that we have found of great benefit in submandibular gland excision.