Complete nasal obstruction secondary to pacemaker insertion.

We present the case of a 71-year-old man who presented to the ear, nose and throat department with complete nasal obstruction and facial plethora on bending forward. Clinical examination was positive for Pemberton's sign. Computed tomography and ultrasonography demonstrated bilateral brachiocephalic vein thrombosis secondary to pacemaker insertion. This case highlights a novel complication of pacemaker insertion.

Endonasal Microdebrider Assisted Excision of Congenital Intranasal Nasolacrimal Duct Cyst or Inferior Mucocoele.

OBJECTIVE: Congenital intranasal nasolacrimal duct (NLD) cyst is a rare clinical entity in the newborn whilst inferior mucocoeles are more common. We reviewed our case series of the management of patients presenting with congenital intranasal NLD cysts and inferior mucocoeles treated using powered instrumentation under endoscopic guidance. METHODS: A retrospective review identified three patients, between 2010 and 2013, who have had microdebrider assisted endoscopic marsupialisation of congenital intranasal NLD cysts under joint ENT and Ophthalmology care. RESULTS: Diagnosis was made based on intraoperative endoscopic nasal examination carried out during treatment of patients with epiphora. All patients were 2 years old or younger presented with persistent epiphora since birth with sticky eyes. All had normal development with no other past medical history of note. Two patients had unilateral and one patient had bilateral congenital intranasal NLD cysts/inferior mucocoels identified. These were treated by endoscopic incision of the cyst with drainage of pus and excision of excess mucosal tissue using a powered microdebrider to effect marsupialisation and prevent re healing of the floppy redundant flaps of the incised cyst. No silastic tubes were placed. All patients were discharged from clinic 3 months post surgery with complete resolution of symptoms and no complications. CONCLUSIONS: Microdebrider assisted endoscopic marsupialisation is a safe and effective treatment for removal of excess tissue in the treatment for congenital intranasal NLD cyst/inferior mucocoele whilst also obviating the need for silastic intubation and a further general anaesthetic for stent removal.

Radiological and radionuclide investigation of malignant otitis externa.

This study looks at case series of malignant otitis externa, outlines detailed structural (radiological) and functional (radionuclide) investigations, and discusses their utility in the initial diagnosis, patient management and follow up of this condition. Patients were investigated by computerized tomography (CT), magnetic resonance imaging (MRI), two-phase planar and single-photon emission tomography (SPECT), technetium-99m methylenediphosphonate bone scans, gallium-67 planar and SPECT scans, and indium-111 or technetium-99m labelled WBC planar and SPECT scintigraphy. We discuss example case reports with the various radiological and scintigraphic findings and outline a protocol for rational investigation. It is concluded that CT and/or MRI should be supported by routine SPECT bone imaging for initial diagnosis of malignant otitis externa. Routine SPECT bone imaging further supplemented by gallium scintigraphy should be the investigation of choice in the follow up of these cases for assessing response to treatment and disease recurrence.

The facial ridge and the discharging mastoid cavity.

This study evaluates the causes for a persistently discharging mastoid cavity and attempts to weight the importance of each identified factor. It consists of a temporal bone dissection to evaluate the anatomy of the facial nerve and a clinical prospective study measuring the factors that contribute to a wet cavity. The factors measured were height of the facial ridge, the size of the meatus, state of the tympanic membrane, and size of the mastoid cavity. The height of the facial ridge and the kidney shape of the cavity were found to be the most significant factors contributing to the state of the cavity. The tympanic membrane and size of the meatus were also found to significantly influence the state of the cavity, whereas the size of the cavity was not significant. These results illustrate the importance of the facial ridge in mastoid surgery and that most poor results in mastoid surgery are due to the surgeon, not the disease.

Complicated acute sinusitis and the computed tomography anatomy of the ostiomeatal unit in childhood.

The ostiomeatal unit is postulated to be a critical area in the pathogenesis of sinus disease and accurate assessment of this anatomical area has made possible by the coronal computed tomography (CT) scan. Data from the CT scans of 24 patients with complications of acute sinusitis were retrospectively reviewed and compared with a set of normative data of the infundibular length, and width and the uncinate angle in 196 scans of healthy children. In the patients with complicated sinusitis the infundibular length was found to be less and the infundibular width greater than the normative data. No difference in the mean uncinate angle of the two groups was shown. One, therefore, has to assume that the pathological process at the ostiomeatal unit is more likely to be mucosal than bony.

Facial nerve palsy in mastoid surgery.

The risk of facial nerve injury during mastoid surgery has decreased substantially since the advent of the microscope and the otological drill. However, the facial nerve remains at risk during mastoid surgery with the present day incidence suggested to be one per cent. Despite the severity of this complication there are no recent studies that accurately quantify the incidence or discuss its management. The aims of this study were to identify the risk of facial nerve injury for both the specialist as well as the trainee specialist and to review a management protocol for this complication. During the 10-year period from 1985 to 1994, 1024 consecutive mastoidectomies were reviewed. A total of 17 palsies was identified, seven were complete and 10 were incomplete. Of the seven complete palsies, four patients had decompression only and recovered to House Brackmann Grade 2 or better while three patients had decompression and grafting, of these, two were available for follow-up and recovered to House Brackmann Grade 4 only. All the partial palsies, barring one lost to follow-up, who were treated conservatively with pack removal, toilet and topical therapy recovered to House Brackmann Grade 2 or better. A management protocol followed for the above patients is presented and the results analysed. Specific operations and manoeuvres which may put the facial nerve at risk intra-operatively are also discussed.

The role of MIBG scintigraphy in the management of a case of metastatic glomus jugulare tumour.

Glomus jugulare tumours with metastases are rare as the diagnosis of metastases in this condition can be difficult. In the past this diagnosis has been made on histology of the metastatic lesions which were identified on clinical grounds. This is one of the reasons why there have been only 20 reported cases in the literature up to 1990 (Johnstone et al., 1990). This case report examines the role of meta-iodobenzylguanidine (MIBG) scintigraphy in the diagnosis of metastases. MIBG scintigraphy is an injected radionucleotide isotope scanning technique which is cheap, non-invasive, sensitive as well as being a specific investigation for identifying sites of ectopic neuroendocrine tissue. It may also have a role in the treatment of these tumours.

Glycerol and ichthammol: medicinal solution or mythical potion?

Glycerol and ichthammol (G & I) has been used for generations by otologists. However, there is a paucity of information on both its mode of action and its anti-bacterial properties. The aim of this paper was to ascertain firstly, what the most common organisms found in discharging ears were and secondly, what antibacterial activity G & I had against these organisms. All ear swabs from 1992-1994 in our unit were reviewed to ascertain the prevalence of the commonly isolated organisms. Fresh isolates of these organisms were collected and plated onto agar with wells of glycerol, ichthammol and a combination of both as used in clinical practice. The diameters of the zones of inhibition observed after incubation were measured in millimetres. Common isolates were: Pseudomonas aeruginosa, Staphylococcus aureus, Proteus mirabalis, Streptococcus pyogenes in descending order of frequency. Pure glycerol showed no significant zones of inhibition against any of the organisms tested. The average zones of inhibition for G & I and ichthammol alone were for Staphylococcus aureus 15 mm and 18 mm and for Streptococcus pyogenes: 16 mm and 23 mm. Ichthammol alone was significantly more effective than G & I (p < 0.001). There was no significant activity against Proteus mirabalis and Pseudomonas aeruginosa. The therapeutic benefit of G & I is due in part to the inherent anti-bacterial activity of ichthammol against the Gram positive organisms as well as its anti-inflammatory action and the dehydrating effect of the glycerol.

Hypoparathyroidism after the treatment of laryngopharyngeal carcinoma.

Thirty patients with squamous cell carcinoma of the laryngopharynx were treated with surgery (total laryngectomy and hemithyroidectomy) and radiotherapy. Group 1 (n = 7) patients had surgery only; Group 2 (n = 7) had radiotherapy followed by salvage surgery while Group 3 (n = 16) had surgery followed by radiotherapy. Parathyroid hormone and calcium levels were measured pre- and post-operatively and post-radiotherapy. In Group 1 no patients were hypoparathyroid. In Group 2, 29 per cent of patients preoperatively and 57 per cent post-operatively, were hypoparathyroid. In Group 3, no patients were hypoparathyroid pre-operatively, while 25 per cent were hypoparathyroid post-operatively and post-radiotherapy. Parathyroid hormone and calcium levels were averaged and compared within and between each group. There was no significant difference within each group, when comparing levels post-operatively and post-radiotherapy from those of pre-operatively. There was no significant difference in levels between each of Groups 1, 2 or 3 (p > 0.05).

Radiological staging of the chest and abdomen in head and neck squamous cell carcinoma--are computed tomography and ultrasound necessary?

The need for, and choice of, radiological staging investigations for distant metastases in the management of head and neck squamous cell carcinoma is a contentious issue. To address this problem a retrospective audit of routine computerized tomography (CT) and ultrasound scanning of the chest and abdomen respectively was undertaken. The records of 103 patients who, over a six and a half year period, underwent major surgery for head and neck squamous cell carcinoma were reviewed. A total of 57 patients (59 per cent) had CT scanning of the chest of whom two were identified as having synchronous tumours. In both cases, the lesions were identified on chest X-ray prior to scanning. Seventy patients (68 per cent) had routine ultrasound scanning of the abdomen. In none of these was metastatic disease identified. As a result of the audit findings routine CT and ultrasound scanning of the chest and abdomen has been discontinued.

Coagulation studies in patients admitted with epistaxis--current practice in Scotland.

Epistaxis remains the most common ENT emergency. The use of coagulation studies in Scotland to manage these patients was investigated to determine current practice. The study took the form of a postal questionnaire sent to all practising ENT consultants and a telephone survey of ENT senior house officers working in Scotland. Of the 60 questionnaires circulated amongst consultants, 55 responses were received (92 per cent). Thirty-eight consultants (70 per cent) indicated that they did not routinely request a coagulation screen for their patients, however, 30 per cent (16) did. Forty-three of the 45 junior staff were available for interview, 22 (51 per cent) of whom routinely requested coagulation studies. While the majority of consultants did not request routine coagulation studies, there did not appear to be any consensus among the junior staff. Although there is a paucity of scientific information with regard to this aspect of epistaxis patient management, there is support in the literature for targeted rather than blanket testing. There is perhaps a need to address this issue within individual departments, to achieve uniformity of practice, and to improve communication between junior and senior staff.

Surgical management of septal perforation: an alternative to closure of perforation.

The surgical closure of septal perforations remains a distinctive challenge to the otorhinolaryngologist. This is demonstrated by the modest success in most techniques. An alternative method, involving surgical enlargement of the perforation with posterior edge repair, is described and the outcome is investigated. Thirteen patients with perforations of up to 50 mm in size underwent this technique. A questionnaire interview was conducted and symptom scores were obtained. The length of hospitalization, follow-up period and post-operative complications were evaluated as were measures of morbidity. The results showed a significant improvement in the symptom scores for nasal crusting, epistaxis and overall discomfort. This technique is straightforward and is especially suitable for larger perforations. The successful improvement in symptoms and an associated low morbidity makes it a complement to alternative surgical closure techniques.

Routine coagulation screening in the management of emergency admission for epistaxis--is it necessary?

The role of routine coagulation studies in the management of patients suffering from epistaxis is unclear. In an attempt to address this issue the case notes of all emergency admissions for epistaxis to a large Scottish teaching hospital were retrospectively reviewed over a one-year period. One hundred and forty patients (63 male, 77 female) were admitted between January and December 1998. The patients who had coagulation studies were identified and their results analysed. A total of 121 patients (86.4 per cent) had coagulation studies performed. Of these, 10 (8.3 per cent) had abnormal results and all were taking warfarin or a combination of warfarin and aspirin. No other coagulation abnormalities were identified. This study supports the view that there does not appear to be a role for routine coagulation studies in patients admitted with epistaxis. The investigation for potential haemostatic disorders should be performed when clinically indicated and, if necessary, in consultation with the haematology service.

The antibacterial activity of acetic acid and Burow's solution as topical otological preparations.

At present there are no topical otological preparations on the World Health Organisation's essential drug list, largely due to the ototoxic potential of preparations containing aminoglycoside antibiotics. Acetic acid and Burow's solution have long been used in the treatment of the discharging ear. The aim of this study was to ascertain the antibacterial activity of these two preparations against the most commonly occurring bacteria isolated from discharging ears in our department. Twenty fresh isolates of each of the following organisms--Pseudomonas aeruginosa, Staphylococcus aureus, Proteus mirabilis and Streptococcus pyogenes--were plated onto blood agar and tested against one per cent, two per cent and three per cent acetic acid and Burow's solution (13 per cent aluminium acetate). The activity of each agent was ascertained by the size of the zone of inhibition of bacterial growth. Burow's solution showed significantly larger average zones of inhibition than acetic acid (p < 0.001). The two per cent and three per cent acetic acid as well as the Burow's solution were active against all the organisms tested.

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.

Miller Fisher syndrome: a diagnosis not to be missed.

We report a case of Miller Fisher syndrome presenting in an ENT setting. The referral was made on the basis of worsening nasal regurgitation following Campylobacter jejuni enteritis. The aim of this report is not to add to the recorded instances of Miller Fisher syndrome, but to help raise the level of its awareness amongst otolaryngologists. Emphasis is placed on the mode of presentation and management issues, as early diagnosis is crucial and confers a favourable prognosis. In that respect, we consider this case noteworthy and instructive.

Do the complications of mastoid surgery differ from those of the disease?

During mastoid surgery there is a risk to the facial nerve and hearing but at present it is unclear how substantial this risk is. This information is necessary for adequate informed consent to be given, as consent requires information about both the potential risks of the surgery as well as the risks of leaving the disease untreated. The aim of this study is to establish the risks of mastoid surgery and the incidence of complications as a consequence of mastoid disease. The records of all patients undergoing mastoidectomy between 1985 and 1994 were reviewed for preoperative and intra-operative complications. Preoperatively there were 21 (2%) facial nerve palsies, 67 (6.5%) dead ears and 58 (5.7%) intracranial complications of the mastoid disease. If this risk is extrapolated for the population of the Western Cape over a 40-year period (average expected life-span after presentation), the risk of developing a serious complication (facial palsy, dead ear or intracranial) from mastoid disease during this period was 3.8%. The incidence of intra-operative iatrogenic facial nerve palsy was 1.7% (n = 17) and of dead ear was 1.7% (n = 17). Although the comparative risk of developing a severe complication from untreated disease was similar to the risks of surgery (facial palsy, dead ear), the number (58) of intracranial life-threatening preoperative complications presenting in the 10-year period reviewed was significant. These figures provide a base from which otologists can inform patients about the possible risk of mastoid surgery as well as allowing these risks to be compared with the risks of leaving the disease untreated.

Radiological staging for squamous carcinoma of the head and neck: a standardised practice?

The choice of investigations for radiological staging of squamous carcinoma of the head and neck can be highly variable. The aims of this study were to establish the practice amongst otolaryngologists in Scotland, to determine what, if any, consensus of practice exists and also to stimulate debate in this controversial area. The results of a postal survey to which there was a 65% response rate are reported. Of the primary sites, the greatest consensus on the need for imaging was of the nasopharynx, oropharynx and hypopharynx. For metastatic disease, all respondents imaged the chest but most did not image the abdomen or skeleton. The results for the other sites and imaging modalities chosen are discussed. A protocol for radiological staging based on the survey findings and interpretation of the literature is suggested.