Epiphora: an evidence based approach to the 12 minute consultation.

BACKGROUND: Epiphora is the presence of a watering eye which may be due to reflex tearing or defective drainage of tears. Whilst most cases present to the ophthalmologist the otolaryngologist has a key role to play in both assessment and management of these patients. METHODS: This review was based on a literature search last performed on 21st October 2009. MEDLINE and Cochrane databases were searched using the subject headings 'epiphora' or 'functional epiphora' in combination with diagnosis, investigation, management, treatment, intervention and surgery. Results were limited to English language articles. The personal biographies of the senior authors were also used. CONCLUSION: An accurate assessment of the site and degree of obstruction is important to ensure the correct management is undertaken. Medical treatment with nasal steroid spray may be effective but the majority of obstructed cases will require surgical intervention in the form of dacryocystorhinostomy (DCR). There is increasing evidence that powered endoscopic DCR has outcomes comparable with the 'gold standard' procedure of external DCR.

Chondrosarcoma arising in an osteochondroma: an unusual cause of an abdominal mass.

Secondary chondrosarcomas are rare tumours, which can develop in up to 2% of patients with single osteochondromas. The rarity of presentation of these tumours to the general surgeon can lead to difficulty and delay in diagnosis. We describe such a tumour presenting as an abdominal mass and discuss the appropriate investigations necessary to establish the diagnosis and plan subsequent management.

Suturing of digital lacerations: digital block or local infiltration?

A prospective trial was carried out to assess the relative efficiency of digital block and local infiltration as methods of anaesthesia when suturing lacerations of the digits. A standard technique and questionnaire were applied to a consecutive group of 62 patients attending the Accident Department of the Bristol Royal Infirmary. Digital block was found to be a more effective technique than local infiltration for anaesthetising digital lacerations.

Branchial cysts: congenital or acquired?

Branchial cysts are one of the commonest causes of neck lumps in the young adult. Their aetiology is the subject of some controversy, although available evidence suggests that they are derived from lymphoid tissue. We present two cases of branchial cysts, and emphasise the importance of excluding more sinister causes of neck lumps before excision, even when the clinical features suggest benign pathology.

Quality of life of octogenarians after aneurysm surgery.

Abdominal aneurysm repair in octogenarians is controversial. To justify surgery, survival with a reasonable quality of life is required. Between 1980 and 1988, 34 octogenarians underwent aortic aneurysm surgery (14 elective, 20 emergency). Of the 21 survivors, 20 were interviewed to determine their quality of life. At the time of interview the patients had a median survival of 19 months (range 4-67 months). Twenty age/sex matched normal patients, from the same GP population, were interviewed for comparison. A structured questionnaire was used to assess: physical mobility, activities of daily living, sleep and emotional problems. A symptom survey was also performed. The survival trend of elective patients was similar to that of a demographically similar 'normal' population. The survival trend of emergency patients returned to 'normal' after the first postoperative month. Quality of life of the 20 patients was comparable to the lifestyle enjoyed by normal subjects. Of the 20 patients interviewed, 18 had returned home after surgery. Elective and emergency aortic aneurysm surgery can be performed with reasonable survival and a good quality of life, and therefore cannot be denied to octogenarians on the basis of age alone.

Wegener's granulomatosis presenting as a temporal headache.

Formerly a fatal condition, Wegener's granulomatosis is now treated with good results. Clinical morbidity is often due to failure by clinicians to make the diagnosis. Many patients (including our cases reported here) present with atypical symptoms, and only a high index of suspicion will ensure early diagnosis. Classical chest and renal symptoms often indicate late stage disease. We present two cases that underline the limitations of current 'diagnostic' immunological tests whilst emphasising the importance of clinical features in diagnosis. Standard treatment with Cytotoxic agents and corticosteroids are effective but carry considerable morbidity. We have followed the current trend of incorporating a less toxic antibiotic agent in the management of this enigmatic condition.

The fish hook retractor.

We describe a simple and easily adjustable method of retracting skin flaps during head and neck surgery. It involves the use of a modified fish hook and rubber band. The retractor is easily applied and adjusted, and inexpensive to manufacture.

Endoscopic laser dacryocystorhinostomy. An unusual post-operative finding: re-opening of the nasolacrimal duct.

Endoscopic laser dacryocystorhinostomy (DCR) is a recognized technique for the surgical treatment of epiphora. Nasolacrimal duct obstruction is surgically bypassed by creating a passage from the lacrimal sac to the nasal cavity (rhinostomy). Some patients have undergone endonasal laser-assisted DCR, and were found to have an obstructed rhinostomy at follow-up. However, they reported a subjective improvement in their symptoms. Five such patients, at six months follow-up, were found to have a non-functioning rhinostomy with fluorescein dye emerging from under the inferior turbinate. These five patients along with four controls had post-operative macrodacryocystograms (MDCG) to delineate the anatomical passage by which tears were entering the nasal cavity. In the control group, clear passage of contrast into the middle meatus was demonstrated in three of the four subjects. In the study group, passage of dye to the inferior meatus, via the nasolacrimal duct was demonstrated in four of the five subjects. It is well recognized that a proportion of patients suffering from epiphora will have a natural resolution of their symptoms. Our results demonstrate that the resolution of epiphora in some operated patients was due to a re-opening of the nasolacrimal duct, and not because of a patent rhinostomy.

Transmastoid extracranial repair of CSF leaks following acoustic neuroma resection.

Acoustic neuromas may be resected either by a suboccipital craniectomy or translabyrinthine approach; the latter gives good access without unduly traumatising the brainstem, but can lead to a higher incidence of cerebrospinal fluid (CSF) leaks. The surgical management of these leaks can be difficult; we describe a transmastoid extracranial technique using pedicled sternomastoid muscle that has produced complete resolution of the leak in all cases managed in this way.

A long term view of myringoplasty in children.

Fifty-nine type 1 tympanoplasties in children under 14 years of age were assessed by recall to a special follow-up clinic up to 15 years post-operatively. Overall 78 per cent of tympanic membranes were found to be intact with a late failure of grafts noted in 6 per cent of cases. An improvement in the audiological threshold was found in 51 per cent, 24 per cent were unchanged, the remaining 25 per cent suffered a deterioration which was seen both immediately post-operatively and thereafter until reviewed in the special clinic. The age at operation, size of the perforation, grade of surgeon carrying out the operation and prior adenoidectomy had no statistically significant influence on the success rate or the audiological outcome. Revision procedures achieved similar graft take rates to the initial procedures but fared worse audiologically. We conclude that in the majority the operation was successful but hearing gain was not as good as expected and subject to late deterioration. A long term follow-up is important to detect this and other complications.

Epistaxis as an unusual presentation of an antrochoanal polyp.

Antrochoanal polyps rarely present with severe epistaxis. We present the case of a young male patient who presented in such a manner, thus leading to the suspicion of an angiofibroma as the underlying pathology. The radiological investigations, treatment and pathological features are discussed.

Papillary adenocarcinoma of the middle ear.

A case of papillary adenocarcinoma of the middle ear is presented. The patient had an unusually short history of otalgia, aural discharge and facial palsy, and, at presentation the tumour was too large for surgical resection to be a feasible option. The management of this rare tumour is discussed and the relevant literature reviewed.

A conservative approach to the management of otitis media with effusion in cleft palate children.

Otitis media with effusion (OME) is almost universal in children born with a cleft palate. Early placement of a ventilation tube to alleviate hearing problems is common. A retrospective study has been carried out to assess whether the practice of tube placement only for definite clinical indications is successful in terms of subsequent hearing levels and speech and language development. This was assessed by a case note review, analysis of speech therapy data and by means of a special follow-up clinic. There was no difference in speech development between those treated with tube insertion for OME and those untreated. Audiological thresholds were worse in the treated group. A similar number in each group required regular speech therapy. More abnormal otological findings were present at follow up in those who had tubes inserted, some of these were directly attributable to the presence of tubes. A conservative management of OME in cleft palate children, with tube insertion for only definite clinical indications, is an appropriate management, and will lead to fewer otological complications of tube insertion.

MRI as a single screening procedure for acoustic neuroma: a cost effective protocol.

Magnetic resonance imaging (MRI) is accepted as the 'gold standard' in diagnosing acoustic neuromas. Limited availability and perceived high costs have prevented clinicians from using it as a first-line investigation. A prospective study was set up in a specially designated screening session to audit the cost effectiveness and accuracy of audiovestibular investigations compared to MRI. Ninety-nine patients with asymmetrical audiovestibular symptoms or signs were investigated. Of these 54 evoked response audiometry tests, and 39 calorics were either not performed or were inconclusive. One patient refused to enter the MRI machine. All others received an unequivocal report after MRI and four tumours (three intracanalicular) were detected. The total cost of the audiovestibular protocol was 12,545 pounds compared to 12,900 pounds for the MRI protocol, which is a diagnostic and well-tolerated procedure. This study shows that MRI can be cost effective, as well as accurate, when used as a single screening procedure for acoustic neuromas.

Pharyngeal angiosarcoma following multimodal treatment for oropharyngeal squamous cell carcinoma.

It is well established that angiosarcoma can develop following radiotherapy. We present an unusual case of angiosarcoma of the pharynx that developed three years after treatment with surgery and adjuvant chemoradiotherapy for a T2N2bM0 squamous cell carcinoma of the oropharynx. The patient was tumour free until developing dysphagia, which was found to be caused by an angiosarcoma. The patient underwent surgery of the pharyngeal angiosarcoma by laryngopharyngectomy, tongue base resection, selective neck dissection and radial forearm microvascular free flap reconstruction. Angiosarcoma following head and neck malignancy is rare but must be considered as part of the differential diagnosis in patients with new symptoms after radiotherapy.

Can head and neck cancer patients be discharged after three years?

BACKGROUND: Follow-up surveillance of head and neck cancer patients varies throughout the UK. The heterogeneity of these patients limits the applicability of a standardised protocol. Improvements in our understanding of the natural history of the disease may assist in the tailoring of resources to patients. METHOD: Prospective data collected at the Cumberland Infirmary over a 13-year period were analysed, primarily focusing upon recurrence rates and time to recurrence. RESULTS: In keeping with other studies, recurrence of head and neck squamous cell carcinoma was found to be maximal within the first three years of treatment, regardless of subsite. CONCLUSION: Hospital-based surveillance may be safely discontinued after three years for some patients. Laryngeal carcinoma may require further surveillance due to possible delayed recurrence of a second primary formation. Emphasis must be placed on patient education, accessibility to head and neck services, and the existence of a robust system to facilitate urgent referrals.

Laryngeal cancer management in a small, rural, multidisciplinary team setting: 15-year review.

BACKGROUND: The Cumberland Infirmary, Carlisle, serves a largely remote, rural population of 330 000. The aim of this study was to report the treatment and survival figures for patients treated for laryngeal cancer at this centre. METHODS: The study included 209 consecutive patients with squamous cell carcinoma of the larynx diagnosed between 1996 and 2010 at the Cumberland Infirmary. RESULTS: Disease-specific survival was 100 per cent for stage one, 76 per cent for stage two, 87 per cent for stage three and 46 per cent for stage four. In total, 76 patients (36 per cent) had a laryngectomy, either as primary treatment or as a salvage procedure. CONCLUSION: Our tumour-specific survival rate was very high, and this success may be due in part to high rates of surgical intervention. Survival data compared favourably with other centres, despite less radical radiotherapy regimes. Laryngeal cancer can be managed effectively in a small, relatively remote, multidisciplinary team setting.