Hairy polyp of the oropharynx in association with a first branchial arch sinus.

OBJECTIVES: Hairy polyps are rare, congenital malformations of the oropharynx and nasopharynx. To date, approximately 145 cases have been reported. However, the histogenesis of these lesions remains unclear. CASE REPORT: We report the case of a 2-day-old neonate presenting with a hairy polyp attached to the left palate, who re-presented aged 16 months with a discharging first branchial arch sinus. CONCLUSION: We propose this case as supporting evidence for the theory that hairy polyps are a malformation of the first branchial arch system.

Presentation of laryngeal papilloma in childhood: the Leeds experience.

INTRODUCTION: The human papilloma virus (HPV) can cause laryngeal papillomatosis in childhood. The aetiology is thought to be vertical transmission. Clinically these children are usually asymptomatic for the first 6 months of life. As the papillomas develop locally, symptoms begin to develop. The symptoms range from voice change to frank hoarseness, and 'noisy' breathing, most commonly inspiratory stridor. METHOD: Clinical images from microlaryngoscopy and bronchoscopy over a 12-year period were assessed for laryngeal papilloma. RESULTS: In Leeds seven cases presented to the specialist centre over the past 12 years, the average age at presentation was 6.8 years and duration of onset of symptoms to specialist review was 21 months. Five of the children had been treated for asthma and two presented in extremis. CONCLUSION: The take home message for clinicians is hoarse voice associated with shortness of breath needs specialist referral.

The use of ice-lollies for pain relief post-paediatric tonsillectomy. A single-blinded, randomised, controlled trial.

OBJECTIVES: To assess whether the use of ice-lollies after tonsillectomy with or without adenoidectomy in children aged 2-12 reduces pain in the immediate postoperative period. DESIGN: A prospective, randomised, single-blinded study design consisting of two groups with an intention to treat analysis. SETTING: Tertiary referral centre. PARTICIPANTS: Children aged 2-12 undergoing tonsillectomy with or without adenoidectomy. MAIN OUTCOME MEASURES: Pain assessment by nursing staff in the form of the validated modified Children's Hospital of Eastern Ontario Pain Scale at 15, 30 and 60 min and 4 h. RESULTS: Ninety-two patients were recruited into the study with 46 allocated to receive an ice-lolly and 41 not to receive an ice-lolly after exclusion of those with incomplete data. The two groups were comparable for number, age, sex and diagnosis. The pain score at every time interval was lower in the group that had received the ice-lolly compared with the group that had not. This was statistically significant at 30 (P = 0.008) and 60 min (P = 0.049). CONCLUSION: Our data suggest that ice-lollies are a cheap, effective and safe method of reducing postoperative pain up to one hour following paediatric tonsillectomy.

Diode laser for paediatric airway procedures: a useful tool.

OBJECTIVE: A wide range of lasers have been used in the larynx. Diode laser is a portable and relatively inexpensive laser which is delivered via a glass fibre hand-held probe. The objective of this study was to report our experience with the use of diode laser in a variety of paediatric airway pathologies. METHODS: In this study, 90 diode laser laryngeal procedures were performed on 31 patients in the age range of 1 month to 16 years at the time of the operation. The follow up after the procedure has been in the range of 6 months to 3 years. RESULTS: As per our records 19/31 (61.3%) patients have been cured of their initial pathologies and were not under further review, 3/31 (9.6%) were having repeated laser treatments. The remaining 9/31 (29.0%) had to undergo further treatment. There was no laser-related intra-operative or postoperative complications. CONCLUSIONS: Diode laser is a good tool for several paediatric laryngeal pathologies. The ability to guide the laser light using the flexible glass fibre directly onto the area requiring vapourisation enables very precise treatment.

Endoscopic sinus surgery as day-case procedure.

OBJECTIVE: Functional endoscopic sinus surgery is the mainstay of surgical treatment for chronic sinusitis. Day-case surgery has the advantage over in-patient surgery of being cost-effective and resource sparing. The objectives of this study were to assess our results for day-case functional endoscopic sinus surgery. METHODS: This was a retrospective case note review of day-case functional endoscopic sinus surgery procedures performed at Leeds General Infirmary from February 2004 to February 2007. We recorded patients' demographic data, operative details, post-operative course and follow-up results. RESULTS: A total of 105 day-case functional endoscopic sinus surgery procedures were included in the study. Patients' ages ranged from 16 to 93 years; 44 (41.9 per cent) were female and 61 (58.1 per cent) were male. Of these patients, 39 (37.1 per cent) had chronic sinusitis and the rest (66; 62.8 per cent) had nasal polyposis and sinusitis. Sixty-one patients (58.1 per cent) underwent surgery on the morning operating list, while the rest (44; 41.9 per cent) underwent surgery in the afternoon. Of the 105 patients, 24 (22.8 per cent) had undergone previous nasal surgery. The majority of patients (90/105; 85.7 per cent) were discharged on the same day as surgery. The only complication recorded in this study was bleeding, noted in seven patients (6.7 per cent). At the follow-up appointment, 90/105 (85.7 per cent) patients were satisfied with their post-operative results. CONCLUSIONS: Day-case endoscopic sinus surgery can be performed safely as a day-case procedure. The most important factors for a successful outcome are correct patient selection, in terms of general health and social circumstances, and a dedicated day-case team.

Obstructive sleep apnoea adenotonsillectomy in children: when to refer to a centre with a paediatric intensive care unit?

OBJECTIVE: To identify regional surgical referral patterns for adenotonsillectomy in children with obstructive sleep apnoea to our tertiary centre with paediatric intensive care unit facilities and to establish guidelines for elective paediatric intensive care unit referral and admission. METHODS: Two methods were used. A questionnaire was sent to ENT consultants in five surrounding hospitals with no in-house paediatric intensive care facilities. The second was a prospective observational study undertaken in our tertiary centre for a sub-set of patients undergoing obstructive sleep apnoea adenotonsillectomy between January 2002 and February 2005. These children were considered high risk as judged clinically by an ENT surgeon. Most had obstructive sleep apnoea and a co-morbidity. Otherwise healthy children with simple obstructive sleep apnoea were excluded. RESULTS: 15 out of 20 consultants responded to the questionnaire. Four referred on the grounds of clinical history, five referred based on pulse oximetry, nine referred syndromal children and four did not refer electively. Of the 49 high risk patients operated on, only 12 required paediatric intensive care admission with no emergency paediatric intensive care admissions. No otherwise healthy children with uncomplicated obstructive sleep apnoea symptoms required paediatric intensive care admission during the study period. CONCLUSION: There was no regional consensus regarding paediatric intensive care unit referral for obstructive sleep apnoea adenotonsillectomy. Clinical judgement without complex sleep studies by those experienced in this area was sufficient to detect complicated cases of obstructive sleep apnoea with co-morbidity requiring paediatric intensive care.

Aryepiglottoplasty for laryngomalacia: results and recommendations following a case series of 84.

OBJECTIVES: To examine one consultant's experience of aryepiglottoplasty at Leeds General Infirmary. To identify risk factors for post-operative complications. Comparing the outcomes of surgery with the published literature on aryepiglottoplasty. DESIGN: A retrospective case series of consecutive patients undergoing aryepiglottoplasty identified from theatre records. SETTING: The Otolaryngology Department, Leeds General Infirmary. This is part of Leeds Teaching Hospitals NHS Trust and is a tertiary referral centre with regional paediatric intensive care unit (PICU) and specialises in managing paediatric airway pathology. PARTICIPANTS: Ninety-one consecutive cases of aryepiglottoplasties, between 1997 and 2005. The medical records for 84 cases were reviewed. MAIN OUTCOME MEASURES: Unplanned admissions to PICU, complication rate, length of post-operative hospital stay, and successful resolution of symptoms amongst our patient group. RESULTS: The primary indication for surgery was found to be severe stridor. There was a low rate (3.6%) of unplanned admissions to the PICU. 7.1% of patients suffered a post-operative aspiration pneumonia. The majority (66.7%) of patients were able to return home after just one night in hospital. 11.9% of patients continued to have some stridor at follow-up. CONCLUSIONS: The majority of patients undergoing aryepiglottoplasty for isolated laryngomalacia can be monitored overnight on a paediatric surgical ward and return home the following day (85%). Furthermore, they should expect improvement of their stridor with a single procedure (90%). Aryepiglottoplasty at an experienced unit is a low-risk procedure with a high success rate.

Laryngeal inflammatory pseudotumour: an unusual cause of airway obstruction.

We report a rare case of a laryngeal pseudotumour in a child presenting with stridor, which was treated by endoscopic laryngeal resection, without the need for a tracheostomy. A short review of the literature is also presented. Although rare, laryngeal pseudotumour should be considered as part of the differential diagnosis of stridor and upper airway obstruction in children.

Radiopharmaceuticals for targeting the angiogenesis marker alpha(v)beta(3).

A common feature of solid tumors is the formation of new blood vessels (angiogenesis) within the tumor. A receptor called alpha(v)beta(3) is found on endothelial cells lining newly growing blood vessels at a higher density than on mature blood vessels. This receptor may provide a target for radioligands to permit imaging of a wide variety of solid tumors. The radioligands may range from macromolecules such as native ligands or monoclonal antibodies, to small proteins to very small peptides. The differing characteristics of these bio-molecules have an affect on target delivery and clearance time.

Non-oncologic applications of radiolabeled peptides in nuclear medicine.

Radiolabeled peptides have been investigated for diagnostic imaging in a variety of non-oncologic diseases. For imaging thromboembolic disease, peptides which bind to various components of thrombi have been tested. For targeting the fibrin component of thrombi, peptide analogues of fibrin or fragments of fibronectin which have a distinct binding domain for fibrin have been studied. For targeting activated platelets within thrombi, linear and cyclic peptide antagonists of the glycoprotein IIb/IIIa receptor on platelets have been studied, as well as naturally occurring antagonists of this receptor which are found in venoms. Analogues of laminin and thrombospondin which bind to other receptors on platelets have also been tested. There is an approach which uses a peptide to target thrombin which is sequestered within a fibrin clot. Another area of investigation has been to develop an improved radiopharmaceutical for imaging sites of infection and/or inflammation. Peptides which would bind to leukocytes in vivo, such as antagonists to the tuftsin receptor, chemotactic peptides, interleukin-8, or a platelet factor 4 analogue, have been radiolabeled for this purpose. These agents would enable imaging of both infection and inflammation. Development of a radiopharmaceutical for specifically imaging infection has focused on antimicrobial peptides such as human neutrophil defensin, ubiquicidin, human lactoferrin and alafosfalin, which are expected to bind selectively to microorganisms and not to leukocytes. Radiolabeled peptides are also being explored as agents for assessing unstable atherosclerotic plaque (endothelin), amyloid deposits (amyloid beta peptides), and the consequences of diabetes mellitus (human C-peptide).

Imaging pulmonary emboli and deep venous thrombi with 99mTc-bitistatin, a platelet-binding polypeptide from viper venom.

UNLABELLED: An imaging test that could locate both pulmonary emboli (PE) and their source, active deep venous thrombi (DVT), would be valuable in patient management. Bitistatin, an 83-amino-acid polypeptide isolated from Bitis arietans venom, binds avidly to the glycoprotein IIb/IIIa receptor on platelets. The goal of this study was to label bitistatin with 99mTc and assess its potential for imaging thrombi and emboli in vivo. METHODS: Molecular modeling of bitistatin indicated that its primary amines are located on the opposite side of the molecule from the receptor-binding domain. The primary amines were reacted with succinimidyl-4-hydrazino nicotinate hydrochloride to place 2.4 hydrazino nicotinate (Hn) chelating groups per peptide molecule. Hn-bitistatin was labeled by incubation with 99mTc-glucoheptonate to 96 TBq/mmol and then tested for binding to platelets in vitro and for imaging of 24-h-old DVT and PE in a canine model used previously for other thrombus tracers. RESULTS: 99mTc-Hn-bitistatin bound to stimulated platelets with a dissociation constant (Kd) = 32 nmol/L, similar to that of 125I-bitistatin (Kd = 41 nmol/L). In vivo, focal uptake was observed in planar images as early as 30 min (DVT) and 60 min (PE) after injection. Lesion uptake of 99mTc-Hn-bitistatin at 4 h after injection was calculated in terms of percentage injected dose per gram (%ID/g) of tissue and averaged 0.89 %ID/g PE and 0.79 %ID/g DVT. Lesion-to-background ratios averaged 34:1 (PE-to-lung), 18:1 (DVT-to-blood), and 284:1 (DVT-to-muscle). These values were not significantly different from iodinated bitistatin, but uptakes were higher than other tracers tested in the same model. CONCLUSION: 99mTc-Hn-bitistatin retains the functional activity of the iodinated peptide, has higher DVT and PE uptakes than other thrombus tracers in this standardized model, and has target-to-background characteristics suitable for imaging both PE and DVT in a single test.

Tonsillectomy by guillotine is less painful than by dissection.

Most tonsillectomies are carried out by dissection. Only a small minority of otolaryngologists still routinely perform guillotine tonsillectomy. We carried out a prospective study on 86 children undergoing tonsillectomy utilising a standard anaesthetic and analgesic regimen to compare post-operative pain after dissection tonsillectomy and guillotine tonsillectomy using a Popper's hemostatic guillotine. Guillotine tonsillectomy was significantly less painful (P<0.001) than dissection tonsillectomy. The relative risk of experiencing moderately severe to severe pain was 0.36 (95% CI, 0.18-0.72) in the guillotine group. A significant proportion of children experience moderately severe to severe pain despite a comprehensive analgesic regimen confirming that post operative pain remains an important issue after this operation. On the basis of our findings we advocate tonsillectomy by guillotine in children. The less pain that arises within the first 24 h may be particularly important if performing tonsillectomy as a day-case procedure.

Nasal pH measurement: a reliable and repeatable parameter.

The nasal mucosal pH is approximately 5.5-6.5, and increases in rhinitis to 7.2-8.3. This knowledge has not led to the widespread measurement of the nasal mucosal pH as an objective clinical parameter. The purpose of this study was to assess whether repeatable measures of nasal mucosal pH could be obtained in the clinical setting. Fifty-four adults without nasal symptoms were prospectively recruited. Using a semi-disposable antimony pH catheter, the nasal mucosal pH was measured in four specific areas of the nose and each reading repeated three times. The patients' age, sex, smoking habits, nasal anatomical variation and clearest nostril at the time of measurement were also recorded. The data shows that it is possible to obtain reliable and repeatable values for the pH of the nasal mucosa (Spearman-Brown R = 0.84). Analysis shows there is no significant difference between septal and turbinate mucosal pH. Subset analysis implies that nasal mucosal pH is higher in men then women (P < 0.05). The other variables did not affect the nasal mucosal pH significantly.

In vitro platelet binding compared with in vivo thrombus imaging using alpha(IIb)beta3-targeted radioligands.

Radioligands for the alpha(IIb)beta3 integrin on platelets are being studied for their ability to image venous thrombi and pulmonary emboli. One such radioligand, 123I-bitistatin, was previously shown to have higher thrombotic uptake in an animal model than other disintegrins, but the reason for this difference was not clear. The purpose of this study was to evaluate three labeled disintegrins, bitistatin, kistrin and barbourin, to look for in vitro differences in platelet binding which could explain the in vivo behavior. Disintegrins labeled with 121I were compared in vitro for extent of binding to platelets and rates of binding and dissociation. These findings were related to organ distribution and image quality for imaging thrombotic lesions, following administration of 123I-disintegrins in an animal model. Fibrinogen at 8.8 micromol/l was able to displace 125I-barbourin and 125I-kistrin more rapidly from ADP-stimulated platelets, with half-times of 3.5 and 10.7 min, compared with 125I-bitistatin (31.6 min). At equivalent concentrations in whole blood, a higher percentage of bitistatin bound to platelets compared with the other two. In vivo, kistrin and barbourin had significantly lower thrombus:muscle and pulmonary embolus:lung ratios in images compared with bitistatin. There was evidence of more metabolic deiodination of labeled kistrin and barbourin in vivo compared with bitistatin. A surprising finding was that conventional in vitro platelet binding studies did not predict the relative in vivo behavior of labeled disintegrins. The results suggest that labeled bitistatin has improved targeting of thrombi because it is less easily displaced from stimulated platelets, permitting longer lesion retention. It also appears to have a greater association with resting platelets in the blood, which may increase bioavailability and delay metabolic breakdown.

Hearing aids and glue ear.

This study was designed to determine the acceptance and effectiveness of a hearing aid in the management of children with persistent hearing loss due to glue ear (otitis media with effusion [OME]). Forty-eight children with OME, in whom the main symptom was deafness, were treated with a hearing aid instead of surgery and reviewed at 3-monthly intervals over 6-12 months. Seventy-one per cent reported unequivocal satisfaction with the aid. Sixty-five per cent used the aid continuously throughout the day whilst 35% used it only at specific times of need. Ninety-eight per cent noticed a definite improvement in their hearing whilst using the aid and this was confirmed audiometrically in 100%. Disability was considered in terms of speech development and educational achievement. In 66% there had been a subjective decline in these parameters prior to aid prescription. In all but one child significant improvement was made sufficient to alleviate parental and teachers' concern. No children reported significant symptoms due to OME other than deafness and there were no complications of hearing aid usage. At follow-up, however, 13% of children continued to use a hearing aid in an ear in which the OME had resolved. This study has shown that in this preselected group of children with persistent OME and the predominant symptom of deafness, a hearing aid was an effective treatment for their deafness with high acceptance and compliance.

Comparison of iodine-123-disintegrins for imaging thrombi and emboli in a canine model.

UNLABELLED: Disintegrins are peptides found in viper venoms which bind to platelets through the glycoprotein IIb-IIIa receptor. The purpose of this work was to evaluate the ability of disintegrins to image thrombi and emboli in vivo. METHODS: Eight disintegrins (bitistatin, albolabrin, echistatin, eristostatin, kistrin, mambin, halysin and barbourin) were purified from snake venom. After radiolabeling with 123I, disintegrins were tested for their ability to image 24-hr-old experimental deep vein thrombi (DVT) and pulmonary emboli in a canine model. Labeled fibrinogen and platelets were used as controls. Gamma camera imaging was performed during the first 4 hr, after which tissue samples were collected for counting. RESULTS: Of the disintegrins tested, 123I-bitistatin had higher uptake in DVT (0.21 +/- .06% ID/g) than any other disintegrin (0.009-0.036%/g, p < 0.05). Bitistatin had higher DVT-to-blood ratios (9.8 +/- 2.5) than all other disintegrins, 125I-fibrinogen or 99mTc-HMPAO-platelets (p < 0.05). Images of DVT obtained with 123I-bitistatin were focally positive within 1 hr and improved by 4 hr. In pulmonary emboli, the absolute uptake of 123I-bitistatin (0.64 +/- 0.17% ID/g) was higher than all other compounds (p < 0.05), although barbourin had moderate uptake (0.23 +/- 0.11% ID/g) and may also be useful for imaging pulmonary embolism (PE). The uptake of bitistatin in PE was superior to both 125I-fibrinogen (0.18 +/- 0.02% ID/g) (p < 0.05) and 99mTc-HMPAO-platelets (0.14 +/- 0.02% ID/g, p < 0.05). Iodine-123-bitistatin had embolus-to-blood ratios averaging 27 +/- 7, which was higher than platelets, fibrinogen, echistatin, mambin or halysin (p < 0.05). Iodine-123-bitistatin background in lungs, liver and heart were low, which permitted visualization of all pulmonary emboli by 2-4 hr after injection. CONCLUSION: Labeled bitistatin should be investigated further as an agent which may permit rapid imaging of both thrombi and emboli.

Thrombus imaging with technetium-99m synthetic peptides based upon the binding domain of a monoclonal antibody to activated platelets.

UNLABELLED: Monoclonal antibodies which recognize fibrin or platelets have enabled imaging of vascular thrombi, however, early imaging has been difficult because of the slow blood disappearance of even small antibody fragments. It was theorized that it might be possible to synthesize peptides which possess the same thrombus affinity as monoclonal antibodies, but which would leave the blood pool much more rapidly. METHODS: In this study, peptides were synthesized with amino acid sequences based on the primary binding region of the platelet glycoprotein IIb/IIIa-directed monoclonal antibody PAC1. Both termini of the peptides were blocked to prevent rapid proteolysis and a metallothionein-derived sequence was incorporated as a chelating agent for reduced technetium. RESULTS: Technetium-99m-labeled peptides produced images of fresh clots in the jugular veins of rabbits and day-old thrombi in the femoral veins of dogs within 2 hr after injection. In control experiments, a 99mTc-labeled nonspecific peptide failed to produce focal images of thrombus. Another control compound, 99mTc-glucoheptonate, did produce images of fresh clots in rabbits but failed to produce focal images of day-old thrombi. As was hoped, blood clearance of the 99mTc peptides was rapid, with excretion through the kidneys, however, none of the peptides studied had better thrombus-to-blood ratios than iodinated fibrinogen and all had significantly lower deposition in the thrombus. CONCLUSION: Using labeled synthetic peptides appears to be technically feasible but the absolute binding to thrombus is not yet sufficient for reliable imaging of pre-existing thrombi.

Bladder permeability in interstitial cystitis is similar to that of normal volunteers: direct measurement by transvesical absorption of 99mtechnetium-diethylenetriaminepentaacetic acid.

Bladder permeability was directly measured with the radionuclide used clinically for detecting vesicoureteral reflux (99mtechnetium-diethylenetriaminepentaacetic acid, 99mTc-DTPA) in 10 interstitial cystitis patients diagnosed according to National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases criterion and compared to 9 sex matched, symptom-free, normal volunteers. After functional bladder capacity was determined (capacity at which the patient demands fluid inflow to stop), the bladder was emptied and 5 mCi. 99mTc-DTPA in 10 ml. of saline were infused followed by normal saline to 80% of functional capacity. This was done to normalize the patients to the same low bladder pressure, since previous studies of rabbits indicated that bladder permeability is low and not significantly different at 20% and 60% of anesthetized bladder capacity (defined as the volume producing an intravesical pressure of 20 cm. water). Radioactivity of 1 ml. serum specimens taken at 0, 2, 15 and 30 minutes after radionuclide infusion was determined in a gamma counter, corrected for radioactive decay and converted to per cent of instilled dose per whole body based on blood volume estimated from body weight for each individual. There was considerable interindividual variability in the absorption between the patients and the volunteers. Analysis of variance of these data showed no statistically significant difference between the patients and controls at any time sampled. These results indicate that while some interstitial cystitis patients have a more permeable bladder than others, the same is true for normal, symptom-free volunteers. Thus, the concept of increased bladder permeability in interstitial cystitis is not supported by this direct measurement of bladder permeability.

Scintigraphic methods for detecting vascular thrombus.

Vascular thrombosis is a common and potentially life-threatening condition, but objective diagnosis is highly desirable before anticoagulant therapy is instituted. Existing nonscintigraphic modalities such as contrast venography and ultrasonography can image venous morphology but cannot reliably indicate the hematologic state of thrombi. Radiopharmaceuticals that bind specifically to fibrin or platelets afford the ability to determine whether a thrombus is hematologically active and therefore likely to propagate and/or embolize. Ideally, the test should produce a diagnostic result within a few hours and be capable of imaging thrombi that are several days old. A number of radiolabeled materials have been tested for their ability to bind to and permit scintigraphic detection of thrombi. These have included labeled fibrinogen, autologous platelets, monoclonal antibodies, fibrin fragment E1, plasminogen activators and synthetic peptides that mimic the molecular recognition units of antibodies. The current status of investigation of each of these radiopharmaceuticals is reviewed in this article.

An amalgam tattoo of the soft palate: a case report with energy dispersive X-ray analysis.

A pigmented lesion of the soft palate was excised to exclude melanoma. The histology suggested an amalgam tattoo which was confirmed on energy dispersive X-ray analysis by the detection of silver and copper. This represents a very rare mimic of melanoma of the soft palate.