A mixed thyroglossal cyst.

The case is described of a boy who presented at age six months with symptoms and signs of a thyroglossal cyst, which seemed to be confirmed by ultrasound findings. The cyst slowly increased in size, and eventually the patient underwent Sistrunk's procedure at age four years. Histology showed that the cyst was in fact a mixed thyroglossal and dermoid cyst. This casts doubt on the doctrine that thyroglossal cysts and dermoid cysts are anatomically and histologically separate entities, and strengthens the view that these cysts should be more appropriately named 'thyroglossal abnormalities'.

Caustic soda ingestion -- a case presentation and review of the literature.

We present a case report of a 2-year-old child with a hypopharyngeal stricture secondary to caustic soda ingestion. We discuss the initial and long-term management of caustic soda ingestion. In this case the hypopharynx was successfully reconstructed using a pedicled pectoralis major flap. We demonstrate the versatility of this flap, which is traditionally known for its use in adult head and neck surgery.

Management and outcome of choanal atresia correction.

OBJECTIVES: Outcome analyses of factors that may either maximize success or predict a better outcome following choanal atresia correction. METHODS: A retrospective review of children undergoing choanal atresia correction at Great Ormond Street Hospital for Children, London between January 1990 and April 1998. Children with unilateral or bilateral choanal atresia were studied. In all cases, correction was by a transnasal approach under endoscopic control. A 120 degrees Hopkins rod telescope was used to visualize the atretic plate from the nasopharynx. Straight urethral sounds were used to perforate the plate followed by use of an air drill to remove the bony component. Portex endotracheal tubes were subsequently inserted as nasal stents. RESULTS: Sixty-five children (19 M, 46 F: age range 1 day to 17 years) presented with choanal atresia and the outcomes for 46 were included in the study. Twenty-six patients (40%) had other major anomalies. In children with unilateral atresia neither duration of stenting nor presence of facial anomalies had an impact on outcome. Of those children with bilateral choanal atresia and associated facial anomalies (n=9), 56% were asymptomatic following correction. In children with isolated bilateral choanal atresia (n=19), 74% were asymptomatic following correction; 29% (n2.3 kg (n3. 5 mm (n=6) had an 83% chance of a good outcome. Those patients stented with a tube

Maxillary myxoma: a rare midfacial mass in a child.

The case of a maxillary myxoma in a 13-month-old child is presented. This case highlights the difficulties associated with managing such cases. The tumour was found at operation to be unencapsulated and infiltrative. This was contrary to the preoperative CT scan findings and necessitated a change from a sublabial to a lateral rhinotomy approach. This case illustrates a potential pitfall of CT scanning in such cases: it is likely that a MRI scan would have demonstrated the invasive nature of this tumour. To the authors' knowledge this is the second youngest reported case of maxillary myxoma in the literature.

Cimetidine treatment for recurrent respiratory papillomatosis.

Effective adjuvant treatment for recurrent respiratory papillomatosis (RRP) is at present limited to alpha-interferon, which may have significant side effects including rebound growth of papillomata following its withdrawal, is given by injection and is expensive. High dose cimetidine is known to have immunomodulatory side effects and has been reported as a useful treatment for cutaneous warts. We report a case of very advanced RRP with tracheo-bronchial-pulmonary involvement treated with adjuvant cimetidine at a dose of 40 mg/kg for 4 months. The patient enjoyed a remarkable improvement in her clinical condition following treatment. The literature regarding cimetidine treatment for cutaneous warts is reviewed.

Otologic and laryngologic manifestations of mucopolysaccharidoses after bone marrow transplantation.

INTRODUCTION: Children with mucopolysaccharidosis have significant functional impairment of a number of systems because of deposition of glycosaminoglycans. The otolaryngologic system is affected, resulting in conductive and sensorineural hearing loss and voice abnormality. METHOD: Eleven children who had undergone bone marrow transplantation had their hearing and voices assessed. Unmatched data from patients who had not undergone transplantation were collected for nonstatistical comparison. RESULTS: The hearing loss in children who had undergone bone marrow transplantation was variable but on average was less severe than in the younger children who had not undergone transplantation. The incidence of otitis media with effusion was diminished in the transplanted group. Approximately half had normal voices. DISCUSSION: Diminution of the progression of hearing loss and voice abnormality probably occurs in patients after treatment by bone marrow transplantation.

Auditory brainstem responses after radiotherapy for nasopharyngeal carcinoma.

The effect of irradiation for nasopharyngeal carcinoma on auditory brainstem responses and hearing was investigated in 19 otologically normal patients undergoing standard fractionated megavoltage radiotherapy. Auditory brainstem responses and pure tone audiometry were performed before radiotherapy, and at 3 and 12 months after completion of radiotherapy. There were no significant changes in the wave I-III and III-V interpeak intervals, or in sensorineural hearing thresholds (bone conduction at 4 kHz and average of bone conduction at 0.5, 1, 2 and 4 kHz), after radiotherapy. In contrast to previous studies, we found no evoked potential evidence of subclinical brainstem damage arising from irradiation for nasopharyngeal carcinoma.

The developing role of a paediatric voice clinic: a review of our experience.

OBJECTIVE: We report our experience in developing a paediatric voice clinic within a tertiary otolaryngology department and describe the emerging role of this specialized clinic. MATERIALS: Currently our referral base is divided between other otolaryngologists within our department who require voice assessment as part of the pre- or post-operative management of laryngeal disorders (e.g. cysts, webs, vocal fold palsies, laryngo-tracheal reconstruction) and other professionals within our hospital who require characterisation of voice within the broader task of defining medical conditions in which voice abnormalities exist (e.g. mucopolysaccharidoses, functional dysphonias). METHODS: The patients were assessed by a team consisting of a paediatric laryngologist and a speech and language therapist. Each patient underwent a perceptual voice assessment and qualitative voice assessment using electrolaryngography. Direct visualisation was attempted and methods of and suitability for, such examination are discussed. RESULTS: Our experience is reviewed and guidelines for the establishment of a paediatric voice clinic are presented.

Prevalence and prognostic significance of tumor-associated tissue eosinophilia in nasopharyngeal carcinoma.

BACKGROUND: Tumor-associated tissue eosinophilia (TATE) has been associated with an improved prognosis in a variety of neoplasms. METHODS: Diagnostic biopsy specimens from 96 patients with nasopharyngeal carcinoma (NPC) were reviewed for the presence of TATE by an observer blinded to the patients' clinical histories. Comparisons between patients with and without TATE with respect to the probabilities of local recurrence, distant metastasis, and survival were performed using the log rank test on Kaplan-Meier product-limit estimates and the Cox proportional hazards model. RESULTS: The prevalence of TATE in these patients was 32%, and was not significantly associated with local recurrence, distant metastasis, or survival. CONCLUSIONS: These results are discordant with those of studies in other tumor models, although comparison is hampered by varying definitions of TATE. The differing results may be due to variations in the degree of activation of the eosinophils present in TATE in different tumors.

Swallowing in motor neurone disease.

Ninety-two patients with motor neurone disease have been assessed clinically and radiologically for evidence of swallowing problems. At the time of examination, moderate or severe swallowing difficulty was present in 89% of those whose disease had presented as bulbar palsy, in 45% of those in whom the disease began many months before as progressive muscular atrophy and in 29% of those with amyotrophic lateral sclerosis. Patients with more severe swallowing symptoms appeared more likely to have abnormal findings on videofluoroscopy overall. However, not all patients with an abnormal radiological picture had swallowing difficulties. It is suggested that radiological signs should only be used within the context of clinical symptoms and signs in the selection of patients for palliative surgery. Thirteen patients with pseudobulbar symptoms and signs had a cricopharyngeal myotomy performed: two suffered major post-operative complications. However, the satisfaction rate was 89% and we recommend cricopharyngeal myotomy for such patients. Pharyngostomy was performed for seven patients unable to initiate swallowing, six had post-operative complications.

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.

Benign thyroid disease and vocal cord palsy.

The case notes of 2453 consecutive patients admitted for thyroid surgery and with successful preoperative laryngoscopy were examined retrospectively. Of the 2408 patients who had not had previous operations on the gland, 2321 proved to have benign pathology. A total of 29 patients had a preoperative vocal cord palsy of which 22 were associated with benign disease. Return of cord movement after surgery occurred in 89% of the patients with a benign goitre. We advocate routine preoperative laryngoscopy to detect vocal cord paresis. Such a finding with a goitre does not necessarily indicate malignancy. The recurrent laryngeal nerve should therefore be identified at surgery and preserved to allow for recovery of vocal cord movement.

Day case adenoidectomy.

The Audit Commission recommends that more day surgery be undertaken in the Health Service. In a prospective study of 62 children undergoing adenoidectomy one major complication commenced within 2 hours of surgery. Of 15 minor complications, 78% occurred within 6 hours of surgery; they did not herald later major complications. Day adenoidectomy can safely be performed if patients remain in hospital for 6-8 hours post-operatively and then fulfil the following discharge criteria: they are apyrexial, eating, drinking and with no signs of haemorrhage. This will not result in a significant increase in workload for general practitioners. Day adenoidectomy for medically and socially appropriate patients increases our day surgery figures by 74% to 43% of the routine paediatric ENT caseload. There are immediate benefits to patients but the potential economic benefits to the Health Service will not be felt unless these children are treated in a designated Day Case Unit.

The role of CT imaging in the management of chronic suppurative otitis media.

CT imaging of the temporal bone is highly predictive of the presence of cholesteatoma but its value in the routine management of cholesteatoma has not been assessed. We aimed to establish the indications for CT imaging in CSOM by a prospective study of patients suspected of having cholesteatoma. The patients were assessed clinically and a management plan chosen; this was later adjusted, if indicated, on the basis of radiological findings. Surgical findings were recorded and correlation with CT appearances evaluated. Twenty patients completed the study. CT altered the management plan in 10 and was considered helpful in a further 6. We recommend its routine use in children, medically unfit patients, only or better hearing ears, patients in whom the tympanic membrane cannot be adequately visualized, patients who have had previous mastoid surgery whose operative records are available and patients with intratemporal or intracranial complications of disease.

The value of head dressings for middle ear surgery.

A prospective trial was performed to ascertain the value of head dressings in the post-operative management of patients undergoing middle ear and mastoid surgery. One hundred consecutive patients were randomly allocated to a head dressing or no head dressing group after wound closure. Nine patients in the head dressing group developed a wound complication as opposed to four patients in the no head dressing group. The application of a pressure dressing following middle ear and mastoid surgery is unnecessary and may contribute to increased wound morbidity.

Pseudomonal supraglottitis occurring in a patient with profound neutropenia secondary to virus-associated haemophagocytic syndrome.

We present a case of virus-associated haemophagocytic syndrome following Epstein-Barr virus infection in which a fulminant pseudomonal supraglottitis developed. Increasingly, unusual pathogens have been found in immunocompromised patients. This is the first reported case of pseudomonal supraglottitis.

CSF drainage in patients with posterior fossa tumours.

The management of hydrocephalus secondary to a posterior fossa tumour is controversial. We audited recent practice with a retrospective analysis of 287 consecutive patients undergoing posterior fossa exploration for tumour. 85 shunts and 112 external ventricular drains (EVD) were placed. The overall CNS infection rate in the series was 6%. There was a significantly higher (p less than 0.01) infection rate in patients who had a drainage procedure, and a trend towards higher infection rates in patients with two drainage procedures. Early infection rates with EVDs and shunts were the same (7%). One third of patients with hydrocephalus had pre-operative drainage, a third had per-operative drainage but only a quarter required a permanent shunt. The majority of patients will not require a permanent shunt and where temporary CSF diversion is required EVD is reasonable.

Audit of stapedectomy results in a teaching hospital.

The number of stapedectomies performed annually has declined since 1963. Also, surgery has become available at an increasing number of centres, resulting in a further fall in the number of such operations performed in teaching hospitals. Several studies have suggested benefit might be gained, both by patients and by otology as a speciality, from limiting training to post-graduates who show an aptitude for otology, and concentrating surgery in a small number of specialized centres. We report a series of 179 patients who had stapedectomy performed for otosclerosis in a teaching hospital. We have retrospectively compared the audiological outcome and complication rates for consultants and surgical trainees. For the two groups, there is no significant difference in postoperative hearing levels and complication rates are similar. Our success rate is comparable to other major series. We conclude that stapedectomy is a safe procedure to teach adequately experienced and supervised trainees.

Metastatic meningioma in the neck.

Although meningiomas represent 15 per cent of tumours of the central nervous system, they rarely metastasize. A case is presented in which metastasis to a cervical lymph node occurred, together with local recurrence, nine years after initial diagnosis and treatment. This case serves to illustrate that malignant meningioma is a rare cause of a neck mass.