Septotomy: a useful approach to the anterior maxillary sinus.

In endonasal surgery, approaching the anterior maxillary wall via the ipsilateral nostril is difficult. It is necessary to have good visual and instrument control when removing lesions such as inverted papilloma. We describe an approach through a temporary septotomy which provides good access from the contralateral nostril. The contralateral mucoperichondrial incision is anterior and the ipsilateral one posterior. The cartilage is hinged superiorly. There is minimal chance of perforation.

Vestibular schwannoma: role of conservative management.

OBJECTIVE: To assess the outcome of conservative management of vestibular schwannoma. STUDY DESIGN: Observational study. SETTING: Tertiary referral centre. PATIENTS: Four hundred and thirty-six patients with vestibular schwannoma (490 tumours), including 327 sporadic tumours and 163 tumours in 109 patients with neurofibromatosis type two. MAIN OUTCOME MEASURES: The relationship of tumour growth to tumour size at presentation, and to certain demographic features. RESULTS: The initial tumour size was significantly larger in the neurofibromatosis type two group (11 mm) than in the sporadic vestibular schwannoma group (5.1 mm). In both groups, 68 per cent of tumours did not grow during follow up (mean 3.6 years; range one to 14 years). The mean growth rate was 1.1 mm/year (range 0-15 mm/year) for sporadic tumours and 1.7 mm/year (range 0-18 mm/year) for neurofibromatosis type two tumours. The tumour growth rate correlated positively with tumour size in the sporadic tumour group, and correlated negatively with age in the neurofibromatosis type two group. CONCLUSION: Two-thirds of vestibular schwannomas did not grow. Radiological surveillance is an acceptable approach in carefully selected patients. Once a sporadic vestibular schwannoma reaches 2 cm in intracranial diameter, it is likely to continue growing. We do not recommend conservative management for sporadic tumours with an intracranial diameter of 1.5 cm or more. Vestibular schwannoma management is more complex in patients with neurofibromatosis type two.

Transtympanic gentamicin treatment using Silverstein MicroWick in Ménière's disease patients: long term outcome.

OBJECTIVE: To assess the long term outcome of gentamicin inner-ear perfusion using the Silverstein MicroWick in the treatment of Ménière's disease. STUDY DESIGN: Retrospective questionnaire survey of patients and review of medical records. SETTING: A district general hospital. PARTICIPANTS: All 15 patients who completed a minimum follow up of at least 24 months were included. MAIN OUTCOME MEASURES: Subjective symptoms, change in hearing thresholds and Glasgow benefit inventory scores. RESULTS: Based on the American Association of Otolaryngology-Head and Neck Surgery (1995) guidelines for reporting, 80 per cent of respondents obtained class A vertigo control and 20 per cent obtained class B control. Respondents' functional level improved from pre-operative levels of between three and six to post-operative levels of between one and three. Three respondents had pre-operative 'dead ears' and one developed the condition post-operatively. Hearing deteriorated further in three respondents, improved in two and remained unchanged in the rest. Respondents with class A control demonstrated improved quality of life, with a mean Glasgow benefit inventory total score of +34. CONCLUSION: Transtympanic gentamicin therapy via the Silverstein MicroWick results in good vertigo control. Patients should however be made fully aware of the risk of hearing deterioration.

Homeopathic Arnica montana for post-tonsillectomy analgesia: a randomised placebo control trial.

OBJECTIVE: To evaluate the efficacy of Homeopathic Arnica in reducing the morbidity following tonsillectomy. METHODS: Randomised double blind, placebo controlled trial at a tertiary referral centre. 190 patients over the age of 18 undergoing tonsillectomy were randomised into intervention and control groups receiving either Arnica 30c or identical placebo, 2 tablets 6 times in the first post-operative day and then 2 tablets twice a day for the next 7 days. The primary outcome measure was the change in pain scores (visual analogue scale) recorded by the patient on a questionnaire over 14 days post-operatively; Secondary outcome measures were: analgesia consumption, visits to the GP or hospital, antibiotic usage, the day on which their swallowing returned to normal and the day on which they returned to work. RESULTS: 111 (58.4%) completed questionnaires were available for analysis. The Arnica group had a significantly larger drop in pain score from day 1 to day 14 (28.3) compared to the placebo group (23.8) with p < 0.05. The two groups did not differ significantly on analgesic consumption or any of the other secondary outcome measures (number of post-operative visits to GP, use of antibiotics and secondary haemorrhage readmissions). CONCLUSION: The results of this trial suggest that Arnica montana given after tonsillectomy provides a small, but statistically significant, decrease in pain scores compared to placebo.

Metastatic carcinoma mimicking a facial nerve schwannoma: the role of computerized tomography in diagnosis.

Secondary deposits in the temporal bone are uncommon but well recognized. Such tumours may involve the facial nerve by direct extension of the destructive process into the fallopian canal. We present a rare case of metastasis from a breast carcinoma in the facial nerve itself, involving the nerve in the internal acoustic meatus with extension into the labyrinthine segment, the first genu and into the middle-ear segment. The rest of the temporal bone was not involved. The lesion resembled a facial schwannoma on a routine magnetic resonance (MR) image. The diagnosis was confirmed after a post-operative computed tomography (CT) scan showed another separate secondary deposit in the basisphenoid. Histology was consistent with secondary tumour from a breast carcinoma. The case highlights the importance of keeping a high degree of suspicion for metastatic tumours in patients with a previous history of malignancy and the usefulness of CT scan in the evaluation of such cases.

Solid-state phase transitions of AG337, an antitumor agent.

The object of this investigation was to perform detailed solid-state characterization studies on the different solid forms of AG337 and to determine the conditions of their interconversions. Solid-state characterization was done using differential scanning calorimetry (DSC), thermogravimetric analysis (TGA), hot stage microscopy, Karl Fischer titrimetry, ambient and variable temperature X-ray powder diffractometry (XRD) and TGA coupled with FTIR (TGA/FTIR). In addition to five polymorphic forms of the anhydrate (I alpha to I epsilon), a hemihydrate (C14H12N4OS.2HCl.0.5H2O, II), a monohydrate (C14H12N4OS.2HCl.H2O; III), as well as a dihydrate (C14H12N4OS.2HCl.2H2O; IV) were identified. The 'as is' anhydrate, I alpha, resisted water uptake until stored at 98% RH (room temperature), where it transformed directly to IV, II and III transformed to IV at RH values > or = 7.6 and 84% respectively. Heating II and III to 130 degrees C in the variable temperature XRD resulted in the formation of I beta and I gamma respectively. On the other hand, I delta and I epsilon were obtained when II and III were respectively stored at 60 degrees C under vacuum. Variable temperature XRD, by providing information about the solid-state as a function of temperature, assisted in the interpretation of the DSC and TGA results. TGA/FTIR provided direct evidence that the thermal events observed in the temperature ranges of 25-150 degrees C and 200-250 degrees C were due to loss of water and loss of hydrogen chloride respectively. In addition to the conventional analytical techniques such as XRD, DSC, TGA and KFT, two other techniques, (variable temperature XRD and TGA/FTIR), were very useful in these solid-state characterization studies.