Audiologist-led screening of acoustic neuromas in patients with asymmetrical sensorineural hearing loss and/or unilateral tinnitus: our experience in 1126 patients.

OBJECTIVE: To determine whether patients within an otolaryngology department presenting with asymmetrical sensorineural hearing loss and/or unilateral tinnitus can be safely and cost-efficiently screened for acoustic neuroma by audiologists as a first or only point of contact. METHODS: A prospective case series and cost analysis were conducted at a tertiary referral centre. Between April 2013 and March 2017, 1126 adult patients presented to the audiology department with asymmetrical sensorineural hearing loss and/or unilateral tinnitus. All were screened for acoustic neuroma with magnetic resonance imaging, based on pre-determined criteria. The main outcome measure was the presence of acoustic neuroma or other pathology on magnetic resonance imaging. RESULTS: Twenty-five patients (2.22 per cent) were found to have an acoustic neuroma (size range: 3-20 mm) and were referred to the otolaryngologist for further assessment. The remaining patients were appropriately managed and discharged by the audiologists without ENT input. This resulted in an overall cost saving of £164 850. CONCLUSION: Patients with asymmetrical sensorineural hearing loss and/or unilateral tinnitus can be safely screened for acoustic neuroma and independently managed by audiologists as a first or only point of contact, resulting in considerable departmental cost savings.

Bilateral glossopharyngeal nerve palsy following tonsillectomy: a very rare and difficult complication of a common procedure.

OBJECTIVES: Tonsillectomy is one of the most commonly performed otolaryngological procedures. Bilateral palsy of the glossopharyngeal nerve is an exceedingly rare complication that can result in significant morbidity. This case report aimed to raise awareness of this complication and outline management strategies. CASE REPORT: A 31-year-old woman who underwent routine tonsillectomy presented with progressive numbness of the palate, dysgeusia, xerostomia, paraesthesia of the tongue and the feeling of something in her throat within 2 weeks of surgery. She reported the post-operative onset of snoring. Examination revealed a symmetrically low, 'dropped' soft palate. Over time, her symptoms have lessened, but dysgeusia and snoring remain. CONCLUSION: The position of the glossopharyngeal nerve in the tonsillar bed makes it prone to injury during tonsillectomy, especially if 'hot' methods are used. Bilateral injury can result in significant morbidity that can be difficult to treat. Patients should be warned about this risk and care should be taken to minimise it.

The intra-operative incidence of Fallopian canal dehiscence during surgery for cholesteatoma: a prospective case-control study and review of the literature.

OBJECTIVE: To investigate Fallopian canal dehiscence (FCD) during cholesteatoma surgery. STUDY DESIGN: Prospective case-control study. PATIENTS: Four hundred and one patients with cholesteatoma and 172 with otosclerosis. INTERVENTIONS: Therapeutic. SETTING: District general hospital. MAIN OUTCOME MEASURES: (i) Intra-operative incidence of FCD during (a) surgery for cholesteatoma versus a homogeneous control group (patients with otosclerosis); (b) revision surgery for cholesteatoma as compared to primary surgery. (ii) Intra-operative incidence of a fistula if FCD is present. RESULTS: Data were prospectively collected and analysed using chi-square tests. FCD was found in 19% of cases versus 5.2% of controls. Intra-operative incidence of (i) FCD during cholesteatoma surgery versus otosclerosis surgery was statistically very highly significant (P < 0.0001, OR = 5.43); (ii) FCD during revision versus primary cholesteatoma surgery was not statistically significant (P = 0.83); and (iii) encountering a fistula in the presence of FCD during cholesteatoma surgery was statistically very highly significant (P < 0.0001, OR = 6.71). CONCLUSIONS: A surgeon is more likely to encounter FCD during cholesteatoma surgery than in stapes surgery. If during cholesteatoma surgery FCD is found, then a fistula is also more likely to be present, mainly of the semicircular canal. The incidence of FCD is not increased in revision surgery. These findings are very relevant for any otologist undertaking cholesteatoma surgery.

Consultant-led, multidisciplinary balance clinic: process evaluation of a specialist model of care in a district general hospital.

OBJECTIVE: A specialist balance clinic to effectively deal with dizzy patients is recommended by ENT-UK. We audit the patient pathway before and following the introduction of a consultant-led dedicated balance clinic. DESIGN: Process evaluation and audit. SETTING: ENT outpatients department of a district general hospital. MAIN OUTCOME MEASURES: The journey of dizzy patients seen in the general ENT clinic was mapped from case notes and recorded retrospectively. A consultant-led, multidisciplinary balance clinic involving an otologist, a senior audiologist and a neurophysiotherapist was then set up, and the journey was prospectively recorded and compared with that before the change. RESULTS: Of the 44 dizzy patients seen in the general clinic, 41% had further follow-up consultations; 64% were given definitive or provisional diagnoses; 75% were discharged without a management plan. Oculomotor examination was not systematically performed. The mean interval between Visits 1 and 2 was 8.4 weeks and the mean number of visits was 3. In the consultant-led dedicated balance clinic, following Visit 1, only 8% of patients required follow-up; 97% received definitive diagnoses, which guided management; all patients left with definitive management plans in place. In all patients, oculomotor assessment was systematically performed and all patients received consultant and, where necessary, allied healthcare professional input. CONCLUSIONS: By standardising the management experience for dizzy patients, appropriate and timely treatment can be achieved, allowing for a more seamless and efficient patient journey from referral to treatment. A multidisciplinary balance clinic led by a consultant otologist is the ideal way to achieve this.

Salivary gland pathology in the paediatric population: implications for management and presentation of a rare case.

INTRODUCTION: Salivary gland pathology in the paediatric population is rare and can present management challenges regarding both investigation and treatment. METHOD: Case report and review of available literature. RESULTS: A seven-year-old, fit, well girl presented with a two-month history of a painless mass over the left parotid area. Ultrasonography confirmed the presence of a well-defined, 1.5 × 2 cm, predominantly solid lesion with minor internal cystic spaces arising from the superficial part of the gland. Magnetic resonance imaging showed no invasion of the deep lobe or skeletal erosion. Superficial parotidectomy was performed via a facelift incision. Histopathology confirmed a diagnosis of pleomorphic adenoma. Review of the literature emphasised important differences in managing this pathology in the paediatric population when compared with adults. CONCLUSION: We present the youngest reported case of a pleomorphic adenoma of the parotid gland, detail its management, and discuss the general approach to parotid pathology management in the paediatric population.

The case for mistletoe in the treatment of laryngeal cancer.

INTRODUCTION: Complementary and alternative medicine usage, though rising, remains largely devoid of a sound scientific basis; however, there is increasing evidence to support its use in cancer therapy. AIM: To present the case of a patient with laryngeal carcinoma who made a full recovery following mistletoe therapy, despite failing to respond to chemoradiotherapy and salvage laryngectomy. DESIGN: Case report with relevant literature review. RESULTS: The patient developed extensive, unresectable stomal recurrence, and it was deemed appropriate to supply palliative care only. Following treatment with mistletoe extract injections after palliative radiotherapy, he recovered fully and was eventually discharged from care. CONCLUSION: The benefit of mistletoe in laryngeal cancer treatment requires further investigation, and might be considered in selected patients, as an adjunct or when other conventional therapies have failed.

The role of caffeine in otorhinolaryngology: guilty as charged?

Caffeine is implicated as causing or aggravating numerous otorhinolaryngological conditions, including tinnitus, Ménière's disease, laryngopharyngeal reflux, globus pharyngeus and dysphonia. We address caffeine's effects in such conditions and to determine whether such implications are founded. The defined search limits of data sources included human trials and either randomised control trials, meta-analyses, editorials, letters, clinical trials, case reports, comments or journal articles over the last 40 years. MEDLINE, EMBASE and CINAHL databases were searched using 'otorhinolaryngological diseases' and 'caffeine' as a duplicate filter. PubMed databases were searched using 'caffeine' in combination with 'tinnitus', 'Ménière's', 'vertigo', 'motion sickness', 'imbalance', 'vestibular migraine', 'voice', 'vocal hygiene', 'reflux', 'ear', 'nose', 'throat' and 'head neck cancer', respectively. Searches were not limited to the English language. MEDLINE, EMBASE and CINAHL database searches identified 417 papers. Of these, 200 abstracts were chosen for further scrutiny, following which 30 full manuscripts were chosen for full review. The PubMed database search identified 275 abstracts of which 33 were reviewed. Of the total 692 studies searched, 63 studies were reviewed and 36 were finally used. At present, there is little evidence in the literature to support the notion that caffeine causes or aggravates otorhinolaryngological conditions. In tinnitus, its withdrawal may actually worsen symptoms whereas in motion sickness, there is some clinical evidence for its benefit. More research is needed into the role caffeine plays in otorhinolaryngological conditions to allow clinicians to give informed advice to their patients.

Plasmacytoma of the atlas presenting as hoarseness: a rare cause of unilateral vocal fold palsy.

INTRODUCTION: Solitary bone plasmacytoma is a rare haematological malignancy that can present in a variety of ways. This study aimed to present a case of plasmacytoma of the atlas, as a rare cause of unilateral vocal fold palsy. METHOD: Case report. RESULTS: Following diagnosis via imaging and direct biopsy through the posterior pharyngeal wall, the patient was referred to the haematologists for further treatment of his plasmacytoma. CONCLUSION: Solitary bony plasmacytoma of the cervical spine is a rare haematological malignancy. Its presentation with a unilateral vocal fold palsy has not been previously described.

Internet and e-mail use in ENT: a survey of patient usage and satisfaction.

Nowadays, internet and e-mail are important modes of communication and information. This paper seeks to determine internet usage as a source of health information amongst ENT patients and to investigate whether patients prefer to communicate primarily with the hospital via e-mail. The method used is a questionnaire study and 201 patients attending an ENT clinic completed questionnaires over 2 weeks in December 2010. Of those with internet access (85%), 37% had used it for health information prior to their appointment; 90% rated the information between average and excellent; over half stated they would like doctor-recommended websites. Overall, 8% had previously used e-mail to communicate with healthcare professionals, but 50% stated that they wished to use e-mail in the future. ENT patients are becoming increasingly computer-literate. As healthcare professionals, we must do more to incorporate the internet as a source of reliable healthcare information. Properly implemented, e-mail can become an invaluable method of communication with patients.

Visual loss following head and neck surgery.

INTRODUCTION: Non-arteritic ischaemic optic neuritis is a known post-operative complication of ophthalmological and maxillofacial surgery, but has not been widely described as a potential consequence of head and neck surgery. AIM: To highlight non-arteritic ischaemic optic neuritis as a potential risk in patients undergoing head and neck surgery. SUBJECT AND METHOD: Case report of a 60-year-old man undergoing total laryngectomy and bilateral neck dissection for laryngeal squamous cell carcinoma. RESULT: On day 14 post-operatively, the patient suffered substantial oral bleeding secondary to an internal jugulo-neopharyngeal fistula. Following emergency haemostatic measures, the patient was immediately aware of visual disturbances. The ophthalmologists concluded that these were due to non-arteritic ischaemic optic neuritis, caused by acute hypoxaemia secondary to substantial blood loss. CONCLUSION: The prognosis of non-arteritic ischaemic optic neuritis is poor. Thus, it is crucial that otolaryngologists are aware of this complication of head and neck surgery, as immediate diagnosis and treatment can help prevent worsening visual loss.

Traditional and complementary and alternative medicines make for unwilling bedfellows in the management of cancer: a case report with a tragic outcome.

BACKGROUND: Complementary and alternative medicine is very much in the public arena as a treatment option. The pharmacodynamics of most complementary and alternative medicines are not well understood, and some can lead to significant adverse drug interactions. This report aims to present the case of a cancer patient who abandoned traditional medicine in favour of complementary and alternative medicine. METHOD: Case report. RESULTS: The patient refused potentially curative adjuvant radiotherapy for his oral cavity carcinoma following surgery, and eventually succumbed to disease. CONCLUSION: Recently, there appears to be much public awareness of and empathy for complementary and alternative medicine. Healthcare professionals should be aware of such therapies so that they can advise their patients in an informed manner. The role of such therapies in benign conditions may not be as critical as that in malignancy, where life-saving conventional treatment may be abandoned in favour of complementary and alternative medicine, with consequent loss of life.

Unilateral blindness secondary to acute sphenoid sinusitis.

OBJECTIVES: To highlight a rare scenario where a delay in diagnosis caused unilateral blindness. CASE REPORT: A 45-year-old Aboriginal woman with a history of non-Hodgkin's lymphoma presented with a severe left-sided headache, pyrexia and positive blood cultures. Following admission, the patient rapidly developed unilateral blindness, but did not inform her physician until 21 hours after onset. High-resolution CT scanning of the sinuses showed erosion of the bony covering of the optic nerve. Sinus surgery was performed. RESULTS: Despite the discovery of pus under considerable pressure, and clearing the sphenoid sinus of pus and debris, vision was not restored, even at 2-month follow-up. CONCLUSIONS: Two pathological processes are postulated here: that erosion of the bony optic canal allowed the optic nerve to be exposed, allowing the ensuing sinusitis to cause irreversible nerve ischemia, and immunosuppression meant the patient's immune response was inadequate to cope with the sinusitis, with devastating effects.

An unusual myofibroblastic proliferation of the pinna.

INTRODUCTION: Myofibrosis of the ear is rare. Myofibromas are mesenchymal tumours which usually present in infancy but have been reported sporadically in adults. OBJECTIVE: To present a rare case of trauma as a cause of pinnal myofibrosis. DESIGN AND METHOD: Case report. A 29-year-old soldier suffered repeated trauma from helmet wear and sports, and presented to our clinic with an exquisitely painful lump in the anti-helix of the pinna. RESULTS: The lump was excised uneventfully. Pathology revealed a reactive myofibroblastic proliferation which, given the history of trauma, raised the possibility of a florid cellular repair process. The main differential diagnosis was myofibroma. Immunohistochemistry was used to exclude other possible causes. CONCLUSION: No similar case has previously been reported. The aetiology of myofibroma is unclear, but repeated trauma may be a trigger. Histological and immunohistochemical analysis are recommended when the diagnosis is ambivalent.

The follow-up of patients with head and neck cancer: an analysis of 1,039 patients.

In all cancer specialities, there has been much debate about the best follow-up regime. The provision of a service that meets high standards whilst being cost-effective is increasingly pertinent. The objectives of the study were to examine: whether routine follow-up facilitates early diagnosis and recurrence; whether there is a cohort of patients who require a more intensive follow-up regime; whether follow-up should be customised to individual patients. A total of 1,039 consecutive outpatient consultations were prospectively analysed in a multicentre study. All adult patients who had undergone multidisciplinary, multimodality management for head and neck cancer were included. The case mix was representative of all head and neck tumour sites and stages. Suspicion of recurrence was noted in 10% (n = 96/951) of patients seen routinely. This rose to 68% (n = 60/88) for the subset of patients who had requested an appointment. Most recurrences were found within the first follow-up year (n = 64/156, 54%). Only 0.3% (n = 3/1,039) of asymptomatic patients attending routine appointments were suspected of having a recurrence, and two (0.2%) were found to have an actual recurrence following investigation. Of the total number of patients reporting a new suspicious symptom, recurrence was suspected in 56% (n = 152/270). Patients thus had a 98.1% sensitivity to raising suspicion for a recurrence based on the reporting of new symptoms with a 99.6% negative predictive value. Our data show that the efficiency of the current follow-up regime at detecting suspected recurrence of head and neck cancer is low, suggesting the need for a customised, more focused follow-up regime, tailored to individual cases. Patient education and close relationships with clinicians and allied health-care professionals are essential for early diagnosis and management of cancer recurrence. Follow-up regimes within the first year should be most intensive as recurrence is most likely within this time, and it serves to alleviate patient anxiety in the early post-treatment period. More research needs to be carried out to investigate the role of patient self-reporting and surveillance of cancer recurrence.