Rhodotorula rubra ventriculitis.

We describe a case of post-operative ventriculitis in an immunocompetent patient caused by an unusual organism, namely Rhodotorula rubra. The patient was treated successfully with antifungal agents.

Treatment of tympanic membrane retraction pockets by excision. A prospective study.

The treatment of tympanic membrane retraction pockets by simple excision is described in 66 ears in 50 patients. After one operation 65 per cent of the retraction pockets were successfully treated (mean follow up 14.1 months). Persisting perforations occurred in five patients after one excision. Retrotympanic cholesteatoma was found in one patient, after two retraction pocket excision operations. The number of myringotomies with grommet insertion and the presence of bilateral disease does not predict the outcome of the procedure. Simple excision should be considered in the first instance, rather than reinforcement tympanoplasty using temporalis fascia or cartilage graft, in the treatment of tympanic membrane retraction pockets.

Bing-Neel syndrome or malignant external otitis in Waldenstrom's macroglobulinaemia?

Malignant external otitis is classically associated with insulin-dependent diabetes mellitus probably due to generalized systemic immunodeficiency (Mowet and Baum, 1971). A unique case of malignant external otitis associated with Waldenstrom's macroglobulinaemia is presented.

Complications of paediatric tonsillectomy post-discharge.

A post-operative survey of 291 children was conducted to assess morbidity found at home in the first five days post-tonsillectomy. Analgesic requirement (92.4 per cent), signs of distress (90.4 per cent), otalgia (69.1 per cent), halitosis (66.7 per cent) were common. Physical or behavioural changes (36.8 per cent) and secondary haemorrhage (8.9 per cent) were also prominent features. Nausea was reported in 59 children (20.3 per cent) and delayed return to a normal diet which in turn predisposed to secondary haemorrhage. Return to normal diet was independent of pain. General Practitioners were consulted by 60.6 per cent and more than half were prescribed drugs. The presence of an organized clot in the tonsillar fossa (3.45 per cent) post-operatively did not delay discharge from hospital and none of these patients re-presented with secondary haemorrhage. Based on their child's experience in this study, only one third of the parents approved of day-case tonsillectomy in principle, a finding which has implications for the instigation of day-case tonsillectomy procedures.

Myringoplasty for the anterior perforation: experience with the Kerr flap.

Surgical closure of the anteriorly located tympanic membrane perforation can present a problem. The lack of anterior support for the graft frequently leads to graft failure if an underlay method is used whereas anterior blunting is a complication of onlay techniques in this situation. The experience with the Kerr flap, an underlay graft fashioned to include a tab of fascia which is placed laterally under the annulus and the anterior meatal skin, is presented. This method gave a 97.5 percent closure rate with no cases of anterior marginal blunting and a mean auditory threshold gain of 8.5 dB (95 percent confidence limits 5 to 11.9 dB, P less than 0.01) was achieved at the frequencies tested. The use of the Kerr flap is recommended when repairing the anteriorly placed tympanic membrane perforation.

Gustatory sweating of the external auditory canal.

Gustatory sweating of the external auditory canal is extremely rare. A clinical case, that is only the second in the English literature, is presented. The potential pathogenesis and its treatment options are discussed.

Atypically located submandibular gland diagnosed by Doppler ultrasound.

The anatomical location and relationships of the submandibular gland are well-known to most otolaryngologists and gross variations from the norm are rare. We report a case of an atypical submandibular gland located 2 cm below the mandible which presented as a painful neck swelling with non-diagnostic fine needle aspiration cytology. Using Doppler ultrasound the mass was noted to be closely located to the facial artery and vein and following the administration of oral lemon juice, the peak systolic velocity of a small artery within the mass rose from 8.5 cm/s to 16.4 cm/s, confirming the tissue's salivary nature. We review the literature on using Doppler ultrasound in this area of the neck and discuss realistic practical applications of the technique.

Combined study to assess the role of calcium alginate swabs and ligation of the inferior tonsillar pole in the control of intra-operative blood loss during tonsillectomy.

Bleeding is the major source of morbidity and mortality of tonsillectomy and most operative time is spent securing haemostasis. Calcium alginate reduces experimental wound blood loss. This study assessed the efficacy of alginate swabs during tonsillectomy and inferior tonsillar pole ligation in the control of blood loss during tonsillectomy. Ninety-nine tonsillectomy patients were randomized to gauze or alginate swab use. A haemoglobinometer measured blood losses collected by suction during dissection and by swab until haemostasis was secured. Operative time, complications and healing were also assessed. Mean total blood losses and operative times were similar for the two groups. Swab blood loss was significantly lower for surgeons who ligated the lower tonsillar pole, compared with surgeons who used a snare. This finding was independent of swab type. Independent assessment showed no difference in the healing rate. Alginate swabs offer no advantage over gauze in terms of blood loss, operative time or complications of tonsillectomy. The results show that routine lower pole ligation significantly reduces post-dissection blood loss. We suggest that this technique should be more widely adopted.

Vertebro-carotid anastomosis as a cause of uncontrollable epistaxis.

Uncontrolled epistaxis may require a long hospital stay, multiple blood transfusions and multiple arterial ligations. This case report highlights vertebro-carotid anastomosis as a rare cause of uncontrolled epistaxis. The importance of angiography in the identification of rare arterial anastomoses is stressed.

Aberrant common carotid artery encountered during free jejunal graft repair of oesophageal stricture.

The origin and course of the carotid arterial system in the superior mediastinum and neck are remarkably constant. Although variations are rare, they can have important implications in certain clinical problems. In this report, a patient underwent free jejunal graft repair of a cervical oesophageal stricture caused by radiotherapy for a post-cricoid carcinoma. The common carotid artery on the side of the surgical approach was found to cross the midline to the other side of the neck, and created difficulties both with the procedure and future management. This has not been previously reported.

Facial schwannoma without facial paralysis.

A 64-year-old man with right aural discharge presented complaining of progressive deafness. Other otological symptoms were absent and specifically there was no seventh nerve paresis. A right aural polyp was identified and biopsied. Histology showed the polyp to be a schwannoma. Subsequent temporal bone computed tomography showed expansion of the distal facial canal. At operation, the schwannoma filled the middle ear cleft and extended from the genu to the region of the stylomastoid foramen. The floor of the middle ear had been eroded, exposing the jugular bulb. Facial paresis is the usual presenting feature of a facial schwannoma, while deafness, ageusia and reduced lacrimation are variable, dependent upon the site of the lesion. The absence of facial palsy as a presenting feature is very rare and this case illustrates the need for histological examination of all abnormal aural material.

Chondroma of the external auditory canal.

Chondroma, a benign tumour which is common at many sites in the body, has not been reported in the English literature in the bony external auditory canal. The first such case at this anatomical site is described and the pathogenesis is considered.

Angiolymphoid hyperplasia with eosinophilia.

Angiolymphoid hyperplasia with eosinophilia is a rare condition and is poorly recognized in the otolaryngological literature. The condition is characterized by the appearance of cutaneous nodules within the head and neck region especially around the external ear. Variable lymphadenopathy and peripheral eosinophilia can occur and the condition can mimic neoplasia. It is important to be aware of this disease entity in order to avoid overtreatment. Surgical removal is the treatment of choice; however, this often multilobulated and poorly delineated lesion often precludes initial wide excision and local recurrence is common. We present three cases of this unusual condition and a brief resumé of the literature.

Routine X-rays in nasal trauma: the influence of audit on clinical practice.

The introduction of treatment protocols require audited prospective data. The use of X-rays in patients with simple nasal trauma is common but of limited value. A prospective audit of this practice and the implications of introducing a 'no X-ray' policy for these patients into the local casualty department are presented. Patients are spared radiation exposure and there are savings in patient throughput time and departmental costs. Casualty departments which have not already adopted such a policy are urged to do so. Where such a protocol is in use, audit to ensure adherence is encouraged.

Direct hearing aid referral: the effect upon outpatient waiting times in a district general hospital.

One hundred elderly patients referred for hearing aids have been assessed with a view to setting up a direct hearing aid referral system, based upon the criteria laid down by the liaison group for Technicians, Therapists and Scientists in Audiology (TTSA). Sixty-three per cent of the patients could have been fitted with a hearing aid directly. Adequate prior wax removal, could increase this figure to 84%, with a reduction in the waiting time for a hearing aid of 6.1 months.

The uvulopalatopharyngoplasty operation: the Edinburgh experience.

The experience of the uvulopalatopharyngoplasty operation, performed on 24 patients for the relief of loud or heroic snoring, is presented. The operation successfully reduced the severity of snoring in 96% of patients. Postoperative complications were uncommon but included nasal regurgitation and intrapharyngeal adhesions in one patient. The role of the uvulopalatopharyngoplasty operation in the treatment of obstructive sleep apnoea is undecided but the authors do not perform this operation on such patients.

Ear wax removal: a survey of current practice.

OBJECTIVE: To determine the methods of removing ear wax used by local general practitioners and the incidence of associated complications. DESIGN: Postal survey of 312 general practitioners serving a population of about 650,000; supplementary study of ear, nose, and throat outpatients to quantify the improvement in aural acuity after wax removal. SETTING: Catchment area of the Edinburgh otolaryngological unit. PARTICIPANTS: 289 General practitioners who responded to the survey; 21 outpatients in the ear, nose, and throat department with occlusive wax. RESULTS: 274 General practitioners removed wax by syringing, but only 53 (19%) always performed the procedure themselves; the remainder routinely delegated the task to practice nurses, some of whom had received no instruction. Ears were rarely examined again after the procedure. Complications had been experienced by 105 practitioners (38%) and included perforation, canal lacerations, and failure of wax removal. The removal of occlusive wax improved hearing by a mean of 5 dB over the frequencies analysed. CONCLUSIONS: About 44,000 ears are syringed each year in the area and complications requiring specialist referral are estimated to occur in 1/1000 ears syringed. The incidence of complications could be reduced by a greater awareness of the potential hazards, increased instruction of personnel, and more careful selection of patients.

Diverticulosis of the appendix.

Diverticulosis of the appendix is rarely reported. Two cases with this condition, including a unique example of appendiceal diverticulosis presenting at herniorrhaphy, are described. The aetiology of the condition and factors involved in incidental appendicectomy are considered.