Aminosidine (paromomycin) in the treatment of leishmaniasis imported into the United Kingdom.

We report 11 patients with leishmaniasis from different endemic areas, treated in the UK with intravenous aminosidine alone or in combination with other drugs. Clinical and parasitological cures were achieved in all 7 patients from the Mediterranean zone who had visceral disease, with one relapse. Two of 4 patients with cutaneous or mucosal disease were cured; the other 2, from Iraq and Iran, did not respond. Toxic effects were high-tone deafness in 2 patients, one of whom had pre-existing renal impairment, and transient, mild elevation of serum creatinine in 3. Aminosidine is an effective, tolerable and relatively non-toxic alternative to existing antileishmanial drugs for the treatment of visceral leishmaniasis. Further studies will be needed to assess its place in cutaneous and mucosal disease.

Postcricoid carcinoma: a retrospective study of 13 patients.

Thirteen consecutive patients presenting with squamous cell carcinoma in the postcricoid region (PCC) are studied and details of their age, sex, TNM status, treatment and results are analysed. Follow-up ranges from 33 months to 11 years. Three patients presented with cervical node involvement and 2 of these remain disease free without surgical intervention, at 33 months and 9 years. The principal treatment policy has been the combination of multi-agent chemotherapy with radical radiotherapy, reserving wide excision surgery for patients with residual or recurrent carcinoma. Only 4 patients underwent pharyngolaryngectomy, one radical neck dissection was performed and 7 of the 13 patients have remained free of disease for more than 3 years.

Syringomyelia after chemotherapy and radiotherapy for advanced oropharyngeal carcinoma: cause or coincidence?

A patient presented with syringomyelia 18 months after the completion of treatment with both chemotherapy and radiotherapy for an advanced oropharyngeal carcinoma. The link with therapy is discussed.

The effect of palate repair on otitis media with effusion.

Cleft palate in children is very frequently associated with otitis media with effusion. In this prospective study of 150 cleft palate children aged between 2 and 18 months, the prevalence of otitis media with effusion at myringotomy before palate repair was 92 percent. Otoscopic and tympanometric follow-up assessments for 140 children indicate that there is minimal improvement in middle ear status after palate repair. The condition is persistent in 70 percent of children up to 4 years of age. Furthermore, there is no evidence that age at repair or type of cleft is influential. These findings have implications for otologic management of cleft palate children. Early routine unilateral ventilation to ensure adequate hearing but minimize the morbidity of ventilation tubes is advocated.

Secretory otitis media and mastoid air cell development.

Controversy continues over the factors involved in the development of the mastoid air cell system (MACS). This study examines the effect of persistent secretory otitis media with effusion (SOME) on the development of the MACS. Thirty-one children, aged 4, were drawn from a cohort of cleft palate children in a multi-centre, prospective otological study set up in 1984. The initial presence of SOME was assessed by otoscopy, tympanometry and bilateral myringotomy, performed under the same anaesthetic as surgical repair of the cleft lip or palate. Only one ear in each child was ventilated with a tube and the other, the control ear, was assessed by regular follow-up otoscopy and tympanometry. The persistence of SOME after palate repair in over 70% of the non-ventilated ears in 4 years olds and the presence of a contralateral ventilated middle ear provides the perfect model for assessing the effect of SOME on MACS development. Plain, lateral mastoid X-rays were assessed by planimetry to give a well accepted measurement of mastoid pneumatization. Nine children were excluded from analysis as they did not meet the strict criteria of one persistently ventilated middle ear and one with persistent SOME. 22 children (44 ears) were available for analysis, 9 children were tubed at 3 months and 13 were tubed at 12 to 16 months. In 19 of the 22 ears the mastoid air cell system was larger on the tubed side.(ABSTRACT TRUNCATED AT 250 WORDS)

Resection of the cervical trachea: a different incision?

Excision of the entire trachea at laryngectomy may make it impossible to suture retrosternal tracheal circumference to skin without tension if traditional skin incisions are used. A satisfactory and possibly original approach to this problem is described with two illustrative case histories. The incision described using a laterally based skin flap allows adjacent skin to be drawn into the neck and any resulting defect is closed with partial thickness skin. The advantages of such a flap over traditional incisions are discussed.

Endoscopic sinus surgery: are junior doctors being properly trained?

Endoscopic sinus surgery (ESS) is a technique which carries great potential benefits for the treatment of many nasal conditions. However, it also carries substantial risks. The key to safe surgery lies with adequate training. A survey carried out as part of a North (East) Thames Region audit of higher surgical trainees revealed large discrepancies in their training and in their subsequent clinical practice. Almost half the trainees had started ESS without having been on a training course or performed any cadaver dissections. Despite the potential hazards of ESS, audit of complications and outcome received a low priority. The trainees made several suggestions for improving training, including better provision of courses, regional training programmes and improved access to cadavers for dissection. Other surgical specialties are being forced to examine the prospect of specific accreditation for minimally invasive techniques and otorhinolaryngology may have to follow suit.

Chemotherapy for head and neck tumours. Observations on a twelve-month study.

This paper describes a multiagent protocol of chemotherapy suitable for head and neck cancer which has been used at King's College Hospital since 1974. It studies a twelve month period in which 30 patients received chemotherapy and offers details of eight patients who were free of tumour from two to twelve months after completing the treatment. No statistical evaluation is attempted as the follow-up period is so short and the clinical material so diverse.

The response of adenoid cystic carcinoma to tamoxifen.

Adenoid cystic carcinoma of the parotid gland often recurs locally, or metastases develop, after initial treatment with surgery and radiotherapy. We report a patient with an inoperable local recurrence of previously irradiated adenoid cystic carcinoma, who was treated with tamoxifen, an oestrogen receptor antagonist. After 18 months of treatment with tamoxifen, MRI showed a partial response, and further clinical progression of the disease was halted.

NdYAG laser treatment of a glomus tympanicum tumour.

Glomus tympanicum tumours are highly vascular tumours of the middle ear. Their removal by conventional surgical methods requires an extensive procedure in many cases, often with ossicular disarticulation to allow adequate exposure prior to the 'chaotic' and haemorrhagic event of tumour removal. This paper reports on the use of an NdYAG laser in a case of a large glomus tympanicum tumour. The laser facilitated a transcanal approach, avoided ossicular disarticulation and allowed accurate and almost bloodless ablation of the entire tumour. The NdYAG laser appears to be a very useful treatment modality in the management of these highly vascular tumours. Care should be taken to avoid accidental energy transmission to the cochlea.

Laryngeal leishmaniasis.

A patient suffering from persistent hoarseness was eventually shown to have laryngeal leishmaniasis. The incubation period for the disease must have been at least 16 years, following infection in Southern Europe. Mucosal leishmaniasis is rare in the Eastern hemisphere, and laryngeal leishmaniasis has not previously been reported in the UK. Previous Mediterranean cases have run a similar chronic course and have caused diagnostic difficulty, in particular being mistaken for malignancy. Treatment with aminosidine was ineffective, but the patient responded to liposomal amphotericin.

Mastoid obliteration with the temporoparietal fascia flap.

Obliteration of persistently discharging open mastoid cavities is one surgical option to achieve a dry ear. All the currently described techniques involve the use of random pattern local tissue flaps or free grafts. Ten patients have undergone obliteration procedures using the vascularized temporoparietal fascia flap. This resulted in rapid epithelialization by six weeks in seven out of 10 cases. The remaining three patients have persistent non healed areas over the medial attic wall, but are not troubled by otorrhoea. The indications, technique and complications of mastoid obliteration by this axial pattern flap are described.

A new technique for the management of inaccessible anterior glottic lesions.

We describe a new technique for removing anterior vocal fold lesions, which cannot be visualized with conventional suspension laryngoscopy. These situations are rare and the only alternative surgeons have had previously is an open laryngeal procedure. The technique we describe involves the use of a laryngeal mask airway (LMA), a flexible bronchoscope with biopsy channel, a 400 microm laser fibre and KTP/532 nm laser. This method was used to treat two patients in whom conventional suspension laryngoscopy had previously been attempted and abandoned.

A simple reconstructive procedure for radiation-induced necrosis of the external auditory canal.

Localized necrosis of the bone, cartilage, and soft tissue of the external auditory canal is an uncommon side effect of radiotherapy to the parotid region. Five patients developed late onset skin necrosis of a quadrant of the ear canal secondary to an underlying osteoradionecrosis of the tympanic ring. We report a one-stage procedure to excise the necrotic tissue and replace it with a local rotational flap derived from the post-auricular skin. Otological side effects of radiotherapy are discussed.

Laryngeal Kaposi's sarcoma in patients with AIDS.

Over a period of 10 years 17 human immunodeficiency virus(HIV)-infected patients with laryngeal Kaposi's sarcoma were seen and treated at University College London Hospitals. All patients had advanced HIV disease. Their presentation was with symptoms of upper airway obstruction in the majority of cases and the diagnosis was made by fibreoptic examination of the larynx. Biopsy was associated with brisk haemorrhage in one patient, who required a temporary tracheostomy, and was not performed in the other 16 cases. The commonest site of laryngeal involvement was the supraglottis in 11 patients, with glottic lesions noted in eight patients: subglottic lesions were seen in only three. Treatment of laryngeal Kaposi's sarcoma was, in general, conservative, five patients received low dose radiotherapy to the larynx and 10 were treated with systemic chemotherapy for disseminated Kaposi's sarcoma. Laryngeal Kaposi's sarcoma did not contribute to patient mortality.

Primary composite squamous cell carcinoma and large cell neuroendocrine carcinoma of the hypopharynx.

Neuroendocrine carcinomas are rare neoplasms of the larynx and hypopharynx. Tumours composed of both neuroendocrine and squamous cell elements are very rare. We report a case of a primary hypopharyngeal carcinoma composed of both squamous cell and large cell neuroendocrine carcinoma and discuss the treatment of this patient and management of neuroendocrine carcinomas of the larynx and hypopharynx.

Polycystic disease of salivary glands.

Polycystic disease of salivary glands is a rare condition which hitherto has been reported only in the parotid glands. We report a case in which an accessory salivary gland had evidence of polycystic disease.

Post-irradiation carcinosarcoma of the parotid gland.

Carcinosarcoma of the salivary glands are rare tumours, often associated with a history of pleomorphic adenoma. A case of carcinosarcoma of the parotid arising following irradiation to the resection site of a pleomorphic adenoma is presented. The clinical and histological features are discussed and the literature reviewed.

Dual infection with atypical mycobacteria and Mycobacterium tuberculosis causing cervical lymphadenopathy in a child.

The most common presentation of mycobacterial infection encountered in otolaryngological practice is cervical lymphadenitis. We report a child with an unusual cause of cervical lymphadenopathy, i.e. dual tuberculous infections. This had clinical ramifications as, initially Mycobacterium avium-intracellulare was grown in culture and was resistant to standard anti-tuberculous agents, and hence treated with excision of the lymph node. However, the cultures from the excised lymph node grew out Mycobacterium tuberculosis that was sensitive to standard anti-tuberculous drugs. To our knowledge, no such presentation has been reported previously. We also review the literature on cervical lymphadenitis due to atypical mycobacteria and Mycobacterium tuberculosis, with particular emphasis on clinical presentation, diagnosis and management.

Craniofacial resection. An alternative incision and skull base repair.

Neoplasia of the superior group of paranasal sinuses (frontal, ethmoidal and sphenoidal) has an extremely poor prognosis. Resection, preceded or followed by radiotherapy offers a 5 year survival of less than 30% (1). Satisfactory surgical excision has been undermined by difficulties of access to the cribriform plate area, a common site for residual disease. Furthermore the practice of piecemeal removal invariably resulted in inadequate clearance. The craniofacial approach allows not only excellent access to the anterior skull base but also in bloc excision. The results of treating 7 patients with craniofacial resection for tumours in this area are presented. Particular reference is made to a horizontal forehead skin crease incision for intracranial access. A new technique using a combination of surgical, pericranium, partial thickness skin and fibrin glue to repair the skull base defect is described.