Frontoethmoidal mucocele following pediatric craniofacial surgery.

BACKGROUND: Mucoceles occur as a result of accumulation and retention of mucous secretions in a paranasal sinus and are uncommon in the pediatric age group. Persistent or intermittent closure of its ostium through a variety of causes, including previous surgery, is implicated in etiology. The authors report 2 cases of frontoethmoidal mucocele that followed box osteotomies for the treatment of orbital dystopia, with medical literature review and discussion of possible causal factors and events. METHODS: Case histories and radiological imaging are presented on 2 patients presenting with frontoethmoidal mucoceles following craniofacial surgery. Both had transcranial craniofacial techniques where all orbital walls and globe are moved en bloc as a "box." RESULTS: Patient 1, a 12-year-old male patient with Crouzon syndrome, developed mucoceles within 18 months of monobloc distraction surgery and box osteotomies. This was successfully marsupialized with a combined external and endoscopic surgical approach. The second patient, a 15-year-old boy with previously corrected right-sided facial cleft, developed mucocele 9 years following box osteotomies; this was successfully managed by endoscopic drainage. Of 3 other patients having similar box osteotomies in our unit, no other mucoceles were noted as complications. CONCLUSIONS: Mucoceles are a rare complication of craniofacial surgery, and literature review confirms a paucity of reports. Only 1 case has previously been alluded to of mucocele complicating box osteotomy for orbital dystopia. Our 2 cases illustrate and highlight a successful management approach in a multidisciplinary craniofacial unit.

Multidisciplinary difficult airway simulation training: two year evaluation and validation of a novel training approach at a District General Hospital based in the UK.

Our objective was to devise and assess a multidisciplinary simulated course in training junior doctors for possible difficult airway scenarios. The authors have run a multi-disciplinary difficult airway simulation that was designed to simulate the stresses and complications of a live situation. The course comprised of six to eight difficult airway simulations (using a Laerdal SimMan2 mannequin remote controlled by a "driver") with two teams moving through the simulations over half a day. The simulation lasted 20 min and was followed by 40 min of in-depth structured facilitated debrief. The course was set in the anaesthetic room of a district general hospital theatre. Seventy-eight candidates (28 anaesthetic trainees, 18 ENT trainees, 19 theatre nurses and 13 operating theatre practitioners) attended this course over 6 training days set over 2 years. The main outcome measures of candidate feedback scored for eight questions on a 1-6 Likert scale. From the results, Audit of Trust inpatient airway fatalities revealed three deaths in 2 years leading up to the introduction of the simulation course. Re-audit of the subsequent 2 years, during which time the course was running, has shown no airway fatalities. A 100 % candidate feedback response rate was obtained. Delegates gave an average score of 4.8 to the simulator replicating the stress of 'live' situations; 5.5 to the simulator addressing training needs; 5.6 to the course improving clinical knowledge, teamwork, leadership and non-technical skills. In our conclusions, successful management of a difficult airway situation requires rapid evaluation, effective communication, strong leadership and teamwork, as well as knowledge of local environment and equipment. The results show that candidates felt an improvement in clinical knowledge, teamwork, leadership and non-technical skills, as well as the mutual understanding and respect between related medical and non-medical team members. In addition, audit of airway mortality showed a Trust-wide reduction in inpatient airway related mortality following the course. The results emphatically demonstrate the universal success of this multi-disciplinary training method for all team members, regardless of hierarchical position or background.

Surgical palliation in poorly differentiated neuroendocrine carcinoma of the hypopharynx: Case report.

BACKGROUND: Primary neuroendocrine carcinomas (NECs) are very rare entities accounting for 0.49% of all malignancies. Within the head and neck, the most common sites are the larynx and paranasal sinuses, while the hypopharynx is seldom described. CASE: We present a patient with a poorly differentiated metastatic NEC of the hypopharynx treated palliatively with organ-preserving surgery and post-operative chemotherapy, and literature review for well-documented pure hypopharyngeal NECs. Our patient died of chest infection during chemotherapy, 4 months after surgery. CONCLUSION: Chemotherapy remains the mainstay of treatment in the presence of metastases with 2-year overall survival of 15.7%. Due to the aggressive nature of poorly differentiated metastatic NECs, surgical management is seldom considered. We report and advocate the successful palliative role of organ-preserving, minimally invasive trans-oral LASER micro-surgery and neck dissection to control loco-regional head and neck disease, safe-guarding better quality of home life, despite limited life expectancy for this condition.

Necrotising fasciitis of the posterior neck crossing the midline: A case report.

INTRODUCTION AND IMPORTANCE: Craniofacial necrotising fasciitis is a complex condition, with high mortality given its propensity to descend via the deep neck spaces into the chest and mediastinum. Management requires optimal antimicrobial therapy with associated aggressive surgical debridement. PRESENTATION OF CASE: A 64-year-old man presented to ENT with a posterior neck swelling. Despite incision and drainage of the swelling following a trial of antimicrobial therapy, it increased in size, with areas of overlying necrosis demonstrated. Based on radiological and clinical findings, a diagnosis of necrotising fasciitis was made. He was taken to theatre for debridement. Intra-operatively, carotid sheath suppuration was noted, after tissue retraction resulted in copious bleeding from the anterior wound bed, requiring vigorous resuscitation and clamping of underlying structures to achieve haemostasis. Senior ENT and vascular surgery involvement was quickly sought to achieve haemostasis, however bleeding from the wound bed was difficult to control. This was due to the significant watershed area at the posterior neck which would not have been amenable to selective vessel ligation. After multiple cardiac arrests, a team decision was taken to discontinue resuscitation. CLINICAL DISCUSSION: Operating in this area of anatomical complexity required input from a number of different specialty teams. Although input from infectious diseases, microbiology, plastic surgery and tissue viability was commendable, there was room for optimising this further. Early patient referral to a tertiary centre where on-site input was available from maxillofacial surgery and plastic surgery would have been beneficial; a set-up commonly seen in regional trauma networks. CONCLUSION: This case demonstrates the intricacies surrounding a rare occurrence of necrotising fasciitis of the neck crossing the midline. Multi-disciplinary team involvement is imperative and should be encouraged at an early stage.

Optical Loupes: A Useful Tool for the Oncall Otorhinolaryngologist-Our Experience.

We aimed to evaluate the efficacy and utility of loupes for ENT on-calls. We conducted a 2 month prospective clinical study using loupes during on-calls. We examined patients twice, with and without loupes and compared visibility and diagnostic ease. We used the loupes in a total of 71 patients for a variety of ENT emergencies. We found that visibility and diagnostic ease was improved in all cases. During procedures we found that improved visibility led to better instrument placement and more satisfactory outcomes. Loupes have been previously used intra-operatively with good results. The obstacles to wider usage are reportedly the expense and learning curve required. We have acquired some cheap loupes and have found evidence that earlier usage eases the transition. We have found that they are a useful addition to the on-call ENT armoury as they facilitate superior visibility and improved instrument placement.

Dual-modality endoscopic probe for tissue surface shape reconstruction and hyperspectral imaging enabled by deep neural networks.

Surgical guidance and decision making could be improved with accurate and real-time measurement of intra-operative data including shape and spectral information of the tissue surface. In this work, a dual-modality endoscopic system has been proposed to enable tissue surface shape reconstruction and hyperspectral imaging (HSI). This system centers around a probe comprised of an incoherent fiber bundle, whose fiber arrangement is different at the two ends, and miniature imaging optics. For 3D reconstruction with structured light (SL), a light pattern formed of randomly distributed spots with different colors is projected onto the tissue surface, creating artificial texture. Pattern decoding with a Convolutional Neural Network (CNN) model and a customized feature descriptor enables real-time 3D surface reconstruction at approximately 12 frames per second (FPS). In HSI mode, spatially sparse hyperspectral signals from the tissue surface can be captured with a slit hyperspectral imager in a single snapshot. A CNN based super-resolution model, namely "super-spectral-resolution" network (SSRNet), has also been developed to estimate pixel-level dense hypercubes from the endoscope cameras standard RGB images and the sparse hyperspectral signals, at approximately 2 FPS. The probe, with a 2.1 mm diameter, enables the system to be used with endoscope working channels. Furthermore, since data acquisition in both modes can be accomplished in one snapshot, operation of this system in clinical applications is minimally affected by tissue surface movement and deformation. The whole apparatus has been validated on phantoms and tissue (ex vivo and in vivo), while initial measurements on patients during laryngeal surgery show its potential in real-world clinical applications.

Subglottic Metastatic Rectal Adenocarcinoma: A Specialist Multidisciplinary Airway Team Approach for Optimized Voice and Airway Outcome.

A 56-year-old female with a background of metastatic rectal adenocarcinoma presented with a subglottic mass causing biphasic stridor. Transoral laser microsurgery and the use of fibrin glue prevented the need for tracheostomy. Six months postoperatively there was no evidence of recurrence. Laryngeal metastasis of colorectal adenocarcinoma, although remarkably rare, is perhaps more prevalent than commonly perceived and the presence of laryngeal symptoms in a patient with colorectal adenocarcinoma should raise concern. This case is presented to aid physicians should they encounter a similar presentation of metastasis to the subglottis.

Workshop Report: Aerosol Delivery to Spontaneously Breathing Tracheostomized Patients.

The number of pediatric and adult patients requiring tracheostomy has increased. Many of them require aerosol therapy as part of their treatment. Practitioners have little guidance on how to optimize drug delivery in this population. The following is a report of a workshop dedicated to review the current status of aerosol delivery to spontaneously breathing tracheostomized patients and to provide practice recommendations.

Conjunctival melanoma: the role of conservative surgery and radiotherapy in regional metastatic disease.

OBJECTIVE: To evaluate prognostic factors and determine the role of conservative surgery and radiotherapy in managing metastatic conjunctival malignant melanoma (MM) involving preauricular/submandibular lymph nodes. METHOD: A retrospective analysis (1990-2003) of clinical and histopathologic data from 12 patients presenting with regional metastases after failed local treatment for conjunctival MM. Patients received a common, multispecialty, conservative management approach: wide local excision, topical cryotherapy or radiotherapy to conjunctival MM (orbital exenteration for more advanced local disease), lumpectomy, and adjuvant "ring" radiotherapy of regional metastases, with chemotherapy for distant metastases. RESULTS: Median age at primary diagnosis was 51 (range 28-86) years with equal sex predilection. Six of the 12 patients had primary tumors of the bulbar conjunctiva; the remainder arose in the palpebral conjunctiva, the caruncle, or the fornix. Of 11 originating in primary acquired melanosis (PAM), 2 were amelanotic. Epithelioid tumor cells were noted histologically in seven of eight specimens in which cell type could be determined. Eight tumors metastasised to preauricular nodes, three to submandibular and one to both, with a median interval of 23 (range 12-108) months after primary diagnosis. After conservative surgery and "ring irradiation," 7 of 12 patients remained free of regional nodal relapse at median interval of 16 (range 3-126) months. Five patients developed regional nodal recurrence at median interval of 11 (range 6-13) months, 3 of whom were within radiotherapy portals. Eight patients developed distant metastasis at median interval of 44 (range 22-138) months. Eleven patients had tumor-related death. The mean Kaplan-Meier adjusted survival time after primary diagnosis was 76 months with death ensuing postregional metastasis within a median 18 (range 4-127) months. The sole survivor's follow-up duration was 56 months. CONCLUSION: Locoregional metastasis after treatment for conjunctival MM is associated with a poor prognosis. Both epithelioid tumor cells and PAM are associated with disseminating disease and poorer outcome. Literature review has failed to demonstrate advantages of mutilating radical surgery over a conservative approach in this rare disease.

Teary eyes due to 21 pence?

A woman in her late 70s with chronic bilateral epiphora under ophthalmology review was referred to our department for dacryocystorhinostomy after punctoplasty and detection of nasolacrimal duct obstruction. A CT scan of the paranasal sinuses for preoperative planning revealed complete opacification of the right maxillary, anterior ethmoid, frontal and sphenoid sinuses, left septal deviation and an incidental finding of foreign bodies in the right anterior nasal airspace. She proceeded with functional endoscopic sinus surgery (FESS) and removal of foreign bodies. To our surprise, a partially eroded 20 pence and 1 penny coin were found and removed from her right nasal airway. There was no history given about foreign bodies in her nose. Her symptoms improved postoperatively.

Delayed presentation of an undiscovered nasopharyngeal foreign body.

Suspected paediatric aerodigestive tract foreign body (FB) ingestion or aspiration is a commonly encountered emergency. Management may require a general anaesthetic for retrieval with bronchoscopy, laryngoscopy and oesophagoscopy, each dependent on the history and investigations of the case in question. We describe the case of a foreign body, which was missed in the nasopharynx for more than 3 years and also discuss how pressures on National Health Service (NHS) referral and follow-up patterns may have altered the time course of the eventual discovery.

Delayed Diagnosis of Pharyngeal Perforation following Exploding Tyre Blast Barotrauma.

Introduction. Pharyngoesophageal perforation secondary to barotrauma is a rare phenomenon that can have serious complications if identified late. It is challenging to detect due to nonspecific symptoms. We present a case in which detection proved difficult leading to delayed diagnosis. Case Report. A 27-year-old mechanic presented with haemoptysis, dysphonia, and odynophagia after a car tyre exploded in his face. Flexible nasoendoscopy (FNE) revealed blood in the pharynx, thought to represent mucosal haemorrhage. Initial treatment consisted of IV dexamethasone and antibiotics. After 3 days, odynophagia persisted prompting a CT scan. This revealed a defect in the posterior hypopharynx and surgical emphysema in the deep neck tissues. Contrast swallow confirmed posterior hypopharyngeal leak. NG feeding was commenced until repeated contrast swallow confirmed resolution of the defect. Discussion. Prompt nonsurgical management of pharyngoesophageal perforation has good outcomes but untreated perforation can have serious complications. FNE should be performed routinely, but only a contrast swallow can diagnose a functional perforation. Clinicians should have a high index of clinical suspicion when patients present with barotrauma and odynophagia. Patients should be kept nil by mouth until perforation has been excluded. Conclusion. When faced with cases of facial barotrauma, clinicians should have a low threshold for further imaging to exclude pharyngoesophageal perforation.

Inadvertent insertion of hearing aid impression material into the middle ear: Case report and implications for future community hearing services.

INTRODUCTION: The creation of ear moulds for hearing aids is generally considered a safe and routine procedure for trained professionals. In the literature there are reports of otological complications caused by hearing aid mould impression material in the middle ear cavity but such complications are considered rare. PRESENTATION OF CASE: We present the case of a patient in whom impression material entered the middle ear through a perforation of the tympanic membrane during the process of making a hearing aid mould and review how this was managed. DISCUSSION: We discuss how many aspects of the British Society of Audiology guidelines were not followed during this procedure and make recommendations as to how independent community practitioners need to be closely supervised with regular review to minimise the risks of such complications. CONCLUSION: Our report demonstrates how a serious otological complication from the creation of a hearing aid impression in a community based private hearing clinic was managed. The reporting of such complications is rare but the incidence is likely to be much higher than the literature would suggest. We recommend and advise how these adverse incidents may be minimised and managed through competency reviews and formal referral links from community centres to hospital otolaryngology/audiology departments.

Dual instrument for in vivo and ex vivo OCT imaging in an ENT department.

A dual instrument is assembled to investigate the usefulness of optical coherence tomography (OCT) imaging in an ear, nose and throat (ENT) department. Instrument 1 is dedicated to in vivo laryngeal investigation, based on an endoscope probe head assembled by compounding a miniature transversal flying spot scanning probe with a commercial fiber bundle endoscope. This dual probe head is used to implement a dual channel nasolaryngeal endoscopy-OCT system. The two probe heads are used to provide simultaneously OCT cross section images and en face fiber bundle endoscopic images. Instrument 2 is dedicated to either in vivo imaging of accessible surface skin and mucosal lesions of the scalp, face, neck and oral cavity or ex vivo imaging of the same excised tissues, based on a single OCT channel. This uses a better interface optics in a hand held probe. The two instruments share sequentially, the swept source at 1300 nm, the photo-detector unit and the imaging PC. An aiming red laser is permanently connected to the two instruments. This projects visible light collinearly with the 1300 nm beam and allows pixel correspondence between the en face endoscopy image and the cross section OCT image in Instrument 1, as well as surface guidance in Instrument 2 for the operator. The dual channel instrument was initially tested on phantom models and then on patients with suspect laryngeal lesions in a busy ENT practice. This feasibility study demonstrates the OCT potential of the dual imaging instrument as a useful tool in the testing and translation of OCT technology from the lab to the clinic. Instrument 1 is under investigation as a possible endoscopic screening tool for early laryngeal cancer. Larger size and better quality cross-section OCT images produced by Instrument 2 provide a reference base for comparison and continuing research on imaging freshly excised tissue, as well as in vivo interrogation of more superficial skin and mucosal lesions in the head and neck patient.

Toothache: an unlikely presentation of secondary breast malignancy.

An 81-year-old female presented to the maxillo-facial department with a 6-month history of left-sided toothache and upper lip and cheek numbness. She had previously undergone a right mastectomy for breast adenocarcinoma, followed 6 years later by left mastectomy with pneumonectomy for contralateral breast and lung metastases. Following buccal biopsies and MRI of the head and neck, the patient was referred to our head and neck team. The MRI showed a large left maxillary sinus mass and transnasal endoscopic biopsies under general anaesthesia of this confirmed distant breast carcinoma metastasis. The patient was discussed at the Head and Neck Multidisciplinary Team meeting. Further surgical resection was not thought appropriate and the patient has subsequently undergone curative dose radiotherapy to the face. She remains alive with symptom control 8 months following this presentation.

Intracranial polyps in patients with Samter's triad.

BACKGROUND: We describe three patients with Samter's triad (nasal polyps, aspirin intolerance, and asthma) with skull base dehiscence in whom the polyps extended into the extradural space and also resulted in hypertelorism and widening of the nasal bridge. METHODS: One patient died in a road traffic accident while awaiting surgery. The other two patients underwent endoscopic resection of the polyps with a combined osteoplastic flap. RESULTS: Histology confirmed benign eosinophilic polyps with edematous stroma and a markedly thickened basement membrane. There were no complications or revision procedures. Both are symptomatically well with improvement of the hypertelorism. CONCLUSION: These cases indicate that polyps in Samter's triad may be extremely aggressive, resulting in intracranial extension. A combined endoscopic and osteoplastic flap approach is a safe and effective surgical option.