Role of transnasal flexible laryngo-oesophagoscopy (TNFLO) in investigating patients with globus symptoms.

OBJECTIVE: To explore the rationale for investigating patients presenting with globus symptoms. In this regard, we also assess the efficacy and safety of transnasal flexible laryngo-oesophagoscopy (TNFLO). METHODS: A prospective study in a head and neck cancer centre of patients with persistent globus symptoms with normal flexible nasoendoscopy/indirect mirror laryngoscopy and failure of first-line medical treatment. The role of TNFLO in investigating these patients was assessed. RESULTS: A total of 218 patients were recruited in this study. Positive findings included upper aerodigestive cancers in two patients, other pathologies included reflux (four patients), cricopharyngeus-related pathologies (19 patients), candida (five patients). There were only five re-referrals of patients who were discharged following normal examination with TNFLO. In nine patients, TNFLO could not be completed and they went on to have other diagnostic procedures CONCLUSION: This article is the largest to date in the UK to assess the role of TNFLO in investigating patients with globus symptoms. TNFLO is equal to rigid endoscopy as a diagnostic tool. However, it is superior in terms of image clarity, ability to record video images and safety.

Outpatient-based injection laryngoplasty for the management of unilateral vocal fold paralysis - clinical outcomes from a UK centre.

OBJECTIVE: To assess voice outcomes in patients undergoing vocal fold injection (VFI) augmentation laryngoplasty in a clinic-based setting. METHODS: A prospective study of patients with unilateral vocal cord palsy undergoing Radiesse(®) vocal cord augmentation. We used the ten-item voice handicap index (VHI-10) as a postal survey before and after the intervention. RESULTS: A total of 43 patients were referred to our ENT clinic from June 2011 to October 2014 with unilateral vocal cord palsy. The majority were referred from the oncology department with mediastinal tumours. Fifteen patients died of malignant disease. Twenty-one patients responded to our survey. VHI-10 scores were analysed using one-way analysis of variance (anova), and the results suggest a sustained improvement before and after the intervention (pre-injection versus 3 months post-injection P < 0.01; pre-injection versus 6 months post-injection P < 0.033). CONCLUSION: This is the largest case series of patients who had a local anaesthetic vocal cord injection with calcium hydroxylapaptite using the trans-thyrohyoid approach. Early data would suggest that the results are similar to injections performed under general anaesthesia when performed by an experienced laryngologist. VFI in a clinic-based (awake) setting has the distinct advantage of providing instant feedback of vocal fold closure and voice outcome during the procedure, avoiding general anaesthesia with its inherent risks and cost and also the limitations of difficult exposure.

Laser tongue base mucosectomy is a useful diagnostic tool in the management of unknown primary cancers of the head and neck region.

OBJECTIVE: Tongue base mucosectomy identified cancer in 78 per cent of cancers of unknown primary in a recent meta-analysis. The carbon dioxide laser is an alternative technique if there is no access to a robot. This study aimed to describe the steps for undertaking tongue base mucosectomy using the carbon dioxide laser and its diagnostic utility in cancers of unknown primary. METHOD: This was a prospective feasibility study utilising carbon dioxide laser for tongue base mucosectomy in cancers of unknown primary. Data collected included demographic data and p16 status. RESULTS: There were 14 cancers of unknown primary with 86 per cent p16 positivity on immunohistochemistry. Laser tongue base mucosectomy alone identified the cancer primary in 7 of 12 (58 per cent) cancers of unknown primary among p16 positive tumours and 0 of 2 (0 per cent) among p16 negative tumours. Combining bilateral tonsillectomy with laser tongue base mucosectomy resulted in identification of the primary cancer in 8 of 12 (67 per cent) p16 positive tumours. CONCLUSION: In centres without a robot, tongue base mucosectomy using the carbon dioxide laser is a viable alternative, especially in combination with bilateral tonsillectomy in p16 positive cases.

Manipulation under anaesthesia of fractured nasal bones - a 10-year retrospective study.

BACKGROUND: Nasal bone fractures are treated by manipulation under general or local anaesthesia procedures. Data on long-term benefits of manipulation under local anaesthesia are limited. This study aimed to quantify the proportion of patients requiring septoplasty or septorhinoplasty after manipulation under general and local anaesthesia procedures. METHODS: Anonymised data were collected from electronic records of all patients who underwent manipulation under anaesthesia at our centre over a 10-year period, including demographics, manipulation under anaesthesia timing and further surgery requirements. RESULTS: The study identified 625 manipulation under general anaesthesia and 52 manipulation under local anaesthesia procedures. Manipulation under local anaesthesia procedures were performed earlier (local anaesthesia = 9 days, general anaesthesia = 15 days; p < 0.05) and were more likely to achieve manipulation (local anaesthesia = 83 per cent, general anaesthesia = 76 per cent; p < 0.05). There was no difference between techniques in the percentage of patients requiring further surgery. CONCLUSION: This paper describes a large cohort of patients who underwent manipulation under anaesthesia over a 10-year period. Manipulation under local anaesthesia procedures have increased since the coronavirus disease 2019 pandemic, and the results are comparable to manipulation under general anaesthesia, with reduced delays between injury and manipulation.

De novo adamantinomatous craniopharyngioma with long-term pre-diagnostic imaging.

Adamantinomatous craniopharyngioma has a bimodal age distribution occurring in children aged 5-15 years and less frequently in adults aged 45-60 years. The current embryogenetic hypothesis suggests that adamantinomatous craniopharyngioma (ACP) arises from epithelial remnants of the craniopharyngeal duct or Rathke's pouch. It is thought that this tumor exists early on during childhood but remains indolent, growing very slowly until it is diagnosed incidentally or due to symptoms. Recent reports of de novo development of ACP, however, have challenged this theory. Herein, we present a case of an incidentally discovered de novo adamantinomatous craniopharyngioma that was documented to arise de novo on serial MRIs performed for a different indication. To our knowledge, this is the first report of a middle-aged patient who is diagnosed with a de novo ACP documented with contrast-enhanced MRIs of the sella over a 16-year period. This case challenges our current understanding of the pathophysiology of adamantinomatous craniopharyngioma.

Extended role of transnasal oesophagoscopy: a review of the literature.

BACKGROUND: Advances in endoscopic technology have allowed transnasal oesophagoscopy to be used for a variety of diagnostic and therapeutic procedures. METHOD: A review of the literature was carried out to look into the extended role of transnasal oesophagoscopy within otolaryngology, using the Embase, Cinahl and Medline databases. RESULTS: There were 16 studies showing that transnasal oesophagoscopy is safe and cost effective and can be used for removal of foreign bodies, tracheoesophageal puncture, laser laryngeal surgery and balloon dilatation. CONCLUSION: This study presents a summary of the literature showing that transnasal oesophagoscopy can be used as a safe and cost-effective alternative or adjunct to traditional rigid endoscopes for therapeutic procedures.

Out-patient flexible carbon dioxide laser surgery for benign laryngopharyngeal pathologies via transnasal flexible laryngo-oesophagoscopy.

OBJECTIVE: To assess the feasibility and outcomes of flexible carbon dioxide laser surgery in a clinic-based setting. METHODS: A prospective study was conducted in a tertiary centre. Clinical indications, clinical outcomes and patient satisfaction were assessed in patients treated with flexible carbon dioxide laser surgery via transnasal endoscopy and followed up over a period of up to nine months. Patients who were not fit for general anaesthesia or those with lesions that cannot be accessed by micro-laryngoscopy were included. RESULTS: A total of 13 patients (14 procedures) were included. Clinical indications for surgery were small-to-medium sized benign pathologies in the upper aero-digestive tract. Patient satisfaction was assessed using a validated questionnaire. CONCLUSION: Early data suggest that flexible carbon dioxide laser is a versatile and feasible instrument with potential applications for a range of benign pathologies in the upper aero-digestive tract.

Spontaneous apical lung herniation presenting as a neck lump in a patient with Ehlers-Danlos syndrome.

Ehlers-Danlos syndrome (EDS) is a heritable group of disorders of connective tissue characterised by skin hyperlaxity, joint hypermobility and tissue fragility. We report on a 49-year-old man with EDS who presented with spontaneous swelling at the root of the right neck during coughing. The size and site of the lesion led to diagnostic uncertainty. Subsequent computerised tomography (CT) scanning during a Valsalva manoeuvre demonstrated a large apical lung hernia arising through the costo-vertebral fascia into the root of the neck. No previous reports have documented spontaneous apical lung herniation in patients with EDS. This case serves to remind all practitioners dealing with the head and neck to remember the apical lung as a potential source of pathology in the neck.

Negative pathology following endoscopic resection of T1a squamous carcinoma of the glottis.

Endoscopic CO(2) laser excision for T(1a) glottic cancer is a recognized treatment modality producing equivalent disease-free and voice results to external beam radiotherapy. On reviewing a series of 15 patients who had undergone endoscopic resection of a T(1a) glottic squamous cancer, it was noted that five patients had negative excisional pathology following the initial biopsy of an invasive squamous carcinoma. The histopathology of each patient's resected specimen was reviewed by a second pathologist who confirmed the accuracy of the results in all cases. We conclude that a significant number of early squamous carcinomas of the glottis present with very small localized, minimally invasive disease and that a proportion may be treated by biopsy alone.

Retraction. A new antifungal labdane diterpene from the leaves of Saraca indica.

A new labdane diterpene, along with 10 known sterols and flavonoids, was isolated from the hydroalcoholic extract of the leaves of Saraca indica. The chemical structure of the new compound was identified as 6,9-epoxy marrubiinic acid on the basis of spectroscopic analyses including two-dimensional NMR. The antimicrobial potential of the new compound was evaluated against Gram-positive and Gram-negative bacteria as well as fungi. It showed a significant antifungal activity against Geotrichum candidum with MIC 0.48 µg/mL. It also showed potential cytotoxicity against human cancer cell lines with IC50 ranging from 1.07 to 1.29 µg/well.

Effects of leukotriene receptor antagonist therapy in patients with chronic rhinosinusitis in a real life rhinology clinic setting.

Although there is evidence from randomised controlled trials that leukotriene receptor antagonists are efficacious in chronic rhinosinusitis there are still little data on their use in everyday real life clinical practice. We report on a pragmatic case series of 32 patients referred from primary care with uncontrolled chronic rhinosinusitis (allergic or non-allergic) who have been treated with montelukast in our joint medical/surgical rhinology clinic. Patients' symptoms were scored according to "facial pain", "headache", "nasal blockage", "nasal discharge", "sense of smell" and "daily activity", and measurements of peak inspiratory nasal flow were made, before and after the introduction of montelukast 10 mg/day. There were significant (p < 0.05) improvements in subjective scoring for headache, nasal discharge & blockage, sense of smell and daily activity but not for facial pain, when montelukast was added along with other alterations in chronic rhinosinusitis medication (all receiving intra-nasal corticosteroids). Subgroup analysis of 10 patients, were the addition of montelukast was the only change to medical therapy, showed significant (p < 0.05) improvements in headache, nasal discharge and blockage and their daily activity. There was no significant improvements in nasal peak inspiratory flow or spirometry. In conclusion, montelukast may be a useful therapeutic option in addition to standard therapy (i.e. intra-nasal corticosteroids or anti-histamines) when treating patients with chronic rhinosinusitis in a real life clinical setting.

Cysts of the parotid gland. Review and report of two unusual cases.

Cysts of the major salivary glands are most frequent in the parotid where they form a small percentage of its benign tumours. They can be congenital or acquired and of parotid or extraparotid origin. Two unusual cysts are reported: a cholesteatoma arising from the ipsilateral mastoid, twenty years after successful radical mastoidectomy, and a deeply located cysts of probably congenital origin. The literature is reviewed and the management discussed. Parotidectomy, often with extensive dissection, remains in general the treatment of choice.

[Development and contribution to the validation of a brief French version of the Yesavage Geriatric Depression Scale]. / Mise au point et contribution à la validation d'une version française brève de la Geriatric Depression Scale de Yesavage.

Depression in old age is underdiagnosed. In order to help detection, Yesavage et al. (1983) developed the Geriatric Depression Scale in a 30 items original version, with good reliability and validity. To abbreviate duration of examination, a shortened 15 items version was proposed (Sheikh et al., 1986) and a 4 items GDS for primary care attenders was also developed (D'Ath et al., 1994) with satisfactory metrological characteristics. The aim of this study is to develop a short French version and to contribute to its validation. French elderly depressives (181) and controls (66) were asked to complete the 30 items GDS (french version) and an other french self-rating scale, the QD2A (Pichot, 1986). In an attempt to devise the short scale, data were subjected to logistic regression analysis, multiple regression analysis, item-total Spearman's rank correlation coefficients and finally to mean choice ranks combination method. The generated 4 items version (mini-GDS) was found to be highly correlated with GDS 30 (r = 0.84, p < 0.0001) and with QD2A (r = 0.64, p < 0.0001) and had a high level of internal consistency (KR20 = 0.66). The sensitivity and specificity of the GDS 4 were 69% and 80% (cut-off 0/1) and against QD2A were 75% and 75% (cut-off 0/1). Out of the four items, two were common with the D'Ath's 4 items version. Method with its different statistical developments was discussed and the 4 selected items of the mini-GDS were compared with data from several authors who evaluated, discussed or examined factor structures of the 30 items GDS. Conclusion is that mini-GDS is reliable to easily detect a depressive symptomatology in the elderly, in different circumstances.

Hepatitis C virus : prevalence in Lebanese blood donors and brief overview of the disease.

Hepatitis C virus (HCV) is recognized as the major cause of non-A, non-B hepatitis. Its prevalence in different patient populations and blood donors has been reported worldwide but not yet from Lebanon. This study was performed to determine the prevalence of HCV antibodies in 536 random Lebanese blood donors using three enzyme immunoassay kits: ETI-AB-HCVK (Sorin, Biomedica, Italy), UBI HCV EIA (Organon Teknika, Netherlands) and ORTHO HCV 2.0 ELISA (Ortho Diagnostic Systems, USA). The latter was also used as an arbitrator test. Though ETI-AB-HCVK and UBI HCV EIA kits gave higher initial positive results (5.8% and 3.7%, respectively) than ORTHO HCV 2.0 ELISA (1.1%), the over all prevalence of HCV antibody in these blood donors was 0.7%. A brief review of the HCV virus, its epidemiology, clinical features and diagnostic aspects is also presented. A similar testing approach was carried out on additional 3643 blood donors. Confirmatory testing based on CHIRON*RIBA*HCV 2.0 strip immunoblot assay (Ortho) revealed that the HCV antibody seroprevalence in random Lebanese blood donors is 0.11% and not 0.7% as found by ELISAs alone.

Prevalence and etiology of intestinal parasites in Lebanon.

As there are no studies done on the prevalence of intestinal parasites in Lebanon since 1967, this study was undertaken to reveal the current patterns of intestinal parasitic infestations in Lebanese patients from two geographic regions: Beirut and Tripoli. Analysis was based on 33,253 stool specimens examined at the American University of Beirut Medical Center (AUH) and 11,611 specimens examined at the Islamic Hospital (IH) in Tripoli over five and three years, respectively. The prevalence of intestinal parasites at AUH and IH were 8.47% and 45.35%, respectively (overall 18%). The prevalence in males vs females was almost the same; being 8.23% vs 8.74%, and 44.67% vs 45.88%, at AUH and IH, respectively. Multiple infections were noted in 8.8% and 3.5% of stool specimens at AUH and IH, respectively. Although 18 different types of parasites were encountered, the most common pathogenic parasites found at AUH vs IH were: Giardia lamblia (20.7% vs 10.5% of parasites found), Entamoeba histolytica (19.41% vs 1.25%), Taenia spp. (6.03% vs 4.08%) and Ascaris lumbricoides (2.09% vs 46.97%). The overall yearly or monthly prevalence of parasites recovered from both hospitals did not show clear seasonal patterns. Compared to developed countries, Lebanon still suffers from a high prevalence and a wide spectrum of intestinal parasites.

Molecular and epidemiological analysis of methicillin-resistant Staphylococcus aureus otorrhoea: hospital- or community-acquired?

OBJECTIVES: (1) To identify newly diagnosed cases of methicillin-resistant Staphylococcus aureus ear infection in our local population; (2) to determine the risk factors involved in these patients' clinical courses, and (3) to type the bacterial strains isolated and thus identify whether they were hospital- or community-acquired. DESIGN AND SETTING: Retrospective review of case notes, together with laboratory-based molecular studies in the departments of otolaryngology and medical microbiology in a university teaching hospital in Scotland, UK. SUBJECTS: Over a two-year period, 35 patients were identified with ear swabs positive for methicillin-resistant Staphylococcus aureus infection. These cases came from both hospital and community settings. MAIN OUTCOME MEASURES: (1) Identification of primary methicillin-resistant Staphylococcus aureus otorrhoea in patients with no previously documented colonisation; and (2) molecular typing of the strains isolated, using spa technology, to identify whether they were hospital- or community-acquired. RESULTS: Of the 35 positive patients, 27 were previously known carriers of methicillin-resistant Staphylococcus aureus. The eight patients with newly diagnosed methicillin-resistant Staphylococcus aureus otorrhoea presented initially in the community. All of these patients had had contact with hospital staff (as in-patients or out-patients) in the weeks preceding development of their ear infection. Using the spa technique for molecular typing, we identified hospital-acquired ('epidemic') methicillin-resistant Staphylococcus aureus type 15 in all eight patients' isolates. All were sensitive to topical gentamicin. CONCLUSIONS: In our cohort, hospital-acquired methicillin-resistant Staphylococcus aureus type 15 was the commonest cause of methicillin-resistant Staphylococcus aureus otorrhoea, despite the fact that these patients all first presented in the community. We believe that contact with hospital staff or health care workers is a risk factor for acquiring methicillin-resistant Staphylococcus aureus otorrhoea in the community.