The behaviour of residual tumour after the intentional incomplete excision of a vestibular schwannoma: is it such a bad thing to leave some behind?

OBJECTIVES: To evaluate the biological behaviour of tumour remnants intentionally left in the surgical bed following the incomplete excision of vestibular schwannomas (VS) and to review the relation between extent of resection and preservation of facial nerve function. METHODS: A retrospective chart review of 450 patients who underwent surgery for resection of VS over 23 years (1992-2014). Of these, 50 (11%) patients had residual tumour intentionally left on/around the facial nerve (near-total or subtotal excision) to preserve facial nerve function intra-operatively. The growth of residual tumour was evaluated using serial magnetic resonance imaging scanning; pre- and postoperative facial nerve function was assessed using the House-Brackmann grading scale. SETTING: Tertiary referral neurotology unit. RESULTS: Of the 42 non-NF2 cases where the tumour was intentionally incompletely excised, 28 (67%) patients underwent subtotal resection (mean follow-up 68.5 ± 39.0 months) and 14 (33%) underwent near-total resection (mean follow-up 72.9 ± 48.3 months). Three patients (all in subtotal resection group) showed regrowth. This was not statistically different from the near-total resection group (χ2 = 0.92, P = 0.31). The mean overall growth for these cases was 0.68 mm ± 0.32 mm/year. 5 (one near total, four subtotal) of the eight NF2 patients (62.5%) were excluded from our analysis. In the non-NF2 group, poor facial nerve outcomes (House-Brackmann scores of III-IV) were seen in 2/14 and V-VI in 3/14 of the near total compared with 7/25 and 4/25 respectively in the subtotal group. CONCLUSIONS: Given that the primary surgery for the VS was only for tumours that were relatively large or grew during conservative treatment, the low rate of tumour remnant growth (7%) is reassuring. It may be appropriate to have a lower threshold for leaving tumour on the facial nerve in non-NF2 patients where complete resection may jeopardise facial nerve function.

Olfactory and cochleovestibular dysfunction after head injury in the workplace: an updated series.

OBJECTIVES: The objective of this study was to determine the incidence of olfactory dysfunction in workers following head injury in the work place, to define its relationship to the site, severity of injury and direction of force. The demographics of head injured workers were also assessed to determine whether those with olfactory loss were more likely to have sustained a cochleovestibular injury. DESIGN: Retrospective case analysis. SETTING: Tertiary referral university hospital in Toronto, Ontario. PARTICIPANTS: A total of 3438 consecutive patients referred from the Workplace Safety and Insurance Board (WSIB) in the province of Ontario who sustained a work-related head injury were assessed between 1987 and 2014. MAIN OUTCOME MEASURES: Olfactory and cochleovestibular dysfunction assessed by history, clinical examination and subjective and objective tests. RESULTS: Olfactory dysfunction (OD) was identified in 413 of 3438 patients (12.0%) of which 321 were diagnosed with anosmia and 92 with hyposmia. In our series, injuries from a fall were the commonest cause for OD and a frontal or mid-face impact was more likely to result in OD than other regions (P = 0.0002). A loss of consciousness (LOC) of any duration correlated with OD. In those with olfactory dysfunction, an associated skull fracture occurred in 37.1% of patients and a CSF leak in 4.1%, which was significantly higher compared with those without OD(<0.0001). Patients with OD had a higher incidence of cochlear and vestibular loss (19.9% and 20.6%, respectively) compared with those without OD (14.3% and 17.1%, respectively). CONCLUSIONS: Post-traumatic olfactory dysfunction is more likely to occur in patients who experienced a moderate to severe head injury, LOC and more likely to result from a frontal or mid-face blow to the skull. Cochleovestibular dysfunction is likely to occur concurrently with olfactory dysfunction.

Oral Mycostatin as a possible alternative treatment for intractable Ménière's disease: preliminary cohort study.

Background: The potential efficacy of antifungal agents (e.g. Mycostatin) in treating acute attacks of Ménière's disease was first suggested in 1983 but few data have been published. Oral Mycostatin has been used as second-line medical treatment for intractable Ménière's disease at our institution for many years. Objective: This preliminary cohort study investigated the role of oral Mycostatin in intractable Ménière's disease. Methods: A retrospective review of patients with intractable Ménière's disease who started oral Mycostatin treatment between 2010 and 2012 was conducted. Results: Of 256 patients presenting with vertiginous disorders, 26 had definite Ménière's disease and had not responded to standard first-line treatment. Following oral Mycostatin treatment, improvements were reported for vertigo (n = 8), aural fullness (n = 7), tinnitus (n = 3) and subjective hearing loss (n = 3). Half of those with symptom improvement persisted with oral Mycostatin for two years and continued to remain asymptomatic. Conclusion: The use of oral Mycostatin to alleviate symptoms of intractable Ménière's disease showed promising results in this case series. Mycostatin may offer a safe and useful alternative for the management of Ménière's disease for patients with chronic unremitting symptoms in whom first-line treatment options have failed.

Bismuth iodoform paraffin paste hypersensitivity reactions in mastoid cavities following isolation of mucosal lining: a series of 587 patients.

AIM: (1) To assess hypersensitivity to bismuth iodoform paraffin paste impregnated ribbon gauze following its use in packing canal wall down mastoidectomy cavities; (2) to determine if isolation of the skin and mucosa from the pack, using thin Silastic sheeting and Cortisporin ointment, reduces hypersensitivity reactions, compared with a previous series; and (3) to review the literature and to determine if bismuth iodoform paraffin paste hypersensitivity precludes the consumption of seafood (due to its high iodine content). MATERIALS AND METHODS: All patients undergoing canal wall down mastoidectomy with intra-operative bismuth iodoform paraffin paste packing between 1985 and 2009 were identified and reviewed. RESULTS: Of 587 patients identified, the overall bismuth iodoform paraffin paste reaction rate was 1 per cent. All reactions were in patients undergoing revision mastoidectomy procedures, giving a reaction rate for revision procedures of 2.4 per cent. CONCLUSION: Reactions are an uncommon event following post-operative mastoid cavity packing using bismuth iodoform paraffin paste. Reaction rates may be lowered by preparing the cavity with Silastic sheeting and Cortisporin ointment prior to packing, thus isolating the skin and mucosal surfaces. Development of such a reaction does not preclude the consumption of seafood.

Scars and satisfaction: do smaller scars improve patient-reported outcome?

Thyroidectomy has few complications, as a result, many patients are concerned about the prominence of their scar. Performing thyroid surgery through excessively small incisions in order to maximise cosmesis may increase the likelihood of complications. This study investigates the relationship between conventional approach thyroidectomy scar length and patient satisfaction. A validation of self-measurement of neck circumference and thyroidectomy scar was carried out with the measurements taken by patients compared with those taken by an investigator. One hundred consecutive patients who had undergone conventional thyroidectomy and total thyroidectomy within 24 months were invited to measure their scars and neck circumference, and to score their satisfaction on a Likert scale of 1-10. Spearman's correlation was calculated for the relationship between absolute and relative scar length, and patient satisfaction. Thirty-four patients entered the preliminary study and 80 patients entered the main study (80% response rate). Measurements by patients and investigators were closely associated: Spearman's Rank correlation coefficient for neck circumference and for scar length were ρ = 0.9, p < 0.0001 and ρ = 0.93, p < 0.0001 respectively. No significant correlation was evident between scar length and patient satisfaction (ρ = 0.068, p = 0.55), or between relative scar length ratio and patient satisfaction (ρ = -0.045, p = 0.69). Mean scar length was 6.96 cm [standard deviation (SD) 2.70], and mean satisfaction score 8.62 (SD 2.04). Thyroidectomy scar length appears to have no association with patient satisfaction. Thyroid surgery should, therefore, not be performed through unnecessarily small incisions for purely aesthetic reasons.

Readability of out-patient letters copied to patients: can patients understand what is written about them?

UNLABELLED: The National Health Service Plan of 2000 proposed that patients should receive a copy of all correspondence regarding their care. There is concern that the readability of patients' letters may not be appropriate for many patients. MATERIALS AND METHODS: This study determined readability scores for sequential letters written to general practitioners and copied to patients, following ENT consultations at the Royal United Hospital in Bath. Intervention involved educating clinicians in techniques to improve readability. RESULTS AND ANALYSIS: A total of 295 letters from eight clinicians were assessed in the pre-intervention phase. The mean Flesch reading ease score was 61.8 (standard deviation 8.7) and the mean Flesch-Kincaid reading grade was 9.0 (standard deviation 1.7). Re-audit analysed a further 301 letters. There was no significant change in the readability of the letters post-intervention. DISCUSSION: It may not be feasible to present medical information intended for general practitioners in a way that is readable to most of the UK adult population.

Patient-orientated web sites on laryngectomy: is their information readable?

The objective of the study was to determine levels of readability of commonly accessed websites containing patient information on laryngectomy. A Cross-sectional study of Internet websites was designed. The first 20 websites obtained from a Google search of the word "laryngectomy" that contained a patient information section were selected. Primary outcome measures were the Flesch Readability Ease Score (FRE) and Flesch-Kincaid readability grade (FKRG) score; from these data UK reading age was calculated. The secondary outcome measure was whether or not a site was accredited by an online readability organisation. The reading ages of the 20 sites ranged from 7.8 to 14.7 years with a median of 11.7 years. Half of the Flesch Reading Ease scores were in the "Difficult" or "Fairly difficult" category with 30% falling into the "Standard" or "Fairly easy" categories. Only 20% sites fell into the "Easy" or "Very Easy" categories that are the recommended level for comprehension by the general UK population. Sites not accredited by an online healthcare quality and content control organisation had worse readability scores than those that were not (FRE: p = 0.007, FKRG: p = 0.012). The poor readability of many of the encountered sites about laryngectomy on the Internet may confuse patients who turn to the Internet for information. Methods to improve patient information websites are discussed.

Complications following gastrostomy tube insertion in patients with head and neck cancer: a prospective multi-institution study, systematic review and meta-analysis.

OBJECTIVES: To measure morbidity and mortality rates following insertion of gastrostomy tubes in head and neck cancer patients. To determine evidence for any relationship between gastrostomy insertion technique and complication rates. DESIGN: A prospective cohort study and qualitative systematic review. SETTING: Multi-cancer networks in the South West of England, Hampshire and the Isle of White. PARTICIPANTS: One hundred and seventy-two patients with head and neck cancer undergoing gastrostomy tube insertion between 2004 and 2005. Percutaneous endoscopic gastrostomy (PEG) was performed in 121 patients. Fifty-one patients had radiologically inserted gastrostomy (RIG). Twenty-seven studies reporting outcomes following 2353 gastrostomy procedures for head and neck cancer. MAIN OUTCOME MEASURES: Post-procedure mortality, major and minor complications. RESULTS: In the present series, mortality rates were 1.0% (1/121) for PEG and 3.9% (2/51) for RIG. Overall major complication rates following PEG and RIG were 3.3% (4/121) and 15.6% (9/51) respectively. In our systematic review and meta-analysis of 2379 head and neck cancer patients, we observed fatality rates of 2.2% (95% CI 0.014-0.034) following PEG and 1.8% (95% CI 0.010-0.032) following RIG. Furthermore, major complication rates following PEG were 7.4% (95% CI 5.9-9.3%) and 8.9% (95% CI 7.0-11.2%) after RIG. CONCLUSIONS: Procedure related mortality rates following gastrostomy in head and neck cancer patients are higher than those in mixed patient populations. Major complication rates following RIG in head and neck cancer patients are greater than those following PEG. Major complications following PEG in patients with head and neck cancer appear no worse than in mixed pathology groups. We have identified that RIG is associated with increased morbidity and mortality in patients who are ineligible for PEG. The serious nature of the complications associated with gastrostomy particularly in patients with head and neck cancer requires careful consideration by the referring physician.

A potential danger of flexible endoscopy sheaths: a detached tip and how to retrieve it.

OBJECTIVE: To report an unrecognised complication of fibre-optic nasendoscopy, and its management. CASE REPORT: A protective, transparent nasendoscopy sheath is often used to reduce nasendoscope 'downtime' and to prevent cross infection, with minimal effect on the obtained image quality. We report the case of a subcutaneous tracheostomy procedure during which, without undue strain, the tip of the sheath became detached and acted as a foreign body within the trachea. A urological stone retrieval basket was used to retrieve the sheath, after failure of conventional methods. DISCUSSION: Clinicians should be aware that any instrument introduced into the airway has the potential to fail and in the process produce a foreign body which may cause serious complications. The urological stone retrieval basket may be a useful addition to the current set of instruments used to deal with difficult airway foreign bodies.