Laryngectomy and coloplasty for major oesophagogastric corrosive stricture: case report and literature review.

A 25-year old male with a major corrosive stricture of the larynx, oesophagus and stomach had left isoperistaltic colon interpostion with good results. The colon was passed transpleuraly to emerge in the neck lateral to the sternomastoid.

Drug-induced epistaxis?

To assess the aetiological contribution made to spontaneous epistaxis in adults over the age of 50 years by various groups of drugs, a controlled study was designed. Fifty-three consecutive epistaxis patients were compared with 50 controls. Significant differences were found between the groups in their consumption of warfarin, dipyridamole and non-steroidal anti-inflammatory drugs. Hypertension was equally common in the two groups, but tended to be less well controlled in the epistaxis patients compared to the controls. It is thought that the link between the use of nonsteroidal anti-inflammatory drugs and the occurrence of epistaxis may be due to alteration of platelet function.

Nasal surgery: does the type of nasal pack influence the results?

A prospective study was performed on 106 patients undergoing routine nasal surgery to compare the influence of three different packing methods on the final outcome. Pneumatic balloons were found to cause persistent nasal obstruction and an increased incidence of adhesion formation, while lubricated ribbon gauze was more uncomfortable for the patient. Glove finger packs were associated with the least problems.

Swimming in chlorinated water and its effect on Eustachian tube function.

Middle-ear effusion in children is considered to be the result of multiple factors. Swimming in chlorinated water has been incriminated as one such possible aetiological factor. To test the hypothesis that the chemical disinfectant in the swimming pool is probably responsible for the Eustachian tube dysfunction, 30 children between the ages of four and eight years were selected at random from the community health department computer records and were randomly allocated into two groups. Eustachian tube function was assessed by standard tympanometry both immediately prior to swimming (control) and 30 to 45 minutes following swimming in Group 1 and approximately 14 hours following swimming in Group 2. The results of the study showed no significant change (p greater than 0.05) between pre- and post-swimming tympanometry. It is therefore concluded that swimming on the surface of chlorinated water does not compromise the Eustachian tube function in children with healthy middle ears.

Salivary gland tumours studied by means of the AgNOR technique.

Difficulty is sometimes encountered in distinguishing between pleomorphic adenoma, adenoid cystic carcinoma and adenocarcinoma, especially in small biopsies from salivary glands. The argyrophil (AgNOR) staining technique for nucleolar organizer regions (NORs) has been applied to a series of benign and malignant salivary gland tumours. We studied 35 salivary gland tumours, 13 benign and 22 malignant. In all specimens clearly defined silver-stained intranuclear AgNOR dots were visible. The differences between the numbers of AgNORs in the benign and malignant groups, notably pleomorphic adenomas, adenoid cystic carcinoma and adenocarcinoma, were highly significant. In view of this difference we propose that the AgNOR staining technique is of diagnostic help in distinguishing between these salivary gland tumours.

S-100 protein localization in minor salivary gland tumours: an aid to diagnosis.

The clinician is almost entirely dependent on the histopathologist to accurately diagnose minor salivary gland tumours, but in some cases the histological interpretation of the specimen is very difficult. Recently it has been demonstrated using immunohistochemical techniques that S-100 protein is present in some salivary gland tissues and its localization has been used as an aid in the differentiation of major salivary gland tumours. To assess its value in the diagnosis of minor salivary gland tumours it was localized in sections from 15 such tumours using both a standard peroxidase-antiperoxidase (PAP) and a newly developed immunogold-silver staining sequence (IGSS) technique. Strong staining for S-100 protein was seen in the nuclei and cytoplasm of the cellular areas and also in the cells in the chondroid and myxoid areas of pleomorphic adenomas. Generally the staining was more intense and widespread with the IGSS method. No staining was observed in any of the other tumour types. We conclude that S-100 protein localization is a valuable aid in the differentiation of minor salivary gland tumours. Furthermore, the IGSS method enables more sensitive 'reading' of the staining reaction.

Minitracheotomy and laryngeal function. A prospective study.

The 'minitracheotomy', i.e. an indwelling narrow-bore endotracheal tube which is inserted via the cricothyroid membrane to provide access for the removal of secretions from the tracheobronchial tree following major thoracic and abdominal surgery, has recently been developed. In order to investigate whether its use may be injurious to the larynx, a prospective study was carried out assessing laryngeal function pre- and post-operatively in 14 patients. No permanent changes in laryngeal function were found and it was concluded that, when used for short post-operative periods, the larynx is not adversely effected.

The presentation of laryngeal tuberculosis.

Laryngeal tuberculosis is now a rare disease. We report 6 patients presenting within a 10-year period (1976-1986). Symptoms and signs often mimic carcinoma or chronic non-specific laryngitis. Greater clinical awareness and a chest radiograph prior to direct laryngoscopy may alert the clinician to the possibility of tuberculosis. The diagnosis is established by laryngeal biopsy.

Dysphonia caused by inhaled steroids: recognition of a characteristic laryngeal abnormality.

Nine of 14 asthmatic patients who presented with persistent dysphonia while taking inhaled corticosteroids had a bilateral adductor vocal cord deformity with bowing of the cords on phonation. This causes the dysphonia and usually occurs without candidiasis. It was seen with beclomethasone dipropionate (in both pressurised aerosol and dry powder preparations), betamethasone valerate, and budesonide. It was related to the dose and potency of inhaled steroid and may represent a local steroid myopathy. It was reversed when the inhaled steroid was stopped, although resolution sometimes took weeks. Laryngeal candidiasis may have contributed to the vocal cord abnormality in two of these nine patients. Of the five patients without vocal cord deformity, laryngeal candidiasis was the sole cause of dysphonia in three. In the remaining two dysphonia was thought to be psychogenic. The vocal cord deformity may exist subclinically. Of nine patients who started to take aerosol steroid and who were examined monthly for one year, three developed vocal cord deformity but only one had persistent dysphonia. Vocal abuse did not appear to contribute to dysphonia.

A controlled study of the reliability of pure tone audiometry for the detection of gentamicin auditory toxicity.

Hearing changes in patients treated with gentamicin have been prospectively investigated. A group of patients who had a similar spectrum of clinical conditions but did not receive gentamicin have been studied as a control group. The audiometric technique was first validated by recording audiograms from healthy volunteers, once in an anechoic chamber and twice in a ward. It was concluded that changes in threshold less than 20 db. should not be regarded as significant when measured in a ward. In the gentamicin-treated group an initial audiogram was not a reliable measure of the patients' normal hearing because of the influence of their clinical condition. Twenty-one of the control patients were elective admissions to hospital and had their hearing first tested when they were clinically well. There was a 24 per cent incidence of unexplained hearing abnormalities--similar to the incidence of hearing loss in the gentamicin-treated group at follow-up. It was concluded that aminoglycoside auditory toxicity should not be assessed retrospectively. The incidence of hearing changes in the control and gentamicin-treated groups were similar. Possible causes of hearing loss in surgical patients are discussed and recommendations are made for the conduct of future studies of drug-induced auditory toxicity.

Variability and habituation of nystagmic responses to hot caloric stimulation of normal subjects. Evidence that this test may be inapplicable to monitoring drug-induced vestibular toxicity.

Experiments were performed on 25 otoneurologically "normal' subjects to evaluate the hot caloric test as a screening test for aminoglycoside vestibular toxicity. Using portable equipment under non-ideal conditions, it was found that there was a large inter-subject variability in nystagmic response and that, instead of a random test-retest variability, a systematic variation in response occurred on repeated caloric stimulation with water at 44 degrees C. A response decline (habituation) evident in both the maximum slow phase velocity and the maximum frequency occurred at second test, although the inter-test interval ranged from 24 to 72 hours. After a 3-month interval with no intervening tests, the mean value of the maximum frequency reverted back to the original level. However, there was still a significant reduction in maximum slow phase velocity at this time. Some individuals had a sustained reduction in both parameters. Hence it is concluded that the hot caloric test, used under the conditions described in this study, is not a suitable serial screening method for aminoglycoside vestibular toxicity. The reproducibility of this test under other conditions, or any other caloric test, should be established in normal subjects before employing it as a serial screen for aminoglycoside vestibular toxicity.

The use of pure-tone audiometry in the assessment of gentamicin auditory toxicity.

The results of previous studies of gentamicin auditory toxicity have depended largely on the criteria set for a significant change in hearing threshold. This paper proposes a design for future studies of aminoglycoside toxicity based on an investigation of factors other than aminoglycoside therapy which may influence the measurement of hearing threshold. Audiometry can be performed reliably in a ward but a patient's condition has both temporary and permanent effects on hearing threshold. Ototoxicity cannot be detected by assessing hearing after aminoglycoside therapy. However, an audiogram taken at the start of treatment may be misleading if the patient is seriously ill. Permanent hearing loss may be due to factors other than aminoglycoside therapy so that future studies must be controlled.