Complications and predisposing factors from a decade of total laryngectomy.

BACKGROUND: Total laryngectomy is often utilised to manage squamous cell carcinoma of the larynx or hypopharynx. This study reports on surgical trends and outcomes over a 10-year period. METHOD: A retrospective review of patients undergoing total laryngectomy for squamous cell carcinoma was performed (n = 173), dividing patients into primary and salvage total laryngectomy cohorts. RESULTS: A shift towards organ-sparing management was observed. Primary total laryngectomy was performed for locoregionally advanced disease and utilised reconstruction less than salvage total laryngectomy. Overall, 11 per cent of patients developed pharyngocutaneous fistulae (primary: 6 per cent; salvage: 20 per cent) and 11 per cent neopharyngeal stenosis (primary: 9 per cent; salvage: 15 per cent). Pharyngocutaneous fistulae rates were higher in the reconstructed primary total laryngectomy group (24 per cent; 4 of 17), compared with primary closure (3 per cent; 3 of 90) (p = 0.02). Patients were significantly more likely to develop neopharyngeal stenosis following pharyngocutaneous fistulae in salvage total laryngectomy (p = 0.01) and reconstruction in primary total laryngectomy (p = 0.02). Pre-operative haemoglobin level and adjuvant treatment failed to predict pharyngocutaneous fistulae development. CONCLUSION: Complications remain hard to predict and there are continuing causes of morbidity. Additionally, prior treatment continues to affect surgical outcomes.

Audit of transoral laser-assisted microsurgical resection of early laryngeal cancer.

OBJECTIVE: This study aimed to report our current practice of transoral laser microsurgery for early glottic cancer against the standards outlined by the ENT UK Head and Neck Group and assess the oncological outcome. METHOD: A retrospective review of case notes of patients diagnosed with early glottic cancer (tumour stages Tis, T1 and T2) who underwent transoral laser microsurgery as a primary curative treatment. The minimum follow-up period was two years. RESULTS: Thirty-one patients had transoral laser microsurgery for early glottic cancer during the study period. Eighty-four per cent of cases were discussed by a multidisciplinary team prior to transoral laser microsurgery. Complete circumferential excision was achieved in 77 per cent of cases. Sixty-five per cent of specimens were subjected to histological analysis; they complied with standard pathology reporting for margins. Within 12 months of transoral laser microsurgery, there were 10 residual cases and 2 recurrences. Kaplan-Meier survival analysis gave disease-free survival rates of 96.8 per cent at 18 months and 93.5 per cent at 24 months. The laryngectomy-free survival rate was 96.8 per cent at two years. CONCLUSION: The findings of this audit are encouraging and have highlighted areas for further discussions, recommendations, training and education.

A case-based discussion on a patient with non-otogenic fungal skull base osteomyelitis: pitfalls in diagnosis.

OBJECTIVE: To discuss the diagnostic pitfalls and limitations of imaging investigations in non-otogenic skull base osteomyelitis. CASE REPORT: This paper reports a fatal case of non-otogenic fungal skull base osteomyelitis in an immunosuppressed patient. The patient initially presented with headache and later diplopia during multiple hospital admissions. A retrospective review of the initial imaging studies of his skull base revealed subtle signs of early infection at the inferior portion of the nasopharynx. Biopsies were taken from the posterior nasopharyngeal wall. Fungal cultures isolated Aspergillus fumigatus and mucor species. CONCLUSION: The insidious onset of the clinical features and the limitations of the currently available investigations make early diagnosis of skull base osteomyelitis difficult. This case highlights that skull base osteomyelitis should be suspected in immunocompromised patients with subtle radiological abnormalities on initial imaging. There is still controversy regarding the

Squamous cell carcinoma of the larynx in HIV-positive patients: difficulties in diagnosis and management.

Patients who are infected with human immunodeficiency virus (HIV) are at increased risk of developing laryngeal squamous cell carcinoma. This malignancy on average appears in a younger age group at a more advanced stage and has a more aggressive course in HIV patients. These patients have difficult management challenges, diagnostically, in staging, and particularly in determining the optimal treatment for each individual patient because their underlying HIV infection can markedly increase morbidity associated with active treatments. They frequently have problems associated with swallowing both before and after treatment. We present two cases that highlight difficulties in the diagnosis and management of these patients as well as post-treatment complications, with particular emphasis on swallowing problems.

Reinke's oedema, hormones and hormone replacement therapy.

OBJECTIVE: To study the implications of hormone replacement therapy (HRT) treatment in the pathogenesis of Reinke's oedema (via a possible pseudo-hypothyroidism effect), and also to study why the disease affects a predominantly post-menopausal female population. DESIGN: Prospective case series study. SETTING: Two teaching hospitals and two district general hospitals in Scotland, UK. SUBJECTS: Thirty-three patients diagnosed with Reinke's oedema who presented in the out-patient department before or after treatment. RESULTS: Thyroid function tests were normal in all but two cases. Only three patients were receiving HRT treatment. CONCLUSIONS: The study produced no evidence to support a relationship between HRT treatment and the pathogenesis of Reinke's oedema; this supports previous studies which concluded that thyroid function was not related to the development of Reinke's oedema. Some new ideas regarding hormonal factors in Reinke's oedema are discussed.

Surgery-induced thyroiditis following laryngectomy.

A 77-year-old euthyroid man developed atrial fibrillation on the fourth post-operative day following a total laryngectomy and right radical neck dissection including a hemi-thyroidectomy for a squamous cell carcinoma of the larynx with nodal metastases. The episode of atrial fibrillation coincided with an elevated serum free thyroxine of 3.36 ng/dl (43.3 pmol/L) (reference values: 0.71-1.85 ng/dl or 9.1-23.8 pmol/L), normal total triiodothyronine of 104 ng/dl (1.6 nmol/L) (reference values: 46-137 ng/dl or 0.7-2.1 nmol/L) and a suppressed thyroid-stimulating hormone (TSH) of 0.05 mIU/L (reference values: 0.35-5.0 mIU/L). These values, in relation to those prior and subsequent, suggested a surgery-induced thyroiditis. The limited literature about this controversial entity is reviewed.

Idiopathic epistaxis, haemostasis and alcohol.

Recent studies have suggested a link between antiplatelet medications and alcohol in the aetiology of acute adult epistaxis. The possibility that adult epistaxis may be associated with alcohol induced platelet dysfunction has not previously been investigated. This study evaluated primary haemostasis in 50 adult patients with idiopathic epistaxis. A detailed alcohol history was recorded and the Simplate bleeding time device was used to test haemostatic function. Forty-six per cent of patients were found to have an abnormality of primary haemostasis. Prolongation of the bleeding time was significantly associated with a history of alcohol use. The effect of alcohol on the bleeding time duration was significant (P < 0.001) even at low levels of intake of between 1 and 10 units per week. Although prevalent in the study group (42%) the use of non-steroidal anti-inflammatory drugs did not confer a significant additional risk of increased bleeding time. These findings support the importance of alcohol induced haemostatic abnormalities in the aetiology of adult epistaxis.

Bilateral sensorineural hearing loss in members of a maternal lineage with mitochondrial point mutation.

Pure-tone audiometry was carried out on members of a recently described maternal lineage with sensorineural deafness, harbouring a novel mitochondrial mutation in the gene for tRNA-ser(UCN). This revealed a characteristic pattern of symmetrical bilateral sensorineural hearing losses in each affected individual, predominantly affecting the high-frequencies, but with considerable variability between individuals. No clear correlation was observed between age and severity, but most subjects reported progressive worsening of their condition. Some members of the lineage were found to be heteroplasmic for the tRNA-ser(UCN) mutation. However, the severity of hearing loss was poorly correlated with the representation of the mutant mtDNA, indicating that other, as yet unidentified factors must be involved in the aetiology of this disorder.

Head and neck carcinoma--stage at presentation.

A prospective study was performed during a 2-year-period. A total of 127 patients presenting with a squamous cell carcinoma of the head, neck and upper aerodigestive tract were entered into the study. Patients were classified according to the primary site, namely: larynx (n = 44), oropharynx (n = 28), hypopharynx (n = 17) and oral cavity (n = 19) and others (n = 19). Patients were staged according to the UICC TNM classification (1987) and the nature and duration of their symptoms were recorded. Sixty-one per cent of patients were found to be presenting with advanced disease (stages 3 and 4): oropharynx--71%; hypopharynx--77%; oral cavity--50%; larynx--34%. No relationship could be established between stage at presentation and duration of symptoms and 53% of patients with advanced disease had been symptomatic for less than 3 months at the time of diagnosis. Only 28% of patients presenting with stage 3 or 4 disease had symptoms for 3 months or longer. Earlier diagnosis will not make a significant impact on the overall prognosis in head and neck cancer.

A novel mitochondrial point mutation in a maternal pedigree with sensorineural deafness.

We have detected a novel mitochondrial mutation in a maternal pedigree, at least 13 of whose members have sensorineural hearing loss of varying severity, but who exhibit no other pathological features. The mutation, at np 7445, converts the 3' terminal T residue of tRNA-ser(UCN) to a C, and also brings about a silent alteration to the COI stop codon. The mutation destroys an XbaI site, within which a second mutation, at np 7444, has previously been reported in association with Leber's hereditary optic neuropathy. Predominantly mutant mtDNA was found in all 13 family members surveyed, whether or not they are overtly affected by deafness, and some individuals appeared homoplasmic, within the limits of detection. The novel mutation was not found in over 600 normal controls, nor in any of 27 other maternally unrelated individuals with deafness Other mutations found in mitochondrial disorders were also absent from this pedigree.

Nasal leishmaniasis.

Leishmaniasis is an uncommon condition in Western Europe, except around the Mediterranean coast. However, it may occasionally be seen in the United Kingdom, in patients who acquired the infection in foreign lands. An unusual case of localized cutaneous leishmaniasis recidiva affecting the nose after septal surgery is presented.

Case report: radiological features of epidermal inclusion cyst of the tympanic membrane.

Computed tomography (CT) proved to be invaluable in diagnosing and ascertaining the extent of an epidermal inclusion cyst of the tympanic membrane secondary to a previous myringoplasty.

Acute myeloid leukaemia presenting with acute Branhamella catarrhalis epiglottitis.

Acute supraglottic laryngitis and epiglottitis is increasingly recognised in adults. We present a case in which the condition was the presenting feature of acute myeloid leukaemia and in which Branhamella catarrhalis was the causative organism.