Acute airway obstruction secondary to vocal fold heterotopic ossification.

A 29-year old man of Eritrean origin presented with acute stridor and respiratory distress on a background 1 year history of progressive breathing difficulty and worsening inspiratory stridor. Fibreoptic laryngoscopy revealed an indeterminate swelling of the left vocal fold leaving no clear airway visible. The patient refused surgical tracheostomy. Microlaryngoscopy revealed a hard, calcified mass arising from the left cord preventing intubation. Histological analysis after excision revealed features consistent with heterotopic ossification. At 4 months repeat microlaryngoscopy was performed revealing normal appearance of the larynx and subglottis. Heterotopic ossification in the larynx is a very rare condition that presents a diagnostic and therapeutic challenge. In the first documented case in the larynx, we describe how the disease caused life threatening airway obstruction, but was managed in a way that led to preservation of laryngeal function and complete resolution of the condition.

Patient aesthetic satisfaction with timing of nasal fracture manipulation.

Introduction. To determine patient cosmetic satisfaction following nasal fracture manipulation under general anaesthetic when offered at different time intervals after injury. Materials and Methods. Prospective chart review of adult patients with nasal fractures treated by closed reduction at a busy district general hospital in Greater London over a 10-month period. Patients were asked by a standardised telephone interview about satisfaction with nasal cosmesis pre- and postoperatively using a Likert scale. Results. Seventy-six of 106 patients presented for nasal manipulation at up to 9 weeks after injury and were successfully contacted (72%) postoperatively. Forty-nine patients (64%) reported that they still would have had the surgery in retrospect. Those done within 1-2 weeks after injury resulted in the highest mean satisfaction score (4.56 ± 0.25). There was a negative correlation between patient satisfaction and timing of surgery (ρ = -0.37, P = 0.001). Of the patients satisfied or very satisfied with their procedure, 96% had it done within 4 weeks. Conclusion. The majority of patients treated with closed reduction of nasal fractures under general anaesthetic are satisfied with the cosmetic outcome and would still have undergone surgery in retrospect. Increasing time of surgery after 2 weeks resulted in lower patient satisfaction.

A report on a rare case of Klebsiella ozaenae causing atrophic rhinitis in the UK.

Ozena is a chronic disease of the nasal cavity characterised by atrophy of the mucosa and bone caused by Klebsiella ozaenae. It is endemic to subtropical and temperate regions affecting the lower socio-economic group, usually the poor who live in unhygienic conditions. It is a rare disease in the UK. There is usually a delay in diagnosis due to unfamiliarity of the disease. A 25-year-old Nigerian migrant presented with nasal obstruction with purulent nasal discharge. Isolation of the bacterium was found from cultures of nasal discharge, crusting and tissue biopsies. She was treated successfully with ciprofloxacin. It is important to consider this rare condition in cases of nasal obstruction even in non-endemic areas especially with the advances of modern travel.

An immunocompetent patient presenting with severe nasal herpes simplex: a case report.

BACKGROUND: Cutaneous manifestations of common viral pathogens or disease processes more common in immunocompromised individuals need to be considered when assessing patients with unusual clinical presentations. To our knowledge this is the first published case of severe nasal herpes simplex infection in an immunocompetent individual. CASE PRESENTATION: A 27-year-old Burmese woman presented to the Accident and Emergency department with increasing facial pain and fever having sustained local trauma to her nose 7 days prior. Despite 5 days of treatment with oral Amoxicillin 500 mg TDS and topical Neomycin sulphate cream the patient developed blistering followed by de-epithelialisation of the nasal skin. CONCLUSION: Herpes simplex virus is very common, occasionally patients present with severe and potentially disfiguring lesions. This case is important for any sub specialists dealing with facial lesions. Early accurate diagnosis can improve outcome and reduce long-term morbidity.

Measurement of absolute dimensions in endoscopic sinus surgery.

OBJECTIVE: To develop and evaluate a simple, noninvasive technique for the precise measurement of antrostomy dimensions using standard endoscopic views. METHODS: We produced an antrostomy probe and devised a method, on the basis of techniques of aerial planimetry, for measuring antrostomies using standardized endoscopic views. Ten shapes of known surface areas were measured independently by three experienced endoscopic sinus surgeons using 30 and 70 degree endoscopes. The accuracies of surgeon assessment and interobserver concordance were calculated. RESULTS: The three surgeons were able to calculate the surface areas with great precision (Pearson's coefficient of correlation > 0.85 in all cases) using both 30 and 70 degree endoscopes. An intraclass correlation coefficient of 0.92 was obtained, indicating a high degree of concordance between the measurements obtained by different surgeons. CONCLUSION: This technique shows considerable promise as a tool for precise measurement of antrostomy dimensions in both clinical and research settings.

The effect of silver nitrate on nasal septal cartilage.

Epistaxis from the anterior septum is frequently treated with a topical application of silver nitrate, which cauterizes the bleeding vessel. However, this treatment causes a septal perforation in a small percentage of patients. We report our study of the histologic effect of topical silver nitrate on samples of septal tissue obtained from 11 patients. We found that 30 seconds of exposure allowed silver nitrate to penetrate to a depth of approximately 1 mm. Longer exposure (45 and 60 sec) resulted in no significant additional penetration. Similarly, the amount of silver nitrate deposition into the chondrocytic lacunae did not vary significantly with the length of exposure. On the other hand, the depth of deposition into the extracellular matrix was positively associated with the duration of exposure. We found no direct evidence that silver nitrate exerted any damaging effect on septal cartilage. Instead, the development of septal perforations in patients who receive topical silver nitrate may be attributable to necrosis of the septal cartilage following damage to the overlying perichondrium, from which it derives its blood supply.

The changing indications for paediatric tracheostomy.

OBJECTIVE: To investigate whether the incidence and indications for paediatric tracheostomy in this unit have changed over recent years. METHODS: All paediatric tracheostomies performed between 1993 and 2001 were identified from our departmental database. The indications for these were ascertained by retrospective case note review. RESULTS: Over the 9-year period studied 362 tracheostomies were performed, the number increased slightly between the first and second half of the period, with peaks in 1997 and 1999. The commonest indication was prolonged ventilation due to neuromuscular or respiratory problems. CONCLUSIONS: This large series shows that the increase in frequency of paediatric tracheostomy performed in this unit over the past decade has been due to conditions such as subglottic and tracheal stenosis, respiratory papillomatosis, caustic alkali ingestion and craniofacial syndromes. Conditions in which tracheostomy are now less common are subglottic haemangioma and laryngeal clefts. Prolonged ventilation remains the commonest indication overall.