Balloon sinuplasty: two-year follow up using Sino-Nasal Outcome Test-22 outcomes.

BACKGROUND: Balloon sinuplasty is a relatively new surgical technology proposed as a less invasive way of treating chronic rhinosinusitis and frontal sinus disease. It is crucial to monitor safety and efficacy to allow informed clinical decisions and appropriate counselling of patients. There are few papers with long-term follow up. METHOD: Patients were selected for surgery based on symptoms of frontal pain and pressure or headache, pre-operative Sino-Nasal Outcome Test-22 scores, and computed tomography findings. All were resistant to appropriate medical therapy. Balloon sinuplasty was performed followed by a Sino-Nasal Outcome Test-22 questionnaire at two months and then two years. RESULTS: All patients underwent successful operations with no failure of technology or technique. There were no significant complications. The average Sino-Nasal Outcome Test-22 score reduced from 46 pre-operatively (standard error: +/- 5.7, n = 9) to 23 at 2 months (standard error: +/- 7.6, n = 7). At 2 years, the average Sino-Nasal Outcome Test score was 23 (standard error: +/- 4.3, n = 6). There was an even larger lasting benefit when pain or pressure symptoms were analysed in isolation. CONCLUSION: This study adds to the evidence of technique safety and feasibility. The procedure resulted in a significant long-term improvement in symptoms.

The diagnostic value of fine needle aspiration in parotid lumps.

INTRODUCTION: Fine needle aspiration (FNA) is a safe and quick method of diagnosing superficial lumps, which aids preoperative planning. However, FNA of the parotid gland has not gained the widespread acceptance noted in other head and neck lumps. The aim of this study was to determine the ability of FNA of the parotid gland to differentiate benign and malignant disease, and to determine the impact on surgical outcome. METHODS: A retrospective analysis of 201 consecutive parotid operations with preoperative FNA in a large district hospital in the UK was performed. The diagnostic characteristics were calculated for benign and malignant disease, and the impact on surgical procedure was determined. RESULTS: In identifying benign disease, FNA has a sensitivity of 85% and a specificity of 76%. In detecting malignant disease, FNA has a sensitivity and specificity of 52% and 92% respectively. A false positive on FNA was associated with a higher incidence of neck dissection. CONCLUSIONS: FNA is a useful diagnostic test. However, owing to low sensitivity, it is necessary to interpret it in the context of all other clinical information.

Sinonasal malignant melanoma: an analysis of 115 cases assessing outcomes of surgery, postoperative radiotherapy and endoscopic resection.

BACKGROUND: Melanomas account for 4% of sinonasal malignancies. We present the largest single institution series reported thus far and analyze the outcome with reference to lymph node involvement, radiotherapy and endoscopic resection. METHODOLOGY: Survival and recurrence data were analyzed on sinonasal melanoma cases collected from 1963-2010 to compare treatment strategies and to ascertain factors predicting outcome. RESULTS: 115 cases (mean age 65.9) were treated at our institution during this period. All underwent surgical resection of the tumour, 31 (27%) endoscopically, and 51 (44%) also received radiotherapy. Five year overall survival was 28% and disease-free survival was 23.7%. Local control was achieved for a median of 21 months, 5-year disease control rate of 27.7%. Endoscopically resected cases showed a significant overall survival advantage up to 5 years. Radiotherapy did not improve local control or survival. Cervical metastases conferred a dramatically worse outcome. CONCLUSIONS: Endoscopic resection of sinonasal melanoma does not prejudice outcome. The role of radiotherapy is unproven.

Surgical voice restoration after total laryngectomy: an overview.

Total laryngectomy is potentially a debilitative surgery resulting in compromise of some of the most basic functions of life including speech and swallowing. This may have a profound adverse effect on the patient's physical, functional, and emotional health, and may result in a decreased quality of life (QOL). Until the 1980s, total laryngectomy was regarded as a dreadful, but often, life-saving procedure for which there was little alternative, and was used as a last resort. At that time survival at any cost in terms of QOL was paramount and many laryngectomies were forced into an isolated life as a mute and dysphasic recluse. Most attempts at voice restoration produced inconsistent results and often techniques were laborious, expensive, and ineffective, particularly when carried out as a salvage procedure after failed radiotherapy. Progress in voice rehabilitation, following total laryngectomy, over the last 30 years, has made an enormous difference in the whole concept of the management of laryngeal cancers. Currently there are several options available for these patients, namely, esophageal speech, artificial larynx, and tracheoesophageal speech. The choice of speech rehabilitation varies from patient to patient, but tracheoesophageal voice has become the preferred method. This article provides a brief account of surgical voice restoration after total laryngectomy. Special emphasis has been given to the surgical technique, special considerations, complications, and the prevention / treatment of tracheoesophageal voice restoration.

Multinodular goitre in lingual thyroid: case report.

OBJECTIVE: We report a case of a multinodular goitre developing in a lingual thyroid. METHOD: Case report, and discussion of the embryology and treatment of lingual thyroids. CASE REPORT: A 66-year-old woman presented with dysphagia secondary to a multinodular lingual goitre. A previously silent lingual thyroid had undergone multinodular change to cause dysphagia and eventually airway compromise. The goitre was excised via a midline, mandible-splitting approach. CONCLUSION: Lingual thyroids have an incidence of one in 3,000 to 10,000. There has not previously been a reported case of such an ectopic gland undergoing multinodular changes and presenting in later life.

Evaluation of 18fluoro-2-deoxyglucose positron emission tomography in iodine scan negative, differentiated thyroid cancer recurrence.

BACKGROUND: Follow up of patients with differentiated thyroid cancer is based upon anatomical imaging, thyroglobulin assay and functional imaging in the form of iodine uptake scanning. A significant cohort of such patients have rising thyroglobulin levels but negative iodine scans. In this group, 18fluoro-2-deoxyglucose positron emission tomography scans have been commonly employed. The aim of this study was to assess the usefulness of such investigation. METHODS: The sensitivity of 18fluoro-2-deoxyglucose positron emission tomography for detecting recurrence of differentiated thyroid cancer was calculated from a retrospective review of scan results from patients with iodine scan negative recurrence. RESULTS: Eighteen patients with rising thyroglobulin levels underwent 18fluoro-2-deoxyglucose positron emission tomography scanning. Fourteen patients had negative (and four equivocal) whole body iodine scintigraphy scans. Of these 14, six patients had a positive 18fluoro-2-deoxyglucose positron emission tomography scan, giving a sensitivity of 42.9 per cent. CONCLUSIONS: When assessed in the clinical setting and restricted to patients with negative iodine scans, the sensitivity of 18fluoro-2-deoxyglucose positron emission tomography was found to be lower than in previous case series.

Gene therapy in head and neck cancer: a review.

Gene therapy for cancer is a rapidly evolving field with head and neck squamous cell cancer being one of the more frequently targeted cancer types. The number of clinical trials in the UK is growing and there is already a commercially available agent in China. Various gene therapy strategies along with delivery mechanisms for targeting head and neck cancer are reviewed.

Influence of ethnicity on the frequency of nasal surgery.

OBJECTIVE: To determine whether surgery for nasal obstruction differs in frequency between ethnic groups. METHOD: Ethnicity data was collected from all patients attending otolaryngology clinic appointments and compared to census data. Odds ratios with confidence intervals were calculated for attendance at otolaryngology clinics, rhinology clinics, undergoing septoplasty, septorhinoplasty and/ or turbinate surgery for each ethnic group over a 3-year period. RESULTS: The ethnic groups of the 39493 outpatient attendees closely mirrored demographic data from the 2001 Census. Non-Chinese Asian ethnic groups were more likely to undergo septal surgery than the general (mainly white) population (odds ratio 1.44, 95% CI 1.25 to 1.66, p < 0.00001), whereas Black groups (odds ratio 0.31 [0.23 - 0.41], p < 0.00001) and Chinese (odds ratio 0.28 [0.11 - 0.70], p = 0.00311) were much less likely. Similar results were found for rhinoplasty and turbinate surgery. CONCLUSIONS: There is strong statistical evidence for large differences in the frequency of surgery for nasal obstruction between ethnic groups. Asian groups were more likely to undergo surgery, whereas Chinese and Blacks were less likely than the general population, which was predominantly white in this study. This may be due to anatomical variations, differences cultural views towards surgery, or inequalities in clinician's attitudes.

Magnetic resonance imaging scans for vestibulocochlear nerve tumours: what is actually found?

BACKGROUND: Approximately 20 per cent of adult patients presenting to otolaryngology clinics have symptoms pertaining to the inner ear. These are investigated with magnetic resonance imaging (MRI) internal auditory meatus scans. This study analysed all findings from 736 sequential MRI internal auditory meatus scans performed on 731 patients over a one year period. METHODS: Six hundred and seventy-two patients were included for analysis. Of these, 419 (62.35 per cent) had normal MRI scans, 221 (32.90 per cent) had MRI findings thought to be unrelated to their presenting symptoms, 32 (4.76 per cent) had findings thought to be the cause of their symptoms, and eight (1.19 per cent) had the typical appearance of an VIIIth nerve schwannoma. CONCLUSIONS: Magnetic resonance image scanning of the inner ears and auditory pathways yields a diagnosis of VIIIth nerve tumours of the order of 1 per cent, does not show other causes of inner-ear symptoms in a further 4 per cent, and shows incidental intra- and extracranial abnormalities in a further 33 per cent, most of which are not clinically significant.

Adenoid size assessment: a comparison of palpation, nasendoscopy and mirror examination.

OBJECTIVES: To compare the digital, mirror and nasendoscopic assessment of adenoid size and posterior choanal obstruction in patients undergoing adenoidectomy. DESIGN: Prospective, blinded study. SETTING: Otorhinolaryngology department at a London teaching hospital. PARTICIPANTS: Twenty-eight consecutive patients undergoing adenoidectomy in conjunction with tonsillectomy or myringotomy under general anaesthesia, aged 17 months to 16 years. MAIN OUTCOME MEASURES: Adenoid size and postnasal space obstruction as assessed by digital examination, nasendoscopy and trans-oral mirror visualization. These examination methods were each compared with each other. RESULTS: Nasendoscopy and mirror examination correlated well (Spearman's R(S) = 0.71, P < 0.0001) but Passing and Bablock regression analysis demonstrated that mirror examination consistently underestimated the degree of choanal obstruction in comparison with nasendoscopy. There was no significant correlation between nasendoscopy and palpation (R(S) = 0.26, P = 0.17) and only a moderate correlation between mirror examination and palpation (R(S) = 0.46, P = 0.014). CONCLUSION: If nasendoscopy is considered the gold standard, then palpation is a poor measure of adenoid hypertrophy and mirror examination consistently underestimates choanal occlusion.

An objective evaluation of the waterproofing qualities, ease of insertion and comfort of commonly available earplugs.

Earplugs are commonly recommended to protect the middle ear from water in patients with exposed middle ears. This study assessed the waterproofing qualities, ease of insertion and comfort of six commonly available earplugs. Ten subjects (20 ears) were assessed by placing a pre-weighed neurosurgical pattie in their cleaned ear canal under microscope guidance. The subjects underwent a standardized head wetting regime. The outer ear was dried, earplug and pattie removed and pattie reweighed. The difference in weight was calculated. The subjects were also asked to score the difficulty of insertion and comfort of the earplugs on a visual analogue scale. The results show a significant difference in the waterproofing qualities of the various types of earplugs. Cotton wool with petroleum jelly was the most effective (P < 0.001). It was also the easiest to insert and the most comfortable for the subject (P < 0.001).

Bowel obstruction due to extrinsic compression by metastatic lobular carcinoma of the breast.

The commonest sites for breast cancer metastases are the bones, lungs, liver, pleura, adrenals and central nervous system. However, although other sites have been reported, solitary metastases to the gastrointestinal tract are extremely uncommon. Widely disseminated gastrointestinal metastases may be found in up to 20% of patients. Although only 15% of patients with breast cancer will have the lobular variety, these make up the majority of patients with solitary gastrointestinal metastases. Here we present three cases where solitary lobular breast cancer metastases have been demonstrated to be the cause of bowel obstruction. In two cases of duodenal obstruction was demonstrated and in the third colonic obstruction. In all cases a focal extrinsic compression was found.

Closure of transverse loop colostomy and loop ileostomy.

The aim of a defunctioning stoma is to protect patients from the consequences of faecal leakage and pelvic sepsis, should it occur. A retrospective audit of 77 patients who had undergone closure of a loop stoma between 1988 and 1996 was performed. Sixty patients had either transverse loop colostomy (52) or loop ileostomy (8) to defunction distal colorectal/anal anastomoses or pathology, and 17 patients had a loop ileostomy to defunction an ileoanal pouch. Those who had restorative proctocolectomy experienced a much higher (24%) complication rate than the loop colostomy group (5%), despite similar perioperative care and surgery performed by surgeons of equivalent seniority. The complication rate of ileostomy closure in pouch patients is similar to other published series. As a result of these findings, a selective approach to the use of loop ileostomy to protect pouches has been introduced. The absence of wound infections in our series would suggest that primary closure of the stomal wound without drainage can be achieved.

Clostridium difficile toxic megacolon following splenectomy.

A case of toxic megacolon following splenectomy for lymphoma is presented. The aetiology of Clostridial difficile infection is reviewed and the hazards of perioperative prohylactic antibiotics are discussed.