Neck dissection can be avoided after sequential chemoradiotherapy and negative post-treatment positron emission tomography-computed tomography in N2 head and neck squamous cell carcinoma.

AIMS: This study assessed neck control in patients with N2 head and neck squamous cell carcinoma (HNSCC) treated with sequential chemoradiotherapy (SCRT) and the incidence of neck recurrence when neck dissection was withheld in those with negative post-treatment fluorine-18 fluorodeoxyglucose positron emission tomography (FDG PET). MATERIALS AND METHODS: Thirty-four consecutive patients with N2 HNSCC who were treated with radical intent using SCRT were included. Twenty-seven patients received concomitant platinum-based chemotherapy with their radiotherapy. Nineteen patients were treated with intensity-modulated radiotherapy. PET-computed tomography (PET-CT) was obtained 3 months after the completion of radical radiotherapy. Neck dissection was carried out only in those with increased FDG uptake in the neck. RESULTS: The median follow-up was 39.1 months. One patient had increased FDG uptake in the neck post-treatment, which was false positive for malignancy. The remaining 33 patients were observed without neck dissection. No regional recurrence occurred. The negative predictive value (NPV) of post-treatment PET-CT was 100%. CONCLUSIONS: Good disease control in the neck can be achieved in patients with N2 HNSCC with SCRT. Post-treatment PET-CT has a high NPV. Neck dissection can be avoided if post-treatment PET-CT is negative.

Early results for treatment of unilateral vocal fold palsy with injection medialisation under local anaesthetic.

BACKGROUND: The diagnosis and treatment of unilateral vocal fold palsy is a common part of otolaryngology practice. In those patients in whom resolution of symptoms is slow, the resulting dysphonia can have a dramatic effect on the patient's quality of voice and life. We have previously described the procedure of direct phonoplasty under local anaesthesia using the transnasal laryngoesophagoscope. OBJECTIVE: To examine the subjective and objective data for the first five patients to undergo this procedure, in the form of laryngographic speech analysis, perceptual assessment and therapy outcome measures. RESULTS: Analysis showed a statistically significant improvement in voice quality, in all the above assessment categories, following local anaesthetic direct phonoplasty using the transnasal laryngoesophagoscope. CONCLUSION: Collagen injection via transnasal flexible laryngoesophagoscopy is a particularly useful technique for treating vocal fold medialisation, especially in palliative care patients and those with shortened life expectancy.

The management of foreign bodies in the pharynx and oesophagus using transnasal flexible laryngo-oesophagoscopy (TNFLO).

INTRODUCTION: We describe our experience of the diagnosis and removal of foreign bodies from the pharynx and oesophagus using transnasal flexible laryngo-oesophagoscopy (TNFLO) under local analgesic. The advantages of this novel instrumentation and technique are discussed. PATIENTS AND METHODS: Patients were examined with a Pentax 80K Series Digital Video Endoscope after local analgesia. The instrument was passed transnasally examining the oro- and hypopharynx, and then passed into the oesophagus. The presence, type and site of a foreign body could then be established. If a foreign body was detected, such as fish bone, it was extracted using flexible grabbing forceps passed down the instrument channel and delivered through the nasal or oral cavity. The object was then inspected to ensure removal in its entirety. RESULTS: Five cases have been successfully managed using TNFLO. CONCLUSIONS: TNFLO represents an improvement in the diagnosis and subsequent treatment of a selected group of foreign bodies as compared with established methodologies.

How we do it: secondary tracheoesophageal puncture under local anaesthetic, using a trans-nasal flexible laryngo-oesophagoscope (TNFLO).

We describe our technique for the formation of a secondary tracheoesophageal puncture and insertion of a voice prosthesis under local anaesthetic in the out-patient department. We use a trans-nasal flexible laryngo-oesophagoscope (TNFLO) to provide direct visualization of the procedure allowing early detection and rectification of any problems that might arise.

Is current UK management of oesophageal food bolus obstruction evidence based? An e-mail survey and literature review.

There is a great deal of variation in individual management of non-sharp oesophageal food bolus obstruction in the United Kingdom. An e-mail survey of consultants and specialist registrars in ENT was carried out to establish current UK practice. A review of the published literature was under-taken to establish whether current practice is evidence based. The majority of practitioners (95%) do not proceed immediately to rigid oesophagoscopy but use antispasmodic drugs (83%), most commonly hyoscine butylbromide (Buscopan) and diazepam, to try to induce spontaneous passage of the obstruction. There is currently no evidence in the published literature to support the use of these drugs. The use of Buscopan seems to have been encouraged by a misquoted reference in a prominent ENT textbook. Better evidence is needed to establish the best form of treatment for this relatively common problem.

Meta-analysis of the timing of haemorrhage after tonsillectomy: an important factor in determining the safety of performing tonsillectomy as a day case procedure.

OBJECTIVES: To perform a meta-analysis of studies of the timing of primary tonsillectomy haemorrhage. In particular to compare the difference in risk between 0-8 and 8-24 h; that is whether overnight inpatient tonsillectomy is required. DESIGN: Medline search of all tonsillectomy studies to perform a meta-analysis of the timing of primary haemorrhages. SETTING: Literature-based study. PARTICIPANTS: All adult and paediatric tonsillectomy studies giving the absolute number and timing of all primary haemorrhages. MAIN OUTCOME MEASURES: The overall incidence of haemorrhage occurring between 0-8 and 8-24 h. The overall incidence of haemorrhage for each of the first 24 h after operation. Compare risk of a bleed occurring 0-8, 8-24 and >24 h where data were available. RESULTS: From a 1.4% overall risk of a primary haemorrhage only one in 14 occur after 8 h, i.e. 0.1% (95% CI=0.08-0.16%). A total of 833 patients would require to be kept overnight in order to identify one case of bleeding after 8 h. CONCLUSIONS: Little benefit was conferred from overnight admission from the point of view of monitoring for primary haemorrhage. A case can be made for either day-case tonsillectomy (hospital stay over the period in which 93% of primary haemorrhages would occur) or the 'belt-and-braces' approach of a 1-week stay (during which all haemorrhages would occur) but current 24-h admission appears illogical.

Intralaryngotracheal thyroid--ectopic thyroid or invasive carcinoma?

Intralaryngotracheal thyroid is a rare clinical condition with only about 125 cases described so far in the literature. We present an unusual case of intralaryngotracheal thyroid which had many clinical features of malignancy and yet appeared benign on histology. As in this case, well-differentiated thyroid cancer can present with locally aggressive clinical features and can pose a dilemma in management if treatment decisions are guided solely by histological features.

Infectious pseudomonas subglottic stenosis occurring in a patient with acquired immunodeficiency syndrome.

Pseudomonas aeruginosa is emerging as an increasingly common opportunistic infective agent in the immunocompromised human immunodeficiency virus (HIV) positive patient (Kielhofner et al., 1992). Improvements in the prevention and treatment of opportunistic infections in HIV and acquired immunodeficiency syndrome (AIDS) has led to longer life expectancy (Graham et al., 1992), and this has changed the incidence of Pseudomonas aeruginosa infection in this population (Baron and Hollander, 1993). We present a case of a patient with AIDS who developed a fulminant Pseudomonas aeruginosa stenosing subglottic infection. We are unaware of any previous reports of this particular manifestation of Pseudomonas aeruginosa infection.

Paraffinoma revisited: a post-operative condition following rhinoplasty nasal packing.

Paraffin impregnated tulle is frequently used as a post-operative dressing after surgical repair of wounds, on skin-donor sites and in packing of tissue cavities. Historically, paraffin has been injected into various sites of the body and paraffinoma is a well-described complication. Despite this, nasal packing with paraffin gauze is still common after rhinoplasty. We report a case of paraffinoma occurring after rhinoplasty and discuss the avoidance of this rare but serious complication and suggest silicon mesh as an alternative dressing.

Invasive candidiasis of a late presentation laryngeal chondroradionecrosis.

Laryngeal chondroradionecrosis is an unusual condition which may present many years after the initial radiotherapy. We present a case of late onset chondroradionecrosis which was complicated by invasive candidiasis of the arytenoid cartilages which had themselves been extruded through the laryngeal mucosa.

Early diagnosis of Wegener's granulomatosis presenting with facial nerve palsy.

Wegener's granulomatosis is a multi-system disease characterized by granuloma formation and a necrotizing vasculitis. It classically presents with involvement of the upper and lower respiratory and renal systems. However locoregional disease is common and may include otological manifestations. Facial nerve palsy has been reported during the course of the disease process but it is extremely rare for it to be the presenting feature. Previously reported cases have involved a protracted diagnostic process including exploratory tympanotomy, mastoidectomy and facial nerve decompression. We report a case of Wegener's granulomatosis which presented with a facial nerve palsy. An early diagnosis was achieved by measurement of the erythrocyte sedimentation rate (ESR), followed by serological assay of cytoplasmic anti-neutrophil cytoplasmic antibody (cANCA). Histological examination of nasal mucosal biopsies confirmed granuloma formation consistent with a diagnosis of Wegener's granulomatosis. This allowed early treatment with immunosuppressive therapy and avoided unnecessary and potentially hazardous middle ear surgery.

Microbiological features and pathogenesis of peritonsillar abscesses.

Samples of pus aspirated from 53 peritonsillar abscesses were examined in detail for aerobic and anaerobic bacteria, and the microbiological results correlated with clinical data in 44 cases. In 45 samples (85%) cultures were positive: 7 yielded organisms consistent with an aerobic infection, mainly Lancefield group A beta-haemolytic streptococci (5/7), and 38 yielded organisms consistent with an anaerobic infection. The anaerobic infections were usually mixed, but in two cases Fusobacterium necrophorum was isolated in pure culture. Peptostreptococcus micros and Streptococcus milleri were the predominant isolates in this group. Direct Gram stain smear and gas-liquid chromatography were useful indicators of the type of infection present. Samples from ten patients (18.9%) grew one or more beta-lactamase-producing isolates. Of the 25 patients prescribed antibiotics by their general practitioners prior to admission, 18 received one or more beta-lactam antibiotics. Most cases of peritonsillar abscess were due to mixed anaerobic infections, Lancefield group A beta-haemolytic streptococci playing a central role in only a minority of cases. In light of these findings and the possibility of infection with beta-lactamase-producing isolates, it is suggested that the first-line antibiotic therapy in this group of patients should include a chemotherapeutic agent directed against anaerobic bacteria.

Eye protection in ear, nose and throat surgery.

The aim of this study was to quantify the risk of blood splashes to the conjunctiva during ear, nose and throat surgery. Two hundred and sixty consecutive operations by three surgeons were assessed for contamination of safety glasses and other factors. We found that 15 per cent of operations resulted in blood droplet contamination of safety glasses. In 92 per cent of these, contaminations were on the exterior of the glasses and eight per cent were on both sides. We concluded that about one and a half per cent of operations would result in droplet contamination of the conjunctiva and that safety spectacles reduced the risk by a factor of about 10. This study generally concurs with that of previous research in the areas of general and orthopaedic surgery and necropsies. We substantiate the need for eye protection for all ear, nose and throat procedures. Spectacles do provide a reasonable degree of protection but where absolute protection is needed i.e. in high risk groups, goggles should be used in preference to safety spectacles.

Acute pneumonitis caused by low density barium sulphate aspiration.

The aspiration of contrast medium during the investigation of swallowing disorders is a well recognized hazard. It is therefore essential that the contrast medium administered is non-irritant to the lungs. A case is presented to illustrate the problems associated with the aspiration of a relatively non-irritant contrast medium.

Nasal teeth.

Ectopic and supernumerary teeth occur in a wide variety of sites. Those that have been reported include the mandibular condyle, coronoid process, orbit, palate, nasal cavity and the maxillary antrum. Eruption of teeth into these sites is rare, and easily overlooked. We present two cases in which eruption of teeth into the nose and paranasal sinuses was associated with significant morbidity and show how this was relieved by appropriate surgery.