Acute otolaryngological presentations in Northland, New Zealand: analysed with respect to geography and rurality.

AIM: Otorhinolaryngology, head and neck surgery (ORL) diagnoses and treats disorders of the ear, nose, throat, head and neck which can be commonly seen across a range of medical specialities. Rural patients experience a burden of ORL diseases and face greater barriers to healthcare than their urban counterparts. We aim to provide information on the diagnoses of rural patients presenting with ORL symptomatology to provide data that may be useful in targeting resources and training towards rural patients. METHODS: A 6-year retrospective study was performed between 1 January 2015 to 31 December 2020. The Northland District Health Board (NDHB) data warehouse was searched using ICD-10 codes relevant to ORL. The study included any patient acutely presenting to an NDHB hospital with an ORL diagnosis. Patients with a diagnosis that was not related to ORL, a non-acute presentation, or a diagnosis not usually managed by hospital ORL services were excluded. RESULTS: Five thousand, five hundred and thirty-four presentations in 4,671 individual patients were included in the study. The mean age of patients was 35.1 years (SD 26.58). Two thousand, three hundred and twenty-six (49.8%) patients were female and 2,345 (50.2%) were male. One thousand, nine hundred and sixty-five (42.1%) were Maori and 2,699 (57.8%) were non-Maori. Median decile was 8 (4 IQR). Two thousand and seventy-seven (44.5%) patients were classified as rural and 2,594 (55.5%) as urban. The most common presentation was epistaxis with 16.8% (n=927/5534) of total presentations. The four next most common presentations were otological. There was a total of 224 complications including post-operative bleed, post-operative infection, and other post-operative complications. There was a significant difference in the rate of discharge with 1,819/2,430 (74.9%) rural patients and 2,518/3,104 (81.1%) urban patients being discharged directly from the emergency department (ED) (p <0.001). CONCLUSION: This retrospective study provides a picture of acute ORL presentations in Northland patients, analysed with respect to geography and rurality. It highlights the large volume of ORL patients who are seen and managed by rural and ED physicians, and the importance of rural provision of care in Northland. These findings support the need for targeting resources and training to centres treating rural patients for the management and treatment of ORL conditions.

COVID-19 vaccine associated cervical lymphadenopathy: a case series.

BACKGROUND: COVID-19 is an evolving worldwide pandemic causing significant morbidity and mortality. COVID-19 vaccinations have been developed to increase immunity against the virus. In New Zealand, the Pfizer BioNTech mRNA vaccine has been provisionally approved for use. Axillary lymphadenopathy is a recognized side effect of the mRNA vaccine, however cervical lymphadenopathy has also been reported. Due to a wide range of differential diagnoses, the finding of cervical lymphadenopathy requires thorough investigation which can include imaging and invasive diagnostic procedures. METHODS: Five patients were identified by otorhinolaryngology (ORL) consultants at Whangarei Base Hospital and Waikato Hospital between 15/7/2021 and 21/12/2021 after being investigated through high suspicion of cancer triage pathways set by the New Zealand Ministry of Health. Inclusion criteria were adult patients with cervical lymphadenopathy following vaccination. Exclusion criteria were no history of vaccination or lymphadenopathy present before vaccination. RESULTS: All patients were identified to have cervical lymphadenopathy on radiological imaging and a recent history of COVID-19 vaccination with the Pfizer BioNTech vaccine. Interval vaccination to fine needle aspiration time ranged between 41 and 76 days. All patients had cytological or histological diagnosis showing reactive findings or interval imaging showing resolution of lymphadenopathy. CONCLUSION: With increasing levels of COVID-19 vaccination and booster vaccinations we will continue to see cases of COVID-19 vaccine associated cervical lymphadenopathy. We highlight the importance of taking a COVID-19 vaccination history and including COVID-19 associated cervical lymphadenopathy in the differential diagnosis of presentation with a neck lump.

Management of retrosternal goiter: Retrospective study of 72 patients at two secondary care centers.

OBJECTIVE: Data pertaining to the outcomes of retrosternal goiter surgeries performed at secondary care centers, where thoracic surgery expertise is not readily available, is infrequently reported. Careful patient selection is crucial to avoid an unexpected need for a sternotomy during surgery. We sought to evaluate the surgical management of patients with retrosternal goiters treated at two secondary care centers. METHODS: Retrospective review of clinical records and computed tomographic (CT) scans of 557 patients who underwent thyroid surgery at the Departments of Otolaryngology, Head and Neck Surgery of Manukau Surgery Center and Whangarei Base Hospital. Inclusion criterion was extension of goiter below the plane of the thoracic inlet on CT scan. Clinicopathologic features and surgical outcomes were recorded. RESULTS: The prevalence of retrosternal goiter was 72 of 557 patients (12.9%). All patients in this series underwent thyroidectomy transcervically. Dyspnea was present in 48 patients (66.7%). On preoperative CT scans, the goiter was noted to extend beyond the aortic arch in seven patients (9.7%), tracheal bifurcation in five patients (6.9%) and posterior mediastinum in 15 patients (20.8%). Malignancy was diagnosed in eight patients (11.1%) histologically. Postoperatively, vocal cord paralysis was temporary in 5 patients (6.9%) and permanent in 1 patient (1.4%). Hypocalcaemia was transient in 10 patients (13.9%). No permanent hypocalcemia, tracheomalacia, postoperative hematoma or patient death was reported. During the study period, 4 patients were encountered in the outpatients setting whereby the evaluation of their CT imaging demonstrated features deemed to be at high risk of requiring a sternotomy: primary mediastinal goiter (n=2) and inferior extent of goiter to the level of right atrium (n=2). These patients were pre-emptively referred to a tertiary center where thoracic surgery service was available and their data was reported separately. CONCLUSION: With careful patient selection, the majority of retrosternal goiter can be resected transcervically with minimal morbidities. Preoperative CT scan yielded useful surgical information; in the presence of primary mediastinal goiter or inferior extent of goiter to the level of the right atrium, surgery should be planned in a tertiary center where thoracic surgeon is available.

The extent of surgery for benign parotid pathology and its influence on complications: A prospective cohort analysis.

BACKGROUND: The surgical management of benign parotid tumors is aimed at complete extirpation of the mass with preservation of facial nerve function. There is a relative paucity of literature pertaining to complications after benign parotid surgery and related risk factors. We aim to critically review the outcomes following treatment of benign parotid pathology when surgery entailed either complete superficial parotidectomy (CSP), partial superficial parotidectomy (PSP) or extracapsular dissection (ECD). MATERIAL AND METHODS: This is a review of prospectively collected data of all parotidectomies performed between June 2006 to June 2016 for histologically-proven benign pathology of the parotid. Median follow-up time was 31.6weeks. RESULTS: A total of 101 parotidectomies were carried out on 97 patients (40 CSP, 56 PSP and 5 ECD). Pleomorphic adenoma (48.4%) and Warthin's tumors (32.7%) were the most common pathologies. Temporary facial weakness occurred after 7 operations (6.9%). Facial weakness was permanent in 4 cases (3.9%). The rates of sialocele and salivary fistula were 4.9% and 0.9%, respectively. Only one patient (0.9%) developed Frey Syndrome postoperatively. No significant associations between extent of parotid surgery and postoperative facial nerve dysfunction (p=0.674) or wound complications (p=0.433) were observed. Univariate analyses for potential contributing factors such as advanced age, smoking status, tumor location or histology did not demonstrate any increased risk with developing postoperative complications. CONCLUSION: Partial superficial parotidectomy was associated with low rates of morbidity to the facial nerve and surgical wound. The results were comparable to complete superficial parotidectomy. We recommend offering patient partial superficial parotidectomy where appropriate and this is in line with the current trend of minimising surgical dissection, thereby potentially decreasing the risk of short-term and long-term complications.

Classification of parotidectomy: a proposed modification to the European Salivary Gland Society classification system.

Parotidectomy remains the mainstay of treatment for both benign and malignant lesions of the parotid gland. There exists a wide range of possible surgical options in parotidectomy in terms of extent of parotid tissue removed. There is increasing need for uniformity of terminology resulting from growing interest in modifications of the conventional parotidectomy. It is, therefore, of paramount importance for a standardized classification system in describing extent of parotidectomy. Recently, the European Salivary Gland Society (ESGS) proposed a novel classification system for parotidectomy. The aim of this study is to evaluate this system. A classification system proposed by the ESGS was critically re-evaluated and modified to increase its accuracy and its acceptability. Modifications mainly focused on subdividing Levels I and II into IA, IB, IIA, and IIB. From June 2006 to June 2016, 126 patients underwent 130 parotidectomies at our hospital. The classification system was tested in that cohort of patient. While the ESGS classification system is comprehensive, it does not cover all possibilities. The addition of Sublevels IA, IB, IIA, and IIB may help to address some of the clinical situations seen and is clinically relevant. We aim to test the modified classification system for partial parotidectomy to address some of the challenges mentioned.

Nasopharyngeal fibroepithelial polyp in a New Zealand Maori man.

Adult nasopharyngeal polyps have not previously been described in the literature. We present the case of a 42-year-old New Zealand Maori man who presented with a large, 11 cm mobile mass in his nasopharynx. We discuss his history and management, emphasising the need for early assessment and intervention.

Role of histopathology as an aid to prognosis in rhino-orbito-cerebral zygomycosis.

Rhino-orbito-cerebral zygomycosis is a rapidly progressive opportunistic fungal infection characterized by a set of clinical and radiological findings that help in prognostication. The present study is aimed to evaluate its histopathologic features as an aid to prognosis in order to guide the physician at the stage of tissue diagnosis to optimize surgery, chemotherapy and immunosuppression. The study comprises of a microscopic analysis of specific histopathologic variables on 33 cases of zygomycosis that were diagnosed and treated in a seven-year period. Fungal load in the tissue (graded as mild, moderate and marked), mean diameter of fungus, degree of neutrophilic and granulomatous response, tissue invasion and necrosis were graded and assessed for their prognostic significance. Seasonal variation, signs and symptoms, extent of involvement and laboratory parameters were also analyzed to examine the trend of occurrence of the disease and to associate these with patient's outcome, which was categorized as either survived or expired. The follow-up ranged from 1 month to 7 years. Of all the histological variables, angioinvasion was directly related to the mortality rate. Diameter of the fungal hyphae and its intraorbital or intracranial invasion also proved to be significant indicators of poor prognosis. (P = 0.04 and 0.0037, respectively) though angioinvasion was directly related to the mortality rate. Thus, histopathology could assist the clinician in assessing patient's progress and thus optimize the treatment in such patients.

Isolated lingual mucormycosis in an infant with Down syndrome.

Mucormycosis is characterized by severe infection with rapid progression and a high mortality rate. In immunocompromised hosts, the most common type is the rhinocerebral form of mucormycosis. Invasive mucormycosis affecting only the tongue is extremely rare. We report one such case that occurred in an immunocompromised 4-month-old girl with Down syndrome who had been hospitalized for acute gastroenteritis. The infant had metabolic acidosis secondary to diarrhea. It was suspected that the infection had been contracted through the use of a wooden tongue depressor during oral examination. We present this case report in the hope that it will discourage clinicians from using wooden tongue depressors in vulnerable infants. We also wish to emphasize that mucormycosis should be considered in all patients--regardless of age--who present with localized bluish-black discolored mucosa of the oral mucosa and/or tongue.

Botulinum toxin type-A (Botox-A) injections for treatment of sialorrhoea in adults: a New Zealand study.

AIM: We report our initial experience using Botox-A injection to the salivary glands to control sialorrhoea. METHODS: Eight adult patients with significant sialorrhoea were referred from an inpatient rehabilitation unit, GP referral, and internal medicine department. All subjects underwent bilateral submandibular gland injections and, in addition, one patient (the first) also had intraparotid injections. Injections were performed with ultrasound guidance at Dunedin Hospital, New Zealand. Six patients received a total of 30 Units and two patients received 60 Units in the submandibular glands without any complications. Outcome was assessed using a drooling scale and VAS self report of sialorrhoea. RESULTS: Of the eight patients treated, six reported a marked reduction in salivation following treatment, and one patient improved partially. One patient did not find the Botox injection helpful in controlling sialorrhoea and was offered escalation of the Botox dose with a subsequent partial response. No serious adverse events occurred, and no procedure-related complications were noted. CONCLUSIONS: Our initial experience suggests that injection of Botox-A injected at a relatively low dose to the submandibular glands can be used to achieve desired results for the treatment of sialorrhoea. This is an easily performed procedure with low morbidity and can be recommended as a first-line intervention in the treatment of adult sialorrhoea.