Image-guided transnasal endoscopic fine needle aspiration or biopsy of parapharyngeal space tumours.

BACKGROUND: Parapharyngeal space biopsy is an important investigation in the management of parapharyngeal space tumours. These tumours are relatively rare and the surgeon is often faced with a wide range of differential diagnoses. There are several ways to access the parapharyngeal space, with varying degrees of associated morbidity. METHODS: This paper describes a seldom used, but a simple and safe, image-guided endoscopic approach to parapharyngeal space biopsy that enables tissue to be obtained transnasally. The procedure is conducted under general anaesthesia using computed tomography image guidance via the LandmarX system, with transnasal access to the parapharyngeal space achieved using a sampling needle. RESULTS: This procedure is relatively simple, safe and reproducible. It is a less invasive approach to parapharyngeal space biopsy, and one which has been successfully used by the senior author for years without any significant morbidity. CONCLUSION: Transnasal image-guided endoscopic aspiration or biopsy of the parapharyngeal space is a novel technique that has not been previously described.

Musical hallucination following whiplash injury: case report and literature review.

INTRODUCTION: A musical hallucination is defined as a form of auditory hallucination characterised by the perception of music in the absence of external acoustic stimuli. It is infrequently cited in the literature, although population studies suggest a greater prevalence. The aetiology of this unusual disorder remains unclear. CASE REPORT: A 70-year-old man with acquired hearing loss suffered a whiplash injury in a low-speed road traffic accident, and subsequently presented with bilateral 'tinnitus.' On closer questioning, he described hearing orchestral music. There was no evidence of psychosis, delirium or intoxication, and the patient was managed expectantly. CONCLUSION: This patient represents the first published case of musical hallucination precipitated by whiplash injury. We explore the possible pathophysiological underpinnings of musical hallucination and highlight the need for a greater awareness of this disorder. A management strategy is suggested.

Safety of sublingual grass pollen immunotherapy after anaphylaxis.

AIM: To demonstrate that sublingual immunotherapy is a safe treatment option in patients who have previously suffered anaphylaxis when undergoing subcutaneous grass pollen immunotherapy. CASE REPORT: We report two patients who developed a systemic anaphylactic reaction following subcutaneous grass pollen immunotherapy, resulting in discontinuation of treatment. Following treatment of the acute anaphylactic episode, both patients were subsequently safely commenced on sublingual grass pollen immunotherapy. CONCLUSION: Injection immunotherapy has a relatively low risk of severe adverse events, although anaphylaxis is a potentially fatal complication and usually results in termination of the immunotherapy programme. Sublingual immunotherapy has a safer side effect profile than subcutaneous immunotherapy, with no reported cases of anaphylaxis.

A preliminary randomised controlled trial evaluating the efficacy of saline douching following endoscopic sinus surgery.

OBJECTIVE: To assess whether saline reduces postoperative signs following endoscopic sinus surgery (ESS). DESIGN: Within subject, single blinded randomised controlled trial. SETTING: Single secondary referral centre. PARTICIPANTS: Adults undergoing bilateral ESS for chronic rhinosinusitis or nasal polyposis. INTERVENTION: Saline douching of one side of the nasal cavity, three times per day for 6 weeks. MAIN OUTCOME MEASURES: Presence of adhesions, polyps, crusting, discharge or oedema under endoscopic examination at 3 weeks and 3 months postoperative. RESULTS: Twenty-three patients were recruited. Attendance was 22 patients at 3 weeks and 17 patients at 3 months. At 3 weeks saline douching significantly improved the presence of discharge (P = 0.046) and non-significantly improved the presence of oedema (P = 0.059) with minimal difference with regard to polyps (P = 0.32) and no difference with adhesions or crusting. At 3 months there was minimal difference with regard to crusting (P = 0.18) and oedema (P = 0.32) and no difference with adhesions, discharge and polyps. CONCLUSIONS: Saline douching reduces nasal discharge and may improve oedema during the healing phase following ESS which may represent a possible anti-inflammatory role. No long-term effect was found.

Endoscopic dacrocystorhinostomy in lacrimal canalicular trauma.

A case is presented where the common insertion of the upper and lower canaliculus of the lacrimal sac was repaired using endoscopic dacrocystorhinostomy (DCR) techniques, with silicone stenting and securing of stents intranasally.

Conchopexy suture to prevent middle turbinate lateralisation and septal haematoma after endoscopic sinus surgery.

Endoscopic ethmoidectomy is now one of the commonest surgical procedures performed by ear, nose and throat surgeons. Access to the ethmoid air cells is via the middle meatus following medialisation of the middle turbinate and uncinectomy. The most satisfactory postoperative results are achieved by maintaining patency of the middle meatus. This allows delivery of topical medication and sinus aeration. Spontaneous lateralisation of the middle turbinate during the healing period, with or without synechiae, can compromise the surgical benefit. This paper describes a conchopexy suture placed at completion of ethmoidectomy. A carefully placed yet simple suture technique will maintain a widely patent middle meatus during the phase of post-operative healing. A slight modification allows quilting of mucoperichondrial flaps after septal surgery.

Carcinoma ex-pleomorphic adenoma of the nasal septum with adenoid cystic and squamous carcinomatous differentiation.

Carcinoma ex-pleomorphic adenoma of the nose or paranasal sinuses is extremely rare. We report the first histopathologically confirmed case with adenoid cystic carcinomatous differentiation to present arising from the nasal septum.

Surgical decompression in traumatic optic neuropathy.

BACKGROUND: The management of traumatic optic neuropathy remains controversial. This retrospective study presents the results of 19 cases of indirect optic neuropathy where surgical decompression represented the primary mode of treatment. METHODS: Nineteen patients (20 optic nerves) with traumatic optic neuropathy underwent primary surgical decompression. The surgery was performed using the transethmoidal technique. RESULTS: The extent of bony optic canal injury documented during surgery indicated that this had been underestimated in this series by CT findings. Vision improved in eight patients, five of whom had had no light perception preoperatively. CONCLUSION: Primary surgical decompression of the optic nerve within 48 h of injury produces beneficial results. Testing of visual acuity 6 weeks after surgery does not serve as a reliable predictor of final outcome.

Eosinophilic angiocentric fibrosis affecting the nasal cavity. A mucosal variant of the skin lesion granuloma faciale.

Eosinophilic angiocentric fibrosis (EAF) is an unusual fibrotic condition affecting the mucosa of the upper respiratory tract, of which there have been eight reported cases. The condition is thought to be associated with the rare skin disorder granuloma faciale, which is histologically identical, and was present in two cases of EAF. We report the third case where EAF and granuloma faciale occurred together, to highlight this type of intranasal fibrosis as a distinct pathological entity.

Treatment of squamous cell carcinoma of the lip using Foscan-mediated photodynamic therapy.

Carcinoma of the lip is a common cancer of the head and neck area; its incidence is approximately one-quarter that for oral cavity cancers. It occurs most frequently on the lower lip of elderly males. This non-randomized Phase II study aimed to estimate the complete response (CR) rate to Foscan-mediated photodynamic therapy (Foscan-PDT) in patients with primary cancer of the lip, duration of CR, and the tolerability and safety of Foscan-PDT. Twenty-five patients with squamous cell carcinoma (SCC) of the lip (Tis, T1, T2/N0/M0) and Karnofsky status > or = 70 received 0.15 mg/kg Foscan intravenously, followed 4 days later by a single non-thermal illumination of the tumour (light dose 20 J/cm2, irradiance 100 mW/cm2, lambda=652 nm). Response was determined after 12 weeks and mean follow up is 424 days so far. After 12 weeks, 96% of cases (24/25) showed CR, and all CRs were confirmed by biopsy. The most common adverse event was swelling and local pain at the treatment site. Tumour recurrence was observed in two patients 4 and 18 months after PDT. One patient developed a single lymph node metastasis 7 months after therapy. Photosensitivity reactions occurred in five patients. The functional results were excellent in all patients without any signs of limited mouth opening or impaired lip closure. The cosmetic outcome was better than after surgical therapy. Foscan-PDT is an effective treatment modality for small primary tumours of the lips. Foscan-PDT yields complete response rates comparable to those published for surgery or radiotherapy without causing major toxicity. It allows preservation of form and function and does not compromise future treatment options for recurrent, residual or second primary disease.

Are pre-operative vocal fold checks necessary?

Over a 26-year period, from 1970 to 1995, 2250 pre-operative vocal fold checks were carried out by the ENT team at Manchester Royal Infirmary in patients undergoing thyroid, parathyroid and cardiothoracic surgery. A register was kept of all pre-operative fold checks. This register was retrospectively analysed and 23 vocal fold palsies were documented. In six of these patients the notes were either missing or incomplete. All of the remaining 17 patients had a history suggestive of vocal fold palsy. We suggest that in the absence of symptoms, either current or on history, a routine pre-operative vocal fold check is unnecessary.

Imaging of temporal bone brain hernias: atypical appearances on magnetic resonance imaging.

Brain tissue with or without its dural covering may protrude into the temporal bone through a defect in the tegmen tympani. Infection or granulation tissue, with or without cholesteatoma may make diagnosis difficult. While computed tomography (CT) may demonstrate a bony defect, it is difficult to distinguish between herniated brain, cholesteatoma or granulation tissue. Magnetic resonance imaging (MRI) clearly demonstrates healthy herniated brain tissue, but ischaemic or necrotic elements may mimic other lesions. We present a series of five patients with brain hernia, highlighting the spectrum of preoperative radiological appearances, and some of the difficulties encountered in interpreting these images. MRI demonstrated herniation of healthy brain in two patients but in three, showed irregular soft tissue with signal characteristics consistent with cholesteatoma. Surgery in these three patients demonstrated necrotic brain with coexisting cholesteatoma in two. Brain hernias are often necrotic and may have morphological and signal characteristics similar to cholesteatoma with which they may coexist.

Acquired immune deficiency syndrome (AIDS) presenting as a nasal septal perforation.

Patients infected with the Human Immunodeficiency Virus (HIV) and those with AIDS may present with many head and neck manifestations. We report a case of an undiagnosed HIV positive male who presented with symptoms due to a nasal septal perforation, and rapidly developed AIDS. The histopathology of the perforation margins revealed active chronic inflammation with no evidence of neoplasia or granuloma. No viral or fungal infection was demonstrable on immunological testing and fungal stain. This is the first reported case of a patient developing AIDS presenting with a nasal septal perforation.

Non-cardiogenic pulmonary oedema due to foreign body aspiration.

A patient who developed non-cardiogenic pulmonary oedema secondary to acute airway obstruction caused by an aspirated foreign body is presented. The literature is reviewed, discussing the theories regarding the formation of non-cardiogenic pulmonary oedema. The case highlights the importance of this rare complication of foreign body aspiration and surgeons and anaesthetists should be alert to continued respiratory symptoms following relief of acute airway obstruction.

Paediatric pyogenic granuloma presenting as a unilateral nasal polyp.

The presence of a rapidly growing intranasal mass in a child is an alarming clinical sign that requires adequate clinical and radiological assessment and prompt histological diagnosis. We present two cases of children with unilateral intranasal pyogenic granulomas. There is only one previous report of this histological diagnosis in the nasal cavity in children. Pyogenic granuloma of the nasal cavity is rare. Pyogenic granuloma should be included in the differential diagnosis of an intranasal mass in the paediatric age group.

Multiple cutaneous metastases from laryngeal carcinoma.

A case of laryngeal squamous cell carcinoma recurrence presenting as multiple cutaneous metastases is presented. Such metastases are rare and are associated with a poor prognosis. Treatment is usually aimed at providing pain relief in these patients with a limited life expectancy.

Aspergillus mastoiditis in a patient with acquired immunodeficiency syndrome.

We present the case history of a patient who was severely immunocompromised due to infection with the human immunodeficiency virus (HIV), and who subsequently developed acute mastoiditis due to Aspergillus fumigatus. Fungal otomastoiditis is a rarely reported complication of HIV infection. A high index of suspicion is required in these patients to facilitate early diagnosis and appropriate therapy.