The Nottingham and Nottinghamshire Hospital for Diseases of the Throat, Ear and Nose (1886-1947): its formation, rise and demise.

BACKGROUND: The Nottingham and Nottinghamshire Hospital for Diseases of the Throat, Ear and Nose existed in Nottingham for over 60 years, but there is little knowledge or documentation regarding its existence. METHODS: The following resources were searched to find out more about the hospital: the Nottinghamshire Archives; Manuscripts and Special Collections at the University of Nottingham Libraries; and Nottingham Central Library. Information was also obtained from the founders' relatives. RESULTS: The hospital was founded in 1886, by Dr Donald Stewart, supported by political and clerical leaders. Initially, it treated out-patients only; in-patients were admitted for surgical treatment from 1905. Suitable accommodation was purchased in 1925, on Goldsmith Street, but required much building extension and alteration. Building restrictions during and following World War II prevented expansion. The National Hospital Survey conducted in 1945 considered the clinical work undertaken to be of a minor character, and recommended closure and amalgamation with the services provided by the Nottingham General Hospital. The hospital closed in 1947. CONCLUSION: The specialist hospital was deemed unfit and unsuitable to compete with the comprehensive service provided by the Nottingham General Hospital.

Provision of surgical voice restoration in England: questionnaire survey of speech and language therapists.

AIM: To conduct a questionnaire survey of speech and language therapists providing and managing surgical voice restoration in England. METHOD: National Health Service Trusts registering more than 10 new laryngeal cancer patients during any one year, from November 2009 to October 2010, were identified, and a list of speech and language therapists compiled. A questionnaire was developed, peer reviewed and revised. The final questionnaire was e-mailed with a covering letter to 82 units. RESULTS: Eighty-two questionnaires were distributed and 72 were returned and analysed, giving a response rate of 87.8 per cent. Forty-four per cent (38/59) of the units performed more than 10 laryngectomies per year. An in-hours surgical voice restoration service was provided by speech and language therapists in 45.8 per cent (33/72) and assisted by nurses in 34.7 per cent (25/72). An out of hours service was provided directly by ENT staff in 35.5 per cent (21/59). Eighty-eight per cent (63/72) of units reported less than 10 (emergency) out of hours calls per month. CONCLUSION: Surgical voice restoration service provision varies within and between cancer networks. There is a need for a national management and care protocol, an educational programme for out of hours service providers, and a review of current speech and language therapist staffing levels in England.

Salivary duct carcinoma: what is already known, and can we improve survival?

Salivary duct carcinoma is an aggressive malignancy with a high mortality rate, which phenotypically resembles high-grade breast ductal carcinoma. The parotid gland is the most common location. Standard treatment is surgery to the primary tumour together with post-operative radiotherapy. Despite this, there is a high rate of local recurrence, cervical nodal involvement and distant metastasis. Chemotherapy is currently considered only for end-stage, disseminated disease; however, current evidence indicates that chemotherapy used with radiotherapy may result in improved disease control and survival.Human epidermal growth factor receptor-2 is a proto-oncogene which is over-expressed in both breast ductal carcinoma and salivary duct carcinoma. Clinical studies of patients with metastatic breast cancer, using trastuzumab, a monoclonal antibody directed against human epidermal growth factor receptor-2, have shown significant efficacy in tumour response, resulting in improved survival. Such advances in immunohistochemistry, and in targeted immunotherapy for breast ductal carcinoma, should be applied to the treatment of salivary duct carcinoma.

Malignant melanoma of nasal cavity and paranasal sinuses: report of 24 patients and literature review.

OBJECTIVE: To report our experience of the management of patients with primary sinonasal malignant melanoma, and to review the relevant medical literature. METHOD: Retrospective review examining treatment and outcomes. RESULTS: Twenty-four patients were treated between 1982 and 2007. The mean age at presentation was 67.5 years. The overall five-year survival was 30 per cent; mean survival was three years and eight months. CONCLUSION: Sinonasal malignant melanoma is associated with a poor outcome, and survival statistics have not improved over the last 40 years. Treatment should include radical surgery wherever possible. Local recurrence is common; radiotherapy may help control this but does not appear to affect overall survival. The limited evidence available suggests that endoscopic removal of sinonasal malignant melanoma is as effective as other local surgical means, but that craniofacial resection remains the 'gold standard' for tumours that contact or traverse the skull base. Novel biological treatments are emerging and hold promise for the future.

Consensus statement on management in the UK: transoral laser assisted microsurgical resection of early glottic cancer.

BACKGROUND: Transoral laser assisted microsurgical resection of early glottic laryngeal cancer is a relatively new treatment modality that is practised in many centres across the UK. In the absence of the results from randomised clinical trials, clinicians may be guided by an expert panel consensus statement on transoral laser assisted microsurgical resection of early squamous cell cancer of the larynx. OBJECTIVE: To provide consensus recommendations on the various aspects of transoral laser assisted microsurgical resection for early glottic cancer. EVALUATION METHOD: Nine centres across the UK were invited to describe current practice and outcomes for transoral laser assisted microsurgical resection of early glottic cancer. Four working groups were created to draw consensus on standard of care, surgical procedures, outcomes measures and training/certification. The feedback from these groups was integrated into the consensus statement. CONCLUSIONS: The consensus meeting confirmed the stablished and widespread use of transoral laser assisted microsurgical resection for early glottic cancer throughout the UK. The common experience gained allowed a full discussion of all aspects of the management with consensus achieved in key areas of standards of care, surgery, histopathologic reporting, outcomes assessment and training. This consensus statement will result in closer auditing of management and dissemination of results.

Bleeding around a tracheostomy wound: what to consider and what to do?

All patients with bleeding in and around a tracheostomy must be investigated to exclude a serious cause. The overall incidence is approximately 5 per cent of tracheostomies performed in Adult Intensive Care Units (AICU). When bleeding commences more than 72 hours post-operatively, the possibility of a trachea innominate artery fistula needs to be excluded by endoscopic examination of the trachea in an operating theatre environment, with the facility to proceed to exploration of the neck and possibly to sternotomy to enable ligation of the innominate artery. With appropriate recognition, diagnosis, resuscitation and surgical intervention, the associated high death rate of trachea innominate artery fistula can be reduced.

Squamous carcinoma arising in a branchial cleft cyst: have you ever treated one? Will you?

The existence of primary branchiogenic carcinoma - that is, carcinoma arising in a pre-existing branchial cleft cyst (a benign developmental cyst) - has in recent decades been the subject of increasing scepticism. Recognition of the propensity of a variety of head and neck sites - including in particular the tonsil - to give rise to cervical metastases while the primary tumours themselves remain undetected has given rise to the idea that virtually all cystic carcinomas of the neck represent metastatic deposits, whether or not their primary sites are found. A diagnosis of primary branchiogenic carcinoma should be viewed with extreme scepticism, and every effort should be made (e.g. imaging, panendoscopy, elective tonsillectomy) to exclude the existence of a primary site elsewhere, before considering a diagnosis of primary branchiogenic carcinoma.

Role of limited parotidectomy in management of pleomorphic adenoma.

There is continued controversy over the extent of parotidectomy required for removal of a benign pleomorphic adenoma from the parotid gland. Currently, consensus exists that the integrity of the facial nerve must be preserved when the tumour is totally removed. As a result of experience gained in the first half of the twentieth century, it was recommended that superficial parotidectomy with facial nerve dissection should be the minimal biopsy for pleomorphic adenoma. Since that time, however, research has indicated that partial parotidectomy or extracapsular dissection of benign pleomorphic adenoma can be accomplished with preservation of the facial nerve without an increase in tumour recurrence. Partial parotidectomy or extracapsular dissection results in impaired cosmetic results and a lower incidence of Frey's syndrome, and thus may be the preferred approach when undertaken by experienced surgeons.

Sinonasal inverted papillomas: recurrence, and synchronous and metachronous malignancy.

INTRODUCTION: Inverted papillomas are relatively rare, benign epithelial tumours of the nasal cavity which generate considerable interest because they are locally aggressive, have a tendency to recur and are associated with malignancy. AIMS: To review our experience of the management of inverted papillomas, and to review the literature in order to evaluate recurrence rates, rates of synchronous and metachronous carcinoma, and outcomes of treatment, both endoscopic and conventional. METHODS: We retrospectively reviewed all cases of inverted papilloma that presented to our unit, a tertiary referral centre, over a 20-year period from 1985 to 2005. A Medline review of the literature was performed to identify published case series of inverted papillomas. We undertook a critical analysis of the literature. RESULTS: We treated 65 patients with inverted papilloma over the 20-year period, with a mean follow up of five years (range one to 20 years). Fifty-eight patients initially underwent nasal biopsy, often with polypectomy. Thirty-six had endoscopic surgery, with five (14 per cent) suffering recurrence, whilst 16 had a lateral rhinotomy and medial maxillectomy, of which four (25 per cent) suffered a recurrence. Seven septal inverted papillomas required local resection, with no subsequent recurrences. There were seven (11 per cent) synchronous and two metachronous malignancies.Sixty-three case series with adequate data were identified from the literature. There were 163 (7.1 per cent) cases of synchronous carcinoma, out of 2297 cases. Metachronous carcinomas were reported in 74 out of 2047 cases, representing a transformation rate of 3.6 per cent. However, the true population base for these figures is uncertain, given that many series were reported from tertiary centres, where recurrent and problematic cases are likely to be over-represented. The recurrence rates were 12.8 per cent for endoscopic procedures, 17.0 per cent for lateral rhinotomy with medial maxillectomy, and 34.2 per cent for limited resections such as nasal polypectomy and Caldwell-Luc approaches. No significant association between atypia or dysplasia and recurrence or malignant transformation was found. The mean time taken to develop a metachronous carcinoma was 52 months (range six to 180 months). The estimated malignant potential for recurrent disease was up to 11 per cent. CONCLUSION: Patients with inverted papilloma should undergo thorough surgery to remove all mucosal disease, most probably by the endoscopic, endonasal route when complete resection is possible. Cases demonstrating atypia or dysplasia may be treated by the endoscopic route. Recurrent disease and metachronous carcinoma can develop after a prolonged period of time. Long-term follow up is recommended to detect recurrence, as disease can become quite extensive before it becomes symptomatic.

An audit of clinical resources available for the care of head and neck cancer patients in England.

AIMS: Thirty-four cancer networks are now responsible for the delivery of head and neck cancer services in England. A survey of all cancer networks was carried out to define the services available for the diagnosis, treatment and support of patients with head and neck cancer. MATERIALS AND METHODS: Fifty-two cancer units were identified in England from the Cancer Services Collaborative 'Improvement Partnership', and approached through a variety of methods. One questionnaire was circulated to all 34 network leads to establish the services and resources in each network. A second questionnaire was circulated to all known head and neck teams in the UK. RESULTS: Multidisciplinary team (MDT) working was evident in all centres, although frequently the MDT was not fully staffed, especially in areas of national staff shortages, such as in pathology, radiology, dietetics and speech therapy. Rapid referral pathways were present for initial assessment of patients, but clinically significant delays were identified in complex investigations, access to intensive care beds and oncological care, especially radiotherapy. CONCLUSION: Major changes in service configuration are likely to be required if the current national targets of time to diagnosis and treatment are to be met.

An audit of clinical resources available for the care of head and neck cancer patients in England.

OBJECTIVE: To undertake a postal survey of cancer networks to define the services available for the diagnosis, treatment and support of patients with head and neck cancer in England. FINDINGS: Thirty-four cancer networks are now responsible for the delivery of head and neck cancer services in England and 52 cancer units responded to our questionnaire. Multidisciplinary team working was evident in all centres. However such team working was not always fully staffed, especially in areas of national staff shortages such as pathology, radiology, dietetics and speech therapy. Rapid referral pathways were present for initial assessment of patients but clinically significant delays were identified in the provision of complex investigations, in access to intensive care beds and for oncological care--especially radiotherapy. CONCLUSIONS: Major changes in service configuration are likely to be required if the current national targets of time to diagnosis and treatment are to be met.

Occult carotid pseudoaneurysm following streptococcal throat infection.

Pseudoaneurysm of the internal carotid artery (PAICA) is a rare complication of neck space infection. An 8-year-old girl presented with odynophagia (painful swallowing), trismus and left peritonsillar swelling. Abscess was suspected, but aspiration was dry. The PAICA was diagnosed on computed tomography. The aneurysm and involved left internal carotid artery were occluded endovascularly. She has made an uneventful recovery.

Nasal dermoid sinus cysts in adults.

Nasal dermoid sinus cysts (NDSC) are rare congenital lesions that most frequently present in children, but have been reported in adults. This article reviews adult (more than 16 years of age) nasal dermoid sinus cysts as they present, their radiological investigation, surgical approach and outcome. Thirty-eight previously published cases are reviewed, to which a further six cases are added. All 44 cases are tabulated and reviewed. The risk of intracranial extension is 27.5 per cent, especially men with a dermal sinus. Recurrences are likely if the NDSC is not completely excised. Curative treatment is surgical. It is recommended that all adults who present with a dermal cyst and/or sinus in the region of the nasal dorsum should be investigated by computed tomography (CT) and/or magnetic resonance (MRI). This is to delineate deep tissue involvement and to exclude a possible associated intracranial extension, prior to recommending surgical excision.

Management of chronic parotitis: a review.

Chronic parotitis is an insidious inflammatory disorder, which is characterized by a recurrent, often painful, swelling of the gland or glands. Sialography remains the investigation of choice. Diagnostic siladenoscopy may complement or supersede sialography as the diagnostic procedure of choice, as more experience is gained in this technique and its use becomes more widespread. The management options are conservative or surgical, but controversy exists regarding the timing and method of surgical intervention. The surgical methods that have been described include injection of methyl violet - a sclerosing agent, ductal ligation, ductoplasty, tympanic neurectomy, and parotidectomy. Parotidectomy is considered the ultimate surgical option but because of its significant morbidity the exact technique and procedure that should be used remains contentious.

Are autopsies useful? Do premorbid findings predict postmortem results in head and neck cancer patients?

A total of 53 autopsies were analysed in patients with head and neck squamous carcinoma. The discordance rate, that is the proportion of autopsies that revealed new information, was 53%. One-third of patients did not die of cancer. Clinical findings either misdiagnosed or under-diagnosed loco regional disease in 34% of cases, and distant malignant disease in 36% of cases. It appears that the autopsy reveals new and useful information in the head and neck cancer patient, and consent should be sought.

Aggressive sino-nasal non-Hodgkin's lymphoma diagnosed in Nottinghamshire, UK, between 1987 and 1996.

In the 10-year period 1987 to 1996, 24 patients were diagnosed with aggressive non-Hodgkin's lymphoma of the nasal cavities or paranasal sinuses. The disease occurred in a relatively elderly population of median age 72 years (range 42 to 96) with a male predominance (male 15; female nine). The histology on review was mostly of the large B-cell subtype (21 patients); peripheral T-cell subtype (one), anaplastic large cell of T-cell type (one) and T/natural killer cell nasal lymphoma (one). The disease was localized in 20 patients (Stage IEA). The overall survival at 5 years was 40% (95% confidence interval (CI) 19-61); at 10 years it was 33% (95% CI 12-54). The cause-specific survival (excluding deaths from causes other than lymphoma) at 5 years and 10 years was 62% (95% CI 39-86).

Benign salivary gland disease.

The majority of benign clinical problems that present affect the major salivary glands--parotid and submandibular. However, there are numerous minor salivary glands located in the mucosa of the head and neck which have the same predilection to the same diseases that affect the major glands but to a lesser frequency.

The pro region of Toxoplasma ROP1 is a rhoptry-targeting signal.

The rhoptries of Toxoplasma gondii are regulated secretory organelles involved in the invasion of host cells. Rhoptry proteins are synthesised as pre-pro-proteins that are processed first to pro-proteins upon entrance into the secretory pathway, then processed again to their mature forms late in the secretory pathway. The pro-mature processing site of the rhoptry protein ROP1 has been determined, paving the way for understanding the role of the pro region in rhoptry protein function. We demonstrate here that the ROP1 pro region is sufficient for targeting a reporter protein (amino acids 34-471 of the Trypanosoma brucei VSG117 protein) to the rhoptries. These results, together with our previous work showing that rhoptry targeting is unaffected by deletion of the pro region, indicate that the ROP1 protein contains at least two signals that can function in rhoptry targeting.