A preliminary study of simple voice assessment in a routine clinical setting to predict vocal cord paralysis after thyroid or parathyroid surgery.

OBJECTIVE: To determine if a simple assessment of vocal cord function performed in a routine clinical setting can predict vocal cord paralysis on laryngoscopy in patients following thyroid or parathyroid surgery. METHOD: Prospective observational cohort study of patients undergoing thyroid or parathyroid surgery. Vocal cord function was assessed in terms of an abnormality of voice or cough reported by the patient or detected by the examiner. Laryngoscopy was performed by indirect mirror examination or fibreoptic nasopharyngolaryngoscopy. Examiners included otolaryngology consultants, registrars, senior house officers and a general practitioner with a special interest in otolaryngology. The patient was often examined by a different clinician before and after surgery. RESULTS: Eighty-six patients participated in the study between August 2003 and July 2004. Eleven had a change in their voice postoperatively and one patient had difficulty coughing. Six of these patients had a vocal cord paralysis. A further five apparently asymptomatic patients had a vocal cord paralysis. The positive predictive value of voice assessment for vocal cord paralysis was 55%. CONCLUSION: In a routine clinical setting where the assessment of vocal cord function is often reported by different clinicians of varying experience at each patient attendance, the assessment of a patient's voice following thyroid or parathyroid surgery is not adequately predictive of vocal cord paralysis on indirect laryngoscopy or fibreoptic nasopharyngolaryngoscopy. Further study is required to determine reasons for this.

Descending necrotising mediastinitis: a safe treatment algorithm.

Descending necrotising mediastinitis can complicate oropharyngeal infection and has a high associated mortality. We present three cases treated in our department and propose a treatment algorithm based on our experience and literature review. The primary oropharyngeal infection was peritonsillar abscess in two cases and odontogenic abscess in one. Two patients underwent cervicotomy and later thoracotomy. The third underwent cervicotomy with transcervical mediastinal drainage and later required pericardial drainage via a subxiphoid incision. All recovered fully and were discharged within 6 weeks. To enable successful treatment, diagnosis needs to be prompt and surgical drainage adequate. Thoracic management of the chest is essential.

Soft tissue myoepithelioma: a case report.

Myoepitheliomas are tumours composed predominantly or exclusively of myoepithelial cells. They are well described, especially within the salivary gland, but their occurrence in soft tissues is less well known and this often results in diagnostic problems. We report a case involving the deep soft tissues of the lower neck behind the clavicle. Grossly, the tumour was well circumscribed with solid and cystic areas. Histology showed a richly vascularised tumour composed of bland round, ovoid or spindle-shaped cells. Various growth patterns were present including solid, nested, microcystic and trabecular arrangements. In some areas there was an alveolar pattern with tumour cells lining fibrous septae. Immunohistochemistry showed diffuse strong positivity for S100 protein, calponin, vimentin and glial fibrillary acidic protein and focal positivity for epithelial membrane antigen, 34betaE12 and AE1/AE3, in keeping with myoepithelial differentiation. Electron microscopy revealed tumour cells surrounded by basal lamina with subplasmalemmal densities and containing cytoplasmic myofilaments. This case report highlights the rare occurrence of myoepitheliomas in deep soft tissues. Pathologists should be aware of this and should consider a myoepithelioma in the differential diagnosis of a soft tissue spindle cell neoplasm.

Pharyngo-laryngo-oesophagectomy and gastric pull-up for post-cricoid and cervical oesophageal squamous cell carcinoma.

Pharyngo-laryngo-oesophagectomy and gastric pull-up (PLOGP) is a complex and relatively uncommon procedure. The aim of this study is to analyse the results of PLOGP in patients with post-cricoid and cervical oesophageal squamous cell carcinomas. This study was a retrospective review of 26 patients (11 males + 15 females, mean age 63.5 years) who underwent PLOGP from 1988 to 1997. Eighteen (69 per cent) patients were staged as T(3) and eight (31 per cent) T(4). Eighteen (69 per cent) patients had N(0), seven (27 per cent) N(1) and one (four per cent) N(2) disease. Multiple primary tumours were recorded in three (11.5 per cent) patients. Four (15 per cent) patients had pre-operative radiotherapy with poor response and two (eight per cent) required emergency tracheotomy prior to surgery. Feeding jejunostomy was performed on 19 (73 per cent) and neck lymph node dissection in eight (31 per cent) patients. The mean duration of surgery was five hours (range 3.5 to 7.5) with a mean blood loss of 840 ml (range 160 to 1800), a mean stay in ICU of 4.2 days and hospital stay ranged from nine to 84 days (mean 34). Three (11.5 per cent) patients died (pneumonia - one, congestive heart failure - one, pulmonary embolus - one) in the early post-operative period. Eight (31 per cent) patients remain alive from 30 to 136 months (mean 58 months). Two (eight per cent) patients died with no evidence of disease. Thirteen (50 per cent) patients died of their disease between two to 51 months (mean 17.3 months) post-operatively. Kaplan-Meier survival estimates for one year was 65 per cent, for three years 35 per cent and for five years 26 per cent (see Figure 1). Median survival in the whole series was 18 months. Post-operative speech was with an electrolarynx in 16 (62 per cent). One patient (four per cent) used gastric speech and one patient (four per cent) used a Blom-Singer valve effectively. Five (19 per cent) patients had no speech post-operatively. All patients maintained oral feeding. Gastric transposition constitutes a safe and reliable method of restoring the continuity of the upper digestive tract following pharyngo-laryngo-oesophagectomy.

Synovial sarcoma in the retropharyngeal space.

Synovial sarcoma is an aggressive mesenchymal tumour, rarely occurring in the head and neck. Management guidelines are by extrapolation of management of sarcomas in the extremities. We present a case involving the retropharyngeal space in a 20-year-old male. Analysis of more data on head and neck synovial sarcoma is necessary to make meaningful management recommendations.

Prognostic value of Epstein-Barr virus serology in patients with nasopharyngeal carcinoma.

We report the results of a study which examined the prognostic value of Epstein-Barr virus (EBV) serology in patients with nasopharyngeal carcinoma (NPC). Antibody titres to EBV were estimated by indirect immunofluorescence and correlated with the stage of disease. Neither persistent high titres nor falling titres after treatment were found to be reliable indicators of relapse or survival, respectively, in individual patients. By contrast, four-fold rises in titre, particularly of antibodies to the early antigens of the virus were highly significant predictors of relapse. These increases could be seen well in advance of clinical detection of recurrence of the tumour at the primary or metastatic sites.

Autoinflation in the treatment of glue ear in children.

The use of autoinflation in the treatment of glue ear has been widely recommended. In order to assess its efficacy, 40 children were studied. 21 children practised nasal autoinflation of a toy balloon 3 times daily for 3 weeks and 19 children had no treatment. In the autoinflation group only 4 glue ears improved, while in the untreated group 10 glue ears improved. This study suggests that autoinflation has no part to play in the treatment of glue ear in children.

Management of posterior mesotympanic cholesteatoma.

Contrary to previous practice, the eradication of posterior mesotympanic cholesteatoma can frequently be achieved using a transcanal approach and without the need for more major surgery. For success, certain specific steps are necessary. These are described and the results reported.

Small cavity mastoidectomy.

Disappointment with the long-term results of closed operations for ears with extensive cholesteatoma has led to a renewed preference for open techniques. Although the technical advantages provided by magnification and hypotensive anaesthesia have reduced the numbers of unstable post-operative open mastoidectomy cavities, when large, they are still frequently troublesome. Frequently, surgical cavities have been much larger than necessary because of adherence to a traditional approach to the pathologic lesion from its posterior aspect, and the inevitable removal of much normal bone. It is proposed herein that if, instead, bone removal were commenced from the area proximate to the origin of the disease and extended only as far as necessary in order to achieve adequate and effective exteriorization of the disease, fewer large cavities would result and the proportion of stable post-operative ears would be increased. To test this, 100 patients have been treated by atticoantrotomy in which bone lateral to the cholesteatoma sac was removed from anterior to posterior. The 5-year status of the first 43 patients thus treated supports the view that atticoantrotomy provides a logical, safe and successful means of treating extensive cholesteatoma.

Young's procedure in the treatment of epistaxis.

Intractable epistaxis associated with septal perforation is a difficult problem to treat, particularly if nose-picking appears to be associated. Two such cases are presented in which Young's procedure of nasal closure was used to prevent epistaxis. Although the procedure was fully successful in only one patient, we feel the procedure has a part to play in the management of such cases of epistaxis.

Juvenile nasopharyngeal angiofibroma in a static population: the implications of misdiagnosis.

We present a 20-year review of juvenile angiofibroma in the relatively static population of Northern Ireland. Seventeen cases were identified and new slides were prepared from the stored paraffin blocks of all their original biopsy material, and re-examined. Five females, a 36-year-old and an 18-year-old male had their diagnoses revised. We suggest clinical criteria, which in conjunction with radiological investigations, should be strictly applied in all cases. Such application would, in retrospect, have identified those cases excluded by pathological re-examination, thus avoiding unnecessary surgery and radiotherapy. Atypical cases which do not satisfy the clinical criteria may be subjected to repeat biopsy but routine initial biopsy is not recommended.

Laryngeal stridor due to odontoid peg subluxation.

This is a case of a 58-year-old woman who presented with progressive stridor due to immobile vocal cords. This was found to be due to cervical cord compression by an upwardly subluxed odontoid peg. Despite surgical intervention the outcome was fatal.