Does a specialist voice clinic change ENT clinic diagnosis?

General ENT clinics lack the high quality diagnostic equipment and multidisciplinary advice that is available in the voice clinic. We wished to find out if referral to a specialist voice clinic from general ENT consultant clinics resulted in a change in diagnosis. Lists of voice clinic attendees were reviewed between January 2003 and May 2004. Notes were obtained for 20 patients who attended voice clinic after referral from a general ENT clinic: 3 had no diagnosis on referral to voice clinic, a diagnosis was given after attendance; 8 had their referring diagnosis changed by attendance; and 9 had no change. The voice clinic adds diagnostic value to the service available in general ENT clinics.

Intranasal schwannoma in a young woman.

A rare case of a schwannoma arising from the middle meatus in a 24-year-old woman is reported. The patient presented with a 12-month history of right-sided nasal obstruction, rhinorrhoea, anosmia, headache and recurrent minor nosebleeds. Examination of the right nasal cavity revealed a polypoidal mass. Computerised tomography showed the mass completely occluding the nasal passage with evidence of a secondary maxillary sinusitis. She underwent a complete intranasal excision of the polypoidal mass which was arising from the right middle meatus. The histological features of the lesion were consistent with a schwannoma including diffuse immunoreactivity for S-100 protein. This case illustrates the need to consider schwannoma, amongst many other lesions, in the differential diagnosis of a unilateral nasal mass and reinforces the established principle of sending all material removed from the nose for histological examination.

Degloving of the inferior turbinates: pilot study to assess the effectiveness of a new technique in turbinate reduction.

A pilot study to assess the safety and efficacy of 'degloving' of the inferior turbinate is described. This prospective study reports on the effectiveness of the technique in 37 patients with nasal obstruction due to inferior turbinate hypertrophy. Both objective and subjective measurements of nasal patency were made pre-operatively, and repeated at six weeks, six months and two years post-operatively using nasal inspiratory peak flow rates, saccharin clearance time and an end referenced visual analogue scale to record nasal symptoms. There was a significant improvement in the peak inspiratory flow at six weeks (96.4 to 151.2 l/min) and at six months (148.4 l/min), which was sustained at two years (117.1 l/min, p<0.001). There was an overall improvement in patient satisfaction with nasal symptoms (23.4 to 76.7, 76.8 and 66.8 at six weeks, six months and two years, p<0.001) and a decrease in the sensation of nasal obstruction (71.9 to 21.5, 32.9 and 29.8, p<0.001), which was also sustained. Rhinorrhoea was reduced, and sense of smell increased across the group, but the improvements did not reach statistical significance. The results for postnasal drip and saccharin clearance did not show a significant change over the period of the study. There were no haemorrhagic complications in the group studied. This pilot study demonstrates a new surgical technique for reduction of the inferior turbinates, that yields significant improvement in nasal obstruction, an acceptably low complication rate and is well tolerated by patients. A randomized controlled trial is being planned.

Parotid calcification in systemic lupus erythematosis.

Calcinosis universalis is an unusual complication of systemic lupus erythematosis (SLE). We describe the case of a 22-year-old patient diagnosed with SLE during childhood, who developed a previously unreported complication of parotid calcification. Medical treatment of calcinosis is often ineffective, whereas surgical intervention completely relieved the patient's symptoms.

The whys and wherefores of getting patients to give up smoking.

Smoking-related diseases are responsible for the majority of premature deaths in industrialized societies. It is 50 years since the link between smoking and lung cancer was first established, since when a gradually increasing number of smoking-related illnesses have been identified. The treatment of patients suffering smoking-related illnesses consumes a large proportion of health care budgets. The ever-increasing costs of health care, in part due to the advent of new therapeutic techniques, could be offset by a concerted effort to reduce the number of people smoking. Various strategies, particularly if used in combination, have been shown to produce acceptable smoking cessation rates. At present there appears to be a reluctance on the part of governments to fund a concerted, co-ordinated programme to encourage and assist people to stop smoking. In the absence of such support it is important for all health professionals to provide sensible advice and support to help their patients to stop smoking.

Semi-invasive allergic aspergillosis of the paranasal sinuses.

Aspergillosis of the nose and paranasal sinuses has classically been divided into four types: allergic, non-invasive, invasive and fulminant. Recent reports have suggested that a semi-invasive form with bone destruction and erosion, but without fungal tissue invasion, may occur. We present a case of allergic non-invasive aspergillosis of the paranasal sinuses with associated bone destruction extending into the orbit and anterior cranial fossa, in a non-immunocompromised patient. Surgical debridement combined with a prolonged course of oral itraconazole has resulted in long-term resolution with no evidence of recurrence of disease five years later.

A prospective study of PET-FDG imaging for the assessment of head and neck squamous cell carcinoma.

The main aim of the study was to evaluate the use of positron emission tomography using fluoro-deoxyglucose (PET-FDG) imaging for the detection of squamous cell carcinoma of the head and neck. Fifty-four consecutive patients with malignancies involving the head and neck were studied prospectively. Thirty-one patients presented with primary disease and 23 were suspected of recurrent or residual disease. All patients underwent full clinical staging, PET-FDG scans and anatomical imaging, 37 underwent computed tomography (CT), 13 magnetic resonance (MR) and four had both CT and MR. Clinical assessment, CT/MR, PET-FDG and histological examination were all evaluated independently of each other. All 31 primary head and neck malignant tumours were detected by PET-FDG. Based on 16 patients who underwent neck dissections, the sensitivity and specificity of PET-FDG for detecting nodal disease was 67% and 100% respectively, compared with clinical assessment of 58% and 75% and CT/MR of 67% and 25%. In all 12 patients, PET-FDG correctly identified the presence of absence or recurrent or residual disease. PET-FDG staged 13 post-treatment necks with an accuracy of 100% as compared to CT/MR which was accurate in 7 of 13 and clinical assessment which was accurate in eight. Three sites of abnormal tracer uptake unrelated to malignancy were recorded as incidental findings (mandibular osteomyelitis, 1: post glossectomy site, 2). PET-FDG was more accurate than CT/MR for identifying primary and recurrent tumours as well as metastatic lesions in the neck. If these diagnostic properties of PET-FDG are confirmed in further prospective studies, it could prove a valuable adjunct for the management of head and neck cancer.

The use of positron emission tomography in the evaluation of orofacial malignancy and disease.

Positron emission tomography (PET) is a relatively new imaging technique that depends on the uptake of radionuclides. It has improved imaging ability compared with other modalities. Three case presentations are described illustrating the application of 'PET' in the management of oral cancer.

The use of PET-18FDG imaging in the clinical evaluation of head and neck lymphoma.

Four patients with non-Hodgkin's lymphoma in the head and neck region were studied with positron emission tomography (PET), using the radioactive tracer 2-[F-18]-fluoro-2-deoxy-D-glucose (18FDG). This technique, which exploits the high metabolic rate of glucose in tumour tissue, enabled the extent of disease to be visualized. The localization of the tumour was improved by combining the data from the PET scan with those from CT scans or MRI. This technique (of PET-18FDG), using visual and semiquantitative analysis in the form of standardized uptake values, allowed the differentiation between reactive hyperplasia and nodal involvement with lymphoma. We believe that PET using the tracer 18FDG may play an important role in the evaluation of patients with head and neck lymphoma.

Through-flow revascularization of the tongue using a radial forearm free flap.

Surgery for invasive squamous cell carcinoma involving the tongue base usually necessitates a total glossectomy because complete tumour resection requires sacrifice of both lingual arteries leaving a non-viable anterior tongue. A case is presented in which both lingual arteries were sacrificed to achieve complete tumour excision and the remaining anterior two-thirds of the tongue were successfully revascularized by through-flow from a radial forearm free flap which was used for pharyngeal reconstruction. This technique offers hope of preservation of the tongue when radical surgery would otherwise lead to its removal.

Primary tracheal tuberculosis in an otherwise healthy 65-year-old Caucasian woman.

We report a case of primary tracheal tuberculosis that presented with a hard, fixed lymph node in the right supraclavicular fossa, and progressive dysphagia due to an inflammatory mass caused by a tuberculous lesion in the trachea. This case underlines the old adage that tuberculosis is 'the great masquerader'.

The value of CT scanning in chronic suppurative otitis media.

High definition CT has been advocated for the evaluation of chronic suppurative otitis media (CSOM) either generally or in selected cases. It is said to be capable of producing the fine detail needed to detect lateral canal fistulae, exposed dura and facial canal dehiscences, and to demonstrate the ossicular chain. At present there is no agreement on either the indications for CT scanning in CSOM or the most appropriate scanning plane. To determine the value of high definition CT in CSOM and to decide a unit policy for its application, 36 cases of CSOM underwent pre-operative CT scanning and their scans were compared with the operative findings. Our results show CT to be highly sensitive to the presence of soft tissue disease and bone erosion, moderately sensitive to the presence of lateral canal fistulae but less sensitive to the presence of small areas of exposed dura, ossicular continuity and facial canal dehiscence. Axial scans were better able to demonstrate the lateral canal but otherwise coronal scans were superior; ideally patients should be scanned in both planes. The principle value of CT in CSOM is its ability to demonstrate disease which is not clinically apparent.

Mastoidectomy packs: Xeroform or BIPP?

A retrospective study comparing adverse events using bismuth iodoform paraffin paste (BIPP) and Xeroform as dressings for newly fashioned mastoid cavities after mastoidectomy was undertaken. There were 20 patients in each group. Adverse events were defined as offensive packs, mastoid cavity infections and systemic signs of infection. There were no adverse events using BIPP packs whether or not prophylactic antibiotics were used. Xeroform packs were associated with a significantly higher incidence of adverse events compared to BIPP when using no antibiotic prophylaxis (P less than 0.005) or amoxycillin (P less than 0.005). Adverse events with Xeroform packs were abolished using ciprofloxacin and metronidazole prophylaxis. We conclude that BIPP is the mastoid dressing of choice.

Muscle damage and recovery in the rabbit tongue following photodynamic therapy with haematoporphyrin derivative.

To study the effects of photodynamic therapy on the tissues of the tongue, 20 New Zealand White rabbits were injected intravenously with haematoporphyrin derivative. Their tongues and those of 2 controls were illuminated with 100 J/cm2 of red light from a copper vapour-pumped dye laser emitting light at 625 nm. The rabbits were sacrificed at intervals between 2 days and 12 weeks following treatment. Their tongues were examined histologically. Initially there was marked damage to mucosa, muscle and blood vessels. However, this healed by a mixture of regeneration and scarring.

Long-term results of revision endolymphatic sac surgery.

The results of revision endolymphatic sac surgery on 30 patients with unilateral Menière's disease are presented. Good control is achieved in 73.3 per cent of cases at six months, falling to 56.7 per cent at one year and only 33.3 per cent by four years. The long-term results are disappointing but are more favourable if the initial surgery was successful, if the hearing remains fluctuant and improves on glycerol dehydration prior to the revision procedure and also if the sac is intubated. The current place of endolymphatic sac surgery is discussed and revision surgery only recommended for carefully selected cases.

Verrucous carcinoma of the maxillary antrum.

Verrucous carcinoma is a rare type of squamous cell carcinoma which is most often seen in the oral cavity and larynx. This paper describes a case of verrucous carcinoma of the maxillary antrum, a site in which this tumour has been described on only two previous occasions in the English language literature.

Silicone ear splints in the management of acute haematoma auris.

A discussion of the rationale of management of acute haematoma auris and a description of a simple, reliable method of management using Otoform K Silicone impression material to form ear splints.