Hairy polyp of the oropharynx in association with a first branchial arch sinus.

OBJECTIVES: Hairy polyps are rare, congenital malformations of the oropharynx and nasopharynx. To date, approximately 145 cases have been reported. However, the histogenesis of these lesions remains unclear. CASE REPORT: We report the case of a 2-day-old neonate presenting with a hairy polyp attached to the left palate, who re-presented aged 16 months with a discharging first branchial arch sinus. CONCLUSION: We propose this case as supporting evidence for the theory that hairy polyps are a malformation of the first branchial arch system.

Presentation of laryngeal papilloma in childhood: the Leeds experience.

INTRODUCTION: The human papilloma virus (HPV) can cause laryngeal papillomatosis in childhood. The aetiology is thought to be vertical transmission. Clinically these children are usually asymptomatic for the first 6 months of life. As the papillomas develop locally, symptoms begin to develop. The symptoms range from voice change to frank hoarseness, and 'noisy' breathing, most commonly inspiratory stridor. METHOD: Clinical images from microlaryngoscopy and bronchoscopy over a 12-year period were assessed for laryngeal papilloma. RESULTS: In Leeds seven cases presented to the specialist centre over the past 12 years, the average age at presentation was 6.8 years and duration of onset of symptoms to specialist review was 21 months. Five of the children had been treated for asthma and two presented in extremis. CONCLUSION: The take home message for clinicians is hoarse voice associated with shortness of breath needs specialist referral.

The use of ice-lollies for pain relief post-paediatric tonsillectomy. A single-blinded, randomised, controlled trial.

OBJECTIVES: To assess whether the use of ice-lollies after tonsillectomy with or without adenoidectomy in children aged 2-12 reduces pain in the immediate postoperative period. DESIGN: A prospective, randomised, single-blinded study design consisting of two groups with an intention to treat analysis. SETTING: Tertiary referral centre. PARTICIPANTS: Children aged 2-12 undergoing tonsillectomy with or without adenoidectomy. MAIN OUTCOME MEASURES: Pain assessment by nursing staff in the form of the validated modified Children's Hospital of Eastern Ontario Pain Scale at 15, 30 and 60 min and 4 h. RESULTS: Ninety-two patients were recruited into the study with 46 allocated to receive an ice-lolly and 41 not to receive an ice-lolly after exclusion of those with incomplete data. The two groups were comparable for number, age, sex and diagnosis. The pain score at every time interval was lower in the group that had received the ice-lolly compared with the group that had not. This was statistically significant at 30 (P = 0.008) and 60 min (P = 0.049). CONCLUSION: Our data suggest that ice-lollies are a cheap, effective and safe method of reducing postoperative pain up to one hour following paediatric tonsillectomy.

Diode laser for paediatric airway procedures: a useful tool.

OBJECTIVE: A wide range of lasers have been used in the larynx. Diode laser is a portable and relatively inexpensive laser which is delivered via a glass fibre hand-held probe. The objective of this study was to report our experience with the use of diode laser in a variety of paediatric airway pathologies. METHODS: In this study, 90 diode laser laryngeal procedures were performed on 31 patients in the age range of 1 month to 16 years at the time of the operation. The follow up after the procedure has been in the range of 6 months to 3 years. RESULTS: As per our records 19/31 (61.3%) patients have been cured of their initial pathologies and were not under further review, 3/31 (9.6%) were having repeated laser treatments. The remaining 9/31 (29.0%) had to undergo further treatment. There was no laser-related intra-operative or postoperative complications. CONCLUSIONS: Diode laser is a good tool for several paediatric laryngeal pathologies. The ability to guide the laser light using the flexible glass fibre directly onto the area requiring vapourisation enables very precise treatment.

Endoscopic sinus surgery as day-case procedure.

OBJECTIVE: Functional endoscopic sinus surgery is the mainstay of surgical treatment for chronic sinusitis. Day-case surgery has the advantage over in-patient surgery of being cost-effective and resource sparing. The objectives of this study were to assess our results for day-case functional endoscopic sinus surgery. METHODS: This was a retrospective case note review of day-case functional endoscopic sinus surgery procedures performed at Leeds General Infirmary from February 2004 to February 2007. We recorded patients' demographic data, operative details, post-operative course and follow-up results. RESULTS: A total of 105 day-case functional endoscopic sinus surgery procedures were included in the study. Patients' ages ranged from 16 to 93 years; 44 (41.9 per cent) were female and 61 (58.1 per cent) were male. Of these patients, 39 (37.1 per cent) had chronic sinusitis and the rest (66; 62.8 per cent) had nasal polyposis and sinusitis. Sixty-one patients (58.1 per cent) underwent surgery on the morning operating list, while the rest (44; 41.9 per cent) underwent surgery in the afternoon. Of the 105 patients, 24 (22.8 per cent) had undergone previous nasal surgery. The majority of patients (90/105; 85.7 per cent) were discharged on the same day as surgery. The only complication recorded in this study was bleeding, noted in seven patients (6.7 per cent). At the follow-up appointment, 90/105 (85.7 per cent) patients were satisfied with their post-operative results. CONCLUSIONS: Day-case endoscopic sinus surgery can be performed safely as a day-case procedure. The most important factors for a successful outcome are correct patient selection, in terms of general health and social circumstances, and a dedicated day-case team.

Gastric emptying of a non-digestible solid: assessment with simultaneous SmartPill pH and pressure capsule, antroduodenal manometry, gastric emptying scintigraphy.

Gastric emptying of digestible solids occurs after trituration of food particles. Non-digestible solids are thought to empty with phase III of the migrating motor complex (MMC). The aim of this study was to determine if a non-digestible capsule given with a meal empties from the stomach with return of the fasting phase III MMC or during the fed pattern with the solid meal. Fifteen normal subjects underwent antroduodenal manometry and ingestion of a radiolabelled meal and SmartPill wireless pH and pressure capsule. In five subjects, emptying of the SmartPill was studied in the fasting period by ingesting the SmartPill with radiolabelled water. The SmartPill emptied from the stomach within 6 h in 14 of 15 subjects. SmartPill pressure recordings showed high amplitude phasic contractions prior to emptying. SmartPill gastric residence time (261 +/- 22 min) correlated strongly with time to the first phase III MMC (239 +/- 23 min; r = 0.813; P < 0.01) and correlated moderately with solid-phase gastric emptying (r = 0.606 with T-50% and r = 0.565 with T-90%). Nine of 14 subjects emptied the capsule with a phase III MMC. In five subjects, the SmartPill emptied with isolated distal antral contractions. In five subjects ingesting only water, SmartPill gastric residence time (92 +/- 44 min) correlated with the time to the first phase III MMC (87 +/- 30 min; r = 0.979; P < 0.01). The non-digestible SmartPill given with a meal primarily empties from the stomach with the return of phase III MMCs occurring after emptying the solid-phase meal. However, in some subjects, the SmartPill emptied with isolated antral contractions, an unappreciated mechanism for emptying of a non-digestible solid.

Obstructive sleep apnoea adenotonsillectomy in children: when to refer to a centre with a paediatric intensive care unit?

OBJECTIVE: To identify regional surgical referral patterns for adenotonsillectomy in children with obstructive sleep apnoea to our tertiary centre with paediatric intensive care unit facilities and to establish guidelines for elective paediatric intensive care unit referral and admission. METHODS: Two methods were used. A questionnaire was sent to ENT consultants in five surrounding hospitals with no in-house paediatric intensive care facilities. The second was a prospective observational study undertaken in our tertiary centre for a sub-set of patients undergoing obstructive sleep apnoea adenotonsillectomy between January 2002 and February 2005. These children were considered high risk as judged clinically by an ENT surgeon. Most had obstructive sleep apnoea and a co-morbidity. Otherwise healthy children with simple obstructive sleep apnoea were excluded. RESULTS: 15 out of 20 consultants responded to the questionnaire. Four referred on the grounds of clinical history, five referred based on pulse oximetry, nine referred syndromal children and four did not refer electively. Of the 49 high risk patients operated on, only 12 required paediatric intensive care admission with no emergency paediatric intensive care admissions. No otherwise healthy children with uncomplicated obstructive sleep apnoea symptoms required paediatric intensive care admission during the study period. CONCLUSION: There was no regional consensus regarding paediatric intensive care unit referral for obstructive sleep apnoea adenotonsillectomy. Clinical judgement without complex sleep studies by those experienced in this area was sufficient to detect complicated cases of obstructive sleep apnoea with co-morbidity requiring paediatric intensive care.

Securing a nasopharyngeal airway.

OBJECTIVE: The nasopharyngeal airway is a simple airway adjunct used by various healthcare professionals. It is the least invasive method of safely managing upper airway obstruction. The objective of this report was to describe a rapid and very simple method of securing a nasopharyngeal airway in an agitated patient. METHOD: We describe a simple method of securing a nasopharyngeal airway, using safety pins and tapes. RESULT: This technique has been used by the authors in several emergency situations and has been found to be quick and effective. CONCLUSION: The nasopharyngeal airway is a simple piece of equipment that is cheap and easy to use. The technique described in this article is a simple, practical and effective method of securing a nasopharyngeal airway in an emergency situation.

Aryepiglottoplasty for laryngomalacia: results and recommendations following a case series of 84.

OBJECTIVES: To examine one consultant's experience of aryepiglottoplasty at Leeds General Infirmary. To identify risk factors for post-operative complications. Comparing the outcomes of surgery with the published literature on aryepiglottoplasty. DESIGN: A retrospective case series of consecutive patients undergoing aryepiglottoplasty identified from theatre records. SETTING: The Otolaryngology Department, Leeds General Infirmary. This is part of Leeds Teaching Hospitals NHS Trust and is a tertiary referral centre with regional paediatric intensive care unit (PICU) and specialises in managing paediatric airway pathology. PARTICIPANTS: Ninety-one consecutive cases of aryepiglottoplasties, between 1997 and 2005. The medical records for 84 cases were reviewed. MAIN OUTCOME MEASURES: Unplanned admissions to PICU, complication rate, length of post-operative hospital stay, and successful resolution of symptoms amongst our patient group. RESULTS: The primary indication for surgery was found to be severe stridor. There was a low rate (3.6%) of unplanned admissions to the PICU. 7.1% of patients suffered a post-operative aspiration pneumonia. The majority (66.7%) of patients were able to return home after just one night in hospital. 11.9% of patients continued to have some stridor at follow-up. CONCLUSIONS: The majority of patients undergoing aryepiglottoplasty for isolated laryngomalacia can be monitored overnight on a paediatric surgical ward and return home the following day (85%). Furthermore, they should expect improvement of their stridor with a single procedure (90%). Aryepiglottoplasty at an experienced unit is a low-risk procedure with a high success rate.

Stenting for bilateral congenital choanal atresia--a new technique.

We describe a new nasal stent for the treatment of bilateral congenital choanal atresia. The stent is made up of reinforced endotracheal tube mounted on a portex carrier tube. It potentially causes less internal crusting and stent blockage and is secured without sutures. It remains patent for at least 4 weeks. We have used the stent successfully in six patients between 1998 and 2004 at Leeds General Infirmary and present the data collected retrospectively. The current practice in the UK for treatment and stenting for congenital choanal atresia was investigated by a prospective internet based questionnaire sent to 18 consultant paediatric otolaryngologists of whom 12 (67%) responded. Their experience and results are reported. The literature has been reviewed.

Laryngeal inflammatory pseudotumour: an unusual cause of airway obstruction.

We report a rare case of a laryngeal pseudotumour in a child presenting with stridor, which was treated by endoscopic laryngeal resection, without the need for a tracheostomy. A short review of the literature is also presented. Although rare, laryngeal pseudotumour should be considered as part of the differential diagnosis of stridor and upper airway obstruction in children.

Radiopharmaceuticals for targeting the angiogenesis marker alpha(v)beta(3).

A common feature of solid tumors is the formation of new blood vessels (angiogenesis) within the tumor. A receptor called alpha(v)beta(3) is found on endothelial cells lining newly growing blood vessels at a higher density than on mature blood vessels. This receptor may provide a target for radioligands to permit imaging of a wide variety of solid tumors. The radioligands may range from macromolecules such as native ligands or monoclonal antibodies, to small proteins to very small peptides. The differing characteristics of these bio-molecules have an affect on target delivery and clearance time.

Non-oncologic applications of radiolabeled peptides in nuclear medicine.

Radiolabeled peptides have been investigated for diagnostic imaging in a variety of non-oncologic diseases. For imaging thromboembolic disease, peptides which bind to various components of thrombi have been tested. For targeting the fibrin component of thrombi, peptide analogues of fibrin or fragments of fibronectin which have a distinct binding domain for fibrin have been studied. For targeting activated platelets within thrombi, linear and cyclic peptide antagonists of the glycoprotein IIb/IIIa receptor on platelets have been studied, as well as naturally occurring antagonists of this receptor which are found in venoms. Analogues of laminin and thrombospondin which bind to other receptors on platelets have also been tested. There is an approach which uses a peptide to target thrombin which is sequestered within a fibrin clot. Another area of investigation has been to develop an improved radiopharmaceutical for imaging sites of infection and/or inflammation. Peptides which would bind to leukocytes in vivo, such as antagonists to the tuftsin receptor, chemotactic peptides, interleukin-8, or a platelet factor 4 analogue, have been radiolabeled for this purpose. These agents would enable imaging of both infection and inflammation. Development of a radiopharmaceutical for specifically imaging infection has focused on antimicrobial peptides such as human neutrophil defensin, ubiquicidin, human lactoferrin and alafosfalin, which are expected to bind selectively to microorganisms and not to leukocytes. Radiolabeled peptides are also being explored as agents for assessing unstable atherosclerotic plaque (endothelin), amyloid deposits (amyloid beta peptides), and the consequences of diabetes mellitus (human C-peptide).

Imaging pulmonary emboli and deep venous thrombi with 99mTc-bitistatin, a platelet-binding polypeptide from viper venom.

UNLABELLED: An imaging test that could locate both pulmonary emboli (PE) and their source, active deep venous thrombi (DVT), would be valuable in patient management. Bitistatin, an 83-amino-acid polypeptide isolated from Bitis arietans venom, binds avidly to the glycoprotein IIb/IIIa receptor on platelets. The goal of this study was to label bitistatin with 99mTc and assess its potential for imaging thrombi and emboli in vivo. METHODS: Molecular modeling of bitistatin indicated that its primary amines are located on the opposite side of the molecule from the receptor-binding domain. The primary amines were reacted with succinimidyl-4-hydrazino nicotinate hydrochloride to place 2.4 hydrazino nicotinate (Hn) chelating groups per peptide molecule. Hn-bitistatin was labeled by incubation with 99mTc-glucoheptonate to 96 TBq/mmol and then tested for binding to platelets in vitro and for imaging of 24-h-old DVT and PE in a canine model used previously for other thrombus tracers. RESULTS: 99mTc-Hn-bitistatin bound to stimulated platelets with a dissociation constant (Kd) = 32 nmol/L, similar to that of 125I-bitistatin (Kd = 41 nmol/L). In vivo, focal uptake was observed in planar images as early as 30 min (DVT) and 60 min (PE) after injection. Lesion uptake of 99mTc-Hn-bitistatin at 4 h after injection was calculated in terms of percentage injected dose per gram (%ID/g) of tissue and averaged 0.89 %ID/g PE and 0.79 %ID/g DVT. Lesion-to-background ratios averaged 34:1 (PE-to-lung), 18:1 (DVT-to-blood), and 284:1 (DVT-to-muscle). These values were not significantly different from iodinated bitistatin, but uptakes were higher than other tracers tested in the same model. CONCLUSION: 99mTc-Hn-bitistatin retains the functional activity of the iodinated peptide, has higher DVT and PE uptakes than other thrombus tracers in this standardized model, and has target-to-background characteristics suitable for imaging both PE and DVT in a single test.

Tonsillectomy by guillotine is less painful than by dissection.

Most tonsillectomies are carried out by dissection. Only a small minority of otolaryngologists still routinely perform guillotine tonsillectomy. We carried out a prospective study on 86 children undergoing tonsillectomy utilising a standard anaesthetic and analgesic regimen to compare post-operative pain after dissection tonsillectomy and guillotine tonsillectomy using a Popper's hemostatic guillotine. Guillotine tonsillectomy was significantly less painful (P<0.001) than dissection tonsillectomy. The relative risk of experiencing moderately severe to severe pain was 0.36 (95% CI, 0.18-0.72) in the guillotine group. A significant proportion of children experience moderately severe to severe pain despite a comprehensive analgesic regimen confirming that post operative pain remains an important issue after this operation. On the basis of our findings we advocate tonsillectomy by guillotine in children. The less pain that arises within the first 24 h may be particularly important if performing tonsillectomy as a day-case procedure.

Cholinergic effects on human gastric motility.

BACKGROUND: Cholinergic regulation of chronotropic (frequency) and inotropic (force) aspects of antral contractility and how these impact on gastric emptying are not well delineated. AIMS: To determine the effects of cholinergic stimulation and inhibition on myoelectric, contractile, and emptying parameters of gastric motility. METHODS: Ten normal subjects underwent three studies each, using simultaneous electrogastrography (EGG), antroduodenal manometry, and gastric emptying with dynamic antral scintigraphy (DAS). After 30 minutes of baseline fasting manometry and EGG, subjects received saline intravenously, atropine (0.6 mg then 0.25 mg/hour intravenously), or bethanechol (5 mg subcutaneously). This was followed by another 30 minutes' recording and by three hours of postprandial recording after ingestion of a technetium-99m labelled solid meal. RESULTS: During fasting, atropine decreased, whereas bethanechol increased, the antral manometric motility index and EGG power. Postprandially, atropine decreased the amplitude of antral contractions by DAS, decreased the postprandial antral manometric motility index, and slowed gastric emptying. Atropine caused a slight increase in postprandial frequency of antral contractions by DAS and gastric myoelectrical activity by EGG. Bethanechol slightly increased the amplitude, but slightly decreased the frequency of antral contractions by DAS and decreased the frequency of gastric myoelectrical activity by EGG, with no significant increase in the motility index or gastric emptying. CONCLUSIONS: Cholinergic antagonism with atropine reduces antral contractility and slows gastric emptying. Cholinergic stimulation with bethanechol increases antral contractility, but decreases the frequency of antral contractions, without altering the antral motility index or gastric emptying.

Nasal pH measurement: a reliable and repeatable parameter.

The nasal mucosal pH is approximately 5.5-6.5, and increases in rhinitis to 7.2-8.3. This knowledge has not led to the widespread measurement of the nasal mucosal pH as an objective clinical parameter. The purpose of this study was to assess whether repeatable measures of nasal mucosal pH could be obtained in the clinical setting. Fifty-four adults without nasal symptoms were prospectively recruited. Using a semi-disposable antimony pH catheter, the nasal mucosal pH was measured in four specific areas of the nose and each reading repeated three times. The patients' age, sex, smoking habits, nasal anatomical variation and clearest nostril at the time of measurement were also recorded. The data shows that it is possible to obtain reliable and repeatable values for the pH of the nasal mucosa (Spearman-Brown R = 0.84). Analysis shows there is no significant difference between septal and turbinate mucosal pH. Subset analysis implies that nasal mucosal pH is higher in men then women (P < 0.05). The other variables did not affect the nasal mucosal pH significantly.

In vitro platelet binding compared with in vivo thrombus imaging using alpha(IIb)beta3-targeted radioligands.

Radioligands for the alpha(IIb)beta3 integrin on platelets are being studied for their ability to image venous thrombi and pulmonary emboli. One such radioligand, 123I-bitistatin, was previously shown to have higher thrombotic uptake in an animal model than other disintegrins, but the reason for this difference was not clear. The purpose of this study was to evaluate three labeled disintegrins, bitistatin, kistrin and barbourin, to look for in vitro differences in platelet binding which could explain the in vivo behavior. Disintegrins labeled with 121I were compared in vitro for extent of binding to platelets and rates of binding and dissociation. These findings were related to organ distribution and image quality for imaging thrombotic lesions, following administration of 123I-disintegrins in an animal model. Fibrinogen at 8.8 micromol/l was able to displace 125I-barbourin and 125I-kistrin more rapidly from ADP-stimulated platelets, with half-times of 3.5 and 10.7 min, compared with 125I-bitistatin (31.6 min). At equivalent concentrations in whole blood, a higher percentage of bitistatin bound to platelets compared with the other two. In vivo, kistrin and barbourin had significantly lower thrombus:muscle and pulmonary embolus:lung ratios in images compared with bitistatin. There was evidence of more metabolic deiodination of labeled kistrin and barbourin in vivo compared with bitistatin. A surprising finding was that conventional in vitro platelet binding studies did not predict the relative in vivo behavior of labeled disintegrins. The results suggest that labeled bitistatin has improved targeting of thrombi because it is less easily displaced from stimulated platelets, permitting longer lesion retention. It also appears to have a greater association with resting platelets in the blood, which may increase bioavailability and delay metabolic breakdown.

Effects of in vitro versus in vivo red cell labeling on image quality in gastrointestinal bleeding studies.

OBJECTIVE: Both in vivo and in vitro red cell labeling methods are available for performing gastrointestinal bleeding studies. While in vitro labeling has been shown to result in higher binding efficiency, no comparison of clinical image quality has been reported between those techniques. This study compares in vivo and in vitro methods using both subjective and objective measurements of image quality. METHODS: A consecutive series of gastrointestinal bleeding studies performed on 23 patients using in vivo labeling was compared to a series of 23 studies using in vitro labeling. Images at 30 min postinjection were randomized and analyzed by two observers. Subjective evaluation of image quality, as well as renal activity, was based on a comparison of femoral vein and inferior vena cava activity to adjacent background using numerical scores with a scale of 0-3. Image quality using the subjective scores was further classified as acceptable and poor. Target-to-background measurements of femoral vein to adjacent soft tissue in the thigh and inferior vena cava to adjacent abdominal background also were made. RESULTS: In vitro label subjective image quality was acceptable in 87% and 91% of cases for vascular and renal activity, respectively, but only 35% and 52% for in vivo labeling. In vitro label target-to-background ratios were significantly better than in vivo label for the femoral vein and inferior vena cava, as well as for the subjective assessment of vascular image quality, but not for renal activity. CONCLUSION: In vitro red cell labeling improves clinical image quality as compared with in vivo labeling. Both subjective and objective measurements of image quality are useful for comparing the results of labeling methods.