Late presentation of congenital tracheo-oesophageal fistula.

Congenital tracheo-oesophageal fistula presenting in adulthood is extremely rare. Such a case is presented in a patient who suffered repeated chest problems as an infant, which persisted through the years, and was ultimately diagnosed as 'bakers lung' due to his occupation. He was referred with persistent cough to the ENT department, and an upper endoscopy located a tracheo-oesophageal fistula, which was subsequently resected with complete resolution of his symptoms. Unresolving chest problems or persisting cough should alert the doctor to such a possible diagnosis.

The role of colour flow Doppler in the investigation of the salivary gland tumour.

AIMS: Ultrasound is a highly effective imaging technique to determine salivary gland tumours and may help to identify many benign lesions. The aim of this study is to evaluate whether colour Doppler is able to further differentiate the malignant tumour. METHODS: Fifty-six patients with salivary gland lesions were prospectively assessed using ultrasound imaging with colour flow and power Doppler. The peak systolic velocity (PSV) was measured and the pulsatility index (PI) and resistive index (RI) calculations were performed on the pulsed wave traces. The real time ultrasound morphology and the Doppler information were correlated with the histology. RESULTS: In 18 of the 56 patients, no internal colour flow or power Doppler changes could be detected. The real time ultrasound morphology diagnosed benign disease with sensitivity of 89.7% with specificity of 57.1%. The positive predictive value was 93.6%. There were no significant differences in the colour Doppler appearances in terms of vessel type or intratumour distribution which could separate benign from malignant conditions. However, there was statistical discrimination for PI and RI values (P = 0.0006, P = 0.0002, respectively). No malignant lesions were seen when the PI was less than 1.8 and RI was less than 0.8. The PSV was elevated in several cases (> 50 cm per s) but there was no statistical correlation with malignancy. CONCLUSION: The risk of malignancy increases by a third when the colour Doppler demonstrates increased intratumour vascular resistance (RI > 0.8 and PI > 1.8), with positive predictive value of 97.3% (sensitivity 75.5%, specificity 85.7%).Bradley, M. J. (2000). Clinical Radiology55, 759-762.

Inhalation of a denture fragment complicating facial trauma.

A case of facial trauma is presented, which was complicated by a denture fragment lodged in the larynx. This potentially life threatening event caused minor symptoms only. Its diagnosis and management are reported.

Local anaesthesia for middle ear surgery.

Thirty-two consecutive patients undergoing middle ear surgery using local anaesthesia were assessed on the adequacy of anaesthesia for their surgery, both by the patients themselves, and by the surgeon. A method of local anaesthesia is described which includes the possibility of inducing an iatrogenic transient homolateral facial weakness in order to simplify the technique of administration of anaesthesia. Both the surgeon and the patients were happy with the quality of the anaesthesia, and no adverse effects occurred either as a consequence of the local anaesthesia itself, or of the transient facial weakness.

The outcome of different management patterns for vocal cord nodules.

In 1963, Brodnitz conducted a study which assessed the vocal recovery incidences for patients with voice problems, which included a group of patients with vocal cord nodules (singers' nodules). Nagata et al., (1983), compared the long-term outcome in vocal nodule patients treated by surgery alone, with those treated by minimal conservative measures, and those not treated at all. However, there is no reported study which compares the long-term outcome of patients with vocal cord nodules treated surgically with those treated with a combination of surgery and speech therapy, and those treated only with speech therapy.

Vocal cord nodules: a review.

Vocal cord nodules have a variety of synonyms in the literature, including laryngeal nodules, laryngeal nodes, corditis nodosa, singers' nodes, teachers' nodules, screamers' nodes, parsons' nodes, and nodular laryngitis. All of these refer essentially to the same condition. In 1954 referring to vocal cord nodules, Brodnitz and Froeschels wrote that, 'Ever since Tuerck first described the condition in 1868, discussion of the aetiology, the histological nature, and the therapy still has not ceased'. This statement still applies today.

The effect of local anaesthesia of the nasal vestibule on nasal sensation of airflow and nasal resistance.

The effect of local anaesthesia of the nasal vestibule on nasal sensation of airflow and nasal resistance was assessed in 15 subjects. A single blind parallel group trial was undertaken in 30 subjects, with lignocaine as the active drug, and normal saline as the placebo. Fifteen subjects were included in each group. Both agents were infiltrated bilaterally into the floor of the nasal vestibule on each side via the sublabial route. Local anaesthesia of the nasal vestibule by infiltrating lignocaine produced a sensation of nasal obstruction in 9 out of 15 subjects (P less than 0.02). The infiltration of normal saline had no such effect. The difference between the effect of the 2 agents on nasal airflow sensation was significant (P less than 0.05). Neither injection had any significant effect on nasal resistance to airflow as assessed by active anterior rhinomanometry.

Nasal resistance to airflow (its measurement, reproducibility and normal parameters).

A method of rhinomanometry is described for use in clinical research work. The statistical distribution of nasal resistance values is studied in a sample of 59 normal individuals. The variation of nasal resistance within two individuals is studied over a period of 7 hours. The choice of appropriate statistical tests to be used when comparing nasal resistance values is discussed. The reproducibility of nasal resistance measurements is assessed in 47 normal individuals. The results were used to define a normal range of values for total nasal resistance to airflow.

Does submucosal diathermy to the inferior turbinates reduce nasal resistance to airflow in the long term?

The operation of submucosal diathermy is commonly performed for the relief of nasal obstruction due to mucosal swelling. In this study the effect of the procedure on nasal resistance to airflow is assessed by rhinomanometry. The results show that although the operation is effective in the short term (two months), there is no significant difference between the nasal resistances prior to surgery and at 15 months after surgery.

Rhinomanometry: do the anterior and posterior methods give equivalent results?

Nasal resistance to airflow was measured by both anterior and posterior rhinomanometry in 15 healthy volunteers. It was found that the posterior method gave values on average 16% higher than the anterior method. This difference was statistically significant. We propose that this is due to posterior rhinomanometry measuring the resistance of the nasopharynx as well as the resistance of the nose. In the past a discrepancy between the 2 methods has been claimed to be due to an error in the standard form of the parallel resistance equation. This hypothesis was tested by measuring total nasal resistance by posterior rhinomanometry and comparing this with a total nasal resistance value derived from posterior rhinomanometric measurements of the resistance of the individual nasal cavities. The standard form of the parallel resistance formula was used to derive the total nasal resistance. There was no significant difference between the 2 values for total nasal resistance. We conclude that if measurements are made at the same pressure gradient then the use of this equation is valid.

The effect of lignocaine on nasal resistance and nasal sensation of airflow.

The effect of lignocaine on nasal sensation of airflow and nasal resistance was assessed in twenty-five subjects. A randomised crossover trial was conducted with lignocaine as the active drug and saline as the placebo. Both substances were delivered to the nasal mucosa as a nasal spray. Lignocaine caused a sensation of increased nasal patency in twenty-two of the twenty-five subjects studied. Saline had no such effect. The difference between this subjective effect of the two substances was highly significant (p less than 0.001). Neither spray had any significant effect on nasal resistance to airflow assessed objectively by rhinomanometry.

Transient facial paralysis (a report of three cases).

Local anesthetic infiltrated into the external auditory meatus prior to ear surgery is a cause of transient ipsilateral facial nerve paralysis in the immediate post-operative period. This phenomenon is only rarely described. Three such cases are reported.

Photography and the flexible fibreoptic rhinolaryngoscope.

Documentation of normal and pathological anatomy is important to all medical practitioners. The ability to visualize and photograph the upper respiratory tract has been revolutionized by the advent of the flexible fibreoptic rhinolaryngoscope (FFRL), which demonstrates a one-instrument capability for the examination and photodocumentation of the ears, nasal cavity, nasopharynx, larynx, hypopharynx and trachea (Selkin, 1984). If a large natural maxillary ostium, or surgical window, is present, the antrum may also be examined.

The effect of submucosal diathermy to the inferior turbinates on nasal resistance to airflow in allergic and vasomotor rhinitis.

Twenty-one patients with nasal obstruction due to allergic or vasomotor rhinitis were assessed rhinomanometrically before and after the operation of submucosal diathermy to the inferior turbinates. It was found that the operation significantly improved the nasal airway. Most patients with an objective improvement reported a corresponding reduction in nasal obstruction. There was no tendency for patients with allergic rhinitis to be dissatisfied with the operation.

The flexible fibreoptic rhinolaryngoscope.

An accurate, reliable, inexpensive and safe method for the examination of the upper aero-digestive tract is described. Its efficacy is evaluated retrospectively on 250 patients over an 18-month period.