Use of office based transnasal oesophagoscopy in management of Head & Neck conditions during the COVID-19 pandemic at the Royal Albert Edward Infirmary, Wigan, United Kingdom.

OBJECTIVES: To assess the clinical and cost effectiveness of transnasal oesophagoscopy (TNO) in cases of suspected upper aerodigestive tract malignancy and define its role as a safe alternative to panendoscopy. We have also analysed if the implementation of TNO during the COVID-19 pandemic was beneficial in order to provide uninterrupted care to the patients with the limited resources available in these challenging times. METHODS: All patients who underwent TNO guided biopsies or dilatation attempted over a 7 month period during COVID- 19 pandemic were included by searching the hospital and department database at The Royal Albert Edward Infirmary. A comparative group of patients who underwent panendoscopy over 9 months were included for comparison. Demographic data, histological diagnosis, second procedure and cost involved were recorded. RESULTS: During this period, 20 TNO procedures (16 biopsies and 4 dilatations) were attempted which were compared with 20 panendoscopy procedures. The diagnostic accuracy of TNO biopsy for identifying benign and malignant pathology was 81.1%. The sensitivity and specificity for identifying malignancy was 76.9% and 100% respectively. The most common lesion location was laryngeal (43.8%) followed by oropharyngeal (37.5%), more specifically located at the tongue base. The median waiting period between the procedure being listed and TNO being performed was 5.5 days compared to 12 days for panendoscopy. There were 12/16 patients who did not require further interventions for histological diagnosis of the tumor. The TNO procedure was well tolerated with no complications and all were done under local anaesthesia as outpatient procedure without need for admission. TNO resulted in cost saving of £356 per case on a standard NHS tariff. CONCLUSION: TNO is a valuable diagnostic tool for patients with suspected UADT malignancy and dysphagia and has proven to be an asset during the COVID-19 pandemic when we have to make the best use of the limited theatre time and resources. Also, the cost analysis showed that outpatient based TNO can provide significant cost savings for the current standard of care. Furthermore, it has shown better patient tolerability, lesser complications and shortened the time for diagnosis and hence starting timely treatment for these patients.

MEF2C transcription factor is associated with the genetic and epigenetic risk architecture of schizophrenia and improves cognition in mice.

Large-scale consortia mapping the genomic risk architectures of schizophrenia provide vast amounts of molecular information, with largely unexplored therapeutic potential. We harnessed publically available information from the Psychiatric Genomics Consortium, and report myocyte enhancer factor 2C (MEF2C) motif enrichment in sequences surrounding the top scoring single-nucleotide polymorphisms within risk loci contributing by individual small effect to disease heritability. Chromatin profiling at base-pair resolution in neuronal nucleosomes extracted from prefrontal cortex of 34 subjects, including 17 cases diagnosed with schizophrenia, revealed MEF2C motif enrichment within cis-regulatory sequences, including neuron-specific promoters and superenhancers, affected by histone H3K4 hypermethylation in disease cases. Vector-induced short- and long-term Mef2c upregulation in mouse prefrontal projection neurons consistently resulted in enhanced cognitive performance in working memory and object recognition paradigms at baseline and after psychotogenic drug challenge, in conjunction with remodeling of local connectivity. Neuronal genome tagging in vivo by Mef2c-Dam adenine methyltransferase fusion protein confirmed the link between cognitive enhancement and MEF2C occupancy at promoters harboring canonical and variant MEF2C motifs. The multilayered integrative approaches presented here provide a roadmap to uncover the therapeutic potential of transcriptional regulators for schizophrenia and related disorders.

Laryngopharyngeal reflux and primary snoring: a pilot case-control study.

STUDY OBJECTIVES: Laryngopharyngeal reflux has been implicated as a causative factor in the aetiology of sleep related breathing disorders. However there are no reports on the association of this disorder and primary snoring in the absence of obstructive sleep apnoea. This study was undertaken to investigate any link between primary snoring and the presence of laryngopharyngeal reflux. METHODS: A matched case-control study was performed in a district general Ear Nose Throat outpatient population in the United Kingdom. Twenty six patients referred for snoring without sleep apnoea (cases) were individually matched for gender, body mass index and age, to 26 patients referred for other otorhinolaryngological complaints (controls). Snoring was not an exclusion criterion for the controls. Exclusion criteria for both groups were previous referral or treatment for snoring and/or sleep apnoea, nasal obstruction symptoms (as a potential cause of snoring), and known history of gastrooesophageal reflux with medical treatment longer than two months. The main outcome measure was prevalence of laryngopharyngeal reflux based on the Reflux Symptom Index score. RESULTS: Patients seeking medical advice for primary snoring are fourteen times more likely to report Reflux Symptom Index scores of more than 13 than controls. CONCLUSIONS: Laryngopharyngeal reflux may also be implicated in the pathogenesis of primary snoring in the absence of sleep apnoea. This constitutes 3b level of evidence.

Giant tonsillolith - a rare cause of dysphagia.

Tonsilloliths are calcified concretions that originate within the palatal tonsil crypts. Moreover, development of these concretions into giant tonsilloliths is exceptionally uncommon. We present a 17-year-old female with a two-year history of increasing dysphagia, persistent oral cavity swelling and speech alteration. Clinical examination of the oral cavity revealed a large solid left tonsil with no obvious neck masses. Computer tomography demonstrated a well-defined, large calcified left tonsillar fossa mass of uncertain underlying cause. This patient subsequently underwent surgical excision for histology.

The root and development of otorhinolaryngology in traditional Chinese medicine.

There is an increasing trend in society to look beyond conventional medicine to find answers to problems in health. Traditional Chinese medicine (TCM) is one of the most popular alternative, complementary therapies worldwide. It is becoming a popular alternative in otorhinolaryngology where its use in the treatment of sinusitis, tinnitus, deafness and Meniere's disease is growing. Despite the general awareness of TCM, the literature relating specifically to otorhinolaryngology is relatively scarce. In this review, we have traced the origin and development of otorhinolaryngology with respect to TCM and have provided a few interesting insights into otorhinolaryngology, as it used to be practised. Archaeological sources have shown that diseases affecting the ear, nose and throat were of medical concern as early as the 18th century BC. The first practising otorhinolaryngologist can be traced back to the 5th century BC. Acupuncture, moxibustion, herbal therapy and massage were amongst his treatments. Otorhinolaryngology was recognised as a major specialty when formal medical education began in the 7th century AD. Therapeutic measures since then expanded to include exercise, food therapy and surgery. References to using oesophageal speech as a substitute voice generator, the use of copper wire to excise nasal polyps, procedures for removal of sharp foreign bodies in the oropharynx, repair of lacerated trachea and treatment of cancer of lips can be found in historical notes. In conclusion, from its primitive roots, TCM has developed into a distinct branch of health care system in China today that works alongside Western medicine.

Microvascular decompression of cochleovestibular nerve.

The role of microvascular decompression (MVD) in the management of trigeminal neuralgia, hemifacial spasms and glossopharyngeal neuralgia is well-established. However, controversy persisted as to the use of MVD in cochleovestibular neurovascular compression syndrome. This report provides a review of all the published studies on MVD of the eighth (8th) nerve in alleviating cochleovestibular symptoms and presents three additional patients who underwent MVD of the eighth nerve for tinnitus or vertigo. Nineteen studies were identified. Five were case reports. The remaining have sample sizes ranging from 4 to 207 patients. Quantitative and qualitative reviews of all studies were performed, focusing on the selection criteria for surgery, efficacy and safety of the procedure. Selection criteria for surgery were variable. No standardised outcome measures were used and all studies rely on patient subjective assessment of surgical outcome. Nonetheless, the results suggest that MVD of the eighth nerve produces good outcome with low morbidity in selected cases.

Falls and vestibular impairment.

Unexplained fall is one of the commonest presentations to the Accident and Emergency (A & E) department of a hospital. The objective of this study is to assess the proportion of patients with symptoms of vestibular impairment among those presenting to an A & E department with an unexplained fall. Out of the total 3139 patients (fallers) presenting to an A & E department in 6 months, 546 had no known cause for the fall. Of these, 428 (76%) completed the vestibular symptom scale questionnaire. The presence and severity of vestibular symptoms for the past 12 months were assessed. The results showed that 80% of these patients had symptoms of vestibular impairment. We conclude that a large proportion of unexplained fallers suffered from symptoms of vestibular impairment within the last year, which may be responsible for their imbalance and falls. Identifying this group of patients is important as their symptoms and the resultant postural instability can be ameliorated by vestibular rehabilitation exercises.

Vestibular schwannomas in children.

OBJECTIVE: This article highlights the clinical presentation and management issues of unilateral vestibular schwannomas in children. We demonstrate how the presentation differs from neurofibromatosis type 2 (NF2) and from adult unilateral vestibular schwannomas. STUDY DESIGN: This article is composed of a series of three cases and a literature review. SETTING: The study was performed at a university hospital (tertiary referral center). PATIENTS: Three children, aged 9, 11, and 13 years, with histologically confirmed vestibular schwannomas were studied. All children under 16 years of age in the world literature with unilateral vestibular schwannomas were reviewed. INTERVENTION: Analysis of presentation and surgical management of these three children and those children reported in the literature. MAIN OUTCOME MEASURE: Pattern of presentation relative to children with NF2 and people with adult unilateral vestibular schwannomas. RESULTS: Two patients had multiple cranial nerve weakness and recurrence, and one patient had successful removal of the tumor with preservation of all functions of the cranial nerves, including the facial nerve. CONCLUSION: Vestibular schwannomas in children are very uncommon. It is likely that it is the first manifestation of NF2, but it may also be a variant of sporadic vestibular schwannomas. A presentation of three cases and a review of 36 other cases in the literature demonstrates how the presentation is different from adult sporadic vestibular schwannomas and NF2 because it lacks primary audiological symptoms. The study also provides evidence of non-NF2 vestibular schwannomas presenting in children and suggests that it is likely that these are a variant of unilateral sporadic vestibular schwannomas. The search for the features of NF2 in these cases remains mandatory.

Otology in ancient India.

Sushrutra Samhita is essentially a multi-volume textbook reporting the surgical practices of ancient India. It covers all aspects of surgery. However, specific references are made to otorhinological conditions, their description and subsequent treatments often being described in some detail. In this paper we outline the structure of the document and attempt to explain its underlying philosophies. We highlight the specific references to otological diseases and their treatment and draw the obvious comparisons with modern otological practice.

Carotico-cavernous fistula following septorhinoplasty.

Septorhinoplasty is a very common operation in otolaryngological practice. We report the second case of a carotico-cavernous fistula following septorhinoplasty. This case presented with very severe epistaxis before the appearance of the typical pulsating exophthalmos, ophthalmoplegia, headache and engorged veins on the right side of the face. Our case was treated by endovascular thrombosis with electrolytically detachable coils.

Laparoscopic abdominal incisional hernioplasty: principles, technique and complications.

Repair of incisional herniae by direct approximation of the edges is associated with high incidence of recurrence. Tension free repair with prosthetic material was an advance in decreasing the incidence of recurrence. Repair with prosthetic material, to be successful, re qui res extensive dissection and its associated complications. Advances in laparoscopy along with the improvements in prosthetic materials has opened up opportunity for further decreasing the incidence of recurrence with minimal dissection.

Nothing new under the sun: the management of epistaxis.

The management of epistaxis is reviewed from ancient times onwards. Many curious methods have been employed and indeed epistaxis has been encouraged at times. Although current management is based on sound principles folklore remedies still predominate amongst some of our patients. The basis of contemporary treatments was known and practised by our ancient forbears.

Verrucous squamous carcinoma of the nasal septum.

We document only the second reported case of verrucous squamous carcinoma of the nasal septum. In both cases previous surgical treatment for assumed squamous papillomata had resulted in multiple recurrences necessitating formal surgical resection. Our patient has remained tumour-free during long-term follow-up.

Metastatic melanoma of gastrocolic ligament treated with minimally invasive approach.

A patient with metastatic melanoma of the gastrocolic ligament was rendered clinically tumor free using a minimally invasive procedure. The technique and the rationale for the procedure are reviewed.

Complications of laparoscopic inguinal hernia repair.

Laparoscopic herniorrhaphy has been gaining popularity along with other minimally invasive surgical techniques. With the sophistication of instruments, evaluation of techniques and longer follow-up of patients, the outcome of such repairs is changing. Many authors are reporting a variety of techniques, complications, and results compared to conventional surgery.

Jaundice secondary to spilled gallstone during laparoscopic cholecystectomy.

Advantages of.laparoscopiC cholecystectomy (LC) in terms of shorter hospital stay, less pain, and diminished disabilrty are well documented. Less well documented are the long-term comptications of this procedure. We report a patient who developed obstructive jaundice 8 months following LC from a spilled gallstone. In our review of the literature using MEDLINE from January 1990to June 1995,we did not find this complication reported.

Gonadotropin-producing benign cystic teratoma simulating a ruptured ectopic pregnancy.

Benign cystic teratomas are asymptomatic in many cases. There are some reports of production of thyroid-stimulating hormone, estrogen, testosterone, and prolactin by these tumors. This article reports a patient in whom a twisted cystic teratoma simulated ruptured ectopic pregnancy by beta human chorionic gonadotropin production and hemorrhage into the peritoneal cavity.