A two-centre experience of tonsil biopsies in the investigation of patients with tonsillar asymmetry.

INTRODUCTION: We aim to evaluate our experience of tonsil biopsies in the investigation of patients presenting with asymmetrical tonsils. METHODS: A two-centre retrospective analysis of all patients who underwent histology sampling of the palatine tonsils between 1 January 2013 and 31 December 2018 was completed. Data collected included patient demographics, method of obtaining tonsil tissue, histological diagnosis and need for repeat tissue sampling. A follow-up period of 36 months was allowed to establish whether any patients re-presented with missed diagnoses. RESULTS: In total, 937 patients were included for analysis: 375 (40.0%) had a biopsy, of which 191 (50.9%) were performed in clinic. The mean duration from initial appointment with the ear, nose and throat clinic to tissue sample collection was 17.6 days (range 0-327 days) for all biopsies, reducing to 0.2 days (range 0-17 days) for biopsies performed in clinic. This was significantly shorter than for tonsillectomies (mean 38.9 days, range 0-444 days; p<0.05). Of the patients who underwent tonsil biopsy, six (1.6%) had malignancy that was not unequivocally diagnosed on initial biopsy. In all six patients, prior clinical suspicion was high, and repeat tissue sampling was undertaken on receipt of negative histology results. CONCLUSIONS: Tonsil biopsy is a viable alternative to tonsillectomy for histology in the assessment of tonsil asymmetry. Tonsil biopsy in the outpatient setting has reduced surgical morbidity, significantly less delay in diagnosis, less inconvenience for patients and lower healthcare costs compared with formal tonsillectomy. Although tonsil biopsies should not be used in isolation, they can be useful in the investigation of patients presenting with tonsillar asymmetry.

On-site cytotechnician evaluation of the adequacy of fine needle aspiration in a neck lump clinic.

INTRODUCTION: The gold standard for assessing neck lumps is a one-stop clinic with an on-site cytopathologist who can provide an immediate fine needle aspiration (FNA) report. However, this has considerable resource implications and is not available in all units. In our department, surgeons perform FNAs guided by palpation. The FNA is evaluated for specimen adequacy by an on-site cytotechnician. This study evaluated the impact of the cytotechnician on the adequacy of neck lump FNA. METHODS: FNA performed between June 2010 and February 2012 was examined. The FNA performed at a neck lump clinic with an assessment of adequacy by an on-site cytotechnician were considered the test group. All other neck lump FNAs from other sources without an assessment of adequacy by an on-site cytotechnician were considered the control group. RESULTS: Of the FNAs, 134 met the inclusion criteria for this study. Of these, 87 FNAs (65%) were analysed for adequacy by the on-site cytotechnician and the remaining 47 (35%) were not. The results demonstrated an FNA inadequacy with and without on-site cytotechnician assessment of 29.9% and 40.4% respectively. This is equivalent to an absolute risk reduction of an inadequate FNA of 10.5%, which equates to a number needed to treat of 9.5, ie the cytotechnician needs to assess 9.5 (ie the cytotechnician [...] specimen). CONCLUSIONS: In neck lump clinics where on-site cytopathology is not available, an on-site cytotechnician is a compromise measure that does reduce the number of inadequate FNAs.

Sinusitis: a rare cause for galactorrhoea.

A 32-year-old woman presented to the endocrinology clinic with recent onset galactorrhoea. Investigations revealed raised prolactin levels. An MRI scan demonstrated a normal pituitary gland, and an incidental finding of sphenoid sinusitis with expansion of the sphenoid sinus was thought to be due to a mucocele. It is postulated that either the direct local pressure by the mucocele or localised inflammation secondary to sinusitis might cause hyperprolactinaemia. The patient underwent endoscopic surgery to drain the mucocele, after which her galactorrhoea resolved. A review of the literature reveals only one previously documented case of sinusitis causing hyperprolactinaemia and galactorrhoea.

Does academic output correlate with better mortality rates in NHS trusts in England?

OBJECTIVE: To establish whether there is an association between academic output and mortality rates for National Health Service (NHS) trusts. METHODS: Hospital standardized mortality ratios were obtained from Dr Foster hospital report cards. The Medline database of biomedical citations was queried to establish the number of citations credited to each NHS trust and constituent hospitals from 2006 to 2010. Admissions totals for NHS trusts for 2009-2010 were obtained from Hospital Episode Statistics Online. The number of citations per admission was calculated and used as an indicator of academic output as this reflects the workload of the trust. RESULTS: Spearman's rank analysis was performed to identify any correlation between citations per admission and the inverse of four types of mortality rate: high-risk conditions, r = 0.20 (P = 0.01); low-risk conditions, r = -0.06 (P = 0.46); deaths after surgery, r = 0.193 (P = 0.019); and overall mortality, r = 0.291 (P < 0.01). CONCLUSION: The results of this preliminary study demonstrate a significant correlation between academic output and mortality rates. The correlation coefficients are small, but the findings of this study encourage further debate.

p53 immunoprofiling of potentially malignant oral disorders: a case series analysis.

CONTEXT: p53 tumor suppressor gene which is a frequent target for mutations in a high percentage of oral cancer is regarded as an early event in carcinogenesis. AIM: The role of p53 was assessed in potentially malignant oral disorders (PMOD) to ascertain its prognostic significance. SETTINGS AND DESIGN: Retrospective case series analysis was carried out on 30 paraffin-embedded tissue blocks of confirmed oral leukoplakia with dysplasia. MATERIALS AND METHODS: 10 cases of each of mild, moderate, and severe dysplasia were immunohistochemically analyzed for p53 expression. The intensity of staining, intracellular localization, and basal and/or suprabasal distribution were assessed. STATISTICS: The intensity of p53 staining and its distribution were analyzed by the Chi-square test. The intracellular localization of p53 in different grades of dysplasia was subjected to one way ANOVA. P<0.05 was considered significant. RESULTS: 21/30 cases of epithelial dysplasia were positive for p53 immunopositivity. Intensity of p53 expression was strong in 12 cases and weak in 9 cases (P<0.05). p53 positivity was confined to basal cells in mild dysplasia, while severe dysplasia showed both basal and suprabasal staining (P<0.05). Nuclear and cytoplasmic staining between and within the groups were F=9.027 and F=6.465 respectively with high significance noted between mild dysplasia and severe dysplasia. CONCLUSIONS: Increased p53 expressivity and greater cellular localization with increase in the severity of dysplasia indicated a direct association between the degree of epithelial dysplasia and p53 accretion, which occurs as an early event in oral carcinogenesis.

Surfers' awareness of the preventability of 'surfer's ear' and use of water precautions.

OBJECTIVE: To establish surfers' knowledge of the preventability of external auditory canal exostoses ('surfer's ear'), and their use of water precautions. METHOD: Survey of surfers conducted between December 2009 and March 2010 at beaches in Cornwall, UK. RESULTS: Ninety-two surfers were included (78 males and 14 females, mean age 27 years, standard deviation 7.9 years). Participants were grouped according to their awareness of the preventability of surfer's ear (55 aware, 37 unaware). These groups were comparable in age, surfing history and gender mix (p > 0.05). Surfers aware of the preventability of exostoses (66 per cent) were more likely to use water precautions than those who were not (38 per cent) (p < 0.01). Two surfers used water precautions regularly and 48 used them occasionally. Sixty-one of the 76 surfers who did not use water precautions (ear plugs) suggested they would consider doing so in the future. CONCLUSION: Awareness of the preventability of surfer's ear was associated with greater use of water precautions. Further research should explore reasons for the low uptake of such precautions. Most surfers not already using ear plugs would consider doing so in the future.

Investigation of the influence of ambient temperature, atmospheric pressure and water vapour pressure on epistaxis admission rate.

BACKGROUND: To investigate the relationship between weather variables (atmospheric pressure, temperature, water vapour pressure) and epistaxis admission rates at Derriford Hospital, Plymouth, United Kingdom. METHODOLOGY: Retrospective observational study using hospital inpatient information databases to identify all patients admitted with epistaxis from April 1999 to March 2009 inclusive. Meteorological data for the same period was retrieved from the University of Plymouth Meteorological Archive. Epistaxis admissions were investigated for correlation with weather variables using Pearson correlation, and stepwise multiple regression analysis was performed. RESULTS: During the study period there were 1071 admissions (978 patients) (501 males (mean age 64 years) and 477 females (mean age 72 years)). Less than 10% of the variance in epistaxis admissions is explained by the maximum temperature only. Temperature and water vapour pressure demonstrated statistically significant association with epistaxis admission rates. CONCLUSIONS: Though there is statistical significance in the association of some weather variables and epistaxis admission rates, the findings are not practically relevant (<10% variance). The results of this study do not indicate a need for revision of current healthcare resource allocation.

Trends in the incidence rates of tonsil and base of tongue cancer in England, 1985-2006.

INTRODUCTION: The aim of this study was to investigate whether incidence rates of tonsil and base of tongue cancer in England are increasing using data from the UK cancer registry. SUBJECTS AND METHODS: Cancer registrations for oral cavity and oropharynx cancer from 1985-2006 in England were obtained from the National Cancer Information Service. Population estimates were obtained from the Office for National Statistics. Age-adjusted incidence rates and age-specific incidence rates were calculated. The sexes were considered separately as incidence rates are known to differ significantly between men and women. Linear regression was performed to establish whether there was a relationship between incidence rates and time. RESULTS: There has been an increase in all oral cavity and oropharyngeal cancer in the study period. Linear regression analysis suggests that approximately 90% of the variance in age-adjusted incidence rates for men and women for tonsil, base of tongue and other oral cavity cancer is explained by the passage of time. For other oropharyngeal cancer, the variance is 62% and 46% in men and women, respectively. The estimated annual percentage change from 1985 to 2006 in age-adjusted incidence rates for tonsil and base of tongue cancer is 5.7% and 6.7% for men, and 4.3% and 6.5% for women, respectively. CONCLUSIONS: This study confirms a wide-spread clinical impression that there has been an increase in age-adjusted incidence rates, between 1985 and 2006, in all oral cavity cancer in England. The age range 40-69 years has seen the biggest increases in age-specific incidence rates for tonsil and base of tongue cancer. This reflects the findings of similar studies in other countries.

Current controversies in the management of Warthin tumour.

Warthin tumour is the second most common benign neoplasm of the parotid gland. It has a low rate of growth and exhibits malignant transformation in 0.3% of cases. Although its aggressiveness has not been a concern, surgical resection remains the most common treatment modality. This entails the risk of a general anaesthetic and those pertaining to the procedure itself, most notably permanent facial nerve damage. This has led some authors to use conservative management, albeit rarely. There are those who condemn such a policy despite the encouraging results reported thus far. To understand the rationale underpinning non-operative management, it is imperative that one has a comprehensive understanding of the pathogenesis, clinical presentation and diagnosis of Warthin tumour. The aim of this review therefore is to detail these elements and clarify the current controversies in managing this lesion.

Terminal Ileum Perforation as a Consequence of a Migrated and Fractured Oesophageal Stent.

Covered self-expanding metallic stents are commonly employed to relieve malignant oesophageal obstruction. We report a case of a patient with oesophageal cancer treated by stent insertion and curative chemoradiotherapy with subsequent stent migration to the stomach. The stent fractured with the distal fragment migrating as far as the terminal ileum where it caused perforation of the bowel.

Primary cutaneous mucormycosis (zygomycosis) caused by Apophysomyces elegans.

A 53 year-old male diabetic presented with a month-old, painful ulcer with necrotic margins over the right thigh. Wound debridement was done twice and the ulcer showed recurrent growth of a white, cottony filamentous structure. Cutaneous mucormycosis was suspected and confirmed by histopathology and a culture isolate of Apophysomyces elegans . The patient was treated with liposomal amphotericin-B and itraconazole followed by partial thickness skin grafting, and then discharged after being prescribed posaconazole syrup for three weeks. Regular follow-up was done and during the last visit after six months following discharge, the ulcer was found to have healed well with no recurrence of the fungus.

Is there an association between blood group O and epistaxis?

INTRODUCTION: Blood group O is associated with lower expression of von Willebrand factor suggesting a relative bleeding tendency. A lower admission rate for epistaxis among Asians compared with Caucasians has also been noted, with one explanation being higher prevalence of blood group O among Caucasians. This study investigates whether blood group O is over-represented in patients admitted with epistaxis. METHODS: A retrospective study was conducted, using computerised hospital in-patient and blood bank databases to identify Caucasians admitted with epistaxis between January 2000 and December 2005 inclusive. The control group consisted of 500 consecutive patients who had a primary total hip arthroplasty and 500 consecutive patients who gave birth within the delivery suite. RESULTS: 1261 Caucasians admitted with epistaxis were identified. Among epistaxis patients, 50.44 per cent were blood group O but among the control group this was 45.10 per cent (chi-square test p = 0.008). CONCLUSION: Blood group O appears over-represented in Caucasian patients admitted with epistaxis, compared with the control population, raising the possibility that blood group O is a risk factor for epistaxis.

Laparoscopic repair of direct inguinal hernia: a new technique that reduces the development of postoperative seroma.

BACKGROUND: Seroma are common early postoperative complications encountered in laparoscopic inguinal hernia repair. Previous anecdotal evidence from our surgical practice suggested a lower incidence of postoperative seroma formation with direct hernia repairs when the lax transversalis fascia (TF) is inverted by tacking to the pubic ramus. We undertook a study to investigate whether TF inversion in this way reduces the incidence of postoperative seroma. METHOD: A total of 216 patients undergoing transabdominal preperitoneal (TAPP) laparoscopic inguinal hernia repairs from August 2003 to December 2005 were included in this prospective non-randomised controlled study. Surgeon 1 would routinely invert the TF whereas surgeon 2 would not. At follow-up the presence of postoperative seroma and pain was recorded. RESULTS: Mann-Whitney U test demonstrated no significant difference in terms of age, sex and time to follow-up between the surgeons' patient groups (P > 0.05), and Chi-square test demonstrated significantly that inversion of the TF is associated with a lower incidence of postoperative seroma (P < 0.05). There was no significant difference in terms of postoperative pain at follow-up. CONCLUSION: Inversion of the TF is associated with a statistically lower incidence of postoperative seroma, without increasing postoperative pain despite the use of one or two additional tacks.

Is admission for epistaxis more common in Caucasian than in Asian people? A preliminary study.

OBJECTIVES: Epistaxis is a common ENT complaint. Although casual observation suggested that it is more common in Caucasian, compared with Asian people, a literature search failed to find any studies investigating ethnicity and epistaxis. The aim of this study was to identify any differences in emergency admission rates for epistaxis between Asian and Caucasian people. DESIGN: Retrospective observational study using hospital computerised data (HISS). SETTING: Large University Hospital accepting ENT emergencies. PARTICIPANTS: All Asian and Caucasian patients admitted under ENT care as an emergency (1 January 2000 to 30 November 2005), split into two groups: one composed of epistaxis patients, the other of all other ENT emergency admissions. MAIN OUTCOMES MEASURES: The proportions of Asian and Caucasian patients among the two patient groups, either epistaxis admissions or other ENT emergency admissions. RESULTS: The proportions of Asian and Caucasian patients in the group admitted with emergency epistaxis were 7.1% (100/1410) and 92.9% (1310/1410) respectively. However, the proportions of Asian and Caucasian patients in the group composed of any other ENT emergency were 13.2% (729/5515) and 86.8% (4786/5515), respectively (chi-squared P < 0.01). CONCLUSIONS: Caucasian people form an unexpectedly large, and Asians a smaller proportion of emergency epistaxis admissions. The possibility of an ethnic risk factor for epistaxis warrants further investigation.

Neurologic events in neonates treated surgically for congenital heart disease.

OBJECTIVE: The incidence of acute neurologic events prior to discharge in neonates with congenital heart disease (CHD) was determined and peri-operative characteristics predictive of a neurologic event were identified. STUDY DESIGN: A retrospective chart review over 1 year was conducted of infants <1 month of age with a diagnosis of CHD. Outcomes were measured by the occurrence of an acute neurologic event defined as electroencephalogram (EEG)-proven seizure activity, significant hypertonia or hypotonia, or choreoathetosis prior to hospital discharge. Stepwise logistic regression identified variables most likely to be associated with an acute neurologic event. RESULTS: Surgical intervention occurred in 95 infants who were admitted with a diagnosis of CHD. The survival rate was 92%. Of the survivors, 16 (17%) had an acute neurologic event, with 19% of events occurring preoperatively. Factors associated with neurologic events included an elevated nucleated red blood cell (NRBC) count, an abnormal preoperative brain imaging study, and a 5-min Apgar score <7 (P<0.05). CONCLUSIONS: Neonates with CHD have a significant risk of neurologic events. Preoperative brain imaging, the 5-min Apgar score, and initial serum NRBC counts may identify infants at highest risk for central nervous system injury.

Mycobacterium avium binds to mouse intestinal mucus aldolase.

SETTING: Mycobacterium avium complex (MAC) is known to colonize the gastrointestinal tract of human immunodeficiency virus (HIV) infected patients before causing bacteremia and disseminated disease. However, the mechanism involved in the gastrointestinal colonization is not known. OBJECTIVE: To identify putative intestinal mucus receptors which serve as anchor for MAC colonization. DESIGN: C57BL/6 mouse intestinal mucus was subjected to single and two-dimensional electrophoresis and blotted on nitrocellulose membranes. MAC specific mucus proteins were identified by probing the mucus western blots with biotinylated proteins derived from M.avium strain 101 (MAC101). RESULTS: Biotinylated MAC 101 proteins recognized a 39 kDa intestinal mucus glycoprotein. The protein displaying an isoelectric point (pI) of 9.0, was found to be periodate sensitive but resistant to sialidase, heparinase I and chondroitinase ABC. The internal amino acid sequence of the 39 kDa protein displayed homology with fructose-1-6-bisphosphate aldolase B (aldolase). The proclivity between MAC adhesins and aldolase was confirmed by probing rabbit muscle aldolase with MAC proteins. Furthermore, both 25 and 31 kDa MAC adhesins, superoxide dismutase and heparin binding protein, respectively, were found to bind to aldolase. CONCLUSIONS: MAC binds to intestinal mucus aldolase, conceivably facilitating intestinal colonization of the organism.