Oesophageal function in tracheoesophageal fistula speakers after laryngectomy.

OBJECTIVES: Patients who have undergone tracheoesophageal puncture for surgical voice restoration often use unnaturally high oesophageal air pressures during speech. This study examined the effect of high oesophageal air pressure on oesophageal body motility, lower oesophageal sphincter function and dyspeptic symptoms. DESIGN: Cross-sectional study using several investigative tests of oesophageal function. MATERIALS AND METHODS: Sixteen patients who used tracheoesophageal fistula speech underwent several investigations, including: oesophageal manometry, videofluoroscopy, barium swallow, and tracheal pressure measurements during speech. The patients were also asked to complete a dyspepsia questionnaire. RESULTS: We demonstrated that more than 50 per cent of these patients had subjective or objective disordered oesophageal function. Videofluoroscopy and manometry identified oesophageal dysmotility in the same patients. CONCLUSION: Oesophageal function appears to be altered by tracheoesophageal fistula speech. However, our study showed that there is no contraindication to proceeding with tracheoesophageal fistula voicing even in patients with a history of oesophageal dysfunction.

Lipoma of the parapharyngeal space.

A 75-year-old gentleman presented to our department with dysphagia, nocturnal cough and dysphonia. Clinical examination revealed a large parapharyngeal mass extending from the left nasopharynx to the glottis. A magnetic resonance imaging scan confirmed the lipomatous nature of the lesion and elegantly demonstrated its anatomy. We discuss the aetiology and management of such lesions and focus on the diagnostic radiology of the parapharyngeal space.

Nasal polyposis in the laryngectomee.

We report the cases of two laryngectomy patients who were diagnosed with de novo nasal polyposis, more than 15 years after their laryngectomies. This phenomenon has not previously been reported in the literature. We discuss the changes in nasal physiology of the laryngectomy patient, with regards to the aetiology of polyp formation, and highlight the importance of examining the nose in such patients.

Botulinum toxin injection for failed tracheo-oesophageal voice in laryngectomees: the Sunderland experience.

Spasm of the pharyngo-oesophageal segment is one of the important causes of tracheo-oesophageal voice failure. Traditionally it has been managed by either prolonged speech therapy, surgical pharyngeal myotomy or pharyngeal plexus neurectomy with varying degrees of success. Botulinum neurotoxin has been found to be effective in relieving pharyngo-oesophageal segment spasm. Since 1995, we have used botulinum toxin injection on 10 laryngectomees with either aphonia or hypertonicity due to pharyngo-oesophageal segment spasm. Early results were analysed by the Sunderland Surgical Voice Restoration Rating scale. Seven of the 10 patients, who were previously completely aphonic, developed voice following this therapy and are using their valve choice as their only method of communication. Out of the three patients who were treated for hypertonic voice, two did derive some benefit from the procedure. One patient developed a hypotonic voice, which lasted for a few months.

Emergence of Candida tropicalis as the major cause of fungaemia in India.

The fungal isolates (n = 191) from 1970 consecutive blood cultures over a 9-year period were identified. Candida tropicalis was the predominant isolate accounting for 66% of all isolates whereas Candida albicans ranked only a distant second with 21%. The difference was highly significant (P < 0.00001) The other isolates included C. parapsilosis (5.8%), C. glabrata (2.1%), C. pelliculosa (1.2%), C. lipolytica (1.0%) C. krusei (1.0%) and Trichosporon beigelii (2.6%). The isolates were obtained predominantly from postoperative patients on therapy with more than one antibiotic.

A paediatric otolaryngology pre-admission assessment clinic audited.

Pre-admission clinics are becoming increasingly popular for surgical specialties with a quick turnover as they aid waiting list management and reduce non-attender rates for surgery. As paediatric patients have a high rate of non-attendance, we performed a retrospective audit of otolaryngology paediatric pre-admission assessment clinic notes for June to October 1998 (n = 363). The attendance rate for the clinic was 97 per cent. Of the children who attended the clinic, 90 per cent had their operation as planned, complications occurred in 2.9 per cent. The operation date was delayed in 20 patients, in 11 patients no cause for the delay was given in the case notes. As a result of this audit, the Senior House Officer sees the patient on the day of admission rather than in the pre-admission clinic, which is staffed by nurses.

Malignant peripheral nerve sheath tumour of the spinal accessory nerve.

A 50-year-old man presented with a left-sided neck mass. Clinical examination revealed a large fluctuant 7 cm x 7 cm mass in the left posterior triangle. Magnetic resonance imaging (MRI) revealed an encapsulated soft tissue lesion. He underwent exploration of the neck and a 14 cm by 8 cm mass enfolding the accessory nerve was identified and completely excised. Histological examination of the surgical specimen showed features in keeping with a malignant peripheral nerve sheath tumour (MPNST). We present the clinical and pathological features of this condition.

The use of Indermil (n-butyl cyanoacrylate) in otorhinolaryngology and head and neck surgery. A preliminary report on the first 33 patients.

The authors present their initial experience of a new sterile medical grade cyanoacrylate adhesive (Indermil) in otolaryngeal and head and neck surgery. Thirty-three patients who underwent a variety of head and neck operations consented to have their skin incisions closed using the adhesive and 10 of those also underwent repair of the tympanic membrane, either as part of tympanoplasty or mastoid surgery. The history of the use of this class of adhesive is presented with an explanation of the chemical properties of these compounds. Advantages of using cyanoacrylate adhesives and future possible applications in otolaryngology and head and neck surgery are discussed.

Surgical voice restoration: the Sunderland experience.

Surgical voice restoration following tracheo-oesophageal puncture is a well established procedure and the principal means of speech rehabilitation following laryngectomy and more recently laryngopharyngectomy. A valve prosthesis was used in 65 patients, 50 of whom underwent insertion at the time of surgery. Of the 65, 49 were men, 16 women and 15 have since died; the median length of follow-up of valves in situ has been 24.7 months (range 2-46 months). Of the 50 living patients 80% were using the valve at last examination. Complications arose in 52% but were generally minor and easily overcome.

Hyperacusis and Williams syndrome.

Abnormal sensitivity to environmental sounds is a short-term feature often observed following insertion of grommets. Here we describe a child with this symptom who was found to have Williams syndrome, a condition in which hyperacusis is observed in 95 per cent of patients.

A study of haemostasis following tonsillectomy comparing ligatures with diathermy.

The use of diathermy to achieve haemostasis after tonsillectomy remains controversial. We have reviewed the English language literature, and found no convicting evidence that diathermy is any more likely to cause post-operative haemorrhage than the use of ligatures. The results of a prospective, randomized study of 1036 consecutive tonsillectomies are presented. No significant difference was found in post-operative haemorrhage rates when either diathermy or ligatures were used. Diathermy was found to reduce operating time compared to ligatures. The possibilities for day-case tonsillectomy are discussed.

Frontal bone epidermoid--a rare cause of proptosis.

Frontal bone epidermoid is a rare condition which may present with proptosis, extraocular muscle imbalance, or loss of vision. Clinically and on plain radiographs an epidermoid may be confused with commoner conditions such as frontal mucocoele. However, the characteristic CT scan appearance, which shows a bone cyst with similar density to brain tissue, should lead to an accurate diagnosis and appropriate surgical management.

Aspiration biopsy. An aid in the diagnosis of para-nasal tumours.

Three cases are reported to demonstrate (1) the difficulty in diagnosing the nature of nasopharyngeal tumours (2) the assistance given by the fine-needle aspiration biopsy technique in cases of paranasal tumours. Reliance should not be placed on this technique alone. It should be performed at the initial examination together with conventional techniques. In this way, the patient may be spared the need for multiple anaesthetics and a diagnosis may be arrived at more promptly so that treatment may be instituted more quickly.