Frontal sinus pneumatisation: an isolated finding or a sign of concomitant anatomical variation?

OBJECTIVE: To determine the association between frontal sinus pneumatisation and concomitant anatomical variations in paranasal sinuses as seen on computed tomography. METHODS: A total of 403 patients who underwent paranasal sinus computed tomography were allocated to three groups according to the degree of frontal sinus pneumatisation (type 1 - hypoplasia; type 2 - medium size; and type 3 - hyperplasia). In this unique model, the prevalence of ipsilateral variations on paranasal sinuses on each side of the head were analysed separately within each pneumatisation group. RESULTS: The type 3 frontal sinus pneumatisation group showed a greater association with ipsilateral variations of the sphenoid bone. Variations included pneumatisation of the anterior clinoid process, lateral sphenoid recess, pterygoid process and greater wing, and exposure of Vidian canal. This group also showed significant associations with male gender, and the presence of frontal and Onodi cells. CONCLUSION: Interpretation of the paranasal sinus variations is imperative for pre-operative evaluation in functional endoscopic sinus surgery, particularly in patients with frontal sinus hyperplasia. Attention to variation on the ipsilateral side is informative.

Sphenoid sinus pneumatization: the good, the bad, and the beautiful.

PURPOSE: To study different types of extension of sphenoid sinus pneumatization detected by CT and examine their correlation with other anatomical variants. METHODS: Sphenoid sinus pneumatization was characterized (780 hemi-sinuses) on CT scans. Its incidence and correlations with related anatomical variants were evaluated. Dimensions of surgical window were measured in the lateral type, where pneumatization extends beyond a line connecting Vidian (pteregoid) canal (VC) and foramen rotundum (FR). RESULTS: The lateral recess of the sphenoid sinus was pneumatized in 27.3% of patients with a mean width of 7.59 mm. The distance separating the FR and the VC correlated strongly with the depth of the lateral recess. There was significant positive correlation between pneumatization of lateral recess and Vidian nerve prominence to other pneumatization patterns (lesser sphenoid, frontal, and Maxillary sinuses) (p < 0.0001). Lateral recess pneumatization in coronal cuts was also significantly correlated with anterior-posterior sphenoid pneumatization in sagittal cuts (p < 0.0001). CONCLUSION: Pre-operative assessment of sphenoid sinus pneumatization is essential in the endoscopic approach to skull base structures to facilitate surgical access and avoid injury of the nearby structures. Our study showed significant correlation among anatomical variants and different measurements which allows the surgeon to predict abnormal anatomy with high accuracy.

Interpreting pre-operative mastoid computed tomography images: comparison between operating surgeon, radiologist and operative findings.

OBJECTIVES: This study aimed to compare the interpretations of temporal bone computed tomography scans by an otologist and a radiologist with a special interest in temporal bone imaging. It also aimed to determine the usefulness of this imaging modality. METHODS: A head and neck radiologist and an otologist separately reported pre-operative computed tomography images using a structured proforma. The reports were then compared with operative findings to determine their accuracy and differences in interpretations. RESULTS: Forty-eight patients who underwent pre-operative computed tomography scans in a 30-month period were identified. Six patients were excluded because complete operative findings had not been recorded. Positive and negative predictive values and accuracy of the anatomical and pathological findings were calculated for 42 patients by both reporters. The accuracy was found to be less than 80 per cent, except for identification of the tegmen and lateral semicircular canal erosion. Overall, there was no significant difference in interpretations of computed tomography scans between reporters. There was a slight difference in interpretation for tympanic membrane retraction, facial canal erosion and lateral semicircular canal fistula and/or erosion. CONCLUSION: Pre-operative computed tomography scanning of the temporal bone is useful for predicting anatomy for surgical planning in patients with chronic otitis media, but its reliability remains questionable.

Otolaryngologist-performed head and neck ultrasound: outcomes and challenges in learning the technique.

OBJECTIVE: To assess the feasibility and accuracy of otolaryngologist-performed ultrasound in evaluating head and neck pathology. METHOD: An ENT trainee, who had undergone basic training in neck ultrasonography, performed this on patients referred with suspected neck pathology. The trainee recorded the presence and nature of any abnormality. Findings were compared with those from a repeated scan performed by an experienced head and neck radiologist. RESULTS: The study included 250 patients. The absence or presence of lesion as reported by the trainee correlated with the radiologist's findings in 207 cases (83 per cent). There were 144 true positives, 63 true negatives, 32 false negatives and 11 false positives, yielding a sensitivity of 82 per cent, specificity of 85 per cent and accuracy of 83 per cent. Of the 144 true positive lesions, 81 per cent were interpreted concordantly with the radiologist. CONCLUSION: Neck ultrasonography performed by an otolaryngologist is less accurate than that performed by an experienced radiologist, but is still a useful adjunct to clinical assessment, facilitating assessment in a 'one-stop' clinical setting.

Long-term complications of bone-anchored hearing aids: a 14-year experience.

OBJECTIVES: To report cases of long-term surgical complications, implant failure and revision surgery, within a large bone-anchored hearing aid programme. STUDY DESIGN: Retrospective, case-cohort study. SETTING: Tertiary referral centre. PATIENTS: One hundred and sixty-five adults and children who had undergone a total of 177 bone-anchored hearing aid implantations. INTERVENTION: Diagnosis and explanation of adverse events and device failure. MAIN OUTCOME MEASURES: Operative complications and survival analysis, surgical challenges related to revisions, and causes of failure. RESULTS: Twenty-one per cent of patients (3.4 per cent of those observed) suffered from skin reactions; this rate did not increase over time. Seventeen per cent had loss of osseointegration at a median interval of 6.3 months. Loss of osseointegration was observed more frequently in patients with a 3 mm compared with a 4 mm fixture (p < 0.001). Intra-operatively, the only complication was bleeding, occurring in 3 per cent of patients. Post-operative complications included: primary bleeding (2 per cent); severe skin reactions requiring intravenous antibiotics, cautery or grafting (8 per cent); thickening or overgrowth of skin requiring excision (8 per cent); failure of osseointegration requiring a new fixture (18 per cent); and graft necrosis requiring revision (1 per cent). In two patients, it was necessary to explore the area to remove overgrowth of bone. In 16 patients (10 per cent), the bone-anchored hearing aid had to be abandoned due to failure of osseointegration (n = 4), dissatisfaction with the aid (n = 6), intolerable pain (n = 4), hair growth around the abutment (n = 1) or recurrent infections (n = 1). In 12 of these patients, the bone-anchored hearing aid was removed surgically. Overall, 57 patients (34 per cent) underwent revision surgery. CONCLUSION: Awareness of complications is becoming increasingly important in bone-anchored hearing aid programme. A substantial workload of device maintenance should be anticipated, and patients should be appropriately counselled beforehand. Ninety per cent of our patients chose to persevere with this form of hearing rehabilitation.

Trends in laryngopharyngeal reflux: a British ENT survey.

There is a lot of scepticism surrounding laryngopharyngeal reflux (LPR). Symptoms such as globus pharyngeus, constant throat clearing, chronic cough, idiopathic hoarseness, catarrh and choking episodes may be reflux-related. The aim of this survey was to highlight current treatment trends in LPR. Questionnaires were emailed to 260 members of the British Academy of Otolaryngology-Head and Neck surgery (BAO-HNS). Survey recipients were asked about type, duration and dose of antireflux treatment and length of follow-up appointments, if any. Finally, they were asked about awareness of any reflux symptom and reflux sign questionnaires. Survey response rate was 60%. The vast majority of the otolaryngologists surveyed believe in laryngopharyngeal reflux (90%) and more than 50% prescribe proton pump inhibitors (PPIs). The preferred duration of treatment is 2 months (37%). Only a minority will prescribe PPIs for 6 months or more. Most otolaryngologists will give the standard GORD dose (70%) (once daily) and only a few (20%) will prescribe more aggressive and prolonged doses. The commonest symptoms for which proton pump inhibitors are prescribed are globus (73%), followed by choking episodes (66%) and chronic cough (62%). If LPR is suspected, most of the otolaryngologists will follow-up the patients (61%) and approximately one third (31%) will discharge them back to the general practitioners. Only eight-percent 8% will refer to gastroenterologists. The three commonest laryngoscopic signs that makes them suspect LPR are erythema of the arytenoids (86%) or the vocal cords (57%) and granulomas (42%). The majority of the otolaryngologists (94%) do not use popular questionnaires such as the RFS or RSI. Despite the controversy surrounding laryngopharyngeal reflux, our results suggest that the majority of the otolaryngologists surveyed believe in LPR and attempt to treat it. Interesting findings are: the duration of treatment, the doses used, the length of follow-ups or the lack of, and the fact that the majority does not request any specific diagnostic tests. "symptoms and signs" questionnaires are rarely used.

Laryngocoele presenting as acute airway obstruction.

A laryngocoele is an abnormal dilatation of the laryngeal saccule. Symptomatic laryngocoeles can present as rapidly developing airway obstruction. In this case report of a 37-year-old man with a laryngocoele, we discuss the management dilemma presented by his repeated flight from the hospital prior to definitive treatment. This resulted in repeated admissions with life-threatening airway symptoms, culminating in emergency tracheostomies. Surgical excision of the laryngocoele was not achieved until the third presentation. We recommend early surgical intervention in patients who are potentially non-compliant to treatment or follow-up. A brief literature review of laryngocoele, as well as management of the difficult airway, are also discussed.

Recurrent blockage of the sucker during otological surgery: a simple solution.

We present a unique device for unblocking the sucker during otological surgery. This device can be made cheaply, from parts already available in most hospitals, and is reliable and effective.

Primary cutaneous aggressive epidermotropic CD8 positive cytotoxic T-cell lymphoma of the ear.

We report a case of an epidermotropic CD8+ cutaneous T-cell lymphoma which initially presented as an ulcerated lesion of the pinna. Although T-cell lymphomas may present as cutaneous lesions, the ear is rarely involved. This uncommon presentation and the need for multiple biopsies means that the diagnosis of these lesions may be delayed or missed. A high index of suspicion is required when evaluating cutaneous lesions in the head and neck area.

How we do it: Switching from mechanical perforation to the CO2 laser; audit results of primary small-fenestra stapedotomy in a district general hospital.

The use of laser for stapedotomy was introduced in our department in the year 2002, and since then has taken over the mechanical technique. A total of 85 patients who had undergone primary stapedotomy with either technique are reported with regards to effectiveness and rate of side effects. Although footplate complications were reduced with the laser, short-term hearing outcomes were similar between the two techniques. In four occasions, the surgeon had to switch back to the mechanical technique unexpectedly. Stapedotomy will continue to be performed with the laser in our department, bearing in mind the occasional need for the older technique.

Aspiration of peritonsillar abscess in severe trismus.

We present a novel method of aspirating a peritonsillar abscess in a patient with severe trismus. In our experience, this method is efficient, allows good access to the peritonsillar area and facilitates rapid resolution of the trismus before definitive drainage can be performed.

How we do it: a new 'one stop' ear wick.

In some practices, otitis externa is treated with ear wick and patient is asked to remove it independently without re-attending clinic. * Although this method reduces workload on aural care services, it can be unhygienic and difficult to perform. * We propose a new design whereby the wick is tied to a string to facilitate its later removal. * Out of 18 patients treated with this method, only 4 opted to re-attend for further aural care.

Transtonsillar drainage of parapharyngeal abscess.

We report a parapharyngeal abscess in an adult patient that was drained transorally by performing ipsilateral tonsillectomy and aspirating the pus through the tonsillar bed. This approach is unusual as most previous studies report the aspiration of such abscesses through the lateral pharyngeal mucosa. In addition, the majority of these studies are limited to pediatric cases. Our approach was effective and resulted in a rapid resolution of the symptoms. The management and different approaches to parapharyngeal abscess are discussed, and the literature is reviewed.

Randomized controlled trial comparing Merocel and RapidRhino packing in the management of anterior epistaxis.

OBJECTIVES: A prospective non-blinded randomized controlled trial to compare the efficacy of Merocel and RapidRhino nasal packs in the treatment of anterior epistaxis. METHODS: Fifty-two consecutive participants admitted with anterior epistaxis refractory to digital pressure or nasal cautery were randomized to treatment using one or other of the nasal packs. Patients who required repacking because of continued bleeding, only the first packs were included in the analysis. Haemostatic properties of the packs were measured by grading bleeding during and after removal of the pack (0-4, where four is uncontrollable) and by noting if the nose was re-packed or not. The difficulty of insertion and removal (graded 0-3 by clinician where 3 is the most difficult) and the participant's perception of discomfort (graded 0-10, where 10 is the worst pain) during insertion and removal of the pack were also measured. RESULTS: For bleeding, the mean values for Merocel and RapidRhino during packing and after pack removal were not significant (P = 0.38 and 0.82 respectively). The mean values of patient discomfort on insertion were 6.9 and 5.0 (P = 0.01), and for discomfort on removal were 4.6 and 3.4 (P = 0.05) respectively. The mean values of insertion graded by the clinician were 1.7 and 0.9 (P = 0.0003), and for removal were 1.4 and 0.4 (P < 0.0001). CONCLUSIONS: RapidRhino and Merocel are equally effective in the control of anterior epistaxis but RapidRhino is significantly more comfortable for the patient and easier for the healthcare worker during insertion and removal.

An innovative method of nasal chemical cautery in active anterior epistaxis.

We present a method to cauterize an actively bleeding source in anterior epistaxis. In our experience, this method is efficient, provides full control of the bleeding, and ensures precise cautery of the bleeding source with minimal usage of chemical cautery sticks.

A simple method for preparing an ear wick.

We present a simple method for preparing an ear wick for treating otitis externa in ENT outpatient clinics. In our experience, this method is efficient, economical and clean, and ensures an equal distribution of the medication along the wick.

Transient quadriplegia following re-puncture of tracheo-oesophageal fistula.

We present a case of a laryngectomized patient who underwent re-puncture of tracheo-oesophageal fistula for speaking valve voice restoration, resulting in a previously unreported inherent complication of this procedure: extradural abscess of the cervical spine with transient quadriplegia.