Coblation debulking of a paediatric laryngeal plexiform neurofibroma: a pragmatic response to a rare tumour.

Laryngeal neurofibroma is a rare but important differential diagnosis in a patient presenting with stridor. In paediatric patients, these lesions present a management conundrum: complete surgical resection is the established treatment of choice, but an aggressive approach can be detrimental to developing anatomy. We report the case of a plexiform neurofibroma affecting the right hemilarynx of a 3-year-old boy. Endoscopy revealed a large tumour, involving the right aryepiglottic fold and extending into the piriform sinus, ventricle and the false cord. Given the patient's young age and the challenging tumour location, the lesion was debulked, rather than resected, using coblation (low-temperature plasma radiofrequency ablation). At 30 months follow-up, the neurofibroma has mildly increased in size-in line with expectations that these lesions exhibit slow growth throughout childhood-but there are no significant respiratory symptoms and there is no functional impairment.

Hematological Paraneoplastic Syndrome and Heparin-Induced Thrombocytopenia in Untreated Parotid Acinic Cell Carcinoma - A Case Report.

RATIONALE: Acinic cell carcinoma (ACC) is a rare and indolent malignancy commonly found in the parotid gland. This can give rise to paraneoplastic syndromes, which represent the clinical manifestations of indirect and remote events produced by tumour metabolites. PATIENT CONCERNS: A 38-year-old Afro-Caribbean female suffered an indolent parotid mass. She only presented to our tertiary center when it started to ulcerate and bleed. DIAGNOSIS: She was diagnosed with advanced parotid ACC. She also went on to develop an hematological paraneoplastic syndrome resulting in venous thrombi. This was complicated by her developing heparin-induced thrombocytopenia (HIT). TREATMENT: A difficult multidisciplinary decision was made to proceed with surgery despite her extremely poor condition. OUTCOMES: After the surgery, the patient made a full recovery. TAKE-AWAY LESSONS: ACC is a relatively uncommon and indolent malignancy that is usually found in the parotid gland. It can be associated with a hematological paraneoplastic syndrome and further complicated by iatrogenic HIT.

A case report of an incidental finding of congenital oesophageal diverticulum in a patient presenting with stridor.

Congenital oesophageal diverticulum is incredibly rare and has not commonly been published in the literature. Oesophageal diverticulum can be asymptomatic; however, symptoms such as dysphagia, regurgitation and chest discomfort may be present. We describe the case of a paediatric patient presenting with biphasic stridor, respiratory distress and cyanosis at birth, who was found to have a supraglottic cyst and later the presence of an oesophageal diverticulum shown on ultrasound imaging. There has been one other case reported in the literature of an oesophageal diverticulum presenting with stridor, and we therefore believe this is one of only two cases to illustrate this atypical presentation of congenital oesophageal diverticulum. It highlights the importance of a meticulous multidisciplinary team approach to patient care, as well as conducting appropriate investigations to aid early diagnosis to improve patient outcomes.

Cervicofacial nontuberculous mycobacterium lymphadenitis in children: is surgery always necessary?

INTRODUCTION: The optimal treatment of cervicofacial nontuberculous mycobacterium lymphadenitis (CFNTB) in children is yet to be established. There is a general consensus that surgical excision results in a definitive resolution of the disease. The main aim of surgery is to remove affected nodes so that they do not discharge through the skin. Recently there are some investigators who are reporting successful antibiotic treatment and advocating medical therapy as the first line treatment. METHODS: 16 children consecutively presenting to otolaryngology in a tertiary referral centre over an 8-year period with CFNTB. Inclusion criteria were chronic cervicofacial lymphadenitis with either: (1) a culture positive for atypical mycobacteria (from either a lymph node or fine needle aspirate (FNA) specimen); or (2) acid-fast bacilli identified (from either a lymph node or FNA specimen); or (3) post excision histological findings consistent with mycobacterial infection (i.e. non-caseating granulomas) in the absence of other clinical features suggestive of other granulomatous conditions. Lesions with superficial skin change were treated preferentially with surgery. Children presenting with lymph nodes contained deep to sternocleidmastoid were assessed with FNA cytological and microbiological analysis and MRI or CT, and treated preferentially with antibiotics or watchful waiting. RESULTS: 4 children (2 culture positive, 2 with acid-fast bacilli on needle aspirate) presented with lymphadenopathy deep to sternocleidmastoid and were managed non-surgically. All 4 resolved without cutaneous involvement. 11 children with a clinical presentation of CFNTB underwent complete excision of all involved nodes for superficial lesions (6 were culture positive, and all had granulomatous histology). None recurred. 1 patient presented late with a mature, discharging parotid sinus, which was managed with watchful waiting as the lesion was clinically close to natural resolution. CONCLUSIONS: Depth at presentation may help decide which patients with CFNTB can be treated non-surgically without cutaneous sequelae. We propose that a watch and wait management is an option for deep nodes.

Metastatic carcinoma of unknown primary presenting as jugular venous thrombosis.

Jugular venous thrombosis is unusual and is associated with central venous catheterisation, intravenous drug abuse and head and neck sepsis. It is rarely associated with malignancy. We report a case of metastatic carcinoma of unknown primary in a forty year old female which presented with jugular venous thrombosis. The discussion includes investigation and treatment options for this condition.

Retrospective review of donor site complications after harvest of cancellous bone from the anteriomedial tibia.

Donor site morbidity is important in deciding the site for harvest of cancellous bone for alveolar bone grafts. Many studies have supported the view that tibia is safe with few complications in the short term. We know of no studies on the long-term complications to the donor site after tibial bone grafting in children with alveolar clefts. The casenotes of 40 children who had had tibial bone grafts for alveolar clefts were studied retrospectively, and parents or patients were contacted by telephone and a standardised questionnaire was used to assess any long term complications at the donor site. We found none. We found no evidence of long-term complications at the donor site in children who had had proximal tibial bone grafting for secondary repair of alveolar clefts. We conclude that the proximal tibia is a safe site from which to obtain cancellous bone graft for alveolar clefts in children. This study is preliminary, and highlights the need for a randomised trial.

Audit in clinical practice.

BACKGROUND AND OBJECTIVES: Audit dates back to as early as 1750 BC when king Hammurabi of Babylon instigated audit for clinicians with regard to outcome. Clinical audit is a way of fi nding out whether we are doing what we should be doing. It also verifi es whether we are applying the best practice. METHODS: An audit cycle involves setting-up of standards, measuring current practice, comparing results with standards (criteria), changing practice and re-auditing to make sure practice has improved RESULTS AND INTERPRETATIONS: A 'clinical audit' is a quality improvement process that seeks to improve patient care and clinical outcomes through a systematic review of care against explicit criteria, and the implementation of change. Changes are implemented at an individual, team or service level and a subsequent re-audit is done to confi rm improvement in health care delivery. CONCLUSION: The importance of audit in healthcare sector needs to be appreciated by the relevant authorities. The most frequently cited barrier to successful audit is the failure of organizations to provide suffi cient fund and protected time for healthcare teams.

Tuberculous infection of thyroid gland: a case report.

Introduction. Tuberculosis is one of the leading causes of morbidity and mortality and almost one-third of the world is infected with this disease. Tuberculosis has been reported in many parts of the human body. But thyroid gland involvement is extremely rare and its true incidence is unknown. Case Presentation. We present the case of a 26-year-old woman who presented with a thyroid cyst which turned out to be a primary mycobacterium tuberculosis infection. Conclusion. The correct diagnosis of thyroid tuberculosis is important because of the availability of medical treatment and the limited role of surgery.