Submersion with grommets: contamination is possible at minimal depth, as demonstrated with a novel middle-ear model.

OBJECTIVE: Advice to patients following grommet insertion and waterproofing can vary from clinician to clinician. A laboratory based experiment was performed to determine at what depth water contamination would occur through various grommet tubes. METHODS: A novel experimental ear model was developed using an artificial tympanic membrane and ventilation tubes. Water contamination was identified using an effervescent solid that reacts when in contact with water. Measures of dispersion were used to describe the results. RESULTS: The average depth of water contamination was: 19.64 mm (range = 11-33 mm, standard deviation = 5.55 mm) using a Shepard grommet; 20.84 mm (range = 18-26 mm, standard deviation = 1.97 mm) with a titanium grommet; and 21.36 mm (range = 18-33 mm, standard deviation = 3.03 mm) using a T-tube. Water contamination was possible at depths of 11-33 mm. The average pressure at water effervescent activation was 0.20 kPa. CONCLUSION: Submersion underwater at any depth with grommets is likely to lead to middle-ear contamination. These findings are concordant with clinical studies.

Revision cochlear implantation: The Irish experience.

Objectives: To report a long-term experience on revision cochlear implantation (RCI) in a single institution, categorize their indications and to identify predictive parameters of implant failure. Methods: A retrospective study was conducted on a prospective database of a national cochlear implant unit. Patients requiring RCI between January 1995 and June 2016 were identified and stratified into adult and paediatric group. Medical records, investigation reports and device analysis reports were reviewed and analysed. Results/Discussion: A total of 37 children and 21 adults were identified requiring RCI on 60 devices. 63.3% of the RCI was indicated due to the device failure, while 36.7% was due to various medical reasons. Higher device failure rate was reported in the paediatric group, due to the high number of direct head trauma, which was not observed in the adult group. The leading medical indication for RCI was due to wound infection (10%). The overall RCI rate was 5.0%, among which 3.1% was due to device failures. A brief discussion on various medical indications, surgical challenges, and the mechanism of thought process to consider RCI, including treatment planning was outlined. Conclusion: RCI in the paediatric population poses a unique challenge. Integrity testing is helpful in identifying a potential device malfunction; however, regular clinical follow-up with multidisciplinary assessments is invaluable in the decision process for RCI.

Sentinel lymph node biopsy in node-negative squamous cell carcinoma of the oral cavity and oropharynx.

OBJECTIVES: Considerable controversy exists regarding the merits of elective neck dissection in patients with early stage oral cavity and oropharyngeal squamous cell carcinoma. It is highly desirable to have a method of identifying those patients who would benefit from further treatment of the neck when they are clinically node-negative. The purpose of the present study was to examine the use of sentinel lymph node biopsy in identifying occult neck disease in a cohort of patients with node-negative oral cavity and oropharyngeal squamous cell carcinoma. DESIGN: We evaluated a total of 13 patients with oral cavity and oropharyngeal cancer who were clinically and radiologically node-negative. RESULTS: A sentinel lymph node was found in all 13 patients, revealing metastatic disease in five patients, four of whom had one or more positive sentinel lymph nodes. There was one false negative result, in which the sentinel lymph node was negative for tumour whereas histological examination of the neck dissection specimen showed occult disease. CONCLUSION: In view of these findings, we would recommend the use of sentinel lymph node biopsy in cases of oral cavity and oropharyngeal squamous cell carcinoma, in order to aid the differentiation of those patients whose necks are harbouring occult disease and who require further treatment.

Congenital subglotic haemingiomas.

Congenital subglottic haemingomas are rare however they are important treatable cause of infantile stridor and can be fatal unless treated. They present in a range of ways most noticeably with stridor in infancy period and as they enlarge they can threaten the airway. Thus they require urgent assessment and treatment. We present three cases of subglottic haemingiomas all of which represented different clinical management strategies. We review this interesting topic with discussion on presentation, treatment options and outcome.

Cervical haematoma after thyroid surgery: management and prevention.

The aim of this study was to evaluate the incidence and circumstances of cervical haematomas complicating thyroid surgery. The second objective was to study the effects of modifying our unit's practice on this complication. The study involved a retrospective chart review of 504 consecutive thyroid operations performed by one surgeon from 1994 to 2005. The operations were carried out in the Professorial units of Otolaryngology Head and Neck Surgery in two teaching hospitals in Dublin, Ireland. Indications for surgery included tumour in 338(67%), airway compromise in 60(12%) and thyroid over-activity in 106 (21%). 116(230/c) patients were male and 388(77%) were females. Ages ranged from 16 to 78 years and the mean age was 34.6 years. 292 (58%) patients had two vacuum drains inserted (eighth inch). 126(25%) had a single drain and 86(17%) patients had no drains used. 44 patients were operated through a small incision (4cms.) with the help of rigid endoscopes (Minimally invasive video assisted thyroid surgery (MIVAT)). During the study period seven patients (1.4%) out of 504 were re-explored due to the development of haematomas. None of the patients needed a tracheostomy. Cervical haematomas developed in 1.4 %/o thyroid surgeries which is consistent with current literature. Predisposing factors like coagulation modifying medications are common and avoidable. Most haematomas develop within 6 hours of surgery. Drains and size of incision do not appear to change the rate of this complication. Strict protocols and training of the care teams is vital.

Delayed facial nerve palsy following tympano-mastoid surgery: incidence, aetiology and prognosis.

OBJECTIVE: To establish the frequency of occurrence of delayed facial nerve paralysis following tympano-mastoid surgery in our department and to determine the aetiological factors and long term prognosis. SETTING: Tertiary care academic centre. MATERIALS AND METHODS: A retrospective review of all patients who had undergone tympano-mastoid surgery in our department over the previous five years was carried out. A total of 219 patients were included in the study. Only two patients were identified as having delayed onset facial nerve palsy over this period of time. The patients' medical records were reviewed and the patients clinically assessed. RESULTS: The frequency of delayed onset facial nerve palsy following tympano-mastoid surgery in our series was 0.91 per cent. Facial weakness set in on day eight and day 14 in the two patients. Serological investigations in both patients revealed raised titres of immunoglobulin (Ig) M and IgG to varicella-zoster virus, confirming the presence of varicella-zoster infection. In our experience, the combined use of prednisone and acyclovir was an effective form of treatment for both patients, whose facial nerve function fully recovered within six months of onset. CONCLUSION: The incidence of delayed facial nerve palsy following tympano-mastoid surgery is low. It can occur up to two weeks after the surgery. Our two cases confirm viral reactivation to be an important aetiological factor in the development of delayed onset facial nerve palsy. The overall prognosis for delayed facial nerve palsy following tympano-mastoid surgery appears to be good.

Submandibular gland stones, a clinical review.

The purpose of this study is to highlight the role of per-oral extraction of submandibular calculi in the management of salivary sialadenitis. This study was based on a retrospective review of patients presenting with submandibular sialadenitis over a 5-year period. 26 patients presented with a history of sialadenitis, with a palpable stone in the floor of the mouth and were considered candidates for surgery. 21 (80%) underwent per-oral extraction using marsupialization of the duct to maintain duct patency. 4 (15%) were deemed unsuitable when assessed under general anaesthesia due to inaccessible calculi. 2 (9%) of the 21 patients that underwent per-oral extraction required gland excision, due to persistence of symptoms. The remaining 19 (91%) are symptom free with a mean follow-up of 18 months. There were no neurological post-operative sequelae in the group. 1 patient had no surgical intervention at the end. In conclusion, per-oral extraction of submandibular salivary calculi is a safe method of relieving symptoms due to sialadenitis in patients with palpable accessible calculi in the floor of the mouth.

Virtual laryngoscopy--preliminary experience.

PURPOSE: Computed tomographic virtual laryngoscopy is a non-invasive radiological technique that allows visualisation of intra-luminal surfaces by three-dimensional reconstruction of air/soft tissue interfaces. It is particularly useful when the patient cannot tolerate clinical examination, when infection, neoplasm or congenital defects compromise the lumen and for assessment of the sub-glottic region. We have performed virtual laryngoscopy on patients referred because of upper airway symptoms, and compared the findings with those at conventional laryngoscopy. MATERIALS AND METHODS: Axial scans were obtained using a Toshiba Xpress helical scanner. Virtual laryngoscopy was then performed on a workstation using Toshiba "Fly-thru" software and was completed within 5 min. RESULTS: Pathology included vocal cord nodules, laryngeal cysts, Reinke's oedema, laryngeal neoplasms and leukoplakia. CONCLUSIONS: Virtual laryngoscopy displays anatomical detail comparable to conventional endoscopy. Impassable obstructions are no hindrance and all viewing directions are possible. It is especially useful for providing views of the larynx from below.

An unusual complication of tonsillectomy.

We report the case of a 30-year-old man who experienced a potentially fatal haemorrhage on the tenth post-operative day after the development of a pseudoaneurysm of the muscular branch of the lingual artery. Due to the nature of the development of these pseudoaneurysms they are difficult to detect until such time that they present with a massive haemorrhage or a rapidly expanding parapharyngeal swelling. There are only several reported cases in the literature to date.

Parotid masses in patients with previous ear surgery.

This paper describes three cases of patients presenting with lumps in their parotid gland, the origin of which was difficult to define. In each case the past medical history revealed that the patients had undergone previous ipsilateral middle ear surgery. We highlight the fact that where there has been previous incisions in the skin about the ear, there is a risk of epidermal inclusion cysts in the parotid gland. These cysts can occur many years after the initial surgery and therefore may not be identified as an obvious origin to lumps in the parotid gland. Rarely as this series highlights there may also be extension of a cholesteatoma (a collection of keratin which arises from the eardrum and extends into the middle ear space) from the mastoid bone to the parotid gland. We recommend formal ear examination where there is a history of previous ear surgery and an ipsilateral parotid gland lump is present.

An alternative technique for nasal biopsy.

OBJECTIVES/HYPOTHESIS: The objective was to investigate the effectiveness of co-phenylcaine as a topical anesthetic agent for nasal mucosal biopsy. STUDY DESIGN: A prospective study. METHODS: Nasal mucosal biopsy specimens were taken from a site just anterior to the inferior turbinate following topical anesthesia with co-phenylcaine. All volunteers graded pain according to standard visual analogue scale (0-10) (VAS) scoring, and all were followed up after 24 hours for any epistaxis. RESULTS: Ninety nasal biopsy specimens were removed from 41 patients in all. Eight-two percent did not report any discomfort following this procedure (VAS score, 0). Ten patients reported mild discomfort (VAS scores ranging between, 1 and 3) and only six reported pain (VAS scores ranging from 5 to 7). However, five of these patients agreed to further biopsy and documented no discomfort during the repeat procedure. Only one patient required immediate intervention for hemorrhage after the procedure. In cases in which bleeding occurred (seven patients) it was documented within the first 6 hours, was minimal in content, and was controlled with local pressure. No systemic side effects were experienced. CONCLUSION: Co-phenylcaine is a suitable topical anesthetic agent for nasal mucosal biopsy. Removal of nasal tissue from a site anterior to the inferior turbinate can be performed under direct vision and provides sufficient tissue for histological assessment.

Manipulation of nasal bone fractures under local anaesthetic.

This article describes the technique of manipulation of nasal bones under local anaesthesia. With increased demand on day ward and in patient hospital beds there is a growing need to treat fractured nasal bones under local anaesthesia at the ENT clinic. Ten patients were treated in this fashion in the out patient setting. All had X rays confirming a fracture of the nasal bones. All ten had an obvious cosmetic deformity of the nose as a result of the fracture. All ten patients underwent satisfactory reduction under local anaesthesia and without the need for intra nasal manipulation to elevate overlapping bones. Reduction of nasal bones in the clinic under local anaesthesia should become the accepted practice where there is a deformity but no overlap of the nasal bones.

Hair cell regeneration in the inner ear: a review.

Hair cell regeneration has been shown to occur in the inner ear of mammals. Specifically, it has been demonstrated in the vestibular system and not the organ of Corti. Recent evidence suggests that the degree of the regenerative response may be augmented pharmacologically. This review discusses the field of hair cell regeneration in fish, amphibians, birds and mammals, and the relationship of regeneration to functional recovery

Co-phenylcaine as an alternative to Brompton's solution in rigid nasendoscopy: a pilot study.

BACKGROUND: Rigid nasendoscopy is a diagnostic aid that is frequently used in otorhinolaryngology clinics. Topical local anaesthetic and vasoconstriction is advised prior to the procedure. Options include both Brompton's solution and co-phenylcaine. Brompton's solution contains 10% cocaine, a controlled drug that has potentially serious side-effects. Even deaths have been reported as a consequence of its use as a nasal preparatory agent. OBJECTIVE: To compare the efficacy of cocaine in the form of Brompton's solution versus co-phenylcaine as both a vasoconstrictor and a local anaesthetic in out-patient diagnostic rigid nasendoscopy. METHOD: Thirty-three patients awaiting diagnostic rigid nasendoscopy were recruited to the study. Each patient served as his own control. Co-phenylcaine was delivered as a metered dose of two sprays to one nasal passage and Brompton's solution was delivered on a cotton wool pledget placed in the other nasal passage with the aid of Tilly's forceps. An endoscopist who was unaware of which nasal passage was treated with which agent scored the vasoconstricion at endoscopy 10 min after drug application using a scoring sheet. The patients gave a numerical assessment of how painful the procedure was for each nasal passage. Mean scores were compared using Student's t-test. RESULTS: There was no difference between the two agents with regard to nasal analgesia and vasoconstriction during rigid nasal endoscopy.

The role of computerized tomography in the preoperative assessment of chronic suppurative otitis media.

Twenty patients awaiting mastoid surgery for chronic suppurative otitis media underwent preoperative high resolution computerized tomography (CT) of the temporal bones. The CT scans were compared with the intraoperative findings. CT was helpful in determining the anatomy of the middle ear and mastoid, and accurately predicted the extent of the disease process in the sinus tympani and facial recess. However, it was unable to distinguish between cholesteatoma, mucosal disease and fluid, and it contributed little to the surgical management of the patients. This suggests that routine preoperative CT scanning of patients before uncomplicated virgin mastoid surgery is of questionable value.

The potential of virtual laryngoscopy in the assessment of vocal cord lesions.

Virtual laryngoscopy is a useful adjunctive radiological tool in the assessment of laryngeal lesions. A total of 10 patients requiring direct laryngoscopy for the investigation of laryngeal lesions underwent preoperative virtual laryngoscopy using three-dimensional reconstruction of two-dimensional computerized tomography (CT) images. All lesions were correctly diagnosed on virtual laryngoscopy before direct laryngoscopy. Its main advantages are that it does not require general anaesthesia, it allows three-dimensional visualization of the airway beyond areas of narrowing and it gives a highly accurate representation of vocal cord lesions, both in terms of definition and spatial representation. Its disadvantages are that it does not provide histology, it requires an air-mucosa interface to produce an image and it cannot identify functional lesions of the vocal cords.