Vocal cord paralysis and tumour length in staging postcricoid cancer.

The present UICC classification of postcricoid cancer is based on directions of tumour spread which are uncommon and difficult to assess clinically. The classification takes no note of spread into the cervical oesophagus and fails to correlate staging with survival. The aim of this study was to assess the value of other criteria, including vocal cord paralysis and tumour length, in staging 157 patients with postcricoid cancer. Both vocal cord paralysis and tumour length could be assessed in most patients, and correlated with the mode of treatment. Generalized Linear Interactive Modelling (GLIM) identified vocal cord paralysis (P less than 0.001), performance status (P less than 0.025) and the interaction of length and histological grade (P less than 0.05) as significant predictors of survival. None of these variables is included in the current UICC classification.

Staging of maxillary cancer. Which classification?

Of the many proposed classifications for staging maxillary sinus cancer, none has been adopted universally and none is known to be superior to the others. This study identified the best of six currently used classifications using data from 53 previously untreated patients with squamous cell carcinoma of the maxillary sinus. Analysis of each classification's ability to stage the majority of patients, produce a balanced distribution of T stages, and correlate T stage with treatment and prognosis revealed Harrison's classification to be the best. Harrison's classification should be adopted worldwide as the classification of choice for staging squamous cell carcinoma of the maxillary sinus.

Continuous infrared thermometry of the nasal mucosa.

This study aims to continuously measure nasal mucosal temperature without interruption of nasal breathing using infrared thermometry. An infrared thermometer (Medi-Therm 310; Everest Interscience, Inc.) was directed at the nasal septum from a distance of 15 cm. Infrared radiation was continuously collected, then converted to an electrical signal proportional to the mucosal temperature and output to a chart recorder. In 70 subjects the mean nasal mucosal temperature was 30.4 +/- 2.0 degrees C on inspiration and 32.0 +/- 1.8 degrees C on expiration. Using multiple regression, nasal mucosal temperature was significantly related to atmospheric temperature (p < 0.0001) and inversely related to the airway patency of the ipsilateral nasal passage (p < 0.05).

Prognostic factors in labyrinthectomy.

Labyrinthectomy for unilateral Menière's disease may be complicated by persistent unsteadiness postoperatively. The aim of this study is to identify the unfavourable factors in recovery following labyrinthectomy. Twenty-one patients gave a detailed history and underwent neuro-otological, ophthalmic and cardiovascular examination, as well as psychological and psychiatric assessment. Sedentary occupations, external health locus of control, extraverted personality, and an anxious and/or depressed psychiatric state were associated with poor post-operative recovery. These factors therefore should be taken into consideration in the pre-operative assessment and post-operative rehabilitation of labyrinthectomy patients.

Cryotherapy in the treatment of nasal obstruction: indications in adults.

Cryotherapy is an established method of treating hypertrophic obstructive inferior turbinates. The long-term effectiveness of the technique is assessed in this study, using the need for alternative nasal surgery as an objective way of distinguishing success from failure. Over 50 per cent of patients with obstructive symptoms, including those with minor septal deviation or allergy derived lasting benefit from the technique. Cryotherapy is an effective means of treating nasal obstruction due to mucosal hypertrophy of the turbinates and may replace the need for more radical surgery.

Do antral washouts have a place in the current management of chronic sinusitis?

Antral washouts have been widely used in the management of chronic sinusitis. With the advent of modern antibiotics and powerful topical nasal steroids, we sought to establish if a role remains for this procedure. One hundred and fourteen patients with chronic sinusitis were randomised into two groups. Patients in Group A received antral washouts followed by antibiotics and topical nasal steroids. Patients in the Group B received antibiotics and topical nasal steroids alone. In each group 51.6 per cent and 50 per cent of patients respectively improved with treatment. The outcome of treatment is also not influenced by endoscopic abnormality. The difference was not statistically significant (p = 0.86). The study indicates that half of patients with chronic sinusitis will improve with medical treatment but the addition of antral washout confers no additional benefits.

A prospective randomized trial of suture material in aural wound closure.

The aim of the study was to compare synthetic monofilament suture materials with chromic catgut and silk in aural wound closure. Forty patients undergoing mastoidectomy or tympanoplasty were randomized to closure with either 3o PDS (Polydioxanone) to fascia plus 3o Prolene to skin, or 2o chromic catgut to fascia plus 3o silk to skin. Known or suspected factors affecting wound healing were recorded. Nine patients had post-operative wound infections. The infection rate was significantly lower in wounds closed with PDS and Prolene (chi 2 = 6.05, p less than .05), and in tympanoplasty operations (chi 2 = 4.42, p less than .05). Four patients suffered wound dehiscence, all four had been closed with catgut and silk. No other complication of wound healing was noted in the trial. In conclusion, PDS and Prolene are superior suture materials to catgut and silk in the closure of aural wounds.

Nasal airflow: resistance and sensation.

For many years nasal resistance to airflow measured by rhinomanometry has been regarded as the objective measure of nasal patency. However, recently it has become apparent that this may not be the case. The present study was designed to affirm or refute this view by using large numbers of subjects and observations. Five hundred estimations of (objective) nasal resistance to airflow and (subjective) nasal sensation of airflow where carried out. No correlation could be demonstrated between these two parameters. It is concluded nasal resistance to airflow and nasal sensation of airflow are two separate modalities which are not directly related. The possible reasons for this finding are discussed with reference to previous work on nasal sensation.

Nasal septum buttons: symptom scores and satisfaction.

Patients with symptomatic septal perforations require treatment, with many surgeons advocating primary treatment with an obturator if conservative measures fail. Twenty nasal Button Outcome Questionnaires were sent to patients who had undergone insertion of a septal button between 1990 and 2000 in our unit. Fourteen questinnaires were returned. This study reveals that despite a reduction in symptom score in nine patients, septal buttons are poorly tolerated by patients with only 45 per cent of obturators ultimately being in situ. In view of these findings, patients are now offered a choice between primary surgical and mechanical closure in our unit.

The use of inhalers in patients with tracheal stomas or tracheostomy tubes.

Patients with chronic obstructive airways disease (COAD) or asthma who have a tracheostomy tube or tracheal stoma have difficulty using metered dose inhalers (MDIs) because of a failure to achieve a good seal between the tracheostomy tube or stoma and the MDI or spacer device mouthpiece. Many such patients therefore utilize nebulizers. MDIs in comparison to nebulizers have the advantages of being more compact, portable, easy to use, less time-consuming, and cheaper. We present the case of a 74-year-old man who underwent a laryngectomy with tracheal stoma formation who had a poor response with nebulizers and required oral steroids. He was subsequently, with the help of a number of attached devices, able to use his MDIs to good effect. We describe a number of devices and adaptors to enable patients with laryngectomy stomas or tracheostomy tubes to utilize MDIs and undergo respiratory function tests. We recommend that all such patients should have the benefit of a consultation with a dedicated respiratory nurse who can provide the appropriate MDIs, devices and adaptors to optimize the treatment of their lower respiratory tract condition.

Incidental findings on magnetic resonance imaging screening for cerebellopontine angle tumours.

The otolaryngologist who requests magnetic resonance imaging (MRI) scans to exclude cerebellopontine angle (CPA) tumours may discover incidental pathologies. We retrospectively reviewed the results of 644 consecutive MRI screening scans with the aim of identifying findings other than CPA tumours. Two hundred and eighty-nine (45 per cent) scans featured one or more anomalies or abnormalities, including CPA tumour (23, four per cent), vascular loop (30, five per cent), basilar artery ectasia (13, two per cent), multiple high signal areas (135,21 per cent), brain atrophy (52, eight per cent), sinus findings (56, nine per cent), middle ear/mastoid disease (34, five per cent), and a variety of other findings (39, six per cent) including clinically serious lesions (11, two per cent). The significance and management of these incidental findings is discussed. The majority were not clinically significant but the occasional presence of a serious incidental pathology should be borne in mind. Basilar artery ectasia and multiple high signal areas may be responsible for the symptoms investigated by MRI, and screening for cerebrovascular disease risk factors in such patients may be appropriate.

A method for preparation of fibrin glue.

Otorhinolaryngological operations would be facilitated by the use of a safe, cheap, surgical adhesive. Though commercial fibrin glue is effective, it is both relatively expensive and, because it is prepared from pooled human blood, there has been concern that it carries the risk of transmitting viral disease, in particular hepatitis and acquired immune deficiency syndrome. We describe a rapid, cheap method of preparing sufficient fibrin glue, of adequate bonding power, from a small quantity of the patient's own blood, and therefore with no risk of contracting viral disease. Our method of preparation of fibrin glue promises to provide a valuable adjunct to otorhinolaryngological surgical practice.

Submucous resection for deviated nasal septum: a critical appraisal.

Submucous resection (SMR) for the deviated nasal septum had been criticised to have a higher complication rate and less patient satisfaction than septoplasty. Seventy-five patients who underwent SMR were studied and followed up at 6 months to 56 months post-operatively. The rates of short and long term complications were relatively low: septal haematoma 1.3%, nasal infection 1.3%, epistaxis 2.6%, external nasal deformity 9.3% and septal perforation 2.7%. While most patients achieved short term relief of nasal obstruction (93.4%), about 30% had persistent/recurrent nasal obstruction on long term follow-up. Similar rates had been quoted for the operation of septoplasty. We postulated that this was due to unfavourable airflow patterns as a result of minor residual septal deviation. Some patients had associated pre-operative symptoms of snoring (57.3%), headache (48.0%), rhinorrhoea (38.7%), sneezing (30.7%), hyposmia (30.7%) and epistaxis (21.3%). Frequencies of cure/improvement of these symptoms after SMR were 34.9%, 33.3%, 24.1%, 30.4%, 60.9% and 43.8% respectively. The overall post-operative long term (average 23.5 months) satisfaction rate was almost 70%. SMR, being relatively easy to perform, and having similar complication and patient satisfaction rates as septoplasty, should be retained in the surgical armamentarium for the deviated nasal septum.

Laser reduction of inferior turbinates in children.

Perennial nasal obstruction in children refractory to medical treatment may be managed by turbinate reduction. Turbinectomy may involve a risk of significant postoperative bleeding and requires nasal packing. Submucosal diathermy is followed by nasal congestion and crusting; recurrent nasal obstruction is frequent at fifteen months. This study assesses the benefits of carbon dioxide laser reduction of inferior turbinates in 20 children. Intraoperative blood loss was negligible and no nasal packing was required. There was minimal postoperative discomfort which required no analgesia. No postoperative haemorrhage was recorded. The children were able to drink and eat by 4 and 6 hours respectively. Relief of nasal obstruction occurred one to seven days postoperatively and was confirmed by rhinohygrometry. Nasal patency was maintained on eighteen to twenty-four months follow up. Mucosal healing was completed by four weeks. Mucosal saccharin clearances were normal postoperatively. We conclude laser turbinectomy is an excellent means of turbinate reduction in selected children.

The role of magnetic resonance imaging in the assessment of suspected extrinsic tracheobronchial compression due to vascular anomalies.

AIMS: To evaluate the role of magnetic resonance imaging (MRI) in the assessment of children with suspected extrinsic tracheobronchial compression due to vascular anomalies. METHODS: Retrospective case note review in a tertiary referral centre. Twenty nine children who underwent dynamic laryngotracheobronchoscopy (DLTB) and were found to have a clinical suspicion of extrinsic tracheobronchial compression were evaluated. All subsequently underwent thoracic MRI within 10 days. The findings on endoscopy were compared to those of MRI, and where performed, echocardiography, aortography, and surgery. RESULTS: There were 17 males and 12 females (mean age 5 months, range 28 weeks gestation to 60 months). The most common presenting features were stridor and cyanotic episodes. MRI showed abnormalities in 21 patients. There were five vascular rings (three double aortic arches and two right aortic arches) and 11 cases of innominate artery compression. Other vascular anomalies noted included aberrant right subclavian artery and aneurysmal left pulmonary artery. Echocardiography was generally found to be unhelpful in the diagnosis of extra-cardiac vascular abnormalities. Angiography was subsequently conducted in eight children; findings agreed with those shown on MRI. Surgery was performed on all five vascular rings, one innominate artery compression, and one aneurysmal left pulmonary artery. Surgical findings were also compatible with the preoperative MRI. CONCLUSIONS: This study shows the successful use of MRI as the initial imaging modality in endoscopically suspected extrinsic vascular compression of the upper airway. It enables accurate delineation of vascular anomalies and, unlike aortography, is non-invasive and does not require the use of contrast media.

Children's sore throats related to parental smoking.

There has been concern that the smoking of tobacco can adversely affect the health of non-smokers. This is most cogent in children who are subject to smoke at home. The aim of this study is to relate children's sore throats to the smoking habits of their parents. The parents of 154 children were asked about the age, sex, birthweight, method of postnatal feeding and age at starting school or day nursery of the child, the frequency of sore throats, smoking habits and history of tonsillectomy of all members of the household, the size of family, the dwelling size, and the occupation of the father. Analysis by multiple regression showed a significant association between children's sore throats and maternal smoking. Reduction in domestic cigarette smoke exposure should benefit the child by reducing the number of sore throats he or she suffers.

The prognosis and management of idiopathic vocal cord paralysis.

If a vocal cord paralysis is termed idiopathic, no cause has been identified. The aim of this study was to assess the prognosis and management of patients with an idiopathic vocal cord paralysis. Data of 42 such patients have been stored prospectively. During follow-up 4 patients were found to have malignancies that in retrospect had been responsible for their vocal cord paralysis. Of the remainder approximately half either recovered vocal cord function or regained a near normal voice due to compensatory movement by the non-paralysed cord. No patient over the age of 60 compensated. No patient either recovered vocal cord function or compensated more than 12 months after the onset of his paralysis. In conclusion, patients with an idiopathic vocal cord paralysis should be suspected of harbouring a malignancy unless vocal cord mobility recovers, and management of the laryngeal dysfunction should be expectant for up to 12 months.

Headaches associated with nasal obstruction due to deviated nasal septum.

A deviated nasal septum not only can cause a blocked nose, but may also be associated with headaches. This study evaluates the nature of these headaches, the effect of submucous resection of the nasal septum, and the factors associated with postoperative headache relief. Deviated nasal septa were corrected by submucous resection in 99 men and 17 women. Patients were studied at 4 to 48 months (mean 18 months) postoperatively. Fifty-five of the 116 patients studied (47.4%) had preoperative recurring headaches. Thirty-five of the 55 patients with headaches (63.6%) experienced relief (complete or partial) of their headaches at a mean follow-up period of 18 months. Patients were more likely to be relieved of their headaches following submucous resection if the headaches were most intense over the frontal region, pressurelike in nature, and if the submucous resection resulted in relief of nasal obstruction. It is possible that headaches recur in the long term, and it is postulated that central mechanisms play a role.

The role of the temperature of the nasal lining in the sensation of nasal patency.

The receptors and neural pathways involved in the common symptom of nasal blockage are of great interest. Studies to date suggest that the sensation of nasal patency may be related to the temperature of the nasal passages. Sixty-two subjects were asked to assess their own nasal patency subjectively and indicate this on a visual analogue scale. The temperature of the nasal lining was continuously recorded during quiet nasal respiration using a non-contact infrared thermometer. The cooler the nasal lining, the clearer the nose felt, and the greater the drop in temperature on inspiration again the clearer the nose felt. The study supports the previously proposed hypothesis that the sensation of nasal airflow is derived from a cooling of the nasal lining on inspiration, and this is probably detected by cold thermoreceptors in the mucosa.