The crucial role of imaging in determining the approach to glomus tympanicum tumours.

Glomus tumours are rare vascular tumours arising within the lateral skull base, infratemporal fossa and upper neck. When they are confined to the middle ear cleft, they are termed glomus tympanicum tumours. Traditionally tympanicum tumours have been treated surgically and their removal has generally been regarded as quite straightforward. Our experience with these lesions however, is that they fall into two distinct categories, those with and those without hypotympanic involvement. This distinction can be determined by high resolution CT scanning in coronal and axial planes. Mesotympanic tumours are indeed typically straightforward in their removal and can be approached by a transcanal route. Hypotympanic extension requires additional evaluation by MRI, and a more extensive surgical approach. In this paper, we present our management approach based on a series of nine cases. We conclude that determining the tumour extension preoperatively by using modern imaging techniques is essential in planning the surgery.

Air bag injury as a cause of inflammatory myofibroblastic pseudotumour of the subglottic larynx progressing to myositis ossificans.

Inflammatory myofibroblastic pseudotumour (IMFPT) is a rare condition. The clinical presentation can be indistinguishable from that of a malignant neoplasm. The most frequently affected organ is the lung; a much less common site is the larynx and subglottic involvement is particularly rare. Trauma is purportedly one potential aetiological factor, although there have been no previous reports of IMFPT occurring in the larynx secondary to external laryngeal trauma. We present a case of IMFPT of the subglottis which occurred subsequent to external trauma of the neck sustained during air bag inflation in a road traffic accident. This mechanism has not been previously reported. Furthermore, the lesion progressed uniquely to show myositis ossificans-like maturation over time. The patient was ultimately treated by means of complete local excision.

Study on spontaneous cerebrospinal fluid rhinorrhoea: its aetiology and management.

The aim of this study was to identify the common features in a study group of patients with spontaneous cerebrospinal fluid (CSF) rhinorrhoea, to develop a hypothesis to explain the cause of this condition and to investigate the outcome of surgical techniques adopted to repair the leak. In this retrospective study the authors have reviewed all the cases of spontaneous CSF leaks attending and receiving treatment from the otolaryngology department of Queen Elizabeth Hospital, Birmingham, from 1992 to 2002. Of 34 patients with CSF leaks, 15 were spontaneous in nature and formed the study group. Of these 15 patients, 14 were female; with ages ranging from 37 to 70 years and a median age of 50 years. All the female patients were overweight with a body mass index (BMI) >24.9 and, of these, nine were considered obese with a BMI >30. It was attempted to identify common factors in the study group and it was evident that female sex, obesity and age played a key role in this condition. The follow-up period ranged from two to 98 months. Thirteen patients were asymptomatic but two patients remained symptomatic, one of these despite repeated surgical intervention.

An analysis of diagnostic delay in unilateral facial paralysis.

Bell's palsy or idiopathic facial palsy is the commonest cause of unilateral lower motor neuron facial palsy. Misdiagnosis of facial nerve palsy as Bell's palsy is still seen in clinical practice. The clinician should always consider the possibility of a potentially serious underlying pathology before making the diagnosis of Bell's palsy. We present a series of 13 patients referred to our ENT department with an initial diagnosis of Bell's palsy. Further clinical examination and investigation revealed the underlying cause. Many had additional symptoms and signs related to the ear. In all patients with unilateral facial palsy a detailed history should be taken and thorough clinical examination carried out. Where no recovery occurs within the expected time period further radiological investigations such as computerized axial tomography (CT) and magnetic resonance imaging (MRI) should be performed. Current scanning techniques provide good quality images, which can show occult lesions of the temporal bone, internal acoustic canal and/or cerebellopontine angle. Radiologists with a special interest and experience in otoneurological radiology should ideally report these images, and a close co-operation between ENT surgeon and radiologist is essential in arriving at a proper diagnosis.

Cerebellopontine angle arachnoid cysts in adult patients: what is the appropriate management?

Arachnoid cysts can occur at different intracranial sites, including the cerebellopontine angle (CPA). The incidence of arachnoid cysts is 1 per cent of all intracranial lesions. Recent advances in MRI (magnetic resonance imaging) scan techniques have led to CPA arachnoid cysts being more frequently diagnosed and with a higher degree of certainty. The need for further understanding of their natural history as well as for the development of a management rationale has been highlighted with this increased rate of diagnosis. We present a series of five adult patients with different clinical presentations attributed to CPA arachnoid cysts. These lesions have a characteristic location in the posterior-inferior aspect of the CPA below the facial and vestibulocochlear nerves. These cysts did not show change in size on repeated MRI scan and the patients' symptoms did not progress over the period of follow up. Our findings would support a conservative management approach to the majority of these cysts.

Duplication of internal jugular vein and relation to the spinal accessory nerve.

We report a case of duplication of the internal jugular vein in which the duplication was incomplete and the accessory nerve lay deep to the vein.

Management of laryngeal amyloidosis.

Amyloidosis of the upper aerodigestive tract is rare. However, the larynx is the commonest site within the upper airways to be affected. Three cases of uncomplicated primary amyloidosis of the larynx and one case of laryngeal amyloidosis with more generalized dissemination throughout the head and neck are presented. In this article the different presentations of laryngeal amyloidosis and principles of management of this condition at that site are highlighted.

Wegener's granulomatosis and subglottic stenosis: management of the airway.

Wegener's granulomatosis is a multisystemic disease characterized by foci of necrotizing vasculitis and granuloma formation. Subglottic stenosis may occur either as a presenting feature or a late-stage manifestation of the disease, but will occur in approximately 10-20 per cent of cases. We present a series of seven cases of Wegener's granulomatosis with subglottic stenosis and discuss our management of this condition. Where there is active disease, tracheostomy is the first-line surgical treatment of respiratory obstruction, as an adjunct to full medical therapy. More aggressive or elaborate surgical treatments should be reserved for non-active cases in which patients have not required medical treatment for one year.

Prevalence of hepatitis B and C among blood donors attending the National Blood Transfusion Center in Baghdad, Iraq from 2006-2009.

OBJECTIVE: To estimate the prevalence of hepatitis B and C among blood donors attending the National Blood Transfusion Center (NBTC) in Baghdad, Iraq from 2006-2009 and to compare the results with previous year's results and results from studies on a normal population, and to identify certain demographic characteristics such as age, gender, and residence of positive cases. METHODS: This is a retrospective cross-sectional observational study. Monthly reports from the NBTC during the year 2006-2009 were collected. This study took place at Communicable Disease Control Center (CDC), Baghdad, Iraq in January 2010. Analysis of the reports regarding age, gender, and residence was carried out using Excel 2007. RESULTS: The sample size was 495,648 blood donors. Out of them, only 3258 (0.6%) were positive for hepatitis B and 933 (0.3%) were positive for hepatitis C. The average prevalence of HBsAg was higher in men (0.7%) than women (0.5%) with no statistical significance (p=0.07) while the prevalence of anti-HCV was higher in women (0.4%) than in men (0.2%) with statistical significance (p=0.000). Residence distribution of the positive cases for HbsAg and Anti HCV Ab in both genders was found to be higher in urban areas than in rural areas. Regarding age distributions, most of the affected donors were between 20-40 years age. CONCLUSION: The findings indicate that Baghdad is of low endemicity with hepatitis B and hepatitis C infection. Generally, men are affected more than women and urban areas more than rural areas. Further studies are needed to provide more details about the status of HBV and HCV infection in other provinces of Iraq. Results of these studies could be utilized to determine the most feasible and useful approaches for strengthening prevention and control activities.

Kurz titanium prosthesis ossiculoplasty--follow-up statistical analysis of factors affecting one year hearing results.

OBJECTIVE: Analysis of the one year results of Kurz titanium ossicular prosthesis and the factors affecting the outcome from this prosthesis. The hearing results of titanium partial ossicular replacement prosthesis (PORP) and total ossicular replacement prosthesis (TORP) were compared. METHODS: This is prospective study of 97 Kurz prosthesis ossiculoplasties, performed by the same senior author (VVR) between 2004 and 2006. All patients undergoing ossiculoplasty using Kurz prosthesis between 2004 and 2006 were included. All patients had minimum follow-up period of one year. There were 97 patients in total. 65 patients had PORP's and 32 had TORP's. The mean preoperative and postoperative air-bone gaps for the frequencies (500, 1000, 2000, and 3000Hz) were calculated. The improvement of the mean air-bone gap (ABG) and air conduction over the same frequencies were measured. A postoperative ABG less than or equal to 20dB was considered a successful result. Statistical analysis was used to identify the factors which affect the postoperative results. RESULTS: The mean preoperative ABG was 27.89dB (SD=11.71). The mean postoperative ABG for the entire series was 11.39dB (SD=10.47). The mean improvement in ABG was 16.50dB (SD=14.00). 81.4% (79 patients) had postoperative ABG< or =20dB. 56.7% (55 patients) of the patients had postoperative ABG< or =10dB. The mean postoperative ABG for all PORP patients was 10.6dB (SD=9.7). The mean postoperative ABG of TORP was higher in this study (14.84dB, SD=12.86) but it was not statistically significant (p=0.10, 2-tailed t-test, 95% CI -9.35 to 0.924). There was no significant effect of age, presence or absence of cholesteatoma or retraction pocket, type of mastoid surgery and thickness of the cartilage graft used on the results. The effect of the preoperative ossicular condition on the postoperative hearing results was also analysed. CONCLUSION: Titanium ossicular reconstruction gives stable short-term results. There was no statistically significant difference between the total and partial replacement prostheses. The preoperative status of the stapes superstructure did influence the mean postoperative ABG.

The role of barium swallow in the management of the globus pharyngeus.

Globus pharyngeus is a common benign condition with controversial management. Patients with globus pharyngeus are usually investigated to exclude the possibility of upper aerodiagestive malignancies. There is a great debate about the role of barium swallow in the management of this condition. Review of 1,145 barium swallow repourts of patients presented with globus pharyngeus between 1999 and 2004 has failed to diagnose any patient with pharyngeal or oesophageal cancer. We conclude that barium swallow should not be requested systematically as part of management of globus pharyngeus patients. This approach will reduce the cost and radiation effect of unnecessary investigations.

Topical antibiotic ototoxicity: does it influence our practice?

INTRODUCTION: We hypothesised that general practitioners and ENT specialists manage discharging ears differently. This study was designed to investigate this further. METHODS AND MATERIALS: Postal questionnaires were sent to all general practitioners in the Birmingham area and all UK consultants on the British Association of Otolaryngology-Head and Neck Surgery address list. RESULTS AND DISCUSSION: In the presence of an intact tympanic membrane, 99 per cent of consultants and 90 per cent of general practitioners would use topical antibiotics. In the presence of a perforated tympanic membrane, 97 per cent of consultants would continue to use topical antibiotics, compared with only 43 per cent of general practitioners. This was attributed to a fear of ototoxicity. If a topical non-ototoxic antibiotic of proven efficacy could be made available, 93 per cent of consultants and 88 per cent of general practitioners in this study would seriously consider using it as first line treatment. CONCLUSION: The majority of general practitioners would not use topical antibiotics in the presence of a perforated tympanic membrane. Most doctors would consider using a non-ototoxic topical antibiotic as first line treatment should one be made available.

Role of information leaflets in improving the practice of informed consent for patients undergoing septoplasty.

AIM: To evaluate the effectiveness of an information leaflet in improving patient understanding of the procedure and complications of septoplasty. DESIGN: The baseline knowledge of a group of patients who had attended a pre-assessment clinic prior to septoplasty was assessed. The procedure and its complications were then verbally explained. The patients' knowledge was then re-assessed on the morning of surgery and any improvements noted. In the second arm of the study, an information leaflet was introduced at the time of verbal instruction and any differences in improvement in knowledge were assessed. RESULTS: Data from the two groups were analysed using an analysis of covariance with differences in baseline (pre-instruction) knowledge controlled. Additional improvements in mean recall score following leaflet distribution were highly statistically significant when compared with mean recall in the control group (p<0.001). CONCLUSION: The use of information leaflets increases patients' knowledge about a surgical procedure and its potential complications.

Heterotopic gastric mucosa in the cervical oesophagus (inlet patch) and globus pharyngeus--an under-recognised association.

Globus pharyngeus is a symptom commonly encountered in ENT practice. The usual complaint is that of the sensation of a ball or lump in the throat generally unaccompanied by dysphagia. This sensation is often more pronounced when taking an 'empty swallow'. The precise mechanism of this remains enigmatic in many cases. Irritant factors such as gastroesophageal reflux, postnasal drip and excessive throat clearing may be contributory factors as may be stress and psychological influences. Although gastric type mucosa occupying the cervical oesophagus has been long recognised, mainly in the specialised gastrointestinal literature, there appears to be more limited awareness of the condition in ENT practice and the clinical significance of such heterotopia is not well established. We present five recent cases of globus pharyngeus encountered in our ENT practice in which rigid pharyngoesophagoscopy and biopsy revealed heterotopic gastric mucosa within the postcricoid and cervical oesophagus constituting a so-called gastric 'inlet patch'. One case re-presented with invasive adenocarcinoma within a short time. Herein we compare and contrast inlet patch with columnar lined oesophagus, discuss the potential clinical significance of inlet patch and comment upon further management of the condition.

Pseudoaneurysm after total pharyngolaryngectomy with jejunal graft insertion: two different presentations.

Pharyngeal reconstruction after total pharyngolaryngectomy using a jejunal graft is now a common procedure in head and neck oncological surgery. The vascular supply of this graft comes from the anastomosis between a branch of the mesentric artery and a branch of the external carotid artery. We report two cases of pseudoaneurysm, one at the site of ligation of the lingual artery and the other at the site of arterial anastomosis. One presented with dramatic hematemesis and was managed by the interventional radiologist, and the second presented with a pulsating neck mass and required a surgical revision. In both cases, the jejunal graft survived.

Parapharyngeal abscess: diagnosis, complications and management in adults.

Parapharyngeal abscess may cause life-threatening complications. Peritonsillar abscess and tonsillitis may result in parapharyngeal abscess. Since the introduction of antibiotics, the incidence of parapharyngeal abscess secondary to tonsillitis and peritonsillar abscess has decreased dramatically. We present five cases of parapharyngeal abscess resulting from tonsillitis and peritonsillar infection extending to the parapharyngeal space in adult patients. Two were complicated by mediastinitis despite early treatment by wide spectrum antibiotics. We believe that early diagnosis and aggressive antibiotic treatment with early surgical drainage in cases associated with pus collection are the key points in preventing serious and fatal complications. We emphasize the diagnostic role of computerized tomography (CT) scan and the importance of early and proper drainage of these abscesses.