Impact of Otolaryngology in the diagnosis of early oesophageal malignancy.

INTRODUCTION: A large number of patients present in Otolaryngology clinics with vague upper gastro intestinal symptoms, some potentially originating from the oesophagus. In the United Kingdom there is no consensus for investigation protocols. The concern is that diagnosis of early oesophageal malignancy can be delayed with detrimental effects to the prognosis of the patient. The aim of this paper is to attempt to establish the impact of Ear Nose and Throat (ENT) work up in the diagnostic pathway of these patients. METHODS: Retrospective analysis of case notes of newly diagnosed oesophageal carcinoma over a 15 month period. RESULTS: Sixty five patients with a new diagnosis of oesophageal carcinoma were identified from the upper GI cancer network. A cohort of 7 patients was initially referred to ENT with related symptoms. Delays occurred at different stages during the course of their diagnostic pathways. Only 2 patients were diagnosed from ENT prior to referral to upper GI. CONCLUSION: We support the creation of one stop clinics incorporating the use of transnasal oesophagoscopy. The current literature is discussed.

Success of cricopharyngeal myotomy for specific and non-specific cervical dysphagia.

OBJECTIVE: The present study aimed to compare outcomes of cricopharyngeal myotomy (CPM) in patients with documented cricopharyngeal dysfunction (CPD) and those in whom the diagnosis is complex or in doubt. MATERIALS AND METHODS: Retrospective comparative study of all patients undergoing CPM between 2001 and 2010 at a single UK centre. Patients were classified as having either CPD (n = 15) or non-specific cervical dysphagia (NSCD) (n = 12) based on contrast swallow results. They completed a 10-point visual analogue scale (VAS) questionnaire regarding their ability to swallow solids preoperatively and 6 months postoperatively. Scores were compared between groups, and symptom recurrence at 12 months postoperatively was also noted. RESULTS: The median VAS for all patients in both groups preoperatively was 5.5 and improved postoperatively to 8.0 (p < 0.001), and median preoperative ratings between groups were similar (CPD = 6.0 vs. NSCD = 5.5; p > 0.05). The CPD group scored better postoperatively compared to their NSCD counterparts (CPD = 9.0 vs. NSCD = 7.5; p < 0.001). Recurrence rate at 12 months was lower in CPD (12.5%) compared to NSCD (60%) patients. CONCLUSION: After CPM, patients with CPD showed significant improvement in swallowing solids, as did patients with NSCD, although to a lesser extent. CPD patients experienced better outcomes compared to their NSCD counterparts, including lower complication and recurrence rates. Larger studies are required before CPM can be advocated as the standard of care for NSCD patients.

Indeterminate thyroid nodules (Thy3): malignancy rate and characteristics in a study of 118 patients.

INTRODUCTION: Thyroid nodules are common, and the combined use of ultrasound and fine needle aspiration cytology provides useful information on their malignancy risk. The Thy reporting system is widely used in the United Kingdom, with malignancy rates for Thy3 cytology being quoted between 5% and 30%. This study aims to establish the risk of thyroid cancer in operated patients with Thy3 cytology and correlate it with patient demographics and nodule size. METHODS: This is a retrospective observational study of all thyroidectomies that took place in a single institution over a 3-year period (2019-2022). Those with a preoperative cytology of Thy3 were analysed further and in particular, nodule size, final histology and patients' demographics were documented. RESULTS: Some 260 thyroidectomies were performed during the study period. Of these, 118 patients had Thy3 cytology. In the Thy3a group (n = 70), the malignancy rate was 27.1%. The average age of those with thyroid cancer was 51.4 vs 51.2 years for those with benign disease. The nodule size was under 40mm for both groups (36mm vs 39.7mm). In the Thy3f group (n = 48), the malignancy rate was 43.8%. The average age of those with thyroid cancer was 53.5 vs 56.2 years for those with benign disease. The nodule size was similar (24.5mm vs 27.6mm). CONCLUSIONS: In this study, one in three patients with Thy3 cytology was diagnosed with thyroid cancer. We urge local units to analyse their data, to aid patients' informed decision-making. Within the subgroups, there was no significant difference in average nodule size or patients' age.

The learning curve and safety of continuous intraoperative vagus nerve monitoring in thyroid surgery.

INTRODUCTION: Continuous intraoperative nerve monitoring allows for continuous feedback on the integrity of the recurrent laryngeal nerve (RLN) and the quality of its induced myogenic potential. The aims of this study were to assess the time requirements and risks associated with vagus nerve electrode placement when learning the technique. METHODS: This is a prospective observational study carried out in a single otolaryngology department at the start of a trainee's placement. A total of 40 vagus nerve dissections in 31 consecutive operations (22 hemithyroidectomies, 9 total thyroidectomies) using automatic periodic stimulation (APS, Medtronic) are included. Of the electrode placements, 10 were performed by the trainer and 30 by the trainee. The time required for each surgical step and complications relating to vagus nerve dissection were recorded. RESULTS: The average (median+IQR) total additional time attributable to vagus nerve dissection, electrode placement and baseline electromyogenic assessment was 3.1mins (2.5-3.3) for the trainer and 4.8mins (4.1-5.3) for the trainee (p<0.0001). There was a downward trend in time requirement for the trainee (not statistically significant, p=0.080). Total operative time was 38min (35-45) for hemithyroidectomy and 56min (53-62) for total thyroidectomy. There was a mix of benign (74%) and malignant (26%) histology, no intraoperative complications relating to autonomic dysfunction and one (2.5%) transient nerve palsy. CONCLUSIONS: Operative time attributable to vagus nerve electrode placement is short and the procedure is easy to learn. Appropriate surgical technique and careful anaesthetic considerations allow monitoring to be performed safely, and may reduce the rate of RLN palsy.

Using a 4K three-dimensional exoscope system (Vitom 3D) for mastoid surgery during the coronavirus disease 2019 pandemic.

OBJECTIVE: Microscopic surgery is currently considered the 'gold standard' for middle-ear, mastoid and lateral skull base surgery. The coronavirus disease 2019 pandemic has made microscopic surgery more challenging to perform. This work aimed to demonstrate the feasibility of the Vitom 3D system, which integrates a high-definition (4K) view and three-dimensional technology for ear surgery, within the context of the pandemic. METHOD: Combined approach tympanoplasty and ossiculoplasty were performed for cholesteatoma using the Vitom 3D system exclusively. RESULTS: Surgery was performed successfully. The patient made a good recovery, with no evidence of residual disease at follow up. The compact system has excellent depth of field, magnification and colour. It enables ergonomic work, improved work flow, and is ideal for teaching and training. CONCLUSION: The Vitom 3D system is considered a revolutionary alternative to microscope-assisted surgery, particularly in light of coronavirus disease 2019. It allows delivery of safe otological surgery, which may aid in continuing elective surgery.

The incidence of post-thyroidectomy hypocalcaemia: a retrospective single-centre audit.

INTRODUCTION: The aim of this single centre retrospective observational record-based audit was to assess the incidence of post-thyroidectomy hypocalcaemia. The setting was a district general hospital in Hertfordshire covering a population of 500,000 people. A total of 196 patients who had had total or completion thyroidectomy during a five-year period were included in the study. MATERIALS AND METHODS: The primary outcome measure was to determine the rate of biochemical and symptomatic hypocalcaemia in patients undergoing total or completion thyroidectomy. Secondary outcome measures assessed time taken for biochemical and clinical hypocalcaemia to resolve, whether malignancy affected the rate of hypocalcaemia and if removal of parathyroid glands during surgery were a predictor of hypocalcaemia. RESULTS: The overall incidence of post-thyroidectomy hypocalcaemia (PTHC) within 24 hours was 21.4%. The incidence increased from 6 hours (13.8%) to 24 hours post-thyroidectomy (15.8%) and there was evidence of both transient and delayed PTHC within the first 24 hours. By 6 months post-surgery, 3.6% remained hypocalcaemic and required continual oral supplementation. Patients with benign thyroid disease had a higher risk of PTHC (P = 0.04) and patients younger than 50 years of age had a higher risk of symptomatic hypocalcaemia (P = 0.016). Other clinical factors including sex, type of surgery, neck dissection, oral calcium and/or vitamin D supplementation and inadvertent histological parathyroid gland excision were not associated with an increased incidence of PTHC or symptomatic hypocalcaemia. CONCLUSIONS: Our audit shows that the rate of PTHC within our population was below the national average with higher risk in benign thyroid disease.

Continuous intraoperative nerve monitoring in thyroidectomy using automatic periodic stimulation in 256 at-risk nerves.

INTRODUCTION: Automatic periodic stimulation of the vagal nerve during thyroidectomy provides real-time feedback of recurrent laryngeal nerve function intraoperatively. To assess the validity of this device, the ability of monitoring to predict recurrent laryngeal nerve palsy was determined and the incidence of recurrent laryngeal nerve palsy recorded. MATERIALS AND METHODS: All thyroidectomies using APS® (Automatic Periodic Stimulation, Medtronic) nerve monitoring were reviewed over a 27-month period. Changes in signal amplitude and latency during thyroidectomy were recorded from saved data. Postoperative fibreoptic laryngoscopy determined the incidence of vocal cord immobility and recovery of nerve function was assessed from follow-up letters. RESULTS: A total of 256 at-risk nerves were examined (132 hemi- and 62 total thyroidectomies) in cases involving benign and malignant disease. Permanent recurrent laryngeal nerve palsy occurred in six (2.3%) lobectomies and transient recurrent laryngeal nerve palsy occurred in two lobectomies (< 1%). Sensitivity for detecting postoperative vocal cord immobility was 100% and specificity 85% if the end amplitude was 50% below baseline. The positive predictive value when amplitude was 50% below baseline was 18%. The negative predictive value when amplitude was 50% above or equal to baseline was 100%. Intraoperatively, the amplitude was 50% below baseline more frequently in the vocal cord immobility group (t-test, P < 0.015). No vagal nerve complications occurred. CONCLUSION: Whilst the incidence of recurrent laryngeal nerve palsy is comparable to rates in the literature, the incidence of transient palsy is lower than published averages. APS is able to reliably predict recurrent laryngeal nerve palsy based on end amplitude.

Evaluating nasal cautery techniques in epistaxis.

BACKGROUND: Silver nitrate cautery and bipolar electrocautery are commonly used in the treatment of epistaxis. Currently, there are no recommendations on optimum contact times or power for nasal cautery. ENT consultant practice in the UK has not previously been evaluated. METHODS: This study examined the burn depth associated with silver nitrate (75 per cent concentration) cautery and bipolar electrocautery on porcine septum samples, using varying contact times and power. ENT consultants completed a survey evaluating their practice. RESULTS AND CONCLUSION: ENT consultant practice of nasal cautery was shown to vary widely. Silver nitrate cautery with a contact time of less than 30 seconds does not cause a full thickness burn. The findings lend some support to bilateral cauterisation with silver nitrate. Bipolar electrocautery should be set at lower than 10 W and with a contact time of less than 4 seconds to reduce the risk of complications associated with a full thickness burn.

The assessment of the risk of cross-infection with a multi-use nasal atomizer.

Atomizers working on the Venturi principle are used by otolaryngology departments in the UK to spray cocaine and other local anaesthetic and vasoconstricting solutions into the nasal cavities. These devices are rarely cleaned, nor is the cocaine in the reservoir changed between patients. This study aimed to assess the risk of cross-infection with such an atomizer of the Down's design. Nutrient broth from a sterile atomizer was sprayed into the nasal cavities of 12 healthy volunteers on three occasions, the tip of the nozzle was withdrawn between sprays into the right nostril, but not between sprays into the left. On each occasion the tip of the nozzle, a nutrient broth rinse of the inner tube of the nozzle and the residue of broth in the reservoir of the atomizer were cultured and the colonies compared with those from a nasal swab collected previously. The results show transmisson of bacteria from the nasal vestibule on to the tip, into the nozzle and into the reservoir of the atomizer. Examination of the minimum inhibitory concentration values of 10% cocaine with and without Nipasept preservative indicated poor antibacterial properties. We conclude that the use of an atomizer on more than one patient poses a risk of cross-infection, and recommend their replacement with a single-use disposable nasal atomizer.

Proliferative myositis arising in the tongue.

We describe a rare case of proliferative myositis affecting the lateral border of the tongue. The site of the lesion and its gross pathological presentation were highly suggestive of a malignant process. Subsequent biopsy and characteristic histological appearance led to the diagnosis of this benign condition. This is the first reported case of a painful presentation of proliferative myositis involving the tongue. This report serves to remind the head and neck surgeon of the need to obtain histological diagnosis of malignancy before embarking upon radical surgical treatment. We recommend careful follow-up to ensure complete resolution of the lesion.

Cricothyroidotomy and the anatomy of the cricothyroid space. An autopsy study.

Airway management is one of the main dictums in anaesthesia, emergency medicine and critical care. Endotracheal intubation, tracheostomy and cricothyroidotomy are all approved methods to secure a patient's airway. Cricothyroidotomy is performed in the space between the anterior inferior border of the thyroid cartilage and the anterior superior border of the cricoid cartilage. We studied 107 autopsies with special interest in the anatomy of the cricothyroid space.

Malignant melanoma arising in the frontal sinuses.

Sinonasal malignant melanoma is rare and usually occurs in the nasal cavity. Presentation is often varied and occurs late in the natural history of the disease, resulting in a poor prognosis. A case is reported of a patient with malignant melanoma arising from the frontal sinus who presented with a forehead swelling and progressive confusion. A review of the literature on malignant melanoma in the nasal cavity and paranasal sinuses regarding its presentation, site of origin and principles of management is discussed.

Maxillary antral lavage using inferior meatal cannula anaesthesia.

Antral puncture and lavage through the inferior meatus is a minor but common otolaryngological procedure, usually performed under local anaesthesia. We describe a new method of introducing local anaesthetic into the inferior meatus, via the use of a soft intravenous cannula connected to a syringe containing 10 per cent cocaine paste. We have called this new technique inferior meatal cannula anaesthesia (IMCA).

Laryngeal Kaposi's sarcoma in patients with AIDS.

Over a period of 10 years 17 human immunodeficiency virus(HIV)-infected patients with laryngeal Kaposi's sarcoma were seen and treated at University College London Hospitals. All patients had advanced HIV disease. Their presentation was with symptoms of upper airway obstruction in the majority of cases and the diagnosis was made by fibreoptic examination of the larynx. Biopsy was associated with brisk haemorrhage in one patient, who required a temporary tracheostomy, and was not performed in the other 16 cases. The commonest site of laryngeal involvement was the supraglottis in 11 patients, with glottic lesions noted in eight patients: subglottic lesions were seen in only three. Treatment of laryngeal Kaposi's sarcoma was, in general, conservative, five patients received low dose radiotherapy to the larynx and 10 were treated with systemic chemotherapy for disseminated Kaposi's sarcoma. Laryngeal Kaposi's sarcoma did not contribute to patient mortality.

An in vitro study of tracheostomy tube cuff herniation and inflation characteristics.

Seven of the most commonly used tracheostomy tubes used in the UK were tested for cuff herniation and creasing in synthetic tracheas corresponding to the shapes and sizes found in vivo. Results demonstrated that only two tubes of one particular brand herniated and that creasing occurred in tubes disproportionately large for the trachea used. A discussion of modern tracheostomy tube manufacture is included.

Infectious pseudomonas subglottic stenosis occurring in a patient with acquired immunodeficiency syndrome.

Pseudomonas aeruginosa is emerging as an increasingly common opportunistic infective agent in the immunocompromised human immunodeficiency virus (HIV) positive patient (Kielhofner et al., 1992). Improvements in the prevention and treatment of opportunistic infections in HIV and acquired immunodeficiency syndrome (AIDS) has led to longer life expectancy (Graham et al., 1992), and this has changed the incidence of Pseudomonas aeruginosa infection in this population (Baron and Hollander, 1993). We present a case of a patient with AIDS who developed a fulminant Pseudomonas aeruginosa stenosing subglottic infection. We are unaware of any previous reports of this particular manifestation of Pseudomonas aeruginosa infection.

Early diagnosis of Wegener's granulomatosis presenting with facial nerve palsy.

Wegener's granulomatosis is a multi-system disease characterized by granuloma formation and a necrotizing vasculitis. It classically presents with involvement of the upper and lower respiratory and renal systems. However locoregional disease is common and may include otological manifestations. Facial nerve palsy has been reported during the course of the disease process but it is extremely rare for it to be the presenting feature. Previously reported cases have involved a protracted diagnostic process including exploratory tympanotomy, mastoidectomy and facial nerve decompression. We report a case of Wegener's granulomatosis which presented with a facial nerve palsy. An early diagnosis was achieved by measurement of the erythrocyte sedimentation rate (ESR), followed by serological assay of cytoplasmic anti-neutrophil cytoplasmic antibody (cANCA). Histological examination of nasal mucosal biopsies confirmed granuloma formation consistent with a diagnosis of Wegener's granulomatosis. This allowed early treatment with immunosuppressive therapy and avoided unnecessary and potentially hazardous middle ear surgery.

Laparoscopically assisted total laryngopharyngoesophagectomy with gastric transposition.

Pharyngolaryngoesophagectomy (PLO) for post-cricoid tumour offers opportunity for cure or reasonable paliation. However, it carries significant morbidity and mortality. We present two patients with post-cricoid carcinomas who underwent laparoscopically-assisted total PLO with gastric transposition without a laparotomy, thoracotomy or thoracoscopy. This technique appears promising for patients with post-cricoid or hypopharyngeal malignancy in reducing operative morbidity, and may represent improvement on conventional open and thoracoscopic techniques in selected patients.