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.

The impact of tracheostomy on the nose.

To establish the effect of tracheostomy on nasal function and quality of life. Teaching Hospital, Scotland, UK. Cross-sectional case-control study. Two groups of patients were selected; a group of ten patients who underwent surgical tracheostomy and a control group of ten patients with confirmed or suspected head and neck malignancy that did not require tracheostomy. Two questionnaires, the SNOT-22 quality of life instrument, and the Rhinogram nasal symptoms score were used to evaluate each group. For the Rhinogram questionnaire the median total score was 13.5 for the tracheostomy group and 2 for the control group (P = 0.02) whilst for the SNOT-22, the mean total scores were 39 and 29, respectively (P = 0.205). The tracheostomy group scored worse for all Rhinogram questions, and for the anosmia score this was independently statistically significant (5 vs. 0 units, P = 0.001). The tracheostomy group most commonly identified "loss of smell & taste" as their most important symptom, compared with only 2 subjects in the control group. Tracheostomy can give rise to nasal symptoms. This needs to be addressed in the routine follow up of these patients.

Globus sensation as early presentation of hypopharyngeal cancer.

OBJECTIVES: To identify if patients with early hypopharyngeal carcinoma can present with only the single complaint of globus sensation. DESIGN: Retrospective case review. SETTING: Teaching Hospital in Scotland. PARTICIPANTS: Cohort of 23 patients with hypopharyngeal carcinoma. Retrospective review of their case notes with regards to their hospital pathway from initial referral from the General Practitioner to diagnosis. OUTCOME MEASURES: Symptoms & signs on presentation, subsequent investigations and time interval between initial presentation and diagnosis. RESULTS: We identified two patients (9%) who presented early with globus or other soft symptoms as the only complaint and with normal clinical findings. There was a 78%'pick up' rate of abnormalities in the barium swallow examination. CONCLUSION: We believe this can have important clinical implications in the screening & investigation of globus patients who represent a significant outpatient workload. We review the relevant literature.

The cause of death in patients with head and neck squamous cell carcinoma.

For patients with head and neck squamous cell carcinoma the cause of death is not well described in world literature. We report data on 106 patients diagnosed with head and neck squamous cell carcinoma who subsequently died. The literature related to this topic is discussed, and recommendations are made for data collection.

Primary sinonasal amyloidosis.

Primary amyloidosis localized to the sinonasal tract is extremely rare with only 20 reported cases in the English literature. We describe a further case and review the literature.

Laryngeal gout.

A review of the literature reveals only 12 reported cases of laryngeal gout. We describe three further cases of laryngeal gout, the largest series ever published. The first case is previously undescribed acute gouty cricoarytenoiditis resulting in acute airway embarrassment requiring tracheotomy, and then we describe two cases of chronic tophaceous involvement of the thyroid lamina with computed tomography (CT) images of this process. The paucity of literature on this subject may not only be due to rarity but also lack of clinical awareness. Gouty involvement of the larynx must be considered in any patient with a history of gout who presents with hoarseness, odynophagia, dysphagia, stridor or neck lump. Acute airway compromise may require tracheotomy, whereas chronic airway problems may necessitate endoscopic tophi removal, lateralization procedures or even permanent tracheostomy.

Recommendations on follow-up strategies for idiopathic vocal fold paralysis: evidence-based review.

INTRODUCTION: Vocal fold paralysis can be an early warning sign of serious extra-laryngeal pathology. Even if imaging investigations show no pathology, there is always concern about the emergence of new pathology in the future. There is currently no consensus on the best follow-up protocol for vocal fold paralysis patients with no abnormalities on investigation. METHODS: Systematic review, using an Ovid and Medline database search of papers written in the English language and published in the last 20 years. RESULTS: Eight relevant studies were identified. Not all of them were directly comparable. A narrative review of the studies is presented and conclusions are drawn. CONCLUSION: Current diagnostic modalities are sufficiently reliable and sensitive to diagnose any significant existing extra-laryngeal pathology. Thus, once initial investigation (including computed tomography) has concluded, no further follow up is necessary.

Reinke's oedema, hormones and hormone replacement therapy.

OBJECTIVE: To study the implications of hormone replacement therapy (HRT) treatment in the pathogenesis of Reinke's oedema (via a possible pseudo-hypothyroidism effect), and also to study why the disease affects a predominantly post-menopausal female population. DESIGN: Prospective case series study. SETTING: Two teaching hospitals and two district general hospitals in Scotland, UK. SUBJECTS: Thirty-three patients diagnosed with Reinke's oedema who presented in the out-patient department before or after treatment. RESULTS: Thyroid function tests were normal in all but two cases. Only three patients were receiving HRT treatment. CONCLUSIONS: The study produced no evidence to support a relationship between HRT treatment and the pathogenesis of Reinke's oedema; this supports previous studies which concluded that thyroid function was not related to the development of Reinke's oedema. Some new ideas regarding hormonal factors in Reinke's oedema are discussed.

Endonasal bilateral simultaneous orbital decompression.

OBJECTIVE: To study the morbidity of the operation, to investigate it's safety and effectiveness in order to establish if it is reasonable to offer it as treatment to patients in one sitting instead of a staged procedure. Finally, to indentify the patient's long term satisfaction and to establish best practice. DESIGN: Retrospective case series study and prospective telephone interview. SETTING: Teaching General Hospital, Scotland, UK. SUBJECTS: 14 patients with dysthyroid orbitopathy who underwent the operation over a 4 year period. RESULTS: Proptosis improved in all but one of the cases. There was a relatively small morbidity and short inpatient stay. A significant amount of patients reported satisfaction with the results. All patients expressed strong preference for the simultaneous procedure instead of a staged one. CONCLUSIONS: The study shows that for the management of orbitopathy , bilateral simultaneous orbital decompression with endoscopic approach is a safe and effective operation, with small morbidity and significant patient satisfaction. Therefore, it is reasonable to offer it to patients instead of a staged procedure.

The management of acute oesophageal obstruction from a food bolus. Can we be more conservative?

The objective was to assess the number of patients with acute oesophageal bolus obstruction that resolves spontaneously and to aid the identification of the best practice. This prospective and retrospective case series study at a teaching hospital and a district general hospital in Scotland, UK, involved 37 patients with acute oesophageal obstruction from a food bolus who were observed for 24 h from the beginning of symptoms. The bolus passed spontaneously in 54% of the patients during the observational period. A short observational period following the admission of patients with acute food bolus obstruction is reasonable as it may reduce exposure to surgical morbidity and decrease inpatient stay.

Management pathways and the surgical diagnosis of tuberculous lymphadenitis: can they be improved? The Bradford experience.

OBJECTIVE: To study the diagnostic pathway for tuberculous lymphadenitis from initial referral to the commencement of antituberculous therapy with the object of identifying potentially avoidable delays. DESIGN: Retrospective case series study. SETTING: District General Hospital, England, UK. SUBJECTS: Thirty-four patients with head and neck tuberculous lymphadenitis diagnosed by a positive histological specimen over the 3-year period 1998-2000. RESULTS: There were no clear pathways for referral and management. There were substantial variations in the management between different specialties and even sometimes within the same specialty. There was evidence of poor communication between various teams. CONCLUSIONS: The study shows that for the management of head and neck tuberculous lymphadenitis, there is a need for a 'hospital' or 'trust' approach. It also reinforces the arguments for a dedicated 'neck lump clinic' with easy access both from the general practitioners and from other specialties within the hospital and for a protocol for handling biopsy specimens from nodes.

Olfactory groove meningiomas.

Olfactory groove meningioma is a rare clinical entity. The principal symptoms associated with olfactory groove meningiomas are anosmia and headache which lead the patient to the ENT specialist. Frontal sinusitis, migraine and neuralgia are most frequent incorrect diagnoses. This retrospective study of 13 consecutive patients who underwent excision of Olfactory Groove meningiomas in the North Staffordshire Royal Infirmary, Department of Neurosurgery over a 20-year period was undertaken to study the presenting features, duration of symptoms, results of surgery, and long-term follow-up. Symptoms were present for less than 6 months to 3 years. Although excision was thought to be complete reoccurrences occurred in four patients. The morbidity of surgery was significant.

The delivery of topical nasal sprays and drops to the middle meatus: a semiquantitative analysis.

The distribution of nasal drugs specifically to the middle meatus is of vital importance in the treatment of rhinosinusitis and nasal polyposis. It is widely assumed that the intranasal distribution is superior with nasal drops rather than spray delivery. However, a comparison of nasal spray and drop delivery specifically to this area has not been studied before. This study aims to compare semiquantitatively the intranasal distribution of nasal sprays and drops to the middle meatus in vivo. A novel method was used whereby a neurosurgical patty was placed in the middle meatus. Topical nasal drops and aqueous sprays dyed with methylene blue (0.1% v/v) were administered in a standardized fashion in normal volunteers. The subsequent absorption of administered dye was classified on a four-point scale. A randomized prospective cross-over design was used for the study. We found that there was no difference in the delivery of nasal drug to the middle meatus between either method of drug administration (P > 0.2). The perceived superiority of nasal drops may therefore be as a result of the acknowledged systemic effect of betamethasone drops.

Are topical antibiotics necessary in the management of otitis externa?

Otitis externa is an inflammatory disorder of the skin of the outer ear canal frequently associated with bacterial or fungal infection. It is normally treated with aural toilet and topical preparations containing antibiotic/antifungal and steroid preparations. A group of 39 patients presenting with otitis externa were randomized in a double-blind manner into those receiving drops containing an aminoglycoside and steroid preparation and those receiving the same preparation without the aminoglycoside. All patients were reviewed on days 0, 3, 7 and 11 of a 14-day course of drops and their response to medication monitored. Patients documented their symptoms at each appointment and clinical response was also measured by a blinded observer. The study suggests that an aminoglycoside antibiotic conveys no significant benefit in this condition.

Inflammatory myositis: a rare differential diagnosis of a neck lump.

Inflammatory myositis is an extremely rare benign inflammatory condition of skeletal muscle. It usually affects the extremities, and there are only 10 cases reported in the head and neck region. Its significance is that in this region it can be clinically mistaken for a neoplasm. We describe a case and review the literature.

Allergic otitis externa.

Chronic otitis externa is a common condition, which is usually successfully treated by topical medications and aural toilet. In cases that persist despite conventional treatment, a diagnosis of allergic otitis externa should be considered. Sensitization to otic medications (secondary contact otitis) is not uncommon. Topical aminoglycosides are the most common sensitizers although many components of topical preparations can cause sensitization. Patients who may have developed allergic otitis externa should undergo patch testing. Otolaryngologists should consider using topical antibiotics with a low allergenic potential and avoiding neomycin when treating patients with otitis externa. Primary contact otitis may occur to metals used in earrings and also to hearing aid moulds. Treatment of both primary and secondary contact otitis consists of identifying the allergen, avoiding further contact and use of simple preparations avoiding common sensitizers.