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.

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.

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.

Is reflux noted at diagnostic rigid oesophagoscopy clinically significant?

This study assessed the ability of otolaryngologists to diagnose and grade reflux disease at rigid endoscopy. Twenty-one out of 25 senior otolaryngologists who were questioned by means of a telephone survey said that if they find evidence of reflux disease at rigid endoscopy of the oesophagus and larynx, their practice is to place the patient on a proton pump inhibitor for six weeks without requesting pH and manometry studies, and without referral to a gastroenterologist. Over a two year period, 21 patients were diagnosed as having reflux disease at rigid endoscopy. This was based on the finding of fluid and erythema in the aerodigestive tract and upper oesophagus. Subsequent oesophageal pH and manometry was performed. Nine out of 21 patients were confirmed as refluxers. This demonstrated an accuracy of less than 50 per cent when using these findings to diagnose gastro-oesophageal reflux at rigid endoscopy.

The problem of seeing hospital staff without G.P. referral--the otolaryngological experience.

Over a three month period, a record was kept of the number of hospital staff who approached the E.N.T. team requesting help for a medical problem. Staff members included doctors, nurses, clerical staff, paramedical staff and porters. The total number of employees in the hospital was recorded. The average General practitioner public patient list (General medical Service cardholders) for South Dublin was recorded (our hospital is in south west Dublin). The total number of hospital staff seen by E.N.T. in 3 months was seventy seven. The total number of hospital staff seen by other surgical specialties was approximately one hundred and sixty seven. Extrapolation of numbers seen by E.N.T. service in three months to numbers seen over a one year period is 308 patients. The numbers seen by the E.N.T. service in three months corresponds to 11.7% of the average South Dublin General Practitioner Medical card list. It has been estimated that approximately 20% of all problems the average General practitioner sees in a week are E.N.T. related. Those practices with a smaller paediatric population would have approximately 15% of the total practice concearned with E.N.T. problems. Therefore as 15% of 2,400 (total hospital staff) = 360, there is potentially a small General Practice which is 'hidden' within the hospital.

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.

Malignant otitis externa--a high index of suspicion is still needed for diagnosis.

Malignant otitis externa is a destructive inflammatory process of the petrous temporal bone which if untreated leads to osteomyelitis of the skull base and can be fatal. It is more common in immunocompromised and elderly insulin-dependant diabetic patients and is caused by infection with Pseudomonas species. Despite a range of laboratory and radiological tests it still remains difficult to diagnose, particularly in the early stages when it can be treated medically. We describe three cases which presented to this department in the past twelve months. In all cases the diagnosis was made clinically and confirmed per-operatively. Interestingly all three cases were relatively young patients who did not have an immunocompromised status and were not diabetic.

Maxillary artery embolisation in the management of epistaxis.

Serious consideration needs to be given to the importance of early embolisation of the maxillary artery in severe and refractory epistaxis. This is particularly true in the young fit person with traumatic epistaxis and in the elderly person who is unfit for general anaesthesia. Embolisation is now a safe and reliable technique. Six patients were embolised. In the two institutions from 1999 - 2000. All responded well to embolisation without complication. This paper describes the technique used in our hospitals and suggests that with the advent of platinum coils and pre embolisation arteriography, the chances of cerebrovascular accident is very small.

The use of botulinum toxin in otorhinolaryngology.

In recent years, the use of botulinum toxin has become more popular for the treatment of a wide variety of diseases in the head and neck. It offers the possibility of non-invasive treatment of conditions whose aetiology lies in neuromuscular dyskinesis.