Long-term results with a simple technique of stoma creation after laryngectomy.

Stomal stenosis after laryngectomy has a major impact on patient rehabilitation. The major contributory factor is the operative technique. The goal is to achieve a widely patent stoma. The objective of the study was to review the long-term results of the technique of stoma creation used by the senior author (CJW). The simple technique, using skin triangles for tracheostoma creation after laryngectomy, has been used by the senior author for past 6 years. Review of 59 cases of total laryngectomy with or without partial pharyngectomies in whom this technique was used for stomaplasty. The technique described for stoma creation after total laryngectomy has been used in 59 patients (48 male, 11 female) over 6 years. The follow-up of these patients varies from 6 months to 6 years. Of these patients 54/59 (91.5%) did not have any problems with the stoma. A total of 5/59 (8.5%) patients, the stoma was narrow. Amongst these patients with narrow stoma, only 1 patient (1.7%) has had dilatation done and the others are managing reasonably with a stoma button. None of the patients in this study has required revision procedures on the stoma. The simple technique of stoma creation described in this study has good long-term results.

Clinical outcomes of total laryngectomy for laryngeal carcinoma.

BACKGROUND: Controversy exists as to the management of advanced laryngeal carcinoma. In general primary radical surgery is favoured. OBJECTIVE: The aim of this study was to analyse the clinical outcome of patients having total laryngectomy for cancer of larynx. MATERIALS AND METHODS: This study was a retrospective case note review and questionnaires were used for evaluating voice handicap. These laryngectomies included in this study were performed by the senior author (CJW) from January 2001 till June 2007 at Leeds General Infirmary, Leeds. Some of the patients had partial or total pharyngectomy in addition to total laryngectomy. RESULTS: In this study a total of 59 patients were included. Seventeen (28.8%) of these patients had preoperative radiotherapy and laryngectomy was performed for residual or recurrent disease. The initial TNM staging of the tumour ranged from T(1)N(0) to T(4)N(2C). Tracheoesophageal puncture for speech prosthesis was done in 48/59 (81.4%) patients. Post-operative complications were seen in 30.5% (18/59) patients. In this study group 9 patients (15.2%) developed pharyngocutaneous fistulas. For communication 31/51 (60.8%) patients were using speech valves. In this study 30.4% had minimal, 26.1% moderate and the rest 43.4% feeling severely handicapped with regards to voice use after total laryngectomy. Five year survival after laryngectomy in this study was 65.2%. CONCLUSION: Long term disease control and survival is achievable with total laryngectomy with or without postoperative radiotherapy with minimal risks in patients with advanced carcinoma of larynx.

Dendritic cells and HNSCC: a potential treatment option? (Review).

Patient survival in head and neck squamous cell cancer (HNSCC) has not changed significantly in many years, despite progress in surgical, radiotherapy and chemotherapy techniques. Immunotherapy, a rapidly progressing alternative cancer treatment, aims to prompt or assist the body's immune system to combat the disease itself. A number of strategies exist including the use of dendritic cells, natural antigen presenting cells capable of stimulating an anti-tumor immune response. Encouraging work has been performed using these cells as vaccines against a number of tumors especially melanoma. Work with head and neck cancer is also encouraging, but less advanced. Dendritic cell presence in head and neck squamous cell cancers is associated with an improved prognosis, however due to immunosuppression, the exact mechanism of which remains poorly understood, these cells do not function efficiently. This prevents the stimulation of an effective anti-tumor immune response by the patient and allows tumor growth to continue. This review summarises the current level of understanding of dendritic cells and their relationship with HNSCC. It briefly summarises work with dendritic cells and other cancers where relevant to HNSCC; dendritic cells and head and neck cancer; the possible causes of dendritic cell impairment; the techniques used to restore their function and the methods used to prime the dendritic cells prior to their use as vaccines for the stimulation of an anti-tumor response.

Luteinizing hormone surge in adult female rats after androgen priming.

The effects of androgens alone and in combination with oestrogens on luteinizing hormone secretion in adult female rats were studied after 1, 2 and 4 months of priming. Each adult female rat was implanted with a Silastic capsule filled with testosterone or dihydrotestosterone alone or together with another similar capsule of oestradiol. An oestrogen challenge test was carried out in each rat after priming. Blood samples were collected before androgen priming. During the oestrogen challenge test, blood samples were collected before (0 h or day 0) and at 12, 24, 36 and 48 h after the intramuscular injection of 50 µg oestradiol vaierate for rats primed for 1 month, or daily for 5 days (days 1 to 5) for other rats. An oestrogen challenge test was also performed in two groups of untreated male and female rats which served as controls. The results indicated that long-term androgen priming had resulted in the attenuation or total blockade of the luteinizing hormone surge which normally occurs during an oestrogen challenge test in adult female rats. This suggests that androgens may be important modulators of the luteinizing hormone surge mechanism in rats. Furthermore, the fact that the luteinizing hormone surge can be blocked by androgen priming in adult female rats suggests that the sexual dimorphic response to oestrogen feedback is not immutably imprinted in the hypothalamic-pituitary axis as was originally proposed.

The impact of long-term testosterone replacement therapy on lipid and lipoprotein profiles in women.

The lipid and lipoprotein profiles of 39 female transsexuals, exposed to testosterone esters (250 mg monthly) for an average duration of 33 months after their sex reassignment operation (group 2), were compared to those of 29 normal menstruating female transsexuals prior to starting androgen therapy (group 1). A third group, comprising 17 post-operative female transsexuals were studied while on, and after stopping their androgen therapy for 6-12 months (group 3). The average concentration of testosterone in androgenized women was comparable to those found in normal males and levels of SHBG were significantly lower than those in the control group. No significant difference was noted between all levels of lipids and lipoproteins in pre-operative subjects of group 1 and corresponding levels in subjects of group 3 after they had stopped their androgen therapy for 6-12 months. Significantly higher levels of triglyceride (Trig), total cholesterol (TC), low-density lipoprotein (LDL-C) and apolipoprotein-B (Apo B) and a significantly lower level of high-density lipoprotein-cholesterol (HDL-C) were noted in androgenized women (group 2) when compared to controls (group 1). The two atherogenic indices, LDL-C/HDL-C and Apo-AI/Apo-B were significantly raised and lowered, respectively. Similar results were noted when comparing lipid and lipoprotein profiles in subjects of group 3 while they were on and after stopping their androgen therapy. Results from this study indicate that testosterone, per se, at supraphysiological doses may promote atherogenicity in women. Furthermore, the male predilection for coronary vascular diseases (CVD) may be due to the adverse effects of higher androgen levels on lipid and lipoprotein profiles.

Effect of Norplant implants on liver, lipid and carbohydrate metabolism.

In this study involving 100 women, the metabolic changes seen with Norplant use were evaluated. Besides a significant increase in serum bilirubin, there were no other changes in liver function to suggest possible hepatocellular dysfunction at the end of five years. Even the raised mean levels of bilirubin remained within the normal clinical range for the local population. As regards lipid metabolism, total triglycerides, cholesterol and LDL-cholesterol were decreased through the five years of Norplant use. The HDL-cholesterol showed a significant increase in the first year; it then decreased over the years to its preinsertion level at the end of five years. As a result, the HDL-cholesterol/Total cholesterol - HDL-cholesterol showed a significant increase in the first year and then decreased to almost its preinsertion value at the end of five years. The findings appear to indicate Norplant use not to be contributory to cardiovascular risk. The use of Norplant was not associated with any significant effect on carbohydrate metabolism.

PIP: Health workers at the National University Hospital in Singapore drew blood samples from 100 women prior to insertion of Norplant and at month 6, 12, 24, 36, 48, and 60 to study the effects of Norplant on metabolic function. After 5 years of use, the bilirubin level was significantly higher (50%) than preinsertion levels (p.001). This was the only significant change in liver function. Further the mean level of bilirubin and other parameters of liver function were within the clinical range for all 100 women. High density lipoprotein (HDL) cholesterol level rose considerably the 1st year (p.001), but within 2 years it fell significantly below the mean preinsertion level (p.01). At the end of the study, however, it increased to almost its preinsertion level. The HDL cholesterol/total cholesterol - HDL cholesterol increased considerably the 1st year (p.001), but decreased over the remaining years to almost the preinsertion level (p.05). In fact, it always remained above 0.200--a level below this indicated an increased risk of acquiring coronary heart disease or progression of existing disease. No significant changes in carbohydrate metabolism occurred during the 5 years of the study. The results of the lipid and carbohydrate metabolic tests indicated that Norplant does not increase cardiovascular risk and may indeed protect against cardiovascular conditions. The researchers concluded that the evidence shows that Norplant can be used more often in the future.

Effect of Norplant-2 rods on liver, lipid and carbohydrate metabolism.

The effect of Norplant-2 rods on liver, lipid and carbohydrate metabolism was evaluated in 100 women using Norplant-2 rods. Besides a significant increase in serum bilirubin, there was no other obvious evidence to suggest any possible hepatocellular dysfunction with the use of Norplant-2 rods. As regards lipid metabolism, decreases in total triglycerides, cholesterol and LDL-cholesterol and HDL-cholesterol were initially seen. These parameters returned to their preinsertion mean at the end of five years. As a result, the value of the HDL-cholesterol/total cholesterol - HDL-cholesterol and LDL-cholesterol/HDL-cholesterol ratios remained around their preinsertion value at the end of five years. All this appears to indicate that the use of Norplant-2 rods is not directly contributory to cardiovascular risk. The use of Norplant-2 rods was not associated with any significant effect on carbohydrate metabolism.

Lipid and biochemical changes after low-dose oral contraception.

A randomized double-blind study of the metabolic effects of 2 low-dose combined oral contraceptives was carried out in Singaporean women. The subjects comprised 58 women randomly allocated to two treatment groups (29 each): norethisterone 1 mg/ethinyl estradiol 35 micrograms (NET/EE) or levonorgestrel 150 micrograms/ethinyl estradiol 30 micrograms (LNG/EE) and a control group of 23 women using intra-uterine devices (IUD). Blood samples were taken on admission and at 3 and 12 months after pills or insertion of IUDs. Fasting glucose levels were decreased while 2h glucose and triglyceride were increased throughout the treatment period in NET/EE group [corrected]. LNG/EE group only showed significant increase of 2h glucose at 12 months and decrease of LDL cholesterol at 3 months while total cholesterol was significantly suppressed at 3 and 12 months [corrected]. The atherogenic index, LDL/HDL cholesterol was significantly reduced by 12 months. Both groups had no change in hemoglobin, hematocrit and total protein levels but alkaline phosphatase, bilirubin and aspartate transaminase (SGOT) were suppressed. While NET/EE suppressed albumin significantly, this was not observed with LNG/EE group. However, these differences observed with use of each pill preparations, were not so obvious between treatment groups and control. Changes in total, HDL and LDL cholesterol and SGOT were not significantly different than the IUD group. Furthermore, except for 2h glucose, there was no increase in the number of abnormal parameters after treatment. On the contrary, there was a reduction of abnormal values in most liver function parameters. Thus, except for glucose intolerance, the observed changes in metabolic parameters may not constitute any clinical significance.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: This randomized double-blind study of the metabolic effects of two low-dose oral contraceptives was conducted in 58 randomly selected Singaporean women. Study subjects were divided into two treatment groups: 1) norethisterone 1 mg/ethinyl estradiol 35 mcg (NET/EE) or levonorgestrel 150 mcg/ethinyl estradiol 30 mcg (LNG/EE) were given to 35 women; 2) a control group of 23 women using IUDs. Blood samples were taken on admission and at 3 and 12 months after pills or insertion of IUDs. Findings demonstrate a significant decrease in mean fasting glucose and in 2-hour glucose loading, while triglycerides were increased throughout the treatment period in the NET/EE group. The LNG/EE group only showed significant suppression of the 2-hour glucose loading at 12 months and low-density lipoprotein/high-density lipoprotein (LDL/HDL) cholesterol was significantly reduced by 12 months. Both groups had no change in hemoglobin, hematocrit and total protein levels, but alkaline phosphatase, bilirubin and aspartate transaminase (SGOT) were decreased. Decreased albumin was observed in the NET/EE group, but not in the LNG/EE group. Changes in total HDL and LDL cholesterol and SGOT were not significantly different in the treatment group compared to the IUD group, except for the 2-hour glucose loading. There was no increase in the number of abnormal parameters after treatment. On the contrary, there was a reduction of abnormal values in most liver function parameters. Thus, except for glucose intolerance, the observed changes in metabolic parameters may not be of any clinical significance.

A comparative study of the effects of a monophasic and a triphasic oral contraceptive containing ethinyl estradiol and levonorgestrel on lipid and lipoprotein metabolism.

A comparative study of the effects of a monophasic and a triphasic oral contraceptive containing ethinylestradiol (EE) and levonorgestrel (LNG) on lipid and lipoprotein metabolism was conducted on 45 Singapore women under the WHO Special Programme of Research in Human Reproduction. The women were randomly allocated to one of the two pill groups--a triphasic preparation containing low doses of LNG and EE in various proportions and a monophasic preparation of 150 micrograms LNG and 30 micrograms EE, and an additional 18 women, choosing to use IUDs, were recruited as controls. Blood samples were taken at admission, 3 and 12 months thereafter. For both pill groups, total cholesterol decreased with duration of use, while HDL cholesterol decreased slightly at 3 months and thereafter increased. LDL cholesterol decreased slightly at 3 months, returning to baseline at 12 months for the monophasic group, while remaining unchanged at 12 months for the triphasic group. The monophasic preparation appeared to lower total, LDL and HDL cholesterols to a greater extent at 3 months than the triphasic preparation. Compared with IUD users, for the monophasic group, both total and HDL cholesterols were significantly lower at 3 months and HDL and LDL cholesterols were lower at 12 months. In addition, ratios of HDL cholesterol/LDL cholesterol and HDL cholesterol/total cholesterol were significantly lower at 12 months. Changes in triglycerides were minimal for both pill groups. However, at 3 months, triglycerides for the triphasic group were significantly higher than the IUD users, but this observation was not of any clinical importance since comparison of changes with their respective pretreatment values were not statistically significant. These results indicate that these changes are related to the dosage and estrogen-progestogen ratio of the preparation. Furthermore, the monophasic preparation may have a disadvantage over the triphasic preparation since it appears to cause more disturbance in lipid metabolism. However, it is noted that these changes in lipids and lipoproteins were minimal and did not appear to be of any clinical significance.

Endoscopic division of the ary-epiglottic folds in severe laryngomalacia.

OBJECTIVE: Laryngomalacia is the commonest cause of congenital stridor. The underlying anatomical abnormality associated with this condition is a prolapse of the supraglottic tissues into the laryngeal inlet during inspiration, and may involve the epiglottis, ary-epiglottic folds and the corniculate mounds of the arytenoids. However, it has been noted that the most consistent structural abnormality seen in these cases is the shortening of the ary-epiglottic folds and marked side to side curling of the epiglottis. We describe the follow-up and outcome of 33 cases treated by the simple division of the ary-epiglottic folds. METHOD: All case notes were reviewed with respect to indications of operation, age of operation, endoscopic findings, operative technique, complications and follow-up until resolution of symptoms. RESULTS: Surgical outcomes could only be ascertained in only 32 patients. Twenty-two cases (68.7%) showed complete resolution of stridor and associated complications of laryngomalacia. In the remaining ten cases who could be followed up (31.2%), seven patients (21.8%) showed partial resolution with no further surgery required, two patients (6.2%) required additional excision of redundant mucosa as second procedure, one patient (3%) with associated cleft lip/palate and tracheomalacia had to undergo a tracheostomy. There was improvement in feeding after surgery in all the 12 patients (100%) who had had pre-operative feeding difficulties. All the four patients with cyanosis pre-operatively were cured, but one of the two patients with apnoeic episodes pre-operatively continued to have apnoeic spells despite resolution of their laryngomalacia. CONCLUSION: Simple endoscopic excision of the ary-epiglottic folds is a quick, reliable, highly effective procedure with very few complications. We recommend its use as the first line option in the management of severe laryngomalacia, with more extensive methods reserved for the very occasional case of primary failure.

Open septorhinoplasty approach for the excision of a dermoid cyst and sinus with primary dorsal reconstruction.

Adult nasal dermoid cysts and sinuses are rare. Here we describe the surgical management of a 37-year-old patient with a longstanding nasal dermoid cyst and discharging sinus. A combination of an open rhinoplasty approach with a small dorsal incision was used to excise the lesion followed by primary reconstruction with septal cartilage.

The use of a nasal obturator in hereditary haemorrhagic telangiectasia: an alternative to Young's procedure.

Epistaxis associated with hereditary haemorrhagic telangiectasia (HHT) is a challenging condition. Septodermoplasty, electrocautery and laser treatment often provide short-term relief only. The surgical closure of the nostrils ('Young's procedure') represents a longer term solution but has the disadvantage of causing permanent complete nasal obstruction. A Silastic obturator has the advantage of being a non-surgical intervention and allows temporary relief of the nasal obstruction. We present the cases of three patientswith HHT who used the obturator with good clinical effect, suggesting that this is a realistic non-surgical alternative to Young's procedure for patients with HHT.

Glycosylated haemoglobins in women with low risk for diabetes in pregnancy.

Glycosylated haemoglobin levels (HbA1) were determined in 489 normal pregnant Singaporean women, attending a diabetic screening programme using a 50g glucose challenge test. All subjects had no risk factors for diabetes mellitus nor a history of previous gestational diabetes. They were selected when the 1h 50g glucose challenge (GCT) is < 6.66 mmol/l or a 2h post-glucose level of < 7.77 mmol/l (a 75g OGTT is repeated within a week of an abnormal GCT). Another 18 subjects with normal OGTT but did not have a 50g glucose challenge done were also included in the study. Mean and normal range (2 SD) of HbA1 levels in all subjects were 4.64% and 3.66-5.62%, respectively. Mean HbA1 levels also varied with gestation and ethnic group. The HbA1 appeared to be low at early gestation with nadir at 21-24 weeks and thereafter returned to initial levels at term. In Chinese, mean HbA1 levels, random plasma glucose and 1h glucose challenge were significantly higher than those of the Malays but not the Indians. In referring to these levels, the variation within gestation and ethnic group must also be considered.

The 75 and 50g OGTT response in normal pregnant women.

The 75 and 50g OGTT (Oral Glucose Tolerance Test) responses were studied in 86 normal healthy pregnant women (mean age 28.7 +/- 0.4 (SEM) years) at 28 and 32 weeks respectively. Of these were 50 Chinese, 20 Malays and 16 Indians. Mean glucose responses at fasting, 1 and 2h post glucose load were 78.3 +/- 0.7, 132.2 +/- 2.8 and 116.2 +/- 2.1 mg/dl respectively for the 75g OGTT and 78.5 +/- 0.7, 130.5 +/- 2.5 and 106.7 +/- 1.8 mg/dl respectively for the 50g OGTT. Except for the 2h responses, corresponding responses between both OGTTs were not significantly different. All races showed a similar OGTT response. Using a set criteria for diagnosis of abnormals resulted in gross inconsistency in the number of abnormals diagnosed for both OGTTs. However, the use of 95th percentile shows a closer agreement in the diagnosis of abnormal cases for both OGTTs. Also, the 2h OGTT response for the 75g OGTT is higher than that of WHO's criteria for impaired glucose tolerance. This emphasizes the need to establish our own reference range.

Long-term oestrogen priming on basal and oestradiol-induced release of luteinising hormone secretion in male rats.

The response of prolonged oestrogen priming (by silastic implants) of the male rat hypothalamic-pituitary axis (HPA) to an oestrogen challenge test was investigated. Basal LH levels were suppressed to a maximum at two months and remained unchanged by four months. In contrast to response in human, oestrogen priming had failed to stimulate a positive feedback response to an oestrogen challenge test in the male rats. Instead, oestrogen priming might have attenuated the negative LH feedback response. Increasing the dose of oestrogen priming by increasing the duration was not effective in inducing positive feedback in the male rats. The failure of these priming regimes to stimulate positive feedback in male rats may reaffirm our earlier suggestion that oestrogen does not play an important role in activating the cyclic centre in rats. This would also contradict the suggestion that testicular secretions may have acted through conversion to oestradiol in the suppression of the cyclic system in males during the critical period of differentiation of the HPA.

Use of narrow-band imaging in detection of nasopharyngeal carcinoma.

AIM: To compare narrow-band images of nasopharyngeal carcinoma with those of normal adenoidal tissue. METHOD: Patients with a nasopharyngeal mass were evaluated using both conventional white light and narrow-band light. Biopsies were performed and Epstein-Barr viral serology was tested for all patients. RESULTS: Thirty consecutive patients were recruited. Twenty-one patients had normal adenoidal tissue and seven had nasopharyngeal carcinoma. One patient with papillary adenocarcinoma was excluded. The features of narrow-band imaging in normal adenoidal tissue were: (1) a regularly arranged follicular pattern, and (2) each 'follicle' comprising a pale centre with surrounding dark periphery. The features of narrow-band imaging in nasopharyngeal carcinoma were: (1) absence of surface patterns (n = 7), and/or (2) 'reverse', haphazard follicular pattern comprising a dark brown centre and pale periphery (n = 3). CONCLUSION: Narrow-band imaging of the surface of adenoidal tissue and nasopharyngeal carcinoma appears to identify distinct, characteristic features as described. Narrow-band imaging may be a useful adjunct in differentiating normal adenoidal tissue from malignancy. Further studies are needed to evaluate its diagnostic accuracy.

Recurrent nasopharyngeal carcinoma masquerading as acoustic neuroma.

This is the first report of recurrent nasopharyngeal carcinoma (NPC) presenting as a cerebellopontine angle mass. The clinical presentation, investigation and management of this case, as well as the confusion and dilemma caused, are discussed. We hope to increase awareness on the multifaceted ways in which recurrent NPC could present and to share the lessons learnt from our management of this unusual and unfortunate case.

Breaking the speed limits of phase-change memory.

Phase-change random-access memory (PCRAM) is one of the leading candidates for next-generation data-storage devices, but the trade-off between crystallization (writing) speed and amorphous-phase stability (data retention) presents a key challenge. We control the crystallization kinetics of a phase-change material by applying a constant low voltage via prestructural ordering (incubation) effects. A crystallization speed of 500 picoseconds was achieved, as well as high-speed reversible switching using 500-picosecond pulses. Ab initio molecular dynamics simulations reveal the phase-change kinetics in PCRAM devices and the structural origin of the incubation-assisted increase in crystallization speed. This paves the way for achieving a broadly applicable memory device, capable of nonvolatile operations beyond gigahertz data-transfer rates.

A quality assurance survey to improve communication between ENT specialists and general practitioners.

INTRODUCTION: Communication between medical specialists and primary care providers in the community plays a pertinent role in patient care and doctor education. Referral and reply letters are the most common means by which doctors exchange information. Much of clinician time is spent writing letters, but the information or the format in which the letter is written may not meet the needs of the recipient. This study aimed to determine the type of reply letter preferred by general practitioners (GPs) and as such, attempts to improve communication between doctors as part of a quality assurance survey. METHODS: Questionnaires were mailed out to 1,700 GPs in Singapore. Each questionnaire was accompanied by two sample reply letters from the Department of Otorhinolaryngology-Head and Neck Surgery. The sample letters were written in different formats. Letter 1 was written in a non-structured, free text format and Letter 2 included a structured summary at the beginning. Both letters contained the same amount of information and the same number of words. RESULTS: A total of 535 replies (response rate 32 percent) were received. Letter 2 was preferred in 97 percent of the responses. 96 percent of the doctors found Letter 2 to be easier to read, while 86 percent felt it contained more information and 64 percent felt that Letter 1 took a longer time to read. CONCLUSION: Our study shows that there is a preference for diagnosis and treatment plan to be presented in a summary style report rather than as free text. A structured format for reply letters, including the use of headings, allows readers to easily identify the information desired and thus improves the quality of correspondence between specialists and GPs.