Audit of GP Referrals for Tonsillectomy to the ENT Clinic Using Present HIQA Guidelines.

Recurrent sore throat for possible tonsillectomy is the commonest clinical entity referred to the ENT outpatient department. The numbers involved represent a large clinical burden on the service. Not all of these patients require surgical intervention. Patients who fit the criteria for tonsillectomy are faced with two stage obstacles; the long waiting time until assessed by the Otolaryngologist at OPD and the time spent on long operative waiting lists. The aim of this study was to analyze the percentage of referred patients with sore throats requiring tonsillectomy versus those not needing surgery, using the present HIQA guidelines for this operation.

Mediastinal masses masquerading as common respiratory conditions of childhood: a case series.

INTRODUCTION: Leukaemia and lymphoma may present with symptoms and signs mimicking common respiratory conditions of childhood such as asthma or croup. The UK National Institute for Clinical Excellence guidelines for referral for suspected cancer state that "the primary healthcare professional should be ready to review the initial diagnosis in patients in whom common symptoms do not resolve as expected" and "must be alert to the possibility of cancer when confronted by unusual symptom patterns" (National Institute for Health and Clinical Excellence, 2005). RESULTS AND DISCUSSION: A child with an undiagnosed mediastinal mass presenting with signs and symptoms suggestive of asthma or croup may be given oral systemic steroids. We report four such illustrative cases presenting to a single institution within the last 3 years. CONCLUSION: We highlight key points from the history and examination findings which should lead to review of the original diagnosis, the benefit of early chest X-ray in such cases and the dangers of steroid pretreatment.

One to make the diagnosis. A case of non tuberculous mycobacterial mastoiditis in a nine year old female.

Some members of the Non-Tuberculous Mycobacteria family are free living organisms in the environment. They may be pathogenic in the immunocomprimised or in chronic lung disease. We describe a case of a nine year old of Asian descent who presented with clinical mastoiditis where the pathogenic organism was Mycobacterium Gordonae. The decision was made to give the patient full antimycobacterial treatment and subsequently the patient made a full recovery.

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.

Guidelines for the medical management of Irish children and adolescents with Down syndrome.

Down syndrome (DS) is the most common chromosomal cause of developmental disability in Ireland. Children with DS have a high incidence of associated treatable medical disorders where early intervention carries a better outcome. Currently there are no agreed protocols for the screening and management of children and adults with DS in Ireland. A cross-sectional study of 394 children and adolescents was undertaken in the Eastern Regional Health Authority (ERHA) to assess the medical needs of children and adolescents with DS, in order to develop medical management guidelines. This study provides evidence-based data that children and adolescents with DS have a high incidence of treatable medical disorders, which supports the need for the medical management guidelines presented.

General practitioner ENT referral audit.

BACKGROUND: During 2009, there were 3.3 million outpatient attendances at outpatient clinics across Ireland. Up to 20 % of these are directed towards ENT services. AIMS: To determine the compliance rate of general practitioners with the ICGP referral guidelines. METHODS: One-hundred referrals received were compared to the ICGP standardised form and graded accordingly. Each referral letter was graded to a maximum of 37 points. RESULTS: The average score recorded for referrals was 16/37. The referrer detail section scored the highest with a mean of 75.42 % (paediatric referrals) and 72.9 % (adult referrals). The clinical information provided demonstrated compliance rates of 34 % (paediatrics) and 35 % (adults). In total, only 32 letters made any reference to findings on examination. Both paediatric and adult referrals scored an average of 42 % when patients' details are considered. CONCLUSION: This study demonstrates poor compliance rates with the introduced ICGP standardised referral form, which has implications for the accurate grading of referral letters received.

Hemispheric specialization for speech and non-verbal stimuli in Chinese and French Canadian subjects.

Dichotic speech (CV syllables) and non-verbal stimuli (melodies, tones and triple tones) were presented to 20 French Canadian (10 men, 10 women) and 19 Chinese (10 men, 9 women) right-handed university students to investigate cultural and sexual differences in auditory functional asymmetry. Analyses of variances on correct scores showed a REA in the perception of speech and a LEA in the perception of melodies and triple tones for both groups. Cross-cultural effects were observed for speech only, indicating a better overall performance on the part of French Canadian students. Moreover, women were better than men in the perception of tones and triple tones, suggesting that women may attend more to intonational information. Finally, the results for both ethnic groups showed the same pattern of interhemispheric functional asymmetry for speech and non-speech material.

Intracellular glutathione levels in T cell subsets decrease in HIV-infected individuals.

The authors have shown previously that intracellular glutathione (GSH) plays an important role in the regulation of human immunodeficiency virus (HIV) transcription and replication in vitro, through modulation of signal transduction by inflammatory cytokines. Moreover, intracellular GSH levels are known to regulate T-lymphocyte function. In multiparameter FACS studies presented here, we show that relative GSH levels in CD4+ and CD8+ T cells from HIV+ individuals are significantly lower than in corresponding subsets from uninfected controls. These studies define the relative intracellular glutathione (GSH) levels in CD4+ T cells, CD8+ T cells, B cells, and monocytes from 134 HIV-infected individuals and 31 uninfected controls. The greatest decreases in intracellular GSH occur in subsets of T cells in individuals in the later stages of the HIV infection. In AIDS patients, GSH levels are 63% of normal in CD4+ T cells (p less than 0.0001) and are 62% of normal in CD8+ T cells (p less than 0.0001). Similarly, in AIDS-related complex (ARC) patients, GSH levels are 66% of normal in CD4+ T cells (p less than 0.003) and are 69% of normal in CD8+ T cells (p less than 0.003). These findings suggest that low intracellular GSH levels may be an important factor in HIV infection and in the resulting immunodeficiency.

Transhiatal esophagectomy with gastric transposition for pharyngolaryngeal malignant disease.

Between 1981 and 1988, 41 patients underwent pharyngolaryngoesophagectomy with transhiatal gastric transposition and primary pharyngogastrostomy for hypopharyngeal, laryngeal, and cervical esophageal carcinoma. All patients had squamous cell carcinoma. Twenty-one patients had been treated initially by high-dose radiotherapy, but the tumor had either persisted or recurred. Four patients had previously received high-dose local radiotherapy to the neck for unrelated diseases, and in 16 patients no preoperative radiotherapy was given. There was one operative death. Anastomotic leaks developed in nine previously irradiated patients and three required flap reconstructions. Thirty patients had satisfactory swallowing postoperatively and three swallowed poorly. Delayed gastric emptying was a serious problem in two patients, necessitating pyloric bag dilatation in one and pyloroplasty in another. The average postoperative stay was 31 days. Thirty-seven percent survived longer than 12 months and 15% longer than 24 months. The probability of survival after 2 years is 35%. All deaths from recurrent disease occurred within 412 days postoperatively. At present, pharyngolaryngoesophagectomy with gastric transposition and primary pharyngogastric anastomosis offers the best chance for cure or palliation with acceptable morbidity and function for selected patients with advanced hypopharyngeal and laryngeal tumors.

Multiresistant Pseudomonas aeruginosa in a pediatric cystic fibrosis center: natural history and implications for segregation.

It has been suggested that cystic fibrosis (CF) patients harboring multiresistant (MR) Pseudomonas aeruginosa (PA) should be seen in separate clinics. The aim of this study was to test the feasibility of this by longitudinally studying the consistency of isolates of MRPA in individuals. We analyzed all respiratory tract cultures undertaken in 1 year from a pediatric CF clinic population (n = 367). PA was classified as MR according to the definition of the American CF Foundation: resistance to all agents in at least two of the following groups of antibiotics: beta-lactams, aminoglycosides, and fluroquinolones. PA was cultured from 96 children during the year of study. Thirty-six were infected with at least one MR strain. Following initial identification of MRPA, MR in subsequent cultures was highly variable. Twenty-three of 36 patients had subsequent cultures in which PA was identified. However, 21 of 23 patients had at least one isolate that was not MR following detection of MRPA. The variability with time in isolation of MR strains from individuals demonstrates the potential difficulties in designing segregation policies based on antibiotic sensitivity patterns.

Inflammatory endobronchial polyps in childhood: clinical spectrum and possible link to mechanical ventilation.

Inflammatory polyps of the airways are now regarded as histopathologically distinct nonneoplastic endobronchial lesions, which in adults are associated with a variety of chronic inflammatory insults. However, their clinical presentation in the pediatric population is extremely rare, with the etiology of such polyps poorly defined. The clinical and histopathological data from four pediatric patients, identified in the histopathology files of the Royal Brompton Hospital, were retrospectively reviewed. Three out of 4 patients had a history of mechanical ventilation in the neonatal period. In these 3 patients, the polyps were all situated in the proximal airways on the right side. These 3 patients presented at 6 weeks, 7 weeks, and 2 years, respectively, and were successfully treated by polypectomy at rigid bronchoscopy, with subsequent return to normality. One patient, presenting at 12 years of age without history of iatrogenic intervention, underwent a left lower lobectomy for a polyp sited in a segmental bronchus. Presentation in 3 of the 4 patients was with lobar collapse. The fourth patient presented with hyperinflation. We conclude that inflammatory endobronchial polyps may be associated with a history of mechanical ventilation in the neonatal period, polyp formation perhaps being secondary to airway trauma. The small caliber of the main airways in neonates may also be a contributory factor in presentation.

Tonsillitis, tonsillectomy and weight disturbance.

To determine the relationship between tonsillitis, tonsillectomy and abnormalities in body weight, we have analyzed pre- and post-operative weights in a population of 55 children who underwent adenotonsillectomy in our department. Pre-operative mean weight was 9.8% heavier than the standard mean normal weight for age and post-operative mean weight was 22% greater than standard mean weight for age. The mean weight gain during the follow-up period was 12% greater than that which would be normally expected (p < 0.001). This study suggests that children undergoing tonsillectomy are slightly heavier than their peers and that following the procedure this discrepancy increases.

Tympanostomy tubes and early post-operative otorrhea.

Otorrhea is a recognized complication of tympanostomy tube insertion. This may be caused by external contamination or by the pre-existing conditions in the middle ear cleft. Some surgeons try to reduce the risk of surgical contamination by using a non-touch technique, never allowing the gloved hand to come into contact with the tympanostomy tube. A prospective study was carried out on 66 children to evaluate the efficacy of the non-touch technique. One tympanostomy tube was inserted by the non-touch method with the contralateral ear acting as a touched control in each patient. Postoperative otorrhea occurred within 10 days in 1.67% of the non-touch ears and in 1.67% of the controls. This study demonstrates a low incidence of otorrhea in the early post-operative period with either technique. Time-consuming and costly sterile precautions are unnecessary for this common procedure.

Improvements in health and behaviour following childhood tonsillectomy: a parental perspective at 1 year.

To determine subjective parental impressions following routine tonsillectomy we have interviewed the parents of 80 children 1 year following the procedure. Results show that the procedure carried a 100% parental satisfaction rating. All parents felt their child's symptoms of recurrent acute tonsillitis had improved and over 90% of parents felt their child's general health had improved. Sixty-four percent of the parent population reported a noticeable improvement in their child's sleeping pattern and over 30% described an improvement in their child's general behavior. Although this study reports subjective data, and we do not have a comparable control population, these findings provide an interesting insight into parental impressions regarding alterations in their child's health, sleep pattern and behaviour following this procedure.

The role of the middle ear and tonsil in the etiology of febrile convulsions.

The middle ear and tonsil are thought to be important sources of infection in children with febrile seizures. However, these patients are rarely examined by an otolaryngologist in the acute phase and we are unaware of any previous studies where otolaryngologists have documented the presence of acute suppurative otitis media (ASOM) and tonsillitis in a series of children with febrile convulsions. We carried out a prospective study on 47 children admitted to two Dublin hospitals with a diagnosis of simple febrile convulsion. All children were examined by an otolaryngology resident within 6 h of admission. Nine children were noted to have ASOM and 18 had acute tonsillitis. The otolaryngology resident's opinion of the condition of the ears and throat often differed from that of the admitting pediatric resident, as documented in the clinical records. We review the recent literature on febrile convulsions and discuss the possible role of the otolaryngologist in the prevention of seizure recurrence.

Nasal granuloma gravidarum.

Nasal granuloma gravidarum is a rare condition that arises exclusively during pregnancy. It usually presents with the non-specific symptoms of nasal bleeding and obstruction though occasionally a patient may notice an intra-nasal mass herself. Three cases of nasal granuloma gravidarum are presented to add to those previously recorded in the literature. Although the aetiology of this condition is unclear, the authors speculate that it probably represents an excessive healing response to some minor trauma sustained in a tissue primed and sensitized by pregnancy. The management of this lesion is discussed and a simple surgical procedure described for its removal.

Bacterial tracheitis.

Bacterial tracheitis is the term used to describe a severe infraglottic infection characterized by toxicity, brassy cough, inspiratory stridor, subglottic oedema and the presence of copious mucopurulent secretions in the trachea. It is an uncommon condition that requires prompt diagnosis and intensive medical therapy if significant morbidity and mortality are to be avoided. Since the condition was first described in 1979 approximately one hundred cases have been reported. In this paper we present four children with bacterial tracheitis to add to the current literature. Interestingly, one child was admitted on two separate occasions with the disease, an event not previously recorded. All patients underwent endoscopy which revealed findings typical of bacterial tracheitis in each case. None required tracheostomy though three required nasotracheal intubation. Post-endoscopy all were managed in the Intensive Care Unit. There were no fatalities or significant morbidity. The average duration of hospitalization was seven days.

B-mode ultrasound demonstration of non-luminal carotid artery invasion by tumour.

Invasion of the adventitia of the carotid artery by tumour is not demonstrated by contrast CT scanning. We report a case in which B-mode ultrasound was successfully used to demonstrate this.

ENT surgery in children with inherited bleeding disorders.

Inherited bleeding disorders are frequently considered an absolute contraindication to tonsillectomy and other ENT procedures. Over a 15-year period we have performed ten elective tonsillectomies and five bilateral myringotomies on children with inherited bleeding disorders. All procedures were carried out with the close co-operation of the Haematology Department in the hospital. All patients underwent uneventful surgery. One patient returned after tonsillectomy with a secondary haemorrhage which did not require surgical intervention. We present our team approach to the management of these children and demonstrate that necessary surgical intervention can be undertaken safely in this select group of patients.

Upper airway invasion by well-differentiated thyroid carcinoma.

Invasion of the upper airway by well-differentiated thyroid carcinoma is very unusual. Treatment is primarily surgical resection, but the extent of the resection has been controversial. Adjuvant treatment using I131 or radiotherapy also has an important role in management. We describe two cases of direct infiltration of the larynx and trachea by well-differentiated thyroid carcinoma and discuss the current recommendations for the management of this difficult problem.