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An unusual clivus mass is reported, following investigation of memory disturbance and headaches in a patient with β thalassaemia and sickle cell disease. This lesion proved to be a site of extramedullary haematopoiesis.
Computed tomography demonstrated a 2 cm mass at the base of the sphenoid. However, magnetic resonance imaging showed little bony expansion, and the differential diagnosis included chordoma, dermoid cyst and fibrodysplasia.
Examination of the biopsy showed the presence of bone marrow demonstrating erythroid hyperplasia and small aggregates of B-cell lymphocytes. The features were considered compatible with erythroid hyperplasia associated with haemolytic anaemia.
The patient was reassured that she did not have a neoplastic lesion, and was referred back to the haematologists for further management of her sickling β thalassaemia.
Extramedullary haematopoiesis occurs outside the reticuloendothelial system in response to haemolytic anaemia. Extramedullary haematopoiesis causing a clivus mass is an unusual ENT presentation. Such haematopoiesis is occasionally seen in the calvarial skull, but this is the first report of this process occurring in the anterior skull base, to our knowledge.
We report an extremely rare case of malignant triton tumour.
Case report and review of the world literature concerning malignant triton tumour and heredity.
We present the case of a 47-year-old woman who underwent a lateral rhinotomy surgical resection of a malignant triton tumour of the right paranasal sinuses, a rare location for this tumour. Thereafter, she received adjuvant radiotherapy. The prognosis for this group of tumours is poor. Radical surgical excision of the tumour followed by radiation therapy must be the treatment of choice.
To our knowledge, this is a rare report in the world literature of malignant triton tumour. This case indicates that malignant triton tumour of the paranasal sinuses is a rare disease which otolaryngologists should be aware of, and one which should be included in the differential diagnosis of malignant lesions involving the sinonasal tract.
Congenital cholesteatoma occurring behind the tympanic membrane is typically located in the anterior middle ear.
To investigate the location, clinical features and treatment of cholesteatomas located behind an intact tympanic membrane in adults.
Review of a series of 265 consecutive, new, adult cases of previously untreated cholesteatoma seen by the author over a 22-year period.
Seventeen (6 per cent) cases were located behind an intact tympanic membrane without any evidence of a retraction pocket of the attic or pars tensa. Ten (59 per cent) of these patients had undergone previous ear surgery and therefore the disease could reasonably be considered to be iatrogenic. The most common presentation was conductive deafness with no other symptoms (71 per cent). In all of the cases, the disease was located in the posterior half of the middle-ear space. The most common surgical management was simple excision of the disease via a tympanotomy. Two cases (12 per cent) developed residual disease.
The majority of the cases in this series were likely to be acquired cholesteatomas. This type of disease often presents with conductive hearing loss alone.
Young's syndrome describes a combination of male infertility, azoospermia, bronchiectasis and sinusitis. Although Young's syndrome is a well accepted disorder within the realms of infertility medicine, it is also accepted as being a potential cause of sino-nasal disease which is rarely seen by otolaryngologists. However, the significance of the sinus component within this triad is not fully understood. To gain further insight into the relationship of sinusitis with Young's syndrome, we reviewed all of the currently available published literature.
Within the reviewed literature, the diagnosis of sinusitis in Young's syndrome was crude and poorly defined; there was little emphasis on sinus disease in most publications.
The prevalence of Young's syndrome is reported to be declining, and the level of evidence regarding sinus disease within this syndrome is limited to case series only. There is, in fact, little evidence to support Young's syndrome being a significant aetiological factor for sinus disease, nor indeed to support the existence of Young's syndrome as an entity in its own right. The only documented aetiological factor is mercury exposure in childhood, an event that is seldom currently encountered; this would support our theory of the extinction of the condition. As an incidental finding, we found that the term Young's syndrome refers to two different medical conditions.
The aim of this study was to investigate the effect of local application of platelet-rich plasma to perforated rat tympanic membranes, in terms of healing time and histopathological outcome.
Eighty-eight tympanic membranes of 44 rats were given a standard 3 mm perforation, and platelet-rich plasma was applied to the right tympanic membrane perforations. The left tympanic membranes were left to heal spontaneously, as controls. The 44 rats were divided into two groups. In group one, comprising 20 rats, daily otomicroscopic examination of the tympanic membrane perforations was performed. The 24 rats in group two were subdivided into four subgroups of six rats each; these subgroups were sacrificed sequentially on days three, seven, 14 and 28 for histopathological examination, regardless of tympanic membrane healing stage.
In group one, the mean tympanic membrane healing times for tympanic membrane perforations receiving platelet-rich plasma and controls were respectively 10.2 ± 2.1 and 13.0 ± 2.9 days (mean ± standard deviation). This difference was statistically significant (p < 0.001). In group two, histopathological evaluation of tympanic membrane perforation healing at days three, seven, 14 and 28 did not reveal any statistically significant difference, individually or within the four groups as a whole.
These findings suggest that earlier healing of tympanic membrane perforations occurred in the platelet-rich plasma group compared with the control group. These findings suggest that platelet-rich plasma is effective in accelerating tympanic membrane perforation healing, and that it may be effective in human subjects, particularly as it is an autologous material.
To describe problems and complications associated with cochlear implantation, and their management, in a Danish patient population comprising both paediatric and adult patients.
Retrospective chart review.
Tertiary referral centre.
Three hundred and thirteen consecutive cochlear implantations were studied. The median age of the study population was 10 years. Sixty per cent of patients were children and 40 per cent were adult; 52 per cent were female and 48 per cent were male.
Two hundred and ninety-four patients received a Cochlear Nucleus® implant. The remaining 19 received an Advanced Bionics implant.
Main outcome measure:
Presence of problems and complications after cochlear implantation.
Post-operative complications were found in 15.7 per cent of patients. The majority of these complications (11.2 per cent) were minor; 4.5 per cent were major. The major complications included one patient with meningitis, one patient with multiple antibiotic resistant Staphylococcus aureus infection of a radical cavity, and one diabetic patient who developed a severe skin infection and whose implant became exposed.
Cochlear implantation is a safe procedure within the studied setting. However, it is essential that careful attention be paid to surgical planning and technique, and it is important that healthcare staff and patients be aware of the possible problems and complications.
To determine if there is a difference in infection rates between Aboriginal and non-Aboriginal children, following tympanostomy and ventilation tube placement, in the Northern Territory, Australia.
Materials and methods:
A cohort of 213 patients aged zero to 10 years who had undergone tympanostomy and ventilation tube placement at the Royal Darwin Hospital between 1996 and 2004 were identified. Patients were divided into Aboriginal or non-Aboriginal groups, from their medical record. Factors such as age, sex, dwelling (remote or urban) and season were compared for each group, in order to ascertain if they contributed to infection rates. A retrospective analysis of cases was conducted for the two-year post-operative period.
There was no statistically significant difference in infection rates between the two groups (37 vs 35 per cent). There was no statistically significant difference when comparing the two groups for age, sex, season, or remote vs urban dwelling.
Aboriginal children were not prone to more infections following tympanostomy tube placement when compared with non-Aboriginal children.
To determine the causes of delay in diagnosis and treatment of Indian patients with vestibular schwannomas.
In a prospective study from 2003 to 2005, 50 patients with a confirmed diagnosis of vestibular schwannoma were interviewed to determine the causes for (1) the delay between the patient noting the initial symptom and the definitive diagnosis, and (2) the reasons for delayed diagnosis.
In 90 per cent of patients, the initial symptom was either hearing loss (62 per cent), vertigo (24 per cent) or tinnitus (4 per cent). However, most patients had been diagnosed and had presented for surgery only after neurological symptoms had became apparent. The delay between the initial medical consultation and the final diagnosis ranged from one month to 204 months (mean ± standard deviation, 32.2 ± 38.9 months). After the patient had noted symptoms, the diagnosis of vestibular schwannoma was delayed due to doctor-related causes in 80 per cent of cases, and due to patient-related causes in 20 per cent. Delay following diagnosis was minimal.
Delay in the diagnosis of vestibular schwannoma in Indian patients is due to both doctor- and patient-related factors.
In patients with severe nasal polyposis resistant to strict medical treatment, surgery is indicated, but no prognostic factors for surgery efficacy have yet been determined. Some authors suggest that eosinophilic infiltration of nasal polyps could indicate a risk of surgical ineffectiveness.
Surgical plus medical treatment was evaluated over a mean follow-up period of 64 months. One hundred and forty-four subjects were separated into two groups: those with eosinophilic infiltration of >50 per cent (n = 73); and those with ≤50 per cent infiltration (n = 71).
Combined surgery and corticosteroid therapy was effective in the treatment of severe nasal polyposis. No significant difference was found between the two groups in terms of control of nasal obstruction and sense of smell loss. However, a significant difference was found in terms of control of posterior rhinorrhoea (p = 0.01).
Eosinophilic infiltration influences the outcome of nasal polyposis surgery, mainly regarding control of posterior rhinorrhoea. It could be considered as a risk factor for surgery in patients with nasal polyposis.
To investigate the impact of nasal irrigation with isotonic or hypertonic sodium chloride solution on mucociliary clearance time in patients with allergic rhinitis, acute sinusitis and chronic sinusitis.
Patients and methods:
Mucociliary clearance time was measured using the saccharine clearance test on 132 adults before and after 10 days' application of intranasal isotonic or hypertonic saline. Patient numbers were as follows: controls, 45; allergic rhinitis, 21; acute sinusitis, 24; and chronic sinusitis, 42. The results before and after irrigation were compared using the Wilcoxon t-test.
Before application of saline solutions, mucociliary clearance times in the three patient treatment groups were found to be significantly delayed, compared with the control group. Irrigation with hypertonic saline restored impaired mucociliary clearance in chronic sinusitis patients (p < 0.05), while isotonic saline improved mucociliary clearance times significantly in allergic rhinitis and acute sinusitis patients (p < 0.05).
Nasal irrigation with isotonic or hypertonic saline can improve mucociliary clearance time in various nasal pathologies. However, these solutions should be selectively prescribed rather than used based on anecdotal evidence. Further studies should be conducted to develop a protocol for standardised use of saline solution irrigation in various nasal pathologies.
Following a suggestion by ward patients that Rapid Rhino™ nasal packs may deflate over time, allowing recurrence of epistaxis, we aimed to demonstrate deflation of 7.5 cm Rapid Rhino packs when used in vivo for post-operative nasal packing.
Materials and methods:
The volume of air insufflated and retrieved from Rapid Rhino nasal packs used for post-operative nasal packing was recorded, as was the pressure following inflation and prior to removal. The time taken for the initial inflation pressure to stabilise was monitored in a number of packs. Similar pressure and volume measurements were repeated in a series of in vitro packs for comparison.
Fourteen consecutive patients undergoing septoplasty were recruited. High but unsteady pressure values were obtained in the first patient's packs. In the subsequent five patients, continuous pressure monitoring demonstrated that gradual depressurisation occurred over the first 16 to 22 minutes following inflation. A typical pressure was 35 cmH2O after inflating with 8 ml of air. Only one Rapid Rhino pack was demonstrated to leak air in vivo.
When used in vivo, Rapid Rhino nasal packs initially depressurise over a period of about 20 minutes. Actual leakage (deflation) was not demonstrated to be an expected feature of Rapid Rhino packs in this study.
To report the short- and long-term results of two techniques (mental imagery and manual shaking of the larynx) in patients with non-organic dysphonia or aphonia.
Retrospective review of patient records, plus follow-up survey (questionnaire).
Academic teaching hospital.
One hundred and sixteen patients with moderate to severe non-organic dysphonia or aphonia.
Cure (i.e. normal voice) and improved voice quality, judged by clinicians and patients.
One hundred (86 per cent) of the 116 patients were cured. Ninety-four (81 per cent) patients regained their normal voice within one therapy session. The follow-up survey revealed that 43 of the 87 (49 per cent) patients who responded had not had a relapse since therapy ended. Of those patients suffering relapse, 15 successfully applied mental imagery in order to retrieve their voice, compared with three patients who applied shaking of the larynx.
Mental imagery, combined if necessary with manual therapy, is an effective therapeutic technique in patients with non-organic voice disorders.
To investigate and compare the sensitivity and specificity of computed tomography and of endoscopy, as diagnostic tests for foreign body ingestion.
Materials and methods:
Over a two-year period, Asian patients with suspected foreign body ingestion were studied. The clinical findings, computed tomography images, endoscopic results, treatment and outcomes were prospectively analysed.
Over the study period, 193 patients were admitted for foreign body ingestion, complaining of a persistent foreign body sensation in the neck. The sensitivity and specificity of computed tomography were 78 and 96 per cent, respectively; the positive predictive value was 75 per cent and the negative predictive value 97 per cent. The diagnostic accuracy of computed tomography was 94 per cent.
Our study showed that computed tomography had high negative predictive value and accuracy in the diagnosis of foreign body ingestion. It was useful if endoscopy showed negative findings but the patient still had persistent symptoms of foreign body ingestion.
Given its rarity, varied histological presentation and often pseudosarcomatous appearance, nodular fasciitis is frequently misdiagnosed on pre-operative, intra-operative and final analyses.
Four cases of nodular fasciitis are reviewed.
Physical and radiological findings were consistent with a parapharyngeal tumour, probably neurogenic, a level four neck mass suspicious for lymphoma; a sternoclavicular mass in a patient with a history of breast cancer suspicious for metastasis; and a cheek mass consistent with an accessory parotid tumour. Fine needle aspiration results were consistent with a neurogenic tumour in two patients and an undifferentiated malignancy in two patients. Frozen section examination most commonly included masses with spindle-type cells. The final diagnosis of nodular fasciitis was made only after permanent section and immunohistological analysis.
In a patient with nonspecific results following investigation of a head or neck mass, nodular fasciitis should be considered. Use of appropriate immunohistochemical markers will aid in the final diagnosis.
To determine the frequency of altered tongue sensation following tonsillectomy, and its relationship to different surgical techniques.
District general hospital.
One hundred and four consecutive adults undergoing tonsillectomy, and 43 control patients.
Main outcome measures:
Altered tongue sensation.
Twenty-eight of 100 patients described altered tongue sensation post-tonsillectomy. No patients in the control group experienced altered tongue sensation. There was a difference in rates of altered sensation between tonsillectomy patient groups undergoing bipolar diathermy and ‘cold steel’ techniques (p < 0.019). Three months after surgery, 22/23 contactable patients reported complete recovery of tongue sensation. One patient experienced tongue paraesthesia persisting until one year post-tonsillectomy.
Tonsillectomy resulted in altered tongue sensation in 28 per cent of our study group. Bipolar diathermy dissection was significantly more likely to cause altered sensation than cold steel dissection. Ninety-six per cent of these disturbances resolved by three months, all by one year. Possible alteration of tongue sensation should be discussed whilst obtaining consent for tonsillectomy.
To analyse correlations between quality of life measures, aspiration and extent of surgical resection in patients who have undergone free-flap tongue reconstruction.
Patients and methods:
Nine consecutive patients (seven men and two women; average age 51 years) who had been diagnosed with T4a carcinoma of the mobile tongue and/or tongue base and treated by glossectomy, free-flap reconstruction, and either radiation therapy or chemoradiation responded to the European Organization for Research and Treatment of Cancer Head and Neck-35 questionnaire, the performance status scale questionnaire and the hospital anxiety–depression scale questionnaire, an average of 43 months after treatment (range 18–83 months). Aspiration was evaluated by fibre-optic laryngoscopy. Correlations between quality of life domain scores, extent of surgery and the presence of aspiration were evaluated using non-parametric statistical analysis.
Scores for the swallowing and aspiration domains of the European Organization for Research and Treatment of Cancer Head and Neck-35 questionnaire were significantly correlated with the extent of tongue base resection (Spearman's correlation, p = 0.037 and 0.042, respectively). Despite a strong correlation between the European Organization for Research and Treatment of Cancer Head and Neck-35 questionnaire results and the performance status scale global scores (correlation coefficient = 0.89, p = 0.048), the performance status scale domain scores were not correlated with the extent of tongue resection. Clinically apparent aspiration was not correlated with the extent of tongue resection, nor were the anxiety or depression scores. However, clinically apparent aspiration was significantly related to the swallowing and aspiration domain scores of the European Organization for Research and Treatment of Cancer Head and Neck-35 questionnaire (p = 0.017 in both cases).
Our results imply that the volume of tongue base resection is a major factor in swallowing- and aspiration-related quality of life following tongue resection and free-flap reconstruction. Free-flap reconstruction does not seem to palliate the effect of the loss of functional tongue base volume, as regards swallowing-related quality of life.