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To recount experience with cerebrospinal fluid otorrhoea and temporal bone meningoencephalocele repair in a tertiary care hospital.
A retrospective review was conducted of 16 cerebrospinal fluid otorrhoea and meningoencephalic herniation patients managed surgically from 1991 to 2016.
Aetiology was: congenital (n = 3), post-traumatic (n = 2), spontaneous (n = 1) or post-mastoidectomy (n = 10). Surgical repair was undertaken by combined middle cranial fossa and transmastoid approach in 3 patients, transmastoid approach in 2, oval window plugging in 1, and subtotal petrosectomy with middle-ear obliteration in 10. All patients had successful long-term outcomes, except one, who experienced recurrence after primary stage oval window plugging, but has been recurrence-free after second-stage subtotal petrosectomy with middle-ear obliteration.
Dural injury or exposure in mastoidectomy may lead to cerebrospinal fluid otorrhoea or meningoencephalic herniation years later. Congenital, spontaneous and traumatic temporal bone defects may present similarly. Middle cranial fossa dural repair, transmastoid multilayer closure and subtotal petrosectomy with middle-ear obliteration were successful procedures. Subtotal petrosectomy with middle-ear obliteration offers advantages over middle cranial fossa dural repair alone; soft tissue closure is more robust and is preferred in situations where hearing preservation is not a priority.
The need for perineal repair after childbirth affects millions of women worldwide. In the United Kingdom, approximately 85% of women sustain some form of perineal trauma during vaginal delivery, and 69% of these will require stitches.
Sinonasal undifferentiated carcinoma is a rare aggressive tumour arising from the Schneiderian epithelium lining the sinonasal tract. Although considered the cornerstone of therapy, surgical resection can only be performed in a limited number of patients. This report describes the experience of treating sinonasal undifferentiated carcinoma with a multimodality approach.
The treatment charts of sinonasal undifferentiated carcinoma patients treated at a tertiary care centre from 2004 to 2012 were retrospectively reviewed.
A total of 16 sinonasal undifferentiated carcinoma patients with a median age at diagnosis of 47.5 years (range 8–65 years) were included: 19 per cent had neck nodal metastasis at presentation. Four patients (25 per cent) underwent surgery: of these, two had post-operative radiotherapy, one had pre-operative radiotherapy and one had adjuvant chemotherapy alone. Six patients (38 per cent) received definitive radiotherapy: five had received neoadjuvant chemotherapy to reduce tumour size and help in radiotherapy planning, while four (25 per cent) received palliative radiotherapy. The median follow up was 10.4 months (range 1–42.5 months). The estimated median progression-free survival time was 29.3 months. One- and three-year progression-free survival rates were 77 per cent and 41 per cent, respectively.
Surgery is the best treatment option for sinonasal undifferentiated carcinoma, although most patients require post-operative radiotherapy for advanced disease and close tumour margins. Definitive radiotherapy with or without chemotherapy may be suitable for patients with inoperable locally advanced disease. Elective nodal irradiation to address the high nodal involvement rates should be considered to improve the survival rate.
Laboratory experiments indicate that changes in retinal image size result in adaptive recalibration or suppression of the vestibulo-ocular reflex. Myopia correction with spectacles or contact lenses also leads to retinal image size changes, and may bring about similar vestibulo-ocular reflex alterations.
A hypothesis-generating preliminary investigation was conducted. In this cross-sectional study, findings of electronystagmography including bithermal caloric testing were compared between 17 volunteer myopes using spectacles or contact lenses and 17 volunteer emmetropes (with no refractive error).
Bilateral hypoactive caloric responses were demonstrated in 6 of 11 spectacle users, in 1 of 6 contact lens users and in 1 of 17 emmetropes. Hypoactive caloric responses were significantly more likely in spectacle users than in emmetropes (p < 0.01; relative risk = 9.3).
A significant proportion of myopes using spectacles have vestibulo-ocular reflex suppression, as demonstrated by the caloric test. This has implications for the interpretation of electronystagmography and videonystagmography results, and highlights spectacle use as a possible cause of vestibular impairment. Further corroboration of these findings is warranted, with more precise and direct vestibulo-ocular reflex tests such as rotational tests and the head impulse test.
Archaeologists studying shell assemblages from prehistoric sites along the Pacific coast of North America have been interested in the influences of collecting intensity and environmental variability on California mussel (Mytilus californianus) size. To determine the variation in mussel size within a shell assemblage, researchers have developed a variety of proxies of mussel valve length based on measurements of morphological features occurring at or near the valve’s umbo. We propose four additional measurements that can serve as proxies and evaluate their correlation with valve length using regression analysis. Of the four, anterior adductor scar length has the strongest correlation, and we present two examples of its application. We also evaluate a popular visual technique based on a set of outline drawings of valves of varying lengths, and we found that it systematically underestimated valve length but could be useful under certain circumstances. We conclude that the selection of a particular proxy of mussel valve length depends on the nature of the mussel shell assemblage being studied and the research context.
To present the profile of patients undergoing surgical treatment for vertigo at a contemporary institutional vertigo clinic.
A retrospective analysis of clinical charts.
The charts of 1060 patients, referred to an institutional vertigo clinic from January 2003 to December 2012, were studied. The clinical profile and long-term outcomes of patients who underwent surgery were analysed.
Of 1060 patients, 12 (1.13 per cent) were managed surgically. Of these, disease-modifying surgical procedures included perilymphatic fistula repair (n = 7) and microvascular decompression of the vestibular nerve (n = 1). Labyrinth destructive procedures included transmastoid labyrinthectomy (n = 2) and labyrinthectomy with vestibular nerve section (n = 1). One patient with vestibular schwannoma underwent both a disease-modifying and destructive procedure (translabyrinthine excision). All patients achieved excellent vertigo control, classified as per the American Academy of Otolaryngology – Head and Neck Surgery 1995 criteria.
With the advent of intratympanic treatments, surgical treatments for vertigo have become further limited. However, surgery with directed intent, in select patients, can give excellent results.
Animate foreign bodies in the ear are frequent occurrences in otology practice. Such foreign bodies may lead to hazardous complications.
This paper describes a retrospective study of six patients with a recent history of an insect in the ear who presented with various complications following intervention received elsewhere.
An insect was retrieved from the external auditory canal in four cases and from the antrum in two cases. The patients presented with progressive otological complications: two patients who presented with orbital apex syndrome and cavernous sinus thrombosis succumbed to the disease; three patients suffered sensorineural hearing loss; and two patients had persistent facial palsy. One patient with sigmoid sinus thrombosis, who presented early, experienced complete recovery.
Insects in the ear can lead to hazardous complications. Animate foreign bodies should preferably be managed by a trained otologist, even in an emergency setting. Patients with delayed presentation and complications have a guarded prognosis.
To explore the treatment outcomes of patients treated with re-irradiation for recurrent or second primary head and neck cancer.
An analysis was performed of 79 head and neck cancer patients who underwent re-irradiation for second primaries or recurrent disease from January 1999 to December 2011.
Median time from previous radiation to re-irradiation for second primary or recurrence was 53.6 months (range, 2.7–454.7 months). Median age at diagnosis of first primary was 54 years. Median re-irradiation dose was 45 Gy (range, 45–60 Gy). Acute grade 3 or worse toxicity was seen in 30 per cent of patients. Median progression-free survival for recurrent disease was 15.0 months (95 per cent confidence interval, 8.33–21.66). The following factors had a statistically significant, positive impact on progression-free survival: patient age of less than 50 years (median progression-free survival was 29.43, vs 13.9 months for those aged 50 years or older; p = 0.004) and disease-free interval of 2 years or more (median progression-free survival was 51.66, vs 13.9 months for those with less than 2 years disease-free interval).
Re-irradiation of second primaries or recurrences of head and neck cancers with moderate radiation doses yields acceptable progression-free survival and morbidity rates.
To analyse the aetiological profile and surgical results of patients with acquired chronic subglottic stenosis, and formulate a surgical scheme based on an audit of various surgical procedures.
Thirty patients were treated by 65 procedures (31 endoscopic and 34 external) between 2004 and 2009.
Isolated subglottic stenosis was noted as unusual in the majority (27 cases), demonstrating contiguous tracheal or glottic involvement. The major aetiologies were intubation injury (n = 8) and external injury (n = 21) (i.e. blunt trauma, strangulation or penetrating injury). Vocal fold immobility and cartilage framework involvement were frequent with external injury and infrequent with intubation injury. Luminal restoration was achieved by endoscopic procedures in 2 cases, external procedures in 19 cases, and external plus adjuvant endoscopic procedures in 8 cases. The preferred surgical options were: endoscopic procedures, restricted to short, recent, grade I or II mucosal stenosis cases; and external procedures for all other stenosis situations, including isolated subglottic (anterior cricoid split plus cartilage graft), subglottic and glottic or high subglottic (anterior plus posterior cricoid split with cartilage graft), and subglottic and tracheal (cricotracheal resection with anastomosis).
External injury stenosis has a worse profile than intubation injury stenosis. Anatomical categorisation of subglottic stenosis guides surgical procedure selection. Endoscopic procedures have limited indications as primary procedures but are useful adjunctive procedures.
The aggressiveness of cholesteatoma in children compared with adults is well known. However, the factors influencing the poorer prognosis of paediatric cholesteatoma are not well understood. This study compared the proliferative potential of paediatric cholesteatoma with that of adult cholesteatoma, using Ki-67 as a proliferation marker.
A prospective study of 67 patients with aural cholesteatoma was performed. Thirty-eight adult and 29 paediatric cases were evaluated using clinical parameters including bone erosion, complications and extent of disease. A surgical specimen underwent histological evaluation and measurement of the proliferation index using Ki-67 labelling. Normal epithelium from a control group was also examined.
Cholesteatoma epithelium has a greater rate of proliferation than normal skin. There were however no statistical differences between the paediatric and adult cholesteatoma groups in terms of clinical behaviour or proliferation potential. Paediatric cholesteatoma was similar to adult cholesteatoma in terms of complications, bone erosion and disease spread.
Cholesteatoma is a disorder of epithelial proliferation. Although postulated to be more aggressive in children than adults, this study found no clinicopathological differences between paediatric and adult cases.
Artefacts during uroflowmetry may arise owing to several factors, which can be broadly classified into two groups: extracorporeal and intracorporeal. Recommendations to minimise uroflowmetry artefacts include ensuring privacy, checking the report and tracing immediately, correcting artefacts manually and checking that the void was representative of normal. Initial quality checks will prevent the majority of artefacts. Artefacts may arise during the voiding phase owing to displacement of the vesical or rectal pressure transducer or inadequate pressure transmission. Artefacts are spurious and inaccurate urodynamic observations. Artefacts at uroflowmetry are minimised by checking calibration regularly and asking the patient to void normally in private. Artefacts during cystometry can be minimised by zeroing transducers to atmospheric pressure, expelling air bubbles and checking for good subtraction with cough testing before filling, at 1-minute intervals during filling and before and after voiding.
This book provides a practical guide for anyone performing or training to perform urodynamic studies. Details on how to set up urodynamic equipment and perform individual urodynamic techniques are discussed, ranging from basic tests such as uroflowmetry and subtracted cystometry through to the more complex videocystometry, ambulatory monitoring and urethral function tests. Many of the chapters include case studies to place the investigations within the context of a symptom complex. This book has a place in every urodynamics laboratory as an easy reference guide and is an essential illustrative text for teaching the fundamentals of good urodynamic practice.
Urodynamic investigations are used to investigate bladder function and dysfunction in women with urinary symptoms, the most common being urinary incontinence. Guidance from the National Institute for Health and Clinical Excellence covers much of when investigations should be performed. Women are often anxious and embarrassed when they attend the tests. Recognition of the artificial test conditions and the feelings of the woman are crucial to optimising the chances of reproducing symptoms. Before cystometry, written information explaining the test should be provided with the appointment letter or when the woman attends the clinic. The information should include instructions on providing a urine sample in a sterile container, bladder chart and questionnaires and advice to come with a comfortably full bladder. Women who are using drugs to treat lower urinary tract dysfunction should normally stop using the medication for an appropriate period of time before the investigation.