Introduction
The majority of epistaxes are anterior in nature, resolve with simple first aid measures and require no further follow up. However, some cases pose more of a diagnostic challenge, and prove resistant to standard investigation and treatment.
Case report
We present the case of a 65-year-old lady with recurrent epistaxis despite four previous cauterisation and bilateral sphenopalatine artery ligation procedures. Computed tomography (CT) angiogram revealed a left internal carotid artery (ICA) aneurysm and a defect in the adjacent bone, which raised the possibility of a false aneurysm as the cause for the epistaxis. The case was referred to the skull base multidisciplinary team and a recommendation was made for surgical obliteration of the sphenoid sinus, followed by radiological coiling of the ICA aneurysm. Following sinus surgery, the patient agreed to undergo a cerebral angiogram and trial balloon occlusion of the aneurysm. However, the procedure was abandoned intra-operatively, as the subtraction angiogram demonstrated a small, very vascular blush of contrast under the left inferior turbinate. A repeat examination under anaesthesia of the nose, this time with out-fracturing of the inferior turbinate, revealed a small intranasal haemangioma, which was excised endoscopically. At two months’ follow up, the patient had experienced no further episodes of epistaxis.
Discussion
The case highlights the shortcomings of CT imaging and the importance of thorough examination technique. Nasal haemangiomas are a rare but recognised cause of epistaxis, and should be considered in refractory cases. A CT angiogram is a useful clinical tool in diagnosing intracerebral aneurysms, but the ‘gold standard’ is digital subtraction angiogram.
Introduction
Spontaneous pneumocephalus is very rare. Evidence for its aetiology and management is understandably lacking. We report a case of spontaneous pneumocephalus in a patient found to have a temporal bone defect. In doing so, we discuss the associated literature recommendations regarding management of spontaneous pneumocephalus.
Case report
A 53-year-old woman presented to the emergency department with increasing headache and preceding coryzal illness. Two days prior to presentation, she briefly lost consciousness, with possible associated head injury. On presentation, her computed tomography head scan confirmed generalised pneumocephalus, with an associated large and possibly old mastoid defect. She was admitted under ENT, with a neurosurgical recommendation of Pneumovax® vaccination, broad-spectrum antibiotics, strict 48-hour, 30-degree bed rest, and high-flow oxygen therapy. Magnetic resonance imaging did not demonstrate any causative pathology. Defect repair was considered. She was managed conservatively and effectively.
Discussion
Twenty-two previous spontaneous pneumocephalus cases were identified in the literature. Dehiscence of the temporal or mastoid bone has been suggested to be linked to mastoid hyperpneumatisation, repeated Valsalva manoeuvre, deep-sea diving, and obesity. Eighteen of the identified cases were managed surgically with mastoid defect repair and/or obliteration. Four cases were managed non-surgically. Clinical resolution was equivalent. There is no high-quality evidence for Pneumovax, antibiotics, bed rest or oxygen therapy in spontaneous pneumocephalus. However, these interventions are supported by post-surgical pneumocephalus recommendations, and are logical to at least some extent.
Introduction
The attitudes towards day-case hemithyroidectomy and parathyroidectomy have fluctuated over time. There has been a growing trend towards day-case surgery across all specialties. This study aimed to attain feedback from those who have undergone day-case surgery, to help inform future patients and to assess patients’ satisfaction and concerns regarding day-case hemithyroidectomy and parathyroidectomy.
Methods
Patients who underwent day-case hemi-thyroid and parathyroid surgery within a three-year period (2016–2018) were contacted to answer six ‘yes’ or ‘no’ questions and provide any additional comments. The study aimed to assess patients’ satisfaction with their day-case experience and inform us of any concerns they had regarding their day-case experience. Questionnaires were completed over the telephone.
Results
Thirteen patients underwent day-case hemithyroidectomy in this period and 22 patients underwent parathyroidectomy. There was one complication of unilateral recurrent laryngeal nerve neuropraxia, which fully resolved. There were two readmissions in the first 30 days post-operatively: one for wound infection and one for ‘reaction to anaesthetic’. There was a 91 per cent response rate; three patients who underwent parathyroidectomy failed to respond. Eleven of the 13 patients who underwent hemithyroidectomy said they would recommend day-case surgery over in-patient surgery to someone needing to undergo this procedure. Eighteen out of 19 patients who underwent parathyroidectomy as a day-case surgery would recommend day-case surgery over in-patient surgery to someone needing to undergo this procedure.
Conclusion
As attitudes towards day-case hemithyroidectomy and parathyroidectomy continue to change, this questionnaire from a single site suggests that, overall, patients who underwent this procedure felt safe, and would recommend day-case surgery to a friend or relative. Additional information gleamed from the hemithyroidectomy group suggests that preparation of family members for day-case surgery may ease the day-case process.
Introduction
Ever increasing demand for healthcare services and limited resources prompt us to re-evaluate the way we provide care to our patients. Current pathways seem no longer fit for purpose, and can, in fact, lead to inaccurate and delayed diagnosis and treatment.
Objective
In 2018, the Royal College of Surgeons commissioned a report on the future of surgery. Amongst various highlighted points, the commissioners agreed on the need for overall increased efficiency and productivity of the service that puts the patient at the centre of all activities. In line with the recommendation, we evaluated our one-stop ENT out-patient service utilising the existing innovative technology of cone beam computed tomography (CT).
Method
A retrospective review was conducted of the current rhinology practice utilising a cone beam CT scan in the oral surgery department.
Results
During the period between February 2017 and February 2019, we performed 179 cone beam CT scans of the sinuses. Of all patients, we were able to discharge 27 by excluding sinus disease on the scan. Thirty-nine patients were directly scheduled for surgery. Because of the setup of the current practice, 66 patients were seen in our evening rhinology clinic. These patients unfortunately cannot use our one-stop service because of the unavailability of the scanner out of hours.
Conclusion
The one-stop rhinology clinic benefits patients by helping to establish immediate diagnosis and treatment, reduce time off work, enhance activity and productivity, and increase satisfaction and experience with the service.
Introduction
Increasing evidence suggests that thyroid lobectomy aloneprovides excellent outcomes for patients with early well-differentiated thyroid carcinomas. This provides similar oncological outcomes and decreases potential complications, reducing length of stay. However, de-escalation of surgery is associated with an appreciable completion rate due to contralateral lobe recurrence. Novel management strategies should maximise oncological benefits whilst minimising complications.
Objective
We aim to describe a novel protocol of thyroid lobectomy follow up and to determine its safety.
Method
A retrospective review of 159 prospectively collected British Association of Endocrine and Thyroid Surgeons database cases from 2014 to 2018 was conducted. Seventeen relevant patients’ notes were reviewed. A retrospective analysis was performed to 2011 by interrogation of our operating theatre procedure database. The follow-up protocol was agreed and registered as part of the standard operating procedure of our multidisciplinary team. Patients underwent a baseline ultrasound scan prior to surgery, and were followed up with an ultrasound scan and thyroglobulin at six months intervals for the first two years, and then yearly if stable.
Results
Of 159 patients with well-differentiated thyroid carcinoma in the British Association of Endocrine and Thyroid Surgeons wing, 17 (10.6 per cent) underwent lobectomy whilst the rest had total thyroidectomy. There were 14 women and 3 men. Nine had T1a tumours, six had T1b tumours and two had T2 tumours. The recurrence rate with a minimum follow up of six months is 0 per cent. This analysis will be extended to an additional 30 patients in the retrospective cohort.
Conclusion
Lobectomy represents a safe option in the management of early well-differentiated thyroid carcinoma. Although this is a small study, the current protocol appears to be appropriate to manage early well-differentiated thyroid carcinoma treated with thyroid lobectomy alone.
Introduction
Efficient head and neck cancer investigation is vital to optimise cancer outcomes and improve the patient experience. Radiological investigations are key to this process and likely to become even more vital with the implementation of the 28-day, faster diagnostic standard. Imaging pathway errors can cause delays in cancer diagnosis and significant financial losses.
Objective
We aimed to improve the efficiency of our pathway.
Method
A week-long rapid improvement event created a streamlined imaging requesting protocol. This resulted in a standardised imaging protocol and a number of same-day appointment slots for computed tomography (CT) and magnetic resonance imaging (MRI). A cross-platform mobile application of the imaging protocol was created, along with posters, emails and educational talks. A prospective audit of multidisciplinary team (MDT) meeting discussions and an online clinician survey allowed us to assess their impact.
Results
Following implementation of the above interventions, we observed a 72 per cent reduction in the number of MDT meeting deferrals because of incomplete CT imaging, and a 37 per cent reduction in MDT meeting deferrals because of incomplete MRI imaging. However, we did not see an improvement in the overall MDT meeting deferral rate.
Conclusion
Diagnostic pathways can be improved using our protocol. However, more than one cycle is likely to be required, as implementation of this pathway may expose additional bottlenecks in the system. With greater demands being placed on limited resources, novel head and neck cancer diagnostic pathways will be essential in ensuring excellent patient care.
Introduction
Our centre runs a regular ENT casualty clinic, run by a senior house officer (SHO), for rapid assessment and treatment of simple, acute ENT cases. The ENT-UK guidelines from 2017 recommend that no more than six patients be booked to see an SHO during a 4-hour clinic session.
Objective
This study aimed to assess whether our centre meets ENT-UK guidelines on patient load in SHO-led clinics.
Method
Data were retrospectively collected from MedWay, our networked booking system. The number of patients booked for each ENT casualty clinic was counted over a period of two months. This was repeated two months after intervention, to close the loop.
Results
In the first cycle, 2 out of 22 clinics (9 per cent) were found to be compliant with guidelines. Our intervention was to inform clinic booking staff of the guidelines. In the second cycle, 20 of 24 clinics (83 per cent) were compliant.
Conclusion
Prior to intervention, the casualty clinic caseload was too high, and clinics would overrun. Our clinic booking staff members were not previously aware of ENT-UK guidelines, and the number of clinic slots was set arbitrarily. This was easily resolved by staff education. We can learn that de facto management practice is not always based on guidelines or evidence. The study also highlights the importance of auditing all aspects of how our organisations are run. Further quality improvement studies should focus on what happens to patients who can no longer be fit into existing casualty clinics.
Introduction
Cricopharyngeal spasm and pharyngeal pouch can result in severe dysphagia symptoms that can have a severe impact on a patient's quality of life. Several surgical interventions have been demonstrated, including balloon dilatation, Botox injection, and both open and endoscopic cricopharyngeal myotomy procedures.
Objective
We aimed to describe our technique for endoscopic cricopharyngeal myotomy, and compare pre- and post-operative swallowing outcomes using objective swallowing questionnaires.
Method
Eight patients diagnosed with cricopharyngeal spasm (n = 5) or grade 1 pharyngeal pouch (n = 3) on barium swallow, and who had given informed consent for surgical intervention, were prospectively observed. The MD Anderson Dysphagia Inventory and Dysphagia Handicap Index were given to patients pre-operatively and two months post-operatively. All patients underwent the same surgical technique. The cricopharyngeal bar was identified under direct vision with a diverticuloscope and injected with Botox. Myotomy was performed with a carbon dioxide laser; dissolvable sutures were used for primary closure of the defect.
Results
Mean in-patient stay was 4.5 days (range, 1–8 days) and mean time to resumption of a soft diet was 2.3 days (range, 1–4 days). Two patients (25 per cent) required nasogastric feeding because of reduced oral intake secondary to odynophagia. Pre- and post-operative MD Anderson Dysphagia Inventory scores showed considerable improvement over all domains (emotional 49.2 vs 88.9, functional 58 vs 88, physical 44.4 vs 87.5), with improvements in Dysphagia Handicap Index scores (emotional 32.4 vs 8, functional 41.9 vs 13, physical 17 vs 5). A post-operative chest infection occurred in two patients (25 per cent) and was treated with oral antibiotics. No other complications were documented.
Conclusion
Post-operative questionnaires demonstrate that cricopharyngeal myotomy can result in significant improvements to a patient's swallowing symptoms, emotional wellbeing and quality of life.
Introduction
Cancellation of operative cases on the day is an avoidable expense in an already over-burdened National Health Service (NHS). Over 25 000 elective operations were cancelled on the day in the first quarter of 2018, the highest quarterly figure to date. These may be because of capacity restraints and understaffing; however, many can be avoided with appropriate listing and adequate pre-assessment.
Objective
We aimed to reduce the on-the-day cancellations of manipulation under anaesthesia of fractured nasal bones.
Method
A retrospective audit across two ENT departments within the same trust measured the reduction in unnecessary listings of manipulation under anaesthesia of the nose and subsequent on-the-day cancellations.
Results
Over a 14-month period, there were 25 on-the-day cancellations out of 155 planned procedures in the tertiary hospital, and 15 out of 123 in the district general hospital. Senior review prior to listing was minimal, with only 3.2 per cent reviewed in the former and 14 per cent in the latter. Not surprisingly, none of the cases reviewed were cancelled in the district general hospital, and two out of five were cancelled in the tertiary centre. As an intervention, a proforma, to be completed by junior physicians when reviewing patients in clinic, will be implemented. This will help the junior physicians establish whether the patient needs operative management.
Conclusion
On an already strained NHS, on-the-day cancellations provide further strain on finite resources. In addition to having senior review on presentation, implementing a more uniform method of assessing nasal fractures could reduce the subjective bias of the junior doctor listing these cases. This approach would be beneficial for reducing the current negative impact of these cancellations on operating theatre utilisation, financial expenditure and the patient journey.
Introduction
Transoral robotic surgery is an effective alternative treatment for moderate to severe obstructive sleep apnoea (OSA) in patients who cannot tolerate continuous positive airway pressure (CPAP). Unfortunately, the lack of high dependency unit beds in a level 1 trauma centre has led to many elective cancellations, which is potentially detrimental to patients with unresolved OSA.
Objective
This study aimed to determine the actual requirement of the high dependency unit for patients with OSA undergoing transoral robotic surgery.
Method
This is a closed-cycle audit of a single centre that performs transoral robotic surgery for OSA. The outcome measure is the use of CPAP post-surgery.
Results
Eleven patients underwent transoral robotic surgery for OSA between January and October 2018. There was no recorded use of CPAP in 10 patients in the high dependency unit. One patient self-administered their CPAP. Patients could not tolerate CPAP because of post-operative pain.
Intervention
Patients undergoing transoral robotic surgery for OSA were placed on a standard surgical ward. An educational session was given to nursing and clinical staff, and an informative front sheet was made for the patients. In the second cycle, 10 patients were audited. All patients were admitted to the surgical ward and did not require CPAP post-operatively.
Conclusion
Continuous positive airway pressure was very infrequently used after transoral robotic surgery for OSA. Standard surgical ward care was adequate in the post-operative setting. The limitations of this audit are that it is a small retrospective study, and therefore the correlation between pre-operative OSA severity and post-operative CPAP use cannot be analysed. Caution may need to be taken in patients with severe OSA.
Introduction
First discovered by American otolaryngologist Watt W Eagle in 1937, the eponymous syndrome refers to a group of characteristic symptoms that result from regional compression of structures due to a calcified stylohyoid ligament or an elongated styloid process. Symptoms fall under two categories: ‘classic’, involving pharyngeal pain with dysphagia; and ‘stylocarotid artery syndrome’, where an elongated styloid compresses the internal or external carotid artery, causing pain along its course as a result of sympathetic chain stimulation. The classic presentation is much more common than the latter, and despite intermittent compression with the stylocarotid type, carotid artery dissection secondary to an elongated styloid is extremely rare.
Case report
Following an extensive literature review, we will explore an unusual presentation of Eagles syndrome diagnosed following multiple cerebrovascular accidents in an otherwise fit young patient.
Results
The patient had suffered three ischaemic strokes or transient ischaemic attacks from a dissected internal carotid secondary to the elongated styloid process compression, resulting in an internal carotid pseudoaneurysm. He underwent a styloidectomy approached through a transcervical incision and the carotid was not stented at the time. The styloid was trimmed and was measured to be roughly 4 cm long. Post-operatively, he recovered well, and regained full power in his upper and lower limbs. He was discharged home on dual anti-platelets 7 days later.
Conclusion
When searching for a diagnosis for an atypical presentation of cerebrovascular accidents and/or carotid artery dissection in young fit patients, a broader search is often necessary and stylocarotid Eagle's syndrome should be part of the differential diagnosis.
Introduction
Intensive treatment unit patients frequently require surgical tracheostomies to aid weaning when a percutaneous tracheostomy is contraindicated because of: co-morbidities, anatomical variations or unfavourable body habitus. Demand on emergency theatre lists can often lead to significant delays in getting the patient to the operating theatre. The technique for hybrid tracheostomy utilises a surgical approach with puncture and serial dilatation of the trachea over a guidewire, as described by Mani et al. The technique can be performed in the intensive treatment unit without the need for a time-consuming transfer to the operating theatre.
Objective
Our project aimed to compare the outcomes from hybrid tracheostomies carried out by a single surgeon over an eight-month period with patients undergoing surgical tracheostomy.
Method
A retrospective review of the intensive treatment unit electronic patient record system was performed for patients with hybrid and surgical tracheostomies. Outcomes recorded included: bleeding, cuff leak, tube displacement, referral time, indication for tracheostomy or unsuitability for percutaneous tracheostomy, and return to the operating theatre. Demographic data for both groups were also compared. A literature review was performed using the following terms: surgical tracheostomy, hybrid tracheostomy and percutaneous tracheostomy.
Results
Over an eight-month period, 14 hybrid tracheostomies and 5 surgical tracheostomies were carried out on intensive treatment unit patients. There were no significant increases in bleeding, cuff leak or tube displacement in patients undergoing hybrid tracheostomy. A total of 22 hours of emergency theatre time was saved, with an estimated cost saving of £26 400.
Conclusion
Our series demonstrates hybrid tracheostomy to be a safe, cost-effective and valuable alternative to surgical tracheostomy in selected patients.
Introduction
Tinnitus refers to the perception of sound without an external sound. Its prevalence in adults is 8.2–20 per cent; less than 10 per cent of these are pulsatile cases. Pulsatile tinnitus has various causes. To our knowledge, this is the first reported case of pulsatile tinnitus caused by arteriovenous malformation arising from the cervical vertebral artery.
Case report
A 61-year-old gentleman presented to the ENT department with a 4-week history of pulsatile tinnitus. There was no worsening of hearing loss and ear examination findings were normal. A left occipital and mastoid bruit was heard on auscultation. Computed tomography showed a prominent vein in the left cervical spinal canal, and a vessel arising from the vertebral artery at level C3 running into the vein under the left skull base. A filling defect was found within the left internal jugular vein and a small linear defect within the left transverse sinus, which were likely due to a thrombi, resulting in a left skull base artery arteriovenous malformation formation. The patient was managed conservatively, as the risk of surgery was deemed too high. The patient was asked to return if there was any change in the character of his tinnitus, as this may indicate a worsening of the malformation.
Discussion
Arteriovenous malformations causing pulsatile tinnitus have been reported to arise from the internal acoustic canal or external ear, such as malformations arising from the posterior auricular artery. However, to our knowledge, this is the first reported case of arteriovenous malformation of the vertebral artery arising from the level of C3 vertebra causing pulsatile tinnitus.
Introduction
We report a case of mediastinitis associated with both cervical sepsis and oesophageal perforation.
Case report
A 74-year-old woman was referred urgently to the ENT team following a computed tomography (CT) finding of mediastinal collection. She had been admitted under the medical team with respiratory distress. A CT pulmonary angiogram was performed to investigate for pulmonary embolism. On ENT review, it appeared that two weeks prior to admission, there had been an episode of neck swelling, with sore throat, dysphagia and coughing. The neck swelling had fully resolved, but she had remained generally unwell and the dysphagia persisted. Examination revealed normal neck movements, with no swelling and unremarkable palpation, and normal pharyngeal and laryngeal anatomy. A barium swallow study showed a distal oesophageal perforation, later confirmed by oesophago-gastro-duodenoscopy. A contrast-enhanced CT scan of the neck identified a left retropharyngeal abscess extending to the posterior mediastinum. Management involved intensive treatment unit care with ventilatory and cardiovascular support, antibiotic therapy, surgical drainage of the neck abscess, and conservative management of the mediastinal component and the oesophageal perforation. The patient made an excellent recovery.
Discussion
Both deep neck space abscesses and oesophageal perforations may lead to mediastinitis. The unusual presentation in this case does not permit us to determine which event initially led to mediastinal involvement. There was no obvious trigger for the spontaneous oesophageal perforation, and there was a long delay between the onset of neck symptoms and septic deterioration. Several theories have been suggested to explain the onset and progression of pathology.
Introduction
Parapharyngeal space tumours are rare, typically benign lesions that pose a significant challenge to the head and neck surgeon. A number of surgical approaches have been proposed; however, these can result in significant post-operative morbidity, with a substantial impact on speech and swallowing function.
Objective
We discuss the technique used in our centre to access large parapharyngeal space tumours and present a case series.
Method
The clinical records of 17 patients who underwent excision of large parapharyngeal space tumours between 2010 and 2018 were retrospectively reviewed. All patients underwent the same surgical technique involving a modified Blair incision with a transcervical extension. The digastric and stylohyoid muscles are divided, and a level 2 neck dissection is performed for access. Division of the stylomandibular ligament is important as it allows excellent access to the parapharyngeal space for safe dissection of the tumour capsule and surrounding neurovascular structures.
Results
Fifteen patients demonstrated benign pathology and two had a malignant diagnosis. Mean in-patient stay was 3.11 days, with 16 patients (94.1 per cent) resuming a normal diet day 1 post-operatively. Four patients (23.5 per cent) suffered first bite syndrome that resolved spontaneously. Vocal fold paresis was noted in four patients (23.5 per cent), with two cases resolving and two requiring surgical intervention. Mean follow-up duration was 24.4 months, with no episodes of recurrence.
Conclusion
Our external approach to the parapharyngeal space for large tumours is safe, with minimal post-operative complications and a short in-patient stay. Division of the stylomandibular ligament confers good surgical views, without the need for aggressive mandibular osteotomy or ‘swing’ approaches that are associated with significant post-operative morbidity.
Introduction
Metastases to the parotid lymph nodes are commonly seen in head and neck squamous cell carcinoma (SCC) and lymphoma. Nasal septal SCC is an exceedingly rare malignancy that infrequently exhibits metastatic deposits in regional lymph nodes. We report a case of a nasal septal SCC presenting as an unknown primary SCC around the parotid lymph nodes, a phenomenon that has not been reported previously in the literature.
Case report
A 39-year-old man presented with new-onset left-sided cervical lymphadenopathy and nasal polyposis. He was previously well with a 20 pack-year smoking history. Ultrasound showed irregular nodes close to the parotid gland. Fine needle aspiration revealed p16 positive undifferentiated SCC. Magnetic resonance imaging (MRI) and positron emission tomography - computed tomography (PET-CT) did not demonstrate a primary source. Thus, the patient underwent panendoscopy, nasal examination under anaesthesia (EUA) and parotidectomy. Once again, a primary lesion was not found. The patient was therefore scheduled for transoral robotic-assisted tonsillectomy, mucosectomy and repeat nasal EUA. Biopsies from the left nasal septum contained invasive SCC. In order to achieve oncological clearance, a combined endoscopic and lateral rhinotomy approach resection was performed. The histological diagnosis was pathologically confirmed T2N2bM0 nasal septal SCC. The patient underwent post-operative chemoradiotherapy and remains under close clinical follow up.
Discussion
When a patient presents with an unknown primary SCC, we advocate thorough investigation, including MRI, PET-CT, EUA, bilateral tonsillectomy and mucosectomy. Although uncommon, nasal septal SCC carries a good prognosis when managed with combined modality surgical and oncological treatment. Thorough multidisciplinary team investigation is essential to the successful diagnosis and management of this cancer.
Introduction
Eagle's syndrome is classically described as unilateral throat pain secondary to an elongated styloid process. Less commonly, patients experience ‘stylocarotid syndrome’, where compression or dissection of the internal carotid artery (ICA) results in acute neurological symptoms. Here, we discuss the management of the youngest reported case of stylocarotid Eagle's syndrome in the world literature.
Case report
A 16-year-old male presented with sudden-onset left-sided limb hemiparesis. Magnetic resonance imaging and computed tomography angiography revealed a right-sided ICA dissection and middle cerebral artery stroke. He underwent acute thrombolysis, before commencing oral anticoagulation and a prolonged period of rehabilitation. He re-presented aged 17 years with acute left-sided limb hemiparesis, paraesthesiae, dysarthria and headache. He again received acute thrombolysis. Imaging revealed extension of the ICA dissection without an acute infarct. Further review of imaging by our skull base multidisciplinary team indicated bilateral elongated styloid processes and calcification of the stylohyoid ligaments in close proximity to the ICA. The patient was scheduled for a right-sided styloidectomy via transcervical incision. He made a swift post-operative recovery and remains under close clinical surveillance by his stroke team.
Discussion
A literature review revealed 20 cases of ICA dissection due to elongated styloid processes. Nine patients underwent surgical intervention for recurrent symptoms or the presence of acute infarction on imaging. A 61-patient case series advocated open styloidectomy, as it confers the greatest access to the deep neck spaces, with minimal post-operative complications. We therefore advise definitive surgical management for stylocarotid syndrome in young patients and those presenting with recurrent neurological symptoms.
Introduction
Internal carotid artery (ICA) dissection is a potentially life-threatening condition that is often difficult to diagnose. Affected patients can, as a result, present to multiple different specialties. We aim to highlight the recognised but uncommon presentation of an internal carotid dissection as a painful Horner's syndrome with dysgeusia.
Case report
A 52-year-old man presented to the ENT clinic with symptoms that included persistent right-sided headache accompanied by a dull ache on the right side of the face, scalp tenderness, right eyelid droop, and a change in taste. The symptoms started approximately one month prior following a flu-like illness. He denied any change in sweating on either side of his face. He has a background of hypertension and is a non-smoker. Examination findings revealed a right-sided ptosis and miosis. An urgent magnetic resonance imaging scan was requested, which showed an ICA dissection. The case was discussed with both the vascular and stroke team. It was decided to start him on antiplatelet therapy, amitriptyline and paracetamol. Unfortunately, the patient did not attend his follow-up appointment so it is not known whether his symptoms have now resolved.
Discussion
We describe a patient with ICA dissection who presented with a painful right-sided Horner's syndrome and dysgeusia. It is likely that the glossopharyngeal nerve was affected in isolation. This case highlights a rare disease that does not routinely present in an ENT clinic, but which should trigger an ICA dissection differential and prompt referral for urgent imaging.
Introduction
Post-tonsillectomy bleeds that require arresting surgically can be managed with a variety of surgical techniques, including the well-documented method of tonsillar fossa closure with a haemostatic agent placed within the tonsillar bed. Our case report describes a complicated post-operative recovery following the use of this surgical technique with Equitamp®, a similar haemostatic material to Surgicel®.
Case report
A 56-year-old woman presented with a large post-tonsillectomy bleed, requiring surgical intervention. An active bleeder in the left tonsillar fossa was found, cauterised and sutured. Equitamp was then placed in the fossa and the pillars were closed. On the 1st post-operative day, the patient complained of nausea, with a foreign body sensation in her throat. A large clot in the left tonsillar fossa was visible, and so she was managed with hydrogen peroxide gargles. However, the sensation gradually worsened, leading to agitation and retching. A large foreign body, which was visibly obstructing her oropharynx, was removed promptly with Magill forceps, with symptomatic relief. The foreign body (and presumed clot) was in fact the Equitamp, which had expanded significantly, so that it had burst the sutures holding the tonsillar pillars together, leading to partial airway obstruction.
Discussion
Haemostatic materials are routinely used in surgery to achieve haemostasis intra-operatively. Because of their bioabsorbable properties, they can be left in the surgical bed. Absorption of Equitamp typically takes 4 days to occur, but there is no documented risk of material expansion post-operatively. This particular haemostatic agent will require further research to identify how and where it is best used.
Introduction
Facial nerve schwannoma is an encapsulated tumour of Schwann cell origin. Although rare and benign, it can be associated with life-changing sequelae, precipitating social isolation and depression. Surgical intervention can often ameliorate some of the functional and psychological effects of facial nerve schwannoma. However, this case report highlights a subgroup of patients whose complex clinical picture may dictate poorer outcomes.
Case report
A 69-year-old woman with an extensive facial nerve schwannoma was admitted for elective tumour excision via a transparotid/transmastoid approach. Symptoms included progressive occipito-temporal pain, significant unilateral conductive hearing loss, vestibular symptoms and notable right-sided facial weakness, leading to both impaired function of the oral seal and eye pain due to lagophthalmos. The patient has numerous co-morbidities and an extensive family history of autoimmune disease. Post-operatively, the patient still has complete loss of tone in the middle and lower facial muscles, for which a fascia lata static sling procedure will later be performed.
Discussion
This case outlines the possible extreme sequelae of a particularly large facial nerve schwannoma. By pertinently highlighting the psychosocial impact of such pathology, the case demonstrates that, although rare, facial nerve schwannoma should form a key part of the differential for unilateral facial and/or hearing loss. Further, the complex risk–benefit assessment required in surgical decision-making for facial nerve schwannoma is discussed, the case being particularly challenging in this regard. Finally, this case offers a valuable opportunity to consider key prognostic factors, and to learn from a subgroup of patients with poorer long-term outcomes. Thus, future developments that may improve outcomes are considered.
Introduction
Nasal injuries are routinely referred for ENT review, but a large proportion of patients require no more than reassurance and advice. In the absence of detailed national guidelines, can a pathway be designed to improve the patient experience, and to streamline the assessment and management of nasal injury patients?
Objectives
We assessed the management of nasal injury patients at a UK teaching hospital. We wanted to identify whether patients requiring manipulation of nasal fracture undergo the procedure within 14 days. We aimed to design a new referral pathway to reduce the burden of DNA and patients not requiring clinical intervention.
Method
All patients referred to ENT emergency clinic for the assessment of a nasal injury in the month of November 2018 were included in this study. Thirty-six patients (21 males, 15 females) were referred, with a mean age of 38 years (range, 5–92 years).
Results
The mean time from injury to ENT clinic appointment was 10 days (standard deviation (SD) = 4.7 days). Of the 36 patients referred, 5 (14 per cent) did not attend. Fifty per cent (n = 18) did not require intervention. Thirty-nine per cent (n = 14) underwent manipulation under general anaesthesia procedures, of which 79 per cent (n = 11) were performed under local anaesthetic in clinic, and 21 per cent (n = 3) under general anaesthesia. Mean time to manipulation under general anaesthesia was 10 days (SD = 3.6 days). Patients spent less time in the accident and emergency department if they were discharged and referred at the end of the shift (1 hour and 46 minutes vs 3 hour and 50 minutes, p<0.03).
Conclusion
We can improve patient experience with an online referral tool that speeds up accident and emergency department referral and advises patients to cancel appointments if they are satisfied with the recovery of their nose.
Introduction
Cancerous tissues are more likely to host bacterial, viral and fungal infections, and the role of chronic infection in oncogenesis is increasingly well described, with a clear link between viruses such as human papilloma virus and oropharyngeal cancers. However, the role of fungal infections has been little studied. Can the common commensal yeast Candida albicans be a contributor to oncogenesis?
Objective
This study aimed to compare the prevalence of candida in histology specimens from benign and malignant vocal fold lesions.
Method
Sixty patients were included in this case–control study. Thirty consecutive multidisciplinary team patients with glottic squamous cell carcinoma (SCC) (mean age of 65 years; all male) and 30 patients with benign lesions (mean age of 48 years; 12 males and 18 females) had their histology slides re-examined for evidence of candida hyphae using periodic acid–Schiff stain. Benign lesions included granuloma, polyp, Reinke's oedema and keratosis.
Results
Only one patient showed candida hyphae on periodic acid–Schiff stain, from the SCC group (male, aged 66 years, T2N0M0). This contrasts with existing literature suggesting candida colonisation of the oropharynx is prevalent, and calls into question whether candida infection plays an important role in the subsequent development of cancer. Although this is a negative finding, the results could suggest that candida infection is less significant in glottic compared to other oropharyngeal cancers.
Conclusion
The next investigative steps would involve comparing rates of past candida infection, and more comprehensive candida testing, via oropharyngeal swabs and polymerase chain reaction. Other thinner fungal hyphae were observed on some of these samples, and we await characterisation of these fungal species.
Introduction
Glomangiopericytoma, also known as sinonasal haemangiopericytoma, is a rare vascular neoplasm of the nasal cavity, accounting for less than 0.5 per cent of all sinonasal neoplasms. It is characterised by a prominent pattern of perivascular growth. Unusual reported histological features include keloid-like collagen deposition and lipomatous change. We report a recent case of glomangiopericytoma showing this peculiar microscopic characteristic of lipomatous changes.
Case report
A 57-year-old man presented to another centre with right-sided nasal cavity lesion in 2002. This was subsequently excised. Histopathology of the excised specimen revealed an angiofibroma/angiomatoid fibrous histiocytoma. In 2016, the patient presented to our centre with symptoms of right-sided nasal block and epistaxis. Magnetic resonance imaging of the sinuses showed right-sided inferior nasal turbinate focal soft tissue lesion with increased vascularity. The patient underwent endoscopic endonasal excision of this nasal mass. Histopathology of the excised lesion showed a vascular spindle cell neoplasm. Differential diagnosis included cellular angiofibroma and spindle cell lipoma with vascular telangiectasia. A supplementary histopathology report confirmed this lesion as a sinonasal glomangiopericytoma with lipomatous change.
Discussion
Glomangiopericytoma is an uncommon tumour almost exclusively arising from the nasal cavity and/or paranasal sinuses, characterised by a prominent pattern of perivascular growth. It is thus a surprise that the patient discussed showed histological features of sinonasal glomangiopericytoma with lipomatous change, as one would not normally expect to find adipose cells in the nasal cavity, paranasal sinuses and nasopharynx. Knowledge of the histological variations of glomangiopericytoma, such as lipomatous changes, would help avoid errors in diagnosis, and hence mismanagement of such cases.
Introduction
There is an increasing trend towards head and neck procedures such as superficial parotidectomy to be undertaken as a day-case.
Objective
To establish the frequency and causes of day-case failure in patients undergoing superficial parotidectomy in one surgeon's practice.
Method
A retrospective review was carried out of all patients undergoing superficial parotidectomy performed by a single surgeon between January 2016 and January 2019. The reasons for failure of same-day discharge were established. Our standard approach for a superficial parotidectomy includes the use of a harmonic scalpel and a 10 Fr suction drain, the latter of which is removed at 4 hours post-operatively if the output is less than 20 ml.
Results
Seventy-two patients underwent a superficial parotidectomy with the pre-operative intention of being a day-case. Sixteen patients (22 per cent) failed to be discharged on the same day as surgery. Most of these failures (n = 9) occurred within the first year of adopting day-case. The most common reason for admitting patients was a late finish (n = 5, 31 per cent). Four patients (25 per cent) were admitted because of anaesthetic complications including nausea and urinary retention. Three patients had surgical complications; however, only one of these was for bleeding that did not require a return to the operating theatre. Two patients had issues that were not highlighted at pre-assessment requiring admission. The reason for admission in the remaining two patients is not clear from the documentation available.
Conclusion
Day-case parotidectomy is feasible in appropriately selected patients. In our experience, surgical complications are not a common cause for day-case failure.
Background
Paediatric tracheostomy is required in cases of bilateral vocal fold palsy, severe obstructive sleep apnoea and severe retrognathia, and for secretion management. The surgical technique for paediatric tracheostomy involves the placement of maturation sutures to reduce the risk of inadvertent decannulation. However, this may increase the rate of non-closure following planned decannulation. This retrospective, single-cycle audit aimed to estimate our rate of non-closure of paediatric tracheostomy at a UK regional paediatric ENT centre, and compare findings with national and international data.
Method
A systematic review of published data was undertaken. This revealed a non-closure rate of between 13 and 43 per cent. Operating theatre records were searched for all consecutive paediatric tracheostomies performed between 2008 and 2018, and case notes were reviewed. The rate of non-closure of tracheostomy after decannulation was calculated.
Results
A total of 103 paediatric tracheostomies were performed between 2008 and 2018 at our institution. Forty (39 per cent) had healed following decannulation; 18 cases (17 per cent) required formal closure because of persistent tracheocutaneous fistula.
Conclusions
Non-closure of tracheocutaneous fistula is a complication of tracheostomy following decannulation. This can require surgical intervention. Our rates of non-closure are comparable to national data.
Introduction
Although oral cancer accounts for 2.1 per cent of all cancer cases globally, it is surfacing as a major public threat in India. Oral cancer is amongst the three most common types of cancer in the Indian subcontinent, with an incidence rate of 30 per cent. The increased availability and use of smokeless tobacco and betel quid in recent years have further aggravated the situation.
Objective
The scarcity of reports on the contribution of various tobacco forms in oral cancer incidence remains a prime concern. This study investigated the association between smokeless tobacco and cancer of the gingivobuccal sulcus.
Method
The medical records of 249 patients with cancer of the gingivobuccal sulcus, attending the Dr BR Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, were retrospectively examined from 2009 to 2016. Demographic and clinical data, including history of addictions (smoking, smokeless tobacco), were collected. Patients were staged according to the eighth edition of The AJCC Cancer Staging Manual (2017).
Results
Use of smokeless forms of tobacco was more prevalent amongst the patients (50.7 per cent), in contrast to smoked tobacco (19.53 per cent), whilst 29.77 per cent of patients reported consuming both forms. A higher proportion of patients with smokeless tobacco addiction were diagnosed with advanced stages of cancer (56.9 per cent had stage III/IV cancer). These rates were even higher (65.6 per cent) in patients using both smokeless and smoked tobacco.
Conclusion
A strong association was observed between smokeless tobacco and gingivobuccal sulcus cancer, particularly in patients who kept the tobacco in the buccal vestibule after chewing, to suck, sometimes overnight. Elucidating the potential risk factors can be a key approach to designing effective intervention programmes to combat the growing pandemic of oral cancer in India.
Introduction
Oral cancer is amongst the top three types of cancers in India. Most of the oral cancer cases occur between the fifth to seventh decades of life. There is limited knowledge of the aetiology and natural history of early-onset oral cancer in India.
Objective
This study investigated the demographics and clinical characteristics of oral cancer in young patients (age<25 years) in a North Indian population.
Method
A retrospective analysis of 33 oral cancer patients aged 25 years or less was conducted, between 2009 and 2016, in the Allied Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India. Data of patient's age, gender, primary cancer site and history of addictions (tobacco smoking, smokeless tobacco and alcohol) were collected. Patients were staged using The AJCC Cancer Staging Manual (2002).
Results
The median age of presentation was 24 years (range, 19–25 years) with no age difference in site-specific incidence. The proportion of early-onset oral cancer was higher in males (91 per cent). Buccal mucosa was the commonest site of cancer (45.5 per cent), followed by the tongue (39.3 per cent). Seventy-nine per cent of patients used either tobacco (smoking or smokeless) or alcohol. There was no usage history in female patients and 87 per cent usage in male patients. Seventy-six per cent of patients used smokeless forms of tobacco. Of the addictions, smokeless forms of tobacco had the most users (81 per cent). One of the seven non-addicted patients had a history of radiotherapy. Most cases presented with advanced disease (62 per cent of patients had stage IVA or IVB disease; 79 per cent had stage III or IV). Patients with concomitant usage of tobacco and alcohol presented with advanced disease.
Conclusion
Oral cancer in patients aged 25 years or less is proportionately higher in males, has buccal mucosa as the commonest site, is associated with tobacco or alcohol use, with smokeless forms of tobacco used by most patients, and presents at an advanced stage.
Introduction
Oral cancer is a major problem in India and is amongst the top three types of cancers in the country. The incidence of oral cancer in India is 20 per 100 000 people and it accounts for over 30 per cent of all cancers in the country. In the recent years, awareness regarding the adverse effect of tobacco products is increasing amongst younger Indians.
Objective
This study aimed to evaluate the trends in patients’ mean age at incidence and diagnosis of oral cancer, from 2000 to 2017.
Method
A retrospective study of 3262 oral cancer patients was conducted from 2000 to 2017 in the Dr BR Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi. Data of patient's age, gender and cancer site were collected and analysed by non-parametric trend tests.
Results
The proportion of oral cancer was higher in males (82 per cent) as compared to females (18 per cent). The tongue was the most common site of oral cancer occurrence (37 per cent). The patients’ mean age at diagnosis of oral carcinoma significantly decreased over time, from 50 years during 2000–2001 to 48 years during 2016–2017 (p < 0.05).
Conclusion
There has been a decline in patients’ mean age at diagnosis of oral cancer, from 50 years in 2000 to 48 years in 2017.This can be attributed to increased awareness, raised by the National Tobacco Control Program and other governmental efforts.
Introduction
Epistaxis is a common ENT presentation. The National Epistaxis Audit 2017 produced guidelines on management of acute epistaxis. They stated that cauterisation of the nose should be the first-line treatment, with electrocautery being preferred as this is associated with lower treatment failure.
Objective
We conducted a retrospective audit of our epistaxis patients and implemented new guidelines highlighting the use of electrocautery as a treatment, and prospectively collected data on these patients following guideline implementation.
Method
Based on the National Epistaxis Audit 2017, the British Rhinological Society produced guidelines on the management of acute epistaxis. We conducted a retrospective review of 58 patients. We devised a management algorithm, and educated our accident and emergency and ENT departments. We collected prospective data on 21 epistaxis patients following implementation of the guideline.
Results
A retrospective review was conducted of 58 patients over a six-month period. This revealed an average length of stay of 3.7 days, with six patients being re-admitted and four undergoing surgery. One patient had an ischaemic event during surgery, and another three patients had complications. Prospective data of 21 patients showed an average length of stay of 1.8 days, with 1 patient re-admitted and 1 patient undergoing surgery.
Conclusion
The use of electrocautery and implementation of our epistaxis guideline not only reduced the length of hospital stay for patients, but also resulted in successful patient outcomes, with less patients requiring surgery as a result. Thus, the complications and risks associated with artery ligation and undergoing general anaesthesia were avoided.
Introduction
Some Ménière's disease patients will progress to an advanced form of the disease, which dramatically affects hearing loss. Although this is a relatively small portion of patients with a relatively rare disease, guidelines suggest the use of cochlear implants in these cases. Currently, there are no up-to-date, extensive review papers that critique the evidence behind this management option, and details on whether it should be performed alongside concomitant surgical procedures is unclear.
Objective
This literature review aimed to determine the effectiveness of using cochlear implants in Ménière's disease.
Method
The following databases were used to search for literature: PubMed, Cochrane Library, Cochrane ENT Trials Register, Cumulative Index to Nursing and Allied Health Literature, World Health Organization International Clinical Trials Registry Platform, Web of Science, and Evidence-Based Medicine Reviews. An internet search was performed to identify appropriate non-research literature. The journal literature was critiqued using the Critical Appraisal Skills Programme checklist, and Moule and Hek's research framework. Non-research literature such as guidance and policies was analysed using the Appraisal of Guidelines, Research and Evaluation 2009 (‘AGREE II’) tool.
Results
Overall, cochlear implantation appears to effectively improve the hearing of Ménière's disease sufferers. This literature review supports their simultaneous insertion with destructive surgical management. The impact of implantation on vertigo and tinnitus is, however, less clear, and future studies are required to address this uncertainty.
Conclusion
Overall, this review supports the use of cochlear implantation in advanced Ménière's disease. Future innovations may in fact replace the need for cochlear implantation, and it will be interesting to see how these evolve in the field of otology.
Introduction
Patient complaints correlate with surgical complication rates and litigation. In the context of a continually evolving National Health Service (NHS) and ongoing financial pressures, identifying current complaint trends can drive future improvements in delivery of healthcare.
Objective
Complaints received in the ENT departments of two large teaching hospitals in London were reviewed and analysed to determine current patient complaints and changes in complaints. Suggestions to mitigate and deal with complaints are also discussed.
Method
All complaints registered with the Patient Advice and Liaison Service from the ENT departments at our institutions were collected between June 2016 and August 2018. Demographic information was collated, and complaints were analysed and interpreted as per a standardised coding taxonomy.
Results
A total of 242 patient complaints were collected. Most complaints (91.7 per cent) were logged by patients themselves, who had a mean age of 48.3 years (range, 3–98 years). The majority of complaints were directed at the administrative team (52 per cent), followed by management staff (23.5 per cent) and clinicians (16.9 per cent). Administrative issues were the most common complaints (50.1 per cent), followed by clinical (25.1 per cent) and relationship or communication complaints (24.7 per cent). The bulk of complaints focused on delays in access to services and treatment in the form of cancellations and long appointment waiting times (37 per cent).
Conclusion
There has been a significant shift in complaint themes from clinical to administrative. This may reflect increasing financial and staffing pressures in the NHS. We propose the use of a coding taxonomy to ease the collection and analysis of data, and a stepwise management algorithm in the early management of informal complaints.
Introduction
Thyroidectomy is the most common form of endocrine surgery performed throughout the world. Injury to the recurrent laryngeal nerve (RLN) is a well-recognised cause of vocal fold paralysis and morbidity post-thyroidectomy. Intra-operative nerve identification prior to the ligation of vessels is the current ‘gold standard’ to prevent RLN palsy. However, this can be challenging, as the RLN has a complicated and varied course. Even anatomical variation to a minor degree has been suggested to represent a major risk of RLN injury.
Objective
This study aimed to determine the prevalence of major anatomical variations of the RLN and the influence of variation on RLN palsy post-thyroidectomy.
Method
An eight-week dissection project of a detailed bilateral neck dissection and literature review were conducted.
Results
The RLN lies most commonly inside the trachea-oesophageal groove, posterior to the inferior thyroid artery and posterior to Zuckerkandl's tubercle. Extra-laryngeal branching of the RLN is a common variation and bifurcation is the most prevalent form. However, the impact of branching on RLN palsy rates post-operatively remains unclear. The non-RLN, although rare, is clinically important given the significant risk it poses to nerve injury.
Conclusion
In-depth knowledge of anatomical variations of the RLN and its effective identification are important in the future of thyroid surgery. It is hugely important that clinicians are aware of these variations and that clinicians employ the most effective methods to detect these variations.
Introduction
Transoral robotic surgery is an increasingly advancing ENT sector. It is used for various operations, such as tonsillectomies, tongue base resections, cordectomies and laryngectomies, as well as in skull base surgery. Transoral robotic surgery has multiple objective advantages, including the three-dimensional image, the various movement angles and the minimalisation of incisions. There is also evidence showing shorter hospital stays and fewer post-operative complications when transoral robotic surgery approach is used for certain procedures. It is still a controversial issue as to whether transoral robotic surgery should be the dominant minimally invasive technique, and there is ongoing research regarding its effectiveness and value in different ENT operations.
Objective
This study aimed to investigate the current state of the art of robotics in ENT surgery, focusing on transoral robotic surgery.
Method
A literature review was conducted in Pubmed and Medline databases using the following key words: ‘transoral’, ‘TORS’, ‘ENT robotic surgery’ and ‘otolaryngology robotic’.
Results
A review was conducted of current transoral robotic surgery applications, limitations and future applications, critically analysing and reflecting on ongoing research on the subject.
Conclusion
Transoral robotic surgery is a massively progressing sector in ENT, with various applications and significant future perspectives; however, disadvantages and limitations have been mentioned.
Introduction
Day-case tonsillectomy patients are often observed for 6 hours post-operatively. Patients operated on in the afternoon are frequently admitted overnight as a result of the 6-hour observation time. This takes up valuable beds and increases costs.
Objective
Can the observation time be safely reduced for patients deemed appropriate for day-case tonsillectomy?
Method
We conducted a retrospective study of all patients undergoing tonsillectomy between August 2016 and August 2018 at Great Western Hospital, a district general hospital in Swindon. The data on post-operative haemorrhage within 24 hours of surgery were obtained from the health informatics office.
Results
A total of 516 patients underwent a tonsillectomy. Of those, 174 patients (34 per cent) underwent a further procedure alongside their tonsillectomy. Of the patients, 287 (56 per cent) were paediatric. Sixty-four procedures (32 per cent) were performed as a day-case and 54 (10 per cent) were planned as a day-case but the patients were subsequently admitted overnight. No patients had a tonsillar haemorrhage requiring surgical intervention within the first 24 hours of surgery. One patient had an adenoid haemorrhage immediately after surgery.
Conclusion
There should be no minimum observation time for the appropriately selected day-case tonsillectomy patients. Patients should be discharged when medically ready and safe, following a review from the operating surgeon.
Introduction
Whilst there have been studies reviewing the various techniques available for auricle reattachment, no systematic review has specifically focused on the paediatric population.
Objective
This systematic review aimed to examine the best microsurgical technique for successful ear replantation in children.
Method
A literature search of all children undergoing microsurgical ear replantation was performed between 1980 and 1st June 2018 using the Medline and Cochrane databases.
Results
A total of three articles were included in the final analysis, all of which were case reports. Two articles reported on artery-only replantation, and one reported a combined artery and venous replantation. All replantations survived until the end of the follow-up period (range, eight months to four years). Arterial thromboses occurred in one artery-only anastomosis and one artery and venous anastomosis. However, the artery-only anastomoses resulted in more complications overall, including areas of partial necrosis requiring debridement and reconstruction, and the need for blood transfusion with the use of medicinal leeches.
Conclusion
From the cases examined, techniques involving both arterial and venous anastomoses seem the most effective, with the fewest complications. However, it has been demonstrated that successful replantation in the absence of venous anastomosis is still possible, as long as post-operative venous congestion is managed adequately. These findings appear to be in keeping with those of studies in adults, but there is a relative lack of data at present and more cases must be examined in order for firmer conclusions to be made.
Introduction
Previous reports demonstrate that injuries to the jugular bulb during ear surgery have been managed using a variety of techniques. We present a case where Floseal® haemostatic agent was used to effectively control bleeding.
Case report
A 64-year-old woman was scheduled electively for a revision tympanoplasty with or without ossiculoplasty for a discharging anterior pars tensa tympanic membrane perforation and conductive hearing loss. Whilst lifting the tympanomeatal flap, a gush of blood was noted from the postero-inferior portion of the middle ear, resulting in blood loss of nearly 800 ml within 10 minutes. As the bleeding failed to stop, the decision was made to pack the ear with ribbon gauze. Post-operatively, computed tomography of the temporal bones revealed a high riding dehiscent jugular bulb at the level of the cochlea. The patient returned to the operating theatre 4 days later, and on removal of the ribbon, there was a further gush of blood in the medial hypotympanum. The bleeding was temporarily controlled with a Zoellner suction tube whilst a pre-prepared syringe of Floseal was instilled in the area of the injured jugular bulb. The middle and external ear was filled with Floseal and the original tympanoplasty surgery was abandoned. The patient was observed overnight and subsequently discharged after 24 hours with a view for a bone-conducting or bone-anchored hearing aid.
Discussion
We demonstrated that the use of Floseal alone for haemostasis in this situation is a simple and effective method, making it an option for closed-cavity haemorrhages such as this.
Introduction
Varicella zoster virus is commonly contracted during childhood, presenting as chickenpox. Polyneuropathy as a result of varicella zoster virus infection, however, is exceedingly rare.
Case report
A 79-year-old man with a 2-week history of right-sided otalgia presented to the emergency department with a new-onset right-sided facial weakness. He was initially referred to the ENT department with a diagnosis of Bell's palsy. Detailed history-taking revealed that the patient had been experiencing progressive dysphagia and hoarseness 2 days prior to the onset of facial weakness, with no systemic symptoms. Despite treatment with high-dose steroids and oral acyclovir since admission, he developed worsening dysphagia and new right-sided hearing loss. Examination including flexible nasendoscopy showed left uvula deviation and right-sided vocal fold palsy. A computed tomography scan of the head and neck and magnetic resonance imaging of the brain were normal. The neurology team were contacted and cerebrospinal fluid samples were obtained. These samples showed a raised white cell count with 95 per cent lymphocytes. Viral polymerase chain reaction assay confirmed varicella zoster virus infection. A diagnosis of varicella zoster virus polyneuropathy was made. The patient was switched to intravenous acyclovir, receiving a 14-day course as an in-patient. During this time, his cranial nerve palsies improved. He was subsequently discharged with neurology follow up.
Discussion
Varicella zoster polyneuropathy is uncommon, with only small numbers reported in the literature. It is therefore prudent that all clinicians have a high index of suspicion for varicella zoster virus infection in patients with multiple cranial nerve palsies. After all, not all VIIth cranial nerve palsy is ‘just’ a Bell's palsy.
Introduction and objective
There is little guidance for otitis externa swab use. The National Institute for Health and Care Excellence (NICE) suggest swab use if treatment fails, for recurrent or chronic otitis externa, following inefficient topical treatment, and if infection spreads beyond the external auditory canal or is too severe for oral antibiotics. Microbiologically, the ‘start smart then focus’ approach is recommended for antimicrobial stewardship. In addition, no local guidelines currently exist. Most common organisms include Pseudomonas aeruginosa, Staphylococcus aureus and yeast. The former two organisms are empirically covered by aminoglycoside drops, but these do not cover fungal or atypical growth. It is known that the diabetic and immunocompromised populations are at risk of malignant otitis externa. Bearing this in mind, the current swabbing practise has been reviewed with a focus on diabetic or immunocompromised patients.
Method
Data from E-clinics held between December 2017 and March 2018 were retrospectively collected. Demographics, medical history, diagnosis, examination findings and treatment details were collated with microbiology findings. All patients with clinical otitis externa were included, with no exclusion criteria.
Results
The study comprised 45 patients (23 males and 22 females), including 6 diabetic or immunocompromised patients. Twenty-two of the 45 patients were swabbed. Management changed following 13 swabs (59.1 per cent). Of the 22 patients, 2 were diabetic or immunocompromised. Management changed for one of the swabs. Aspergillus species triggered the majority of treatment changes.
Conclusion
At least half of the swab results led to management change. For efficient otitis externa treatment, a swab should be taken prior to or at the patient's first appointment (in line with NICE criteria). All diabetic or immunocompromised patients should have a swab taken prior to or at their first appointment, given their risk for malignant otitis externa. After these changes are implemented, it is imperative to re-audit and assess the effectiveness of these new standards.
Introduction
Sinonasal neoplasms represent a rare yet histologically diverse group of tumours, with explanations attributed to occupational and social factors. Occupational hazards such as wood dust have been previously reported. The present case report describes a rare fronto-ethmoid tumour associated with exposure to metalworking fluids.
Case report
A 63-year-old man presented with a 2-year history of right-sided facial discomfort, medial canthal swelling and nasal obstruction. Past medical history was unremarkable; he was a non-smoker who worked as an engineer with open machines where he was exposed to metalworking fluids. Flexible nasoendoscopy confirmed a mass arising from the right middle meatal opening.
Discussion
Magnetic resonance imaging and navigation computed tomography scanning of the paranasal sinuses was conducted, with a view to either performing a biopsy or resecting the mass. Following multidisciplinary team discussion, it was decided that the suspicious nasal mass should be resected. The patient eventually underwent right-sided spheno-ethmoidectomy with excision of the nasal tumour. Histological examination of the surgical specimen was diagnostically challenging for our team. A series of discussions amongst two different head neck expert teams led to the diagnosis of an occupation-related granulomatous lesion. Occupational exposure to certain inhalants, such as wood dust and formaldehyde, is a well-known risk factor for sinonasal neoplasms. However, we present a rare association between a sinonasal neoplasm and a metal working fluid – soluble cutting oil – that has not been previously reported in the literature.
Introduction
ENT surgery is given little weight in medical school curricula, despite ENT problems being extremely common. Many UK medical schools do not offer ENT placements, and of those that do, nearly half are not compulsory. This leaves students unaware of ENT as a career option and with poor understanding of common conditions. We hypothesise that poor consideration of specialist surgery results from a lack of exposure to information about careers and daily practice.
Objective
Our objective is to assess whether a specialty showcase day was sufficient to boost informed consideration of ENT careers.
Method
We designed a half-day course involving an interactive careers workshop alongside simulation stations of commonly presenting ENT problems, led by ENT doctors. We used pre- and post-course evaluations to explore factors that encourage and discourage students’ surgical careers, and their perceptions of ENT. The participants, who were mainly in their third year of study, had variable aspirations towards surgical and non-surgical careers, with a minority considering ENT before the course.
Results
Our results demonstrate that all students found the session useful and had a much better understanding of ENT practice, with almost all students leaving more likely to consider a career in ENT.
Conclusion
We find our results a good case for including informative careers workshops as part of medical school teaching. We posit that interactive workshops exploring specialist surgical careers are a valid way to help students make informed career decisions, particularly in specialties that are under-represented at medical school.
