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Introduction: Adenotonsillectomy is successful at eliminating airway obstruction in the majority of otherwise normal children with obstructive sleep apnoea syndrome. Children with this condition are at significantly higher risk of post-operative respiratory complications. Identifying children at risk of post-operative respiratory complications after adenotonsillectomy for obstructive sleep apnoea syndrome remains a challenge for clinicians, especially those at district general hospitals.
Aim: To review the evidence and to proffer a pragmatic approach to diagnosis and management, by classifying those at risk of post-operative respiratory complications into different risk subsets, with guidelines for management.
Conclusion: Patients in the high risk group should be operated upon at paediatric specialist centres with intensive care facilities. Those in the moderate risk group may undergo adenotonsillectomy at their district general hospital, provided facilities for administering continuous positive airway pressure are available on-site. Most children with obstructive sleep apnoea syndrome may be classified as low risk candidates and may safely be operated upon at their local district general hospital.
The proximity of the paranasal sinuses to important anatomical structures creates the potential for serious complications following endoscopic sinus surgery. Over recent years, navigational systems have been developed and are increasingly being used by some centres.
We summarise the history and principles of navigational sinus surgery, review the medical literature on the topic, and try to assess what role navigational systems should play in modern day rhinology practice.
Background: Bone-anchored hearing aids are well established in the treatment of patients with a conductive or mixed hearing loss. However, one of the main problems is that of sound localisation. This can be improved with a directional microphone. This study compared the quality of life of bone-anchored hearing aid wearers before and after the use of a directional microphone.
Method: Eleven patients were included. They were required to wear the directional microphone for 12 weeks. Quality of life was measured using the Glasgow benefit inventory questionnaire, before and after the study period.
Results: The response rate was 82 per cent. The total benefit from the directional microphone was +49.7. The three components of the Glasgow benefit inventory were analysed separately, as follows: general subscale +57.4; physical health +42.6; and social scale +25.9.
Conclusion: This is the first study to demonstrate a significant improvement in quality of life from a directional microphone fitted to a bone-anchored hearing aid.
Background: We present the results of a retrospective review of children undergoing implantation with bone-anchored hearing aids (BAHAs) at the Great Ormond Street Hospital for Children.
Methods: The case notes of 71 children undergoing BAHA placement at the Great Ormond Street Hospital for Children between December 1990 and August 2002 were reviewed. Outcome measures included hearing thresholds, incidence of fixture loss, skin reaction and need for revision. Quality of life outcomes were also measured.
Results: Eighty-five ears had been implanted. Fifty-four per cent of children had experienced no complications, 42 per cent had required revision surgery and 26 per cent had experienced fixture loss at some point. Young age at implantation was associated with an adverse outcome. Trauma and failure of osseointegration had been the commonest reasons for failure. A skin reaction around the abutment had occurred at some point in 37 per cent of children but had persisted for longer than six months in only 9 per cent; this had been associated with fixture loss. The use of fixture site split skin grafts had reduced problems with skin hypertrophy and hair overgrowth. Hearing thresholds when using BAHAs had been comparable to those when using bone conduction hearing aids. However, BAHAs had significant additional benefits in terms of sound quality, ease of use and overall quality of life.
Conclusion: Bone-anchored hearing aids provide significant benefits over other types of hearing aid, both audiologically and in terms of quality of life. Careful selection of candidates and meticulous follow up are required in order to minimize complications.
It is well known that cholesteatoma is three-dimensional; hence, we feel that its surgical management requires a three-dimensional approach in order to achieve the best curative and functional results. Retraction pockets are undeniably caused by chronic and recurrent eustachian tube obstruction. However, we found that the presence of a large mastoid antrum was an important, additional aetiological factor in the formation of a retraction pocket and its progression to cholesteatoma formation, with bone destruction and subsequent complications.
Canal wall down tympanomastoidectomy – the ‘on-disease’ approach – is an innovative, three-dimensional technique based on universally accepted surgical principles. We modified the technique to ensure complete exposure and thereby eradication of the disease, with a resultant small cavity. Working in a three-dimensional field, we began drilling at the posterior meatal wall, lowering it while simultaneously widening the cavity as the mastoid was drilled to reach the antrum and the aditus. The bridge was lowered and the incus removed to completely expose the entire disease. The facial ridge was debulked and the temporalis fascia graft placed so as to simplify the middle-ear cleft.
We present a comprehensive report of this technique, based upon 600 patients studied retrospectively over a five-year period. After one-year follow up, 546 patients had a dry, healed cavity.
Canal wall down tympanomastoidectomy performed by the on-disease approach ensures complete eradication of the disease, with excellent curative as well as functional results.
Objective: To introduce simple underlay myringoplasty which is widely performed in Japan.
Patients: 391 ears with perforated eardrum underwent simple underlay myringoplasty from 2000 to 2004, and which were followed up for more than six months after surgery.
Methods: After removing the margin of the perforation by a transcanal approach under local anaesthesia, a connective tissue graft was inserted through the perforation and lifted to contact the edge. Fibrin glue was dropped on the contact area. There was no packing in the canal or in the middle-ear cavity. If the perforation remained, re-closure was attempted using the patient's frozen tissue.
Results: The rate of closure after the initial attempt was 304/391 (77.7 per cent), and that after re-closure for unsuccessful cases was 70/87 (80.5 per cent). The overall rate was 374/391 (95.7 per cent). There were no serious complications such as sensorineural hearing loss.
Conclusions: Simple underlay myringoplasty is a simple and minimally invasive procedure employing fibrin glue and has led to a high closure rate of the eardrum.
Aims: The aim of this study was to investigate hearing loss in patients with ankylosing spondylitis.
Study design: Prospective, case–control study.
Methods: Fifty-nine ankylosing spondylitis patients (118 ears) and 52 healthy control subjects (104 ears) were included. Pure tone audiometry at 250, 500, 1000, 2000, 4000 and 6000 Hz and immittance measures, including tympanometry and acoustic reflex tests, were performed in the patients and controls.
Results: Sensorineural hearing loss was found in 21 patients (35.5 per cent), bilateral in 15 patients and unilateral in six. Pure tone thresholds significantly differed between patients and controls at all frequencies (p<0.05). There was no statistically significant difference between the right and the left ears' thresholds at all frequencies, except at 4000 Hz in ankylosing spondylitis patients. The right ears' thresholds were higher than those of the left ears. Patients' pure tone average (PTA) thresholds were significantly different from those of controls in all three PTA groups (i.e. 250 Hz; 500, 1000 and 2000 Hz; and 4000 and 6000 Hz) (p<0.05). The differences were most prominent in the higher frequencies.
Conclusion: Our findings suggest a decreased hearing level in ankylosing spondylitis patients, mostly at high frequencies, although the pure tone thresholds of patients and controls significantly differed at all frequencies.
Objective: To determine if there is a relationship between a foreign body in the external auditory canal and undiagnosed otitis media with effusion or significant eustachian tube dysfunction in children.
Study design and setting: This is a prospective, uncontrolled analysis of 37 consecutive children with a foreign body in the external auditory canal (group I) and 37 children with non-ENT complaints as a control (group II), seen over two years in the ENT unit of a district general hospital. All the children underwent removal of the foreign body, examination of both ears by a senior ENT surgeon followed by tympanometry within seven to 10 days.
Result: Thirty-seven children with a foreign body in the external auditory canal (group I) were analysed and a similar number of children with non-ENT problems (group II) were taken as a control. The age range for both groups was two years to 10 years with a median age of six years. Of the 37 children, 25 (68 per cent) in group I had an abnormal view of the tympanic membrane compared to only five (14 per cent) in group II (p < 0.04 – chi-squared test). In group I 20 children (54 per cent) and in group II three children (8 per cent) had abnormal middle-ear compliance (either type B or type C2) (p < 0.05 – chi-squared test). Nineteen (51 per cent) children in group I had a history of previous ear symptoms such as irritation, otalgia, blockage or deafness more than once in the past six months, and none had in the control group (p < 0.03 – chi-squared test).
Conclusion: There is clinical and statistical evidence to suggest that children may insert a foreign body in the ear as a result of irritation/pressure sensation secondary to otitis media with effusion or significant eustachian tube dysfunction. Therefore, we recommend that all children with a history of a foreign body in the ear should be screened in an ENT clinic.
Background: We have previously found by lateral cephalometry an association between nasopharyngeal anatomy and the risk of acute otitis media (AOM). We evaluate here the association of nasopharyngeal dimensions in magnetic resonance imaging (MRI) with the occurrence of AOM in otherwise healthy children.
Methods: Sixty-one healthy children (mean age 5.7 years, range 3.9–6.9) were recruited from child care centres. The parents filled in a questionnaire on the child's history of ear infections and adenoidectomy. MRI was performed with a 4 mm slice thickness during an upper respiratory infection. Five dimensions and two angles expressing the structure of the bony nasopharynx were measured in sagittal images.
Results: The dimension from the caudal edge of the septum to the midpoint of the sella, reflecting the height of the nasopharynx, was on average 2.2 mm smaller in the children who had had AOM attacks during the last 12 months than those without attacks (95% confidence interval (CI) 0.9 to 3.4, p=0.001) and the nasal base angle was on average 2.1 degrees smaller (95% CI 0.7 to 3.5, p=0.004). These differences remained significant after adjustment for age, sex and previous adenoidectomy in the logistic modelling. A history of adenoidectomy did not have any effect on the dimensions.
Conclusions: The nasopharynx was smaller in the children with AOM attacks during the last year. The value of this finding for predicting susceptibility to recurrent AOM and directing preventive procedures should be evaluated.
Introduction: Inverted papillomas are relatively rare, benign epithelial tumours of the nasal cavity which generate considerable interest because they are locally aggressive, have a tendency to recur and are associated with malignancy.
Aims: To review our experience of the management of inverted papillomas, and to review the literature in order to evaluate recurrence rates, rates of synchronous and metachronous carcinoma, and outcomes of treatment, both endoscopic and conventional.
Methods: We retrospectively reviewed all cases of inverted papilloma that presented to our unit, a tertiary referral centre, over a 20-year period from 1985 to 2005. A Medline review of the literature was performed to identify published case series of inverted papillomas. We undertook a critical analysis of the literature.
Results: We treated 65 patients with inverted papilloma over the 20-year period, with a mean follow up of five years (range one to 20 years). Fifty-eight patients initially underwent nasal biopsy, often with polypectomy. Thirty-six had endoscopic surgery, with five (14 per cent) suffering recurrence, whilst 16 had a lateral rhinotomy and medial maxillectomy, of which four (25 per cent) suffered a recurrence. Seven septal inverted papillomas required local resection, with no subsequent recurrences. There were seven (11 per cent) synchronous and two metachronous malignancies.
Sixty-three case series with adequate data were identified from the literature. There were 163 (7.1 per cent) cases of synchronous carcinoma, out of 2297 cases. Metachronous carcinomas were reported in 74 out of 2047 cases, representing a transformation rate of 3.6 per cent. However, the true population base for these figures is uncertain, given that many series were reported from tertiary centres, where recurrent and problematic cases are likely to be over-represented. The recurrence rates were 12.8 per cent for endoscopic procedures, 17.0 per cent for lateral rhinotomy with medial maxillectomy, and 34.2 per cent for limited resections such as nasal polypectomy and Caldwell–Luc approaches. No significant association between atypia or dysplasia and recurrence or malignant transformation was found. The mean time taken to develop a metachronous carcinoma was 52 months (range six to 180 months). The estimated malignant potential for recurrent disease was up to 11 per cent.
Conclusion: Patients with inverted papilloma should undergo thorough surgery to remove all mucosal disease, most probably by the endoscopic, endonasal route when complete resection is possible. Cases demonstrating atypia or dysplasia may be treated by the endoscopic route. Recurrent disease and metachronous carcinoma can develop after a prolonged period of time. Long-term follow up is recommended to detect recurrence, as disease can become quite extensive before it becomes symptomatic.
Objectives: To assess the pattern and severity of globus-type symptoms, as measured by the Glasgow Edinburgh throat scale, in individuals who had never sought health care for a feeling of something in the throat, in order to generate the first useful normative dataset for the Glasgow Edinburgh throat scale.
Methods: One hundred and seventy-four participants recruited from non-ENT clinics completed the Glasgow Edinburgh throat scale. They were distributed among three age groups (21–45, 46–65 and >65 years).
Results: The commonest throat symptoms reported were ‘coughing to clear the throat’, followed by ‘catarrh down the throat’ and ‘discomfort/irritation in the throat’.
Conclusions: The results of the study – a normative dataset for the Glasgow Edinburgh throat scale – may form the basis for: (a) the use of the Glasgow Edinburgh throat scale in primary care to identify patients for whom referral to secondary care may be appropriate; (b) monitoring the natural history of globus sensation; and (c) assessing response to intervention, in terms of resolution to baseline population levels of symptom severity.
Two methods can be used to assess the intra-cuff pressure of tracheostomy tubes: digital palpation of the pilot balloon and use of a hand-held manometer. We conducted a telephone survey to determine the prevalence of both methods in intensive care units within 21 teaching hospitals across the United Kingdom. Forty-two per cent of the intensive care units surveyed used a protocol for monitoring cuff pressure with a manometer.
A study to compare these two methods, using the manometer as the reference standard, was then carried out. The cuff pressure was correctly estimated in pre-inflated tracheostomy tubes, in a tracheal model, by 61 per cent of a cross-section of intensive care unit and otolaryngology staff.
Using pilot balloon palpation is inaccurate and leaves a significant proportion of patients at risk of tracheal injury. We advocate the wider availability of hand-held pressure manometers in intensive care units and the institution of protocols for monitoring cuff pressure for any patient with a tracheostomy tube with an inflated cuff in situ.C Faris and E Koury are the joint lead authors.
Parotid abscess is an uncommon complication of suppurative infection of the parotid gland parenchyma, commonly bacterial or viral. Ductal ectasis, primary parenchymal involvement, or infection of the intraparotid or periparotid lymph nodes can result in abscess formation. Parotid abscess may arise from ductal ectasis, primary parenchymal involvement, or infection of the subcapsular lymph nodes.
The operative records for all the patients who underwent surgeries in the Department of Otorhinolaryngology, Head and Neck Surgery of the National University Hospital, Kuala Lumpur, Malaysia between January 2001 and December 2005 were retrospectively reviewed. Our case series comprises 15 patients, with 10 males and five females with a median age at presentation of 51 years old. Diabetes mellitus is a significant comorbid factor, with six patients being diabetics. Among the diabetics, two patients presented with facial nerve palsy and one of them also died due to overwhelming septicaemia. Here, we discuss the presenting symptoms, predisposing factors, investigations, microbiology and complications of this condition.
Objective: To review the results of surgical management of chronic parotid sialadenitis refractory to medical therapy, with particular respect to long-term symptom resolution and development of post-operative complications.
Methods: A retrospective review of parotidectomies performed for chronic intractable parotid sialadenitis. Information was collected about presentation, pre-operative investigations, surgical treatment, post-operative complications and outcome.
Results: 36 parotidectomies were performed for chronic sialadenitis between 1991 and 2002. Age at presentation was 56±9.6 years, with median symptom duration of 2.3 years. For patients with non-specific presentations, magnetic resonance imaging (MRI) was the most useful pre-operative investigation. Superficial parotidectomy with duct preservation was the main treatment with a 94 per cent success rate, and near-total parotidectomy was reserved for patients with extensive deep-lobe involvement. Duct ligation significantly increased the risk of transient facial palsy. There was a 56 per cent and 22 per cent incidence of temporary facial paresis and Frey's syndrome, respectively.
Conclusions: Controversies exist regarding the optimal pre-operative investigation and surgical treatment of chronic parotid sialadenitis. We advocate magnetic resonance image (MRI) scanning for patients with non-specific symptoms of sialadenitis, and sialography in the presence of reasonable clinical suspicion. We propose superficial parotidectomy without parotid duct ligation as the standard of care, with near-total parotidectomy reserved for extensive deep-lobe disease.
Globus pharyngeus is a symptom commonly encountered in ENT practice. The usual complaint is that of the sensation of a ball or lump in the throat generally unaccompanied by dysphagia. This sensation is often more pronounced when taking an ‘empty swallow’. The precise mechanism of this remains enigmatic in many cases. Irritant factors such as gastroesophageal reflux, postnasal drip and excessive throat clearing may be contributory factors as may be stress and psychological influences. Although gastric type mucosa occupying the cervical oesophagus has been long recognised, mainly in the specialised gastrointestinal literature, there appears to be more limited awareness of the condition in ENT practice and the clinical significance of such heterotopia is not well established. We present five recent cases of globus pharyngeus encountered in our ENT practice in which rigid pharyngoesophagoscopy and biopsy revealed heterotopic gastric mucosa within the postcricoid and cervical oesophagus constituting a so-called gastric ‘inlet patch’. One case re-presented with invasive adenocarcinoma within a short time. Herein we compare and contrast inlet patch with columnar lined oesophagus, discuss the potential clinical significance of inlet patch and comment upon further management of the condition.
Basal cell adenocarcinoma is a rare and relatively recently characterised malignant salivary gland tumour. It accounts for 5 per cent of parotid gland tumours and 1 per cent of salivary gland malignancies. It is very rarely documented in anatomical sites other than the major salivary glands. Basal cell adenocarcinoma has only been described once before in the ethmoid sinus.
We report a case of basal cell adenocarcinoma in the ethmoid sinus, extending into the right orbit and anterior cranial fossa. We describe the clinical aspects of the patient's management and detail the histopathological features of this very rare diagnosis.
Objectives: To describe the use of the great auricular nerve as a 'road map' for locating the accessory nerve in the anterior and posterior triangle, in comparison with other methods described in the literature.
Design: A review of the literature using Medline and Embase searches was performed. Illustrative photographs were taken from consenting, elective patients.
Results: Various methods have been described, using different anatomical landmarks. We describe a new method, based on the fact that the great auricular nerve runs, with relation to the edges of the sternocleidomastoid muscle, 1 cm superior to the accessory nerve anteriorly and 1 cm inferior posteriorly.
Conclusions: This is a reliable and safe method, used by the senior authors in their extensive work as head and neck and skull base surgeons. It allows the accessory nerve to be located in both the anterior and posterior triangle. This avoids the inherent dangers of following the nerve's tortuous course through the sternocleidomastoid.
This article describes the technique of ultrasound-guided core-needle biopsy in the head and neck, and also warns of its risks. In contrast to fine-needle aspiration, this minimally invasive procedure has the advantage of supplying a histological specimen rather than a cytological smear. Therefore, it could be used as an additional diagnostic tool in the investigation of head and neck lesions, and can be carried out within the out-patients clinic.
Meningitis is a life-threatening complication of otitis media. The appropriate management and the role of surgical intervention are still controversial, and there are no evidence-based guidelines in this regard.
We report three cases of otogenic meningitis, initially treated with parenteral antibiotics and myringotomy, followed by surgery. Two patients had an emergency mastoidectomy and one patient underwent surgery one month post-recovery due to the suspicion of bone erosion on a computed tomography scan. In two cases, a canal wall up procedure was performed, and one patient underwent revision of a radical mastoidectomy. In all cases, no pus or granulations were seen in the mastoid. Two patients fully recovered and one patient died.
We review the literature and critically discuss the role, timing and preferred type of surgery for otogenic meningitis.
Vestibular schwannomas containing cystic parts are common, but it is extremely rare for a vestibular schwannoma to contain fluid–fluid levels. In this report, we present two cases of vestibular schwannoma with magnetic resonance imaging findings of a fluid–fluid level, and we discuss the radiological features and possible mechanism of fluid–fluid level formation.