Sudden sensorineural hearing loss: when is it idiopathic?

OBJECTIVE: To highlight the importance of assessing the certainty of a diagnosis of idiopathic sudden sensorineural hearing loss, and of modifying patient management accordingly. CASE REPORT: A patient presented with sudden sensorineural hearing loss in the right ear. Following assessment and preliminary investigation, a diagnosis of idiopathic sudden sensorineural hearing loss was made. Steroid treatment was commenced. Two weeks later, the patient experienced sudden sensorineural hearing loss in the left ear, and scalp tenderness. Subsequent biopsy confirmed giant cell arteritis. CONCLUSIONS: Management of idiopathic sudden sensorineural hearing loss should be guided by the level of certainty of diagnosis. If there is relative uncertainty, risk factors for specific diagnoses should be sought, the patient should be followed more closely, and investigation should be tailored appropriately. Giant cell arteritis should be considered in patients older than 50 years, those exhibiting suggestive signs or symptoms, and those with elevated inflammatory markers or deranged liver function tests.

Observer error in the assessment of nodal disease in head and neck cancer.

BACKGROUND: There is no previously published information on clinicians' abilities to accurately differentiate between different stages of node positive disease in head and neck cancer. METHODS: Forty-two surgeons examined standardized nodes in a model neck and estimated nodal size. Each recorded their confidence in their ability to perform the task using a visual analogue scale. Reference nodes of known size were provided for comparison during a second examination of each node. The study was repeated after 1 month. RESULTS: Accuracy was poor and was not dependent on experience or confidence. There was a tendency to underestimate the size of smaller nodes. Estimates were strongly influenced by volume independent of largest diameter (p <.001). Reference nodes aided accuracy (p =.031). Subjects were not consistent on repeated testing (p <.001). CONCLUSIONS: Both trainees and specialists are poor at accurately staging nodal disease using palpation alone.

Non-pseudomonal malignant otitis externa and jugular foramen syndrome secondary to cyclosporin-induced hypertrichosis in a diabetic renal transplant patient.

We present the case of a 58-year-old diabetic renal transplant patient who developed a left jugular foramen syndrome, secondary to an ipsilateral staphylococcal malignant (necrotizing) otitis externa. This followed a protracted episode of uncomplicated otitis externa with no evidence of bone involvement on computed tomography (CT) scanning. Cyclosporin-induced hypertrichosis (excess hair growth) in his external auditory canal contributed greatly to the initial difficulty in managing his otitis externa. Following an initial successful treatment with prolonged intravenous antibiotics the patient relapsed with a secondary infection in the same anatomical site due to Candida parapsilosis. Despite further intensive treatment including antimicrobials, a subtotal petrosectomy and hyperbaric oxygen therapy he eventually succumbed to his disease.

Otological complications following basal skull fractures.

A retrospective review is presented of 50 patients, with a basal skull fracture, who had radiological or clinical evidence of temporal bone involvement. The study looks at the incidence of significant otological symptoms reported during the admission and we review the subsequent patient management. We propose that all patients presenting with a head injury, and one or more of a number of symptoms characteristic of a temporal bone fracture, should automatically have an otological assessment. This will facilitate the early detection and subsequent follow up of potentially correctable middle ear disorders. We review the literature to highlight the high incidence of complications associated with these fractures.

Oro-nasal transfer of nasogastric tube following endoscopic placement.

After placement of a nasogastric tube through a rigid oesophagoscope it is necessary to transfer the proximal end from the mouth to the nose. Observation of surgeons performing this apparently simple task has indicated that many find it somewhat difficult. We describe a simple solution to the problem.

Papillary endothelial hyperplasia (Masson's tumour) of the maxillary sinus.

In 1923, Masson described a neoplastic process consisting of papillary hyperplasia of the endothelial cells, with a consequent obliteration of the vascular lumen, followed later by degenerative changes. Masson coined the term vegetant intravascular haemangioendothelioma, however, these days it is more commonly known as papillary endothelial hyperplasia (PEH), or by the pseudonym, Masson's tumour. Although relatively rare, there are numerous accounts of PEH in the literature, describing its predilection for the head and neck region. Our case report describes the finding of a PEH within the paranasal sinuses, a site not previously mentioned even in the largest of series found on literature search. We will then discuss the relevant histological features of the lesion, and its natural history.

Training model for nasal packing.

A model is described for practising packing of the nose with ribbon gauze in the treatment of epistaxis. The model was constructed from accurate casts of a cadaveric nasal cavity. The value of the model as a practical teaching aid is shown by a trial on a group of 15 accident and emergency (A&E) doctors. After training on the model, there was a significant improvement in the confidence of the doctors to pack a nose, the amount of gauze packed and the visual appearance of the pack. Use of the model should raise the generally poor standard of nasal packing by doctors working in A&E departments.

The Jepson whistle: a simple device for laryngectomees.

A simply manufactured whistle for the use of laryngectomees is described. It is useful for attracting attention in an emergency.

Late congenital syphilis of the larynx and pharynx presenting at endotracheal intubation.

The case of a 73-year-old lady with late congenital pharyngo-laryngeal syphilis is presented. Its finding was at a potentially difficult intubation during the induction of general anaesthesia. She was asymptomatic; there was no evidence of active disease on either clinical examination or serology and no treatment was required. However, it is important to differentiate this condition from others which may require treatment.

Lingual thyroid presenting after previous thyroglossal cyst excision.

Lingual thyroid is a rare lesion caused by maldescent of the thyroid gland. It is an important cause of a mass on the posterior third of the tongue, and may coexist with other developmental abnormalities such as thyroglossal cyst. The diagnosis is made by radioisotope scan. Treatment is indicated in the presence of symptoms and consists initially of thyroxine. Severe or unresponsive cases require complete excision through a lateral pharyngotomy. Hypothyroidism is common postoperatively, but may be avoided in some cases by transplantation of excised tissue. We present a case report and review of the literature.

Carbon dioxide laser cordectomy in the management of bilateral vocal cord paralysis.

Bilateral vocal cord paralysis is a rare but major complication of thyroid surgery. Since 1983, patients with bilateral cord paralysis have been managed in this department using the carbon dioxide laser. Six patients with bilateral cord paralysis secondary to thyroid surgery underwent partial cordectomy and arytenoidectomy. Two patients were operated on with tracheostomy tubes in situ, and both were successfully decannulated. In the remaining four patients, ventilation was maintained during anaesthesia using a Venturi jet ventilation system. None of these patients required a perioperative tracheostomy. Adequate airway improvement and satisfactory voice quality were achieved. Follow-up ranged from 6 to 17 months.