Cartilage grafts mimicking cholesteatoma recurrence on diffusion-weighted magnetic resonance imaging: a case series.

BACKGROUND: Cholesteatomas present a high risk for residual and recurrent disease, and the surveillance of post-operative patients can be challenging. Diffusion-weighted magnetic resonance imaging is becoming the preferred method for investigating recidivism; however, false positive imaging findings increase the risk of patients undergoing unnecessary second look surgery. CASE REPORTS: This study reports two patients with false positive diffusion restriction associated with cartilage grafts that mimicked cholesteatoma and resulted in second look surgery with no disease found at operation. This study also discusses the related medical literature, including potential causes of abnormal diffusion restriction and methods to negate this. CONCLUSION: Caution should be exercised when considering second look surgery in the presence of a cartilage graft and a high confidence of disease clearance. A multi-disciplinary approach is recommended for the operating surgeon to review the images with a radiologist.

Vascular abnormalities - a true cause of pulsatile tinnitus?

OBJECTIVE: Pulsatile tinnitus can be a symptom of vascular pathology. However, many of these pathologies present as incidental findings on scanning for unrelated symptoms. This study investigated whether the pathologies attributed to pulsatile tinnitus could instead be considered incidental findings. METHODS: This retrospective study evaluated imaging results of 272 pulsatile tinnitus cases for clinically relevant pathologies, and examined correlations between the site of symptoms and the imaging findings. RESULTS: Of 272 patients, 238 (88 per cent) had normal scans, 17 (6 per cent) had clinically insignificant incidental findings, and 18 (7 per cent) had findings requiring further investigation or intervention; regarding these latter 18 patients, findings for 8 patients (42 per cent) did not correlate with the symptomatic side. The rates of intracranial aneurysm and arteriovenous malformation in the pulsatile tinnitus group were comparable to those in normal populations. CONCLUSION: The comparable rates of vascular abnormalities within the symptomatic pulsatile tinnitus group, plus clinically relevant findings contralateral to symptoms, suggest that vascular pathologies could be incidental findings rather than causes of pulsatile tinnitus. Evaluation is recommended of the effectiveness of the new National Institute for Health and Care Excellence guidelines for pulsatile tinnitus investigation.

How we do it: cost-benefit analysis of implementing a telephone review system in an ENT outpatient setting.

There is an increasing pressure on the National Health Service (NHS) hospital consultants to reduce the waiting times. We have used an optional telephone review for a certain number of our outpatients so as to reduce the need for their in-person attendance. The result of our study, which was conducted in two phases, showed that almost half of the telephone follow-up patients (48%) were discharged over the phone. There was a direct saving of approximately 30 pounds per patient having a telephone follow-up.

Lymphoma presenting as a parotid tumour: a population-based study of diagnosis, treatment and outcome on behalf of the Scotland and Newcastle Lymphoma Group.

AIMS: Lymphoma presenting as a parotid tumour is rare. Previous published studies have been small and have not characterised fully the nature of lymphoma presenting this way. We studied the clinical features, diagnosis, prognosis and treatment in a patient group identified from the Scotland and Newcastle Lymphoma Registry, which is a prospectively collected population-based register of consecutive cases of lymphoma since 1979. MATERIALS AND METHODS: The study includes all patients with a biopsy-proven lymphoma in the parotid gland as the first presentation of their disease. RESULTS: Of 136 cases identified, 128 had non-Hodgkin's lymphoma (representing 1.5% of the 8499 non-Hodgkin's lymphomas in the registry) and eight had Hodgkin's disease (0.3% of the 2716 cases registered). Female to male ratio was 1.3:1, and median age was 69 years (range 19-94 years). Fifty-six per cent of patients had stage I, 16% had stage II, 11 % had stage III and 17% had stage IV disease. Diagnostic method was recorded in 81 cases; 47 of these were by parotidectomy. Overall median survival was 90 months, with a 5-year survival of 54%, but there was substantial variation according to age, grade, stage and International Prognostic Index (IPI). Diagnosis was often made by unnecessary major facial surgery, which could be avoided in many cases. CONCLUSION: Treatment should be directed by standard practice for lymphoma according to stage and histological classification.

The fish hook retractor.

We describe a simple and easily adjustable method of retracting skin flaps during head and neck surgery. It involves the use of a modified fish hook and rubber band. The retractor is easily applied and adjusted, and inexpensive to manufacture.

Endoscopic laser dacryocystorhinostomy. An unusual post-operative finding: re-opening of the nasolacrimal duct.

Endoscopic laser dacryocystorhinostomy (DCR) is a recognized technique for the surgical treatment of epiphora. Nasolacrimal duct obstruction is surgically bypassed by creating a passage from the lacrimal sac to the nasal cavity (rhinostomy). Some patients have undergone endonasal laser-assisted DCR, and were found to have an obstructed rhinostomy at follow-up. However, they reported a subjective improvement in their symptoms. Five such patients, at six months follow-up, were found to have a non-functioning rhinostomy with fluorescein dye emerging from under the inferior turbinate. These five patients along with four controls had post-operative macrodacryocystograms (MDCG) to delineate the anatomical passage by which tears were entering the nasal cavity. In the control group, clear passage of contrast into the middle meatus was demonstrated in three of the four subjects. In the study group, passage of dye to the inferior meatus, via the nasolacrimal duct was demonstrated in four of the five subjects. It is well recognized that a proportion of patients suffering from epiphora will have a natural resolution of their symptoms. Our results demonstrate that the resolution of epiphora in some operated patients was due to a re-opening of the nasolacrimal duct, and not because of a patent rhinostomy.

Screening for vestibular schwannoma: magnetic resonance imaging findings and management.

We report the contrast-enhanced magnetic resonance imaging (MRIg) findings from a series of 1139 patients who underwent screening to exclude a diagnosis of vestibular schwannoma. An acoustico-facial nerve bundle tumour was found in 3.1 per cent of patients imaged and vestibular schwannoma incidence is estimated at 1.4 per 100,000 population per annum. MRIg showed an abnormality in 14 per cent of patients; about one third of the findings may have accounted for the presenting symptom(s). A small number of patients had unexpected pathology revealed that required onward referral for further active management.

Internal jugular vein thrombosis in association with the factor V Leiden mutation.

We report an unusual case of internal jugular vein thrombosis in a 57-year-old female, with the recently discovered factor V Leiden (FVR506Q) mutation. The molecular basis of this mutation is described, and the importance of screening for hereditary venous thrombotic states is emphasized.

Lymphoma arising from Hashimoto's thyroiditis: an unusual cause of acute stridor.

We report an unusual presentation of non-Hodgkin's lymphoma of the thyroid which mimicked an acute infective thyroiditis and was associated with acute stridor and dysphagia. The mode of presentation and diagnosis of thyroid lymphoma are discussed and the value of early fine needle aspiration emphasised.

Randomised controlled trial of single-dose azithromycin in treatment of trachoma.

Blindness due to trachoma is a serious public health issue world wide. The currently recommended treatment of active trachoma with repeated doses of tetracycline eye ointment has many disadvantages. The new azalide antibiotic azithromycin is effective as a single oral dose in the chemotherapy of genital Chlamydia trachomatis infections, and we have assessed its efficacy for trachoma treatment. We carried out a randomised single-blind comparison of azithromycin (a single oral dose of 20 mg/kg) with conventional treatment (6 weeks of topical tetracycline plus erythromycin for severe cases) in two villages with endemic trachoma in The Gambia. The patients were followed up for 26 weeks from the start of treatment by an observer unaware of treatment allocation. By 6 months' follow-up, trachoma had resolved in 76 (78%) of 97 subjects who received azithromycin compared with 70 (72%) of 97 who were treated conventionally (95% CI for difference -6% to 18%). Compliance with both treatments was good, but that for conventional treatment could probably not be achieved outside the research setting. There were no significant differences in treatment effect, baseline characteristics, or re-emergent disease between the treatment groups. Azithromycin was well tolerated. As a systemic treatment effective in a single dose it has important potential for trachoma control.

PIP: Azithromycin is effective against Chlamydia trachomatis in vitro and as a single dose for the treatment of chlamydia infection of the genital tract. A randomized single-blind study was conducted in 2 Gambian villages (Jali with a population of 900 and Berending with 500) in order to assess the effectiveness and safety of a single oral dose of 20 mg/kg azithromycin compared with conventional treatment in ocular C. trachomatis infection. In May 1992 an ocular survey was done in both villages, and 199 subjects with active trachoma were identified (128 in Jali and 71 in Berending). Of these, 194 patients were randomly assigned to conventional or azithromycin treatment. Azithromycin was administered in a single dose of 20 mg/kg. Subjects receiving conventional treatment were given 1% tetracycline eye ointment to each eye twice daily for 6 weeks. Severe cases were given oral erythromycin stearate based on an adult dose of 250 mg 4 times daily for 2 weeks. Subjects were examined 4, 8, 16, and 26 weeks after treatment. In 20% of the subjects diarrhea, vomiting, and abdominal pain occurred. Clinical signs had resolved by 6 months' follow-up in 146 patients: 70 (72%) in the conventional treatment group, and 76 (78%) in the azithromycin group. At 6 months the symptoms of 9 subjects with severe disease, and 21 with moderate disease had resolved. However, during follow-up, 11 of those with severe disease, 30 of those with moderate disease, and 129 of those with mild disease had resolution at some point, which reflects the scale of re-emergent disease. To allow for the effect of recrudescent disease on point prevalences at follow-up, a survival analysis of time to loss of clinical signs as outcome was done. There was no difference between treatments (p 0.9). 21 of the 194 subjects were antigen positive in their nasal secretions at baseline. Of these, 18 still had clinical signs at 4 weeks compared with 87 of the 173 with antigen-negative nasal secretions ( p = 0.004; odds ratio 5.93).