A pain in the throat: a 19-year history of symptoms relating to the carotid artery.

A 38-year-old man presented with a 19-year history of sore throat and an ache radiating from the centre of the anterior neck to the both ears and the occiput. Computed tomography angiography revealed a tortuous submucosal right internal carotid artery, which was causing tonsillar displacement. The diagnosis of carotidynia has a controversial history within the literature and is currently not accepted as a distinct pathological entity by the International Headache Society. In this patient, the clinical and imaging features, in addition to the absence of any other pathology confers support to the diagnosis of carotidynia.

Malignant otitis externa: experience with hyperbaric oxygen therapy.

INTRODUCTION: The treatment of malignant otitis externa (MOE) with hyperbaric oxygen therapy (HBOT) remains controversial. The rarity of MOE, combined with poor access to hyperbaric facilities, explains the paucity of existing data. METHODS: We retrospectively reviewed all patients with a diagnosis of MOE referred to the Prince of Wales Hospital hyperbaric unit over a period of six years, and report one of the largest case series to date. RESULTS: From August 2001 to October 2007, 17 patients with MOE were referred, of whom 15 (88%) completed therapy, one did not tolerate HBOT and one was withdrawn due to pulmonary complications. Length of admission averaged 48 days (range 8-93 days) and three received outpatient care. Five patients had complications attributable to HBOT: acute pulmonary oedema (n = 2), seizure (n = 1), tympanic membrane perforation (n = 1) and claustrophobia (n = 1). Average time to follow up was 47 months (range 1-94 months). Twelve patients (70%) were considered cured of their disease, being disease-free at follow up, including four patients who had died of other causes but were symptom-free at the time of death. Three patients died directly from MOE (18%), one after a recurrence of their disease. Two further patients had recurrent disease, both successfully treated with a second cycle of HBOT and antibiotics. Nine patients (53%) had facial nerve palsy before commencement of HBOT, of whom four died, three from MOE, four had ongoing facial paralysis, and one resolved. CONCLUSIONS: HBOT confers minimal morbidity, but its role in MOE remains uncertain. The high mortality of MOE despite maximal therapeutic intervention highlights the need for more effective treatment protocols.

Mastoiditis in a paediatric population: a review of 11 years experience in management.

OBJECTIVE: This study explores the experience at Sydney Children's Hospital (SCH) managing children with acute mastoiditis and establishes a robust treatment algorithm. METHODS: Retrospective review of all patients admitted to SCH with an ICD-10 coding of "Mastoiditis" from 1 January 1996 through 31 December 2006 inclusive. Criteria assessed included demographic characteristics, clinical features, symptom duration and treatment initiated by the general practitioner. The results of investigations at SCH were reviewed including white blood cell count, microbiology and imaging. The presence of complications was determined and the results of medical and surgical treatment were assessed. RESULTS: Seventy-nine episodes of acute mastoiditis were managed in 76 patients. Treatment prior to SCH was commenced by the family practitioner or district hospital doctor in 53/79 patients. The mean duration of community initiated treatment before presentation to SCH was 3.7 days. In 33 episodes a previous history of acute otitis media was noted (42%). In the remaining 46 episodes (58%) mastoiditis was the initial diagnosis. Complications were found in 30 episodes (38%) and 36 episodes (46%) required surgical treatment. CONCLUSIONS: Mastoiditis often develops rapidly but may be treated very effectively. The potential for significant morbidity remains high but excellent outcomes can be expected for those who are managed without delay. Children with acute mastoiditis should be managed in centres where timely and complete medical and surgical treatment is available.

Lingual tonsillectomy: a review of 5 years experience and evolution of surgical technique.

OBJECTIVES: To assess the indications for lingual tonsillectomy; to report our experience with lingual tonsillectomy, and to present the evolution of our surgical technique. METHODS: A review of 5-years experience from a prospectively maintained database of 28 patients was performed together with a focused review of the international literature. Therapeutic procedures included lingual tonsillectomy with access via the Boyle-Davis gag or suspended video laryngoscope and with the resection via diathermy, CO(2) laser, or microdebrider. RESULTS: The indication for lingual tonsillectomy was upper airways obstruction in 22 patients and recurrent infection in six. The operative time for lingual tonsillectomy ranged from 35 to 80 minutes (mean time, 43 minutes). The perioperative in-hospital stay ranged from one to three days for 27 patients. All did very well postoperatively. CONCLUSION: Lingual tonsillar pathology may cause significant morbidity and is frequently the cause of persisting peripheral obstructive sleep apnea syndrome after adenotonsillectomy. Lingual tonsillectomy performed with video laryngoscopy and microdebrider resection is feasible and safe and provides good results.

Emergency surgery after unsuccessful coronary angioplasty: a review of 15 years' experience.

BACKGROUND: Emergency coronary artery bypass grafting (CABG) is occasionally necessary for failed percutaneous transluminal coronary angioplasty (PTCA). The aim of this study was to assess the outcome of patients receiving emergency CABG after unsuccessful PTCA over a 15-year study period. METHODS: From January 1982 through December 1996, 74 patients underwent emergency CABG after unsuccessful PTCA (crash group). This group was compared with a matched group of 74 patients having primary elective CABG (control group). RESULTS: All 74 crash group patients were to have PTCA of one coronary system. After PTCA failure, 58 patients (78.3%) developed electrocardiographic changes of evolving acute myocardial infarction (AMI). The overall rate of AMI was 8.1% for the crash group and 2.7% for the control group. Two patients in the crash group died, with no deaths in the control group. There was no significant difference between mean in-hospital length of stay. CONCLUSIONS: With prompt, aggressive, and complete myocardial revascularization, patients who required emergency CABG after PTCA failure had an outcome not significantly different from that of patients having elective CABG.

Atypical presentation of intramedullary spinal cord lesion.

We report a patient who presented with atypical clinical manifestations including worsening abdominal pain from an intramedullary spinal cord lesion. It is important to consider non-abdominal causes of abdominal pain for patients with an atypical presentation. The described case demonstrates the challenges facing the physician with the early diagnosis of acute abdominal pain. Spinal cord lesions, although uncommon, remain a potentially disabling and life-threatening cause of abdominal pain.

Short-term resolution of psoriasis after total thyroidectomy for euthyroid multinodular goitre.

A 36-year-old Chinese female with an 8-year history of chronic, generalized plaque psoriasis demonstrated a marked improvement of the disease after removal of an intercurrent euthyroid multinodular goitre. Thyroxine was commenced immediately postoperatively. No thyroid antibodies were detected and thyroid function and calcium levels remained within normal limits both pre- and postoperatively. Four weeks following surgery, narrow-band ultraviolet B (nbUVB) therapy was recommenced for recurrent psoriasis. The manifestations of psoriasis at this stage were less severe than before thyroidectomy and responded well to treatment, whereas before surgery the response to therapy had been poor. One year following total thyroidectomy, the patient received very effective psoriasis control with nbUVB therapy. The possible role of surgery and thyroid hormones in altering the pathogenesis of psoriasis in the acute setting is clearly of interest and warrants further research consideration.

Total thyroidectomy is now the preferred option for the surgical management of Graves' disease.

PURPOSE: Subtotal thyroidectomy has been advocated as the standard treatment for Graves' disease because of the possibility of avoiding thyroxine therapy as well as the assumed lower risk of complications compared to total thyroidectomy. However, the long-term results of subtotal thyroidectomy are not as good as they were previously believed to be, as evidenced by the increasing incidence of hypothyroidism. If the risk of complications from total thyroidectomy is no higher,then that procedure offers significant advantages in the surgical management of Graves' disease. The aim of this study therefore was to compare the complication rate of the two procedures in patients with Graves' disease. METHODS: This was a retrospective case control study in a tertiary referral hospital. Information was obtained from an endocrine surgery database over the study period from January 1957 to December 2000. During that period 1246 patients with Graves' disease underwent subtotal thyroidectomy and 119 patients underwent total thyroidectomy. RESULTS: Prior to 1987 total thyroidectomy was rarely if ever performed whereas in the last 12 months total thyroidectomy comprised 95% of all procedures. There was no significant difference in the rate of permanent complications between the two procedures although temporary hypocalcaemia was significantly more common following total thyroidectomy. Permanent hypoparathyroidism resulted in one patient each who underwent total thyroidectomy (0.8%) and subtotal thyroidectomy (0.1%). Permanent recurrent laryngeal nerve palsy occurred in one patient who underwent total thyroidectomy (0.8%) and 5 patients undergoing subtotal thyroidectomy (0.4%). CONCLUSION: Given that subtotal thyroidectomy provides an unpredictable outcome and that the risk of permanent complications is no greater than with total thyroidectomy, there appears little logical reason to continue to recommend subtotal thyroidectomy for the surgical management of Graves' disease. We believe that Graves' disease should join the increasing list of thyroid conditions for which total thyroidectomy is the preferred option.

Management of acute superior mesenteric artery occlusion.

BACKGROUND: This review examines the surgical management of acute superior mesenteric artery (SMA) occlusion and the impact of interventional radiology techniques. METHODS: Eight consecutive patients with SMA occlusion were treated at the Lismore Base Hospital, Lismore, NSW, Australia, from 1996 through to 2001 and of these, one patient was managed successfully with catheter-directed lytic therapy. The study group included five male and three female patients with a mean age of 71.3 (range 57-88) years. The records of these patients were reviewed to determine demographic characteristics, clinical features, predisposing factors and the duration of symptoms before intervention, management details and final outcome. RESULTS: Embolic phenomena due to atrial fibrillation were the most frequently identifiable cause of acute SMA occlusion, present in six of eight patients. Seven patients were managed with open surgery in the first instance and of these, four died. Three patients remain alive and well at a mean 2.8 years follow-up. Patient number eight developed acute SMA occlusion from embolism secondary to atrial fibrillation and was managed initially with SMA urokinase thrombolysis. This patient's pain was relieved 1 h after initiation of the procedure. Delayed films after 18 h from initiation of thrombolysis demonstrated re-opening of all the ileo-colic branches and at 6 weeks' follow-up the patient remains well with normal bowel function. CONCLUSIONS: There is a role for selective SMA cannulation and urokinase thrombolysis in the management of patients with acute SMA thrombosis.