Coblator-Assisted Endoscopic Transnasal Resection of a Large Nasopharyngeal Pleomorphic Adenoma.

BACKGROUND: Pleomorphic adenomas occurring in the adult nasopharynx are rare, with our literature search identifying only 11 previous English-language reports. We document the unusual case of a large nasopharyngeal pleomorphic adenoma that was resected using radiofrequency coblation via an endoscopic transnasal approach. METHODS: A 39-year-old male presented with worsening nasal congestion, intermittent otalgia, and a progressive change in voice. Flexible nasendoscopy showed a large homogeneous mass occupying the postnasal space, and computed tomography confirmed a 28 × 31 × 22 mm nasopharyngeal tumour. The biopsy-proven benign tumour was locally dissected using a coblator-assisted transnasal approach. RESULTS: Histology confirmed complete excision of a myoepithelial-rich pleomorphic adenoma. The patient was symptom-free postoperatively, and no signs of recurrence were seen at one-year follow-up. CONCLUSIONS: This is a useful addition to the existing literature on surgical procedures used to treat benign pathology in the nasopharynx. The minimally invasive technique was well tolerated and had favourable patient outcomes.

Return to theatre in secondary post-tonsillectomy haemorrhage: a comparison of coblation and dissection techniques.

The aim of this study is to examine the incidence of return to theatre (RTT) for post-operative haemorrhage following coblation and dissection tonsillectomy and to investigate those that required RTT more than 10 days post-surgery. Retrospective review of post-tonsillectomy haemorrhages requiring RTT from April 2005 to March 2009 was conducted. Of 2,541 tonsillectomies performed, 81% were by coblation and 19% by dissection methods. The overall RTT rate was 1.7%. No difference was found in the overall RTT rates for primary and secondary haemorrhage between the two techniques. However, the overall RTT rates for primary and secondary haemorrhage were higher in adults than children (P = 0.0456 and P = 0.0215, respectively). RTT for secondary haemorrhage during the first ten post-operative days occurred in both coblation and dissection tonsillectomy with no significant difference. After the first post-operative week, late secondary bleeding requiring RTT occurred only in the coblation group (P = 0.0676). Four patients required blood transfusion; all were in the coblation group, three of which were required during RTT in the late secondary haemorrhage (after 10 days). The post-operative RTT rates for coblation tonsillectomy did not reveal a change of trend over the 4-year study period. Our RTT rate for secondary haemorrhage is higher than earlier published results. A learning curve could not be identified in RTT for coblation tonsillectomy haemorrhage. Late secondary haemorrhages requiring surgical intervention have only been identified in cases performed by coblation and could potentially be life threatening as 33% (3/9) required blood transfusion. This phenomenon may be explained by a particular physiological healing process associated with coblation.

Solid variant of alveolar rhabdomyosarcoma in the head and neck region: a case report of a diagnostic dilemma in a head and neck fine needle aspiration clinic.

BACKGROUND: Alveolar rhabdomyosarcoma (ARMS) is one of the major categories of rhabdomyosarcomas; it encompasses malignant tumors of striated muscle and occurs more frequently in the extremities. It is uncommonly reported in young adults and extremely rarely found in middle-aged and elderly patients. CASE: A 54-year-old man presented to a rapid head and neck clinic with a history of rapid enlargement of neck lumps on the right side of his neck over a period of 5 weeks. The diagnosis of an undifferentiated malignant small round cell tumor was made from cytologic examination of the aspirated sample, and biopsy of the lesion was advised. On histologic analysis, diagnosis of solid variant of ARMS was made. CONCLUSION: A solid variant of ARMS in an older population has not been published in the literature within the settings of a rapid head and neck clinic. Therefore, the remote possibility of this diagnosis should be considered in the differential diagnosis of a malignant, round cell tumor in fine needle aspiration cytology in an older patient's neck lump.

Postoperative drainage in head and neck surgery.

INTRODUCTION: A major factor affecting patients' length of hospitalisation following head and neck surgery remains the use of surgical drains. The optimal time to remove these drains has not been well defined. A routine practice is to measure the drainage every 24 h and remove the drain when daily drainage falls below 25 ml. This study aims to determine whether drainage measurement at shorter intervals decreases the time to drain removal and hence the length of in-patient stays. PATIENTS AND METHODS: A 6-month prospective observational study was performed. The inclusion criteria were patients who underwent head and neck surgery without neck dissection and had a closed suction drain inserted. Drainage rates were measured at 8-hourly intervals. Drains were removed when drainage-rate was ≤ 1 ml/h over an 8-h period. RESULTS: A total of 43 patients were evaluated. The highest drainage rate occurred in the first 8 postoperative hours and decreased significantly in the subsequent hours. The median drainage rates at 8, 16, 24, 32 and 40 postoperative hours were 3.375, 1, 0, 0 and 0 ml/h, respectively. Applying our new removal criteria of ≤ 1 ml/h drainage rate, the drains were removed in 22 (51%) patients at the 16th postoperative hour; 37 (86%) were removed by 24 h after operation. In comparison, only nine (20.9%) patients could potentially be discharged the day after surgery if previous criteria of ≤ 25 ml/24-h were used to decide on drain removal. CONCLUSIONS: Our 8-hourly drainage-rate monitoring has facilitated safe earlier discharge of an additional 28 (65%) patients on the day after surgery. This has led to improvement in patient care, better optimisation of hospital resources and resulted in positive economic implications to the department.

Supraglottic stenosis in localized Wegener granulomatosis.

We present what we believe is the first reported case of a patient with supraglottic stenosis secondary to Wegener granulomatosis. The diagnosis was unclear initially because the biopsy results were nonspecific, but a finding of an elevated cytoplasmic-pattern antineutrophil cytoplasmic antibody (c-ANCA) level established the diagnosis of localized supraglottic Wegener granulomatosis. Wegener granulomatosis is characterized by necrotizing vasculitis that is localized predominantly to the kidneys and the upper and lower airways. In the airways, subglottic involvement is well documented, but to the best of our knowledge, supraglottic stenosis has not previously been described. Localized forms of Wegener granulomatosis are characterized by limited disease that involves only the upper airway. The diagnosis in localized forms is complex because histology is diagnostic in only 50% of cases, and only 60% of patients have a positive c-ANCA level. We discuss the diagnostic criteria and management strategies for these localized forms.

The community management of chylous fistula using a pancreatic lipase inhibitor (orlistat).

We describe two innovative ideas in the treatment of iatrogenic chyle leak. The first is the early use of a pancreatic lipase inhibitor (Orlistat) to reduce fat absorption and chyle production, with consequent faster fistula healing. The second is the treatment of these patients at home in the community by district nurses backed by the hospital staff. This domiciliary approach has a positive psychological effect on the patient, permits the patient to take responsibility for their treatment, and reduces hospital length of stay minimising patient exposure to nosocomial infections.

Coblation tonsillectomy versus dissection tonsillectomy: postoperative hemorrhage.

OBJECTIVES/HYPOTHESIS: Coblation tonsillectomy is a recently introduced surgical technique. To measure its benefits against traditional tonsillectomy techniques, it is necessary to compare their complication rates. The study aims to identify differences in reactionary and secondary hemorrhage proportions, comparing coblation with dissection tonsillectomy. STUDY DESIGN: Prospective observational cohort study. METHODS: Rates of reactionary and delayed postoperative hemorrhage were measured, comparing 844 coblation tonsillectomies with a control group of 743 tonsillectomies performed by blunt dissection with bipolar diathermy hemostasis. RESULTS: The secondary hemorrhage rate with coblation-assisted tonsillectomy was 2.25% compared with 6.19% in the control group (P <.05). The rate of secondary hemorrhage in children following coblation tonsillectomy was 0.95% compared with 4.77% in the control group (P <.05). The difference was also significant (P <.05) in the adult population (4.40% vs. 8.81%, respectively). No difference was found in the reactionary hemorrhage proportions. CONCLUSION: In the study, coblation tonsillectomy was associated with a lesser incidence of delayed hemorrhage, more significantly in the pediatric population. The new technique using tissue coblation for tonsil dissection offers significant advantages in the postoperative period compared with dissection tonsillectomy with bipolar diathermy hemostasis. Coblation is associated with less postoperative pain and early return to daily activities. Also, there are fewer secondary infections of the tonsil bed and significantly lower rates of secondary hemorrhage with coblation. These results and the disposable nature of the coblation equipment promote coblation tonsillectomy as the authors' preferred dissection method.