Reversal of Young's procedure in hereditary haemorrhagic telangiectasia.

BACKGROUND: Hereditary haemorrhagic telangiectasia is an autosomal dominant condition characterised by multiple venous malformations of the skin and mucous membranes which can bleed on contact. A Young's procedure is used to control severe epistaxis in patients with this condition. However, there has been no previous report of a reversal of Young's procedure in such a patient. OBJECTIVE: A patient with hereditary haemorrhagic telangiectasia had his Young's procedure reversed under general anaesthetic by dividing the mucocutaneous flaps. Nasal vestibule patency was maintained using a custom-made silicone nasal mould. Intra-operative photographs show the patient's nasal mucosa shortly following reversal of his Young's procedure, and also illustrate the creation of the custom-made nasal mould. CONCLUSION: Stopping airflow through the nasal cavity via a Young's procedure prevents the telangiectasia from bleeding but does not make them disappear completely. Young's procedure does not seem to have any long-lasting effect on the nasal mucosa of patients with hereditary haemorrhagic telangiectasia.

The impact of methicillin-resistant Staphylococcus aureus on ENT practice.

Antibiotic-resistant bacteria are increasingly common and present a major problem for the modern day ENT surgeon. This article reviews the development of methicillin resistance in Staphylococcus aureus and how it has come to affect ENT practice. We look at the evidence behind measures taken to help deal with methicillin-resistant Staphylococcus aureus (MRSA) and to prevent its spread. We go on to suggest a departmental guideline for infection control, which we hope can be implemented to help deal with the problems created by MRSA.

Unfounded worries about cancer in patients attending a routine otolaryngology clinic.

To investigate a suspicion that many ear, nose and throat patients have unfounded concerns about cancer, we questioned 50 patients who had attended a routine clinic after screening-out of those with possibly cancer-related features. None of the 50 proved to have cancer. 15 (30%) had been worried about cancer and 7 of these were still worried despite the consultation. Unwarranted fears about cancer are best dealt with by the referring clinician, especially when the wait for an appointment will be long. Such fears also need to be recognized and addressed by the specialist.

Inferior turbinate reduction in children using Holmium YAG laser-a clinical and histological study.

BACKGROUND AND OBJECTIVES: To compare the efficacy and safety of inferior turbinate reduction in children using Holmium:YAG (Ho:Yag) laser and diathermy. Histological effects of these treatments on turbinate tissue are also studied. STUDY DESIGN/MATERIALS AND METHODS: A retrospective review and structured telephone interview of paediatric cases treated with Ho:Yag laser and diathermy to inferior turbinates. The complications, morbidity and efficacy were quantified. Histological sections of inferior turbinates treated with diathermy (surface and submucosal) and laser were compared. RESULTS: Efficacy in the laser (n = 8) and diathermy group (n = 11) was similar. The complication/morbidity score was lower in the laser group, 1.92 versus 3.48, (P = 0.04, CI: 0.01, 2). Long-term benefit was 50 and 36% in the laser and diathermy group respectively. Histology showed very limited tissue damage in all methods of treatment. CONCLUSIONS: Ho:Yag laser treatment is equally efficacious, but causes less complications and morbidity compared to surface diathermy. Both treatment methods have poor long-term efficacy, which may be related to limited tissue damage.

Endonasal laser dacryocystorhinostomy: its role in anticoagulated patients.

OBJECTIVE: To report the results of endoscopic laser-assisted dacryocystorhinostomy in anticoagulated patients. STUDY DESIGN: A retrospective study of 16 consecutive anticoagulated patients with distal nasolacrimal duct obstruction treated by endoscopic laser-assisted dacryocystorhinostomy. METHODS: A case note review was made of all patients treated with endoscopic laser-assisted dacryocystorhinostomy who were taking coumadin in two centers between 1993 and 2000. The parameters of age, gender, indications for surgery, surgical findings, complications, and outcome were analyzed. The mean follow-up time was 14 months (range, 9-26 mo). RESULTS: Fifteen of the 16 patients who were treated had an eventual successful outcome, but 6 patients required revision surgery. The patient whose symptoms were not improved was shown to have functional epiphora. No patient had a problem with primary or secondary epistaxis, and no patient required admission. A major benefit was the lack of disruption of anticoagulant therapy. CONCLUSIONS: Endoscopic laser-assisted dacryocystorhinostomy is a safe, efficient technique for the relief of distal nasolacrimal duct obstruction in anticoagulated patients. Not only does it avoid any disruption to their anticoagulant therapy, but it also can be performed as an outpatient procedure.

Endoscopy in the assessment of children with nasal obstruction.

Nasal obstruction is common in children, and is often attributed to adenoid enlargement. This prospective study was performed to determine whether routine nasal endoscopy is of value for children undergoing surgery for nasal obstruction. Forty-eight children aged two to nine years undergoing adenoidectomy, and six normal controls, were examined under general anaesthesia with a 4 mm rigid endoscope. A video of the endoscopy was subsequently assessed independently by an observer blinded to the original findings and the presence of nasal symptoms. The endoscopist and independent assessor were in agreement regarding 86 per cent of the findings. Three quarters of the children had abnormalities on endoscopy in addition to enlarged adenoids, and in 23 per cent these were potentially of major clinical significance (unsuspected foreign body, gross septal deviation, gross hypertrophy of the turbinates). Endoscopy produced no post-operative complications and was possible in children as young as two years of age, without decongestants. Nasal endoscopy is a safe, objective and useful means of identifying potentially significant abnormalities in children with nasal obstruction.

Can nasal endoscopy be used to predict residual symptoms after adenoidectomy for nasal obstruction?

BACKGROUND: the efficacy of adenoidectomy in relieving nasal symptoms has been questioned. Although enlarged adenoids are often blamed for nasal obstruction, other causes can be missed if examination is not thorough. We suggest that endoscopy at the time of adenoidectomy may be useful to confirm large adenoids and exclude other causes, and the findings may help predict residual symptoms 2 years after adenoidectomy. METHOD: a prospective study of a consecutive series of children undergoing adenoidectomy for nasal obstruction was performed. All underwent endoscopy with a 4-mm rigid endoscope without decongestants under GA immediately prior to adenoidectomy. Two years later a postal symptom questionnaire was sent, with telephone follow up for non-responders. The findings on endoscopy were compared with residual symptoms at 2 years. RESULTS: Forty-eight children aged 2-9 (mean 4) years were enrolled, 26 of them female. At 2 years follow up, data were available for 34 children (71%). Complete obstruction of the posterior choanae of the nose by adenoids was seen in 21 (62%). Additional findings (e.g. septal deviation, hypertrophic mucosa on the turbinates) were present in 22 (65%). Of them 9 (26%) had residual nasal symptoms. Of the children with less than occlusive adenoids, six (50%) out of 12 had residual symptoms, compared with three (14%) out of 21 with occlusive adenoids (chi(2)=4.91, P<0.05). Although residual symptoms were more common in those with additional findings on the original endoscopy (32 vs. 17%), this did not reach statistical significance. CONCLUSIONS: residual nasal symptoms are common when children are followed up in the medium term. The findings on endoscopy may predict the success of adenoidectomy in relieving the symptoms, and may help to guide further treatment.

Dacryocystorhinostomy in nasolacrimal duct obstruction secondary to sarcoidosis.

Over the past 3 years we have treated 4 patients with nasolacrimal duct obstruction secondary to sarcoidosis. These patients have had mixed outcomes following endonasal laser-assisted dacryocystorhinostomy (DCR). A literature search from 1966 to the present yielded a further 11 cases of patients thought to have sarcoid who underwent DCR. The outcome of these 15 patients indicate that while all were initially successful, the subsequent failure rate is high. These patients are older than the majority of patients with sarcoidosis and there is a female preponderance. Systemic steroids reversed obstruction in one patient. We recommend nasal examination in all patients with nasal symptoms in whom DCR is proposed to help identify sarcoidosis or other intranasal disease and/or to allow treatment of specific diseases prior to surgery.

Laryngeal involvement by cutaneous lymphoma.

Laryngeal involvement by cutaneous lymphoma is rare; it may be isolated or part of systemic spread. We report a case of cutaneous T-cell lymphoma with isolated extracutaneous spread to the larynx, confirmed by the polymerase chain reaction in addition to histology. Awareness of this association may allow early recognition of symptoms heralding laryngeal embarrassment.

The Safety of Common Voice Prostheses with ENT Lasers.

Silicone voice prostheses, or valves, are inserted into the common tracheo-oesophageal wall of patients after laryngectomy, to allow speech rehabilitation. Granulation tissue around these voice prostheses is often removed by laser and the safety of these valves with lasers had not been confirmed. The common valves were exposed to increasing energies from the carbon dioxide, potassium-titanyl-phosphate and holmium YAG lasers, in air. The energies used were those in common clinical use. The Provox valves proved especially vulnerable to all laser energies. Other methods of removing granulation tissue should be tried prior to lasering, or the valves should be removed, as damage to them, or the patient's airway, can result.

Torsion of the palatine tonsil.

Torsion of a pedunculated part of the palatine tonsil is extremely rare. This paper discusses the clinical presentation, differential diagnosis, treatment of such a case and reviews the existing literature.

Analysis of CT scanning referrals for chronic rhinosinusitis.

The principal role of computed tomography (CT) scanning in rhinosinusitis is as a planning investigation for patients requiring functional endoscopic sinus surgery (FESS). The pre-operative scan is used to highlight any potential surgical hazards, and to delineate the extent of disease reducing unnecessary intervention in disease-free areas. It is inappropriate for CT to be used purely as a diagnostic investigation for chronic rhinosinusitis. As concern has been expressed over the steady rise in the referrals for CT of the sinuses, we conducted a retrospective review of all patients having these scans at two CT scanner sites in Scotland during 1993. Of the 162 scans performed for rhinosinusitis, 58 patients (36 per cent) had not had nasendoscopy performed or had a trial of medical treatment. Subsequently, only 61 patients (38 per cent) went on to FESS. The inappropriate use of CT for these patients can be reduced by insisting that nasendoscopy is performed prior to scanning. Furthermore, radiologists and surgeons should audit the number of patients not having FESS after scanning.

A pilot study of the holmium YAG laser in nasal turbinate and tonsil surgery.

A pilot study of the holmium YAG laser (a solid-state pulsed laser, wavelength 2.1 mum) was performed for tonsillectomy and nasal turbinate surgery. In the nose, intraoperative bleeding was negligible, facilitating an excellent view of the operative field and avoiding the need for postoperative nasal packs. There was no occurrence either of primary or secondary hemorrhage. Some intranasal crusts separated with no difficulty between 3 and 6 weeks. There was no significant delayed tissue destruction. Tonsillectomy was almost bloodless. There was some minor difficulty in mobilizing the upper tonsillar pole. Postoperative pain was no worse than routine tonsillectomy pain and may have been less than would be expected. The tonsil beds healed within two weeks. The comparable roles of the CO 2, the neodymium YAG, and the KTP/532 laser for nasal and oropharyngeal surgery are discussed. These preliminary results suggest a potential role for the holmium YAG laser in nasal turbinate and tonsillar surgery and the need for further evaluation.

A comparison of performance of Shepard and Sheehy collar button ventilation tubes.

This study was designed to confirm the longer in situ life of the Sheehy collar button compared with the Shepard tube and to assess the complication rates associated with the two tubes. Cases of bilateral otitis media with effusion had a Shepard tube inserted in one ear and a Sheehy contralaterally. The insertion position was allocated randomly. The patients were then assessed at three-monthly intervals for two years. In 71 per cent of those in whom at least one tube had extruded, the Sheehy remained in situ longer. The antero-inferior tube remained longer than the postero-inferior whichever type was used. There was no significant difference between complication rates, or recurrence rates of middle ear effusion after tube extrusion, for the two types. We conclude that use of a Sheehy rather than a Shepard tube carries no increased risk of complications and the patient may require further surgery less often in total.

Aspirating middle ear effusions when inserting ventilation tubes: does it influence post-operative otorrhoea, tube obstruction or the development of tympanosclerosis?

This prospective study examined the influence of aspirating middle ear effusions, immediately prior to ventilation tube insertion, upon the subsequent development of otorrhoea and tympanosclerosis. 50 children were studied and aspiration of effusions did not influence the incidence of purulent otorrhoea or ventilation tube obstruction within 1 month of surgery. The development of tympanosclerosis did not correlate with effusion aspiration, but in those ears which had an effusion aspirated there was a relation between operative bleeding and the development of tympanosclerosis.

Episodic macroglossia in Down's syndrome.

We report a unique case of recurrent gross enlargement of the tongue associated with lymphangiectasia and tongue protrusion in an adult male with Down's syndrome. There were three episodes of acute macroglossia with no clinically identifiable cause. Spontaneous resolution always occurred after five to six days. Histological examination of the tongue, at post mortem, revealed a primary lesion of the lingual lymphatics. The possible mechanisms of acute macroglossia and the surgical techniques which could have been used to reduce the tongue bulk are discussed.

Granular cell tumour of the larynx.

A granular cell tumour may present as clinically innocuous lesions on the vocal cords and the diagnosis is usually made by histopathology. However, the granular cells characteristic of this tumour may not be obvious and accompanying epithelial hyperplasia may be interpreted by the pathologist as invasive squamous cell carcinoma. Good communication between pathologist and surgeon is required to ensure that clinically benign lesions on the vocal cords are not misdiagnosed. The diagnosis of granular cell tumour can be confirmed by immunocytochemical staining for S100 antigen.