Endoscopic dacryocystorhinostomy in functional lacrimal obstruction.

INTRODUCTION: We performed endoscopic dacryocystorhinostomy in cases diagnosed with both anatomical and functional lacrimal obstruction, and here report results for the latter cases. METHODS: Sixty-eight endoscopic dacryocystorhinostomies were performed for functional obstruction on 44 patients. The indication for surgery was epiphora in 66 patients and recurrent dacryocystitis in two. The minimum follow up was six months. RESULTS: There was complete cure in 44 (65 per cent) patients, partial cure in nine (13 per cent) and no improvement in 15 (22 per cent). Revision surgery was performed in five of the 15 cases with no improvement, after which there was an overall complete cure in 47 patients (69 per cent), partial cure in 10 (15 per cent) and no improvement in 11 (16 per cent). DISCUSSION: Endoscopic dacryocystorhinostomy is indicated in cases of epiphora with a diagnosis of functional lacrimal obstruction. Currently available investigations cannot reliably distinguish partial anatomical obstruction from pump failure.

Is routine biopsy of the lacrimal sac wall indicated at dacryocystorhinostomy? A prospective study and literature review.

OBJECTIVE: To determine whether routine biopsy of the lacrimal sac wall at dacryocystorhinostomy (DCR) is indicated. METHODS: A prospective study and literature review. In 193 consecutive endoscopic DCRs performed on 164 patients (108 females and 56 males) part of the medial wall of the lacrimal sac was sent for histological examination. The mean age of the patients was 64 years with a range of 2.5-89 years. Previous reported series were reviewed. RESULTS: Of the 193 specimens, 44 (23%) showed normal histology, 146 (76%) showed varying degrees of non-specific chronic inflammation, and three (1.2%) showed specific pathology. Of the three specimens that showed specific pathology two showed sarcoidosis and one showed transitional cell papilloma. The two specimens with sarcoidosis were obtained from one patient who underwent bilateral surgery. In this and the six previous reported series only seven of 1294 specimens (0.5%) showed specific pathology, which was definitely not suspected preoperatively or intraoperatively, and only one of these (0.08%) was found to be malignant (a lymphoma). CONCLUSIONS: Biopsy of the lacrimal sac wall at DCR is not indicated routinely and is only indicated if there is a reason to suspect pathology other than chronic inflammation preoperatively or intraoperatively.

Lemierre's syndrome: the link between a simple sore throat, sore neck and pleuritic chest pain.

An unusual case of tonsillitis which showed progression to this rare syndrome despite treatment with intravenous antibiotics. Lemierre's syndrome is a rare condition characterised by a triad of: sepsis, thrombophlebitis of the internal jugular vein along with pleuropulmonary and/or distant metastatic abscesses. Diagnosis rests on a high index of suspicion and is confirmed by culture of Fusobacterium spp. from blood or infected sites. Radiological investigations are established aids for confirmation of diagnosis. Treatment is with appropriate antibiotics for at least 6 weeks and surgical drainage of abscesses if required. This case has been presented to highlight the mode of presentation, diagnostic tools employed and the management of the complications that featured in this condition.

Lignocaine as a topical analgesia for post-operative nasal pack removal: a prospective, randomized, double-blind, controlled trial.

The objective of this study was to assess the efficacy of topical lignocaine in reducing the pain of pack removal after nasal surgery. Fifty-eight patients with Merocel nasal packs in situ after nasal surgery were randomized to receive 10 ml of either 2 per cent lignocaine or 0.9 per cent saline on the packs 10 minutes prior to their removal and the pain experienced on their removal was recorded on a visual analogue scale. The median pain score was 3.4 in the lignocaine group and 2.9 in the saline group with no statistical evidence of a difference between the two groups. There was no statistical evidence of an association between the group and the operation performed, the use of intra-operative Moffat's solution or the use of post-operative oral analgesia. We conclude that lignocaine used in this way does not reduce the pain of pack removal after nasal surgery.

Ceravital revisited: lessons to be learned.

OBJECTIVE: To report the long-term results in a series of ossiculoplasties using Ceravital prostheses. STUDY DESIGN: Retrospective case review. SETTING: District general hospital. PATIENTS: Ossiculoplasties using Ceravital prostheses were performed in 25 patients with a mean age of 39 years. Cholesteatoma was present in 9 cases and absent in 16 cases before surgery. The reconstruction was single stage in 23 cases and second stage in 2 cases. MAIN OUTCOME MEASURES: Hearing gain and prosthesis-related complications. The mean length of follow-up was 6 years 6 months. RESULTS: In the short term, the mean air-bone gap improved from 43 dB preoperatively to 24 dB 6 months postoperatively. In the long term, the results were as follows: good in 4 cases, absorption of the prosthesis in 9 cases, slippage of the prosthesis in 4 cases, extrusion of the prosthesis in 3 cases, atelectasis of the tympanic membrane in 2 cases, and unknown in 3 cases. The mean time for complications to become apparent was 6 years 4 months for absorption, 3 years 3 months for extrusion, 7 months for slippage, and 1 year 9 months for atelectasis. Revision surgery was performed on 11 of the 18 cases in which the results were poor. CONCLUSIONS: Ceravital prostheses highlight the potential complication of absorption of ossicular prostheses. Absorption takes much longer to become apparent than other complications such as extrusion, slippage, or atelectasis. The much higher rate of absorption in this series than in previous series with shorter follow-up times suggests that the rate of absorption increases significantly over time.

A comparison of the user-friendliness of hydroxyapatite and titanium ossicular prostheses.

Both hydroxyapatite (Ha) and titanium (Ti) are well-accepted alloplastic materials for ossicular prostheses. Many different designs of Ha and Ti prostheses are presently available. Fourteen surgeons of different seniority and surgical experience were asked to 'test-drive' four different types of ossicular prostheses in cadaveric temporal bones to investigate the user-friendliness of these protheses. The Goldenberg design Ha incus prosthesis and the Dusseldorf design Bell Ti prosthesis were used as partial ossicular replacement prostheses (PORP). The Richards design Ha incus-stapes prosthesis and the Dusseldorf design Aerial Ti prosthesis were used as a total ossicular replacement prostheses (TORP). Nine out of 14 surgeons found the Ha PORP to be more user-friendly because of the notch design in the head. The Ti prosthesis was found to be more difficult to manipulate because it was too light. Half of the surgeons preferred the Ti TORP because of the open design of the top-plate. The Ha TORP was thought to be too top-heavy and to have a tendency to fall over.

Model for demonstrating the canalith repositioning procedure.

Benign positional vertigo is a common condition which may be easily treated with the canalith repositioning procedure. This procedure may be difficult for patients to understand and for medical staff to learn. This paper describes a model of the vestibular apparatus which may be used to demonstrate the procedure.

Dual infection with atypical mycobacteria and Mycobacterium tuberculosis causing cervical lymphadenopathy in a child.

The most common presentation of mycobacterial infection encountered in otolaryngological practice is cervical lymphadenitis. We report a child with an unusual cause of cervical lymphadenopathy, i.e. dual tuberculous infections. This had clinical ramifications as, initially Mycobacterium avium-intracellulare was grown in culture and was resistant to standard anti-tuberculous agents, and hence treated with excision of the lymph node. However, the cultures from the excised lymph node grew out Mycobacterium tuberculosis that was sensitive to standard anti-tuberculous drugs. To our knowledge, no such presentation has been reported previously. We also review the literature on cervical lymphadenitis due to atypical mycobacteria and Mycobacterium tuberculosis, with particular emphasis on clinical presentation, diagnosis and management.

Metastases from glomus jugulare tumours.

This review describes the features of glomus jugulare tumours with metastases. There were 100 sites of metastasis in the 53 cases previously reported. The sites of metastasis may be summarized as bone (33), lungs (23), lymph nodes (19), liver (nine) and other (16). Metastases presented up to 30 years after the initial treatment. The mean age of patients was 45 years and the sex ratio was approximately two females to one male, with no significant difference compared to non-metastatic tumours. There was a significantly higher incidence of pain and a significantly lower incidence of hearing loss at presentation compared to non-metastatic tumours. The commonest treatment was a combination of surgery and radiotherapy. The duration of symptoms before diagnosis was significantly shorter and the rates of persistent or recurrent local disease and death were significantly higher than for non-metastatic tumours. This review highlights the fact that glomus jugulare tumours are not always benign.

Glomus jugulare tumour with metastases to cervical lymph nodes.

Glomus jugulare tumours are classically described as benign tumours with a long time course often measured in decades. Although these tumours may be locally invasive, most cases are histologically benign and metastases are rare. The case of a malignant glomus jugulare tumour with a particularly aggressive pattern of spread is presented. At the time of surgery, which was within 12 months of the development of symptoms, intracranial spread and metastasis to cervical lymph nodes had already occurred, demonstrating that glomus jugulare tumours are not always benign.

Treatment of lymphangiomas of the head and neck in children by intralesional injection of OK-432 (Picibanil).

The treatments previously used for lymphangiomas of the head and neck in children-surgery and intralesional injection of sclerosants-are associated with significant morbidity. A new treatment-intralesional injection of OK-432-was used for lymphangiomas of the head and neck in 11 children. The results were total shrinkage in two, marked shrinkage in two, slight shrinkage in five and no response in two. The results were not affected by previous surgery nor by whether aspiration prior to injection was possible. There were no recurrences in those children in whom shrinkage occurred and no child had subsequent surgery following injection. The results of this series support those of previous series showing that OK-432 injection is an effective and safe treatment for lymphangiomas of the head and neck in children.

Investigation and treatment of thyroglossal cysts in children.

Thyroglossal cysts are the commonest midline neck masses in children. To evaluate current practice questionnaires were sent to all ear, nose and throat (ENT) and paediatric surgeons in the UK and 72% responded. The commonest investigation requested was an ultrasound scan (54%) and the commonest operation was a variant of Sistrunk's procedure (78%). Paediatric surgeons did fewer investigations than ENT surgeons and tended to excise more of the thyroglossal tract. Review of the published work suggests that ultrasound scanning and Sistrunk's procedure are the best management policy. The scan can avoid inadvertent excision of an ectopic thyroid gland. Extensive thyroglossal tract excisions give lower recurrence rates.

Maxillary myxoma: a rare midfacial mass in a child.

The case of a maxillary myxoma in a 13-month-old child is presented. This case highlights the difficulties associated with managing such cases. The tumour was found at operation to be unencapsulated and infiltrative. This was contrary to the preoperative CT scan findings and necessitated a change from a sublabial to a lateral rhinotomy approach. This case illustrates a potential pitfall of CT scanning in such cases: it is likely that a MRI scan would have demonstrated the invasive nature of this tumour. To the authors' knowledge this is the second youngest reported case of maxillary myxoma in the literature.

Localized tracheomalacia as a complication of the Cole tracheal tube.

The Cole tracheal tube is designed for use in neonates. Subglottic stenosis is a recognized complication of prolonged use of the tube. We report a case of tracheomalacia as a further complication of prolonged use of the tube. A 4-month-old infant with a history of repeated failed extubation and multiple medical problems was found to have an unusual region of severe inspiratory collapse localized to the upper 1 cm of the trachea. This was felt to be the result of pressure from the shoulder of the Cole tube which had been used for prolonged intubation. A tracheostomy was performed to bypass the collapse, but the infant subsequently died due to other medical problems.

'Farmer's ear': sudden sensorineural hearing loss due to Chlamydia psittaci infection.

A case of sudden sensorineural hearing loss in association with a Chlamydia psittaci pneumonia is reported. Rapid recovery was seen when the patient was treated with high dose steroids and appropriate antibiotics. This is the first such case report in the literature.

Anxious attachment and psychological distress in cardiac rehabilitation patients.

This study investigated the relevance of anxious attachment to the differentiation of psychologically distressed and non-psychologically distressed cardiac patients. Attachment is a biologically based behavioral system in which proximity to a special other is sought or maintained to achieve a sense of safety and security. Anxious attachment, as the name denotes, fails to achieve the function of attachment in the sense of individuals having little or no confidence in the availability of their attachment figures. Empirically, three scales (feared loss of the attachment figure, proximity seeking and separation protest) capture the features of anxious attachment as elaborated by Bowlby. These scales were administered to 178 cardiac rehabilitation patients drawn from the cardiac rehabilitation program of the Calgary General Hospital. The results indicate that feared loss and proximity seeking differentiated psychologically distressed from non-psychologically distressed patients. The implications of this finding for the understanding of psychologically distressed cardiac patients are discussed.