Oesophageal perforation during stapling of a pharyngeal pouch: adverse clinical incident report.

Endoscopic stapling is a relatively new surgical technique for the treatment of pharyngeal pouch. We present a serious complication of the technique, resulting in a large perforation of the posterior pharyngeal wall, and discuss possible causes.

Day-case tonsillectomy--is it appropriate?

There is continued encouragement to increase the use of day surgery. Recent publications have suggested that day-case tonsillectomy is a safe procedure due to the low primary haemorrhage rates (0.14-3.5%). One of the suggested benefits of day surgery is that patients want it. They prefer to recover at home after an operation. With tonsillectomy, personal experience suggested that this was not the case. A review of 117 patients having tonsillectomy was undertaken. All patients stayed in for at least one post-operative night. No patients or parents thought that the post-operative stay was too long (80% 'just right', 20% 'too short') and only 7% would have been happy to go home on the day of operation. 'Safety' does not automatically make an operation suitable for day-case surgery. Pain, nausea, vomiting, drowsiness and anxiety about the operation and post-operative course were all reasons given for not wanting to go home on the day of surgery. The justification for the increased use of day surgery is that it increases efficiency by reducing costs per case while maintaining the quality of care. One aspect of quality of care is patient acceptability and before day-case tonsillectomy is acceptable to patients the factors responsible for the post-operative morbidity need to be addressed.

The use of Merocel nasal packs in the treatment of epistaxis.

Over the period of a year, Merocel nasal packs were used routinely as the primary form of packing in patients referred to the hospital with epistaxis that had not resolved with simple measures, and in whom packing was thought to be required. Their effectiveness was assessed. The packing was usually performed by inexperienced senior house officers. The Merocel packs successfully controlled bleeding in 91.5 per cent of the patients in whom they were used. Use of the correct insertion technique is very important but is very easy to learn and perform. The actual insertion takes only a couple of seconds. Discomfort during insertion, whilst in situ and on removal was assessed. Merocel nasal packing is an effective form of first line treatment in patients with epistaxis.

Non-tuberculous mycobacterial infections presenting as salivary gland masses in children: investigation and conservative management.

Non-tuberculous mycobacterial (NTM) infections in children commonly present as cervicofacial masses. The importance of early diagnosis is in the exclusion of infection requiring treatment, particularly tuberculosis and the rare case of malignancy. Five children with NTM presenting with salivary gland masses illustrate the value of skin testing with new tuberculins and the place of fine-needle aspiration cytology in the investigation of these infections. Four children who were skin tested reacted specifically to one of the new tuberculins, two indicating infection with Mycobacterium malmoense, confirmed by culture, the others responding to tuberculins from M. scrofulaceum and M. avium-intracellulare, neither having a positive culture. The one case not skin tested produced M. avium-intracellulare on culture. All five patients were managed conservatively. The place for conservative management when the facial nerve is at risk and extensive skin excision is indicated are discussed.

A comparison of packing materials used in nasal surgery.

A prospective study was performed to compare Telfa, paraffin gauze, Merocel and BIPP used postoperatively following septal or turbinate surgery. Packs were assessed in terms of patient comfort, control of bleeding and ease of removal. There was little to choose between the packs while they were in situ and there was no significant difference in ease of removal. On removal the Telfa and paraffin gauze were associated with less discomfort and less bleeding than BIPP or Merocel (p < 0.05).

Primary cerebral lymphoma presenting with bilateral cerebellopontine angle lesions.

A case is described of a primary cerebral lymphoma which presented with bilateral cerebellopontine angle lesions. No similar case has been reported in the English language in the last 25 years. The literature is reviewed and discussed.

Necrotizing fasciitis of the face without significant trauma.

Necrotizing fasciitis is a rare but well recognized clinical entity which most often occurs on the trunk, perineum or legs following surgery or trauma. The condition is much less common in the head and neck and it is particularly uncommon in the midface/periorbital region. In almost all the cases occurring in the neck the condition follows obvious dental or oropharyngeal sepsis and in all the cases of the scalp there is a history of previous surgery or trauma. However, necrotizing fasciitis of the midface/periorbital region may lack any obvious traumatic aetiology or may follow relatively minor trauma. The diagnosis in these cases may not be suspected and treatment may be delayed with fatal consequences. Treatment by wide excision of all affected skin can lead to disastrous cosmetic consequences in facial disease and it is suggested that disease control can be achieved by raising wide based skin flaps with excision of the underlying necrotic tissue. The flaps are then returned onto normal muscle with much improved cosmetic results. This paper discusses the diagnosis and treatment of patients with necrotizing fasciitis of the face which has arisen without significant trauma.

The relationship between intracranial pressure and tympanic membrane displacement.

Transmission of intracranial pressure (ICP) to the perilymph of the cochlea may occur via the cochlear aqueduct and possibly other routes. Indirect measurement of perilymphatic pressure may be investigated by observing tympanic membrane (TM) displacement during stapedial reflex contraction. In a previous study we investigated the effects of changes in ICP on perilymphatic fluid pressure in three patients who underwent ventriculo/lumbar-peritoneal shunt operations. The TM displacement technique proved extremely sensitive and revealed marked changes in cochlear fluid pressure brought about by changes in ICP (Marchbanks et al., 1987). The study has been extended to 58 patients with hydrocephalus, intracranial tumours and other neurological conditions associated with abnormal ICP. Significant differences in the TM displacement were found between patients with raised and normal ICP. We have shown that changes in ICP can affect the hydrostatic pressure of the cochlea and influence the peripheral auditory system. The finding that ICP can be correlated with TM displacement strengthens the association between an abnormal TM displacement and abnormal cochlear hydrostatic status, irrespective of cochlear aqueduct patency. We suggest that the TM displacement technique provides a useful non-invasive method for the assessment of perilymphatic fluid pressure.

Management of the inflammatory aural polyp.

Investigation into the underlying disease causing an aural polyp is often hampered when the polyp itself obscures the tympanic membrane. This retrospective analysis of 65 patients undergoing aural polypectomy was carried out to identify any predictive factors for underlying cholesteatoma and to determine a correct management strategy for aural polyps. The duration of symptoms, size of polyp, size of conductive component of hearing loss and bacteriology of otorrhoea were unhelpful as predictors of the underlying disease. Radiological evidence of bony erosion of the mastoid is a useful sign of cholesteatoma when present. Aural polypectomy resulted in 58.3 per cent of ears becoming inactive. It is proposed that aural polypectomy and histological assessment should be employed as initial treatment with mastoid exploration reserved for those ears thus identified as high risk for cholesteatoma.

Mean intracranial pressure monitoring by a non-invasive audiological technique: a pilot study.

Intracranial pressure is normally transmitted to the perilymph of the cochlea via the cochlear aqueduct. The relationship between perilymphatic pressure, indirectly measured by tympanic membrane displacement, and mean intracranial pressure defined either clinically or by direct measurement has been examined in 58 patients (aged 5-77 years), with hydrocephalus, benign intracranial hypertension, intracranial tumours, subarachnoid haemorrhage and head injuries. The most consistent results were obtained in young patients with hydrocephalus and benign intracranial hypertension. However, the technique was not suitable when the stapedial reflex was absent as a result of middle ear/brainstem dysfunction and did not reflect intracranial pressure when the cochlear aqueduct was not patent. This pilot study suggests that the tympanic membrane displacement technique may provide a useful non-invasive method for serial monitoring of intracranial pressure in young patients with hydrocephalus or benign intracranial hypertension.

The effect of raised intracranial pressure on intracochlear fluid pressure: three case studies.

The effects of changes in intracranial fluid pressure (ICP) on cochlear fluid pressure have been studied in 3 patients who underwent ventriculo/lumbar-peritoneal shunt operations. The operations were performed in order to alleviate problems caused by an abnormally raised ICP. Indirect measurements of perilymphatic pressure were made before and after surgery using a non-invasive technique which measures tympanic membrane displacement. This technique proved extremely sensitive and revealed changes in cochlear fluid pressure brought about by changes in the ICP. The results emphasise the need to consider audiological measurements in the context of ICP abnormalities. These findings have important implications in that an audiological technique may be used for the simple and non-invasive serial monitoring of changes in ICP and may even assist differential diagnosis in a number of neurological patients.

Tracheal airway obstruction: a custom made tracheostomy tube.

Tracheal obstruction is encountered in primary malignancy of the trachea and invasion or compression from extrinsic lesions. No commercially available tracheostomy tube can be suitable for all cases. A flexible cannula of adjustable length can be produced from universally available anaesthetic equipment. Intubation is facilitated by the use of fibreoptic endoscopy.

Clinical assessment of the irradiated larynx. Salvage laryngectomy in the absence of histological confirmation of residual or recurrent carcinoma.

Following radiotherapy for squamous carcinoma of the larynx, it may be impossible to differentiate occult persisting tumour from irradiation effects, possibly with chondroradionecrosis, even after repeated biopsy. In seven of the cases presented, post-treatment laryngoscopy failed to provide histological evidence of residual or recurrent carcinoma, which clinical examination had indicated. Nonetheless, total laryngectomy was performed, subsequently revealing tumour in five of the seven excised larynges. The two tumour-free larynges were associated with cervical metastases. The clinical indications of persisting tumour, the factors compromising post-irradiation evaluation and the role of diagnostic aids are discussed.

Cochlear deafness in the presentation of a large acoustic neuroma.

It is exceptional for a large tumour, as presented, to present a cochlear pattern of hearing loss. Only a rigid adherence to a battery of audiological, vestibular and radiological tests can exclude neuroma. The possibility of hearing conservation in neuroma surgery (Clemis et al., 1981) demands further understanding of the mechanism of cochlear damage produced by CP angle tumours.

A complication of the use of the laser in ENT surgery.

A case is reported of severe epistaxis resulting from the use of an aluminium foil-wrapped nasotracheal tube during laser surgery to the uvula.