Vocal cord movement: can it be accurately graded?

INTRODUCTION: Flexible nasendoscopy (FNE) is the principal assessment method for vocal cord movement. Because the procedure is inherently subjective it may not be possible for clinicians to grade the degree of vocal cord movement reliably. The aim of this study was to assess the accuracy and consistency of grading vocal cord movement as viewed via FNE. METHODS: Thirty FNE videos, without sound or clinical information, were assessed by six consultant head and neck surgeons. The surgeons were asked to assess and grade right and left vocal cord movement independently, based on a five-category scale. This process was repeated three times on separate occasions. Agreement and reliability were assessed. RESULTS: Mean overall observed inter-rater agreement was 67.7% (sd 1.9) with the five-category scale, increasing to 91.4% (sd 1.9) when a three-category scale was derived. Mean overall observed intra-rater agreement was 78.3% (sd 9.7) for five categories, increasing to 93.1% (sd 3.3) for three categories. Discriminating vocal cord motion was less reliable using the five-category scale (k = 0.52) than with the three-category scale (k = 0.68). CONCLUSIONS: This study demonstrates quantitatively that it is challenging to accurately and consistently grade subtle differences in vocal cord movement, as proven by the reduced agreement and reliability when using a five-point scale instead of a three-point scale. The study highlights the need for an objective measure to help in the assessment of vocal cord movement.

Endoscopic vocal fold injection using a 25-gauge butterfly needle.

OBJECTIVE: To describe a useful technique for infiltrating a bulking agent using a butterfly needle, as part of a transoral endoscopic vocal fold medialisation procedure. METHODS: This paper describes the procedure of grasping the needle with phonosurgery forceps and administering the injectate to the vocal fold through careful application of the syringe plunger via a length of rubber tubing from outside the mouth. RESULTS: This procedure is performed routinely in our institution without complication. The advantages of this technique are discussed. CONCLUSION: This is a safe and easy method of injecting into a vocal fold.

Is there a change in the epidemiology of nasal fractures in females in the UK?

OBJECTIVE: To determine whether there is a change in the epidemiology of nasal fractures in females in the UK, and the potential contribution of the 'ladette' culture. METHODS: This paper reports a multi-centre retrospective study. Operating theatre data for all females who underwent manipulation of nasal fractures under anaesthesia between 2002 and 2009 were analysed. In addition, the case notes of all females presenting with nasal fractures over a five-year period (2004-2009) were retrospectively reviewed and the cited cause of the fracture was noted. RESULTS: From 2002 to 2009, there was an 825 per cent increase in nasal fractures in women aged 13-20 years. Almost one-quarter of all nasal fractures in one centre was attributed to non-domestic violence. The highest incidence of nasal fractures (67 per cent) was amongst white British females. CONCLUSION: There is an increasing trend in the number of women sustaining nasal fractures in the UK. The cause may be multi-factorial, but could be partially attributed to a rise in ladette culture. Further research on the role of alcohol consumption in this phenomenon is needed.

Internal nasal valve incompetence is effectively treated using batten graft functional rhinoplasty.

Introduction. Internal nasal valve incompetence (INVI) has been treated with various surgical methods. Large, single surgeon case series are lacking, meaning that the evidence supporting a particular technique has been deficient. We present a case series using alar batten grafts to reconstruct the internal nasal valve, all performed by the senior author. Methods. Over a 7-year period, 107 patients with nasal obstruction caused by INVI underwent alar batten grafting. Preoperative assessment included the use of nasal strips to evaluate symptom improvement. Visual analogue scale (VAS) assessment of nasal blockage (NB) and quality of life (QOL) both pre- and postoperatively were performed and analysed with the Wilcoxon signed rank test. Results. Sixty-seven patients responded to both pre- and postoperative questionnaires. Ninety-one percent reported an improvement in NB and 88% an improvement in QOL. The greatest improvement was seen at 6 months (median VAS 15 mm and 88 mm resp., with a P value of <0.05 for both). Nasal strips were used preoperatively and are a useful tool in predicting patient operative success in both NB and QOL (odds ratio 2.15 and 2.58, resp.). Conclusions. Alar batten graft insertion as a single technique is a valid technique in treating INVI and produces good outcomes.

Oncological safety of the Hayes-Martin manoeuvre in neck dissections for node-positive oropharyngeal squamous cell carcinoma.

INTRODUCTION: The Hayes-Martin manoeuvre involves ligation of the posterior facial vein and superior reflection of the investing fascia below the mandible to preserve the marginal mandibular nerve. The peri-facial nodes thus remain undissected. We perform this manoeuvre routinely during modified radical neck dissection for metastatic oropharyngeal squamous cell cancer. Here, we review the oncological safety and marginal mandibular nerve preservation rates of this manoeuvre from 2004 to 2009. METHOD: Retrospective review of the head and neck oncology database (2004-2009) at Addenbrooke's Hospital, Cambridge, UK, a tertiary referral centre for head and neck oncology. RESULTS: Thirty-four patients underwent modified radical neck dissection for metastatic oropharyngeal squamous cell carcinoma. The primary tumour included the tonsil in 19 cases, base of tongue in 10 and posterior pharyngeal wall in 5. The neck nodal status was N1 in 4 cases, N(2a) in 11, N(2b) in 10, N(2c) in 4 and N(3) in 5. All patients had adjuvant radiotherapy. Median follow up was four years (range, two to five). No peri-facial nodal region recurrences were seen. Four patients had temporary marginal mandibular nerve weakness; beyond two months, no weakness was seen. CONCLUSION: In neck dissections for oropharyngeal squamous cell carcinoma, the marginal mandibular nerve and accompanying facial nodes can be safely preserved without oncological risk using the Hayes-Martin manoeuvre.

Ultrasound-guided core-needle biopsy and magnetic resonance imaging in the accurate diagnosis of intramuscular haemangiomas of the head and neck.

INTRODUCTION: Intramuscular haemangiomas of the digastric muscle are often misdiagnosed due to their low incidence and non-specific manifestation. Only two out of six previously reported cases were diagnosed correctly before excision. Ultrasound may not reveal their vascularity, and fine-needle aspiration biopsy is unhelpful as it reveals only blood. METHODS: A case of intramuscular haemangioma of the posterior belly of the digastric muscle is described. Previously reported cases are reviewed. Investigations used to diagnose the lesions and reasons for their common failure are discussed. RESULTS: Core-needle biopsy led to the correct histological diagnosis, and magnetic resonance imaging precisely located the lesion within the digastric muscle. CONCLUSION: Core-needle biopsy was safely used in the diagnosis of an intramuscular haemangioma. The combination of core-needle biopsy and meticulous review of magnetic resonance imaging enables accurate diagnosis pre-operatively.

Safety of extracapsular dissection in benign superficial parotid lesions.

INTRODUCTION: The current practice for removal of clinically benign superficial parotid lesions is an appropriate superficial parotidectomy with a cuff of normal parotid tissue for complete pathological clearance. This technique requires the identification of the facial nerve at the main trunk and dissection of the segment of the facial nerve deep to the lesion. The reported major complications of this procedure include temporary or permanent facial nerve weakness, Frey's syndrome and salivary leaks. In order to avoid these complications, a local extracapsular dissection technique can be utilised in the management of small inferiorly located benign lesions of the parotid gland. METHODS: A retrospective case note review was performed for all parotidectomies between 2004 and 2009 in Addenbrooke's Hospital, Cambridge by the senior authors. RESULTS: A total of 172 cases were identified out which 46 underwent an extracapsular dissection. The average size of these lesions was 1.9 cm (0.9-2.4 cm) with all universally located inferior or posterior to the angle of the mandible. The pathologies were 14 pleomorphic adenomas, 24 Warthin's tumours, 6 lymphangiomas and 2 simple cysts. There were no post-operative facial nerve weaknesses, Frey's syndrome or salivary leaks within the extracapsular dissection group. The median follow-up of these patients were 4.6 years (2-6 years) with 6 patients lost to follow-up. No recurrences have been noted in the cohort at follow-up.

Initial UK experience of patient satisfaction with the Meniett® device for Ménière's disease treatment.

OBJECTIVES: To evaluate patient satisfaction and symptom improvement following treatment of Ménière's disease with the Meniett® device. METHODS: Retrospective, questionnaire-based audit and analysis of unilateral Ménière's disease patients' records, following on from a previous study from our departments on intra-tympanic gentamicin for Ménière's disease, using the Vertigo Symptom Scale and Glasgow Benefit Inventory as outcome measures. RESULTS: Of 33 consecutive patients treated with the Meniett® device for four to six weeks, 30 responded to the questionnaires (90.9 per cent). Respondents' mean Vertigo Symptom Scale score was 0.7 (range 0-2.1), and their mean Glasgow Benefit Inventory general subscale score was 24.1. Nineteen (63.3 per cent) patients felt that the device had alleviated their vertigo and tinnitus. CONCLUSIONS: This is the first UK study of the effectiveness of the Meniett® device in treating Ménière's disease. It shows that the Meniett® device is a well tolerated, useful and minimally invasive means of treating Ménière's disease after medical treatment has failed, and before more potentially cochleo- and vestibulo-toxic therapies and invasive procedures are utilised.

Internal jugular vein thrombosis secondary to a permanent cardiac pacemaker: an unusual case of lateral neck swelling.

OBJECTIVE: To describe an unusual case of lateral neck swelling in a patient with a permanent cardiac pacemaker. CASE REPORT: We describe a patient who presented with a painful, lateral neck swelling due to an internal jugular vein thrombus. This thrombus originated from around pacemaker wires in the subclavian vein. This case is unusual, as the vast majority of thromboses in patients with cardiac pacemakers are found in the subclavian vein alone. We also review the literature on the relationship between cardiac pacemakers and internal jugular vein thrombosis, and on the management of the latter. CONCLUSION: Our patient illustrates a rare cause of a painful, lateral neck swelling: an internal jugular vein thrombus secondary to a cardiac pacemaker. Clinicians should be wary of such pathology in similar patients, in order to ensure early treatment and avoidance of complications.

Frontal mucocele caused by an ectopic maxillary tooth.

OBJECTIVE: To present a previously unreported cause of frontal mucocele. CASE REPORT: A patient presented with a frontal mucocele and maxillary sinusitis. Computed tomography revealed an ectopic maxillary tooth as the cause of her signs and symptoms. Removal of the tooth by a Caldwell-Luc procedure facilitated resolution of the mucocele. Conventional treatment of mucoceles by endoscopic sinus surgery, and other rhinological sequelae of ectopic teeth, are considered. CONCLUSION: This is the first documented case of an ectopic tooth causing a frontal mucocele, and demonstrates how effectively the patient's symptoms resolved on removal of the tooth.

Oncogenes in thyroid cancer.

There have been significant advances in our understanding of carcinogenesis at the molecular level over the last 25 years. Oncogenes are of major interest as part of our search for knowledge surrounding the aetiology of cancer. There are several oncogenes associated with thyroid cancer. Detailed investigation of the nature and function of these tumour genes has provided important insights into both the tumour biology and the complex biochemical pathways of normal cellular functioning. Our knowledge of oncogene biology offers the hope of better diagnostic, therapeutic and prognostic modalities in our fight against this and other common cancers. Development of specific thyroid tumour markers and gene therapy is now a realistic prospect to supplement our present armamentarium of surgery and radiotherapy. This review aims to outline the pertinent information gained so far from studies of these oncogenes and provides both clinical relevance and fuel for further interest amongst the ENT thyroid community in this exciting area of research.

Primary defects in the lens underlie complex anterior segment abnormalities of the Pax6 heterozygous eye.

We describe lens defects in heterozygous small eye mice, and autonomous deficiencies of Pax6(+/-) cells in the developing lens of Pax6(+/+) <--> Pax6(+/-) chimeras. Two separate defects of the lens were identified by analyzing the distribution of heterozygous cells in chimeras: Pax6(+/-) cells are less readily incorporated into the lens placode than wild type, and those that are incorporated into the lens are not maintained efficiently in the proliferating lens epithelium. The lens of chimeric eyes is, therefore, predominantly wild type from embryonic day 16.5 onwards, whereas heterozygous cells contribute normally to all other eye tissues. Eye size and defects of the iris and cornea are corrected in fetal and adult chimeras with up to 80% mutant cells. Therefore, these aspects of the phenotype may be secondary consequences of primary defects in the lens, which has clinical relevance for the human aniridia (PAX6(+/-)) phenotype.

Thyroid auto-antibodies, lymphocytic infiltration and the development of post-operative hypothyroidism following hemithyroidectomy for non-toxic nodular goitre.

BACKGROUND: Auto-immune thyroiditis, associated with detectable thyroid auto-antibodies (TAAs) and lymphocytic infiltration into the gland, is known to be associated with progressive development of hypothyroidism. This study examines those patients who required surgical treatment of non-toxic nodular goitre by hemithyroidectomy to determine whether the presence of TAAs in the circulation and/or lymphocytic infiltration of the gland resulted in a significant degree of post-operative hypothyroidism. METHOD: This was a prospective study, with data collected retrospectively. All patients operated on for thyroid disease in the unit over a 5-year period were documented, and those patients treated by hemithyroidectomy for non-toxic nodular goitre formed the study group. TAAs were measured, histology re-examined and patients followed up for at least 2 years to detect clinical or sub-clinical hypothyroidism. RESULTS: Of the 158 patients who comprised the study group, 38 (24.1%) developed hypothyroidism. Forty-one (25.9%) had circulating levels of TAAs, 31 of these (75.6%) having high levels. Of these 41 patients, 22 (53.7%) became hypothyroid. Twenty (64.5%) of the 31 patients with high levels of TAAs required post-operative thyroxine. Of the remaining 117 patients with no detectable TAAs, only 16 (13.7%) became hypothyroid. CONCLUSION: All patients requiring treatment by hemithyroidectomy should have circulating TAA measurements carried out pre-operatively. If positive, they should be followed up indefinitely because of the strong possibility (P < 0.001) of the development of hypothyroidism.

Development of improved electrical-substitution radiometers at the National Research Council of Canada.

We describe the development of a third generation of electrical-substitution radiometers (ESR's) at the National Research Council of Canada. The new ESR's follow the same general design as before, but incorporate improved thermopiles and electrical heating elements. The ESR's have a responsivity between 0.6 and 1.0 VW(-1), a time constant of approximately 2.0 s, a uniformity of 0.1% over a 6-mm-diameter region, and a noise level of approximately 6 nW. Performance characteristics of the new ESR's are discussed. It is shown that calibrations performed with these ESR's agree with those made with the previous generation of ESR's to better than 0.05%.

Autocrine growth and progression of murine X-ray-induced T cell lymphomas.

Primary tumors of X-ray-induced murine T cell lymphomas comprise autocrine, growth factor-dependent cells. We have grown cell lines from primary X-ray-induced thymic lymphomas (PXTLs) under conditions which minimize the progression of the cells from factor dependence to factor independence. All (22) PXTL lines grown secrete a growth factor which supports their own growth and which we will call lymphoma growth factor LGF. LGF-dependent cells are non-tumorigenic or poorly tumorigenic, do not clone in soft agar, have no detectable rearrangements in the c-myc or Pim-1 region and possess near diploid or pseudodiploid karyotypes without evidence for trisomy of chromosomes nos. 15 or 17. PXTL-secreted LGF has no interleukin 1, 2, or 3 activity nor do LGF-secreting cells synthesize detectable IL-1, -2, or -3 mRNA. LGF contains no detectable interferon or GM-CSF activity in specific bioassays. Purified EGF, TGF beta, and interleukin preparations are inactive on LGF-dependent PXTL cells. Thus LGF appears to be a new growth factor that is required for the proliferation of non-progressed T lymphoma cells. Upon progression PXTL cells become growth factor independent, are highly tumorigenic in vivo, clone in soft agar, and assume a near triploid karyotype containing numerous chromosomal aberrations. Thus in X-ray-induced lymphomagenesis an autocrine, LGF-dependent phase precedes the progressed phase characterized by rearrangements in the myc and/or Pim-1 regions as well as by many chromosomal aberrations visible in the karyotype.