Patient perception of a randomised, controlled trial of laryngeal reinnervation versus thyroplasty for unilateral vocal fold paralysis.

OBJECTIVES: To explore unilateral vocal fold paralysis patients' perception of a proposed randomised, controlled trial of laryngeal reinnervation versus thyroplasty, and to identify patients' concerns regarding their voice. METHODS: Seventeen patients from five voice clinics in London were identified as being eligible for the randomised, controlled trial. Eleven of these patients (9 females and 2 males; age range, 18-65 years) were interviewed using a semi-structured topic guide (they were given a minimum of 2 weeks to read through the study information sheet). The interviews were recorded, transcribed and analysed using thematic analysis. RESULTS: The patients were satisfied with the clarity of the information sheet. Most of them perceived that reinnervation was a more 'attractive' option than thyroplasty. This may have been the result of certain phraseology used in the information sheet and by recruiters. Patients' main concern was reduced voice strength and the effects of this on work and social life. CONCLUSION: Phraseology that needed changing was identified; these changes may optimise the recruitment process for a trial. We propose using the voice handicap index 10 as the primary measure of outcome in the proposed randomised, controlled trial.

T cells producing the anti-inflammatory cytokine IL-10 regulate allergen-specific Th2 responses in human airways.

BACKGROUND: Murine models suggest a critical functional role for the anti-inflammatory cytokine IL-10 in local regulation of allergic airways inflammation. There is little corresponding information on human airway cells. This study aimed to investigate whether local IL-10 production regulates responses by respiratory mucosal leucocytes isolated from nasal polyps. MATERIALS AND METHODS: Nasal polyp tissue was harvested from 24 patients sensitised to aeroallergens with chronic rhinitis and polyposis undergoing routine polypectomy. Cells were isolated by matrix proteolysis. Cytokine production by polyp cells was determined by cytometric bead array (CBA) and intracellular cytokine analysis. Surface marker expression by polyp cells was determined by flow cytometry. RESULTS: Allergen stimulation significantly enhanced production of IL-10, but not IL-5 or IFN-γ by nasal polyp cell suspensions. Under the same conditions, neutralisation of IL-10 significantly increased allergen-specific IL-5 and IFN-γ production by nasal polyp cells. Cell depletion experiments showed that T cells themselves were primarily responsible for IL-10 production or for inducing its production by other cells. Intracellular cytokine staining confirmed production of IL-10 in the absence of IL-2 production by T cells in response to allergen. CONCLUSION: T cells within the human respiratory mucosa produce IL-10, which is capable of inhibiting pro-inflammatory Th2 and Th1 cytokine production in an antigen-specific fashion.

Multinodular thyroid goitre causing obstructive sleep apnoea syndrome.

BACKGROUND: Obstructive sleep apnoea syndrome has been linked to obesity, nasal obstruction and adenotonsillar hypertrophy, but rarely to large thyroid goitres. OBJECTIVE: To study the possible association between multinodular retrolaryngo-pharyngeal or retrosternal goitres and obstructive sleep apnoea syndrome. SUBJECTS AND METHODS: Retrospective case series at a tertiary referral centre (2000-2010). Study parameters included body mass index, Epworth sleep score and polysomnographic index. RESULTS: Five patients were diagnosed with obstructive sleep apnoea syndrome and managed with nasal continuous positive airway pressure ventilation. Computed tomography showed a retrolaryngo-pharyngeal or retrosternal goitre with significant tracheal compression, displacement and laryngeal oedema. After total thyroidectomy, obstructive sleep apnoea resolved in all patients. CONCLUSION: Large, multinodular goitres with retrolaryngo-pharyngeal extension can cause obstructive sleep apnoea syndrome due to laryngeal compression and oedema. In such cases, total thyroidectomy enables resolution of symptoms. Patients with obstructive sleep apnoea syndrome should be screened for thyroid goitre.

Counter regulation of the high affinity IgE receptor, FcepsilonRI, on human airway dendritic cells by IL-4 and IL-10.

BACKGROUND: Immunoglobulin E is a signalling molecule within the environment of the respiratory tract, the high affinity receptor for which, FcepsilonRI, is expressed by dendritic cells (DC). Little is known, however, of the expression and function of FcepsilonRI on DC in the human respiratory tract. METHODS: CD1c(+) DC were purified from surgically resected nasal turbinates of 11 atopic and 12 nonatopic patients with chronic rhinosinusitis. Expression of FcepsilonRI was determined by flow cytometry. Cytokine production by DC was determined by cytometric bead array. RESULTS: Expression of FcepsilonRI was significantly elevated on respiratory tract dendritic cells (RTDC) from atopic as compared to nonatopic patients. Activation of RTDC through FcepsilonRI induced production of the pro-inflammatory cytokines IL-6 and TNF-alpha, and the anti-inflammatory cytokine IL-10. The production of IL-6 and TNF-alpha was elevated in atopic compared to nonatopic patients studied. Conversely IL-10 production was elevated in nonatopic patients. Concomitant activation of FcepsilonRI and stimulation of RTDC with IL-4 inhibited production of IL-10 by RTDC. Neutralization experiments with anti-IL-10 Ab enhanced whereas addition of exogenous IL-10 to RTDC inhibited FcepsilonRI-mediated inflammatory cytokine production. CONCLUSION: The function of FcepsilonRI on RTDC from patients with rhinosinusitis is susceptible to counter regulation by IL-4 and IL-10.

Does a specialist voice clinic change ENT clinic diagnosis?

General ENT clinics lack the high quality diagnostic equipment and multidisciplinary advice that is available in the voice clinic. We wished to find out if referral to a specialist voice clinic from general ENT consultant clinics resulted in a change in diagnosis. Lists of voice clinic attendees were reviewed between January 2003 and May 2004. Notes were obtained for 20 patients who attended voice clinic after referral from a general ENT clinic: 3 had no diagnosis on referral to voice clinic, a diagnosis was given after attendance; 8 had their referring diagnosis changed by attendance; and 9 had no change. The voice clinic adds diagnostic value to the service available in general ENT clinics.

Association between polymorphisms of the GPX1 gene and second primary tumours after index squamous cell cancer of the head and neck.

We investigated the association between genetic polymorphisms in GPX1 gene amongst patients who had index squamous cell carcinoma (SCCHN) and a second primary tumour (SPT) after a primary SCCHN in a case-control study. GPX1 genotypes were determined for 61 patients with SPT and for 259 control subjects by a PCR technique using a fluorescent-labelled primer. Analysis was by an ABI automated fluorescent sequencer. The associations between specific genotypes and the development of SPT were examined by logistic regression. A significant difference was found between the control group and the SPT cases in allele frequencies of GPX1 ALA( *)6 and ALA( *)7 (p(trend)=0.04). These results suggest that polymorphisms in the GPX1 gene may be a marker for SPT development and further studies are indicated.

Intranasal schwannoma in a young woman.

A rare case of a schwannoma arising from the middle meatus in a 24-year-old woman is reported. The patient presented with a 12-month history of right-sided nasal obstruction, rhinorrhoea, anosmia, headache and recurrent minor nosebleeds. Examination of the right nasal cavity revealed a polypoidal mass. Computerised tomography showed the mass completely occluding the nasal passage with evidence of a secondary maxillary sinusitis. She underwent a complete intranasal excision of the polypoidal mass which was arising from the right middle meatus. The histological features of the lesion were consistent with a schwannoma including diffuse immunoreactivity for S-100 protein. This case illustrates the need to consider schwannoma, amongst many other lesions, in the differential diagnosis of a unilateral nasal mass and reinforces the established principle of sending all material removed from the nose for histological examination.

Degloving of the inferior turbinates: pilot study to assess the effectiveness of a new technique in turbinate reduction.

A pilot study to assess the safety and efficacy of 'degloving' of the inferior turbinate is described. This prospective study reports on the effectiveness of the technique in 37 patients with nasal obstruction due to inferior turbinate hypertrophy. Both objective and subjective measurements of nasal patency were made pre-operatively, and repeated at six weeks, six months and two years post-operatively using nasal inspiratory peak flow rates, saccharin clearance time and an end referenced visual analogue scale to record nasal symptoms. There was a significant improvement in the peak inspiratory flow at six weeks (96.4 to 151.2 l/min) and at six months (148.4 l/min), which was sustained at two years (117.1 l/min, p<0.001). There was an overall improvement in patient satisfaction with nasal symptoms (23.4 to 76.7, 76.8 and 66.8 at six weeks, six months and two years, p<0.001) and a decrease in the sensation of nasal obstruction (71.9 to 21.5, 32.9 and 29.8, p<0.001), which was also sustained. Rhinorrhoea was reduced, and sense of smell increased across the group, but the improvements did not reach statistical significance. The results for postnasal drip and saccharin clearance did not show a significant change over the period of the study. There were no haemorrhagic complications in the group studied. This pilot study demonstrates a new surgical technique for reduction of the inferior turbinates, that yields significant improvement in nasal obstruction, an acceptably low complication rate and is well tolerated by patients. A randomized controlled trial is being planned.

Otological trauma resulting from the Soho Nail Bomb in London, April 1999.

We report the otological effects of the April 1999 Soho Nail Bomb on 17 patients. Twenty-one (62%) tympanic membranes were perforated (pars tensa only); 78% closed spontaneously within 6 months. The mean size of the perforation in the tympanic membrane nearer to the blast was significantly larger than the opposite side [33% +/- 8.3 (mean +/- SD) and 13% +/- 4.1 respectively; P = 0.02]. All patients reported hearing losses that were mixed conductive and sensorineural but mainly high-frequency sensorineural (4, 6 and 8 kHz, pure tone average 42.3 dB +/- 20.5). The sensorineural hearing loss correlated inversely with the distance from the explosion but not with the size of perforation. There was no significant difference in the hearing loss between the ear facing the blast and the opposite ear. Fifteen patients (88%) had temporary tinnitus. No patient complained of any vestibular symptoms. The otological effects of a nail bomb in an enclosed space have not been previously reported. Furthermore, an inverse correlation between hearing loss and distance from the explosion and a significant difference in perforation size facing the blast, compared with the opposite side, are also presented for the first time. The high spontaneous closure rate of perforations and minimal ongoing disability from sensorineural losses favour conservative management in most cases.

Parotid calcification in systemic lupus erythematosis.

Calcinosis universalis is an unusual complication of systemic lupus erythematosis (SLE). We describe the case of a 22-year-old patient diagnosed with SLE during childhood, who developed a previously unreported complication of parotid calcification. Medical treatment of calcinosis is often ineffective, whereas surgical intervention completely relieved the patient's symptoms.

The whys and wherefores of getting patients to give up smoking.

Smoking-related diseases are responsible for the majority of premature deaths in industrialized societies. It is 50 years since the link between smoking and lung cancer was first established, since when a gradually increasing number of smoking-related illnesses have been identified. The treatment of patients suffering smoking-related illnesses consumes a large proportion of health care budgets. The ever-increasing costs of health care, in part due to the advent of new therapeutic techniques, could be offset by a concerted effort to reduce the number of people smoking. Various strategies, particularly if used in combination, have been shown to produce acceptable smoking cessation rates. At present there appears to be a reluctance on the part of governments to fund a concerted, co-ordinated programme to encourage and assist people to stop smoking. In the absence of such support it is important for all health professionals to provide sensible advice and support to help their patients to stop smoking.

Semi-invasive allergic aspergillosis of the paranasal sinuses.

Aspergillosis of the nose and paranasal sinuses has classically been divided into four types: allergic, non-invasive, invasive and fulminant. Recent reports have suggested that a semi-invasive form with bone destruction and erosion, but without fungal tissue invasion, may occur. We present a case of allergic non-invasive aspergillosis of the paranasal sinuses with associated bone destruction extending into the orbit and anterior cranial fossa, in a non-immunocompromised patient. Surgical debridement combined with a prolonged course of oral itraconazole has resulted in long-term resolution with no evidence of recurrence of disease five years later.

A prospective study of PET-FDG imaging for the assessment of head and neck squamous cell carcinoma.

The main aim of the study was to evaluate the use of positron emission tomography using fluoro-deoxyglucose (PET-FDG) imaging for the detection of squamous cell carcinoma of the head and neck. Fifty-four consecutive patients with malignancies involving the head and neck were studied prospectively. Thirty-one patients presented with primary disease and 23 were suspected of recurrent or residual disease. All patients underwent full clinical staging, PET-FDG scans and anatomical imaging, 37 underwent computed tomography (CT), 13 magnetic resonance (MR) and four had both CT and MR. Clinical assessment, CT/MR, PET-FDG and histological examination were all evaluated independently of each other. All 31 primary head and neck malignant tumours were detected by PET-FDG. Based on 16 patients who underwent neck dissections, the sensitivity and specificity of PET-FDG for detecting nodal disease was 67% and 100% respectively, compared with clinical assessment of 58% and 75% and CT/MR of 67% and 25%. In all 12 patients, PET-FDG correctly identified the presence of absence or recurrent or residual disease. PET-FDG staged 13 post-treatment necks with an accuracy of 100% as compared to CT/MR which was accurate in 7 of 13 and clinical assessment which was accurate in eight. Three sites of abnormal tracer uptake unrelated to malignancy were recorded as incidental findings (mandibular osteomyelitis, 1: post glossectomy site, 2). PET-FDG was more accurate than CT/MR for identifying primary and recurrent tumours as well as metastatic lesions in the neck. If these diagnostic properties of PET-FDG are confirmed in further prospective studies, it could prove a valuable adjunct for the management of head and neck cancer.

Validation and clinical application of computer-combined computed tomography and positron emission tomography with 2-[18F]fluoro-2-deoxy-D-glucose head and neck images.

BACKGROUND: Positron emission tomography with 2-[18F]fluoro-2-deoxy-D-glucose (PET-FDG) improves the detection of head and neck squamous cell cancer (HNSCC), but lacks anatomical detail. The accuracy of registered computed tomography/magnetic resonance (CT/MR) and PET-FDG in delineation of HNSCC at the primary site and its clinical application was investigated. METHOD: Preoperatively 30 patients were staged clinically and each had either CT (23), MR (5), or both CT and MR (2) scans, as well as CT/MR-PET-FDG registration. Tumor margins or infiltration of specific anatomical landmarks on the different scans were compared and judged against histology. RESULTS: For primary tumors CT-PET-FDG (97%) and MR-PET-FDG (100%) delineated the tumor more accurately than CT (69%) or MR (40%) alone. Similarly, CT-PET-FDG (98%) and MR-PET-FDG (100%) were better than CT (70%) and MR alone (80%) in identifying tumor invasion of specific anatomical structures. Management was altered in 7 of 30 patients. The registered images were particularly useful in delineating tumor extension in the infratemporal fossa, maxilla and mandible, and identifying recurrences obscured by scar tissue. CONCLUSIONS: It is possible to accurately register CT, MR, and PET-FDG data sets in the head and neck. The initial results show that registered CT/ MR-PET-FDG images provide additional clinically relevant information over that obtained from clinical evaluation or conventional CT/MR imaging.

The use of positron emission tomography in the evaluation of orofacial malignancy and disease.

Positron emission tomography (PET) is a relatively new imaging technique that depends on the uptake of radionuclides. It has improved imaging ability compared with other modalities. Three case presentations are described illustrating the application of 'PET' in the management of oral cancer.

The use of PET-18FDG imaging in the clinical evaluation of head and neck lymphoma.

Four patients with non-Hodgkin's lymphoma in the head and neck region were studied with positron emission tomography (PET), using the radioactive tracer 2-[F-18]-fluoro-2-deoxy-D-glucose (18FDG). This technique, which exploits the high metabolic rate of glucose in tumour tissue, enabled the extent of disease to be visualized. The localization of the tumour was improved by combining the data from the PET scan with those from CT scans or MRI. This technique (of PET-18FDG), using visual and semiquantitative analysis in the form of standardized uptake values, allowed the differentiation between reactive hyperplasia and nodal involvement with lymphoma. We believe that PET using the tracer 18FDG may play an important role in the evaluation of patients with head and neck lymphoma.

Through-flow revascularization of the tongue using a radial forearm free flap.

Surgery for invasive squamous cell carcinoma involving the tongue base usually necessitates a total glossectomy because complete tumour resection requires sacrifice of both lingual arteries leaving a non-viable anterior tongue. A case is presented in which both lingual arteries were sacrificed to achieve complete tumour excision and the remaining anterior two-thirds of the tongue were successfully revascularized by through-flow from a radial forearm free flap which was used for pharyngeal reconstruction. This technique offers hope of preservation of the tongue when radical surgery would otherwise lead to its removal.