How many growing vestibular schwannomas tend to stop growing without any treatment?

OBJECTIVE: To determine the long-term, spontaneous growth arrest rates in a large cohort of vestibular schwannoma patients. METHODS: This paper describes a retrospective case series of 735 vestibular schwannoma patients organised into four groups: group A patients showed tumour growth which then stopped without any treatment; group B patients showed tumour growth which continued, but were managed conservatively; group C patients had a growing vestibular schwannoma and received active treatment; and group D patients had a stable, non-growing vestibular schwannoma. Demographics, tumour size and vestibular schwannoma growth rate (mm/month) were recorded. RESULTS: A total of 288 patients (39.2 per cent) had growing vestibular schwannomas. Of the patients, 103 (35.8 per cent) were managed conservatively, with 52 patients (50.5 per cent of the conservative management group, 18 per cent of the total growing vestibular schwannoma group) showing growth arrest, which occurred on average at four years following the diagnosis. Eighty-two per cent of vestibular schwannomas stopped growing within five years. Only differences between age (p = 0.016) and vestibular schwannoma size (p = 0.0008) were significant. CONCLUSION: Approximately 20 per cent of growing vestibular schwannomas spontaneously stop growing, predominantly within the first five years; this is important for long-term management.

Benefits of pre-labyrinthectomy intratympanic gentamicin: contralateral vestibular responses.

OBJECTIVE: To determine the impact of pre-operative intratympanic gentamicin injection on the recovery of patients undergoing translabyrinthine resection of vestibular schwannomas. METHODS: This prospective, case-control pilot study included eight patients undergoing surgical labyrinthectomy, divided into two groups: four patients who received pre-operative intratympanic gentamicin and four patients who did not. The post-operative six-canal video head impulse test responses and length of in-patient stay were assessed. RESULTS: The average length of stay was shorter for patients who received intratympanic gentamicin (6.75 days; range, 6-7 days) than for those who did not (9.5 days; range, 8-11 days) (p = 0.0073). Additionally, the gentamicin group had normal post-operative video head impulse test responses in the contralateral ear, while the non-gentamicin group did not. CONCLUSION: Pre-operative intratympanic gentamicin improves the recovery following vestibular schwannoma resection, eliminating, as per the video head impulse test, the impact of labyrinthectomy on the contralateral labyrinth.

Cochlear patency following translabyrinthine vestibular schwannoma resection: implications for hearing rehabilitation.

OBJECTIVE: To examine when cochlear fibrosis occurs following a translabyrinthine approach for vestibular schwannoma resection, and to determine the safest time window for potential cochlear implantation in cases with a preserved cochlear nerve. METHODS: This study retrospectively reviewed the post-operative magnetic resonance imaging scans of patients undergoing a translabyrinthine approach for vestibular schwannoma resection, assessing the fluid signal within the cochlea. Cochleae were graded based on the Isaacson et al. system (from grade 0 - no obstruction, to grade 4 - complete obliteration). RESULTS: Thirty-nine patients fulfilled the inclusion criteria. The cochleae showed no evidence of obliteration in: 75 per cent of patients at six months, 38.5 per cent at one year and 27 per cent beyond one year. Most changes happened between 6 and 12 months after vestibular schwannoma resection, with cases of an unobstructed cochlear decreasing dramatically, from 75 per cent to 38.5 per cent, within this time. CONCLUSION: The progress of cochlear obliteration that occurred between 6 and 12 months following vestibular schwannoma resection indicates that the first 6 months provides a safer time window for cochlear patency.

Quality of life in patients with vestibular schwannomas managed conservatively.

Since the era of magnetic resonance imaging (MRI) scanning, vestibular schwannomas are being diagnosed earlier, growth has been shown to be static in up to 70% of cases and patients have admitted to a reduced quality of life following acoustic neuroma surgery. The aim of this study was to assess the quality of life in patients with vestibular schwannomas managed conservatively. Fifty patients with a vestibular schwannoma were identified who were being managed by interval MRI scanning. Fifty patients attending the general otolaryngology clinic with similar symptoms were prospectively recruited. Each group was assessed using the short form 36 (SF-36) health survey. Both groups were adequately age and sex matched and the SF-36 scores were comparable across all eight health domains.

Growth rate of non-vestibular intracranial schwannomas.

A group of nine patients with non-vestibular intracranial neuromas (four jugular, four facial, one trigeminal) underwent an interval scanning management policy, with serial annual magnetic resonance (MR) imaging. Tumour volume was assessed by manual measurement of the tumour area by MR imaging. Tumour volume was assessed by manual measurement of the tumour area on MR imaging axial cuts. The mean tumour size at presentation was 4.6 cm(3) (range 0.7-17.8 cm(3)). During a mean follow-up of 36 months (range 22-50 months), five out of nine tumours grew significantly at a rate of more than 5% of their initial volume per year. Only those tumours growing at a rate of more than 20% initial volume per year exhibited symptom progression. During a 36-month period of interval scanning, just over 50% of non-vestibular intracranial neuromas exhibited significant growth. Symptom progression was found to be a strong indicator of a high growth rate. This proportion exhibiting growth is higher than that demonstrated by unilateral sporadic vestibular schwannomas, but less than in patients with neurofibromatosis II. Early treatment of non-vestibular intracranial neuromas should therefore be considered.

Aberrant internal carotid artery in the middle-ear space.

The incidence of an aberrant internal carotid artery in the middle ear is approximately one per cent and most patients are asymptomatic. We present two patients with an aberrant internal carotid artery who presented with pulsatile tinnitus and an intra-tympanic mass. Here we discuss the clinical presentation, relevant radiographic investigations and further management of these patients.

Consent--who, what, where, when?

OBJECTIVE: An investigation of current practise for obtaining and documenting informed consent in Scottish Ear, Nose and Throat (ENT) departments. DESIGN: A telephone survey of junior representatives of each ENT department. Each junior was asked a series of questions regarding who discussed the operations with patients who signed the consent forms and whether any form of training was given. SETTING: May 1999. RESULTS: In 80% of cases the responsibility for taking written consent fell to the most junior members of staff. Consultants have a pre-operative discussion, with their patients most of the time but only rarely is this discussion documented. Training in the process of consent is given in only one of 15 departments. CONCLUSION: Despite increasing negligence claims and clear guidelines from the General Medical Council the responsibility for obtaining written consent from pre-operative patients still rests with the most junior medical staff of the ENT departments of Scotland. We suggest that this situation is neither prudent nor fair and have put forward two simple proposals to rectify the situation.

Head and neck carcinoma--stage at presentation.

A prospective study was performed during a 2-year-period. A total of 127 patients presenting with a squamous cell carcinoma of the head, neck and upper aerodigestive tract were entered into the study. Patients were classified according to the primary site, namely: larynx (n = 44), oropharynx (n = 28), hypopharynx (n = 17) and oral cavity (n = 19) and others (n = 19). Patients were staged according to the UICC TNM classification (1987) and the nature and duration of their symptoms were recorded. Sixty-one per cent of patients were found to be presenting with advanced disease (stages 3 and 4): oropharynx--71%; hypopharynx--77%; oral cavity--50%; larynx--34%. No relationship could be established between stage at presentation and duration of symptoms and 53% of patients with advanced disease had been symptomatic for less than 3 months at the time of diagnosis. Only 28% of patients presenting with stage 3 or 4 disease had symptoms for 3 months or longer. Earlier diagnosis will not make a significant impact on the overall prognosis in head and neck cancer.

Acute myeloid leukaemia presenting with acute Branhamella catarrhalis epiglottitis.

Acute supraglottic laryngitis and epiglottitis is increasingly recognised in adults. We present a case in which the condition was the presenting feature of acute myeloid leukaemia and in which Branhamella catarrhalis was the causative organism.

Effect of nasal packing on eustachian tube function.

Sixty-three patients undergoing surgery to the nasal septum followed by bilateral packing had pre- and post-operative tympanometry in order to determine the effect on eustachian tube function. Fifty-five of the 126 ears tested (46 per cent) developed a reduction in middle ear pressure of at least 50 daPa; 76 per cent became normal within 24 hours of removing the nasal packs. All ears were asymptomatic and no patient had evidence of middle ear effusion. Nasal packing following septal surgery is a frequent cause of short-lasting eustachian tube dysfunction but rarely severe enough to cause symptoms or middle ear effusion. Tubal dysfunction is most likely due to a combination of surgical oedema and a direct effect of the nasal packing.

Medical treatment of chronic otitis media: steroid or antibiotic with steroid ear-drops?

The aim of this study was to evaluate whether, in the treatment of active non-cholesteatomatous chronic otitis media, the effectiveness of gentamicin with hydrocortisone ear-drops is due solely to the contained steroid or to the combination of antibiotic and steroid. Sixty-four patients presenting to the Ear, Nose and Throat outpatient department with active non-cholesteatomatous chronic otitis media were randomly allocated to receive either gentamicin with hydrocortisone ear-drops, or betamethasone ear-drops, for up to 4 weeks. Activity in the ear was assessed at 2 and 4 weeks. Gentamicin with hydrocortisone combination drops were significantly more effective than betamethasone drops (P less than 0.001) in producing inactivity of chronic otitis media, being effective in 80% as opposed to 29% of cases. The effectiveness of gentamicin with hydrocortisone ear-drops appears to be due to the combination of antibiotic and steroid.

Osteochondroma of the tongue.

A case is described of osteochondroma of the tongue and the literature on osteomata, chondromata and osteochondromata of the tongue is reviewed. The tendency for these tumours to arise in the region of the foramen caecum has been noted in previous reports as has the female preponderance. It has been suggested that they arise from remnants of branchial arch cartilage. The variation in the duration and age at presentation of the lesion has not been explained and an alternative theory is suggested.

Effect of anesthesia on acoustically evoked middle latency response in guinea pigs.

Increased recent interest in the middle latency response (MLR) has necessitated a clarification of the possible effects of anesthesia on the response. Our study was designed to examine the changes, in the guinea pig MLR, which occurred during anesthesia with ketamine, xylazine or both ketamine and xylazine. Under anesthesia the response remained present and the threshold remained stable. After anesthesia, significant changes in amplitude, latency, and general morphology of the waveform took place, however these were consistent and predictable. For studies requiring the MLR, it is best to avoid anesthetic agents. However, with care the MLR can be used as a reliable measure of auditory system sensitivity under anesthesia.

Provision of hearing aids: does specialist assessment cause delay?

OBJECTIVE: To identify the main delay in the provision of hearing aids for people with impaired hearing and identify possible problems and short-comings caused by a community based hearing aid dispensing service. DESIGN: Prospective cohort analysis based on data collected from patients on the duration of hearing impairment, from the referral letters in respect of the general practitioners' findings on otoscopy, and from the ear, nose, and throat assessment in the clinic with respect to the outcome of specialist otoscopy and management of the hearing impairment. SETTING: General ear, nose, and throat outpatient clinic. PATIENTS: 100 Consecutive patients aged 19-94 referred by general practitioners for the provision of hearing aids or for assessment and treatment of impaired hearing. RESULTS: Most patients with impaired hearing did not seek medical advice for at least a year. The time from referral by the general practitioner to the provision of a hearing aid was under two months. General practitioners consistently recognised normality on otoscopy but failed to recognise abnormality in eight of 45 cases. Seven patients required further investigation to exclude serious disease and nine had conditions amenable to surgery. CONCLUSIONS: The main cause of delay in treating impaired hearing is failure by patients to seek help promptly. Specialist assessment of patients with impaired hearing is preferable and does not necessarily cause delay in providing hearing aids. The provision of hearing aids should remain a hospital based service.

Primary nasal tuberculosis masquerading as a malignant tumour.

Primary nasal tuberculosis is rare. We report a case of primary nasal tuberculosis in an elderly lady who presented with symptoms and signs suggestive of a nasal fossa tumour. Histological examination of the lesion revealed the diagnosis. Treatment was with standard anti-tuberculous chemotherapy. The implications of primary nasal tuberculosis are discussed.

A simple screening test for hearing impairment in elderly patients.

This study investigated the reliability of simple bedside free-field voice testing in the detection of hearing impairment in patients admitted to a geriatric unit. Sixty-two consecutive admissions were assessed at four graduated levels of loudness by geriatrician and otolaryngologist independently. Pure tone audiometry was then performed blind. Voice testing by both observers was concordant in 88% of all ears and in 100% of ears able to hear a whispered voice (WV) at 2 ft (approximately 0.6 m). The WV at 2 ft was the most discriminant test with a sensitivity of 100%, a specificity of 84% and a predictive value of 92% for hearing impairment likely to benefit from provision of a hearing aid. Free-field voice testing appears a simple, reliable and reproducible test for detecting hearing impairment in elderly patients.

Local anaesthetic with vasoconstrictor combinations in septal surgery.

Local anaesthetic with vasoconstrictor combinations are often used to reduce bleeding and hence improve the operating field in septal surgery. Two commonly used combinations are lignocaine with adrenaline and prilocaine with felypressin (citanest with octapressin). Most surgeons prefer to use lignocaine with adrenaline but because of the risks of cardiac dysrhythmias when used with halothane anaesthetists prefer prilocaine with felypressin. In a trial with lignocaine 2 per cent and adrenaline 1 in 200,000 against prilocaine 3 per cent and felypressin 0.03 international units/ml in 18 patients undergoing septal surgery with local anaesthesia alone there was significantly less blood loss in the lignocaine with adrenaline group, p less than 0.01. The mean blood loss in the adrenaline group was 7.5 ml. and 32.7 ml. with felypressin. Both combinations were equally effective in producing adequate local anaesthesia. It is concluded that lignocaine with adrenaline is superior to prilocaine with felypressin in achieving a dry operating field in septal surgery under local anaesthesia.

The broken nose: does familiarity breed neglect?

A questionnaire method was used to assess the ability of early primary reduction to treat the fractured nose. Questionnaires were sent to one hundred and twenty eight such patients of whom eighty five (66%) replied. Seventy two (85%) of the patients expressed satisfaction with their nasal appearance with only thirteen (15%) requesting corrective surgery. Thirty one patients (36%) experienced nasal obstruction following reduction and of those, eighteen (21%) wished to undergo further surgery. In a separate study the cause of nasal deformity in fifty five patients undergoing septorhinoplasty was ascertained. In thirty six of these patients (65.5%) the deformity resulted from a neglected nasal injury. The value and limitations of early primary reduction of nasal fractures is discussed.