The post-operative tonsillectomy (POPT) study: A multi-centre prospective paediatric cohort study.

OBJECTIVES: Tonsillectomy is the most common operation performed by otolaryngologists in the UK, despite this we have a poor understanding of the post-operative recovery. We aimed to investigate post-operative bleeding and pain following paediatric tonsillectomy using a patient diary. DESIGN: Prospective observational cohort study. SETTING: Multi-centre study involving 12 secondary and tertiary otolaryngology units across the North of England. Patients were recruited from 1st March 2020 to 30th June 2022. Multilevel ordered logistic regression model statistics were performed. PARTICIPANTS: Children (≥4 years, ≤16 years) undergoing tonsillectomy (with or without adenoidectomy) for benign pathology. MAIN OUTCOME MEASURES: Frequency and severity of post-operative bleeding. Intensity and pattern of post-operative pain. RESULTS: In total 297 children were recruited, with 91 (30.6%) diaries eligible for analysis. Post-operative bleeding occurred in 44% of children. Most frequently blood in the saliva was reported (82.9%). Increasing age significantly increased bleeding odds by 17% per year (p = .001). Bleeding frequency decreased with higher surgeon grade (p = .003) and when performing intracapsular coblation tonsillectomy (p = .02) compared with other techniques. Lower age and intracapsular coblation tonsillectomy, against other techniques, significantly reduced rates of pain post-operatively (p < .0001 and p = .0008). CONCLUSION: A high level of low-level post-operative bleeding was observed. Pain scores remained high for 5 days post-operatively then gradually reduce to normal by day 13. Intracapsular coblation tonsillectomy appears to be superior to all other techniques in terms of reducing post-operative bleeding and pain. These findings should be used to guide patients in the consent process to inform them of the expected nature of post-surgical recovery.

Acute otitis externa: Consensus definition, diagnostic criteria and core outcome set development.

OBJECTIVE: Evidence for the management of acute otitis externa (AOE) is limited, with unclear diagnostic criteria and variably reported outcome measures that may not reflect key stakeholder priorities. We aimed to develop 1) a definition, 2) diagnostic criteria and 3) a core outcome set (COS) for AOE. STUDY DESIGN: COS development according to Core Outcome Measures in Effectiveness Trials (COMET) methodology and parallel consensus selection of diagnostic criteria/definition. SETTING: Stakeholders from the United Kingdom. SUBJECTS AND METHODS: Comprehensive literature review identified candidate items for the COS, definition and diagnostic criteria. Nine individuals with past AOE generated further patient-centred candidate items. Candidate items were rated for importance by patient and professional (ENT doctors, general practitioners, microbiologists, nurses, audiologists) stakeholders in a three-round online Delphi exercise. Consensus items were grouped to form the COS, diagnostic criteria, and definition. RESULTS: Candidate COS items from patients (n = 28) and literature (n = 25) were deduplicated and amalgamated to a final candidate list (n = 46). Patients emphasised quality-of-life and the impact on daily activities/work. Via the Delphi process, stakeholders agreed on 31 candidate items. The final COS covered six outcomes: pain; disease severity; impact on quality-of-life and daily activities; patient satisfaction; treatment-related outcome; and microbiology. 14 candidate diagnostic criteria were identified, 8 reaching inclusion consensus. The final definition for AOE was 'diffuse inflammation of the ear canal skin of less than 6 weeks duration'. CONCLUSION: The development and adoption of a consensus definition, diagnostic criteria and a COS will help to standardise future research in AOE, facilitating meta-analysis. Consulting former patients throughout development highlighted deficiencies in the outcomes adopted previously, in particular concerning the impact of AOE on daily life.

Functional optimisation in chondrosarcoma of the subglottis: a novel surgical approach.

Chondrosarcoma of the larynx is rare accounting for approximately 1% of laryngeal cancers; clear cell subtype is a rare variant. Given the low risk of occult nodal disease, they present a unique opportunity to maximise tissue preservation in order to optimise both recovery and long-term functional outcomes. We present a case of laryngeal clear cell chondrosarcoma causing critical airway obstruction. An emergency tracheostomy was performed and mapping biopsies were taken. The tumour originated from the cricoid and extended into both arytenoid superstructures precluding cricotracheal resection. A modified narrow-field laryngectomy was performed, preserving all pharyngeal mucosa and neurovascularly intact infrahyoids. Organ preservation surgery is preferred in the management of laryngeal chondrosarcoma. If laryngectomy is required, the surgeon must ensure that all uninvolved, functional tissue is preserved carefully to improve swallow and voice outcomes postoperatively. We describe a novel technique used to achieve this outcome.

A 10-Year Review of the Complications Caused by Ingested and Aspirated Dentures.

INTRODUCTION: Dentures are worn by 20% of the United Kingdom population for both physical and psychological symptoms associated with tooth loss. However, significant morbidity and mortality can result if dentures are swallowed or aspirated. This 10-year review investigated the development of complications following denture aspiration or ingestion, and identified key learning points. METHODS: The Medline database was searched for cases of denture ingestion or aspiration from October 1, 2009, to October 31, 2019. Search terms included "dental prosthesis, denture, dental plate, bridge and false teeth" and "swallow, ingest, eat, aspirate and inhale." Potential factors influencing the development of complications were assessed (hollow viscus perforation, fistula formation, abscess, bowel obstruction, necrosis, hemorrhage, and airway obstruction). Statistical analysis was performed using χ2 and Pearson correlation tests in R Studio. No ethical approval was required. RESULTS: Eighty-five patients were identified from 77 case reports. Fourteen articles were excluded due to insufficient information. Complications were documented in 37.6% (n = 32) of patients with 2 cases resulting in death. Duration of symptoms over 1 day (P = .005) and delayed removal beyond 4 days post-ingestion (P = .017) was significantly associated with increased rates of complications. There was no significant association between complication rate and patient age, denture type, level of impaction, or radiolucency. CONCLUSION: Denture aspiration or ingestion can have serious consequences. Factors impacting complication rate revolve around early recognition and treatment. Clinician awareness of the potential risks of dentures is paramount to early diagnosis. We recommend early intervention to reduce the morbidity associated with this unassuming device.

Confocal Laser Endomicroscopy Assessment of Pituitary Tumor Microstructure: A Feasibility Study.

This is the first study to assess confocal laser endomicroscopy (CLE) use within the transsphenoidal approach and show the feasibility of obtaining digital diagnostic biopsies of pituitary tumor tissue after intravenous fluorescein injection. We confirmed that the CLE probe reaches the tuberculum sellae through the transnasal transsphenoidal corridor in cadaveric heads. Next, we confirmed that CLE provides images with identifiable histological features of pituitary adenoma. Biopsies from nine patients who underwent pituitary adenoma surgery were imaged ex vivo at various times after fluorescein injection and were assessed by a blinded board-certified neuropathologist. With frozen sections used as the standard, pituitary adenoma was diagnosed as "definitively" for 13 and as "favoring" in 3 of 16 specimens. CLE digital biopsies were diagnostic for pituitary adenoma in 10 of 16 specimens. The reasons for nondiagnostic CLE images were biopsy acquisition <1 min or >10 min after fluorescein injection (n = 5) and blood artifacts (n = 1). In conclusion, fluorescein provided sufficient contrast for CLE at a dose of 2 mg/kg, optimally 1-10 min after injection. These results provide a basis for further in vivo studies using CLE in transsphenoidal surgery.

Stellate Ganglion Catheter Effective for Treatment of Ventricular Tachycardia Storm in a Pediatric Patient on Extracorporeal Membrane Oxygenation: A Case Report.

Ventricular tachycardia (VT) storm, defined as recurrent VT requiring electrical cardioversion ≥3 times within 24 hours, is a rare presentation of long-QT syndrome. Pharmacologic autonomic modulation and/or left cardiac sympathetic denervation are established therapies in long-QT syndrome in adults but may not be effective or practical in the emergent treatment of VT storm. We present a novel case of a child with drug-refractory VT storm and prolonged QT requiring extracorporeal membrane oxygenation (ECMO) support. Continuous stellate ganglion blockade was remarkably effective in stabilizing his rhythm and should be considered in similar pediatric cases.

Effect of Intravenous Versus Intraosseous Access in Prehospital Cardiac Arrest.

OBJECTIVE: The prevailing standard of care in prehospital emergency medical services (EMS) is that either intravenous (IV) or intraosseous (IO) access is an acceptable route for obtaining vascular access and delivery of resuscitation medications and volume expanders in cardiac arrest patients. The aim of this study was to evaluate the effectiveness of IV access versus IO access in terms of return of spontaneous circulation (ROSC) for patients suffering from cardiac arrest. METHODS: A retrospective chart review examining cardiac arrest data with a single advanced life support EMS agency over a 4-year period was performed. Cardiac arrest patients were identified from a quality assurance database. Exclusion criteria included trauma arrest, pediatrics, pregnancy, and obvious signs of death. RESULTS: A total of 795 patients remained after applying the exclusion criteria. A total of 183 (45.1%) out of 406 cardiac arrest patients achieved ROSC who had an IV placed. A total of 389 cardiac arrest patients had an IO placed with ROSC in 100 (25.7%). CONCLUSIONS: Higher ROSC rates were achieved with IV access versus IO access. Limitations include the small sample size, a single EMS agency, and the retrospective nature of the study. Future studies should further evaluate the effectiveness of IO versus IV access in cardiac arrest and other low perfusion states.

Adjunctive Therapies During Extracorporeal Membrane Oxygenation to Enhance Multiple Organ Support in Critically Ill Children.

Since the advent of extracorporeal membrane oxygenation (ECMO) over 40 years ago, there has been increasing interest in the use of the extracorporeal circuit as a platform for providing multiple organ support. In this review, we will examine the evidence for the use of continuous renal replacement therapy, therapeutic plasma exchange, leukopheresis, adsorptive therapies, and extracorporeal liver support in conjunction with ECMO.

Immediate Label-Free Ex Vivo Evaluation of Human Brain Tumor Biopsies With Confocal Reflectance Microscopy.

Confocal microscopy utilizing fluorescent dyes is widely gaining use in the clinical setting as a diagnostic tool. Reflectance confocal microscopy is a method of visualizing tissue specimens without fluorescent dyes while relying on the natural refractile properties of cellular and subcellular structures. We prospectively evaluated 76 CNS lesions with confocal reflectance microscopy (CRM) to determine cellularity, architecture, and morphological characteristics. A neuropathologist found that all cases showed similar histopathological features when compared to matched hematoxylin and eosin-stained sections. RNA isolated from 7 tissues following CRM imaging retained high RNA integrity, suggesting that CRM does not alter tissue properties for molecular studies. A neuropathologist and surgical pathologist masked to the imaging results independently evaluated a subset of CRM images. In these evaluations, 100% of images reviewed by the neuropathologist and 95.7% of images reviewed by the surgical pathologist were correctly diagnosed as lesional or nonlesional. Furthermore, 97.9% and 91.5% of cases were correctly diagnosed as tumor or not tumor by the neuropathologist and surgical pathologist, respectively, while 95.8% and 85.1% were identified with the correct diagnosis. Our data indicate that CRM is a useful tool for rapidly screening patient biopsies for diagnostic adequacy, molecular studies, and biobanking.

A 58-Year-Old Man With Fatigue, Weight Loss, and Diffuse Miliary Pulmonary Opacities.

CASE PRESENTAION: A 58-year-old man presented with a 6-month history of profound fatigue and a weight loss of 35 to 40 pounds. He reported occasional night sweats and mildly painful knees and elbows without swelling or redness. He denied respiratory symptoms, rashes, or fevers. He had no respiratory symptoms. The patient's history was significant for rheumatoid arthritis (with arthralgias and joint involvement), paroxysmal atrial fibrillation, and hypothyroidism. His medications included digoxin and metoprolol. He had been taking methotrexate and low-dose prednisone (5 mg) for approximately 10 years but discontinued taking these medications 2 years prior to current presentation. Originally from West Virginia, the patient had relocated to Arizona during the early 1980s. There was no history of international travel or TB. He had no exposure history to birds, bird feathers, or mold; however, he did report exposure to dust at his current job as a home building superintendent. He reported a 10 pack-year history of smoking, having quit 20 years ago. His family history was significant for renal sarcoidosis in his mother.

Ischiofemoral impingement due to a lipoma of the ischiofemoral space.

Non-focal hip and groin pain can frequently be a diagnostic problem, particularly if it is related to uncommon causes such as ischiofemoral impingement. The vast majority of published cases of ischiofemoral impingement are caused by osseous changes of the ischiofemoral interval. We describe an unusual case of ischiofemoral impingement caused by an intermuscular lipoma. Surgical resection of the tumour and histology confirmed the lipomatous nature of the tumour, with subsequent resolution of symptoms. To the best of our knowledge, this is the first case of a lipoma causing ischiofemoral impingement described in the English literature and emphasises that impingement can occur on the basis of a soft tissue mass occupying the interval of otherwise normal osseous interval and boundaries.

Liposarcoma of the great toe: a case report.

Soft tissue sarcomas are rare malignancies, of which liposarcomas are the most common. Pleomorphic liposarcoma accounts for 5% of liposarcoma diagnoses and most commonly presents in the thigh. A 57-year-old female presented with a 5-year history of a persistent, painless swelling of the left great toe that had been previously diagnosed and treated as an in-grown toenail. After magnetic resonance imaging and core biopsy, a grade 2 pleomorphic liposarcoma was diagnosed. Treatment consisted of neoadjuvant radiotherapy and amputation of the great toe and proximal half of the first metatarsal with primary closure. The patient had no evidence of local recurrence or metastatic disease after 1 year of follow-up and, with the use of a prosthesis, had a good functional outcome. This is the first documented presentation of a high-grade pleomorphic liposarcoma of the great toe to our knowledge. Although soft tissue sarcomas are rare, a high index of suspicion is required by clinicians when presented with a soft tissue mass to promptly diagnose and treat these potentially fatal lesions.

Catatonia: clinical aspects and neurobiological correlates.

Catatonia is a neuropsychiatric syndrome that can occur due to medical or psychiatric disorder. This review synthesizes over 20 years of original research and comprehensive review articles with attention to the most recent findings. Though catatonia is common and highly treatable, there have been few research studies investigating the syndrome. Pooled case reports suggest that catatonia due to an underlying general medical condition and catatonia due to a psychiatric illness can be treated similarly and that the catatonic symptoms and the underlying illness must be addressed in both types. Benzodiazepines and ECT continue to be mainstays of treatment. Evidence is mounting for the use of NMDA antagonists in catatonia refractory to lorazepam.

Psychosocial interventions for cancer patients.

PURPOSE OF REVIEW: To evaluate recent studies of psychosocial interventions to improve survival, health, quality of life, and somatic symptoms for patients with cancer. RECENT FINDINGS: Survival in advanced breast cancer was not affected by group therapy in two large randomized controlled studies. However, several recent trials have shown improvements in quality of life and physical symptoms with both group and individual therapies. Specific therapies for symptomatic patient types are more likely to be efficacious than those applied to more general populations. There continues to be a predominance of studies in breast cancer. SUMMARY: The experience and training of therapists are crucial. New therapies are targeting meaning as an approach to optimize adaptation and ameliorate distress. Effective treatment of anxiety and depression will remain the mainstay of work for the psychooncologist.