Trismus following different treatment modalities for head and neck cancer: a systematic review of subjective measures.

The aim of this review was to compare systematically the subjective measure of trismus between different interventions to treat head and neck cancer, particularly those of the oropharynx. Using The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) Guidelines, Six databases were searched for the text using various terms which include "oropharyngeal/head and neck cancer", "trismus/mouth opening" and the various treatment modalities. Included in the review were clinical studies (> or =10 patients). Three observers independently assessed the papers identified. Among the six studies reviewed, five showed a significantly worst outcome with regard to the quality-of-life questionnaire scores for a radiotherapy or surgery and radiotherapy (RT) ± chemotherapy or chemoradiotherapy when compared to surgery alone. Only one study showed no significant difference between surgery alone and other treatment modalities. Subjective quality-of-life measures are a concurrent part of modern surgical practice. Although subjective measures were utilised to measure post operative trismus successfully, there was no consensus as to which treatment modality had overall better outcomes, with conflicting studies in keeping with the current debate in this field. Larger and higher quality studies are needed to compare all three treatment modalities.

Laser Eustachian Tuboplasty for Eustachian Tube Dysfunction: a case series review.

The authors reviewed the literature regarding the safety and efficacy of Laser Eustachian Tuboplasty (LETP) in the treatment of Eustachian tube dysfunction (ETD). Medline via Pubmed, OvidSP and Science Direct were consulted, with a supplementary manual review of citations. English language case series constituted a baseline for inclusion. Primary outcome measures were pre- and post-operative tympanometry, otoscopy findings, subjective symptoms and pure tone audiometry, and findings were stratified into short term (≤6 months) and long term (>6 months-5 years). Eight unique case series were identified, detailing LETP procedures in 306 patients (462 Eustachian tubes). LETP demonstrated mixed short-term and positive long-term results across primary outcome measures. There was an overall complication rate of ≈4.4%, and no major adverse events were reported. Poor documentation of pre- and post-operative primary outcome measures and inter-study outcome heterogeneity prevents substantive comment on efficacy. Whilst LETP is safe, its use should remain limited to research in adults. Future trials should be case controlled, and detail pre- and post-operative tympanometry, otoscopy findings, subjective symptoms, and pure tone audiometry. Patients should also be stratified into those suffering from baro-challenge induced ETD, and those suffering from ETD with intractable sequelae, such as Chronic Otitis Media.

Exercise induced laryngeal obstruction: a review of diagnosis and management.

Exercise induced laryngeal obstruction (EILO) is a condition where inappropriate vocal cord or glottic closure occurs during exercise. This review of the literature provides an overview of the current understanding of the definition, epidemiology, diagnosis and management of EILO. Using The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines the Cochrane, Embase, Ovid MEDLINE and PubMed databases were searched. Four search domains "exercise", "induced", "laryngeal" and "obstruction" were used. Primary searching found 469 records, 308 were excluded following screening of titles and citation. 100 were duplicates, a further 47 studies were excluded after applying inclusion and exclusion criteria. Two studies were identified following cross-referencing. A total of 15 studies were included. The last search date was 6/06/15. Average prevalence in the general adolescent population and athletes was 7.1 and 35.2 %, respectively. Dyspnoea was reported in 96.5, 99 and 100 % of three EILO patient cohorts. Two studies (n = 107) reported continuous laryngoscopy during exercise (CLE) testing could differentiate between patients and controls. In two studies (n = 33) the visual analogue scale (VAS) showed a beneficial effect of endoscopic supraglottoplasty (ES). Thirty-eight out of 43 patients who received two or more laryngeal control therapy sessions (LCT) had improvement or resolution of EILO symptoms. Exercise induced dyspnoea is the most common EILO symptom. EILO has a high occurrence in adolescents and athletes. The CLE test is the current gold standard for EILO diagnostics. Management of EILO includes both surgical and non-surgical interventions.

Post-sinus surgery insertion of steroid-eluting bioabsorbable intranasal devices: A systematic review.

OBJECTIVES/HYPOTHESIS: Postendoscopic sinus surgery corticosteroid administration reduces polyp formation, inflammation, and adhesions. Steroid-eluting bioabsorbable intranasal devices (SEBID) are novel interventions thought to improve local drug delivery while minimizing systemic side effects. The primary aim of this systematic review is to evaluate the efficacy and safety of bioabsorbable SEBIDs. The secondary aim is to inform clinical recommendations and to introduce clinicians to this novel technology. STUDY DESIGN: MEDLINE, PubMed, Embase, and Cochrane Database were searched according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. METHODS: Original articles assessing the efficacy of SEBIDs inserted after endoscopic sinus surgery. For each study, we recorded the efficacy endpoints and safety outcomes. RESULTS: Seven studies met the inclusion criteria from 737 initial articles identified, including five prospective randomized controlled trials and two prospective single-cohort studies involving 394 sinuses within treatment arms. Patients were followed up for 2 to 6 months. Six studies demonstrated SEBID efficacy with statistical significance (P < 0.05). Steroid-eluting bioabsorbable intranasal devices were effective in reducing adhesion formation, polyp formation, inflammation, Lund-Kennedy scores, and perioperative sinus endoscopy scores. The devices improved patient-reported outcomes and olfaction while reducing postoperative interventions. They were not associated with adverse events and pose no ocular safety risk. Complications in three SEBID applications were reported. CONCLUSION: There is limited data available on SEBIDS; further studies are required to determine whether they are safe and effective adjuncts postendoscopic sinus surgery. Future studies are needed to optimize the dosing regimen, compare devices, and provide long-term outcomes. Steroid-eluting bioabsorbable intranasal devices may tentatively be incorporated into future evidence-based practice.

Treatment-based strategy for the management of post-kala-azar dermal leishmaniasis patients in the Sudan.

UNLABELLED: Post-kala-azar dermal leishmaniasis (PKDL) is a dermatosis that affects more than 50% of successfully treated visceral leishmaniasis (VL) patients in Sudan. PKDL is considered an important reservoir for the parasite and its treatment may help in the control of VL. Currently, treatment is mainly with sodium stibogluconate (SSG), an expensive and fairly toxic drug and without universally in treatment protocols used. A literature review, a consensus of a panel of experts, and unpublished data formed the basis for the development of guidelines for the treatment of PKDL in the Sudan. Six treatment modalities were evaluated. Experts were asked to justify their choices based on their experience regarding of drug safety, efficacy, availability, and cost. The consensus was defined by assigning a categorical rank (first line, second line, third line) to each option. Regarding the use of AmBisome the presence of the drug in the skin was confirmed in smears from PKDL lesions. RECOMMENDATIONS: AmBisome at 2.5 mg/kg/day/20 days or SSG at 20 mg/kg/day/40 days plus four/weekly intradermal injection of alum-precipitated autoclave L. major vaccine are suggested as first- and second-treatment options for PKDL in the Sudan, respectively. SSG at 20 mg/Kg/day/60 or more days can be used if other options are not available.

Evaluating internet health resources in ear, nose, and throat surgery.

OBJECTIVES/HYPOTHESIS: To assess the quality, accessibility, usability, reliability, and readability of Web sites that provide information on common ear, nose, and throat conditions. STUDY DESIGN: Several standardized and validated appraisal instruments and questionnaires designed to rate Web sites providing online health information were used to evaluate the content of online ear, nose, and throat health information. METHODS: The terms "cholesteatoma," "sinusitis," "tonsillitis," "acute otitis media," "epistaxis," and "quinsy" (peritonsillar abscess), representing six common ear, nose, and throat conditions, were entered separately into the Internet search engine Google. Web sites satisfying the inclusion criteria from the first 30 results of each search were evaluated for content quality using the DISCERN rating instrument, for accessibility, usability, and reliability using the LIDA rating instrument, and for readability using the Flesch Reading Ease score. RESULTS: Of the 180 Web sites identified, 124 (68.9%) satisfied the inclusion criteria. The mean overall DISCERN score for quality was "poor," at 39/80 (range, 16-70). The DISCERN instrument rated 2 (1.6%) Web sites as "excellent," 14 (11.3%) as "good," 40 (32.3%) as "fair," 38 (30.6%) as "poor," and 30 (24.2%) as "very poor." The mean overall LIDA score for accessibility, usability, and reliability was "moderate," at 114/165 (69.3%; range, 61-142). The mean Flesch Reading Ease score for the readability of Web sites was 42.3/100 (range, 10.7-71.9). CONCLUSIONS: The use of validated instruments is necessary to reduce the risks from patients accessing misinformation. They can guide health care professionals with their role in directing patients to high-quality sources of information and endorsing Web sites that meet high standards.

MRSA contaminated venepuncture tourniquets in clinical practice.

INTRODUCTION: Meticillin-resistant Staphylococcus aureus (MRSA) hospital-acquired infection is associated with increased patient mortality. National guidelines state that shared patient equipment must be cleaned after use. The authors sought to identify MRSA contamination in a sample of non-disposable venepuncture tourniquets and audit cleaning habits between patient contacts. MATERIALS AND METHODS: Fifty tourniquets were collected from junior doctors, nursing staff and wards from two district general hospitals in Essex, UK in 2007. A questionnaire was completed at the time of collection for each tourniquet. The tourniquets were cultured using standard microbiology techniques. FINDINGS: 18/50 (36%) tourniquets were positive for S. aureus and of these 6/50 (12%) were MRSA positive. 33/43 (77%) healthcare professionals using non-disposable tourniquets for venepuncture made no attempts at cleaning their tourniquets. 10/43 (23%) staff admitted to cleaning their tourniquets. The tourniquets were used for an average of 14 weeks on approximately three different patients per day. 30/50 (60%) tourniquets were visibly soiled and of these 13 were blood stained and 20/50 (40%) appeared 'clean'. Worn tourniquets when compared with the 'clean' tourniquets were more likely to be contaminated with S. aureus, 15/30 (50%) vs 3/20 (15%), and MRSA 5/30 (17%) vs 1/20 (5%). CONCLUSION: Non-disposable venepuncture tourniquets are contaminated with MRSA and pose a risk to patients. The majority of clinical staff do not clean them between patient contacts as recommended by guidelines. The use of non-disposable venepuncture tourniquets should be abandoned. The introduction of disposable tourniquets to clinical practice should be an adjunct to current measures for MRSA prevention.

The safety and efficacy of itraconazole for the treatment of patients with eumycetoma due to Madurella mycetomatis.

This prospective study aimed to determine the safety and efficacy of itraconazole for the treatment of patients with mycetoma due to Madurella mycetomatis. The study consisted of 13 patients with confirmed disease; all were treated with oral itraconazole in a dose of 400mg daily for three months after which the dose was reduced to 200mg daily for nine months. All patients showed good clinical response to 400mg itraconazole daily, but when the dose was reduced to 200mg daily, the clinical response was gradual and slow. Post-treatment surgical exploration showed that, in all patients, the lesions were well localized, encapsulated with thick capsule and they were easily removed surgically. In all these lesions, grains colonies were encountered and they were viable on culture. Post-operative biopsies showed no significant changes in the morphology of the grains. A constant finding was the presence of between 5-7 grains in a single cavity walled by fibrous tissue. The reaction surrounding the grains was a Type I tissue reaction characterized by a neutrophil zone around grains. Patients were followed up post-operatively for variable periods (range 18-36 months) and only one patient had recurrence. Initial pre-operative treatment with itraconazole may be recommended for eumycetoma patients to enhance lesions encapsulation and localization which can facilitate wide local excision to avoid unnecessary massive mutilating surgery and recurrence.

Gastrointestinal stromal tumours (GISTs): case report and review of the literature.

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract, the majority of which is KIT (CD117) positive. In this case report, we describe a case of recurrent and metastatic GIST who presented with hepatic and brain metastases. Despite the patient's GISTs was negative for c-Kit (CD 117), he responded to imatinib mesylate (Glivec) treatment with complete resolution of his liver and brain lesions. The patient has been and still in complete remission for 18 months of follow-up.

Surrogate markers of subtle renal injury in patients with visceral leishmaniasis.

Sudanese visceral leishmaniasis (VL) is a disease of children that is characterized by fever, hepatosplenomegaly, lymphadenopathy, pancytopenia, and renal injury. Microalbuminuria (MA) and urinary retinol binding protein (urRBP) are useful markers for glomerular and tubular dysfunctions, respectively. We report the prevalence of subtle renal injury in 88 parasitologically confirmed VL patients in a cross-sectional and hospital-based study. Blood and urine were collected before treatment for hematological, biochemical profiles in addition to MA and urRBP measurement using competitive solid phase, sandwich enzyme-linked immune sorbent assay (ELISA), and immunoturbidometry. All the patients had normal serum urea and creatinine levels and no detectable urRBP. However, 40% of the patients had MA detected by ELISA, and 42% were reactive with turbidometry. The sensitivity, specificity, positive and negative predictive values for MA turbidometric technique were calculated as 100%; 96%; 95% and 100%, respectively. In conclusion; subtle renal injury in VL is mainly glomerular. Turbidometry for MA measurement is a simple, inexpensive, sensitive, and specific technique with high predictive values.

Leishmania donovani: genetic diversity of isolates from Sudan characterized by PCR-based RAPD.

Drug unresponsiveness in patients with visceral leishmaniasis (VL) is a problem in many endemic areas. This study aimed to determine genetic diversity of Leishmania donovani isolates from a VL endemic area in Sudan as a possible explanation for drug unresponsiveness in some patients. Thirty clinically stibogluconate (SSG)-sensitive isolates were made SSG-unresponsive in vitro by gradually increasing SSG concentrations. The sensitive isolates and their SSG-unresponsive counterparts were typed using mini-circle kDNA and categorized using PCR-RAPD. All the isolates were typed as L. donovani, the resulting PCR-RAPD characterization of the SSG-sensitive isolates gave three distinct primary genotypes while, the SSG-unresponsive isolates showed only a single band. L. donovani isolates from eastern Sudan are diverse; this probably resulted from emergence of new L. donovani strains during epidemics due to the pressure of widespread use of antimonials. In this communication the possible role of isolates diversity in antimonial unresponsiveness and the in vitro changing PCR-RAPD band pattern in SSG-unresponsive strains were discussed.

Haematogenous dissemination of tuberculous lymphadenitis.

OBJECTIVE: To determine whether Mycobacterium tuberculosis infection spreads through the blood to different lymph-node groups in patients with tuberculous lymphadenitis. DESIGN: Prospective analytical study. SETTING: The patients were recruited, managed and followed at the lymphodenopathy clinic, Central Police Hospital, Burr, Khartoum, Sudan. SUBJECTS: Fifty two sequential patients were enrolled. Thirty patients with FNAC diagnosis of tuberculous lymphadenitis and positive PCR for M. tuberculosis complex had a mean age of 26.9 +/- 11.2 years and similar male, female affection. Nine patients with FNAC tuberculous lymphadenitis, but negative PCR had a slightly higher mean age (32.6 +/- 18.2 years) with similar male: female proportions. Patients with reactive lymphadenopathy (9/52) were older than patients with tuberculous lymphadenitis with a mean age of 45 +/- 24.6 years. RESULTS: None of the patients were positive for HIV or had clinical or radiological evidence of pulmonary tuberculosis. M. tuberculosis DNA was detected in the blood samples of 30/39 (77%) patients with tuberculous lymphadenitis, but in none of the cases with reactive or malignant lymphadenopathy. The presence of M. tuberculosis DNA correlated strongly to multiple lymph-node involvement [OR (odds ratio) = 96.7, 95% confidence interval (CI) 9.0 - 1,039] and to caseating-granulomatous and predominantly necrotic cytomorphological categories [OR = 70, 95% confidence interval (CI) 7.0 - 703]. CONCLUSION: M. tuberculosis most probably disseminates through the blood from one node group to the other in patients with tuberculous lymphadenitis.

Granulomatous mammary disease: ten years' experience with fine needle aspiration cytology.

OBJECTIVE: To determine the aetiological types of granulomatous disease of the breast in women presenting with mammary complaints in the Sudan. METHODS: Clinical history and physical examination, complete blood counts, Mantoux test, histopathology and fine needle aspiration cytology (FNAC). RESULTS: Granulomatous mastitis was seen in 11/2500 (0.44%) patients with mammary disease over a 10-year period. All were of childbearing age (mean 26.0 +/- 5.9 years). Common presentations were diffuse swelling, well-circumscribed masses, nipple retraction, multiple sinuses and superficial skin ulcers. Lymphadenopathy was seen in more than 60% of the patients. Diagnosis was based on cytomorphological features in 10/11 cases and histopathology in one. Nine were diagnosed with tuberculous mastitis and two with idiopathic granulomatous mastitis. Acid-fast bacilli (AFB) could not be demonstrated in any of the cytology smears. Tuberculous mastitis responded to empirical anti-tuberculosis treatment, with a minimum follow-up of 2 years in seven women. CONCLUSION: Tuberculous mastitis is a rare entity in women with mammary disease in the Sudan. Alternative diagnoses such as idiopathic granulomatous mastitis should be made only after failure of an adequate trial of anti-tuberculosis treatment. FNAC is a useful diagnostic tool even if AFB cannot be demonstrated.

Bioactive constituents of Leptadenia arborea.

The aerial part of Leptadenia arborea has been shown to contain pinoresinol (1), syringaresinol (2), leucanthemitol (3) and E-ferulaldehyde (4). These known compounds are being reported for the first time from this plant. Among them, syringaresinol has shown an inhibitory effect against acetylcholinesterase. The IC(50) (the concentration of 50% enzyme inhibition) value of this compound was 200 microg/ml.

Post-kala-azar dermal leishmaniasis.

Post-kala-azar dermal leishmaniasis (PKDL) is a complication of visceral leishmaniasis (VL); it is characterised by a macular, maculopapular, and nodular rash in a patient who has recovered from VL and who is otherwise well. The rash usually starts around the mouth from where it spreads to other parts of the body depending on severity. It is mainly seen in Sudan and India where it follows treated VL in 50% and 5-10% of cases, respectively. Thus, it is largely restricted to areas where Leishmania donovani is the causative parasite. The interval at which PKDL follows VL is 0-6 months in Sudan and 2-3 years in India. PKDL probably has an important role in interepidemic periods of VL, acting as a reservoir for parasites. There is increasing evidence that the pathogenesis is largely immunologically mediated; high concentrations of interleukin 10 in the peripheral blood of VL patients predict the development of PKDL. During VL, interferon gamma is not produced by peripheral blood mononuclear cells (PBMC). After treatment of VL, PBMC start producing interferon gamma, which coincides with the appearance of PKDL lesions due to interferon-gamma-producing cells causing skin inflammation as a reaction to persisting parasites in the skin. Diagnosis is mainly clinical, but parasites can be seen by microscopy in smears with limited sensitivity. PCR and monoclonal antibodies may detect parasites in more than 80% of cases. Serological tests and the leishmanin skin test are of limited value. Treatment is always needed in Indian PKDL; in Sudan most cases will self cure but severe and chronic cases are treated. Sodium stibogluconate is given at 20 mg/kg for 2 months in Sudan and for 4 months in India. Liposomal amphotericine B seems effective; newer compounds such as miltefosine that can be administered orally or topically are of major potential interest. Although research has brought many new insights in pathogenesis and management of PKDL, several issues in particular in relation to control remain unsolved and deserve urgent attention.