Peritonsillar abscess after tonsillectomy: a review of the literature.

INTRODUCTION: Peritonsillar abscess (PTA) is a common condition with a complicated aetiology. PTA after tonsillectomy is rare. This literature review of PTA in the absence of tonsil tissue aims to collate experience of these cases and examine the wider implications for understanding the aetiology of PTA formation. METHODS: A structured literature review was performed using Ovid MEDLINE®. Keywords 'quinsy' or 'peritonsillar abscess' were combined with 'tonsillectomy'. RESULTS: The search resulted in 212 citations and the identification of 11 cases of PTA formation in the absence of tonsil tissue. The most common indication for tonsillectomy was recurrent tonsillitis or PTA. Nine patients had no interval peritonsillar infection (ie a peritonsillar infection after a tonsillectomy) prior to presenting with the PTA. The mean interval between tonsillectomy and PTA was 16 years. All patients were managed either by incision and drainage or by needle aspiration with or without antibiotics. CONCLUSIONS: PTA in the absence of tonsil tissue is rare. Potential sources of infection include congenital branchial fistulas, Weber's glands and dental disease. These alternatives should also be considered in patients presenting with PTA formation in the absence of concurrent tonsillitis and may influence management decisions.

Coblation® inferior turbinate reduction: a long-term follow-up with subjective and objective assessment.

This article presents long-term outcomes following Coblation® inferior turbinate reduction surgery (CITR) using both subjective and objective outcome measures in a cohort of patients with nasal obstruction secondary to enlarged inferior turbinate. Subjective assessment of the severity of nasal obstruction was assessed using a 100 mm visual analogue scale anchored by the descriptors 'nose completely clear' (0 mm) and 'nose completely blocked' (100 mm). Nasal conductance of airflow was measured by posterior rhinomanometry. Of the original cohort of 18 patients, 13 patients (76%) were available for follow-up at 32 months after surgery. The mean baseline nasal conductance was 248.6 cm3/s (range 2.5-614.8), which improved significantly (p=0.033) to 342.1 cm3/s (range 166.7-500) at 32 months post-operatively. Improvement in the subjective sensation of nasal obstruction was indicated by a lower VAS score compared to baseline. The mean pre-operative VAS was 72 mm (range 49-98), which improved to 53 mm (range 2-93) but this did not achieve statistical significance (10/13 patients scored improved airflow). This was a pilot study of the long-term outcomes of CITR. Despite the small study cohort, there appears to be sustained improvement in nasal conductance of air-flow up to 32 months follow-up. Although there was improvement in the subjective assessment of nasal obstruction, this did not achieve statistical significance.

Efficacy of inferior turbinate coblation for treatment of nasal obstruction.

OBJECTIVE: To determine the efficacy of inferior turbinate coblation for the treatment of nasal obstruction. METHODS: Twenty patients awaiting submucosal diathermy to the inferior turbinates were recruited into the study. All underwent inferior turbinate coblation. Pre-operative and post-operative nasal function was investigated using posterior rhinomanometry and subjective symptom scales. RESULTS: There was no significant increase in nasal conductance two weeks after inferior turbinate coblation (p = 0.159). However, three months after inferior turbinate coblation, median nasal conductance had increased significantly, from 203 to 324 cm3/s (p = 0.004). The median increase in nasal conductance was 73 cm3/s or 43.5 per cent. Post-operative visual analogue patients' reported post-operative visual analogue scales scores for nasal obstruction decreased significantly, both two weeks (p = 0.006) and three months after inferior turbinate coblation (p = 0.001) when compared to Pre-operative values. There was no change in the reported severity of rhinorrhoea, nasal itching or sneezing. There was a significant relationship (rho = -0.57, p = 0.014) between pre-operative nasal conductance and change in nasal conductance after inferior turbinate coblation. CONCLUSIONS: This study confirms the short-term efficacy of inferior turbinate coblation for the treatment of nasal obstruction. The benefit was greatest in patients with lower pre-operative nasal conductance. Objective measures of nasal obstruction may be important when selecting patients for inferior turbinate coblation.

Selective dorsal rhizotomy for children with cerebral palsy: the Oswestry experience.

BACKGROUND: Although three randomised control trials have shown that selective dorsal rhizotomy (SDR) reduces spasticity in children with cerebral palsy, a meta-analysis of the results demonstrated that the procedure conferred only small functional benefit on the patient. AIM: To determine whether applying strict criteria for patient selection as practised in Oswestry leads to improved outcomes, using gait analysis as an outcome measure. METHODS: Ambulant children with cerebral palsy were selected for SDR using very strict clinical criteria. Instrumented gait analysis was used as the main outcome measure. RESULTS: Of 53 children referred for the procedure, only 19 (35%) fulfilled our strict criteria for selection. These children underwent surgery and when pre- and post-SDR data were compared, they showed improvement in cosmesis of gait, clinical examination and temporal, kinetic and kinematic parameters of gait. After SDR the children walked, on average, 0.15 m/s faster, with a step length improvement of 0.11 m. Changes were seen at hip, knee and ankle, with those at the knee being most marked. A 0.3 grade improvement in knee extensor power on clinical examination led to a 13 degrees improvement in stance phase knee extension. Knees also became less stiff, with an 82 degrees /s improvement in the rate of flexion into swing phase. A functional tool (the GMFCS) applied retrospectively also confirmed post-operative improvement, with 15 of the 19 children improving by at least one level. CONCLUSION: Application of strict selection criteria when considering children for SDR leads to encouraging results as demonstrated by gait analysis and other measures.

Understanding submucosal electrosurgery for the treatment of nasal turbinate enlargement.

The surgical management of inferior turbinate enlargement is controversial. Submucosal electrosurgical techniques for turbinate reduction include conventional diathermy, radiofrequency tissue reduction and coblation. All electrosurgical techniques use radiofrequency electricity to damage turbinate tissue but differ in the control and delivery of energy. This review will examine the history of submucosal electrosurgery and clarify the various techniques. This review will also examine the evidence for the efficacy and safety of electrosurgery for the treatment of nasal turbinate enlargement, and will make a case that no progress will be made in clinical trials on the safety and efficacy unless there is standardisation of equipment and techniques in nasal electrosurgery.

The effect of fixed ankle foot orthoses in children with cerebral palsy.

PURPOSE: To identify the characteristics of children with cerebral palsy who benefited from tuning of their fixed ankle foot orthoses (AFOs) to create a screening tool. METHOD: A retrospective review was conducted using video records of 21 independently walking children with cerebral palsy who were referred to a Gait Laboratory for AFO tuning. All showed a ground reaction vector (GRV) in front of the knee (extending) when barefoot. The stance phase was digitised to obtain kinematic and kinetic parameters. Effectiveness of AFO tuning was judged by optimisation of the GRV at the knee and statistical and scatter plot analysis sought to discriminate between those who tuned and those who did not. RESULTS: Analysis showed clear distinction between the two groups based on knee kinematics. Those who tuned showed flexion of no more than 20 degrees in the first third of stance combined with movement towards extension in the second third of stance to a minimum of 10 degrees flexion or less. CONCLUSIONS: This study has created a screening tool to identify children likely to benefit from AFO tuning based on kinematic data and which could be used in the community.

The use of stock orthoses to assist gait in neuromuscular disorders: a pilot study.

This pilot study compares the effect on walking speed, in eight subjects with neuromuscular conditions, of wearing Ligaflex ankle-foot orthoses (AFO), Leafspring orthoses and shoes or with shoes alone. Range of motion, muscle strength and sensation were tested in the lower leg. Subjects underwent a standardized timed 10-m walking test five times in each of the orthoses and shoes as a measure of gait efficiency. A self-administered questionnaire was used to seek the subjects' perceptions of their functional difficulties and their opinions about the relative comfort and stability of these orthoses. Subjects had reduced ranges and strength of dorsiflexion and eversion. Some had proprioceptive deficiencies. Mean walking speed was 0.99 m/s (Leafspring) and 1.1 m/s (Ligaflex or shoes) compared to about 1.3 m/s for a normal population. Repeated measures ANOVA revealed that subjects were significantly slower in Leafspring compared to Ligaflex or to shoes. Questionnaire results rated the Leafspring as least comfortable and the Ligaflex most stable. Providing stability may be more important than assisting foot clearance when weakness is restricted to distal muscles. Further research is required to evaluate the comfort and effectiveness of orthoses to compensate for ankle instability in people with neuromuscular conditions.

Chronic inferior turbinate enlargement and the implications for surgical intervention.

Nasal obstruction due to chronic enlargement of the inferior turbinate is a common problem for the ENT surgeon. This review will discuss the pathology of 'bilateral' and 'unilateral' turbinate enlargement associated with chronic rhinitis and nasal septal deviation, and focus on the structural changes in the turbinates. Cellular hyperplasia, tissue oedema and vascular congestion all contribute to turbinate enlargement, but there is some evidence that bony enlargement is associated with unilateral turbinate enlargement. There is no evidence for cellular hypertrophy despite the common use of the term 'turbinate hypertrophy' and this term should be replaced with the more correct term of 'turbinate enlargement'. The underlying pathology of turbinate enlargement has important implications for the surgical management of nasal obstruction.

Contractures in orthopaedic and neurological conditions: a review of causes and treatment.

PURPOSE: To examine the techniques used for the treatment of contracture in the context of current scientific knowledge of muscle. METHOD: Synthesis of data available from MEDLINE, RECAL, EMBASE, the Cochrane Library and relevant texts. RESULTS: The development of contractures through immobilisation, muscle weakness and spasticity is described. The effects of passive stretching, continuous passive movement, serial plastering, splinting, electrical stimulation, botulinum injections and surgical tenotomies in the treatment of contractures in persons with neurological and orthopaedic conditions are identified. The strengths and weaknesses of these modalities are discussed. CONCLUSION: Predisposing factors persist after treatment of contractures thus for treatment to be effective long-term management programmes need to be developed. New treatment techniques, used in series or combined, offer the prospect of improved management of contracture. Scientific and clinical research is needed to investigate the effect of contracture treatment.

A new papillomavirus of possums (Trichosurus vulpecula) associated with typical wart-like papillomas.

A previously unknown, cutaneous papillomavirus (Papovaviridae) in a brushtail possum (Trichosurus vulpecula) was demonstrated. This represents one of the first viruses reported in this species. Possum papillomas were identified by typical wart-like appearance and histology. Papillomavirus particles were detected by electron microscopy in tissue homogenates following purification and negative staining. The polymerase chain reaction amplified a conserved portion of the L1 gene which was purified and sequenced. Comparison of the DNA and deduced amino acid sequence from the possum papillomavirus with other papillomavirus sequences, together with phylogenetic analysis, indicated that this was a new papillomavirus.

A review of 42 patients of 16 years and over using the ORLAU Parawalker.

A 7 year retrospective review of 42 patients of 16 years or over using the ORLAU Parawalker has been conducted to establish the degree of long-term compliance in using the orthosis on a regular basis. Regular use was defined as putting the orthosis on at least once a week. All subjects had been supplied with an ORLAU Parawalker via the routine supply procedures adopted in Oswestry, and were followed up at regular 6 month intervals as part of the standard treatment regime. The records from routine follow-up were surveyed for those patients who were continuing to use their orthosis to establish age, length of time since supply of orthosis and cause of lesion. Average period of usage is calculated for those still using their orthosis, and for all patients in the study. Of the 42 subjects, 32 were myelomeningocele patients with confirmed absence of innervation of hip extensors and abductors, the remainder being paraplegic patients with traumatic or acquired complete thoracic lesions. Compliance figures were extracted from the results, as were the minimum possible average periods of usage. The respective results were: of the 32 myelomeningocele patients 59.4% continued usage after an average period of 85.5 months, and of the 10 traumatic or acquired lesion patients 60% continued usage after an average period of 24.8 months respectively, which gave a combined compliance of 59.5% after a minimum average 71.1 months of use. The performance or myelomeningocele patients suggests that their additional deformities do not lead to inferior compliance as adults and that a high proportion to continue to walk after adolescence.

Improvement in gait parameters following late intervention in traumatic brain injury: a long-term follow-up report of a single case.

OBJECTIVE: To evaluate the effect of using an optimally adjusted fixed ankle foot orthosis to control knee pain and promote improvement in gait parameters in a subject with hemiplegia following a traumatic brain injury 11 years previously. DESIGN: This is the report of a single case, using gait laboratory facilities to monitor force alignment relative to the knee and single leg balance time with the subject barefoot. SUBJECT: A 35-year-old woman with a right hemiplegia seen 11 years after onset. INTERVENTION: A polypropylene fixed ankle foot orthosis was supplied to the hemiplegic limb and shoe modifications were made to optimize the position of the ground reaction force relative to the knee during stance phase of gait. This orthosis was used on a daily basis for one year. RESULTS: Knee pain was controlled after three months use of the orthosis. Graphical results of force alignment during stance phase of gait are presented for initial assessment and at one and four years postorthotic supply. A large knee-extending effect was noted on the hemiplegic limb at initial assessment and this was reduced by 67% of its initial value at one year. A compensatory early heel lift was initially noted on the opposite limb and this was reduced by 42% of the initial height at one year. These results were maintained at four years. Right leg standing balance was not initially possible but was recorded as 5 s duration at three months and this was maintained at one and at four years. CONCLUSIONS: The use of an optimally adjusted ankle foot orthosis was effective in controlling knee pain and improving barefoot gait parameters with maintenance of the improvement after use of the orthosis was discontinued. Further research is required to fully establish the potential of this approach in subjects with traumatic brain injury.

The potential for ambulation by severely handicapped cerebral palsy patients.

Whereas walking for paraplegic patients is now a routine clinical option, ambulation for heavily handicapped cerebral palsy patients is less well established. There are good reasons for supposing that therapeutic benefits similar to that achieved with paraplegic patients are possible for this group. However, the biomechanical problems which must be overcome are different and in many ways more difficult to address. The most important factors are identified as appropriate truncal support, control of abduction/adduction, rotation and flexion range at the hip, and of knee flexion. A means of applying these controls is described as being a combination of a walking frame and orthosis. The special walking frame provides adjustable support at thoracic, abdominal and sacral levels and incorporates castor steering and upper limb support. Controls on lower limb movements are applied through a special orthosis which has a readily available variation of specification to accommodate the wide range of conditions met in cerebral palsy. Practical application of a prototype system has shown that it can enable patients to walk unaided. However, in most cases it was used indoors only. Evaluation of the experience in applying the system has enabled the fundamental principles to permit more practical applications to be defined.