Outcomes for patients referred urgently with suspected head and neck cancer.

INTRODUCTION: The 1998 National Health Service White Paper stated that anyone suspected of having a cancer would be seen by a specialist within two weeks. The 'trigger symptoms' prompting such referral have been nationally agreed by the National Institute for Health and Clinical Excellence. This study aimed to quantify the diagnostic yield of urgent referrals for suspected head and neck malignancy, and to identify reasons why patients ultimately diagnosed with malignancy may not have been referred via this pathway. MATERIALS AND METHODS: All patients referred to the trust with suspected head and neck malignancy in 2005 were included in the study. Data were obtained on date of referral, date of appointment, reason for referral and which National Institute for Health and Clinical Excellence guideline heading the referral fell under, clinical findings, and final diagnosis. Concurrently, all patients in the trust with a histological diagnosis of head and neck malignancy were identified using the computer records of the pathology department. RESULTS: One hundred and seventy-seven patients were referred with suspected head and neck malignancy over the one-year study period. Of these, 169 were seen within two weeks. The commonest causes of referral were hoarseness and neck lumps. Of these patients, 22 (12 per cent) were ultimately diagnosed with malignancy. During the one-year study period, 39 patients were diagnosed hospital-wide with head and neck malignancy, 17 of whom had not been referred via the urgent referral pathway. No unifying theme was identified to explain why these patients had not been referred via this pathway. CONCLUSION: In a group of patients with symptoms suggestive of head and neck malignancy, only 12 per cent were ultimately diagnosed with cancer. Of all the patients within the trust diagnosed with head and neck cancer, 44 per cent had come from outside the urgent referral pathway.

Role of otoacoustic emission in children with middle-ear effusion and grommets.

OBJECTIVE: To evaluate the role of otoacoustic emission in children with middle-ear effusion and grommets. MATERIALS AND METHODS: A prospective study was carried out on a total of 90 ears. All children listed for grommet insertion had a pre-operative and post-operative (three to six months after grommet insertion) pure tone audiometry, tympanometry and otoacoustic emission recorded. A comparison was made between pure tone audiometry and otoacoustic emission both pre-operatively and post-operatively. RESULTS: Pre-operatively, 63 ears had an abnormal pure tone audiometry of which 59 had absent otoacoustic emission. Therefore the sensitivity of otoacoustic emission in detecting a conductive loss was 59/63 = 94 per cent (95 per cent confidence interval 85 to 98 per cent). All 27 ears with normal hearing pre-operatively had normal otoacoustic emission. The specificity of otoacoustic emission was 27/27 = 100 per cent, (95 per cent confidence interval, 88 to 100 per cent). The positive predictive value was 59/59 = 100 per cent (95 per cent confidence interval, 94 to 100 per cent). After three to six months all post-operative patients with grommets had a normal pure tone audiometry and otoacoustic emission. So both pure tone audiometry and otoacoustic emission were strongly related both in patients with middle-ear effusion and in patients with grommets. CONCLUSION: As the demonstration of hearing in young and difficult-to-test children can be problematic and time-consuming, we suggest that otoacoustic emission can be used as an alternative to pure tone audiometry in patients with middle-ear effusion and grommets.

Horner's syndrome following tonsillectomy.

Tonsillectomy is one of the commonest procedures performed in the United Kingdom. Peri-operative infiltration of local anaesthetic is a well documented adjunct to post-operative analgesia. We report the first case of temporary Horner's syndrome in a patient who received such treatment and postulate an anatomical explanation.

Nerve injury and the laryngeal mask airway.

The laryngeal mask airway is a widely used, non-invasive, general purpose airway. We report the case of a temporary vocal cord palsy following the use of such an airway. The development of inappropriately high cuff pressures secondary to nitrous oxide diffusion into the cuff is proposed as the most likely cause. Knowledge of the existence of nerve injuries complicating laryngeal mask use is particularly important when counselling certain patients. Mandatory intraoperative cuff pressure monitoring should lower the risk of subsequent voice problems.

Relevance of conventional radiography in indicating maxillary antral lavage.

The conventional radiographs of 84 antra were used to study the relationship of radiographic interpretation with the lavage result. In addition, the interpretations by a clinician and a radiologist were compared, showing that there was no significant difference between the predictive accuracy of either. The only reliable radiographic predictor of lavage result was the presence of normality or a fluid level; opacity and so-called mucosal thickening were deemed unreliable and their validity was questioned.

Oral chemotherapy in tinnitus.

A double-blind triple cross-over trial was designed for 21 patients suffering from tinnitus; mexiletine, diazapam, betahistine and placebo were taken each for a month sequentially during which time the patients recorded their tinnitus loudness subjectively on a visual analogue scale. The results showed that these medications did not influence the tinnitus loudness. Since mexiletine is an oral analogue of lignocaine and a cardiovascular drug, any untoward cardiovascular history and clinical finding disqualified such patients from the trial. Twenty-one such patients were rejected from an original group of 42 patients. In a volunteer trial mexiletine unrelated to this, it was reported that a vasovagal attack was suffered by someone who had just consumed 400 mg mexiletine orally. After ethical considerations the tinnitus trial was stopped. Eleven patients completed the cycle of medications, 10 did not. The dangers of using a cardiovascular drug for a non-cardiovascular condition is thus exposed.