Sinonasal natural killer/T-cell lymphoma presenting as pyrexia of unknown origin with nasal symptoms.

A 68-year-old Chinese man presented with an eight-month history of pyrexia of unknown origin and chronic sinusitis despite multiple courses of antibiotics. He underwent extensive investigations, including workups for infections, chronic granulomatous diseases and malignancy. Nasal biopsies were performed twice under local anaesthesia, but did not show any evidence of malignancy. Eventually, the patient was diagnosed with natural killer (NK)/T-cell lymphoma, nasal variant, based on histopathological findings from harvested deep tissue obtained via functional endoscopic sinus surgery. This study highlights that, for patients presenting with pyrexia of unknown origin and nasal symptoms, NK/T-cell lymphoma must be considered as a differential diagnosis. Generous amounts of tissue should be harvested under general anaesthesia rather than limited tissue under local anaesthesia, in order to facilitate and ensure a definitive diagnosis.

Topical antimicrobials in the management of chronic rhinosinusitis: a systematic review.

BACKGROUND: Chronic rhinosinusitis (CRS) is a common disease that can significantly impact health. The mainstay of medical treatment is topical steroids and oral antibiotics, but little is known about the efficacy of topical antibiotics. The purpose of this study was to identify evidence for the use of topical antibiotics in the treatment of CRS and exacerbations of CRS. METHODS: Systematic review of literature with a search of the MEDLINE, EMBASE, and CINAHL databases; Cochrane Central Register of Controlled Trials (Third Quarter 2007); and Cochrane Database of Systemic Reviews (3rd Quarter 2007) databases were performed. The dates of search were from December 1, 1949 to September 30, 2007. RESULTS: Fourteen studies that fulfilled the inclusion criteria were identified: seven were controlled trials and of these, five were double blinded and randomized. Only one of the randomized studies showed a positive outcome. Overall, there was low-level corroborative evidence for the use of antibacterials. No definite conclusions could be made regarding the use of antifungals. Currently, there is evidence for the use of nasal irrigation or nebulization rather than delivery by nasal spray. For the antibacterial studies, the highest level of evidence currently exists for studies that have used postsurgical patients and culture-directed therapy. Both stable and acute exacerbations of CRS appear to benefit from topical antimicrobials. CONCLUSION: Topical antibiotics appear effective in the management of CRS. Given the combination of low-level evidence (level III, with inherent potential confounders of natural progression of disease and placebo effect) and the level IIb evidence being limited to the cystic fibrosis group of patients, topical antibiotics should not be first-line management but may be attempted in patients refractory to the traditional topical steroids and oral antibiotics. Larger and better-designed randomized double-blind placebo-controlled trials are required to more fully evaluate this emerging modality of treatment.

The relationship between subjective assessment instruments in chronic rhinosinusitis.

PROBLEM: To provide an evidence-based definition for the relationship between three subjective instruments for assessing severity of chronic rhinosinusitis- visual analogue scale, 'mild' 'moderate' and 'severe' (MMS) classification and perception of whether quality of life (QoL) is affected. METHOD OF STUDY: One hundred sixteen subjects with chronic rhinosinusitis filled in a questionnaire rating simultaneously their perception of disease severity based (1) upon visual analogue scale, (2) MMS classification and (3) stating whether they felt their QoL was affected. MAIN RESULTS: The mean age of subjects was 50. The inter-quartile range of VAS scores for the respective MMS groups were: Mild 0.80-3.50, Moderate 4.40-6.33, Severe 7.70-9.50. In the group who perceived effects on QoL, the inter-quartile range for VAS scores was 5.10-8.68. This range was 1.53-4.57 in the other group with no effects on QoL. 30.3% of patients in the 'mild' category, 79.6% in the 'moderate' category and 97.4% in the 'severe' category felt that their QoL was affected. PRINCIPLE CONCLUSIONS: We propose a statistically validated definition of the relationship between MMS classification and VAS scoring. Based on our study we would define 'mild' as being 0- 3 inclusive, 'moderate, as > 3- 7 inclusive and 'severe' as > 7- 10 inclusive on the VAS scoring system. We further propose that in general QoL is more likely to be affected with VAS scores of 5 or more.

Frontoethmoidal mucocele associated with bilateral increased intraocular pressure and proptosis.

CASE REPORT: We describe the case of a 53-year-old man presenting with bilateral proptosis and raised intraocular pressure. Computed tomography imaging revealed these signs to be secondary to a frontoethmoidal mucocele with bilateral orbital invasion. COMMENTS: Bilateral increased intraocular pressure is unusual in cases of frontoethmoidal mucoceles, but prompt imaging and treatment can prevent permanent visual loss.

Management of upper airway obstruction secondary to warfarin therapy: the conservative approach.

Airway obstruction secondary to bleeding from warfarin therapy is difficult to manage and uncommon but has been previously described. Previous reports have emphasized the need for reversal of therapy using vitamin K and fresh frozen plasma (FFP). Where a definitive airway has been required, cricothyroidotomy or tracheostomy seem to have been favoured. Several authors have reported failed attempts at endotracheal intubation due to the obstructive effects of a sublingual haematoma. We report here a case which illustrates how endotracheal intubation can be used successfully under the right conditions. It also highlights the superiority of prothrombin complex concentrate over FFP in achieving rapid reversal of abnormal international normalized ratio in the emergency situation.

A new head and neck surgical drain fixation technique.

We describe a simple technique of drain fixation in head and neck surgery using a beaded 2/0 nylon suture and a 'clove hitch' to achieve a non-slip fixation to the drain.