Use of narrow-band imaging in detection of nasopharyngeal carcinoma.

AIM: To compare narrow-band images of nasopharyngeal carcinoma with those of normal adenoidal tissue. METHOD: Patients with a nasopharyngeal mass were evaluated using both conventional white light and narrow-band light. Biopsies were performed and Epstein-Barr viral serology was tested for all patients. RESULTS: Thirty consecutive patients were recruited. Twenty-one patients had normal adenoidal tissue and seven had nasopharyngeal carcinoma. One patient with papillary adenocarcinoma was excluded. The features of narrow-band imaging in normal adenoidal tissue were: (1) a regularly arranged follicular pattern, and (2) each 'follicle' comprising a pale centre with surrounding dark periphery. The features of narrow-band imaging in nasopharyngeal carcinoma were: (1) absence of surface patterns (n = 7), and/or (2) 'reverse', haphazard follicular pattern comprising a dark brown centre and pale periphery (n = 3). CONCLUSION: Narrow-band imaging of the surface of adenoidal tissue and nasopharyngeal carcinoma appears to identify distinct, characteristic features as described. Narrow-band imaging may be a useful adjunct in differentiating normal adenoidal tissue from malignancy. Further studies are needed to evaluate its diagnostic accuracy.

Breaking the speed limits of phase-change memory.

Phase-change random-access memory (PCRAM) is one of the leading candidates for next-generation data-storage devices, but the trade-off between crystallization (writing) speed and amorphous-phase stability (data retention) presents a key challenge. We control the crystallization kinetics of a phase-change material by applying a constant low voltage via prestructural ordering (incubation) effects. A crystallization speed of 500 picoseconds was achieved, as well as high-speed reversible switching using 500-picosecond pulses. Ab initio molecular dynamics simulations reveal the phase-change kinetics in PCRAM devices and the structural origin of the incubation-assisted increase in crystallization speed. This paves the way for achieving a broadly applicable memory device, capable of nonvolatile operations beyond gigahertz data-transfer rates.

Recurrent nasopharyngeal carcinoma masquerading as acoustic neuroma.

This is the first report of recurrent nasopharyngeal carcinoma (NPC) presenting as a cerebellopontine angle mass. The clinical presentation, investigation and management of this case, as well as the confusion and dilemma caused, are discussed. We hope to increase awareness on the multifaceted ways in which recurrent NPC could present and to share the lessons learnt from our management of this unusual and unfortunate case.

A quality assurance survey to improve communication between ENT specialists and general practitioners.

INTRODUCTION: Communication between medical specialists and primary care providers in the community plays a pertinent role in patient care and doctor education. Referral and reply letters are the most common means by which doctors exchange information. Much of clinician time is spent writing letters, but the information or the format in which the letter is written may not meet the needs of the recipient. This study aimed to determine the type of reply letter preferred by general practitioners (GPs) and as such, attempts to improve communication between doctors as part of a quality assurance survey. METHODS: Questionnaires were mailed out to 1,700 GPs in Singapore. Each questionnaire was accompanied by two sample reply letters from the Department of Otorhinolaryngology-Head and Neck Surgery. The sample letters were written in different formats. Letter 1 was written in a non-structured, free text format and Letter 2 included a structured summary at the beginning. Both letters contained the same amount of information and the same number of words. RESULTS: A total of 535 replies (response rate 32 percent) were received. Letter 2 was preferred in 97 percent of the responses. 96 percent of the doctors found Letter 2 to be easier to read, while 86 percent felt it contained more information and 64 percent felt that Letter 1 took a longer time to read. CONCLUSION: Our study shows that there is a preference for diagnosis and treatment plan to be presented in a summary style report rather than as free text. A structured format for reply letters, including the use of headings, allows readers to easily identify the information desired and thus improves the quality of correspondence between specialists and GPs.

Long-term results with a simple technique of stoma creation after laryngectomy.

Stomal stenosis after laryngectomy has a major impact on patient rehabilitation. The major contributory factor is the operative technique. The goal is to achieve a widely patent stoma. The objective of the study was to review the long-term results of the technique of stoma creation used by the senior author (CJW). The simple technique, using skin triangles for tracheostoma creation after laryngectomy, has been used by the senior author for past 6 years. Review of 59 cases of total laryngectomy with or without partial pharyngectomies in whom this technique was used for stomaplasty. The technique described for stoma creation after total laryngectomy has been used in 59 patients (48 male, 11 female) over 6 years. The follow-up of these patients varies from 6 months to 6 years. Of these patients 54/59 (91.5%) did not have any problems with the stoma. A total of 5/59 (8.5%) patients, the stoma was narrow. Amongst these patients with narrow stoma, only 1 patient (1.7%) has had dilatation done and the others are managing reasonably with a stoma button. None of the patients in this study has required revision procedures on the stoma. The simple technique of stoma creation described in this study has good long-term results.

Clinical outcomes of total laryngectomy for laryngeal carcinoma.

BACKGROUND: Controversy exists as to the management of advanced laryngeal carcinoma. In general primary radical surgery is favoured. OBJECTIVE: The aim of this study was to analyse the clinical outcome of patients having total laryngectomy for cancer of larynx. MATERIALS AND METHODS: This study was a retrospective case note review and questionnaires were used for evaluating voice handicap. These laryngectomies included in this study were performed by the senior author (CJW) from January 2001 till June 2007 at Leeds General Infirmary, Leeds. Some of the patients had partial or total pharyngectomy in addition to total laryngectomy. RESULTS: In this study a total of 59 patients were included. Seventeen (28.8%) of these patients had preoperative radiotherapy and laryngectomy was performed for residual or recurrent disease. The initial TNM staging of the tumour ranged from T(1)N(0) to T(4)N(2C). Tracheoesophageal puncture for speech prosthesis was done in 48/59 (81.4%) patients. Post-operative complications were seen in 30.5% (18/59) patients. In this study group 9 patients (15.2%) developed pharyngocutaneous fistulas. For communication 31/51 (60.8%) patients were using speech valves. In this study 30.4% had minimal, 26.1% moderate and the rest 43.4% feeling severely handicapped with regards to voice use after total laryngectomy. Five year survival after laryngectomy in this study was 65.2%. CONCLUSION: Long term disease control and survival is achievable with total laryngectomy with or without postoperative radiotherapy with minimal risks in patients with advanced carcinoma of larynx.

Role of information leaflets in improving the practice of informed consent for patients undergoing septoplasty.

AIM: To evaluate the effectiveness of an information leaflet in improving patient understanding of the procedure and complications of septoplasty. DESIGN: The baseline knowledge of a group of patients who had attended a pre-assessment clinic prior to septoplasty was assessed. The procedure and its complications were then verbally explained. The patients' knowledge was then re-assessed on the morning of surgery and any improvements noted. In the second arm of the study, an information leaflet was introduced at the time of verbal instruction and any differences in improvement in knowledge were assessed. RESULTS: Data from the two groups were analysed using an analysis of covariance with differences in baseline (pre-instruction) knowledge controlled. Additional improvements in mean recall score following leaflet distribution were highly statistically significant when compared with mean recall in the control group (p<0.001). CONCLUSION: The use of information leaflets increases patients' knowledge about a surgical procedure and its potential complications.

Investigation of interleukin 10, 12 and 18 levels in patients with head and neck cancer.

Head and neck squamous cell carcinoma (HNSCC) is an aggressive epithelial malignancy. It is the most common neoplasm arising in the upper aerodigestive tract. Interleukin (IL) 12 and IL-18 are cytokines which have a major anti-tumour activity via stimulation of a T-helper type 1 (Th1) immune response. Interleukin 10, a potent antagonist of IL-12, is a cytokine which possesses immunosuppressive activity mainly produced via T-helper type 2 (Th2) cells. Studies of other types of cancer have shown that the level of IL-12 in serum or tissues is suppressed and/or the IL-10 level is increased, suggesting that there is an impaired cell-mediated anti-tumour response. The aim of this study was to measure pre-operative serum cytokine concentrations in HNSCC patients in order to detect any changes in IL-10, IL-12 and IL-18, compared with non-tumour controls. The relationship between cytokine levels and standard clinicopathological features, including tumour site, tumour stage and presence of nodal metastasis, was also examined. Fifty-seven patients with primary HNSCC were prospectively recruited, together with 40 non-tumour control patients with a similar age and sex distribution. Serum cytokine levels were measured using commercial quantitative enzyme-linked immunosorbent assay. The HNSCC patients had significantly lower IL-12 levels (median; interquartile range) than controls (42.8 pg/ml, 26.2-61.6 vs 52.3 pg/ml, 37.5-113.7; p=0.018). Also, patients were more likely to have detectable IL-10 levels than were controls, as IL-10 was positive in 27/55 patients but in only 9/39 controls (p=0.011). Furthermore, IL-10 detectability varied according to primary site, being more commonly observed in hypopharyngeal and laryngeal tumours, and IL-10 was more likely to be detected with advanced tumour stage (T3 and T4). No differences in IL-18 levels were observed between patients and controls (p=0.169). These results suggest (in agreement with studies on other solid malignancies) that HNSCC causes a significant change in the serum levels of specific Th1 and Th2 cytokines, producing an in vivo environment that is unlikely to promote an effective cell-mediated anti-tumour response.

Dendritic cells and HNSCC: a potential treatment option? (Review).

Patient survival in head and neck squamous cell cancer (HNSCC) has not changed significantly in many years, despite progress in surgical, radiotherapy and chemotherapy techniques. Immunotherapy, a rapidly progressing alternative cancer treatment, aims to prompt or assist the body's immune system to combat the disease itself. A number of strategies exist including the use of dendritic cells, natural antigen presenting cells capable of stimulating an anti-tumor immune response. Encouraging work has been performed using these cells as vaccines against a number of tumors especially melanoma. Work with head and neck cancer is also encouraging, but less advanced. Dendritic cell presence in head and neck squamous cell cancers is associated with an improved prognosis, however due to immunosuppression, the exact mechanism of which remains poorly understood, these cells do not function efficiently. This prevents the stimulation of an effective anti-tumor immune response by the patient and allows tumor growth to continue. This review summarises the current level of understanding of dendritic cells and their relationship with HNSCC. It briefly summarises work with dendritic cells and other cancers where relevant to HNSCC; dendritic cells and head and neck cancer; the possible causes of dendritic cell impairment; the techniques used to restore their function and the methods used to prime the dendritic cells prior to their use as vaccines for the stimulation of an anti-tumor response.

The use of a nasal obturator in hereditary haemorrhagic telangiectasia: an alternative to Young's procedure.

Epistaxis associated with hereditary haemorrhagic telangiectasia (HHT) is a challenging condition. Septodermoplasty, electrocautery and laser treatment often provide short-term relief only. The surgical closure of the nostrils ('Young's procedure') represents a longer term solution but has the disadvantage of causing permanent complete nasal obstruction. A Silastic obturator has the advantage of being a non-surgical intervention and allows temporary relief of the nasal obstruction. We present the cases of three patientswith HHT who used the obturator with good clinical effect, suggesting that this is a realistic non-surgical alternative to Young's procedure for patients with HHT.

Open septorhinoplasty approach for the excision of a dermoid cyst and sinus with primary dorsal reconstruction.

Adult nasal dermoid cysts and sinuses are rare. Here we describe the surgical management of a 37-year-old patient with a longstanding nasal dermoid cyst and discharging sinus. A combination of an open rhinoplasty approach with a small dorsal incision was used to excise the lesion followed by primary reconstruction with septal cartilage.

Endoscopic division of the ary-epiglottic folds in severe laryngomalacia.

OBJECTIVE: Laryngomalacia is the commonest cause of congenital stridor. The underlying anatomical abnormality associated with this condition is a prolapse of the supraglottic tissues into the laryngeal inlet during inspiration, and may involve the epiglottis, ary-epiglottic folds and the corniculate mounds of the arytenoids. However, it has been noted that the most consistent structural abnormality seen in these cases is the shortening of the ary-epiglottic folds and marked side to side curling of the epiglottis. We describe the follow-up and outcome of 33 cases treated by the simple division of the ary-epiglottic folds. METHOD: All case notes were reviewed with respect to indications of operation, age of operation, endoscopic findings, operative technique, complications and follow-up until resolution of symptoms. RESULTS: Surgical outcomes could only be ascertained in only 32 patients. Twenty-two cases (68.7%) showed complete resolution of stridor and associated complications of laryngomalacia. In the remaining ten cases who could be followed up (31.2%), seven patients (21.8%) showed partial resolution with no further surgery required, two patients (6.2%) required additional excision of redundant mucosa as second procedure, one patient (3%) with associated cleft lip/palate and tracheomalacia had to undergo a tracheostomy. There was improvement in feeding after surgery in all the 12 patients (100%) who had had pre-operative feeding difficulties. All the four patients with cyanosis pre-operatively were cured, but one of the two patients with apnoeic episodes pre-operatively continued to have apnoeic spells despite resolution of their laryngomalacia. CONCLUSION: Simple endoscopic excision of the ary-epiglottic folds is a quick, reliable, highly effective procedure with very few complications. We recommend its use as the first line option in the management of severe laryngomalacia, with more extensive methods reserved for the very occasional case of primary failure.

Glycosylated haemoglobins in women with low risk for diabetes in pregnancy.

Glycosylated haemoglobin levels (HbA1) were determined in 489 normal pregnant Singaporean women, attending a diabetic screening programme using a 50g glucose challenge test. All subjects had no risk factors for diabetes mellitus nor a history of previous gestational diabetes. They were selected when the 1h 50g glucose challenge (GCT) is < 6.66 mmol/l or a 2h post-glucose level of < 7.77 mmol/l (a 75g OGTT is repeated within a week of an abnormal GCT). Another 18 subjects with normal OGTT but did not have a 50g glucose challenge done were also included in the study. Mean and normal range (2 SD) of HbA1 levels in all subjects were 4.64% and 3.66-5.62%, respectively. Mean HbA1 levels also varied with gestation and ethnic group. The HbA1 appeared to be low at early gestation with nadir at 21-24 weeks and thereafter returned to initial levels at term. In Chinese, mean HbA1 levels, random plasma glucose and 1h glucose challenge were significantly higher than those of the Malays but not the Indians. In referring to these levels, the variation within gestation and ethnic group must also be considered.

The impact of long-term testosterone replacement therapy on lipid and lipoprotein profiles in women.

The lipid and lipoprotein profiles of 39 female transsexuals, exposed to testosterone esters (250 mg monthly) for an average duration of 33 months after their sex reassignment operation (group 2), were compared to those of 29 normal menstruating female transsexuals prior to starting androgen therapy (group 1). A third group, comprising 17 post-operative female transsexuals were studied while on, and after stopping their androgen therapy for 6-12 months (group 3). The average concentration of testosterone in androgenized women was comparable to those found in normal males and levels of SHBG were significantly lower than those in the control group. No significant difference was noted between all levels of lipids and lipoproteins in pre-operative subjects of group 1 and corresponding levels in subjects of group 3 after they had stopped their androgen therapy for 6-12 months. Significantly higher levels of triglyceride (Trig), total cholesterol (TC), low-density lipoprotein (LDL-C) and apolipoprotein-B (Apo B) and a significantly lower level of high-density lipoprotein-cholesterol (HDL-C) were noted in androgenized women (group 2) when compared to controls (group 1). The two atherogenic indices, LDL-C/HDL-C and Apo-AI/Apo-B were significantly raised and lowered, respectively. Similar results were noted when comparing lipid and lipoprotein profiles in subjects of group 3 while they were on and after stopping their androgen therapy. Results from this study indicate that testosterone, per se, at supraphysiological doses may promote atherogenicity in women. Furthermore, the male predilection for coronary vascular diseases (CVD) may be due to the adverse effects of higher androgen levels on lipid and lipoprotein profiles.

Interrelationships of serum paraoxonase, serum lipids and apolipoproteins in normal pregnancy. A longitudinal study.

Serum paraoxonase (EC 3.1.1.2) may be implicated in the lipid metabolism. In order to substantiate this view we conducted a longitudinal study of interrelationships of serum paraxonase, lipids and apolipoproteins during pregnancy. Fasting serum levels of paraoxonase, serum lipids (total, HDL and LDL cholesterols, triglycerides) and apolipoproteins (AI, AII and B) were estimated in 91 pregnant women at 28 and 32 weeks of gestation and 6 weeks after delivery, and 40 nonpregnant women. Serum paraoxonase, total HDL and LDL cholesterol levels were significantly higher during pregnancy along with corresponding apolipoprotein (p < 0.001). The most striking increase was seen in serum triglycerides and paraoxonase levels (p < 0.001). Serum paraoxonase levels had a significant correlation with triglycerides (r: 0.45-0.60) and Apo-AII (r: 0.32-0.41) in both pregnant and nonpregnant states (p < 0.001). Moreover, both serum paraoxonase and triglyceride levels at 28 weeks of pregnancy were negatively correlated with birth weight (r: 0.3, p < 0.05), suggesting a possible role of paraoxonase in energy delivery for fetal development derived from maternal hypertriglyceridemia.

Glycosylated hemoglobins in pregnant women with normal and abnormal glucose tolerance.

Glycosylated hemoglobin (HbA1) levels were compared in low risk pregnant Singaporean women with normal and abnormal glucose response. HbA1 (mean +/- 1 SD) levels in normal and abnormal groups (489 and 72, respectively) were 4.65 +/- 0.49 and 4.85 +/- 0.50, respectively. While mean levels were significantly different, there was a considerable overlap of levels in both groups. At various gestation periods, mean HbA1 levels between normal and abnormal groups showed significant difference only at late gestation. The latter may have contributed to significant differences in HbA1 levels between normal and abnormal groups as a whole. The considerable overlap of HbA1 values in normal and abnormal groups indicate that HbA1 may be insensitive as a screening method for glucose intolerance.

Evaluation of liver function and lipid metabolism following Norplant-2 rods removal.

The effect of Norplant-2 rods on liver function and lipid metabolism was evaluated in 100 Singaporean women. As with the Norplant six-capsule, the only change noted in liver function was that of a significantly elevated bilirubin, which was within the normal clinical range for the local population. As regards lipid metabolism, the mean values for total triglycerides, cholesterol, LDL-cholesterol and HDL-cholesterol seen at the end of five years of Norplant-2 rod use and six months postremoval were similar to the preinsertion mean. As a result, the HDL-cholesterol/total-cholesterol-HDL-cholesterol and LDL-cholesterol/HDL-cholesterol ratio remained fairly constant. This indicates that the use of Norplant-2 rods does not directly contribute to cardiovascular risk.

Evaluation of liver function and lipid metabolism following Norplant implant removal.

A final evaluation of this longitudinal study involving 100 Singaporean women shows that, besides a significantly elevated bilirubin level, there is no other evidence of hepatocellular dysfunction with the use of Norplant implants. The elevated bilirubin levels remained significantly elevated six months after removal of the implant. Despite this, all values of bilirubin remained within the clinical range for the population studies. As regards lipid metabolism, total cholesterol, LDL-cholesterol and total triglycerides continued to remain below the pre-insertion mean at six months post-removal. The HDL-cholesterol showed a significant increase following removal of the implants. As a result, the HDL-cholesterol/(total cholesterol-HDL-cholesterol) ratio continued to remain above 0.200. This indicates that Norplant implants are not directly contributory to cardiovascular risk.

Evaluation of hemostatic function following Norplant implant removal.

Norplant implant use in Singapore showed a decrease in vitamin K-dependent Factors II, V, VII and reduction in fibrinolytic activity at the end of 5 years of use. Increased platelet numbers and accelerated platelet aggregation were also found throughout the 5 years of Norplant use. It thus appears that unlike the combined pill, prolonged Norplant use does not activate the coagulation system and does not enhance a state of hypercoagulation. On removal of the Norplant implants at the end of 5 years, the significant changes seen in hemostatic function observed with Norplant use remained.