Economic impact of recurrent respiratory papillomas in a UK adult population.

OBJECTIVE: To calculate the financial burden of recurrent respiratory papilloma. This study is UK-based, where up until now no financial estimates have been calculated for this group of patients. BACKGROUND: Recurrent respiratory papilloma is caused by the human papilloma virus (subtypes 6 and 11). The burden for the patient and the healthcare system is significant given the recurrent nature of the disease. METHODS: Data were collected, using a questionnaire completed during routine clinical follow up, from a single centre managing recurrent respiratory papilloma in Glasgow, Scotland. Cost information was sourced from the Scottish Government's Information Services Division. RESULTS: Fourteen patients with active recurrent respiratory papilloma between 2013 and 2014 were identified. The direct measurable cost to NHS Greater Glasgow and Clyde amounted to £107 478. CONCLUSION: Recurrent respiratory papilloma is a benign condition, but the financial implications of diagnosis are significant. Recurrent respiratory papilloma has a natural history of relapse and remission, and patients may require healthcare input over a period of several years.

Validation of a family-centred outcome questionnaire for pinnaplasty: a cross-sectional pilot study.

OBJECTIVES: Comparison of pinnaplasty techniques is difficult due to variation in the reporting of outcomes. We aimed to develop a family-centred outcome questionnaire for use after pinnaplasty and assess it for reliability and validity. DESIGN: Cross-sectional study. SETTING: Tertiary referral paediatric otolaryngology centre. PARTICIPANTS: 20 prospective and 71 retrospective pinnaplasty patients and their parent(s). METHODS: The Post-Operative Pinnaplasty Questionnaire (POPQ) was developed after semi-structured interview with families of children undergoing pinnaplasty. Children aged 4-16 were recruited. Three different ear measurements (auriculocephalic angle, helix-mastoid distance and Walker's ratio) were performed pre-operatively. Children were reviewed 3 months post-operatively and asked to complete a POPQ and Glasgow Children's Benefit Inventory with their parent(s). Ear measurements were repeated and data collected on surgical technique and complications. 200 retrospective pinnaplasty patients were posted a POPQ and Glasgow Children's Benefit Inventory and data collected on surgical technique, complication rate and Walker's angle. MAIN OUTCOMES MEASURES: Validity and reliability of the POPQ. RESULTS: Age range was 4-16 (median 12). POPQ correlated well with Glasgow Children's Benefit Inventory (Spearman's rho = 0.776, P < 0.001). There was no correlation of POPQ scores with age, sex, complication or surgical technique. POPQ score was not associated with severe prominence pre-op nor change or degree of prominence post-op. POPQ displayed good internal consistency (Cronbach's alpha 0.850) and ease-of-use scores. CONCLUSIONS: We have developed a family-focused outcome tool for pinnaplasty that displays good face validity, internal consistency and correlation with health-related quality of life and that is simple and easy to use. No correlation was seen with more traditional measures of outcome such as complications or ear measurements. Further refinement and testing of validity and reliability on a larger sample is planned.

Paediatric thyroid cancer: the Scottish experience.

BACKGROUND AND AIMS: Paediatric thyroid cancer is a rare disease, making diagnosis and treatment particularly challenging. Here we present the Scottish experience of thyroid cancer in the paediatric population and give an overview of how a child or adolescent that presents with a thyroid nodule should be investigated and managed. METHODS AND RESULTS: Data has been obtained from ISD Scotland, giving population-based information on paediatric thyroid cancer. A literature review has been performed on the management and treatment of thyroid cancer in the younger population. Paediatric thyroid cancer in Scotland is a rare disease, although the incidence is increasing each year. In general, differentiated paediatric thyroid cancer carries a good prognosis, while the results are more mixed in the rarer pathologies such as medullary cancer. CONCLUSION: Due to the small numbers of patients diagnosed each year in Scotland, it is imperative that these patients are discussed at a multidisciplinary thyroid MDT and managed in a tertiary referral centre by consultants and medical/nursing support staff who have experience in treating these patients.

Diagnosis of tuberculosis in the head and neck.

OBJECTIVES: To establish the features of Mycobacterium tuberculosis infection in the head and neck region, and to determine which investigations have the greatest diagnostic accuracy. STUDY DESIGN: Region-based, retrospective cohort study. METHOD: The study included 148 patients with tuberculosis of the head and neck treated in the Greater Glasgow and Clyde region between 2000 and 2007. RESULTS: The following diagnostic sensitivities were calculated: 53 per cent for fine needle aspiration, 95 per cent for core biopsy and 91 per cent for lymph node excision biopsy. There was a statistically significant difference between the sensitivity results for fine needle aspiration versus core biopsy (p = 0.0003) and fine needle aspiration versus excision biopsy (p < 0.0001). There was no statistically significant difference between the sensitivity results for core biopsy and excision biopsy. CONCLUSION: Core biopsy has equivalent diagnostic accuracy to excision biopsy in the investigation of head and neck tuberculosis. We suggest that core biopsy should be used in preference to lymph node excision, as it can be performed under local anaesthetic outside the operating theatre. A proposed algorithm for diagnostic management is included.

Spontaneous cervical lymphocoele: case reports and management decisions.

INTRODUCTION: Neck lumps in young adults are not uncommon, and most represent benign, reactive lymphadenopathy. Cystic swellings are less common. Spontaneous cervical lymphocoeles are very rare, and present as fluctuant, asymptomatic, cystic swellings in the neck in otherwise fit individuals. CASE REPORTS: We report two healthy young women who presented with spontaneous cervical lymphocoeles and who were treated successfully with surgical excision. The timing of surgical intervention was influenced in both cases by their imminent wedding celebrations. CONCLUSIONS: Whilst sclerotherapy has been advocated by some authors, we found it unhelpful; however, surgery provided definitive treatment.

Neck lumps and head and neck tumours in children.

This article discusses the presentation, investigation and treatment of both benign and malignant lumps encountered in the head and neck region in children.

Foregut duplication cyst of the pharynx.

INTRODUCTION: Foregut duplication cysts are heterotrophic rests of foregut-derived epithelium which are usually found in the abdomen and thorax; rarely are they found in the head and neck. CASE REPORT: We describe the case of a pharyngeal foregut duplication cyst presenting with airway obstruction in a neonate. We also review the pathology, investigation and management of this rare condition. DISCUSSION: The occurrence of a foregut duplication cyst in the head and neck region mandates vigilance with respect to the airway. Magnetic resonance imaging is a useful part of pre-operative evaluation but cannot be relied upon for definitive diagnosis. Although foregut duplication cysts are benign lesions, definitive cure ultimately requires surgical excision, and this is often the means by which a definitive diagnosis is made. The prognosis for these lesions is excellent, with no reports in the literature of recurrence following excision.

Quality of life and voice following endoscopic resection or radiotherapy for early glottic cancer.

OBJECTIVES: To assess whether proposed voice and quality of life (QoL) outcome measures were likely to be acceptable to patients previously treated for early glottic cancer by either radiotherapy or endoscopic resection, as well as looking for differences in QoL and voice between treatments. DESIGN: Questionnaire-based cohort study. SETTING: Secondary care, three centres. PARTICIPANTS: All patients treated for T1a or in situ glottic carcinoma between 1997 and 2003. Fifty-three patients were identified; those who had undergone salvage surgery or radiotherapy were excluded. A proportion refused to participate or could not be contacted and two patients had died of unrelated causes. Thirty-six patients completed the trial with 18 from each treatment arm. MAIN OUTCOME MEASURES: Quality of voice as assessed by three questionnaires, Voice Handicap Index (VHI), Vocal Performance Questionnaire (VPQ), Voice Symptom Score (VoiSS) and perceptual analysis of voice by Grade, Roughness, Breathiness, Asthenia and Strained (GRBAS) assessment of vocal recordings. Quality of life as assessed by the Hospital Anxiety and Depression Scale (HADS), University of Washington Quality of Life Questionnaire (UW-QoL), and the Functional Assessment of Cancer Therapy (FACT) questionnaire. RESULTS: All patients included in the trial were able to complete the questionnaires; however, 19% required assistance of some kind. GRBAS assessment showed no difference between groups for any criteria. All QoL questionnaires gave equivalent good scores. All of the voice questionnaires showed no statistical difference between groups except for the emotional subscale of the VoiSS which showed a significantly better score for the radiotherapy arm (P = 0.04). CONCLUSION: All outcome measures were applicable and acceptable to the patient group. Overall QoL and voice appears similar despite treatment arm, apart from the emotional subscale of the VoiSS. A randomized controlled trial is required to further assess this question.

Current aetiology of unilateral vocal fold paralysis in a teaching hospital in the West of Scotland.

Between May 1997 and May 2001 all patients presenting with a unilateral vocal fold palsy at Gartnavel General hospital were entered into a prospective observational study. The sex, age, side of palsy and aetiology were documented. The aim of the study was to assess the current aetiology of vocal fold palsy in a large teaching hospital in the West of Scotland, and to compare this with the established aetiology in other parts of the world. Seventy-seven patients were studied. Eighty-three per cent were found to have a left and 17 per cent a right vocal fold palsy. The male to female ratio was 2:1, with an age range of 23-85, mean 61. Forty-three per cent of all vocal fold palsies were secondary to an underlying bronchogenic carcinoma and a further nine per cent due to other malignancies. This contrasted with figures quoted in other studies, that gave lung cancer causes of vocal fold palsies ranging from four to 22 per cent. Surgical trauma accounted for 24 per cent and in 11 per cent no cause was found. In conclusion, in our hospital population there is a high rate of vocal fold palsy secondary to bronchogenic carcinoma. This is likely to be associated with the high levels of smoking found in Scotland. Lung cancer rates in Scotland are 1.6 times greater for men, and two times greater for women than the world standard. Malignancies overall cause over 50 per cent of our vocal fold palsies. Vigilance is required in any patient presenting with a vocal fold palsy to ensure a malignancy is not overlooked.

Bioplastique medialization therapy improves the quality of life in terminally ill patients with vocal cord palsy.

Unilateral vocal cord palsy can result in a weak breathy voice and an inability to communicate effectively. This study was designed to assess prospectively the efficacy of polymethylsiloxane elastomer (Bioplastique) medialization injection therapy in patients with vocal cord palsy and terminal disease with particular regard to quality of life issues. Patients with unilateral vocal cord palsy secondary to malignant disease were offered Bioplastique injection. A digital voice recording was taken preoperatively and at 1 month, 3 months and 6 months postoperatively. Maximum phonation time (MPT) was recorded at the same intervals, and patients completed two questionnaires: the voice handicap index (VHI) and SF 36 general health questionnaire. Sixteen patients were entered into the study. There was a significant improvement in voice score, MPT, VHI and in three subgroups of the SF 36 at 1 month postoperatively, and the improvement was maintained in the small number who survived to 3 and 6 months. Bioplastique injection for unilateral vocal cord palsy produces a significant improvement in quality of life in addition to measured voice quality in patients with terminal disease. It should be recommended in patients even when the life expectancy is short.

Vocal fold paralysis following carotid endarterectomy.

Injury to the vagus nerve or one of its branches during carotid endarterectomy (CEA) can result in vocal fold paralysis (VFP). This study assessed prospectively 73 patients undergoing CEA. A total of 76 procedures were performed in these patients over a one-year period. All patients underwent pre-operative and post-operative assessment of vocal fold mobility by indirect laryngoscopy and/or flexible nasendoscopy. All patients had normal vocal fold mobility pre-operatively. Eight patients (10 per cent) complained of hoarseness after surgery and in three patients (four per cent) examination confirmed an ipsilateral VFP. This persists in all three patients at six-month follow-up. Vocal fold assessment is important in patients undergoing CEA, particularly when performing second side surgery. We recommend that patients should be informed of the risk of VFP following CEA when obtaining consent.

The case of the missing carotid artery--a well aimed knife!

A 20-year-old male presented with a small stab wound to the neck and with haemodynamic signs of significant haemorrhage, but no signs of local bleeding. On exploration, an intact vagus nerve and internal jugular vein were found, but the common carotid artery was not immediately apparent. Careful dissection confirmed a completely transected common carotid artery with the two ends contracted and retracted. A primary repair was performed and post-operatively the patient recovered completely and had no neurological deficit.

Myasthenia gravis presenting with dysphagia and postoperative ventilatory failure.

We report a case of myasthenia gravis presenting to the department of otolaryngology with acute dysphagia on two separate occasions over a one-year period. Diagnosis of myasthenia gravis was made when the patient developed ventilatory failure after his second general anaesthetic for rigid oesophagoscopy. Our patient required emergency transfer to the intensive therapy unit for ventilation. He improved after treatment with corticosteroids, anticholinesterase and immunosuppressive medications. Our case was unusual in that cricopharyngeal spasm causing dysphagia and significant aspiration was demonstrated by a barium swallow and this was completely resolved after treatment of the myasthenia gravis.

Topical corticosteroids potentiate mucin secretion in the normal nose.

The exact mode of action of topical nasal corticosteroids is still uncertain. The aim of this study was to determine their effects on microvascular permeability and cellular and glandular secretion by measuring the levels of total protein, albumin, lysozyme and mucin recovered in nasal lavage fluid before and after 3 weeks of treatment with a topical nasal corticosteroid in 12 normal non-atopic subjects. Six subjects applied 200 micrograms fluticasone propionate and six applied 200 micrograms beclomethasone dipropionate to one nostril in each 24 h: matched placebo was applied to the other nostril. There was a significant rise in the level of mucin recovered compared with baseline values following fluticasone administration (baseline 76.2 micrograms/ml (mean) +/- 5.5 (SEM), fluticasone 118.3 micrograms/ml +/- 11.6 P = 0.015) and beclomethasone administration (baseline 64.3 micrograms/ml +/- 6.6, beclomethasone 87.2 micrograms/ml +/- 4.8, P = 0.041). There was no significant change in the levels of total protein, albumin or lysozyme following either active medication or placebo treatment. Topical corticosteroids appear to potentiate mucin secretion and do not alter serous secretion or microvascular permeability in the unchallenged non-atopic nose.

Racial differences in nasal fossa dimensions determined by acoustic rhinometry.

Sixty acoustic rhinographs from subjects of three different ethnic groups (Caucasian [Europeans], Negro, and Oriental) were examined at baseline and after decongestion. The main parameters analysed were minimal cross-sectional area (MCA), the distance at which this occurred (D), nasal volume at 0-4 cm (Vol), mean cross-sectional area at 0-6 cm (MA), and the cross-sectional area at 10 points in the nose (0, 0.5, 1, 1.5, 2, 2.5, 3, 4, 5, and 6 cm) analysed as a series (A). Values from left and right were combined and mean values used. Analysis was carried out using multiple linear regression and grouped linear regression with analysis of covariance and, for A, multifactorial analysis of variance. For MCA, race was the main determining factor with Orientals and Caucasians significantly lower than Negroes: p<0.0001 (corrected means and 95% confidence intervals [c.i.]: Orientals: 0.63 cm2, 0.55-0.71 cm2; Caucasians: 0.69 cm2, 0.62-0.77 cm2; Negroes: 0.87 cm2, 0.79-0.95 cm2). Height alone correlated with D in the decongested state (p<0.0001); race as well as height in non-decongested noses (p = 0.018). There were significant racial differences in Vol in both decongested (p = 0.014), and non decongested noses (p<0.0001). In the non-decongested state MA was significantly different in all racial groups: p<0.0001 (corrected means and c.i.: Orientals: 3.89 cm2, 3.47-4.31 cm2; Caucasians: 4.67 cm2, 4.27-5.09 cm2; Negroes: 5.13 cm2, 4.72-5.53 cm2). In the decongested state there was a significant difference between Negroes and the other two groups (p = 0.015), and Orientals and Caucasians were a homogenous population. We conclude that race has a significant effect on acoustic rhinometry measurements and this needs to be taken into account.

Post-operative morbidity following paediatric tonsillectomy; a comparison of bipolar diathermy dissection and blunt dissection.

In a prospective study of 76 children aged between 18 months and 13 years, 40 children underwent tonsillectomy using the traditional blunt dissection technique with bipolar diathermy to establish haemostasis while 36 children underwent tonsillectomy where bipolar diathermy alone was used to dissect out the tonsils. Blood loss was significantly reduced in the diathermy dissection group (10.5 ml +/- 2.05, diathermy dissection, 33.56 ml +/- 1.95, blunt dissection, P < 0.05). More analgesia was required in the diathermy dissection group prior to hospital discharge (P = 0.01). The diathermy dissection group took a significantly longer period of time to re-establish a normal diet (7.07 days +/- 0.44, diathermy dissection, 5.15 days +/- 0.36, blunt dissection, P = 0.001). Fifteen percent of children in the blunt dissection group and 31% in the diathermy dissection group were taken to the general practitioner between days 3-10 because of sore throat, poor oral intake or otalgia. Twenty two point four percent of children overall were prescribed antibiotics. This recently described technique of bipolar diathermy dissection could be a useful technique in selected cases such as the very small or those with a bleeding diathesis but is associated with increased postoperative morbidity and requires good postoperative analgesia.

Peritonsillar infiltration with bupivacaine for paediatric tonsillectomy.

In a double-blind study forty-two children scheduled for elective adenotonsillectomy were randomized to receive peritonsillar infiltration, following induction of anaesthesia, with either 0.25% plain bupivacaine or 0.9% saline, 0.5 ml/kg to a maximum of 10 ml. The children were assessed on awakening, and then 10 minutes, 1 hour, 4 hours and 24 hours later. On each occasion the observer gave the child a pain score from 1 (no pain) to 5 (severe pain). The scores on awakening and after 10 minutes were significantly lower in the bupivacaine group (P < 0.05, Mann-Whitney U test). Thereafter there was no difference between the groups. The authors conclude that peritonsillar infiltration with bupivacaine is only moderately useful as analgesia for children having tonsillectomy.

Vocal fold palsy: a re-evaluation of investigations.

With easier access to more sophisticated imaging techniques, the investigation of vocal fold palsy is reassessed. A questionnaire was sent to all ENT surgeons in the UK to establish which imaging techniques are available to ENT departments and which tests are currently requested during the investigation of vocal fold palsy. An extensive literature review established the aetiology of vocal fold palsy and the sensitivity and specificity of radiological investigations. A simple protocol is proposed which would be suitable to implement in the majority of ENT departments in the UK.

Nasal dermoids: the significance of a midline punctum.

Nasal dermoids are rare and their diagnosis is often delayed until complications occur. Signs such as a midline nasal punctum may be noted at birth but the significance of this finding frequently passes unrecognised. The cases are reported of two patients which illustrate the typical presentation of these lesions and their subsequent management is discussed.