Management of epistaxis: a guide for junior doctors.

Epistaxis is commonly seen as an acute presentation to the emergency department. The level of severity can range from a minor ooze to a life-threatening bleed. The initial management is often the responsibility of junior doctors working in otolaryngology or the emergency department, so they must be familiar with the initial steps in treating this often distressing condition. The COVID-19 pandemic has complicated matters further as much of the management takes place in the upper airway. This article outlines the key considerations in the management of epistaxis, especially during the COVID-19 pandemic.

Atypical presentation of Bezold's and Citelli's abscesses, with recollection following an incomplete postoperative course of antibiotics.

Bezold's and Citelli's abscesses are rare complications of otitis media. We present a case of a 44-year-old Eastern European man, with a history of recurrent otitis media, who was admitted to hospital with mastoiditis and initially treated with antibiotics. Despite clinical improvement, a CT scan showed mastoiditis with Bezold's and Citelli's abscesses. The patient underwent a myringotomy and grommet insertion, in addition to a cortical mastoidectomy and curettage of the neck abscesses. After a good recovery, he was discharged home. However, likely due to the language barrier, he did not complete a course of antibiotics as prescribed, and the abscess re-collected, necessitating a re-admission and re-operation. This report illustrates the importance of considering rare features of a common disease in the differential, and of communication in ensuring compliance.

Fourier transform infrared for noninvasive optical diagnosis of oral, oropharyngeal, and laryngeal cancer.

The 5-year survival rate for advanced head and neck cancers is 50%. There is currently no noninvasive method or effective screening procedure available to diagnose head and neck cancer at the earliest stages when it is still highly curable. This study aims to show how Fourier transform infrared (FTIR) spectroscopy could be used as a sensitive, noninvasive, low cost technique to diagnose head and neck cancer at an earlier stage and, thus, increase the likelihood of survival. Sputum samples were collected from 16 cases with oral or oropharyngeal cancer, 8 cases with laryngeal cancer patients and 15 normal controls. Cell pellets were produced from each of these samples and used to generate FTIR spectra within the 'biochemical fingerprint' wavenumber region of 1800 to 950 cm(-1). Discrimination between cancer and normal sputum was achieved using infrared wavenumbers 1650 cm(-1), 1550 cm(-1), and 1042 cm(-1) determined by robust feature selection. These 3 wavenumbers were used to develop potential models to discriminate both oropharyngeal and laryngeal cancer from normal control. In cancer cases, the absorbance levels for 1550 cm(-1) were increased relative to controls, whereas 1042 cm(-1) absorbance was decreased suggesting changes to protein and glycoprotein structure within sputa cells. This preliminary study shows potential for how FTIR could be developed into a simplistic diagnostic tool that could easily be implemented by a nonspecialist to diagnose and monitor head and neck cancer. The method could especially provide a means for detecting laryngeal cancer hidden from noninvasive observation.

Long term survival following the detection of circulating tumour cells in head and neck squamous cell carcinoma.

BACKGROUND: Techniques for detecting circulating tumor cells in the peripheral blood of patients with head and neck cancers may identify individuals likely to benefit from early systemic treatment. METHODS: Reconstruction experiments were used to optimise immunomagnetic enrichment and RT-PCR detection of circulating tumor cells using four markers (ELF3, CK19, EGFR and EphB4). This method was then tested in a pilot study using samples from 16 patients with advanced head and neck carcinomas. RESULTS: Seven patients were positive for circulating tumour cells both prior to and after surgery, 4 patients were positive prior to but not after surgery, 3 patients were positive after but not prior to surgery and 2 patients were negative. Two patients tested positive for circulating cells but there was no other evidence of tumor spread. Given this patient cohort had mostly advanced disease, as expected the detection of circulating tumour cells was not associated with significant differences in overall or disease free survival. CONCLUSION: For the first time, we show that almost all patients with advanced head and neck cancers have circulating cells at the time of surgery. The clinical application of techniques for detection of spreading disease, such as the immunomagnetic enrichment RT-PCR analysis used in this study, should be explored further.

Benign extracranial nerve sheath tumors of the skull base: postoperative morbidity and management.

The purposes of this retrospective case series study were to examine the outcome of the operative treatment of extracranial nerve sheath tumors (NSTs) of the skull base and to learn the optimal management. The study was conducted at a university teaching hospital and a regional referral center. A total of 19 cases of benign extracranial NSTs of the skull base who presented to the otolaryngology department over a period of 10 years were studied regarding the clinical, radiological, and pathological features and the operative and postoperative management. In the majority, these tumors originated from cranial nerves; postoperative complications were frequent and depended on the nerve of origin. Postoperative nerve deficit was apparent in 10 cases, and a second operation was necessary in 8 cases. The greatest postoperative morbidity was associated with the parapharyngeal NSTs (i.e., dysphagia in 30%, dysphonia in 30%, and Horner's syndrome in 20% of cases). The conclusion from this study is that high postoperative morbidity resulting from surgery on skull base NSTs demands an integrated approach between the otolaryngologist, plastic surgeon, neurosurgeon, speech therapist, physiotherapist, dietician, and occupational therapist and a clear strategy of long-term follow-up.

The presenting features of middle ear facial nerve sheath tumors: a clinical review.

Facial nerve sheath tumors are the most common middle ear benign neoplasms. Four facial nerve sheath tumors in the middle ear were diagnosed in our department over a 12-year period, and we described our experience in the management of these tumors. A thorough review of the English literature on middle ear peripheral nerve sheath tumors has been conducted, and the findings of this review are presented and discussed. We have paid particular attention to the presenting features of these tumors with the aim of enhancing diagnostic ability.

Extracranial head and neck schwannomas--a 10-year review.

OBJECTIVES: To present our experience in managing a large case series of extracranial schwannomas highlighting presenting features, diagnostic difficulties, and outcomes associated with surgical treatment of these tumours. METHOD: A retrospective case note study of 31 patients with a diagnosis of extracranial schwannoma seen in the Department of Otolaryngology, Head and Neck Surgery at Southmead Hospital, a tertiary referral centre and University hospital between 1 June 1993 and 30 May 2003. RESULTS: The commonest anatomical location was in the neck (42%) and an isolated neck lump was the commonest presentation (77%). Pressure symptoms were the next most common mode of presentation, and were often a helpful indicator of the nerve of origin. The nerve of origin was identified in 47% of patients who underwent surgery. Immunohistochemistry was a useful tool in the diagnosis of these tumours and magnetic resonance imaging was the preferred imaging technique to delineate their extent. The most significant postoperative morbidity was associated with the schwannomas of the vagus nerve, sympathetic chain, hypoglossal nerve, glossopharyngeal nerve and the facial nerve. CONCLUSION: Schwannomas can present in a wide variety of sites within the head and neck region and therefore it is important that otolaryngologists and head-neck surgeons are familiar with the more common sites of presentation and the potential difficulties associated with the diagnosis and management of these tumours. Adequate imaging should be carried out preoperatively to gain as much information as possible about the individual tumour and allow informed patient counseling regarding to potential risks and morbidity of surgical intervention.

Extubation of the surgically resected airway--a role for remifentanil and propofol infusions.

PURPOSE: To report the use of propofol and remifentanil infusions to facilitate smooth extubation of a surgically resected airway. CLINICAL FEATURES: A 19-yr-old man weighing 85 kg was scheduled for tracheal resection surgery following postintubation tracheal stenosis. He had a relatively long segment (4 cm) of his trachea resected and anastomosed. Postoperatively, he was sedated and electively ventilated for four days in a chin to chest position by stay sutures. In order to reduce any risk of traumatic disruption to the tracheal anastomosis, we planned to extubate his trachea under light general anesthesia. Attempts to extubate his trachea using propofol and alfentanil infusions failed. We used propofol and remifentanil infusions to achieve a state of sedate cooperation and extubated his trachea with fibreoptic bronchoscope guidance. CONCLUSION: Propofol and remifentanil infusions in combination can facilitate successful extubation of the surgically resected airway with high risk of disruption.