A discussion of airway and respiratory complications along with general considerations in obese patients.

Obesity is defined as the degree of excess weight associated with adverse health consequences. Within Great Britain, it is reported that a quarter of men and women are obese; these rates have trebled over the past 20 years. In 2001, it was estimated that obesity cost the National Health Service at least half a billion pounds, with a further two billion pounds lost on lower productivity and lost output. Obesity poses a significant risk factor for diseases, such as coronary heart disease, diabetes mellitus and certain forms of cancer, amongst others. Obese individuals pose significant problems to the clinician because of airway and respiratory complications. Sleep apnoea, obesity-hypoventilation syndrome, pulmonary atelectasis are associated with obesity and tracheostomy insertion is made all the more difficult in these patients. This article aims to discuss some of these issues relevant to the clinician and examine present strategies for dealing with them.

Laryngeal gout.

A review of the literature reveals only 12 reported cases of laryngeal gout. We describe three further cases of laryngeal gout, the largest series ever published. The first case is previously undescribed acute gouty cricoarytenoiditis resulting in acute airway embarrassment requiring tracheotomy, and then we describe two cases of chronic tophaceous involvement of the thyroid lamina with computed tomography (CT) images of this process. The paucity of literature on this subject may not only be due to rarity but also lack of clinical awareness. Gouty involvement of the larynx must be considered in any patient with a history of gout who presents with hoarseness, odynophagia, dysphagia, stridor or neck lump. Acute airway compromise may require tracheotomy, whereas chronic airway problems may necessitate endoscopic tophi removal, lateralization procedures or even permanent tracheostomy.

Primary sinonasal amyloidosis.

Primary amyloidosis localized to the sinonasal tract is extremely rare with only 20 reported cases in the English literature. We describe a further case and review the literature.

Nasal pH and saccharin clearance are unrelated in the physiologically normal nose.

A group of 56 asymptomatic non-smoking men was prospectively recruited to study the relationship between nasal mucosal pH and saccharin clearance rate. No significant relationship was found between the two variables (Pearson correlation coefficient = -.105, p = 0.44). This finding suggests that in vivo mucociliary flow rates are resistant to change within the pH range of the physiologically normal nose.

Olfactory groove meningiomas.

Olfactory groove meningioma is a rare clinical entity. The principal symptoms associated with olfactory groove meningiomas are anosmia and headache which lead the patient to the ENT specialist. Frontal sinusitis, migraine and neuralgia are most frequent incorrect diagnoses. This retrospective study of 13 consecutive patients who underwent excision of Olfactory Groove meningiomas in the North Staffordshire Royal Infirmary, Department of Neurosurgery over a 20-year period was undertaken to study the presenting features, duration of symptoms, results of surgery, and long-term follow-up. Symptoms were present for less than 6 months to 3 years. Although excision was thought to be complete reoccurrences occurred in four patients. The morbidity of surgery was significant.

Post-irradiation liposarcoma of the temporal bone.

The first reported case of liposarcoma of the temporal bone is presented. Its association with previous irradiation for benign parotid disease is discussed.

Long-term ventilation of the middle ear using a tympanotomy technique.

The technique of long-term middle ear ventilation using a tympanotomy technique is presented. This has proved successful in the management of persistent middle ear effusion despite numerous previous short- and intermediate-term tympanic membrane ventilation tubes. The technique is particularly appropriate in the presence of severe tympanosclerosis as a result of previous tympanostomy tubes, posterior tympanic membrane collapse and adhesion, and atelectasis.

Pharyngo-oesophageal fistula following iatrogenic perforation of a pharyngeal pouch.

A unique, previously undescribed case of iatrogenic perforation of a pharyngeal pouch which resulted in pharyngo-oesophageal fistulation is described. The correct management of such complications is discussed.

Right vocal fold paralysis as a result of central venous catheterization.

Invasive peri- and post-operative monitoring is being increasingly utilized, and a corresponding increase of concomitant complications are becoming apparent. Two cases of complete right vocal fold paralysis are reported as a possible complication of right central venous catheterization. The underlying aetiology of this complication is presumed to be either direct trauma at the time of introduction of the central venous catheter, or by thrombosis and fibrosis around the recurrent laryngeal or vagus nerve. It is suggested that multiple attempts at cannulation and leaving the central line in situ for long periods increases the risk of this complication. When the integrity of the left recurrent laryngeal nerve or vagus is jeopardized or must be sacrificed during surgery, it is suggested that ipsilateral central lines are inserted to minimize the risk of bilateral vocal fold paralysis. Cases of vocal fold paralysis secondary to central line insertion should be followed expectantly and surgical intervention only be considered after 12 months review.

The management of benign thyroid goitre causing tracheo-oesophageal embarrassment.

The case of a massive benign thyroid goitre extending from the arch of aorta to the nasopharynx presenting with acute aerodigestive obstruction is reported. The management of the case is discussed and also a review of the relevant literature.

Vestibulocochlear dysfunction following epidural anaesthesia in labour.

A case is reported of vestibulocochlear dysfunction following accidental dural tap during epidural anaesthesia in labour. The aetiology and the world literature are reviewed.

Improvement in hand-held CO2 laser safety.

A modification of the CO2 laser hand-piece is presented which utilizes a simple finger controlled mechanical shutter. This instrument safeguards against accidental direction of the laser beam.

Conchal flap meatoplasty.

A meatoplasty technique is described which has proved successful in the treatment of chronic otitis externa. The procedure opens the superficial meatus by eliminating the sharp rim at the junction of the conchal bowl and the posterior canal wall cartilage; thinning the skin and increasing the circumference of the external auditory orifice.

Clinical audit: is day-case adenotonsillectomy safe?

The trend towards day-case procedures is growing, as a consequence not only of improved medical care but the increasing importance of economic considerations in today's healthcare environment. In the largest worldwide study to date to assess the safety of day-case adenotonsillectomy, we reviewed the records of 4386 patients at the otolaryngology department of the Bradford Royal Infirmary. We found a reactionary haemorrhage rate of 0.57%. All patients who underwent surgery in the morning session had presented with haemorrhage and returned to the operating theatre before the end of the afternoon session. We discuss the implications of these findings, and consider that with careful monitoring day-case tonsillectomy and/or adenoidectomy may safely be introduced.

Autosuture GIA gun: a new application in the treatment of hypopharyngeal diverticula.

A new surgical technique for the treatment of moderate to large hypopharyngeal diverticula is described. The procedure is particularly useful in debilitated patients in that it is quick and guarantees closure of the party wall between the pouch and upper oesophagus.

Relapsing polychondritis--a study of four cases.

Four case reports of relapsing polychondritis, (RP), are presented, together with a literature review and management suggestions. There are approximately 211 reported cases in world literature making RP an uncommon condition associated with high morbidity and mortality rates. The key to the management of RP is based on accurate and early diagnosis though the ideal medical regimen has yet to be elucidated.

Oncocytic papillary cystadenomatosis of the larynx.

Symptomatic oncocytic disease of the larynx is rare. Review of the world literature reveals that isolated, symptomatic cases of oncocytoma of the larynx have been previously reported to involve discrete sites usually the laryngeal ventricles and vestibular folds. A unique case of multifocal cystic oncocytic hyperplasia necessitating laryngectomy is reported. CT scan of the larynx suggested destruction of the cartilage. Malignant histological features were not present. This report raises the question whether previously described cases of oncocytoma of the larynx also had diffuse involvement. If oncocytosis is a diffuse process then it is suggested that patients should be kept under review for recurring lesions.

Orbital cellulitis.

Orbital cellulitis is an emergency. It may cause blindness and progress to life-threatening sequelae such as brain abscess, meningitis and cavernous sinus thrombosis. Successful management is dependent upon urgent referral and immediate treatment. Although isolated eyelid erythema and swelling usually indicate primary infection anterior to the orbital septum, they may also be the first signs of an underlying frontal or ethmoidal sinusitis. The condition always requires emergency referral to both an ophthalmologist and otorhinolaryngologist.

Intranasal malignant melanoma arising in an inverted papilloma.

A case of intranasal malignant melanoma arising in the epithelium of an inverted papilloma is described. The use of immunohistochemistry to delineate the in situ component of the malignant tumour is illustrated and the characteristic features of malignant melanomas at this site discussed.