Systematic review with meta-analysis: endoscopic balloon dilatation for Crohn's disease strictures.

BACKGROUND: Endoscopic balloon dilatation (EBD) is recognised treatment for symptomatic Crohn's strictures. Several case series report its efficacy. A systematic analysis for overall efficacy can inform the design of future studies. AIM: To examine symptomatic (SR) and technical response (TR) and adverse events (AE) of EBD. Stricture characteristics were also explored. METHODS: A systematic search strategy of COCHRANE, MEDLINE and EMBASE was performed. All original studies reporting outcomes of EBD for Crohn's strictures were included. SR was defined as obstructive symptom-free outcome at the end of follow-up, TR as post-dilatation passage of the endoscope through a stricture, and adverse event as the presence of complication (perforation and/or bleeding). Pooled event rates across studies were expressed with summative statistics. RESULTS: Twenty-five studies included 1089 patients and 2664 dilatations. Pooled event rates for SR, TR, complications and perforations were 70.2% (95% CI: 60-78.8%), 90.6% (95% CI: 87.8-92.8%), 6.4% (95% CI: 5.0-8.2) and 3% (95% CI: 2.2-4.0%) respectively. Cumulative surgery rate at 5 year follow-up was 75%. Pooled unweighted TR, SR, complication, perforation and surgery rates were 84%, 45%, 15%, 9% and 21% for de novo and 84%, 58%, 22%, 5% and 32% for anastomotic strictures. Outcomes between two stricture types were no different on subgroup meta-analysis. CONCLUSIONS: Efficacy and complication rates for endoscopic balloon dilatation were higher than previously reported. From the few studies with 5 year follow-up the majority required surgery. Future studies are needed to determine whether endoscopic balloon dilatation has significant long-term benefits.

Concomitant colonic disease (Montreal L3) and re-resectional surgery are predictors of clinical recurrence following ileocolonic resection for Crohn's disease.

AIM: Ileocolonic resection is reserved for patients with moderate to severe Crohn's disease. Postoperative clinical recurrence can occur in up to 55% of patients within 5 years. Predicting the risk of recurrence is key in deciding upon appropriate treatment strategies. This study aims to determine the incidence of postoperative clinical recurrence and predictors of recurrence in a specialist institution. METHOD: The clinical case records of 142 patients who underwent either a one-stage or two-stage procedure for ileocolonic Crohn's disease from 1 January 2005 to 31 December 2010 were reviewed. Preoperative, perioperative and postoperative variables were extracted. Postoperative clinical recurrence was defined as an initiation or change in medical treatment for recurrent symptoms with endoscopic or radiological evidence of active disease. Time to clinical recurrence was measured in months after surgery. Univariate and multivariate analyses were performed. RESULTS: Over the 6-year period, follow-up data were obtained on 142 patients over a median of 28.5 months. Clinical recurrence was demonstrated in 59 (41.5%) patients. The proportion of patients with clinical recurrence at 5 years was 48.2%. Predictors of recurrence included a re-resection for recurrent disease [hazard ratio (HR) 1.9; 95% CI 1.1-3.3; P = 0.02] and ileocolonic disease (HR 1.7; 95% CI 1.0-2.9; P = 0.05). CONCLUSION: Identifying the predictors for postoperative clinical recurrence is important for determining the postoperative strategy. This study provides a unique perspective on the incidence of recurrence and associated predictors from the perspective of a specialist unit.

Tonsillectomy under threat: auditing the indications for performing tonsillectomy.

BACKGROUND: The 2009 McKinsey National Health Service report considered that tonsillectomy was relatively ineffective and often unjustified, and that its frequently could be greatly reduced. ENTUK argued against this, for severe recurrent tonsillitis. This study audited clinical indications for tonsillectomy. CRITERIA AND STANDARDS: Current guidelines state that patients with recurrent tonsillitis must have disabling sore throat episodes five or more times per year, and symptoms for at least a year, to justify tonsillectomy. METHODS: Seventeen recurrent tonsillitis patients receiving tonsillectomy were audited prospectively. Indications were poorly documented in the referral letter, so surgeons agreed to list specified tonsillectomy criteria when scheduling patients for tonsillectomy. A pro forma reminder was distributed to all clinics, and the next 100 scheduled tonsillectomy patients were audited. RESULTS: In the first audit, all 17 tonsillectomies were justified but only two (11.8 per cent) had documented indications. In the second audit, 85 per cent of patients had all essential criteria, which were documented in the listing letter. CONCLUSION: Tonsillectomy risks being removed from the UK essential otolaryngological surgical register, risking increased patient morbidity and work absence, despite valid supporting evidence of efficacy for recurrent tonsillitis. All UK otolaryngology units should strictly adhere to the ENTUK and Scottish Intercollegiate Guidelines Network recommendations for tonsillectomy, and should document essential criteria in the listing letter, to strengthen the advocacy argument for tonsillectomy as essential, valid treatment for recurrent tonsillitis.

Management of jejunal pouch dysfunction following total gastrectomy and Roux-en-Y reconstruction for gastric cancer: a case report.

INTRODUCTION: Total gastrectomy with oesophagojejunal pouch anastomosis and Roux-en-Y reconstruction is a well recognised procedure for patients undergoing curative resections for gastric malignancy. The formation of a jejunal pouch is thought by some to create a reservoir that, when compared with straight oesophagojejunal anastomosis, reduces the incidence of post-operative dumping. CASE HISTORY: A patient presented two years after a total gastrectomy with oesophagojejunal pouch anastomosis and Roux-en-Y reconstruction for a T3N2M0 adenocarcinoma of the stomach, with postprandial vomiting and dysphagia resulting in massive weight loss and malnutrition. Recurrent cancer and stricturing was ruled out by gastroscopy and computed tomography, and distal obstruction was ruled out by an oral contrast study. The diagnosis of a functional jejunal pouch disorder was made by exclusion. Balloon dilatation of the pouch and the oesophagojejunal anastomosis found little symptomatic improvement. The patient's deteriorating nutritional status prompted us to urgently perform revisional surgery. A re-laparotomy and pouch-jejunal bypass procedure was performed. Post-operatively, the patient made a full symptomatic recovery and began gaining weight. CONCLUSIONS: A pouch-enteric bypass is a suitable treatment option for patients with functional jejunal pouch dysmotility following a total gastrectomy and jejunal pouch formation in the absence of distal obstruction and recurrent disease.

A rare case of necrotising epiglottitis.

We report a case of an acute necrotizing supraglottitis in a healthy patient. Only seven cases of necrotizing epiglottitis/supraglottitis have been reported in medical literature; all in immunocompromised patients. The features and characteristics of necrotizing epiglottitis are discussed with review of all previously reported cases.

12 minute consultation: a patient with nasal crusting.

BACKGROUND: Nasal crusting is frequently encountered by the otorhinolaryngologist and often requires no specific treatment. It is, however, important to carry out a full history and examination, followed by appropriate investigations, in order to detect the small number of cases in which crusting is caused by systemic or malignant disease. METHODS: This review was based on a literature search last performed on 30th July 2009. The MEDLINE, EMBASE and Cochrane databases were searched using the subject headings (nasal crusting OR crusts) and in combination with diagnosis, therapy and surgery. Similar searches were performed for relevant diseases, e.g. Wegener's granulomatosis, sarcoidosis. Results were limited to English language articles including clinical trials, meta-analyses, systematic reviews and review articles. Relevant references from selected articles were reviewed. RESULTS: Knowledge of the causes of nasal crusting will help to target the history, examination and investigation of patients with this condition. Screening tests for systemic conditions can be useful but most have limited sensitivity and must be interpreted cautiously. Nasal septal biopsy is indicated when there is a suspicion of malignancy, or to support a suspected diagnosis of vasculitis. The treatment offered depends upon the cause of crusting and the severity of symptoms. CONCLUSION: A careful and thorough history and examination, and targeted investigation, of the patient with nasal crusting will ensure correct diagnosis and treatment of patients with this common condition.

Randomized-controlled study comparing post-operative pain between coblation palatoplasty and laser palatoplasty.

OBJECTIVES: This study aimed to evaluate differences in post-operative pain comparing KTP laser-assisted uvulopalatoplasty without tonsillectomy (LAUP) with a new described surgical method: coblation uvulopalatoplasty with tonsillectomy (CP). We also evaluate the impact of each surgical technique in reduction of snoring loudness. MATERIAL AND METHODS: Single blind randomized-controlled trial. From a population of 41 consecutive patients on the waiting list for uvulopalatoplasty for simple snoring, the study group was reduced to 17 CP and 13 LAUP. Post-operative pain and reduction of snoring loudness were recorded using visual analogue scales (VAS) during the first 15 post-operative days. Post-operative snoring loudness was documented for 1-year period. RESULTS: Both groups had similar post-operative pain during the first seven post-operative days. A statistically significant reduction in post-operative pain was observed in the CP group after day 8, and maintained until the end of the study. Reduction of snoring loudness was significant in both groups, but no differences were observed between them. DISCUSSION: Coblation uvulopalatoplasty compared with LAUP demonstrates a reduction in post-operative pain, significant after the first post-operative week. The collateral thermal injury caused by laser is responsible for the slow-healing rate and maintained post-operative pain. Coblation dissociates tissue at lower temperatures with minimal collateral thermal injury and consequently faster and less painful recovery. Both surgical procedures have significant and similar reduction in snoring loudness. CONCLUSIONS: Both methods are adequate treatment options for snoring. The less painful recovery in CP promotes this surgical technique as our preferred choice for palate surgery.

Coblation tonsillectomy versus dissection tonsillectomy: postoperative hemorrhage.

OBJECTIVES/HYPOTHESIS: Coblation tonsillectomy is a recently introduced surgical technique. To measure its benefits against traditional tonsillectomy techniques, it is necessary to compare their complication rates. The study aims to identify differences in reactionary and secondary hemorrhage proportions, comparing coblation with dissection tonsillectomy. STUDY DESIGN: Prospective observational cohort study. METHODS: Rates of reactionary and delayed postoperative hemorrhage were measured, comparing 844 coblation tonsillectomies with a control group of 743 tonsillectomies performed by blunt dissection with bipolar diathermy hemostasis. RESULTS: The secondary hemorrhage rate with coblation-assisted tonsillectomy was 2.25% compared with 6.19% in the control group (P <.05). The rate of secondary hemorrhage in children following coblation tonsillectomy was 0.95% compared with 4.77% in the control group (P <.05). The difference was also significant (P <.05) in the adult population (4.40% vs. 8.81%, respectively). No difference was found in the reactionary hemorrhage proportions. CONCLUSION: In the study, coblation tonsillectomy was associated with a lesser incidence of delayed hemorrhage, more significantly in the pediatric population. The new technique using tissue coblation for tonsil dissection offers significant advantages in the postoperative period compared with dissection tonsillectomy with bipolar diathermy hemostasis. Coblation is associated with less postoperative pain and early return to daily activities. Also, there are fewer secondary infections of the tonsil bed and significantly lower rates of secondary hemorrhage with coblation. These results and the disposable nature of the coblation equipment promote coblation tonsillectomy as the authors' preferred dissection method.

Oropharyngeal carriage and lower airway colonisation/infection in 45 tracheotomised children.

BACKGROUND: A study was undertaken to determine the oropharyngeal carrier state of potentially pathogenic microorganisms (PPM) and the magnitude of colonisation and infection rates of the lower airways with these PPM in children requiring long term ventilation first transtracheally and afterwards via a tracheotomy. METHODS: A 5 year, prospective, observational cohort study was undertaken in 45 children (33 boys) of median age 6.4 months (range 0-180) over a 5 year period at the Royal Liverpool Children's NHS Trust of Alder Hey, a university affiliated tertiary referral centre. The children were first admitted to the 20-bed paediatric intensive care unit (PICU) and, following placement of a tracheotomy, they were transferred to a four bedded respiratory ward. The two main indications were neurological disorders and airway obstruction. All children were ventilated transtracheally for a median period of 12 days (range 0-103) and, after placement of the tracheotomy, for a similar period of 12 days (range 1-281). Surveillance cultures of the oropharynx were taken on admission to the PICU and on the day of placement of the tracheotomy. Throat swabs were taken twice weekly during ventilation, both transtracheal and via the tracheotomy. Tracheal aspirates were taken once weekly and when clinically indicated (in cases where the lower airway secretions were turbid). RESULTS: Twenty five patients (55%) had abnormal flora, mainly aerobic Gram negative bacilli (AGNB), particularly Pseudomonas aeruginosa, while the community PPM Staphylococcus aureus was present in the oropharynx of 37% (17/45) of the study population. The lower airways were sterile in six children; the other 39 patients (87%) had a total of 82 episodes of colonisation. "Community" PPM significantly increased once the patients received a tracheotomy, independent of the number of patients enrolled, episodes of colonisation/infection, and the number of colonised/infected patients. "Hospital" PPM significantly decreased after tracheotomy only when episodes were compared. CONCLUSIONS: While P aeruginosa present in the admission flora caused primary endogenous colonisation/infection during mechanical ventilation on the PICU, S aureus not carried in the throat was responsible for the exogenous colonisation/infection once the patients had a tracheotomy. This is in sharp contrast to adult studies where exogenous infections are invariably caused by AGNB. This discrepancy may be explained by chronic underlying conditions such as diabetes, alcoholism, and chronic obstructive pulmonary disease which promote AGNB, whereas the children were recovering following tracheotomy.

Rheumatoid nodule of the nasal septum.

Necrotizing granulomatous nodules are a common feature in patients with rheumatoid disease, affecting 20 per cent of seropositive patients. Although most commonly found subcutaneously at points of pressure, these nodules may occur in the connective tissues elsewhere in the body. In the upper aerodigestive tract, nodules have been described in diverse locations, but commonly in the trachea, larynx and the ear. We present the first reported case of a rheumatoid nodule affecting the nasal septum.

Ballooned trachea caused by cuffed tracheostomy tube.

Despite the dramatic decrease in cuff-related complications with the introduction of high-volume low-pressure devices for intubation and tracheostomy, notable problems can still occur. A case is reported of a patient who developed persistent dilatation of the trachea after prolonged mechanical ventilation. This is an under-recognized, life threatening clinical entity occurring after cuffed intubation for prolonged time. At present there is no definitive treatment regarding the management of a dilated trachea on a ventilator-dependent patient and therefore emphasis is directed at prevention. The patient presented was managed with periodical alterations of the cuff level which although not achieving any reversal of the dilatation, have prevented further progression of tracheal damage. During the follow-up period, regular assessment with flexible endoscopy has provided more reliable information on the condition of the trachea than computed tomography (CT) scanning.

Topical antibiotics on tracheostoma prevents exogenous colonization and infection of lower airways in children.

INTRODUCTION: Patients requiring long-term ventilation are at high risk of lower airway infections, generally of endogenous development. Patients on long-term ventilation, in particular via a tracheostomy, may develop tracheobronchitis or pneumonia of exogenous pathogenesis, ie, caused by microorganisms not carried in the oropharynx. The frequency of exogenous colonization or infection has previously been reported to be as high as 33%. A prospective observational cohort study of 2 years was undertaken to evaluate the efficacy of topical antibiotics in the prevention of exogenous colonization or infection of the lower airways. The antibiotic combination of polymyxin E and tobramycin in a 2% paste was applied four times a day on the tracheostoma. MATERIALS AND METHODS: A total of 23 children (median age, 4.1 months; range, 0 to 215 months) were enrolled in the study from September 1, 1996, until August 30, 1998. Surveillance samples of the oropharynx were obtained before tracheostomy and thereafter twice weekly. Diagnostic samples of the lower airways were taken once weekly and on clinical indication. RESULTS: Fourteen children (61%) had a total of 16 episodes of tracheal colonization or infection with 20 potentially pathogenic microorganisms. Only one child had tracheobronchitis with Streptococcus pneumoniae and Haemophilus influenzae during the 2-year study. Of the 16 colonization episodes, 12 (75%) were of primary endogenous pathogenesis, ie, caused by microorganisms present in the oropharynx at the time of tracheostomy. Community microorganisms including S pneumoniae, H influenzae, Moraxella (Branhamella) catarrhalis, and Staphylococcus aureus were the predominating bacteria. Three patients acquired nosocomial bacteria Pseudomonas aeruginosa and Hafnia alvei in the oropharynx, subsequently followed by secondary colonization of the lower airways. There was one failure of the prophylaxis: one patient (4%) had exogenous colonization with Pseudomonas pickettii. CONCLUSION: Topical antibiotics applied to the tracheostoma were found to be effective in reducing the exogenous route of colonization of the lower respiratory tract, compared with clinical experience and the literature. This promising technique requires further evaluation in randomized trials.

Localized amyloidosis of the parotid gland: a case report and review of the localized amyloidosis of the head and neck.

BACKGROUND: Localized amyloidosis in the head and neck is a rare and benign process. METHODS: We present the first case report in the literature of localized amyloidosis of the parotid glands and also comprehensively review the literature regarding localized amyloidosis of the head and neck. RESULTS: Amyloidosis affecting the head and neck region is uncommon and is mostly in the form of localized amyloidosis. Larynx is the commonest site of involvement and accounts for 0.2% to 0.5% of benign laryngeal tumors. Laryngeal involvement could be either diffuse subepithelial deposition or discrete tumor nodules. Although localized amyloidosis occurs much more frequently in the oral cavity and pharynx, only seven cases of nasopharyngeal amyloidosis and eight cases of nasal septum amyloidosis have been reported. There is no documentation to suggest that localized amyloidosis can progress to systemic amyloidosis. Local surgical excision is the treatment of choice for laryngeal amyloidosis and laser excision is probably the best. CONCLUSION: While localized amyloidosis of the head and neck region is rare, it should be recognized, understood, evaluated, and properly treated.

Impact of tracheotomy on colonization and infection of lower airways in children requiring long-term ventilation: a prospective observational cohort study.

STUDY OBJECTIVES: Determination of the following: (1) colonization and infection rates in children requiring long-term ventilation initially via a transtracheal tube and subsequently via a tracheotomy; (2) the number of infection episodes per 1,000 ventilation days, during both types of artificial airways; and (3) routes of colonization/infection of the lower airways, ie, whether the pathogenesis was endogenous (via the oropharynx) or exogenous (via the transtracheal tube or tracheotomy). DESIGN: Observational, cohort, prospective study over 2 1/2 years. SETTING: Pediatric ICU (PICU), Royal Liverpool Children's National Health Service Trust of Alder Hey, a tertiary referral center. PATIENTS: Twenty-two children requiring long-term mechanical ventilation initially transtracheally and subsequently via a tracheotomy. INTERVENTION: Nil. RESULTS: The lower airways were colonized in 71% of children during transtracheal ventilation; posttracheotomy, this was 95% (p=0.03). Children developed significantly fewer infections following colonization with a microorganism posttracheotomy (8/15 pretracheotomy vs 6/21 posttracheotomy; p=0.013). Throughout the study, there were a total of 17 episodes of infection, all of which were preceded by colonization. Haemophilus influenzae, Staphylococcus aureus, Acinetobacter baumannii, and Pseudomonas aeruginosa were the same four causative pathogens during mechanical ventilation both transtracheally and via tracheotomy. Forty-nine episodes of colonization were observed, 15 pretracheotomy and 34 posttracheotomy; of these, 12 (80%) and 19 episodes (56%), respectively, were primary endogenous, ie, present in the oropharynx on hospital admission and subsequently at tracheotomy. Only one colonization episode (7%) of exogenous pathogenesis was observed during transtracheal intubation, while 12 (35%) (p=0.02) occurred after tracheotomy. An equal number of secondary endogenous colonization episodes (two and three, ie, acquired in the oropharynx after PICU admission and after tracheotomy, respectively, were recorded. CONCLUSIONS: (1) Despite a high level of hygiene, exogenous colonization without subsequent infection was common. (2) Although all patients were colonized, the infection rate was lower after tracheotomy. This may be due to enhanced immunity (medically stable) and improved tracheobronchial toilet. (3) Microorganisms in children with tracheotomy differ from those in adults.

General practitioner consultations after a paediatric tonsillectomy.

General Practitioner (GP) consultations were audited in paediatric patients who have undergone an elective tonsillectomy on our unit over a 6 month period. As there is no formal follow-up, it is the department's practice to discuss with the patients the problems to expect following the operation. This is reinforced with a tonsillectomy advice sheet. An initial audit of GP consultations was performed by a telephone survey of the relevant GP. This revealed an attendance rate of 41%. Following the implementation of a change in management (chewing gum was added to the post operative care instructions) a subsequent audit of 91 children was performed. A marked reduction in the GP attendance was observed. We now routinely recommend the use of chewing gum in the post-operative period after tonsillectomy to our patients.

Spontaneous retropharyngeal haematoma attributable to Epstein-Barr virus infection.

Life-threatening sequelae of Epstein-Barr virus infection are uncommon but may present as: local pharyngeal manifestations, splenic rupture, neurological and haematological disorders and altered hepatic function. We present a case of retropharyngeal haematoma with posterior hypopharyngeal wall necrosis, thrombocytopenia and altered clotting function as a result of Epstein-Barr virus infection. A review of the literature on retropharyngeal haematoma reveals this to be the only recorded case which can be directly attributed to Epstein-Barr virus infection.