Case series: Endoscopic management of fourth branchial arch anomalies.

INTRODUCTION: Fourth branchial arch anomalies represent <1% of all branchial anomalies and present as recurrent neck infections or suppurative thyroiditis. Traditionally, management has consisted of treatment of the acute infection followed by hemithyroidectomy, surgical excision of the tract and obliteration of the opening in the pyriform fossa. Recently, it has been suggested that endoscopic obliteration of the sinus tract alone using laser, chemo or electrocautery is a viable alternative to open surgery. OBJECTIVES: To determine the results of endoscopic obliteration of fourth branchial arch fistulae in children in our institute. METHODS: Retrospective case note review of all children undergoing endoscopic treatment of fourth branchial arch anomalies in the last 7 years at the Royal Manchester Children's Hospital. Patient demographics, presenting symptoms, investigations and surgical technique were analysed. The primary and secondary outcome measures were resolution of recurrent infections and incidence of surgical complications, respectively. RESULTS: In total 5 cases were identified (4 females and 1 male) aged between 3 and 12 years. All presented with recurrent left sided neck abscesses. All children underwent a diagnostic laryngo-tracheo-bronchoscopy which identified a sinus in the apex of the left pyriform fossa. This was obliterated using electrocautery in 1 patient, CO2 laser/Silver Nitrate chemocautery in 2 patients and Silver Nitrate chemocautery in a further 2 patients. There were no complications and no recurrences over a mean follow-up period of 25 months (range 11-41 months). CONCLUSION: Endoscopic obliteration of pyriform fossa sinus is a safe method for treating fourth branchial arch anomalies with no recurrence.

The management of cochlear nerve deficiency.

The assessment process is critical in deciding whether a profoundly deaf child with cochlear nerve deficiency (CND) will be suitable for a cochlear or auditory brainstem implant (ABI). Magnetic resonance imaging (MRI) using submillimetric T2 weighted gradient echo or turbo spin echo sequences is mandatory for all profoundly deaf children to diagnose CND. Evidence of audition on behavioural or electrophysiological tests following both auditory and electrical stimulation sometimes allows identification of significant auditory tissue not visible on MRI. In particular electric auditory brainstem response (EABR) testing may allow some quantification of auditory tissue and help decide whether a cochlear implant will be beneficial. Age and cognitive development are the most critical factors in determining ABI benefit. Hearing outcomes from both cochlear implants and ABIs are variable and likely to be limited in children with CND. A proportion of children will get no benefit. Usually the implants would be expected to provide recognition of environmental sounds and understanding of simple phonetics. Most children will not develop normal speech and they will often need to learn to communicate with sign language. The ABI involves a major neurosurgical procedure and at present the long term outcomes are unknown. It is therefore essential that parents who are considering this intervention have plenty of time to consider all aspects and the opportunity for in depth discussion.

Effect of central compartment neck dissection on hypocalcaemia incidence after total thyroidectomy for carcinoma.

INTRODUCTION: Central compartment neck dissection is increasingly performed as part of surgical management of differentiated thyroid carcinoma. However, elective central neck dissection remains controversial due to complications and lack of evidence of survival benefit. OBJECTIVE: To investigate and compare rates of transient and permanent hypocalcaemia following total thyroidectomy alone, compared with total thyroidectomy with central neck dissection, for differentiated thyroid carcinoma. METHODS: Retrospective study of 127 consecutive patients referred with differentiated thyroid carcinoma, 2004-2006; 78 patients had undergone total thyroidectomy (group one) and 49 total thyroidectomy with central compartment node dissection (group two). Surgery was performed in various hospitals by both otolaryngologists and endocrine surgeons. RESULTS: In groups one and two, the incidence of transient hypocalcaemia was 18 per cent (14/78) and 51 per cent (25/49) (p < 0.001), and the incidence of permanent hypocalcaemia 1 per cent (one of 77) and 12 per cent (six of 49) (p < 0.01), respectively. Most patients undergoing central neck dissection had evidence of pathological level six lymphadenopathy (29/49). CONCLUSION: Total thyroidectomy combined with central neck dissection for the treatment of differentiated thyroid carcinoma is more likely to result in transient (51 per cent) and permanent (12 per cent) hypocalcaemia. Elective neck dissection should be performed selectively, with a high expectation of post-operative hypocalcaemia.

The role of nervus intermedius in side specific nasal responses.

BACKGROUND: Nervus intermedius (NI) dysfunction is common in patients who have had vestibular schwannoma (VS) surgery. Such patients have a unilateral parasympathetic-denervated nasal cavity. A number of side-specific nasal reflexes have been demonstrated in normal individuals, including hand cold-water immersion. It is not understood whether these reflexes have parasympathetic or sympathic efferent pathways. We aimed to evaluate the side specific nasal reflex to cold-water immersion in post-operative VS patients with NI dysfunction, in order to determine the nature of the efferent pathway of these reflexes. METHOD: Side specific responses to cold-water immersion were tested by acoustic rhinometry in 10 normal individuals and 18 patients with NI dysfunction (proven by Schirmer s test) after VS surgery. RESULTS: A consistent pattern of ipsilateral congestion and contralateral decongestion after the cold-water immersion was seen in normal individuals (p smaller than 0.001). We found no consistent response in VS patients both ipsilateral and contralateral to the side of NI dysfunction. CONCLUSIONS: We confirm the consistent side-specific nasal reflexes to cold-water hand immersion in normal individuals. This is disturbed in patients with NI dysfunction. We have also shown unexpectantly that the contralateral side-specific reflex is disturbed in these patients. These data suggest that the reflex is parasympathetic and crosses the midline.

Safety of sublingual grass pollen immunotherapy after anaphylaxis.

AIM: To demonstrate that sublingual immunotherapy is a safe treatment option in patients who have previously suffered anaphylaxis when undergoing subcutaneous grass pollen immunotherapy. CASE REPORT: We report two patients who developed a systemic anaphylactic reaction following subcutaneous grass pollen immunotherapy, resulting in discontinuation of treatment. Following treatment of the acute anaphylactic episode, both patients were subsequently safely commenced on sublingual grass pollen immunotherapy. CONCLUSION: Injection immunotherapy has a relatively low risk of severe adverse events, although anaphylaxis is a potentially fatal complication and usually results in termination of the immunotherapy programme. Sublingual immunotherapy has a safer side effect profile than subcutaneous immunotherapy, with no reported cases of anaphylaxis.

Dimensional analysis - its role in our preoperative surgical planning of rhinoplasty.

With the advent of new reconstructive rhinoplasty techniques, we have the opportunity to correct a larger number of nasal deformities. Dimensional analysis using non-nasal references assists in identifying the abnormalities in a deformed nose. Analysis of 98 patients undergoing rhinoplasty plus or minus septal surgery was performed to identify the prevalent abnormalities with the help of the dimensional approach.