The value and role of low dose methylene blue in the surgical management of hyperparathyroidism.

INTRODUCTION: Methylene blue (MB) has been used in the identification of abnormal parathyroid glands in surgery for hyperparathyroidism. Its efficacy and safety profile have been questioned recently and this study sought to demonstrate such aspects in a unit where its use is routine. METHODS: Prospective data collected over six years in a single surgeon's practice were interrogated to identify factors affecting MB staining, side effects suffered and unusual cases where the dye was invaluable in locating the diseased gland. RESULTS: A total of 98 patients underwent MB infusion. Of these, 77 cases (78.6%) stained positively with MB and 21 (21.4%) did not. Six patients suffered side effects but there were no cases of neurotoxicity. No positive predictive factors of dye uptake were found. MB was particularly useful in cases of intrathyroidal and ectopic glands as well as improving efficiency in both targeted and open parathyroidectomy. CONCLUSIONS: This series shows that when used correctly, MB is efficacious in locating diseased parathyroid glands, with similar sensitivity rates to preoperative ultrasonography and radionucleotide imaging. Adverse effects were much lower than published previously, which may be attributed to the low dose of MB used (3.5 mg/kg).

Culturomics identified 11 new bacterial species from a single anorexia nervosa stool sample.

The rebirth of bacterial culture has been highlighted successively by environmental microbiologists, the design of axenic culture for intracellular bacteria in clinical microbiology, and, more recently, by human gut microbiota studies. Indeed, microbial culturomics (large scale of culture conditions with the identification of colonies by MALDI-TOF or 16S rRNA) allowed to culture 32 new bacterial species from only four stool samples studied. We performed culturomics in comparison with pyrosequencing 16S rRNA targeting the V6 region on an anorexia nervosa stool sample because this clinical condition has never been explored before by culture, while its composition has been observed to be atypical by metagenomics. We tested 88 culture conditions generating 12,700 different colonies identifying 133 bacterial species, with 19 bacterial species never isolated from the human gut before, including 11 new bacterial species for which the genome has been sequenced. These 11 new bacterial species isolated from a single stool sample allow to extend more significantly the repertoire in comparison to the bacterial species validated by the rest of the world during the last 2 years. Pyrosequencing indicated a dramatic discrepancy with the culturomics results, with only 23 OTUs assigned to the species level overlapping (17 % of the culturomics results). Most of the sequences assigned to bacteria detected only by pyrosequencing belonged to Ruminococcaceae, Lachnospiraceae, and Erysipelotrichaceae constituted by strictly anaerobic species, indicating the future route for culturomics. This study revealed new bacterial species participating significantly to the extension of the gut microbiota repertoire, which is the first step before being able to connect the bacterial composition with the geographic or clinical status.

Intratympanic gentamicin treatment for unilateral Ménière's disease: long-term follow up of a proven regime.

OBJECTIVE: To determine the long-term efficacy of a fixed-dose intratympanic gentamicin treatment regime in controlling unilateral Ménière's disease. METHODS: Pfleiderer (1998) published two-year follow-up results for a series of 16 patients treated with a 4-day, 12-dose intratympanic gentamicin regime for unilateral Ménière's disease that was refractory to medical treatment. In 2010, a long-term telephone follow up (mean 17 years and 3 months) of this same cohort was conducted to determine long-term vertigo control. Of the 16 patients, 13 were eligible for the long-term follow up. RESULTS: At 2 years' follow up, all 16 patients experienced substantial control of vertigo, with complete control achieved in 87 per cent of cases. At the long-term follow up, 9 of the 13 eligible patients were contactable, and all reported complete control of vertigo. CONCLUSION: Fixed-dose intratympanic gentamicin controlled symptomatic unilateral Ménière's disease in both the short and long term.

Caliper measurement to improve clinical assessment of palpable neck lumps.

INTRODUCTION: One-stop neck lump clinics with ultrasonography and cytopathology support are an expensive and finite resource. Consequently, many neck lump patients are assessed in general ear, nose and throat or head and neck clinics. Optimal clinical assessment of neck lump size is important to guide investigation, monitor change and provisionally stage nodal disease. The aims of this study were to investigate whether caliper measurement is more accurate than clinical palpation in assessing neck lump size and whether caliper measurement of neck lump size correlates closely with accurate ultrasonography measurement. METHODS: A prospective study was carried out involving 50 patients with clinically palpable neck lumps presenting to the one-stop neck lump clinic. Long and short axis neck lump dimensions were estimated first by clinical palpation and second by caliper measurement. Estimations were compared with accurate ultrasonography measurement. RESULTS: The mean combined long and short axis measurement deviation from accurate ultrasonography measurement was smaller for caliper measurement (7.80 mm) than for clinical palpation (12.38 mm) (p <0.01). There was no significant difference observed between combined axis ultrasonography and combined axis caliper measurement of neck lumps (p = 0.462). CONCLUSIONS: Caliper measurement is more accurate than clinical palpation in estimating the size of clinically palpable neck lumps. The use of calipers to measure the skin surface dimensions of palpable neck lumps is statistically comparable to accurate ultrasonography measurement.

Fibroepithelial polyp of the tonsil: case report of a rare, benign tonsillar lesion.

OBJECTIVE: We report the case of a man presenting with a tonsillar mass causing difficult breathing, snoring and disturbed sleep. METHOD: Case report. RESULTS: The patient was found to have a fibroepithelial polyp of the left tonsil. CONCLUSION: To our knowledge, this is the first case of its type to be presented in the English-language literature. The case is presented and the tumour and its management are discussed.

The timing of calcium measurements in helping to predict temporary and permanent hypocalcaemia in patients having completion and total thyroidectomies.

INTRODUCTION: Postoperative hypocalaemia commonly occurs after extensive thyroid surgery and may require calcium and/or vitamin D supplements to alleviate or prevent the symptoms. In this study, we determined the risk factors for developing hypocalcaemia and whether early serum calcium levels can predict the development of or differentiate between temporary or permanent hypocalcaemia. PATIENTS AND METHODS: A total of 162 patients who either had a completion or total thyroidectomy formed the basis of this prospective study. Serial serum calcium measurements were recorded as well as details of the operation, pathology, indications for surgery, number of parathyroids identified at operation and any complications. RESULTS: Eighty-four (52%) patients did not develop hypocalcaemia but 69 (43%) were found to have temporary hypocalcaemia and 9 (5%) had permanent hypocalcaemia. Hypocalcaemia was more common after total than completion thyroidectomies and the identification of parathyroids at operation appears to have a significant adverse effect on outcome. The calcium levels measured on day 1 postoperatively and the slope (serum calcium levels of day 1 postoperative minus day of operation) were statistically significant in predicting the development of hypocalcaemia and possibly to differentiate between temporary or permanent hypocalcaemia. DISCUSSION: Although almost half the patients having extensive thyroid surgery developed hypocalcaemia (as defined by any postoperative corrected serum calcium level of < 2.12 mmol/l) only 24% had a serum calcium of < 2.12 mmol/l associated with clinical symptoms of hypocalcaemia or a calcium level of < 2.0 mmol/l. Only 5% had persistent hypocalcaemia defined as requiring exogenous supplements at 6 months' postoperatively. Patients having a completion thyroidectomy appear to be less likely to develop hypocalcaemia perhaps as a result of any iatrogenic effects on the parathyroids at the first operation being reversed before the second operation. Identification and, therefore, exposure of parathyroids at operation may have an adverse effect on the blood supply to the glands affecting their function. CONCLUSIONS: Serum calcium levels measured 6 hours' post-surgery and on day 1 postoperatively can be useful in predicting if the patient will develop hypocalcaemia and the slope may indicate whether the hypocalcaemia will be temporary or permanent. Patients with toxic goitres and those having a one-stage total thyroidectomy are most at risk of developing hypocalcaemia.

Posterior nasal septal abscess in a healthy adult patient.

OBJECTIVE: We report an extremely rare case of bilateral posterior nasal septal abscess in an otherwise healthy adult patient. METHOD: Case report and a review of the world literature concerning atraumatic nasal septal abscess and its management. RESULTS: The development of an atraumatic nasal septal abscess is rare, but it has been reported in association with acute sinusitis, in patients with poor immunity and in children. The presentation, clinical course and treatment are discussed in the presented patient. CONCLUSION: To our knowledge, this is the first report in the world literature of a bilateral posterior septal abscess associated with acute sinusitis in an otherwise healthy adult.

An unusual case of laryngeal spindle cell carcinoma metastasising to the orbit and heart.

We report the first case in the world literature of laryngeal spindle cell carcinoma metastasising to the orbit. A 65-year-old woman was previously treated for T3 N0 Mx laryngeal spindle cell carcinoma, with laryngectomy and post-operative radiotherapy. Five months following this treatment, she developed proptosis, diplopia and reduced right visual acuity, secondary to an enlarging mass within the right orbit. This was biopsied, and subsequent histology confirmed a diagnosis of metastatic spindle cell carcinoma. Subsequent post-mortem examination demonstrated additional pulmonary, hepatic and cardiac metastatic disease, in the absence of any other primary tumour or locoregional disease. The radiological investigation of patients with laryngeal spindle cell carcinoma is discussed and contrasted with that of laryngeal squamous cell carcinoma.

'Boil and Bite' mouth guards for direct laryngoscopy.

'Boil and Bite' mouth guards are an alternative to conventional silicone guards in direct laryngoscopy. These guards are less likely to displace. They are cheap and easy to prepare.

A national survey amongst UK otolaryngologists regarding the treatment of Ménière's disease.

Since Dr Prosper Ménière described the vertiginous syndrome that now bears his name, a large variety of medical and surgical treatments have been introduced. To determine the way in which this condition is currently managed in the United Kingdom, a postal survey amongst consultant otolaryngologists was carried out. It revealed that 52 per cent were actively involved in the treatment of patients with Ménières disease using a wide range of medical and surgical therapies that have little or no evidence base. The survey found that 94 per cent of surgeons prescribe betahistine, 63 per cent diuretics and 71 per cent advise salt restriction to their patients, while 52 per cent of surgeons continue to recommend saccus decompression and 50 per cent are still inserting a grommet. However, two thirds of respondents now advocate the use of gentamicin therapy despite it only being introduced to this country just over 10 years ago. The results of this study and their relevance to the recommended present day management of Meniere's disease are discussed.

Pneumomediastinum secondary to an apparently trivial stab wound to the neck: the value of the Hamman's sign and thorough radiological investigation.

Perforation of the pharynx and upper oesophagus after stab wounds to the neck is easily overlooked because of the relative lack of symptoms. A case is reported in which pneumomediastinum occurred after an apparently trivial neck wound.

A study of recurrence of retraction pockets after various methods of primary reconstruction of attic and mesotympanic defects in combined approach tympanoplasty.

The major drawback of combined approach tympanoplasty (CAT) is a relatively high rate of cholesteatoma recurrence compared to open-cavity techniques, which is thought to occur primarily by recurrence of retraction pockets. In this series of 63 CATs carried out by one surgeon, scutum reconstruction to prevent recurrent attic retraction was carried out in 43 cases. Repair with bone pate proved much more successful in achieving this (20.7%; 6/29 recurrent retraction pockets) compared to tragal cartilage (57.1%; 8/14) (Fisher's exact test, P = 0.0205) and was found to be a result of the greater incidence of cartilage resorption. Recurrence of retraction in pars tensa defects was more common as the only material used was a simple temporalis fascia graft. The mean time to development of recurrences was 21.1 months and that has important implications for follow-up. We conclude that the use of bone pate for scutum reconstructions reduces the incidence of attic retraction pockets, and therefore the risk of cholesteatoma recurrence following CAT.

The use of the KTP laser in the management of hypertrophic tracheal mucosa and granulation tissue around Provox valve protheses.

The development of hypertrophic mucosa and granulation tissue around a tracheo-oesophageal fistula voice prosthesis is a commonly encountered problem occurring in 15-20 per cent of patients. Upsizing of the voice prosthesis as well as cautery (silver nitrate and electocautery) are used to counteract this problem to a varying degree of success. The use of the CO2 laser has been mentioned by some authors but details of the method and results have not been published. We report the successful use of the KTP laser for removing such granulations whilst retaining the valve and discuss the reasons why this method should be considered.

Assessment of a cytology grading system for head and neck masses.

A grading system for Fine Needle Aspiration Biopsy Cytology (FNAC) has been in routine use in Peterborough since 1994 for reporting on fine needle aspiration biopsies of neck lumps. The records of all 276 patients who had neck lump fine needle aspiration biopsies performed between 1994 and 1999 were reviewed retrospectively. The 193 patients who had definitive histology available were included in the study of whom 154 (80.2%) were considered adequate for grading. A learning curve for adequacy of specimens obtained is demonstrated, with adequacy rate increasing with increasing experience or seniority of the sampler. The grading system produced an overall accuracy rate of 73.3% with a predictive value for malignancy of 88.6% and a predictive value for benign conditions of 67.3%. Individual grades were assessed for predictive value of benign or malignant disease. Grade 5 proved completely reliable, with a predictive value for malignancy of 100%. The shortcomings of the other grades and the difficulties in diagnosing lymphoma by FNAC are discussed.

Osteoradionecrosis of the hyoid presenting as a cause of intractable neck pain following radiotherapy and the role of magnetic resonance image scanning to aid diagnosis.

Osteoradionecrosis of the hyoid has been reported rarely in the worldwide literature. We present the case of a 56-year-old gentleman who presented with intractable neck pain, following surgery and radiotherapy for a T(2)N(2c)M(0) tongue base carcinoma, to highlight the need to consider osteoradionecrosis of the hyoid rather than recurrence of the carcinoma as the cause of such symptoms. The previously unreported appearance of osteoradionecrosis of the hyoid on a magnetic resonance image (MRI) scan and the use of this investigation to aid diagnosis is discussed.

The use of maggots in head and neck necrotizing fasciitis.

Historically maggots have been used to clean necrotic war wounds. With the ready availability of sterile maggots, they are being used increasingly in surgical practice. Although maggots have most frequently been employed in the management of necrotic wounds and ulcers involving the lower limb, we have identified a particularly useful application in the head and neck and describe a case in which maggots played a significant part in the successful treatment of a florid necrotizing cervical fasciitis in a patient, who was unfit for repeated surgical debridement.

Bilateral defects of the tegmen tympani associated with brain and dural prolapse in a patient with pulsatile tinnitus.

A pulsating ear drum is a rare otological finding and usually indicates a vascular pathology. We report the case of a woman who presented with pulsatile tinnitus following an upper respiratory tract infection. She was found to have bilateral pulsating tympanic membranes on otological examination, in association with bilateral dehiscence of the tegmen tympani and a spontaneous encephalocele on the right side and a meningocele on the left side, demonstrated on computerized tomography (CT) scan of her temporal bones.

[Milestones in Gynecological Oncology over the Last 20 Years]

In den letzten Jahrzehnten vollzog sich auch auf dem Gebiet der gynäkologischen Onkologie ein grundlegender Wandel - dafür stehen Meilensteine. In der Natur der klinischen Medizin liegt jedoch, dass die für die Entwicklung, Diagnostik und Therapie relevanten <> erst dann, wenn sie sich bewährt und als dauerhaft erwiesen haben, als solche zu erkennen sind. Deshalb darf es nicht verwundern, dass sie auf dem Gebiet der gynäkologischen Onkologie meist schon vor über 20 Jahren gesetzt wurden. Obwohl es heute scheint, als seien zur Diagnose und Therapie gynäkologischer Karzinome keine grundlegend neuen Gesichtspunkte und Techniken hinzugekommen, gab es in dieser Zeit gravierende Veränderungen. Copyright 2000 S. Karger GmbH, Freiburg