Development and validation of a symptom questionnaire for recording outcomes in adult lacrimal surgery.

BACKGROUND: A symptom-based questionnaire (the `Lac-Q` questionnaire) for adult patients undergoing lacrimal drainage surgery was developed. The questionnaire yields a numerical score that can be used to assess severity of symptoms. METHODOLOGY: In this study, the questionnaire was evaluated in 17 consecutive patients undergoing 22 dacryocystorhinostomy (DCR) procedures. The questionnaire was administered pre- and postoperatively. The pathology encountered at operation was recorded. The success of surgery was judged by patient satisfaction, endoscopic evaluation of DCR stomal patency, and objective lacrimal drainage testing using the functional endoscopic dye test (FEDT). In a further group of 12 pre-operative cases, the questionnaire was repeated after 4-6 weeks but before surgery, to assess test-retest reliability in the absence of clinical change. RESULTS: The Lac-Q questionnaire was based on two broad categories of eye-specific scores and social impact scores. A numerical score, the `Lac-Q` score, was generated pre- and postoperatively. When compared to pre-operative scores, the reduction in Lac-Q scores postoperatively was significant. Postoperative scores also correlated well with objective lacrimal drainage testing using the FEDT. Analysis of symptom scores shows that the questionnaire was reliable with regard to content validity, internal consistency, test-retest reliability, and responsiveness to clinical change. CONCLUSIONS: We conclude that the Lac-Q questionnaire is a useful clinical tool to evaluate outcomes after adult lacrimal surgery.

Myringostapediopexy and myringolenticulopexy in mastoid surgery.

OBJECTIVE: To compare hearing results in patients undergoing myringostapediopexy or myringolenticulopexy in canal wall down mastoidectomy. STUDY DESIGN: Case series of one surgeon. A retrospective review of 83 consecutive mastoid cavity operations for primary cholesteatoma. Only those patients who had undergone either myringostapediopexy or myringolenticulopexy were included. SETTING: District general hospital. PATIENTS: Forty-two procedures were performed in 40 patients. The mean age was 42 years old. The average follow up was 5.9 years. INTERVENTION: Seventeen patients underwent myringolenticulopexy (the incus head was excised, leaving the lenticular process attached to the stapes prior to graft placement) and 25 underwent myringostapediopexy (type III tympanoplasty). MAIN OUTCOME MEASURES: Audiometry three to six months after surgery, and status of mastoid cavity after a minimum follow up of one year. RESULTS: Comparison of post-operative hearing results for the two groups showed a statistically significant hearing advantage for myringolenticulopexy (p = 0.029). In the myringolenticulopexy group, 92 per cent achieved a post-operative air-bone gap of less than 30 dB, compared with 62 per cent in the myringostapediopexy group. The mean post-operative air-bone gaps in the two groups were 17.5 and 24.7 dB, respectively. CONCLUSION: When surgically feasible, the technique of myringolenticulopexy is a useful method of preserving serviceable hearing in single-stage mastoid cavity surgery.

Long-term Paparella II grommet use in the management of persistent childhood otitis media: a 5-year follow-up study.

A comprehensive 5-year follow-up study of Paparella grommet use in UK. Study group consists of children previously treated with short-term grommets and with persistent glue ear. Mean functional period was 3.73 years with 52% being retainde for the full 5 year duration of the study. Infection and perforation rates increased with the duration of grommet in-situ and this was especially marked after 36 months. We advise the elective removal of these long-term grommets after 3 years of function to reduce compication rate.

A comparison of cocaine and 'co-phenylcaine' local anaesthesia in flexible nasendoscopy.

Cocaine is widely used as a local anaesthetic in the nose. However, it is potentially toxic, a known drug of addiction, and its spray delivery devices can theoretically transfer infection. This two-part study investigates a less toxic alternative, 5% lidocaine and 0.5% phenylephrine ('co-phenylcaine') solution, presented in a disposable spray. In the first part, the efficacy of co-phenylcaine was assessed in 25 healthy volunteers. Serial acoustic rhinometry showed a significant, sustained nasal decongestion after co-phenylcaine administration. Visual analogue scale (VAS) scores in response to a painful nasal stimulus confirmed a significant anaesthetic effect. In the second part, co-phenylcaine was compared with 10% cocaine spray in a randomized double-blind trial in 74 patients undergoing out-patient transnasal fibrescopic laryngoscopy. VAS pain ratings and nasal inspiratory peak flow recordings showed no difference between the two solutions. No adverse effects were noted. It is concluded that co-phenylcaine is an excellent alternative to cocaine nasal spray.

Sinusitis in the hypoplastic maxillary antrum: the crucial role of radiology in diagnosis and management.

Maxillary sinus hypoplasia (MSH) is occasionally encountered in otorhinolaryngological practice. The hypoplastic sinus is liable to mucus retention, and cases of MSH usually present as a persistent maxillary sinusitis. Endoscopic surgery has been recommended as an effective treatment for the sinus infection. However, MSH is associated with anomalies of the lateral nasal wall which, if not recognized pre-operatively, can lead to inadvertent surgical damage to the orbit. Although some of these abnormalities can be evident endoscopically, the role of imaging in diagnosis and identification of important surgical landmarks is paramount. A posteriorly placed middle meatal antrostomy is recommended as the surgical treatment of choice.

Facial paralysis caused by a lymphoepithelial cyst located in the parotid gland.

We report the case of an acute onset facial paralysis which was caused by a benign lymphoepithelial cyst found in the parotid, an association which is a rarity in the literature. The diagnosis and surgical management is discussed. This report emphasises the clinical principle that parotid masses causing an acute facial palsy are not necessarily malignant in nature. Intra-operative frozen section histology is helpful in saving the patient from unnecessarily radical surgery.

The middle ear as a baroreceptor.

Under pressure in the middle ear is thought to be important in the pathogenesis of chronic otitis media with effusion and its sequelae, but the cause of the under pressure and the mechanisms responsible for regulation of the normal middle ear pressure are a matter of debate. Numerous studies have examined the effect of large pressure changes on the ear; however, the ear's sensitivity to smaller pressure changes has received little attention. This study examines the sensitivity of the ear to atmospheric air pressure changes induced in the external ear canal. It is concluded that the normal ear is a very sensitive pressure receptor, and that the sensation is probably registered by stretch receptors in the tympanic membrane. Pathological changes in the tympanic membrane are associated with impaired baroreceptor function. The implications of these findings in the physiology of the ear and the regulation of middle ear pressure are discussed.

Staging carcinoma: its value in cancer of the larynx.

Three thousand four hundred and forty-five cases of cancer of the larynx were examined and 3,235 assigned to their TNM group. While good correlation with prognosis could be seen, the value of the detailed subsite (as opposed to the main laryngeal regions) was limited to defining T1a and T1b and aiding that of T2. T status gives some indication of prognosis, but the N status is of almost overriding importance.

Primary treatment of cancer of the larynx.

Analysis of 3,445 cases of cancer of the larynx with a follow-up of 99.8 per cent shows that over a period in which the survival has improved neither the modality of the treatment nor the severity of the cancer has changed. Improved survival may be due to socioeconomic factors or an improvement in the quality of treatment.

Survival of cancer of the larynx related to treatment.

Analysis of 3445 cases of cancer of the larynx has been made with reference to primary (first) and secondary treatments. It is easy to confirm that while radiotherapy is inferior to laryngectomy in the cure of larger glottic tumours, it is preferable in many cases because salvage surgery is possible and successful. Salvage surgery cannot be shown to be successful in larger supraglottic tumours, which should be considered for primary surgery. Radiotherapy appears better than surgery for small tumours.

Post-laryngectomy stomal recurrence: tumour implantation or paratracheal lymphatic metastasis?

In the treatment of obstructing laryngeal cancer, an association has often been noted between emergency tracheotomy for airway relief and subsequent post-laryngectomy stomal recurrence. It is however unclear whether this is due to tumour implantation in the tracheotomy track, or paratracheal lymph node metastasis. To investigate the pathophysiology of stomal recurrence, the recurrence rate and clinical outcome of 26 cases of T3N0M0 glottic cancer treated with emergency tracheotomy and subsequent laryngectomy were analysed, and compared with 65 stage-matched cases treated with laryngectomy alone. Analysis shows the 'emergency tracheotomy' group to have a very poor prognosis with a higher incidence of recurrence at the stoma, and also in the regional lymph nodes. These findings suggest that paratracheal lymph node metastasis is an important mechanism in the development of stomal recurrence and thus has considerable implications for the prevention of such a recurrence following laryngectomy in the patient presenting with malignant airway obstruction.

Outer ear canal shape and its relation to the effectiveness of sound attenuating earplugs.

This investigation was undertaken to explore the relationship between the level of sound attenuation achieved by the wearing of hearing protectors, and the shape of the external ear canal. Bilateral molds of the outer portion of the external ear canal were made in 93 males and females with normal hearing, who had participated in a previous study on the effect of gender on sound attenuation, measured for a variety of insert type devices. The ear canal molds were analyzed in terms of tortuosity, caliber, and degree of funneling. The results showed that individuals with straight canals achieved significantly higher attenuation scores than those with twisted canals. With regard to caliber, the more important of the two parameters reviewed was the cross-sectional area of the canal measured at the cartilaginous-bony junction (IA). The relationship between IA and attenuation depended on both gender and the type of earplug tested. Funneling, measured by the ratio of concheomeatal and cartilaginous-bony cross-sectional areas, had the opposite effect of that for IA. These findings underscore the need for more controlled prescription and fitting procedures for the insert type of hearing protectors commonly used in the industrial setting.

Glomus bodies in the temporal bone.

There are very few studies in the literature of the anatomy of glomus bodies in the temporal bone, and their function in the normal ear remains undiscovered. In this study, human, squirrel monkey, and cat temporal bone sections were examined by light microscopy for the presence of glomus bodies, and the anatomy and distribution of glomus bodies in the temporal bone is described. For the first time, glomus bodies have been identified in non-human temporal bone sections. A possible function for these chemoreceptor-like structures in the ear is discussed.

The glomus tympanicum: a middle ear chemoreceptor?

Negative pressure in the middle ear has been identified as an important factor in the pathogenesis of middle ear disease. Unfortunately, to date, the physiological mechanisms that control middle ear pressure are poorly understood. Recent interest has focused on the possible role of carotid body-like tissue in the middle ear (the glomus tympanicum) as a chemoreceptor for changes in the gas composition of the middle ear. From the few anatomical studies of normal glomus tissue in the temporal bone it would seem that glomus bodies may not be consistently present in the middle ear. In this study, glomus bodies were sought in histological preparations of the promontory mucosa and tympanic plexus. It was found that the glomus tympanicum is only occasionally present in the middle ear mucosa, and thus a chemoreceptor role specific to the middle ear is unlikely.

Secretory otitis media--evidence for an inherited aetiology.

In a study to determine whether or not there is a familial or hereditary predisposition to develop secretory otitis media (SOM), the parents of 73 children with persistent SOM and 35 controls were examined clinically, and abnormalities of the tympanic membrane (TM) noted. Analysis of the findings suggests that heredity plays a large part in determining a child's likelihood of developing SOM.