Tumour-to-tumour metastasis: breast carcinoma to an olfactory neuroblastoma.

Tumour-to-tumour metastasis is a rare phenomenon. It occurs when a primary tumour is a recipient of a separate tumour within the same individual. We present a case of a 66-year-old woman with known breast cancer who presented with one-sided nasal symptoms. Examination and imaging revealed a unilateral polyp arising from the skull base. She underwent endoscopic polypectomy with the histology demonstrating tumour-to-tumour metastasis from a breast carcinoma to an olfactory neuroblastoma, a rare sinonasal tumour. Clinicians should be cautious of distant metastases in any patient presenting with head and neck symptoms and a known primary tumour. This is the first documented case of this type.

Metastatic endometrial cancer of the paranasal sinuses.

Endometrial carcinoma is the fourth most common cancer affecting women in the UK. Its most frequent sites of spread are to the pelvic and para-aortic lymph nodes, vagina and peritoneum. We report a case of a 63-year-old woman with known endometrial cancer who presented with left facial swelling and eye displacement. Investigations revealed an expansile soft-tissue density mass arising within the bone, centred on the left zygoma, with exophytic extension into the left maxillary antrum, infratemporal fossa and inferiorly into the orbit. Endoscopic biopsies were taken and histology confirmed metastatic deposits of endometrial cancer. Clinicians should be aware that distant spread of endometrial cancer is linked with advanced disseminated disease and palliative treatments should be considered.

Evidence-based management of epistaxis in hereditary haemorrhagic telangiectasia.

BACKGROUND: There are currently no guidelines in the UK for the specific management of hereditary haemorrhagic telangiectasia related epistaxis. The authors aimed to review the literature and provide an algorithm for the management of hereditary haemorrhagic telangiectasia related epistaxis. METHOD: The Medline and Embase databases were interrogated on 15 November 2013 using the search items 'hereditary haemorrhagic telangiectasia' (title), 'epistaxis' (title) and 'treatment' (title and abstract), and limiting the search to articles published in English. RESULTS: A total of 46 publications were identified, comprising 1 systematic review, 2 randomised, controlled trials, 27 case series, 9 case reports, 4 questionnaire studies and 3 in vitro studies. CONCLUSION: There is a lack of high-level evidence for the use of many of the available treatments for the specific management of epistaxis in hereditary haemorrhagic telangiectasia. Current management should be based on a multidisciplinary team approach involving both a hereditary haemorrhagic telangiectasia physician and an ENT surgeon, especially when systemic therapy is being considered. The suggested treatment algorithm considers that the severity of epistaxis merits intervention at different levels of the treatment ladder. The patient should be assessed using a reproducible validated assessment tool, for example an epistaxis severity score, to guide treatment. More research is required, particularly in the investigation of topical agents targeting the development and fragility of telangiectasiae in hereditary haemorrhagic telangiectasia.

Patient reported outcome measures in septorhinoplasty surgery.

INTRODUCTION: Surgical procedures incorporating a cosmetic element such as septorhinoplasty and otoplasty are currently under threat in the National Health Service (NHS) as they are deemed to be procedures of 'limited clinical benefit' by many primary care providers. Patient reported outcome measures (PROMs), which assess the quality of care delivered from the patients' perspective, are becoming increasingly important in documenting the effectiveness of such procedures. METHODS: The Rhinoplasty Outcomes Evaluation (ROE) questionnaire, a validated PROM tool, was used to assess patient satisfaction in 141 patients undergoing septorhinoplasty surgery over a 90-month period at the University Hospital Southampton NHS Foundation Trust. RESULTS: Overall, 100 patients with a mean follow-up period of 36 months completed the study. The mean ROE score was 73.3%. In addition, 75% of patients questioned were happy with the final result of their operation and 83% would undergo the procedure again if required. These benefits occurred irrespective of age, sex and primary versus revision surgery, and were maintained for up to 71 months following surgery. CONCLUSIONS: This study has shown that patients are generally satisfied with their functional and cosmetic outcomes following septorhinoplasty surgery. These results help support the case for septorhinoplasty surgery to continue being funded as an NHS procedure.

Computer or not? Use of image guidance during endoscopic sinus surgery for chronic rhinosinusitis at St Paul's Hospital, Vancouver, and meta-analysis.

BACKGROUND: The advantages and limitations of image guidance systems for endoscopic sinus surgery are unclear. We report our experience and present a meta-analysis of the evidence. METHODS: We performed a retrospective analysis of endoscopic sinus surgery procedures performed with versus without image guidance. A total of 355 cases was included. Primary outcomes included complication rates and time to revision surgery. A literature search was conducted to enable identification and analysis of studies of similar comparisons. RESULTS: Within 1.5 years of the index sinus surgical procedure, the risk of revision surgery was significantly higher for patients treated with non-assisted versus computer-assisted endoscopic sinus surgery (p = 0.001). Meta-analysis did not indicate a reduction in complications or revision surgery procedures with the use of image guidance systems, although the majority of included studies showed a non-significant reduction in revision surgery. CONCLUSION: Our study offers some evidence that computer-assisted endoscopic sinus surgery may delay residual disease and reduce the requirement for revision surgery. Although this finding was not borne out in the meta-analysis, the majority of identified studies demonstrated a trend towards fewer revision procedures after computer-assisted endoscopic sinus surgery. This type of surgery may offer other advantages that are not easily measurable.

Guillotine versus dissection tonsillectomy: randomised, controlled trial.

OBJECTIVE: This trial aimed to compare the guillotine technique of tonsillectomy with 'cold steel' dissection, the current 'gold standard'. DESIGN: A single centre, randomised, controlled trial. METHODS: One hundred children aged 3 to 11 years who were listed for bilateral tonsillectomy were recruited. Patients had one tonsil removed by each technique, and were blinded to the side. The operative time, intra-operative blood loss, haemostasis requirement and post-operative pain scores were recorded and compared. RESULTS: Operative time and intra-operative blood loss were both significantly less for the guillotine technique (p < 0.001) and there was a significantly reduced haemostasis requirement (p < 0.001). Pain was also less on the guillotine side (p < 0.001). There were no tonsillar remnants or palatal trauma for either technique. There was no significant difference between techniques in the frequency of secondary haemorrhage. CONCLUSION: This study provides level Ib evidence that guillotine tonsillectomy in children with mobile tonsils is an effective and time-efficient procedure which produces less intra-operative blood loss and post-operative pain than cold steel dissection.

Rapidly progressing giant invasive prolactinoma.

OBJECTIVE: We report an extremely rare case of a giant invasive prolactinoma presenting as a nasopharyngeal tumour. METHOD: Case report and literature review regarding giant prolactinoma. RESULTS: Giant prolactinoma is a rare form of prolactinoma which accounts for 0.5-4.4 per cent of all pituitary tumours. It is more common in men and generally presents with symptoms of endocrine disturbance or neurological deficit. CONCLUSION: To our knowledge, this is the first report of giant prolactinoma presenting with symptoms of sinusitis and nasopharyngeal tumour.

Guillotine tonsillectomy: a neglected technique.

BACKGROUND: Increased post-operative tonsillectomy haemorrhage rates have been observed following 'hot' tonsillectomy techniques, compared with 'cold steel' dissection. Post-tonsillectomy haemorrhage rates and the degree of blood loss during guillotine tonsillectomy have not been reported in the recent literature. METHODS: This retrospective case note review assessed the degree of blood loss during guillotine tonsillectomy, as measured by the number of tonsil swabs used, and the post-tonsillectomy haemorrhage rate. RESULTS: In a group of 168 patients, no tonsil swabs were used in 13.1 per cent of cases, and less than two tonsil swabs were used in 41.1 per cent of cases. CONCLUSION: Guillotine tonsillectomy, when performed by the method described in this article, resulted in minimal intra-operative blood loss in 54 per cent of cases, and appeared to have comparable post-tonsillectomy haemorrhage rates to cold steel dissection techniques.

The effect of auditory stimulation on the tensor tympani in patients following stapedectomy.

CONCLUSION: We believe that a tensor tympani reflex, in response to loud sound, is present in a minority of people, although its functional significance with regard to sound transmission is questionable. The absence of startle response in our stapedectomized subjects makes us question whether the tensor component of the startle response is large enough to be identified by manometry. OBJECTIVES: This study was organized to examine reflex activity to stimulation by loud sound or by startle in the tensor tympani. Although many previous studies have been carried out, results have been contradictory, and methodological flaws have rendered the interpretations questionable. PATIENTS AND METHODS: Stapedectomized patients were invited to take part in the study. Thirteen patients underwent testing by extratympanic manometry, using a standard tympanometer. Responses were observed during repeated stimuli with loud sound at 500, 1000, 2000 and 4000 Hz to the ipsilateral and contralateral ears, and with an air jet against the closed eye. A control group was also studied for the startle test. RESULTS: Three clear ipsilateral (23%) and two clear contralateral (14%) responses to auditory stimuli were seen in the 13 patients. We found responses to startle stimuli in none of our study group and eight (42%) of control ears.

Superior semicircular canal dehiscence with a large tegmental defect.

We report on the presentation and clinical manifestations of superior semicircular canal dehiscence in association with a large defect of the tegmen tympani in a 41-year-old woman with no previous history of trauma. Based on this case we recommend that clinicians consider the possibility of superior semicircular canal dehiscence in patients presenting with symptoms associated with tegmen defects.

Is unilateral tonsillar enlargement alone an indication for tonsillectomy?

INTRODUCTION: Unilateral tonsillar enlargement is often seen in the out-patient setting. Frequently, these patients are listed for tonsillectomy for the purpose of ruling out malignant histology. This study aims to determine the necessity for tonsillectomy. METHOD: This retrospective case-note review looks at all the tonsillectomies performed for histological examination at our institution over a five year period, and analyses the histological findings in those with unilateral tonsillar enlargement (UTE) alone, and those with UTE with other clinical features (history of chronic pain, dysphagia, the presence of tonsillar or peritonsillar mucosal abnormality, those with cervical lymphadenopathy). All patients who underwent tonsillectomy for the purpose of histological examination from 1 June 1998 to 30 May 2003 were identified and their notes reviewed. Exclusion criteria included cases where there were no pre-operative out-patient notes, those patients where the specimens had been sent from other hospitals, those patients who had malignancy already diagnosed, and those cases where tonsillectomy had been performed by other surgical specialties (e.g. maxillofacial, plastics). There were 1475 tonsillectomies, of which 181 performed over this period were sent for histological analysis. After excluding those patients that did not meet our criteria, we were left with 53 patients who had UTE. The primary outcome measure was the rate of malignancy in the two groups. RESULTS: Of these, 33 had UTE alone, 20 had associated clinical features. In the former group, none of the patients were found to have malignancy. In the latter, nine (45 per cent) had a malignancy. Fisher's exact test was used to test for differences between the UTE alone group versus the UTE plus other features group (p<0.001). DISCUSSION: The prevalence of malignancy in tonsils which exhibit asymmetry with no other clinical features is very low; in our study it was zero. However, other studies have found a small percentage representing underlying malignancy. In view of this, we feel that a 'watch and wait' policy is initially more appropriate, and if symptoms or signs are progressive, tonsillectomy should then be advised.

Bony overgrowth onto fixture component of a bone-anchored hearing aid.

An eight-year-old boy with Treacher Collins syndrome was fitted with a bone-anchored hearing aid. The audiometric result was excellent. Two years later, the abutment began to loosen and could not be tightened. It was thought that a new fixture would be required, with loss of use of the aid for three months. At surgery, bone was found to be growing over the hexagonal joint between fixture and abutment. A simple and rapid solution to this problem is described.

Subdural haematoma: a complication of cochlear implantation.

Cochlear implants have transformed the treatment of sensorineural hearing loss. They have few major complications. The authors describe the case of a man fitted with a cochlear implant who suffered a postoperative subdural haematoma. The haematoma is thought to have been caused by bleeding from emissary veins opened by the drill passages used to anchor the sutures for the receiver/stimulator. The authors have abandoned tie down sutures in cochlear implants, preferring an appropriately deep well with squared-off rims, which would secure the implant in place. They have had no further complications of this nature.