Use of lidocaine with phenylephrine (Co-phenylcaine) spray for anaesthesia of the external auditory canal.

OBJECTIVE: A method is described for topical local anaesthesia of the tympanic membrane and ear canal using lidocaine and phenylephrine (Co-phenylcaine) spray and soaked micropatties. DISCUSSION: The advantages of this method are discussed in comparison to existing methods.

Do wind and brass players snore less? A cross-sectional study of snoring and daytime fatigue in professional orchestral musicians.

OBJECTIVES: To determine whether playing a wind or brass musical instrument is associated with reduced snoring or daytime fatigue. DESIGN: Cross-sectional, controlled, anonymous, questionnaire-based observational study. SETTING: Rehearsal and performance halls. PARTICIPANTS: Three hundred and forty musicians from Scotland's five professional orchestras. MAIN OUTCOME MEASURES: Snore Outcomes Survey questionnaire and the Epworth Sleepiness Score. STATISTICAL METHOD: Hierarchical linear regression analysis. RESULTS: No significant difference was found between the snoring severity (Snore Outcomes Survey score) or daytime sleepiness (Epworth score) of wind/brass and other professional musicians. A regression model with snoring severity (Snore Outcomes Survey score) as the dependent variable and the three covariates of gender, age and body mass index as independent variables was significant [F(3, 206) = 28.77, P < 0.01, adjusted r(2) = 0.285]. Increasing age, body mass index and male gender were all significantly associated with lower Snore Outcomes Survey scores (i.e. worse snoring).The addition of instrument type did not significantly increase the fit of the model, and the regression coefficient for instrument type was not significant. There were similar results when the Epworth Sleepiness Score was used as the dependent variable. CONCLUSIONS: This study demonstrated no significant difference between the snoring severity or daytime sleepiness of brass/wind players and other professional orchestral musicians. This result may have been attributed to comparatively low levels of snoring/daytime sleepiness in the population studied. The findings contrast with previous studies examining the effects of singing and didgeridoo playing but concur with a recent similar study of orchestral musicians. A prospective interventional study would be required to determine whether playing a wind or brass instrument improves these variables in patients complaining of disruptive snoring.

Vanishing tumour of the internal auditory meatus.

OBJECTIVES: We report a very rare case of prostatic metastasis in the internal auditory meatus, which disappeared with treatment. CASE REPORT: An elderly man presented with a history of hearing loss, dizzy spells and, more recently, facial palsy. He also complained simultaneously of urological symptoms, which on investigation revealed advanced, metastatic prostate cancer. Radiological investigation, in the form of magnetic resonance imaging, revealed an internal auditory meatus mass which resembled an acoustic neuroma. The patient was treated with hormone injections.Tumours of the internal auditory meatus and cerebellopontine angle are mostly primary. Rarely, metastatic deposits have been described in this region, from squamous cell carcinoma, malignant melanoma, malignant parotid oncocytoma, renal carcinoma, and lung and thyroid primaries. CONCLUSION: To our knowledge, this is a very rare report in the world literature of prostatic metastasis to the internal auditory meatus. We discuss the common presenting features, investigations and treatment options for metastatic prostatic tumours of the internal auditory meatus and cerebellopontine angle.

Management of suspected foreign body aspiration in children.

We aimed to establish prevailing consultant opinion on the management of children with a history suggestive of foreign body (FB) aspiration but no clinical or radiological findings. FB aspiration is a common problem in children. Most agree that bronchoscopy should be performed if a child has clinical or radiological signs. With suggestive history but no such signs, the decision is more difficult; both bronchoscopy and neglected FBs have the potential for serious consequences. A postal questionnaire was sent to all British Association of Otolaryngologists and Head and Neck Surgeon (BAO-HNS) consultants. The 563 questionnaires sent elicited a 63% reply rate. With suspected organic FBs, 52% would bronchoscope immediately, 38% would observe, and 10% would discharge. With suspected inorganic FBs, 35% would bronchoscope, 42% would observe, and 23% would discharge. Thus, the majority suggest admission, showing a preference for bronchoscopy with a history of organic FB, and observation if inorganic. Unless justified, it may be unacceptable to discharge these patients.

A randomized control trial of post-operative care following endoscopic sinus surgery: debridement versus no debridement.

Endoscopic sinus surgery (ESS) has undergone exponential growth worldwide in the last decade. It is now accepted as a safe and effective means of treating sinonasal disease. The purpose of this study was to determine whether post-operative debridement is necessary after ESS. Seventeen patients undergoing bilateral primary ESS were randomized to receive debridement of either the left or right ethmoid cavity. All patients included in the study had symmetrical disease. Saline douches and all other concomitant treatments were delivered bilaterally. Outcome measures were based on regular symptom scores and surgeons' semi-quantitative assessment of the debrided and non-debrided cavities, over a three-month period. Analysis of adhesion rates, healing and symptom scores showed no statistically significant difference between the two groups. In conclusion, this study did not demonstrate significant benefit from post-operative ESS cavity debridement, at least with regard to cavity healing. This should be considered a pilot study and therefore limited conclusions can be drawn. Further work is needed to determine the optimum post-operative care for ESS.

Contact endoscopy of the larynx: a quantitative study.

Contact endoscopy is a technique of obtaining detailed magnified images of living epithelium, using a modified glass rod lens endoscope placed on the surface of the tissue. The technique has been extensively described in gynaecological, and more recently, laryngeal and nasal tissues. However, no quantitative studies of its diagnostic accuracy yet exist. A prospective partially blinded controlled study of eight cases with a variety of laryngeal pathologies is described. A single pathologist with no knowledge of the ultimate histological diagnoses successfully identified six of eight laryngeal pathologies on contact endoscopic findings, while the other two cases were identified to a degree of accuracy that was sufficient to positively identify the need for standard tissue biopsy. The advantages and disadvantages of the technique are described, along with suggestions for its role in clinical practice.

Tonsillitis and chronic psoriasis.

Although the relationship between streptococcal tonsillitis and acute guttate psoriasis is well recognized, its relationship to chronic forms of psoriasis is less established. In order to explore this further, the authors questioned 35 patients with severe psoriasis and 35 age-matched eczema controls about their history of significant sore throats (i.e. requiring a GP visit) and any resultant worsening of the skin condition. A third of the psoriasis patients reported recurrent sore throats which worsened their skin condition. This was true of only one (3%) of the 35 eczema controls. The authors discuss these findings in the context of recent laboratory work on the association between streptococcal infection and psoriasis.

On which day is pain worst following adult tonsillectomy?

Anecdotal evidence from several ENT departments suggests that pain following tonsillectomy is worst on the second and/or third days after surgery. This study tests this hypothesis. A pilot study with 19 subjects suggested this theory might well be true. A fuller study was then carried out on 91 subjects with standardised surgical and anaesthetic techniques, and standardised analgesia for five days postoperatively. Pain on the second and third postoperative days was compared with that eight hours after the operation and on the first, fourth and fifth postoperative days. No statistically significant difference was found. There is increasing pressure for early discharge from hospital after surgery. If pain following tonsillectomy is not going to become worse at home, this will tend to make early discharge more acceptable to patients.

Sensorineural hearing loss in MELAS syndrome.

A case of sensorineural hearing loss (SNHL) in MELAS syndrome, a variety of mitochondrial cytopathy, is presented. Mitochondrial cytopathies have gone almost unreported in the otolaryngology literature, despite evidence from a recent review that about 60 per cent of such patients suffer from SNHL (Gold and Rapin, 1994). The same review revealed that only one of 117 case reports in the period 1984-1993 contained an audiogram (Swift and Singh, 1988), and none presented sequential audiograms. However, audiometry has since been published on 23 members of a family with a mitochondrial point mutation causing only sensorineural hearing loss with no other symptoms (Vernham et al., 1994). We present a case of mitochondrial cytopathy three years after diagnosis with two sequential audiograms.

Stridor in patients with HIV infection.

The immunodeficiency which results from HIV infection is associated with a range of opportunistic infections and tumors which may present with the symptoms of upper airways disease. This paper presents three cases of stridor from different causes in patients with HIV infection, all of whom recovered following treatment. The management of this problem requires consideration of the likely aetiology which, in those with advanced immunodeficiency, includes bacterial and fungal laryngitis and epiglottitis as well as rapidly growing laryngeal tumours. Recommendations for the treatment of those with HIV infection who present with severe or rapid-onset stridor should include a combination of aggressive airway intervention and broad-spectrum antibacterial and antifungal agents. Laryngeal biopsy for histology and culture is particularly important for those patients who fail to respond to the aforementioned treatment.

Lateral cutaneous nerve of the thigh blockade as primary anaesthesia for harvesting skin grafts.

The lateral cutaneous nerve of the thigh (LCNT) supplies a large area of skin in an ideal site for harvesting a split skin graft. LCNT block was used as primary local anaesthesia for harvesting split skin grafts in 23 patients with a variety of injuries. Their ages ranged from 26 to 99 years. The mean age was 69 years. The onset of full anaesthesia took between 15 and 20 min. The area anaesthetised ranged from 250 cm2 to 1020 cm2 with a mean of 569 cm2. There were 17 successful blocks and 6 failures. Most of the 6 failures occurred during the early phase of the study. We have found that, with experience, LCNT block is a safe, simple and reliable method for achieving adequate anaesthesia for harvesting split skin graft from the thigh and that it provided excellent postoperative analgesia.

Persistent stapedial artery preventing successful cochlear implantation: a case report.

A case of persistent stapedial artery preventing cochlear implantation is described and the literature relating to this congenital anomaly is reviewed. The computed tomographic features of the artery are illustrated, and it is recommended that preoperative computed tomography be specifically screened for this anomaly.

The management of acute sigmoid volvulus in Nottingham.

Forty previously undiagnosed cases of acute sigmoid volvulus presenting over five years in Nottingham are retrospectively reviewed. The average age was 71.6 years with an even sex ratio. Fifteen (38%) patients lived in nursing homes or institutions. At presentation, all had clinical features of large bowel obstruction, confirmed on plain abdominal X-ray. Sigmoidoscopy and rectal tube decompression was successful in 23 cases. The remaining 17 patients were treated surgically, within 24 hours, at which time the sigmoid was sutured to the abdominal wall (2 cases), resected and brought out as a colostomy (10 cases) or resected and primarily anastomosed (5 cases). Whilst in hospital, of those treated conservatively five died, and three from those treated surgically, four from those in which a colostomy was formed died and three from those in which a primary anastomosis was fashioned died. Of those that survived 11 from the conservative group had at least one recurrence, but none recurred following surgery. In conclusion, acute sigmoid volvulus affects an old and infirm population and carries a poor prognosis. Conservative management is initially preferable, but if emergency surgery is necessary a colostomy rather than primary anastomosis is indicated.

Significant plain film findings in sigmoid volvulus.

The aim of this study was to evaluate the plain abdominal radiographs of patients thought clinically to have a sigmoid volvulus. Strict diagnostic criteria based on the findings at barium enema and/or surgery were applied to establish or refute a diagnosis of sigmoid volvulus. The presenting plain abdominal radiographs were assessed for 10 radiological signs considered valuable in the diagnosis of sigmoid volvulus. Of the 17 patients with a volvulus, 88% had 6 or more signs, and in the 5 patients without a volvulus, 80% had 4 signs or less. Five signs achieved significance in differentiating between the groups. Three signs, apex of the loop under the left hemi-diaphragm, inferior convergence on the left and the left flank overlap sign, were 100% specific as well as being highly sensitive. The signs which were least specific were a distended ahaustral sigmoid loop and an air fluid ratio greater than 2:1.

Mycobacterium avium acute mastoiditis.

To our knowledge, atypical mycobacterium has not previously been implicated in de novo acute mastoiditis. We encountered a case in which Mycobacterium avium was the causative agent in acute mastoiditis, in the absence of any bacterial infection.