Improved quality of life in adults undergoing tonsillectomy for recurrent tonsillitis. Is adult tonsillectomy really a low priority treatment?

There is a paucity of studies on patient-reported outcome measures in adult tonsillectomy. Our aim was to add to the body of health-related quality of life (HRQOL) evidence on adult tonsillectomy at a time when this intervention is being branded a low priority treatment in the United Kingdom (UK). We designed a prospective questionnaire study that was carried out in two UK district general hospitals. 41 patients were recruited into the study and completed a pre-operative short form 36 questionnaire. All 41 were contacted at least 1 year after tonsillectomy and were asked to complete the same SF-36 questionnaire and three additional HRQOL questions. There was a significant improvement in quality of life shown by both the mean SF-36 scores and the HRQOL questions. The SF-36 summary measures and the total SF-36 scores improved significantly (p < 0.01). The study emphasises the importance of tonsillectomy being available on the National Health Service to adults with recurrent tonsillitis. This proven quality of life improvement is also highly likely to confer a secondary health economic benefit from less GP attendances and fewer missed work days.

Partial laryngectomy for recurrent laryngeal carcinoma.

From July 1975 to January 1998, 33 patients underwent partial laryngeal resection for residual or recurrent tumour after primary radical radiotherapy. Sixteen patients had T1 tumours on presentation, 14 were T2 and three were T3. Six patients underwent a supraglottic (horizontal) laryngectomy, 24 had a vertical partial laryngectomy, two had an endoscopic laser resection and one had an endoscopic laser resection followed by a vertical partial laryngectomy. The median time interval between radiotherapy and salvage surgery was 10 months (range 2-188 months). The median follow-up period was 41 months (range 12-185 months). There were five major postoperative complications (15%); two patients developed a pharyngeal fistula and three required further surgery for laryngo-tracheal stenosis. Twenty-five patients (76%) retained their larynx with satisfactory speech and swallowing. Eight patients (24%) had to be converted to a total laryngectomy, seven for recurrent disease and one for laryngeal stenosis. Of the eight patents converted, seven had normal swallowing and six developed good tracheo-oesophageal speech. Seven patients (21%) developed recurrent tumour after partial laryngectomy and were subjected to total laryngectomy; six of these seven were salvaged. Only one of the 33 patients died with recurrent tumour, giving an ultimate disease-related survival of 97%. Conservation laryngeal surgery for salvage of selected patients who fail radical radiation therapy is safe, effective, and results in reasonable preservation of laryngeal function.

Penetrating oral foreign body presenting as an aural polyp.

A case of a penetrating oral foreign body presenting with an aural polyp is described. The possibility of a penetrating oral injury should be considered whenever a child's fall is unwitnessed, as it is easily overlooked. An underlying foreign body should be considered in cases where an aural polyp fails to respond to standard therapy. MRI may be the best imaging technique to identify plastic foreign material.

The predictive value of tympanometry in the diagnosis of middle ear effusion.

Over a 12-month period 501 children (age range 11 months to 15 years) underwent surgery for a possible middle ear effusion. All had tympanometry performed within 2 h of surgery. The results of tympanometry were correlated with the surgical findings in 955 ears. A type-B tympanogram has a high sensitivity (0.91) in predicting middle ear effusion with good specificity (0.79). A type-A tympanogram has a very high specificity (0.99) in predicting a dry middle ear but low sensitivity (0.34). Both the positive (0.91) and negative (0.84) predictive values of a type-A tympanogram are high. The addition of a type-C tympanogram increases the sensitivity of predicting a dry middle ear to 0.79. The positive predictive value of a peaked (type-A or -C) tympanogram is 0.71 and should be considered strong evidence that the middle ear is dry. Tympanometry is the best clinical test for the presence or absence of a middle ear effusion, and on the basis of preoperative tympanometry alone the need for surgery should be carefully reassessed.

Rosai-Dorfman disease presenting as a parotid mass.

Sinus histiocytosis with massive lymphadenopathy (SHML) is a rare, benign disease of unknown aetiology. This disease typically presents with massive, painless cervical lymphadenopathy but may occur in a wide variety of extranodal sites. Our report describes a 71-year-old man who presented with a discrete, unilateral parotid mass which was clinically suggestive of a primary salivary gland tumour. Initial cytological examination of a fine needle aspirate specimen taken from the mass demonstrated a discohesive cell population with nuclear atypia, raising the possibility of malignancy. However, excision of the mass and histological examination enabled a definitive diagnosis to be made.

Metastatic papillary thyroid carcinoma presenting as a typical branchial cyst.

Two cases of papillary thryoid carcinoma presenting as a cystic lateral neck mass are reported. This tumour characteristically presents in patients under 40-years-old and in the presence of an occult primary tumour may mimic a branchial cyst. In such cases simple aspiration of the cyst will produce a chocolate-brown serous fluid which excludes the diagnosis of a branchial cyst and is characteristic of papillary thyroid carcinoma. Cytological examination of the fluid has a high degree of sensitivity and specificity in the diagnosis of thyroid malignancy and should avoid delay in diagnosis and unnecessary surgical exploration prior to definitive treatment.

Atypical carcinoid tumour of the larynx.

The case of an atypical carcinoid tumour of the larynx is described in a 65-year-old man. This rare tumour may present diagnostic difficulties, but the diagnosis should be considered in a patient presenting with symptoms of local or referred pain and an apparently small, non-ulcerating supraglottic tumour. Immunocytochemistry has an important role in establishing the diagnosis. A very unusual feature of this case was positive staining for S-100 protein by sustentacular cells. Atypical carcinoid tumours do not respond well to radiotherapy so the primary treatment should be surgical resection.

Chondrosarcoma of the temporal bone.

Eight patients with a chondrosarcoma of the temporal bone have been treated at the National Hospital for Neurology and Neurosurgery over a 16-year-period. Patients usually presented with symptoms and signs of lower cranial nerve palsies, though in most cases these resolved after surgery. This result, combined with the fact long-term survival can be achieved, makes surgical treatment of these tumours the best option, as the response to primary radiotherapy is uncertain. Surgical access is difficult, but an infratemporal approach is probably the most satisfactory. The use of post-operative adjuvant radiotherapy may provide some benefit. Long-term follow-up is necessary, and for this magnetic resonance imaging (MRI) is preferable to computed tomography (CT) scanning.

Smooth muscle tumours of the larynx.

Two cases of laryngeal smooth muscle tumours are reported: one a benign leiomyoma, the other a malignant leiomyosarcoma. These tumours may present diagnostic difficulties and immunocytochemistry is helpful in distinguishing smooth muscle tumours from other connective tissue neoplasms and spindle cell squamous carcinoma. Primary treatment in both cases should be surgical resection with small (T1, T2) malignant tumours suitable for partial laryngectomy. Postoperative radiotherapy may have a role in allowing a more limited surgical resection.

Outcome following discharge from an ENT out-patient clinic: patient and general practitioner satisfaction.

Fifty consecutive patients discharged from clinic were assessed by questionnaire at the time of discharge and 6 months later. Each patient's practitioner (GP) was sent a questionnaire at 6 months. On discharge, 12.5% of patients would have preferred another appointment and 7.5% were unhappy at being discharged. After 6 months 14% would have preferred ENT follow-up. Twenty-six per cent of patients said they saw their GP within 6 months of discharge with symptoms related to their initial ENT complaint. From the GP questionnaire the proportion was 31.5%. General practitioners were happy to manage the patients themselves and only one patient was seen again in the ENT department within 6 months. In no case did the GP feel discharge to be premature. Pre-reading of notes leading to an increase in the proportion of patients discharged from ENT clinics does not result in more discharges being premature or inappropriate. The majority of patients and general practitioners are happy for ongoing medical care to be continued without further ENT appointments if the nature of the condition and its long-term management is explained clearly.

Out-patient management by junior staff: the value of consultant supervision.

The effect of consultant supervision on management of patients by junior staff was assessed. Supervision was exercised by pre-reading the notes with the consultant at the start of the clinic. The principle finding was that less patients were brought back for another appointment. For new patients, the proportion fell from 40% to 19%, and for follow-up patients it fell from 49.5% to 29%. The overall rate fell from 46% to 23.5%. This has major implications with respect to use of resources and, in the unit studied, this change would make available 38 extra clinic appointments for each registrar per month. The study also raises issues regarding the use of out-patient clinics for post-graduate training and consultant supervision of patient management in general.

Isolated sphenoid sinusitis due to Pseudallescheria boydii.

A case of sphenoid sinusitis due to Pseudallescheria boydii is described in a 52-year-old non-immunocompromised woman. Treatment should always involve surgical drainage, and antifungal chemotherapy may be of benefit if there is histological evidence of invasion of surrounding tissue. For P. boydii infection miconazole should be the agent of choice, rather than amphotericin B. For this reason it is important to obtain culture and histological examination of sinus contents if fungal infection is suspected.