Complications of trans-sphenoidal surgery: the Wellington experience.

BACKGROUND: All patients who underwent trans-sphenoidal surgery between January 1984 and December 1998 were reviewed to assess morbidity resulting from this operation. METHODS: There were 185 operations on 165 patients. The operative approach was sublabial in 80 cases and transnasal in 105. One surgeon (VB) performed the vast majority of operations. RESULTS: Complications included nasal perforation (7.6%), transient diabetes insipidus (4.9%), permanent diabetes insipidus (3.8%), cerebrospinal fluid fistula (4.3%), donor site haematoma (2.2%) and residual tumour haemorrhage (1.6%) causing ophthalmoplegia (1.1%) and loss of vision (1.1%). Other complications included epistaxis (1.1%), meningitis (0.5%) and sinusitis (0.5%). Injury to the anterior superior alveolar nerve also occurred in the sublabial approach in 6.3% of patients. There were no perioperative deaths. CONCLUSIONS: There is a small but significant risk of a number of complications that should be considered for informed consent of this procedure.

Non-functioning pituitary adenomas: indications for postoperative radiotherapy.

To determine the indications for postoperative radiotherapy after surgical resection of a nonfunctioning pituitary macroadenoma. A retrospective chart review of 72 patients with histologically proven chromophobe adenoma who presented for pituitary surgery between January 1985 and June 1998, with a minimum follow-up period of 12 months. The study endpoint was tumour recurrence or progression detected either by routine follow-up imaging or by clinical progression with subsequent confirmation by imaging. A proportional hazards model was used to determine independent prognostic factors. Mean follow-up was 64 months. In the radiotherapy group 13 of 50 recurred (or progressed) (26%), while in the nonradiotherapy group 10 of 22 recurred (46%), logrank test, P = 0.025. In patients assessed as having complete excision of tumour (n = 20) only two recurred (10%), both in patients without radiotherapy. No further treatment has been required in either case to date. In patients with residual tumour (n = 52), 41 had radiotherapy with 13 recurrences (32%), while 11 patients had no radiotherapy with eight subsequent recurrences (73%); logrank test, P = 0.007. Further treatment has been required in the majority of these cases. Cox's proportional hazards model analysis showed that only complete tumour removal and postoperative radiotherapy were independent favourable prognostic factors. The goal of surgery should be complete surgical excision where possible. The risk of recurrence in patients with no residual tumour on postoperative imaging is low enough to justify withholding routine postoperative radiotherapy in this group. In patients with residual tumour, conventional external beam radiotherapy administered within 12 months of surgery is effective at reducing recurrence or progression.

Validation of the combined olfactory test.

A new test of olfactory function, the combined olfactory test, has been designed to assess odours easily recognizable by the test population. The test consists of an odour recognition test of nine odours, where an odour in a bottle is chosen from a list of four possible odours in a forced choice manner. This is followed by a threshold test using a series of three-fold dilutions of 1-butanol. The mean of the two scores is the combined olfactory score. The test was subjected to a validation study. It was performed on 133 participants with a normal sense of smell and a normal rhinological examination and on 94 participants who said that they did not have a sense of smell. There was a highly significant difference between the combined olfactory score in the normal and 'anosmic' groups (P < 0.001). This significant difference was the same between the two groups for the threshold and odour recognition arms of the test. There was a highly significant difference (P < 0.001) between the two subgroups of 'completely anosmic' and 'almost anosmic' participants, indicating that the test could grade the degree of olfactory dysfunction.

Advanced head and neck cancer: proportionally higher in southland than Otago.

AIMS: To compare the proportion of advanced head and neck cancer presenting from Otago and Southland, and to discuss any differences observed. METHOD: Retrospective review of 186 patients resident in Otago and Southland who presented with a head and neck squamous cell carcinoma to the department of otolaryngology, Dunedin Hospital, between 1985-95. RESULTS: Otago patients had advanced disease in 43% of cases, compared to 66% in Southland patients (p = 0.004). Patients from rural Southland areas had advanced disease in 88% of cases. The incidence of cases was not significantly different between Otago and Southland. No difference was seen in local tumour size, however, Southland had a significantly higher rate of lymph node metastases (p = 0.0003). No difference was also seen in age, gender, duration of presenting symptoms, or delay in referral or diagnosis. CONCLUSIONS: Southland had a significantly higher proportion of advanced head and neck cancer than Otago. Significant differences in access to tertiary health care could not be found. The reasons for the differences observed were unclear.

When does middle ear effusion signify nasopharyngeal cancer?

AIM: To analyse the presenting symptoms of patients with nasopharyngeal carcinoma seen in Auckland, New Zealand, with emphasis on the significance of otological symptoms. METHOD: The records of 85 patients with nasopharyngeal carcinoma seen in the department between 1980-93 were reviewed. RESULTS: Twenty eight of patients were Pacific Island Polynesian, 21 caucasian, and 18 Chinese. The youngest patient was 11 years old. The most prominent symptoms were neck mass (53), deafness/otalgia (45), nasal obstruction (35) and epistaxis (30). The ear symptoms, representing middle ear effusion were evident for more than 9 months, on average, before a diagnosis was made. Most patients presented with multiple symptoms: 95% of patients had one or more of the above four cardinal symptoms. Only two patients presented with middle ear effusion alone: 95 of the patients with middle ear effusion had another, accompanying, cardinal symptom. Nineteen patients had cranial nerve involvement. CONCLUSIONS: Neck mass, deafness/otalgia, progressive nasal obstruction and epistaxis are the cardinal symptoms of nasopharyngeal carcinoma. A persisting middle ear effusion in people over 10 years of age must be examined for nasopharyngeal carcinoma, if an accompanying cardinal symptom is also present, or develops.

Nasopharyngeal carcinoma and middle ear effusion: natural history and the effect of ventilation tubes.

Middle ear effusion is a common occurrence in nasopharyngeal carcinoma, and is often treated by myringotomy and ventilation tube insertion. However, this can be complicated by a high rate of otorrhoea after radiotherapy. The natural history and management of middle ear effusion was examined in this retrospective study of 81 patients. An effusion was noted in 52% of patients at presentation and developed in 26% of patients after radiotherapy. At the end of the observation period there was no difference in the rate of resolution of effusions in patients with ventilation tubes insertion compared with patients with no tube insertion. A significantly greater incidence of otorrhoea and persistent perforation was found in patients with tubes (P = 0.0497). When otorrhoea occurred it was often persistent and troublesome, and so conservative management of effusions in patients with nasopharyngeal cancer should be considered.