Critical Care Admissions following Total Laryngectomy: Is It Time to Change Our Practice?

Critical Care Unit (CCU) beds are a limited resource and in increasing demand. Studies have shown that complex head and neck patients can be safely managed on a ward setting given the appropriate staffing and support. This retrospective case series aims to quantify the CCU care received by patients following total laryngectomy (TL) at a District General Hospital (DGH) and compare patient outcomes in an attempt to inform current practice. Data relating to TL were collected over a 5-year period from 1st January 2010 to 31st December 2015. A total of 22 patients were included. All patients were admitted to CCU postoperatively for an average length of stay of 25.5 hours. 95% of these patients were admitted to CCU for the purpose of close monitoring only, not requiring any active treatment prior to discharge to the ward. 73% of total complications were encountered after the first 24 hours postoperatively at which point patients had been stepped down to ward care. Avoiding the use of CCU beds and instead providing the appropriate level of care on the ward would result in a potential cost saving of approximately £8,000 with no influence on patient morbidity and mortality.

Inverted Papilloma Originating Primarily from the Nasolacrimal Duct: A Case Report and Review of the Pertinent Literature.

Introduction. Inverted papilloma (IP) is an uncommon, benign yet aggressive neoplasm characterised by high recurrence rates and tendency towards malignant transformation. The majority of IP cases originate in the ethmoid region, lateral wall of the nasal fossa, and maxillary sinus. The authors report a case of an IP originating primarily from the nasolacrimal duct (NLD). Case. A 69-year-old Caucasian gentleman presented with a lump in his right medial canthal region, epiphora, and discharge bilaterally. Radiological investigation revealed a well-defined, heterogeneous mass within the proximal NLD eroding the bony canal, protruding into the middle meatus and into the right orbit. The tumour was excised en bloc utilizing a combined external and endoscopic approach based on its location. Histology revealed hyperplastic ribbons of basement membrane-enclosed epithelium growing endophytically into the underlying stroma with no evidence of invasive malignancy. The patient made an uneventful recovery with unchanged visual acuity and normal extraocular movements. Conclusion. The case demonstrates variability within the sinonasal tract that IP can develop and the individuality of each case necessitating tailored operative techniques for complete excision whilst minimising recurrence rates. We also present a combined endoscopic approach for the en bloc resection of a NLD IP with no clinical recurrence at 15-month follow-up.

Laryngeal oncocytic cyst presenting with an acute onset of stridor.

Oncocytic lesions of the larynx are rare. When they have occurred, their presentation has been varied; these tumors may be completely asymptomatic and discovered incidentally, but more commonly they present with voice alteration. We report a case of an oncocytic cyst in a patient who presented with an acute onset of stridor. We also discuss the clinical manifestations and management of laryngeal oncocytic cyst and its relevant pathologic features.

Investigation of aspiration: milk nasendoscopy versus videofluoroscopy.

Videofluoroscopy has become the gold standard investigation for assessment of aspiration in patients with clinically diagnosed dysphagia due to neurological causes. Modified nasendoscopy has been described for detection of aspiration with varying findings. Milk nasendoscopy is a simple clinic-based technique to evaluate swallow dysfunction, requiring no radiological input. This paper aims to review the correlation of milk nasendoscopy and videofluoroscopy in the detection of aspiration among patients with clinically diagnosed neurological dysphagia. Retrospective notes of 100 patients attending a combined Swallow Clinic for clinically diagnosed aspiration were reviewed. All patients were subjected to both milk nasendoscopy and videofluoroscopy. Correlation of investigation results was reviewed by Kappa test, and difference was statistically examined with Chi square test. Assessment of aspiration in pre-swallow, swallow and post-swallow phases was reviewed using milk nasendoscopy and videofluoroscopy. The significance of difference was measured using Chi square test. Milk nasendoscopy detected post-swallow phase aspiration significantly more than videofluoroscopy with no significant difference in pre-swallow phase, whereas videofluoroscopy was the investigation of choice in detecting aspiration during the swallow phase. In the investigation of clinically diagnosed neurological dysphagia, substantial correlation was seen in detection between videofluoroscopy and milk nasendoscopy. We suggest that milk nasendoscopy should be used as a preliminary clinic-based test thereby reducing the need for investigations requiring radiation doses.

Myringoplasty: surgical outcomes and hearing improvement: is it worth performing to improve hearing?

The purpose of our study was to determine the success rate of myringoplasty in adults and children and to examine whether the hearing improvement is a potential indication for surgery. We performed a 6-year prospective audit study in a cohort of patients undergoing myringoplasty at the University Teaching Hospital, Department of Otolaryngology and Head and Neck Surgery. Two hundred and eleven patients who underwent myringoplasties were included in the study. All were performed by a postaural approach using autologous temporalis fascia and underlay technique. The total success rate, in terms of graft uptake at 3-6 months, was 91.5% and an overall hearing improvement was achieved in 91.5% of cases. This was statistically significant (P < 0.001). Only weak correlation was found between hearing improvement and age (Pearson's r = 0.175, P = 0.024), and there was no significant difference in hearing improvement across gender (P = 0.164), size (P = 0.198) or site (P = 0.447) of the perforation. Myringoplasty is an operation that can improve hearing in many cases independently of age, gender and the size and site of the perforation. Patients who undergo myringoplasty should be advised whilst been consented that there is a good chance of hearing improvement.

Selective surgicel packing for the treatment of posterior epistaxis.

Rod lens endoscopes provide residents in otolaryngology a means of more accurately identifying the site of bleeding and, when possible, cauterizing the bleeding vessel. Identification of a posterior bleeding point is often difficult and sometimes impossible. Intranasal manipulation for electrocautery is painful, may require general anesthesia, and is associated with complications. We describe a pilot study designed to evaluate selectively packing the bleeding site with Surgicel (oxidized cellulose) to control the hemorrhage without packing the nasal cavity and to reduce patient morbidity and length of stay in the hospital. We describe the technique and present the results of treating 8 patients admitted with acute posterior epistaxis over a 10-month period in 1995-1996.

Pleomorphic adenoma of the base of the tongue.

We describe a rare case of pleomorphic adenoma involving the base of the tongue and adjacent valleculae. We also discuss the incidence, diagnosis, and treatment of these cases.