On-site cytotechnician evaluation of the adequacy of fine needle aspiration in a neck lump clinic.

INTRODUCTION: The gold standard for assessing neck lumps is a one-stop clinic with an on-site cytopathologist who can provide an immediate fine needle aspiration (FNA) report. However, this has considerable resource implications and is not available in all units. In our department, surgeons perform FNAs guided by palpation. The FNA is evaluated for specimen adequacy by an on-site cytotechnician. This study evaluated the impact of the cytotechnician on the adequacy of neck lump FNA. METHODS: FNA performed between June 2010 and February 2012 was examined. The FNA performed at a neck lump clinic with an assessment of adequacy by an on-site cytotechnician were considered the test group. All other neck lump FNAs from other sources without an assessment of adequacy by an on-site cytotechnician were considered the control group. RESULTS: Of the FNAs, 134 met the inclusion criteria for this study. Of these, 87 FNAs (65%) were analysed for adequacy by the on-site cytotechnician and the remaining 47 (35%) were not. The results demonstrated an FNA inadequacy with and without on-site cytotechnician assessment of 29.9% and 40.4% respectively. This is equivalent to an absolute risk reduction of an inadequate FNA of 10.5%, which equates to a number needed to treat of 9.5, ie the cytotechnician needs to assess 9.5 (ie the cytotechnician [...] specimen). CONCLUSIONS: In neck lump clinics where on-site cytopathology is not available, an on-site cytotechnician is a compromise measure that does reduce the number of inadequate FNAs.

Sinusitis: a rare cause for galactorrhoea.

A 32-year-old woman presented to the endocrinology clinic with recent onset galactorrhoea. Investigations revealed raised prolactin levels. An MRI scan demonstrated a normal pituitary gland, and an incidental finding of sphenoid sinusitis with expansion of the sphenoid sinus was thought to be due to a mucocele. It is postulated that either the direct local pressure by the mucocele or localised inflammation secondary to sinusitis might cause hyperprolactinaemia. The patient underwent endoscopic surgery to drain the mucocele, after which her galactorrhoea resolved. A review of the literature reveals only one previously documented case of sinusitis causing hyperprolactinaemia and galactorrhoea.

Separation of serum glycated proteins by agarose gel electrophoresis and nitroblue tetrazolium staining in diabetic and normal cats.

BACKGROUND: The total glycated protein (fructosamine) concentration in serum consists mainly of glycated albumin and lipoproteins. Measurement of fructosamine is used to diagnose and monitor diabetes mellitus in cats. OBJECTIVE: The aims of this study were to measure glycated proteins in diabetic and healthy (nondiabetic) cats using a semiquantitative technique and to determine whether measurement of any of the fractions of glycated protein could be potentially advantageous for the diagnosis and monitoring of diabetic cats. METHODS: Serum samples from 6 cats with diabetes mellitus and 10 clinically healthy adult cats were assayed for total glycated protein using a nitroblue tetrazolium (NBT) fructosamine assay. Serum proteins were separated by agarose gel electrophoresis and stained with NBT to identify individual glycated proteins within the bands. Gels were scanned by densitometry at 525 nm and the glycated protein content was calculated with reference to the total glycated protein content of the sample. RESULTS: Diabetic cats with increased total fructosamine concentrations had higher concentrations of glycated albumin and glycated alpha- and beta-lipoproteins compared with healthy cats. The concentration of glycated proteins in each of the fractions had a positive linear association with the total glycated protein content of serum, but there was large variation in the relative contributions of the 3 protein fractions to the total glycated protein concentration. CONCLUSIONS: Based on the results of this study, measurement of individual glycated fractions does not seem to offer any potential diagnostic advantage over measurement of total glycated protein (fructosamine) concentration alone. In some diabetic and healthy cats, glycated lipoproteins formed the major part of the total glycated protein, whereas in other cats albumin was the major contributor.

Patient burden of centralization of head and neck cancer surgery.

This study was undertaken to assess the impact on patients of proposals to centralize head and neck oncology services in the UK. A retrospective audit of the 2001-2002 head and neck cancer database at South Devon district general hospital identified 85 patients (50 males: 35 females; median age 66 years; range 29-93) diagnosed with head and neck cancer. The total number of hospital visits for diagnostic, therapeutic and other management services were recorded (median number of visits 28; range 1-78). Using this data, the extra distance required to travel to a potential regional cancer centre located in Bristol during the first six months of management was extrapolated. It was calculated that each patient would have to travel on average an extra 5333 miles (median 5658; range 185-13 759). Published documents advocating centralization of oncology services make no reference to the patient burden of geographic relocation of medical services. Agencies involved with restructuring oncology services must recognize the non-clinical impact of centralization and make some provision to overcome the burden facing patients and their carers.

Transnasal endoscopic repair of cerebrospinal fluid rhinorrhoea.

The complications associated with the employment of neurosurgical techniques for the management of cerebrospinal fluid rhinorrhoea has led to the development of extracranial approaches. The nasal endoscope can be used to improve visualisation of the site of the leak and to facilitate free graft or septal flap placement. This ensures a high rate of dural defect healing with minimal morbidity. This study describes four cases with CSF fistulas that were repaired endoscopically and the specific surgical techniques that were used. The authors believe that, in carefully selected cases, transnasal endoscopic management of CSF leaks can be the initial surgical treatment of choice.

Double epiglottis in Weyer's acrofacial dysostosis.

While evaluating a 61-year-old patient for stridor we incidentally detected a double epiglottis. The patient was also diagnosed of having Weyer's acrofacial dysostosis which is characterized by hexadactyly affecting all four extremities, small and deeply set nails, dental deformities with small, conical teeth and mandibular hypoplasia. The double epiglottis was not the cause for the stridor. Because of the covert symptomatology of double epiglottis it is suggested that the association with Weyer's syndrome is common. Embryological evidence and a review of the literature on laryngeal abnormalities is discussed.

Merkel cell carcinoma of the pinna.

Merkel cell carcinoma is an increasingly recognized tumour of the skin. The commonest presentation is the head and neck region. Only three cases of this rare tumour have been reported on the pinna. A further such case is presented here.

An analysis of the results of myringoplasty in children.

An analysis of the results of 100 temporalis fascia underlay myringoplasties in children between the ages of 2-17 years is presented. The follow-up period in this retrospective review was from 6 to 24 months. There was no statistically significant correlation between the age of patient, a history of previous ear surgery, previous general anaesthesia, previous adenotonsillar surgery, preoperative otorrhoea, impaired eustachian tubal function, individual surgeon performing the surgery, size of perforation or operative technique and the outcome of the surgery with respect to graft take rate. The overall graft take rate was 75.3% of the 93 patients that returned for follow-up. The seniority of the surgeon and by implication the degree of operative experience of the surgeon is found to be significantly correlated with the graft take rate (P < 0.05). On audiometric testing, the mean pre-operative air conduction threshold improved significantly (P < 0.0001) from 32.0 dBHL (S.D. 11.22) to 20.18 dBHL (S.D. 15.54) while the speech reception threshold improved from a mean of 25.34 dBHL (S.D. 12.88) to 18.79 (S.D. 15.5) (P < 0.0005). Although not statistically significant, patients under the age of 8 years were found to have a low graft take rate (56%) when compared to the mean. The audiometric results in this age group were comparable to the rest of the group. The findings in this study suggest that myringoplasty is a beneficial procedure in the pediatric population in the hands of a skilled and experienced surgeon. The learning curve seen in the surgeons in this study suggests that suitable cases for junior surgeons should be carefully selected.

Defects of the first branchial cleft.

Four cases of first branchial arch defects are presented. The literature relating to such defects is reviewed and a possible embryogenic mechanism is proposed with particular reference to the disposition of the facial nerve. The classification of these defects into Types I and II by Work (1972) is supported.

Measurement of drill-generated noise levels during ear surgery.

The results of intraoperative monitoring of the electrocochleogram in patients undergoing surgery for poorly controlled Menières Disease are presented with particular reference to the masking effect of drill-generated noise. The results obtained using a direct, in vivo, electrophysiological method of assessment of drill-generated noise levels are compared with previous postmortem and intraoperative studies and the implications with respect to the likelihood of drill-generated noise induced acoustic trauma are discussed.

Submucous resection of the nasal septum as an outpatient procedure.

We report our experience of submucous resection of the nasal septum under local anaesthesia as an outpatient procedure. We have audited 50 consecutive cases and compared the results with a similar group of patients in whom the operation was carried out in the usual way under general anaesthesia. We have found the procedure to be safe, effective and economically advantageous.

Hazardous party trick (infolding of the pinna).

Two cases of habitual pinna folding are reported. One case was complicated by the development of bilateral haematoma auris as a direct result of the trauma caused by the folding.

Ventilation tube insertion under local anesthesia.

A new technique for tympanocentesis and grommet insertion using local anesthetic is described. Its routine application in suitable patients will greatly simplify the management of ventilation tube insertion in the modern health care system.

Does post-operative nasal packing cause nocturnal oxygen desaturation?

Previous studies have shown an increased frequency and duration of apnoeic episodes during sleep when the nose is occluded. The aim of this study was to ascertain whether oxygen desaturation occurs with nasal occlusion by post-operative packing. Continuous digital pulse oximetry was carried out before and after submucous resection of the nasal septum in 17 otherwise healthy patients. Post-operative nasal packing produced a statistically significant change in oxygen saturation during sleep. The change was, however, of such small magnitude that it is unlikely to be clinically significant.

Tracheostomy closure in restrictive respiratory insufficiency.

A retrospective study is presented of 31 patients who required ventilatory support via a tracheostomy for periods of one month to 27 years whilst in a tertiary referral centre for the care of patients with restrictive respiratory insufficiency. All patients underwent closure of a long-standing tracheostomy. Post-operative follow-up periods of up to 16 years are documented. The indications for and the complications of tracheostomy closure in patients with severe chronic restrictive respiratory insufficiency requiring long-term respiratory support are discussed. It is concluded that the benefits of operative tracheostomy closure outweigh the disadvantages in this unusual type of patient.

Mid-line presentation of cervical lymphomata.

Three cases of lymphoma are reported, all of which presented as a mid-line cervical swelling and appeared to be localised disease. The importance of early removal of such lesions is emphasized.

Unterberger stepping test: a useful indicator of peripheral vestibular dysfunction?

Deviation of gait in a stepping test has been proposed as a useful indicator of peripheral labyrinthine dysfunction. A prospective study of 26 patients suspected of having uncompensated peripheral labyrinthine dysfunction and 49 normal patients with normal labyrinthine dysfunction showed no significant difference in performance of the Unterberger stepping test between patients with electronystagmographically significant canal paresis and those with normal vestibular function.

Electrocochleography: a new technique.

The near field monitoring of an auditory evoked response from the cochlear (electrocochleography) is a tried and trusted clinical tool. Conventional techniques for performing electrocochleography are cumbersome to use and frequently uncomfortable for the patient. We present a simple, modified technique which provides more flexibility with regard to where and when electrocochleography may be performed and also improves patient comfort during the test.

Adenoidal hypertrophy as the presenting feature of HIV infection.

A case of symptomatic recurrent adenoidal hypertrophy, as the presenting feature of HIV infection in a haemophiliac child, is reported. The incidence of non-malignant nasopharyngeal lymphoid hyperplasia in HIV infection is examined and the relevance of the histological appearance is discussed in relation to progression of disease.