Evidence-based applications of mitomycin C in the nose.

BACKGROUND: Mitomycin C (MMC) is an antimitotic drug that may, when applied topically, prevent postoperative stenosis. Its use remains controversial. This review aims to provide otolaryngologists with an update of the evidence on the applications of this agent in the nose and sinuses. METHODS: A systematic review was performed. Inclusion criteria were as follows: English literature, original articles, reviews, and case series. Exclusion criteria were as follows: animal and in vitro studies, nonendoscopic and nonsinonasal applications of MMC, and external lacrimal surgery. Studies that used other ways of dilating stenoses in conjunction with MMC were excluded. RESULTS: Out of 48 studies published, 9 fulfilled our inclusion criteria, totaling 322 patients. Eighty-five percent were primary and 15% were revision cases. Follow-up ranged from 1 to 42 months. Main outcome measures used were endoscopic examination, anatomical measurements, radiological scoring systems, dye tests, and subjective symptom resolution. Main overall outcomes from studies where extrapolation of data was feasible were (1) patency rate, which ranged from 63% to 94.4% (mean, 81.3%); (2) adhesions: 5.1% (MMC) vs 15.05 (control); and (3) stenosis: 14.05% (MMC) vs 32.6% (control). CONCLUSIONS: There appears to be a favorable short-term effect of MMC, but no robust evidence regarding long-term prevention of restenosis. Larger homogenous and multicenter randomized trials are needed to assess the long-term effects of MMC in sinonasal surgery.

Influence of audit on clinical practice: multidisciplinary team data documentation for cutaneous head and neck malignancy.

BACKGROUND: Prognosis of cutaneous head and neck malignant neoplasms is related to type, site, and histologic feature but may also be influenced by delays in the referral process. Treatment aims to address the primary lesion and when necessary the secondary disease but at the same time maintaining quality of life and minimizing cosmetic deformity. The management plan should ideally be the "product" of a multidisciplinary team (MDT) approach of dermatologists, surgeons, oncologists, pathologists, and radiologists. AIMS: The purposes of the study were as follows: (i) to review current documentation practice of cutaneous head and neck malignancies in a district hospital, (ii) to generate an MDT-approved data collection proforma, and finally (iii) to reaudit documentation of head and neck skin lesions based on the "new" standardized proforma. The MDT-approved proforma was instituted in an effort not only to collect data in a coherent and structured way but also to achieve early diagnosis and avoid delays from urgent referral to treatment with the aim of curing disease and restoring patients to as near-normal appearance and quality of life as possible. METHODS: The notes of patients with head and neck cutaneous lesions were prospectively audited for a 6-month period (August 2006-January 2007). The presence and absence of a minimal standardized data set required for MDT discussion and review were recorded. RESULTS: Documentation was deficient and a need for change in practice emerged. An MDT-approved data collection standardized proforma was designed and distributed throughout the hospital departments involved in management of patients with head and neck cutaneous lesions. The notes of these patients were prospectively reaudited through a second cycle for a 6-month period (February 2007-August 2007). The completion and deficiency of sections of the MDT-approved data collection standardized proforma were recorded, resulting in closure of the audit loop. CONCLUSIONS: The data documentation for head and neck cutaneous lesions has significantly improved after the implementation of an MDT-approved data collection standardized proforma. This has resulted in improved patient quality of care and progression on appropriate management plans.

Lemierre's syndrome: A systematic review.

OBJECTIVES/HYPOTHESIS: Lemierre's syndrome is characterized by a history of recent oropharyngeal infection, clinical or radiological evidence of internal jugular vein thrombosis, and isolation of anaerobic pathogens, mainly Fusobacterium necrophorum. It was once called the forgotten disease because of its rarity, but it may not be that uncommon after all. This review aims to provide physicians with an update on the etiology, management, and prognosis of Lemierre's syndrome. METHODS: Systematic review using the terms: Lemierre's syndrome, postanginal septicemia, fusobacterium, internal jugular vein thrombosis. INCLUSION CRITERIA: English literature; reviews, case reports, and case series. EXCLUSION CRITERIA: variants or atypical Lemierre's syndrome cases, negative fusobacteria cultures, and papers without radiological evidence of thrombophlebitis. RESULTS: Eighty-four studies fulfilled our inclusion criteria. The male to female ratio was 1:1, 2, and the ages ranged from 2 months to 78 years (median, 22 years). Main sources of infection were tonsil, pharynx, and chest. Most common first clinical presentation was a sore throat, followed by a neck mass and neck pain. The most common offending micro-organism was F. necrophorum. Treatment modalities used were antimicrobial, anticoagulant, and surgical treatment. Morbidity was significant with prolonged hospitalization in the majority of patients. The overall mortality rate was 5%. CONCLUSIONS: Lemierre's syndrome may not be as rare as previously thought. This apparent increase in the incidence may be due to antibiotic resistance or changes in antibiotic prescription patterns. Successful management rests on the awareness of the condition, a high index of suspicion, and a multidisciplinary team approach.

A systematic review of outcomes following surgical decompression for dysthyroid orbitopathy.

OBJECTIVES: To systematically review and compare the surgical outcomes of orbital decompression for dysthyroid orbitopathy. METHODS: Data sources used were PubMed, EMBASE, and Cochrane search for English-language literature from January 1990 to April 2008, combined with manual review of citations within article bibliographies. Citations acquired from the targeted search were filtered independently by two researchers. Relevant articles were reviewed to obtain information including interventions and outcome measures. Articles were then assigned level-of-evidence grades as defined by the Oxford Centre for Evidence-Based Medicine. RESULTS: A total of 516 citations were generated from which 135 abstracts were regarded as potentially relevant. After other relevant articles identified from the bibliography and duplicate articles excluded, 56 studies were available for analysis. Fifty studies were identified as level 4 and six as level 3 evidence. A total of 2,315 patients were pooled, from which 4,176 orbits were decompressed. Fifteen different surgical techniques were broadly identified. The most common surgical indication was cosmesis. Decompression by combined transpalpebral-endoscopic technique resulted in the highest average reduction in postoperative proptosis. The largest improvement in visual acuity was after coronal approach orbital decompression. The overall complication rate was 9.3%. The most significant complications were vision loss and cerebral vascular accident. The highest complication rate was associated with combined endoscopic and transpalpebral decompression. CONCLUSIONS: There are myriad techniques in practice for decompressing the orbit, but no one technique has yet to achieve consistently good outcome and low complication rates. The reporting of outcomes should conform to a minimum dataset. Laryngoscope, 2009.

Challenging airways in deep neck space infections.

Skilful airway management is critical in deep neck space infections. Although relatively uncommon, this spectrum of disease presents a clinical challenge for otolaryngologists and anesthetists. There is currently no universal agreement on the ideal method of airway control for these patients because this depends on various factors including available local expertise and equipment. We review the literature and discuss the available options of airway management in these head and neck emergencies. Special consideration is given to awake fiberoptic intubation and tracheotomy under local anesthesia. Relevant anatomy, route of spread and microbiology of deep neck space infections are also briefly discussed.

Unusual complications of tonsillectomy: a systematic review.

AIMS: Common complications of tonsillectomy are well recognized and are frequently explained to patients during the process of informed consent. This systematic review serves as a reminder of the unusual complications of this routine procedure. METHODS: Studies were located using systematic searches in Medline, Embase, Cinahl, and the Cochrane Library electronic databases, together with hand searching of key texts, references, and reviews relevant to the field. Keywords used included the terms tonsillectomy, complications, unusual, and rare. References from the relevant articles were also searched for. INCLUSION CRITERIA: The review was limited to English-language articles. Because of the low incidence of these complications, all cases were included regardless of age. EXCLUSION CRITERIA: Complications of tonsillectomy in children with various syndromes were excluded. RESULTS: Based on our criteria, 20 articles were identified. Only 10 articles were found suitable for review. All articles were either single case reports or small case series. Because of the small study cohort, the patients' ages ranged widely, from 3 to 21 years, with no sex dominance. The complications were categorized into intraoperative and immediate postoperative (<24 hours), intermediate (<2 weeks), and long-term (>2 weeks) unusual complications. Rare complications reviewed include intraoperative vascular injury, subcutaneous emphysema, mediastinitis, Eagle syndrome, atlantoaxial subluxation, cervical osteomyelitis, and taste disorders. CONCLUSIONS: It is important that the otolaryngologist is aware that although the complications discussed are rare and interesting, they are associated with significant morbidity and mortality risks. Tonsillectomy, a very common ear, nose, and throat procedure, may not be so straightforward after all.