Endolaryngeal cysts presenting with acute respiratory distress.

This is a retrospective review of benign cysts of the adult endolarynx that presented as airway emergencies in four teaching hospitals of Dublin, Ireland, over 2 years. During that period nine patients with endolaryngeal cysts necessitating emergency airway intervention were managed. All cases were treated by endoscopic microlaryngeal marsupialization after securing the airway either at the same time or as a staged procedure. Four of these patients required tracheostomies, one performed under local anaesthesia and the others after initial endotracheal intubation. Definitive treatment was carried out in six cases at initial endoscopic diagnosis. Three of the tracheostomized patients had a staged management, two because of their medical status and one for further investigations. On the basis of our findings we suggest that all benign cysts around the endolarynx should simply be called 'endolaryngeal cysts' instead of the current practice of trying to classify them into various histological and morphological types with no prognostic or management differences. Benign cysts of the endolarynx presenting with airway obstruction would appear to be more frequent than is generally maintained in the literature.

Temporal bone Manifestations of Eosinophilic Granuloma.

Eosinophilic granuloma is one of the triad of conditions collectively known as Histiocytosis-X. It is an uncommon granulomatous diseas which can affect the temporal bone(1) Allthough initially quiescent the disease may erode the mastoid cortex, destroy tegmen and extend into the cranial as well as erode the semicircular canals, cochlea or facial canal, giving rise to facial palsy. These lesions almost always become infected and can confused with chronic otomastoiditis. When diagnosed, theraphy consists of conservative surgery, radiation theraphy, steroids and chemotherapy(2).

The accuracy of citation and quotation in otolaryngology/head and neck surgery journals.

A high rate of errors of citation and quotation has been reported in the publications of many medical specialties. The aim of this study was to determine the prevalence of citation and quotation errors in otolaryngology/head and neck surgery journals. A retrospective analysis was performed based on the first issue for 1997 of each of four journals: Laryngoscope; Annals of Otology, Rhinology and Laryngology; Clinical Otolaryngyology; and Journal of Laryngology and Otology. A sample of 50 references from each journal was randomly selected and each was checked for accuracy against the original referenced paper. Citation errors were categorized as major, intermediate or minor and quotation errors as major or minor. Citation errors occurred in 37.5% of the references, 11.9% of which were considered major errors. Quotation errors occurred in 17%, with 11.1% major errors. This prevalence is similar to the established error rate in medical literature.

Improvements in health and behaviour following childhood tonsillectomy: a parental perspective at 1 year.

To determine subjective parental impressions following routine tonsillectomy we have interviewed the parents of 80 children 1 year following the procedure. Results show that the procedure carried a 100% parental satisfaction rating. All parents felt their child's symptoms of recurrent acute tonsillitis had improved and over 90% of parents felt their child's general health had improved. Sixty-four percent of the parent population reported a noticeable improvement in their child's sleeping pattern and over 30% described an improvement in their child's general behavior. Although this study reports subjective data, and we do not have a comparable control population, these findings provide an interesting insight into parental impressions regarding alterations in their child's health, sleep pattern and behaviour following this procedure.

Tonsillitis, tonsillectomy and weight disturbance.

To determine the relationship between tonsillitis, tonsillectomy and abnormalities in body weight, we have analyzed pre- and post-operative weights in a population of 55 children who underwent adenotonsillectomy in our department. Pre-operative mean weight was 9.8% heavier than the standard mean normal weight for age and post-operative mean weight was 22% greater than standard mean weight for age. The mean weight gain during the follow-up period was 12% greater than that which would be normally expected (p < 0.001). This study suggests that children undergoing tonsillectomy are slightly heavier than their peers and that following the procedure this discrepancy increases.

Occult pharyngeal perforation secondary to 'pencil injury'.

Palatopharyngeal injuries due to impaction of rigid objects held in the mouth are common. Most are essentially innocuous injuries requiring no specific treatment. However, there is the potential for perforation of the pharyngeal wall with the subsequent development of serious infection such as retropharyngeal abscess or mediastinitis. This possibility is more likely to be suspected in the presence of a visible laceration or puncture wound at the site of impact in the mouth or pharynx. We report three cases in which occult pharyngeal perforation occurred without any clinical signs of breech of the pharyngeal wall. In all cases a lateral soft tissue neck X-ray was diagnostic of perforation, showing the presence of retropharyngeal air. We, therefore, advocate the routine performance of soft tissue neck X-rays in all patients who present with a history of falling on a rigid object held in the mouth.

Bilateral acoustic neurofibromatosis camouflaged by corticosteroid treatment of sudden sensorineural hearing loss.

We report a case of bilateral acoustic neurofibromatosis which presented with the atypical symptom of sudden sensorineural deafness. Following corticosteroid therapy the hearing loss returned to near normal levels. The pathogenesis of reversible sudden sensorineural hearing loss in the presence of an acoustic neuroma is discussed. The importance of Gadolinium-enhanced magnetic resonance imaging in the detection of bilateral acoustic neurofibromatosis is highlighted by the case report.

Migrating foreign body: a new cause of trismus.

A unique case of delayed trismus secondary to an infratemporal foreign body is presented. The pathophysiology and treatment options are discussed.

ENT and general practice: a study of paediatric ENT problems seen in general practice and recommendations for general practitioner training in ENT in Ireland.

A questionnaire survey of 225 general practitioners was carried out to establish the proportion of their workload formed by paediatric ENT problems. Approximately 50% of children seeking medical care from their general practitioners had problems in this area. Infections of the upper respiratory tract and associated organs were the most commonly dealt with complaints. The monthly referral rate by GPs of paediatric patients in their practice to an ENT outpatient clinic was 4.3%. As ENT problems are seen so commonly in general practice it is important that teaching of otolaryngology at undergraduate and postgraduate levels is emphasised. We examined the present teaching structure of ENT in Irish universities and established that the appointment of a professorial unit dramatically improved the extent of the undergraduate curriculum. Non-specialist postgraduate ENT exposure was found to be inadequate and a number of mechanisms to improve postgraduate ENT training for GPs are suggested.

The role of the middle ear and tonsil in the etiology of febrile convulsions.

The middle ear and tonsil are thought to be important sources of infection in children with febrile seizures. However, these patients are rarely examined by an otolaryngologist in the acute phase and we are unaware of any previous studies where otolaryngologists have documented the presence of acute suppurative otitis media (ASOM) and tonsillitis in a series of children with febrile convulsions. We carried out a prospective study on 47 children admitted to two Dublin hospitals with a diagnosis of simple febrile convulsion. All children were examined by an otolaryngology resident within 6 h of admission. Nine children were noted to have ASOM and 18 had acute tonsillitis. The otolaryngology resident's opinion of the condition of the ears and throat often differed from that of the admitting pediatric resident, as documented in the clinical records. We review the recent literature on febrile convulsions and discuss the possible role of the otolaryngologist in the prevention of seizure recurrence.

Recurrent laryngeal nerve palsy secondary to benign thyroid disease.

A recurrent nerve palsy occurring in the presence of a goitre is considered to be caused by thyroid malignancy until proven otherwise. Three cases are described in which benign thyroid disease resulted in recurrent laryngeal nerve paralysis. Recent haemorrhage was implicated histologically as the possible aetiology in all three cases. The importance of identifying and preserving the recurrent laryngeal nerve in the surgical management is highlighted.

The role of total laryngectomy in the management of intraluminal upper airway invasion by well-differentiated thyroid carcinoma.

Intraluminal invasion of the upper airway by well differentiated thyroid carcinoma is very uncommon, and the management can be problematic. Many conservative, reconstructive-type surgical procedures have been advocated to maintain normal laryngeal function. Although voice preservation is desirable, it may not always be in the patient's best interest and radical surgery, including total laryngectomy, may be necessary. We describe three cases in which total laryngectomy was performed, and review the indicators for this procedure in the treatment of this difficult to manage condition.

Tympanostomy tubes and early post-operative otorrhea.

Otorrhea is a recognized complication of tympanostomy tube insertion. This may be caused by external contamination or by the pre-existing conditions in the middle ear cleft. Some surgeons try to reduce the risk of surgical contamination by using a non-touch technique, never allowing the gloved hand to come into contact with the tympanostomy tube. A prospective study was carried out on 66 children to evaluate the efficacy of the non-touch technique. One tympanostomy tube was inserted by the non-touch method with the contralateral ear acting as a touched control in each patient. Postoperative otorrhea occurred within 10 days in 1.67% of the non-touch ears and in 1.67% of the controls. This study demonstrates a low incidence of otorrhea in the early post-operative period with either technique. Time-consuming and costly sterile precautions are unnecessary for this common procedure.

Monostotic fibrous dysplasia of the temporal bone with associated lymphadenopathy.

Fibrous dysplasia of the temporal bone is a very unusual condition and its association with an abnormal lymph node has not been previously reported. Although it is benign condition causing conductive deafness, cholesteatoma may develop insidiously as illustrated by this case. We recommend regular long term follow up and surgical exploration if a changing clinical picture suggests the possibility of complications.

Indications for paediatric tonsillectomy GP versus Consultant perspective.

Tonsillectomy is a commonly performed operation in children. Although the justification for this procedure has been debatable in the past, more rigorous criteria in defining the need for tonsillectomies are becoming established. The role of the primary care physician in the management of tonsillar disease in children is important as the decision to refer a child for tonsillectomy is made by the general practitioner. A questionnaire survey of 400 general practitioners (GPs) and 31 consultant ENT surgeons was carried out to establish the important criteria used in deciding the need for paediatric tonsillectomy. We found that in general there was a good correlation between GP and Consultant indications for tonsillectomy. However there were two important areas of difference, while most of the GPs felt that recurrent ear infections and 'glue ear' were important indications for tonsillectomy, Consultants did not. Therefore we must be aware of the current recommendations for tonsillectomy and inform present and future GPs.

An audit of the E.N.T. casualty service at the Royal Victoria Eye and Ear Hospital.

The only specialised Accident and Emergency unit for ENT in Ireland is at The Royal Victoria Eye and Ear Hospital, Dublin. This provides a service for the entire Republic, operating on a 9 am to 5 pm, Monday to Friday, basis. The aim of the present study was to define the role of this specialised unit. A prospective study of the service over a one month period was conducted. During this time 779 patients were seen of which 350 (45%) were new patients and 429 (55%) were return patients. Fifty two per cent were self referred, 35% were referred by their General Practitioners, 8% by other hospitals and 5% from other sources. The most common diagnosis was otitis externa (21% of new patients and 63% of returns), followed by ear wax (15% of new patients), and epistaxis (9% of new patients). Five per cent of patients required removal of foreign bodies from their ear, nose or oesophagus, and 3% received treatment for trauma to these regions. Of note during this period six new cases of head and neck cancer were detected. From these figures it is the authors' opinion that many of the problems seen could have been dealt with by General Practitioners or as non-emergency referrals to the out-patient department. This indicates the need for further training for primary care physicians and expansion of the present outpatients services. The specialised casualty service should continue to exist to provide a genuine emergency service and valuable training in the speciality.

What causes acute otitis externa?

External otitis is an extremely common condition and can affect between five to twenty per cent of the patients attending ENT clinics (Hawke et al., 1984). Its precise pathogenesis remains unclear, despite several aetiological classifications in the literature. The aim of this study was to investigate the relationship between infection, water exposure and trauma and the development of acute otitis externa. The study comprised 100 patients with their first attack of otitis externa and 150 age and sex matched controls. In only 40 per cent of cases could a primary microbiological cause be found. There was no significant statistical difference found between the two groups regarding the use of agents capable of traumatizing the external canal. Regular swimming, showering and hair washing were significantly more common in patients with acute otitis externa. Allergic disorders were nearly three times more common in the external otitis group suggesting a possible immunological aetiology.

Upper airway invasion by well-differentiated thyroid carcinoma.

Invasion of the upper airway by well-differentiated thyroid carcinoma is very unusual. Treatment is primarily surgical resection, but the extent of the resection has been controversial. Adjuvant treatment using I131 or radiotherapy also has an important role in management. We describe two cases of direct infiltration of the larynx and trachea by well-differentiated thyroid carcinoma and discuss the current recommendations for the management of this difficult problem.