The use of diagnostic sleep nasendoscopy in the management of children with complex upper airway obstruction.

In this paper we present a prospective study of the role of diagnostic sleep nasendoscopy in the investigation and treatment of 20 children referred to a tertiary children's hospital with obstructive awake apnoea or severe obstructive sleep apnoea (apnoea/hypopnoea index greater than 30/h). We describe the technique of diagnostic sleep nasendoscopy and provide a classification system for documenting the findings. We demonstrate sleep nasendoscopy is an invaluable tool in the management of children who continue to have upper airway obstruction despite previous adenotonsillectomy and in children with airway obstruction due to cerebral palsy, syndromes and craniofacial malformations. With the use of pre- and post-intervention sleep studies we have shown that sleep nasendoscopy is accurate in deciding the most appropriate mode of intervention in the individual child with obstructive breathing, from (continuous positive airway pressure) CPAP to site-specific surgery. We conclude that sleep nasendoscopy combined with rigid laryngo-bronchoscopy should be standard practice in the evaluation of children with complex upper airway obstruction.

A three-centre prospective pilot study to elucidate the effect of uvulopalatopharyngoplasty on patients with mild obstructive sleep apnoea due to velopharyngeal obstruction.

In this paper we describe the outcome of a prospective study designed to investigate the role of uvulopalatopharyngoplasty in the management of mild obstructive sleep apnoea. A group of 21 patients fulfilling strict inclusion and exclusion criteria underwent uvulopalatopharyngoplasty performed by a single surgeon using a modified technique. Specifically designed daily pain questionnaires were completed by the patients for 2 weeks after surgery and the morbidity associated with the procedure was assessed at 2, 6 and 12 weeks after operation. Thirteen of the 21 patients underwent a postoperative sleep study at 3 months after operation. The outcome measures used were the apnoea/hypopnoea index, the minimum O2 saturation, the sleep arousal index, the sleep architecture the Epworth Sleepiness Scale score, the subjective improvement in both the patient's and their partner's sleep and the morbidity associated with uvulopalatopharyngoplasty. We conclude that the patients with mild obstructive sleep apnoea most likely to obtain significant benefit from uvulopalatopharyngoplasty are those with a body mass index of between 27 and 30 with no cephalometric disproportion, those with frequent arousals not associated with periodic limb movements, those whose sleep related breathing disorder is not positional and most importantly those with symptomatic day time sleepiness.

Lymphangioma of the tongue presenting as Ludwig's angina.

In this paper we present a case of a 6-year-old child who presented with Ludwig's angina caused by an infected tongue base lymphangioma. We provide a literature review of tongue lymphangioma and Ludwig's angina in the paediatric population. Both Ludwig's angina and tongue base lymphangioma are rare conditions in their own right and a combination of the two has not previously been described in the literature.

The development of a paediatric quality of life questionnaire to measure post-operative pain following tonsillectomy.

In this paper we describe the process through which a Paediatric Quality of Life Questionnaire was developed to assess the pain experienced by children following tonsillectomy. The impetus behind the questionnaire development was the clinical observation that the pain experienced by children undergoing tonsillectomy was not being detected and analgesia was not being prescribed in adequate amounts. The eight-item questionnaire provides the independent observer with an objective measure of the physical and emotional distress a child experiences post-tonsillectomy to which analgesic requirements can be titrated. The questionnaire was tested on a sample of 48 children aged between 2 and 13 years (average age 7.1 years) who underwent elective dissection tonsillectomy by the same surgeon using a standardised operative technique. The conclusions substantiate the hypothesis that there is the need for an assessment tool based on non-verbal behaviour to measure post-operative pain in children. In the discussion we summarise the increasing role of quality of life assessments in surgical practice.

A skull base extradural hypoglossal neurilemmoma resected via an extended posterolateral approach.

The case of a 43-year-old man with a right skull base hypoglossal neurilemmoma excised via the extended posterolateral approach is presented. There is only one previous case of hypoglossal neurilemmoma in the literature. The surgical technique described is a new approach to the posterior skull base involving a suboccipital craniectomy, mastoidectomy and the removal of the lateral process of the atlas. It provides an inferior approach to the jugular foramen and hypoglossal canal that allows the lower cranial nerves to be identified as they exit from their skull base foramina. In the discussion we compare this technique to other surgical approaches previously described for access to the region of the jugular foramen.

A transpalatal approach to the parapharyngeal space.

The case of a 75-year-old lady with a large parapharyngeal pleomorphic adenoma excised via a transpalatal peroral technique is presented. This is a new approach to the parapharyngeal space not previously described. A laterally placed full thickness soft palate split from the superior pole of the tonsil to 1 cm proximal to the pterygoid hamulus provided good surgical access to the whole length of the parapharyngeal space and allowed complete tumour excision with minimal morbidity.

Snoring--a simple surgical solution.

In this paper a new palatal surgical technique for the treatment of snoring is described and evaluated. All 22 patients were severe snorers with no significant obstructive sleep apnoea, as confirmed by detailed sleep studies. The aim of the surgical technique was to eliminate the vibration of the soft palate and the posterior pillars which occurs during snoring. This was achieved under general anaesthetic by making a 1.5 cm vertical full thickness incision in the soft palate from the superior pole of the tonsil towards the pterygoid hamulus using monopolar cutting diathermy. Specifically designed daily pain questionnaires were completed by the patients during the first 2 post-operative weeks and the level of snoring was assessed by the patient's sleeping partner at 2, 6 and 12 weeks. The presence of any complications was also documented at these times. The results demonstrate that this surgical technique is effective, quick, simple and bloodless. The post-operative pain created is mild and quickly resolves. All patients experienced a dramatic diminution of their snoring and in 55% complete cessation was achieved.

Bilateral antrochonanal polyps in a child: a case report.

In this paper we present the first ever reported case of simultaneously occurring bilateral antrochoanal polyps in a fit 12-year-old child. The antrochoanal polyps (ACP) were removed using functional endoscopic sinus surgery (FESS) which achieved complete cure. Histological analysis of the polyps showed them to be of benign inflammatory origin.

Acute airway obstruction due to primary thyroid lymphoma.

We report the case of 71 year old woman who presented with severe inspiratory stridor due to a compressing primary thyroid lymphoma. This is only the third case of thyroid lymphoma presenting with stridor reported in the literature and it is particularly unusual in that there was'no preceding history of Hashimoto's thyroiditis. The clinical presentation of a rapidly enlarging thyroid mass with compressive symptoms, coupled with its miraculous response to steroids, created a difficult diagnostic and management challenge.

Peri-umbilical superficial fascial graft myringoplasty--a simple alternative.

We present new material in the surgical repair of the perforated tympanic membrane. Forty-two patients with a unilateral tympanic membrane perforation and eight patients with bilateral perforations had their perforations closed with peri-umbilical superficial fascia via a transtympanic route. Of the 58 tympanic membranes repaired, 51 were successful while seven failed. The technique is cost-effective and quick, making bilateral repairs possible under the same anaesthetic.

Sensorineural hearing loss in sickle cell anaemia--a United Kingdom study.

Sensorineural hearing loss (SNHL) has been a well-documented complication of sickle cell disease in the literature from West Africa, West Indies, United States of America and the Middle East. We present a study of 52 patients with homozygous sickle cell disease and 36 control patients with haemoglobin genotype AA, matched for age and sex. Seven patients with sickle cell disease (13.5 per cent) were found to have sensorineural hearing loss i.e. > 20 dB at two or more frequencies, while all the patients in the control group had normal hearing (p < 0.05). Our study shows the incidence of SNHL in the UK to be similar to that reported in the USA and much lower than that found in malaria endemic areas of the tropics. We highlight the factors which we consider responsible for these differences and suggest that the crucial period in the development of SNHL in sickle cell disease may be intra-uterine or during the first few years of life. All sickle cell patients should be encouraged to have regular hearing assessment.

Sensorineural hearing loss in sickle cell anaemia: a United Kingdom study

Sensorineural hearing loss (SNHL) has been a well-documented complication of sickle cell disease in the literature from West Africa, West Indies, United Stated of America and the Middle East. We present a study of 52 patients with homozygous sickle cell disease and 36 control patients with haemoglobin genotype AA, matched for age and sex. Seven patients with sickle cell disease (13.5 per cent) were found to have sensorineural hearing loss i.e. > 20 dB at two or more frequencies, while all the patients in the control group had normal hearing (p < 0.05). Our study shows the incidence of SNHL in the UK to be similar to that reported in the USA and much lower than that found in malaria endemic areas of the tropics. We highlight the factors which we consider reponsible for these differences and suggest that the crucial period in the development of SNHL in sickle cell patients should be encouraged to have regular hearing assessment (AU)