Management of isolated cricopharyngeal dysfunction: systematic review.

OBJECTIVE: A systematic review was performed to evaluate the safety and efficacy of different therapeutic interventions available for the management of isolated cricopharyngeal dysfunction. METHODS: Studies were identified using the following databases: Ovid (Medline, Embase), the Cochrane Library, PubMed and Google Scholar. An initial search identified 339 articles. All titles and abstracts were reviewed. Fifty-six relevant articles were inspected in more detail; of these, 47 were included in the qualitative analysis. RESULTS: No relevant randomised trials were found. A range of case series were used to perform a qualitative analysis. Botulinum toxin A injection and cricopharyngeal dilatation were associated with a higher risk of recurrence, but appear to be more suitable in elderly and co-morbid patients. In those patients requiring formal myotomy, endoscopic approaches appear to be as effective but less morbid when compared with classical open surgery. CONCLUSION: There is good evidence for the safety and efficacy of the different therapeutic options for isolated cricopharyngeal dysfunction. However, further studies are required to compare the efficacy of the various treatment modalities.

Prognostic scoring in necrotising otitis externa.

OBJECTIVE: To collect and analyse data from the published literature concerning the rare condition necrotising otitis externa, in order to formulate a prognostic scoring model based on signs and symptoms. DESIGN: Retrospective data collection from published literature, and binary logistic regression analysis of the effect on outcome of identified signs and symptoms. RESULTS: Six factors were identified as prognostic of a poorer outcome, including facial nerve involvement, additional cranial nerve involvement, non-cranial nerve neurological involvement, extensive granulations (or oedema) in the external auditory canal, bilateral symptoms and aspergillus species as the causative organism. A four-point scoring model based on these findings is presented. CONCLUSIONS: A novel, systematic method of data analysis was utilised to construct a prognostic scoring model for necrotising otitis externa. This will better equip clinicians to treat this potentially fatal condition.

Complications following gastrostomy tube insertion in patients with head and neck cancer: a prospective multi-institution study, systematic review and meta-analysis.

OBJECTIVES: To measure morbidity and mortality rates following insertion of gastrostomy tubes in head and neck cancer patients. To determine evidence for any relationship between gastrostomy insertion technique and complication rates. DESIGN: A prospective cohort study and qualitative systematic review. SETTING: Multi-cancer networks in the South West of England, Hampshire and the Isle of White. PARTICIPANTS: One hundred and seventy-two patients with head and neck cancer undergoing gastrostomy tube insertion between 2004 and 2005. Percutaneous endoscopic gastrostomy (PEG) was performed in 121 patients. Fifty-one patients had radiologically inserted gastrostomy (RIG). Twenty-seven studies reporting outcomes following 2353 gastrostomy procedures for head and neck cancer. MAIN OUTCOME MEASURES: Post-procedure mortality, major and minor complications. RESULTS: In the present series, mortality rates were 1.0% (1/121) for PEG and 3.9% (2/51) for RIG. Overall major complication rates following PEG and RIG were 3.3% (4/121) and 15.6% (9/51) respectively. In our systematic review and meta-analysis of 2379 head and neck cancer patients, we observed fatality rates of 2.2% (95% CI 0.014-0.034) following PEG and 1.8% (95% CI 0.010-0.032) following RIG. Furthermore, major complication rates following PEG were 7.4% (95% CI 5.9-9.3%) and 8.9% (95% CI 7.0-11.2%) after RIG. CONCLUSIONS: Procedure related mortality rates following gastrostomy in head and neck cancer patients are higher than those in mixed patient populations. Major complication rates following RIG in head and neck cancer patients are greater than those following PEG. Major complications following PEG in patients with head and neck cancer appear no worse than in mixed pathology groups. We have identified that RIG is associated with increased morbidity and mortality in patients who are ineligible for PEG. The serious nature of the complications associated with gastrostomy particularly in patients with head and neck cancer requires careful consideration by the referring physician.

Phantom larynx: a clinical survey.

A phantom phenomenon has been reported to occur after amputation or deafferentation of a limb or another body part. A phantom phenomenon following laryngectomy has not been described before. In the search for a phantom phenomenon, we carried out a retrospective clinical study on 35 post total laryngectomy patients who attended the Head and Neck Clinic of Southmead Hospital, Bristol (a tertiary referral centre for head and neck cancer), comparing them to a control group of 57 patients who attended the same clinic but had not undergone a total laryngectomy. The main outcome measures were, charting subjective sensation of phantom larynx and eliciting phantom phenomenon by cutaneous stimulation of neck and face. In 24 (69%) patients, there was either a subjective sensation of phantom or a positive response to cutaneous stimulation. There was no response to cutaneous stimulation in the control group. In conclusion, a phantom phenomenon does appear to occur after total laryngectomy.

Long-term follow-up of endoscopic stapled diverticulotomy.

We report a consecutive series of 31 patients who underwent endoscopic stapled diverticulotomy. The patients' notes were reviewed retrospectively to gather data on their original admission and a postal survey was conducted to establish patient satisfaction, their ability to swallow and re-operation data. Three patients were lost to follow-up. Nine of the remaining 28 died at a median of 18 months. The remaining 21 were followed up for a median of 59 months. The data showed that, at 5 years, 94.4% of patients had an improvement in their swallowing, and 50% had an entirely normal swallow. In order to achieve this result, 19% of patients required a second procedure, and one patient (3.2%) required a third (open) procedure. Endoscopic stapled diverticulotomy has well-established, short-term advantages. This series shows that it has a good long-term outcome that is similar to established open techniques and probably better than other techniques of endoscopic diverticulotomy, i.e. diathermy or laser.

Complete fusion of the vocal cords; an unusual case.

A case is presented of a woman who sustained a 35% body surface area mixed depth cutaneous burn, together with a significant inhalational injury. The patient required emergency resuscitation with endotracheal intubation and subsequently tracheostomy. This resulted in an unfortunate complication of a total adhesion between the vocal cords which extended into the subglottic area, causing complete occlusion of the airway.

Meningiomas involving the internal auditory canal: a diagnostic and surgical challenge.

Meningiomas are the second most common lesion encountered within the cerebello-pontine angle (CPA) and rarely project into or originate from the internal auditory meatus (IAM). It is important to distinguish between meningiomas and acoustic neuromas preoperatively as the choice of surgical approach may differ depending on the tumour type. Fortunately, most lesions can be accurately diagnosed with gadolinium-enhanced magnetic resonunce imaging (MRI). We report six cases of meningioma involving the IAM, often leading to an incorrect preoperative MRI diagnosis. We highlight the challenges these tumors present to radiologists and surgeons.

Endoscopic stapled diverticulotomy: a real advance in the treatment of hypopharyngeal diverticulum.

Between November 1993 and May 1996, 51 patients with a hypopharyngeal diverticulum were treated by endoscopic stapled diverticulotomy. Normal swallowing was resumed within 36 h of surgery in 73%, and in 93% by 72 h. Two patients required nasogastric feeding for 5-7 days. There were no operative deaths or serious operative morbidity, and there have been no recorded cases of clinical recurrence of pouches to date (maximum follow-up 562 days: 46 cases over 12 months). The low morbidity, short hospital stay and early return to normal feeding, combined with a relative absence of complications or pouch recurrence, make endoscopic stapled diverticulotomy the treatment of choice for the majority of patients.

Development and calibration of field-effect transistor-based sensor array for measurement of hydrogen and ammonia gas mixtures in humid air.

A sensor array for analyzing hydrogen and ammonia gas mixtures in humid air has been developed, built into a rugged system, and calibrated for laboratory testing. The sensor array is comprised of four chemically sensitive field-effect transistors (CHEMFETs). Chemically sensitive layers for the sensors were developed and tested using a Kelvin probe. A combination of catalytic and noncatalytic thin layers (palladium and polyaniline) was selected for the four-sensor array. The work function responses of the CHEMFET sensor array to mixtures of hydrogen, ammonia, and humid air were measured. Chemometric multivariate methods, linear and nonlinear partial least squares, were used for the calibration of the sensor array using gas mixtures in the concentration range from 0 to 10 000 ppm hydrogen and ammonia in humid air. The sensor array for ammonia showed good sensitivity, selectivity, response time, and stability and is recommended for field deployment. In contrast, the sensor array for hydrogen, though highly sensitive to hydrogen, demonstrated inadequate stability, requiring further development before deployment is recommended.

Intra-operative image guidance in otolaryngology--the use of the ISG viewing wand.

The ISG viewing wand is an intra-operative guidance system with a proprioceptive robotic-like jointed arm. It provides surgeons with almost instantaneously reconstructed computer-generated CT or MRI images in two or three dimensions and can correlate any point within the operative field to its corresponding locus on the reformatted scan images. In addition to having been used in over 400 neurosurgical patients in Bristol, 14 patients with skull-base, cerebello-pontine angle or temporal bone lesions have also undergone wand-guided resections. The wand has proved to be particularly useful in pre-operative planning, allowing minimally-invasive incisions, providing per-operative navigation, identifying the relationship and proximity of important anatomical structures and in assessing the extent of lesion resection. We illustrate the advantages of intra-operative image-guidance by discussing four cases. The potential applications of this form of imaging technology to other otolaryngological procedures are discussed.

Supraglottic transection: results of repair and functional outcome.

We present two cases of supraglottic transection, with concomitant neurotemesis of the superior laryngeal nerve. Both cases were repaired primarily and a temporary tracheostomy was used to protect the airway. In both cases subsequent decannulation was achieved within four weeks, following the initial injury. No long-term swallowing or voice disturbance was noted in either case. We recommend that in such cases it is unnecessary to repair the nerves directly, but that careful repair of the wound itself will achieve a functional result.

Day-case adenoidectomy, parental opinions and concerns.

Day-case surgery has been urged on the National Health Service by the Audit Commission in the last decade despite concerns about safety. A questionnaire was posted to the parents of 109 children who had recently undergone day-case adenoidectomy, addressing parental concerns and opinions. Eighty per cent of the questionnaires were returned. A high level of satisfaction with day-case adenoidectomy was expressed by the parents. All the children were observed for six hours after surgery prior to discharge. One child was visited at home by his general practitioner in the first 24 hours of discharge but there were no serious post-operative complications and none of the children required re-admission to hospital. Day-case adenoidectomy is safe, very acceptable to parents and does not result in a greatly increased workload for general practitioners.

Cochlear blood flow and microvascular resistance changes in response to hypertonic glycerol, urea, and mannitol infusions.

The effect of hyperosmotic agents on cochlear blood flow (CBF) was tested in normal guinea pigs and in guinea pigs having prior unilateral operations to ablate the endolymphatic duct. Laser-Doppler-measured CBF was normalized to remove apparent changes related directly to systemic blood pressure. Hyperosmotic fluids were given via venous infusion: glycerol (20% and 40% solutions), urea (10%, 30%, and 40% solutions), and mannitol (40% solution). All agents were dissolved in 0.9% saline and the mixtures were given at a rate of 0.3 to 0.6 mL/min for 5 minutes. Control infusions were of 0.9% saline and isotonic dextran 70 (Pharmacia). All hyperosmotic infusions resulted in similar increases in normalized cochlear blood flow (nCBF) that extended to a maximum of 300% of the baseline value in a dose-dependent way during the infusion time period. Within approximately 30 minutes following infusions, nCBF had returned to baseline levels. Saline infusion alone had little effect on nCBF, but isotonic dextran 70 gave a sustained increase to 122% of the baseline levels. There was no difference between the responses of nCBF in hydropic and normal cochleas for either control or hyperosmotic solutions. Measurements of systemic hematocrit at time intervals during and following the infusions showed that transient reductions of up to approximately 8% (for the maximum osmotic challenge) occurred during the infusion. It is concluded that the hyperosmotic treatments tested here are equally effective for short-term enhancements of nCBF in both normal and hydropic cochleas. The basis of the flow increase is partially rheologic and partially due to a local vasodilation.

Influence of topically applied adrenergic agents on cochlear blood flow.

This study was designed to assess the role of adrenergic receptors in the control of cochlear blood flow. Laser Doppler flowmetry was used to determine the effects of adrenergic drugs topically applied to the round window membrane of the cochlea. The relative influence of the various receptor types (alpha 1, alpha 2, beta 1, and beta 2) was examined by a selection of agonists and antagonists. The agonists norepinephrine and epinephrine, which have mixed alpha- and beta-receptor effects, and phenylephrine, a strong alpha 1-agonist, all induced a dose-dependent reduction in cochlear blood flow. The agonists isoproterenol (beta-active), salbutamol (alpha 2-active) had no effect on cochlear blood flow. Of the antagonists, when tested alone, only the selective alpha 1-antagonist prazosin had a direct effect on cochlear blood flow, demonstrating an increase in cochlear blood flow. The selective alpha 2-antagonist idazoxan, the beta-antagonist propranolol, and the unselective alpha-antagonist phentolamine had no effect on cochlear blood flow. Interaction studies of agonists and antagonists were performed to specifically define the receptor subclasses responsible for the cochlear blood flow increases with norepinephrine and epinephrine. The results are consistent with the presence of an alpha 1-adrenergic sympathetic control of cochlear blood flow.

Hearing conservation in acoustic neuroma surgery via the posterior fossa.

An increasing number of patients with an acoustic neuroma present with useful hearing in the tumour ear. Surgical removal of these tumours via the posterior fossa route may enable preservation of the cochlear nerve and otic capsule without increasing the morbidity to the facial nerve. The results of treating 51 cases of acoustic neuroma via the posterior fossa is presented. Forty four tumours measured less than 20 mm in diameter in the cerebellopontine angle and surgery was undertaken with hearing preservation as a principle objective. In 26 cases, the cochlear nerve was preserved anatomically and post-operative hearing at levels better than mean pure tone threshold of 50 dB or 50 per cent speech discrimination was recorded in 14 patients. The preservation of hearing represents a worthwhile surgical goal in selected patients with an acoustic neuroma without increasing the operative morbidity.

Immune status in patients with Menière's disease.

Sera of 164 patients with classical Meniere's disease were screened for autoantibodies, immune complexes and HLA status. Increased thyroid microsomal antibodies were significant in those patients in the 40- to 60-year age range. Raised IgM complexes and C1q component of complement were significant in all age groups. Low levels of IgA complexes were a consistent finding and were significantly lower in the HLA Cw7 group. Patients with migraine had no increased incidence of immune disturbances.