Metachronous bilateral submandibular gland metastases from carcinoma of the breast.

Metastases to the salivary glands from distant neoplasms are unusual, with most reported cases involving the parotid gland. Metastatic deposits in the submandibular gland are extremely rare with bilateral involvement not previously reported. We present the case of a patient with advanced breast carcinoma who has had metachronous involvement of both submandibular glands and review the literature on this subject.

Measurement of health status in patients with vertigo.

In order to assess how much disability is caused by vertigo, health status scores of patients referred with dizziness or vertigo were compared with local population normative data and with the severity of illness, measured by a disease-specific questionnaire. The questionnaires were administered by post to patients awaiting an ENT out-patient appointment. There was a strong correlation (P = 0.001) between the eight dimensions of the SF-36 (Mos 36 item short-form health survey) and disease severity, measured by the Dizziness Handicap Inventory questionnaire. Compared with the general population, vertigo sufferers had significant role limitation due to physical problems and social functioning (men) and physical problems and vitality (women). General health status is significantly affected by both the presence and severity of vertigo and the SF-36 may prove useful in assessing outcomes.

Audit of the treatment of tonsillar and peritonsillar sepsis in an ear, nose and throat unit.

We became aware that a range of antibiotics were being used in our unit to treat patients suffering from tonsillitis or peritonsillar abscess (quinsy). There appeared to be no rationale to determine which antibiotics were used, and we felt that we were possibly using expensive antibiotics when cheaper equally effective ones were available. An audit project was therefore devised to establish the current practice in the ENT Unit at the City Hospital at Edinburgh. Following a six-month prospective pilot study, a protocol for the treatment of tonsillar and peritonsillar sepsis was drawn up and subsequent practice and outcome was then audited, thus completing the audit cycle. As a result substantial savings in the cost of prescribed antibiotics have been made without compromising patient care.

An audit of the management of acute otitis externa in an ENT casualty clinic.

The management of acute otitis externa is variable, despite the fact that it is one of the commonest otological emergencies. We formed the impression that many patients attending our ENT casualty clinic with otitis externa were being treated and followed up inappropriately. To test this hypothesis we performed a retrospective pilot study on our practice which revealed a lack of uniformity in the management and follow-up of these patients. And as a result of this, guidelines were developed to improve our management of otitis externa and decrease the number of unnecessary review visits. Our practice was then audited prospectively over a six-month period with the guidelines in place. An improvement in the overall management and a rationalization of follow-up for otitis externa was seen by applying basic audit principles to this common clinical problem.

Submental abscess: an unusual delayed complication of primary Blom-Singer valve insertion.

Voice restoration following laryngectomy can be achieved by the now well accepted technique of inserting a 'Blom-Singer' prosthesis through a tracheo-oesophageal fistula created either primarily or secondarily. Recognized complications of primary puncture and valve insertion include haemorrhage, oesophageal perforation, peristomal cellulitis and aspiration of saliva. We describe the previously unreported complication of a submental abscess developing probably as a result of air being forced from the fistula up between the trachea and the pharynx, this plane not having fully healed as a result of previous radiotherapy. The problem was compounded by the patient's over-zealous attempts to phonate. To prevent this problem arising in future we recommend leaving the fistula at least six weeks to mature before inserting the valve, when the patient has had previous radiotherapy, and encouraging relaxation when learning to phonate with this technique.

Laryngotracheal stenosis: a serious complication of percutaneous tracheostomy.

Tracheostomy in patients requiring prolonged artificial ventilation in intensive care is increasingly being performed by a percutaneous dilatational technique, in preference to the standard surgical method. Since its introduction numerous series have reported favourably on its general safety in the short-term, but there have been few reports of longer term follow-up of patients. We present four cases of laryngotracheal stenosis, a previously unreported complication associated with the technique, and discuss the relevance of these to the future practice of percutaneous tracheostomy.

Warfarin and epistaxis--a case controlled study.

Patients anticoagulated with warfarin form a small proportion of those admitted with epistaxis annually to ENT units. The authors formed the impression that such patients spend longer in hospital and have more complicated management than controls. A prospective age and sex matched controlled study of 20 consecutive patients admitted with epistaxis whilst anticoagulated was performed. This showed that these patients spent significantly longer in hospital than controls, with an additional expense in the study period of 10,500 pounds for inpatient bed nights alone. The management of these patients is more complicated and there is a subgroup of poorly controlled patients who present most of the problems. A potential solution is to improve community warfarin control and to involve general practitioners and haematologists in the re-establishment of warfarin following admission for epistaxis.

Otolaryngological indicator operations: one year's experience.

One year's experience of otolaryngological indicator operations is presented. Of 59 myringoplasties, 47 (79%) were successful; trainees performed 44 (74%) of the procedures. Seventy patients undergoing septal surgery reported significant improvements in nasal obstruction (P < 0.001), catarrh and facial pain (P < 0.005). Seventeen laryngectomies were performed for stage III and IV disease. The median operative time of 3.1 h rose to 5.1 h with a concomitant neck dissection. Eleven complications ensued, and the median stay for an uncomplicated laryngectomy was 16 days and 30 days following complications. Forty-one parotidectomies, 19 submandibular gland excisions and 10 ductal procedures were performed with 5 wound complications and 5 minor temporary facial nerve weaknesses. We have established a baseline for comparison of our practice with others and concluded that septal surgery gives good symptomatic relief, trainees perform reasonable numbers of myringoplasties, and improvements remain to be made in our outpatient septal surgery data collection.

Basaloid carcinoma of the prostate gland: histogenesis and review of the literature.

The clinicopathological features of a basaloid carcinoma of the prostate gland are described in a 28-year-old man, and the management and prognosis discussed. Basaloid tumours of the prostate are very rare and only a few cases have been described in detail. Those cases which have been reported as adenoid cystic carcinoma, adenoid cystic-like carcinoma and adenoid basal cell tumour are reviewed.

CT-guided stereotactic neurosurgery using the Brown-Roberts-Wells system: experience with 125 procedures.

Experience with a consecutive series of 125 computerized tomographic (CT) image guided stereotaxic neurosurgical procedures, performed using the Brown-Roberts-Wells (BRW) system is described. Operative objectives included tissue sampling for diagnostic purposes, intra-operative localization of craniotomy flaps and intracerebral lesions, cyst and abscess aspiration and lesion to modulate tremor. A neuropathological diagnosis was possible in 96% of the biopsies, and lesions were precisely localized in all patients undergoing microsurgical stereotaxic craniotomy. Two patients (2.2%) undergoing stereotaxic biopsy died as a result of the procedure and one patient's hemiparesis was permanently worsened (0.8%). In only one of three patients undergoing stereotaxic thalamotomy was tremor abolished. This report confirms that CT image guided stereotaxic neurosurgery is safe, accurate and versatile. There is, however, a moderate incidence (7.2%) of lesser complications that can occur with this type of surgery. These complications, which are emphasized in this paper, are related to both the site of surgery and the neuropathology.

Management of patients aged over 60 years with supratentorial glioma: lessons from an audit.

This audit of clinical management confirmed the poor prognosis for patients (n = 80) aged over 60 years with a diagnosis of supratentorial glioma. The median survival time after diagnosis was 9 weeks following steroids and 7 weeks after biopsy and steroids. Cytoreductive surgery and radiotherapy improved median survival time by a maximum of 16 weeks, but there was significant morbidity in some patients undergoing craniotomy. Although 92% of the biopsied lesions were either glioblastoma or anaplastic astrocytoma, the median survival of these patients was similar to the 8% of patients confirmed as having intermediate grade astrocytoma. Patients presenting with minimal functional deficit (WHO grade I or II) had longer median survival times than those presenting in poor condition (WHO grade III or IV). In this series there was no relationship between management undertaken and clinical status of the patient. The 9% of the cohort that survived 1 year were treated in a variety of ways. This audit, together with results from other studies, suggests that a prospective clinical trial of different management regimes in elderly patients with supratentorial gliomas is needed. Since median survival time in the most intensively treated patients will be around 6 months, treatment evaluation must consider the quality of life provided.

Morbidity following cystoscopy: comparison of flexible and rigid techniques.

Recent reports on the value of local anaesthetic flexible cystoscopy have emphasised excellent tolerance and preference for the technique over general anaesthetic rigid cystoscopy. However, no study has yet compared the post-operative morbidity rates of these procedures. Tolerance, preference and post-operative symptoms in 100 patients undergoing local anaesthetic flexible cystoscopy were compared with those in 100 patients undergoing general anaesthetic rigid cystoscopy. On initial questioning, 89% of patients found flexible cystoscopy painless and 92% expressed a preference for the same procedure on a future occasion; 98 patients who underwent flexible cystoscopy and 87 who underwent rigid cystoscopy returned a questionnaire on symptoms 1 week after the procedure. The incidence of post-operative symptoms was 33% following flexible cystoscopy and 76% following rigid cystoscopy. Patients in both groups who were undergoing check cystoscopy had a lower incidence of morbidity than those undergoing cystoscopy for other reasons. The results suggest that flexible cystoscopy was well tolerated and preferred by most patients. The morbidity associated with the procedure was also significantly less than that associated with rigid cystoscopy under general anaesthesia.