Lymphoma presenting as neck lumps: causes of waiting time target breaches and potential solutions.

OBJECTIVES: This study aimed to assess the speed of referral, diagnosis and treatment of patients with lymphoma presenting with a neck lump, and to identify where delays are occurring that prevent UK national targets from being met. METHOD: The study entailed a retrospective survey of patients presenting with a neck lump secondary to lymphoma between 2006 and 2008 in Gloucestershire, UK. RESULTS: Forty-seven of 54 patients (87 per cent) were seen within 2 weeks of referral. However, the 62-day rule, which covers the time from referral to the initiation of treatment, was met in only 32 of the 54 cases (59 per cent). There were no breaches of the 31-day target, which concerned the time from decision to treat to the initiation of treatment. Subsequent target breaches were due to longer waiting times for radiological and pathological investigations. CONCLUSION: Radiological examinations should be ordered at the first consultation and biopsies performed as soon as possible. Establishing one-stop, rapid access clinics should improve the achievement of a maximum 62-day wait for patients with lymphoma presenting with neck lumps.

Flexibility within the middle ears of vertebrates.

INTRODUCTION AND AIMS: Tympanic middle ears have evolved multiple times independently among vertebrates, and share common features. We review flexibility within tympanic middle ears and consider its physiological and clinical implications. COMPARATIVE ANATOMY: The chain of conducting elements is flexible: even the 'single ossicle' ears of most non-mammalian tetrapods are functionally 'double ossicle' ears due to mobile articulations between the stapes and extrastapes; there may also be bending within individual elements. SIMPLE MODELS: Simple models suggest that flexibility will generally reduce the transmission of sound energy through the middle ear, although in certain theoretical situations flexibility within or between conducting elements might improve transmission. The most obvious role of middle-ear flexibility is to protect the inner ear from high-amplitude displacements. CLINICAL IMPLICATIONS: Inter-ossicular joint dysfunction is associated with a number of pathologies in humans. We examine attempts to improve prosthesis design by incorporating flexible components.

A case of paraganglioma of the hypoglossal nerve.

INTRODUCTION: Paragangliomas are rare tumours arising from the paraganglia of the autonomic nervous system. CASE REPORT: We present a case of a paraganglioma arising from the hypoglossal nerve and producing an unusual clinical picture at presentation. DISCUSSION: We supply radiological evidence of a paraganglioma originating from the hypoglossal nerve, and thus extend the evidence base for this rare site of origin. Our patient presented as an emergency with long tract neurological symptoms and progressive brainstem involvement. This presentation is not characteristic of paragangliomas in general, which usually have an indolent growth pattern and often demonstrate benign symptoms for a number of years prior to diagnosis. The location of a hypoglossal paraganglioma differs significantly from more common paragangliomas described in the neck and skull base, and this should inform the surgical approach undertaken.