A new technique for the management of inaccessible anterior glottic lesions.

We describe a new technique for removing anterior vocal fold lesions, which cannot be visualized with conventional suspension laryngoscopy. These situations are rare and the only alternative surgeons have had previously is an open laryngeal procedure. The technique we describe involves the use of a laryngeal mask airway (LMA), a flexible bronchoscope with biopsy channel, a 400 microm laser fibre and KTP/532 nm laser. This method was used to treat two patients in whom conventional suspension laryngoscopy had previously been attempted and abandoned.

Mandibular advancement splints and continuous positive airway pressure in patients with obstructive sleep apnoea: a randomized cross-over trial.

This prospective, randomized, cross-over trial was designed to compare the efficacy of a mandibular advancement splint (MAS) with that of nasal continuous positive airway pressure (nCPAP) in patients with obstructive sleep apnoea (OSA). Twenty-four patients (20 males and four females) with mild to moderate OSA (AHI between 10 and 49 events per hour) were enrolled in the study. Each patient used both MAS and nCPAP, with the initial therapy being allocated at random. Treatment periods lasted for two months with a two-week wash-out interval between. Polysomnography was performed prior to the study and after each clinical intervention. Patient and partner questionnaires were used to assess changes in general health and daytime somnolence. The AHI decreased from 22.2 to 3.1 using nCPAP, and to 8.0 using the MAS (P < 0.001 for both devices) and there was no statistically significant difference between the two treatments. The Epworth Sleepiness Score (ESS) fell from 13.4 to 8.1 with nCPAP, and to 9.2 with MAS (P < 0.001), again with no differences between the use of MAS or nCPAP. The questionnaire data showed an improvement in general health scores (P < 0.001) after both treatments, but daytime sleepiness only improved significantly using nCPAP (P < 0.001). Despite this, 17 out of the 21 subjects who completed both arms of the study preferred the MAS. The splints were well tolerated and their efficacy suggests that the MAS may be a suitable alternative to nCPAP in the management of patients with mild or moderate OSA.

Long-term use of mandibular advancement splints for snoring and obstructive sleep apnoea: a questionnaire survey.

A mandibular advancement splint (MAS) may be an alternative treatment for snoring and obstructive sleep apnoea (OSA). However, there is little subjective or objective information concerning long-term effectiveness, compliance and side effects. A retrospective questionnaire was used to survey these issues plus patient satisfaction and maintenance requirements in 166 patients who could have worn a mandibular advancement splint for over a year. One-hundred and twenty-six (76%) subjects returned the questionnaire, (84 with OSA, 42 snorers), of whom 69 (55%) reported still using the splint regularly, 47 (37%) every night. The most common reported reasons for stopping use were discomfort (29/ 57; 52%) of nonusers), and poor perceived efficacy (12 subjects). Users reported more daytime symptoms, and they and their partners were more likely to observe improvements with splint use. Side effects were reported by 49 subjects, more commonly in nonusers. Sixty-five of 67 current users and 23 of 41 nonusers reported less snoring with splint use (p = < 0.001). Long-term mandibular advancement splint usage appeared less satisfactory than previously reported, however, splints were considered effective by 97% of current users and even by over half of those who had stopped use. Reasons for stopping use included side effects, social circumstances, dental treatment, as well as lack of perceived efficacy.

Dual infection with atypical mycobacteria and Mycobacterium tuberculosis causing cervical lymphadenopathy in a child.

The most common presentation of mycobacterial infection encountered in otolaryngological practice is cervical lymphadenitis. We report a child with an unusual cause of cervical lymphadenopathy, i.e. dual tuberculous infections. This had clinical ramifications as, initially Mycobacterium avium-intracellulare was grown in culture and was resistant to standard anti-tuberculous agents, and hence treated with excision of the lymph node. However, the cultures from the excised lymph node grew out Mycobacterium tuberculosis that was sensitive to standard anti-tuberculous drugs. To our knowledge, no such presentation has been reported previously. We also review the literature on cervical lymphadenitis due to atypical mycobacteria and Mycobacterium tuberculosis, with particular emphasis on clinical presentation, diagnosis and management.

Endoscopic sinus surgery: are junior doctors being properly trained?

Endoscopic sinus surgery (ESS) is a technique which carries great potential benefits for the treatment of many nasal conditions. However, it also carries substantial risks. The key to safe surgery lies with adequate training. A survey carried out as part of a North (East) Thames Region audit of higher surgical trainees revealed large discrepancies in their training and in their subsequent clinical practice. Almost half the trainees had started ESS without having been on a training course or performed any cadaver dissections. Despite the potential hazards of ESS, audit of complications and outcome received a low priority. The trainees made several suggestions for improving training, including better provision of courses, regional training programmes and improved access to cadavers for dissection. Other surgical specialties are being forced to examine the prospect of specific accreditation for minimally invasive techniques and otorhinolaryngology may have to follow suit.

Syringomyelia after chemotherapy and radiotherapy for advanced oropharyngeal carcinoma: cause or coincidence?

A patient presented with syringomyelia 18 months after the completion of treatment with both chemotherapy and radiotherapy for an advanced oropharyngeal carcinoma. The link with therapy is discussed.

A simple reconstructive procedure for radiation-induced necrosis of the external auditory canal.

Localized necrosis of the bone, cartilage, and soft tissue of the external auditory canal is an uncommon side effect of radiotherapy to the parotid region. Five patients developed late onset skin necrosis of a quadrant of the ear canal secondary to an underlying osteoradionecrosis of the tympanic ring. We report a one-stage procedure to excise the necrotic tissue and replace it with a local rotational flap derived from the post-auricular skin. Otological side effects of radiotherapy are discussed.

The response of adenoid cystic carcinoma to tamoxifen.

Adenoid cystic carcinoma of the parotid gland often recurs locally, or metastases develop, after initial treatment with surgery and radiotherapy. We report a patient with an inoperable local recurrence of previously irradiated adenoid cystic carcinoma, who was treated with tamoxifen, an oestrogen receptor antagonist. After 18 months of treatment with tamoxifen, MRI showed a partial response, and further clinical progression of the disease was halted.

Laryngeal Kaposi's sarcoma in patients with AIDS.

Over a period of 10 years 17 human immunodeficiency virus(HIV)-infected patients with laryngeal Kaposi's sarcoma were seen and treated at University College London Hospitals. All patients had advanced HIV disease. Their presentation was with symptoms of upper airway obstruction in the majority of cases and the diagnosis was made by fibreoptic examination of the larynx. Biopsy was associated with brisk haemorrhage in one patient, who required a temporary tracheostomy, and was not performed in the other 16 cases. The commonest site of laryngeal involvement was the supraglottis in 11 patients, with glottic lesions noted in eight patients: subglottic lesions were seen in only three. Treatment of laryngeal Kaposi's sarcoma was, in general, conservative, five patients received low dose radiotherapy to the larynx and 10 were treated with systemic chemotherapy for disseminated Kaposi's sarcoma. Laryngeal Kaposi's sarcoma did not contribute to patient mortality.

Imported mucocutaneous leishmaniasis.

We report a case of mucocutaneous leishmaniasis in a otherwise fit Caucasian man who had traveled in an endemic area. Initial tissue microscopy failed to identify the causative organism, which was only determined by subsequent culture as Leishmania braziliensis. This case illustrates the variability in the presence of Leishman-Donovan (LD) bodies in histopathological studies and emphasizes the need for culture in suspected cases of leishmaniasis, particularly given the ability of certain Leishmania species such as L. braziliensis to cause recalcitrant and destructive infections of the nose and mouth.

Polycystic disease of salivary glands.

Polycystic disease of salivary glands is a rare condition which hitherto has been reported only in the parotid glands. We report a case in which an accessory salivary gland had evidence of polycystic disease.

Laryngeal leishmaniasis.

A patient suffering from persistent hoarseness was eventually shown to have laryngeal leishmaniasis. The incubation period for the disease must have been at least 16 years, following infection in Southern Europe. Mucosal leishmaniasis is rare in the Eastern hemisphere, and laryngeal leishmaniasis has not previously been reported in the UK. Previous Mediterranean cases have run a similar chronic course and have caused diagnostic difficulty, in particular being mistaken for malignancy. Treatment with aminosidine was ineffective, but the patient responded to liposomal amphotericin.

Complications in ENT--a nationwide audit carried out in November 1992.

We report a prospective audit of complications following ENT surgery during November 1992 from 42 consultants across the United Kingdom. Complications were reported as codes, and results were analysed at the Royal College of Surgeons Comparative Audit Unit. A total of 174 complications were reported, giving an annualized complication rate per consultant of 5.7-7.0% (depending on whether only the most severe complication per patient is counted or all complications). This compares with an annual complication rate of 1.49% reported retrospectively for the year of 1991 by the same consultants.

Post-irradiation carcinosarcoma of the parotid gland.

Carcinosarcoma of the salivary glands are rare tumours, often associated with a history of pleomorphic adenoma. A case of carcinosarcoma of the parotid arising following irradiation to the resection site of a pleomorphic adenoma is presented. The clinical and histological features are discussed and the literature reviewed.

Royal College of Surgeons comparative ENT audit 1990.

The Royal College of Surgeons Comparative Audit Service was set up in 1990 so that surgeons could pool their audit data, to provide 'standards' with which to compare their own figures. A total of 405 consultant otolaryngologists were circularized in December 1991 inviting them to return data about their resources, workload, case-mix and complications, and about two specific audit topics-Myringoplasty and Carcinoma of the Larynx--for the calendar year 1990. A total of 65 consultants returned proformas with data on 52208 admissions and 31240 surgical procedures. The 'average' respondent admitted 829 patients in the year (19% of these day cases and 14% emergencies) and performed 744 surgical procedures with a mean complication rate of 1.39% using three theatre sessions per week. Cancelled theatre sessions per annum per consultant ranged from 0 to 71. The mean known success rate after myringoplasty was 65%, with hearing improvement in 53%. The 'average' ENT surgeon saw 3.5 new cases of invasive carcinoma of the larynx and treated 69% of these with radiotherapy alone, compared with 14% surgery alone. As well as allowing a profile to be drawn up of the 'average' respondent, this audit allowed individual consultants returning data to compare their own figures in detail with the pooled data, which were presented graphically at a meeting in April 1992.

Paranasal sinus disease in HIV antibody positive patients.

OBJECTIVE: To investigate the prevalence of radiologically-diagnosed paranasal sinus disease in HIV-1 seropositive patients. SUBJECTS AND SETTING: 476 patients admitted to a dedicated inpatient unit for HIV and AIDS at the Middlesex Hospital, London, between September 1988 and February 1992. DESIGN: Retrospective review of patients' case notes and radiological records. RESULTS: 30 patients (6.3%) had radiological evidence of paranasal sinus disease. At the time of admission, sinusitis was in the differential diagnosis in only 12 of the 30 patients; 13 patients were initially diagnosed as having meningitis. Pseudomonas aeruginosa was the causative organism in four patients, all of whom had advanced HIV disease. All four responded to appropriate antibiotics but had early relapse of infection. CONCLUSIONS: Sinusitis is an important and under-recognised cause of morbidity in patients with HIV disease.

NdYAG laser treatment of a glomus tympanicum tumour.

Glomus tympanicum tumours are highly vascular tumours of the middle ear. Their removal by conventional surgical methods requires an extensive procedure in many cases, often with ossicular disarticulation to allow adequate exposure prior to the 'chaotic' and haemorrhagic event of tumour removal. This paper reports on the use of an NdYAG laser in a case of a large glomus tympanicum tumour. The laser facilitated a transcanal approach, avoided ossicular disarticulation and allowed accurate and almost bloodless ablation of the entire tumour. The NdYAG laser appears to be a very useful treatment modality in the management of these highly vascular tumours. Care should be taken to avoid accidental energy transmission to the cochlea.

Secretory otitis media and mastoid air cell development.

Controversy continues over the factors involved in the development of the mastoid air cell system (MACS). This study examines the effect of persistent secretory otitis media with effusion (SOME) on the development of the MACS. Thirty-one children, aged 4, were drawn from a cohort of cleft palate children in a multi-centre, prospective otological study set up in 1984. The initial presence of SOME was assessed by otoscopy, tympanometry and bilateral myringotomy, performed under the same anaesthetic as surgical repair of the cleft lip or palate. Only one ear in each child was ventilated with a tube and the other, the control ear, was assessed by regular follow-up otoscopy and tympanometry. The persistence of SOME after palate repair in over 70% of the non-ventilated ears in 4 years olds and the presence of a contralateral ventilated middle ear provides the perfect model for assessing the effect of SOME on MACS development. Plain, lateral mastoid X-rays were assessed by planimetry to give a well accepted measurement of mastoid pneumatization. Nine children were excluded from analysis as they did not meet the strict criteria of one persistently ventilated middle ear and one with persistent SOME. 22 children (44 ears) were available for analysis, 9 children were tubed at 3 months and 13 were tubed at 12 to 16 months. In 19 of the 22 ears the mastoid air cell system was larger on the tubed side.(ABSTRACT TRUNCATED AT 250 WORDS)

Aminosidine (paromomycin) in the treatment of leishmaniasis imported into the United Kingdom.

We report 11 patients with leishmaniasis from different endemic areas, treated in the UK with intravenous aminosidine alone or in combination with other drugs. Clinical and parasitological cures were achieved in all 7 patients from the Mediterranean zone who had visceral disease, with one relapse. Two of 4 patients with cutaneous or mucosal disease were cured; the other 2, from Iraq and Iran, did not respond. Toxic effects were high-tone deafness in 2 patients, one of whom had pre-existing renal impairment, and transient, mild elevation of serum creatinine in 3. Aminosidine is an effective, tolerable and relatively non-toxic alternative to existing antileishmanial drugs for the treatment of visceral leishmaniasis. Further studies will be needed to assess its place in cutaneous and mucosal disease.