Surgical management of nasal stenosis following chemoradiation for nasopharyngeal carcinoma.

BACKGROUND: Nasal stenosis is a rare but significant complication of chemoradiation treatment for nasopharyngeal carcinoma. It can cause distressing obstructive symptoms for the patient and potentially interfere with monitoring for recurrence. Quality-of-life indicators are known to be very poor in this group of patients; however, there is very little evidence in the literature as to management of this complication. METHODS: This paper presents an endoscopic day-case surgical procedure to address total posterior nasal stenosis, as conducted in three patients, which involves division of adhesions and removal of the posterior septum and posterior inferior turbinates, without the need for packing or stenting. RESULTS: In this series, there was resolution of obstructive symptoms and no recurrence of stenosis during follow up (up to 20 months). CONCLUSION: This endoscopic procedure performed to manage total nasal stenosis differs from those previously described in the literature, as post-operative stenting or packing is not required, and removal of the posterior aspect of the septum is performed routinely.

Aetiology and pathology of otitis media with effusion in adult life.

OBJECTIVES: To gather and analyse information concerning the aetiology and pathology of otitis media with effusion in adults. METHOD: A review of the English language literature from 1970 to the present was conducted. RESULTS: The available evidence suggests that otitis media with effusion in adult life is best viewed as a syndrome with a number of causes, including: infiltration of the eustachian tube by nasopharyngeal carcinoma and other local malignancies; changes in the middle ear and eustachian tube induced by radiotherapy; and systemic disease. CONCLUSION: There is now a body of evidence specifically related to the aetiology and pathology of otitis media with effusion in adult life. However, further research is required to fill in the gaps in our knowledge and understanding of this condition.

Incidence of neoplasia in patients with clinically suspicious nasal lesions and the value of computed tomography imaging in diagnosis.

BACKGROUND: There is no consensus as to whether all routine bilateral polypectomy specimens should be sent for formal histopathological diagnosis to exclude underlying neoplastic pathology. This study assessed the necessity for histopathological investigation as routine practice in cases of bilateral and unilateral nasal lesions by estimating the incidence of unexpected pathologies. It also evaluated the ability of computed tomography to predict histopathological diagnosis in patients with unilateral nasal lesions. METHODS: A retrospective analysis was conducted of 98 patients undergoing nasal polypectomy over a 12-month period. RESULTS: Five of 23 patients with a unilateral lesion on nasendoscopy had inverted papillomas on histopathological examination. None of the 75 patients with clinically bilateral lesions on nasendoscopy showed evidence of neoplasia on histopathological examination. Patients with inverted papillomas had significantly lower total Lund-Mackay scores than those with bilateral polyps. Asymmetry scores of inverted papilloma patients were significantly higher compared to both bilateral and unilateral polyps patients. CONCLUSION: The results suggest that histopathological diagnosis is only necessary in unilateral lesion patients as no unexpected histopathological diagnoses were made in bilateral lesion patients. Computed tomography imaging may have a role in predicting histopathological diagnosis by demonstrating asymmetry and less overall sinus opacification in patients with neoplastic lesions.

Postoperative nasal debridement following functional endoscopic sinus surgery, a systematic review of the literature.

BACKGROUND: Chronic rhinosinusitis is a significant health problem, and the optimal postoperative treatment regime for patients post functional endoscopic sinus surgery has been a topic debated for years. OBJECTIVE OF REVIEW: To systematically review and critically evaluate the evidence relating to postoperative debridement of the nasal cavity following functional endoscopic sinus surgery to guide best practice. SEARCH STRATEGY: A search of the following databases was performed: Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, and Cochrane Central Register of Control Trials. Ovid Medline, EMBASE, Pubmed. The following key words were used: Postoperative, functional endoscopic sinus surgery, sinus surgery, debridement, follow-up, from 1970 to 2013. EVALUATION METHOD: Two independent reviewers assessed the relevant articles using the consort guidance on systematic reviews Moher et al. BMJ 2010; 340: c869. RESULTS: The best evidence available was 1B, with six Randomsied control trial (RCTs) identified. Four studies compared debridement against no debridement, and two looked at the frequency of the debridement. Cumulatively, results for 337 patients were included. Visual analogue scores were used in all studies. None of the results at the long-term follow-up showed any difference in sino-nasal outcome test scores or objective endoscopic scores. Four of the six studies demonstrated some benefit in symptom scores but only one in the long term. Two papers demonstrated the debridement group suffered more pain in the postoperative period. CONCLUSIONS: Currently, there is no clear evidence for frequent postoperative debridement. Further well-designed RCTs are required to establish clear benefit, optimal frequency, extent and timing of debridement.

The effect of two sphenoidotomy approaches on the sense of smell: trans-ethmoidal versus trans-sphenoethmoidal.

BACKGROUND: There are generally two methods to access the sphenoid sinus: either through the natural ostium {trans-sphenoethmoidalor via sphenoethmoidal recess), or by creating a second opening through the posterior ethmoids (trans-ethmoidal).This study psychophysically and subjectively evaluates the effect of the trans-sphenoethmoidal technique to the trans-ethmoidal technique for sphenoid sinusotomy on olfactory function. METHODS: Prospective cohort analysis of 48 patients with comparable sinus disease underwent primary sphenoidotomy via transsphenoethmoidal(n = 24) versus trans-ethmiodal (n = 24) technique between September 2011 and February 2012. The patients had their olfaction measured psychophysically with "Sniffin' Sticks" and subjectively with a visual analogue scale (VAS) pre-operatively and at 5 weeks post-operatively. RESULTS: Psychophysical scores from the Sniffin' sticks provide a Threshold, Discrimination and Identification (TDI) score out of 48.The TDI change (post-operative TDI score minus pre-operative score) as well as VAS change (post-operative VAS minus pre-operativeVAS) were analyzed using t-test analysis, which showed no significant difference between the two measurements. CONCLUSION: If the trans-sphenoethmoidal technique is done meticulously, patients have the same olfactory relief, psychophysically and subjectively, as those undergoing the trans-ethmoidal technique.

Bilateral acute mastoiditis and subperiosteal abscesses in a child managed by simultaneous bilateral mastoid surgery.

OBJECTIVE: We report a case of bilateral acute mastoiditis and subperiosteal abscesses successfully managed with simultaneous surgery. METHOD: A case report and literature review are presented. RESULTS: A two-year-old boy presented with fever, otalgia, otorrhoea and bilateral protruding ears. He was treated for 72 hours with intravenous antibiotics but failed to improve. Computed tomography confirmed bilateral mastoid abscesses with destruction of the mastoid cortex. Bilateral drainage of the subperiosteal abscesses and bilateral cortical mastoidectomies were carried out. Post-operatively, he recovered well, and free field audiometry showed a normal hearing threshold of 20 dB across all test frequencies. CONCLUSION: This is only the second reported case of bilateral mastoiditis and subperiosteal abscesses. This case illustrates the use of bilateral cortical mastoidectomy in the successful management of this condition following failed antibiotic therapy, and highlights important management considerations.

Hyoid bone fracture identified only with nasal Valsalva manoeuvre.

OBJECTIVE: We present two cases of a hyoid bone fracture identified through careful clinical examination with a Valsalva manoeuvre during nasendoscopy. METHOD: Case reports and review of the literature, with emphasis on technique during nasendoscopy. RESULTS: The first patient had sustained a blow to the neck with a stick, six months prior to presentation with a globus sensation. External examination and standard nasendoscopy were unremarkable. The second patient had been struck across the neck by a wire whilst riding a motorbike at low speed. Endoscopy revealed swelling of the supraglottis. He recovered and was asymptomatic at review one month later. Computed tomography scans on both patients were unremarkable. During nasendoscopy, both patients were asked to forcibly expire with their mouths closed (the so-called nasal Valsalva manoeuvre), and the hyoid bone was seen to swing into view on the side where the first patient complained of symptoms, and in the second case where swelling had been noticed previously. CONCLUSION: We would not ordinarily have reached a diagnosis in these patients, as radiography and examination were otherwise unremarkable. The use of the nasal Valsalva manoeuvre during routine nasendoscopic examination is recommended, as unusual pathology may be demonstrated and the need for direct laryngoscopy under general anaesthesia may, in some instances, be avoided.

Nurse-led triage of otolaryngology out-patient referrals: an acceptable alternative?

OBJECTIVES: To establish the safety and effectiveness of nurse-led triage of otolaryngology out-patient referrals. METHOD: One hundred consecutive general practitioner referrals were reviewed by two consultants, two specialist registrars, two foundation year two senior house officers and two otolaryngology nurses. One of the nurses had received triage training. All referrals were triaged as 'urgent', 'soon' or 'routine' by each rater. RESULTS: The triage-trained nurse's results demonstrated good agreement with those of the senior consultant (80 per cent). This agreement was similar to that with the other consultant (77 per cent) and the specialist registrars (79 and 82 per cent). Weighted kappa statistics (correcting for chance agreement) showed that the triage-trained nurse had the second closest agreement to the senior consultant (0.66). After the actual out-patient appointments, retrospective review of the patients' case notes revealed that none had been triaged inappropriately by the trained nurse, and no urgent cases had been missed. CONCLUSIONS: Triage of out-patient referrals by trained ENT nurses is safe and effective, and is an acceptable alternative to traditional consultant vetting of referrals.

The impact of endonasal dacryocystorhinostomy (DCR), on patient health status as assessed by the Glasgow benefit inventory.

OBJECTIVE: To measure the effect of Endonasal DCR on the health status of patients, using a validated outcomes measure, the Glasgow Benefit Inventory. METHOD: Postal questionnaire with telephone follow up of patients undergoing Endonasal DCR in two institutions in Scotland. The same surgical technique is used in both centres. Patients were identified from prospectively collected data on consecutive patients undergoing this procedure. All adult patients, a minimum of twelve months post-intervention, were included. RESULTS: Ninety two of 123 patients (75%) completed the questionnaire, the mean age was 59 years and the sex ratio m:f was 1:1.8. The mean overall GBI for this intervention was + 32.7 (95% confidence intervals 27.8 - 37.6). The patients were grouped according to the indication for intervention: Obstruction of lacrimal system GBI + 32.7 (26.3-37.1), mucoecele + 40.1 (28.7-51.4), dacryocystitis + 19.4 (10.0-28.9). CONCLUSION: The GBI provides a measure of the effect of an ORL intervention on the health of a patient. Endonasal DCR scores highly when compared with a number of other rhinological procedures including rhinoplasty (GBI + 20), endoscopic sinus surgery (GBI + 23), and septal surgery (mean ranges from + 6 to + 24). Endonasal DCR is a successful intervention with demonstrable health benefits to the patient.

Leishmaniasis presenting to the otolaryngologist: a rare but important cause of persistent hoarseness.

OBJECTIVE: We report a rare UK case of laryngeal leishmaniasis, mimicking laryngeal candidiasis, associated with long term steroid inhaler use. METHODS: Case report and review of the world literature concerning leishmaniasis. RESULTS: Laryngeal leishmaniasis is a protozoal infection which is rare in the Western world. It is becoming more common, however, with increased foreign travel. The disease can be difficult to diagnose histologically, and diagnosis is often delayed because of its rarity. It can mimic malignant laryngeal disease, and patients may therefore be subjected to significant and inappropriate treatment interventions. CONCLUSIONS: A diagnosis of leishmaniasis should be considered if initial treatment for persistent hoarseness is ineffective, particularly in a patient who is at low risk of malignancy.

What are the occlusal outcomes for unilateral cleft lip and palate patients? A national project in the UK.

AIM: This national project assessed the orthodontic outcome for unilateral cleft lip and palate (UCLP) patients in the UK. METHOD: Six consecutively treated fixed appliance cases where orthognathic surgery was not undertaken were assessed using the peer assessment rating (PAR) index on orthodontic study models. These cases were submitted by NHS consultant orthodontists undertaking treatment on patients with cleft lip and/or palate. SETTING: UK NHS consultant-led hospital service. RESULTS: The mean reduction in PAR score was 69% + or - 22. The mean start PAR score was 41 + or - 11. The mean end of treatment PAR was 12 + or - 9. The proportion of cases where the score was worse or no different was 7.5%. CONCLUSION: The mean percentage PAR reduction compares well with other national projects looking at outcome from patients treated in the hospital service. The mean PAR reduction could be used as a benchmark for outcome in UCLP orthodontic treatments in future audit projects and the annual consultant appraisal process.

Early surgical outcomes in 5-year-old patients with repaired unilateral cleft lip and palate.

OBJECTIVE: To assess the surgical outcome of 5-year-old subjects with repaired unilateral cleft lip and palate who had been operated on by a single surgeon. DESIGN: Retrospective consecutive outcome study. SETTING: The cleft lip and palate center at Frenchay Hospital, North Bristol NHS Trust, U.K. PARTICIPANTS: All patients born with unilateral cleft lip and palate between May 1992 and April 1998 were identified and their study models were located. MAIN OUTCOME MEASURES: The reasons for failing to obtain study models were recorded. The "test" study models were combined randomly with a "gold standard" set of study models to give a group of 53 for assessment purposes. These study models were assessed twice by two examiners independently using the 5-Year-Olds' Index. The weighted kappa (kappa) statistic and components of variance were used to establish the levels of agreement within and between examiners, as well as between the gold standard and the examiners. RESULTS: Thirty sets of study models out of a possible 43 were located. The most common reason for not obtaining records was poor cooperation. More than 50% of study models were assessed as being good outcomes (Index groups 1 and 2), whereas fewer than 20% of the records were evaluated as being poor outcomes (Index groups 4 and 5). There was good inter- and intraexaminer agreement and agreement with the gold standard values. CONCLUSION: Study model collection in this age group can be difficult due to patient cooperation.

Centralization of services: standard setting and outcomes.

OBJECTIVE: To test specific standards set in the newly established cleft lip and palate service in three regions of the U.K. The standards relate to record collection and outcomes. DESIGN: Retrospective analysis. PATIENTS: Records of 31 children, 5 years of age, who were born in 1997 with complete unilateral clefts of lip and palate and were treated by surgeons in three regions. MAIN OUTCOME MEASURES: Record collection standards were measured by collecting dental study models. Outcomes were measured with the 5-Year-Old Index. RESULTS: Of the 31 subjects, 52% had excellent and good outcomes. The 31 cases represented 62% of the total records collected. CONCLUSIONS: The three regions examined fell short of the standards set, but the outcomes were improved compared with previous national outcomes. The failings in record collection need to be rectified. This study provides baseline data for further development of cleft services within three regions.