Drain-free parotidectomy: a pilot study using ARTISS fibrin sealant.

PURPOSE: Parotidectomy is the definitive procedure for diagnosis and treatment of most parotid masses but, due to the risk of haematoma and seroma formation, has traditionally included a drain. The drain itself comes with its own risks and, in most hospitals, the need for overnight admission, which has significant cost implications (Mallon et al. Ann R Coll Surg Engl 95(4):258-262; 2013). Fibrin glue, with its haemostatic and adhesive properties, reduces the risk of collection or haematoma and therefore may negate the need for a drain. This is the first study to look at the use of ARTISS as an alternative to drains in parotidectomy. METHODS: We performed a retrospective study of all the patients who underwent a partial parotidectomy over a 4-year period from 2014 until 2018 under the same senior surgeon. Patients were divided into those that had a drain and those that had ARTISS. Their operative record, inpatient notes and clinic letters were reviewed to record information regarding length of stay, histology, complications and recurrence. RESULTS: A total of 34 patients were identified; 17 ARTISS and 17 drain patients. We showed that the mean length of stay improved significantly from 1.6 days with the drain to 0.5 days with ARTISS (Fig. 1) but without a difference in complication rate (Fig. 2), which was 5/17 (29%) in each group. CONCLUSIONS: In conclusion, parotidectomy can be undertaken safely as a day-case procedure with the application of ARTISS. This new approach to parotid surgery not only offers less morbidity for patients but also positive financial revenue for public health institutions.

Airway emergency from spontaneous haemorrhagic thyroid cancer.

Spontaneous thyroid haemorrhages are rare. There are reported cases occurring in thyroid nodules and cysts but none in thyroid malignancies. We describe a 48 year old who presented to the on-call ENT team with a rapidly progressing neck swelling that was interfering with his airway. After resuscitation, the patient underwent a right lobectomy to stop the bleeding. Histology showed a thyroid follicular carcinoma. As per the regional multidisciplinary team discussion, he underwent a completion thyroidectomy followed by radioactive iodine treatment. We conclude that spontaneous haemorrhages of the thyroid gland can occur in malignancies and stress the importance of early histological diagnosis.

Rapid thyrotoxicosis in anaplastic thyroid carcinoma.

We present the case of a 71-year-old man with anaplastic thyroid cancer. On presentation, his thyroid function was normal, but he subsequently developed sudden, rapid thyrotoxicosis. Thyrotoxicosis in anaplastic thyroid carcinoma is very rare, but in all previously reported cases the patient was thyrotoxic at presentation. Our case is unusual as our patient presented euthyroid, and thyrotoxicosis developed subsequently. We challenge current ideas regarding the biochemical pathophysiology of rapid thyrotoxicosis in anaplastic thyroid carcinoma and provide an alternative explanation.

The facial skin lesions "see and treat" clinic: A prospective study.

Facial lesions are commonly referred to ear, nose and throat surgeons. Almost all are amenable to excision under local anaesthetic as a day case. However, in the UK, there is still a significant delay between referral by the general practitioner (GP) and final surgery. To address this delay, a one stop see and treat consultant led clinic was set up in the community. The aim of this study was to assess the impact of the one stop clinic on waiting times and to ascertain the satisfaction of patients with the treatment they received in this clinic. Patients with facial skin lesions were referred by the GPs to the ENT department in the usual manner. The referral letters were screened by two consultants, the appointments were booked by telephone and the patients were seen and treated in a single visit. The clinics were held in a minor surgery unit of a centrally located GP practice. Patients were seen, assessed and if the facial lesion was considered amenable to excision under local anaesthetic, the patient was consented and the procedures carried out immediately. The clinic was audited over a 1 year period. Waiting times were compared before and after the start of the project. Patients were asked to fill in a questionnaire immediately after surgery. The attendance rate was 96%. The waiting time was reduced from 121 to 47 days. Patients rated the clinic experience as excellent (88%) or good (12%) indicating a very high satisfaction rate. During the study period, 160 lesions were excised of which 22% were malignant. Patients with malignant lesions did not show any sign of recurrence at a follow up of 9 months, except in one case with basal cell carcinoma. This was operated on and removed completely. Our project shows that the aims of reducing waiting times and improving patient care were achieved with this community model of a one stop facial lesions clinic. This clinic is now an integral part of the service provided by the ear, nose and throat department at Ipswich hospital, UK.

Current practices of cocaine administration by UK otorhinolaryngologists.

The aim of this study was to determine which anaesthetic and vasoconstrictor preparations UK Otorhinolaryngologists use for rhinological surgery, with particular reference to cocaine and adrenaline. The incidence and types of adverse reactions to cocaine were also recorded. A postal survey of all BAO-HNS consultant members was performed. Of the 360 consultant surgeons included in the survey, the majority still use peri-operative cocaine on a regular basis, 66 per cent use cocaine and adrenaline together and more than 40 per cent use cocaine in paediatric patients. Sixteen per cent of respondents did not use cocaine. Only 11 per cent of surgeons had experienced cocaine toxicity in their patients, with only one recorded case of mortality. Most surgeons in the UK use cocaine because of the superior operative field it provides and because they consider it to be safe even with adrenaline. The actual incidence of adverse reactions to cocaine is low, with serious complications being less common than the risks from general anaesthesia. Cocaine remains a valuable agent in the armamentarium of the rhinologist.

Sagittal computerized tomography reconstruction of the lateral nasal wall for functional endoscopic sinus surgery.

Coronal computerized tomography (CT) scanning is imperative in the preoperative work-up for functional endoscopic sinus surgery (FESS). This study describes additional information provided by lateral CT reconstruction with special attention to the (naso-) frontal recess. Thin axial scans were taken from 10 patients suffering from chronic rhinosinusitis. This procedure avoided artefacts from dental fillings on the computerized reconstructions. The common landmarks of the lateral nasal wall as described in the surgical anatomy of FESS were easily identified on sagittal views. The average angulation of the sagittal plane from the midline required to obtain optimal images of the frontal recess was antero-posteriorly 8.7 degrees (SD, 2.4), cranio-caudally 7.7 degrees (SD, 2.6). Size and condition of the frontal recess could be demonstrated. Variations of the angle between frontal sinus and ethmoid infundibulum appeared to depend on the anterior projection of the frontal sinus and may give an indication as to the optimal endoscopic angle for visualization of the frontal ostium. Sagittal reconstructions provide information for better spatial orientation particularly in the plane of the surgical approach and may help to diagnose underlying functional changes of chronic frontal sinusitis.

Adenocarcinoma of the larynx--a distant metastasis from a rectal primary.

Laryngeal metastases from remote primary tumours are uncommon. They derive mostly from melanomas or renal cell carcinomas. The generally rare laryngeal adenocarcinomas can only be classified as metastatic tumours in the presence of a distant primary of the same histology. Only five cases of a laryngeal secondary originating from adenocarcinoma of the large bowel have been reported in the world literature. A further case is presented which to our knowledge is the first to arise from the rectum, a site which suggests haematogenous tumour spread. This paper emphasizes the need for the search of synchronous metastatic disease and discusses the therapeutic options on the grounds of current management of singular colorectal secondaries.

Papillary carcinoma arising in a thyroglossal duct cyst: a case report and literature review.

Papillary carcinoma arising in a thyroglossal duct cyst is a rare finding. Less than 100 cases have been reported in the English literature. In most cases the diagnosis is only established after excision of a clinically benign thyroglossal duct cyst. The aetiology of such tumours is unclear but de novo origin and spread from a primary thyroid gland tumour has been suggested. This has important implications for therapeutic approaches. A further case of thyroglossal duct carcinoma is presented and the management is discussed on the basis of the current rationale for treatment of thyroid cancer.

The possible relationship between transient evoked otoacoustic emissions and organ of Corti irregularities in the guinea pig.

Otoacoustic emissions are believed to arise from an active process associated with the outer hair cells in the mammalian organ of Corti. They have been attributed to the presence of impedance discontinuities on the basilar membrane which might be caused by hair cell irregularities. To test this hypothesis we have investigated the possible relationship between transient evoked otoacoustic emissions (TEOAEs) and anatomical integrity in the organ of Corti. Click-evoked TEOAEs have been measured from the ear canals of normal, pigmented guinea pigs using an Otodynamics ILO88 analyser. Emissions were present in 18 out of 19 animals tested and the major frequencies observed were consistently present in different measurements over periods of up to ten weeks provided recording conditions were satisfactory. The frequency spectra of the TEOAEs resembled those measured in humans but the latencies of the responses were considerably shorter. In one acute experiment, the TEOAEs were shown to be dependent on metabolic energy as they were lost rapidly following termination with an overdose of anaesthetic. In another case, evoked emissions of long duration (sustained) at about 1 kHz were obtained from both ears. All cochleae examined showed irregularities, especially patches of mainly apical outer hair cell loss of differing extents. However, there was no evidence that substantial lesions coincided consistently with the frequency regions corresponding to the major emissions. Nevertheless, it was noted that the total energy level of emissions was proportional to the total outer hair cell loss, except in one case, where the outer hair cell loss was substantial and the energy level of TEOAEs was considerably lower. Although there is no clear relationship between TEOAEs of specific frequencies and abnormalities at the corresponding cochleotopic location in the organ of Corti which could represent impedance discontinuities, the degree of irregularity may determine the overall emission level. This finding is consistent with the idea that emissions arise as a result of irregularity producing variations in the reflection coefficient.