Masked pseudomonal skull base osteomyelitis presenting with a bilateral Xth cranial nerve palsy.

Skull base osteomyelitis classically presents as a complication of severe external otitis, middle ear, mastoid or sinus infection and can lead to multiple lower cranial nerve palsies when the jugular foramen is involved as a consequence of widespread involvement of the skull base. Bilateral skull base osteomyelitis is a recognized phenomenon, but has not previously been reported secondary to pseudomonal infection in the absence of a clinically obvious focus of infection. We report the case of a 77-year-old diabetic patient who presented with dysphonia and dysphagia and had a bilateral Xth cranial nerve palsy. No focus of infection was evident on presentation. Subsequent radiological investigation confirmed the diagnosis of bilateral skull base osteomyelitis.

Novel use of nebulised adrenaline in the treatment of secondary oropharyngeal haemorrhage.

We report the use of nebulised adrenaline in the treatment of secondary oropharyngeal haemorrhage. Cases involving two adults and one child are presented to illustrate the usefulness of this technique in helping to achieve haemostasis without the need for a general anaesthetic. The mechanisms of the haemostatic action of adrenaline are also explored. We believe that in selected cases nebulised adrenaline is both safe, effective and easily tolerated and represents a useful additional tool in the treatment of oropharyngeal haemorrhage.

Laryngoscopy findings in outpatient notes: the accuracy of the recording of the side of the lesion.

An analysis of 100 patient notes was performed in the South-west Thames Region to determine the accuracy of recording the side of the abnormality in outpatient clinic notes when compared to the findings at direct laryngoscopy. Direct laryngoscopy was felt to be the most accurate method of viewing the larynx. The results were analysed to determine if the specific method of outpatient laryngoscopy or grade of examiner influenced the error rates. Inconsistencies occurred in 29% of the clinic notes when a diagram of the larynx was present. Specialist Registrars made 59% of the errors. Flexible nasendoscopy accounts for more errors than indirect laryngoscopy.

Patient benefit from functional and cosmetic rhinoplasty.

The Glasgow Benefit Inventory, a validated post-interventional questionnaire, was used to determine patient benefit from septorhinoplasty according to indication (function, cosmesis or a combination) in 87 patients. We showed a very significant patient benefit from this procedure and have demonstrated that the benefit is greatest when cosmesis is an indication (P = 0.05).

A national survey of disinfection techniques for flexible nasendoscopes in UK ENT out-patient departments.

Flexible fibre-optic nasendoscopes have become a ubiquitous ENT out-patient tool for the inspection of the nasopharynx, larynx and hypopharynx. Disinfection of the instrument between patient use is important to prevent potential spread of infection but the methods used vary considerably. We designed a questionnaire which was piloted and then sent to 115 UK ENT out-patient departments to establish current UK practice. Most units (67 per cent) use a chemical soak system but the type of chemical disinfectant, the method of delivery and the duration of soak varied considerably. A few hospitals use a disposable plastic sheath system and others simply wipe the instrument with an alcohol swab in between patient use. The protocols for disinfection after high risk patients e.g. human immunodeficiency virus (HIV), hepatitis B varied from hospital to hospital. The results demonstrate a lack of standard practice that is wasteful of financial resources and may expose patients to unnecessary risk. There is a need for an authoritative ENT body to publish national guidelines as may be found in other specialties and other countries.

Air rifle injury to the oropharynx. The essential role of computed tomography in deciding on surgical exploration.

Gunshot wounds specific to the oropharynx are extremely rare with no reported cases of such injury in the world literature. The importance of such cases rests on the use of modern imaging techniques including computed tomography, magnetic resonance imaging, and vascular imaging in the making of management decisions and particularly in deciding the need for exploration of such an injury. In our case a conservative approach was adopted in view of the computed tomography finding and the stable clinical condition of the patient.

Day case rhinoplasty.

Rhinoplasty is considered by many to be an inpatient surgical procedure. This may be because the operation is thought to be traumatic with a risk of epistaxis and periorbital haematoma. Since 1992 rhinoplasty surgery at St George's hospital has been routinely performed on a planned day case basis. The hospital records of 97 patients were examined of which 17 patients (18%) underwent planned admission and 12 (12%) unplanned admission. No patients were re-admitted to hospital after discharge. With the advances in day case surgical practice within the UK we consider that the practice of day case rhinoplasty is likely to have its place. Such surgery should ideally be performed in a dedicated day case unit and provision for admission overnight should be available.

Mycotic aneurysm of the external carotid artery.

Mycotic aneurysms of the extracranial carotid arteries are extremely rare. A case is reported of a false aneurysm of the left external carotid artery. This developed secondary to cervical lymphadenitis which did not settle with high dose antibiotic therapy. The diagnosis was made on investigation with carotid doppler ultrasound and confirmed with computerized tomography. Digital subtraction angiography was performed to highlight the vascular anatomy. In addition percutaneous balloon catheter control of blood flow in the external carotid artery was used as an adjunct to surgical management.

Neonatal and paediatric fibre-optic laryngoscopy and bronchoscopy using the laryngeal mask airway.

Endoscopy of the upper airways in neonates and infants was traditionally been accomplished using rigid laryngoscopes and bronchoscopes. The laryngeal mask may be used both to control the airway for anaesthetic ventilation and to guide a fibre-optic endoscope to the laryngeal inlet and beyond. We report our experience with five neonatal and paediatric cases where fibre-optic laryngoscopy and bronchoscopy were performed through the laryngeal mask airway. All were cases in which standard rigid endoscopy had proved difficult with only a poor and restricted view of the laryngeal inlet being obtained due to the age of the infants, or abnormal anatomy of the upper airways. No problems have been encountered with maintenance of the airway or with endoscopic view obtained. In fact in neonatal patients, this technique has been found to be preferable with regard to safety and ease of use when compared to the ventilating bronchoscope. With the size 1 laryngeal mask airway it is not possible to simultaneously ventilate and endoscope the patient. Cases included, a vascular ring, Goldenhar's syndrome, laryngomalacia, supraglottis and vocal fold paresis. This technique provides a secure method of maintaining anaesthetic ventilation during airway endoscopy, and also a means of easily locating the glottis.

Otoacoustic emissions: assessment of hearing after tympanostomy tube insertion.

This study evaluates the use of transient evoked otoacoustic emissions as an alternative to pure tone audiometry for the assessment of hearing after tympanostomy tube insertion. Otoacoustic emissions and pure tone audiometry were carried out in 32 patients in whom tympanostomy tubes had been inserted. Otoacoustic emissions were detected in 78% of patients, whereas pure tone audiometry testing was only possible in 59%. Of 13 children who were 3 years of age or under, otoacoustic emissions could be measured in 62%, compared to pure tone audiometry which was only possible in 8%. Otoacoustic emission testing took on average 3 min, which was less than half the time for pure tone audiometry testing which took 7 min.

An in vitro comparison of the Erbium: YAG laser and the carbon dioxide laser in laryngeal surgery.

This study compares the relative thermal damage caused by a surgical CO2 laser and the Erbium:YAG laser when used to incise the human vocal fold in vitro. Results show that charring is completely eliminated when using the Erbium:YAG laser. The depth of coagulative necrosis adjacent to an incision is reduced from 510 microns (+/- 75) using the CO2 laser to 23 microns (+/- 12) using the Ebrium:YAG laser and at the base is reduced from 125 microns (+/- 45) using the CO2 laser to 12 microns (+/- 8) using the Erbium:YAG laser. The potential advantages regarding post-operative healing after laryngeal surgery are discussed.

Shy-Drager syndrome presenting as Menière's disease.

A 59-year-old patient with a history of Menière's disease is presented. She developed signs of progressive autonomic failure suggesting a diagnosis of Shy-Drager syndrome, a rare degenerative neurologic condition of unknown etiology. The most common otolaryngologic presentation of this syndrome is with stridor attributable to abductor paralysis of the vocal cords. The association with endolymphatic hydrops has not been previously described.

Parental cigarette smoking and tonsillectomy in children.

The deleterious effects of parental smoking on the upper respiratory tracts of children are becoming increasingly recognized. This study examines the effect of parental smoking on the frequency of tonsillitis and incidence of tonsillectomy in children. A group of children being admitted for tonsillectomy and a control group of children from an orthoptic clinic were studied. Details recorded about the children included a history of tonsillectomy and the number of courses of antibiotics taken for sore throats in the previous 12 months. Parents were questioned about their smoking habits. A marked and statistically significant association has been found between the incidence of tonsillectomy in children and parental smoking in the home environment. There was a higher frequency of attacks of tonsillitis requiring antibiotic treatment in those children whose parents smoked. This effect may be mediated by altered oropharyngeal flora, mucociliary dysfunction, increased cross infection or a combination of these. If parents are encouraged to stop smoking there will be a reduction in tobacco smoke levels in the home environment and this should lead to a fall in both the incidence of tonsillitis and the need for tonsillectomy in their children.

Criteria for hearing preservation in acoustic schwannoma surgery: the concept of useful hearing.

In the quest for hearing preservation in patients with acoustic schwannomas it is essential that surgeons do not lose sight of the concept of 'useful' hearing. There is an important difference between hearing preservation which pleases the surgeon and that which will be appreciated by the patient. Tumour size, pure tone audiogram average differences between ears and speech discrimination scores have been recorded in a series of 114 patients with unilateral acoustic schwannomas. Criteria for useful hearing are presented in terms of pure tone audiogram average difference and speech discrimination scores. There were 11 patients (10 per cent) with a speech discrimination score of 50 per cent or more, a pure tone audiogram average difference of 30 dB or better and a tumour size of no more than 2 cm. Only one patient (0.9 per cent) had a speech discrimination score of 50 per cent or more, a pure tone audiogram average difference of 20 dB or better and a tumour size of no more than 1 cm. It is concluded that hearing preservation techniques may be applicable to between 1 and 10 per cent of patients with unilateral acoustic schwannomas.

Latent mastoiditis: no room for complacency.

The administration of antibiotics in otitis media alters the natural course of the disease process. If the antibiotics used are inappropriate, or if dosage or duration of treatment is inadequate, an imminent intracranial complication may be masked. A case of latent mastoiditis presenting with Pott's puffy tumour is described.

Incidence and prevention of conjunctival contamination with blood during hazardous surgical procedures.

The incidence and risks of conjunctival contamination with patients' blood during a range of otolaryngological surgical procedures was assessed. Risks were found to be highest in three groups of procedures; tracheostomy, operations preceded by local anaesthetic injections and procedures involving the use of the air drill. A simple and effective method of protection using spectacles with large plain lenses is presented.

Spontaneous dissection of the intrapetrous internal carotid artery.

Two cases of cervicocephalic arterial dissection of the intrapetrous carotid artery are described. One patient presented with intolerable objective pulsatile tinnitus, the other with a cerebral infarction. Both were successfully treated with anticoagulants. The significance of minor degrees of trauma and of neck extension in the aetiology of these apparently spontaneous lesions is discussed.

Blood loss and haematological consequences related to nasal surgery.

A prospective study was carried out to compare blood loss from various types of nasal surgery, to investigate how accurately this loss was estimated during surgery and to find out how soon any losses were replenished. Blood loss during surgery was estimated, and by serial blood tests actual blood loss and continuing changes in haematological parameters were recorded. It was found that blood loss was highest when a nasal polypectomy and submucous resection were performed together and over the whole range of nasal surgery studied the actual blood loss was more than double the estimate during surgery. Although the blood volume recovers soon after surgery it was found that even after 6 weeks many patients had still not made up their loss of haemoglobin.

Anterior shoulder dislocation as a complication of surgery for burns.

An example of anterior dislocation of the shoulder resulting from the positioning of a patient for skin grafting of burns is presented. Complications of positioning patients prone and with their arms abducted and practical measures for their avoidance are discussed.