Oral Mycostatin as a possible alternative treatment for intractable Ménière's disease: preliminary cohort study.

Background: The potential efficacy of antifungal agents (e.g. Mycostatin) in treating acute attacks of Ménière's disease was first suggested in 1983 but few data have been published. Oral Mycostatin has been used as second-line medical treatment for intractable Ménière's disease at our institution for many years. Objective: This preliminary cohort study investigated the role of oral Mycostatin in intractable Ménière's disease. Methods: A retrospective review of patients with intractable Ménière's disease who started oral Mycostatin treatment between 2010 and 2012 was conducted. Results: Of 256 patients presenting with vertiginous disorders, 26 had definite Ménière's disease and had not responded to standard first-line treatment. Following oral Mycostatin treatment, improvements were reported for vertigo (n = 8), aural fullness (n = 7), tinnitus (n = 3) and subjective hearing loss (n = 3). Half of those with symptom improvement persisted with oral Mycostatin for two years and continued to remain asymptomatic. Conclusion: The use of oral Mycostatin to alleviate symptoms of intractable Ménière's disease showed promising results in this case series. Mycostatin may offer a safe and useful alternative for the management of Ménière's disease for patients with chronic unremitting symptoms in whom first-line treatment options have failed.

A simple method to prevent the obstruction of post-tympanoplasty ventilation tubes.

The simultaneous insertion of a ventilation tube or grommet during tympanoplasty is a well-recognised practice among otologists. It is used to reverse atelectasis and to repneumatise the middle ear. A troublesome problem which can occur is post-operative, intraluminal grommet obstruction by blood or viscous mucoid secretions. Routine post-operative use of eardrops may help prevent grommet obstruction but cannot be administered after tympanoplasty when the ear canal is packed with dressings for up to three weeks post-operatively. In this article, we describe a simple method to prevent post-tympanoplasty grommet obstruction.

Sudden bilateral sensorineural hearing loss associated with urticarial vasculitis.

BACKGROUND: Bilateral sensorineural hearing loss associated with recurrent urticarial skin lesions may be signs of underlying Muckle-Wells syndrome. Previous reports have described the hearing loss to be progressive in nature. METHOD: To our knowledge, this paper presents the first published case of sudden onset, bilateral sensorineural hearing loss associated with urticarial vasculitis due to underlying Muckle-Wells syndrome. RESULTS: The patient underwent a cochlear implantation with a modest outcome. CONCLUSION: Cochlear implantation may help to rehabilitate sudden hearing loss associated with this condition, but early diagnosis may allow treatment with interleukin-1ß inhibitors such as anakinra.

Multinodular thyroid goitre causing obstructive sleep apnoea syndrome.

BACKGROUND: Obstructive sleep apnoea syndrome has been linked to obesity, nasal obstruction and adenotonsillar hypertrophy, but rarely to large thyroid goitres. OBJECTIVE: To study the possible association between multinodular retrolaryngo-pharyngeal or retrosternal goitres and obstructive sleep apnoea syndrome. SUBJECTS AND METHODS: Retrospective case series at a tertiary referral centre (2000-2010). Study parameters included body mass index, Epworth sleep score and polysomnographic index. RESULTS: Five patients were diagnosed with obstructive sleep apnoea syndrome and managed with nasal continuous positive airway pressure ventilation. Computed tomography showed a retrolaryngo-pharyngeal or retrosternal goitre with significant tracheal compression, displacement and laryngeal oedema. After total thyroidectomy, obstructive sleep apnoea resolved in all patients. CONCLUSION: Large, multinodular goitres with retrolaryngo-pharyngeal extension can cause obstructive sleep apnoea syndrome due to laryngeal compression and oedema. In such cases, total thyroidectomy enables resolution of symptoms. Patients with obstructive sleep apnoea syndrome should be screened for thyroid goitre.

Lymphoproliferative disorder of nasopharynx after long-standing cyclosporin therapy for psoriatic arthritis.

BACKGROUND: The increased risk of developing lymphoproliferative disorders, mainly linked with Epstein-Barr virus infection, is well documented in patients with cyclosporin-induced immunosuppression following organ transplantation. Lymphoproliferative disease is extremely rare in the non-transplant setting. METHODS: We present the first published case of non-Epstein-Barr virus associated lymphoproliferative disease in a patient receiving long-standing cyclosporin therapy for psoriatic arthritis, which presented as a recurrent nasopharyngeal mass. RESULTS: Histological examination showed lymphoid hyperplasia in repeated biopsies. Macroscopic clearance was persistently followed by aggressive recurrence. Spontaneous regression occurred upon cyclosporin withdrawal. CONCLUSION: This rare complication of cyclosporin therapy in non-transplant patients is highlighted from an otolaryngological perspective, as the sole presentation may be a recurrent nasopharyngeal mass. Repeated biopsies showing lymphoid hyperplasia, together with aggressive recurrence, should prompt immediate drug withdrawal to reduce immunosuppression and promote spontaneous regression.

Nasal septal cyst: a rare phenomenon.

INTRODUCTION: Well-recognized complications of nasal septal surgery i.e. septoplasty or submucous resection (SMR), include septal haematoma, infection, septal perforation and external nasal deformity. Nasal septal cysts are extremely rare in rhinology. OBJECTIVES: To discuss the underlying aetiological theories, management and strategies for prevention of this very rare complication of a commonly performed rhinological procedure such as SMR. CASE REPORT: We describe a case of a nasal septal cyst several years after an SMR had been performed, which was excised using an open rhinoplasty approach that has not previously been described for this purpose. CONCLUSION: Entrapment of free nasal mucosal remnants or inward folding of incised septal mucosa in the submucosal space is postulated as the cause of this phenomenon, leading to the development of this type of "inclusion" cyst. Postoperative nasal packing, especially if traumatic, may exacerbate this. We recommend that anterior nasal packing should be used only if necessary, and packs inserted with care, possibly under endoscopic guidance.

Superficial temporal vein graft in stapedotomy: a functional and aesthetic alternative.

The Causse technique of performing stapedotomy with vein graft interposition is widely-employed, with the vein graft harvested from the dorsum of the hand/wrist. Donor site scarring may be of cosmetic concern, especially in female patients. A prospective series of 19 patients undergoing stapedotomy with vein graft harvested from the superficial temporal vein is evaluated from aesthetic and functional perspectives. Results show that vein interposition from this donor site is not only aesthically acceptable but just as successful in improving hearing outcome after stapedotomy. We suggest the use of the superficial temporal vein and/or its branches as an alternative vein graft in stapedotomy.

Primary assessment of the vertiginous patient at a pre-ENT balance clinic.

INTRODUCTION: Due to problems with long waiting times for assessment of vertiginous patients (more than 24 weeks), we changed practice and instituted a pre-ENT balance clinic assessment; we then audited the results. In particular, we looked at the subgroup with benign positional paroxysmal vertigo. METHODS: One hundred and fifteen patients were seen at the pre-ENT balance clinic from October 2003 to September 2004. Those diagnosed with benign positional paroxysmal vertigo received particle repositioning therapy at the same clinic and did not subsequently need ENT assessment. RESULTS: By the end of the audit period, waiting times were reduced to three weeks, and more than one-quarter of vertiginous patients (i.e. those diagnosed with benign positional paroxysmal vertigo) did not need to be reviewed at an ENT clinic. CONCLUSION: We believe this to be the first study to present prospective data showing that patients with benign positional paroxysmal vertigo may be safely diagnosed and effectively managed at a pre-ENT balance clinic.

Morbidity after adenotonsillectomy for paediatric obstructive sleep apnoea syndrome: waking up to a pragmatic approach.

INTRODUCTION: Adenotonsillectomy is successful at eliminating airway obstruction in the majority of otherwise normal children with obstructive sleep apnoea syndrome. Children with this condition are at significantly higher risk of post-operative respiratory complications. Identifying children at risk of post-operative respiratory complications after adenotonsillectomy for obstructive sleep apnoea syndrome remains a challenge for clinicians, especially those at district general hospitals. AIM: To review the evidence and to proffer a pragmatic approach to diagnosis and management, by classifying those at risk of post-operative respiratory complications into different risk subsets, with guidelines for management. CONCLUSION: Patients in the high risk group should be operated upon at paediatric specialist centres with intensive care facilities. Those in the moderate risk group may undergo adenotonsillectomy at their district general hospital, provided facilities for administering continuous positive airway pressure are available on-site. Most children with obstructive sleep apnoea syndrome may be classified as low risk candidates and may safely be operated upon at their local district general hospital.

'Bones of contention': a donor register for temporal bone donation?

INTRODUCTION: Temporal bone dissection is essential training for otological surgery. Organ retention scandals have made it difficult to obtain consent for cadaveric temporal bone removal. The current literature does not address the means of acquiring a steady supply of cadaveric temporal bones for medical education and training. The US national temporal bone registry has established a temporal bone donor bank for medical education and research. Could a similar programme in the UK be an answer to the paucity of temporal bones? OBJECTIVES: (1) To ascertain the degree of interest amongst our regional patient population in a 'living will' pledge for temporal bone donation for medical education and research. (2) To delineate a demographic profile of potential temporal bone donors. DESIGN, SETTING AND PARTICIPANTS: One thousand questionnaires were distributed to patients and relatives attending out-patient clinics; 920 people responded. RESULTS: Seventy per cent of respondents supported temporal bone donation for medical education and research. Potential temporal bone donors tended to be ENT clinic attenders, to suffer from hearing difficulties or to have had previous ear surgery (p<0.001). Strong support also came from non-ENT clinic attenders. CONCLUSIONS: There was strong support amongst our regional patient population for a 'living will' pledge for temporal bone donation for medical education and research. Based on our donor profile, we propose a temporal bone donor programme, starting on a regional basis with possible expansion nationwide. This programme would recruit donors from amongst patients attending ENT out-patient clinics, as a long term solution to improve the supply of temporal bones.

A non-randomized comparison of earwax removal with a 'do-it-yourself' ear vacuum kit and a Jobson-Horne probe.

OBJECTIVES: Do-it-yourself ear vacuum kits (ear vacs) have recently been introduced as an effective method of earwax removal. This study assesses the efficacy of ear vacs in comparison with a conventional mechanical method of earwax removal, the Jobson-Horne probe. METHODS: Forty healthy relatives who had accompanied family members to orthopaedic and haematology clinics were screened with otoscopy. Sixteen participants with earwax were selected. MAIN OUTCOME MEASURES: (i) Weight of earwax removed, (ii) proportion of tympanic membrane visible before and after each intervention, (iii) participants' subjective assessment of any improvement in hearing. Suction pressure generated by the ear vac was also compared with that of microsuctioning. RESULTS: No earwax was removed with the ear vac but the Jobson-Horne probe was significantly more effective at removing a greater weight of earwax (P < 0.001, mean weight 92.4 mg). There was no improvement in visibility of the tympanic membrane after the ear vac but the Jobson-Horne probe restored visibility to 100% (P < 0.001). No participant felt that there was an improvement in their hearing after the ear vac, but the majority (88%) reported an improvement in their hearing after the Jobson-Horne probe. CONCLUSION: A Jobson-Horne probe is significantly more effective than an ear vac for the removal of earwax.

Cell cycle proteins do not predict outcome in grade I infiltrating ductal carcinoma of the breast.

Infiltrating ductal mammary carcinomas are histologically graded according to their extent of differentiation. Well-differentiated, grade I, tumours have low proliferative activity, usually form tubules and exhibit little nuclear pleomorphism. Despite an apparently reassuring morphology, 10-15% of grade I ductal carcinomas metastasize, albeit after a prolonged period. Recent evidence supports the view that evolution to higher grade malignancies occurs rarely and that grade I tumours are biologically distinct from grade III tumours. We have examined a series of 148 grade I ductal carcinomas in order to ascertain whether information about the level of expression of cyclin D1, p27, p53, oestrogen receptor status (ER) or proliferative activity could be used to identify those patients with a poor outcome. The majority of tumours expressed high levels of cyclin D1, p27 and ER, low levels of p53 and had low Ki-67 expression and mitotic counts. Cyclin D1, p27 and ER expression were all significantly correlated with each other but not with p53 (cyclin D1 correlation with ER, p = 0.01; cyclin D1 correlation with p27 and ER correlation with p27 both p < 0.0001). Cyclin D1 and ER were also both correlated with Ki-67 (p = 0.01 and p < 0.0001) but not with mitotic count. Our results suggest that cyclin D1, ER and p27 are all markers of well-differentiated tumours and that their detection is related to proliferative activity in a manner reflecting their functional role within the normal cell cycle. However, none of the proteins or markers of proliferative activity were sensitive enough to predict which patients were likely to have a poor outcome.

The biological and prognostic significance of cell polarity and E-cadherin in grade I infiltrating ductal carcinoma of the breast.

Grading of breast cancer based on the modified Scarff, Bloom, and Richardson system provides invaluable prognostic information. Recent evidence suggests that most tumours do not usually progress between grades and that groups of tumours within each grade are biologically distinct. This study has explored one potential aspect of biological tumour heterogeneity within grade by examining the relationship between cell polarity, the cell adhesion molecule E-cadherin, a major effector of cell polarity, and outcome, in 149 grade I infiltrating ductal breast carcinomas. Polarity was evaluated by studying the degree to which three features of polarized epithelial cells-nuclear ordering, basal positioning of nuclei within cells, and apical snouting/blebbing-were present in these tumours. E-cadherin expression was investigated using the antibody HECD-1. A low degree of tubule formation was correlated with poor nuclear ordering ( p< 0.01). The three histological features-nuclear ordering, basal nuclei, and apical blebbing-were all correlated with each other (all p< 0.0001). Polarity measurements did not correlate with survival. E-cadherin expression did not correlate with polarity and negative tumours were still able to form tubules. Surprisingly, strong E-cadherin immunostaining correlated with poor survival, tumour size, and nodal status. On univariate parametric (Weibull) survival models, high E-cadherin scores and tumour size were both significant predictors of survival in this group.