A unique case of a digital tourniquet in ichthyosis vulgaris.

We report a unique case of a digital tourniquet in a patient with ichthyosis vulgaris. We have identified no previous case reports documenting the occurrence of a digital tourniquet in patients caused by this condition. Ichthyosis vulgaris is a skin condition which causes increased scaling of the skin and in this case, resulted in the formation of a tourniquet-like circumferential constriction to one of the patient's digits.

Progressive, reversible sensorineural hearing loss caused by azathioprine.

OBJECTIVE: This paper describes the first reported case of progressive sensorineural hearing loss caused by azathioprine, which was reversed on stoppage of the drug. CASE REPORT: A female patient with previously normal hearing presented with progressive sensorineural hearing loss after being started on azathioprine. Otological and neurological examination findings were unremarkable. After stopping the drug, the patient reported an improvement in hearing, which was confirmed on pure tone audiometry. CONCLUSION: This previously unreported side effect of azathioprine is highlighted in order to increase clinical awareness. Early recognition of this adverse effect is important to minimise the possibility of permanent sensorineural hearing loss.

15-Year review of laryngeal and oral dysplasias and progression to invasive carcinoma.

The objective of this study is to identify a management or follow-up strategy for patients with laryngeal and oral dysplasia. A chart review of all patients with laryngeal and oral dysplasia over a 15-year period was performed. All patients were followed for a minimum period of 5 years from initial diagnosis of oropharyngeal or laryngeal dysplasia. If invasive carcinoma was demonstrated on subsequent biopsies, the exact time of this was recorded and Kaplan-Meier survival curves were plotted. In the laryngeal cohort, 45 patients were identified, 15 (33%) developed carcinoma, 7 of 30 patients (23%) with mild or moderate dysplasia, compared with 8 of 15 (53%) with severe dysplasia or CIS (P = 0.01). Thirteen of the carcinomas (87%) developed within 36 months of original biopsy. In the oral cohort, 32 patients were identified, 17 (53%) developed carcinoma, 1 of 9 patients (11%) with mild dysplasia, compared with 8 of 12 (67%) with severe dysplasia and 8 of 10 (80%) with CIS (P < 0.001). Fifteen of the 17 patients (88%) developed carcinoma within 36 months of original biopsy. In conclusion, although numbers are small, our results show that mild and moderate laryngeal dysplasia behaves differently to severe dysplasia and CIS. Mild oral dysplasia also behaves differently to severe dysplasia or CIS. In general, progress to malignancy happens within a 3-year period. Severe dysplasia or CIS should be managed aggressively.

A comparison of xylometazoline (Otrivine) and phenylephrine/lignocaine mixture (Cophenylcaine) for the purposes of rigid nasendoscopy: a prospective, double-blind, randomised trial.

OBJECTIVE: To evaluate if phenylephrine-lignocaine mixture (Cophenylcaine) nasal spray performs better than xylometazoline (Otrivine) spray for the purposes of out-patient rigid nasendoscopy preparation. DESIGN: Prospective, double-blind, randomised trial comparing visual analogue scores for out-patients receiving either phenylephrine-lignocaine mixture or xylometazoline, prior to undergoing rigid nasendoscopy as part of their assessment. SUBJECTS: Seventy-three patients requiring rigid nasendoscopy as part of their assessment were recruited to the study from Raigmore Hospital's out-patient clinic. These patients were randomised to receive a nasal spray comprising either phenylephrine-lignocaine mixture or xylometazoline, 10 minutes prior to rigid nasendoscopy. Double-blinding was adopted. After the procedure, the patient and the doctor independently completed separate visual analogue score-based questionnaires regarding the pain of the procedure and the ease of the examination, respectively. RESULTS: Analysis of the data using standardised statistical methods demonstrated that the phenylephrine-lignocaine mixture did not perform better than xylometazoline, to any statistically significant extent. CONCLUSION: Phenylephrine-lignocaine mixture is considerably more expensive and has potentially more side effects than xylometazoline. These study findings suggest that it is difficult to justify the use of phenylephrine-lignocaine mixture over xylometazoline, for nasal preparation prior to rigid nasendoscopy.

The use of topical nasal anaesthesia before flexible nasendoscopy: a double-blind, randomized controlled trial comparing cophenylcaine with placebo.

The objective was to evaluate the necessity to use topical nasal anaesthesia before flexible nasendoscopy and to compare its use with placebo. The study was carried out using a double-blind randomized controlled trial, with three treatment arms, at the out-patient department at Raigmore Hospital, Inverness. The participants were 90 patients attending the otolaryngology out-patient department who required flexible nasendoscopy as part of their assessment. Each participant was randomized to one of three groups. Group 1 received cophenylcaine spray, group 2 received a placebo spray, and group 3 received no nasal preparation. Flexible nasendoscopy was carried out via a stated protocol and the patient's diagnosis and findings were discussed in the usual way. After the consultation, the patient filled in a questionnaire marking answers on a visual analogue scale. The main outcome measures were pain and overall unpleasantness of procedure. Patient anxiety and willingness to be examined again in the same way if necessary were also assessed. Ease of examination and quality of view were asked from the operator's perspective. The mean scores on a visual analogue scale showed the main outcome measures to be as follows. Pain score measured 1.7 for cophenylcaine, 2.1 for no spray and 2.2 for placebo. Overall unpleasantness scores were 2.0 for cophenylcaine, 1.9 for no spray and 2.4 for placebo. On a visual analogue scale of 0-10, none of these mean main outcome measures reached levels of significance. It was concluded that the use of cophenylcaine spray before flexible nasendoscopy does not give significant advantages over the use of no nasal preparation.

Radiological staging for squamous carcinoma of the head and neck: a standardised practice?

The choice of investigations for radiological staging of squamous carcinoma of the head and neck can be highly variable. The aims of this study were to establish the practice amongst otolaryngologists in Scotland, to determine what, if any, consensus of practice exists and also to stimulate debate in this controversial area. The results of a postal survey to which there was a 65% response rate are reported. Of the primary sites, the greatest consensus on the need for imaging was of the nasopharynx, oropharynx and hypopharynx. For metastatic disease, all respondents imaged the chest but most did not image the abdomen or skeleton. The results for the other sites and imaging modalities chosen are discussed. A protocol for radiological staging based on the survey findings and interpretation of the literature is suggested.

Radiological staging of the chest and abdomen in head and neck squamous cell carcinoma--are computed tomography and ultrasound necessary?

The need for, and choice of, radiological staging investigations for distant metastases in the management of head and neck squamous cell carcinoma is a contentious issue. To address this problem a retrospective audit of routine computerized tomography (CT) and ultrasound scanning of the chest and abdomen respectively was undertaken. The records of 103 patients who, over a six and a half year period, underwent major surgery for head and neck squamous cell carcinoma were reviewed. A total of 57 patients (59 per cent) had CT scanning of the chest of whom two were identified as having synchronous tumours. In both cases, the lesions were identified on chest X-ray prior to scanning. Seventy patients (68 per cent) had routine ultrasound scanning of the abdomen. In none of these was metastatic disease identified. As a result of the audit findings routine CT and ultrasound scanning of the chest and abdomen has been discontinued.

A randomised clinical trial of antiseptic nasal carrier cream and silver nitrate cautery in the treatment of recurrent anterior epistaxis.

Sixty-four consecutive patients with a history of recurrent epistaxis were randomly assigned in the outpatient clinic to receive treatment with either Naseptin antiseptic nasal carrier cream alone (Group A) or a combination of Naseptin cream and silver nitrate cautery (Group B). Results were available on 50 patients, 22 in Group A and 28 in Group B. Twenty patients (91%) in Group A and 25 patients (89%) in Group B demonstrated improvement in their symptoms. There was no statistically significant difference in outcome between the two treatment arms (P = 0.7569). On comparing the different age groups (under and over 16 years) in the two treatment arms, once again there was no statistically significant difference in the treatment outcome (P = 1.000). In conclusion, silver nitrate cautery offers no added advantage to the management of simple epistaxis in both children and adults.

Target oriented computed tomography-scanning of the paranasal sinuses.

A limited computed tomography (CT) scanning protocol for the paranasal sinuses is proposed consisting of only seven cuts in the coronal plane. A retrospective observational study has shown the ability of these cuts to demonstrate the regions of interest to the FESS surgeon. The regions are detected at a rate ranging from 85% to 96% in this sample of 100 patients. The novelty of the protocol is the principle of targeting those regions. We believe that the targeted protocol is practically feasible and provides the necessary information concerning benign sinus disease, along with the expected reduction of exposure to radiation and reduction of cost.

Exophthalmos and facial swelling: a case of limited Churg-Strauss syndrome.

We report a case of vasculitis causing facial swelling and exophthalmos which on clinical and histological grounds is thought to be limited Churg-Strauss syndrome. An excellent response was achieved to high doses of systemic steroids and cyclophosphamide.

Angiomatous malformation of the floor of the mouth associated with fluctuating macroglossia in an adult: an unusual case report.

We report an unusual case of a large vascular lesion of the floor of the mouth of rapid onset in a 50-year-old man who presented with an external swelling in the submental region and a history of fluctuating swelling of the tongue. The clinical features, investigations, treatment and course of this rare condition are discussed.

Characterization of severely and profoundly hearing impaired adults attending an audiology clinic.

Despite the fact that around 12 per cent of adult patients attending an audiology department will be severely hearing impaired (pure tone averages of 0.5, 1, 2 and 4 kHz of 70 dB HL or worse in the better hearing ear), their clinical and audiometric characteristics have not been well documented. These characteristics were collected prospectively in 132 adult patients attending a Severe Impairment Clinic, set up to manage their specific problems. The inability to provide sufficient masking makes audiometric assessment of the severity of the impairment uncertain in the poorer hearing ear in 52 per cent of these patients. In addition, the limited bone conduction output makes it almost invariably impossible to assess the masked bone conduction thresholds and hence the air-bone gap in the poorer ear. Hence, accurate characterization is only practical of the better hearing ear in such patients. In 67 per cent of the better hearing ears, there was a mixed hearing impairment, the air-bone gap being 20 dB or greater. The aetiology of the conductive component was almost equally otosclerosis and chronic otitis media. In only 19 per cent was the impairment of a pure sensorineural type, broken down as 6 per cent congenitally acquired, 5 per cent due to meningitis and 9 per cent being adult in onset. In the remaining 14 per cent of patients the type of impairment could not be classified as the bone conductive thresholds were off scale. Having had experience of managing these patients at a special clinic and knowing the workload involved, it is argued that consideration be given to setting up such clinics in most departments.

Reliability of patient choice between hearing aid systems.

Various hearing aid provision strategies have been suggested but it is important to compare patient benefit from these, not only in the laboratory, but in everyday life. The latter can only be assessed by patient report. The false positive report rate of a difference between aids and the reproducibility of patient choice of aids was assessed in two groups of patients. The first received the same system on two occasions and were asked to report if they had any preference. The second group received two different systems on two occasions and the reproducibility of any preference was assessed. Of the 22 patients who were given the same hearing aid system on each visit, eight (36%) reported no differences, 10 (45%) a little and four (18%) a moderate or large difference between them when, in fact, there was none. Of the 34 patients who were asked to compare two acoustically different aids, 32 chose an aid on both occasions but only 22 (65%) chose the same aid, of whom 11 (32%) reported a moderate or large difference on both occasions. If reports of a little difference between aids are discounted and only moderate or large differences are accepted, it is concluded that the false positive report rate of a difference is approximately 20%. In addition, when patients are being asked to compare two NHS hearing aid systems, the rules of chance, order effect and reproducibility of patient choice have all to be controlled for, before decisions regarding patient preference can be made.

Epistaxis: a study of the relationship with weather.

Epistaxis is the commonest ENT emergency requiring hospital admission. A seasonal variation in the admission rate has been documented. The role of weather in accounting for this variation is uncertain. A retrospective review of 686 adult hospital admissions for idiopathic spontaneous epistaxis over a 2-year period in the Greater Glasgow area was carried out. The most significant weather parameter which correlated with monthly admissions was mean monthly temperature (Pearson's correlation coefficient -0.81, P less than 0.01). Admissions increased by over 100% from the warmest to the coldest months. This is the first report of the high correlation between hospital admissions for epistaxis and mean monthly temperature.

Noise levels and exposure patterns to do-it-yourself power tools.

The noise levels produced by a variety of do-it-yourself power tools were measured in a real-life situation. Most of the devices tested produced noise of 100 dB(A) or greater at the user's ear. A questionnaire was issued to 100 males who used these devices. The vast majority used the devices infrequently and therefore are unlikely to be directly at risk of hearing damage. A group of users who may be more at risk from using power tools in the home are those who are, or have been exposed to occupational noise.

Relationship between earmould venting, comfort and feedback.

Although earmould venting is considered to make an earmould more comfortable, whether it does so remains to be proven in hearing-aid users. A hundred and six patients were sequentially fitted with a hearing aid in a randomized order with an unvented, a 0.8 mm vented or a 2 mm vented mould and questioned about various aspects of discomfort at the end of each trial period. The three moulds were equally uncomfortable (approximately 17% overall), moist (approximately 34% overall) and associated with an itchy sensation (approximately 36% overall). However, a 0.8 mm and a 2 mm vent significantly reduced the sensation of blockage from 35 to 22% (P less than 0.05) and 13% (P less than 0.001) respectively. A potential disadvantage of venting is feedback, but patients' reports of this can be confused with feedback due to incorrectly inserting the mould. A separate study showed that a 2 mm vent might cause feedback in approximately 10% of patients when used in conjunction with behind-the-ear aids whose maximum gain was 45 dB, but only when the gain was at 42 dB or greater.

Charles Rennie Mackintosh and cancer of the tongue.

The Scottish architect and artist Charles Rennie Mackintosh died of an advanced cancer of the tongue at the age of 60 in 1928. He was treated by radium which was a controversial method at that time. There is good evidence that he was well palliated, and was able to live a fairly normal life for over a year. In recent years there has been an increase in interest in Mackintosh's life and work, but an examination of the literature of the 1920s shows that despite advances in treatment methods over the past 60 years, this has not been matched by an improvement in survival rates for cancer of the tongue. In this unpleasant tumour which history has shown to be particularly resistant to attempts at cure it is important that quality of life is fully considered.

Osteogenic sarcoma of the ethmoid sinus.

A case of osteogenic sarcoma of the ethmoid sinus is reported in a 45 year old man. The tumour extended superiorly through the frontal sinus and involved the medial wall of the left orbit causing diplopia. Treatment comprised partial excision followed by radiotherapy and chemotherapy with symptomatic improvement, although 13 months later the patient died from progressive local and metastatic disease. A possible relationship to previous radiation exposure is discussed.