The timing of calcium measurements in helping to predict temporary and permanent hypocalcaemia in patients having completion and total thyroidectomies.

INTRODUCTION: Postoperative hypocalaemia commonly occurs after extensive thyroid surgery and may require calcium and/or vitamin D supplements to alleviate or prevent the symptoms. In this study, we determined the risk factors for developing hypocalcaemia and whether early serum calcium levels can predict the development of or differentiate between temporary or permanent hypocalcaemia. PATIENTS AND METHODS: A total of 162 patients who either had a completion or total thyroidectomy formed the basis of this prospective study. Serial serum calcium measurements were recorded as well as details of the operation, pathology, indications for surgery, number of parathyroids identified at operation and any complications. RESULTS: Eighty-four (52%) patients did not develop hypocalcaemia but 69 (43%) were found to have temporary hypocalcaemia and 9 (5%) had permanent hypocalcaemia. Hypocalcaemia was more common after total than completion thyroidectomies and the identification of parathyroids at operation appears to have a significant adverse effect on outcome. The calcium levels measured on day 1 postoperatively and the slope (serum calcium levels of day 1 postoperative minus day of operation) were statistically significant in predicting the development of hypocalcaemia and possibly to differentiate between temporary or permanent hypocalcaemia. DISCUSSION: Although almost half the patients having extensive thyroid surgery developed hypocalcaemia (as defined by any postoperative corrected serum calcium level of < 2.12 mmol/l) only 24% had a serum calcium of < 2.12 mmol/l associated with clinical symptoms of hypocalcaemia or a calcium level of < 2.0 mmol/l. Only 5% had persistent hypocalcaemia defined as requiring exogenous supplements at 6 months' postoperatively. Patients having a completion thyroidectomy appear to be less likely to develop hypocalcaemia perhaps as a result of any iatrogenic effects on the parathyroids at the first operation being reversed before the second operation. Identification and, therefore, exposure of parathyroids at operation may have an adverse effect on the blood supply to the glands affecting their function. CONCLUSIONS: Serum calcium levels measured 6 hours' post-surgery and on day 1 postoperatively can be useful in predicting if the patient will develop hypocalcaemia and the slope may indicate whether the hypocalcaemia will be temporary or permanent. Patients with toxic goitres and those having a one-stage total thyroidectomy are most at risk of developing hypocalcaemia.

Posterior nasal septal abscess in a healthy adult patient.

OBJECTIVE: We report an extremely rare case of bilateral posterior nasal septal abscess in an otherwise healthy adult patient. METHOD: Case report and a review of the world literature concerning atraumatic nasal septal abscess and its management. RESULTS: The development of an atraumatic nasal septal abscess is rare, but it has been reported in association with acute sinusitis, in patients with poor immunity and in children. The presentation, clinical course and treatment are discussed in the presented patient. CONCLUSION: To our knowledge, this is the first report in the world literature of a bilateral posterior septal abscess associated with acute sinusitis in an otherwise healthy adult.

'Boil and Bite' mouth guards for direct laryngoscopy.

'Boil and Bite' mouth guards are an alternative to conventional silicone guards in direct laryngoscopy. These guards are less likely to displace. They are cheap and easy to prepare.

A national survey amongst UK otolaryngologists regarding the treatment of Ménière's disease.

Since Dr Prosper Ménière described the vertiginous syndrome that now bears his name, a large variety of medical and surgical treatments have been introduced. To determine the way in which this condition is currently managed in the United Kingdom, a postal survey amongst consultant otolaryngologists was carried out. It revealed that 52 per cent were actively involved in the treatment of patients with Ménières disease using a wide range of medical and surgical therapies that have little or no evidence base. The survey found that 94 per cent of surgeons prescribe betahistine, 63 per cent diuretics and 71 per cent advise salt restriction to their patients, while 52 per cent of surgeons continue to recommend saccus decompression and 50 per cent are still inserting a grommet. However, two thirds of respondents now advocate the use of gentamicin therapy despite it only being introduced to this country just over 10 years ago. The results of this study and their relevance to the recommended present day management of Meniere's disease are discussed.

A study of recurrence of retraction pockets after various methods of primary reconstruction of attic and mesotympanic defects in combined approach tympanoplasty.

The major drawback of combined approach tympanoplasty (CAT) is a relatively high rate of cholesteatoma recurrence compared to open-cavity techniques, which is thought to occur primarily by recurrence of retraction pockets. In this series of 63 CATs carried out by one surgeon, scutum reconstruction to prevent recurrent attic retraction was carried out in 43 cases. Repair with bone pate proved much more successful in achieving this (20.7%; 6/29 recurrent retraction pockets) compared to tragal cartilage (57.1%; 8/14) (Fisher's exact test, P = 0.0205) and was found to be a result of the greater incidence of cartilage resorption. Recurrence of retraction in pars tensa defects was more common as the only material used was a simple temporalis fascia graft. The mean time to development of recurrences was 21.1 months and that has important implications for follow-up. We conclude that the use of bone pate for scutum reconstructions reduces the incidence of attic retraction pockets, and therefore the risk of cholesteatoma recurrence following CAT.

The use of the KTP laser in the management of hypertrophic tracheal mucosa and granulation tissue around Provox valve protheses.

The development of hypertrophic mucosa and granulation tissue around a tracheo-oesophageal fistula voice prosthesis is a commonly encountered problem occurring in 15-20 per cent of patients. Upsizing of the voice prosthesis as well as cautery (silver nitrate and electocautery) are used to counteract this problem to a varying degree of success. The use of the CO2 laser has been mentioned by some authors but details of the method and results have not been published. We report the successful use of the KTP laser for removing such granulations whilst retaining the valve and discuss the reasons why this method should be considered.

Assessment of a cytology grading system for head and neck masses.

A grading system for Fine Needle Aspiration Biopsy Cytology (FNAC) has been in routine use in Peterborough since 1994 for reporting on fine needle aspiration biopsies of neck lumps. The records of all 276 patients who had neck lump fine needle aspiration biopsies performed between 1994 and 1999 were reviewed retrospectively. The 193 patients who had definitive histology available were included in the study of whom 154 (80.2%) were considered adequate for grading. A learning curve for adequacy of specimens obtained is demonstrated, with adequacy rate increasing with increasing experience or seniority of the sampler. The grading system produced an overall accuracy rate of 73.3% with a predictive value for malignancy of 88.6% and a predictive value for benign conditions of 67.3%. Individual grades were assessed for predictive value of benign or malignant disease. Grade 5 proved completely reliable, with a predictive value for malignancy of 100%. The shortcomings of the other grades and the difficulties in diagnosing lymphoma by FNAC are discussed.

Osteoradionecrosis of the hyoid presenting as a cause of intractable neck pain following radiotherapy and the role of magnetic resonance image scanning to aid diagnosis.

Osteoradionecrosis of the hyoid has been reported rarely in the worldwide literature. We present the case of a 56-year-old gentleman who presented with intractable neck pain, following surgery and radiotherapy for a T(2)N(2c)M(0) tongue base carcinoma, to highlight the need to consider osteoradionecrosis of the hyoid rather than recurrence of the carcinoma as the cause of such symptoms. The previously unreported appearance of osteoradionecrosis of the hyoid on a magnetic resonance image (MRI) scan and the use of this investigation to aid diagnosis is discussed.

The use of maggots in head and neck necrotizing fasciitis.

Historically maggots have been used to clean necrotic war wounds. With the ready availability of sterile maggots, they are being used increasingly in surgical practice. Although maggots have most frequently been employed in the management of necrotic wounds and ulcers involving the lower limb, we have identified a particularly useful application in the head and neck and describe a case in which maggots played a significant part in the successful treatment of a florid necrotizing cervical fasciitis in a patient, who was unfit for repeated surgical debridement.

Bilateral defects of the tegmen tympani associated with brain and dural prolapse in a patient with pulsatile tinnitus.

A pulsating ear drum is a rare otological finding and usually indicates a vascular pathology. We report the case of a woman who presented with pulsatile tinnitus following an upper respiratory tract infection. She was found to have bilateral pulsating tympanic membranes on otological examination, in association with bilateral dehiscence of the tegmen tympani and a spontaneous encephalocele on the right side and a meningocele on the left side, demonstrated on computerized tomography (CT) scan of her temporal bones.

An extreme and unusual variant of Ramsay Hunt syndrome.

Ramsay Hunt syndrome is characterized by facial nerve paralysis, herpetic vesicles in or around the ear and pain often associated with vestibulocochlear nerve involvement. It is thought to be a cranial polyneuropathy caused by the herpes zoster virus. We present an extreme and unusual variant of this disease with involvement of VIIth, VIIIth, Xth, XIth and XIIth cranial nerves as well as C2-4 sensory dermatomes and profound systemic upset which caused some diagnostic uncertainty.

Nasal splints, revisited.

A study was carried out to compare the effectiveness of nasal splints (in preventing intranasal adhesions) with the morbidity associated with their use in nasal surgery. One hundred and ten patients undergoing a routine nasal operation were randomly allocated into two equal groups, one with splints and the other without. Post-operative pain and discomfort was assessed by a visual analogue scale at 48 hours and a week following surgery when either nasal suction (non-splinted group) or removal of splints was carried out. All patients were examined after six weeks for development of adhesions. Results showed that there was no significant difference in the incidence of adhesions between the splinted and non-splinted patient groups. However, the patients with splints had significantly more pain and nasal discomfort when assessed one week after surgery. It is concluded that the morbidity associated with nasal splints does not justify their use in routine nasal surgery if the aim is to prevent nasal adhesions, but they may still be indicated for enhancing the stability of the septum following septoplasty.

The current role of local intratympanic gentamicin therapy in the management of unilateral Menière's disease.

Over the past 5 years 25 patients suffering from disabling unilateral Menière's disease have been treated in our unit with local intratympanic Gentamicin therapy with the specific intent of creating a medical labyrinthectomy, together with preservation of hearing on the treated side. Results from the 16 patients who have completed a 2-year follow-up show that substantial control of vertigo was obtained in all subjects, while 87% experienced complete control of vertigo following treatment. In 66% this was achieved in association with a complete medical labyrinthectomy (no caloric response to an iced water stimulus). In 94% of patients the hearing on the treated side has remained unaffected, but tinnitus was largely unchanged. The simple treatment protocol uses a customized self-retaining intratympanic catheter system (courtesy of Exmoor Plastics Ltd). The findings suggest that local Gentamicin therapy is an effective treatment in patients with incapacitating unilateral Menière's disease and is associated with low morbidity and good hearing preservation and thus provides a potentially superior alternative to the surgical treatment options currently available.

Lymphoma arising from Hashimoto's thyroiditis: an unusual cause of acute stridor.

We report an unusual presentation of non-Hodgkin's lymphoma of the thyroid which mimicked an acute infective thyroiditis and was associated with acute stridor and dysphagia. The mode of presentation and diagnosis of thyroid lymphoma are discussed and the value of early fine needle aspiration emphasised.

A rare case of intramuscular haemangioma in a six-year-old boy--a diagnostic dilemma.

Intramuscular haemangiomas are uncommon tumours of the head and neck, occurring mainly in adults and usually located in the region of the masseter muscle and parotid gland. We report the case of a child with an intramuscular haemangioma over the left maxilla, which caused some diagnostic confusion in view of its atypical location combined with the unusual age and inflammatory mode of presentation.

Intratympanic gentamicin instillation as treatment of unilateral Menière's disease: update of an ongoing study.

A prospective study using intratympanic gentamicin instillation as treatment for disabling unilateral Meniere's disease has been ongoing at our institution for 4 years. Treatment effectiveness is evaluated based on the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) 1985 guidelines. This report is based on 30 patients who have become eligible for assessment. We conclude that gentamicin intratympanic instillation as currently used in our protocol is an effective, safe, and easily administered method of achieving a predictable measure of vertigo control.

Metastatic spread of osteosarcoma to the temporal bone in a patient with Paget's disease: a case report.

Secondary tumors involving the temporal bone are comparatively rare. We report a case of secondary osteosarcoma presenting in the temporal bone which arose from a primary lesion in the tibia in a patient with Paget's disease. To our knowledge secondary osteosarcoma of the temporal bone has never previously been described.

Treatment of Menière's disease with topical gentamicin: a preliminary report.

We evaluated the hypothesis that topical intratympanic gentamicin can relieve the vertigo of disabling Menière's disease, reduce or ablate vestibular caloric excitability, and preserve hearing. Between July 1988 and June 1989, 33 patients were treated in the Dizziness Unit at the Sunnybrook Health Sciences Centre in a prospective controlled trial. This preliminary report presents the results of 29 patients with follow-up averaging 8.3 months and ranging from one to 18 months. All patients had either complete (86.2%) or substantial (13.8%) control of vertigo. Caloric excitability was ablated in 63% and reduced in 25.9% of subjects. Hearing was improved in 35.7%, unchanged in 39.3%, and worse in 25.0% of patients. In this preliminary review, the overall success rate for this treatment is 89.7% if control of vertigo and improvement in disability level are the criteria examined.

Assessment of the otoscopic skills of general practitioners and medical students: is there room for improvement?

Ear, nose and throat problems are common in general practice, yet undergraduate and postgraduate teaching in the subject is variable and often sparse. The assumption that direct experience in otoscopy in practice will compensate for inadequate previous tuition was tested by assessing a group of 53 general practitioners and 59 medical students. Confidence in otoscopy was assessed using a visual analogue scale and skill was assessed by clinical examination of four ears. Otoscopy was divided into identifying the tympanic membrane, distinguishing a normal from an abnormal membrane and identifying specific features of the membrane. The medical students and general practitioners were comparable in both confidence and skill for all parameters except skill in identification of specific features of the tympanic membrane, in which the students' ability was greater (Student's t-test, P < 0.01). In both groups the percentage of false negative observations was reassuringly low--for students the mean was 3.0%; and for general practitioners 4.3%. There is room for improvement in general practitioner's training in otoscopy. Supervised tuition is essential and cannot be compensated for by unsupervised experience. More involvement with ear, nose and throat problems in vocational training or attendance at continuing education courses is suggested.

Chemical labyrinthectomy: local application of gentamicin for the treatment of unilateral Menière's disease.

The use of aminoglycosides for selective vestibular function ablation without hearing alteration is described in the literature. Parenteral administration of streptomycin for the alleviation of vertigo in cases of bilateral Meniere's disease is well accepted. The instillation of aminoglycosides into the middle ear to produce a similar result, has been successfully used in the treatment of unilateral Meniere's disease. However, the use of chemical vestibulectomy has not gained acceptance as a practical means of treatment when compared to vestibular neurectomy. The reason for this is not clear, but may stem from the lack of definitive protocol for the application and lack of treatment results that have been assessed according to an acknowledged standard (i.e., the American Academy of Otolaryngology Criteria). A prospective study was undertaken to examine the efficacy of chemical vestibulectomy as the treatment for vertigo in unilateral, incapacitating Meniere's disease. A standardized drug administration protocol was utilized, and academy criteria for the assessment of treatment were applied. This report details the first group of patients to complete 2 years of post-treatment follow-up. Based on our experience, we conclude that chemical vestibulectomy is an efficient alternative to surgery. A standardized regimen of drug administration that can be carried out on an outpatient basis is put forward.