Laryngeal solitary fibrous tumour: diagnostic challenge in a rare presentation.

Solitary fibrous tumours (SFT) are rare spindle cell mesenchymal neoplasms, most commonly appearing as well-circumscribed localised lesions arising from the abdominal or pelvic peritoneum. Their presence in the head and neck region is very rare; even more so in the post-cricoid region, with only one case described in the literature to date. The clinical behaviour of SFT may vary from benign to malignant, but only 10-15% of SFT demonstrate local recurrence or distant metastasis. The usual presenting symptoms of dysphagia and weight loss are very vague to give a definite diagnosis, and examination, even under general anaesthesia, combined with biopsies can sometimes be misleading, as in our case. Here, we describe a very challenging case of supraglottic SFT originating from the post-cricoid area. Our 73-year-old patient presented with dysphagia and upon examination a large supraglottic mass was revealed. Biopsies from the mass pointed to malignancy and the patient underwent total laryngectomy. The laryngeal specimen contradicted the biopsy and revealed a rare solitary fibrous tumour with benign features and thus adjuvant treatment was not necessary. Ever since the patient has been attending regular follow-up sessions and remains disease-free 18 months after surgery.

The effect of packaging on consumer eating quality of beef.

This experiment examined 3 packaging systems: overwrap packaging using oxygen permeable film (OWP); vacuum skin packaging (VSP) and modified atmosphere packaging (MAP, 80%O2 and 20%CO2) on consumer sensory. Three primals from 48 carcasses were aged in vacuum packs for 5, 12 or 40 days. Steaks from longissimus lumborum, gluteus medius and psoas major muscles were packed in OWP, VSP and MAP for 9 days. Untrained consumers scored grilled steaks for tenderness, juiciness, liking of flavour and overall acceptability. Steaks in MAP had 10-12 points lower sensory scores (on a 100 point scale) compared to the OWP, or VSP systems (P < 0.001). The packaging effect was independent of days aging and muscle. It was concluded that high oxygen MAP has the potential to be included as an input variable in the Meat Standards Australia beef grading model. This would be contingent upon research into when the MAP effect occurred and the effect of using different gas mixtures on eating quality.

Physical activity recommendations for children with specific chronic health conditions: Juvenile idiopathic arthritis, hemophilia, asthma and cystic fibrosis.

As a group, children with a chronic disease or disability are less active than their healthy peers. There are many reasons for suboptimal physical activity, including biological, psychological and social factors. Furthermore, the lack of specific guidelines for 'safe' physical activity participation poses a barrier to increasing activity. Physical activity provides significant general health benefits and may improve disease outcomes. Each child with a chronic illness should be evaluated by an experienced physician for activity counselling and for identifing any contraindications to participation. The present statement reviews the benefits and risks of participation in sport and exercise for children with juvenile arthritis, hemophilia, asthma and cystic fibrosis. Guidelines for participation are included.

Anatomical variations in the anatomy of the posterolateral corner of the knee.

This cadaveric study of 22 knees described the anatomy of the deeper structures of the posterolateral corner, the popliteus-tendon complex, arcuate ligament complex, the popliteofibular ligament, and the coronary ligament. Most variations occurred in the popliteofibular ligament; the variations and the different nomenclatures used in the literature for these structures make it difficult to diagnose and repair injuries to them. Untreated injuries may result in chronic functional instability to the posterolateral corner of the knee.

Reducing referral-to-treatment waiting times in cancer patients using a multidisciplinary database.

INTRODUCTION: Modern delivery of cancer care through patient-centred multidisciplinary teams (MDT) has improved survival. This approach, however, requires effective on-going co-ordination between multiple specialties and resources and can present formidable organisational challenges. The aim of this study was to improve the efficiency of the MDT process for head and neck cancer. PATIENTS AND METHODS: A systems analysis of the MDT process was undertaken to identify bottlenecks delaying treatment planning. The MDT process was then audited. A revised process was developed and an Intranet-based data management solution was designed and implemented. The MDT process was re-evaluated to complete the audit cycle. RESULTS: We designed and implemented a trust-wide menu-driven database with interfaces for registering and tracking patients, and automated worklists for pathology and radiology. We audited our MDT for 11 and 10 weeks before and following the introduction of the database, with 226 and 187 patients being discussed during each period. The database significantly improved cross-specialtity co-ordination, leading to a highly significant reduction in the number of patients whose treatment planning was delayed due to unavailability of adjunctive investigations (P < 0.001). This improved the overall efficiency of the MDT by 60%. CONCLUSIONS: The NHS Cancer Plan aspires to reduce the referral-to-treatment time to 1 month. We have shown that a simple, trust-wide database reduces treatment planning delays in a sizeable proportion of head and neck cancer patients with minimal resource implications. This approach could easily be applied in other MDT meetings.

Estimation of tracheostomy tube cuff pressure by pilot balloon palpation.

Two methods can be used to assess the intra-cuff pressure of tracheostomy tubes: digital palpation of the pilot balloon and use of a hand-held manometer. We conducted a telephone survey to determine the prevalence of both methods in intensive care units within 21 teaching hospitals across the United Kingdom. Forty-two per cent of the intensive care units surveyed used a protocol for monitoring cuff pressure with a manometer.A study to compare these two methods, using the manometer as the reference standard, was then carried out. The cuff pressure was correctly estimated in pre-inflated tracheostomy tubes, in a tracheal model, by 61 per cent of a cross-section of intensive care unit and otolaryngology staff.Using pilot balloon palpation is inaccurate and leaves a significant proportion of patients at risk of tracheal injury. We advocate the wider availability of hand-held pressure manometers in intensive care units and the institution of protocols for monitoring cuff pressure for any patient with a tracheostomy tube with an inflated cuff in situ.

Airway obstruction: a rare complication of thrombolytic therapy.

Bleeding into head and neck structures as a complication of thrombolysis is extremely rare but potentially lethal. It is usually associated with local trauma. We describe a case of a 67-year-old woman who developed spontaneous, massive pan aerodigestive tract haemorrhage precipitating airway obstruction following administration of streptokinase for myocardial infarction; a previously unreported complication. This case highlights the importance of being vigilant of airway symptoms following such treatment, prompting early involvement of anaesthetic and otolaryngology personnel.

Laryngeal cleft type I: a novel method of repair using Bioplastique.

The authors report a novel treatment of a case of type I laryngeal cleft diagnosed in an adult. They describe a technique of endoscopic obliteration of the posterior commissure defect. Initially, a test implant of starch and adrenaline was used, followed by permanent staged injections of Bioplastique to the posterior commissure. This rare congenital anomaly usually presents in childhood but late presentation should be considered when adults present with lifelong dysphonia especially when associated with gastro-oesophageal reflux disease.

Audit of referrals for head and neck cancer - the effect of the 2-week, fast track referral system.

The NHS Cancer Plan sets out targets for the diagnosis and treatment of cancer. Ideally, there should be a maximum of a 2-week wait from a referral for suspected cancer to an outpatient appointment. A fast track referral system has been established nationally, with general practitioners given guidelines as to appropriate referrals. In the South Essex region, we audited all such referrals using this system for a 12-month period and also all new patients diagnosed with head and neck cancer during the same period. We found that 71% of patients diagnosed with cancer were not referred using the fast track system and that only 15% of patients who were referred by the fast track system were subsequently found to have cancer. For patients with cancer who were referred using standard letters, the time from referral to initial consultation was generally much longer than the recommended period of 2 weeks. We conclude that improvements in utilizing the fast track system need to be made if it is to bring about an improvement in early diagnosis of head and neck cancer. As things stand, it may actually be detrimental for most cancer patients.

Computed tomography in the evaluation of penetrating neck trauma: a preliminary study.

HYPOTHESIS: Penetrating neck trauma has traditionally been evaluated by surgical exploration and/or invasive diagnostic studies. We hypothesized that computed tomography (CT), used as an early diagnostic tool to accurately determine trajectory, would direct or eliminate further studies or procedures in stable patients with penetrating neck trauma. DESIGN: Retrospective case series. SETTING: Academic, urban, level I trauma center. PATIENTS: Hemodynamically stable patients without hard signs of vascular injury or aerodigestive violation who had sustained penetrating trauma to the neck. INTERVENTIONS: Patients underwent a spiral CT as an initial diagnostic study after initial evaluation in the trauma bay. Further invasive studies were directed by CT findings. MAIN OUTCOME MEASURES: Number of invasive studies performed. RESULTS: Twenty-three patients were identified during the 30-month period. Nineteen patients sustained gunshot wounds; 3, shotgun wounds; and 1, a stab wound. One patient died of a cranial gunshot wound. Three isolated zone I, 1 isolated zone II, 9 isolated zone III, and 10 multiple neck zone trajectories were evaluated. Thirteen patients were identified by CT to have trajectories remote from vital structures and required no further evaluation. Ten patients underwent angiography. Only 2 underwent bronchoscopy and esophagoscopy. Four patients were discharged from the emergency department; 7 other patients were discharged within 24 hours. No adverse patient events occurred before, during, or after CT scan. CONCLUSIONS: Computed tomography in stable selected patients with penetrating neck trauma appears safe. Invasive studies can often be eliminated from the diagnostic algorithm when CT demonstrates trajectories remote from vital structures. As a result, efficient evaluation and early discharge from the trauma bay or emergency department can be realized. Further prospective study of CT scan after penetrating neck trauma is needed.

Proliferative myositis arising in the tongue.

We describe a rare case of proliferative myositis affecting the lateral border of the tongue. The site of the lesion and its gross pathological presentation were highly suggestive of a malignant process. Subsequent biopsy and characteristic histological appearance led to the diagnosis of this benign condition. This is the first reported case of a painful presentation of proliferative myositis involving the tongue. This report serves to remind the head and neck surgeon of the need to obtain histological diagnosis of malignancy before embarking upon radical surgical treatment. We recommend careful follow-up to ensure complete resolution of the lesion.

An unusual case of Pneumocystis carinii presenting as an aural mass.

Extrapulmonary involvement of organs with the protozoan Pneumocystis carinii is rare. We describe a case of Pneumocystis carinii presenting as an erosive aural mass in a young male patient with acquired immunodeficiency syndrome. As far as the authors are aware such an example has never been described in a British journal and is the first case worldwide where otic pneumocystosis has extended into the middle cranial fossa. We also present a review of the literature on otological manifestations of Pneumocystis carinii.

Pictorial assessment of the delivery of oropharyngeal rinse versus oropharyngeal spray.

Oral rinses/gargles and oral sprays are frequently used in the management of oropharyngeal inflammation. This pictorial study, using methylene blue dye as a marker of the distribution of these topical preparations in the oropharynx, suggests that oral sprays are more effective in coating the oropharynx than oral rinses, whilst oral rinses are better at staining the oral cavity and base of tongue. The authors therefore suggest that oral rinses should be used to treat disease in the oral cavity and oral sprays should be used to treat ailments in the oropharynx.

A case of malignant otitis externa following mastoidectomy.

We present a case of a 63-year-old diabetic male who developed malignant otitis externa following mastoidectomy. Extensive skull base osteomyelitis caused thrombosis of the jugular bulb and subsequent paralysis of cranial nerves VII, IX, X and XII. He was treated aggressively with intravenous antibiotics and debridement of granulation tissue in the mastoid bowl with full recovery of the cranial nerve palsies associated with recanalization of the jugular bulb. We believe this is the first reported case of malignant otitis externa to occur following mastoidectomy with complete recovery of the cranial nerve paresis.