Cholesteatoma in children and adults: are there really any differences?

BACKGROUND: Cholesteatoma is widely considered to be more aggressive in children than adults, yet few studies have directly compared the operative findings and surgical outcomes between these two groups. This study aimed to assess differences between childhood and adult cholesteatoma. METHODS: The operative caseload of a single consultant surgeon was reviewed between January 2006 and May 2017 using the online Common Otology Audit database. Extracted data were categorised according to patient age (children, aged below 16 years, and adults, aged 16 years or over) and compared. RESULTS: This study included data from 71 operations on children and 281 operations on adults, performed for cholesteatoma. Childhood cholesteatoma demonstrated significantly more extension (into the sinus tympani, mastoid antrum and mastoid air cells) and ossicular erosion (of the malleus, incus and stapes superstructure) compared to adults. No significant differences were seen in revision rates, post-operative complications or hearing gain. CONCLUSION: Childhood cholesteatoma was more extensive and destructive compared to adults, representing a more aggressive disease in this cohort.

Perilymph fistula: the patients' experience.

OBJECTIVE: This study aimed to assess the experiences and outcomes of patients who underwent surgical repair of a perilymph fistula in Norfolk, UK. METHODS: The study involved a retrospective questionnaire-based patient survey and case note review of patients who had undergone tympanotomy and perilymph fistula repair between 1998 and 2012 in two district general hospitals. RESULTS: Fourteen patients underwent 20 procedures, of whom 7 completed the pre- and post-operative Vertigo Symptom Scale. In five patients, there was no obvious precipitating cause. Perilymph fistula was precipitated by noise in one patient, by a pressure-increasing event in six patients and by trauma in two patients. The Vertigo Symptom Scale scores showed a statistically significant improvement following surgical repair, from a median of 67 (out of 175) pre-operatively to 19 post-operatively. CONCLUSION: In selected patients with vertigo, perilymph fistula should be considered; surgical repair can significantly improve symptoms.

Initial UK experience of patient satisfaction with the Meniett® device for Ménière's disease treatment.

OBJECTIVES: To evaluate patient satisfaction and symptom improvement following treatment of Ménière's disease with the Meniett® device. METHODS: Retrospective, questionnaire-based audit and analysis of unilateral Ménière's disease patients' records, following on from a previous study from our departments on intra-tympanic gentamicin for Ménière's disease, using the Vertigo Symptom Scale and Glasgow Benefit Inventory as outcome measures. RESULTS: Of 33 consecutive patients treated with the Meniett® device for four to six weeks, 30 responded to the questionnaires (90.9 per cent). Respondents' mean Vertigo Symptom Scale score was 0.7 (range 0-2.1), and their mean Glasgow Benefit Inventory general subscale score was 24.1. Nineteen (63.3 per cent) patients felt that the device had alleviated their vertigo and tinnitus. CONCLUSIONS: This is the first UK study of the effectiveness of the Meniett® device in treating Ménière's disease. It shows that the Meniett® device is a well tolerated, useful and minimally invasive means of treating Ménière's disease after medical treatment has failed, and before more potentially cochleo- and vestibulo-toxic therapies and invasive procedures are utilised.

A study of olfactory testing in patients with rhinological pathology in the ENT clinic.

BACKGROUND: Despite the common occurrence of rhinological pathology presenting to the ENT clinic, routine testing of olfactory ability is rarely performed. OBJECTIVES: The aim of this study was to determine the role of routine olfactory testing. METHODS: This was a prospective study conducted in the outpatient clinic of a district general hospital. Patients presenting with rhinological complaints had their olfactory status assessed using the combined olfactory test (COT) before and after rhinological surgery. RESULTS: Eighty patients (56 men, 24 women) had tests completed over a 12-month period. Patients assessed mostly had nasal polyposis, chronic rhinosinusitis or septal deformity. 83% of patients had either a complaint of olfactory disturbance or a COT score of 6 or less, or had both; but correlation between symptoms and scores was poor. Post-operative COT scores showed significant improvement (p = 0.02) with post-septoplasty patients showing the most significant improvement as a group (p = 0.001). CONCLUSIONS: Olfactory disturbance is very common in rhinological pathology and the patient's history alone cannot be relied upon. Simple olfactory assessment, such as with the combined olfactory test, is easy to perform and cheap to use and should be a commonly used resource in the ENT clinic. Formal testing can help to document any pre-existing olfactory loss and any post-operative changes as well as detecting unreported hyposmia.

Frontal mucocele caused by an ectopic maxillary tooth.

OBJECTIVE: To present a previously unreported cause of frontal mucocele. CASE REPORT: A patient presented with a frontal mucocele and maxillary sinusitis. Computed tomography revealed an ectopic maxillary tooth as the cause of her signs and symptoms. Removal of the tooth by a Caldwell-Luc procedure facilitated resolution of the mucocele. Conventional treatment of mucoceles by endoscopic sinus surgery, and other rhinological sequelae of ectopic teeth, are considered. CONCLUSION: This is the first documented case of an ectopic tooth causing a frontal mucocele, and demonstrates how effectively the patient's symptoms resolved on removal of the tooth.

Intratympanic gentamicin treatment in Meniere's disease: patients' experiences and outcomes.

OBJECTIVE: The aim of this study was to assess the experiences and outcomes of patients receiving intratympanic gentamicin treatment for Ménière's disease in Norfolk, UK. DESIGN: This study was based on a retrospective questionnaire survey and a review of patients' medical records. SETTING: Two district hospitals. PARTICIPANTS: All 29 patients treated between 1999 and 2001, with a minimum follow up of two years post-treatment, were included in the study. Twenty-three patients completed the questionnaires (79 per cent response rate). MAIN OUTCOME MEASURES: Glasgow benefit inventory (GBI) and vertigo symptom scale (VSS) scores, plus change in hearing thresholds. RESULTS: The mean GBI total score was +36, indicating substantial improvement in patients' overall quality of life following gentamicin treatment. The VSS scores demonstrated low levels of vertigo or unsteadiness in treated patients. Three patients suffered deterioration in their hearing thresholds following a single injection of gentamicin. However, 96 per cent of responders stated that they would be willing to have such treatment again, if necessary. CONCLUSION: Intratympanic gentamicin treatment ought to be offered to Ménière's patients suffering from disabling vertigo, with the proviso that they be made aware of the possibility of hearing deterioration.

An unusual presentation of sphenoid sinusitis with septicaemia in a healthy young adult.

Streptococcus pneumonia and Haemophilus influenzae account for more than 50% of bacterial acute sinusitis. Isolated sphenoid sinusitis is a rare disease with potentially devastating complications such as cranial nerve involvement, brain abscess, and meningitis. It occurs at an incidence of about 2.7% of all sinus infections. There have been no previous reported cases of unilateral sphenoid sinusitis presenting as septicaemia in an otherwise healthy young immunocompetent adult.

Audit of specialist registrar training in tympanomastoid surgery for chronic otitis media.

BACKGROUND: A prospective audit of specialist registrars' (SRs') training in tympanomastoid surgery for chronic otitis media within the Anglia Regional Training Scheme is described. This audit recorded the surgical activity of the trainees and their contribution to operative procedures, and assessed the results of the procedures. This type of systematic approach to the audit of surgical training is important in light of the current shortened training programmes and increased accountability of trainers. OBJECTIVES: The study aimed to establish the levels of exposure to, supervision of and outcome of ear operations for chronic otitis media performed by ENT trainees in the East Anglia region. METHOD: A prospective, region-wide, minimum otology dataset-based proforma audit was undertaken, with compulsory SR participation. Proformas were completed at the time of operation (form one) and at a minimum interval of nine months post-operatively (form two). Data on form one included hospital, supervising consultant, name and training year of SR, contribution of SR (based on England Royal College of Surgeons guidelines interpreted by the SR), pre-operative audiology average (air conduction/bone conduction over 0.5, 1, 2 and 4 kHz), the pathology and the state of the ear at the time of surgery, and a breakdown of the procedure(s) undertaken. Form two recorded data relevant to form one as well as information regarding patient satisfaction and the operative result obtained, graded as 'gold' (no disease, dry ear and hearing average < 25 dB), 'silver' (two of these three) and 'bronze' (one of these three). All completed forms were analysed using Microsoft Access software. RESULTS: Completed copies of 409 form ones and 156 form twos were analysed. With advancing years, SRs' contributions to procedures increased without significant effect on the graded outcome, which appeared to be independent of SR year of training. Different regional hospitals were compared. Data collected also provided an otology training portfolio for SRs, forming part of their registrar in-training assessment (RITA). CONCLUSION: The East Anglia SR audit of SRs' training in tympanomastoid surgery for chronic otitis media was a powerful training tool. It demonstrated the safe progression of SR training in supervised ear surgery, with SRs' results being comparable to those for consultant-performed procedures.

Spitting in the ear: a falsified disease using video evidence.

We present the case of Munchausen's syndrome by proxy (MSBP) in which the mother spat and placed blood in her child's ear, and videoed the result, in order to gain the attentions of the medical profession. This is the first case report of this kind and may represent a disturbing trend in the use of digital photography and video to support factitious illnesses.

Bilateral objective tinnitus secondary to congenital middle-ear myoclonus.

Subjective tinnitus (heard only by the patient) is a common otological complaint. Objective tinnitus (heard by the examiner as well as the patient) is extremely rare. There are only a few cases of objective tinnitus, secondary to middle-ear myoclonus, described in the literature. We present the case of a child with bilateral, congenital, objective tinnitus, secondary to middle-ear myoclonus, with otherwise normal hearing thresholds (250 Hz-8 kHz), and with no evidence of intra-cerebral or systemic disorders. No similar case has been reported in the world literature.

Swallowed nasal pack: a rare but serious complication of the management of epistaxis.

Packing of the nose with a suitable material remains a popular method of treating epistaxis. The authors report a serious complication of a new design of nasal pack; Rapid Rhino, which was swallowed during the treatment of a patient with epistaxis, resulting in bowel perforation.

Reidel's thyroiditis and Tolosa-Hunt syndrome, a rare association.

A previously undescribed association of Reidel's thyroiditis with Tolosa-Hunt syndrome is reported. A 33 year-old Caucasian female presented with a two-year history of painful progressive goitre, histologically a Reidel's thyroiditis. She underwent left partial thyroidectomy. Post-operatively she developed severe right retro-orbital pain, right temporal headache and a partial right occulomotor nerve palsy. A diagnosis of Tolosa-Hunt syndrome was made. Some important aspects of this case are discussed.

Sudden unilateral deafness after bilateral knee replacement.

This case report presents profound unremitting hearing loss in a 76-year-old man after having a bilateral knee replacement. There have been no other cases of permanent post-operative deafness after joint replacement in the world literature. Sudden post-operative deafness is rare. We conclude that this man's deafness is due to a fat embolism in his auditory circulation.

Model for demonstrating the canalith repositioning procedure.

Benign positional vertigo is a common condition which may be easily treated with the canalith repositioning procedure. This procedure may be difficult for patients to understand and for medical staff to learn. This paper describes a model of the vestibular apparatus which may be used to demonstrate the procedure.

Pneumopericardium: an unusual manifestation of blunt tracheal trauma.

A case of pneumopericardium in a child following blunt injury to his trachea is described. Such a case has not been previously described in the literature. A probable anatomical explanation for this rare event is offered.

Cervical lymphadenopathy due to mycobacterial infection: a diagnostic protocol.

Mycobacterial cervical lymphadenopathy is relatively uncommon in the United Kingdom; when cases do occur opportunities for early diagnosis and treatment may be missed. We have reviewed twenty-three cases of mycobacterial cervical lymphadenopathy presenting to an urban general hospital over a four-year period. We discuss the techniques available to aid a diagnosis of mycobacterial disease and suggest a protocol to allow efficient use of these techniques.

Massive haemorrhage from the vallecula: a diagnostic difficulty. Case report.

A case is presented of massive bleeding from a vessel in the vallecula. This was confused with haemoptysis and haematemesis. The bleeding may have resulted from trauma to the vessel during intubation for emergency surgery. 25 units of blood were transfused before the site of the bleeding was identified and controlled by diathermy coagulation.

Massive metastasis from squamous carcinoma of the tonsil.

Squamous carcinomas of the oro-pharynx are associated with a high incidence of distant metastases at post-mortem. A case of a massive distant metastasis from a squamous cell carcinoma of the tonsil is presented. This occurred despite excellent local control. The pathology and the possible management implications are discussed.