Management of serum calcium levels in post-thyroidectomy patients.

Otolaryngologists are increasingly performing thyroid surgery and are responsible for optimising parathyroid function postoperatively. The aim of this study was to establish an evidence-based algorithm for the management of postoperative calcium levels and to try and answer some relevant postoperative management issues. These include the following: (1) What is the risk of hypocalcaemia both temporary and permanent? (2) When should calcium replacement be commenced and in what form? (3) What is the best method for calcium replacement without suppressing a recovering parathyroid? (4) How to identify recovering parathyroid function if the patient is already on calcium replacement? A systematic review of the literature was carried out supported by a retrospective analysis of postoperative calcium levels obtained from clinical records of patients undergoing thyroidectomy under our care (n = 167). We present an evidence based, user-friendly algorithm for the management of the serum calcium in patients undergoing thyroid surgery.

Intramuscular capillary hamartoma of the tongue.

Intramuscular vascular lesions in the tongue are rare and are usually the capillary form of haemangioma. A case is described of a lingual mass that resembled intramuscular haemangioma but had unique histological features that do not appear to have been described previously. The term intramuscular capillary hamartoma is suggested to describe it.

Rapidly invading sebaceous carcinoma of the external auditory canal.

A very rare case of a sebaceous carcinoma of the external auditory canal with basal cell differentiation is presented. Fewer than 400 cases affecting any part of the body have so far been reported and of that only seven cases have been known to involve the external auditory canal. The clinical features, pathology and treatment are described and the relevant literature has been reviewed.

Adjuvant radiotherapy for primary mucosal malignant melanoma of the larynx.

Primary mucosal malignant melanoma (PMML) of the larynx continues to be a rare entity. To date, there are few cases reported in the world literature consisting of mainly isolated case reports and literature reviews. Traditionally believed to be radioresistant, we present a case of PMML of the right vocal fold managed with right cordectomy and adjuvant radiotherapy. The patient is well without any evidence of local recurrence or metastasis three years and four months from presentation.

An unusual cutaneous presentation of Hodgkin's disease.

Hodgkin's disease is a neoplasm of lymphoid tissue defined histopathologically by the presence of Reed-Sternberg cells in an appropriate cellular background. Hodgkin's disease extends only rarely into the skin. Sinus and fistula formation has been reported in very occasional cases. We now report a case of a 34-year-old woman presenting with a cutaneous lesion surrounding a discharging blind-ending sinus in the neck, subsequently diagnosed as Hodgkin's disease. To our knowledge this form of presentation of Hodgkin's disease has not been reported in the English literature before, and at the same time we would like to outline the difficulties in diagnosis encountered with these cutaneous lymphoid lesions.

Vocal fold palsy following vinca alkaloid treatment.

We report two patients with Hodgkin's disease on chemotherapy, one with vincristine, the other with vinblastine, who were referred to the ENT department with a vocal fold palsy. These drugs are commonly used in the treatment of haematological malignancies, and head and neck sarcomas. Examination showed a unilateral immobile fold. No causative local pathology was identified, and they were otherwise thought to be achieving remission, but the development of a fold palsy suggested a poor response to treatment. One patient's palsy resolved following completion of chemotherapy, but the other patient's persists, despite an otherwise good response to the treatment. The vinca alkaloids are neurotoxic, usually causing a peripheral neuropathy, but cranial mononeuropathies are a rare side-effect. A total of 27 previous cases of vocal fold palsy have been reported with the use of the vinca alkaloids, and such a lesion should not be assumed to be due to advancing lymphoma.

A rare case of Salmonella neck abscess.

A case of a deep neck abscess caused by Salmonella enteritidis in a 29-year-old previously undiagnosed diabetic patient is reported. Review of relevant literature has shown 11 cases of Salmonella neck abscess. Predisposing conditions include immunosuppression due to any cause. Salmonella sp. should be included in the differential diagnosis of head and neck abscesses in predisposed individuals and treated accordingly.

Actinomycosis of the posterior triangle: a case report and review of the literature.

Actinomycosis presents acutely as an abscess, or as a chronic lesion mimicking malignancy, tuberculosis, or aspergillosis. Most disease involves the mouth and its immediate site of lymphatic drainage, the anterior triangle of the neck. We present a case of actinomycosis at the apex of the posterior triangle, suspected of being a malignancy, and discuss the importance of being aware of this as a cause of neck lumps. The diagnosis is usually made late because of the difficulties in culturing the organism, or in identifying characteristic 'sulphur granules' in pus or biopsy specimens. For these reasons, the disease is underdiagnosed. When acute or chronic neck lesions prove difficult to diagnose, microscopy and prolonged anaerobic culture of pus and biopsy specimens should be performed in addition in Ziehl-Neelsen staining, tuberculosis and fungal cultures. The tests should be repeated if negative. Specific treatment requires prolonged courses of antibiotics, despite adequate surgical excision, to prevent relapse.

Long-term results of the use of cultured autologous epithelial cell grafting to mastoid cavities.

Thirty-nine patients (42 ears) who have had a cultured autologous epithelial cell graft technique to a continuously discharging mastoid cavity have been evaluated to determine the continued effectiveness of this procedure. A postal questionnaire indicated a 58% improvement in both the smell and quantity of discharge, and our conclusion is that this is a very effective measure to provide extended symptomatic improvement in this troublesome condition.

An unusual foreign body migrating from pharynx to mediastinum.

A case of a swallowed foreign body migrating from the pharynx into the soft tissues of the neck is presented, whose management was complicated by its undetected migration to the superior mediastinum occurring between radiological localization in the neck three days prior to exploration and its attempted removal. A median sternotomy was then required to retrieve the object. Radiological guidance with regard to the localization of a foreign body in the neck can only be relied on when performed immediately prior to surgical removal.

Extra-pharyngeal neck pathology complicating pharyngeal pouch surgery.

One case each of: (1) low grade thyroid lymphoma; (2) supraclavicular and para-oesophageal metastasis of a uterine adenocarcinoma; and (3) recurrent multinodular goitre have been encountered in very intimate relationship with the neck of a pharyngeal pouch within the tracheo-oesophageal gutter raising the possibility that the two conditions were interrelated. The practical importance of these cases is that a surgeon excising a pouch from the neck ought to be able to resect a thyroid lobe should it prove necessary, and occasionally endoscopic diverticulotomy is the only reasonable option.

Lateral temporal bone resection for extensive pinnal malignancy. Has anything changed in forty years?

This paper offers an account of the contemporary surgical approach to advanced tumours of the external ear based on a series of 11 patients. There were eight squamous, two basal cell carcinomas and one mucoepidermoid tumour. The traditional method of excision was slightly modified by performing microsurgical dissection of the lateral part of the temporal bone rather than chisel osteotomies, and then including it en bloc with the involved soft tissues. The defect was then closed using a scalp or myocutaneous flap and this combination of otological and reconstructive expertise has proved satisfactory. Four patients are alive with no evidence of disease a mean of 4.2 (range 1.0-7.0) years from surgery: two patients who remained free of disease have subsequently died of unrelated conditions 12 and 24 months post-operatively, and in three cases death from recurrent disease occurred a mean of 1.4 (range 0.9-2.1) years after our surgery. There were two post-operative deaths. Based on the actuarial survival of 36 per cent and a successful disease clearance rate of 54 per cent, our conclusion is that the outlook of this condition has not dramatically improved since the original descriptions of the management of this problem first appeared, although intervention remains justifiable because of the potential curability and relief of symptoms.

A new technique using cultured epithelial sheets for the management of epistaxis associated with hereditary haemorrhagic telangiectasia.

A new technique for the treatment of severe epistaxis associated with hereditary haemorrhagic telangiectasia is described. The nasal septum and inferior turbinates, surgically denuded of respiratory epithelium, were grafted using autografts of cultured epithelial sheets derived from buccal epithelium. All patients upon whom this technique has been used have shown considerable lessening in the frequency and severity of their epistaxes although two patients received grafts on two occasions, in each case approximately three months apart. It is postulated that a nasal lining of stratified squamous epithelium is likely to be more resistant to trauma than the normal respiratory type, and this is supported by the observation that bleeds very seldom occur from the oral cavity in this syndrome.

Clinical and vestibulometric status following labyrinthectomy or vestibular nerve section for Menière's disease.

A clinical and vestibulometric comparison of 10 patients following labyrinthectomy, 5 following vestibular nerve section, and 10 control subjects was undertaken in order to evaluate the long-term effectiveness of these procedures. Testing was performed a mean of 8.5 years after surgery. Vestibulometry assessed time constants, gain, and phase advance of the vestibulo-ocular reflex (VOR) in both horizontal and vertical planes of head movement. Loss of the anticipated increase in phase advance in the vertical VOR of the labyrinthectomy group, significantly different from the vestibular nerve section group (P less than 0.05 and P less than 0.01 for each direction of rotation), suggests that posterior and superior semicircular canal function remains intact following per-meatal labyrinthectomy. Although stabilometry suggested that balance in the labyrinthectomy group was poorer than in the two other groups (P less than 0.025 without optic fixation), clinical assessment demonstrated excellent functional results. Per-meatal labyrinthectomy remains a safe and effective procedure for the relief of vestibular symptoms, although vestibular nerve section may provide more complete removal of contributory end-organ function.

Multiple ganglioneuroma of the neck.

A case of multiple ganglioneuroma arising along the entire length of the cervical sympathetic chain of one side of the neck is described. This is a distinctly unusual site and distribution of the disease and computed tomography proved invaluable to demonstrate its extent, in addition to excluding involvement of more caudal regions.

Mesenchymal tumors of the skull base with particular reference to surgical management and outcome.

Nine patients with mesenchymal tumors of the skull base have undergone radical tumor excision by the use of the Infratemporal fossa approach. Three cases of chondrosarcoma, two of leiomyosarcoma, and one case each of synovial sarcoma, chondroid chordoma, myxoma, and fibromatosis were managed. In the mean postoperative review time of 6.6 years (range 1.7 to 13) there are no clinical or radiologic signs of recurrence at the primary site in any patient, although two have developed distant metastases. The purpose of this article is to demonstrate that, with aggressive and preferably early surgical management using this type of access to the skull base, complete removal of these tumors can be undertaken, and it is now possible to achieve permanent ablation of this type of pathologic condition at the skull base.

The infratemporal fossa approach for adenoid cystic carcinoma of the skull base and nasopharynx.

The infratemporal fossa approach to the skull base is an established method of treating neoplasms of this region. The type C variation has proved an effective means of removing adenoid cystic carcinoma invading the infratemporal fossa and skull base from the nasopharynx. A classification of these tumors is proposed, the surgical technique is described, and the results are given in this article.

Leiomyosarcoma of a lower limb presenting with multiple cranial nerve palsies.

Leiomyosarcoma is a relatively uncommon soft tissue sarcoma usually presenting as a mass at the primary site. It arises in the retroperitoneal region, in the cutaneous or subcutaneous tissue of the extremities or, less commonly, from a large vein. A case is described where a patient presented with unilateral third, fourth, and sixth cranial, and ophthalmic division of trigeminal nerve palsies in whom biopsy of a longstanding lower limb mass demonstrated leiomyosarcoma. The presentation of this type of pathology has not been described previously.