Pharyngeal pouch: comparison of surgical treatment with botulinum toxin injection to the cricopharyngeus.

BACKGROUND: Pharyngeal pouch surgical treatments can be carried out via an endoscopic or open approach. Injection of botulinum toxin into the cricopharyngeus was first described as an alternative treatment to the more invasive surgical procedures performed for cricopharyngeal dysfunction. It has not been previously described as a treatment option for pharyngeal pouch. OBJECTIVES: To compare operative time, average stay, complication rates and symptom control between endoscopic laser diverticulotomy, botulinum toxin injection and open procedures for pharyngeal pouch patients. METHODS: The medical records for 66 pharyngeal pouch procedures, carried out on 47 patients treated between 2011 and 2017, were identified and reviewed. RESULTS: The mean operative time was 21 minutes for botulinum toxin injection, 38 for endoscopic laser diverticulotomy and 104 for open surgery. The mean hospital stay was 0.6 days for botulinum toxin injection, 4.7 for endoscopic laser diverticulotomy and 4 for open surgery. The improvement in Reflux Symptom Index scores was statistically significant for both endoscopic laser diverticulotomy and botulinum toxin injection. Botulinum toxin injection had a 0 per cent complication rate. CONCLUSION: Botulinum toxin injection is a safe and effective treatment for pharyngeal pouch.

Tuberculosis: the great imitator in the head and neck - our experience of 24 cases in 22 years.

This retrospective study covered over two decades, during which an individual head and neck surgeon treated 24 patients with cervicofacial lymphadenitis that was related to both Mycobacterium tuberculosis complex (n=17, made up of M tuberculosis (n=16) and M bovis (n=1)), and non-tuberculous mycobacteria. The seven cases of non-tuberculous mycobacteria were caused by M avium complex (n=3), M malmoense (n=3), and M kansaii (n=1). By using a tailored management approach, at times selective combined surgical and antimycobacterial treatment, he achieved a success rate of 23/24 cases, with only one recurrence and no major complications. The results suggest that patients with tuberculosis confined to the head and neck rarely develop constitutional symptoms, so the absence of such symptoms may not exclude tuberculosis. There was also a good correlation between predictive variables (immune state, inflammatory markers on admission, causative mycobacterium, and the antimycobacterial regimen used) and time spent under follow-up at the head and neck outpatient clinic.

A hybrid discrete-continuum mathematical model of pattern prediction in the developing retinal vasculature.

Pathological angiogenesis has been extensively explored by the mathematical modelling community over the past few decades, specifically in the contexts of tumour-induced vascularisation and wound healing. However, there have been relatively few attempts to model angiogenesis associated with normal development, despite the availability of animal models with experimentally accessible and highly ordered vascular topologies: for example, growth and development of the vascular plexus layers in the murine retina. The current study aims to address this issue through the development of a hybrid discrete-continuum mathematical model of the developing retinal vasculature in neonatal mice that is closely coupled with an ongoing experimental programme. The model of the functional vasculature is informed by a range of morphological and molecular data obtained over a period of several days, from 6 days prior to birth to approximately 8 days after birth. The spatio-temporal formation of the superficial retinal vascular plexus (RVP) in wild-type mice occurs in a well-defined sequence. Prior to birth, astrocytes migrate from the optic nerve over the surface of the inner retina in response to a chemotactic gradient of PDGF-A, formed at an earlier stage by migrating retinal ganglion cells (RGCs). Astrocytes express a variety of chemotactic and haptotactic proteins, including VEGF and fibronectin (respectively), which subsequently induce endothelial cell sprouting and modulate growth of the RVP. The developing RVP is not an inert structure; however, the vascular bed adapts and remodels in response to a wide variety of metabolic and biomolecular stimuli. The main focus of this investigation is to understand how these interacting cellular, molecular, and metabolic cues regulate RVP growth and formation. In an earlier one-dimensional continuum model of astrocyte and endothelial migration, we showed that the measured frontal velocities of the two cell types could be accurately reproduced by means of a system of five coupled partial differential equations (Aubert et al. in Bull. Math. Biol. 73:2430-2451, 2011). However, this approach was unable to generate spatial information and structural detail for the entire retinal surface. Building upon this earlier work, a more realistic two-dimensional hybrid PDE-discrete model is derived here that tracks the migration of individual astrocytes and endothelial tip cells towards the outer retinal boundary. Blood perfusion is included throughout plexus development and the emergent retinal architectures adapt and remodel in response to various biological factors. The resulting in silico RVP structures are compared with whole-mounted retinal vasculatures at various stages of development, and the agreement is found to be excellent. Having successfully benchmarked the model against wild-type data, the effect of transgenic over-expression of various genes is predicted, based on the ocular-specific expression of VEGF-A during murine development. These results can be used to help inform future experimental investigations of signalling pathways in ocular conditions characterised by aberrant angiogenesis.

Dynamics of angiogenesis during murine retinal development: a coupled in vivo and in silico study.

The manner in which the superficial retinal vascular plexus (RVP) develops in neonatal wild-type mice is relatively well documented and poses an interesting challenge to the mathematical modelling community. Prior to birth, astrocyte sprouting and proliferation begin around the edge of the optic nerve head, and subsequent astrocyte migration in response to a chemotactic gradient of platelet-derived growth factor (PDGF)-A results in the formation of a dense scaffold on the surface of the inner retina. Astrocytes express a variety of chemotactic and haptotactic proteins that subsequently induce endothelial cell sprouting and modulate growth of the RVP. An experimentally informed, two-dimensional hybrid partial differential equation-discrete model is derived to track the outward migration of individual astrocyte and endothelial tip cells in response to the appropriate biochemical cues. Blood perfusion is included throughout the development of the plexus, and the evolving retinal trees are allowed to adapt and remodel by means of several biological stimuli. The resulting wild-type in silico RVP structures are compared with corresponding experimental whole mounts taken at various stages of development, and agreement between the respective vascular morphologies is found to be excellent. Subsequent numerical predictions help elucidate some of the key biological processes underlying retinal development and demonstrate the potential of the virtual retina for the investigation of various vascular-related diseases of the eye.

Review article: reflux and its consequences--the laryngeal, pulmonary and oesophageal manifestations. Conference held in conjunction with the 9th International Symposium on Human Pepsin (ISHP) Kingston-upon-Hull, UK, 21-23 April 2010.

BACKGROUND: Gastro-oesophageal reflux disease (GERD) is one of the commonest diseases of Western populations, affecting 20 to 30% of adults. GERD is multifaceted and the classical oesophageal symptoms such as heartburn and regurgitation often overlap with atypical symptoms that impact upon the respiratory system and airways. This is referred to as extra-oesophageal reflux disease (EERD), or laryngopharyngeal reflux (LPR), which manifests as chronic cough, laryngitis, hoarseness, voice disorders and asthma. AIM: The 'Reflux and its consequences' conference was held in Hull in 2010 and brought together a multidisciplinary group of experts all with a common interest in the many manifestations of reflux disease to present recent research and clinical progress in GERD and EERD. In particular new techniques for diagnosing reflux were showcased at the conference. METHODS: Both clinical and non-clinical key opinion leaders were invited to write a review on key areas presented at the `Reflux and its consequences' conference for inclusion in this supplement. RESULTS AND CONCLUSION: Eleven chapters contained in this supplement reflected the sessions of the conference and included discussion of the nature of the refluxate (acid, pepsin, bile acids and non-acid reflux); mechanisms of tissue damage and protection in the oesophagus, laryngopharynx and airways. Clinical conditions with a reflux aetiology including asthma, chronic cough, airway disease, LPR, and paediatric EERD were reviewed. In addition methods for diagnosis of reflux disease and treatment strategies, especially with reference to non-acid reflux, were considered.

The signature of supernova ejecta in the X-ray afterglow of the gamma-ray burst 011211.

Now that gamma-ray bursts (GRBs) have been determined to lie at cosmological distances, their isotropic burst energies are estimated to be as high as 1054 erg (ref. 2), making them the most energetic phenomena in the Universe. The nature of the progenitors responsible for the bursts remains, however, elusive. The favoured models range from the merger of two neutron stars in a binary system to the collapse of a massive star. Spectroscopic studies of the afterglow emission could reveal details of the environment of the burst, by indicating the elements present, the speed of the outflow and an estimate of the temperature. Here we report an X-ray spectrum of the afterglow of GRB011211, which shows emission lines of magnesium, silicon, sulphur, argon, calcium and possibly nickel, arising in metal-enriched material with an outflow velocity of the order of one-tenth the speed of light. These observations strongly favour models where a supernova explosion from a massive stellar progenitor precedes the burst event and is responsible for the outflowing matter.

Tattooed Army soldiers: examining the incidence, behavior, and risk.

Primary prevention is a priority for medical personnel. Despite societal popularity and a long association of the military with tattooing, little is known about the tattooed Army soldier, which hampers primary health planning. Basic recruits and advanced individual training students (N = 1,835) at one mid-western military installation completed a questionnaire about any tattooing experiences. Almost half (48%) of the soldiers were serious/very serious about getting a tattoo, with 31% stating that there were "no reasons" to keep them from getting a tattoo. More than one-third (36%) were tattooed, with 22% possessing three or more tattoos. Many soldiers (64%) entered the military with the tattoos. Limited use (15%) of alcohol and/or drugs before tattooing was reported. Findings included a high incidence of tattooing, a strong determination to obtain tattoos, the possession of tattoos for self-identity reasons, and the supportive role of friends. Reported procedural bleeding (76%) documents the potential for blood-borne disease transmission. These results confirm the need for targeted health education regarding the safety and potential risks of tattooing.

Candidal abscess in a second primary neoplasm of the neopharynx.

A candidal abscess is a known complication of disseminated candidiasis, particularly in immunocompromised patients. We report a second primary growth in the neopharynx brought to light by a candidal abscess in a non-immunocompromised patient.

Vaginal bleeding and abuse: assessing pregnant women in the emergency department.

PURPOSE: This study was done to determine the prevalence of physical abuse among an ethnically stratified group of pregnant women experiencing vaginal bleeding. DESIGN: The design of this study was a cross-sectional survey using two screening tools: the Abuse Assessment Screen (AAS) and the Danger Assessment (DA). SAMPLE: The study sample consisted of 261 African-American, Hispanic, and Anglo pregnant women seen for vaginal bleeding in private and public emergency departments in a large (more than 2,000,000 people) metropolitan area. METHOD: All women with vaginal bleeding were interviewed in a private examination room. With the help of an interviewer, each subject completed both screening tools and was later offered information about abuse as well as community resources. Each woman's pregnancy status was validated with either a urine pregnancy test or a serum beta human chorionic gonadotropin, and her discharge diagnosis was obtained from the emergency department record. DATA ANALYSIS: Of the 261 pregnant women interviewed, 87 (33.3 percent) reported abuse, that is, 26.7 percent of the African-American women, 25.2 percent of the Hispanic women, and 58.3 percent of the Anglo women. Overall, Anglo women reported significantly more abuse (X2 = 21.96; df = 2; p < .00002) than non-Anglo women. We found no significant differences in reported abuse among the diagnostic groups. Abused and nonabused women significantly (p < .0005) differed on their DA scores (2.89 vs .55, respectively), but these scores were not significantly different among ethnicities. CONCLUSIONS: Abuse of pregnant women reporting to emergency departments is common and can be detected readily with a two-question, five-minute screen. Once an abused woman is identified, a danger assessment screen can further identify whether she is at high risk for escalating violence in her home.

Do patients with epistaxis have drug-induced platelet dysfunction?

Aspirin and other non-steroidal anti-inflammatory drugs (NSAID) are being used increasingly. A positive correlation has been shown between epistaxis and the use of NSAID in the over 50s. This prospective study compared the NSAID intake and platelet function in 50 patients with epistaxis and 50 controls. Standard haematological parameters and the platelet response to collagen and arachidonic acid aggregation and adenosine triphosphate release were measured. The patients showed a significant increase in NSAID intake (P < 0.01, 95% confidence for the difference in the medians = 4-36%) and hypertension (for diastolic blood pressure > 100 mmHg, P < 0.01, 95% confidence for the difference in the medians = 5.9-16.1). The patients showed a significant reduction in platelet aggregation to collagen (P = 0.025). Non-steroidal anti-inflammatory drugs produce a significant platelet dysfunction which should be considered in the multifactorial aetiology of epistaxis.

Negative ANCA in Wegener's granulomatosis.

Wegener's granulomatosis is a systemic vasculitis characterized by necrotizing granulomata and without treatment is associated with a poor prognosis. Antineutrophil cytoplasmic antibodies (ANCA) have proved to be a useful serological marker allowing for early diagnosis and treatment of this condition. We report two cases of patients who were ANCA-negative on presentation despite clinical suspicion of Wegener's granulomatosis. In both cases the patients developed a positive ANCA titre as the disease progressed.

A study of haemostasis following tonsillectomy comparing ligatures with diathermy.

The use of diathermy to achieve haemostasis after tonsillectomy remains controversial. We have reviewed the English language literature, and found no convicting evidence that diathermy is any more likely to cause post-operative haemorrhage than the use of ligatures. The results of a prospective, randomized study of 1036 consecutive tonsillectomies are presented. No significant difference was found in post-operative haemorrhage rates when either diathermy or ligatures were used. Diathermy was found to reduce operating time compared to ligatures. The possibilities for day-case tonsillectomy are discussed.

Measurement of range of motion of the finger after flexor tendon repair in zone II of the hand.

The purpose of this study was to compare classification systems of active range of motion of the finger after flexor tendon surgery in zone II of the hand. Active range of motion of 20 fingers (16 subjects) was classified according to five systems. Agreement between the systems was only fair. Strickland's original system and the Louisville system rated the results most strictly, followed by Strickland's adjusted system. Buck-Gramcko's systems (in centimeters and degrees) rated the results least strictly. Strickland's systems conformed most closely to measurement principles. This article concludes that at this time Strickland's original classification system is preferable for scientific and clinical purposes. However, additional research is needed to evaluate reliability of the measurement, the variability of the scaling factor of 175 degrees, the sensitivity of the measurement, and the validity of the measurement with regard to functional use of the finger and gliding of the repaired tendon.

Is 'lateral aberrant thyroid' always metastatic tumour?

It is now a widely held belief that so-called 'lateral aberrant thyroid' tissue actually represents a metastasis from a malignant tumour of the thyroid gland. A case is presented which suggests that this is not always true, and an extensive review of the relevant literature is discussed.

Pseudoaneurysm of the internal carotid artery: a forgotten complication of tonsillitis?

Pseudoaneurysm of the internal carotid artery is an uncommon but potentially lethal complication of tonsillar or peritonsillar sepsis, which appears to have occurred more frequently prior to the introduction of penicillin. Management of such a case is discussed, and a literature review presented.

Non-Hodgkin's lymphoma involving the tonsil: an immunohistochemical study.

Twenty-one patients with non-Hodgkin's lymphoma involving the palatine tonsil were studied in an attempt to relate pathological data to clinical outcome. Eleven tumours were classified as low-grade and ten as high-grade on morphological criteria. The results of immunohistochemical investigations are presented; all tumours but one were of B-cell origin. None of the pathological factors studied were found to be useful prognostic indicators.

Diathermy haemostasis at tonsillectomy: current practice--a survey of U.K. otolaryngologists.

The use of diathermy in achieving haemostasis at tonsillectomy was assessed by means of a postal questionnaire sent to consultant otolaryngologists practising in the U.K. A response of 81 per cent was obtained. Forty-four per cent presently use diathermy. Few considered the age of the patient or a history of a quinsy a contraindication to its use. The diathermy experience of users and non-users with regard to speed, post-operative pain and haemorrhage differs markedly. This dichotomy of opinions is confirmed by a review of the literature. Clearly there is a need for further studies to clarify the role of diathermy in tonsillectomy.

Intranasal adhesions which recur despite splinting: an ominous sign?

Intranasal adhesions are a common complication following nasal surgery. They may be prevented by the use of silastic splints, which are also a very effective treatment for established lesions. We report a patient where intranasal adhesions rapidly recurred despite the use of splints, who was found to be suffering from Wegener's granulomatosis.

Drug-induced epistaxis?

To assess the aetiological contribution made to spontaneous epistaxis in adults over the age of 50 years by various groups of drugs, a controlled study was designed. Fifty-three consecutive epistaxis patients were compared with 50 controls. Significant differences were found between the groups in their consumption of warfarin, dipyridamole and non-steroidal anti-inflammatory drugs. Hypertension was equally common in the two groups, but tended to be less well controlled in the epistaxis patients compared to the controls. It is thought that the link between the use of nonsteroidal anti-inflammatory drugs and the occurrence of epistaxis may be due to alteration of platelet function.