Akhtar Hussain

Pre-treatment anaemia alters outcome in early squamous cell carcinoma of the larynx treated by radical radiotherapy.

The purpose of this study was to examine the effect of pre-treatment anaemia on tumour recurrence and survival in patients treated with primary radiotherapy for early squamous cell carcinoma of the larynx. A retrospective analysis of 117 patients with previously untreated T1N0M0 and T2N0M0 squamous cell carcinoma of the larynx was carried out. Patients were considered anaemic if their pre-treatment haemoglobin levels were below 13 g/dl in males and 11.5 g/dl in females. The influence of pre-treatment haemoglobin levels on local control and survival were evaluated using Cox proportional hazards regression models. Two- and five-year local-regional control estimates for anaemic patients were 58 per cent and 53 per cent respectively while patients with normal haemoglobin levels had two and five-year local-regional control rates of 90 per cent and 81 per cent respectively (p = 0.002). Multivariate Cox regression analysis showed pre-treatment haemoglobin significantly influencing recurrence-free survival (p = 0.0094). Patients with a low haemoglobin level prior to radiation therapy suffered higher levels of local-regional failure.

Reconstruction of mastoid cavity with hydroxyapatite cement and postauricular flap.

INTRODUCTION The care of the mastoidectomy cavity is not problem free. The difficulties vary from minor, infrequent debridement to chronic, recurrent, and sometimes persistent purulent otorrhoea requiring frequent aural toilet and topical treatment. Other problems include dizziness associated with cold caloric testing response, frequent cavity infections with swimming, and difficulty with fitting hearing aids. It is generally accepted that an adequate meatoplasty is necessary to minimize problems with the open mastoid cavity, but some patients object to the size of the proposed meatus. Middle ear reconstruction with an open cavity is relatively difficult because of the absence of the posterior canal wall. Various techniques are recommended to eliminate problems associated with open cavity including obliteration, skin grafting, and reconstruction of posterior canal wall. Obliteration and reconstruction generally involve use of soft tissue flaps such as temporalis muscle, temporoparietal fascia, or use of cartilage, bone, and postauricular flap. Pedicled muscle flaps such as the Rambo flap or the flap of Palva and Makinen, although readily available, have the disadvantage of being unable to obliterate the entire mastoid cavity and later atrophy leading to recurrent cavity formation. Tympanomastoid obliteration using tragal or conchal cartilage has been shown to have good integration properties but the cartilage tend to undergo fibrous degeneration and graft resorption over time. Similarly, reconstruction using autogenous bone may leave sharp edges of the newly constructed ear canal wall, facilitating crust formation and infection in the ear canal. In addition, the bone may undergo resorption over time with recurrent cavity formation. In recent years, bioactive materials are increasingly being used in surgical practice for reconstruction, augmentation, or replacement of lost tissue. Although the search for an ideal bioactive material continues, at present, hydroxyapatite cement (Howmedica Leibinger GmbH & Co., Freiburg, Germany) appears to be most favored and has been shown to be associated with minimal side effects. Hydroxyapatite cement is a mixture of tetracalcium phosphate and dicalcium phosphate anhydrous. It is inert, biocompatible, rigid, and easy to handle and, when placed in contact with the bone, has been shown to be osteoconductive. Long-term studies have shown no evidence of implant resorption, encapsulation, inflammation. or foreign body reaction. We propose reconstruction of mastoid cavity and posterior canal wall during the same procedure with hydroxyapatite cement and postauricular flap. The hydroxyapatite cement is used to reconstruct the bony defect in the mastoid and is covered and isolated from the middle ear with anteriorly based postauricular periosteal connective tissue flap. We report a longitudinal cohort of 29 patients who underwent both primary and secondary mastoid cavity reconstruction using this technique and discuss their outcomes and complications.

Stapled closed technique for laryngectomy and pharyngeal repair

BACKGROUND AND AIMSnTotal laryngectomy is a recognised treatment for advanced laryngeal carcinoma. Traditionally, pharyngeal repair is performed with layered sutures. We describe our experience with a technique of closed pharyngoplasty using a linear stapler device.nnnMATERIAL AND METHODSnTen total laryngectomies were performed from July 2002 to July 2004, using an Ethicon TLC 75 linear stapler for pharyngeal closure. Data collected included age, sex, staging, endoscopic assessment, surgical margins and post-operative course (including complications and swallowing).nnnRESULTSnPatients comprised eight men and two women. The mean age was 55.4 years. Six patients had stage T4 endolaryngeal carcinoma and four had stage T3. Four patients underwent pre-operative radiotherapy. Clear surgical margins were achieved in all patients. One patient developed a pharyngocutaneous fistula. Patients resumed oral intake at 48 hours, or at 72 hours if they had undergone pre-operative radiotherapy. Patients mean hospital stay was seven days.nnnCONCLUSIONnThis stapled closed technique for pharyngoplasty is efficient and eliminates the risk of wound contamination, thus theoretically reducing the risk of tumour seeding. In addition, we were able to commence patients on oral fluids at a mean of 48 hours after surgery. The mean hospital stay was seven days. We recommend this technique as an alternative for repairing the pharynx in patients undergoing total laryngectomy for endolaryngeal carcinoma.

Selective lateral laser thyroarytenoid myotomy for adductor spasmodic dysphonia

OBJECTIVEnSelective lateral laser thyroarytenoid myotomy is a conceptually sound, simple, minimally invasive, repeatable and predictable new surgical procedure for treating adductor spasmodic dysphonia. This paper aims to introduce and describe the surgical technique, and to present a clinical case series and its outcomes.nnnSTUDY DESIGNnA prospective, clinical case series treated with selective lateral laser thyroarytenoid myotomy, with follow up of 2.5 years.nnnMETHODnPre- and post-operative data were collected prospectively for patients undergoing selective lateral laser thyroarytenoid myotomy. These data included patient demographics, previous interventions for adductor spasmodic dysphonia, technical aspects of surgery and clinical outcome. Outcome data included clinical assessment, voice handicap index, need for further intervention, and patient satisfaction assessed by subjective improvement (detailed subjectively by the patients themselves and objectively using the Glasgow benefit inventory).nnnRESULTSnFour patients (two men and two women; mean age 65 years; age range 41-80 years) were included. The mean duration of adductor spasmodic dysphonia was 11 years. All patients had previously been treated with botulinum toxin A. All patients reported improvement in voice quality, fluency, sustainability and elimination of voice breaks over 2.5 years follow up. Clinical assessment revealed no alteration in mucosal wave, and complete relief of hyperadduction was observed on phonation. No patients required supplementary botulinum toxin treatment during follow up.nnnCONCLUSIONnSelective lateral laser thyroarytenoid myotomy seems to represent a curative procedure for adductor spasmodic dysphonia, a chronic, debilitating condition. This procedure is conceptually simple, minimally invasive and repeatable. It also seems to offer a safe and lasting alternative to botulinum toxin therapy.

Trans-oral resection of large parapharyngeal space tumours

The aim of this study is to describe minimally invasive trans-oral approach for resection of parapharyngeal space (PPS) tumours and to demonstrate surgical technique, resection, repair and outcomes. Five cases were prospectively included in the study. The data collected include age, sex, site, size, pathology, radiological investigations, surgical excision, complications and outcomes. Three females and two male patients underwent trans-oral resection of PPS tumours sized 4–8 cm. The pathology included two deep lobe parotid tumours, one schwannoma, one hibernoma and one primary adenocarcinoma arising form the minor salivary gland. All tumours were resected completely without any technical difficulty. The healing was quick and by primary intention. Patients resumed oral feeding on recovery from general anaesthesia and did not require any significant analgesia beyond the first 2xa0days. Patient with adenocarcinoma received postoperative radiotherapy and remained disease-free during 4xa0years post-treatment. No recurrences were observed in patients with benign tumours. No neurovascular injury occurred during surgery and no secondary bleeding was observed. We have demonstrated successful and safe execution of trans-oral resection of large PPS tumours. There were no intra and post-operative complications and there has been no recurrence during the follow-up period. In our experience, it appears to be efficient, safe and minimally invasive compared to the established techniques.

Traditional and complementary and alternative medicines make for unwilling bedfellows in the management of cancer: a case report with a tragic outcome.

BACKGROUNDnComplementary and alternative medicine is very much in the public arena as a treatment option. The pharmacodynamics of most complementary and alternative medicines are not well understood, and some can lead to significant adverse drug interactions. This report aims to present the case of a cancer patient who abandoned traditional medicine in favour of complementary and alternative medicine.nnnMETHODnCase report.nnnRESULTSnThe patient refused potentially curative adjuvant radiotherapy for his oral cavity carcinoma following surgery, and eventually succumbed to disease.nnnCONCLUSIONnRecently, there appears to be much public awareness of and empathy for complementary and alternative medicine. Healthcare professionals should be aware of such therapies so that they can advise their patients in an informed manner. The role of such therapies in benign conditions may not be as critical as that in malignancy, where life-saving conventional treatment may be abandoned in favour of complementary and alternative medicine, with consequent loss of life.

Para-incisional tattooing with electrocautery.

The authors present a technique using electrocautery diathermy to make surgical tattoos. This method has been used in over 300 patients who underwent head and neck surgery at Aberdeen Royal Infirmary and Albany Medical College, New York, over a period of five years. A wide variety of operative procedures such as total laryngectomies and neck dissections were performed. The electrocautery surgical tattoos have a major advantage of persisting until the end of the operative procedure by which time other types of tattoos have faded. The technique is widely available, inexpensive, and has to date been complication free.

Open surgical management of auricular haematoma: incision, evacuation and mattress sutures.

OBJECTIVEnA large variety of techniques have been used for auricular haematoma management. The open surgical management of auricular haematoma involves incision, evacuation and the obliteration of dead space using biodegradable mattress sutures. Our goal was to describe open surgical management for primary, recurrent and spontaneous auricular haematoma.nnnMETHODSnAuricular haematoma patients who underwent open surgical management were prospectively audited (2010-2013). Information was collected on demographics, clinical presentation, aetiology, examination findings, previous interventions, details of open surgical management and post-operative follow up.nnnRESULTSnIn all, 12 male and 3 female patients with a mean age of 33 years (range 16-86 years) were evaluated. Contact sport injury was the most common aetiology. Ten patients had undergone previous unsuccessful interventions to treat auricular haematoma before open surgical management was performed. All patients were managed successfully without significant recurrence. One patient had a minor local reaccumulation which required reinsertion of a mattress suture. One elderly patient developed localised cellulitis which responded well to antibiotics.nnnCONCLUSIONnOpen surgical management of auricular haematoma has been successful. The technique is simple and reliable, and can be accomplished in a clinical setting under local anaesthesia.

Mislaid dentures: a cause for unusual presentation of bilateral vocal cord palsy

An 81-year-old man was referred urgently to the head and neck clinic with symptoms of worsening dysphagia, dysphonia and weight loss. He had a history of chronic lymphocytic leukaemia. On full ear, nose and throat examination, he was found to have fixed vocal cords with pooling of saliva in the bilateral pyriform fossa. Hypopharyngeal malignancy was suspected and further imaging was performed. Imaging also raised the suspicion of malignancy in the hypopharynx. Rigid endoscopic examination under general anaesthesia was carried out which revealed an impacted denture in the cricopharynx and upper oesophagus. The patient was aware of his loss of dentures 3u2005months ago (corresponds to the onset of his symptoms) but felt that he had mislaid them and had never mentioned this to anyone. We present a case highlighting a delay in diagnosis, a missed diagnosis on CT scan and an unusual presentation leading to bilateral vocal cord paresis.

Atrioventricular and Interventricular Groove and Septal Extension of Right Sinus of Valsalva Aneurysm: A Rare Cause of Complete Heart Block

A 26 years old male presented with vertigo and history of fall. The electrocardiogram revealed 2:1 second-degree heart block and later progression to complete heart block. Transthoracic echocardiography revealed aneurysm at the site of ascending aorta and computed tomographic scan showed an aneurysm of right sinsus of Valsalva extending into right atrioventricular and interventricular groove and causing complete heart block by compression on the conduction system. He also suffered from lymph node tuberculosis. This case report is unique because of rare presentation as complete heart block.