Anthony Wright

Immunohistochemical characterization of the epidermoid formation in the middle ear.

Objective To study the incidence, size, and origin of epidermoid formations after accurately characterizing them by cytokeratin immunohistochemical analysis.

Laryngocele: a rare complication of surgical tracheostomy

BackgroundA laryngocele is usually a cystic dilatation of the laryngeal saccule. The etiology behind its occurrence is still unclear, but congenital and acquired factors have been implicated in its development.Case presentationWe present a rare case of laryngocele occurring in a 77-year-old Caucasian woman. The patient presented with one month history of altered voice, no other associated symptoms were reported. The medical history of the patient included respiratory failure secondary to childhood polio at the age of ten; the airway management included a surgical tracheostomy.Flexible naso-laryngoscopy revealed a soft mass arising from the posterior pharyngeal wall obscuring the view of the posterior commissure and vocal folds. The shape of the mass altered with respiration and on performing valsalva maneuver. A plain lateral neck radiograph revealed a large air filled sac originating from the laryngeal cartilages and extending along the posterior pharyngeal wall. The patient was then treated by endoscopic laser marsupialization and reviewed annually.We discuss the complications of tracheostomy and the pathophysiology of laryngoceles and in particular the likely aetiological factors in this case.ConclusionA laryngocele presenting in a female patient with tracheostomy is extremely rare and has not been to date reported in the world literature. A local mechanical condition may be the determinant factor in the pathogenesis of the disease.

Development of the fallopian canal in humans: a morphologic and radiologic study.

Aims This study investigated the development of the fallopian canal with particular reference to the mode of ossification and dehiscences, sites of incomplete closure around the facial nerve. Background The precise sequence of events surrounding ossification of the tissues around the facial nerve is uncertain. Incomplete ossification results in dehiscence of the adult structure, which places the nerve at increased risk of damage from disease processes in the middle ear and iatrogenic trauma during otologic surgery. Methods Twenty-four temporal bones from 12-to 36-week human fetuses were resected. Eight temporal bones from 22-to 36-week fetuses were microsliced to produce 1.5-mm horizontal sections and radiographed. Sixteen temporal bones from 12-to 35-week fetuses were serially microtomed to produce 7-&mgr;m slices, which were stained with hematoxylin and eosin. Quantitative and qualitative analyses of these sections were performed to document patterns of closure of the primitive canal and dehiscence formation. Results The tympanic part of the primitive fallopian canal, the facial sulcus, developed anteroposteriorly from the geniculate fossa to enclose the facial nerve. The mesenchyme that formed the facial sulcus underwent endochondral ossification, while the bone which capped or closed the sulcus developed in membrane. In the tympanic segment, permanent congenital dehiscences were elliptical and about 1 mm in length. Conclusions This study clarifies the mode of development of the fallopian canal, with particular reference to dehiscences, and provides a scientific basis for otologic practice.

How we do it: a method of neck dissection for histopathological analysis

BackgroundDissection of the lymphatic structures in the neck is an integral part of the management of many head and neck cancers.We describe a technique of surgical dissection, preparing the tissue for more precise histological analysis while also reducing operative time and complexity.MethodsWhen dissected, each level is excised between lymph nodes groups and put into a separate pot of formalin taking care to avoid rupture of any obvious pathological nodes.ResultsThis makes for a simpler dissection as the surgeon progresses, as a larger more cumbersome specimen is avoided and manipulation of involved nodes is actually reduced with a reduced risk of tumour spillage.ConclusionWe feel that our technique provides several advantages for the histopathologist as well as the surgeon. As the dissection of the specimen into the relevant levels has already been performed, time is saved in orientating and then dissecting the specimen. Accuracy of dissection is also improved and each piece of tissue is a more manageable size for processing and analysis.This technique may also have several surgical advantages when compared with the commonly practiced techniques e.g. with reducing in-vivo specimen manipulation, hence reducing the risk of inadvertent injury to important structures and tumour spillage.

The role of surgical audit in improving patient management; nasal haemorrhage: an audit study.

BackgroundNasal bleeding remains one of the most common Head & Neck Surgical (Ear Nose and Throat [ENT]/Oral & Maxillofacial Surgery [OMFS]) emergencies resulting in hospital admission. In the majority of cases, no other intervention is required other than nasal packing, and it was felt many cases could ideally be managed at home, without further medical interference. A limited but national telephone survey of accident and emergency departments revealed that early discharge practice was identified in some rural areas and urban departments (where adverse socio-demographic factors resulted in poor patient compliance to admission or follow up), with little adverse patient sequelae. A simple nasal packing protocol was also identified.The aim of this audit was to determine if routine nasal haemorrhage (epistaxis) can be managed at home with simple nasal packing; a retrospective and prospective audit.Ethical committee approval was obtained. Similar practice was identified in other UK accident and emergency centres. Literature was reviewed and best practice identified. Regional consultation and feedback with regard to prospective changes and local applicability of areas of improved practice mutually agreed upon with involved providers of care.MethodsRetrospective: The Epistaxis admissions for the previous four years during the same seven months (September to March).Prospective: 60consecutive patients referred with a diagnosis of Nasal bleeding over a seven month time course (September to March). All patients were over 16, not pregnant and gave fully informed counselled consent.New Guidelines for the management of nosebleeds, nasal packing protocols (with Netcel®) and discharge policy were developed at the Hospital. Training of accident and emergency and emergency ENT staff was provided together with access to adequate examination and treatment resources. Detailed patient information leaflets were piloted and developed for use.ResultsPreviously all patients requiring nasal packing were admitted. The type of nasal packing included Gauge impregnated Bismuth Iodoform Paraffin Paste, Nasal Tampon, and Vaseline gauge. Over the previous four year period (September to March) a mean of 28 patients were admitted per month, with a mean duration of in patient stay of 2.67 days.In the prospective audit the total number of admissions was significantly reduced, by over 70%, (χ2 = 25.05, df = 6, P < 0.0001), despite no significant change in the number of monthly epistaxis referrals (χ2 = 4.99, df = 6, P < 0.0001). There was also a significant increase in the mean age of admitted patients with epistaxis (χ2 = 22.71, df = 5, P < 0.0001), the admitted patients had a mean length of stay of 2.53 days. This policy results is an estimated saved 201.39 bed days per annum resulting in an estimated annual speciality saving of over £50,000, allowing resource re-allocation to other areas of need. Furthermore, bed usage could be optimised for other emergency or elective work.ConclusionExclusion criteria have now been expanded to exclude traumatic nasal haemorrhage. New adjunctive therapies now include direct endoscopic bipolar diathermy of bleeding points, and the judicious use of topical pro-coagulant agents applied via the nasal tampon. Expansion of the audit protocols for use in general practice.This original audit informed clinical practice and had potential benefits for patients, clinicians, and provision of service. Systematic replication of this project, possibly on a regional and general practice basis, could result in further financial savings, which would allow development of improved patient services and delivery of care.

Direct microvascular monitoring of a free autologous jejunal flap using microendoscopy: a case report

BackgroundEarly identification of flap failure is an indispensable prerequisite for flap salvage. Although many technical developments of free flap monitoring have now reached clinical application, very few are considered to be reliable and non-invasive for early recognition of flap failure.Case presentationWe used microendoscopic technique for microvascular monitoring of free autologous jejunal flap by the direct visualisation of the flow of erythrocytes through the capillary vasculature on both the mucosal and serosal surfaces.Blood flow was seen to be pulsatile, with individual erythrocytes visible in the capillaries. The best view was obtained when the scope was focussed directly on the capillary rather than the graft surface. The view of the unstained mucosal surface was bland apart from the fine capillary loops which were seen to fill with each pulsatile event. The microendoscopic examination of the serosal surface revealed much larger calibre vessels with obvious blood flow.ConclusionThe microendoscopic monitoring technique is simple and safe with direct visualisation of blood flow. The technique may also be useful for the monitoring of other free bowel transplants.

Rheumatoid nodule of the thyrohyoid membrane: a case report

BackgroundRheumatoid nodules are common extra-articular findings occurring in 20% of rheumatoid arthritis patients. They develop most commonly subcutaneously in pressure areas (elbows and finger joints) and may occasionally affect internal organs including pleura, lungs, meninges, larynx, and in other connective tissues elsewhere in the bodyCase presentationWe present the case of a 62-year-old male who presented with a midline neck mass. Clinically it moved on swallowing and tongue protrusion-suggesting attachment to the thyrohyoid membrane. Ultrasound examination revealed a cystic lesion in the absence of cervical lymphadenopathy in a non-smoker. The neck was explored and histological examination of the excised lesion which was attached to the thyrohyoid membrane revealed a rheumatoid nodule.ConclusionA rheumatoid nodule of the thyrohyoid membrane is very rare. The triple diagnostic scheme of clinical examination supplemented with ultrasound and guided fine needle aspiration for neck lumps remains valid in most cases. If excision is indicated we feel it should be performed in such a manner that the scar tract could easily be encompassed in a neck dissection excision should definitive histological examination be adverse. We suggest that when dealing with patients with established rheumatoid arthritis one should consider a rheumatoid nodule as a differential diagnosis for any swelling on the patient whether it be subcutaneous or deep.