Hisham Khalil

Thyroglossal duct remnants.

Thyroglossal duct remnants presenting as a lump in the neck are usually called thyroglossal cysts. Meticulous dissection of the cyst and duct, along with the body of the hyoid bone (Sistrunks operation) is necessary to avoid recurrence. The authors have reviewed the histology of 61 consecutive specimens diagnosed preoperatively as thyroglossal cysts and have found that a true cyst exists in only 46 per cent of cases.

The burden of revision sinonasal surgery in the UK-data from the Chronic Rhinosinusitis Epidemiology Study (CRES): a cross-sectional study.

Objectives The aim of this study was to investigate the surgical revision rate in patients with chronic rhinosinusitis (CRS) in the UK CRS Epidemiology Study (CRES). Previous evidence from National Sinonasal Audit showed that 1459 patients with CRS demonstrated a surgical revision rate 19.1% at 5 years, with highest rates seen in those with polyps (20.6%). Setting Thirty secondary care centres around the UK. Participants A total of 221 controls and 1249 patients with CRS were recruited to the study including those with polyps (CRSwNPs), without polyps (CRSsNPs) and with allergic fungal rhinosinusitis (AFRS). Interventions Self-administered questionnaire. Primary outcome measure The need for previous sinonasal surgery. Results A total of 651 patients with CRSwNPs, 553 with CRSsNPs and 45 with AFRS were included. A total of 396 (57%) patients with CRSwNPs/AFRS reported having undergone previous endoscopic nasal polypectomy (ENP), of which 182 of the 396 (46%) reported having received more than one operation. The mean number of previous surgeries per patient in the revision group was 3.3 (range 2–30) and a mean duration of time of 10 years since the last procedure. The average length of time since their first operation up to inclusion in the study was 15.5 years (range 0–74). Only 27.9% of all patients reporting a prior ENP had received concurrent endoscopic sinus surgery (ESS; n=102). For comparison, surgical rates in patients with CRSsNPs were significantly lower; 13% of cases specifically reported ESS, and of those only 30% reported multiple procedures (χ2 p<0.001). Conclusions This study demonstrated that there is a high burden of both primary and revision surgery in patients with CRS, worst in those with AFRS and least in those with CRSsNPs. The burden of revision surgery appears unchanged in the decade since the Sinonasal Audit.

Radiological findings in patients undergoing revision endoscopic sinus surgery: a retrospective case series study

BackgroundFunctional endoscopic sinus surgery (FESS) is now a well-established strategy for the treatment of chronic rhinosinusitis which has not responded to medical treatment. There is a wide variation in the practice of FESS by various surgeons within the UK and in other countries.ObjectivesTo identify anatomic factors that may predispose to persistent or recurrent disease in patients undergoing revision FESS.MethodsRetrospective review of axial and coronal CT scans of patients undergoing revision FESS between January 2005 and November 2008 in a tertiary referral centre in South West of England.ResultsThe CT scans of 63 patients undergoing revision FESS were reviewed. Among the patients studied, 15.9% had significant deviation of the nasal septum. Lateralised middle turbinates were present in 11.1% of the studied sides, and residual uncinate processes were identified in 57.1% of the studied sides. There were residual cells in the frontal recess in 96% of the studied sides. There were persistent other anterior and posterior ethmoidal cells in 92.1% and 96% of the studied sides respectively.ConclusionsAnalysis of CT scans of patients undergoing revision FESS shows persistent structures and non-dissected cells that may be responsible for persistence or recurrence of rhinosinusitis symptoms. Trials comparing the outcome of conservative FESS techniques with more radical sinus dissections are required.

Teaching Otolaryngology skills through simulation.

Over the last couple of decades, learning through simulation has become popularised for various reasons and is continuing to expand exponentially despite a lack of robust evidence that it actually improves outcomes for patients and learners. There has been a particular growth in the use of high-fidelity virtual reality simulators for surgical training as the technology has become more affordable. In the field of Otolaryngology, simulation appears to help teach simple procedural skills through to complex surgery of the temporal bone and paranasal sinuses. This is happening in an era when quality of care and patient safety are top of the agenda and cadaveric material is in short supply. In this article, we explore the history behind simulation, review the available evidence and discuss its applications within Otolaryngology.

Sinonasal malignancy: presentation and outcomes

OBJECTIVE We wanted to identify the presentation, diagnostic work-up and treatment outcomes of patients with sinonasal malignancy at Derriford Hospital, Plymouth, UK and compare these with the European Position Paper on Endoscopic Management of Tumours of the Nose, Paranasal Sinuses and Skull Base. MATERIALS AND METHODS This was a retrospective audit of all patients diagnosed with sinonasal malignancy over a five-year period. The clinical records and picture archiving and communications system data of the patients were reviewed. RESULTS Thirty patients with sinonasal malignancy were identified out of 570 head and neck cancer patients. The nasal cavity was the most common site for presentation, followed by the maxillary sinuses. Fifty per cent of patients had a squamous cell carcinoma and 27 per cent had a malignant melanoma. Half of the patients presented at stage IV of the cancer and 20 per cent at stage III. Thirty-seven per cent of patients underwent surgical management and only 20 per cent of the total patient group underwent endoscopic surgery. The mortality in our series was 30 per cent over the studied period. CONCLUSION Late-stage presentation of sinonasal malignancy has resulted in increased patient mortality in our case series. Also, we found a high incidence of malignant melanoma with high recurrence and survival rates.

Well-differentiated liposarcoma of the hypopharynx

We present a case of well-differentiated liposarcoma of the hypopharynx in a 51-year-old male, with a review of the literature of this very rare condition.

Speech therapy in the treatment of globus pharyngeus: how we do it.

1 Young E.W. (1991) The ethics of non treatment of patients with cancers of the head and neck. Arch. Otolaryngol. Head Neck Surg. 117, 769–773 2 Kowalski L.P. & Carvalho A.L. (2000) Natural history of untreated head and neck cancer. Eur. J. Cancer 36, 1032–1037 3 Sesterhenn A.M., Folz B.J., Bieker M. et al. (2008) End-of-life care for terminal head and neck cancer patients. Cancer Nurs. 31, E40–E46 4 Shedd D.P., Carl A. & Shedd C. (1980) Problems of terminal head and neck cancer patients. Head Neck Surg. 2, 476–482 5 Lyon L., Gleich C., Collins M. et al. (2003) Therapeutic decision making in stages III and IV head and neck squamous cell carcinoma. Arch. Otolaryngol. Head Neck Surg. 129, 26–35

Investigation of the influence of ambient temperature, atmospheric pressure and water vapour pressure on epistaxis admission rate

BACKGROUND To investigate the relationship between weather variables (atmospheric pressure, temperature, water vapour pressure) and epistaxis admission rates at Derriford Hospital, Plymouth, United Kingdom. METHODOLOGY Retrospective observational study using hospital inpatient information databases to identify all patients admitted with epistaxis from April 1999 to March 2009 inclusive. Meteorological data for the same period was retrieved from the University of Plymouth Meteorological Archive. Epistaxis admissions were investigated for correlation with weather variables using Pearson correlation, and stepwise multiple regression analysis was performed. RESULTS During the study period there were 1071 admissions (978 patients) (501 males (mean age 64 years) and 477 females (mean age 72 years)). Less than 10% of the variance in epistaxis admissions is explained by the maximum temperature only. Temperature and water vapour pressure demonstrated statistically significant association with epistaxis admission rates. CONCLUSIONS Though there is statistical significance in the association of some weather variables and epistaxis admission rates, the findings are not practically relevant (<10% variance). The results of this study do not indicate a need for revision of current healthcare resource allocation.

Cavernous sinus thrombosis secondary to contralateral sphenoid sinusitis: a diagnostic challenge

OBJECTIVE To report what we believe to be the first case in the English language literature of unilateral cavernous sinus thrombosis complicating contralateral sphenoid sinusitis. CASE REPORT A 62-year-old man presented to his general practitioner with a severe, right-sided, temporal headache. He was diagnosed with temporal arteritis and treated with systemic steroids. After five days, he developed right proptosis, ophthalmoplegia and ptosis. He was referred to the neurologists. After an urgent computed tomography head scan and computed tomography angiogram, a diagnosis of carotido-cavernous fistula was made. However, this was subsequently excluded after a negative cerebral angiogram. A review of the scans enabled diagnosis of right cavernous sinus thrombosis secondary to left sphenoiditis. The patient was referred to the otolaryngology team. After an urgent endoscopic sphenoidotomy and medical treatment, all symptoms and signs improved dramatically. CONCLUSIONS Sphenoiditis can lead to contralateral cavernous sinus thrombosis. Urgent surgical sphenoidotomy, with appropriate medical treatment, can be successful in this life-threatening complication.

The diagnosis and management of globus: a perspective from the United Kingdom.

Purpose of reviewGlobus pharyngeus is a common disorder that accounts for approximately 4% of new ear, nose and throat referrals. The presenting symptoms are a cause of anxiety for patients and clinicians alike. There is a great deal of controversy surrounding the diagnosis and treatment of this disorder. This article discusses current trends in the management of this condition. Recent findingsGlobus symptoms are associated with proximal reflux. Globus symptoms in patients with laryngopharyngeal reflux treated with proton pump inhibitor resolve more slowly than classic reflux symptoms in patients with gastroesophageal reflux. Thyroid surgery may help improve globus symptoms in patients with goiter. Short-tem results suggest that speech therapy is effective in relieving symptoms of globus. SummaryThe cause of globus symptoms remains an enigma. The diagnosis of this symptom complex is essentially clinical. There is a limited role for investigations in patients with atypical symptoms. Treatment remains controversial and includes reassurance, speech therapy and proton pump inhibitors in patients with laryngopharyngeal reflux.