Jagdeep Singh Virk

Endoscopic Management of Cerebrospinal Fluid Rhinorrhea: The Charing Cross Experience

Objective To describe our experience of cerebrospinal fluid (CSF) rhinorrhea management. Design Retrospective. Setting Charing Cross Hospital, London, a tertiary referral center. Participants Fifty-four patients with CSF rhinorrhea managed from 2003 to 2011. Main outcome measures Surgical technique; Recurrence. Results Etiologically, 36 were spontaneous and 18 traumatic. Eight patients with spontaneous and two with traumatic leaks had previous failed repairs in other units. Success rates after first and second surgery were 93% and 100%, respectively. Mean follow-up was 21 months. Four patients, all of spontaneous etiology, had recurrences; three of these underwent successful second repair with three layered technique, and the fourth had complete cessation of the leak after gastric bypass surgery and subsequent weight reduction. Adaptation of anatomic three-layered repair since then averted any further failure in the following 7 years. Mean body mass index was 34.0 kg/m(2) in spontaneous and 27.8 kg/m(2) in traumatic cases (p < 0.05). Fifty percent of spontaneous leaks were from the cribriform plate, 22% sphenoid, 14% ethmoid, and 14% frontal sinus. In the traumatic CSF leak group: 33.3% were from the cribriform plate, 33.3% sphenoid, 22.2% ethmoid, and 11.1% frontal. Conclusion Endoscopic CSF fistula closure is a safe and effective operation. All sites of leak can be accessed endoscopically. We recommend the use of an anatomic three-layered closure in difficult cases.

Preoperative Superselective Mesenteric Angiography and Methylene Blue Injection for Localization of Obscure Gastrointestinal Bleeding

Localizing obscure gastrointestinal bleeding can be a clinical challenge, despite the availability of various endoscopic, imaging, and visceral angiographic techniques. We reviewed the management of patients presenting with obscure gastrointestinal bleeding during the period from 2005 to 2011. Four patients had preoperative localization of the bleeding site with superselective mesenteric angiography, which was confirmed by the use of intraoperative methylene blue injection. This novel technique allowed us to identify the abnormal pathology, and, consequently, resection of the implicated segment of small bowel was performed without any postoperative complications. Final histology showed that 2 patients had arteriovenous malformations: one had a benign hemangioma of the small bowel, and the other had chronic ischemic ulceration in the ileum. Superselective mesenteric angiography combined with intraoperative localization with methylene blue is an important and innovative technique in the management of patients with unclear sources of gastrointestinal bleeding and allows for effective hemorrhage control with a focused and therefore limited bowel resection.

Endoscopic ear surgery: A case series and first United Kingdom experience.

AIM To present the United Kingdoms first case series of 70 otological cases of endoscopic and non-endoscopic ear surgeries. METHODS Prospective case series incorporating a range of endoscopic procedures performed using a 4 mm, 18 cm rigid endoscope, performed by a single surgeon at a single centre. Primary outcome measures included mean average pre and post-operative air-bone gap hearing thresholds and duration of surgery. RESULTS Thirty-eight patients underwent endoscopic assisted ear surgery and 32 underwent non-endoscopic assisted ear surgery. In both surgical groups, there was a significant difference between pre and post-operative mean air-bone gaps (P = 0.02). Mean operating time was comparable between both groups. Eight patients developed post-operative complications. CONCLUSION Endoscopic ear surgery can be performed safely in a range of otological procedures. This has the potential to become a well-established surgical option for middle ear surgery in the near future. Advantages and limitations are discussed.

Prosthetic reconstruction of the trachea: A historical perspective

This review discusses the history of tracheal reconstruction; from early work to future challenges. The focus is primarily on prosthetic tracheal reconstruction in the form of intraluminal stents, patch repairs, circumferential repairs and replacement of the trachea. A historical perspective of materials used such as foreign materials, autografts, allografts, xenografts and techniques, along with their advantages and disadvantages, is provided.

Improving efficiency and saving money in an otolaryngology urgent referral clinic.

A closed loop audit of the ear nose and throat (ENT) urgent referral clinic at a London hospital was conducted assessing the number of patients reviewed, referral source, appropriateness of referral, presenting complaint and assigned follow-up appointments. Data was sourced from clinic letters and the patient appointment system over a 3-mo period. The initial cycle analysed 490 patients and the subsequent cycle 396. The initial audit yielded clinically relevant and cost effective recommendations which were implemented, and the audit cycle was subsequently repeated. The re-audit demonstrated decreased clinic numbers from an average 9.8 to 7.2 patients per clinic, in keeping with ENT United Kingdom guidelines. A 21% decrease in patient follow-up and 13% decrease in inappropriate referrals was achieved. Direct bookings into outpatient clinics decreased by 8%, due to correct referral pathway utilisation. Comparisons of all data sets were found to show statistical significance P < 0.05. We reported a total financial saving of £32490 in a period of 3 mo (£590 per clinic). We demonstrated that simple guidelines, supervision and consultant-led education which are non-labour intensive can have a significant impact on service provision and cost.

Fibrohistiocytoma: a rare tumour of the trachea.

### Learning Point for Clinicians Fibrohistiocytomas of the trachea are rare tumours of the trachea. It may be difficult on histology to distinguish benign and malignant disease and expert opinion is required. These tumours can be successfully excised through interventional rigid bronchoscopy. A 54-year-old Caucasian male was referred with haemoptysis. There was no associated dyspnoea, noisy breathing or loss of weight. His medication consisted of montelukast and loratidine for allergic rhinitis. Family history included his father having a pituitary tumour and grandfather having a liver tumour. He had no known allergies, and he had never smoked. He was a retired electronics engineer and may have been exposed to asbestos and beryllium in the past. Examination of the pharynx, cardiovascular, respiratory and gastrointestinal systems was normal. Investigations revealed a normal full blood count, coagulation profile, inflammatory markers and biochemistry. A postero-anterior chest radiograph was unremarkable, and the patient had flexible bronchoscopy to identify a cause of his haemoptysis. At bronchoscopy, an exophytic lesion of the trachea just below the vocal cords …

Diagnostic performance of high resolution computed tomography in otosclerosis

AIM To determine the sensitivity and specificity of high resolution computed tomography (HRCT) in the diagnosis of otosclerosis. METHODS A systematic literature review was undertaken to include Level I-III studies (Oxford Centre for Evidenced based Medicine) that utilised HRCT to detect histology confirmed otosclerosis. Quantitative synthesis was then performed. RESULTS Based on available level III literature, HRCT has a relatively low sensitivity of 58% (95%CI: 49.4-66.9), a high specificity, 95% (95%CI: 89.9-98.0) and a positive predictive value of 92% (95%CI: 84.1-95.8). HRCT is better at diagnosing the more prevalent fenestral form of otosclerosis but remains vulnerable to inframillimetre, retrofenestral and dense sclerotic lesions, despite the advent of more advanced CT scanners with improved collimation. CONCLUSION Whilst the diagnosis of otosclerosis remains largely clinical, HRCT remains the gold standard imaging of choice for the middle ear and serves as a useful adjunct to the clinician, helping to delineate extent of disease and exclude other causes.