S Hickey

Post-operative pain in tonsillectomy : bipolar electrodissection technique vs dissection ligation technique. A double-blind randomized prospective trial

The two commonly employed methods for tonsillectomy at present are electrodissection and ligature dissection. This study was carried out on 70 patients as a randomized prospective double blind trial to compare the post-operative morbidity of these methods with special reference to pain. The post-operative pain appears to be much less for the ligation dissection technique compared to the electrodissection method except during the first post-operative day. Irrespective of the technique employed for tonsillectomy, the worst pain was experienced on the fifth and sixth post-operative day by almost all of the patients.

Patient burden of centralization of head and neck cancer surgery

This study was undertaken to assess the impact on patients of proposals to centralize head and neck oncology services in the UK. A retrospective audit of the 2001-2002 head and neck cancer database at South Devon district general hospital identified 85 patients (50 males: 35 females; median age 66 years; range 29-93) diagnosed with head and neck cancer. The total number of hospital visits for diagnostic, therapeutic and other management services were recorded (median number of visits 28; range 1-78). Using this data, the extra distance required to travel to a potential regional cancer centre located in Bristol during the first six months of management was extrapolated. It was calculated that each patient would have to travel on average an extra 5333 miles (median 5658; range 185-13 759). Published documents advocating centralization of oncology services make no reference to the patient burden of geographic relocation of medical services. Agencies involved with restructuring oncology services must recognize the non-clinical impact of centralization and make some provision to overcome the burden facing patients and their carers.

Rare presentation of laryngeal neuroma in a patient with multiple endocrine neoplasia type two B.

OBJECTIVE We present a rare case of laryngeal mucosal neuroma, and its management, in a patient with multiple endocrine neoplasia type 2 B. METHOD We present a case report and a review of the world literature concerning laryngeal mucosal neuroma and its association with multiple endocrine neoplasia type 2 B. CASE REPORT An 11-year-old girl was diagnosed with multiple endocrine neoplasia type 2 B on the basis of clinical presentation and genetic testing. Several years later, whilst undergoing general anaesthesia for routine dental treatment, the anaesthetic team were concerned by masses on the patients vocal folds, which they felt could compromise her airway. The ENT team were informed of the situation and an urgent microlaryngoscopy was performed. Biopsies taken at the time were reported as showing benign mucosal neuromas. A few months later, the patient presented with acute stridor, and flexible nasal endoscopy revealed recurrence. This episode settled without surgery. CONCLUSION Multiple endocrine neoplasia syndromes are inherited autosomal cancer syndromes. Laryngeal mucosal neuroma can manifest as potentially airway compromising lesions in patients with multiple endocrine neoplasia type 2 B. Although apparently rare, we feel this case highlights the need for vigilance and prompt recognition of this treatable condition.

Merkel cell carcinoma of the pinna

Merkel cell carcinoma is an increasingly recognized tumour of the skin. The commonest presentation is the head and neck region. Only three cases of this rare tumour have been reported on the pinna. A further such case is presented here.

Finding the most effective cerumenolytic

AIM To conduct an in-vitro study to determine the most effective topical cerumenolytic. METHOD Cerumen was collected from patients who attended the ENT out-patient clinic. The collected cerumen was formed into a homogeneous ball. Discs of wax were punched out and weighed to create samples of uniform shape and size. Each cerumen sample was placed in a tube which contained one of six test solutions. The tubes were observed at specific time points. Digital photographs were taken to record the degree of cerumen disintegration. The cerumen discs were then removed from the solutions, dried and re-weighed. RESULTS Distilled water caused the greatest reduction in the mass of the cerumen disc. Cerumen placed in distilled water and in sodium bicarbonate solution showed substantial disintegration at 12 hours. Cerumen placed in solutions containing oil-based agents showed no visible sign of disintegration and no reduction in dried weight. CONCLUSION Distilled water resulted in the greatest degree of cerumenolysis. Oil-based cerumenolytics were ineffective.

Double epiglottis in Weyer's acrofacial dysostosis

While evaluating a 61-year-old patient for stridor we incidentally detected a double epiglottis. The patient was also diagnosed of having Weyers acrofacial dysostosis which is characterized by hexadactyly affecting all four extremities, small and deeply set nails, dental deformities with small, conical teeth and mandibular hypoplasia. The double epiglottis was not the cause for the stridor. Because of the covert symptomatology of double epiglottis it is suggested that the association with Weyers syndrome is common. Embryological evidence and a review of the literature on laryngeal abnormalities is discussed.

Nasopharyngeal carcinoma: United Kingdom National Multidisciplinary Guidelines.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. Although much commoner in the eastern hemisphere, with an age-standardised incidence rate of 0.39 per 100 000 population, cancers of the nasopharynx form one of the rarer subsites in the head and neck.1 This paper provides recommendations on the work up and management of nasopharyngeal cancer based on the existing evidence base for this condition. Recommendations • Patients with nasopharyngeal carcinoma (NPC) should be assessed with rigid and fibre-optic nasendoscopy. (R) • Nasopharyngeal biopsies should be preferably carried out endoscopically. (R) • Multislice computed tomographic (CT) scan of head, neck and chest should be carried out in all patients and magnetic resonance imaging (MRI) where appropriate to optimise staging. (R) • Radiotherapy (RT) is the mainstay for the radical treatment for NPC. (R) • Concurrent chemoradiotherapy offers significant improvement in overall survival in stage III and IV diseases. (R) • Surgery should only be used to obtain tissue for diagnosis and to deal with otitis media with effusion. (R) • Radiation therapy is the treatment of choice for stage I and II disease. (R) • Intensity modulated radiation therapy techniques should be employed. (R) • Concurrent chemotherapy with radiation therapy is the treatment of choice for stage III and IV disease. (R) • Patients with NPC should be followed-up and assessed with rigid and/or fibre-optic nasendoscopy. (G) • Positron emission tomography–computed tomography (PET–CT), CT or MRI scan should be carried out at three months from completion of treatment to assess response. (R) • Multislice CT scan of head, neck and chest should be carried out in all patients and MRI scan whenever possible and specially in advanced cases with suspected recurrence. (R) • Surgery in form of nasopharyngectomy should be considered as a first line treatment of residual or recurrent disease at the primary site. (R) • Neck dissection remains the treatment of choice for residual or metastatic neck disease whenever possible. (R) • Re-irradiation should be considered as a second line of treatment in recurrent disease. (R)

Does the continuation of warfarin change management outcomes in epistaxis patients

OBJECTIVE This study aimed to compare management, readmission rates and length of in-patient stay amongst warfarinised and non-warfarinised patients to ascertain future treatment protocols. METHODS A 12-month retrospective review was conducted of ENT epistaxis admissions. Admission details such as length of in-patient stay, clotting profile and management plan were recorded. Comparisons of management and outcome for warfarinised and non-warfarinised patients were made using the Fishers exact paired t-test. RESULTS Of 176 epistaxis patients admitted, 31 per cent were warfarinised, 18 per cent were on another form of anticoagulation or antiplatelet therapy, and 51 per cent were not on any medication that might impose a bleeding risk. The international normalised ratio at admission was high in 13 per cent of warfarinised patients; the remaining patients had therapeutic or sub-therapeutic international normalised ratios and so warfarin was continued. The mean in-patient stay was similar for all cohorts; however, warfarinised patients had a higher readmission rate. CONCLUSION Warfarinised epistaxis patients may be safely managed without stopping their anticoagulation therapy, provided their international normalised ratio is at therapeutic or sub-therapeutic levels. By continuing regular anticoagulation therapy, warfarinised patients may be discharged without delay.

Optimising the use of otowicks in otitis externa

OBJECTIVE Otowicks are used to treat otitis externa with significant ear canal oedema. This study investigates how well drops penetrate through to reach the deep canal and whether it is safe to leave otowicks in the canal for more than 2 days. METHODS Sterile otowicks were inserted into mock ear canals and vertically over pseudomonas-seeded agar plates whilst gentamicin or ciprofloxacin drops were administered. The time taken for drops to penetrate through the otowick was recorded. Separately, pseudomonas-seeded otowicks were treated with saline or antibacterial drops. The penetrating drops were observed for bacterial growth on sterile agar. RESULTS It took six drops before penetration occurred for both antibiotics. When sterile saline drops were applied to bacterially contaminated otowicks, the penetrating drops displayed bacterial growth on agar, indicating that pseudomonas penetrated through the otowick. However, when antibiotic drops were applied, penetrating drops showed no bacterial growth on the corresponding agar plate. CONCLUSION Bacteria can penetrate otowicks but this is prevented by continuous application of antibacterial ear drops. Ear wicks need priming with six drops before starting a regimen, so that the initial dose is fully absorbed.