Samuel M. Jayaraj

Ancient schwannoma masquerading as parotid pleomorphic adenoma

Pleomorphic adenoma of the parotid gland is common. We report a typical case of a parotid gland swelling which clinically, radiologically and cytologically represented a pleomorphic adenoma. Only following surgical excision and histological examination however, was the true diagnosis of ancient schwannoma made. Benign peripheral nerve sheath tumours should always be considered in the differential diagnosis of parotid gland tumours.

Kikuchi-Fujimoto's syndrome masquerading as tuberculosis.

We report a case of a 27-year-old Asian man presenting with the typical features of tuberculous cervical lymphadenitis who was commenced on anti-tuberculous therapy on the strength of the clinical presentation. Histological examination of an excised cervical lymph node however, revealed the diagnosis of Kikuchis syndrome; a histiocytic necrotizing lymphadenitis which is usually self-limiting.

Delayed massive epistaxis due to traumatic intracavernous carotid artery pseudoaneurysm

Recurrent epistaxes after head injury may rarely be due to a traumatic intracavernous carotid artery pseudoaneurysm. The head injury is usually associated with fracture of the skull base and the epistaxes are severe with the first episode generally occurring one to three months after the initial trauma. We present a case which illustrates the role of high resolution computed tomography (CT) scanning and also magnetic resonance angiography (MRA) in achieving the diagnosis.

Malignant melanoma arising in the frontal sinuses

Sinonasal malignant melanoma is rare and usually occurs in the nasal cavity. Presentation is often varied and occurs late in the natural history of the disease, resulting in a poor prognosis. A case is reported of a patient with malignant melanoma arising from the frontal sinus who presented with a forehead swelling and progressive confusion. A review of the literature on malignant melanoma in the nasal cavity and paranasal sinuses regarding its presentation, site of origin and principles of management is discussed.

Assessment of the chin in patients undergoing rhinoplasty: What proportion may benefit from chin augmentation?

Objective: The chin is an important determinant of the lower third of the face, carrying much significance in an esthetically balanced facial appearance. It is, however, often neglected in patients undergoing rhinoplasty procedures in the UK National Health Service (NHS). The aim of this study was to establish the percentage of a cohort of rhinoplasty patients who may also have benefited from chin augmentation. Study Design: A cross-sectional study. Subjects and Methods: The digital preoperative pictures of the last 100 patients who underwent rhinoplasty at our institution were retrieved. Four popular methods of assessment were used to assess the chin, that is, those advocated by Silver, Legan, Merrifield, and Gonzales-Ulloa. All analyses were performed on Adobe Photoshop CS4 by two ENT registrars. Values were regarded as positive when there was interobserver agreement. Relevant angles were averaged. Results: A total of 94 photographs were suitable for analysis. There were 58 males. Depending on the method of assessment, the percentage of males who fulfilled criteria for augmentation ranged from 17 to 62 percent and for females the range was 42 to 81 percent. Additionally, 21 percent of males were positive on three or more of the methods utilized. The respective figure was 58 percent for females. Conclusion: Surgeons who practice rhinoplasty should consider making an objective assessment of the need for possible chin augmentation. Our study shows that as many as 81 percent of patients may benefit, although this figure varies with the method of assessment. In this study, the necessity for further analysis with a view to chin augmentation was more likely in women.

Submucosal squamous cell carcinoma of the subglottis.

noma (SCC) of the larynx is direct laryngoscopy with the patient under general anaesthesia, which allows biopsy of the mucosal lesion. This procedure also allows tumour staging according to American Joint Committee on Cancer guidelines. 1 A small proportion of laryngeal SCCs are submucosal with no mucosal abnormality present. This leads to difficulties in both diagnosis and staging. The first reported case of primary subglottic submucosal SCC is presented.

Pictorial assessment of the delivery of oropharyngeal rinse versus oropharyngeal spray

Oral rinses/gargles and oral sprays are frequently used in the management of oropharyngeal inflammation. This pictorial study, using methylene blue dye as a marker of the distribution of these topical preparations in the oropharynx, suggests that oral sprays are more effective in coating the oropharynx than oral rinses, whilst oral rinses are better at staining the oral cavity and base of tongue. The authors therefore suggest that oral rinses should be used to treat disease in the oral cavity and oral sprays should be used to treat ailments in the oropharynx.

Prions and the otolaryngologist

Much scientific and general media interest has developed regarding the potential threat to the public health posed by prion diseases. The likely transmissible agents responsible for these diseases have been shown to accumulate in high levels in central nervous and, in the case of variant Creutzfeldt–Jakob disease, lymphoid tissues. They demonstrate profound resistance to standard sterilization methods used in surgical practice. There are therefore substantial implications regarding the safety of multiple-use surgical instruments in otolaryngology and other surgical disciplines. The departments of health in England and Scotland have now insisted that all adenotonsillectomy instruments be disposed of after each procedure. This review outlines the history of our understanding of prion diseases, the development of pre mortem diagnostic tools for Creutzfeldt–Jakob disease (including pharyngeal tonsil biopsy), and the issues concerning the risk to public health by the possible iatrogenic transmission of Creutzfeldt–Jakob disease by surgical instruments.

A Randomized Controlled Trial Protocol for GeloRevoice Throat Lozenges as Adjunctive Analgesic in Post-tonsillectomy Pain

Objectives: There has been recent controversy with regard to optimal postoperative pain control for tonsillectomy. Codeine is no longer recommended for children under the age of 12 years because of the risk of respiratory depression. Hence, identifying alternative/adjunct analgesia for post-tonsillectomy pain is a high clinical priority. This is a protocol for a randomized controlled trial. The primary objective is to determine whether GeloRevoice throat lozenges (contain sodium hyaluronate) are effective as adjunct therapy to standard analgesia (paracetamol, ibuprofen, difflam spray) in post-tonsillectomy pain. Methods: A total of 72 patients were randomized to 2 groups. Parents with children aged 6 to 18 years undergoing tonsillectomy were approached to participate in the study. The intervention group received GeloRevoice throat lozenges and the control group received a placebo. The study was subject to trust research and audit and safety reporting procedures, and ethical approval was applied for. Results: The primary endpoint was a pain score using a visual analog scale for pediatric populations. Pain scores were recorded on a diary card daily for 1 week postoperatively. Visual analog scale data were compared between 2 groups using a 2-tailed t test where P < .05 was considered to be statistically significant. Conclusions: This double-blinded randomized controlled trial provides evidence on the safety and efficacy of GeloRevoice throat lozenges when used as adjunctive analgesia for post-tonsillectomy pain.

Successful Endoscopic Dacryocystorhinostomy: What Factors Make Revision Surgery More Likely?

Objectives: Endoscopic dacryocystorhinostomy (DCR) is indicated for treatment of nasolacrimal duct obstruction, which manifests as a watery eye. Endoscopic techniques have gained popularity in recent years compared to open DCR, which leaves a facial scar. Success rates have been reported to be between 65-95%. We report the success rate of endoscopic DCR at our institution and analyze factors leading to revision surgery. Methods: This is a retrospective analysis of endoscopic DCR performed at a district general hospital between August 2010 and December 2013. We perform this as a day case procedure using a DCR burr and leave silastic stents in situ. We do not routinely use anti-mitotic agents. We collected and analyzed demographic data (age, co-morbidity, medications), technical notes, rate of symptom resolution at follow-up, and need for revision surgery. Results: A total of 33 endoscopic DCRs were performed in this time period. The overall success rate (satisfactory resolution of symptoms at minimum 3 months follow up) was 76%. Rate of revision surgery was 15%. In 50% of cases scar tissue obstructing the DCR opening was the cause of surgical failure. Previous surgery (external DCR/punctoplasty) was not associated with a higher rate of endoscopic DCR failure (P = .616). Conclusions: Endoscopic DCR is a safe technique for treating nasolacrimal duct obstruction with local success rates of 76%. A common reason for failure is scar tissue obstructing the rhinostomy opening and greater attention is being given to surgical techniques that maintain wide patency of the opening, as this may reduce rates of failure.