W.M. Tsang

Mucoepidermoid carcinoma expleomorphic adenoma of the submandibular gland.

We described a rare case of carcinoma expleomorphic adenoma in which mucoepidermoid carcinoma arise from a previous incompletely excised pleomorphic adenoma of the submandibular gland. The tumor was surgically resected along with a modified radical neck dissection and postoperative radiotherapy. The patient remained disease free 3 years after the last operation. The pathology showed concurrent presence of Warthins tumor in the specimen. The concurrent presence of mucoepidermoid carcinoma, pleomorphic adenoma, and synchronous Warthins tumor make this case unique, and such a combination associated with the submandibular gland has not been documented in the literature before.

Reconstruction Challenge — Combined Use of Pectoralis Major and Gastric Pull-up Flaps for Massive Naso-oropharyngeal/Oesophageal Defects

Massive defects of the upper aerodigestive tract present a reconstructive challenge. We report a case in which a large defect of the naso-oropharyngeal and oesophagus was reconstructed with a combination of a gastric pull-up and a pectoralis major muscle flap. Postoperative function was good and survival was in excess of 16 months. The history of such reconstructions and possible alternative techniques are also discussed.

Nasogastric‐tube‐induced unilateral vocal cord palsy

Decontamination of medical equipment, the combination of cleaning, disinfecting and/or sterilisation is used to render a reusable item safe for further use. The alternative is single use followed by disposal. There is currently much variation in decontamination practice for laryngoscopes and the majority of hospitals do not have local guidelines [1]. General guidelines for the decontamination of medical equipment are available [2] but, as Ballin and McCluskey have pointed out, these do not specifically refer to laryngoscopes [3]. The Editor of this Journal has announced that the Association of Anaesthetists has formed a group to advise on appropriate decontamination procedures for laryngoscopes [3]. While we welcome this move, we write to warn that times are changing and that new guidance is urgently needed, not only in relation to laryngoscopes, but for all reusable airway equipment. We now face the presently unquantified risk of our equipment transmitting variant Creutzfeldt±Jakob disease (vCJD). The transmissible agent, an altered form of prion protein, has been isolated from tonsillar and lymphoreticular tissue of human victims [4]. It has also been found in the appendix removed from a patient who subsequently developed the disease [5]. The prion protein is remarkably resistant to common techniques of decontamination, with complete removal considered very difficult [6]. The Department of Health has recently announced that they will follow the advice of the Spongiform Encephalopathy Advisory Committee and introduce single-use instruments for tonsil surgery [7]. Tonsillectomy is currently one of the most frequently performed surgical procedures in the United Kingdom, amounting to about 20% of all ENT operations [8] and this announcement may have major implications for anaesthetic practice. The mainstay of our practice involves airway control, currently using reusable equipment such as laryngoscopes and laryngeal mask airways. Soiling of this equipment with blood is common during ENT procedures such as tonsillectomy. It has been suggested that laryngoscopes used on patients with suspected vCJD are destroyed [1]. In light of the recommendation of single-use surgical equipment for tonsil surgery, we believe that there is an urgent need for national guidance on best practice regarding the decontamination of all airway equipment and advice on the need for singleuse, disposable equipment.

Vascular complications of central venous line insertion.

Edward W.H. To,1 Peter C.W. Pang,2 W.M. Tsang,3 Michael D. Williams,4 Jack H.H. Cheng2 and Anil Ahuja,6 1Oral and Maxillofacial Surgery Center, St. Teresa’s Hospital, 2Division of Head & Neck/Plastic & Reconstructive Surgery, Department of Surgery, Chinese University of Hong Kong, Hong Kong, 3Oral Maxillofacial Surgery & Dental Unit, Prince of Wales Hospital, Hong Kong, 4Department of Maxillofacial Surgery, Kings College Hospital, London and 6Department of Diagnostic Radiology & Organ Imaging, Chinese University of Hong Kong, Hong Kong.