Chee-Yean Eng

Intravascular papillary endothelial hyperplasia (IPEH) is a benign lesion of a vascular origin that is caused by excessive proliferation of endothelial cells in blood vessels or vascular malformations. It is a rare entity that can present in any region of the body, but with particular predilection to the head and neck region and the extremities. We also present the results of the English literature search, which to our knowledge are all the published cases of IPEH in the head and neck region (No = 213). IPEH has not been reported to arise from the glottic region previously. We present a first case of IPEH arising from the vocal fold of a 48-year-old male. Histological differential diagnosis of IPEH includes several entities, most importantly angiosarcoma. Presentation and histology are discussed. The main treatment option is a complete surgical resection. Prognosis of IPEH is excellent, with the exception of some intracranial cases.

Parathyroid surgery is the acceptable definitive treatment for primary hyperparathyroidism (pHPT) due to parathyroid adenoma. Open mini-incision parathyroidectomy (O-MIP) has an excellent cure rate and minimal morbidity. We aim to demonstrate the safety, efficacy and subjective patient satisfaction of O-MIP and investigate the accuracy of pre-operative radiological localisation in relation to operative findings. A retrospective review of patients who underwent O-MIP for pHPT due to solitary parathyroid adenoma from April 2006 to August 2012 was performed. All patients were initially investigated by an endocrinologist to confirm pHPT with pre-operative localisation imaging using ultrasound scan (USS) and 99mTc-sestamibi (MIBI). One hundred and fifty consecutive patients were included with a median age of 62 years. Pre-operative USS and MIBI scans were concordant in 71 % of cases. In combined modality (USS and MIBI), localisation was 94.8 % accurate. There was 95.5 % identification of parathyroid tissue confirmed by intra-operative frozen section. Ninety-one percent of patients were treated as a day case. The median operative time was 60 min. The mean pre-operative calcium level was 2.98 mmol/l, and the short-to-medium term mean calcium level was 2.49 (Paired t test, p < 0.001). There was no significant complication. O-MIP confers significant advantages over the traditional gold standard treatment of bilateral neck exploration. Accurate localisation is the key to successful O-MIP. In experienced hands, ultrasound and MIBI may be the only pre-operative investigations required for accurate localisation.

Introduction: Stapes fixation resulting in a conductive hearing loss is a condition that can be successfully treated surgically, although other common management options include observation and hearing aid(s). Most otologists perform stapedotomy by creating a small fenestra in the stapes footplate to allow insertion of a solid piston prosthesis. We present our outcomes following stapes surgery, in particular looking at the effect of surgery on closure of the air-bone gap, tinnitus and taste disturbance. Methods: A retrospective case notes review of 137 consecutive stapedotomies performed by a single consultant ENT surgeon, using the Fisch Teflon-platinum piston prosthesis, was analysed over a five year period. Results: 137 operative cases from 109 patients were identified and included into this study. The average age at operation was 46 years. Incudo-stapedotomy was performed in 88% of cases and malleo-stapedotomy in 12% of cases. The average pre-operative air-bone gap was 31.5 db HL (SD=10.70) and the average post-operative air-bone gap at 1 year was 13.8 dB HL (SD=10.45). Subjective hearing improvement was reported by 94% of patients at 1 month follow-up and 83% at 1 year. Taste disturbance was reported by 3% patients at 1 year follow up. Pre-operative tinnitus was present in 50% of patients, and this reduced to 16% at 1 year. Conclusion: Our study has shown a statistically significant reduction in the air-bone gap and improvement in hearing in all patients who had stapedotomy performed for otosclerosis. In this series, there was an improvement in post-operative tinnitus with minimal complication rates overall.

Objective: Assess the efficacy of ala suspension sutures in the management of nasal valve collapse causing nasal obstruction. Method: Retrospective study of patients with ala suspension sutures inserted for nasal valve collapse in Doncaster Royal Infirmary from January 2009 to December 2010. Subjective nasal congestion was measured using visual analogue scale (VAS 0-10), and objective measurement using Peak inspiratory flow rate (PIFR) before and after the operation was performed. Results: Twenty-six patients with ala suspension sutures inserted were identified. Five patients who had concurrent procedures carried out on septum and turbinates were excluded. Twenty-one patients were included in our study. Ninety percent of patients were satisfied with the surgery, supported by significant improvement in the VAS (0 - 10) for nasal congestion and PIFR scores. The average VAS score improvement was 4.6 points, and PIFR increased by 23.3L/min. Of the 21 patients, 4 required revision procedures to achieve satisfactory outcome. Two out of these 4 developed neuralgia, which was controlled with Amitriptyline. Conclusion: The result of our study shows a significant improvement in patient symptoms following insertion of ala suspension suture for nasal valve collapse causing nasal obstruction. This is a short and well tolerated procedure with minimal side effects.

Objective: Ventilation tube insertion is the primary surgical intervention in persistent otitis media with effusion. Around 7% of ventilation tubes require elective removal. The objective is to discover the tympanic membrane healing rate after ventilation tube removal and identify measures that improve this. Method: Retrospective case note review performed for patients who had elective ventilation tube removed over an 8-year period. Information gathered included if any concomitant procedure was performed to repair the tympanic membrane and final outcome of the tympanic membrane status. Results: A total of 113 cases were included in this study. The average age at grommet insertion and removal was 5.8 years old and 8.3 years old, respectively. After ventilation tube removal the perforation edges were freshened in all cases. The majority of patients (84.1%) subsequently had an intact tympanic membrane. Additional procedures were performed on 19 ears, 6 with insertion of overlay absorbable material and 14 with a fat plug. Closure rate in these patients was 100%. Shah and Sheperd grommets had a significantly lower residual tympanic membrane perforation rate compared to T-Tube and Titanium grommets. Conclusion: Tympanic membrane closure rate after ventilation tube removal was 84.1%. Additional procedures, ie, overlaying of absorbable material, appear to improve the closure rate. We therefore advocate the technique. In selected cases such as T-tube removal a concurrent fat plug myringoplasty may be appropriate.

Acute onset stridor in a neonate following general anaesthesia is commonly attributed to laryngeal oedema secondary to anaesthetic airway trauma. The authors present a case of recurrent laryngeal nerve injury resulting in vocal cord paralysis causing stridor following central venous catheterisation under general anaesthesia in a neonate. This was managed expectantly and resolved spontaneously over a period of 6 months.

Healthy ear canal skin has an acidic pH. Evidence suggests that reacidification of the ear canal may lead to resolution of otitis externa. The pH of 15 commonly prescribed topical ear drop preparations used in the treatment of otitis externa was measured using a Jenway 3020 pH meter with temperature compensation at 37.5 °C. The pH values ranged from 2.89 to 7.83. Two-thirds of preparations tested were of acidic pH. The remaining one-third were alkaline. Reacidification of the ear canal may help in the treatment of otitis externa.

Thyroid nodule is a common presentation and requires a structured diagnostic approach to ascertain the risk of malignancy and determine appropriate management. This review article highlights the key points in the history and examination which can help with risk stratification. It also discussed the application of fine needle aspiration cytology findings and the British Thyroid Association Guidelines in clinical practice.

To evaluate if phenylephrine-lignocaine mixture (Cophenylcaine) nasal spray performs better than xylometazoline (Otrivine) spray for the purposes of out-patient rigid nasendoscopy preparation. Prospective, double-blind, randomised trial comparing visual analogue scores for out-patients receiving either phenylephrine-lignocaine mixture or xylometazoline, prior to undergoing rigid nasendoscopy as part of their assessment. Seventy-three patients requiring rigid nasendoscopy as part of their assessment were recruited to the study from Raigmore Hospital's out-patient clinic. These patients were randomised to receive a nasal spray comprising either phenylephrine-lignocaine mixture or xylometazoline, 10 minutes prior to rigid nasendoscopy. Double-blinding was adopted. After the procedure, the patient and the doctor independently completed separate visual analogue score-based questionnaires regarding the pain of the procedure and the ease of the examination, respectively. Analysis of the data using standardised statistical methods demonstrated that the phenylephrine-lignocaine mixture did not perform better than xylometazoline, to any statistically significant extent. Phenylephrine-lignocaine mixture is considerably more expensive and has potentially more side effects than xylometazoline. These study findings suggest that it is difficult to justify the use of phenylephrine-lignocaine mixture over xylometazoline, for nasal preparation prior to rigid nasendoscopy.

We describe an unusual case of recurrent, refractory anterior epistaxis in an 86-year-old man with two mechanical heart valves who was on permanent warfarin therapy. His numerous episodes of epistaxis were incited by chronic nose-picking and strong nose-blowing, practices that he continued to engage in despite repeated medical advice to stop. Stopping his anticoagulation therapy was not considered as a management option because of an unacceptably high risk that this would lead to a thromboembolic event. Eventually, we temporarily sutured his nares closed, and his nosebleeds ceased. The suturing was performed in the ward with local anesthesia. This procedure was simple to perform,fairly well tolerated, easily reversible, and highly effective.

A variety of topical preparations are used for symptomatic relief following nasal surgery. The aim of this study was to compare the effect of two commonly used products on patient symptom scores following nasal surgery. Randomised, single-blinded, comparative clinical trial. A single, secondary otorhinolaryngology centre. One hundred and twenty patients undergoing septoplasty or functional endoscopic sinus surgery as an isolated procedure between November 2003 and January 2006. Patients undergoing additional nasal procedures were excluded, as were those requiring additional post-operative medications other than standardised analgesia. Following nasal surgery, patients were randomised to receive either xylometazoline hydrochloride 0.1 per cent nasal spray or a sterile physiological saline aerosol. Main outcome measures: Visual analogue scale symptom scores for nasal obstruction, rhinorrhoea, pain, loss of sense of smell and bleeding were assessed at day 10 post-operatively. Post-operative symptom scores were compared between treatment groups. Overall, median pain scores were significantly higher in the xylometazoline group (p = 0.03, chi-square test). When analysed by procedure, median pain scores were significantly higher in septoplasty patients using xylometazoline (p = 0.019, chi-square test). There is no evidence to support the use of xylometazoline hydrochloride 0.1 per cent nasal spray over aerosolised physiological saline alone, following nasal surgery. Furthermore, there may be more pain associated with the post-operative use of xylometazoline.

Traditionally secondary post-tonsillectomy haemorrhage has been thought to be due to post-operative infection and as such is treated with broad-spectrum antibiotics. The aim of this study was to identify clinical evidence of infection in patients with secondary post-tonsillectomy haemorrhage that might justify the use of antibiotics in these patients. Prospective data collection. Tertiary University Teaching Hospital. Adult patients admitted with post-tonsillectomy haemorrhage over a 2-year period. Temperature, white cell count, Neutrophil count and C-reactive protein. 47 patients were admitted with secondary post-tonsillectomy haemorrhage. Fifteen out of 47 patients (32%) had an elevated white cell count but in them the other indicators of temperature and C-reactive protein were extremely variable: none of these 15 patients was pyrexial (> 37.6 C). An elevated C-reactive protein was found in 55% of patients but none had an elevated white cell count. The elevated C-reactive protein may have been influenced by the recent surgery rather than infection. Overall there was no clear interrelation between the indicators of infection in the patients and none had the three main indicators of infection (pyrexia, increased white cell count and elevated C-reactive protein). Our results suggest that clinical signs of infection are lacking in patients with secondary tonsillectomy bleeding. Correspondingly the routine use of antibiotics should be questioned for secondary tonsillectomy haemorrhage.

To compare the complication rates of parotidectomy operations on benign histology performed by ENT and non-ENT surgeons. A seven-year (1994-2000) retrospective case notes review of patients undergoing parotidectomy in a United Kingdom district general hospital was performed. Patients with malignant histology were excluded. Patients were identified from the hospital computer database. One hundred and fifty-nine patients underwent parotidectomy for both benign and malignant conditions over the seven-year period. One hundred and thirty-seven (86 per cent) patients had parotidectomy for benign conditions and were included in this study. The presence or absence of facial palsy and other associated complications following parotidectomy surgery in both groups. The temporary facial palsy rates for ENT and non-ENT surgeons were 56 per cent and 57 per cent, respectively. The permanent facial palsy rates for ENT and non-ENT surgeons were 2 per cent and 7 per cent, respectively. Differences in facial palsy were not statistically significant. The difference in other complication rates such as Frey's syndrome, haematoma, salivary fistula, and neuroma were also not statistically significant. Our complication rates were comparable with published results. There was no significant difference in the observed rate of post-operative facial nerve palsy and other known complications following parotid surgery performed by ENT and non-ENT surgeons.

To determine if antibiotics improve recovery following tonsillectomy. Data sources: Electronic databases Medline, Embase, and Cochrane Controlled Trials Register were searched using relevant search terms. Additional trials, if any, were retrieved by searching the references from all identified trials, reviews, correspondences, editorials, and conference proceedings. No language restriction was applied. Study selection: Systematic review of trials in which antibiotic was administered as a study medication intraoperatively and/or postoperatively, in children or adults undergoing tonsillectomy or adenotonsillectomy. Only randomized, placebo-controlled, double-blind trials attaining preset quality scores were included. Outcomes analyzed: 1) pain, need for analgesia, fever, halitosis, and return to normal diet and activities; 2) secondary hemorrhage using 2 parameters-significant hemorrhage (ie, warranting readmission, blood transfusion, or return to theatre for hemostasis) and total hemorrhage; and 3) adverse events. Five trials met the eligibility criteria. Antibiotics significantly reduced the number of subjects manifesting fever (relative risk [RR]: 0.62, 95% confidence interval [CI]: 0.45, 0.85) and duration of halitosis (-1.94 [-3.57, -0.30] days), and marginally reduced the time taken to resume normal activity (-0.63 [-1.12, -0.14] days), but had no significant effect in reducing pain scores (-0.01 [-0.60, 0.57]) or need for analgesia. Similarly, there was no significant difference in the time taken to resume normal diet or incidence of significant and total hemorrhage, although data was underpowered to detect differences for these outcomes. In the antibiotic group 4 patients developed an adverse reaction (3 cases of rash and 1 case of oropharyngeal candidiasis), while in the control group 1 patient had an adverse reaction (rash). The RR of antibiotic-related adverse events was 2.45 (0.45, 13.31). Antibiotics appear to be effective in reducing some, but not all, morbid outcomes following tonsillectomy, and may increase the risk of adverse events. Further trials are needed to better define the role of antibiotics in facilitating post-tonsillectomy recovery. EBM rating: A-1a.

Certain medical conditions may affect one's ability to drive safely. In the United Kingdom, the Driver and Vehicle Licensing Agency (DVLA) issues guidelines outlining which medical conditions drivers must notify them of. In order to assess our knowledge of, and ability to apply, the current DVLA guidelines with regard to otolaryngological conditions, a postal survey was sent to all otolaryngologists in Scotland. The responses obtained suggest that the current DVLA guidelines are not well understood or easily applied, and it is recommended that all otolaryngologists familiarize themselves with these guidelines in order to better advise their patients with regard to driving.

The relative incidence of paediatric Bell's palsy is two to four times less than the condition in adults. The number encountered in our otolaryngology department falls short of the above prediction. This could either reflect the general practitioners' (GPs) patterns of referral or a lower incidence in our locality. Postal questionnaires were sent to our local GPs to determine their referral practice when managing children presenting with acute facial paralysis. Of 233 questionnaires, 172 (74 per cent) were returned and analysed. Fifty-four per cent of GPs referred their patients to the local paediatric services, 22 per cent to an otolaryngologist, and the remaining 24 per cent of GPs were confident in diagnosing and managing Bell's palsy in children themselves. Of the GPs surveyed 78 per cent did not refer children presenting with acute facial paralysis to an otolaryngologist. We suggest minimum investigations for acute facial paralysis in children before diagnosing Bell's palsy and stipulate otolaryngology referral for all.

Objectives: To assess the difference in incidence and duration of facial nerve palsy following parotidectomy comparing ENT and non-ENT surgeons.Methods: Retrospective case note review of patients undergoing parotidectomy in a UK district general hospital between January 1993 and November 2000. Patients with malignant histology or those undergoing revision surgeries were excluded.Results: A total of 178 patients underwent total or partial parotidectomy in the study period; 137 patients met the inclusion criteria. Ninety-three (68%) had surgery performed by ENT surgeons and 44 (32%) by non-ENT surgeons (general surgeons and maxillofacial surgeons). In the ENT operated group, 52 (56%) had temporary postoperative facial nerve palsy; 2 (2%) had permanent facial palsy in one or more divisions; 39 (42%) had intact facial nerve function postoperatively. In the non-ENT group, 25 (57%) had temporary facial palsy; 3 (7%) suffered permanent facial palsy in one or more divisions; 16 (36%) had intact facial nerve function postoperatively. These differences were not statistically significant (P = 0.43, Fischer’s Exact test). In addition, the mean duration of temporary facial palsy (18 weeks in the ENT operated group and 26 weeks in the non-ENT operated group) and incidence of other postoperative complications (hematoma, neuroma, Frey’s syndrome, and salivary fistula) were also not statistically significant.Conclusion: There was no significant difference in the observed rate of postoperative facial nerve palsy and other known complications following parotid surgery performed by ENT and non-ENT surgeons in our series.