Waiting-list prioritization in the National Health Service

The aim of this study was to find out whether there is a consensus of opinion among healthcare providers and different sections of the public on the relative prioritization of common otolaryngological conditions for outpatient consultations and inpatient treatment. ENT consultants, general practitioners, administrators, NHS employees, non-ENT patients and members of the general public were given common scenarios of otolaryngological conditions and asked to prioritize them in order of importance. All the groups gave top priority for patients with suspected cancer of the larynx (outpatients) and for surgical treatment of cancer. Children with hearing problems were more commonly ranked in the top three categories than children requiring treatment for sore throats. All groups assigned those requiring rhinoplasty, treatment for snoring or hearing aids to the last three ranks. This study shows that there is a remarkable uniformity of opinion in determining clinical priorities which is similar to the traditional policies practised by UK ENT consultants.

Two case reports of cervical spinal cord injury in football (soccer) players

STUDY DESIGN

Two case reports of male football players who sustained injury to cervical spinal cord as a direct result of the sport.

OBJECTIVE

To raise the awareness that playing football (soccer), a very popular sport, may cause injury to the cervical spinal cord with dire consequences, albeit rarely.

SETTING

North West Regional Spinal Injuries Centre, Southport, UK.

CASE REPORT

We report two male football players, who sustained injury to the cervical spine and developed tetraplegia as a direct result of the sport. Case 1: A 21-year-old football player was tackled from behind while running with the football, he lost his balance and landed on his head resulting in burst fracture dislocation of C5/C6 associated with immediate onset of complete tetraplegia (ASIA-A). Case 2: A 24-year-old football player collided, head first, with his own team goalkeeper, causing a hyperextension of neck. He developed motor complete tetraplegia at C5 level, with some sensation sparing below the level of injury (ASIA-B).

CONCLUSION

Injury to the cervical spinal cord is known to occur in some team contact sports such as rugby and American football. Over time the laws and the preparation of the athletes for these games have been changed in order to minimize the neck injuries. What might not be appreciated is that playing football (soccer), a very popular sport worldwide, may cause injury to cervical spinal cord with dire consequences.

Bedside assessment of sympathetic skin response after spinal cord injury: a brief report comparing inspiratory gasp and visual stimulus

STUDY DESIGN

A case control study in five controls, and 20 tetraplegic and paraplegic patients, complete and incomplete.

OBJECTIVE

The aim was to assess the feasibility of a simple test for sympathetic system preservation after spinal cord damage in a pain-free manner and which could be undertaken worldwide without specialist equipment or manpower.

SETTINGS

Patients were attending the Southport Regional Spinal Injuries Centre, England, either as outpatients or as in-patients during rehabilitation.

METHODS

The sympathetic skin response (SSR) was recorded on a single-channel ECG recorder from the right hand and right foot in turn after inspiratory gasp (IG) or visual stimulation.

RESULTS

Unlike the visually evoked SSR, the gasp-evoked SSR was reliable, albeit of variable amplitude, and there was little difference between the hand and foot. Paraplegics had similar SSRs in the hands as the controls. There was minor insignificant habituation of response for the gasp reflex. There was occasional unexpected SSR distally in patients with complete lesions, and in patients with incomplete lesions the responses could not have been predicted from the sensory motor pattern.

CONCLUSIONS

Trained IG induces an SSR which is sufficient to elucidate sympathetic loss following spinal cord injury. It is superior to visual stimulation in this respect. Habituation is not a problem with at least 1 min between tests, and high doses of anticholinergics agents may impair the response.

Ethnic differences in obesity among immigrants from developing countries, in Oslo, Norway

OBJECTIVES

To compare ethnic and gender differences in generalized and central obesity and to investigate whether these differences persisted after adjusting for socio-demographic and lifestyle factors.

DESIGN

In 2002, the population-based cross-sectional, Oslo Immigrant Health study was conducted.

SUBJECTS

A total of 7890 Oslo residents, born between 1942 and 1971 in Turkey, Iran, Pakistan, Sri Lanka and Vietnam, were invited and 3019 attended.

MEASUREMENTS

Participants completed a health questionnaire and attended a clinical screening that included height, weight, waist and hip measurements.

RESULTS

Generalized obesity (BMI> or =30 kg/m2) was greatest among women from Turkey (51.0%) and least among men from Vietnam (2.7%). The highest proportions of central obesity (waist hip ratio (WHR)>or =0.85) were observed among women from Sri Lanka (54.3%) and Pakistan (52.4%). For any given value of BMI, Sri Lankans and Pakistanis had higher WHR compared to the other groups. Despite a high mean BMI, Turkish men (27.9 kg/m2) and women (30.7 kg/m2) did not have a corresponding high WHR. Ethnic differences in BMI, waist circumference and WHR persisted despite adjusting for socio-demographic and lifestyle factors.

CONCLUSION

We found large differences in generalized and central obesity between immigrant groups from developing countries. Our data find high proportions of overweight and obese subjects from Pakistan and Turkey, but low proportions among those from Vietnam. Subjects from Sri Lanka and Pakistan had the highest WHR for any given value of BMI. Our findings, in light of the burgeoning obesity epidemic, warrant close monitoring of these groups.

Socio-demographic differences in food habits and preferences of school adolescents in Jiangsu Province, China

OBJECTIVE

To identify the differences in food habits and preferences among the adolescents according to socio-demographic characteristics.

DESIGN

Cross-sectional, cluster design survey in 2002.

SETTING

Eight middle schools in two distinct socio-economic areas of the Jiangsu province, China.

SUBJECTS

Some 824 young adolescents (12-14 y) attending public schools with a response rate of 99%.

METHODS

A self-administered questionnaire containing questions on food and meal frequencies, food preferences and socio-demographic characteristics was used.

RESULTS

High socio-economic status (SES) and urban residence was positively associated with intake of high-energy foods, such as foods of animal origin, Western style foods and dairy products. In all, 76% of the students had three meals a day regularly , but 8.1% urban students vs 3.4% rural students had breakfast only 1-3 times per week or less often. Daily fruit consumption was fairly common, but with clear differences by SES. Only about 42% of the boys and 55% of the girls from low SES families ate fruit daily, compared with 66% and 72%, respectively in the high SES families. Urban boys had the lowest proportion of daily consumers of vegetables (67.0%). More urban students drank milk daily than the rural students (68.7 vs 38.5%). The frequency of milk drinking also showed a strong positive association with SES. About 10% of the high SES boys consumed hamburgers daily compared with 2.8% of the low SES boys. More than half of the students reported a liking for Western style fast foods including hamburgers, soft drinks and chocolate. Among high SES boys, 21.5% consumed soft drinks on a daily basis; however, as many as 72.3% wanted to drink soft drinks more often if they could afford it.

CONCLUSIONS

SES and urban location were positively associated with frequency of intake of high-energy foods. Reported food preferences may enforce this trend. Nutrition education for adolescents and parents is needed to promote healthy eating. Health Authorities should strengthen the monitoring of food intake and its association with overweight/obesity.

SPONSORSHIP

This study was funded by the Norwegian Directorate of Health and Social affairs under the auspices of the Norway-China Health Agreement.

Ethnic differences in body mass index and associated factors of adolescents from minorities in Oslo, Norway: a cross-sectional study

OBJECTIVES

To examine ethnic differences in body mass index (BMI), food habits and physical activity, and determine the factors contributing to differences in BMI.

DESIGN AND METHOD

In 2000-2001, 7343 (response rate 88%) 15- and 16-year-old students, enrolled in lower secondary schools in Oslo, participated in the cross-sectional Oslo Health Study. Of these participants, 1719 were defined as ethnic minorities.

RESULTS

Significant gender and ethnic differences in mean BMI were observed. Of the ethnic minority adolescents, 5.8% were underweight (<5th percentile of the US Centers for Disease Control and Prevention (CDC)/National Center for Health Statistics (NCHS) reference distribution) and 9.1% were overweight (>85th percentile of the US CDC/NCHS reference distribution). BMI was not significantly associated with either socio-economic factors or physical activity. Food habits and physical activity differed with ethnicity but not with socio-economic factors. An ordinal regression showed that girls from East Asia (odds ratio (OR) 0.4) and boys from sub-Saharan Africa (OR 0.4) had lower BMI than the Western group. Among girls, higher BMI was associated with less frequent consumption of chocolates and sweets, full-fat milk and breakfast (OR 2.4, 1.7 and 1.7, respectively). Higher BMI, for both boys and girls, was associated with current and past dieting (OR 3.7 and 4.2, respectively).

CONCLUSIONS

Adolescent food habits and physical activity varied by gender and ethnicity but not with socio-economic factors. BMI was associated with ethnicity, gender and food habits, but no significant relationship was observed with socio-economic factors or physical activity. Ethnicity, in addition to gender, should be taken into consideration when studying BMI and associated factors among adolescents.

Sensorineural hearing loss associated with psoriatic arthritis

Autoimmune inner ear disease is a well described entity. We report a case of sudden-onset sensorineural hearing loss in association with psoriatic arthritis, which has not been reported in the literature. The case satisfies the criteria for the presumptive diagnosis of autoimmune hearing loss. A high index of suspicion, with early diagnosis and aggressive treatment with steroids and/or immunosuppressive agents, is essential to prevent irreversible hearing loss. The condition of psoriatic arthritis must be added to the pantheon of autoimmune diseases that can lead to sensorineural hearing loss.

Correlation between symptoms and radiological findings in patients with chronic rhinosinusitis: an evaluation study using the Sinonasal Assessment Questionnaire and Lund-Mackay grading system

Computerised tomography (CT) scans are routinely performed prior to endoscopic sinus surgery (ESS) in order to confirm the diagnosis, assess the response to medical treatment and provide important landmarks for surgery. However, the correlation between the findings of CT scans and the patient's symptoms remains ambiguous. The objective was to assess the correlation between preoperative symptom scores using the validated Sino-Nasal Assessment Questionnaire and CT scores in patients undergoing ESS. Twenty-two patients who attended otolaryngology clinics with chronic rhinosinusitis (CRS) were prospectively enrolled in the study. All of these patients completed Sinonasal Questionnaires (SNAQ) before they had ESS. Their CT scans were scored blindly by the surgeon and a radiologist following Lund-Mackay grading. Patients with high preoperative SNAQ scores had high or low CT scores. The same applied for patients with low preoperative SNAQ scores. There was no statistically significant correlation between SNAQ and Lund-Mackay scores (P = 0.5). However, there was a very strong correlation (P < 0.001) between the scoring of scans by the surgeon and the radiologist, while there was a moderate degree of discrepancy in the grading of anterior ethmoid sinuses and osteo-meatal complexes. Morbidity of patients with CRS cannot be predicted from the magnitude of changes in their CT scans. Significant inter-rater variability exists in the grading of pathological changes in anterior ethmoid sinus and osteo-meatal complex as recorded in CT scans.

Autoimmune sensorineural hearing loss

Autoimmune sensorineural hearing loss has been increasingly recognized as a clinical entity since its description by McCabe in 1979. Recognition and proper management of this condition is important, as it is one of the very few forms of sensorineural hearing loss that can be successfully treated by medical therapy. Recent studies have provided experimental evidence to suggest that immune processes can cause sensorineural hearing loss in animals and humans. However, antigenic targets within the inner ear are diverse and as a result conclusive evidence for specific autoimmune damage to the inner ear has been elusive. This review focuses on the recent progress in understanding of the aetio-pathogenesis of autoimmune hearing loss along with a description of the various clinical conditions in which they occur. Recent advances in the laboratory diagnosis and management of this interesting condition are also described.

Autoimmune sensorineural hearing loss: is it still a clinical diagnosis?

Inner ear involvement with sensorineural hearing loss (SNHL) has been reported in many autoimmune disorders including ulcerative colitis. The pathogenetic mechanism of hearing loss in ulcerative colitis is thought to be immune mediated. Diagnostic tests are being developed to identify inner ear autoantibodies, that may be the cause of such hearing loss. The only test that is currently available for clinical use is the Otoblot test. This, however, tests only for antibodies against bovine heat shock protein 70 which is only one of the many cross-reacting proteins against the inner ear in suspected immune-mediated hearing loss. The clinical response to steroid therapy is thus the mainstay in the diagnosis of immune-mediated hearing loss. This paper presents a series of patients with clinically suspected autoimmune hearing loss. Diagnostic assays for this condition are discussed along with a review of the recent advances in the pathogenesis and laboratory diagnosis of immune-mediated sensorineural hearing loss.

Has the internet overtaken other traditional sources of health information? Questionnaire survey of patients attending ENT outpatient clinics

The aim of this study was to find out whether patients attending ENT clinics obtain health information about their medical condition and to assess satisfaction with the sources of health information, including the internet. Three hundred and thirty patients attending ENT outpatient clinics at District General Hospitals in Wigan and Warrington during June 2001 were asked to complete detailed questionnaires. Fifty-seven per cent of patients attempted to obtain health information before their visit to the specialist clinic. Forty-five per cent of patients had access to the internet, but only 13% used it to obtain health information. General practitioners were the source of health information for 64%, but the NHS-Direct help line was only used by 16%. Patients also trusted the health information provided by their GPs the most. In the twenty-first century, patients turn to their GP as the main source of health information.

Impacted foreign body in the hypopharynx and oesophagus

We report a rare case of an unusual impacted foreign body (titanium mesh stent) in the hypopharynx and upper oesophagus of a 66-year-old gentleman. He was a known patient with carcinoma of the mid-oesophagus admitted under the gastroenterologists for dilatation of the carcinomatous stricture with a stent. During the procedure the titanium mesh spring coil got displaced and was impacted in the retropharyngeal space, submucosally in the hypopharynx and upper oesophagus. He was referred to us for surgical removal of the stent, which he underwent successfully. We believe this to be the first case of such an unusual foreign body to be reported in the literature.

Long-term results of tympanic neurectomy for chronic parotid sialectasis

BACKGROUND

Chronic parotid sialectasis presents as troublesome recurrent swellings of the parotid salivary gland during swallowing and mastication. The main treatment options are parotidectomy with its associated high morbidity and tympanic neurectomy.

AIM

The aim of this study is to present the long-term results of our experience about tympanic neurectomy for chronic parotid sialectasis.

PATIENTS AND METHODS

Twenty two patients underwent tympanic neurectomy (14 males; 8 females) between 1983 and 1999 with an mean follow up of over six years. The hallmark of our surgery is to interrupt as many branches of the tympanic nerve as possible by extensively drilling in the hypotympanum and below the basal turn of cochlea, with removal of the anterior and posterior branches.

RESULTS

17 of the 22 patients had a marked to total reduction in symptoms on follow-up. Four patients were troubled enough to go on to undergo a superficial parotidectomy. There was no significant morbidity associated with the procedure.

CONCLUSION

Tympanic neurectomy performed by an experienced otologist should be the preferred surgical option for chronic parotid sialectasis, with parotidectomy being reserved for those patients who fail to improve.

Surgical voice restoration following ablative surgery for laryngeal and hypopharyngeal carcinoma

Surgical voice restoration is an important part of functional rehabilitation of patients following ablative surgery for laryngeal and hypopharyngeal carcinoma. The aim of this retrospective study was to assess the functional status with regard to speech of a cohort of 100 patients (age ranged 34-84 years), who underwent laryngectomy and laryngopharyngectomy over a 10-year period (1989-1999). Ninety-two patients consented to surgical voice restoration. Primary tracheoesophageal punctures were performed in 70 and secondary punctures in 22 (mainly after jejunal flap reconstruction). Nine patients were excluded from this analysis (seven patients died prior to assessment, one had the prosthesis removed at her request and one patient had insufficient follow-up). Tracheoesophageal speech was assessed in the remaining 83 patients using a rating scale measuring the number of syllables per breath, use of voice and intelligibility by non-professional listeners. Currently, Provox 2 valves are being used in the majority of patients. Overall tracheoesophageal speech results were good in 45/83 (54.2 per cent), average in 22/83 (26.5 per cent) and poor in 15/83 (18 per cent). One patient could not develop tracheoesophageal speech. The majority of laryngectomy patients had good speech but in patients who had complex reconstructions tracheoesophageal speech was mostly rated as average. Average to good speech in more than two-thirds of the cohort of patients show that surgical voice restoration is a highly successful and valuable technique to restore speech functions after ablative surgery for laryngeal and hypopharyngeal carcinoma.

Sensorineural hearing loss in ulcerative colitis

Sensorineural hearing loss has been described in a small number of patients with ulcerative colitis. At present, it is not known whether this is a rare and sporadic association, or whether these reports represent an under recognised extra-intestinal manifestation of ulcerative colitis. The aim of this study was to determine the prevalence of hearing loss in patients with ulcerative colitis. Twenty patients with active ulcerative colitis (mean age 45 years) were recruited prospectively along with 20 healthy age- and sex-matched controls. Otoscopy, tympanometry and pure tone audiometry were performed. The activity of the disease was scored according to a 12-month cumulative disease activity index. No patients complained of auditory symptoms. Otoscopy and tympanometry were normal in all patients and controls. Pure tone audiometry showed significant sensorineural hearing loss over all frequencies in patients with ulcerative colitis compared with controls. This preliminary study indicates that subclinical sensorineural hearing loss is associated with ulcerative colitis. Further study is warranted to determine the nature of the relationship and its pathological basis.

Free jejunal patch flaps in oral and oro-pharyngeal reconstruction

Free jejunum has been commonly tubed to provide a reconstructive pharyngeal conduit following pharyngolaryngectomy. It is also common practice to repair small oral and oro-pharyngeal defects with skin-lined flaps i.e. radial free forearm or pectoralis major myocutaneous flap. Free jejunal patch flaps can provide cover for large defects, secrete mucus, tolerate radiotherapy well and do not contract. The operation is associated with a low morbidity and early return of swallowing is feasible. Here we describe the functional results of free jejunal patch flap reconstruction of extensive oral and oro-pharyngeal defects.

Direct listing' for tonsillectomy by general practitioners

The aim of this prospective study was to determine the suitability of 'direct listing' of patients for tonsillectomy by their General Practitioner. All General Practitioners were issued guidelines outlining the indications and contraindications for direct listing. One hundred consecutive patients, referred over a 6-month period, were screened by an otolaryngologist. Thirty-three of these patients were referred inappropriately. The high rate of inappropriate referrals would suggest that this is an unacceptable practice.

Treatment of chronic otitis externa by KTP/532 laser

The traditional meatoplasty operations performed for chronic otitis externa, which has entered the 'fibrotic' phase, are often unsatisfactory because the results in terms of canal patency, hearing gain and patient satisfaction are variable. Although the use of laser in chronic ear surgery is well recognized, it has not been previously reported as a meatoplasty technique. Ten KTP laser meatoplasty operations were performed on eight patients with chronic otitis externa. This pilot study shows the technique to be effective, fast and with a high patient satisfaction rate in the short-term (mean follow-up period 9.3 months). The average increase in hearing thresholds was 24 dB HL. Significant patient benefit was obtained in at least six out of eight patients using the Belfast rule of thumb. The technique has many advantages over the traditional meatoplasty operations but the long-term results require evaluation.

Castleman's disease: an unusual cause of a neck mass

Castleman's disease is an unusual cause of a neck mass; in only 6% of the cases reported in the literature is the disease primarily located in the neck. We present 2 cases of Castleman's disease restricted to the neck, who underwent successful surgical excision. We discuss the histopathology in the different forms of the disease and review the literature.

Post-tonsillectomy bacteraemia in children

It has been postulated that the bacteraemia rate following guillotine tonsillectomy is lower than that following dissection tonsillectomy due to intra-operative compression of tonsillar blood vessels by the guillotine. The aim of this study was to evaluate the incidence of bacteraemia following dissection and guillotine tonsillectomy. Sixty-four patients undergoing elective tonsillectomy for recurrent acute tonsillitis were randomly selected, 32 underwent dissection tonsillectomy and 32 guillotine tonsillectomy. Positive intra-operative blood cultures were obtained in 16 patients (25 per cent), nine (28.1 per cent) of the dissection group and seven (21.8 per cent) of the guillotine group. There was no significant difference between the two methods (Chi-squared test, p = 0.77).

Laryngeal foreign body: an unusual complication of percutaneous tracheostomy

Impaction of a foreign body in the larynx is a serious event. While inhaled foreign bodies may occasionally impact in the larynx especially in children, a laryngeal foreign body as a complication of percutaneous tracheostomy has not been reported in the literature. We describe the case of a fragment of a Seldinger wire retained in the larynx for two years following a percutaneous tracheostomy and review the literature on the complications of this procedure.

Histiocytic necrotizing lymphadenitis (Kikuchi's disease) of the cervical lymph nodes

Histiocytic necrotizing lymphadenitis (HNL), or Kikuchi's disease, is a benign cause of lymph node enlargement of unknown origin. It may be mistaken for malignant lymphoma, both clinically and histologically. Though well recognized in the pathological literature few clinicians are aware of the disease. We present a case of cervical HNL and review the literature.