Evaluation of quality of life and psychiatric morbidity in patients with malignant tumours of the skull base

In general, patients with malignant tumours of the skull base have a poor prognosis. Treatment may have a disfiguring physical and disabling mental effect on patients. To evaluate the effect of treatment on physical and mental quality of life in patients with skull base malignancy, we conducted a cross-sectional patient survey of 18 patients treated for such tumours, using the University of Washington (version 4) quality of life questionnaire and the hospital anxiety and depression scale. The total quality of life score (median value) was 980 (550-1125). Patients with anterior skull base malignancy scored lower than those with lateral skull base malignancy (p=0.003). In general, the worst individual domain scores were: mood (64 per cent); activity (69 per cent); and, specifically for patients with anterior skull base malignancy, taste (54 per cent, p=0.004) and anxiety (60 per cent, p=0.034). One-third of skull base cancer patients were at risk of suffering from mental distress and psychiatric morbidity (indicated as a score of more than seven on the hospital anxiety and depression scale).

Trigeminal neurinoma presenting with trismus

We describe a patient with trigeminal neurinoma whose main presenting symptom was trismus. This has not previously been reported in the literature. We review the previously described symptoms and signs of trigeminal neurinoma.

Extracranial internal carotid artery aneurysm in a child: a diagnostic and surgical challenge

This paper reports the presentation and management of an extra-cranial internal carotid artery aneurysm in a 15-year-old male. To our knowledge there is no previous report of a similar case in childhood.

Fibrous dysplasia and ossifying fibroma of the paranasal sinuses

Fibro-osseous lesions involving the paranasal sinuses, the mid-face and anterior skull base are uncommon. In addition, there appears to be no clear pathological or clinical classification that embraces the variety of lesions that exhibit such diverse pathological and clinical behaviour, yet may still be referred to as a fibro-osseous lesion. The diagnosis of fibrous dysplasia and ossifying fibroma is made on a combination of clinical, radiological and pathological criteria. This paper emphasizes the clinical and pathological differences between fibrous dysplasia and ossifying fibroma. The more aggressive clinical behaviour of the latter is highlighted and a more radical surgical approach is recommended. In contradistinction, fibrous dysplasia can exhibit a more benign behaviour and radical surgery is not always justified. A clinicopathological distinction between these two conditions is important from a management perspective despite the fact that they both may be encompassed under the 'umbrella' term fibro-osseous lesion.

MRI in the detection of acoustic neuromas--a suggested protocol for screening

Magnetic resonance imaging (MRI) is the definitive investigation in the detection of an acoustic neuroma and its use is becoming increasingly widespread for this purpose. In the Oxford region, this facility has been available for 3 years, resulting in the scanning of the internal auditory meati and cerebellopontine angles of 892 patients and the detection of 38 acoustic neuromas. Based on our use of this investigation over this time period, we have attempted to rationalize our entry protocol for screening by limiting the availability of the test to those patients up to 70 years of age presenting with unilateral audiovestibular symptoms in the absence of significant neurological symptoms or signs, with an average difference in hearing threshold of 15 dB between normal and symptomatic ears or unilateral tinnitus with normal hearing. By following these entry criteria, we would hope to maximize the available resources.

Outcome following discharge from an ENT out-patient clinic: patient and general practitioner satisfaction

Fifty consecutive patients discharged from clinic were assessed by questionnaire at the time of discharge and 6 months later. Each patient's practitioner (GP) was sent a questionnaire at 6 months. On discharge, 12.5% of patients would have preferred another appointment and 7.5% were unhappy at being discharged. After 6 months 14% would have preferred ENT follow-up. Twenty-six per cent of patients said they saw their GP within 6 months of discharge with symptoms related to their initial ENT complaint. From the GP questionnaire the proportion was 31.5%. General practitioners were happy to manage the patients themselves and only one patient was seen again in the ENT department within 6 months. In no case did the GP feel discharge to be premature. Pre-reading of notes leading to an increase in the proportion of patients discharged from ENT clinics does not result in more discharges being premature or inappropriate. The majority of patients and general practitioners are happy for ongoing medical care to be continued without further ENT appointments if the nature of the condition and its long-term management is explained clearly.

Out-patient management by junior staff: the value of consultant supervision

The effect of consultant supervision on management of patients by junior staff was assessed. Supervision was exercised by pre-reading the notes with the consultant at the start of the clinic. The principle finding was that less patients were brought back for another appointment. For new patients, the proportion fell from 40% to 19%, and for follow-up patients it fell from 49.5% to 29%. The overall rate fell from 46% to 23.5%. This has major implications with respect to use of resources and, in the unit studied, this change would make available 38 extra clinic appointments for each registrar per month. The study also raises issues regarding the use of out-patient clinics for post-graduate training and consultant supervision of patient management in general.

MRI as a Single Screening Procedure for Acoustic Neuroma: A Cost Effective Protocol

Magnetic resonance imaging (MRI) is accepted as the ‘gold standard’ in diagnosing acoustic neuromas. Limited availability and perceived high costs have prevented clinicians from using it as a first-line investigation. A prospective study was set up in a specially designated screening session to audit the cost effectiveness and accuracy of audiovestibular investigations compared to MRI. Ninety-nine patients with asymmetrical audiovestibular symptoms or signs were investigated. Of these 54 evoked response audiometry tests, and 39 calorics were either not performed or were inconclusive. One patient refused to enter the MRI machine. All others received an unequivocal report after MRI and four tumours (three intracanalicular) were detected. The total cost of the audiovestibular protocol was £12 545 compared to £12 900 for the MRI protocol, which is a diagnostic and well-tolerated procedure. This study shows that MRI can be cost effective, as well as accurate, when used as a single screening procedure for acoustic neuromas.

MRI as a single screening procedure for acoustic neuroma: a cost effective protocol

Magnetic resonance imaging (MRI) is accepted as the 'gold standard' in diagnosing acoustic neuromas. Limited availability and perceived high costs have prevented clinicians from using it as a first-line investigation. A prospective study was set up in a specially designated screening session to audit the cost effectiveness and accuracy of audiovestibular investigations compared to MRI. Ninety-nine patients with asymmetrical audiovestibular symptoms or signs were investigated. Of these 54 evoked response audiometry tests, and 39 calorics were either not performed or were inconclusive. One patient refused to enter the MRI machine. All others received an unequivocal report after MRI and four tumours (three intracanalicular) were detected. The total cost of the audiovestibular protocol was 12,545 pounds compared to 12,900 pounds for the MRI protocol, which is a diagnostic and well-tolerated procedure. This study shows that MRI can be cost effective, as well as accurate, when used as a single screening procedure for acoustic neuromas.

Isolated sphenoid sinusitis due to Pseudallescheria boydii

A case of sphenoid sinusitis due to Pseudallescheria boydii is described in a 52-year-old non-immunocompromised woman. Treatment should always involve surgical drainage, and antifungal chemotherapy may be of benefit if there is histological evidence of invasion of surrounding tissue. For P. boydii infection miconazole should be the agent of choice, rather than amphotericin B. For this reason it is important to obtain culture and histological examination of sinus contents if fungal infection is suspected.

The role of CT imaging in the management of chronic suppurative otitis media

CT imaging of the temporal bone is highly predictive of the presence of cholesteatoma but its value in the routine management of cholesteatoma has not been assessed. We aimed to establish the indications for CT imaging in CSOM by a prospective study of patients suspected of having cholesteatoma. The patients were assessed clinically and a management plan chosen; this was later adjusted, if indicated, on the basis of radiological findings. Surgical findings were recorded and correlation with CT appearances evaluated. Twenty patients completed the study. CT altered the management plan in 10 and was considered helpful in a further 6. We recommend its routine use in children, medically unfit patients, only or better hearing ears, patients in whom the tympanic membrane cannot be adequately visualized, patients who have had previous mastoid surgery whose operative records are available and patients with intratemporal or intracranial complications of disease.

Management of verrucous carcinoma of the larynx

Eight patients with a verrucous carcinoma of the larynx have been seen at the Charing Cross Hospital between 1970 and 1985. Seven patients were treated by primary radiotherapy and one by primary endoscopic laser excision. Four of those treated with radiotherapy developed recurrent disease which was treated by radical surgery in three and by endoscopic laser excision in one. The place of radiotherapy in the management of this condition requires further evaluation in view of the high rate of recurrence. Endoscopic laser excision may be a reasonable alternative to more radical surgery in this highly differentiated neoplasm.

The influence of calcium alginate haemostatic swabs upon operative blood loss in adenotonsillectomy

Although adenotonsillectomy is regarded as a minor procedure, it has been shown that 18% of patients may experience an operative blood loss of 10-20% of the total blood volume. The aim of this study was to determine whether calcium alginate haemostatic swabs reduce operative blood loss in adenotonsillectomy. Seventy-two patients (ages 2-12 years) entered a prospective trial in which the operation was performed either with normal gauze swabs or calcium alginate swabs. Thirty-six children were randomized to each group. The mean blood loss was found to be 34.9 ml (2.07% of total blood volume) and 47.8 ml (2.97% of total blood volume) respectively. Although there was no significant reduction in operative blood loss using calcium alginate, in both groups the blood loss was much smaller than that stated by the majority of previous workers.

Multiple submucosal out-fractures of interior turbinates

Nasal obstruction caused by the inferior turbinate is a common clinical problem. There are many surgical procedures which attempt to relieve it, but all of them have associated difficulties. We describe, for the first time, a new method, namely multiple submucosal out-fractures of the inferior turbinates, which is both effective and free from serious complication.

Pseudotumour of the maxillary antrum

Orbital pseudotumour is a non-specific inflammation of the orbit which forms a tumour-like mass composed of increased connective tissue and ground substance with vascular proliferation and an infiltrate of chronic inflammatory cells. No demonstrable aetiological agents are found locally, and there is no evidence of specific disease entities such as Hodgkins, SLE or temporal arteritis. The condition may present in many different ways to the otolaryngologist, and is therefore a rare but important differential diagnosis to be born in mind. We report a rare case of orbital pseudotumour presenting initially with involvement of the maxillary antrum and in association with Riedel's thyroiditis.

Long-term safety and efficacy study of intranasal ipratropium bromide

Forty patients presenting with watery rhinorrhoea as their main complaint were entered in an open trial of long-term intranasal ipratropium bromide. Fourteen of these (35 per cent) found it to be beneficial and completed one year of treatment. Side-effects were seen in 28 patients (70 per cent) but these were local and mild in nature. All resolved during the trial as patients adjusted the dosage to individual severity and frequency of symptoms. No significant systemic effects were noted during the course of therapy. Ipratropium is a useful drug in the treatment of watery rhinorrhoea and appears safe for long-term use.

A review of the role of radiology in non-healing granulomas of the nose and nasal sinuses

This paper reviews the radiological features of 20 patients with Wegener's granulomatosis and seven cases of lethal midline granulomas. It compares the findings of plain sinus radiographs and tomography. There are no specific radiological features of either Wegener's granulomatosis or lethal midline granuloma. Plain sinus radiographs underestimate the extent of bony changes and the differences between Wegener's and lethal midline granulomas are one of degree. Computerised tomography will show the extent of the disease. The role of nuclear magnetic resonance is also discussed. Nuclear magnetic resonance does not show bone destruction but the T2 weighted response of the tissues helps to differentiate the condition from neoplasia. The literature is reviewed and compared with the study.

Fasting in children for day case surgery

Thirty-four children admitted for day case surgery were studied to determine the period of preoperative fasting and blood sugar concentrations at the time of induction of anaesthesia. Of these, 88% fasted for 12 h or more, 20% fasted for 16 h or more. Three were found to be hypoglycaemic. The introduction of routine 'mid-day' operating lists for paediatric day case surgery is suggested as a method of reducing the period of fasting and risk of hypoglycaemia.

Steady-state auditory evoked potentials to amplitude-modulated tones in hearing-impaired subjects

Evoked potentials to sinusoidal amplitude-modulated tones have been described in normally hearing adults. Our aim was to test the use of this response to estimate pure tone threshold in adults with a sensorineural hearing loss. Patients with symmetrical pure tone audiograms with near-normal responses in the lower frequencies but with a hearing loss of greater than 65 dB HL at 8 kHz were tested. The stimulus carrier frequency was 1, 2, 4 and 8 kHz and this was modulated at a frequency of 40 kHz to a depth of 85%. The resulting EEG response is a sine wave of the same frequency as the modulation frequency. Threshold is determined when the sine wave disappears. Twenty-two patients were tested. None showed a response to the high frequencies. At the lower frequencies 18 patients showed clear responses and the threshold was 16 to 27 dB above the psychoacoustical threshold. The remaining four cases showed responses at the lower frequencies but only at higher threshold levels. These evoked potentials may provide a rapid method to assess hearing in those subjects unable to provide a reliable volitional response.

Carcinoma arising in a pleomorphic adenoma of the epiglottis

Despite the abundance of minor salivary glands within the larynx, pleomorphic adenomas are rarely found. It is therefore not surprising that there are few reports of malignant mixed tumours in this site. We describe a case of carcinoma arising in a pleomorphic adenoma of the epiglottis which, to our knowledge, has not been described previously. The patient underwent a horizontal partial laryngectomy and functional neck dissection and is well one year postoperatively. We feel this represents a suitable approach to treatment for this rare tumour.

A British experience of surgical voice restoration as a primary procedure

It has been the aim of surgeons since Billroth first described laryngectomy to restore speech to the patient. However, a substantial percentage of patients fail to develop esophageal speech. Many authors have confirmed the success of the tracheoesophageal fistula procedure as a means of surgical voice restoration as a secondary procedure. We have performed tracheoesophageal puncture as a primary procedure at the time of laryngectomy in 36 patients, with a success rate of 89%. We believe that primary puncture is the method of choice for surgical voice restoration following laryngectomy.

Bilateral carcinoma of the middle ear

We describe the first reported case of bilateral carcinoma of the middle ear.

Radiology of the paranasal sinuses in non-healing granulomas of the nose

The few accounts of the radiographic features in the nose and sinuses of Wegener's granulomatosis and lethal midline granuloma have involved small numbers. This paper reviews these changes in 20 cases of Wegener's granulomatosis and 7 cases of lethal midline granuloma. Fifteen cases of Wegener's granulomatosis showed either negative or non-specific changes on plain sinus views. In the remaining 5 cases some evidence of bone destruction was seen. The range of changes was much greater in lethal midline granuloma. The radiographic changes varied from normal appearances (1 case) through generalized soft tissue opacity (3 cases), to massive destruction of the nasal bones and sinus walls (3 cases). The difference in radiological pattern in Wegener's and lethal midline granuloma would seem to be one of degree only.