TRLS-07. Intracavitary carrier-embedded Cs131 brachytherapy for recurrent brain metastases: A randomized phase II study

Background

The salvage treatment of recurrent brain metastases after failed irradiation is a clinical challenge. Adjuvant SRS is standard of care for resected brain metastases in the upfront post-resection setting given a significant local control advantage over surgery alone. However, the role of reirradiation following salvage resection of recurrent post-irradiation metastases is unclear owing to both reduced efficacy of subsequent courses of external beam radiation, and likely increased risk of radiation injury. Intracavitary cesium 131 (Cs131) brachytherapy offers a highly conformal adjunct radiation option that we hypothesize may allow for improved local control while also theoretically conveying a low risk of radiation necrosis. In this randomized controlled study, we aim to define the potential benefits and risks of resection plus permanently implanted, carrier-embedded intracavitary Cs131 brachytherapy versus conventional care (surgery alone).

Methods

This is a single-center randomized controlled study of patients undergoing resection of recurrent, previously-irradiated brain metastases. Exclusion criteria include prior in-field infection, prior radiation >100Gy (in 2Gy fraction equivalents), >5 additional active or untreated CNS lesions, or leptomeningeal carcinomatosis. Subjects are randomized 1:1 to undergo either surgery with placement of Cs131 brachytherapy or surgery alone. The primary endpoint is freedom from treated-site progression at 9 months. Secondary endpoints include wound complications at 3 months and time to local retreatment at the index site, and exploratory objectives include neurocognitive function prior to surgery and at 3 and 12 months postoperatively, with correlative analyses of the previously irradiated brain metastasis tissue. Accrual began on December 24, 2020 and 5 of a planned 76 patients have enrolled. This is the first randomized controlled trial of surgery plus permanently implanted intracavitary Cs131 brachytherapy versus surgery alone for recurrent brain metastases.

ClinicalTrials.gov Identifier: NCT04690348

Application of Community Detection Algorithm to Investigate the Correlation between Imaging Biomarkers of Tumor Metabolism, Hypoxia, Cellularity, and Perfusion for Precision Radiotherapy in Head and Neck Squamous Cell Carcinomas

The present study aimed to investigate the correlation at pre-treatment (TX) between quantitative metrics derived from multimodality imaging (MMI), including 18F-FDG-PET/CT, 18F-FMISO-PET/CT, DW- and DCE-MRI, using a community detection algorithm (CDA) in head and neck squamous cell carcinoma (HNSCC) patients. Twenty-three HNSCC patients with 27 metastatic lymph nodes underwent a total of 69 MMI exams at pre-TX. Correlations among quantitative metrics derived from FDG-PET/CT (SUL), FMSIO-PET/CT (K1, k3, TBR, and DV), DW-MRI (ADC, IVIM [D, D*, and f]), and FXR DCE-MRI [Ktrans, ve, and τi]) were investigated using the CDA based on a "spin-glass model" coupled with the Spearman's rank, ρ, analysis. Mean MRI T2 weighted tumor volumes and SULmean values were moderately positively correlated (ρ = 0.48, p = 0.01). ADC and D exhibited a moderate negative correlation with SULmean (ρ ≤ -0.42, p < 0.03 for both). K1 and Ktrans were positively correlated (ρ = 0.48, p = 0.01). In contrast, Ktrans and k3max were negatively correlated (ρ = -0.41, p = 0.03). CDA revealed four communities for 16 metrics interconnected with 33 edges in the network. DV, Ktrans, and K1 had 8, 7, and 6 edges in the network, respectively. After validation in a larger population, the CDA approach may aid in identifying useful biomarkers for developing individual patient care in HNSCC.

Multi-site, multi-platform comparison of MRI T1 measurement using the system phantom

Recent innovations in quantitative magnetic resonance imaging (MRI) measurement methods have led to improvements in accuracy, repeatability, and acquisition speed, and have prompted renewed interest to reevaluate the medical value of quantitative T₁. The purpose of this study was to determine the bias and reproducibility of T₁ measurements in a variety of MRI systems with an eye toward assessing the feasibility of applying diagnostic threshold T₁ measurement across multiple clinical sites. We used the International Society of Magnetic Resonance in Medicine/National Institute of Standards and Technology (ISMRM/NIST) system phantom to assess variations of T₁ measurements, using a slow, reference standard inversion recovery sequence and a rapid, commonly-available variable flip angle sequence, across MRI systems at 1.5 tesla (T) (two vendors, with number of MRI systems n = 9) and 3 T (three vendors, n = 18). We compared the T₁ measurements from inversion recovery and variable flip angle scans to ISMRM/NIST phantom reference values using Analysis of Variance (ANOVA) to test for statistical differences between T₁ measurements grouped according to MRI scanner manufacturers and/or static field strengths. The inversion recovery method had minor over- and under-estimations compared to the NMR-measured T₁ values at both 1.5 T and 3 T. Variable flip angle measurements had substantially greater deviations from the NMR-measured T₁ values than the inversion recovery measurements. At 3 T, the measured variable flip angle T₁ for one vendor is significantly different than the other two vendors for most of the samples throughout the clinically relevant range of T₁. There was no consistent pattern of discrepancy between vendors. We suggest establishing rigorous quality control procedures for validating quantitative MRI methods to promote confidence and stability in associated measurement techniques and to enable translation of diagnostic threshold from the research center to the entire clinical community.

Dynamic contrast-enhanced MRI model selection for predicting tumor aggressiveness in papillary thyroid cancers

The purpose of this study was to identify the optimal tracer kinetic model from T1 -weighted dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) data and evaluate whether parameters estimated from the optimal model predict tumor aggressiveness determined from histopathology in patients with papillary thyroid carcinoma (PTC) prior to surgery. In this prospective study, 18 PTC patients underwent pretreatment DCE-MRI on a 3 T MR scanner prior to thyroidectomy. This study was approved by the institutional review board and informed consent was obtained from all patients. The two-compartment exchange model, compartmental tissue uptake model, extended Tofts model (ETM) and standard Tofts model were compared on a voxel-wise basis to determine the optimal model using the corrected Akaike information criterion (AICc) for PTC. The optimal model is the one with the lowest AICc. Statistical analysis included paired and unpaired t-tests and a one-way analysis of variance. Bonferroni correction was applied for multiple comparisons. Receiver operating characteristic (ROC) curves were generated from the optimal model parameters to differentiate PTC with and without aggressive features, and AUCs were compared. ETM performed best with the lowest AICc and the highest Akaike weight (0.44) among the four models. ETM was preferred in 44% of all 3419 voxels. The ETM estimates of Ktrans in PTCs with the aggressive feature extrathyroidal extension (ETE) were significantly higher than those without ETE (0.78 ± 0.29 vs. 0.34 ± 0.18 min-1 , P = 0.005). From ROC analysis, cut-off values of Ktrans , ve and vp , which discriminated between PTCs with and without ETE, were determined at 0.45 min-1 , 0.28 and 0.014 respectively. The sensitivities and specificities were 86 and 82% (Ktrans ), 71 and 82% (ve ), and 86 and 55% (vp ), respectively. Their respective AUCs were 0.90, 0.71 and 0.71. We conclude that ETM Ktrans has shown potential to classify tumors with and without aggressive ETE in patients with PTC.

Intravoxel incoherent motion diffusion-weighted MRI during chemoradiation therapy to characterize and monitor treatment response in human papillomavirus head and neck squamous cell carcinoma

PURPOSE

Characterize and monitor treatment response in human papillomavirus (HPV) head and neck squamous cell carcinoma (HNSCC) using intra-treatment (intra-TX) imaging metrics derived from intravoxel incoherent motion (IVIM) diffusion-weighted magnetic resonance imaging (DW-MRI).

MATERIALS AND METHODS

Thirty-four (30 HPV positive [+] and 4 HPV negative [-]) HNSCC patients underwent a total of 136 MRI including multi-b value DW-MRI (pretreatment [pre-TX] and intra-TX weeks 1, 2, and 3) at 3.0 Tesla. All patients were treated with chemo-radiation therapy. Monoexponential (yielding apparent diffusion coefficient [ADC]) and bi-exponential (yielding perfusion fraction [f], diffusion [D], and pseudo-diffusion [D*] coefficients) fits were performed on a region of interest and voxel-by-voxel basis, on metastatic neck nodes. Response was assessed using RECISTv1.1. The relative percentage change in D, f, and D* between the pre- and intra-TX weeks were used for hierarchical clustering. A Wilcoxon rank-sum test was performed to assess the difference in metrics within and between the complete response (CR) and non-CR groups.

RESULTS

The delta (Δ) change in volume (V)_1wk-0wk for the CR group differed significantly (P = 0.016) from the non-CR group, while not for V_2wk-0wk and V_3wk-0wk (P > 0.05). The mean increase in ΔD_3wk-0wk for the CR group was significantly higher (P = 0.017) than the non-CR group. ADC and D showed an increasing trend at each intra-TX week when compared with pre-TX in CR group (P < 0.003). Hierarchical clustering demonstrated the existence of clusters in HPV + patients.

CONCLUSION

After appropriate validation in a larger population, these IVIM imaging metrics may be useful for individualized treatment in HNSCC patients.

LEVEL OF EVIDENCE

2 J. Magn. Reson. Imaging 2017;45:1013-1023.

Radiological anatomy of the anterior ethmoidal artery for functional endoscopic sinus surgery

AIM

This study investigated the extent to which the anterior ethmoidal artery and anterior ethmoidal foramen could be reliably identified on routine coronal sinus computed tomography scans. Where they could be identified, the relationship of these structures with the vertical height of the skull base, and their distance from an anterior landmark, were measured.

METHODS

Fifty consecutive coronal sinus computed tomography scans were viewed independently by two observers. Scans were reviewed when the observers' opinions differed.

RESULTS

Inter-observer concordance was high. The anterior ethmoidal foramen was visualised in 95 per cent of cases bilaterally and in the remaining 5 per cent unilaterally. The anterior ethmoidal artery was visualised in 33 per cent of scans. The anterior ethmoidal foramen was at skull base level in 72 per cent of sides studied, and below it in the remainder. The distance from the lacrimal crest to the anterior ethmoidal foramen was 22.4 mm (mean; standard deviation 3.7).

CONCLUSION

The anterior ethmoidal foramen is a reliable landmark on coronal computed tomography scans of the paranasal sinuses. From this, the position of the anterior ethmoidal artery can be inferred.

What proportion of patients referred to an otolaryngology vertigo clinic have an otological cause for their symptoms?

Background:

Dizziness is a common and often complex complaint. Between nine and 13 per cent of patients seen in general practice are referred to a variety of specialist clinics. The diagnoses and outcomes of these referrals are seldom reported.

Aims:

To determine the proportion of patients referred to an otology led vertigo clinic in whom an otological cause for vertigo could be identified.

Design of study:

Prospective cohort study of consecutive new clinic attendees over one year.

Setting and methods:

Otology led vertigo clinic in an urban teaching hospital in England. Patients' details including age, sex, referring clinician, investigations, diagnoses, treatment and final outcome were recorded in an anonymised database.

Results:

91 new patients, 31 men and 60 women with a mean age of 52.6 years (range 16–81) were seen. General practitioners referred 87 per cent of the patients. Twenty-seven patients underwent further investigations including imaging, electronystagmography and other audiological tests. A labyrinthine disorder accounted for 50 per cent of the diagnoses. Ménière's disease or a variant was diagnosed in 20 patients (21 per cent). Fifty-six patients (61 per cent) reported resolution of or improvement in their symptoms. Thirty-one patients (34 per cent) were asymptomatic and free of abnormal findings on initial attendance and were discharged from hospital care.

Conclusions:

Forty-six patients (50.6 per cent, 95 per cent confidence interval, 40.4–60.6 per cent) had vertigo due to an otological disorder. The selection of an otolaryngology based vertigo clinic by the general practitioner for initial referral seems appropriate.

Quality of life outcome analysis in patients undergoing submandibular duct repositioning surgery for sialorrhoea

Bilateral submandibular duct transposition is one of several surgical methods described to control sialorrhoea in the paediatric patient. The purpose of this study is to assess the effect of submandibular duct repositioning surgery on the quality of life of children using the Glasgow Benefit Inventory outcome measure. Consecutive children who underwent submandibular duct repositioning surgery were invited to participate in the study. The parents or guardians of children who gave consent were interviewed. The carer's opinion of the change in salivation, responses to the items in the Glasgow Benefit Inventory score and report of the complications were recorded. Nine children aged two and a half to 16 years were studied. The mean follow-up time was four years. The mean Glasgow Benefit Inventory score of +33 related to the procedure demonstrates that submandibular duct repositioning leads to a substantial measurable improvement in the quality of life (QoL) of the drooling child.

Functional endoscopic sinus surgery for chronic rhinosinusitis

BACKGROUND

Rhinosinusitis is a well-recognised clinical syndrome affecting patients of all ages and gender. FESS has now become a well-established strategy, comprising several techniques, for the treatment of chronic rhinosinusitis refractory to medical treatment.

OBJECTIVES

The aim of this review was to assess the effectiveness of functional endoscopic sinus surgery as a treatment for patients with chronic rhinosinusitis.

SEARCH STRATEGY

The Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to January 2006) and EMBASE (1974 to January 2006) were searched. Reference lists were handsearched and experts in the field contacted to identify further studies.

SELECTION CRITERIA

Randomised controlled trials. Inclusion criteria were any of the following criteria singly or in combination: patients with chronic rhinosinusitis diagnosed by a health professional; patients with sinusitis symptoms for more than 12 weeks; endoscopic evidence of sinusitis or radiological evidence of sinusitis. Exclusion criteria were immune suppression; cystic fibrosis; Wegener's disease; previous sinus surgery or sinonasal malignancy.

DATA COLLECTION AND ANALYSIS

All studies meeting the inclusion criteria underwent validity assessment and the data were extracted independently by the two authors. Comparisons were:FESS versus medical treatmentFESS versus conventional sinus surgeryFESS + medical treatment versus medical treatmentFESS + medical treatment versus conventional sinus surgery + medical treatment

MAIN RESULTS

The three included studies were randomised controlled trials. The evidence available does not demonstrate that FESS, as practiced in the included trials, is superior to medical treatment with or without sinus irrigation in patients with chronic rhinosinusitis. A middle meatal antrostomy fashioned by FESS was also not shown to be superior to an inferior meatal antrostomy formed by traditional sinus surgery techniques, although the small sample size in the study does not exclude a type II error. In one study there was a relapse rate of 2.4% in the FESS and sinus irrigation group compared to 5.6% in the sinus irrigation only group. The relapse rates were not mentioned in the other studies. There were no major complications such as orbital injury or cerebrospinal fluid leak reported in any of the included trials.

AUTHORS' CONCLUSIONS

FESS as currently practiced is a safe surgical procedure. The limited evidence available suggests that FESS as practiced in the included trials does not confer additional benefit to that obtained by medical treatment (+/- sinus irrigation) in chronic rhinosinusitis. More randomised controlled trials comparing FESS with medical and other treatments, with long-term follow up, are required.

Do mobile 'phones have a detrimental impact on auditory function?

Mobile telephones are now an integral part of modern telecommunications. The widespread use of mobile telephones has given rise to concern about the potential influences of electromagnetic fields (EMFs) on human health. The effects of EMFs on human beings are under investigation. Anatomically, the ear is in close proximity to the mobile telephone during use. The effect of mobile phones on auditory function has rarely been studied. The aim of this review is to determine if there is evidence that mobile phones have a detrimental effect on auditory function.

Chronic rhinosinusitis: a comparative study of disease occurrence in North of Scotland and Southern Caribbean otolaryngology outpatient clinics over a two month period

A comparative study of the occurrence of chronic rhinosinusitis in clinics in the North of Scotland and Southern Caribbean was performed, to test the hypothesis that patients with chronic rhinosinusitis present more commonly in temperate climates than tropical climates. The data was collected prospectively over two month periods from outpatient clinics at both sites. A higher surgical trainee or consultant otolaryngologist made the diagnosis of chronic rhinosinusitis. Eight-hundred-and-seventy-two otolaryngology outpatients were studied 311 were from Trinidad and 561 from Aberdeen. The proportion of patients presenting with chronic rhinosinusitis in both samples is similar, 54 (9.6%) patients in Aberdeen and 29 (9.3%) in Trinidad. The proportion of chronic rhinosinusitis patients with a history of allergy is greater in Trinidad 79.3% (23) than in the Aberdeen sample 50% (27). Patients with chronic rhinosinusitis were seen as commonly in otolaryngology clinics in a tropical setting as in a temperate setting.

Training opportunities for specialist registrars post-calmanization: audit of trainees' exposure to repair of the tympanic membrane

Specialist training at the registrar grade in the United Kingdom has undergone significant change in the recent past. One of the effects has been a reduction in the length of time spent in training. This and the application of the European working time directive have the potential to reduce trainees' surgical exposure. The proportion of tympanic membrane procedures performed by reconstructive otolaryngology registrars in the Grampian University hospitals was audited to monitor the impact of these changes. Case notes of all patients who underwent myringoplasty or tympanoplasty between July 1998 and June 1999 were analysed retrospectively. Details of the surgeons' grade were recorded. The proportion of myringoplasties performed by registrars as determined by the Royal College of Surgeons of England National Comparative Audit survey, carried out in 1995 before the widespread implementation of recommended changes in otolaryngology registrar training, was set as the gold standard. In the period July 1998-1999 registrars had performed fewer myringoplasties than the standard, 17 per cent versus 34.2 per cent respectively (p = 0.035). A strategy to increase registrar exposure to myringoplasty surgery was then adopted by the department and the proportion of myringoplasties performed by registrars re-audited prospectively. The proportion of myringoplasties undertaken by registrars increased in the period January 2001 to July 2001 compared to July 1998-1999, 53 per cent versus 17 per cent respectively (p < 0.0007). Changes in working practice can address shortfalls in registrars' exposure to surgical procedures.

Does synchronous nasal surgery increase the risk of post-operative haemorrhage in adult patients undergoing tonsillectomy?

Otolaryngologists occasionally perform simultaneous procedures on their patients, the indication being co-existent pathology. This is not a universally accepted practice as some feel that the post-operative morbidity is increased in such patients. Tonsillectomy is a common otolaryngological procedure and the main life-threatening complication, haemorrhage is easily identifiable. This study compares the incidence of post-operative haemorrhage requiring admission in patients undergoing tonsillectomy alone with that in patients undergoing tonsillectomy and nasal surgery. A retrospective study was undertaken of all adult patients undergoing tonsillectomy alone or tonsillectomy and synchronous nasal surgery in Aberdeen Royal Infirmary. Seventy-one patients (34 male) with a mean age of 23 years underwent tonsillectomy and synchronous nasal surgery over a nine-year period 1991-1999. The commonest nasal procedure was reduction of the inferior turbinates (in 48 cases). Three hundred and ninety-eight patients (131 male) with a mean age of 23 years underwent tonsillectomy alone over a nine-month period, July 1998 to April 1999. The incidence of post-tonsillectomy haemorrhage in the synchronous nasal surgery group was 12.7 per cent (9 out of 71) compared with four per cent (16 out of 398) in the tonsillectomy alone group (p <0.01, Chi-squared test). There was no difference in hospital stay between the two groups (mean two days). Synchronous nasal surgery increases the incidence of post-tonsillectomy haemorrhage.

Audit of a change in otolaryngology discharge letters using the Scottish Intercollegiate Guidelines Network (SIGN) recommendations

Hospital and general practitioners should establish good communications so that continuity of care can be maintained when patients are discharged from hospital. A discharge letter was routinely prepared utilizing the standardized morbidity registration forms by the house surgeon for delivery to the patients general practitioner. The authors developed a new discharge letter, which was sent under separate cover to the general practitioner. The two discharge letters were assessed utilising data fields recommended by the Scottish Intercollegiate Guidelines Network (SIGN). A total of 162 consecutive paediatric patient discharges were identified. The mean number of items present in the existing and the new discharge letters were 13.7 + 1.8 and 12.2 + 3 respectively. The new discharge letter met the SIGN guidelines more closely than the existing discharge letter.

Combined risk factors contributing to cerebral venous thrombosis in a young woman

Cerebral venous thrombosis is a rare condition affecting predominantly adolescents or young adults. The presentation is often non-specific, and delay in diagnosis is common. The otolaryngologist may be consulted about the radiological findings of lateral sinus thrombosis and mastoid changes. The association of congenital thrombophilia with unusual presentations of venous thrombosis, especially in young individuals is now well documented. We present a case of lateral and sagittal sinus thrombosis complicated by cerebral venous infarction in a girl with protein C deficiency and masked mastoiditis. Unusual forms of venous thrombosis, including cerebral venous thrombosis may develop in association with a single risk factor for thrombosis, but additional risk factors should be sought especially when thrombosis presents in very young individuals. This case draws attention to the multi-causal nature of cerebral venous thrombosis in young adults, and highlights the issue of masked mastoiditis. A coordinated approach by otolaryngological and haematological teams is recommended in such cases.

A randomised clinical trial of turbinectomy for compensatory turbinate hypertrophy in patients with anterior septal deviations

Turbinectomy is performed at the time of nasal septal surgery by many otolaryngologists. One reason given for this procedure is the presence of a hypertrophied contralateral inferior turbinate. A randomised trial was undertaken to evaluate the relief of nasal obstruction following contralateral turbinectomy with septal surgery. Patients presenting with nasal obstruction who had a unilateral septal deviation and contralateral inferior turbinate enlargement were prospectively randomized to contralateral turbinectomy or no turbinate surgery at the time of septal surgery. Questionnaires and active anterior rhinomanometry were used for evaluation. Twenty-six patients (mean age 31 years) demonstrated a reduction in subjective and objective measures of nasal obstruction (P < 0.05) 8 weeks after operation. There was no intergroup difference, the median total decongested nasal resistance postoperatively in the non-turbinectomized patients was 0.17 kPal-1 s and 0.21 kPal-1 s in the turbinectomized patients. Contralateral inferior turbinectomy does not add to the relief of nasal obstruction beyond that attained by septal surgery in these patients.

A randomised controlled trial of the effect of regional nerve blocks on immediate post-tonsillectomy pain in adult patients

Post-operative pain is the main cause of morbidity following tonsillectomy. The efficacy of glossopharyngeal and lesser palatine nerve blocks in controlling postoperative pain in adult patients was investigated prospectively. Patients 16 years and older admitted for elective tonsillectomy were randomised to one of three groups to receive a pre-incisional oropharyngeal injection of 0.5% bupivicaine, a 'dummy' injection of saline or no injection. Dissection tonsillectomy and general anaesthetic techniques were standardized. Postoperative pain was monitored for 24 h. ANOVA, chi2 and Fisher's exact test were used for intergroup comparisons. Ninety-two patients (72 women and 20 men), mean age 22 years were studied. Twenty-nine patients received 0.5% bupivicaine, 30 saline and 33 no pre-incisional injection. The overall mean pain scores of 2.1, 1.9 and 1.9 in the bupivicaine, saline and no injection groups were similar. Glossopharyngeal and lesser palatine 0.5% bupivicaine nerve blocks are not effective in reducing early post-tonsillectomy pain.

Base of tongue varices associated with portal hypertension

A symptomatic case of tongue base varices in a patient with portal hypertension secondary to liver cirrhosis is presented. There are no previously documented cases in the world literature. Oesophageal varices may not be the only source of expectorated blood in a patient with portal hypertension.

Postoperative tonsillectomy pain in pediatric patients: electrocautery (hot) vs cold dissection and snare tonsillectomy--a randomized trial

OBJECTIVE

To determine the effect of the method of tonsillectomy on postoperative pain in pediatric patients.

DESIGN

Prospective, randomized, single-blind, controlled clinical trial.

SETTING

A university pediatric hospital in Aberdeen, Scotland.

PATIENTS

A volunteer sample of 54 children, aged 3 to 12 years, with recurrent tonsillitis or symptomatic adenotonsillar hypertrophy. Two patients withdrew consent.

INTERVENTIONS

Twenty-six children underwent a nonelectrical (ie, cold) dissection tonsillectomy with cold steel instruments, 5 of whom also had adenoidectomy by curettage. Monopolar diathermy forceps were used for tonsillar bed hemostasis. Twenty-four children had electrocautery (ie, hot) dissection tonsillectomy, 7 of whom underwent adenoidectomy by curettage without a suction coagulator.

MAIN OUTCOME MEASURES

Postoperative analgesic consumption, time to regain normal diet and activity levels, and complications.

RESULTS

Patients who underwent hot dissection tonsillectomy showed no difference in time to first drink or analgesic use within the first 24 postoperative hours compared with children undergoing cold nonelectrical dissection tonsillectomy. The hot dissection tonsillectomy group took 7.5 (95% confidence interval [CI], 1-14.1) more doses of analgesics than the cold dissection group over the next 12 days (P<.05). The hot dissection tonsillectomy group took 2.5 more days than the cold dissection tonsillectomy group to regain normal diet (P<.05). Thirteen children (54%; 95% CI, 34-74) in the hot dissection tonsillectomy group and 6 (23%; 95% CI, 7-39) in the cold dissection tonsillectomy group sought outpatient care for throat pain, otalgia, poor diet, pyrexia, and/or bleeding (P<.05). Throat pain delayed in onset or of prolonged duration affected 9 children (38%; 95% CI, 19-57) in the hot dissection tonsillectomy group as opposed to 3 children (12%; 95% CI, 0-24) in the cold dissection tonsillectomy group (P<.05).

CONCLUSION

Hot dissection tonsillectomy increases morbidity in pediatric patients in the recovery period following hospital discharge.

Trends in the UK contribution to the otolaryngological literature

Ten leading otolaryngological journals were reviewed with a view to detecting the UK contribution to the ENT literature from 1985 to 1994. From a total number of 12,293 publications studied 2414 (19.6%) papers were found to originate from British and Northern Irish otolaryngological departments, with the proportion of UK papers remaining at around 20% throughout the whole 10-year period. These papers were fully reviewed and the number of authors, paper type, names of authors and originating department recorded. Eleven departments were responsible for 50.2% of the total number of publications with the most prolific author being responsible for 2.5% (n = 60) of the total number of UK papers. Over the 10-year period, there has been a significant change towards the publication of more clinical research at the expense of pure laboratory research in these 10 journals (chi 2 P < 0.001). There has also been a move towards multiple authorship (three or more co-authors) over the same period with fewer single-author papers (P < 0.001).

Non-Hodgkin's lymphoma of the lacrimal sac and concomitant pansinusitis

Paranasal sinus disease has an established propensity to breach anatomical barriers and present with orbital clinical features. Lacrimal sac lymphomas on the other hand are rare, usually present in males in the sixth decade and 50 per cent of cases have systemic lymphoma/leukaemia. Atypical presentations of lymphomas at this and other sites are reported in patients with acquired immunodeficiency syndrome (AIDS). The clinical features, investigations and treatment of a young human immunodeficiency virus (HIV) sero-negative woman with a non-Hodgkin's lymphoma localized to the lacrimal sac and presenting with a concomitant ipsilateral pansinusitis is described. The importance of submitting surgical material for pathological investigation is stressed.

Do ventilated packs reduce post-operative eustachian tube dysfunction?

Nasal packing is associated with post-operative Eustachian tube dysfunction in patients undergoing nasal surgical procedures. The effect of cannulated nasal packs which may improve nasopharyngeal ventilation was investigated in a prospective randomized controlled trial. Adult elective patients without tympanometric evidence of pre-operative Eustachian tube dysfunction were recruited. All subjects underwent single or combined intranasal surgical procedures and were randomized to receive either bilateral cannulated or non-cannulated Merocel nasal packs. Middle ear pressures (MEP) were recorded pre-operatively and post-operatively before nasal pack removal. Left and right ear results were amalgamated for analysis and 40 adults, 20 in each group were analysed. There was no difference in pre-operative MEP, -15 dPa (median value) in both groups. Post-operatively the MEP changed in both groups P < 0.0001. There was no significant inter group difference in the post-operative median MEP, -85 dPa in the cannulated and -70 dPa in the control groups, (95% c.i. for the difference in the medians -25-55 dPa). Nasal surgery with post-operative packing leads to an objective reduction in MEP which is not altered by venting the packs.

A simple method for retaining the aural speculum

In middle ear surgery via the permeatal approach, aural specula are frequently used to improve visualization of the operative field. Mechanical holders designed for retaining the aural speculum, are expensive and require sterilization for reuse. A simple technique for retaining the speculum which overcomes the drawbacks of a mechanical holder is described.

Human papilloma viruses in the human hypopharynx

The possible association of human papilloma viruses (HPV) with laryngopharyngeal squamous cell carcinoma is under investigation. Recent work suggests regional differences in the prevalence of HPV infection in the hypopharynx. The present study investigates the prevalence of HPV in tissue obtained from a series of piriform fossae. Piriform fossa epithelium was harvested from 12 autopsy cases free of local disease. DNA was obtained by SDS/Proteinase K digestion. Evidence of HPV infection was documented by the polymerase chain reaction using oligonucleotide primers complementary to sequences in the E6 region of HPV types 11, 16 and 18. All the specimens were positive for beta-globin. HPV11 was isolated from two patients. None were positive for HPV16 or HPV18. An 18% prevalence rate for HPV11 in the normal human hypopharynx was found.

Human papilloma viruses: a study of their prevalence in the normal larynx

The association of human papilloma viruses (HPV) with laryngopharyngeal squamous cell carcinoma is under investigation. The suitability of control tissue in the reported series, invariably obtained from histologically normal tissue adjacent to a squamous cell carcinoma or from patients with benign laryngopharyngeal disease, is questionable. The present study determined the prevalence of HPV in a series of normal larynges. Twelve autopsy larynges were collected. DNA was obtained by SDS proteinase K digestion. Evidence of HPV infection was documented by the polymerase chain reaction using oligonucleotide primers complementary to sequences in the E6 region of HPV types 11, 16 and 18. Four female and eight male larynges, mean age 65 years (SD = 16 years) were collected 72 hours postmortem (median value). HPV type 11 was isolated from three specimens. A 25 per cent prevalence rate for HPV 11 was found. No other HPV types were isolated.

Inappropriate out-patient referrals increasing?

A study was undertaken to determine if inappropriate general practitioner out-patient referrals have increased. Out-patients referred to an otolaryngology unit in north-east England were analysed. Patient, diagnosis, waiting time and outcome of consultation details of new attenders for a two-month period in 1981 and 1989 were compared. New out-patient attenders without evidence of otolaryngological disease, who required no treatment, investigation or follow-up, were defined as inappropriate referrals. A total of 2200 new attendances were studied, 819 in 1981 and 1381 in 1989. In all, 125 referrals (15%; 95% confidence interval, 12-18%) in 1981 and 180 patients (13%; 11-15%) in 1989 were inappropriate. There was no increase in the proportion of inappropriate referrals.

Otitis media

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Bilateral vocal cord palsy: the alternative to tracheostomy

Bilateral abductor vocal cord paralysis remains a difficult management problem for otolaryngologists. The techniques currently used fall into four main types: arytenoidectomy, cordectomy, cord lateralization and laryngeal re-innervation. These techniques invariably require a tracheostomy either prior to or at the time of the main procedure. A technique for managing patients without performing a tracheostomy which is as effective as the previously mentioned procedures and with no greater morbidity in terms of voice production was initially described by Ejnell, et al (1984). The results in three patients using this technique which involves vocal cord lateralization under endoscopic control confirms its ease and efficacy. All three patients were relieved of their presenting dyspnea and had satisfactory postoperative voice production. This appears to be an effective technique for the treatment of patients with bilateral abductor laryngeal paralysis which obviates the need for tracheostomy and its attendant complications.

Hearing aids: family practitioner referral patterns

This study aims to determine whether the implementation of a direct referral service in which family practitioners received feedback on the appropriateness of their patient selection had any impact on the referral pattern. Six months after the establishment of such a service to which general practitioners were requested to refer patients who satisfied the Hearing Aid Council and Therapist Technicians and Scientists in Audiology group criteria, 40 consecutive patients were analysed. 40 age matched controls referred concurrently to the routine ENT clinic for hearing aid provision were compared. In the 80 ears seen in each group, the number of perforations infected or otherwise were 2 and 7 respectively (P less than 0.01). Conductive hearing losses were more common in the control group (P less than 0.05). The degree of patient selection was higher than noted in the first 6 months of the service when the prevalence of perforations in the direct sample was 7%. It appears that the practice of selective referral has developed.

Aetiological role of otolaryngological disease in paediatric intracranial abscess

Recent reports suggest that congenital heart disease has supplanted otolaryngological disease as the major aetiological factor in the development of paediatric intracranial abscess. A survey of intracranial abscess identified from the records of the Information and Statistics Division of the Scottish Health Service Common Services Agency and the departmental records of the regional neurosurgical units in Scotland for the period 1981-1985 was undertaken to test this hypothesis. A total of 22 cases in individuals under the age of 16 years confirmed at surgery or autopsy were classified aetiologically on the basis of localization, clinical and investigative findings. Three were cardiogenic, four otogenic and three rhinosinugenic in origin; the others were due to miscellaneous causes. The mean(s.d.) age was 9(4.5) years. The overall mortality rate was 18%. Otolaryngological disease is the major aetiological factor in paediatric intracranial abscess in the UK.

An evaluation of post-operative packing in nasal septal surgery

The need for nasal packing in septal surgery is not proven though its use is widespread. Post-operative complications, while uncommon, are frequently pack related. Consenting adults were prospectively randomized to one of the following: Vaseline gauze nasal packing or 30 Dexon mucosal suture. All patients were operated on by one surgeon who was made aware of the randomization decision only when the corrective surgery was complete. Details of post-operative morbidity were collected and pain scored subjectively by a visual analogue scale the morning after surgery. The first 50 available pain scales illustrated a difference between the groups (P less than 0.05), means 4 and 3 in the pack and suture group respectively. There was no demonstrable difference in post-operative haemorrhage, adhesions, nasal crusting or mucosal atrophy. The need for nasal packing is not supported.

Direct referral hearing aid provision in the over sixties age group

A prospective study was designed in which General Practitioners were issued with a standard referral letter for hearing aid provision. Unknown to the General Practitioner an independent otolaryngologist assessment was obtained at the time of first attendance. Three hundred consecutive patients selected by General Practitioners applying these guidelines were seen in a designated hearing aid clinic staffed by audiological technicians of senior grade or above. Referral pro formata were incomplete in 75 patients who were not assessed. Ninety-four patients (31 per cent) (95 per cent confidence interval 29-36 per cent) were accepted by the audiologist. Obstructing wax was the most common criterion failed. Clinical agreement between audiologist and otolaryngologist was 57 per cent greater than chance. None of the cases of clinical disagreement altered treatment. A direct referral system as proposed could have processed only 31 per cent of 300 referrals. However, experienced technical staff reliably detected otological pathology and with aural toilet facilities 91 per cent of 225 patients (confidence interval 88-94 per cent) were aided.

Presentation of rhinosinugenic intracranial abscesses

Intracranial abscesses secondary to rhinosinugenic disease are uncommon and the incidence is poorly documented. It is generally believed that individuals at risk of developing this complication can be identified by presenting clinical features. A ten year retrospective Scottish national survey 1976-1985 of intracranial abscesses was carried out. Clinical and or radiological evidence of nasal/paranasal aetiology in abscesses localised to the frontal lobe, extradural or subdural spaces allowed 23 surgery or autopsy confirmed abscesses to be classified as rhinosinugenic. 12 abscesses occurred in individuals aged 0-19 years, two in patients with risk factors for intracranial spread, 8 of 11 adults had similar predisposing features (p less than 0.01). This is a rare complication and individuals at risk in the first two decades of life can seldom be identified prospectively on clinical grounds.

Risks of developing an otogenic intracranial abscess

One-and-a-half per cent of adults have active chronic otitis media and its management to prevent complications is a considerable workload. The risks of developing these complications is relatively unknown but because of its mortality, intracranial abscess is the most relevant. A 10-year review of all otogenic intracranial absesses in Scotland was carried out. A 15 per cent allowance was made for missing records. The annual risk in an adult with active chronic otitis media of developing an abscess is about one in 10,000 but its development is three times more likely in males. This risk might appear low but the lifetime expectancy of an individual aged 30 years with active chronic otitis media developing an abscess is one in 200. However, as yet, there is no evidence that surgery reduces this risk. Unfortunately, because of the duration of follow-up needed and the size of the sample required, scientific evidence would be difficult to obtain. However, 5 per cent of abscesses currently occur in the immediate post-operative period following mastoid surgery.

Cervical cord compression and femoral neuropathy in hereditary multiple exostoses

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Epistaxis: a study of the relationship with weather

Epistaxis is the commonest ENT emergency requiring hospital admission. A seasonal variation in the admission rate has been documented. The role of weather in accounting for this variation is uncertain. A retrospective review of 686 adult hospital admissions for idiopathic spontaneous epistaxis over a 2-year period in the Greater Glasgow area was carried out. The most significant weather parameter which correlated with monthly admissions was mean monthly temperature (Pearson's correlation coefficient -0.81, P less than 0.01). Admissions increased by over 100% from the warmest to the coldest months. This is the first report of the high correlation between hospital admissions for epistaxis and mean monthly temperature.

Associated carotid body tumour and pharyngeal pouch

Paragangliomas are rare tumours which most commonly present as an asymptomatic neck mass. A small percentage of patients may have associated dysphagia. A 63-year-old male presented with a ten-month history of dysphagia. Physical examination revealed a pulsatile submandibular triangle neck mass. Computed tomography and angiography were diagnostic of a carotid body tumour. Barium swallow illustrated a hypopharyngeal pouch. He was treated by surgical excision of both lesions and cricopharyngeal myotomy. The simultaneous occurrence of both lesions has not been described before and highlights the need to find an alternative cause for dysphagia in patients with chemodectomas who fail to demonstrate oropharyngeal compression or lower cranial nerve palsies.

Breast metastasis from a pharyngeal carcinoma

The reported incidence of metastatic disease in head and neck cancer is increasing. The most common site of metastatic involvement in squamous carcinoma of the head and neck is the lung followed by liver, mediastinal nodes and bone. The breast is rarely infiltrated by metastatic disease, 2 per cent or less of clinically detected breast lumps being of non-mammary origin, most frequently malignant melanoma, lymphoma/leukaemia and primary lung carcinoma. A 73-year-old female presented with a primary posterior pharyngeal wall squamous carcinoma and bilateral enlarged neck nodes. She developed an isolated breast metastasis while receiving palliative radiotherapy and died seven months after presentation. Clinically detected breast metastasis in head and neck squamous cell carcinoma was first documented by Toombs and Kalisher in 1977. This is the first report of such a case originating in the posterior pharyngeal wall. The prognosis is invariably poor.