Vocal cord movement: can it be accurately graded?

INTRODUCTION

Flexible nasendoscopy (FNE) is the principal assessment method for vocal cord movement. Because the procedure is inherently subjective it may not be possible for clinicians to grade the degree of vocal cord movement reliably. The aim of this study was to assess the accuracy and consistency of grading vocal cord movement as viewed via FNE.

METHODS

Thirty FNE videos, without sound or clinical information, were assessed by six consultant head and neck surgeons. The surgeons were asked to assess and grade right and left vocal cord movement independently, based on a five-category scale. This process was repeated three times on separate occasions. Agreement and reliability were assessed.

RESULTS

Mean overall observed inter-rater agreement was 67.7% (sd 1.9) with the five-category scale, increasing to 91.4% (sd 1.9) when a three-category scale was derived. Mean overall observed intra-rater agreement was 78.3% (sd 9.7) for five categories, increasing to 93.1% (sd 3.3) for three categories. Discriminating vocal cord motion was less reliable using the five-category scale (k = 0.52) than with the three-category scale (k = 0.68).

CONCLUSIONS

This study demonstrates quantitatively that it is challenging to accurately and consistently grade subtle differences in vocal cord movement, as proven by the reduced agreement and reliability when using a five-point scale instead of a three-point scale. The study highlights the need for an objective measure to help in the assessment of vocal cord movement.

Safety of extracapsular dissection in benign superficial parotid lesions

INTRODUCTION

The current practice for removal of clinically benign superficial parotid lesions is an appropriate superficial parotidectomy with a cuff of normal parotid tissue for complete pathological clearance. This technique requires the identification of the facial nerve at the main trunk and dissection of the segment of the facial nerve deep to the lesion. The reported major complications of this procedure include temporary or permanent facial nerve weakness, Frey's syndrome and salivary leaks. In order to avoid these complications, a local extracapsular dissection technique can be utilised in the management of small inferiorly located benign lesions of the parotid gland.

METHODS

A retrospective case note review was performed for all parotidectomies between 2004 and 2009 in Addenbrooke's Hospital, Cambridge by the senior authors.

RESULTS

A total of 172 cases were identified out which 46 underwent an extracapsular dissection. The average size of these lesions was 1.9 cm (0.9-2.4 cm) with all universally located inferior or posterior to the angle of the mandible. The pathologies were 14 pleomorphic adenomas, 24 Warthin's tumours, 6 lymphangiomas and 2 simple cysts. There were no post-operative facial nerve weaknesses, Frey's syndrome or salivary leaks within the extracapsular dissection group. The median follow-up of these patients were 4.6 years (2-6 years) with 6 patients lost to follow-up. No recurrences have been noted in the cohort at follow-up.

Frontal mucocele caused by an ectopic maxillary tooth

OBJECTIVE

To present a previously unreported cause of frontal mucocele.

CASE REPORT

A patient presented with a frontal mucocele and maxillary sinusitis. Computed tomography revealed an ectopic maxillary tooth as the cause of her signs and symptoms. Removal of the tooth by a Caldwell-Luc procedure facilitated resolution of the mucocele. Conventional treatment of mucoceles by endoscopic sinus surgery, and other rhinological sequelae of ectopic teeth, are considered.

CONCLUSION

This is the first documented case of an ectopic tooth causing a frontal mucocele, and demonstrates how effectively the patient's symptoms resolved on removal of the tooth.

Oncogenes in thyroid cancer

There have been significant advances in our understanding of carcinogenesis at the molecular level over the last 25 years. Oncogenes are of major interest as part of our search for knowledge surrounding the aetiology of cancer. There are several oncogenes associated with thyroid cancer. Detailed investigation of the nature and function of these tumour genes has provided important insights into both the tumour biology and the complex biochemical pathways of normal cellular functioning. Our knowledge of oncogene biology offers the hope of better diagnostic, therapeutic and prognostic modalities in our fight against this and other common cancers. Development of specific thyroid tumour markers and gene therapy is now a realistic prospect to supplement our present armamentarium of surgery and radiotherapy. This review aims to outline the pertinent information gained so far from studies of these oncogenes and provides both clinical relevance and fuel for further interest amongst the ENT thyroid community in this exciting area of research.

Primary defects in the lens underlie complex anterior segment abnormalities of the Pax6 heterozygous eye

We describe lens defects in heterozygous small eye mice, and autonomous deficiencies of Pax6(+/-) cells in the developing lens of Pax6(+/+) <--> Pax6(+/-) chimeras. Two separate defects of the lens were identified by analyzing the distribution of heterozygous cells in chimeras: Pax6(+/-) cells are less readily incorporated into the lens placode than wild type, and those that are incorporated into the lens are not maintained efficiently in the proliferating lens epithelium. The lens of chimeric eyes is, therefore, predominantly wild type from embryonic day 16.5 onwards, whereas heterozygous cells contribute normally to all other eye tissues. Eye size and defects of the iris and cornea are corrected in fetal and adult chimeras with up to 80% mutant cells. Therefore, these aspects of the phenotype may be secondary consequences of primary defects in the lens, which has clinical relevance for the human aniridia (PAX6(+/-)) phenotype.

Thyroid auto-antibodies, lymphocytic infiltration and the development of post-operative hypothyroidism following hemithyroidectomy for non-toxic nodular goitre

BACKGROUND

Auto-immune thyroiditis, associated with detectable thyroid auto-antibodies (TAAs) and lymphocytic infiltration into the gland, is known to be associated with progressive development of hypothyroidism. This study examines those patients who required surgical treatment of non-toxic nodular goitre by hemithyroidectomy to determine whether the presence of TAAs in the circulation and/or lymphocytic infiltration of the gland resulted in a significant degree of post-operative hypothyroidism.

METHOD

This was a prospective study, with data collected retrospectively. All patients operated on for thyroid disease in the unit over a 5-year period were documented, and those patients treated by hemithyroidectomy for non-toxic nodular goitre formed the study group. TAAs were measured, histology re-examined and patients followed up for at least 2 years to detect clinical or sub-clinical hypothyroidism.

RESULTS

Of the 158 patients who comprised the study group, 38 (24.1%) developed hypothyroidism. Forty-one (25.9%) had circulating levels of TAAs, 31 of these (75.6%) having high levels. Of these 41 patients, 22 (53.7%) became hypothyroid. Twenty (64.5%) of the 31 patients with high levels of TAAs required post-operative thyroxine. Of the remaining 117 patients with no detectable TAAs, only 16 (13.7%) became hypothyroid.

CONCLUSION

All patients requiring treatment by hemithyroidectomy should have circulating TAA measurements carried out pre-operatively. If positive, they should be followed up indefinitely because of the strong possibility (P < 0.001) of the development of hypothyroidism.

Development of improved electrical-substitution radiometers at the National Research Council of Canada

We describe the development of a third generation of electrical-substitution radiometers (ESR's) at the National Research Council of Canada. The new ESR's follow the same general design as before, but incorporate improved thermopiles and electrical heating elements. The ESR's have a responsivity between 0.6 and 1.0 VW(-1), a time constant of approximately 2.0 s, a uniformity of 0.1% over a 6-mm-diameter region, and a noise level of approximately 6 nW. Performance characteristics of the new ESR's are discussed. It is shown that calibrations performed with these ESR's agree with those made with the previous generation of ESR's to better than 0.05%.

Autocrine growth and progression of murine X-ray-induced T cell lymphomas

Primary tumors of X-ray-induced murine T cell lymphomas comprise autocrine, growth factor-dependent cells. We have grown cell lines from primary X-ray-induced thymic lymphomas (PXTLs) under conditions which minimize the progression of the cells from factor dependence to factor independence. All (22) PXTL lines grown secrete a growth factor which supports their own growth and which we will call lymphoma growth factor LGF. LGF-dependent cells are non-tumorigenic or poorly tumorigenic, do not clone in soft agar, have no detectable rearrangements in the c-myc or Pim-1 region and possess near diploid or pseudodiploid karyotypes without evidence for trisomy of chromosomes nos. 15 or 17. PXTL-secreted LGF has no interleukin 1, 2, or 3 activity nor do LGF-secreting cells synthesize detectable IL-1, -2, or -3 mRNA. LGF contains no detectable interferon or GM-CSF activity in specific bioassays. Purified EGF, TGF beta, and interleukin preparations are inactive on LGF-dependent PXTL cells. Thus LGF appears to be a new growth factor that is required for the proliferation of non-progressed T lymphoma cells. Upon progression PXTL cells become growth factor independent, are highly tumorigenic in vivo, clone in soft agar, and assume a near triploid karyotype containing numerous chromosomal aberrations. Thus in X-ray-induced lymphomagenesis an autocrine, LGF-dependent phase precedes the progressed phase characterized by rearrangements in the myc and/or Pim-1 regions as well as by many chromosomal aberrations visible in the karyotype.