Ear, nose and throat (ENT) manifestations and complications of reflux

Laryngopharyngeal reflux disease describes the backflow of acidic stomach content towards the larynx and is associated with symptoms such as cough, throat clearing and globus. It is a common presentation in primary care and the sequelae of symptoms that arise from the disease often present in ear, nose and throat clinics. Assessment and examination of patients presenting with reflux symptoms includes questionnaires, as well as direct visualisation of the pharynx and larynx, and takes a multidisciplinary team approach. Treatment options include lifestyle modification, medical therapy and in some specialist centres, surgical management to address the multitude of symptoms associated with the disease.

Effects of coronavirus disease-2019 on voice: our experience of laryngeal complications following mechanical ventilation in severe coronavirus disease-2019 pneumonitis and review of current literature

PURPOSE OF REVIEW

Dysphonia has been described as a major symptom of coronavirus disease-2019 (COVID-19). A literature review examining this topic was undertaken and is presented here, combined with insights from our experience in managing patients with laryngeal complications following mechanical ventilation for severe COVID-19 pneumonitis.

RECENT FINDINGS

Naunheim et al. reported that patients who are most at risk of needing intubation with COVID-19 disease are those with patient-specific risk factors and these are at an increased risk for subsequent laryngotracheal injury following intubation (1). In our cohort of 105 patients referred with laryngological symptoms postintubation for COVID-19 pneumonitis, 40% presented as urgent reviews, of which almost half had severe postintubation complications requiring surgery. Perceptual voice ratings and patient-reported voice ratings varied widely, but there was no significant change in voice scores postoperatively. The reflux symptom index (RSI) scores did improve significantly (p = 0.0266). The need for surgery was associated with the presence of comorbidities for instance hypertension, diabetes and obesity in our cohort. This is in support of reported association of comorbidity as a risk factor for intubation and subsequent development of postintubation airway complications.

SUMMARY

Dysphonia following COVID-19 infection may have multiple causes. Literature reports demonstrate intubation injury, sensory neuropathy, and postviral neuropathy are associated with voice changes. Our personal experience has confirmed postintubation injury markedly affects glottic function with resultant dysphonia attributable to scar formation, posterior glottic stenosis, granulation and subglottic stenosis. Frequent surgical intervention is required for airway patency and may have short-term further deleterious effects on phonation, although in our cohort this is not statistically significant analysing Grade, Roughness, Breathiness, Asthenia, Strain, Voice Handicap Index-10 or Airway, Voice, Swallow scores. Maximal antireflux medications and advice statistically improved RSI scores postoperatively.

263 Airway, Voice and Swallow Outcomes Following Endotracheal Intubation and Mechanical Ventilation For COVID-19 Pneumonitis: Preliminary Results of a Prospective Cohort Study

Introduction

The COVID-19 pandemic has placed exceptional demands on Intensive Care Units (ICU) across the world – particularly requiring patients to be intubated and mechanically ventilated. Laryngeal injury following intubation is a common occurrence, therefore this study aims to analyse airway, voice, and swallow (AVS) outcomes of patients intubated for COVID-19 pneumonitis and compares it to intubated non-COVID-19 respiratory patients and other ICU admissions.

Method

We collected data from inpatient records, and follow-up clinics on intubated adult patients discharged from a tertiary care hospital ICU between 01/03/20 and 30/04/20. Patients were assessed with the AVS Scale, Voice Handicap Index-10 (VHI-10), and Eating Assessment Tool-10 (EAT-10).

Results

86 patients were admitted with COVID-19 pneumonitis, 17 patients were admitted with non-COVID-19 respiratory failure, and 26 patients were admitted with a non-respiratory diagnosis.

The COVID-19 cohort demonstrated higher rates of AVS difficulties (airway 59% vs 44% and 31%, voice 40% vs 19% and 19%, swallow 21% vs 6% and 12%). VHI-10 and EAT-10 scores showed no significant differences between groups.

Conclusions

Patients intubated for COVID-19 pneumonitis reported higher rates of AVS difficulties against non-COVID-19 reasons for intubation. Robust prospective screening protocols are essential to improving patient outcomes by highlighting and therefore managing laryngological sequelae that occur following intubation.

Abelchia: inability to belch/burp-a new disorder? Retrograde cricopharyngeal dysfunction (RCPD)

Case series

This is retrospective case series involving 72 patients who presented with symptoms associated with inability to burp. The following symptoms was described by almost all the patients; retrosternal pain after eating or drinking, bloating feeling in the stomach, gurgling noise in the throat, excessive flatulence. These symptoms are worse with fizzy/carbonated drinks and beer. A full clinical history and examination plus endoscopic and in some cases barium a swallow radiological investigation was done.

Procedure

The surgery was performed under a general anaesthesia for all cases. Suspension pharyngoscopy in supine position using a Weerda diverticuloscope to identify the cricopharyngeal bar muscle. High dose of botulinum toxin A (botox) 100 iu was injected into the cricopharynxgeus muscle under a general anaesthesia.

Results

A total of 72 patients were diagnosed and undergone surgery between November 2016 and December 2020. There were 50 male and 22 female patients. Their average age was 30 (range 18–68 years old). All patients were able to burp again within first 4 weeks of the injection. This persisted even after the Botox worn off beyond the 3 months in 96% of cases. The average follow-up was 24 months post injection with longest follow-up 48 months (range 1–48 months).

Conclusion

The author reported a new condition of inability to burp due to failure of the cricopharyngeal sphincter to relax spontaneously and outcome of treatment using botulinum toxin A injection into the cricopharyngeus muscle. It is expected that the paralysing action of botulinum toxin injection last approximately 3 months. However, this group of patients seem to be cured even after the effect of the botox is worn off. The author therefore postulated that there might me some neural dysfunction that inhibits the brain to send signals to the cricopharyngeal sphincter to initiate burping. Once burping is re-established with the help of botox injection, spontaneous burping seems to occur and sustained even after the botox is worn off.

Virtual voice clinics in the COVID-19 era: have they been helpful?

Purpose

In response to the coronavirus pandemic, a tertiary combined Laryngology-Speech Therapy voice clinic was converted to a wholly virtual clinic, with consultations carried out via telephone or video. The aim of our mixed method study was to assess (a) how effective are virtual clinics vs face-to-face clinics in progressing patients’ care and (b) what is patient satisfaction with virtual consultation methods.

Methods

Analysis of clinic data from patient databases for both virtual and face-to-face clinics was carried out. A patient satisfaction survey was carried out by 75 of the patients who had attended virtual clinics.

Results

There was statistically a significant difference (p value < 0.01) in the proportion of patients prescribed medical therapy, referred for Speech and Language Therapy (SALT) or listed for surgery in the virtual clinic by comparison to the face-to-face clinic. 75 patients completed the questionnaire. 98% of patients were satisfied overall with the virtual method of consultation. 84% believed they would still benefit from face-to-face review. 83% would like the option of a virtual type of clinic in the future.

Conclusion

Our data clearly demonstrates that face-to-face clinics are superior to virtual clinics, with almost no patients progressed to surgery in virtual consultations. Despite this, virtual methods are still valuable, and many patients have meaningful progression of care. In current circumstances, patients have very high satisfaction with virtual consultations and certain groups have been identified as particularly benefiting. Going forward, an ideal clinic may be a hybrid of face-to-face and virtual appointments as clinically indicated.

Non-aesthetic uses of botulinum toxin in the head and neck

INTRODUCTION

The use of botulinum toxin in the specialty of aesthetic surgery in the head and neck is well known. However, it has also been used for other conditions affecting the head and neck, and in recent years its use, as well as the number of relevant applications, has expanded enormously.

REVIEW

This article presents a summary of the current range of uses in the laryngeal, pharyngeal, cervical, oromandibular and facial muscles and salivary glands. We highlight particular conditions focusing on dystonia (laryngeal, craniocervical, oromandibular and cervical), multiple system atrophy, migraines, facial nerve palsy, post-laryngectomy, cricopharyngeal dysphagia, Zenker's diverticulum, retrograde cricopharyngeal dysfunction disorder, sialorrhea and gustatory sweating (Frey's syndrome).

CONCLUSION

This article should aid the ear, nose and throat surgeon garner knowledge about the range of uses for botulinum toxin in the head and neck.

Use of proton pump inhibitors to treat persistent throat symptoms: multicentre, double blind, randomised, placebo controlled trial

OBJECTIVE

To assess the use of proton pump inhibitors (PPIs) to treat persistent throat symptoms.

DESIGN

Pragmatic, double blind, placebo controlled, randomised trial.

SETTING

Eight ear, nose, and throat outpatient clinics, United Kingdom.

PARTICIPANTS

346 patients aged 18 years or older with persistent throat symptoms who were randomised according to recruiting centre and baseline severity of symptoms (mild or severe): 172 to lansoprazole and 174 to placebo.

INTERVENTION

Random blinded allocation (1:1) to either 30 mg lansoprazole twice daily or matched placebo twice daily for 16 weeks.

MAIN OUTCOME MEASURES

Primary outcome was symptomatic response at 16 weeks measured using the total reflux symptom index (RSI) score. Secondary outcomes included symptom response at 12 months, quality of life, and throat appearances.

RESULTS

Of 1427 patients initially screened for eligibility, 346 were recruited. The mean age of the study sample was 52.2 (SD 13.7) years, 196 (57%) were women, and 162 (47%) had severe symptoms at presentation; these characteristics were balanced across treatment arms. The primary analysis was performed on 220 patients who completed the primary outcome measure within a window of 14-20 weeks. Mean RSI scores were similar between treatment arms at baseline: lansoprazole 22.0 (95% confidence interval 20.4 to 23.6) and placebo 21.7 (20.5 to 23.0). Improvements (reduction in RSI score) were observed in both groups-score at 16 weeks: lansoprazole 17.4 (15.5 to19.4) and placebo 15.6 (13.8 to 17.3). No statistically significant difference was found between the treatment arms: estimated difference 1.9 points (95% confidence interval -0.3 to 4.2 points; P=0.096) adjusted for site and baseline symptom severity. Lansoprazole showed no benefits over placebo for any secondary outcome measure, including RSI scores at 12 months: lansoprazole 16.0 (13.6 to 18.4) and placebo 13.6 (11.7 to 15.5): estimated difference 2.4 points (-0.6 to 5.4 points).

CONCLUSIONS

No evidence was found of benefit from PPI treatment in patients with persistent throat symptoms. RSI scores were similar between the lansoprazole and placebo groups after 16 weeks of treatment and at the 12 month follow-up.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN38578686 and EudraCT 2013-004249-17.

Lansoprazole for persistent throat symptoms in secondary care: the TOPPITS RCT

BACKGROUND

Persistent throat symptoms are commonly attributed to 'laryngopharyngeal reflux'. Despite a limited evidence base, these symptoms are increasingly being treated in primary care with proton pump inhibitors.

OBJECTIVE

To assess the value of proton pump inhibitor therapy in patients with persistent throat symptoms.

DESIGN

This was a double-blind, placebo-controlled, randomised Phase III trial.

SETTING

This was a multicentre UK trial in eight UK ear, nose and throat departments.

PARTICIPANTS

A total of 346 participants aged ≥ 18 years with persistent throat symptoms and a Reflux Symptom Index score of ≥ 10, exclusive of the dyspepsia item, were recruited.

INTERVENTION

Random allocation (1 : 1 ratio) to either 30 mg of lansoprazole twice daily or matched placebo for 16 weeks.

MAIN OUTCOME MEASURE

Symptomatic response (i.e. total Reflux Symptom Index score after 16 weeks of therapy).

RESULTS

A total of 1427 patients were screened and 346 were randomised. The mean age was 52 years (standard deviation 13.7 years, range 20-84 years); 150 (43%) participants were male and 196 (57%) were female; 184 (53%) participants had a mild Reflux Symptom Index minus the heartburn/dyspepsia item and 162 (47%) had a severe Reflux Symptom Index minus the heartburn/dyspepsia item. A total of 172 patients were randomised to lansoprazole and 174 were randomised to placebo.

MAIN OUTCOMES

A total of 267 participants completed the primary end-point visit (lansoprazole, n = 127; placebo, n = 140), of whom 220 did so between 14 and 20 weeks post randomisation ('compliant' group); 102 received lansoprazole and 118 received placebo. The mean Reflux Symptom Index scores at baseline were similar [lansoprazole 22.0 (standard deviation 8.0), placebo 21.7 (standard deviation 7.1), overall 21.9 (standard deviation 7.5)]. The mean Reflux Symptom Index scores at 16 weeks reduced from baseline in both groups [overall 17.4 (standard deviation 9.9), lansoprazole 17.4 (standard deviation 9.9), placebo 15.6 (standard deviation 9.8)]. Lansoprazole participants had estimated Reflux Symptom Index scores at 16 weeks that were 1.9 points higher (worse) than those of placebo participants (95% confidence interval -0.3 to 4.2; padj = 0.096), adjusted for site and baseline severity.

SECONDARY OUTCOMES

Ninety-five (43%) participants achieved a Reflux Symptom Index score in the normal range (< 12) at 16 weeks: 42 (41%) in the lansoprazole group and 53 (45%) in the placebo group. A total of 226 participants completed the end-of-trial follow-up visit (lansoprazole, n = 109; placebo, n = 117), of whom 181 were 'compliant'. The mean Reflux Symptom Index scores at 12 months reduced from baseline in both groups [lansoprazole 16.0 (standard deviation 10.8), placebo 13.6 (standard deviation 9.6), overall 14.7 (standard deviation 10.2)]. A total of 87 (48%) participants achieved a Reflux Symptom Index score in the normal range at 12 months: 33 (40%) in the lansoprazole group and 54 (55%) in the placebo group. Likewise, the Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life total scores and subscales all showed very similar changes in the lansoprazole and placebo cohorts at both 16 weeks and 12 months.

LIMITATIONS

Drop-out rate and compliance are issues in pragmatic clinical trials. The Trial Of Proton Pump Inhibitors in Throat Symptoms (TOPPITS) aimed to detect clinically relevant difference with 90% power. The 346 randomised participants reduced to 283 at the primary end point; 267 completed the primary outcome measure, 220 within the protocol time scale. Despite this, the powers to detect the clinically relevant difference in Reflux Symptom Index score at 16 weeks were 82% (compliant comparison) and 89% (pragmatic comparison). The lack of difference between lansoprazole and placebo is generalisable across NHS clinics.

CONCLUSIONS

Participants on lansoprazole did not report significantly better outcomes than participants on placebo on any of the three patient-reported outcome tools (Reflux Symptom Index, Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life). This multicentre, pragmatic, powered, definitive Phase III trial found no evidence of benefit for patients by treating persistent throat symptoms with lansoprazole.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN38578686 and EudraCT number 2013-004249-17.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 3. See the NIHR Journals Library website for further project information.

Applications of Office-Based 445 nm Blue Laser Transnasal Flexible Laser Surgery: A Case Series and Review of Practice

BACKGROUND

The recent introduction of 445 nm blue laser to office-based laryngology presents potential advantages. These include a desirable combination of cutting and photoangiolytic qualities and a lightweight, shock-resistant design. Despite its increasing use, current evidence is limited to experimental data and case reports.

OBJECTIVES

The authors present a case series and overview of office blue laser transnasal flexible laser surgery (TNFLS), considering indications, patient selection, safety, technique, and surgical outcomes. We also review the safety and relevance of TNFLS to the ongoing coronavirus pandemic.

METHODS

Retrospective case series and narrative review. Our primary outcome measure was preoperative and postoperative Voice Handicap Index (VHI-10) score. Complications were documented by nature and severity.

RESULTS

Thirty-six cases of office blue laser TNFLS were performed. A statistically significant improvement in VHI-10 score was demonstrated in cases of recurrent respiratory papillomatosis (RRP) and benign laryngeal lesions causing dysphonia (P < 0.01 and 0.045). Blue laser also proved effective in assisting office biopsy procedures. A minor and self-limiting complication was reported.

CONCLUSIONS

Office blue laser TNFLS is safe and effective in the treatment of RRP and a range of benign laryngeal lesions. Future research should compare the efficacy and safety of blue laser with potassium titanyl phosphate laser in office-based treatment of these conditions. Further assessment of the cutting qualities of blue laser, initially in the theater environment, is necessary to refine our understanding of future applications.

Tracheostomy care and decannulation during the COVID-19 pandemic. A multidisciplinary clinical practice guideline

Purpose

Traditional critical care dogma regarding the benefits of early tracheostomy during invasive ventilation has had to be revisited due to the risk of COVID-19 to patients and healthcare staff. Standard practises that have evolved to minimise the risks associated with tracheostomy must be comprehensively reviewed in light of the numerous potential episodes for aerosol generating procedures. We meet the urgent need for safe practise standards by presenting the experience of two major London teaching hospitals, and synthesise our findings into an evidence-based guideline for multidisciplinary care of the tracheostomy patient.

Methods

This is a narrative review presenting the extensive experience of over 120 patients with tracheostomy, with a pragmatic analysis of currently available evidence for safe tracheostomy care in COVID-19 patients.

Results

Tracheostomy care involves many potentially aerosol generating procedures which may pose a risk of viral transmission to staff and patients. We make a series of recommendations to ameliorate this risk through infection control strategies, equipment modification, and individualised decannulation protocols. In addition, we discuss the multidisciplinary collaboration that is absolutely fundamental to safe and effective practise.

Conclusion

COVID-19 requires a radical rethink of many tenets of tracheostomy care, and controversy continues to exist regarding the optimal techniques to minimise risk to patients and healthcare workers. Safe practise requires a coordinated multidisciplinary team approach to infection control, weaning and decannulation, with integrated processes for continuous prospective data collection and audit.

Orbital abscess as a complication of Pott's puffy tumour in an adolescent male

Pott's puffy tumour (PPT) is a known complication of frontal sinusitis. It is defined as subperiosteal abscess formation due to osteomyelitis of the frontal bone presenting as a forehead swelling. It is a life-threatening condition that can lead to intracranial and intraorbital complications. Gadolinium-enhanced MRI and contrast CT scan are the best modalities to localise and define the collection, in addition to confirming disease extension. Once confirmed by imaging and depending on disease extension, management of PPT requires a multidisciplinary team approach and depends on the local provision of surgical care. Following surgical drainage of the abscess cavity, a prolonged course of antibiotics is required postoperatively to treat the underlying osteomyelitis.

Does laryngeal reinnervation or type I thyroplasty give better voice results for patients with unilateral vocal fold paralysis (VOCALIST): study protocol for a feasibility randomised controlled trial

INTRODUCTION

A functioning voice is essential for normal human communication. A good voice requires two moving vocal folds; if one fold is paralysed (unilateral vocal fold paralysis (UVFP)) people suffer from a breathy, weak voice that tires easily and is unable to function normally. UVFP can also result in choking and breathlessness. Current treatment for adults with UVFP is speech therapy to stimulate recovery of vocal fold (VF) motion or function and/or injection of the paralysed VF with a material to move it into a more favourable position for the functioning VF to close against. When these therapies are unsuccessful, or only provide temporary relief, surgery is offered. Two available surgical techniques are: (1) surgical medialisation; placing an implant near the paralysed VF to move it to the middle (thyroplasty) and/or repositioning the cartilage (arytenoid adduction) or (2) restoring the nerve supply to the VF (laryngeal reinnervation). Currently there is limited evidence to determine which surgery should be offered to adults with UVFP.

METHODS AND ANALYSIS

A feasibility study to test the practicality of running a multicentre, randomised clinical trial of surgery for UVFP, including: (1) a qualitative study to understand the recruitment process and how it operates in clinical centres and (2) a small randomised trial of 30 participants recruited at 3 UK sites comparing non-selective laryngeal reinnervation to type I thyroplasty. Participants will be followed up for 12 months. The primary outcome focuses on recruitment and retention, with secondary outcomes covering voice, swallowing and quality of life.

ETHICS AND DISSEMINATION

Ethical approval was received from National Research Ethics Service-Committee Bromley (reference 11/LO/0583). In addition to dissemination of results through presentation and publication of peer-reviewed articles, results will be shared with key clinician and patient groups required to develop the future large-scale randomised controlled trial.

TRIAL REGISTRATION NUMBER

ISRCTN90201732; 16 December 2015.

The trumpet player with a swelling in the neck

Bilateral neck swelling in patients following valsalva manouveres could lead to a diagnosis of either a pharyngocele or laryngocele. Distinguishing between them can be complicated but is vital given the possibility for an acute airway in patients with laryngoceles. A 20-year-old trumpet player presents with a 5-year history of neck swelling. Clinical suspicion is that of a pharyngocele but imaging introduces some confusion with the diagnosis. Both pharyngoceles and laryngoceles can occur as a result of prolonged positive pressure. Accurate assessment with fibreoptic examination and imaging is needed to confirm the diagnosis. Pharyngoceles are often misdiagnosed as laryngoceles. Though treatment is similar between the two patient groups it is vital that a distinction is made to enable careful observation of the airway in patients with laryngoceles.

An Audit of Adherence to SIGN Guidelines for Tonsillectomies: Completion of Third Cycle

Objective: It is important to ensure that our listing practice for tonsillectomy is in keeping with the best evidence available, as stated by the Scottish Intercollegiate Guidelines Network (SIGN). We audited the accuracy of documentation of the SIGN guideline indications for tonsillectomies to ensure appropriate listing of such patients.

Method: Medical notes of patients with recurrent tonsillitis presenting to our department were reviewed retrospectively to check for documentation of the SIGN indication for tonsillectomy. Three audit cycles were carried out, each over a 3-month period.

Results: Prior to intervention, only 51% (25/51) patients undergoing tonsillectomy had documented evidence of adherence to SIGN guidelines for surgery. Interventions following the first audit cycle included presentation of audit findings, introduction of guideline templates for doctors to complete, and recruitment of medical secretaries to return the notes to doctors if documentation was incomplete. Postintervention, audit cycles 2 and 3 showed respectively 100% (30/30), and 92% (36/39) of patients had documented evidence of adherence.

Conclusion: The introduction of a simplistic model of intervention as above improved the local adherence to SIGN guidance for tonsillectomy and translated to safe and better care for patients. This model is easily replicable and can be used in other ENT departments to improve patient care.

Audit of Flexible Nasoendoscope Decontamination: Clinical Efficacy and Cost Effectiveness

Objective: There are various methods available for flexible nasoendoscope decontamination. Department of Health, United Kingdom, advocates the use of an automated washer, as it has the advantage of reducing errors resulting from variability of human practice. We aim to compare the efficacy and cost effectiveness of chlorine dioxide wipes versus the automated washer.

Method: The tip of a flexible nasoendoscope is immersed into a Staphylococcus epidermidis culture, with bacteriological swabs taken from the tip before immersion and after the process of decontamination with either chlorine dioxide wipes or automated wash. Bacteriological swabs are then checked for growth of STE. Cost calculation is performed.

Results: Postdecontamination, samples from chlorine dioxide wipes showed 2% (1 out of 50 swabs) growth of STE as opposed to 28% (14/50) from the automated wash. P = .00. On a 10-year cost calculation, the automated wash had a lower cost.

Conclusion: From the study, wipes are more efficacious in decontamination compared with the washer. However, the automated washer costs less. Further studies should also be performed on real patients to check the significance of improper decontamination and the actual risk of disease transmission.

Observational study of bone-anchored hearing aid infection rates using different post-operative dressings

Introduction: Avoidance of infection at the implant site is a crucial element to the success of bone-anchored hearing aid (BAHA) implantation. However, little evidence exists to suggest the best post-operative wound dressing to use.

Material and methods: We report our experience with 160 consecutive BAHA patients, using four types of post-operative BAHA wound dressing (Tri-adcortyl®, Mepitel®, Allevyn®, and Acticoat 7® with Allevyn). Patients were reviewed at week one and week two post-operatively. Infection was defined as a positive wound swab culture or evidence of cellulitis at the BAHA site.

Results: Post-operative BAHA infection rates were 16 per cent, 50 per cent, 10 per cent and 5 per cent, for each of the four dressings respectively, and the mean number of additional visits to wound care clinic were 1.5, 3.7, one and 0.4, respectively.

Discussion: Acticoat 7 with Allevyn produced the lowest infection rate and thus became the dressing of choice for our BAHA programme.

Recurrent periorbital cellulitis in a child. A random event or an underlying anatomical abnormality?

We present a case of recurrent periorbital cellulitis in a child. From the age of 2 years the child was admitted with periorbital cellulitis a total of six times with the first five episodes responding to conservative management with intravenous antibiotics. On the sixth admission endoscopic surgical treatment was carried out. Two abnormalities were noted: an anatomically abnormal uncinate process and an isolated abscess in an ethmoidal cell. It is believed that the abnormal uncinate process caused obstruction of the osteomeatal area, predisposing to recurrent peri-orbital cellulitis. We discuss the importance of early imaging and surgery in recurrent periorbital cellulitis.

A systematic approach to the nasendoscopic examination of the larynx and pharynx

Several nasendoscopic techniques have been described to improve the view of different anatomical subsites when assessing the laryngopharynx. A prospective study was undertaken to compare and evaluate the views obtained with each of the different techniques employed in the nasendoscopic examination of the upper aero-digestive tract. No visualization manoeuvres were found to be beneficial in improving the view of the tongue base; however, tongue protrusion did improve the view of the valleculae. Both the post-cricoid and the upper oesophageal sphincter were best seen when the trumpet manoeuvre was performed along with skin traction of the anterior neck. Pyriform apices were best viewed when the trumpet manoeuvre was coupled with head turn - a manoeuvre we believe not to have been recorded in the literature previously with respect to this topic. The authors present a systematic routine for examining the upper aero-digestive tract by nasendoscope on the basis of obtaining the best view for each anatomical subsite.

Upper airway obstruction resulting from an antiemetic

Stridor and stertor can both be the cause of medical and surgical emergencies. The management of these conditions is largely dependent upon the underlying aetiology. This case report describes dystonia following prochlorperazine resulting in stridor and stertor.