One‐stop neck lump clinic: phase 2 of audit. How are we doing?

One‐stop neck lump clinic: phase 2 of audit. How are we doing? Regular monitoring and audit of a service are integral to ensuring maintenance of efficiency and standards. This is particularly important where the quality of the service is operator dependent, as is the case in the clinical diagnosis of neck lumps and fine needle aspiration cytology. The one‐stop neck lump clinic has now been running in the department for more than 20 months. A previous article described the results of the first phase audit carried out at 6 months and had identified a waiting time to be seen that was longer than that recommended by the British Association of Otorhinolaryngologists, Head and Neck Surgeons. Measures were implemented to reduce this waiting time and a second audit was carried out after another 10 months with the aims of assessing if modification of the means of referral reduces waiting time and if the outcomes of clinical performance in phase 1 could be maintained or improved. We discuss the results of phase 2 in the audit spiral.     

A Decrease in Maxillary Sinus Pressure,as Seen in Upper Airway Allergy or Infection,Results in an Increase in Upper Airway Nitric Oxide Levels

The paranasal sinuses are connected to the nasal cavity via small osties. Ostial occlusion, caused by mucosal swelling, will result in a slowly increasing negative pressure inside the sinus cavity. In parallel, the oxygen content in the sinus will decrease, resulting in the development of relative hypoxia. Hypoxia is a powerful inducer of nitric oxide (NO) synthase, and inducible NO synthase has been shown to be present in considerable amounts in the upper airways, including the sinuses. The present study was designed to investigate whether a reduction in sinus pressure would affect upper airway NO production. Thirteen healthy volunteers were investigated. A pressure chamber was used to lower the ambient pressure to-4.9 kPa. NO was sampled from one nostril or via a drainage tube inserted into the maxillary sinus before, during and after the hypobaric exposure. When the pressure was decreased, NO levels increased from 256 &#45 15 to 316 &#45 19 ppb ( n =13, p <0.001). The NO levels remained elevated (282 &#45 21 ppb; p <0.05) when measurements were repeated 20 min after leaving the chamber. The nasal airway resistance (V2 tot ) also increased as a result of the chamber session (from 16 &#45 2° before to 21 &#45 3° after; p <0.05). An increase in NO levels was also found when the experiments were repeated with NO sampled directly from the maxillary sinus (225 &#45 6 before and 265 &#45 9 ppb after; n =6, p <0.001). For control purposes the nasal analyses were repeated again, this time under hyperbaric conditions (+4.9 kPa). This resulted in a slight decrease in the NO levels (from 273 &#45 22 to 241 &#45 17 ppb; n =10, p <0.001), but there was no change in the nasal airway resistance. We conclude that a reduction in sinus pressure, as seen in upper airway allergy or infection, may result in an increase in upper airway NO production.     

Treatment of Maxillary Sinus Carcinoma: Clinical Results Using the Kitasato Modality

The conventional therapeutic regimen for maxillary sinus carcinoma consists of dissection of the maxilla, full-dose irradiation and extensive chemotherapy. However, the results obtained with this treatment are often poor. Even when patients recover, their quality of life is significantly reduced as a result of deformity of facial structures and swallowing and articulation dysfunctions. A retrospective analysis of 68 patients with maxillary sinus carcinoma treated with the Kitasato modality between 1975 and 1999 was conducted. All patients underwent pergingival maxillary sinus surgery combined with pre- and postoperative irradiation therapy with standardized total doses of 16 Gy; the postoperative irradiation was given in combination with regional intra-arterial infusion chemotherapy administered via the superficial temporal artery. All visible tumor lesions were removed where possible in order to preserve or facilitate cellular immunity after surgery. The cumulative 5-year survival rates were 85.7% for Stage II patients, 88.1% for Stage III, 76.6% for Stage IVA and 75.0% for Stage IVB.     

Tongue Base Reduction with Temperature-controlled Radiofrequency Volumetric Tissue Reduction for Treatment of Obstructive Sleep Apnea Syndrome

In recent years a considerable effort has been made to establish the use of different surgical techniques for the treatment of obstructive sleep apnea syndrome (OSAS). Nevertheless, treatment of hypopharyngeal obstruction due to tongue base hypertrophy remains in many ways an unsolved problem. The aim of this study was to evaluate the safety and efficacy of tongue base reduction with temperature-controlled radiofrequency volumetric tissue reduction in the treatment of OSAS. Twenty patients with OSAS and tongue base hypertrophy were treated with radiofrequency tissue ablation. An intensified treatment protocol was used, delivering 2,800 J per treatment session under local anesthesia. Two nights of polysomnography testing were performed before and after treatment. Daytime sleepiness, snoring and postoperative morbidity were assessed using questionnaires. Mean respiratory disturbance index (RDI) was reduced from 32.1 to 24.9/h after a mean of 3.4 treatment sessions. Six patients (33%) were cured after the procedure (reduction in RDI of &#83 50% and a postoperative RDI of <15/h) and ten (55%) showed an improvement of >20% in their RDI. Daytime sleepiness and snoring improved significantly. Peri- and postoperative morbidity was low; one severe complication occurred (tongue base abscess). We were able to achieve similar cure and responder rates to those reported in a recently published pilot study but with a reduced number of treatment sessions. We believe that this technique may improve patient acceptance and have beneficial cost implications.     

A simple objective evaluation and grading for facial paralysis outcomes

Matrix metalloproteinase (MMP)-2 and -9 degrade type IV collagen, which is one of the major components of the basement membrane in normal tissue and expressed in the surroundings of the cancer nest in squamous cell carinoma. The degeneration of type IV collagen is an essential step in the metastasis to lymph nodes and distant organs. In this study, we examined MMP-2 and -9 levels of cancer tissue and serum obtained from patients with head and neck squamous cell carcinoma (HNSCC) in order to evaluate the relationship between the clinicopathologic features and MMPs. We examined the production of MMP-2 and -9 in cancer tissue homogenates of 73 patients who had HNSCC and the serum MMP levels of 16 patients with HNSCC and 8 healthy volunteers. We also studied the localization of MMP-2 in the carcinoma using an immunohistochemical approach. The concentrations of MMP-2 and -9 in the tissue homogenates and serum were measured by means of a sandwich enzyme immunoassay using a monoclonal antibody. Immunohistochemical analyses were performed with monoclonal antibody to MMP-2. The concentration of MMP-2 in the tumor tissue homogenates was unrelated to tumor size, but that in patients with lymph node metastases was significantly higher than in those without lymph node metastases. The concentration of MMP-9 was unrelated to lymph node metastasis and tumor size. The levels of both MMP-2 and -9 in serum were unrelated to lymph node metastasis. Immunohistochemistry indicated that MMP-2 was mainly expressed in cancer cells. Because MMP-2 degrades type IV collagen, the level of MMP-2 in carcinomas may be a useful indicator of the degree of invasion and metastasis.     

A case of cortical deafness and anarthria

The nasal epithelium protects the underlying tissue from damage. Epithelial cell growth is controlled by epidermal growth factor (EGF) and is possibly affected by toxic proteins, e.g. eosinophil cationic protein (ECP). The aims of this study were to examine nasal fluid epithelial cell counts and their relations to EGF, eosinophils and ECP in 23 patients with seasonal allergic rhinitis and 20 healthy controls. Nasal fluid epithelial cell counts were lower in patients than in controls. EGF levels did not differ between patients and controls, and correlated with epithelial cell counts in controls but not in patients. Eosinophils and ECP were higher in patients than in controls, but did not correlate with epithelial cell counts. The role of growth factors, such as EGF, in regulating epithelial cells merits further study.     

Bilateral versus unilateral cochlear implantation in young children

Objectives

To compare the preverbal communication skills of two groups of young implanted children: those with unilateral implantation and those with bilateral implantation.

Material and methods

The study assessed 69 children: 42 unilaterally and 27 bilaterally implanted with age at implantation less than 3 years. The preverbal skills of these children were measured before and 1 year after implantation, using Tait Video Analysis that has been found able to predict later speech outcomes in young implanted children.

Results

Before implantation there was no significant difference between the unilateral group and the bilateral group. There was still no difference at 12 months following implantation where vocal autonomy is concerned, but a strongly significant difference between the groups for vocal turn-taking and non-looking vocal turns, the bilateral group outperforming the unilateral group. Regarding gestural turn-taking and gestural autonomy, there was a strongly significant difference between the two groups at the 12 month interval, and also a difference before implantation for gestural autonomy, the unilateral group having the higher scores. Multiple regression of non-looking vocal turns revealed that 1 year following implantation, bilateral implantation contributed to 51% of the variance (p < 0.0001), after controlling for the influence of age at implantation and length of deafness which did not reach statistical significance.

Conclusions

Profoundly deaf bilaterally implanted children are significantly more likely to use vocalisation to communicate, and to use audition when interacting vocally with an adult, compared with unilaterally implanted children. These results are independent of age at implantation and length of deafness.     

Correction of the Glosso-Larynx and Resultant Positional Changes of the Hyoid Bone and Cranium

In ankyloglossia with deviation of the epiglottis and larynx (ADEL) the tongue is located forward and as a result the epiglottis is elevated and leans towards the mouth. The larynx is also raised and curves ventrally. Various symptoms have been observed as a result of this condition. Correction of the glosso-larynx (CGL) is the operation performed to treat ADEL. The CGL procedure and the results obtained with it are reported in this paper. In addition, we studied the following six parameters using head and neck X-rays before and after CGL (the changes in these parameters as a result of CGL are shown in parentheses): ( i ) the shortest vertical length between the hyoid bone and mandible (+10.3 mm); ( ii ) the vertical length between the hyoid bone and the tangent line of C2-4 (+4.6 mm); ( iii ) the shortest length between the hyoid bone and the chin (+2.9 mm); ( iv ) the angle between the hyoid bone and the tangent line of C2-4 (+3.3°); ( v ) the length of H-M, where H is the intersection of a tangent line of C2-4 and a vertical line from the hyoid bone and M is the intersection of a tangent line of C2-4 and the mandible (+7.4 mm); and ( vi ) the width of the narrowest part of the hypopharynx (+3.0 mm). The changes in all the measured parameters after CGL were significantly different ( p <0.05).     

Carcinoma of the Nasopharynx: Analysis of Treatment Results in 91 Patients

The outcome of 91 patients (69 males, 22 females; age range 16-82 years) with nasopharyngeal carcinoma treated in our hospital between 1971 and 1999 was evaluated. Factors that appeared to influence prognosis were assessed using the Kaplan -Meier method. The cause-specific cumulative 5-year survival rate for the entire study population was 61.2%. The 1997 International Union Against Cancer classification was used for disease staging. The 5-year survival rates were as follows: 66.7% ( n ¾ 3) for Stage I; 100% ( n ¾ 2) for Stage IIA; 90.9% ( n ¾ 11) for Stage IIB; 78.8% ( n ¾ 25) for Stage III; 53.0% ( n ¾ 29) for Stage IVA; 37.5% ( n ¾ 16) for Stage IVB; and 20.0% ( n ¾ 5) for Stage IVC. The disease-free cumulative 3-year survival rates of the patients classified based on initial therapy were as follows: radiation alone, 50.0% ( n ¾ 28); combined radiotherapy and chemotherapy that included an undefined anti-cancer drug, 67.2% ( n ¾ 39); combined radiotherapy and chemotherapy that included carboplatin (CBDCA), 92.3% ( n ¾ 19). These results showed a statistically significant difference ( p ¾ 0.043; log-rank test). Stage IVC patients were excluded from the analysis. We conclude that combined therapy, including chemotherapy with CBDCA, is necessary for the treatment of nasopharyngeal carcinoma. In terms of radiation therapy, a field covering the bilateral cervical regions seemed to produce favorable results, even if cervical node metastasis was not confirmed by palpation at the first hospital visit.     

Treatment Effects in Patients with Squamous Cell Carcinoma of the Oral Cavity

A total of 221 patients (155 males, 66 females; stage I, n ¾ 55; stage II, n ¾ 58; stage III, n ¾ 57; stage IV, n ¾ 51) with squamous cell carcinoma of the oral cavity were studied. Tumor localization was as follows: cancer of the tongue, n ¾ 161; cancer of the oral floor, n =28; cancer of the hard palate, n ¾ 12; cancer of the buccal mucosa, n ¾ 11; and cancer of the gingiva, n ¾ 9. In order to compare the effect of different treatments, three major treatment groups were defined, namely a surgery group, a radiotherapy group and a combination treatment group. Five-year cumulative survival rates showed significant differences between stage classifications (stage I=91%, stage II=73%, stage III=63%, stage IV=47%; p <0.01) but not between tumor sites. The 5-year cumulative survival rate was highest for oral floor cancer (80%). In the early-cancer group, the 5-year cumulative survival rate for the surgery group (92%) was significantly higher ( p <0.05) than those for both the radiation (69%) and combination (71%) groups. In the advanced-cancer group, the 5-year cumulative survival rate for the surgery group (74%) was significantly higher ( p <0.05) than those for both the radiation (37%) and combination (51%) groups. No significant difference in regional control rates was observed between the treatment groups. Five-year regional control rates were 86% for cervical untreated patients with T1N0 tumors and 60% for cervical untreated patients with T2N0 tumors. Fourteen N0 cases were treated with neck dissection. Cervical metastasis was found pathologically in 2/14 (14%) of these cases. The 5-year survival rate for patients with cervical recurrences after primary tumor resection was 70% ( n ¾ 15). In contrast, the 5-year survival rate for patients with both primary tumor resection and neck dissection was 74% ( n ¾ 14) but no significant difference was observed between these 2 groups.rate .     

Autoimmunity in Sudden Sensorineural Hearing Loss: Possible Role of Anti-endothelial Cell Autoantibodies

In order to verify whether anti-endothelial cell autoantibodies (AECAs) can be used as serological markers of inner ear vasculitis in sudden sensorineural hearing loss (SSHL), 32 patients affected by idiopathic SSHL were investigated. All patients underwent a routine general physical examination and extensive audiovestibular, microbiological and immunological investigations. Fourteen normal subjects without a history of HL, autoimmune or metabolic disease served as controls. Detection of AECAs was performed using an indirect immunofluorescence technique. AECA-positive patients were treated with methylprednisone, while AECA-negative patients were treated with a combined regimen of steroids, plasma expander and aspirin. The average hearing recovery for 5 frequencies (0.25-4 kHz) was analyzed in each subject 1 month after treatment and every 3 months thereafter; median follow-up was 12 months (range 9-18 months). A total of 15/32 patients (46.8%; 11/19 females, 4/13 males) were AECA-positive and thus differed significantly from the normal population in whom only 2/14 tested cases were positive ( p =0.03). Severe hearing loss was associated with being AECA-positive in 8/11 cases. During follow-up, 25/32 patients improved their hearing and 17 of these patients were AECA-negative. The seven cases without hearing improvement were all AECA-positive. In patients with SSHL, immune-mediated vascular damage may have a pathogenetic role and AECAs may represent a serological marker of vasculitis even if they are not inner ear-specific and even if they represent an epi-phenomenon rather than the only cause of SSHL.     

Otolaryngologists may not be doing enough to diagnose pediatric eosinophilic esophagitis

Objective

To systematically evaluate the diagnosis of eosinophilic esophagitis (EE).

Methods

A retrospective review of 657 patients seen at the EE center of a tertiary care children's hospital between 1994 and 2007 was performed. Charts were reviewed for the 144 patients who were also seen by the otolaryngology service.

Results

One hundred forty-four patients received 193 otolaryngology-related diagnoses. Eustachian tube dysfunction (27.5%) and sleep disordered breathing (24.9%) were the most common, followed by dysphagia (13.0%), rhinosinusitis/nasal congestion (9.3%) and airway stenosis (5.2%). Seventy-nine patients (54.9%) had a pre-existing diagnosis of EE at the time of their otolaryngology consultation. Twenty-one patients (14.6%) were referred to the gastroenterology service for evaluation for EE. Forty-four patients (30.5%) remained undiagnosed. Twenty-five of these patients presented with dysphagia, 16 of whom were not previously diagnosed with EE; only 4 of these 16 patients were referred for evaluation for EE. In one case, a child with moderate sized tonsils underwent adenotonsillectomy for dysphagia and failure to thrive; this patient was diagnosed with EE 1 month post-operatively.

Conclusions

Twenty percent of patients with EE may require care by an otolaryngologist for a myriad of complaints. Even experienced pediatric otolaryngologists may not recognize this condition. Otolaryngologists should consider EE in patients presenting with dysphagia. A careful gastroenterology review of symptoms may also allow otolaryngologists to identify EE in patients with allergy mediated nasal complaints, or laryngeal/airway disorders.     

Congenital nasal masses: diagnosis and management

One hundred and nine congenital nasal masses which presented to two children's hospitals over a 20 year period are reviewed. The diagnosis of the nasal mass is discussed with respect to age, mode of presentation, and site of the lesion, and a management protocol is advocated.     

Reverse Optokinetic After-nystagmus Generated by Gaze Fixation During Optokinetic Stimulation

Gaze fixation during optokinetic stimulation generates an after-nystagmus with a slow component towards the reverse direction of the optokinetic stimulation. The duration and maximum slow component velocity (SCV) of this "reverse OKAN" were observed by changing the duration, velocity and direction of the optokinetic stimulation in nine normal volunteers. The duration of reverse OKAN increased with increasing stimulation time but was unaffected by changes in the stimulation velocity. The maximum SCV of reverse OKAN decreased with an increase in the stimulation velocity but was not significantly affected by changes in the optokinetic stimulation time. There was no directional difference among the horizontal, upwards and downwards reverse OKANs. The reverse OKAN was thought to be generated by a mechanism different from the velocity storage mechanism which produced optokinetic nystagmus and the first phase of OKAN. Retinal slip during the optokinetic stimulation was considered to be an input to the mechanism which generated the reverse OKAN. We hypothesize that the mechanism causing the reverse OKAN may be a generator of the second phase of OKAN, which was also intimately connected with self-motion sensation during the optokinetic stimulation.     

鼻用激素预防治疗变应性鼻炎临床研究

目的观察症状发作前4周使用布地奈德鼻喷剂预防治疗蒿属花粉过敏变应性鼻炎（AR）的效果。方法选择变应原为蒿属花粉的中重度持续性AR患者40例,随机分为2组,预防治疗组按照患者既往发作时间提前4周予以布地奈德喷鼻,对照组不予任何处理,定期随访。症状发作患者均予以布地奈德喷鼻和氯雷他定口服治疗。所有患者用药坚持至发作期后2个月,采用日记卡形式记录每天鼻部、眼部症状分数,并定期采用鼻结膜炎相关生活质量问卷（rhinoconjunctivitis quality of life questionnaire,RQLQ）评价对生活质量影响。结果预防治疗组发作7例,对照组全部发作,预防治疗组发作患者中发作时间向后推迟的现象较对照组明显,两组比较差异具有统计学意义（P〈0.001）。预防治疗组发作时鼻部、眼部症状及生活质量影响明显轻,较对照组差异有统计学意义（P均〈0.01）。结论症状发作前4周鼻腔局部使用布地奈德预防治疗蒿属花粉过敏AR,能够减少发作例数,推迟发作时间,减轻发作时鼻部及眼部症状,改善生活质量。     

Tissue-engineered human nasal septal cartilage using the alginate-recovered-chondrocyte method

OBJECTIVES: Tissue engineering of nasal septal cartilage has numerous potential applications in craniofacial reconstruction. Chondrocytes suspended in alginate gel have been shown to produce a substantial cell-associated matrix. The objective of this study was to determine whether cartilage tissue could be generated using the alginate-recovered-chondrocyte (ARC) method, in which chondrocytes are cultured in alginate as an intermediate step in tissue fabrication. METHODS: Nasal septal chondrocytes from five patient donors were isolated by enzymatic digestion, then expanded in monolayer culture. At confluency, a portion of those cells were seeded at high density onto a semipermeable membrane and cultured for 14, 21, or 28 days (monolayer group). The remaining cells were suspended in alginate and cultured until a cell-associated matrix was observed (10-17 days). Cells and their associated matrix were released from alginate (ARC group), seeded onto a semipermeable membrane, and cultured as already described. DNA (Hoechst 33258 Assay), glycosaminoglycan (GAG; dimethylmethylene blue assay), and collagen (hydroxyproline assay) were analyzed biochemically. Immunohistochemistry was performed to assess expression of collagens type I and type II. Histochemistry was performed to localize cells accumulating sulfated GAG (Alcian blue stain). RESULTS: The ARC constructs, in contrast to the monolayer constructs, had substantial structural stability and the histologic and gross appearance of cartilaginous tissue. ARC constructs demonstrated significantly greater GAG and collagen accumulation than monolayer constructs (P <.05). Histologic analysis revealed substantial GAG and collagen type II production and only moderate collagen type I production. The composition of the matrix was thus similar to that of native human septal cartilage. CONCLUSIONS: Tissue-engineered human nasal septal cartilage using the ARC method has the histologic and gross appearance of native cartilage and has biochemical composition more like that of native cartilage than monolayer constructs. This is the first report of human nasal septal neocartilage formation without the use of biodegradable scaffolds.