Unilateral tonsillectomy--indications and results

Seventy-six cases of unilateral tonsillectomy performed over the last 20 years are reported. The average age was 3.75 years. Fifty per cent had adenoidectomy. A review of their case notes and of 54 questionnaires returned by parents, asking their opinion of the change in symptoms before operation and two years after operation, showed that they could be allotted into three groups: Group 1 35 cases (65 per cent) had dramatic improvement in the symptoms of allergy, colds, otitis, sore throats, eating, meat eating and sleep. Group 2 of nine cases (17 per cent) had considerable improvement in most symptoms. Group 3 of 10 cases (18 per cent) had minimal improvement. Post-tonsillectomy hypertrophy of the remaining tonsil occurred within two to four years in nine cases, necessitating removal. Four (11 per cent) in Group 1, (22 per cent) in Group 2, and three (30 per cent) in Group 3. The three secondary tonsillectomies in Group 3 gave good results in two cases. In five cases the other tonsil was removed six to 15 years later. This series of cases has demonstrated that a tremendous decrease in incidence of throat and upper respiratory tract infection in young children, apparently prone to infection can occur in over 80 per cent of cases following unilateral tonsillectomy, in spite of the continued presence of the remaining large tonsil.(ABSTRACT TRUNCATED AT 250 WORDS)     

Lateral saccular cysts of the larynx. Aetiology, diagnosis and management

Lateral saccular cysts have been diagnosed in 17 patients. Definitive diagnosis was made by computed tomography (CT) that showed a fluid-filled cystic swelling of the saccule with no air fluid level in all patients. Fifty-three per cent of cysts were bulging through the thyrohyoid membrane. They were hugely enlarged in 18 per cent, moderately enlarged in 24 per cent, and slightly enlarged in 12 per cent of patients. One patient (six per cent) showed bilateral cysts. Lateral saccular cysts were primary in origin in 82 per cent of patients and secondary to prolonged intubation, hemilaryngectomy, and laryngoscleroma in 18 per cent of patients. Surgical excision via a lateral cervical approach was performed in eight patients, whereas endoscopic CO2 laser vestibulectomy was performed in nine patients. Endoscopic vestibulectomy with CO2 laser proved to be an efficient and safe procedure for excision of small and medium-sized cysts with a diameter equal to or less than 3 cm in the greatest dimension. The external approach appears more efficient than laser vestibulectomy in excision of huge cysts, as 22 per cent of patients undergoing laser surgery showed a recurrence.     

Staging and management of primary cerebellopontine cholesteatoma

Primary cerebellopontine angle (CPA) cholesteatoma grows slowly and silently in the subarachnoidal spaces. The diagnosis is often late, when the lesion has reached large dimensions. Surgical removal is the only available therapy. Fifteen consecutive cases of CPA cholesteatoma managed at a tertiary otoneurosurgical referral unit between September 1985 and April 1999 were reviewed. The study population, consisting of seven males and eight females, had a mean age of 44 years of age (range 21-69) at the time of surgery. The clinical, audiological and radiological presentations were examined. The tumours were classified according to the Moffat classification of CPA cholesteatomas. In 67 per cent of cases the presenting symptom was related to the vestibulo-cochlear nerve. The average duration of symptoms was 23 months (ranging from one month-10 years). The hearing preservation approaches were utilized the most (11 cases), while the translabyrinthine approach alone, or in association with a middle fossa craniotomy, was performed in four cases. Tumour removal was total in 12 cases and subtotal in three cases. In cases undergoing hearing preservation surgery the mean pre-operative pure tone average (PTA) for the frequencies 0.5, 1, 2, and 3 kHz was 19.3 dB HL (SD 13.84) and the mean pre-operative speech discrimination score (SDS) was 89.8 per cent (SD 5.97). In 44.4 per cent of patients the hearing was preserved and the mean post-operative PTA was 20.29 dB HL (SD 15.84). In five patients post-operative complications occurred. No peri- or post-operative death occurred in this series, one patient developed a recurrence 15 years after the initial surgery.     

Experiences with ESR (endolymphatic sac revascularization) in cases of sensorineural hearing-loss

Experience based on 14 cases of severe-to-total sensorineural deafness, treated with endolymphatic sac revascularization, operation, is presented. Changes seen in the endolymphatic sacs and lateral sinuses of these patients have been detailed. Irrespective of the degree and duration of deafness, significant hearing gain (with good improvement in speech discrimination) was obtained in nine out of 14 cases (64.28 per cent). There was no improvement at all in one out of 14 (7.14 per cent), and there was a relapse of the hearing-loss two months post-operatively in one case (7.14 per cent). Tinnitus disappeared in the operated ear in three out of five cases (60 per cent) and vertigo improved considerably in four out of six cases (66.66 per cent). The follow-up in this series has been up to two years.     

Endoscopic stapling of pharyngeal pouches in patients from the Yorkshire region

The treatment of pharyngeal pouches by endoscopic stapling diverticulotomy has gained popularity over the last few years. We assessed the results of this technique in 44 patients by means of a clinical questionnaire and by reviewing case records. Thirty-six (82 per cent) patients commenced oral intake within 18 hours of the procedure and 37 (84 per cent) patients were discharged within 48 hours. Five patients had complications that included throat discomfort, a loose incisor tooth, shoulder pain, pharyngeal perforation and one mortality due to mediastinitis. Of the 37 patients that completed the questionnaire, nine (24 per cent) had some residual symptoms although only two (five per cent) felt that there had been no improvement at all following the stapling procedure. Thirty-five (95 per cent) of the patients stated that they would undergo the procedure again. It appears that pharyngeal pouches can be successfully treated by endoscopic stapling, with patients commencing oral intake within a few hours of surgery and having a short hospital stay. However, as there can be serious complications, we recommend that the procedure be performed by an experienced surgeon.     

Laryngeal tuberculosis in the eighties--an Indian experience

Laryngeal tuberculosis is one of the rarer forms of extrapulmonary tuberculosis. A retrospective analysis of 26 patients seen in the last nine years in our hospital was conducted to illustrate the various modes of clinical presentation. Of the 26 patients, twenty were male and six female. The average age of presentation was 47 years with an age range of 15 months to 71 years. Hoarseness (92.3 per cent) was the commonest symptom. The laryngoscopic appearances often simulated malignancy. Most patients (69.2 per cent) had lesions involving the anterior two-thirds of the true vocal cords. Hypertrophic lesions (69.2 per cent) out-numbered ulcerative ones (38.5 per cent). Laryngeal oedema was infrequent (7.7 per cent). Diagnosis was based on a laryngeal biopsy in 18 patients and on evidence of associated pulmonary tuberculosis and response to anti-tuberculous therapy in eight. Chest X-rays showed apical cavitation and infiltration as the commonest findings. Three patients had miliary tuberculosis and one had no pulmonary lesion. Diabetes mellitus was present in seven (26.9 per cent) patients. Four illustrative cases are described. The problems in diagnosis and management of laryngeal tuberculosis are discussed.     

Functional neck dissection: cure and functional results

In this study, the cure and functional results of 133 functional neck dissections performed between 1992-1997 in Erciyes University Medical Faculty were evaluated. The overall recurrence rate was three per cent. This rate was 1.4 per cent for elective functional neck dissections and five per cent for curative functional neck dissections. Electromyographic studies showed that there was severe neurogenic deficit in the trapezius muscle of seven patients (12.5 per cent), and in the sternocleidomastoid muscle of 12 patients (21.4 per cent) among 56 randomly selected patients. In all cases, the flow rate and diameter of the internal jugular vein was found to be normal by Doppler ultrasonography. The results of this study showed that functional neck dissection is a reliable technique for obtaining a high cure rate and functional results.     

Rare cases of Ménière's disease in children

Classical Ménière's disease is rarely found in children and literature regarding it is scarce. In general, the frequency of Ménière's disease in children is only 0.4-7.0 per cent of that in adults. The progression pattern of Ménière's disease in children is not known well. Here, we report three cases of Ménière's disease in children less than 15 years old, treated over nine years. The three cases comprise 14- and 13-year-old boys and a nine-year-old girl. Two of the three patients initially complained only of recurrent bouts of vertigo, without any tinnitus, ear fullness or hearing impairment. In all three cases, the early pure tone audiograms showed only high tone frequency loss, regardless of subjective hearing loss, and the decrease in the hearing threshold was observed one to eight years after the dizziness attacks began. The hearing threshold was usually decreased to a level of mild or moderate hearing impairment. After diuretic treatment, vertigo was generally well controlled, and some cases showed improvement in hearing. Of the total number of patients with Ménière's disease who visited our department over nine years, 2.6 per cent (3/114) were children, and the overall incidence of Ménière's disease in children with vertigo was 2.0 per cent (3/147). In conclusion, Ménière's disease in children rarely develops and may have characteristics of high tone loss in initial audiograms.     

Topical inhalant steroid (budesonide, Pulmicort nasal) therapy in intubation granuloma.

Intubation granuloma of the larynx is an iatrogenic disease which is induced by endotracheal intubation. It has basically been managed by conservative medical treatment with observation. Surgical excision can be considered as a last resort due to the high recurrence rate which subjects the patients to repeated anaesthesia. The purpose of this study is to evaluate the therapeutic effect of topical steroid in intubation granuloma, comparing the results of conservative medical treatment with, or without, surgery (Group I, 14 patients) and inhalant therapy with topical budesonide (Group II, 20 patients). In Group I, complete disappearance of granuloma occurred in six cases within a year (42.8 per cent) with conservative therapy only. Microlaryngeal surgery was performed on the eight cases of persisting granuloma after conservative therapy for a year, resulting in two cases of recurrence. In Group II, the granuloma disappeared completely in 85 per cent within six months and in 95 per cent within 12 months without any remarkable side-effects. We concluded that intubation granuloma of the larynx could be treated with topical inhalant steroid as the first choice of therapy rather than other medical treatment or surgical intervention.     

Endoscopic laser treatment in pre-malignant and malignant vocal fold epithelial lesions

Endoscopic laser treatment was performed in 43 patients with pre-malignant or malignant vocal fold epithelial lesions, 10 were treated with endoscopic laser surgery for dysplasia, 12 for carcinoma in situ (CIS), five for verrucous carcinoma and 16 patients for squamous cell carcinoma (SCC). Thirty-two patients received laser therapy as their first therapy, whereas 11 patients had had previous radiation therapy for laryngeal carcinoma (n = 9) or CIS (n = 2). Recurrence after initial laser therapy necessitating re-treatment (a second laser treatment or radiotherapy) occurred in nine out of 32 patients (28 per cent), thus 23 (72 per cent) were maintained free of disease during the follow-up period. Besides the 32 patients without previous therapy, patients who had already undergone radiation therapy were also included in this study. In this group there were nine patients with SCC, one patient with CIS and one with dysplasia. They all underwent laser therapy. Four were free of disease during follow-up (36 per cent) and seven developed recurrences. Six (58 per cent of all patients with previous radiation therapy) underwent total laryngectomy.     

Significance of human papillomavirus in sinonasal papillomas

Recent investigations have suggested human papillomavirus (HPV) to be involved in the development of sinonasal papillomas (SNP). Forty-three patients operated for SNP were studied to determine the prevalence of HPV-DNA sequences in these tumours and to evaluate their value as a prognostic parameter. The original sections of all cases were reviewed and reclassified according to the WHO. Paraffin blocks available from 37 patients were subjected to in situ hybridization (ISH) and polymerase chain reaction (PCR). Histology revealed 34 cases of inverted papilloma (IP) (79 per cent), five cases of exophytic papilloma (EP) (12 per cent) and four cases of columnar cell papilloma (CCP) (nine per cent). Recurrences developed in seven of 41 patients (17 per cent), and malignancy occurred in four of 43 patients (nine per cent). HPV was detected in four of 37 specimens (11 per cent) both by ISH and PCR. In particular, HPV-11 was found in three lesions (two EP, one IP) (eight per cent), and HPV-6b was detected in one lesion (one EP) (three per cent). Our findings suggest a possible role for HPV in the pathogenesis of exophytic papillomas. As no correlation was found to malignancy and recurrence of disease, screening for HPV seems not to be useful as a prognostic parameter.     

Modified Bondy radical mastoidectomy: long-term personal experience

The 'Bondy operation', or modified Bondy radical mastoidectomy, consists of a modification of the radical procedure by which the mastoid and epitympanum are exteriorized with preservation of the pars tensa and ossicular chain. In the 10-year period from 1986 to 1996, 53 patients of the ENT Department of the University of Pisa underwent a modified Bondy radical mastoidectomy, performed with a personalized procedure; 45 of them had a follow up of at least five years. After the surgical operation, the ears were free of complications in 38 cases (84.5 per cent), while in the other seven cases residual cholesteatoma (one case), tympanic retraction (four cases) or recurrent otorrhoea and phlogosis (two cases) were observed. The post-operative hearing level was unchanged or improved in 41 patients (91 per cent) (33 subjects had an unchanged gap and eight an improved gap), and only in the remaining four cases was the gap made worse. Based on our experience, the modified Bondy radical mastoidectomy is an extremely effective operation with a clear place in modern ENT surgery. When performed on carefully selected patients, it has been proven to offer good functional and anatomical results.     

The effect of uvulopalatopharyngoplasty without tonsillectomy using local anaesthesia: a prospective long-term follow-up

This paper presents the long-term effect of restricted surgery for snoring and sleep apnoea. Patients with obstructive sleep apnoea (OSAS) (19) or heavy snoring (HS) (36) were studied prospectively for five to seven years after uvulopalatopharyngoplasty without tonsillectomy performed by regular surgical technique using local anaesthesia (LUPP). Five years after surgery, 90 per cent answered a questionnaire. All OSAS patients were offered a polysomnography, and the HS patients were offered a sleep study. Eighty per cent still showed a positive effect on daytime somnolence, and 77 per cent on snoring. Side-effects were reported by 40 per cent; most common was choking (20 per cent) the first year. Eighteen per cent had local problems such as globus sensation. The polysomnography showed that 80 per cent were still 'responders' with an apnoea index (AI) reduction of > 50 per cent. None of the HS patients had developed OSAS. In conclusion, LUPP in selected patients with OSAS or HS has a good long-term effect. Side-effects are common, but diminish with time.     

Skeletal lesions in von Recklinghausen's disease of the head and neck in Nigerian Africans

A study of skeletal lesions in the head and neck region of 20 adult patients with von Recklinghausen's disease, seen in the Surgical Out Patient clinic of Lagos University Teaching Hospital from 1979 to 1985, has been carried out. Among the 20 patients, 13 (65 per cent) had symptoms related to the head and neck while 7 (37 per cent) did not; however, on radiological screening, all of them were observed to have skeletal lesions. The commonest feature was enlarged intervertebral nerve root exit foramina from mesodermal dysplasia, which occurred in 16 (80 per cent) of our patients. Other major findings were erosion of the mandible, 8 (40 per cent); erosion of the wings of the sphenoid, 4 (20 per cent); poor mastoid bone pneumatisation, 3 (15 per cent); erosion of the parietal bone, 3 (15 per cent) and heterotopic bone formation, 1 (5 per cent). Congenital calvarial defects were not detected. In view of the fact that all our patients showed radiologically detectable skeletal lesions of the head and neck, despite absence of symptoms in 35 per cent, it is advisable that all patients with von Recklinghausen's disease should routinely have radiological screening of this region, to detect early lesions.     

Histological features and prognosis of patients with mucoepidermoid carcinoma of the parotid gland

Histological features and prognosis of patients with mucoepidermoid carcinoma of the parotid gland were analysed. Tumours from 13 patients were classified according to histological grades and immunoreactivity for HER-2/neu. Surgical resection of the tumour was performed for all patients, and the overall five-year survival rate was 69 per cent. The patients whose histological grades were 1 or 2 showed a 100 per cent five-year survival rate, but no patient with grade 3 survived five years. Also, patients who had tumours that overexpressed HER-2/neu had a lower survival rate (25 per cent) than patients with tumours that had weaker immunostaining (89 per cent). We considered tumours classified as grade 3 plus strong HER-2/neu expression to be 'high malignancy', and compared them with 'low malignancy' tumours that were grade 1 or 2 and had weaker HER-2/neu staining. Patients with high malignancy tumours had shorter recurrence-free intervals and shorter overall survival than patients with low malignancy tumours. The overall survival period of the low malignancy cases was much longer than the recurrence-free interval; unlike that in the high malignancy tumour patients. These results suggest that the combination of histological grades and expression of HER-2/neu may be a useful predictor of the prognosis for mucoepidermoid carcinomata.     

The investigation of nasal septal perforations and ulcers

This is a retrospective review of 74 consecutive patients who presented with a nasal septal perforation or ulcer. The aim of this study was to evaluate the contribution of the investigations used to identify the pathology underlying their septal perforation or ulcer. In the majority of cases there was an anterior (85 per cent) smooth, well-circumscribed septal lesion with an occasional bleeding point. Seventy-seven per cent were less than two cm in diameter. The primary presenting symptom was intermittent epistaxis, with the exception of patients with granulomatous disease, who presented more frequently with nasal obstruction. Thirty-five patients (47 per cent) were idiopathic, 29 (39 per cent) traumatic, eight (11 per cent) inflammatory and two (three per cent) infectious. The nasal septum was biopsied in 71 cases, and histology showed non-specific or non-diagnostic findings in 39 (55 per cent), chronic inflammation in 12 (17 per cent), acute inflammation in six (eight per cent), acute to chronic inflammation in four (six per cent) and histological changes consistent with trauma in nine (13 per cent). The anti-neutrophil cytoplasmic antibody test (ANCA) successfully identified six patients with Wegener's granulomatosis, and the angiotensin converting enzyme test (ACE) supported a clinical diagnosis of sarcoidosis in one patient. The remaining investigation methods (CRP, ESR, chest radiograph, biochemistry and coagulation screen) did not contribute to the diagnosis. In this study, the appearance of a nasal septal perforation or ulcer or its location did not predict the clinical diagnosis. A nasal septal bopsy did not significantly contribute toward the clinical diagnosis. On the basis of these findings, a biopsy of a septal perforation or ulcer is unlikely to contribute to the management of patients unless the supportive tests of ANCA or ACE are abnormal or unless malignancy is suspected. This conclusion is restricted to the management of septal perforations as we have found nasal biopsies of polyps of other lesions to be of value.     

Salvage surgery following irradiation with different fractionation regimes in the treatment of carcinoma of the laryngo pharynx: experience gained from a British Institute of Radiology study.

The 10-year follow-up of patients in a clinical trial involving the comparison of treatment by three fractions per week versus five fractions per week in radiotherapy of squamous carcinoma of the larynx and hypopharynx has now been completed. The trial involved an intake of 734 patients between 1966 and 1975. No statistically significant differences have been found between the two trial arms in terms of overall survival, age corrected survival, local recurrence, laryngectomy-free rates or effects on the normal tissues. Local recurrence was found in 320 of the 713 evaluable patients (45 per cent). Salvage laryngectomy was performed in 151 of the 320 patients with recurrence (47 per cent). Survival at 10 years for all node negative patients was 50 per cent in those patients without primary recurrence, compared with 40 per cent in those undergoing salvage laryngectomy.     

Pharyngo-laryngo-oesophagectomy and gastric pull-up for post-cricoid and cervical oesophageal squamous cell carcinoma

Pharyngo-laryngo-oesophagectomy and gastric pull-up (PLOGP) is a complex and relatively uncommon procedure. The aim of this study is to analyse the results of PLOGP in patients with post-cricoid and cervical oesophageal squamous cell carcinomas. This study was a retrospective review of 26 patients (11 males + 15 females, mean age 63.5 years) who underwent PLOGP from 1988 to 1997. Eighteen (69 per cent) patients were staged as T(3) and eight (31 per cent) T(4). Eighteen (69 per cent) patients had N(0), seven (27 per cent) N(1) and one (four per cent) N(2) disease. Multiple primary tumours were recorded in three (11.5 per cent) patients. Four (15 per cent) patients had pre-operative radiotherapy with poor response and two (eight per cent) required emergency tracheotomy prior to surgery. Feeding jejunostomy was performed on 19 (73 per cent) and neck lymph node dissection in eight (31 per cent) patients. The mean duration of surgery was five hours (range 3.5 to 7.5) with a mean blood loss of 840 ml (range 160 to 1800), a mean stay in ICU of 4.2 days and hospital stay ranged from nine to 84 days (mean 34). Three (11.5 per cent) patients died (pneumonia - one, congestive heart failure - one, pulmonary embolus - one) in the early post-operative period. Eight (31 per cent) patients remain alive from 30 to 136 months (mean 58 months). Two (eight per cent) patients died with no evidence of disease. Thirteen (50 per cent) patients died of their disease between two to 51 months (mean 17.3 months) post-operatively. Kaplan-Meier survival estimates for one year was 65 per cent, for three years 35 per cent and for five years 26 per cent (see Figure 1). Median survival in the whole series was 18 months. Post-operative speech was with an electrolarynx in 16 (62 per cent). One patient (four per cent) used gastric speech and one patient (four per cent) used a Blom-Singer valve effectively. Five (19 per cent) patients had no speech post-operatively. All patients maintained oral feeding. Gastric transposition constitutes a safe and reliable method of restoring the continuity of the upper digestive tract following pharyngo-laryngo-oesophagectomy.     

Granulomatos cervical lymphadenitis.

One hundred and thirty-nine cases of pathologically involved cervical lymph nodes have been reviewed, and granulomatous lymphadenitis found in 29 patients (20.9 per cent). There were two cases of sarcoidosis, 10 of tularemia, five patients (3.6 per cent) had tuberculous lymphadenitis and 12 (8.7 per cent) fulfilled commonly accepted criteria for infection with atypical mycobacteria. The clinical features of the latter condition, which is probably insufficiently recognized, are reviewed, and surgery is recommended as the primary treatment modality.     

Is vidian neurectomy worthwhile?

Vasomotor rhinitis is a frustrating experience both for the consultant and for the patient. The purpose of vidian neurectomy is to destroy the secretomotor nerve supply to the nasal mucosa, the main indication being severe intractable non-atopic vasomotor rhinitis. A review of 208 cases which have undergone transnasal vidian neurectomy by diathermy coagulation in the last five years is presented. The operation has proved worthwhile, the patients remaining symptom-free in 92 per cent of cases (longest follow-up 5 years). There have been no complications.