Follow-up results in tuberculous cervical lymphadenitis

OBJECTIVE: To investigate the efficacy of medical antituberculous treatment in patients with tuberculous cervical lymphadenitis (TCL). METHODS: In the period 1996-2002, 73 TCL patients were reviewed and the results of clinical and laboratory testing were documented. The efficacy of a four-drug chemotherapy regimen was investigated. RESULTS: Purified protein derivatives (PPD) skin test results were positive in 58 (79 per cent) patients. Chest X-rays revealed changes consistent with tuberculosis in nine (12.3 per cent) patients. The mean duration of medical treatment was 10.04 months. In follow-up evaluation, 14 (20 per cent) patients were considered suspicious for resistant TCL and total excision of all nodes was performed. Histopathology confirmed TB in only 10 of these cases. CONCLUSION: The high incidence of residual disease in our study indicates that medical treatment (at least nine months of four combined antituberculous drugs) did not seem to be effective. If lymphadenopathy persists, total surgical excision of lymph nodes should be the treatment of choice.     

Source of tubercle bacilli in cervical lymph nodes: a prospective study

A prospective study searching for associated mycobacterial infection of the upper aerodigestive tract in patients with cervical tuberculous lymphadenitis (TBLN) was carried out. One hundred and thirteen patients with a clinical suspicion of cervical TBLN were included. All patients had a physical examination of the upper aerodigestive tract. Routine endoscopy and biopsy of the nasopharynx were performed. All of them had surgery to the cervical lymph node. Seventy-five patients had histologically confirmed cervical TBLN. Culture of the lymph node specimen showed Mycobacterium tuberculosis in 68 (90 per cent). In 45 (60 per cent) patients with cervical TBLN the primary foci of infection could not be found. Twenty-nine (39 per cent) had radiographic evidence of active or healed pulmonary tuberculosis. Sputum culture from two patients showed Mycobacterium tuberculosis. Five patients (six per cent) had tuberculous nasopharyngitis. In one of them (one per cent) the tuberculous nasopharyngitis was primary as no other evidence of mycobacterial infection was found. In the present study, mycobacterial infection of other parts of the upper aerodigestive tract was not found.     

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.     

Acute mastoiditis in children: is surgical treatment necessary?

Acute mastoiditis in children remains an otological problem. Although the widespread use of antibiotics has reduced the need for surgical intervention, surgery is frequently used in the treatment of acute mastoiditis and its complications. The charts of 44 patients hospitalized with signs of acute mastoiditis were reviewed. In 43.2 per cent of all patients, acute mastoiditis was the presenting sign of acute middle-ear infection. Post-auricular erythema and protrusion of the auricle were the most frequent signs at presentation. All four signs (post-auricular erythema, oedema, tenderness, and protrusion of the auricle) were present in 40.9 per cent of patients. No bacterial pathogen was isolated in 45.5 per cent of ear cultures. Complicated acute mastoiditis was diagnosed in 13.7 per cent of the patients. Eighty-seven per cent of patients responded well to intravenous antibiotics and myringotomy, and in 11.4 per cent mastoidectomy or abscess drainage were performed. We conclude that nearly all patients with uncomplicated mastoiditis recover following intravenous antibiotics and myringotomy. Mastoidectomy should be performed in selected cases, such as cases of complicated acute mastoiditis.     

The complications of chronic otitis media: report of 93 cases

The aim of this study was to investigate the incidence, mortality and morbidity of complications due to chronic otitis media (COM). During the nine-year period 1990-1999, 2890 cases of COM were reviewed, 93 (3.22 per cent) having 57 (1.97 per cent) intracranial complications (IC) and 39 (1.35 per cent) extracranial complications (EC). In three patients more than one complication was observed. Meningitis and brain abscess were common in the IC group. Subperiosteal abscess (mastoid and Bezold's abscess) was a common complication in the EC group. Cholesteatoma and granulation/polyp in the middle ear/mastoid were the major findings in both groups. Fifteen patients died from IC. Overall, the mortality rate was 16.1 per cent in all patients having complications, and in patients with IC it was 26.3 per cent. In all of the patients with complications, the morbidity rate was 11.8 per cent. Our study supports the finding that meningitis and brain abscess are the common complications of COM and the main reason for mortality.     

Radiotherapy for T1 glottic carcinoma: impact of anterior commissure involvement

The clinical notes of all new patients with T(1) squamous cell carcinoma of the glottis seen in one head and neck cancer unit between 1989 and 1996 were reviewed. Fifty-three patients were treated with radical radiotherapy and of these 42 (79.2 per cent) had no loco-regional recurrence, after a median follow-up of seven years. Eleven (20.8 per cent) developed local recurrence and were treated with salvage surgery. Fourteen of the 53 (26.4 per cent) tumours involved the anterior commissure and eight of these 14 (57.1 per cent) developed recurrence, whereas only three of the 19 (15.8 per cent) tumours arising from the anterior half of the fold but not involving the anterior commissure had recurrence. None of the remaining tumours recurred. This difference is statistically significant (p<0.001). Anterior commissure involvement is a predictor of poor response to radiotherapy. This may be the result of understaging as none of the cases had computed tomography (CT) scans performed. Technical radiotherapy factors may also be important, although in all cases of anterior commissure involvement steps were taken to ensure adequate radiation dose to this region.     

Routine radiological examination of the sinuses before septoplasty

Records of septoplasties performed during the last five years were reviewed with the aim of evaluating the results of routine pre-operative radiological examination of the sinuses. A positive correlation was found between the information of sinusitis within the last two years and the radiological finding of complete density or fluid. The roentgenograms showed normal conditions in 73 per cent of the cases and various degrees of pathology in 27 per cent; no case showed signs of malignancy. Puncture and irrigation or sinoscopy had been performed in 52 per cent of the cases with pathological X-rays. Following this treatment, surgery was postponed in 12 patients, and in nine patients a drainage tube was placed in the maxillary sinus peroperatively. Complications developed post-operatively in five of these nine patients and it is concluded that septoplasty should have been postponed. We find that it is important to identify the four per cent (12 + 9) of patients in whom the radiological findings are so pronounced that operation ought to be postponed.     

Oesophageal carcinoma: endoscopic and clinical findings in 258 patients

During the 10-year period 1971-1980, oesophagoscopy was carried out on a total of 3235 patients in the Department of Otolaryngology, Turku University Central Hospital, Finland. Oesophageal carcinoma was diagnosed in 258 patients, 113 (44 per cent) men and 145 (56 per cent) women. The diagnosis was verified in 228 cases (88.4 per cent) by using an optical rigid oesophagoscope and in 30 cases (11.6 per cent) by a fibreoptic endoscope. The most common and earliest symptom was difficulty in swallowing in 50 per cent of cases. In 44 per cent of patients the symptoms persisted over six months before diagnosis. Upper and middle thoracic portions of the oesophagus were the sites of origin of the carcinoma in 57 per cent of the patients. The macroscopic picture obtained by oesophagoscopy was regarded as malignant in 83 per cent of patients and extraoesophageal spread of the tumour was estimated to be present in 48 per cent of patients by the time of diagnosis. Histological studies showed the tumour to be squamous cell carcinoma in 62 per cent of patients and in 24 per cent well differentiated. Squamous cell carcinoma was seen more often in men than in women. In patients with carcinoma in situ, alcohol and tobacco were regarded as aetiological factors in 53 per cent of cases. The need for repeated oesophagoscopy in patients with symptoms related to swallowing is stressed.     

Nerve origin of the acoustic neuroma.

Two hundred and seventy-one Japanese patients who underwent surgical removal of neuroma from the cerebello-pontine angle using the translabyrinthine approach were retrospectively reviewed in order to investigate the nerve origin on an anatomical basis. In 269 out of the 271 cases, the origin of the neuromas was identified. Among these cases, 84.8 per cent of tumours originated from the inferior vestibular nerve (IVN), followed by the superior vestibular nerve (SVN) (8.9 per cent). Of the 5.6 per cent of tumours arising from the vestibular nerve, however, it could not be determined whether they originated from the SVN or IVN. Two cases of neuromas originating from the facial nerve were seen (0.7 per cent). No neuroma arose from the cochlear nerve. Currently, the diagnosis of acoustic neuromas is best made with Gd-enhanced magnetic resonance imaging (MRI). However, our data indicate that the development of a functional test of the individual IVN can be useful for screening most cases of acoustic neuroma and in facilitating their early diagnosis.     

Functional voice disorders. A review of 109 patients

The records of 109 patients, presenting with functional voice disorder during the years 1977-1981, have been reviewed. The mean age was 45 years and the F : M ratio is 2 : 1. Excess voice use was not obviously an aetiological factor. Sixty-one of the 109 patients (56 per cent) were cured by speech therapy, in that their voices returned to their pre-morbid state, and a further 28 (26 per cent) were improved by therapy; seven patients (6 per cent) did not improve and 13 (12 per cent) were lost to follow-up. Of the patients that were 'cured', 54 per cent were discharged after three months' treatment and 72 per cent after six months' treatment. Eight per cent required treatment for more than a year.     

Dysequilibrium of ageing (presbyastasis)

We reviewed clinical findings in 740 patients over age 65 who consulted the Otological Medical Group, Inc., during a one-year period for dizziness. A thorough neurotologic evaluation is indicated in every such case to determine the specific cause of dizziness. In 21 per cent of these patients, a specific cause of dizziness was found. In the remaining 79 per cent, the diagnosis of primary dysequilibrium of ageing (presbyastasis) was made. We classified dysequilibrium of ageing (presbyastasis) according to the character, time course, and precipitating factors of dizziness. Two clinical types were described: constant and episodic; episodic dizziness was subdivided into orthostatic, positional, and unclassified. The histological findings in the temporal bones of four cases with dysequilibrium of ageing were reviewed. Pathological changes other than those in the peripheral vestibular system seem to be responsible for dysequilibrium of ageing. In the present series, about three-fourths of the patients had a daily dose of nicotinic acid to produce flushing of the skin. In 16 per cent, the dizziness was minor, requiring no special treatment. In the remaining 9 per cent with incapacitating vertigo, a vasodilator regimen, antivertiginous drugs, and Cawthorne's vestibular exercises were prescribed.     

Recurrent respiratory papillomatosis: a 10 year study

Sixty cases of recurrent respiratory papillomatosis in both children and adults treated over a 10 year period were reviewed. An unexpected finding was that nine of the 60 patients (15 per cent) had symptoms by two months of age; an earlier onset than previously described. The control rate was 66 per cent for paediatric onset patients and 44 per cent with adult onset; the former required more operations. No anaesthetic deaths or complications were encountered. Glottic webs were the only surgical complication. The findings confirm that there is no relationship between puberty and the rate of control or recurrence. The necessity for precise and comprehensive endoscopic examination of the upper aerodigestive tract using a range of endoscopes and rigid telescopes under general anaesthetic is emphasized.     

Non-Hodgkin's lymphoma of the tonsil. Experience of treatment over a 27-year period

Over the 27-year period from 1954-1981, 51 patients with non-Hodgkin's lymphoma arising in the tonsil were treated at the Regional Radiotherapy Centre, Mount Vernon Hospital. The original biopsy material was reviewed in each case and reclassified using the British National Lymphoma Investigation criteria. Grade 2 non-Hodgkin's lymphoma was reported in 80 per cent of cases. Ninety per cent of patients presented in stages IE or IIE and were treated with radical local radiotherapy. A 5-year survival of 51 per cent was achieved and a 5-year relapse-free survival of 35 per cent. Stage IE patients had a statistically significant survival advantage compared to stage IIE. Sixty-one per cent of patients relapsed, of whom 74 per cent died from active lymphoma. The abdomen was the most frequent site for relapse with involvement of both nodal and extranodal sites.     

Role of screening for infectious mononucleosis in patients admitted with isolated, unilateral peritonsillar abscess

Two hundred and four cases of in-patient admission with isolated, unilateral peritonsillar abscess over the three-year period 1999-2001 were reviewed retrospectively. One hundred and fifty-one patients had been screened for infectious mononucleosis (IM) using the heterophile antibody screening test. Of these 142 (94 per cent) tested negative and nine (six per cent) positive. There were no IM-typical clinical or haematological signs in any of the IM positive patients to facilitate the prediction of the diagnosis. Due to the comparatively high prevalence of positives, the low cost of screening, the lack of predictive signs and the diversity of potential complications of IM, routine screening in all patients presenting with peritonsillar abscess is recommended.     

Cancer of the naso-pharynx in Kuwait

A clinico-pathological study of 143 cases of malignancy of the naso-pharynx diagnosed and treated at the E.N.T. and Radiotherapy Departments of Al-Sabah Hospital, Kuwait, between the years 1963 to 1974 inclusive is presented. The entire population of Kuwait is served and also a variable but small number of Nomads. During the years of the survey the population has been steadily increasing from about 500,000 in 1963 to about a million in 1974. It is composed of 45 per cent Kuwaitis of pure Arab stock and 55 per cent of immigrant workers, largely of Arabic origin. Cancer of naso-pharynx is the commonest of all head and neck cancers (18.3 per cent) and comprises 4.2 per cent of all malignancies. This is comparable with the 5.1 per cent in the Arab population of North Africa. The sex incidence is 2.2 Kuwaiti males and 0.8 females per 100,000; Non-Kuwaitis 2.0 male and 1.2 female per 100,000, giving an approximate ratio of 2.9 to 1 in both groups. The age distribution shows two peaks in male patients, Kuwaitis and Non-Kuwaitis in the 2nd decade (11.1 per cent) and fifth decade (28.8 per cent). In females, the graph shows a plateau pattern from the 3rd decade onwards. Cervical lymphadenopathy (83 per cent) was the commonest presenting symptom. The commonest histological finding was undifferentiated carcinoma and squamous cell carcinoma (28 per cent each). The hypotheses of the aetiology are reviewed.     

Cricohyoepiglottopexy: long-term results in 55 patients

Near total laryngectomy with cricohyoepiglottopexy (CHEP) allows cure of glottic carcinomas with voice preservation. The subject of this study was to evaluate CHEP in terms of tumour control and functional result in T1 and T2 glottic carcinomas. This study reviewed retrospectively 55 consecutive cases of CHEP performed between January 1, 1981 and September 1, 1992 with the exclusion of post-radiotherapy salvage surgery. CHEP was indicated for a T1a limit to the anterior commissure and/or with dysplasia of the other vocal fold (10 cases), T1b (11 cases) and T2 (34 cases) glottic carcinomas. All our patients have a follow-up of more than five years. The post-operative course after this surgery was generally uneventful. The median time to decannulation was 18 days, to removal of the nasogastric tube was 15 days and to discharge from hospital was 23 days. No significant difference was observed according to the preservation of one or both arytenoid cartilages. The long-term functional result can be considered to be good in three-quarters of cases, with normal oral swallowing and an easily understood voice. The remaining one quarter had a whispery voice and sometimes episodes of aspiration when swallowing liquids. In terms of oncological results, the five-year recurrence-free survival rate was 94 per cent for T1 and 84 per cent for T2. The ultimate tumour control (taking into account four cases of total laryngectomy) was 94 per cent for T1 and 93 per cent for T2. Primary surgery by CHEP therefore appears to be a good option for early glottic carcinomas. The main problem remains that voice recovery is mediocre in one quarter of patients.     

External rhinoplasty: a critical analysis of 500 cases

The study presents a comprehensive statistical analysis of a series of 500 consecutive rhinoplasties of which 380 (76 per cent) were primary and 120 (24 per cent) were secondary cases. All cases were operated upon using the external rhinoplasty technique; simultaneous septal surgery was performed in 350 (70 per cent) of the cases. Deformities of the upper two-thirds of the nose that occurred significantly more in the secondary cases included; dorsal saddling, dorsal irregularities, valve collapse, open roof and pollybeak deformities. In the lower third of the nose; secondary cases showed significantly higher incidences of depressed tip, tip over-rotation, tip asymmetry, retracted columella, and alar notching. Suturing techniques were used significantly more in primary cases, while in secondary cases grafting techniques were used significantly more. The complications encountered intra-operatively included; septal flap tears (2.8 per cent) and alar cartilage injury (1.8 per cent), while post-operative complications included; nasal trauma (one per cent), epistaxis (two per cent), infection (2.4 per cent), prolonged oedema (17 per cent), and nasal obstruction (0.8 per cent). The overall patient satisfaction rate was 95.6 per cent and the transcolumellar scar was found to be unacceptable in only 0.8 per cent of the patients.     

Value of barium swallow in investigation of globus pharyngeus

Globus pharyngeus as a possible presenting symptom of a pharyngeal or upper oesophageal neoplasm is the main reason why barium swallows are requested, although it is essentially a benign disorder that in many cases requires reassurance only. We therefore retrospectively reviewed all barium swallows done in our department for globus pharyngeus during a one-year period to assess their value in the investigation of this condition. Ninety-two patients were identified. All had a normal ENT examination, and symptoms suggestive of acid reflux was the most common associated complaint, at 11 per cent. Acid reflux (18.5 per cent) and hiatus hernia (12 per cent) were the commonest findings of a barium swallow. Three cases of suspicious findings on barium swallow had a normal examination under general anaesthetic. Statistical analysis showed no significant relationship between the symptoms of globus and the barium swallow results. A barium swallow does not seem to add any further useful information to the investigation of globus pharyngeus. But most globus patients will continue to undergo a barium swallow, because although alternative investigations have been extensively assessed, it is still not clear which is the most appropriate mode of investigation for this condition.     

Management strategy of mycobacterial cervical lymphadenitis

The objectives of this study were to investigate the typical clinical presentation, diagnosis and treatment of mycobacterial cervical lymphadenitis (MCL). Medical records of 87 patients who were treated for MCL were retrospectively reviewed. Definitive diagnosis of MCL was made when a neck mass persisted for several weeks or months and one or more of the following was obtained: (1) positive mycobacterial cultures from biopsy material; (2) Positive mycobacterial staining of biopsy material; (3) Granulomatous inflammation and caseating necrosis on histopathological examination of biopsy material. Clinical findings were reviewed prior to treatment. The treatment included standard antituberculous medications followed by surgery in which either total excision or selective nodal dissection of the cervical lump was made. Follow-up results are presented. The chief complaint was a cervical mass that was localized mostly to the posterior cervical or submandibular regions. A fistula formation was encountered in 11.5 per cent. All patients recovered from MCL by combined antituberculous drug and surgical treatments. Clinical presentation of the disease and histopathological assessment are important in the diagnosis of MCL as well as in the differential diagnosis of tuberculous and nontuberculous MCL. Utilizing the combined medical and surgical treatment options, both tuberculous and non-tuberculous cervical adenitis can be treated successfully.     

The behavior of cancer affecting the subglottic space.

This retrospective study comprises 45 patients with subglottic carcinoma, arising either primarily or by spread from glottic carcinoma. The relevant literature is reviewed. Points of interest concerning the natural history of these carcinomata are: 1) The incidence of primary subglottic carcinoma was seven per cent of all laryngeal carcinomata and the incidence of subglottic spread of glottic carcinoma was 11.4 per cent. 2) At the time of presentation, vocal cord fixation was present in 40 per cent of the total group; 16 per cent of the true subglottic group had palpable nodes in the neck, and 5.5 per cent of the subglottic spread group. 3) Of the patients with true subglottic lesions, 44 per cent were women, 64 per cent presented with stridor and 32 per cent required emergency tracheostomy, 32 per cent developed distant metastases, half of these being in bone. 4) Only one of 45 patients developed mediastinal metastasis.