A clinical review of 128 cases of head and neck tuberculosis presenting over a 10-year period in Bradford, UK

Aims: To analyse the epidemiology, presentation and diagnosis of head and neck tuberculosis (TB).

Methods: We conducted a 10-year retrospective study of all cases of tuberculosis of the head and neck region occurring in Bradford, UK.

Results: Of a total of 1315 cases of TB, 128 presented with head and neck TB (12 per cent of which (15/128) were in children). Cervical lymph nodes were most commonly involved (87 per cent, 111/128), other sites being: salivary glands (five cases); larynx, oral cavity, eyes and ears (two cases each); and skin, thyroid, nasopharynx and retropharyngeal space (one case each). Patients' ethnic origins were Asian (89 per cent, 114/128), Caucasian (10 per cent, 13/128) and African (one case). Only 26 per cent (33/128) had constitutional symptoms, and 20 per cent (25/128) had a coexistent site of TB. Only 39 per cent (40/105) of surgical specimens were sent for culture.

Conclusions: Isolated head and neck TB is not uncommon. Atypical presentations render diagnosis challenging, so awareness aids early diagnosis. Mycobacterial cultures should be performed, where possible, for diagnosis.

Role of information leaflets in improving the practice of informed consent for patients undergoing septoplasty

AIM

To evaluate the effectiveness of an information leaflet in improving patient understanding of the procedure and complications of septoplasty.

DESIGN

The baseline knowledge of a group of patients who had attended a pre-assessment clinic prior to septoplasty was assessed. The procedure and its complications were then verbally explained. The patients' knowledge was then re-assessed on the morning of surgery and any improvements noted. In the second arm of the study, an information leaflet was introduced at the time of verbal instruction and any differences in improvement in knowledge were assessed.

RESULTS

Data from the two groups were analysed using an analysis of covariance with differences in baseline (pre-instruction) knowledge controlled. Additional improvements in mean recall score following leaflet distribution were highly statistically significant when compared with mean recall in the control group (p<0.001).

CONCLUSION

The use of information leaflets increases patients' knowledge about a surgical procedure and its potential complications.

Is Clinical Otolaryngology publishing patient-centred research?

We asked how patient centred is Clinical Otolaryngology? Using two new models for analysing the patient-centredness of medical literature, three reviewers classified 176 papers (91 articles and 85 abstracts) published in this journal during the year 2000. Patients appeared as clinical subjects in 98 (56%), were interviewed by closed questionnaires in 21 (12%) and open questionnaires in 6 (3%), represented only by demographic details in 40 (23%) and not part of the study in 11 (6%) of papers. Papers were considered to address a biomedical frame of reference in 48 (27%), the patient's frame of reference in 6 (3%), technical aspects of the clinical encounter in 109 (62%) and communicative aspects in 7 (4%), and the setting for the encounter in 6 (3%) of papers. We show that some patient-centred research is published in Clinical Otolaryngology but suggest that it could publish more.

[Interest of periareolar injection for colorimetric detection of sentinel node in breast cancer]

Most teams working on sentinel node biopsy in the treatment of breast cancer inject either radioactive colloid or vital blue dye around the primary tumour. Many anatomical studies and lymphoscintigraphical studies, some very old, have shown that the lymphatic drainage of the breast is collected first in the periareolar plexus of Sappey, then routed to the axilla in 95% of cases, via one or two primary collectors. In a series of 94 breast cancers measuring less than 3 cm, with any palpable axillary lymph node, 2 ml of patent blue was injected intradermally around the areola, at the two meridians around the tumor. The sentinel node was identified in 89 cases (94,7%), regardless of the location of the primary tumor. All the sentinel nodes were located in the lower axilla. An average of 1.6 nodes were found per patient. In 41 cases, axillary lymph node dissection was performed either immediately (5 technical failures, 9 positive frozen section) or delayed only if the sentinel node was positive, either on standard H&E staining or on immunohistochemistry (27 cases). Thus, axillary lymph node dissection was not performed in 48 patients (55%). In positive node patient, the sentinel node was the only positive lymph node in 20 patients (55%). For 5 positive node patients, axillary lymph node dissection was not performed: poor vital status (2 micro-metastatic nodes) or by decision of patient (3 IHC positive nodes). With this periareolar injection procedure, the rate of detection is highly satisfactory and is comparable to that usually published with peritumoral injection. This procedure seems appropriate in all cases, regardless of the topography, the size or the multifocality of breast cancer.

Human immunodeficiency virus-positive tuberculous lymphadenitis in Central Africa: clinical presentation of 157 cases

SETTING

University Teaching Hospital, Lusaka, Zambia.

OBJECTIVE

To compare the clinical presentation of human immunodeficiency virus (HIV)-positive tuberculous lymphadenitis with primary HIV lymphadenopathy and HIV-negative tuberculous lymphadenitis.

DESIGN

Prospective study of patients undergoing diagnostic lymph node biopsy, with details of lymph node distribution, character and size assessed immediately before biopsy.

RESULTS

In total, 157 patients with HIV-positive tuberculous lymphadenitis, 71 with primary HIV lymphadenopathy and 28 with HIV-negative tuberculous lymphadenitis were examined. Amongst patients with HIV-positive tuberculous lymphadenitis, lymph node enlargement was symmetrical in 29% (45/157); cervical nodes were enlarged in 99% (155/157), axillary nodes in 82% (128/ 157), epitrochlear nodes in 36% (57/157) and ilioinguinal nodes in 54% (84/157). The size of the largest nodes was 3 cm in 36% (57/157), 2 cm in 24% (37/157) and 1 cm in 6% (10/157). This presentation overlapped with that of primary HIV lymphadenopathy, which was usually a symmetrical polylymphadenopathy with nodes < or = 3 cm in size, and contrasted with that of HIV-negative tuberculous lymphadenitis, which mostly presented with focal, asymmetrical cervical lymphadenopathy.

CONCLUSION

Tuberculous lymphadenitis may be more common in HIV-positive African patients with superficial lymphadenopathy than is generally believed. Greater use of lymph node aspiration or biopsy may improve the diagnosis of suspected tuberculosis in Africa.

The increased burden of tuberculous lymphadenitis in central Africa: lymph node biopsies in Lusaka, Zambia, 1981 and and 1990

In order to assess the effect of the HIV epidemic on lymph node biopsies in Central Africa, HIV-1 serology was tested on a cohort of patients undergoing node biopsy in Lusaka in 1990, and the histology of all lymph nodes biopsied in Lusaka in 1981 and 1990 was reviewed. One hundred and eighteen lymph nodes were biopsied in 1981 and 351 in 1990. Cases of tuberculous lymphadenitis increased from 52 (31 children and 21 adults) in 1981 to 186 (22 children, 160 adults, four patients unknown age) in 1990. Sixty-eight of 77 adults (88%) with tuberculous lymphadenitis in 1990 tested HIV-positive. Cases of histology suspicious of primary HIV lymphadenopathy and nodal Kaposi's disease also increased. Cases of malignant lymphadenopathy and overall number of surgical biopsies remained equivalent for 1981 and 1990. The study concludes that the HIV epidemic has led to a large increase in diagnostic lymph node biopsies in Lusaka, mostly through an increase in HIV-related adult tuberculous lymphadenitis.

The value of naked eye examination of biopsied lymph nodes in the diagnosis of tuberculous lymphadenitis

Tuberculous lymphadenitis is common in Central Africa, where diagnosis by histological examination of a biopsied node is often delayed. In the present study, the naked eye appearance of the cut surface of 306 consecutive biopsied lymph nodes was compared with the histological diagnosis. One hundred and eight-eight nodes showed tuberculosis on histology (including two with coexisting second pathology). One hundred and forty-eight (79%) cases of tuberculous lymphadenitis (including both with coexisting second pathology) showed noncaseating tuberculomata or caseation visible on naked eye examination. Such signs were not seen in other nodes. Other signs were seen in another 18 (10%) tuberculous nodes. It is concluded that naked eye examination of nodes provides useful information for the diagnosis of tuberculous lymphadenitis, pending confirmation by histology.

Importance of human immunodeficiency virus-associated lymphadenopathy and tuberculous lymphadenitis in patients undergoing lymph node biopsy in Zambia

The relative importance of human immunodeficiency virus (HIV)-associated lymphadenopathy amongst patients presenting for lymph node biopsy in Central Africa is unknown. HIV-1 serology and histology of patients undergoing superficial lymph node biopsy during 1989-1990 in Lusaka, Zambia, were examined in a prospective cohort study of HIV serology and by retrospective review of laboratory records. Of 727 lymph nodes biopsied in Lusaka in 1989-1990, 380 (52 per cent) showed tuberculous lymphadenitis, 160 (22 per cent) histology suggestive of primary HIV lymphadenopathy and 66 (9 per cent) nodal Kaposi's disease. HIV serology was tested in 280 adults and was positive in 91 per cent (255 patients), including 89 per cent (153 of 171) of those with tuberculous lymphadenitis, 98 per cent (63 of 64) of those with histology suspicious of primary HIV lymphadenopathy and all (24 of 24) with nodal Kaposi's disease. Other HIV-associated lymphadenopathy included nodal lymphomas and lymphoepithelial cysts. HIV serology was tested in 22 children and was positive in eight, including four of 14 with tuberculous lymphadenitis. It is concluded that HIV-associated lymphadenopathy, especially tuberculous lymphadenitis, is very common amongst patients presenting for lymph node biopsy in Central Africa.

Wide needle aspiration cytology in the diagnosis of lymphadenopathy in Zambia

AIMS

To study the value of wide needle (19 gauge) aspiration cytology in the diagnosis of lymph node disease in Zambia in the absence of a trained cytologist.

METHODS

Patients (n = 304) referred for surgical biopsy of an enlarged peripheral lymph node were studied prospectively. Surgical biopsy was routinely preceded by 19 gauge needle aspiration of the same node; aspirates were stained by haematoxylin and eosin and Ziehl Neelsen stains.

RESULTS

Of 232 aspirates, 182 contained sufficient material for cytological characterisation. Tuberculosis was diagnosed or suspected in 122 of 126 aspirates with histologically confirmed tuberculous lymphadenitis; reactive follicular hyperplasia in 31 of 38 patients with primary HIV lymphadenopathy; malignancy in all five patients with malignant nodes; and Kaposi's disease in four of nine patients with this. Tuberculous lymphadenitis was falsely suspected in four patients, as was reactive follicular hyperplasia in four, and Kaposi's disease in four.

CONCLUSIONS

Wide needle aspiration cytology is useful in the diagnosis of lymphadenopathy in Central Africa, with the exception of lymphadenopathic Kaposi's disease.

The value of wide-needle aspiration in the diagnosis of tuberculous lymphadenitis in Africa

OBJECTIVES

To evaluate wide-needle (19-gauge) aspiration in the diagnosis of tuberculous lymphadenitis.

SETTING

Department of Surgery, University Teaching Hospital, Lusaka, Zambia.

PATIENTS

Three hundred and four patients presenting to one surgeon for diagnostic surgical biopsy of a peripheral lymph node during 1989-1990.

DESIGN

Prospective study in which wide-needle aspiration routinely preceded open surgical biopsy.

MAIN OUTCOME MEASURES

Histology and mycobacterial culture of the surgically biopsied lymph node; HIV-1 serology; successful aspiration of material, naked-eye appearance of aspirate, presence of acid-fast bacilli and/or microscopic caseation in the aspirate.

RESULTS

One hundred and eighty-eight out of 304 (61.8%) patients had histologically and/or culture-proven tuberculous lymphadenitis, of whom 155 out of 183 (84.7%) tested HIV-1-seropositive. Material was successfully aspirated from 180 out of 188 (95.7%) of patients with proven tuberculous lymphadenitis. Macroscopic caseation, diagnosable on naked-eye examination alone of the aspirate, was present in 49 out of 120 (40.8%) consecutive aspirates from tuberculous nodes. Acid-fast bacilli and/or microscopic caseation were seen in 116 out of 155 (74.8%) aspirates from tuberculous nodes for which smears stained both by Ziehl-Nielsen and haematoxylin & eosin were available.

CONCLUSIONS

It is recommended that all patients with suspected tuberculous lymphadenitis in Africa, undergo wide-needle aspiration before surgical biopsy or empirical treatment.

The impact of human immunodeficiency virus on presentation and diagnosis of tuberculosis in a cohort study in Zambia

Two hundred and forty-nine patients with tuberculosis were recruited to a cohort study to investigate the interaction between tuberculosis and HIV in Lusaka, Zambia; findings at presentation are presented here. One hundred and eighty-two (73%; 95% confidence interval 67-79%) of the cases were HIV-1 antibody positive. The diagnosis of tuberculosis was confirmed by microscopy for acid-alcohol fast bacilli, culture of Mycobacterium tuberculosis, or histology in 74% of all cases. HIV negative and positive cases differed in site of disease: among HIV negative patients 72% had pulmonary disease alone, 16% extrapulmonary disease alone and 12% had both, whereas among HIV positive patients 40% had pulmonary disease alone, 34% extrapulmonary disease alone and 26% both (P < 0.001). HIV negative and positive cases were compared with regard to outcome of diagnostic procedures: 55% of HIV negative cases could be diagnosed at enrollment by sputum smear, but only 35% of HIV positive cases (P < 0.01). Among pulmonary cases confirmed by sputum culture, 76% of HIV negative patients had a positive sputum smear, compared with 57% of HIV positive patients (P = 0.09). Pleural and pericardial disease were difficult to confirm, but culture of pleural fluid was positive in 12/46 HIV positive patients, compared with 0/11 HIV negative patients. Lymph node disease was readily confirmed by biopsy. The tuberculin test was positive in only 30/110 (27%) of HIV positive cases, but in 21/38 (55%) of HIV negative cases (P < 0.01). Mycobacterium tuberculosis was cultured in 57% of HIV negative cases and 54% of HIV positive cases; no atypical mycobacteria were isolated. Initial resistance to isoniazid was present in isolates from 5% of cases with a positive culture.

Parotid disease and human immunodeficiency virus infection in Zambia

Among the salivary glands the parotid is unusual in that it contains lymphoid tissue within its capsule. The focus of infection with human immunodeficiency virus (HIV) is the lymphatic system and this results in a specific HIV-related pathology in the parotid. This 2-year surgical audit of parotid disease in HIV-infected patients in Lusaka shows patients presenting with parotid lymphadenopathy, bilateral diffuse parotid enlargement and parotid lymphoepithelial cysts. Clinical presentation and management are discussed.

Audit of 'surgery in general' in an African teaching hospital

A 1-year prospective audit of 2233 operations performed by one general surgical unit in a Central African teaching hospital is presented. In addition to the usual 'general surgical' procedures, operations also included emergency craniotomy, reconstructive surgery for open fractures, and hysterectomy. There were 37 (1.7%) postoperative deaths and 45 other deaths in non-operated patients. Ten of 14 deaths due to sepsis in the 20-40-year age group were associated with HIV infection. The implications for teaching and training of surgical specialists in the tropics are discussed.

Cytomegalovirus ileitis presenting as massive rectal bleeding in infancy

Two Zambian infants presented with massive rectal bleeding caused by cytomegalovirus ileitis. The first was seropositive for HIV and the second seronegative, though her mother was seropositive. Both infants died.

British surgeons training abroad--an evaluation

The experience and practice of a surgeon training in Africa is reviewed. Clinical, practical and management skills are invaluable. The value of an elective period in a British training system is suggested.

Reconstruction of the mandible using the scapular spine pedicled upon trapezius muscle; description of the posterior approach to the transverse cervical vessels

We describe the reconstruction of the mandible using the spine of the scapula pedicled upon trapezius in a woman who had undergone previous mandibular irradiation and surgery. We show how the vascular supply to the trapezius scapular spine compound flap can be approached posteriorly and the spine of the scapula used to provide good length and contour for replacement of a wide mandibular defect.