Lemierre's syndrome presenting with peritonsillar abscess and VIth cranial nerve palsy

Lemierre's syndrome is characterized by acute oropharyngeal infection complicated by internal jugular venous thrombosis secondary to septic thrombophlebitis, and metastatic abscesses. We report a case of Lemierre's syndrome in an 18-year-old Caucasian woman presenting with a peritonsillar abscess and ipsilateral VIth cranial nerve palsy.

Swallowing dysfunction in patients with unilateral vocal fold paralysis: aetiology and outcomes

Although unilateral vocal fold palsy (UVFP) is a common problem, data relating to swallowing dysfunction are sparse. We reviewed the clinical findings (method of presentation, underlying diagnosis and position of the vocal folds) of 30 patients and conducted a follow-up telephone survey. Outcome measures used were direct visualization of fold function, position and compensation. In addition, standardized speech and language assessments for swallowing dysfunction and dysphonia were noted and compared to presentation. Our study indicates that 56 per cent of patients with UVFP have associated dysphagia. Outcome with speech therapy is significant, with 73 per cent showing improvement. These data indicate a significant link between UVFP and swallowing dysfunction. There is a marked therapeutic benefit from voice therapy. Further work is required to evaluate the long-term outcomes and establish the mechanism of swallowing dysfunction in these patients.

Is the routine use of antibiotics justified in adult tonsillectomy?

Pain and secondary haemorrhage are the commonest complications of adult tonsillectomy, occurring mostly in the community. This is a randomized, double-blind, placebo-controlled, prospective trial of the effect of perioperative amoxycillin on these complications. The incidence and severity of post-operative haemorrhage was measured. For the first 10 post-operative days patients provided a linear pain score, a record of GP visits, and their use of additional antibiotics and analgesics. Of 95 patients considered: 23 suffered a secondary haemorrhage; 54 consulted their general practitioner (GP) because of pain; additional antibiotics were used by at least 31 and additional analgesics by at least 41. No significant differences were demonstrated between the active and placebo groups for any of these measures. This study demonstrates that secondary haemorrhage is common after adult tonsillectomy. Post-operative pain remains a major problem requiring frequent GP consultations. There appears to be no justification for the routine use of perioperative antibiotics.

Bilateral abductor vocal fold paralysis due to myasthenia gravis

We report a case of bilateral abductor vocal fold paralysis due to myasthenia gravis in a 61-year-old man who presented with stridor requiring tracheostomy. The stridor had been preceded by several weeks' history of diplopia.

The application of endoscopic sinus surgery to the treatment of recurrent sinus barotrauma

Recurrent sinus barotrauma is an uncommon condition but it may terminate the career of an aviator. Sinus barotrauma occurs almost exclusively on descent and probably results from occlusion of the sinus ostia through a combination of mucosal disease and anatomical abnormalities. Traditional methods of treating sinus barotrauma have achieved mixed results so we have employed functional endoscopic sinus surgery (FESS) since 1990. The presentation and outcome of 39 patients with recurrent sinus barotrauma managed by FESS have been reviewed. Ninety-five per cent were able to resume their full flying duties without further treatment or recurrence of sinus barotrauma. Passing a postoperative decompression testing is a reliable indicator of an aviators's fitness to fly after FESS.

Recurrent epistaxis and nasal septal deviation in young adults

Epistaxis is common in young adults but the aetiology is unknown in many cases. To investigate the possibility that septal deviations are associated with epistaxis, 54 servicemen with recurrent epistaxis were compared with 46 controls. The epistaxis group were significantly more likely to have a history of nasal trauma (P = 0.008) and radiologically-proven nasal fracture (P = 0.002); on clinical examination, they were more likely to have a deviated septum (P < 0.00001), maxillary spur (P = 0.00004) and nasal obstruction (P = 0.011); they were also more likely to have radiological evidence of a deviated septum (P = 0.020). Those patients able to locate their epistaxis to one side tended to do so to the side of their septal deviation. This study supports the hypothesis that septal deviation is associated with epistaxis.

VIIIth cranial nerve involvement in sarcoidosis

Hearing loss and vertigo are uncommon but well-recognized complications of neurosarcoidosis. Until recently the site of the lesion has been debatable and the efficacy of steroids commonly prescribed for this type of hearing loss has been said to be doubtful. A case is presented of sarcoidosis-induced hearing loss in which bilateral VIIIth nerve lesions were demonstrable by MRI with gadolinium enhancement. Treatment with high-dose steroids and azathioprine produced a symptomatic improvement and virtual resolution of the lesions.

The role of functional endoscopic sinus surgery in the management of recurrent sinus barotrauma

Sinus barotrauma occurs when an individual is unable to equilibrate the pressure within his sinuses with atmospheric pressure. Aviators affected by recurrent sinus barotrauma are unfit to fly until the underlying cause is established and treated. While most cases result from intranasal pathology, a significant number are the result of sinus pathology or anatomical abnormalities. This latter group have been difficult to manage in the past but the advent of computerized tomography and the Hopkin's rod endoscope have allowed them to be operated on with precision and safety. Complications of this treatment are uncommon and the aviator has usually been able to resume full flying duties after undergoing a decompression test. In our experience it is rare for an aviator who has passed a decompression test to have further episodes of sinus barotrauma.

The laryngeal mask airway in ENT surgery

We report our experience of using the laryngeal mask airway (LMA) over a period of 18 months in 217 patients undergoing a variety of otorhinolaryngological operations. Advantages over conventional intubation for both patient and surgeon are suggested in both safety, speed and economy. An inadequate airway, necessitating replacement of the LMA, only occurred on two occasions whilst two known cases of difficult intubation easily had their airways secured by use of the LMA. Protection of the lower airways from secretions, fluid or blood, arising above the LMA, would appear to be confirmed.

The value of CT scanning in chronic suppurative otitis media

High definition CT has been advocated for the evaluation of chronic suppurative otitis media (CSOM) either generally or in selected cases. It is said to be capable of producing the fine detail needed to detect lateral canal fistulae, exposed dura and facial canal dehiscences, and to demonstrate the ossicular chain. At present there is no agreement on either the indications for CT scanning in CSOM or the most appropriate scanning plane. To determine the value of high definition CT in CSOM and to decide a unit policy for its application, 36 cases of CSOM underwent pre-operative CT scanning and their scans were compared with the operative findings. Our results show CT to be highly sensitive to the presence of soft tissue disease and bone erosion, moderately sensitive to the presence of lateral canal fistulae but less sensitive to the presence of small areas of exposed dura, ossicular continuity and facial canal dehiscence. Axial scans were better able to demonstrate the lateral canal but otherwise coronal scans were superior; ideally patients should be scanned in both planes. The principle value of CT in CSOM is its ability to demonstrate disease which is not clinically apparent.

Total avulsion of an osseointegrated screw

The close union achieved between pure grade titanium and healthy bone makes dislocation a rare event. We report the case of the total avulsion of an apparently well-integrated implant from a healthy mastoid bone.

Long-term results of revision endolymphatic sac surgery

The results of revision endolymphatic sac surgery on 30 patients with unilateral Menière's disease are presented. Good control is achieved in 73.3 per cent of cases at six months, falling to 56.7 per cent at one year and only 33.3 per cent by four years. The long-term results are disappointing but are more favourable if the initial surgery was successful, if the hearing remains fluctuant and improves on glycerol dehydration prior to the revision procedure and also if the sac is intubated. The current place of endolymphatic sac surgery is discussed and revision surgery only recommended for carefully selected cases.

Malignant fibrous histiocytoma of the nasopharynx

Malignant Fibrous Histiocytomas (MFH) are uncommon in the head and neck and extremely rare in the nasopharynx. We report a case of MFH arising in the nasopharynx and describe its diagnosis and management. The literature is reviewed and the likely origins of the tumour and its behaviour are discussed.

Transitional type papilloma of the nasopharynx

A case of transitional-type papilloma arising in the nasopharynx is reported. The various theories for the aetiology of the condition are considered in the light of this finding.

Magnetic resonance imaging in head and neck cancer

The scans of 120 patients with proven head and neck cancer who underwent magnetic resonance imaging (MRI) at Mt. Vernon hospital were reviewed and, where possible, compared with their clinical, computed tomography (CT) and histological findings. MRI was generally superior to both clinical examination and CT in the detection of cervical lymphadenopathy and in the assessment of primary tumour extent, particularly in the tongue base, nasopharynx and parotid gland. Small intracranial tumour extensions were more readily detected by MRI than CT. MRI was no better than CT in distinguishing between malignant and inflamed tissues and was generally inferior to CT in spatial resolution, patient acceptance and examination cost.

Middle ear effusions and myasthenia gravis

A case of ME effusion in a patient with MG is reported. The likely pathogenesis is of TVP muscle weakness causing Eustachian tube dysfunction. ME effusion should be suspected in a myasthenic complaining of sudden hearing loss. Tympanometry with measurement of the ME pressures and reflexes is a useful tool for assessing a myasthenic's response to treatment.

Hodgkin's disease of the nasopharynx

A case of Hodgkin's disease confined to the nasopharynx is presented. From a review of the literature, it seems likely that involvement of the nasopharynx in Hodgkin's disease goes undetected in a significant number of cases.