Greeting once again from The Otorhinolaryngologist. It has been wonderful summer so far with sport in the air in the form of a World cup and here at home Wimbledon and a British Open. We also have been busy here with RILA putting together the most recent edition of the journal and now have an ever increasing bank of great quality articles due to be published in a timely fashion.
Vascular anomalies include a number of conditions of distinct pathology which may be classified as either vascular tumours or vascular malformations. Historically, these diverse lesions have been poorly understood. This is reflected in varied and often incorrectly-applied terminology, difficulties in diagnosis and inconsistent approaches to management. This article considers the advances in our understanding of vascular anomalies, and subsequent evolution of nomenclature, classification and current management strategies.
Neck lumps are a common presentation to the paediatric outpatient clinic. Identifying a malignant process is important but thankfully rare. This article aims to outline the different
pathologies for acquired neck lumps in children, focusing on and presenting an algorithm for the management of lymphadenopathy.
The differential diagnosis of cervical lymphadenopathy in children is different from adults.
Largely lymphadenopathy in children is benign, but malignant causes include lymphoma and sarcomas. Nodes that fluctuate in presence, that are soft and less than 2cm can be safely discharged with advice. Investigations that can help are full blood count, viral serology and chest X- ray. Assessment of overlying skin changes in cases of atypical mycobacterial infection can assist differential diagnosis. Fine needle aspiration and cytology cannot be relied upon because of low sensitivity. Ultrasound can aid management. Excision for histology remains the gold standard, but carries surgical risks.
Nasal obstruction is a common presentation at rhinology clinics. Aetiologies can widely vary from inflammatory, mechanical obstructive to structural / anatomical causes of nasal obstruction.
Nasal valve collapse is a recognised cause of nasal path obstruction, whether presenting as the sole causative or as an addition to another obstructive aetiology. The identification of this cause of obstruction is essential in order to plan patients’ management.
In this article we aim to describe the anatomy, physiology and pathophysiology of the nasal valve area. Then we highlight what the commonly found surgical methods of addressing this issue in literature, and the documented outcomes.
Hearing loss is a common condition affecting up to 1 in 500 newborns and increasing in prevalence with age. A significant proportion of cases are inherited as a result of single gene mutations or genetics plays a part in a multifactorial process leading to the hearing loss. This article reviews the current understanding of the genes known to be involved in this process and outlines recent developments and prospects for the future.
The term ‘Cystic hygroma’ has been used in the past to describe congenital lymphatic malformations, usually presenting before the age of 2 years. The cervico-facial region is the most commonly involved anatomical location. Lymphovascular malformations involving the head and neck may present with cosmetic disfigurement, upper aerodigestive tract symptoms and/or recurrent infections. They are described as macrocystic or microcystic, although often a combination of both is present.
Microcystic disease can be difficult to treat and may necessitate repeated debuking procedures.
Macrocystic disease is usually treated with surgical excision and less commonly sclerotherapy.
Sclerosing agents can cause initial swelling before a reduction in size. Any surgery is aimed specifically at relieving symptoms, maintaining the airway and having minimal or no effect on function. Less frequently, tracheostomy and/or gastrostomy may be needed as part of a management strategy.
Otitis media with effusion (OME) and recurrent acute otitis media (RAOM) are both extremely common, with a significant impact on the child’s and parents’ quality of life. Various treatment options have therefore been investigated to prevent their occurrence. A literature search was carried out on Medline, EMBASE and Cochrane database for relevant randomised controlled trials and meta-analyses. We sought to summarise the current evidence on the management of these common conditions.
Sir Terence Cawthorne was born on 29th September 1902 in Aberdeen, Scotland, where his father worked as a customs official. His early education was at Denstone College in Staffordshire. From there he moved to King's College Hospital in London to embark upon his medical career.1 Although he only spent a limited time in Scotland, (his parents returned South in his early childhood), he placed considerable pride and importance upon his Scottish birthplace.
Introduction: Although most paediatric neck lumps represent common and benign disease, it is important for malignancies and other rare conditions to be considered in order to avoid potentially damaging diagnostic delay.
Case report: A seven month old boy presented to a district general hospital with an enlarging right posterior triangle neck lump. Incisional biopsy was undertaken and reported as reactive sinus histiocytosis, leading to a working diagnosis of Rosai-Dorfman syndrome. The lump grew inexorably, prompting referral to our tertiary centre for definitive management. Initial ultrasound scanning prior to referral had demonstrated a 3.5cm vascular lymph node, with smaller adjacent lymph nodes, in keeping with tuberculosis or lymphoma. Later CT scanning demonstrated a 7.5 x 8.5cm lesion, with the lack of calcification suggesting soft tissue tumour rather than a lymph node. The subsequent resection specimen demonstrated a tumour with a morphological and immunohistochemical profile in keeping with extra-abdominal fibromatosis. Definitive treatment was by surgical excision after review by the regional paediatric oncology services. The tumour was densely adherent to surrounding tissues but was felt to originate from the sternocleidomastoid muscle. Post-operatively the patient was found to have facial nerve weakness that functionally fully recovered.
Conclusion: This case highlights the importance of prompt tertiary referral in all cases of rapidly enlarging neck lumps. The clinical characteristics and treatment of extra-abdominal fibromatosis will be discussed.
Mantle cell lymphoma (MCL) is a distinct subtype of B-cell non-hodgkin lymphoma. It is due to a chromosomal translocation resulting in the overexpression of cyclin D1 gene. The clinical features and growth pattern hinder the recognition of the disease because it has a range of morphologic and growth patterns so a specific marker is important for a correct diagnosis. We report a case of a 58 years old female with a left tonsillar mantle cell lymphoma diagnosed by biopsy of the lesion. The patient underwent chemotherapy with a relapse at two years follow-up.
In conclusion in a monolateral tonsillar hyperplasia in an adult immunohistochemical staining is mandatory in the process of recognizing mantle cell lymphoma due to the confusion that could be made with other similar diseases such as chronic lymphocytic leukemia or small lymphocytic lymphoma and follicular lymphoma.
Rhabdomyosarcoma is a malignant neoplasm derived from striated muscle cells. It is relatively common in the paediatric population and often occurs in the head and neck region. In the adult population, rhabdomyosarcoma usually presents in the limbs and it is extremely rare for this disease to occur in the head and neck. We present the case of an 18 year old male who presented to our ENT department with an aural polyp. Histopathological examination of the lesion confirmed a diagnosis of rhabdomyosarcoma. This case highlights the need for a high level of clinical suspicion and early biopsy of aural polyps to exclude neoplastic conditions.
The past decade has seen an increase in the utilisation of endoscopic laryngeal surgery in the management of early laryngeal cancers (T1-2) but despite this its uptake in the UK has been variable when compared to radiotherapy.
We analysed the outcomes of all early laryngeal cancers initially treated by endoscopic laryngeal surgery in an emerging endoscopic laryngeal surgery service.
49 patients treated by endoscopic laryngeal surgery as a primary modality had a cumulative 5-year survival rate of 91.18% and laryngeal preservation rate of 93.05%.
We found an emerging service can offer excellent DSS and laryngeal preservation rates at 5 years for early glottic tumours.
Background Radiological Inserted Gastrostomy (RIG) is an alternative method of feeding head and neck cancer patients with potential associated complications following insertion.
Methods Data was collected from an interventional radiology database reviewing all head and neck cancer patients undergoing RIG insertion from 2007-2008. This was repeated following changes in suture removal timing from 2009-2010. The patient notes were retrospectively reviewed identifying complication demographics.
Results 63 RIG insertions were collected in the first cycle and 46 in the second cycle with no mortality. Major and minor complication rates were 7.9% and 63.4% in the first cycle versus 0% and 44.4% in the second cycle. Minor complications in surgical patients were significantly higher (P=0.02) than oncological cases in the first cycle. Minor complications were also noted to be significantly higher in the first (P<0.0001) and second (P=0.0009) cycle when compared with the gold standard of 22.1%. Average time of onset for major complications was 2+/-1 days (+/-SD) and for minor complications was 27+/-35 days. Tube dislodgement was the most common minor complication and improved following change in timing of suture removal, however there was an increase in infection rates. There was no significant difference in complication rates based on the grade of radiologist.
Conclusions We report no differences in major complications. Significantly higher rates of minor complications were noted in both cycles compared with the gold standard. The rates of tube dislodgement were reduced by leaving stay sutures in for longer at the expense of increased infection rates.
This otology viva is based on otosclerosis. It will include the salient parts of the history, clinical findings and diagnosis, pathophysiology and management.