Telephone care as an adjunct to routine medical follow-up. A negative randomised trial. Eff. Clin... more Telephone care as an adjunct to routine medical follow-up. A negative randomised trial. Eff. Clin. Pract. 3, 123-130 14 Greenhalgh T. (1997) How to read a paper: papers that tell you what things cost (economic analyses).
Archives of Otolaryngology–Head & Neck Surgery, 2004
A 62-year-old man presented with a 3-month history of progressive hoarseness and a 40-year histor... more A 62-year-old man presented with a 3-month history of progressive hoarseness and a 40-year history of tobacco chewing and frequent smoking (2-3 cigarettes per day). He had no history of alcohol use, voice abuse, dysphagia, pain in the throat, fever, weight loss, or ...
Annals of The Royal College of Surgeons of England, 2007
INTRODUCTION Prions are resistant to conventional sterilisation procedures and, therefore, could ... more INTRODUCTION Prions are resistant to conventional sterilisation procedures and, therefore, could be transmitted iatrogenically through re-usable adenoid and tonsil surgical instruments. Using disposable instruments would avoid the risk of transmission. We present the results of a complete audit loop using BBraun single-use surgical instruments (SUSI). PATIENTS AND METHODS This was a prospective multicentre audit. Surgeons were asked to fill in a standardised questionnaire recording details including postoperative complications, and evaluation of each piece of equipment compared with their own experience of conventional re-usable instruments. In the first cycle, constructive criticisms of the instruments were noted and the manufacturers modified the instruments accordingly. A second cycle of audit was subsequently undertaken. RESULTS A total of 86 patients were audited in the first cycle and 97 in the second cycle. Postoperative haemorrhage rate for both cycles was well within acceptable range. In the first audit cycle, surgeons generally found the Draffin rods, Boyle-Davis gag and bipolar diathermy forceps of poor quality and difficult to use. These were redesigned and, on repeat evaluation during the second audit cycle, were found to be just as good, if not better, than the re-usable instruments. CONCLUSIONS This study suggests that SUSI may be just as good as re-usable instruments. Furthermore, they may be more cost effective.
Cholesteatoma is a non-neoplastic, keratinising lesion which has two forms: congenital and acquir... more Cholesteatoma is a non-neoplastic, keratinising lesion which has two forms: congenital and acquired. Congenital cholesteatoma develops behind a normal, intact tympanic membrane, whilst acquired cholesteatoma is associated with a defect in the tympanic membrane. The pathological substrate of cholesteatoma is keratinising stratified squamous epithelium, but the origin of this epidermal tissue in the middle ear is controversial. Here, we review the most relevant and recent evidence for the principal aetiopathogenic theories of both forms of cholesteatoma, in the light of recent otopathological findings.Congenital cholesteatoma is most plausibly explained by the persistence of fetal epidermoid formation. Conclusive ‘proof’ awaits the unambiguous demonstration of the metamorphosis of an epidermoid nidus into a lesion in vivo.Acquired cholesteatoma may develop by various mechanisms: immigration, basal hyperplasia, retraction pocket and/or trauma (iatrogenic or non-iatrogenic). However, sq...
Schwannomas are benign slow growing solitary tumours of nerve sheath origin and can arise from an... more Schwannomas are benign slow growing solitary tumours of nerve sheath origin and can arise from any myelinated nerve. They have been reported to occur in most parts of the body with the highest incidence (25%) in the head and neck region, although tongue base lesions are rare. The tumour is resistant to radiotherapy, and therefore, the treatment of choice is surgery. We present a case of a tongue base schwannoma which was completely extirpated with a carbon dioxide laser via the transoral approach. The patient experienced virtually no morbidity from the use of the laser. Whilst tongue base schwannoma has been documented, we could not find an earlier report in the English literature describing our method of treatment. We conclude that transoral carbon dioxide laser can be added to the surgical armamentarium for the management of other similar cases in the future.
Adenotonsillectomy is successful at eliminating airway obstruction in the majority of otherwise n... more Adenotonsillectomy is successful at eliminating airway obstruction in the majority of otherwise normal children with obstructive sleep apnoea syndrome. Children with this condition are at significantly higher risk of post-operative respiratory complications. Identifying children at risk of post-operative respiratory complications after adenotonsillectomy for obstructive sleep apnoea syndrome remains a challenge for clinicians, especially those at district general hospitals. To review the evidence and to proffer a pragmatic approach to diagnosis and management, by classifying those at risk of post-operative respiratory complications into different risk subsets, with guidelines for management. Patients in the high risk group should be operated upon at paediatric specialist centres with intensive care facilities. Those in the moderate risk group may undergo adenotonsillectomy at their district general hospital, provided facilities for administering continuous positive airway pressure are available on-site. Most children with obstructive sleep apnoea syndrome may be classified as low risk candidates and may safely be operated upon at their local district general hospital.
Thyroglossal duct cysts most frequently present in childhood as painless midline swellings around... more Thyroglossal duct cysts most frequently present in childhood as painless midline swellings around the level of the hyoid. Classically the cyst moves upwards on protruding the tongue. Here we report a novel case of a thyroglossal cyst in an adult in whom the history, examination and fine needle aspiration cytology were typical of a traumatic haematoma. This case is also unique because the thyroglossal duct cyst extended beyond the thyroid gland to the suprasternal notch and actually required two parallel transverse cervical incisions for its complete en bloc removal.
Cholesteatoma is a non-neoplastic, keratinising lesion which has two forms: congenital and acquir... more Cholesteatoma is a non-neoplastic, keratinising lesion which has two forms: congenital and acquired. Congenital cholesteatoma develops behind a normal, intact tympanic membrane, whilst acquired cholesteatoma is associated with a defect in the tympanic membrane. The pathological substrate of cholesteatoma is keratinising stratified squamous epithelium, but the origin of this epidermal tissue in the middle ear is controversial. Here, we review the most relevant and recent evidence for the principal aetiopathogenic theories of both forms of cholesteatoma, in the light of recent otopathological findings. Congenital cholesteatoma is most plausibly explained by the persistence of fetal epidermoid formation. Conclusive 'proof' awaits the unambiguous demonstration of the metamorphosis of an epidermoid nidus into a lesion in vivo. Acquired cholesteatoma may develop by various mechanisms: immigration, basal hyperplasia, retraction pocket and/or trauma (iatrogenic or non-iatrogenic). However, squamous metaplasia of the normal cuboidal epithelium of the middle ear is a highly unlikely explanation. Chronic inflammation seems to play a fundamental role in multiple aetiopathogenic mechanisms of acquired cholesteatoma. Therefore early treatment of inflammatory conditions might reduce their sequelae, perhaps by preventing the development of hyperplastic papillary protrusions. Continued otopathological, cellular and molecular research would enhance our limited understanding of cholesteatoma and may lead to new therapeutic strategies for this erosive disease, which often defies surgical treatment.
A granular cell tumour is a rare lesion of probable nerve sheath origin. It is typically benign b... more A granular cell tumour is a rare lesion of probable nerve sheath origin. It is typically benign but up to seven per cent may be malignant. Since its original description in the tongue in 1926, the tumour has been reported to occur at many other sites in the body. The authors report a case of a 49-year-old African woman with an oro-naso-parapharyngeal granular cell neoplasm causing mild dysphagia. The location of this tumour, which has not been reported previously, posed a unique surgical challenge. An initial attempt to remove the lesion transorally was only partially successful because it was too tough and adherent for conventional surgical dissecting instruments. Complete resection, however, was achieved with a carbon dioxide laser via the same approach. This information may be helpful in the management of other similar cases in the future.
We report the otological effects of the April 1999 Soho Nail Bomb on 17 patients. Twenty-one (62%... more We report the otological effects of the April 1999 Soho Nail Bomb on 17 patients. Twenty-one (62%) tympanic membranes were perforated ( pars tensa only); 78% closed spontaneously within 6 months. The mean size of the perforation in the tympanic membrane nearer to the blast was signi®cantly larger than the opposite side [33% AE 8.3 (mean AE SD) and 13% AE 4.1 respectively; P 0.02]. All patients reported hearing losses that were mixed conductive and sensorineural but mainly high-frequency sensorineural (4, 6 and 8 kHz, pure tone average 42.3 dB AE 20.5). The sensorineural hearing loss correlated inversely with the distance from the explosion but not with the size of perforation. There was no signi®cant difference in the hearing loss between the ear facing the blast and the opposite ear. Fifteen patients (88%) had temporary tinnitus. No patient complained of any vestibular symptoms. The otological effects of a nail bomb in an enclosed space have not been previously reported. Furthermore, an inverse correlation between hearing loss and distance from the explosion and a signi®cant difference in perforation size facing the blast, compared with the opposite side, are also presented for the ®rst time. The high spontaneous closure rate of perforations and minimal ongoing disability from sensorineural losses favour conservative management in most cases.
Annals of The Royal College of Surgeons of England, 2004
Necrotizing fasciitis is life-threatening bacterial infection which spreads with frightening spee... more Necrotizing fasciitis is life-threatening bacterial infection which spreads with frightening speed along the fascial planes resulting in extensive tissue necrosis and often death. The infection is caused by either Group A streptococci or a combination of aerobic and anaerobic bacteria. Necrotizing fasciitis of the neck is rare and commonly has a dental origin. Here we present a unique case of the condition that was preceded by a sore throat in a young immunocompetent woman. We also describe, for the first time, a successful outcome involving primary skin closure and daily irrigation of the wound with hydrogen peroxide.
... MK Athar 369 A painful swollen hand K Selvarajan, R Vadivelu, AL Armstrong 370 Self assessmen... more ... MK Athar 369 A painful swollen hand K Selvarajan, R Vadivelu, AL Armstrong 370 Self assessment answers ..... PostScript 372 Book reviews 372 Diary ..... Images in medicine 354 Bullosis diabeticorum KP Anand, AS Kashyap ...
Telephone care as an adjunct to routine medical follow-up. A negative randomised trial. Eff. Clin... more Telephone care as an adjunct to routine medical follow-up. A negative randomised trial. Eff. Clin. Pract. 3, 123-130 14 Greenhalgh T. (1997) How to read a paper: papers that tell you what things cost (economic analyses).
Archives of Otolaryngology–Head & Neck Surgery, 2004
A 62-year-old man presented with a 3-month history of progressive hoarseness and a 40-year histor... more A 62-year-old man presented with a 3-month history of progressive hoarseness and a 40-year history of tobacco chewing and frequent smoking (2-3 cigarettes per day). He had no history of alcohol use, voice abuse, dysphagia, pain in the throat, fever, weight loss, or ...
Annals of The Royal College of Surgeons of England, 2007
INTRODUCTION Prions are resistant to conventional sterilisation procedures and, therefore, could ... more INTRODUCTION Prions are resistant to conventional sterilisation procedures and, therefore, could be transmitted iatrogenically through re-usable adenoid and tonsil surgical instruments. Using disposable instruments would avoid the risk of transmission. We present the results of a complete audit loop using BBraun single-use surgical instruments (SUSI). PATIENTS AND METHODS This was a prospective multicentre audit. Surgeons were asked to fill in a standardised questionnaire recording details including postoperative complications, and evaluation of each piece of equipment compared with their own experience of conventional re-usable instruments. In the first cycle, constructive criticisms of the instruments were noted and the manufacturers modified the instruments accordingly. A second cycle of audit was subsequently undertaken. RESULTS A total of 86 patients were audited in the first cycle and 97 in the second cycle. Postoperative haemorrhage rate for both cycles was well within acceptable range. In the first audit cycle, surgeons generally found the Draffin rods, Boyle-Davis gag and bipolar diathermy forceps of poor quality and difficult to use. These were redesigned and, on repeat evaluation during the second audit cycle, were found to be just as good, if not better, than the re-usable instruments. CONCLUSIONS This study suggests that SUSI may be just as good as re-usable instruments. Furthermore, they may be more cost effective.
Cholesteatoma is a non-neoplastic, keratinising lesion which has two forms: congenital and acquir... more Cholesteatoma is a non-neoplastic, keratinising lesion which has two forms: congenital and acquired. Congenital cholesteatoma develops behind a normal, intact tympanic membrane, whilst acquired cholesteatoma is associated with a defect in the tympanic membrane. The pathological substrate of cholesteatoma is keratinising stratified squamous epithelium, but the origin of this epidermal tissue in the middle ear is controversial. Here, we review the most relevant and recent evidence for the principal aetiopathogenic theories of both forms of cholesteatoma, in the light of recent otopathological findings.Congenital cholesteatoma is most plausibly explained by the persistence of fetal epidermoid formation. Conclusive ‘proof’ awaits the unambiguous demonstration of the metamorphosis of an epidermoid nidus into a lesion in vivo.Acquired cholesteatoma may develop by various mechanisms: immigration, basal hyperplasia, retraction pocket and/or trauma (iatrogenic or non-iatrogenic). However, sq...
Schwannomas are benign slow growing solitary tumours of nerve sheath origin and can arise from an... more Schwannomas are benign slow growing solitary tumours of nerve sheath origin and can arise from any myelinated nerve. They have been reported to occur in most parts of the body with the highest incidence (25%) in the head and neck region, although tongue base lesions are rare. The tumour is resistant to radiotherapy, and therefore, the treatment of choice is surgery. We present a case of a tongue base schwannoma which was completely extirpated with a carbon dioxide laser via the transoral approach. The patient experienced virtually no morbidity from the use of the laser. Whilst tongue base schwannoma has been documented, we could not find an earlier report in the English literature describing our method of treatment. We conclude that transoral carbon dioxide laser can be added to the surgical armamentarium for the management of other similar cases in the future.
Adenotonsillectomy is successful at eliminating airway obstruction in the majority of otherwise n... more Adenotonsillectomy is successful at eliminating airway obstruction in the majority of otherwise normal children with obstructive sleep apnoea syndrome. Children with this condition are at significantly higher risk of post-operative respiratory complications. Identifying children at risk of post-operative respiratory complications after adenotonsillectomy for obstructive sleep apnoea syndrome remains a challenge for clinicians, especially those at district general hospitals. To review the evidence and to proffer a pragmatic approach to diagnosis and management, by classifying those at risk of post-operative respiratory complications into different risk subsets, with guidelines for management. Patients in the high risk group should be operated upon at paediatric specialist centres with intensive care facilities. Those in the moderate risk group may undergo adenotonsillectomy at their district general hospital, provided facilities for administering continuous positive airway pressure are available on-site. Most children with obstructive sleep apnoea syndrome may be classified as low risk candidates and may safely be operated upon at their local district general hospital.
Thyroglossal duct cysts most frequently present in childhood as painless midline swellings around... more Thyroglossal duct cysts most frequently present in childhood as painless midline swellings around the level of the hyoid. Classically the cyst moves upwards on protruding the tongue. Here we report a novel case of a thyroglossal cyst in an adult in whom the history, examination and fine needle aspiration cytology were typical of a traumatic haematoma. This case is also unique because the thyroglossal duct cyst extended beyond the thyroid gland to the suprasternal notch and actually required two parallel transverse cervical incisions for its complete en bloc removal.
Cholesteatoma is a non-neoplastic, keratinising lesion which has two forms: congenital and acquir... more Cholesteatoma is a non-neoplastic, keratinising lesion which has two forms: congenital and acquired. Congenital cholesteatoma develops behind a normal, intact tympanic membrane, whilst acquired cholesteatoma is associated with a defect in the tympanic membrane. The pathological substrate of cholesteatoma is keratinising stratified squamous epithelium, but the origin of this epidermal tissue in the middle ear is controversial. Here, we review the most relevant and recent evidence for the principal aetiopathogenic theories of both forms of cholesteatoma, in the light of recent otopathological findings. Congenital cholesteatoma is most plausibly explained by the persistence of fetal epidermoid formation. Conclusive 'proof' awaits the unambiguous demonstration of the metamorphosis of an epidermoid nidus into a lesion in vivo. Acquired cholesteatoma may develop by various mechanisms: immigration, basal hyperplasia, retraction pocket and/or trauma (iatrogenic or non-iatrogenic). However, squamous metaplasia of the normal cuboidal epithelium of the middle ear is a highly unlikely explanation. Chronic inflammation seems to play a fundamental role in multiple aetiopathogenic mechanisms of acquired cholesteatoma. Therefore early treatment of inflammatory conditions might reduce their sequelae, perhaps by preventing the development of hyperplastic papillary protrusions. Continued otopathological, cellular and molecular research would enhance our limited understanding of cholesteatoma and may lead to new therapeutic strategies for this erosive disease, which often defies surgical treatment.
A granular cell tumour is a rare lesion of probable nerve sheath origin. It is typically benign b... more A granular cell tumour is a rare lesion of probable nerve sheath origin. It is typically benign but up to seven per cent may be malignant. Since its original description in the tongue in 1926, the tumour has been reported to occur at many other sites in the body. The authors report a case of a 49-year-old African woman with an oro-naso-parapharyngeal granular cell neoplasm causing mild dysphagia. The location of this tumour, which has not been reported previously, posed a unique surgical challenge. An initial attempt to remove the lesion transorally was only partially successful because it was too tough and adherent for conventional surgical dissecting instruments. Complete resection, however, was achieved with a carbon dioxide laser via the same approach. This information may be helpful in the management of other similar cases in the future.
We report the otological effects of the April 1999 Soho Nail Bomb on 17 patients. Twenty-one (62%... more We report the otological effects of the April 1999 Soho Nail Bomb on 17 patients. Twenty-one (62%) tympanic membranes were perforated ( pars tensa only); 78% closed spontaneously within 6 months. The mean size of the perforation in the tympanic membrane nearer to the blast was signi®cantly larger than the opposite side [33% AE 8.3 (mean AE SD) and 13% AE 4.1 respectively; P 0.02]. All patients reported hearing losses that were mixed conductive and sensorineural but mainly high-frequency sensorineural (4, 6 and 8 kHz, pure tone average 42.3 dB AE 20.5). The sensorineural hearing loss correlated inversely with the distance from the explosion but not with the size of perforation. There was no signi®cant difference in the hearing loss between the ear facing the blast and the opposite ear. Fifteen patients (88%) had temporary tinnitus. No patient complained of any vestibular symptoms. The otological effects of a nail bomb in an enclosed space have not been previously reported. Furthermore, an inverse correlation between hearing loss and distance from the explosion and a signi®cant difference in perforation size facing the blast, compared with the opposite side, are also presented for the ®rst time. The high spontaneous closure rate of perforations and minimal ongoing disability from sensorineural losses favour conservative management in most cases.
Annals of The Royal College of Surgeons of England, 2004
Necrotizing fasciitis is life-threatening bacterial infection which spreads with frightening spee... more Necrotizing fasciitis is life-threatening bacterial infection which spreads with frightening speed along the fascial planes resulting in extensive tissue necrosis and often death. The infection is caused by either Group A streptococci or a combination of aerobic and anaerobic bacteria. Necrotizing fasciitis of the neck is rare and commonly has a dental origin. Here we present a unique case of the condition that was preceded by a sore throat in a young immunocompetent woman. We also describe, for the first time, a successful outcome involving primary skin closure and daily irrigation of the wound with hydrogen peroxide.
... MK Athar 369 A painful swollen hand K Selvarajan, R Vadivelu, AL Armstrong 370 Self assessmen... more ... MK Athar 369 A painful swollen hand K Selvarajan, R Vadivelu, AL Armstrong 370 Self assessment answers ..... PostScript 372 Book reviews 372 Diary ..... Images in medicine 354 Bullosis diabeticorum KP Anand, AS Kashyap ...
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