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This study assesses postoperative quality-of-life outcomes via the Glasgow Benefit Inventory (GBI) in patients undergoing transnasal endoscopic pituitary surgery for pituitary adenoma.This was a retrospective cohort study in a UK tertiary referral centre. 145 patients who had undergone transnasal endoscopic pituitary surgery for pituitary adenoma over a 6-year period at one institution completed the GBI with at least 3 months' follow up. Patients with prior radiotherapy were excluded. The GBI is a patient-reported outcome measure that assesses post-intervention outcomes in three domains: 'general' functioning, 'social support' and 'physical' functioning. Pre- and post-operative visual loss scores were additionally assessed via a 1-5 Likert scale. GBI scores were assessed alongside these visual loss scores, clinical and surgical parameters and demographics.Mean age was 59.5 years (range 20-87 years) and mean follow up was 36 months. A total of 46 of 145 (31.7%) patients had secreting tumours. The most common primary symptom was visual loss. Mean total score for all patients was positive (+8.4); with 'general' domain score the most positive (+10.5). All patient groups had overall positive, 'general' and 'social support' domain scores. Patients with Cushing's disease reported significantly higher mean total scores (+29.6) than all other groups. Acromegaly (+7.9) and non-functioning adenoma (NFA) groups (+5.2) reported lower mean total scores. 'Physical' domain mean scores were negative for acromegaly and NFA groups. There was statistical significance between a pre- to post-operative improvement in visual score and mean total GBI score (These findings can aid preoperative counselling of patients undergoing this surgery. Those with NFA and no anticipated improvement to visual loss symptoms may be advised of possible worsened physical outcomes and of the option to delay the surgery until symptoms are present.

Background/Aims The electronic ‘choose and book’ referral system can lead to patients being allocated to inappropriate ear, nose and throat sub-specialty clinics. Internal re-referrals to the more appropriate sub-specialty clinic is inefficient, leads to wasted appointments and is frustrating for both clinicians and patients. This study aimed to implement a nurse-led vetting system to ensure that new referrals were sent to the appropriate sub-specialty for their first appointment. Methods A team of three nurses were given guidelines and trained to assess GP referrals so that they could re-allocate inappropriate referrals to more appropriate sub-specialty ear, nose and throat clinics before their first appointment. The number of referrals that were re-allocated was calculated. Results Implementing a nurse-led vetting system of GP referrals led to 110/400 (28%) of cases being re-allocated to a more suitable sub-specialty clinic before initial consultation. The expertise of the nurse-led team was found to be sufficient, particularly when supplemented with additional training, to perform this task. Conclusions Nurse-led vetting of choose and book referrals is an efficient way of checking referrals to ensure that patients are sent to the appropriate clinic. This can increase the overall efficiency of the clinic and prevent the wasting of time and resources on inappropriate referrals.

Retrospective analysis of patients acutely managed by Sheffield's Neurosurgery over a 9-years period. Outcome comparison was made between 2 groups ('conservative' versus 'emergency') at early FU and 3 groups ('conservative' versus 'elective' versus 'emergency') at long-term FU.Data from 30 patients (M:F = 2.8:1; mean age: 54 years; median FU: 31.5 months) were collected. 86,7% patients presented with visual disturbances (70% acuity, 50% field, 50% diploplia). 10 (33%) patients underwent emergency surgery and further 8 underwent delayed elective surgery.At early FU, resolution rates of VA (33% versus 38%), VF (40% versus 50%) and CN deficits (71% versus 40%) were not significantly different between groups.At long-term FU, resolution of VA (80% versus 20% versus 75%) and CN deficits (67% versus 50% versus 80%) was not significantly different between groups. Most patients who underwent surgery presented with severe VA deficit (20% versus 40% versus 63%) but severity of initial deficit wasn't correlated with long-term resolution.VF recovery rates showed significant difference between groups (Good results are possible with conservative management in selected cases. Emergency surgery provides better visual outcomes. Decision-making process should be tailored to every single patient. We believe that a tumour vertical diameter35 mm should tip the balance in favour of surgical management in presence of visual deficit.

Introduction Recent guidelines suggest obstructive sleep apnoea (OSA) is not an absolute contraindication for same day discharge following surgery. The aim of this systematic review was to examine the feasibility and safety of day case nasal and/or palatopharyngeal surgery in patients with OSA. Methods We performed a systematic search of PubMed, EMBASE and the Cochrane library. Quality assessment of included studies was done. The protocol of this systematic review was registered with PROSPERO (CRD42021273451). Results A total of 1836 patients from ten observational studies were included. There were 268 (15.4%) nasal surgeries, 738 palatopharyngeal surgeries (42.4%) and 735 (42.2%) combined nasal and palatopharyngeal surgery. The majority of patients had moderate to severe OSA. A total of 860 patients (49.8%) were successfully discharged as day cases. There were no standard criteria for daycase surgery. Post-anaesthetic respiratory events were reported in 86/1750 (4.9%) patients. Oxygen desaturation was the most common respiratory event (83.7%, n = 72). There was no mortality reported. Conclusion Current data suggests day surgery is feasible in carefully selected patients with OSA undergoing nasal and/or palatopharyngeal surgery. Further well-designed prospective studies with an emphasis on the systematic assessment of complications are required to establish safety and daycase criteria.

This case report deals with two patients with lacrimal sac swellings. Case 1 presented with bilateral sac swelling and Case 2 with a unilateral presentation. Dacrocystorhinostomy (DCR) followed by biopsies of both sacs in Case 1 revealed inflammatory polyps of the sac mucosa, identical in appearance to typical nasal allergic inflammatory polyps. The biopsies were accompanied by typical allergic mucin, featuring tiered mucin layers between which were numerous eosinophils, accompanied by Charcot-Leyden crystals. The histology of the dacryocystectomy specimen for Case 2 showed identical histopathological changes with the additional feature of prominent numbers of Immunoglobulin G (IgG)4-positive plasma cells in the stroma of the lacrimal sac inflammatory polyps. These features extend the sites affected by allergic inflammatory polyps and allergic mucin and possible pathogenesis is discussed.

Background During the coronavirus disease 2019 (COVID-19) pandemic, concerns have been raised regarding the increased risk of perioperative mortality for patients with COVID-19, and the transmission risk to healthcare workers, especially during endonasal neurosurgical operations. The Pituitary Society has produced recommendations to guide management during this era. We sought to assess contemporary neurosurgical practice and the effects of COVID-19. Methods A multicenter prospective observational cohort study was conducted at 12 tertiary neurosurgical units (United Kingdom and Ireland). Data were collected from March 23 to July 31, 2020, inclusive. The data points collected included patient demographics, preoperative COVID-19 test results, operative modifications, and 30-day COVID-19 infection rates. Results A total of 124 patients were included. Of the 124 patients, 116 (94%) had undergone COVID-19 testing preoperatively (transsphenoidal approach, 97 of 105 [92%]; expanded endoscopic endonasal approach, 19 of 19 [100%]). One patient (1 of 116 [0.9%]) had tested positive for COVID-19 preoperatively, requiring a delay in surgery until the infection had been confirmed as resolved. Other than transient diabetes insipidus, no other complications were reported for this patient. All operating room staff had worn at least level 2 personal protective equipment. Adaptations to surgical techniques included minimizing drilling, draping modifications, and the use of a nasal iodine wash. At 30 days postoperatively, no evidence of COVID-19 infection (symptoms or positive formal testing results) were found in our cohort and no mortality had occurred. Conclusions Preoperative screening protocols and operative modifications have facilitated endonasal neurosurgery during the COVID-19 pandemic, with the Pituitary Society guidelines followed for most of these operations. We found no evidence of COVID-19 infection in our cohort and no mortality, supporting the use of risk mitigation strategies to continue endonasal neurosurgery in subsequent pandemic waves.

Background CRANIAL (CSF Rhinorrhoea After Endonasal Intervention to the Skull Base) is a prospective multicenter observational study seeking to determine 1) the scope of skull base repair methods used and 2) corresponding rates of postoperative cerebrospinal fluid (CSF) rhinorrhea in the endonasal transsphenoidal approach (TSA) and the expanded endonasal approach (EEA) for skull base tumors. We sought to pilot the project, assessing the feasibility and acceptability by gathering preliminary data. Methods A prospective observational cohort study was piloted at 12 tertiary neurosurgical units in the United Kingdom. Feedback regarding project positives and challenges were qualitatively analyzed. Results A total of 187 cases were included: 159 TSA (85%) and 28 EEA (15%). The most common diseases included pituitary adenomas (n = 142/187), craniopharyngiomas (n = 13/187). and skull base meningiomas (n = 4/187). The most common skull base repair techniques used were tissue glues (n = 132/187, most commonly Tisseel), grafts (n = 94/187, most commonly fat autograft or Spongostan) and vascularized flaps (n = 51/187, most commonly nasoseptal). These repairs were most frequently supported by nasal packs (n = 125/187) and lumbar drains (n = 20/187). Biochemically confirmed CSF rhinorrhea occurred in 6/159 patients undergoing TSA (3.8%) and 2/28 patients undergoing EEA (7.1%). Four patients undergoing TSA (2.5%) and 2 patients undergoing EEA (7.1%) required operative management for CSF rhinorrhea (CSF diversion or direct repair). Qualitative feedback was largely positive (themes included user-friendly and efficient data collection and strong support from senior team members), demonstrating acceptability. Conclusions Our pilot experience highlights the acceptability and feasibility of CRANIAL. There is a precedent for multicenter dissemination of this project, to establish a benchmark of contemporary practice in skull base neurosurgery, particularly with respect to patients undergoing EEA.

Background: The endonasal transsphenoidal approach (TSA) has emerged as the preferred approach in order to treat pituitary adenoma and related sellar pathologies. The recently adopted expanded endonasal approach (EEA) has improved access to the ventral skull base whilst retaining the principles of minimally invasive surgery. Despite the advantages these approaches offer, cerebrospinal fluid (CSF) rhinorrhoea remains a common complication. There is currently a lack of comparative evidence to guide the best choice of skull base reconstruction, resulting in considerable heterogeneity of current practice. This study aims to determine: (1) the scope of the methods of skull base repair; and (2) the corresponding rates of postoperative CSF rhinorrhoea in contemporary neurosurgical practice in the UK and Ireland. Methods: We will adopt a multicentre, prospective, observational cohort design. All neurosurgical units in the UK and Ireland performing the relevant surgeries (TSA and EEA) will be eligible to participate. Eligible cases will be prospectively recruited over 6 months with 6 months of postoperative follow-up. Data points collected will include: demographics, tumour characteristics, operative data), and postoperative outcomes. Primary outcomes include skull base repair technique and CSF rhinorrhoea (biochemically confirmed and/or requiring intervention) rates. Pooled data will be analysed using descriptive statistics. All skull base repair methods used and CSF leak rates for TSA and EEA will be compared against rates listed in the literature. Ethics and dissemination: Formal institutional ethical board review was not required owing to the nature of the study–this was confirmed with the Health Research Authority, UK. Conclusions: The need for this multicentre, prospective, observational study is highlighted by the relative paucity of literature and the resultant lack of consensus on the topic. It is hoped that the results will give insight into contemporary practice in the UK and Ireland and will inform future studies.

To evaluate clinical presentations, diagnosis and management of paediatric patients presenting with pituitary apoplexy. A retrospective case series describing a cohort of paediatric patients presenting with this condition from 2010–2016 to a tertiary referral children’s hospital in the United Kingdom. Pituitary apoplexy is a rare condition that seems to have a higher relative incidence in children than adults. Our series suggests that pituitary apoplexy in paediatric patients with adenomas appears more common than previously described. All our patients required surgery, either as an acute or delayed procedure, for visual compromise. Two patients had commenced growth hormone (GH) for GH deficiency two weeks prior to the onset of pituitary apoplexy. With only a limited number of published case reports surrounding this topic our case series contributes to help further understand and manage this condition.

In patients undergoing endoscopic transsphenoidal hypophysectomy, the nasal mucosa is often infiltrated with local anesthetic solutions that contain epinephrine to aid hemostasis. This may, however, result in hemodynamic changes, especially hypotension. We characterized the cardiovascular changes using a LiDCOrapid monitor in 13 patients after the infiltration of 4% articaine containing 1:200,000 epinephrine. Nine (69%) had a >20% decrease in mean arterial pressure at a median time of 116 seconds after the infiltration of articaine with epinephrine. Analysis of the cardiac output data revealed that this was caused by a sustained reduction in systemic vascular resistance. The arterial blood pressure normalized over a period of 60 to 90 seconds secondary to increases in stroke volume and heart rate producing an elevation in cardiac output. Transient hypotension following the infiltration of epinephrine-containing local anesthetics may be caused by epinephrine stimulation of β2-adrenoceptors producing vasodilation.

This case report deals with two patients with lacrimal sac swellings. Case 1 presented with bilateral sac swelling and Case 2 with a unilateral presentation. Dacrocystorhinostomy (DCR) followed by biopsies of both sacs in Case 1 revealed inflammatory polyps of the sac mucosa, identical in appearance to typical nasal allergic inflammatory polyps. The biopsies were accompanied by typical allergic mucin, featuring tiered mucin layers between which were numerous eosinophils, accompanied by Charcot-Leyden crystals. The histology of the dacryocystectomy specimen for Case 2 showed identical histopathological changes with the additional feature of prominent numbers of Immunoglobulin G (IgG)4-positive plasma cells in the stroma of the lacrimal sac inflammatory polyps. These features extend the sites affected by allergic inflammatory polyps and allergic mucin and possible pathogenesis is discussed.

A 65 year-old lady with metastatic breast cancer presented with pituitary apoplexy. Following surgery, histopathology confirmed metastatic breast carcinoma into a gonadotroph cell adenoma of the pituitary. Tumours that metastasise to a normal pituitary gland are unusual. More so, such neoplasm-to-neoplasm metastasis is extremely rare. This is, as far as we are aware, the first description of a metastasis into a gonadotroph cell pituitary adenoma presenting as apoplexy.

Immunoglobulin G4-related disease (IgG4-RD) is becoming increasingly documented. It was first described in relation to autoimmune pancreatitis. Features of the disease include tissue infiltration by IgG4 plasma cells with associated fibrosis and the growth of pseudotumours. A 71-year-old woman presented with increasing right cheek swelling and mild proptosis. Ten years earlier, she had a similar presentation and was diagnosed with an inflammatory pseudotumour. Examination revealed a lesion in the right nasal cavity. CT and MRI confirmed a mass within the right maxillary antrum extending into the nasal cavity. Endoscopic biopsies showed florid plasma cell infiltrate with marked increase in IgG+ plasma cells. Immunostaining expressed IgG4 (70%). She was started on a course of prednisolone and her symptoms resolved. IgG4-RD is becoming an emerging disease entity. Its involvement in the paranasal sinuses can mimic nasal tumours. Major surgical resection should be avoided as patients can often be treated medically.

Objectives An optimum septoplasty result may require complete detachment of the superior osseocartilaginous junction (OCJ), but this may lead to disruption of the keystone area with loss of nasal support and consequent supratip depression deformity. The aim of this study was to analyse normal keystone anatomy using CT scan images and to estimate the incidence of risk of supratip depression when completely detaching the OCJ. Design Retrospective study. Setting Tertiary referral centre. Participants Adult patients who underwent CT paranasal sinuses prior to transsphenoidal hypophysectomy in a tertiary referral centre between 2009 and 2013. Main outcome measures Length of the keystone area. A length of

Objectives Internal carotid artery (ICA) injury remains a rare but potentially fatal complication of transsphenoidal pituitary or anterior skull base surgery. Preoperative imaging must be scrutinized to minimize risk. On axial computed tomography (CT), the protrusions of the ICAs into the sphenoid resemble a “teddy bear.” This article aims to describe the sign, its grading system (0–2) and quantify its presence. Design Retrospective review of preoperative CT imaging. Setting Tertiary referral center in the United Kingdom. Participants One hundred patients who underwent endoscopic transsphenoidal surgery for pituitary disease were enrolled. Main Outcome Measure The presence and grading of the “teddy bear” sign were assessed on preoperative CT imaging. Results A grade 2 (strongly positive) “teddy bear” sign was identified in 40% at the level of the superior pituitary fossa, 78% at the inferior pituitary fossa, and 59% at the clivus. A grade 1 (intermediate) sign was seen in 23.5, 7.5, and 10% of cases, respectively. In 5% of cases, the sign was grade 0 at all levels—indicating poor intraoperative localization of the ICA. Conclusion The “teddy bear” sign is a useful preoperative tool for identification of anatomy predisposing patients to a higher risk of ICA injury. Those patients who have an absent or grade 0 “teddy bear” sign require extra care to ensure intraoperative localization of the ICAs which may include the use of neuronavigation or a Doppler probe. A grade 2 sign predicts good intraoperative localization of the ICA intraoperatively to inform the safe lateral limit of sellar bone resection.

In the English NHS Payment by Results system, clinical coding of a surgical operation results in one of a range of healthcare resource groups (HRG), each of which has a specific payment national tariff that the hospital receives for each spell of care. Our aim was to audit the clinical coding of our adult otolaryngology operations with a view to prospectively improve coding accuracy and ensure appropriate reimbursement via national tariffs. We reviewed the clinical coding of operations at the end of each month, before national submission of data, over a 9-month period. Using a system that groups operation codes according to anatomical site/type we analysed cases to see if the OPCS codes recorded for the procedure reflected the actual procedure performed or whether accuracy could be improved. Over the 9-month period there were 1087 operations; 1057 (97.2%) were coded accurately and 30 (2.8%) were suboptimally coded, but when corrected for accuracy resulted in a total increase in national tariff income of £33 364. A system that groups related operation codes according to anatomical regions and types of procedure, aids the accuracy of clinical coding. It may be used before coding submission national deadlines to ensure that the appropriate remuneration is received via national tariff, for the care delivered.

In order to perform trans-sphenoidal endoscopic pituitary surgery safely and efficiently it is important to identify anatomical and pituitary disease features on the pre-operative CT and MRI scans; thereby minimising the risk to surrounding structures and optimising outcomes. We aim to create a checklist to streamline pre-operative planning. We retrospectively reviewed pre-operative CT and MRI scans of 100 adults undergoing trans-sphenoidal endoscopic pituitary surgery. Radiological findings and their incidence included deviated nasal septum (62%), concha bullosa (32%), bony dehiscence of the carotid arteries (18%), sphenoid septation overlying the internal carotid artery (24% at the sella) and low lying CSF (32%). The mean distance of the sphenoid ostium to the skull base was 10 mm (range 2.7–17.6 mm). We also describe the ‘teddy bear’ sign which when present on an axial CT indicates the carotid arteries will be identifiable intra-operatively. There are significant variations in the anatomical and pituitary disease features between patients. We describe a number of features on pre-operative scans and have devised a checklist including a new ‘teddy bear’ sign to aid the surgeon in the anatomical assessment of patients undergoing trans-sphenoidal pituitary surgery.

Pituitary surgery has seen a recent shift from a microscopic to an endoscopic trans-sphenoidal approach. We present our early experience with endoscopic surgery and compare the outcome with our recent microscopic experience.From January 2008 until present time, 80 consecutive patients underwent trans-sphenoidal pituitary surgery in our institution. Until September 2009, all patients had a microscopic trans-septal approach. After this time, the patients underwent endoscopic trans-sphenoidal surgery. All patients underwent pre- and post-operative MRI and full endocrinological evaluation. Data was collected prospectively including tumour volume, endocrine function, visual function, length of stay and complications.There were 40 patients in each group. In the microscopic group, there were 26 non-functioning tumours and 14 functioning tumours. In the endoscopic group, there were 24 non-functioning and 16 functioning tumours. There were significantly better results in terms of tumour resection (p = 0.002) and remission (p = 0.018) in the endoscopic group. In this group there was also a lower incidence of CSF leaks and a shorter length of stay for secreting tumours (p = 0.005). 1 patient in the endoscopic group died at day 43 post-operatively, having initially presented in a poor clinical state with pituitary apoplexy.Microscopic trans-sphenoidal surgery remains the benchmark for future surgical techniques. Our early results suggest that endoscopic trans-sphenoidal surgery provides favourable results in both tumour resection and control of secreting tumours in comparison with microscopic surgery. Further longer-term evaluation is required to ensure the outcome of endoscopic surgery.

Clinical coding of a surgical operation produces a health resource group (HRG) code with a specific payment tariff that the hospital receives. Our aim was to review the clinical coding in our ENT department and discover whether there was scope for improving the accuracy of coding and the income tariffs. We retrospectively reviewed the clinical coding of operations over a four month period. Using a system that groups operation codes according to anatomical regions and types of procedure, we analysed each case to see if the actual code attributed to the procedure could be improved. Such a system aids the accuracy and optimisation of income tariffs. It can be used during the coding process and subsequently as a quality assurance tool as well as in the auditing of clinical coding.

ObjectiveTo review the safety and efficacy of the use of radiofrequency coblation for endoscopic resection of upper aero-digestive tract malignancies and to compare length of procedures using coblation with CO2 laser surgery.Study Design and SettingA retrospective case-note review of 40 adult patients with endoscopically treated mucosal squamous cell carcinoma of the head and neck, 20 having undergone resection using radiofrequency coblation and being case-matched to 20 treated with CO2 laser.ResultsCoblation proved to be an effective method for resection of selected head and neck malignancies. It allows for much faster resection times than the CO2 laser (P = 0.017) especially in the oropharynx (P = 0.007), but the large probes currently available can cause problems in assessment of adequate resection margins.ConclusionsAlthough current probe design limits the potential for resection of some tumors, radiofrequency coblation appears to be an attractive evolving technique for the endoscopic resection of sel...

Nasal dermoid sinus cysts are the most common congenital midline nasal lesions. We describe a novel technique for the excision of a nasal dermoid cyst in a 2-year-old boy using a four hand endoscopic approach via a small scalp incision behind the hairline. The technique, although somewhat challenging, avoids a facial scar.

In pharyngeal pouch surgery, the relatively new technique of endoscopic stapling diverticulotomy has a number of advantages over more traditional surgical treatments, such as Dohlman’s procedure and open pouch excision, and now seems to be the procedure of choice. However, a number of iatrogenic perforations and deaths have been reported with this procedure. We present three cases of iatrogenic perforations occurring during endoscopic stapling of a pharyngeal pouch by different surgeons in our unit, and review the management, causes and prevention of this potentially life-threatening complication.

Osteogenesis imperfecta (OI) is a genetic disorder whose primary manifestations are fractures, bone deformity and bone pain. Brainstem compression due to basilar invagination is a rare and potentially life-threatening complication of OI. Children with this condition often require significant medical input and multiple admissions to hospital. Traditionally, anterior decompression is carried out through an open trans-oral route. We describe an endoscopic endonasal approach for resection of the peg in a child with OI and basilar invagination. We believe this approach provides an excellent alternative with minimal morbidity and decreased length of stay especially in the paediatric population.

Objective Intracranial epidermoids (cholesteatomas) mimic arachnoid cysts in their radiologic characteristics, especially in the cerebellopontine angle. It is essential to differentiate the two conditions because they warrant different therapeutic interventions. The objective of this study is to elucidate the different radiologic characteristics of the conditions. Study design and setting This was a retrospective study of 4 patients referred for a differential diagnosis and management of intracranial cystic lesions to the Departments of Neurotology/Neurosurgery and Neuroradiology in a tertiary referral university hospital. Patients Four patients of different age groups with cystic intracranial lesions, diagnosed epidermoid or arachnoid cysts, were chosen. A retrospective analysis of their case charts, radiologic and surgical interventions, and follow-up records was undertaken. Methods The imaging techniques used included computerized tomographic scans, magnetic resonance imaging (MRI) with T1, T2, proton-density, and gadolinium-enhanced T1 images. In addition, special MRI sequences were used that included fluid-attenuated inversion recovery and echo planar diffusion scanning. All the patients underwent an audiovestibular evaluation. Results Both lesions are characteristically well demarcated and have a homogeneous low density, similar to cerebrospinal fluid on computerized tomographic scan, showing no contrast enhancement. On MRI, epidermoids and arachnoid cysts usually appear hypointense on T1-weighted images and hyperintense on T2-weighted images. On fluid-attenuated inversion recovery, an arachnoid cyst tends to follow cerebrospinal fluid intensity, whereas an epidermoid becomes hyperintense. There are occasions when an epidermoid may appear as a low-intensity lesion on fluid-attenuated inversion recovery. This dilemma is resolved with the use of echo planar diffusion scanning, on which an epidermoid remains bright. Conclusion The authors recommend the use of fluid-attenuated inversion recovery and diffusion sequence MRI when definitive radiologic diagnosis of cystic intracranial lesions becomes difficult with routine computerized tomographic scanning and MRI.

Objectives: A case is described in which squamous cell carcinoma was found during surgery for a recurrent pharyngeal pouch previously treated by endoscopic stapling. A search of the English language literature suggests this is the first reported case of a carcinoma developing in a pharyngeal pouch previously treated by endoscopic stapling. Study Design: Case report and literature review. Materials and Methods: The records of a patient who presented with a recurrent pharyngeal pouch after a previous endoscopic stapling procedure were reviewed. The presentation, imaging, and histopathologic findings are presented and the implications of these discussed. Results: Imaging confirmed a recurrent pharyngeal diverticulum. An endoscopic assessment revealed the presence of tumor in the recurrent pouch that histopathologic evaluation confirmed to be squamous cell carcinoma. The patient underwent an external excision of this diverticulum followed by a course of external beam radiotherapy. Conclusions: This is the first reported case of a carcinoma developing in a recurrent pharyngeal diverticulum previously treated by endoscopic stapling and brings to light a rare risk of endoscopic stapling procedures for the treatment of pharyngeal diverticula.

Our aim was to evaluate the routine use of a pedicled nasoseptal flap (NSF) as a primary repair for intra-operative CSF leaks compared with fat/fascia lata graft and lumbar drain insertion by performing a retrospective review of elective patients undergoing primary trans-sphenoidal surgery from January 2008 to present.A retrospective review of consecutive primary elective trans-sphenoidal cases for sellar pathology was undertaken. Prior to September 2009, microscopic trans-sphenoidal surgery (MTSS) was performed in 40 cases and since then endoscopic trans-sphenoidal surgery (ETSS) was performed in 100 cases.In the MTSS group, intra-operative CSF leaks were repaired with fat graft, tisseal and lumbar drain insertion. Intra-operative leaks in the ETSS group were routinely repaired with a pedicled NSF. Post-operative CSF leak rates were 12.5% in the MTSS and 3% in the ETSS groups, respectively. Three patients in the ETSS group developed a post-op CSF leak. All of these patients underwent surgery for craniopharyngiomas. This group had subsequent endoscopic repairs and were managed with repositioning of the NSF.The advent of the pedicled NSF conveys a significant advantage in preventing post-operative CSF leak, decreasing the morbidity associated with lumbar drain insertion and reduces the length of hospital stay.

Nasal dermoid sinus cysts are the most common congenital midline nasal lesions. We describe a novel technique for the excision of a nasal dermoid cyst in a 2-year-old boy using a four hand endoscopic approach via a small scalp incision behind the hairline. The technique, although somewhat challenging, avoids a facial scar.

Objective: In transnasal endoscopic pituitary surgery and transsellar approaches to anterior skull base lesions, a bony sella window is created with the lateral limits being the carotid arteries.Method: Coronal CT scan of the sphenoid sinuses were reviewed in a tertiary referral hospital and compared with intra operative findings.Results: Sphenoid anatomy is variable in terms of the degree of pneumatization and bony anatomy around the pituitary gland and internal carotid arteries. We describe a radiological sign ascertained from computerized tomography (CT) that when present indicates whether the carotid arteries can be readily identified endoscopically on entering the sphenoid sinus. On the axial CT the carotid arteries may produce protuberances either side of the sella which together with the bony sella and dorsum sella appear to form the outline of the head of Mickey Mouse or a teddy bear.Conclusion: When this sign is not present then the junction between the sella and carotids may not be clear and sur...

Objective: Payment by results was introduced to the UK National Health Service in 2004. Specific payment tariff for ENT departments is determined by clinical code of the patient’s episode. Our aim was to review clinical coding in our department and assess scope for improving accuracy of coding and income tariffs.Method: We retrospectively reviewed coding of operations over a 4-month period. A database was obtained including primary operation code and payment tariff. Using a system that grouped operation codes according to anatomic site, we analyzed each case to see if actual code attributed to the procedure could be improved.Results: Over the 4-month period there were 930 operations; 866 (93%) were correctly coded with an optimal tariff, 19 (2%) were incorrectly coded giving an excessive total tariff of £24,840, and 45 (5%) were incorrectly coded losing a tariff of £37,381. Therefore, over the 4-month period, £12,541 was lost due to suboptimal coding.Conclusion: A system that groups ENT operation codes ac...

Objective: Ventilation tube insertion is the primary surgical intervention in persistent otitis media with effusion. Around 7% of ventilation tubes require elective removal. The objective is to discover the tympanic membrane healing rate after ventilation tube removal and identify measures that improve this.Method: Retrospective case note review performed for patients who had elective ventilation tube removed over an 8-year period. Information gathered included if any concomitant procedure was performed to repair the tympanic membrane and final outcome of the tympanic membrane status.Results: A total of 113 cases were included in this study. The average age at grommet insertion and removal was 5.8 years old and 8.3 years old, respectively. After ventilation tube removal the perforation edges were freshened in all cases. The majority of patients (84.1%) subsequently had an intact tympanic membrane. Additional procedures were performed on 19 ears, 6 with insertion of overlay absorbable material and 14 with ...

We report a rare case of mediastinal tuberculosis in a child who presented as a possible inhaled foreign body. A 10-month-old girl was admitted with a five-month history of cough, wheeze and problematic feeding, thought initially to be due to asthma. A clinical deterioration and subsequent X-rays suggested an inhaled foreign body. However, at direct laryngotracheobronchoscopy no foreign body was found and subsequent investigations revealed a subcarinal mediastinal mass. She underwent a thoracotomy and excision of the mass, the histological analysis of which revealed it to be of tuberculous origin. When a patient presents with symtoms of upper airway obstruction which are highly suggestive of a foreign body, other causes such as mediastinal tuberculosis must be borne in mind when no foreign body can be found. Although rare, cases of tuberculosis are apparently increasing and the otolaryngolgoist must be aware of its various manifestations and submit specimens for appropriate analysis. We also briefly review mediastinal lymphadenopathy due to tuberculosis.

Cerebrospinal fluid (CSF) leak following initiation of Dopamine agonist therapy for macroprolactinomas, although uncommon, has been described previously in the literature. Traditional management includes primary repair of the defect using either fat or fascia lata in conjunction with lumbar drain insertion. In this case series we outline two cases of CSF leak secondary to invasive pituitary tumour that were repaired successfully using a nasoseptal flap. We believe that this form of repair is effective and associated with minimal morbidity.

Salivary tissue intraductal papillomas are rare, benign tumours that predominantly affect minor salivary glands. We report a case of an intraductal papilloma arising in the unusual site of the submandibular gland. The tumour was completely excised and recurrence is not expected. A brief review of this histologically distinct lesion is presented.

Patients are seen by both a consultant ophthalmologist and otolaryngologist in a joint epiphora clinic and undergo a full assessment including palpation of the lacrimal sac, probing and irrigation of the canaliculi and lacrimal sac, dye disappearance test, and nasal endoscopy. In cases where the site of obstruction is not obvious, a macrodacryocystogram is performed to confi rm nasolacrimal duct obstruction. If there is a suspicion of lacrimal sac neoplasm or evidence of a severe posttraumatic bony deformity of the lacrimal sac, then an external surgical approach is selected.