Featured cases
01/01/2010 Glue ear
A 3 year old girl attended the ENT clinic with his parents who were concerned about reduced hearing. Charlotte had been struggling for some time to respond to her parents who frequently felt the need to prompt and/or repeat themselves. They had noticed the television was on a louder volume setting compared to Charlotte's elder brother. The nursery teachers where Charlotte went had also expressed some concerns about her attention and also some behavioural issues had come to light. They also commented on the fact that Charlotte's speech development had slowed considerably in the last 6 months compared with her peers. These problems had all begun during a particularly severe upper respiratory viral infection 6 months earlier during which Charlotte also suffered with an ear infection. This passed relatively quickly although the hearing problems persisted.
Examination in the clinic demonstrated that there was fluid trapped behing both ear drums (glue ear). She had a good nasal airway, indicating that the adenoids were not clinically enlarged, and her tonsils were of an average size and not inflamed. A formal paediatric hearing assessment was organised, which demonstrated a severe conductive hearing loss indicating that the fluid was preventing the ear drums from moving thereby impairing the conduction of sound into the middle and inner ears.
It was explained that glue ear frequently resolves by itself, although this usually occurs within the first 3 months following the onset of the hearing difficulties. After 3 months, the chance of spontaneous resolution without treatment becomes increasingly unlikely. Various treatment options were discussed, including surgery in the form of grommet insertion, uae of the otovent balloon or a further period of watchful waiting. The latter two were discounted on account of the long time period that had already elapsed, the severe nature of the hearing loss and also the parents' desire to resolve the problem rapidly and definitively, which insertion of grommets could achieve.
The operation was scheduled 2 months later and took place as a day case. It involved the insertion of a plastic ventilation tube (grommet) into each ear drum, a procedure lasting less than 10 minutes. Charlotte was discharged home the same day with instructions to keep the ears dry whilst bathing or showering for 4 weeks. She was also advised towear ear plugs and a swimming hat for swimming. WHen Charlotte was reviewed in the ENT clinic 6 weeks later, her hearing had returned to normal, she had no discomfort in either ear, and her parents had noticed a change in her behaviour. It was emphasised that further improvements in her speech acquisition would take place over a longer time frame.
29/03/2010 Novel surgery for nasal polyps
A 52 year old lady had a long history of a blocked nose, sinus congestion, inability to smell things and catarrh in the nose and throat. This was despite the regular and prolonged use of topical nasal steroid sprays and drops. She had undergone several previous operations for polyp removal but the polyps kept on recurring. Examination in clinic demonstrated extensive nasal and sinus polyps, which were confirmed on a CT scan. As a result, it was recommended that she should undergo surgery.
During the operation, the majority of the nasal polyps were removed in the conventional way using microscopic power tools and high quality endoscopes to guide the approach. However a novel treatment - balloon sinuplasty - was used to create an opening into the sinus, following which another novel device - the ethmoid spacer - was inserted into the sinuses with the greatest concentration of polyps. This device was filled with steroid which would dissipate into the surrounding polyps over the course of the ensuing 4-6 weeks.
After the surgery, Beverley was discharged home the same day and was prescribed some salt water douches to keep the nose clean. When she was seen in the ENT clinic a few weeks later, her nasal airway was considerably better and she was able to smell and taste for the first time in many months.
01/10/2009 Minimally Invasive Pinnaplasty for Prominent "Bat" Ears
A 3 year old boy attended the ENT clinic with his mother. She was unhappy with the shape of her son's ears, which she says had been prominent since birth. There was no concern about his hearing and he was developing normally according to age-appropriate milestones. However the prominent ears were beginning to cause concern and attract attention particularly by older children.
Because of the type of deformity, it was felt that a minimally invasive approach would be suitable. The advantage of this is that there is no surgical scar, the operation takes considerably less time, and the eventual outcome is at least as good as for a 'conventional' pinnaplasty.
During the operation, the site of the new intended skin crease is marked clearly as shown. The cartilage is then weakened from the front, and sutures are placed from behind the ear into the cartilage to recreate the natural curvature of the ear. No skin incisions are used. Unlike with a conventional pinnaplasty, a tight head bandage is not required following this procedure.
After the operation, the patient returned to the paediatric ward and after a short period of recovery was sent home the same day. Postoperative instructions included the use of a sport's type band at night to prevent the ears from flopping forwards, and also keeping the ears dry.
The patient was then seen two weeks later in the ENT clinic and the appearances of the ears found to be very much improved compared with before the operation. The minially invasive technique had proven to be successful with minimal recovery and no complications.
01/08/2009 Epistaxis (nose bleed)
A 68 year old man experienced a sudden and severe nose bleed which was not stopping despite first aid measures including pinching the nose. Hw was having some breathing difficulties and blood was emerging out of the mouth as well as from the nose. Intravenous access was established, blood tests taken for clotting screen and a group and save in case a transfusion became necessary, and a fluid drip set up. Examination of the nose did not reveal any obvious source of the bleeding, and so his nose was packed with a Merocel dressing on each side which stopped the bleeding.
The patient was admitted to the ward for observation, bed rest and diazepam to reduce any anxiety. The following day, a chest X-ray was performed which demonstrated a right lower lobe pneumonia (*), presumed to be secondary to aspiration of blood at the time of his presentation.
The nasal packs were subsequently removed 24 hours later, but unfortunately the bleeding recurred quickly necessitating a repeat packing with Merocel.
During the interval between nasal packings, examination of the nose revelaed that the bleeding appeared to originate in the posterior nasal cavity from a point on the lateral wall of the nose. It was therefore decided that the patient would require surgical intervention to stop the bleeding as the blood vessel was to inaccessible for cauterisation on the ward.
The patient was prepared for a general anaesthetic. At operation, a rigid endoscope was used to visualise the posterior half of the nasal cavity and an incision made in the lateral wall of the nose to identify the blood vessel responsible for the bleeding (sphenopalatine artery). A clip was then placed across the vessel to stop the bleeding, as shown in the picture.
Following the operation, the patient experienced no further nose bleeds and was discharged home the following day. Advice was given to avoid nose blowing, sneezing and straining for at least 72 hours to minimise the chance of another bleed.
01/07/2009 Obstructive sleep apnoea in children
Charlie is a 3 year old boy who presents to clinic with his mother with a history of severe snoring at night, occurring every night and which on occasions culminates in him stopping breathing for periods of up to 10 seconds. This happens several times a night and causes considerable parental anxiety. In addition, Charlie is invariably a restless sleeper who wakes himself up at night several times although manages to get himself off to sleep on most occasions, much to his parents' relief. He gets hot and sweaty, and often wakes in the morning feeling unrefreshed despite having been in bed for 12 hours. He mouth breathes during the day. There is no history of tonsillitis but mum had noticed some recent hearing loss.
Examination revealed large (grade 3) tonsils. On looking at his nose there was reduced anterior nasal misting on a metal spatula and thick mucopurulent nasal discharge. Both ear drums appeared dull indicative of the presence of middle ear fluid (glue ear).
Although it was explained that snoring is not considered to be a serious medical condition, the presence of apneoic spells (episodes of stopping breathing), restlessness/sweating/wakefulness at night and tiredness on waking in the morning are features indicative of obstructive sleep apnoea. This was felt to be due to enlarged adenoids and tonsils. The large adenoids were also causing blockage of the Eustachian tubes leading to fluid in the middle ears.
As a result, the recommendation was for Charlie to proceed with removal of his tonsils and adenoids (adenotonsillectomy), together with drainage of the glue ear (myringotomy) and insertion of grommets. The operation proceeded well with no immediate or early complications. Charlie's parents could not believe the difference in his nighttime breathing, so much so that his transformation to barely audible breathing continued to cause some parental anxiety for a little while longer.
01/06/2009 Glandular fever
A 16 year old girl had a two week history of a severe sore throat, difficulty in eating, high fever, extreme tiredness and lethargy. Her GP had treated her with a course of penicillin but this did not appear to be improving her symptoms.
On arrival in A&E, examination of the oral cavity revealed enlarged, inflamed tonsils with a greyish yellow surface exudate. Palpation of the neck revealed numerous swollen and tender lymph nodes.
As she was struggling to keep fluids down, she was admitted to hospital for intravenous antibiotics, steroids to reduce the inflammation and intravenous fluids. Blood tests confirmed the diagnosis of Glandular Fever. Examination of the abdomen demonstrated slight enlargement of the liver and spleen, which isassociated with glandular fever, although her liver function tests were within the normal range.
After two days her condition gradually improved to a point where she was able to eat and drink and she was discharged home with a completion course of oral antibiotics. She was given strict advice to avoid contact sports for at least four weeks owing to the potential risk of splenic rupture, and was given an appointment to be reviewed in the ENT clinic at this stage so that repeat examination could be carried out
and if necessary an ultrasound of the abdomen arranged to ensure that the enlarged liver and spleen had subsided before commencement of sporting activities.
She recovered fully from the acute infection over the subsequent 10 days, although she continued to experience waves of lethargy over the ensuing three months, which necessitated occasional days off school. A discussion was had with her ENT surgeon regarding whether her tonsils should be removed. As she had not experienced any episodes of tonsillitis prior to this occurrence of glandular fever, it was agreed that she did not need to have a tonsillectomy owing to the low risk of recurrence of the glandular fever. However she was aware that
this decision could be revisited in the event that she developed recurrent tonsillitis or any complications in the future.
01/05/2009 Nasal injury
A 35 year old man was assaulted during which he sustained significant blows to the face and head. On arrival in the Accident and Emergency department, his nose was seen to be deviated to the right due to a nasal bone fracture and he was having difficulty in breathing thorough both nostrils. X-rays taken of the face showed no other fractures of the facial bones. He was referred to the ENT clinic for manipulation of the fractured nasal bones, which was arranged within 2 weeks of his initial visit.
However, on arrival in the day surgery unit on the morning of the operation, he mentioned that he had noticed a clear watery discharge from the right nostril on the preceding two days. It was suspected that he might have a base of skull fracture resulting in a leak of cerebrospinal fluid (CSF) into the nose. A sample was sent for biochemical analysis which confirmed the clinical suspicion.
A CT scan was also performed, which demonstrates fracturing and comminution of the thin bony floor of the anterior skull base, as shown with asterices in the coronal and sagittal sections above.
The patient then underwent endoscopic endonasal surgical repair of the skull base fracture, using fascia lata, fat and Tisseel(TM) glue.
01/04/2009 Perforated ear drum and hearing loss
A 40 year old lady attended the ear,nose and throat clinic with a long history of recurrent ear infections and reduced hearing in the left ear. She had grommets inserted as a child. Examination revealed a perforated left tympanic membrane (hole in the ear drum). A hearing test (pure tone audiometry) demonstrated a 40 decibel conductive hearing loss.
This degree of hearing loss was felt to be too great to be accounted for by the perforated ear drum alone, and it was suspected that, in addition to this, there must have been a problem with the ossicular chain. A CT scan confirmed a small gap between the incus (anvil) and stapes (stirrup) bones of a sufficient magnitude that prevented sound conduction across the bones.
The treatment options were fully discussed with the patient. These included a hearing aid alone, or surgery to repair the perforation and reconstruct the ossicular chain. After informed consent was taken, she decided to proceed with surgery.
At the operation, a graft was taken to repair the hole in the ear drum. At the same time, biological cement (Sereno Cement) was used to bridge the gap between the two ossicles, as shown in figure 1. An antiseptic dressing was placed in the ear canal at the end of the surgery. The patient was then discharged home the same day.
Two weeks later she returned to clinic for removal of the ear dressing, and then underwent a postoperative hearing test which confirmed improvement of her hearing.