Biomedical subjects
Publications and source records attributed to T J Woolford.
A concha bullosa may require surgical reduction to facilitate access to the middle meatus during endoscopic sinus surgery. Here we describe an original instrument which enables this procedure to be performed simply with minimal mucosal damage.
We describe the technique of implant-site split-skin grafting for the bone-anchored hearing aid (BAHA). Twenty-five patients have undergone this procedure (20 adults and five children) since 1993 with a minimum follow-up of 1 year. Fifteen adults were operated upon as single stage surgery, all other cases (including all children) were performed in two stages. In four patients (16%) significant early graft inflammation was encountered which settled with outpatient treatment. In one the abutment had to be temporarily removed to allow the graft to settle. All patients now have a stable graft site. This surgical technique is straightforward and a separate graft donor site is avoided. It would appear this technique results in a stable BAHA graft site with low associated morbidity.
The bacteriology of the tonsillar surface and core in 30 children undergoing tonsillectomy was studied. Antibiotics taken in the six months before surgery were recorded. Haemophilus influenzae and Staphylococcus aureus were the commonest isolates; Streptococcus pyogenes was relatively rare. Eight children had received no antibiotics, the others had been prescribed 65 different courses of 13 different types. No relationship between the various antibiotic regimens prescribed and tonsillar bacteriology could be demonstrated, and it would appear that the tonsillar bacteriology at the time of tonsillectomy is not altered by antibiotics prescribed in the previous six months.
One hundred and forty-three patients with post-cricoid squamous cell carcinoma are described. Twenty-nine patients (20%) underwent pharyngolaryngoesophagectomy with gastric transposition. Forty-four patients (31%) were treated with radical radiotherapy and 70 (49%) had palliative therapy. Kaplan Meier 5-year survival following surgery was 45% and radiotherapy was 23%. The presence of nodal disease at presentation was the most significant prognostic factor. The 5-year survival of patients undergoing surgery with no palpable lymph node spread at presentation was 63% which compared with 25% following radiotherapy. This difference was statistically significant (P = 0.0153, Logrank test stratified by nodal status). Patients with palpable metastatic nodal spread at presentation had 5-year survivals of 10% and 0% in the surgical and radiotherapy groups respectively. This study demonstrates that patients with post-cricoid carcinoma who present without palpable lymph node spread have a significant improved 5-year survival following surgery when compared with radiotherapy.
This study was performed to assess the survival times of the Provox valve in the Manchester area. Thirty-nine patients from four hospitals, representing 81 valve failures, were studied. The effects of the timing of the tracheo-oesophageal puncture, previous radiotherapy, and the presence and timing of cricopharyngeal myotomy on valve life were analysed. Regression analysis using an extension of the Cox model to allow strata showed that the lifetime of the first valve only is adversely affected by previous radiotherapy. The other covariates do not have a statistically significant effect on valve survival. The median valve survival is 4.5 months, (range one to 12 months). A small percentage of valve users with particularly frequent valve failures may require additional support and prolonged anti-fungal therapy.
The adult cochlear implant programme in Manchester was established in 1988 and the evaluation of the cochlear implant service involved the first 58 implants users (mean age = 51.65 years, range 19-75 years). Questionnaires were sent to implant users and their partners to evaluate the service with regard to provision of information, clinical care during in-patient assessments, waiting times, operation for cochlear implant and post-operative rehabilitation. The results show that the majority of patients (78 per cent) felt that the implant gave them as much or more benefit than expected. Areas identified for improvements include provision of more written information about cochlear implants; reduction in waiting times for first appointments; more information about the surgical risks and more instruction about home auditory training exercises for family and friends. As a consequence of the audit results the clinical practice and service provision for cochlear implantation in Manchester has been modified.
Magnetic resonance imaging (MRI) is currently the 'gold-standard' investigation in patients with a unilateral sensorineural hearing loss. The procedure, however, is expensive and of limited availability. Instead, such patients often undergo a series of audiovestibular tests and computed tomography in an attempt to exclude or diagnose a vestibular schwannoma. We describe seven cases of unilateral vestibular schwannoma in which conventional assessment was either equivocal or failed to demonstrate a tumour subsequently diagnosed by magnetic resonance imaging. Two patients with neurofibromatosis type 2 are also reported to show how magnetic resonance imaging confirmed the presence of a second vestibular schwannoma despite CT that showed only a unilateral lesion. We also illustrate how limited protocol MRI of patients is slightly more expensive yet much more cost effective than the usual battery of tests and propose that it should be the first line investigation for patients in whom the clinical picture requires exclusion of a retrocochlear lesion. Not all of these early diagnosed tumours have been immediately removed. In some of the more elderly or infirm patients a 'wait and rescan' policy has been adopted. Nevertheless, the early establishment of the correct diagnosis facilitates the subsequent management of these patients.
The management of peripheral nerve injuries continues to challenge the surgeon. Despite advances in surgical technique, return of normal function is uncommon after the repair of a transected nerve. It is now possible to enhance the process of nerve regeneration in animals using growth factors carried in silicone nerve guides. In this article the biological process of nerve regeneration is described and contemporary research involving the use of growth factor implants to facilitate nerve regeneration is reviewed.
Since its inception in 1988 the Cochlear Implant Programme in Manchester has successfully implanted 69 adults and 23 children. Of these 92 procedures, three patients have undergone revision surgery with the insertion of either a new implant or re-positioning of the existing device. We examine the circumstances that lead to the need for reimplantation in these patients, discuss the technical aspects of revision surgery together with the functional results of such procedures.
Patients being considered for cochlear implantation undergo, of necessity, a wide-ranging selection process, of which imaging of the temporal bone to assess cochlear patency is an important part. We have studied the correlation between the results of computed tomography (CT) imaging of the cochlea and the cause of hearing loss in this group of patients. The CT scans of 105 patients were reviewed. Of these, 74 (70%) were normal, with the commonest abnormalities being labyrinthitis ossificans in 14 (13.3%) cases and capsular rarefaction in 10 (9.5%) cases. A congenital abnormality was seen in 4 (3.8%) cases and temporal bone fractures in 2 (1.9%) cases; 1 patient had previously undergone a labyrinthectomy. In 25 patients the cause of the hearing loss was known to be meningitis. Of these patients, 15 had normal scans and 10 showed labyrinthitis ossificans. Of note is that none of the 6 patients with tuberculous meningitis had abnormal scans. There was a high correlation between a rarefied capsule on CT imaging and a diagnosis of otosclerosis, with 6 out of 7 otosclerosis patients demonstrating this abnormality. Evidence of a previous temporal bone fracture was seen on the scans of only 2 out of 6 patients in whom the cause of deafness was thought to be severe head injury.
Since its inception in 1988, the Cochlear Implant Programme in Manchester has successfully implanted 61 adults and 15 children. Of these 76 patients, 3 have undergone revision surgery, and these cases are presented. One patient was a 43-year-old blind man who underwent routine implantation with a Nucleus device. Six weeks after implantation the patient experienced sudden device failure following an electric shock from a domestic appliance. The patient was reimplanted with a similar device 3 weeks later and is making good progress. Assessment of the original implant showed a failure of one of the capacitors in the receiver-stimulator circuit. The second patient was a 51-year-old woman who underwent routine implantation with a Nucleus 22-channel device. The patient's audiologic performance fluctuated, and 14 months after the original procedure the patient was reimplanted. Analysis by the manufacturer suggested that the original implant was unstable at higher temperatures. The third patient, a 55-year-old woman, was implanted with an Ineraid multichannel device into the right cochlea. A postoperative radiograph showed the implant to be incorrectly positioned, and the procedure was revised 4 weeks later. Here it was found that the electrode system was running across the promontory, toward the eustachian tube orifice. This was reimplanted with satisfactory results.
An extensive schwannoma in a 54-year-old woman is described. There was extension intracranially to involve the brain stem, laterally to fill the middle ear and external meatus, and inferiorly into the infratemporal fossa. Initially the intracranial portion of the tumour was excised. Later a second operation was undertaken to remove the residual tumour from the temporal bone and infratemporal fossa.
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Spontaneous perforation of the oesophagus is extremely rare in children, as is perforation due to vomiting in pregnancy. We report the case of a 15-year-old in whom vomiting in early pregnancy resulted in oesophageal perforation with subcutaneous emphysema causing marked facial swelling in the absence of other signs. The more common clinical presentation of spontaneous oesophageal rupture (Boerhaave's syndrome) is discussed.
Medical photography is shown to have therapeutic value in illustrating to a patient a previously hidden clinical lesion. The sight of the extent and nature of a hole in her nasal septum which the patient had caused by picking her nose allowed her to stop this habit where previous medication and psychotherapy had failed.
A total of 235 toes were amputated during 125 operations on 100 consecutive patients with lower limb ischaemia. The overall amputation wound healing rate for the series was 58.4 per cent and limb salvage was achieved in 66 patients. Toe amputation was performed under local anaesthesia in 57 cases and 32 (56 per cent) of these healed primarily, not significantly different from the healing rate of 41 (60 per cent) of 68 under general anaesthesia. Reconstructive arterial surgery was performed in conjunction with toe amputation in 39 patients; the healing rate with reconstruction was 32 (82 per cent) of 39, significantly better than the 41 (48 per cent) of 86 patients not undergoing bypass surgery (P less than 0.001). There was no difference in healing rates when comparing diabetic and non-diabetic patients. Multiple regression analysis demonstrated that reconstructive arterial surgery was the only factor which had an independent and significant influence on toe amputation healing. The use of local anaesthesia for distal amputation has no deleterious effects on wound healing.