Chicken, DW

Kanegaonkar, RG

Sivaji, N

UCL Discovery

The Journal of Laryngology & Otologyhttp://journals.cambridge.org/JLOAdditional services for The Journal of Laryngology & Otology:Email alerts: Click hereSubscriptions: Click hereCommercial reprints: Click hereTerms of use : Click hereA warning to users of disposable tonsillectomy instrumentsThe Journal of Laryngology & Otology / Volume 115 / Issue 08 / August 2001, pp 686 ­ 687DOI: 10.1258/0022215011908667, Published online: 08 March 2006Link to this article: http://journals.cambridge.org/abstract_S0022215101002006How to cite this article:(2001). A warning to users of disposable tonsillectomy instruments. The Journal of Laryngology & Otology, 115, pp 686­687 doi:10.1258/0022215011908667Request Permissions : Click hereDownloaded from http://journals.cambridge.org/JLO, IP address: 144.82.107.76 on 08 Oct 2012The Journal of Laryngology & OtologyAugust 2001, Vol. 115, pp. 686–687Letters to the EditorA warning to users of disposable tonsillectomy instrumentsDear Sirs,We wish to draw readers’ attention to a potential hazard ofusing disposable tonsillectomy instruments.Growing concern regarding the tranmission of newvariant Creutzfeldt-Jakob disease during tonsillectomy hasresulted in the widespread adoption of disposable tonsil-lectomy sets. One of the instruments used routinely is aBoyle-Davis mouth gag, which has a tongue blade that issplit in the middle to accommodate the endotracheal tube.The distal ends of the split tongue blade are held togetherby a welded metal loop, which prevents herniation of theendotracheal tube (Figure 1).We experienced a case where this metal loop becamedetached intra-operatively, and came to lie within thepostnasal space. Fortunately, the problem was discoveredintra-operatively, the loop was removed atraumatically andthe patient suffered no harm.We, however feel that this highlights a possible weaknessin the manufacture of these instruments, which creates thepotential for aspiration of a loose foreign body afterextubation. Furthermore, a missing instrument componentcould easily be missed, unless specically looked for.We wish to strongly advise readers to thoroughly inspectdisposable tonsillectomy instruments both pre and post-operatively, to avoid this potentially disastrous complication.D. W. Chicken, M.B.Ch., N. Sivaji, D.L.O.,R. G Kanegaonkar, M.R.C.S., D.L.O.Department of Otolaryngology,Farnborough Hospital,Kent BR6 8ND, UK.Clinical effect of canal plugging for paroxysmal positionalvertigo.J Laryngol Otol 2000;114:959–62Dear Sirs,We read with interest the article by Suzuki et al.1 as well astheir previous experimental work on the subject.2 The reportimmaculately documented the nystagmus and its changeswith position and time and correlated these with apathophysiological explanation accounting for a diagnosisof right LSC cupulolithiasis. The patient was treated byplugging of the implicated LSC and this was claimed to haveprevented further stimulation of the cupulolithiatic LSC.However, the authors explanation that ‘plugging creates aclosed space in the canal between the plugged site and thecupula, thus effectively inhibiting deection of the cupula’ isnot a plausible explanation for positional vertigo secondaryto cupulolithiasis. It is not clear as to how such a creation of a‘closed space’ would in any way inhibit the gravitational pullon a cupulolithiatic cupula which is loaded with otoconia andhas a resultant increased specic gravity.Going by the clinical records presented it is in fact quitepossible that the patient’s clinical improvement resultedfrom the said labyrinth suffering signicant surgicaldamage leading to a loss of function of the right vestibularlabyrinth/LSC.We are ourselves currently treating a similar patientwith ageotropic horizontal positional transient nystagmuspresumably secondary to a left LSC cupulolothiasis. Thepatient has remained refractory to conservative measuresand repositioning maneouvres. We have nevertheless notproceeded to canal plugging due to the lack of a denitelogical explanation for its efcacy in cupulolithiasis. Weeagerly await the authors explanation regarding the same.A. Thakar, F.R.C.S.Ed.,Assistant Professor Otolaryngology & Head-Neck Surgery,All India Institute of Medical Sciences,New Delhi 110029, India.Fax: (91) 11 6862663E-mail: meenaal@ndb.vsnl.net.inReferences1 Suzuki M,Ichimura A, Veda K, Suzuki N. Clinical effect ofcanal plugging for paroxysmal positional vertigo. J LaryngolOtol 2000;114:959–622 Suzuki M, Kadir A, Takamoto M, Hayashi N. Experimentalmodel of vertigo induced by detached otoconia. ActaOtolaryngol 1996;116:269–72Author’s replyThe main point of the question is whether or not theresolution of vertigo is due to dysfunction of the lateralsemicircular canal (LSC). In fact the author had the samequestion, since left beating nystagmus was constantly seen forsome period after surgery. This indicates that the operatedcanal suffered from hypofunction and I was prepared for thisbefore surgery. I understand that canal plugging to thehuman semicircular canal may well induce hypofunctionmore or less, since the human membranous labyrinth is verythin and hence may easily be affected by even gentlemanipulation. Therefore, I presume that mild hypofunctionoccurred after surgery in this particular case, too.However, I do not think that the effect of suppressingthe vertigo and nystagmus is soley due to this hypofunc-tional effect. As I indicated in the paper, the positionalnystagmus and vertigo were extremely intense. If anyhypofunction of LSC should suppress these, it must betotal or near-total loss of LSC function. However,considering that post-operative paralytic nystagmus anddizziness subsided and disappeared in rather a short periodof time (ve to six days), total loss would not be plausible.Furthermore, the experiment on the monkey showed thatthe plugging does not disturb the sensory epithelia(previous publication). In my past report, I demonstratedthat the cupulolithiasis model easily changed the ampullaryFig. 1Disposible Doyle-Davis mouth gag with detached loop.686nerve ring depending on the direction of the impinginggravity on the cupula, but the plugging procedurecompletely abolished this change. From the above ndingsI think plugging effect is the main mechanism ofsuppression of vertigo, however, contribution of slight ormild hypofunction of LSC is also possible.It is my impression that positional vertigo with short andbrisk nystagmus of vertical and torsional direction-chan-ging component is potentially due to canalolithiasis and iswell controlled by physical maneouvre. Another type ofvertigo that shows long lasting and persistent nystagmus ispossibly due to cupulolithiasis of the responsible canal.This type is, regardless if it is of posterior canal or lateralcanal origin, sometimes intractable and bothers patients.The present case is one of this type involving LSC.Mamoru Suzuki, M.D.,Department of Otolaryngology,Tokyo Medical College Hospital,Tokyo 160, Japan.Pleomorphic adenoma of retropharyngeal space: a rarelocation.J Laryngol Otol 2000;114:639–40Dear Sirs,We read with interest the recent case report by Tariq et al.1concerning pleomorphic adenoma of the retropharyngealspace causing dysphagia. In this report the imagingmodality used in the investigation of the patient wascomputerized tomography (CT). A 65-year-old patientsiilarly presented in our ENT department with dysphagiaand on examination there was fullness in her right lateraloro- and nasopharyngeal wall. Magnetic resonance ima-ging (MRI) of the pharynx demonstrated a large mass withimaging characteristics of pleomorphic adenoma in theright parapharyngeal region. This was separate to, butcompressing the deep lobe of the parotid gland (Figure 1).Per-oral ne needle aspiration conrmed this lesion torepresent a pleomorphic adenoma. At operation thetumour was found to arise from ectopic salivary glandtissue in the parapharyngeal space separate from theparotid gland.MR is the imaging modality of choice in the investiga-tion of pathology of the parotid gland because of itsmultiplanar capacity and superior spatial resolution. It alsodemonstrates vessels and lymph nodes related to the glandand is able to visualize the facial nerve. Pleomorphicadenoma on a T2-weighted sequence typically appears thinwalled, well circumscribed and of homogenous high signaldue to high myxoid content. These tumours are of lowsignal on T1-weighting and usually show homogenousenhancement following intravenous gadolinium-DPTAadministration. As pleomorphic adenomas enlarge theymay develop cystic areas and internal calcication andbecome inhomogeneous and diagnosis may then becomemore difcult.2 ,3K. W. Kesse, F.R.C.S. (Ed.),G. Manjaly, F.R.C.S.,D.C. Howlett, M.R.C.P., F.R.C.R.*Departments of Otolaryngology and Radiology* ,Eastbourne District General Hospital,Eastbourne, UK.References1 Tariq M, Surenththrian SS, Kobbe AER. Pleomorphicadenoma of retropharyngeal space: a rare location. JLaryngol Otol 2000;114:639–402 Tsushima Y, Matsumoto M, Endo K, Aihura T, NakajimaT. Characteristic bright signal of parotid pleomorphicadenoma on T-2 MR weighted images with pathologicalcorrelations. Radiology 1994;49:485–93 Joe VQ, Westersson PL. Tumours of the parotid gland: MRimaging characteristics of various histological types. Am JRoent 1994;163:433–8Dear Sirs,I read with great interest the paper by Diamantopolous,Jones and Lowe1 and the letter by Professor ImreFriedmann2 and I would like to express my support forsending all nasal polyps removed for histological examina-tion.Just in the last 12 months I encountered the following:1. Six cases of inverted papilloma – some of these caseswere suspected pre-operatively, but others not.2. ’Normal’ polyps removed for a fth time and thehistological report on that occasion was sarcoidosis.3. Polyps showing worrying features which have notbeen fully sorted out as yet!The idea that all inverted papillomas can be spotted pre-operatively i.e. gross appearance, is in fact not supportedby experience.I congratulate Professor Nick Jones and his group on theexcellent paper.Ahmes L. Pahor, M.A., F.R.C.S., D.L.O., F.I.C.S.,D.H.M.S.A., D.M.Sc.(Path.)Consultant ENT SurgeonCity Hospital,Birmingham B18 7QH, UK.References1 Diamantopoulos II, Jones NS, Lowe J. All nasal polypsneed histological examination: an audit-based appraisal ofclinical practice. J Laryngol Otol 2000;114:755–92 Friedmann I. Letters to the Editor. J Laryngol Otol2001;115:352–3Fig. 1An axial T2-weighted (TR/TE 4700/112 msec) image throughthe oropharynx demonstrates a large, well circumscribed massof relatively homogenous high signal (straight arrow) arisingin the parapharyngeal space, which abuts and displaces theright parotid gland (curved arrow). Biopsy confirmed this torepresent pleomorphic adenoma. This mass can also be seento compress and displace the right lateral wall of theoropharynx.letters to the editor 687

A warning to users of disposable tonsillectomy instruments

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A warning to users of disposable tonsillectomy instruments

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