Biomedical subjects
Publications and source records attributed to D J Howard.
Three cases of periorbital necrotising fasciitis are described, one occurring in a three-year-old child. The cases in adults required debridement of necrotic tissue, in one of whom there was extensive disease involving the face and orbital fat. It is probable that the early stages of this condition are under-recognised; the importance of early signs and intensive treatment of this life-threatening disease are illustrated.
A series of 116 young adults with cancer in the head and neck who had been followed up for five years or longer were reviewed. The study aimed to assess whether malignancy in this age group was increasing, whether their prognosis was worse and if so, why. They were compared with data available on the patient population as a whole treated during the same period. This demonstrated that it is the intrinsic characteristics of the tumour, its site and extent rather than the age of the individual which determines prognosis though the ratio of men to women was less in the young adults in several sites possibly due to a diminished impact of recognized aetiological factors.
A potential for recurrence of juvenile angiofibroma exists after all treatment modalities, both surgical and medical but the methods of defining recurrence and failure to cure varies considerably from series to series. To evaluate factors which might influence successful treatment, a series of 33 patients have been reviewed retrospectively. All patients were treated by simple or extended lateral rhinotomy as a primary or secondary procedure. The final long-term disease control rate was 97% but during the treatment period the overall symptomatic recurrence rate was 50%. However, amongst those treated primarily the recurrence rate was 34%. Of the factors examined, the strongest predictor of recurrence was preoperative embolisation. This group exhibited both early and multiple recurrence when compared with the non-embolised group and the possible reasons for this are examined.
Multiple carcinoma of the upper aerodigestive tract is an increasingly recognized problem, and a concept of 'field cancerization' has been proposed to explain this phenomena. The initial assessment of a patient with an isolated aerodigestive carcinoma must be extensive so as not to miss any synchronous lesions, and may include radiography and endoscopy. Treatment cannot be standardised but must be tailored to suit individual problems and because of the high incidence of metachronous tumours, follow-up must be both thorough and 'lifelong'. A case of three primary synchronous squamous carcinomas of the upper aerodigestive tract is presented. The relevant literature is reviewed.
Wegener's granulomatosis is difficult to diagnose, especially when the presentation is unusual, restricted to an isolated region. We report four cases of recurrent subglottic stenosis posing difficulty in diagnosis. In each case the finding of anti-neutrophil cytoplasm antibodies (ANCA) strongly suggested an underlying vasculitic pathology, Wegener's granulomatosis. We discuss reasons for the difficulty in diagnosis in the past, the possible role of the ANCA assay in such patients, and suggest it should be more widely used in the future.
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An account of experience of tracheostomy performed on patients in the intensive care unit situation is presented. Forty-seven operations were undertaken over a 5-year period and the advantages and disadvantages are discussed. The authors recommend tracheostomy under these circumstances as an acceptable alternative to the procedure performed in an operating theatre.
Permanent loss of mobility has profound physical and mental consequences for both sufferers and carers, and is a major challenge to the National Health Service. A recent study has shown that 42% of beds in departments of Geriatric Medicine are occupied by people with longstanding immobility. These people are highly dependent on nursing staff for their daily activities and quality of life. The assessment of mobility, as a single parameter of dependency, and the measurement of allocated nursing hours are both rapidly and easily performed on geriatric wards. It is felt that a simple correlation of these two variables might highlight areas where more detailed audit is desirable. This study demonstrates that the more immobile patients on a ward, the less the hours allocated to Registered and Learner grade nurses. Some possible reasons for this are suggested and the effects of this deployment on nursing practice and staff recruitment are discussed. It is felt that provision of appropriate nursing care to the most dependent patients in continuing care areas is essential, and that high levels of trained staff are needed to ensure this.
Fifty patients with a wide range of sinus disease have been examined by magnetic resonance. These included congenital conditions, inflammatory and allergic sinus disease, fungus infection, and both necrotising and non-necrotising granulomas. A variety of benign and malignant tumours have been investigated, including eight examples of juvenile angiofibroma and 19 malignant sinus tumours. This experience of magnetic resonance scanning has shown that it is superior to computed tomography in showing the extent of malignant disease and, provided the correct pulse sequences are employed, it is always possible to distinguish tumour from retained secretion or inflamed mucosa. The extent of intracranial invasion can also be optimally demonstrated. One of the advantages of the method is the direct three-plane imaging and multislice technique, which gives total coverage of the head and neck for the assessment of malignant disease. Tissue diagnosis in the paranasal sinuses is less important than the demonstration of tumour extent and distribution. Only one tumour (juvenile angiofibroma) showed diagnostic spin-sequence characteristics, and no differentiation was observed between malignant tumours of epithelial and mesenchymal origin. The major drawback of magnetic resonance is the poor demonstration of bone and calcification in the sinuses, so that in some patients the scans need to be augmented by computed tomography studies.
Many geriatric beds are occupied by bedfast patients. Most were immobile from the time of admission and many were admitted from other hospital departments or residential care. More are discharged home than remain in hospital or are transferred to any other institution. Although a small minority of admissions become long-term bedfast inpatients this group require a disproportionate resource commitment. Reduction in the number of bedfast inpatients is more likely to be effected by changes in unit policy than by improvement in clinical practice.
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A discharge letter which has been introduced into the South and Central Birmingham Geriatric Service is described. This letter combines the features of a discharge notification and a discharge summary. For speed of communication, a handwritten version accompanies the patient on discharge from hospital and a typed copy is posted subsequently. The letter is structured and includes details of the medical assessment, medication, the recommended follow up, the need for support outside the hospital, the relatives involved and the unresolved problems. It has reduced the work of the hospital doctor and the secretaries, has speeded communication with general practitioners (GPs), and is acceptable to most GPs as a substitute for a conventional discharge summary.
A review of a series of 63 patients suggests that a high incidence of recurrence occurs following surgery for this condition. Histological examination demonstrates that this is due to failure to remove the central portion of hyoid bone and inadequate dissection of the tract into the tongue base. To overcome these problems, an en bloc anterior neck dissection is recommended which will encompass multiple duct formation associated with the tract.
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A simple fast reliable technique for closure of an anterior neck defect is described. The technique involves skin grafting directly onto the serosal layer of the anterior stomach wall following pharyngo-laryngo-oesophagectomy and pharyngo-gastric anastomosis.
Primary Ewing's sarcoma of the ethmoid bone has not been previously described. This case presented as a mass at the nasal bridge and posed diagnostic and therapeutic difficulties. The clinical, radiological, macroscopic and microscopic features are described. The treatment by the combined therapies of cranio-facial resection, radiotherapy and chemotherapy are discussed.
Adenoid cystic carcinoma of the nasal cavity and paranasal sinuses has a unique natural history. It has a propensity for frequent local recurrence and early perineural and hematogenous spread. These factors, together with a complex anatomic situation, make adequate oncologic surgery extremely difficult. The incidence of local recurrence is lower in those patients receiving more radical primary surgery, but the choice between conservative and radical management may not alter prognosis. Indeed, it is doubtful if any patients are cured of this disease.