Biomedical subjects
N S Jones
Publications and source records attributed to N S Jones.
The investigation of nasal septal perforations and ulcers.
This is a retrospective review of 74 consecutive patients who presented with a nasal septal perforation or ulcer. The aim of this study was to evaluate the contribution of the investigations used to identify the pathology underlying their septal perforation or ulcer. In the majority of cases there was an anterior (85 per cent) smooth, well-circumscribed septal lesion with an occasional bleeding point. Seventy-seven per cent were less than two cm in diameter. The primary presenting symptom was intermittent epistaxis, with the exception of patients with granulomatous disease, who presented more frequently with nasal obstruction. Thirty-five patients (47 per cent) were idiopathic, 29 (39 per cent) traumatic, eight (11 per cent) inflammatory and two (three per cent) infectious. The nasal septum was biopsied in 71 cases, and histology showed non-specific or non-diagnostic findings in 39 (55 per cent), chronic inflammation in 12 (17 per cent), acute inflammation in six (eight per cent), acute to chronic inflammation in four (six per cent) and histological changes consistent with trauma in nine (13 per cent). The anti-neutrophil cytoplasmic antibody test (ANCA) successfully identified six patients with Wegener's granulomatosis, and the angiotensin converting enzyme test (ACE) supported a clinical diagnosis of sarcoidosis in one patient. The remaining investigation methods (CRP, ESR, chest radiograph, biochemistry and coagulation screen) did not contribute to the diagnosis. In this study, the appearance of a nasal septal perforation or ulcer or its location did not predict the clinical diagnosis. A nasal septal bopsy did not significantly contribute toward the clinical diagnosis. On the basis of these findings, a biopsy of a septal perforation or ulcer is unlikely to contribute to the management of patients unless the supportive tests of ANCA or ACE are abnormal or unless malignancy is suspected. This conclusion is restricted to the management of septal perforations as we have found nasal biopsies of polyps of other lesions to be of value.
Endoscopic management of basal encephaloceles.
Encephaloceles have been traditionally treated by a transcranial or external approach. The advent of endoscopic sinus surgery has allowed a new intranasal approach for the treatment of basal encephaloceles, minimising patient morbidity. We discuss the classification and presentation of encephaloceles, and present our experience in the repair of six cases. We believe transnasal endoscopic repair is the method of choice in dealing with selected basal encephaloceles.
Prevalence of nasal mucosal contact points in patients with facial pain compared with patients without facial pain.
A cohort of 973 consecutive attendants at a rhinology clinic was studied prospectively and divided into patients without facial pain (n = 566, 58 per cent) and patients with facial pain (n = 407, 42 per cent). The prevalence of nasal mucosal contact points was the same in both groups, being four per cent in patients with nasal contact points without facial pain and four per cent in patients with facial pain. A contact point is defined as when contact remains after topical decongestion. Of the 18 patients with facial pain, nine had a spur contacting the lateral nasal wall and nine had a middle turbinate contacting the septum. These 18 patients were followed up for a mean of two years and two months. In the light of their treatment and response the following diagnoses were made: five had tension-type headache, six had midfacial segment pain, one had migraine, two had cluster headache and four had purulent nasal disease. Of the four with unilateral symptoms, two had a contact point on the contralateral side. Eleven of these 18 patients responded to medical treatment for tension-type headache or midfacial segment pain, migraine and cluster headache, three patients were better after surgery for coexisting purulent nasal disease and one patient had a spur removed surgically and remained better at 2 years follow-up, whereas three patients were no better after the same procedure. The results demonstrate that the prevalence of nasal contact points in patients with facial pain is the same as in those within pain. Surgery undertaken to remove mucosal contact points for facial pain is usually unnecessary as the aetiology of this facial pain appears to be a more central processes.
Reducing waiting times for sleep apnoea hypopnoea syndrome and snoring using a questionnaire and home oximetry: results of a second audit cycle.
As a result of a previous audit on the management of sleep apnoea hypopnoea syndrome (SAHS) which showed long waiting times that were primarily due to unnecessary interspecialty referrals, a change in practice was adopted. All referrals are now sent a questionnaire about symptoms suggestive of SAHS, the Epworth Sleepiness Scale score and their body mass index (BMI) which when returned are categorized into having a high, intermediate or low risk of SAHS. Those patients with a high probability have home overnight oximetry and those with intermediate probability have video oximetry. Those with a low probability are referred directly to ENT. We audited the first 100 patients referred. All were General Practitioner referrals to either ENT or respiratory medicine. Only two patients had a low probability score and were seen directly in ENT. Following sleep study analysis, 10 patients were referred directly to ENT with no respiratory medicine follow-up and nine were discharged back to the General Practitioner with no apnoea or snoring. Eighty-one patients were followed up by respiratory medicine. Of these, 49 received a trial of nasal continuous positive airway pressure (nCPAP) and six were referred to ENT. Therefore the majority justified an investigation to exclude SAHS in the first instance and an unnecessary initial ENT appointment was avoided. We have reduced the average waiting times to sleep study by approximately 90 days and to nCPAP trial by 32 days, mostly due to decreased delays in interspeciality referrrals. We have also demonstrated a greater than 50 per cent reduction in ENT clinic visits, a small increase in the number of sleep studies but no increase in respiratory clinic workload.
Use of the auricular composite graft in nasal reconstruction.
We present our experience using conchal composite grafts in major and minor nasal reconstruction. We believe that composite grafts have an important and under-utilized role as an adjunct to the paramedian forehead flap on total and subtotal nasal reconstruction, as well as in providing an internal lining and support in stenosis of the nasal vestibule. The use of a composite conchal graft as an inner lining and support is often preferential to a septal composite or hinge flap that often results in a septal perforation with its associated morbidity. We recognize that a composite conchal graft used for reconstruction of the alar margin provides a suboptimal result after several months. This is because it is not always possible to replace a whole aesthetic subunit and whilst the site the graft is harvested from often allows the correct contour to be chosen, the quality of skin is often different and this can be seen after several weeks when any post-operative oedema has settled.
Classification and diagnosis of facial pain.
This is an interesting time to consider the classification of facial pain because of the emergence of new ideas that challenge our understanding of the mechanisms involved. The new hypotheses that have been proposed appear to be of clinical relevance.
Medicare+Choice: where to from here?
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Cognitive dissonance, the placebo effect and the evaluation of surgical results.
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The nose and nitric oxide: a review.
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Reliable and reproducible anterior active rhinomanometry for the assessment of unilateral nasal resistance.
Unilateral nasal resistance is now thought to be more important than total resistance in promoting obstructive symptoms. We assessed the reproducibility of anterior active rhinomanometry in measuring unilateral nasal resistance. Ten baseline readings of unilateral nasal resistance were made over a 30-min period in seven healthy subjects (14 nostrils) using anterior active rhinomanometry performed according to the International Committee for the Standardization of Rhinomanometry (ICSR) guidelines. Baseline readings revealed that measurements using anterior active rhinomanometry had an unacceptably high coefficient of variation (19%-60%). With a more time-consuming revised protocol involving multiple recordings and the identification and exclusion of erroneous data, coefficients of variation of 7%-15% were obtained. We conclude that single anterior active rhinomanometry readings are potentially prone to large errors and each researcher using such equipment must satisfy his/herself that their methodology has an acceptable coefficient of variation in their hands. The ICSR guidelines are not always sufficient to allow reproducible measurement and specially designed protocols may be necessary to produce reliable results.
A retrospective case-controlled study of 1490 consecutive patients presenting to a neuro-otology clinic to examine the relationship between blood lipid levels and sensorineural hearing loss.
This study set out to test the null hypothesis that the distribution of blood lipid levels is the same in a population with a sensorineural hearing loss (SNHL) as in a control population. Hyperlipidaemia has been implicated as an aetiological factor in SNHL; however, the majority of reports are retrospective, lack adequate controls, or are based on a series of cases which may represent incidental findings and not a true causal relationship. In all, 1490 consecutive patients who presented to a neuro-otology clinic were studied retrospectively. This group is exceptional in that all patients had had fasting lipid profiles done regardless of their presenting problem. Those with a mean SNHL > 25 dB (0.5, 1, 2 and 4 kHz) were compared with those with hearing thresholds < or = 25 dB. An analysis of variance was also done. The study group was also compared with the National Study of Hearing data set to add external validity. Simple correlations were found between hearing thresholds and many parameters such as blood pressure, fasting glucose, triglyceride or fasting cholesterol. Analysis of variance of the neuro-otology group, controlling for variables such as age and sex, showed no significant association between hearing and blood pressure, packed cell volume, mean corpuscular volume, fasting glucose, triglyceride or fasting cholesterol. However, when general linear interactive modelling was used to analyse hearing thresholds, raised total fasting cholesterol was associated with significantly better hearing threshold levels. This study leads to a rejection of the Null hypothesis that the distribution of lipid levels is the same in a population with a hearing loss as in a control population, as hearing thresholds were found to be significantly better in those with raised cholesterol levels.
Medicare competitive pricing: lessons learned in Phoenix and Kansas City.
Many lawmakers have embraced the idea of bringing more competition to the Medicare program as a way to achieve greater cost efficiency and provide more choice for beneficiaries. Advocates of this strategy believe Medicare should move away from its historical administrative pricing approach toward a competitive bidding process similar to those used by many private purchasers. Yet, despite support for the concept, every effort to test it in the marketplace has been met with strong opposition. Most recently, competitive bidding demonstration projects set to take place in Phoenix and Kansas City have been delayed by congressional action. Nevertheless, it is clear that those participating in the demonstration projects-notably private purchasers, consumers, health plans, and the Health Care Financing Administration-have already learned a great deal about the types of issues that must be considered if Medicare is truly to pay health plans in a competitive manner. This article explores the lessons learned so far in Phoenix and Kansas City, including design considerations such as plan participation, the standard benefit package, the bidding process, and the government contribution to premiums. It also examines the reasons for opposition to the project and their implications for broader Medicare reform efforts.
Non-Hodgkin's lymphoma of the sinonasal tract.
OBJECTIVES: A review of the presenting features, management, and outcome of extranodal non-Hodgkin's lymphoma (NHL) of the sinonasal tract during a 10-year period in Nottingham, UK. STUDY DESIGN: Twenty-four patients received a diagnosis of extranodal NHL of the nasal cavity, paranasal sinuses, or both, from 1987 to 1996. The patients' data were collected prospectively in the Nottinghamshire Lymphoma Registry. METHODS: All patients' records and their histology were reviewed along with data entered into the Nottinghamshire Lymphoma Registry, noting the patient's age, sex, presenting symptoms and signs, staging, computed tomography findings, histology, treatment, complications, and outcome. RESULTS: The 24 patients with extranodal NHL of the sinonasal tract represent 1.63% of the 1,457 patients with NHL seen in the 10-year period of this study in Nottinghamshire. The median age was 72 years (range, 42-96 y), with a male dominance (male-to-female ratio: 15:9). Most patients presented with nonspecific nasal symptoms such as nasal obstruction and epistaxis. Only one patient had a relapse involving the central nervous system after treatment. All the histology was reviewed and showed a predominance of large B-cell subtype (21 patients). The overall 5-year survival was 40% (95% CI, 19%-61%) and 33% for 10-year (95% CI, 12%-54%). The cause-specific survival at 5 years and 10 years was 62% (95% CI, 39%-86%). CONCLUSIONS: A high degree of suspicion and appropriate use of computed tomography scans and surgical biopsy are the keys to the management of NHL.
Acute and chronic sinusitis in children.
There is one subject in recent publications on pediatric sinusitis on which most authors agree, and that is that the public cannot continue to receive antibiotics on demand solely because of purulent nasal discharge, and that clinicians cannot continue to prescribe broad-spectrum and expensive antibiotics for minimal indications. Two publications show that the prevalence of various anatomical variations is no greater in children with rhinosinusitis than in a control group. This mirrors recent work in adults and implies that immunity and the way the mucosa reacts to pathogens is likely to be of primary importance, rather than the anatomy. Several good reviews on the management of rhinosinusitis in children all emphasize the need for medical and not surgical management of these patients except in cases in which the complications of sinusitis develop. The fact that computed tomography is poor at diagnosing sinusitis in children is also a recurring theme.
All nasal polyps need histological examination: an audit-based appraisal of clinical practice.
Case details were reviewed from 2021 patients treated surgically for nasal polyposis between 1991 and 1999, seen by six surgeons serving a catchment population of 805,000. The aim of this study was to determine the incidence of discrepancies between clinical and histological diagnosis. Twenty-two patients (1.1 per cent) were identified as having a lesion that differed histologically from the clinical diagnosis made at the time of surgery and which altered their further management. Amongst them were 11 cases of inverted papilloma, two of Wegener's granulomatosis; and two of sarcoid. The rest of the cases comprised three of squamous cell carcinoma, one of adenocarcinoma, one of myeloma, one of angiofibroma and one of microcystic papillary adenoma. In this series, the occurrence of malignancy, inverted papilloma, or other clinically significant pathology among the group of patients with otherwise clinically unsuspected histology justifies sending nasal polyps for routine pathologic examination. A cost-benefit analysis showed that, on the basis of 250 cases per year, the cost of laboratory and pathological services would be 12,000 Pounds, in comparison with the estimated average medicolegal cost of 51,000 Pounds per year incurred as a result of a delay in diagnosis together with the pain and suffering which would result given the case mix in this series.
Endoscopic ligation of anterior ethmoidal artery in treatment of epistaxis.
Arterial ligation of the anterior ethmoidal artery may be required in cases of persistent epistaxis and conventional techniques involving open surgery carry a recognized morbidity. We describe an endoscopic, intranasal technique for ligation of the anterior ethmoidal artery. This technique was performed in a patient who had a severe epistaxis following nasal trauma. Her epistaxis persisted in spite of anterior and posterior nasal packing. Endoscopy showed the bleeding to originate high and lateral to the middle turbinate. Endoscopic exploration defined the frayed end of the anterior ethmoidal artery. A ligaclip was placed with immediate and persistent arrest of her epistaxis. No further nasal packs or treatment were required.
Complementary and alternative therapy for nasal conditions.
Over two-thirds of patients have tried a complementary therapy before seeking conventional medical help. In view of this it is important that doctors keep abreast of developments in this area and of the range of therapies which are now being offered. The interaction between drugs and herbal remedies is one example where this is of particular importance. This review assesses the current evidence base for complementary therapies in nasal disease. Contemporary medicine can learn much from the patient-centred approach that is central to many complementary therapies. There is, as yet, little evidence to support the effect of complementary therapy over those of the placebo effect, cognitive dissonance and the natural resolution of many disease processes.