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Our experience of this technique has been very positive, with excellent control of both obstructive and infective symptoms, and exceptionally low rates of complications. Further work will be required to allow conclusive demonstration of its advantages over extracapsular tonsillectomy.

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Long term cultures (LTC) producing dendritic cells (DC) have been established from spleen. A well developed stromal cell layer supported production of DC in numbers suitable for experimentation. Cells had obvious membrane pseudopodia and could be collected from culture every 2-3 days. Large cells produced in LTC stained with fluorescently labelled monoclonal antibodies specific for DC such as 33D1, and M1/70 which is specific for DC and myeloid cells. These staining patterns confirmed the presence of DC within the LTC population. LTC-DC were tested and shown capable of migration in vivo in B10.A(2R) mice following footpad inoculation. Most cells entered the spleen and a small number entered popliteal lymph node. LTC-DC have migratory capacity comparable with control spleen lymphocytes. LTC-DC were tested for capacity to induce an anti-tumour immune response after exposing cells to tumour cell membranes. LTC-DC pulsed with BL/VL3 tumour antigens were able to induce a BL/VL3-specific primary cytotoxic T lymphocyte (CTL) response detectable in popliteal lymph nodes and spleen of C57BL/6J mice within 6 days of priming. BL/VL3 tumour cells grew in sublethally irradiated C57BL/6J mice giving 100% mortality. Adoptive transfer of spleen cells from mice given BL/VL3 antigen-pulsed LTC-DC, two weeks previously, significantly slowed the growth of BL/VL3 tumour cells in mice. DC produced in LTC can function as antigen presenting cells (APC) when adoptively transferred into animals. Their capacity to migrate effectively, to induce a CTL response and to reduce tumour load suggests that DC grown using this in vitro system may have valuable clinical potential in humans.

Editor-Vallecular cysts are a rare cause of difficulty in intubating the trachea. We describe a case of difficult intubation in a patient, after inhalation induction, for examination under anaesthesia of an infected vallecular cyst. A 31-yr-old male presented with a year-long history of dysphagia, anorexia, and 13 kg weight loss. He had a 3 week history of shortness of breath on exertion and associated dysphonia. There was no evidence of stridor or hoarseness. He was apryexial, haemodynamically stable with oxygen saturation of 98% on room air. His medical history was significant for a 6 yr history of i.v. drug usage and heavy smoking. On examination, there were no palpable masses on his neck or visible abnormalities in his oral cavity. He was Mallampati score 1, and had good mouth opening and neck movement. Flexible fibreoptic nasolaryngoscopy revealed a well-circumscribed pedunculated mass arising from the vallecula. He was taken to the theatre for examination under anaesthesia, pharyngoscopy, and oesphagoscopy. Inhalation induction was carried out with upward titration of 1-8% sevoflurane in 100% oxygen. Anaesthesia was maintained with bolus doses of propofol, in addition to sevoflurane in oxygen via face mask. Spontaneous respiration was maintained. Three attempts at laryngoscopy using Mackintosh blade 3, McCoy blade 3, and Miller laryngoscope were all unsuccessful. Oxygen saturations throughout remained stable and the patient was easy to bag-mask ventilate. Endotracheal intubation was finally obtained by the ENT surgeon using the ENT rigid laryngoscope. Being longer than anaesthetic laryngoscopes, it was possible to pass distal to the cyst, displacing it to one side allowing visualization of the vocal cords. The remainder of the anaesthetic was uneventful. Definitive treatment included aspiration of thick pus followed by excision. IV dexamethasone was administered to limit airway oedema. At the end of the procedure, the patient was extubated uneventfully. Microbiology culture grew Staphylococcus aureus. Histological examination revealed that of a benign cyst. He was treated with i.v. antibiotics and discharged home on the fifth postoperative day. Most laryngeal cysts are asymptomatic. However, all have the potential to present with airway compromise. Non-infected cysts usually present with mild symptoms related to pressure effect on surrounding tissues. Infection of cysts can cause acute epiglottitis or abscess formation and subsequent acute airway obstruction. A review published in 2008 describes an increased incidence of airway obstruction in infected compared with non-infected cysts. 1 There are case reports of patients with vallecular cysts proving difficult to intubate. 2 3 Several describe complications encountered during intubation attempts: bleeding requiring abandonment of the procedure 4 and laryngospasm. 2

Objectives To identify paediatric intracapsular Coblation tonsillectomy procedures from routine administrative data in England, and determine their safety. Design Retrospective observational cohort study of four ENT centres using routine data from Hospital Episode Statistics (HES). Setting Acute NHS trusts in England conducting exclusively intracapsular Coblation tonsillectomy. Participants Children (≤16 years old) undergoing bilateral intracapsular Coblation tonsillectomy. Main outcome measures Number of procedures, readmissions for pain, readmissions for bleeding and requirement for additional surgery for regrowth. Results A total of 5525 procedures were identified. The median patient age was 4 (IQR 2–5). In‐hospital complications occurred in 1%, with 0.1% returning to theatre for arrest of primary tonsil bleeding. Almost half of the procedures were conducted as a day‐case (44%), with only a small proportion staying in hospital more than one night (7%). Within 28 days, 1.2% of patients were readmitted with bleeding, 0.7% with infection and 0.3% with pain; 0.2% of patients required return to theatre for control of secondary haemorrhage. Longitudinal follow‐up has found that revision tonsil surgery is 0.3% at 1 year (n = 4498), 1.1% at 2 years (n = 2938), 1.7% at 3 years (n = 1781), 1.9% at 4 years (n = 905) and 2.2% at 5 years (n = 305). Conclusions Intracapsular coblation tonsillectomy safety outcomes in this study show primary and secondary bleeding rates and emergency return to theatre rates are lower than all tonsillectomy techniques reported in the National Prospective Tonsillectomy Audit and also lower than previously published Hospital Episode Statistics analysis of tonsillectomy procedures.

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