To demonstrate the importance of detailed, multidisciplinary examination of patients with post-tonsillectomy taste distortions, and to show that post-tonsillectomy dysgeusia may originate in the caudal part of the soft palate.

We describe a 29-year-old man who suffered from severe post-tonsillectomy dysgeusia and phantogeusia with secondary weight loss and depression-like symptomatology. The patient had normal electrogustometric thresholds and sensitivity to touch on the posterior tongue. In contrast, elevated taste threshold and reduced sensitivity to touch was found on the caudal part of the soft palate (the palatoglossal arches). More marked elevation of electrogustometric threshold and insensitivity to touch on the right palatoglossal arch correlated with post-operative haemorrhage from the right tonsillar fossa. Psychiatric examination excluded major depression, eating disorders and drug abuse.

Dysgeusia constitutes a rare but significant complication of tonsillectomy. Damage to the lingual branch of the glossopharyngeal nerve innervating the posterior tongue is thought to be a major cause of this complication. However, damage to the tonsillar branches of the glossopharyngeal nerve and the soft palate should also be considered as a cause of post-tonsillectomy dysgeusia. Further studies are needed to assess whether post-operative haemorrhage could indicate heightened risk of dysgeusia.

To present a case of benign mediastinal thymic cyst, and to review the published information on these cysts, including their incidence, presentation, diagnosis and management.

We report the case of a 55-year-old man who presented with a unilateral vocal fold palsy subsequently found to be due to the presence of a benign mediastinal thymic cyst. A literature search was undertaken to identify the incidence, key features and management of this rare condition.

Benign mediastinal thymic cysts are a rare cause of mediastinal masses. Usually diagnosed incidentally, their management is usually surgical. Vocal fold palsy in isolation has not previously been reported in association with mediastinal thymic cysts.

This report describes what we believe to be the first published case of a completely reversible vocal fold palsy presenting in association with a rare benign mediastinal thymic cyst.

To investigate the use of a new technique to close persistent tympanic membrane perforations under general anaesthesia, in patients in whom this has previously been considered impractical.

Twenty patients aged 50 years and over were recruited. All had a persistent, symptomatic tympanic membrane perforation in at least one ear. Pre-operatively, an audiogram was performed and the tympanic membrane was assessed in order to establish the site and size of the perforation. Under general anaesthesia, the edges of the perforation were freshened and a sheet of Epifilm, trimmed to a size roughly 2 mm larger in diameter than the perforation, was tucked through the perforation. The ear was dressed appropriately. Patients were seen two weeks post-operatively in the out-patients department and reassessed.

The study was based at Poole General Hospital, a District General Hospital.

Twenty patients were recruited from the out-patients clinics of Poole Hospital ENT department.

(1) closure of the perforation, as a percentage of the original size; (2) improvement of hearing, as an average across all frequencies, expressed in dB hearing level; and (3) presence or absence of discharge.

Five patients were operated upon and assessed six weeks post-operatively. The Epifilm had dissolved but the perforations remained the same size in all five patients. There were no other adverse effects. Pure tone audiometry at this stage was redundant. The study was subsequently aborted.

The authors conclude that repair of tympanic membrane perforations with hyaluronic acid ester films is not to be recommended.

Herbal remedies and other natural supplements have become popular alternative medical therapy. Patients using these products may present to ENT surgeons with epistaxis or with unexpected, excessive peri-operative bleeding.

The purpose of this review was to consolidate the available data regarding herb–drug interactions and the direct effects of herbal medicines and nutritional supplements in isolation, regarding disturbance in haemostasis, so as to emphasise their individual importance.

A literature review was performed using the Medline (PubMed) and UKMi databases.

Searches of these databases revealed 24 herbal products with documented interactions with anticoagulants and 98 herbal products with theoretical interactions with the coagulation system. Herbal products with effects on coagulation when given alone were also documented.

When encountering patients presenting with epistaxis, or in the elective surgical setting, a thorough enquiry about the use of herbal medicines is of great importance.

The aims of this study were (1) to explore whether the experience at the Radcliffe Infirmary (Oxford, UK) supported the use of combined approach tympanoplasty for cholesteatoma, by determining the rate of disease at subsequent surgery, and (2) to assess whether this rate differed from findings reported elsewhere in the literature, possibly due to the effect of using an oto-endoscope.

Retrospective case review, with data entered prospectively for operations performed by a single surgeon.

Tertiary referral hospital.

Between January 1998 and December 2004 inclusive, 66 patients underwent 68 primary procedures, with data available for all ‘second looks’.

Diagnostic and therapeutic operations for cholesteatoma were performed.

All patients in this study attended follow up and underwent a second look operation, during which the rate of residual and recurrent cholesteatoma was determined. An oto-endoscope was used at all primary and subsequent surgery.

The mean interval between the first and second combined approach tympanoplasty procedures was 16 months, and that between the second and third such procedures was 19 months (10 patients). One patient underwent a fourth combined approach tympanoplasty procedure, 17 months after a third such procedure. The rate of cholesteatoma at second combined approach tympanoplasty was 20.6 per cent (14/68); this was judged to be residual in 10 ears (14.7 per cent) and to be recurrent, with the redevelopment of retraction pockets, in four ears (5.9 per cent). The rate of cholesteatoma at third combined approach tympanoplasty was 20 per cent (two of 10); of these two, one patient had a small pearl in the middle ear removed with the aid of a potassium titanyl phosphate laser. There was no disease present in one patient at a fourth combined approach tympanoplasty. Only four patients required a modified radical mastoidectomy.

Cholesteatoma remains a disease with significant morbidity. Endoscope-assisted surgery may decrease the morbidity of second look surgery and may improve the clearance of disease in appropriately selected patients.

The objective was to assess the presence of Ki-67, and oestrogen and progesterone hormone receptors as well as their clinical correlates in acoustic neuroma.

Medical records of 59 patients who were operated on for acoustic neuroma between 1995 and 2003 were evaluated retrospectively. Formaldehyde-fixed paraffin-embedded archival acoustic neuroma specimens of the patients were used for immunohistochemical assessments of oestrogen and progesterone hormone receptors, and Ki-67 proliferative marker.

Tumour sizes were small (<19 mm), medium (20–39 mm) and large (>40 mm) in 21, 35 and 3 patients, respectively. On immunohistochemistry, all samples were (+) for progesterone receptor and (–) for oestrogen receptor staining. Ki-67 staining was encountered in 34 of 59 (57.6 per cent) patients, and Ki-67 values ranged from 0 per cent to 10.9 per cent (mean 1.36 per cent). There was no correlation between Ki-67, gender, tumour size and symptoms of the patients (p > 0.05).

Oestrogen is not an important hormone in acoustic neuroma due to the absence of oestrogen receptor expression in the tissue samples. Since the progesterone receptor is expressed in all acoustic neuroma samples, further studies are necessary to find out about the inhibitory effect of antiprogesterone treatment on acoustic neuroma growth, which may be important particularly in elderly people or high-risk patients. Although Ki-67 is expressed in the majority of acoustic neuromas, it is not an important marker in clinical practice due to a lack of any correlation with the clinical parameters.

The origin of vestibular schwannoma has always been a matter of debate. The aim of our study was to identify the nerve origin of this tumour.

Prospective case review. This study was conducted at Gruppo Otologico, a private referral centre for neurotology and skull base surgery.

A total of 200 cases of vestibular schwannoma were included in the study. All the tumours were removed surgically utilising the translabyrinthine approach. The origin of the tumour was sought at the fundus of the internal auditory canal.

A total of 200 consecutive cases was included in the study. The origin of the tumour was limited to one nerve at the fundus in 152 cases (76 per cent). Out of these cases, the tumour originated from the inferior vestibular nerve in 139 cases (91.4 per cent), from the superior vestibular nerve in nine cases (6 per cent), from the cochlear nerve in two cases (1.3 per cent) and from the facial nerve in two cases (1.3 per cent).

The vast majority of vestibular schwannomas originate from the inferior vestibular nerve; the incidence of involvement of this nerve increases as the tumour size increases. An origin of vestibular schwannoma from the inferior vestibular nerve can be considered as one of the explanatory factors for the poor functional outcome of the extended middle cranial fossa approach, and probably accounts also for the better hearing preservation rate reported in some series for the retrosigmoid approach.

Due to problems with long waiting times for assessment of vertiginous patients (more than 24 weeks), we changed practice and instituted a pre-ENT balance clinic assessment; we then audited the results. In particular, we looked at the subgroup with benign positional paroxysmal vertigo.

One hundred and fifteen patients were seen at the pre-ENT balance clinic from October 2003 to September 2004. Those diagnosed with benign positional paroxysmal vertigo received particle repositioning therapy at the same clinic and did not subsequently need ENT assessment.

By the end of the audit period, waiting times were reduced to three weeks, and more than one-quarter of vertiginous patients (i.e. those diagnosed with benign positional paroxysmal vertigo) did not need to be reviewed at an ENT clinic.

We believe this to be the first study to present prospective data showing that patients with benign positional paroxysmal vertigo may be safely diagnosed and effectively managed at a pre-ENT balance clinic.

A clear and detailed clinical history is essential in the assessment of patients with balance symptoms. The aim of this study was to assess the usefulness of open-ended questionnaires in the specialist balance clinic.

Fifty-four consecutive new patients completed an open-ended questionnaire, prior to a consultation in which the clinical history was taken using a standardised proforma. The results of the two were compared.

The open-ended questionnaires provided patient-centred data, and did not provide clinicians with sufficient data for diagnosis. Patients were more likely to respond in the affirmative when asked about symptoms directly, than to report the same symptoms spontaneously on an open-ended questionnaire. When questions had a number of possible answers, patients were more likely to report them in full in an open-ended questionnaire than to provide a response during direct questioning.

Dizziness is a common and often complex complaint. Between nine and 13 per cent of patients seen in general practice are referred to a variety of specialist clinics. The diagnoses and outcomes of these referrals are seldom reported.

To determine the proportion of patients referred to an otology led vertigo clinic in whom an otological cause for vertigo could be identified.

Prospective cohort study of consecutive new clinic attendees over one year.

Otology led vertigo clinic in an urban teaching hospital in England. Patients' details including age, sex, referring clinician, investigations, diagnoses, treatment and final outcome were recorded in an anonymised database.

91 new patients, 31 men and 60 women with a mean age of 52.6 years (range 16–81) were seen. General practitioners referred 87 per cent of the patients. Twenty-seven patients underwent further investigations including imaging, electronystagmography and other audiological tests. A labyrinthine disorder accounted for 50 per cent of the diagnoses. Ménière's disease or a variant was diagnosed in 20 patients (21 per cent). Fifty-six patients (61 per cent) reported resolution of or improvement in their symptoms. Thirty-one patients (34 per cent) were asymptomatic and free of abnormal findings on initial attendance and were discharged from hospital care.

Forty-six patients (50.6 per cent, 95 per cent confidence interval, 40.4–60.6 per cent) had vertigo due to an otological disorder. The selection of an otolaryngology based vertigo clinic by the general practitioner for initial referral seems appropriate.

The reliability of nasal obstruction measurements could be improved, and several new techniques are being developed. Our objective was to investigate the use of a new software program, Odiosoft-Rhino, in the assessment of nasal obstruction via analysis of the sounds of nasal expiration.

We compared the nasal symptom scores and Odiosoft-Rhino and acoustic rhinometry test results for 61 patients with known nasal septal deviation.

We found a significant difference, and a correlation, between Odiosoft-Rhino results at 2000–4000 Hz and 4000–6000 Hz intervals, and the minimal cross-sectional area 2.2 cm from the nostril, in the right nasal cavity in patients with right-sided deviations. Similar results were observed for the left nasal cavity in patients with left-sided deviations.

The Odiosoft-Rhino software test is noninvasive, requires minimal cooperation and experience, and provides results that can be saved as digital data. Additionally, data from the Odiosoft-Rhino test are strongly correlated with acoustic rhinometry results and visual analogue scores of nasal obstruction. It seems that sound intensity within the 2000–4000 Hz and 4000–6000 Hz intervals is more sensitive than other sound intensity intervals. Thus, we speculate that Odiosoft-Rhino testing could be used as a new diagnostic method in order to evaluate nasal airflow in clinical practice.

To determine the characteristics of causative factors of taste disorders amongst the elderly, and to examine the therapeutic effect of a zinc agent, taking into account age-related factors.

A total of 408 patients with taste disorders were divided into three groups by age: 49 years or younger, 50 to 64 years old, and 65 years or older.

The incidence of taste disorders caused by drug administration and systemic disease were significantly higher in the elderly group. A serum zinc concentration of 69 µg/dl or lower was found in 33 per cent of the elderly group, significantly more (p < 0.001) than the 19 per cent of the 49 years or younger group with such a concentration. Zinc administration was therapeutically effective in 70 per cent of the whole population studied, and in 74 per cent of the elderly population.

In the elderly, the incidence of taste disorders caused by drug administration or systemic disease was significantly greater compared with other age groups. The curative effects of zinc administration were not observed to be influenced by age.

A variety of paediatric tracheostomy tubes are available. This article reviews those in current use at Great Ormond Street Hospital.

We outline our preferences and the particular indications for the different tubes, speaking valves and other attachments.

Practice has changed significantly in recent years. One product has been re-sized by its manufacturer; others are no longer commonly used. An updated sizing chart is included for reference purposes, together with manufacturers' contact details.

The choice of paediatric tracheostomy tube is driven by clinical requirements. A small range of tubes are suitable for the majority of children, but some will require other varieties in specific circumstances.

The buccinator musculomucosal flap is an axial-pattern flap based on either the buccal or the facial artery. We present our experience with this flap and describe its surgical anatomy, the surgical techniques utilised to raise the flap and its clinical applications.

We retrospectively reviewed all patients who had had buccinator myomucosal flaps created at the Groote Schuur Hospital between 1999 and 2004. Patients were also recalled to assess flap sensation and to record reduction of mouth opening as a consequence of donor site scarring.

Of the 14 patients who had had a buccinator myomucosal flap created, there was one flap failure. Sensation was present in 71 per cent of flaps, and there was no trismus due to donor site scarring.

The buccinator myomycosal flap is a dependable flap with good functional outcome and low morbidity.

Currently, concomitant chemoradiation using cisplatin is one of the standards of care for the management of head and neck cancer, but at the cost of increased acute toxicity. Our aim was to assess whether vinorelbine was less toxic and of at least comparable efficacy, if not better, compared with cisplatin.

A total of 72 patients with squamous cell carcinoma in the head and neck region were recruited, 40 in arm A and 32 in arm B. Patients in arm A received 40 mg/m2 cisplatin weekly. Patients in arm B received 6 mg/m2 vinorelbine weekly. Both arms also received 66 Gy of radiation in conventional fractionation.

There was no statistically significant difference in response rate or toxicities between the two arms, except for nausea and/or vomiting, which was significantly less frequent in the vinorelbine arm.

Vinorelbine was as effective as cisplatin in controlling locoregional disease in locally advanced head and neck cancer, but was only marginally less toxic than cisplatin.