The foundation of mastoid surgery for cholesteatoma has traditionally been a thorough knowledge of the anatomy and familiarity with landmarks, constant alertness to detect unsuspected complications and the experience to tailor the surgery to the pathology encountered. Whilst not indispensable, computed tomography (CT) scanning is a useful adjunct whose potential predictive value is only truly appreciated by skilled interpretation. We present a guide to analysis to maximize the value of pre-operative radiology.

The surfactant system of the nose was examined biochemically in control cases and compared to cases of primary atrophic rhinitis. The study group included 25 cases with primary atrophic rhinitis compared to 10 normal volunteers. Biochemical analysis of the nasal aspirate in these cases revealed the presence of phospholipids constituting surfactant with phosphatidylcholine constituting 75.35 per cent of the total phospholipids. Biochemical analysis of the nasal aspirate in cases with primary atrophic rhinitis revealed a significant decrease in the total phospholipids compared to normal cases and also a significant change in the phospholipid profile. Thus significant biochemical changes in the surfactant system of the nose is an evident and early finding in cases of primary atrophic rhinitis. This suggests a possible role for surfactant deficiency in the aetiopathogenesis of cases of primary atrophic rhinitis.

Twenty-six adult cystic fibrosis patients were studied to compare nasal disease with their laboratory correlates including skin testing, immunoglobulin and Aspergillus fumigatus precipitin levels, saccharin testing and sputum cultures. Six patients were asymptomatic and all of these had negative skin tests, normal IgE levels and negative Aspergillus fumigatus precipitins. Thirteen patients had rhinitis, 12 had positive skin-testing for common allergens, 10 elevated IgE levels and nine positive Aspergillus fumigatus precipitins. Seven patients had polyps, all had normal IgE levels and negative Aspergillus fumigatus precipitins, six had positive skin testing for common allergens. There also appeared to be a relationship between Pseudomonas spp. colonization and positive skin testing.

The purpose of the present study was to evaluate the biological behaviour of the marginal epithelium, that proliferates and eventually covers laryngeal granulomas, and to reveal the applicability of the recently re-introduced Ljubljana classification when reporting reactive epithelial hyperplastic lesions.

A retrospective clinical and histomorphological analysis was performed on 149 laryngeal granuloma biopsies. Epithelial changes were classified according to the Ljubljana classification into normal epithelium; simple, abnormal, or atypical hyperplasia; and carinoma in situ. Atrophic epithelium, not evaluated separately in the Ljubljana classification, was additionally assessed. Simple hyperplasia was found in 98 cases (65.8 per cent), abnormal hyperplasia in seven (4.7 per cent), atrophic epithelium in 24 (16.1 per cent), and normal squamous epithelium in 20 (13.4 per cent). Atypical hyperplasia and carcinoma in situ were not observed.

The results of our study clearly showed that the proliferation of the covering epithelium mostly in the form of simple hyperplasia, is entirely reactive and therefore reversible. No epithelial hyperplastic lesions were found that were previously described to be associated with an increased risk of malignant alteration, namely atypical hyperplasia and carcinoma in situ. However, since an initial growth of an invasive malignant neoplasm might macroscopically imitate the appearance of laryngeal granuloma, a histological examination in all aetiological forms of laryngeal granulomas is required. By clearly discerning the benign nature of epithelial changes in laryngeal granulomas, the recently re-evaluated and further formulated Ljubljana classification may also influence the clinical handling of patients.

Iatrogenic lesions of the superior laryngeal nerve (SLN) are much more common than is generally recognized. Since injury to this nerve may cause transient or even persistent changes either in quality of voice or in deglutition, an attempt should be made to localize and identify the nerve during surgery. This study included 74 patients who underwent surgical dissection near the thyroid apex in the neck. Effective prevention of SLN injury during surgery was achieved by anatomical localization of the nerve in the viscerovertebral angle and its functional identification with the nerve stimulator. Post-operative analysis consisted of subjective interview, rigid laryngoscopy, acoustic analysis, laryngeal videostroboscopy and cricothyroid electromyography. Four patients complained of post-operative voice changes; two were diagnosed as SLN injury (2.4 per cent), one as reflux laryngitis and the fourth as intubation granuloma. Surgical access to the SLN in the periapical area may be achieved through mobilization of the viscerovertebral angle. The use of a nerve stimulator during difficult situations should keep SLN injury at a minimum.

The objectives of this study were to investigate the typical clinical presentation, diagnosis and treatment of mycobacterial cervical lymphadenitis (MCL).

Medical records of 87 patients who were treated for MCL were retrospectively reviewed. Definitive diagnosis of MCL was made when a neck mass persisted for several weeks or months and one or more of the following was obtained: (1) positive mycobacterial cultures from biopsy material; (2) Positive mycobacterial staining of biopsy material; (3) Granulomatous inflammation and caseating necrosis on histopathological examination of biopsy material.

Clinical findings were reviewed prior to treatment. The treatment included standard antituberculous medications followed by surgery in which either total excision or selective nodal dissection of the cervical lump was made. Follow-up results are presented.

The chief complaint was a cervical mass that was localized mostly to the posterior cervical or submandibular regions. A fistula formation was encountered in 11.5 per cent. All patients recovered from MCL by combined antituberculous drug and surgical treatments.

Clinical presentation of the disease and histopathological assessment are important in the diagnosis of MCL as well as in the differential diagnosis of tuberculous and nontuberculous MCL. Utilizing the combined medical and surgical treatment options, both tuberculous and non-tuberculous cervical adenitis can be treated successfully.

This report describes the clinical and radiographic findings together with surgical management of temporomandibular joint contents herniation through the tympanic plate of the external auditory canal. Two patients are reported. A review of the literature is presented, including a brief discussion of the embryological development of the external auditory canal. Excluding infection, trauma or neoplasm, the defect in the tympanic plate of the external auditory canal represents a developmental aberration with failure of the foramen of Huschke to close during development.

A pre-auricular approach with insertion and fixation of an onlay polyethylene implant to prevent prolapse of the peri-articular tissues into the ear canal is presented and described.

The postcricoid subsite is difficult to visualize on flexible laryngopharyngoscopy. The view can be improved with either auto-insufflation manoeuvres or anterior neck skin traction. In this study, the view of the hypopharynx was graded whilst anterior neck skin traction was applied during the trumpet manoeuvre; the latter involves the patient blowing on his finger as if blowing up a balloon. On auto-insufflation alone, the postcricoid site was demonstrated in 22/25 (88 per cent) of cases and the upper oesophageal sphincter (UOS) in two out of 25 (eight per cent). Of the 22 cases in whom only the postcricoid site was demonstrated, subsequent neck skin traction revealed the UOS in eight. Overall, the use of auto-insufflationsolely or in combination with traction resulted in UOS visualization in 40 per cent (10/25) of cases. The application of skin traction during trumpeting is easy to perform and should be used routinely.

Submucosal diathermy to the inferior turbinates is a common surgical procedure performed to improve the nasal airway. We present the case of a previously well six-year-old boy who underwent submucosal diathermy and developed the unusual complication of a left oculomotor nerve palsy. The possible aetiology is discussed.

The authors present a case of bilateral cavernous haemangiomas affecting the posterior ends of both inferior turbinates of the nose. The condition was treated by angiographically controlled embolization. Review of the literature back to 1967 has revealed no other report of embolization being used specifically for this condition. All previous treatments have involved surgery; we describe an alternative therapeutic option.

Aspergillosis of the nose and paranasal sinuses has classically been divided into four types: allergic, non-invasive, invasive and fulminant. Recent reports have suggested that a semi-invasive form with bone destruction and erosion, but without fungal tissue invasion, may occur. We present a case of allergic non-invasive aspergillosis of the paranasal sinuses with associated bone destruction extending into the orbit and anterior cranial fossa, in a non-immunocompromised patient. Surgical debridement combined with a prolonged course of oral itraconazole has resulted in long-term resolution with no evidence of recurrence of disease five years later.

Numerous factors contribute towards a late diagnosis of laryngeal malignancy in childhood. These include its rarity, the similarity of its early symptoms to those of other benign, common childhood conditions as well as the relative difficulty encountered during paediatric laryngeal examination.

We believe that these cases are of sufficient interest when they occur to warrant reporting since the consequences of late diagnosis in these young patients can be serious.

We present a case of an 11-year-old boy with advanced squamous cell carcinoma of the larynx (T3N0M0), who was successfully treated with primary total laryngectomy and bilateral selective neck dissections to avoid the potential additional morbidity of radical radiotherapy.

Amyloidosis of the upper aerodigestive tract is relatively rare. A case of localized amyloidosis involving all components of Waldeyer’s ring with added laryngeal involvement is described. This has not been previously reported. A literature review of this conditions is presented.

Recurrence in mucoepidermoid carcinoma of the salivary gland after 15 years is rare and present difficult therapeutic decisions. A rare case of mucoepidermoid cancer of the base of the tongue that recurred locoregionally after 20 years and was managed judiciously by a planned combined modality approach is presented.

The brown tumour of hyperparathyroidism is a localized bone tumour and an uncommon manifestation of hyperparathyroidism. A 27-year-old woman presented with a mandibular 8 × 10 cm solid mass diagnosed as central giant cell granuloma. Chemical blood analysis revealed increased serum calcium levels of 12.46 mg/dL and the parathyroid hormone level was 124 pg/dL. The patient underwent surgery with removal of a parathyroid mass. Histologically, this parathyroid tissue was seen to be limited by a fibrous capsule with morphological features consistent with atypical parathyroid adenoma. The mandibular tumour has receded and the patient declined further procedures. This is the first case reported of brown tumour as the primary manifestation of an atypical parathyroid adenoma, a lesion that shares some features with parathyroid carcinoma without the unequivocal properties of malignancy.

The clinical and radiological differential diagnosis of cystic lesions of the submandibular region can be difficult. We report an unusual case of a submandibular salivary duct cyst mimicking an external laryngocele on presentation by appearing to expand on Valsalva manoeuvre, and where computed tomography (CT) scanning was unhelpful in reaching a diagnosis. We present the case, discuss the theories of pathogenesis, and review the literature on the differential diagnosis of cystic lesions in the submandibular region.

Cranial nerve damage following head and neck radiotherapy is an unusual event. Cranial neuropathy following concurrent chemotherapy and radiotherapy is unreported. The authors report a case of a 54-year-old man treated with curative chemotherapy and radiotherapy for a stage III nasopharyngeal carcinoma who developed an unilateral hypoglossal nerve palsy five years after therapy. Follow-up examination and magnetic resonance imaging (MRI) show no evidence of recurrent disease. Hypoglossal nerve injury occurring after head and neck radiotherapy is an indirect effect due to progressive soft tissue fibrosis and loss of vascularity. This process develops over years leading to nerve entrapment and permanent damage. Cranial nerve palsies, including damage to the hypoglossal nerve, can develop years after therapy with no evidence of tumour recurrence. Chemotherapy and radiotherapy have improved progression-free and overall survival in advanced nasopharyngeal cancer. As more patients achieve long-term tumour control following chemotherapy and radiotherapy, we must be cognizant of potential late injury to cranial nerves.

The latest 3D-image guidance systems to assist surgeons have greatly improved over earlier models. We describe the use of an optical infra-red system to assist in the removal of a juvenile nasopharyngeal angiofibroma. The specific advantages of this system in pre-operative assessment, intra-operative evaluation and excision of the angiofibroma are discussed.