To describe the pathophysiology of biofilm communities and their role in otorhinolaryngological disease, with reference to the published literature.

Review of relevant literature, using Medline and the combined search terms ‘biofilms’ and ‘otorhinolaryngology’, and also various related keywords such as ‘tonsil’ and ‘adenoid’.

Description of biofilm pathophysiology and of published reports of biofilms in otorhinolaryngological disease.

Virtually all microbes live in biofilm communities. Within these communities, the microbes assume differing specialised roles which confer survival advantages on the community. These communities cause chronic and device-associated infections. Within the specialist field of otorhinolaryngology, biofilms have been shown to play a role in many infections, including: chronic otitis media, cholesteatoma, chronic tonsillitis, chronic sinusitis, and infections of tracheostomies, endotracheal tubes and cochlear implants.

To review Behçet's disease and to describe its clinical features in the head, neck and upper respiratory tract.

A literature review was undertaken, following a Medline search of publications over a 30-year period, and utilising the expert knowledge of one of the authors (RJM) with a specialist interest in Behçet's disease.

Twenty-seven articles with ENT relevance were obtained. Otorhinolaryngological manifestations included symptoms and signs in the mouth, nose, sinus, larynx and ear.

Behçet's disease is usually considered to be a condition affecting the oral cavity, eyes and genitals. This article shows that most patients will also exhibit other ENT symptoms, hearing loss in particular. Indeed, Behçet's disease may present with features other than the classic triad of symptoms. Raised awareness of the clinical features within the head and neck region will hopefully enable early diagnosis and treatment of this potentially serious condition.

To determine the frequency and type of gap junction protein beta-2 gene mutations in Malay patients with autosomal recessive, non-syndromic hearing loss.

A total of 33 Malay patients with autosomal recessive, non-syndromic hearing loss were screened for mutations in the Cx26 coding region. Deoxyribonucleic acid was extracted from buccal swab samples and subjected to polymerase chain reaction. Slow-reannealing was performed, followed by screening using denaturing high performance liquid chromatography.

Eight of the samples (24.2 per cent) showed heterozygous peaks, and further sequencing of these samples revealed four patients (50.0 per cent) with the W24X mutation, two (25.0 per cent) with the V37I mutation and another two (25.0 per cent) with the G4D mutation.

Analysis of buccal swab samples by denaturing high performance liquid chromatography is noninvasive and suitable for rapid and reliable screening of gap junction protein beta-2 gene mutations in patients with autosomal recessive, non-syndromic hearing loss. Malay patients with autosomal recessive, non-syndromic hearing loss have different kinds of gap junction protein beta-2 gene mutations which are rarely found in other populations.

To investigate vestibular function in human immunodeficiency virus positive subjects.

We studied vestibular function in 60 human immunodeficiency virus positive subjects reporting dizziness. All three Center for Disease Control and Prevention categories of human immunodeficiency virus infection were represented in the study group (30 patients in class A, 20 in class B and 10 in class C). Subjects had had no previous history of acute vertigo. All subjects underwent: neurotological screening for spontaneous, positional and positioning nystagmus, using head-shaking and head-thrust (Halmagyi) tests; audiometrical examination; and electronystagmography with bithermal stimulation (Freyss' method). The results of the 30 class A subjects were compared with those of 30 human immunodeficiency virus negative patients reporting dizziness.

Abnormal otoneurological findings increased progressively from the A to C categories, particularly regarding increased central damage (3.3 per cent of class A, 35 per cent of class B and 100 per cent of class C subjects). In contrast, the incidence of peripheral vestibular disorders remained almost the same, comparing the three categories (33.3 per cent in class A and 50 per cent in classes B and C subjects). Moreover, a higher number of human immunodeficiency virus positive subjects showed abnormal otoneurological findings, compared with the dizzy, human immunodeficiency virus negative subjects.

In our opinion, a vestibular disorder may occur in human immunodeficiency virus positive patients as a result of direct viral damage, even in the early phase of infection. Central vestibular damage may be established later on, and may be linked to different causes (e.g. superinfections, vascular causes and drug toxicity).

The aim of this study was to investigate the frequency of posterior semicircular canal benign paroxysmal positional vertigo in each ear, and to assess the association between the ear affected by benign paroxysmal positional vertigo and the head-lying side during sleep onset. Based on a previous study which used objective methods to prove the preference of the elderly for the right head-lying side during sleep, we hypothesised that a predominance of the same head-lying side in benign paroxysmal positional vertigo patients may affect the pathophysiology of otoconia displacement.

We conducted a prospective study of out-patients with posterior semicircular canal benign paroxysmal positional vertigo, confirmed by a positive Dix–Hallpike test.

One hundred and forty-two patients with posterior semicircular canal benign paroxysmal positional vertigo were interviewed about their past medical history, focusing on factors predisposing to benign paroxysmal positional vertigo. All patients included in the study were able to define a predominant, favourite head-lying side, right or left, during sleep onset.

The Dix–Hallpike test was found to be positive on the right side in 82 patients and positive on the left side in 54; six patients were found to be positive bilaterally. During sleep onset, 97 patients habitually laid their head on the right side and the remaining 45 laid their head on the left. The association between the affected ear and the head-lying side during sleep onset was statistically significant (p < 0.001).

Our study found a predominance of right-sided benign paroxysmal positional vertigo, a subjective preference amongst patients for a right head-lying position during sleep onset, and an association between the ear affected by benign paroxysmal positional vertigo and the preferred head-lying side during sleep onset. The clinical and therapeutical implications of this observation are discussed.

The characteristics of otoacoustic emissions that make them ideally suited for universal newborn hearing loss screening could potentially be useful for the screening of older children. This study was performed in order to assess the role of otoacoustic emissions in a screening programme for middle-ear disorders and hearing loss in school-age children.

Cross-sectional, preliminary screening study.

Primary schools of Argolida municipality, south-east Greece, between December 2004 and March 2005.

All the primary school students of Argolida were invited, by press releases and individually by their teachers, to attend a session of otological and audiological screening.

One hundred and ninety-six children were evaluated using transient evoked otoacoustic emissions. Twenty per cent failed in both ears, while in 32 per cent otoacoustic emissions could not be produced in at least one ear. Younger children had higher rates of absent transient evoked otoacoustic emissions. The absence of otoacoustic emissions was highly correlated with tympanic membrane changes seen on otoscopy and the presence of a type B tympanogram. As a single screening modality, otoacoustic emissions had a 100 per cent sensitivity in diagnosing hearing loss worse than 30 dB, and a 90 per cent sensitivity and 64 per cent specificity in diagnosing hearing loss worse than 25 dB, which did not improve by adding tympanometry to the screening protocol.

These results strongly suggest the potential usefulness of otoacoustic emission testing in screening school-age children for hearing loss. Further studies, taking into account cost-effectiveness issues, are indicated.

To determine the decibel sound pressure levels generated during extracorporeal lithotripsy for salivary stones, and if such lithotriptor noise levels have the potential for acoustic trauma.

Minilith SL-1 salivary gland lithotriptor, sound level meter; five patient survey.

Decibel measurements were conducted on the lithotripter-generated sounds, using a sound level meter at specific distances from the active element. In addition, a patient survey was conducted as a cross-reference, to enable comparison of predicted results with actual human perception of sound levels.

Sound levels ranged between 68 and 80 dB during treatment sessions, for both the lithotriptor operator and the patient.

During routine use, no acoustic trauma is incurred by either the lithotriptor operator or the patient.

Recent research has indicated that sphingosine 1-phosphate plays a role in allergy. This study examined the effect of allergen challenge on the expression of sphingosine 1-phosphate receptors on the eosinophils of allergic rhinitis patients, and the effect of steroid treatment on this expression.

A prospective, non-randomised study.

The study had three parts. Firstly, sphingosine 1-phosphate receptor expression on the eosinophils of allergic rhinitis patients and control patients was determined. Secondly, sphingosine 1-phosphate receptor expression was quantified pre- and post-allergen challenge, before and after a short course of fluticasone propionate; all patients underwent symptom scoring and peak nasal inspiratory flow measurement pre- and post-allergen challenge, both before and after steroid or saline treatment. Thirdly, the effect of sphingosine 1-phosphate on eosinophil migration was examined.

The eosinophils of both allergic rhinitis patients and controls expressed sphingosine 1-phosphate1, 3, 4, and 5. Eosinophils from all allergic rhinitis patients demonstrated up-regulation in sphingosine 1-phosphate expression after allergen challenge. These changes were statistically very significant for sphingosine 1-phosphate1, 4, and 5, and moderately significant for sphingosine 1-phosphate3. Sphingosine 1-phosphate receptor expression up-regulation was abolished in the steroid-treated group after allergen challenge; however, the saline-treated group showed no change in sphingosine 1-phosphate receptor expression after allergen challenge. Peak nasal inspiratory flow scores were significantly diminished after allergen challenge prior to treatment, but not after a course of topical nasal steroids. Sphingosine 1-phosphate induced eosinophil chemotaxis was increased following allergen challenge in allergic rhinitis subjects.

Local intranasal steroid therapy acts directly to block allergen-induced up-regulation of sphingosine 1-phosphate receptors on the peripheral eosinophils of allergic rhinitis patients, and this is coincident with post-challenge peak nasal inspiratory flow measurement improvements. These observations support the idea that such an increase in sphingosine 1-phosphate receptor expression is clinically relevant in allergic rhinitis, with potential consequences for eosinophil migration and survival.

Phenotypical Down syndrome includes pharyngeal and maxillary hypoplasia and, frequently, constricted maxillary arch with nasal obstruction.

This clinical trial assessed the effects of rapid maxillary expansion on ENT disorders in 24 children with Down syndrome randomly allocated to receive either rapid maxillary expansion or not. Each group received ENT and speech therapy assessments before expansion and after the device had been removed.

In the rapid maxillary expansion group, the yearly ENT infection rate was reduced when assessed after device removal (p < 0.01). The parents of rapid maxillary expansion children reported a reduction in respiratory obstruction symptoms. Audiological assessment revealed improvements in the rapid maxillary expansion group (p < 0.01). Cephalometry showed increased maxillary width in the rapid maxillary expansion group.

Rapid maxillary expansion resulted in a reduction in hearing loss, yearly rate of ENT infections and parentally assessed symptoms of upper airway obstruction, compared with no treatment. These findings are probably related to expanded oronasal space, due to rapid maxillary expansion.

Traumatic optic neuropathy can be treated by various methods including steroids and surgical decompression. Endoscopic optic nerve decompression has been suggested to be effective in treating this condition. The aim of this study was to assess the outcome of treating traumatic optic neuropathy with steroids and endoscopic surgical decompression.

Two hundred and thirty-seven patients with traumatic optic neuropathy were treated with steroids; 176 also consented to endoscopic optic nerve decompression.

The total vision improvement rate was 55 per cent in the 176 patients treated with both steroids and endoscopic optic nerve decompression, compared with 51 per cent in the 61 patients treated with steroids alone; this difference was not statistically significant (p > 0.05). Treatment with steroids plus endoscopic optic nerve decompression resulted in a significantly greater vision improvement in patients with gradual vision loss, compared with those with immediate blindness (68 vs 42 per cent, respectively). Early surgery (within one week) was an important prognostic factor for vision recovery, compared with more delayed surgical treatment (associated vision improvement rates were 60 and 31 per cent, respectively).

Endoscopic optic nerve decompression is a minimally invasive, safe and efficient treatment for traumatic optic neuropathy. Used in combination with steroids, it provides effective rescue for some patients suffering visual loss. It should be undertaken as soon as possible.

To evaluate the relationship between the incidence of primary post-tonsillectomy haemorrhage and the daily weather condition, over a five-year period.

This was a retrospective study carried out in the ENT department of the Split University Hospital between January 2000 and December 2004.

Out of 3377 patients undergoing tonsillectomy, primary post-operative haemorrhage occurred in 83 (2.5 per cent). The season, daily atmospheric pressure and daily change in atmospheric pressure did not have any significant influence on post-tonsillectomy haemorrhage incidence. However, there was a statistically significant increase in the incidence of primary post-operative haemorrhage when cyclonic conditions prevailed (p = 0.035).

The incidence of primary post-tonsillectomy haemorrhage in our study population was 2.5 per cent. Avoiding tonsillectomy during cyclonic weather conditions may reduce the incidence of primary post-tonsillectomy haemorrhage.

Airway fires pose a risk during laser microlaryngoscopy, and neurosurgical cotton patties, used to prevent tissue injury from stray laser beams, are a potential ignition source. Using a configuration approximating clinical practice, we experimentally assessed the relative impact of changing different ‘fire triad’ components on the occurrence of airway fires, in order to better inform patient care.

The relative effects of wet vs dry neurosurgical patties, oxygen concentration and laser power setting on the patty ignition time were studied in a cadaveric porcine model. Data were analysed using t-test and two-way analysis of variance.

Dry patties ignited after 2.3 ± 1.2 seconds (average ± standard deviation) of continuous 5 W laser fire at 50 per cent oxygen concentration, compared with 63.9 ± 27.8 seconds for wet patties under the same laser and oxygen settings (p < 0.0001). There was a statistically significant reduction in the time to patty ignition when laser power settings were increased from 5 to 7.5 W, but no further reductions occurred when the power was further increased to 10 W (p < 0.05; Tukey test for multiple comparisons; two-way analysis of variance). There was no significant reduction in the time to ignition between oxygen concentrations of 50 and 75 per cent, but the time to ignition fell significantly when the oxygen concentration was further increased to 100 per cent.

We suggest that surgical patties should always be soaked and should be used for relatively short periods, in order to prevent drying. If at all possible clinically, prolonged laser use at high power settings and ventilation with 100 per cent oxygen should be avoided.

Stellate cells in the maculae flavae, located at both ends of the human vocal fold mucosa, have been considered an independent category of cells. We aimed to isolate and subculture these stellate cells, and to observe their morphological characteristics.

Stellate cells from the maculae flavae and fibroblasts from Reinke's space were cultured in three normal, adult human vocal fold mucosa preparations.

The subcultured cells from Reinke's space were conventional fibroblasts. The subcultured cells from the maculae flavae were stellate in shape and had cytoplasmic processes. They were larger than conventional fibroblasts, and lipid droplets in the cytoplasm disappeared in the second culture. These stellate cells proliferated by attaching their cytoplasmic processes to each other. During the seven to 10 month subculture period, each cell type continued to exhibit its own morphological characteristics.

This study demonstrated that such stellate cells form an independent cell category, which should be considered as a new category of cells within the human vocal fold.

Although electrocautery has been used widely in surgery, the fear of delayed wound healing and infection persists. We aimed to evaluate the risk factors for wound complications and the rate of wound complications, comparing the use of electrocautery or scissors in cutaneous flap creation during thyroidectomy.

The study group comprised 239 consecutive patients scheduled for thyroidectomy.

Patients were randomly assigned to cutaneous flap dissection by either electrocautery (group one, n = 126) or scissors (group two, n = 113). Age, gender, body mass index, American Society of Anesthesiology score, tissue weight, operating time, incision length, cutaneous tissue depth, thyroid function and surgeon experience were recorded and compared with the rate of post-operative wound complications in both groups.

There were no significant differences between the overall rate of post-operative wound complications, comparing groups one and two (7.9 vs 10.6 per cent, respectively; p = 0.74). Significant positive correlations were found between wound complication and age (Spearman's rank coefficient (rs) = 0.135, p = 0.036), body mass index (rs = 0.379, p = 0.0001), cutaneous tissue depth (rs = 0.677, p = 0.0001) and tissue weight (rs = 0.643, p = 0.0001). According to logistic regression analysis, a body mass index of more than 27.5 kg/m2 was associated with a 13.7-fold increased rate of post-operative wound complications.

When creating cutaneous flaps during thyroidectomy, the use of electrocautery is as safe as the use of scissors. Such electrocautery does not increase the risk of wound complications in thyroid surgery.

18F-Fluorodeoxyglucose positron emission tomography can detect cervical metastases before they are palpable. However, false positive results are not uncommon. This paper reports the use of ultrasound-guided fine needle aspiration to determine the nature of impalpable cervical nodes that are positive on positron emission tomography scanning.

Ultrasound-guided fine needle aspiration was performed in 10 cancer patients with suspicious cervical nodes revealed by positron emission tomography scan. Clinical data were retrospectively reviewed.

The underlying cancers included lung cancer (three patients), nasopharyngeal carcinoma (two), oesophageal cancer (two), buccal cancer (one), bladder cancer (one) and Langerhan's histiocytosis (one). The lymph nodes were located in the supraclavicular region in four patients, the level II region in four, the level IV region in one and the accessory chain in one. Cytological examination was positive for malignant cells in eight patients, all of whom received salvage treatment. Two of these patients died of distant metastases. Cytological examination revealed a benign or reactive lesion in two patients, who at the time of writing were alive and well, 19 and 36 months after examination.

Ultrasound-guided fine needle aspiration is a minimally invasive procedure which enables cytological examination of suspicious cervical lymph nodes detected by positron emission tomography scanning, allowing further treatment to be planned.

The aim of this review was to examine long-term swallowing and eating outcomes following laryngopharyngoesophagectomy with gastric pull-up reconstruction.

Ten patients underwent clinical examination and completed the performance status scale for head and neck questionnaire and also a gastric pull-up swallowing questionnaire designed for this review. Nine of the 10 patients underwent videofluoroscopic examination of swallowing.

One patient had a stricture at the orogastric anastomosis, and one patient had bilateral tongue immobility secondary to XIIth nerve palsies. Eight participants reported eating a normal diet, and five reported not limiting their eating environment. Regurgitation, slower eating and reduced capacity were the most common functional limitations.

These results support previous opinions that the gastric pull-up procedure has good swallowing outcomes, and indicate that such outcomes continue in the long term.

Within the United Kingdom, there are 50 000 practitioners of complementary and alternative medicine, with five million people consulting these practitioners yearly. The aim of this study was to explore the use of such therapies by patients attending a head and neck oncology clinic in Aberdeen.

Questionnaires were distributed to 200 patients over an eight-week period. The questionnaire consisted of questions regarding: demographic factors; 48 listed herbal preparations and alternative therapies; reasons for their use; and opinions on their efficacy.

One hundred and thirty-eight patients completed the questionnaires. Fifty per cent (69/138) of respondents had used complementary and alternative medicine previously, with 26 per cent having used it in the preceding year. Fifty-five per cent of respondents learned about complementary and alternative medicine use from friends, and the majority obtained such medicines by purchasing from a shop. Fifty per cent (34/69) of respondents stated that their family physician was unaware of their use of complementary and alternative medicine.

All medical practitioners should be aware of increasing complementary and alternative medicine usage by the United Kingdom population, and should be able to counsel patients appropriately.

We present a technique which we have found useful for the management of congenital cholesteatoma extensively involving the middle ear.

A five-year-old boy was presented to our department for management of a white mass on the right tympanic membrane. This congenital cholesteatoma extensively occupied the tympanic cavity. It was removed through an extended tympanotomy approach using our modified sleeve technique. The conventional tympanotomy approach was extended by gently separating the tympanic annulus from its sulcus in a circular manner. The firm attachment of the tympanic membrane at the umbo was not severed, in order to avoid lateralisation of the tympanic membrane.

Although various operative techniques can be used, our modified sleeve tympanotomy approach provides a similarly sufficient and direct visualisation of the entire middle ear, with, theoretically, no possibility of lateralisation of the tympanic membrane and subsequent conductive hearing loss.

We present a patient with persistent hypertrophic skin surrounding the percutaneous implant of a bone-anchored hearing aid system, successfully treated with intralesional applied corticosteroids.

Case report and review of the world literature concerning bone-anchored hearing aid implantation and intralesional applied corticosteroids for the treatment of hypertrophic scars and keloids.

Eight weeks after revision surgery to reduce surplus skin and subcutaneous scar tissue overgrowing the abutment, skin and subcutaneous scar tissue overgrowth reoccurred. As an alternative to yet another surgical procedure, the hypertrophic skin was treated with intralesional injections of triamcinolone acetonide. Three weeks after the treatment, a satisfying result was seen, and no subsequent relapse was observed.

To our knowledge, this is the first, photographically well documented case report of a patient with persistent hypertrophic skin surrounding a percutaneous bone-anchored hearing aid implant, successfully treated with intralesional applied corticosteroids.