To present our experience of running a consultant-based otolaryngology emergency care service for more than five years.

In 2003, we developed a system of consultant-based emergency service: consultants spent a week on-call providing a dedicated emergency service, with routine commitments cancelled.

Our new system had advantages over traditional working practices in terms of consultant involvement, trainee education, continuity and efficiency. It also reduced disruption to elective commitments for both consultants and registrars. This system was fundamental to the successful review of all urgent (and in future elective) cases within target periods. Only 31 per cent of new referrals to the consultant emergency clinics required a further appointment. Good teamwork and flexibility in working arrangements have been essential to the success of this service.

Given that health service changes have reduced junior trainee working hours and numbers, and that patients increasingly expect to be treated by trained doctors, our new consultant-based emergency service has merit. Although implementation in other units may differ, we recommend this new service, for the above reasons.

To compare anatomical and audiological outcomes of ring versus ‘Mercedes-Benz’ cartilage-perichondrium graft tympanoplasty in patients with pars tensa cholesteatoma.

Prospective clinical study.

Otolaryngology department, Tanta University Hospital, Egypt.

Patients and methods: Over three years, 60 ears in 60 patients underwent surgery for either sinus or tensa retraction cholesteatoma, reconstructed using either a ring-shaped (30 ears) or Mercedes-Benz symbol shaped (30 ears) cartilage-perichondrium graft, with at least two years' follow up. Post-operative drum perforation and retraction, cholesteatoma residue and recurrence, middle-ear effusion, and hearing acuity were monitored.

Anatomical outcomes were equivalent in both groups, but slightly better in the Mercedes group. Hearing improved significantly in both groups (pre- vs post-operative results), but significantly more so in the ring group. Within-group hearing outcomes were unaffected by cholesteatoma type or tympanoplasty type.

The Mercedes-Benz technique may be superior to the ring technique in preventing neodrum retraction. However, the ring graft technique had better hearing outcomes, perhaps due to its more physiological design.

Silent sinus syndrome is characterised by spontaneous enophthalmos and hypoglobus, in association with chronic atelectasis of the maxillary sinus, and in the absence of signs or symptoms of intrinsic sinonasal inflammatory disease. Traditionally, correction of the enophthalmos involved reconstruction of the orbital floor, which was performed simultaneously with sinus surgery. Recently, there has been increasing evidence to support the performance of uncinectomy and antrostomy alone, then orbital floor reconstruction as a second-stage procedure if needed.

We performed a retrospective review of 23 cases of chronic maxillary atelectasis managed in our unit with endoscopic uncinectomy and antrostomy alone. All patients were operated upon by the same surgeon.

Twenty-two of the 23 patients had either complete or partial resolution. One patient had ongoing enophthalmos, and was considered for an orbital floor reconstruction as a second-stage procedure.

Our case series demonstrates that dynamic changes in orbital floor position can occur after sinus re-ventilation. These findings support the approach of delaying orbital floor reconstruction in cases of silent sinus syndrome treated with sinus re-ventilation, as such reconstruction may prove unnecessary over time.

To compare Rapid Rhino and Merocel packs for nasal packing after septoplasty, in terms of patient tolerance (both with the pack in place and during removal) and post-operative complications.

Thirty patients (aged 18–40 years) scheduled for septoplasty were included. Following surgery, one nasal cavity was packed with Rapid Rhino and the other one with Merocel. Patients were asked to record pain levels on a visual analogue score, on both sides, with the packs in situ and during their removal the next day. After pack removal, bleeding was compared on both sides.

The mean ± standard deviation pain score for the Rapid Rhino pack in situ (4.17 ± 1.78) was less than that for the Merocel pack (4.73 ± 2.05), but not significantly so (p = 0.314). The mean pain score for Rapid Rhino pack removal (4.13 ± 1.76) was significantly less that that for Merocel (6.90 ± 1.67; p = 0.001). Bleeding after pack removal was significantly less for the Rapid Rhino sides compared with the Merocel sides (p <0.05).

Rapid Rhino nasal packs are less painful and cause less bleeding, compared with Merocel packs, with no side effects. Thus, their use for nasal packing after septal surgery is recommended.

Anterior tongue reduction is indicated when macroglossia causes problems with oral hygiene, airway compromise, deglutition, articulation or orthognathic complications. Causes of macroglossia include hypothyroidism, mucopolysaccharide and lipid storage disease, lymphangioma, haemangioma, neurofibroma, and muscular macroglossia. This paper presents an 11-year experience of anterior tongue reduction at Great Ormond Street Hospital.

Retrospective study of patient medical records identified from the hospital ENT database. Anterior wedge resection was the preferred technique.

Anterior tongue reduction was performed on 18 patients, due to cystic hygroma with tongue involvement (nine patients), Beckwith–Wiedemann syndrome (eight) and Down's syndrome (one). Anterior wedge resection was preferred, using electrocautery in the majority, except for four cases involving CO2 laser. All but one patient had a good surgical outcome (i.e. tongue in mouth at rest). One patient subsequently required multiple laser procedures for recurrent macroglossia.

Anterior tongue reduction can be a safe procedure, with limited post-operative morbidity, consistently resulting in good surgical outcomes and improvement in macroglossia symptoms. Speech development does not appear to be adversely affected.

To investigate the effect of transoral laser microsurgery for early glottic cancer on subjective and objective vocal outcome measures.

Prospective cohort study.

Tertiary care cancer centre.

All patients scheduled for transoral laser microsurgery for untreated early primary glottic cancer over a 22-month period and offered voice assessment (31 patients; 19 tumour stage one, 12 tumour stage two).

Fundamental frequency, maximum phonation time, calculated jitter, shimmer and subjective voice rating, analysed by tumour stage.

Tumour stage T1 patients had significantly different fundamental frequencies and maximum phonation times at three months post-operatively, compared with pre-operative values; these differences resolved by 12 months. At 12 months, tumour stage T2 patients had significantly shorter maximum phonation times, and all patients reported significantly worse subjective voice ratings, compared with pre-operative values.

We found no change in fundamental frequency, jitter and shimmer, one year post-operatively. Maximum phonation time deteriorated but stage one patients appeared to compensate, whereas stage two patients did not. Resection size may be a factor. All patients reported significantly worse subjective voice ratings at one year. Aerodynamic and subjective voice measures appear most sensitive to change in this patient group.

Thyroid lymphomas are relatively uncommon. This study aimed to analyse our experience of thyroid lymphoma management and outcome.

A retrospective case note analysis of 63 patients treated in the previous 13 years was conducted.

The five-year survival rate was 68 per cent, with most patients dying of their lymphoma. This is at odds with the British Thyroid Association statement that the prognosis of this condition is ‘generally excellent’. The only presenting symptom found to be significantly associated with prognosis was dysphagia (p = 0.001). Dual modality treatment provided a significantly better outcome than single modality treatment (p = 0.014). Thyroid lymphoma can present to the head and neck surgeon ‘in extremis’; however, it can respond rapidly to appropriate treatment.

The outcome of thyroid lymphoma seems unrelated to the acuteness of its presentation. Thyroid surgery has no role other than for diagnosis. However, 51 per cent of the study patients underwent some form of thyroidectomy, indicating the need to implement better diagnostic pathways.

To determine the differences in myelination between the human recurrent laryngeal nerve and superior laryngeal nerve.

Fifteen confirmed laryngeal nerve specimens were harvested from five cadavers. Cross-sections were examined under a photomicroscope and morphometric analysis performed.

There was a significantly greater number of myelinated fibres than unmyelinated fibres, in both the recurrent laryngeal nerve (p = 0.018) and the superior laryngeal nerve (p = 0.012). There was a significantly greater number of myelinated fibres in the superior laryngeal nerve, compared with the recurrent laryngeal nerve (p = 0.028). However, there was no significant difference in the number of unmyelinated fibres, comparing the two nerves (p = 0.116).

These findings support those of previous studies, and provide further evidence against the historical plexus theory of laryngeal nerve morphology. The differences in the degree of myelination, both within and between the human laryngeal nerves, may have clinical consequence regarding recovery of function following nerve injury.

Various techniques are used to maintain retraction of the skin flap during open-approach rhinoplasty.

This report aims to present the use of maxillofacial retractors in open-approach rhinoplasty, a previously undescribed technique.

Use of these retractors provides excellent exposure of the lower lateral cartilages for surgery of the nasal tip, as well as access for surgery on the upper lateral cartilages. This technique allows the surgeon and assistant to proceed with surgery without needing to maintain retraction with a hand-held instrument.

We report a case of successful cochlear implantation in a patient with petrous bone cholesteatoma in the only hearing ear.

A 63-year-old man presented with a four-year history of right-sided, progressive hearing loss in his only hearing ear. Computed tomography and magnetic resonance imaging revealed a right supralabyrinthine petrous bone cholesteatoma, with erosion of the superior semicircular canal and the roof of the internal auditory canal. Due to the high risk of post-operative right-sided deafness, we decided first to perform left cochlear implantation. Five months later, the patient had a 40 per cent score for open-set two-syllable word recognition and an 85 per cent score for sentence recognition. Given these good performances, we decided to eradicate the cholesteatoma via a translabyrinthine approach, with insertion of a second cochlear implant, as a single-stage procedure. A successful outcome was achieved.

Cochlear implantation can be an effective method of hearing rehabilitation in patients with petrous bone cholesteatoma, following total eradication of disease, if the cochlea remains intact. To our best knowledge, this is the first English language report of cochlear implantation in a patient with petrous bone cholesteatoma.

We report a case of an arteriovenous malformation within the internal auditory meatus and cerebellopontine angle, and we discuss its imaging appearances and management.

A 50-year-old man presented with a two-year history of vertigo. Magnetic resonance imaging and magnetic resonance angiography demonstrated a lesion consisting of multiple ‘high flow’ vessels within the left internal auditory meatus and cerebellopontine angle. Transarterial embolisation was performed, with obliteration of the arteriovenous malformation.

Arteriovenous malformations of the internal auditory meatus and cerebellopontine angle are exceedingly rare. It is important that a pre-treatment diagnosis is made, as the management of arteriovenous malformation differs from that of other, more common lesions at this site.

We describe a rare case of spontaneous temporomandibular joint herniation into the external auditory canal, and we also review the presentation, aetiology and management of such cases.

An 87-year-old woman presented with a four-month history of left-sided otorrhoea and otalgia. Examination revealed a soft, polypoid mass in the left ear canal. When the patient opened her mouth the lesion disappeared. Subsequent computed tomographic imaging of the patient's temporal bones confirmed an 8.6 mm defect in the antero-inferior portion of the left ear canal, with herniation of retrodiscal soft tissues.

The external auditory canal is intimately related to the temporomandibular joint, separated only by its bony anterior wall. Neoplasm, trauma or inflammation in this area can result in displacement of the temporomandibular joint into the ear canal; however, spontaneous herniation is rare. Persistence of the primitive foramen of Huschke can result in dehiscence of the anterior canal wall, allowing articular tissue to prolapse into the ear canal. Surgical closure of these defects is known to be effective in ameliorating symptomatic cases.

We present a patient with mitochondrial hearing loss and a novel mitochondrial DNA transition, who underwent successful cochlear implantation.

An 11-year-old girl showed epilepsy and progressive hearing loss. Despite the use of hearing aids, she gradually lost her remaining hearing ability. Laboratory data revealed elevated lactate levels, indicating mitochondrial dysfunction. Magnetic resonance imaging showed diffuse, mild brain atrophy. Cochlear implantation was performed, and the patient's hearing ability was markedly improved. Whole mitochondrial DNA genome analysis revealed a novel heteroplasmic mitochondrial 625G>A transition in the transfer RNA gene for phenylalanine. This transition was not detected in blood DNA from the patient's mother and healthy controls. Mitochondrial respiratory chain activities in muscle were predominantly decreased in complex III.

This case indicates that cochlear implantation can be a valuable therapeutic option for patients with mitochondrial syndromic hearing loss.

Epithelial-myoepithelial carcinoma is an uncommon, low-grade carcinoma that generally occurs in the salivary glands. A few cases of epithelial-myoepithelial carcinoma arising in the nasal cavity have been reported. We describe a unique case of aggressive epithelial-myoepithelial carcinoma in the nasal cavity.

A 36-year-old woman presented with a mass in her left nasal cavity. Histopathological evaluation revealed it to be an epithelial-myoepithelial carcinoma with overt nuclear atypia, frequent mitoses and necrosis. The tumour recurred in the contralateral nasal cavity 15 months following primary excision. Medial maxillectomy and radiation therapy were performed. Seven-month follow up revealed extensive bone metastases.

We report a rare case of aggressive epithelial-myoepithelial carcinoma in the nasal cavity, with high-grade histology.

To raise awareness of nasal malignant melanoma, a rare tumour, and to highlight the difficulty associated with its optimum management.

Case report and literature review.

A 71-year-old, Caucasian man was diagnosed with malignant melanoma in the right nasal cavity, after presenting with right-sided epistaxis. He underwent endoscopic medial maxillectomy; histological analysis confirmed that the resection margins were clear. However, within six months he re-presented with a metastatic deposit of malignant melanoma in his right external auditory canal, for which he underwent right temporal bone resection. There was no evidence of distant metastasis on radiological studies. Unfortunately, within a month the tumour recurred in the right nasopharynx. A multidisciplinary team decision was made to offer the patient palliative chemoradiotherapy.

Mucosal malignant melanoma of the nose is very rare, and aural metastasis from this primary site has not previously been reported. Optimum management must involve a multidisciplinary team.