A biofilm is a community of micro-organisms encased within a self-produced, extracellular, polymeric substance. The role of biofilms as a major pathological aetiology in chronic rhinosinusitis would help explain the clinical manifestation of the disease.

To examine the current evidence, and to discuss possible future research directions, in relation to biofilms and chronic rhinosinusitis.

Systematic literature review.

Two assessors independently undertook critical appraisal of the studies identified by the literature search. Significant findings were incorporated into this review. The primary outcome assessed was the presence of biofilm in human mucosal biopsy samples taken from patients with chronic rhinosinusitis, and from healthy controls.

We identified 11 studies examining biofilm formation in human mucosal biopsy samples taken from patients with chronic rhinosinusitis.

It is unlikely that biofilms occur in every case of chronic rhinosinusitis; consequently, the significance of ‘biofilm detection’ in some series should be considered carefully. Several authors have argued strongly for the use of confocal scanning laser microscopy with fluorescent in situ hybridisation probes as the ‘gold standard’ for biofilm imaging. This imaging modality should be combined with further investigation of the microbiology of chronic rhinosinusitis, and of the efficacy of traditional culture techniques used for pathogen identification.

The E-lefENT programme is a collaborative e-learning project developed by the Department of Health and ENTUK. Prior to its introduction, we aimed to assess current use of and attitudes towards e-learning amongst UK otolaryngology trainees.

A web-based questionnaire was distributed to UK otolaryngology trainees via regional programme directors.

A total of 117 responses was received (35 per cent response rate). Most trainees reported increasing exposure to e-learning throughout their training and rated their current computer literacy skills highly, although satisfaction with current e-learning resources was found to vary widely for a variety of reasons.

Meeting the educational needs of otolaryngology trainees in the current era continues to be a challenge. Most trainees are already familiar with e-learning, although the quality and delivery of available websites is currently variable. The majority of trainees who responded seemed receptive to the implementation of a free, otolaryngology-specific e-learning resource.

Vestibular evoked myogenic potentials are short latency electrical impulses that are produced in response to higher level acoustic stimuli. They are used clinically to diagnose sacculocollic pathway dysfunction.

This study aimed to compare the vestibular evoked myogenic potential responses elicited by click stimuli and short duration tone burst stimuli, in normal hearing individuals.

Seventeen subjects participated. In all subjects, we assessed vestibular evoked myogenic potentials elicited by click and short duration tone burst stimuli.

The latency of the vestibular evoked myogenic potential responses (i.e. the p13 and n23 peaks) was longer for tone burst stimuli compared with click stimuli. The amplitude of the p13–n23 waveform was greater for tone burst stimuli than click stimuli. Thus, the click stimulus may be preferable for clinical assessment and identification of abnormalities as this stimulus has less variability, while a low frequency tone burst stimulus may be preferable when assessing the presence or absence of vestibular evoked myogenic potential responses.

To study the effects of the electromagnetic field emitted by cellular telephones upon the inner ear of rats, using distortion product otoacoustic emissions.

Forty Wistar Albino rats were used. Twenty newborn and 20 adult rats were divided into two groups of 10, one to participate in the study and one as a control. The rats were exposed to the electromagnetic field for 6 hours per day, for 30 consecutive days. Before and after the 30 day exposure period, distortion product otoacoustic emissions were measured in each group and a signal-to-noise ratio calculated, which was later used in statistical analysis.

For both the newborn and adult rat groups, there was no significant difference in distortion product otoacoustic emissions recorded before and after exposure to the cellular telephone electromagnetic field (p > 0.05).

Exposure to the electromagnetic field emitted by cellular telephones, for 6 hours a day for 30 consecutive days, had no effect on the hearing of newborn or adult rats, at the outer ear, middle ear or cochlear level.

Jervell–Lange-Nielsen syndrome is characterised by congenital deafness and a long QT interval on electrocardiography.

(1) To survey UK national practice regarding electrocardiography screening of deaf children referred to cochlear implant centres, performed to evaluate for prolonged QT interval as recommended by national guidelines, and (2) to review local practice.

Data were collected via a questionnaire sent to all UK cochlear implant centres, and via review of the medical records of a local cochlear implant centre database.

Eight (42 per cent) of the 19 cochlear implant centres surveyed performed electrocardiographic screening. Thirteen cases of long QT syndrome were reported in seven centres, with two related deaths. In our local cochlear implant centre, 14 (7.1 per cent) of 193 children had abnormal electrocardiograms; one definite long QT syndrome case and 13 borderline cases were identified.

Despite clear national guidelines for electrocardiographic screening of deaf children, there is wide variation in practice. Our local practice of performing investigations, including electrocardiography, during magnetic resonance imaging sedation has been very successful. Electrocardiograms should be reviewed by trained clinicians, and corrected QT intervals should be calculated manually.

Transtympanic administration of gentamicin may be suitable to achieve unilateral vestibular ablation, in order to control unilateral Ménière's disease. In low doses, gentamicin appears to affect selectively the vestibular system, with relative sparing of the cochlea. An experimental study on guinea pigs was conducted to determine what single dose of gentamicin would produce a unilateral vestibular organ lesion when applied to the middle ear.

Experimental and prospective.

Four groups of guinea pigs received different gentamicin doses (1, 5, 10 and 25 mg) administered to the middle ear. The animals' vestibular organs were then assessed by scanning electron microscopy, in order to quantify the level of vestibular damage.

Study of the utricular macula and the ampullar crista of the lateral semicircular canal revealed vestibular neuroepithelial lesions in all infused ears.

The severity of the vestibular neuroepithelial lesions was dose-dependent. Lower gentamicin doses were observed to damage vestibular structures more than cochlear structures.

To analyse intratympanic gentamicin injection as a treatment option in patients with monolateral Ménière's disease resistant to medical treatment.

Longitudinal, prospective, descriptive study of response to gentamicin treatment in 71 patients diagnosed with Ménière's disease and treated medically for more than a year, unsuccessfully. American Academy of Otolaryngology-Head and Neck Surgery criteria were used for diagnosis and follow up.

Complete vertigo control was obtained in 65.6 per cent of patients, and complete or substantial control in 84.37 per cent. Thirteen patients (18.3 per cent) suffered significant hearing loss.

This intratympanic gentamicin injection protocol enabled effective vertigo control in most patients, and represents a good alternative to more aggressive techniques for the treatment of Ménière's disease which does not respond to medical treatment.

To assess the effect of pomegranate extract on acute inflammation due to myringotomy.

Prospective, randomised study.

Thirty Sprague–Dawley rats were divided into three groups. Group one constituted controls. Group two underwent myringotomy. Group three underwent myringotomy and also received 100 µl/day pomegranate extract, via gavage, one day before and two days after surgery. Following sacrifice 48 hours after myringotomy, the animals' right ears were used to determine the concentration of reactive oxygen species, using the chemiluminescence method; left ears were used for histological study.

Reactive oxygen species levels were significantly decreased in group three compared with group two (p < 0.01). The density of inflammatory cells in group three was significantly less than that in group two (p < 0.01). Lamina propria thickness and vessel density were also significantly decreased in group three compared with group two (p < 0.01).

Our results indicate that oral pomegranate extract decreases reactive oxygen species concentration and acute inflammation in the tympanic membrane after myringotomy.

We evaluated use of the periodically rotated overlapping parallel lines with enhanced reconstruction diffusion-weighted imaging sequence, compared with conventional echo planar magnetic resonance imaging, in the detection of middle-ear cholesteatoma.

Sixteen patients awaiting second-stage combined approach tympanoplasty and three patients awaiting first-stage combined approach tympanoplasty underwent magnetic resonance imaging with both (1) the periodically rotated overlapping parallel lines with enhanced reconstruction sequence (i.e. non echo planar imaging) and (2) the array spatial sensitivity encoding technique sequence (i.e. echo planar imaging). Two neuroradiologists independently evaluated the images produced by both sequences. Radiology findings were correlated with surgical findings.

Seven cholesteatomas were found at surgery. Neither of the assessed imaging sequences were able to detect cholesteatoma of less than 4 mm. Rates for sensitivity, specificity, and positive and negative predictive values are presented.

Decisions on whether or not to operate for cholesteatoma cannot be made based on the two imaging sequences assessed, as evaluated in this study. Other contributing factors are discussed, such as the radiological learning curve and technical limitations of the magnetic resonance imaging equipment.

To describe the syndrome of optic nerve involvement in cases of allergic fungal sinusitis.

Academic tertiary care centre.

Analysis of prospectively accrued data for 10 consecutive cases (three bilateral, giving 13 eyes) with visual loss secondary to optic nerve compression, from a total of 70 cases of allergic fungal sinusitis undergoing surgical treatment between June 1997 and May 2007.

The mean duration of rhinological symptoms prior to the onset of visual loss was 22 months. At presentation, visual loss ranged from a visual acuity of 6/12 to complete loss of light perception. Bilateral involvement was noted in three of the 10 cases. Urgent surgical decompression with removal of all fungal debris and decompression of the optic nerve resulted in visual recovery in seven of the 13 eyes. On univariate analysis, recovery was less likely in cases with long standing visual loss, and in cases with complete visual loss.

Long standing allergic fungal sinusitis may be complicated by visual loss due to compression of the optic nerve. Urgent surgery to clear the sinuses and decompress the optic nerve is successful in reversing visual loss in cases with partial visual loss.

To examine the outcomes and treatment cost of transoral removal of submandibular calculi, and to compare the outcomes and costs of other reported techniques.

Retrospective review of 60 consecutive patients undergoing transoral removal of submandibular calculi. All clinical, operative, post-operative and follow-up data were collated and outcomes analysed.

A total of 61 submandibular glands were treated by the transoral approach. Patients with multiple stones (p = 0.034) and stones in the proximal submandibular duct (p = 0.0028) were at greater risk of requiring submandibular gland excision, compared with patients with single stones and stones in the distal duct, respectively. There was a significant difference between the gland preservation rate during the first versus the second half of the study (p = 0.028). Larger calculi were significantly more likely to be seen in the proximal duct (p < 0.001). The mean operating time (28 minutes) and length of hospital stay for transoral removal of submandibular calculi was much less than those for other treatment techniques.

We studied the incidence and bacterial epidemiology of acute epiglottitis presenting in the first 16 years following the introduction of general childhood vaccination against Haemophilus influenzae type b. Our main objectives were to analyse (1) the incidence of Streptococcus pneumoniae epiglottitis in adults and (2) the distribution of pneumococcal serotypes involved.

The medical records of patients with acute epiglottitis (International Classification of Disease code J05.1) were investigated. Streptococcus pneumoniae serotyping was performed using gel precipitation.

The overall incidence of acute epiglottitis was 0.98 cases/100 000/year, compared with 4.5 cases/100 000/year before the vaccination programme. The incidence was reduced both in children and adults, compared with pre-vaccination values. However, the incidence of Streptococcus pneumoniae epiglottitis in adults increased from 0.1 to 0.28 cases/100 000/year over the same time period. The causative agent was Streptococcus pneumoniae in 10 adults. Nine of 10 pneumococcal strains could be serotyped. All but one serotype is represented in the 23-valent pneumococcal polysaccharide vaccine (PPV23) used in adults.

In acute epiglottitis, now a disease of adults, the most important bacterial aetiology is Streptococcus pneumoniae. The serotype distribution found in this study indicates that the infection is preventable by PPV-23 vaccination with the 23-valent polysaccharide vaccine.

To identify the cause of operative failure in patients who have undergone parathyroid surgery for primary hyperparathyroidism.

Retrospective case review.

Patients who had undergone a primary procedure for primary hyperparathyroidism between July 2003 and December 2007. Cases with incomplete post-operative serum calcium data were excluded.

Operative failure was defined as failure to achieve normalisation of serum adjusted calcium levels post-operatively.

A total of 220 primary procedures were conducted over 4.5 years. Data were not available for 16 patients. Thirteen procedures (6.4 per cent) were considered failures, and these cases were individually reviewed and classified according to the reason for failure.

Establishing the cause of failure following surgery for primary hyperparathyroidism can be a complex task. In some instances, diagnostic uncertainty remains despite detailed biochemical and radiological assessment. This paper outlines our approach to maximising the cure rate at primary surgery.

In some cases of epistaxis, anterior packing and/or electrocoagulation are not sufficient and suturing is needed. However, standard suturing techniques are sometimes ineffective. This paper reports the use of a new kind of trans-septal mattress suture, based on regional vascular anatomy, in this clinical context.

Four adult patients with haemorrhage in Little's area underwent standard suturing, but bleeding persisted. These patients were successfully treated with trans-septal mattress suturing, using four punctures around the haemorrhage site.

No relapses or complications were observed over a six-month follow-up period.

In cases of persistent bleeding from Little's area, suturing should surround the bleeding area. The described suturing method is simple, efficacious and cheap.

Only a few benign tumours of the middle ear have been reported to lead to the development of facial palsy. Here, we describe a patient with middle-ear cavernous lymphangioma and facial palsy.

Single case study.

A 61-year-old man presented with left-sided hearing impairment and incomplete left facial palsy. A tumour was confirmed to be occupying the epi- to mesotympanum and to be joined to the facial nerve. The tumour was removed along with facial nerve tissue, which was resected at its horizontal portion, and the remaining facial nerve was fixed by end-to-end anastomosis. Complete facial paralysis occurred after the operation, but the patient's House–Brackmann grade gradually improved to grade III. Post-operative histopathological examination revealed infiltration of the lymphangioma into the facial nerve tissue, together with mild neural atrophy of the facial nerve.

These findings suggested that tumour invasion was the cause of facial palsy in this patient.

Myofibrosis of the ear is rare. Myofibromas are mesenchymal tumours which usually present in infancy but have been reported sporadically in adults.

To present a rare case of trauma as a cause of pinnal myofibrosis.

Case report. A 29-year-old soldier suffered repeated trauma from helmet wear and sports, and presented to our clinic with an exquisitely painful lump in the anti-helix of the pinna.

The lump was excised uneventfully. Pathology revealed a reactive myofibroblastic proliferation which, given the history of trauma, raised the possibility of a florid cellular repair process. The main differential diagnosis was myofibroma. Immunohistochemistry was used to exclude other possible causes.

No similar case has previously been reported. The aetiology of myofibroma is unclear, but repeated trauma may be a trigger. Histological and immunohistochemical analysis are recommended when the diagnosis is ambivalent.

There have been few previous reports of intraosseous schwannomas within the mandible with extension into the cranium. We report two such cases and discuss the relevant clinical features, radiological manifestations and treatment protocols.

Two case reports of trigeminal schwannoma of the mandible with intracranial extension, including analysis of clinical, radiological and pathological aspects.

Panoramic radiographs showed both tumours as multilocular radiolucencies. Solid and cystic components were seen on computed tomography and magnetic resonance imaging. The two tumours extended into the cranium through the pterygomandibular space and an obviously expanded foramen ovale.

Trigeminal schwannoma of the mandible can develop to involve intracranial extension. Radiological identification of an expanded foramen ovale may facilitate pre-operative identification.

Nasal dermoid cysts are congenital lesions which are often diagnosed in infancy or childhood. However, a small number present in adulthood, and some extend intracranially. Traditional treatment for the intracranial portion of these cysts includes frontal craniotomy.

Two intracranial dermoid cysts were resected via a transnasal endoscopic approach, using 70° nasal endoscopy for complete visualisation and intracranial tumour removal. We describe our technique for the procedure itself and for reconstruction of the skull base defect.

The endoscopic transnasal skull base approach is an excellent alternative to a traditional frontal craniotomy, to achieve complete resection of intracranial dermoid cysts.