We report two extremely rare cases of isolated sphenoid ‘fungal ball’ in conjunction with vision loss.

Case reports and a literature review concerning diagnosis and management of isolated sphenoid fungal ball in conjunction with vision loss.

A mycetoma or fungal ball resulting from isolated sphenoid fungal sinusitis is a rare disease. It is frequently difficult to diagnose, as patients present with nonspecific symptoms such as headache, visual disturbance and cranial nerve palsies. Diagnosis of the disease is typically not made until advanced imaging has been performed. We present two cases of patients with sphenoid sinus fungal ball who developed headaches and vision loss. One patient had symptoms of IIIrd cranial nerve palsy and the other partial visual field impairment. After a timely sphenoidotomy, both patients recovered fully, with resolution of all symptoms.

These two cases of sphenoid fungal ball in conjunction with vision loss suggest that the otolaryngologist should keep this disease in mind even when symptoms are nonspecific. Endoscopic surgery can be a safe and viable therapeutic approach for this condition.

To report an extremely rare and interesting case of a woman who developed a laryngeal stone.

A 44-year-old woman was referred to our ENT clinic complaining of dyspnoea and stridor. She had been treated for chest problems for approximately 30 years. On examination, she had a large, spiky, subglottic lesion compromising the airway. A laryngeal computed tomography scan and histopathological and biochemical examination showed the lesion to be a calcium phosphate stone. Review of the literature from the past 50 years, using several search engines, revealed no similar cases.

To the author's knowledge, this is a unique case of a stone that developed in the subglottis. This rare entity was the cause of long-standing chest problems unresponsive to medical treatment. The patient recovered completely from all her symptoms after removal of the laryngolith.

We report a rare case of parotid dermoid cyst.

A case report of parotid dermoid cyst is presented, as well as a brief review of the literature and a summary of the lesion's salient clinicopathological features.

A 69-year-old man presented with a slow-growing, soft tissue mass of the left parotid gland. Pre-operative evaluation included fine needle aspiration cytology and computed tomography. He subsequently underwent a superficial lobectomy; both the macroscopic and histopathological findings were consistent with a dermoid cyst. Although dermoids within the head and neck are not uncommon, such cysts have only rarely been encountered in the parotid gland.

To our knowledge, there are only four previous case reports of parotid dermoid cyst in the English literature. Although the majority of cases of parotid dermoid cyst are diagnosed retrospectively, our case demonstrates the role of fine needle aspiration cytology and highlights the key cytological features suggestive of this entity.

We report a case of a 70-year-old man of Asian origin with lichen sclerosus et atrophicus affecting the tonsil, which presented as a painful, enlarging, exophytic lesion mimicking squamous cell carcinoma.

We present a case report and a review of the world literature regarding lichen sclerosus et atrophicus.

Lichen sclerosus is a chronic, benign, inflammatory dermatosis of the skin and mucous membranes which mostly affects the female genitalia, presenting as white plaques with epidermal atrophy. The cause is unknown, although a number of aetiologies have been proposed. The prevalence is unknown. Women have been reported to be affected six to 10 times more than men, and the condition has no known racial preference.

Our patient illustrates a rare case of the condition lichen sclerosus et atrophicus; to our knowledge, this case represents the first report of tonsillar involvement of the condition. The case presented a diagnostic challenge.

We report a case of vertebral artery dissection following direct laryngoscopy, and we provide an update on current knowledge regarding this condition and its relationship to movements of the neck.

A case report and review of the world literature are presented.

Vertebral artery dissection is an uncommon event leading to stroke. It has been associated with many risk factors, particularly extreme movement of the cervical spine. The pathogenesis of the condition and the true aetiological significance of neck movement are not known.

To our knowledge, we present the first case of vertebral artery dissection following direct laryngoscopy. We highlight the need for caution when considering neck pain in patients after direct laryngoscopy.

To demonstrate that the anatomical structure known as the processus cochleariformis, with its intimate and constant relationships to inner-ear structures, can be used as a reliable landmark during middle cranial fossa surgery, alone or in conjunction with other landmarks.

An anatomical study using cadaveric temporal bones to define six reproducible measurements that relate the processus cochleariformis to inner-ear structures, and to define 14 other measurements that relate inner-ear structures to adjacent structures within the intact bone.

Using 10 cadaver specimens, 20 reproducible measurements were defined. The first six of these defined the relation of the processus cochleariformis to inner-ear structures in the middle cranial fossa approach. The other measurements defined the exact location of the inner-ear structures and adjacent structures within the intact bone.

The vertical crest lies at a 20° angle from the processus cochleariformis to the coronal plane, and at a distance of 5 to 6 mm from the processus cochleariformis. The point at which the medial margin of the basal turn of the cochlea crosses the labyrinthine segment of the facial nerve lies at a 0° angle from the processus cochleariformis to the coronal plane, and at a distance of 6.5 to 7.5 mm from the processus cochleariformis. The superior semicircular canal lies at a 45° angle from the processus cochleariformis to the coronal plane. The other measurements obtained give important clues about the position of the cochlea, vestibulum, greater superficial petrosal nerve and labyrinthine segment of the facial nerve.

If the classical landmarks are indiscernible during middle cranial fossa surgery, then the processus cochleariformis, with its intimate and constant relationships to inner-ear structures, is a safe and constant landmark.

To report cases of long-term surgical complications, implant failure and revision surgery, within a large bone-anchored hearing aid programme.

Retrospective, case–cohort study.

Tertiary referral centre.

One hundred and sixty-five adults and children who had undergone a total of 177 bone-anchored hearing aid implantations.

Diagnosis and explanation of adverse events and device failure.

Operative complications and survival analysis, surgical challenges related to revisions, and causes of failure.

Twenty-one per cent of patients (3.4 per cent of those observed) suffered from skin reactions; this rate did not increase over time. Seventeen per cent had loss of osseointegration at a median interval of 6.3 months. Loss of osseointegration was observed more frequently in patients with a 3 mm compared with a 4 mm fixture (p < 0.001). Intra-operatively, the only complication was bleeding, occurring in 3 per cent of patients. Post-operative complications included: primary bleeding (2 per cent); severe skin reactions requiring intravenous antibiotics, cautery or grafting (8 per cent); thickening or overgrowth of skin requiring excision (8 per cent); failure of osseointegration requiring a new fixture (18 per cent); and graft necrosis requiring revision (1 per cent). In two patients, it was necessary to explore the area to remove overgrowth of bone. In 16 patients (10 per cent), the bone-anchored hearing aid had to be abandoned due to failure of osseointegration (n = 4), dissatisfaction with the aid (n = 6), intolerable pain (n = 4), hair growth around the abutment (n = 1) or recurrent infections (n = 1). In 12 of these patients, the bone-anchored hearing aid was removed surgically. Overall, 57 patients (34 per cent) underwent revision surgery.

Awareness of complications is becoming increasingly important in bone-anchored hearing aid programme. A substantial workload of device maintenance should be anticipated, and patients should be appropriately counselled beforehand. Ninety per cent of our patients chose to persevere with this form of hearing rehabilitation.

This paper reviews our experience of ossicular chain injuries following head trauma treated at Groote Schuur Hospital, Cape Town, South Africa.

We performed a retrospective chart review of all patients with a history of head trauma and a conductive hearing loss who had undergone exploratory tympanotomy. Sixteen patients were included in the study.

Injury was most common at the incudostapedial joint (63 per cent). Disarticulations of the icudostapedial joint were treated with cartilage interposition in all cases. Audiography showed an improvement in 12 of the patients, with an average improvement of 35 dB.

We discuss the various options available to the otologist to repair ossicular disruptions after trauma. In this series, cartilage autografts were used in most incudostapedial joint injuries, with excellent closure of the air–bone gap.

Cartilage interposition was a very successful method of repairing incudostapedial joint dislocation in this series, at short term follow up.

To establish the prevalence of new vestibular and otological symptoms in a group of patients who had sustained a low grade (Quebec grades one or two) whiplash injury.

A retrospective review of the case records of 109 patients undergoing assessment by a single practitioner for the purposes of compiling a medicolegal report on their whiplash injury.

Four patients complained of short-lived, non-specific dizziness symptoms in the acute phase following their original injury. There were no reports of vertigo, tinnitus or hearing loss after a mean period of 149 days following the whiplash injury.

No patients reported otological or persistent vestibular symptoms in the acute phase following their whiplash injury. This suggests that caution should be exercised when attributing these symptoms to such an injury. Before whiplash injuries are admitted as an aetiological factor in the development of such symptoms, other causes should be excluded.

Sinus drainage is impeded by the transition spaces that the anterior paranasal sinuses drain into, not the ostia themselves. Addressing the transition spaces and leaving the ostia intact, using the minimally invasive sinus technique, should reverse chronic rhinosinusitis.

To assess patient benefit following use of the minimally invasive sinus technique for chronic rhinosinusitis.

One hundred and forty-three consecutive patients underwent the minimally invasive sinus technique for chronic rhinosinusitis. Symptoms (i.e. blocked nose, poor sense of smell, rhinorrhoea, post-nasal drip, facial pain and sneezing) were recorded using a visual analogue scale, pre-operatively and at six and 12 weeks post-operatively. Patients were also surveyed using the Glasgow benefit inventory, one and three years post-operatively.

We found a significant reduction in all nasal symptom scores at six and 12 weeks post-operatively, and increased total quality of life scores at one and three years post-operatively (25.2 and 14.8, respectively).

The patient benefits of treatment with the minimally invasive sinus technique compare with the published patient benefits for functional endoscopic sinus surgery.

Methicillin-resistant Staphylococcus aureus infections are becoming an increasing problem, but the link with symptomatic sino-nasal infection has not previously been quantified. The aim of this study was to determine the incidence of methicillin-resistant Staphylococcus aureus infection in patients undergoing sino-nasal surgery.

A retrospective study of case notes.

A district general hospital.

One hundred and fifty-one adult patients undergoing in-patient endonasal surgery over a 12-month period were considered for the study.

Swab results from pre-operative screening and from any intra- and post-operative samples of infective mucopus.

One hundred and fifty-one patients undergoing endonasal surgery were included. All patients had pre-operative nasal swabs taken. Twenty-five patients had peri-operative microbiology samples taken. Only one middle meatal swab was found to contain methicillin-resistant Staphylococcus aureus. No patients had methicillin-resistant Staphylococcus aureus detected on pre-operative screening. Haemophilus influenzae was the most common organism detected.

Methicillin-resistant Staphylococcus aureus infection does not represent a significant source of morbidity in our practice.

We established a series of exercises that evaluated surgeons' marking of excision margins, and we sought to identify factors influencing such marking.

Twenty-four participants were asked to draw preset margins (3, 4, 5, 8 or 10 mm) on a series of life-size images representing noncosmetically and cosmetically sensitive facial sites, and also to draw circles of set diameters (3, 5 and 8 mm) on white paper. Margins were measured with vernier callipers calibrated to 0.05 mm.

In the small margin (3 mm) and noncosmetically sensitive exercises, the mean margins drawn were greater than required. When a 10 mm margin was required in cosmetically sensitive areas and nonsensitive areas, the margin was consistently underestimated in the former group by all participants (p < 0.05).

Surgeons marking facial lesions for excision should use a measurement of scale, in order to eliminate the inherent tendency to underestimate the margin required for large excisions and for cosmetically sensitive areas.

To assess clinical improvement and quality of life measures in patients who had undergone tonsillectomy for recurrent acute and chronic tonsillitis between March 2004 and March 2005.

A retrospective survey of all adults and children who had undergone tonsillectomy for recurrent acute and chronic tonsillitis. Patients were asked to compare their symptoms for the 12-month period before and after tonsillectomy.

A review of 100 patients revealed that, following tonsillectomy: their days off work (or school) due to sore throat reduced by 95.3 per cent (from a mean of 27.6 to 1.3 days; confidence intervals 89.7 and 99.6 per cent); their visits to their general practitioner due to sore throat reduced by 95.6 per cent (from a mean of 7.9 to 0.4 visits; confidence intervals 93.8 and 95.1 per cent); and more than 90 per cent reported improved feelings of well-being, general health and energy.

We conclude that tonsillectomy is of benefit for patients with recurrent acute and chronic tonsillitis. Tonsillectomy significantly reduced general practitioner attendances and resulted in an improved feeling of health and well-being.

The pathophysiology of snoring and obstructive sleep apnoea is still unclear. Two theories are proposed. The first is the obstructive theory, which postulates palatopharyngeal muscle hypertrophy leading to airway narrowing; there is no neural role. The second is the neurogenic theory, which postulates neural degeneration due to vibratory stretch trauma, leading to muscle atrophy and collapse. As identification of nerve fibres in the uvula and palate is difficult and time-consuming, all previous studies aiming to differentiate between these two theories have been based on indirect observation of the muscles, rather than direct study of the nerves.

We conducted a prospective study to directly observe and study nerve fibres in uvular specimens from 10 cases of obstructive sleep apnoea, compared with specimens from 10 cases of simple snoring, using transmission electron microscopy. Five autopsy cases served as controls.

Obstructive sleep apnoea was associated with definite degenerative changes in myelinated and unmyelinated nerve endings. These degenerative changes were present to a lesser degree and in a smaller proportion of cases of simple snoring.

The events postulated by the neurogenic theory of obstructive sleep apnoea appear to play an important role in the pathophysiology of snoring and obstructive sleep apnoea.

We examined the effects of dual silencing of epidermal growth factor and insulin-like growth factor 1 receptors on the growth of nasopharyngeal carcinoma in nude mice; we also assessed potential side effects in these animals.

Short hairpin ribonucleic acid expression vectors targeting epidermal growth factor and insulin-like growth factor 1 receptors were constructed. Short hairpin ribonucleic acid plasmids targeting one or both receptors were transfected into human nasopharyngeal carcinoma cells in nude mice. We then assessed epidermal growth factor receptor and insulin-like growth factor 1 receptor expression and also cellular apoptosis. Peripheral blood was collected and subjected to haematological and biochemical analysis.

The findings demonstrated that transfection with dual plasmids (targeting both epidermal growth factor receptor and insulin-like growth factor 1 receptor) resulted in tumour cell growth inhibition of 84.78 per cent, and a significant increase in the number of necrotic and apoptotic cells, compared with single plasmid treatment. The short hairpin ribonucleic acid had no significant side effects on the heart, liver, kidney, spleen or blood system in this experimental model.

These results indicate that, in nude mice, dual silencing of both epidermal growth factor and insulin-like growth factor 1 receptors results in more apoptosis and greater nasopharyngeal cancer cell growth inhibition, compared with silencing of either epidermal growth factor receptor alone or insulin-like growth factor 1 receptor alone. This occurred without significant side effects in the experimental animals.

To evaluate the efficacy of pure natural honey as prophylaxis against radiochemotherapy-induced mucositis, through clinical scoring of oral and oropharyngeal mucositis, and culturing of pathogenic oral and oropharyngeal microbes.

The study was done in Assiut University Hospital, Egypt, between January 2005 and July 2006. Forty patients diagnosed with head and neck cancer were entered into the trial. Enrolled patients were randomised to either the treatment group, receiving concomitant chemotherapy and radiotherapy (with a significant area of directly visible oral and/or oropharyngeal mucosa included in the radiation fields) plus prior topical application of pure natural honey, or the control group, receiving concomitant chemotherapy and radiotherapy without honey. Patients were evaluated clinically every week to assess development of radiation mucositis. Aerobic cultures and candida colonisation assessment were undertaken, via oral and oropharyngeal swabs, prior to and at the completion of irradiation, and when infection was evident.

In the treatment group, no patients developed grade four mucositis and only three patients (15 per cent) developed grade three mucositis. In the control group, 13 patients (65 per cent) developed grade three or four mucositis (p < 0.05). Candida colonisation was found in 15 per cent of the treatment group and 60 per cent of the control group, either during or after radiotherapy (p = 0.003). Positive cultures for aerobic pathogenic bacteria were observed in 15 per cent of the treatment group and 65 per cent of the control group, during or after radiotherapy (p = 0.007).

This study shows that prophylactic use of pure natural honey was effective in reducing mucositis resulting from radiochemotherapy in patients with head and neck cancer.

Ear, nose and throat emergency clinic services vary greatly between trusts. Their common aim is to enable acute conditions to be seen quickly and effectively within an optimum environment. There is however no ‘gold standard’ for service.

To identify an efficient model of service, and to determine whether introduction of a referral and appointment based system improves patient waiting times and appropriateness of referrals.

A prospective audit, comprising: an initial survey to appraise the existing service; telephone surveys of eight trusts in the West Midlands to determine variability of ENT emergency clinic services and to identify components of an effective service; and re-audit following implementation of a verbal referral and appointment based service.

The new service significantly reduced patient waiting times, from 70 minutes to 35 minutes (t = 6.776; p < 0.01), with an associated reduction in the variability of waiting times. Inappropriate referrals were reduced from 7 to 2 per cent. These results were achieved when a 72 per cent referrer compliance with the service was observed.

A verbal referral and appointment based system improves patient waiting times and appropriateness of referrals. Maintenance of high referrer compliance with such a system should be considered, and a tool for monitoring referring practitioners is suggested. This clinic construct model is offered as an example in order to aid delivery of an effective ENT emergency service in departments with similar patient demand and staff resources.

The process of embedding tissue in paraffin degrades many important molecules involved in respiratory epithelial remodelling. We therefore examined alternative methods.

Inferior turbinate and nasal polyp biopsies were either placed in formalin or immediately snap-frozen in the operating theatre. Novel protocols for staining remodelling markers were compared with current methods.

Our method, using a mixture of three lectins, stained a significantly greater proportion of samples, compared with using Ulex europeaus lectin alone (84 vs 62 per cent; p < 0.005). Comparison of different proliferation markers showed that Ki67 was more suitable than proliferating cell nuclear antigen for frozen sections.

This study indicates that our robust, repeatable methods for examining whole mounts and for staining capillaries, cell proliferation and nuclei on the same section of nasal mucosa are superior to current methods. The use of fresh tissue that has not been paraffin-embedded would allow a greater suite of epitopes to be examined in the future.