Undergraduate medical education requires ongoing improvement in order to keep pace with the changing demands of twenty-first century medical practice. Problem-based learning is increasingly being adopted in medical schools worldwide. We review its application in the specialty of ENT, and we present our experience of using this approach combined with more traditional methods.

We introduced problem-based learning techniques into the ENT course taught to fifth-year medical students at Al-Ahsa College of Medicine, King Faisal University, Saudi Arabia. As a result, the teaching schedule included both clinical and theoretical activities. Six clinical teaching days were allowed for history-taking, examination techniques and clinical scenario discussion. Case scenarios were discussed in small group teaching sessions. Conventional methods were employed to teach audiology and ENT radiology (one three-hour session each); a three-hour simulation laboratory session and three-hour student presentation were also scheduled. In addition, students attended out-patient clinics for three days, and used multimedia facilities to learn about various otolaryngology diseases (in another three-hour session). This input was supplemented with didactic teaching in the form of 16 instructional lectures per semester (one hour per week).

From our teaching experience, we believe that the application of problem-based learning to ENT teaching has resulted in a substantial increase in students' knowledge. Furthermore, students have given encouraging feedback on their experience of combined problem-based learning and conventional teaching methods.

To quantify the noise exposure received while driving a convertible automobile with the top open, compared with the top closed.

Five different convertible automobiles were driven, with the top both closed and open, and noise levels measured. The cars were tested at speeds of 88.5, 104.6 and 120.7 km/h.

When driving with the convertible top open, the mean noise exposure ranged from 85.3 dB at 88.5 km/h to 89.9 dB at 120.7 km/h. At the tested speeds, noise exposure increased by an average of 12.4–14.6 dB after opening the convertible top.

Driving convertible automobiles at speeds exceeding 88.5 km/h, with the top open, may result in noise exposure levels exceeding recommended limits, especially when driving with the convertible top open for prolonged periods.

To present the results of primary myringoplasty procedures together with the perforation cause, perforation size and site, surgeon's experience, and surgical method, and to investigate how these factors relate to graft ‘take’ rates.

Retrospective chart review of 243 consecutive patients undergoing primary myringoplasty with temporalis fascia underlay over a 10-year period from 1994 to 2004.

The overall graft take rate was 95 per cent. The retroauricular approach resulted in a 97 per cent graft take rate, whereas a significantly lower rate (77 per cent) was seen for surgery conducted via the endaural approach, or via an ear speculum. There was no relationship between other factors and tympanic membrane healing.

No association was found between perforation cause and graft take rate. The underlay technique is safe and reliable, and the retroauricular approach is preferable as it enables good surgical access and has better results.

To investigate the efficacy of intratympanic steroid therapy in adults with sudden sensorineural hearing loss, and to analyse the factors associated with treatment outcome.

Retrospective study of patients undergoing intratympanic steroid injection for sudden sensorineural hearing loss between 1 January 2006 and 30 June 2007 at a teaching hospital in Taipei, Taiwan.

Patients who received intratympanic steroid therapy within seven days of disease onset achieved a significantly better response rate (76.1 per cent), compared with the delayed treatment group (50 per cent). The total response rate, after four steroid injections, was 68.9 per cent. Patients with low and mid-frequency hearing loss were more responsive to steroid treatment. Vertigo was a negative prognostic factor for recovery. There were no long-term sequelae of intratympanic steroid treatment.

Intratympanic steroid injection may be a simple and effective treatment for patients with sudden sensorineural hearing loss.

Vogt–Koyanagi–Harada disease is a chronic disorder involving the eye and the central nervous, auditory, vestibular and integumentary systems. This study aimed to determine the auditory and vestibular manifestations of this disease.

Twenty-four patients diagnosed with Vogt–Koyanagi–Harada disease were assessed for auditory and vestibular dysfunction.

Uveitis presents in all cases. Sensory hearing loss was present in 50 per cent of cases, tinnitus in 42 per cent, vertigo in 17 per cent and headache in 17 per cent. Nine patients received systemic steroids. Six patients who were treated early regained their hearing, but three patients whose treatment was delayed did not. One patient with bilateral profound hearing loss underwent cochlear implantation, and achieved excellent post-implantation hearing.

There is a high incidence of cochlear and vestibular end-organ involvement in patients with Vogt–Koyanagi–Harada disease. The adequacy and timing of treatment has a significant effect on the disease outcome. Vogt–Koyanagi–Harada disease appears to affect the inner ear end-organ. Patients who develop bilateral profound sensory hearing loss are suitable candidates for cochlear implantation.

To investigate levels of matrix metalloproteinases 2 and 9, and of their tissue inhibitor (i.e. tissue inhibitor matrix metalloproteinase 1), in the serum of patients with tympanosclerosis.

We included 40 patients (age range 13–63 years) who had undergone surgery in the ENT department of İzmir Atatürk Training and Research Hospital between 2002 and 2007. Twenty had uncomplicated chronic otitis media and 20 had tympanosclerosis. We also included as the control group 20 individuals with no history of previous otic complaints or systemic or infectious disease. Serum levels of serum matrix metalloproteinases 2 and 9 and of tissue inhibitor matrix metalloproteinase 1 were measured in all subjects and compared.

Significantly higher levels of serum matrix metalloproteinases 2 and 9 were found in the tympanosclerosis group, compared with the chronic otitis media and control groups. There was no statistically significant difference in tissue inhibitor matrix metalloproteinase 1 level between the three groups.

Tympanosclerosis surgery has poor success rates, since the pathological process is still active. We suggest that high levels of matrix metalloproteinases may play a role in the continuation of the disease process.

To assess the hearing changes associated with sacrificing an intact ossicular chain during cholesteatoma surgery.

We reviewed the operation notes of surgical procedures performed by the senior author between October 2000 and April 2006. Thirty-three cases were identified in which cholesteatoma surgery had been performed in the presence of a mobile, intact ossicular chain. One set of case notes was missing; therefore, 32 cases were included in the analysis. The ossicular chain was preserved in 17 cases (14 males and three females) and sacrificed in 15 (eight males and seven females).

At the first post-operative assessment, a median air–bone gap deterioration of 3.3 dB was seen in patients in whom the ossicular chain had been sacrificed, while a median air–bone gap improvement of 3.3 dB was seen in those in whom the chain had been preserved. However, multivariable logistic regression analysis suggested that this difference in hearing outcomes was due to pre-operative hearing status, and that preservation of the ossicular chain did not lead to a better outcome.

In cholesteatoma surgery, there is at most a marginal benefit in preserving the ossicular chain. In the current study, the better hearing outcomes associated with preservation of the ossicular chain were accounted for by patients' better pre-operative hearing status. This study did not demonstrate a difference in residual disease rate, but was underpowered to do so.

To investigate the utilisation of bone-anchored hearing aids and Softband, as well as the effects on quality of life, amongst the paediatric and young adult population of Freeman Hospital, Newcastle Upon Tyne, UK.

Retrospective, anonymised, cross-sectional survey using the Glasgow Benefit Inventory and Listening Situation Questionnaire (parent version), administered at least three months following the start of bone-anchored hearing aid or Softband use.

One hundred and nine patients were included, of whom syndromic children made up a significant proportion (22 of 109). Patients using bone-anchored hearing aids obtained significant educational and social benefit from their aids. The mean Listening Situation Questionnaire difficulty score was 17 (15 patients), which is below the trigger score of 22+ at which further reassessment and rehabilitation is required. 87% (of 15 patients) did not require further intervention. The overall mean GBI score for the 22 patients (syndromic and non-syndromic) was +29.

The use of bone-anchored hearing aids and Softband results in significant improvements in quality of life for children and young adults with hearing impairment. There is significant under-utilisation of bone-anchored hearing aids in children with skull and congenital abnormalities, and we would advocate bone-anchored hearing aid implantation for these patients.

To examine the histological effects of radiofrequency thermal ablation on the inferior concha epithelium and subepithelium, over five years post-treatment.

Inferior nasal concha epithelial biopsy specimens were examined histologically before and four, 30, 48 and 60 months after radiofrequency treatment, in six patients with inferior nasal concha hypertrophy.

At four months post-treatment, there was proliferation of blood vessels, increased inflammatory cells and a slightly decreased number of glands. At 30 months post-treatment, the number of inflammatory cells and glands had decreased, but signs of increased vascular proliferation, fibrosis and granulation were seen. At 48 and 60 months post-treatment, the number of inflammatory cells and blood vessels had decreased significantly, the number of glands had increased, and lobulation was observed.

Radiofrequency thermal ablation does not cause carbonisation or osteitis in the inferior concha. The resultant fibrosis causes contraction of the concha and only minor tissue destruction (as shown by the persistence of submucosal glands).

To review outcomes and complications in a series of adults undergoing a frontal osteoplastic flap procedure without obliteration, for endoscopically inaccessible sinus disease.

Retrospective case note review of patients treated at Glasgow Royal Infirmary between January 2004 and October 2008.

Ten patients were identified (age range 19–81 years, mean age 46.3 years). No major intra- or post-operative complications occurred. There were three minor complications: superficial discharging wound, forehead swelling and haematoma.

The frontal osteoplastic flap still has a role in frontal sinus surgery. With minor technical modifications, this procedure may be performed with minimal complication and morbidity for patients with endoscopically inaccessible frontal sinus disease.

We report a case of cholesterol granuloma of the petrous apex which was surgically treated via an endoscopic trans-sphenoidal approach.

Case report and review of the literature concerning cholesterol granulomas of the petrous apex and their management.

The lesion was approached endoscopically via a bilateral sphenoidotomy with removal of the vomer. A large cholesterol granuloma was evacuated and marsupialised. The patient made an uneventful recovery.

Trans-sphenoidal access to the petrous apex represents an alternative route for the drainage and ventilation of cholesterol granulomas. This approach is the technique of choice when the cholesterol granuloma abuts the posterior wall of the sphenoid sinus. The trans-sphenoid approach, unlike other lateral approaches to the petrous apex, spares cochlear and vestibular function and allows post-operative endoscopic follow up.

(1) To evaluate the efficacy of modified arytenoid adduction in the management of patients with symptomatic cancer-related unilateral vocal fold paralysis, and (2) to assess the impact of this treatment on patients' quality of life.

Forty-two patients with cancer-related unilateral vocal fold paralysis underwent modified arytenoid adduction between February 2001 and December 2008. Of these, 37 patients were enrolled in this retrospective study (one patient died of primary disease and four were lost to follow up). Laryngostroboscopy was performed to evaluate vocal fold orientation and mobility. Pre- and post-operative assessment of subjective and objective voice, aerodynamic parameters, and quality of life were also undertaken, and aspiration was subjectively rated.

Laryngostroboscopic findings indicated a significant post-operative improvement in vocal fold posterior glottal closure and vertical gap. Significant improvements in voice quality, aerodynamic parameters and quality of life were noted three months post-operatively in all patients (p < 0.01). The overall success rate for swallowing rehabilitation was 94.6 per cent (35/37). Subjective aspiration ratings decreased significantly post-operatively, compared with pre-operative values (p < 0.01). No major complication occurred in any patient, except for dyspnoea in one patient.

Modified arytenoid adduction is an effective and reliable medialisation technique which can restore satisfactory voice quality, prevent aspiration and lead to a better quality of life for patients with cancer-related unilateral vocal fold paralysis.

Patients with squamous cell carcinoma of the head and neck constitute a high risk group for synchronous and metachronous tumours.

This study aimed to investigate the usefulness of white light and autofluorescence bronchoscopy in the evaluation of pre-malignant and early neoplastic lesions in patients with laryngeal cancer, who are at high risk of concomitant lung cancer.

This prospective, cross-sectional study included 30 patients who had undergone total laryngectomy for squamous cell carcinoma of the larynx. The tracheobronchial system was investigated for the presence of pre-malignant and malignant lesions, using a combination of white light and autofluorescence bronchoscopy. Biopsies were obtained from areas with a pathological appearance, and histopathological studies were performed.

All patients had a permanent tracheostomy. Light and autofluorescence bronchoscopy indicated that the tracheobronchial system was normal in 11 patients. A total of 27 biopsies was taken from the remaining 19 patients, and revealed invasive squamous cell carcinoma in one patient and pre-malignant changes in six.

Bronchoscopy is a valuable and practical tool for screening patients at high risk of lung cancer, and requires minimal intervention especially in patients with a permanent tracheostomy. Of the various bronchoscopic techniques becoming available, autofluorescence bronchoscopy shows promise for the detection of pre-invasive malignant changes of the tracheobronchial system in patients previously operated upon for laryngeal cancer.

People suffer unique health problems in high altitude areas, due to such factors as elevation, aircraft ascent and descent, extreme cold, hypoxia, hypobaria, and low relative humidity. This study was conducted to evaluate ENT morbidity at high altitude.

Serving soldiers introduced to a high altitude environment who presented with various ENT symptoms were examined to identify ENT disease. In addition, patients undergoing hyperbaric chamber therapy, tracheostomy and treatment of cold injuries were also examined for ENT problems.

The following were detected: 13 cases of otic barotrauma, 11 cases of sinus barotrauma, three cases of vertigo, six cases of pinna frostbite, three cases of barotrauma caused by hyperbaric chamber therapy, an unusually high incidence of epistaxis, and innumerable patients with high altitude pharyngitis.

Diseases of the ear, nose and throat contribute significantly to high altitude morbidity. In a military context, health education of troops is necessary to avoid such problems.

To assess the quality of life of UK children with sleep-disordered breathing undergoing adenotonsillectomy, by using the Obstructive Sleep Apnoea 18 questionnaire and determining score changes and effect sizes.

Prospective, longitudinal study.

The otolaryngology department of a university teaching hospital in Northern England.

Twenty-eight children for whom adenotonsillectomy was planned as treatment for sleep-disordered breathing, and who had either a clinical history consistent with obstructive sleep apnoea or a polysomnographic diagnosis.

The Obstructive Sleep Apnoea 18 questionnaire, a previously validated, disease-specific quality of life assessment tool; changes in questionnaire scores and effect sizes were assessed.

The Obstructive Sleep Apnoea 18 questionnaire was administered to each child's parent pre-operatively, then again at the follow-up appointment. Questionnaire scores ranged from 1 to 7. Score changes were analysed using the paired t-test; effect sizes were calculated using 95 per cent confidence intervals.

Complete data were obtained for 22 children (mean age, 61 months). Ten had undergone pre-operative polysomnography. Twenty-one children underwent adenotonsillectomy (one underwent tonsillectomy). Median follow up was eight weeks (interquartile range, six to 11 weeks). Following surgery, the overall mean score improvement was 2.6 (p < 0.0001) and the mean effect size 2.4 (95 per cent confidence interval 1.9 to 2.8). There were significant improvements in each of the individual questionnaire domains, i.e. sleep disturbance (mean score change 3.9, p < 0.0001), physical suffering (2.2, p < 0.0001), emotional distress (2.0, p = 0.0001), daytime problems (1.8, p = 0.0001) and caregiver concerns (2.6, p < 0.0001).

In these children with sleep-disordered breathing treated by adenotonsillectomy, Obstructive Sleep Apnoea 18 questionnaire results indicated significantly improved mean score changes and effect sizes across all questionnaire domains, comparing pre- and post-operative data.

The use of interosseous wire to fix bone grafts is well known. Herein, we describe a technique for fixation of an iliac crest bone graft for nasal augmentation, using a stainless steel wire.

A hole in the cancellous part of the graft guides the wire exactly into a groove in the cortical part, preventing slippage and ensuring rigid fixation. The wire is then threaded through a hollow spinal needle passed underneath the skin envelope; this avoids a dorsal incision and thus minimises scarring, reduces the risk of graft exposure and improves the aesthetic result.

This technique has two distinct advantages: prevention of wire slippage and avoidance of a dorsal nasal incision.

The described method uses an interosseous wire for rigid bone graft fixation, without a dorsal incision. This prevents wire slippage; it also achieves a good cosmetic result by improving the nasal contour via a cantilever effect which raises the nasal tip.