To review the currently available literature on iatrogenic injury of the adult chorda tympani.

Systematic literature review.

Five electronic databases and one search engine were used to access available English language literature on the chorda tympani, focusing on iatrogenic injury.

The chorda tympani is most often injured during middle-ear surgery, after which at least 15–22 per cent of patients experience symptoms, mostly changes in taste and dryness of the mouth. Numerous factors influence whether injury to the chorda tympani causes symptoms, including the extent of injury, type of surgery, age of the patient, anatomical variables and subjective adaptation. Although most patients experience gradual symptomatic recovery, complaints can be persistent and troublesome.

Care should be taken to preserve the chorda tympani during middle-ear surgery, and to warn patients pre-operatively about this potential complication. This is particularly important if surgery is bilateral.

To review our experience of cochlear implant failure and subsequent revision surgery, and to illustrate the experience we have gained by presenting a series of lessons learned.

A combined retrospective and prospective study of revision surgery in a UK regional cochlear implant centre.

Of the 746 cochlear implantations undertaken, 33 (4.7 per cent of adults and 4.1 per cent of children) had a registered failure requiring re-implantation. The mean time to device failure was 60 months in adults and 35 months in children. Causes of cochlear implant failure were medical (n = 11), electrode displacement (n = 2), ‘hard device failure’ (n = 15) and ‘soft device failure’ (n = 5). Chronic suppurative otitis media and post-auricular mastoid abscess were the commonest causes of medical failure. There was one case of electrode array displacement as a direct result of skin flap revision surgery. In 80 per cent of cases, audiological performances were stable or improved following re-implantation.

As the number of cochlear implants increase and patients outlive the lifespan of their devices, we will face a growing number of revision procedures. Audiologists and otologists should be competent in diagnosing and managing device failure and medical complications requiring cochlear re-implantation.

To compare the functional results of type I tympanoplasty performed with either temporalis fascia or a perichondrium and cartilage island flap, in patients with bilateral chronic otitis media.

The study included primary tympanoplasty cases with a subtotal perforation, an intact ossicular chain, a dry ear for at least one month and normal middle-ear mucosa, together with contralateral tympanic membrane perforation. Temporalis fascia tympanoplasty was undertaken in 41 patients, and cartilage tympanoplasty in 39 patients.

The graft success rate was 65.9 per cent for the fascia group and 92.3 per cent for the cartilage group. Post-operatively, the mean ± standard deviation air conduction threshold was 28.54 ± 14.20 dB for the fascia group and 22.97 ± 8.37 dB for the cartilage group, while the mean ± standard deviation bone conduction threshold was 11.71 ± 8.50 dB for the fascia group and 7.15 ± 5.56 dB for the cartilage group.

In patients with bilateral chronic otitis media, cartilage tympanoplasty seems to provide better hearing results and graft success rates.

To characterise balance disorders occurring after head trauma, using videonystagmography, and to test the efficiency of videonystagmography as a diagnostic and monitoring tool.

Prospective, cohort analysis of 126 head trauma patients managed with vestibular evaluation, monitoring and treatment, in a tertiary referral centre. Analytical parameters included: head injury severity; balance disorder type, severity and time of onset; and patient recovery and outcome.

Head trauma was minor in 31.7 per cent, mild in 36.6 per cent, moderate in 19 per cent and severe in 12.7 per cent. Balance disorder symptoms included vertigo in 42.9 per cent, unsteadiness in 15.9 per cent, dizziness in 9.5 per cent and none in 31.7 per cent. Videonystagmographic balance disorder diagnosis type was peripheral vestibular in 23.8 per cent, central in 7.9 per cent, mixed in 12.7 per cent, benign paroxysmal positional vertigo in 4.8 per cent and no findings in 50.8 per cent. Balance disorder was immediate in 47.6 per cent (this included all moderate and severe trauma cases). Benign paroxysmal positional vertigo developed within the first week in two-thirds of cases. More severe trauma cases had longer recovery times. Peripheral, mixed and central balance disorders recovered within the first three months. Early rehabilitation of acute balance disorders led to early recovery regardless of diagnosis.

Videonystagmography enables precise, simple, cost-effective monitoring of balance disorders after head trauma, and improves care and outcomes.

To determine the immediate and long-term taste effects of chorda tympani nerve sacrifice in patients undergoing open cavity mastoidectomy.

A retrospective, questionnaire survey of patients receiving follow up and aural toilet following open cavity mastoidectomy, over a four-month period. The questionnaire assessed taste disturbance, both immediately post-operative and current. Available surgical records were reviewed for chorda tympani references.

Of 57 patients, six had undergone surgery to both ears. Of those who could recall (37/57), 24.3 per cent were aware of taste disturbance immediately after surgery, while 8.7 per cent reported current disturbance (median post-operative interval, 28.5 years; range, one month to 67 years). No bilateral surgery patients were aware of taste disturbance.

Mastoidectomy consent procedure emphasises the risk of hearing loss and facial nerve injury, yet in open cavity surgery chorda tympani division is almost inevitable. Reassuringly, most post-operative taste disturbance resolves, and most patients are not aware of long-term disturbance. However, a small percentage suffer ongoing taste disturbance; this could be significant for professional chefs and wine-tasters. The risk of taste disturbance should be addressed in the consent procedure.

During nasal septum surgery, elevation of mucoperichondrium from the anterior nasal septum may be more difficult than from the medial and posterior septum. This study aimed to evaluate any histological structural differences between the anterior and posterior nasal septum cartilage, mucoperichondrium and intervening tissue.

Unilateral mucoperichondrial flap elevation without infiltration was performed, after nasal tip and dorsum decortication, in four patients undergoing open septorhinoplasty. Full-thickness samples, including cartilage and mucoperichondrium, were removed from the anterior and posterior nasal septum and examined under light and electron microscopy.

Light microscopy showed no difference between anterior and posterior septum specimens regarding perichondrial thickness and subperichondrial cell density. Demarcation between cartilage and perichondrium and between perichondrium and lamina propria was more regular in the posterior versus the anterior septum. Electron microscopy showed no difference in chondroblast activity at the two sites.

The observed tissue demarcation irregularities may explain the greater reported difficulty in elevating anterior versus posterior nasal septum mucoperichondrium. Immunohistochemical examination would further elucidate these interstructural connections.

Dental disease is a recognised cause of sinusitis. We perceived an increased incidence of sinusitis secondary to dental disease in recent years. This study reviews the incidence of odontogenic sinusitis, its clinical features and treatment.

Medical records of patients with odontogenic sinusitis were identified using the senior author's clinical database and Hospital Information Support System data (January 2004 to December 2009).

Twenty-six patients were identified, nine females and 17 males (age range, 17–73 years). Rhinorrhoea and cacosmia were the commonest symptoms (81 and 73 per cent, respectively), with presence of pus the commonest examination finding (73 per cent). Causative dental pathology included periapical infection (73 per cent), oroantral fistula (23 per cent) and a retained root (4 per cent). In all 26 cases, treatment resulted in complete resolution of symptoms; 21 (81 per cent) required sinus surgery. The number of patients with odontogenic sinusitis undergoing surgery has steadily increased, from no cases in 2004 to 10 in 2009 (accounting for 8 per cent of all patients requiring sinus surgery). Reduced access to dental care may be responsible.

The incidence of odontogenic sinusitis appears to be increasing. The importance of assessing the oral cavity and dentition in patients with rhinosinusitis is therefore emphasised.

To investigate voice function following Han's uvulopalatopharyngoplasty.

Acoustic and articulatory function was examined by acoustic analysis and by formant frequency and bandwidth analysis, before and after Han's uvulopalatopharyngoplasty, in 56 patients with obstructive sleep apnoea hypopnoea syndrome.

These patients' normalised noise energy was higher than normal, and improved post-operatively. Their pre-operative F1, F2, and F3 formant frequencies and B1 and B2 formant bandwidths were significantly lower than those of normal controls; however, one month after surgery their F1 and F2 frequencies were markedly higher.

The acoustic and articulatory characteristics of obstructive sleep apnoea hypopnoea syndrome patients differed from those of normal subjects. After Han's uvulopalatopharyngoplasty, obstructive factors in the oropharynx were relieved, allowing oropharyngeal cavity expansion and a gradual increase in formant frequency to within the normal range. Patients' vocal quality improved and their resonator and articulator functions were protected and enhanced.

To compare the key functional results (regarding swallowing and voice rehabilitation) in patients treated by pharyngo-laryngectomy with flap reconstruction, versus standard, wide-field, total laryngectomy.

We studied 97 patients who had undergone total laryngectomy and pharyngo-laryngectomy with flap reconstruction. The main outcome measures were swallowing (i.e. solid food, soft diet, fluid or enteral feeding) and fluent voice development.

There were 79 men and 18 women, with follow up of one to 19 years. Voice (p = 0.037) and swallowing (p = 0.041) results were significantly worse after circumferential pharyngo-laryngectomy than after non-circumferential pharyngo-laryngectomy. There was no significant difference in voice (p = 0.23) or swallowing (p = 0.655) results, comparing total laryngectomy and non-circumferential pharyngo-laryngectomy. The presence of a post-operative fistula significantly influenced voice (p = 0.001) and swallowing (p = 0.009) outcomes.

The additional measures involved in pharyngo-laryngectomy do not confer any functional disadvantage, compared with total laryngectomy, but only if the procedure is non-circumferential. Functional results of circumferential pharyngo-laryngectomy are worse than those of both non-circumferential pharyngo-laryngectomy and total laryngectomy. If oncologically possible and safe, it is better to keep a pharyngo-laryngectomy non-circumferential.

Cochlear implantation has been used to rehabilitate profoundly deafened adults for more than 25 years. However, surgical labyrinthectomy is often considered a contraindication to cochlear implantation, especially if there is a significant delay between the two procedures. As the role of cochlear implantation continues to expand, this idea requires reconsideration.

A 59-year-old woman presented to our clinic after undergoing bilateral surgical labyrinthectomies for intractable Ménière's disease 21 years prior. Despite the significant time delay, she underwent cochlear implantation with a good audiological outcome and improved quality of life.

Changes to the cochlea and vestibule following surgical labyrinthectomy include cochlear ossification and obliteration of the vestibule. These issues have been thought to limit the potential for cochlear implantation, especially when there is a significant delay between the two procedures. However, delayed cochlear implantation, even decades after labyrinthectomy, remains a viable treatment option which can benefit selected patients.

We report an extremely rare case of duplication of the internal auditory canal associated with dysfunction of both the facial and vestibulocochlear nerves. We also review the literature regarding the integrity of the facial and vestibulocochlear nerves in such cases.

A 34-year-old man presented with unilateral, right-sided, sensorineural hearing loss and facial nerve palsy since childhood. Facial nerve function was observed to be House–Brackmann grade III. Computed tomography and magnetic resonance imaging demonstrated ipsilateral duplicate, vacant internal auditory canals. Based on the clinical presentation, we interpreted these radiological findings as aplasia of the vestibulocochlear nerve and severe hypoplasia of the facial nerve.

To our best knowledge, this is the first report of vestibulocochlear nerve aplasia and severe facial nerve hypoplasia in a case of ipsilateral duplication of the internal auditory canal. High resolution gradient echo magnetic resonance imaging sequences are advocated for assessment of neural integrity in patients with an abnormal internal auditory canal and facial and/or vestibulocochlear nerve dysfunction.

We report a rare presentation of otogenic bacterial meningitis secondary to a stapes footplate malformation in a paediatric patient with an auditory brainstem implant.

A patient with Mondini's dysplasia developed meningitis six years after auditory brainstem implantation. The aetiology was believed to be otogenic, secondary to stapes footplate malformation.

To our best knowledge, this is the first report of otogenic bacterial meningitis secondary to stapes footplate malformation in a paediatric patient with an auditory brainstem implant. Subjects with inner ear malformations, especially Mondini's dysplasia, need to be carefully evaluated pre-operatively to reduce or eliminate any anatomical conditions which may predispose to meningitis. In children with an auditory brainstem implant and suspected ear malformation, we recommend pre-operative radiological investigation to look for the ‘bulging oval window’ sign. When radiological signs are positive, bilateral exploratory tympanotomy should be performed to detect any undiagnosed anatomical stapes footplate defects, which may predispose to bacterial meningitis.

To report the first case of treatment of Nager syndrome associated conductive hearing loss with bone-anchored hearing aids, in a three-year-old boy.

Clinical case report and current literature review regarding the use of bone-anchored hearing aids in the treatment of conductive hearing loss in children.

A three year eight month old boy with Nager syndrome was successfully treated for conductive hearing loss using bilateral bone-anchored hearing aids.

This is the first case report of the use of bone-anchored hearing aids to treat Nager syndrome associated conductive hearing loss. Treatment was safe and successful in this case.

Vestibular schwannomas are the hallmark of neurofibromatosis type two. They are difficult to treat, due to their bilateral presentation and the quest for hearing preservation. Our report describes a new treatment approach in this clinical scenario.

We report two cases which confirm that bevacizumab, a monoclonal antibody targeting vascular endothelial growth factor, causes regression of vestibular schwannomas in patients with a previous history of gamma knife radiosurgery or failed treatment with another form of vascular endothelial growth factor targeted therapy.

In 2009, Plotkin et al. reported the volumetric response of vestibular schwannomas to bevacizumab treatment, both in untreated patients and in patients previously treated with erlotinib, an epidermal growth factor receptor inhibitor. The presented cases support the use of bevacizumab to treat vestibular schwannomas. Given the extremely slow growth of these tumours, we note the rapidity of volume reduction following bevacizumab therapy.

Dermoids presenting in early life with a sinus tract along the midline of the nasal dorsum are well described. We present three very unusual variants of this condition.

Case one was a two-year-old child with a pit in the philtrum of the lip. The tract pierced the nasal spine and extended towards the crista galli. Case two was a 15-month-old child with two separate sinus openings on the dorsum, one below and one above a dermoid cyst. Case three was a 17-year-old adolescent with neurological disability. Scanning showed a dermoid cyst deep in the anterior skull base, but the sinus tract had been obliterated by bony overgrowth due to long term use of antiepileptic medication.

Cases one and two were successfully managed by complete excision via an external rhinoplasty approach. Case three, in contrast, was not operated upon due to bony obliteration of the sinus tract.

Surgeons dealing with nasal dermoids must be able to adapt to the variable anatomical and clinical features of these lesions.

Pathological paranasal sinus expansion secondary to air is uncommon. However, this condition may be symptomatic or cosmetically apparent, requiring surgical intervention. Various terms have been used to describe this condition, and nomenclature is controversial.

An 18-year-old man presented with right facial pain, and was subsequently found to have pneumosinus dilatans of the maxillary sinus. A search was conducted of the PubMed, Medline and Embase databases, using the key words ‘pneumosinus dilatans’, ‘pneumoc(o)ele’, ‘pneumatoc(o)ele’ and ‘maxillary sinus’. Articles were also hand-searched. Relevant articles published in English were reviewed.

The literature review identified 36 cases involving the maxillary sinus (including the present case), with 19 cases reported as pneumosinus dilatans, 12 as pneumocoeles, two as pneumatocoeles, two as pneumosinus dilatans multiplex and one as an air cyst. However, based on the strict classification described by Urken et al., the majority of these cases should be reclassified as pneumocoeles.

Whilst the nomenclature of this pathology is confusing, distinctions of terminology do not alter the management. Hence, we support the use of the term ‘air cyst’, to incorporate all these lesions.