Antibiotic-resistant bacteria are increasingly common and present a major problem for the modern day ENT surgeon. This article reviews the development of methicillin resistance in Staphylococcus aureus and how it has come to affect ENT practice. We look at the evidence behind measures taken to help deal with methicillin-resistant Staphylococcus aureus (MRSA) and to prevent its spread. We go on to suggest a departmental guideline for infection control, which we hope can be implemented to help deal with the problems created by MRSA.

Objectives: Sudden sensorineural hearing loss (SSHL) remains a challenge for the clinician. In the majority of cases, no definite cause can be found and the prognosis is variable.

Methods: The present study assessed 114 patients suffering from idiopathic SSHL, with regard to the prognostic value of demographic, epidemiologic, neurotologic and audiometric factors. In addition, the relationship between the identification of wave V in auditory brainstem responses and the final hearing outcome was investigated. All patients received 75 mg/day intravenous prednisolone, divided into three daily doses, for 10 days, with gradual tapering of the dose over the next 10 days.

Results: The results (after one year follow up) revealed the following factors to be related to a better hearing outcome: younger age; male sex; less time elapsed between the onset of hearing loss and the beginning of treatment; and an upward-sloping or cupeloid audiogram contour. The detection of wave V early in recovery and within the first month of medical treatment might also constitute a significant favourable factor in respect to hearing recovery.

Conclusions: The present study revealed that there are certain factors that affect prognosis in idiopathic SSHL. This is very important in counselling patients and may affect current clinical practice.

Stable, self-cleansing retraction pockets of the pars tensa are common incidental findings and require no treatment. In other cases, recurrent discharge occurs and there may also be associated conductive hearing loss. In a minority of cases, cholesteatoma may develop.

This paper presents the results of surgery using a graft composed of cartilage and perichondrium for retraction pockets involving the posterior half of the tympanic membrane, as well as early results using a larger graft designed to manage retraction of the entire tympanic membrane. Data on 51 patients with posterior retraction pockets are presented. Forty-two (82 per cent) patients had no aural discharge one year following surgery and the tympanic membrane was not retracted in 43 (84 per cent). The larger ‘Mercedes-Benz’ graft was used in four patients and the results obtained suggested that it may prove a successful technique for extensive retraction pockets.

Objective: The aim of this study was to assess the experiences and outcomes of patients receiving intratympanic gentamicin treatment for Ménière's disease in Norfolk, UK.

Design: This study was based on a retrospective questionnaire survey and a review of patients' medical records.

Setting: Two district hospitals.

Participants: All 29 patients treated between 1999 and 2001, with a minimum follow up of two years post-treatment, were included in the study. Twenty-three patients completed the questionnaires (79 per cent response rate).

Main outcome measures: Glasgow benefit inventory (GBI) and vertigo symptom scale (VSS) scores, plus change in hearing thresholds.

Results: The mean GBI total score was +36, indicating substantial improvement in patients' overall quality of life following gentamicin treatment. The VSS scores demonstrated low levels of vertigo or unsteadiness in treated patients. Three patients suffered deterioration in their hearing thresholds following a single injection of gentamicin. However, 96 per cent of responders stated that they would be willing to have such treatment again, if necessary.

Conclusion: Intratympanic gentamicin treatment ought to be offered to Ménière's patients suffering from disabling vertigo, with the proviso that they be made aware of the possibility of hearing deterioration.

Tympanoplasty is often a necessary part of middle-ear surgery, the most common defect being that between an intact, mobile stapes and the malleus handle. The most readily available tissue is the patient's incus, reshaped to bridge the space between an intact stapes and the malleus. When the incus cannot be used, the hydroxyapatite Wehrs incus prosthesis® can be used as an alternative.

Twenty-six patients had an autograft incus ossiculoplasty and 20 patients underwent modified Wehrs incus prosthesis ossiculoplasty. The average post-operative air–bone gaps (ABGs) were 16.2 dB hearing loss (dBHL) and 17.2 dBHL, respectively. Air–bone gap closure to within 15 dBHL was achieved for 48 per cent of incus autografts and for 57 per cent of Wehrs prostheses, and to within 20 dBHL for 77 per cent and 62 per cent, respectively. Over four years follow up, the reconstruction was stable for each group, the ABGs being 17.7 dBHL and 17.1 dBHL, respectively.

Three patients with extensive keratosis obturans were treated during a 12-month period. One presented with an idiopathic sensorineural hearing loss and was found to have keratosis obturans in the contralateral, asymptomatic ear. The disease process had resulted in a horizontal semicircular canal fistula in what was now, effectively, the only hearing ear. The second patient had an extensive dehiscence of the tegmen tympani. The third presented with a facial palsy. An automastoidectomy cavity was present, with circumferential skeletonization of the descending facial nerve over a length of 1.5 cm and dehiscence of the temporomandibular joint and jugular bulb. All three patients were successfully treated by surgical formalization of their automastoidectomy cavities. They appeared to represent cases of keratosis obturans rather than external auditory canal cholesteatoma, on the basis of previously published reports.

These complications and patterns of bone erosion have not previously been described in keratosis obturans. The third patient is believed to have the most extensive case of keratosis obturans yet described.

Objective: To establish the frequency of occurrence of delayed facial nerve paralysis following tympano-mastoid surgery in our department and to determine the aetiological factors and long term prognosis.

Setting: Tertiary care academic centre.

Materials and methods: A retrospective review of all patients who had undergone tympano-mastoid surgery in our department over the previous five years was carried out. A total of 219 patients were included in the study. Only two patients were identified as having delayed onset facial nerve palsy over this period of time. The patients' medical records were reviewed and the patients clinically assessed.

Results: The frequency of delayed onset facial nerve palsy following tympano-mastoid surgery in our series was 0.91 per cent. Facial weakness set in on day eight and day 14 in the two patients. Serological investigations in both patients revealed raised titres of immunoglobulin (Ig) M and IgG to varicella-zoster virus, confirming the presence of varicella-zoster infection. In our experience, the combined use of prednisone and acyclovir was an effective form of treatment for both patients, whose facial nerve function fully recovered within six months of onset.

Conclusion: The incidence of delayed facial nerve palsy following tympano-mastoid surgery is low. It can occur up to two weeks after the surgery. Our two cases confirm viral reactivation to be an important aetiological factor in the development of delayed onset facial nerve palsy. The overall prognosis for delayed facial nerve palsy following tympano-mastoid surgery appears to be good.

Objective: To determine if patients who have had multiple previous nasal fractures and who undergo manipulation of fractured nasal bones under general anaesthetic (MUA) are as likely to be satisfied with their post-operative nasal cosmesis as patients who have only sustained a single injury.

Design: Telephone survey.

Setting: District general hospital.

Participants: Adult patients who had undergone MUA over the preceding three years.

Main outcome measures: Patient satisfaction with nasal cosmesis and nasal airway and willingness to consider corrective surgery.

Results: One hundred and two patients were contacted. Overall patient satisfaction with cosmesis and nasal airway was 82 and 77 per cent, respectively, with 15 per cent willing to consider a procedure to improve their nasal cosmesis and 12 per cent willing to consider a procedure to improve nasal airway. Twenty-three (22.5 per cent) gave a history of one or more nasal bone fractures, either treated or untreated, prior to the most recently treated injury. Patient satisfaction with cosmesis in this group was 65 per cent, compared with 87 per cent satisfaction in the single injury group (p = 0.03). No statistically significant differences were demonstrated when comparing these groups for: satisfaction with nasal airway (70 vs 80 per cent, p = 0.46); willingness to consider a procedure to improve cosmesis (26 vs 11 per cent, p = 0.16); and willingness to consider a procedure to improve nasal airway (17 vs 10 per cent, p = 0.46).

Conclusions: A history of multiple previous nasal fractures does appear to alter patient satisfaction with the cosmetic outcome of nasal manipulation. These patients should be informed that they have a decreased chance of attaining a cosmetically acceptable result.

A styloid process (SP) cutter was developed and put into clinical use. The design of components of the ‘styloidectome’ was based on the principles of mechanics. The measurements of the individual parts were determined on the basis of morphological data of the oropharynx from 40 subjects undergoing tonsillectomy under general anaesthesia. Experiments showed that the instrument could be used to transect the SP and excise the amputated bones from the deep tissue space. We used the instrument for the resection of elongated SPs, via an oral approach, in seven in-patients (involving 10 SPs) under general anaesthesia and in two out-patients (involving three SPs) under local anaesthesia. The length of the resected SP ranged from 0.8 to 2.5 cm and the stump of the SP was smooth. The removal lasted only seconds and blood loss was minimal, without any complications. The styloidectome was reliable, easy to use and could be used for the resection of an elongated SP under general or local anaesthesia.

We report a new surgical procedure to treat intractable aspiration: closure of the larynx, using double hinged flaps of the vocal folds and false vocal folds.

The anterosuperior portion of the thyroid cartilage is ablated. A small horizontal incision is made just above the anterior commissure and is continued posteriorly along the laryngeal ventricle; these incisions are continued across the posterior wall of the glottis. Incisions are made into the bilateral vocal folds and false vocal folds in order to create the hinged flaps. The glottis and the supraglottis are closed by approximating the bilateral vocal folds and false vocal folds hinged flaps. Superiorly or inferiorly based sternohyoid muscle pedicles are then inserted into the dead space between the approximated bilateral vocal folds and false vocal folds hinged flaps. The removed lamina of the thyroid cartilage is obliterated between both sternohyoid muscle flaps to enforce the closure of the larynx.

Objectives: Two centre based evaluations of oncologic results of endoscopic resection of supraglottic cancer without post-operative irradiation.

Patients and methods: Twenty-six patients with clinical T1 (n=5) or T2 (n=21) primary squamous cell carcinomas of the supraglottic larynx and with N0 (n=24) or N1 (n=2) neck disease were treated by endoscopic supraglottic laryngectomy coupled with neck dissection(s). Endoscopic resection was standardized whereas neck dissections (NDs) varied from classical modified radical ND to selective ND of levels I to IV.

Results: Pathologically, three T2 patients were upstaged to T3, four N0 patients to N1 and one N2 patient down-staged to N1. Within an average of 42 months, there were no local failures and only one regional failure.

Conclusions: Endoscopic resection of T1 and T2 supraglottic cancer without post-operative irradiation achieved good oncological results. No patients with lateralized primary cancers were found to have contralateral cancer on pathological evaluation from bilateral dissections.

Introduction: Due to the ‘modernizing medical careers’ changes, doctors with a firm career intention will be able to enter a speciality-specific training programme after their foundation years.

Materials and methods: A questionnaire was emailed to all 204 final year medical students at Newcastle Medical School asking about their ENT undergraduate experience and if they felt it was sufficient to consider a career in otolaryngology.

Results: One hundred and forty-four completed questionnaires (71 per cent) were returned, with respondents giving the following information: 54 per cent had had a formal ENT attachment (average seven and a half days); 24/144 (17 per cent) and 60/144 (42 per cent) respectively had not attended ENT clinic or theatre; less than 50 per cent had seen common ENT operations; 12/144 (8 per cent) had never heard of a septoplasty; two-thirds (24/36) of aspiring general practitioners had never seen a tonsillectomy or grommet insertion; and only 6/30 (20 per cent) of aspiring surgeons felt their ENT experience had been enough to consider the speciality as a career.

Discussion: Alternative methods of delivering an otolaryngology curriculum should be considered. We must promote otolaryngology to medical students at every opportunity.

We describe a simple technique of replacement Montgomery T-tube insertion in a closed neck under general anaesthetic.

The use of laser bronchoscopy in the treatment of tracheobronchial stenosis has been reported in the past. It is generally safe and effective; however, the complications of haemorrhage, airway perforation, or airway fire are relatively frequent among less experienced surgeons. We illustrate a modified technique of laser probe location to simplify the laser ablation procedure.

The Finnish type of familial amyloid polyneuropathy due to variant gelsolin is a rare form of familial amyloidosis. The subtype was first described in 1969 and is characterized by progressive cranial neuropathies, corneal lattice dystrophy and distal sensorimotor dysfunction. It is extremely uncommon, with only two families known to be affected in the UK. We discuss the case of a 70-year-old woman who presented with bilateral facial nerve palsies, bilateral sensorineural hearing loss and Finnish type familial hereditary amyloidosis. A literature search of the Medline database (1966–2005) was performed, using the keywords ‘amyloid’, ‘hearing loss’ and ‘facial palsy’; however, this association appears to be a novel finding. We review the current literature and discuss otorhinolaryngological presentations of amyloidosis.

Neurological complications of acute mastoiditis are rare but can be life threatening. Their presentation may be masked by the use of antibiotics. We present a unique case of acute otitis media progressing to occipital, extradural and subdural abscess formation and lateral sinus thrombosis in a child. The clinical course and management of a pre-adolescent male is presented and discussed. We review the incidence, presentation and treatment of occipital abscesses and lateral sinus thrombosis with acute mastoiditis. Following extended cortical mastoidectomy, neck exploration and broad spectrum intravenous antibiotics, the patient made a full recovery. This is the first reported case of acute mastoiditis associated with occipital abscess in a child. Early, aggressive treatment is required for a successful outcome. The rarity of neurological complications, in addition to the insidious onset and subtle symptoms associated with antibiotic therapy, can make diagnosis extremely difficult. Patients with acute otitis media who fail to respond fully to treatment should be referred early for a specialist otology opinion.

Keratosis obturans is characterized by the accumulation of desquamated keratinous material in the bony portion of the external auditory canal. Classically, it is reported to present with severe otalgia, conductive hearing loss and global widening of the external auditory canal. Extensive erosion of the bony meatus, with exposure of the facial nerve, has been previously reported, but no case of facial nerve palsy has as yet been published. We report the first published case, to our knowledge, of a unilateral facial nerve palsy secondary to neglected keratosis obturans.

Extracranial spread of meningiomas to involve the middle ear is very rare. We present the case of a 43-year-old woman with a known cerebellopontine angle meningioma who subsequently presented with left-sided otalgia and a middle-ear mass extruding through the tympanic membrane due to local invasion of the meningioma. The tumour was excised surgically. A discussion of the relevant literature is also presented.

Rehabilitation of voice and speech after total laryngectomy has become established practice in recent years. A voice prosthesis is placed within a surgically produced fistula between the trachea and upper oesophagus and acts as a one way valve, allowing passage of pulmonary air from the trachea into the oesophagus and preventing aspiration of food and fluid from the oesophagus into the trachea. Persistent leakage through or around these prostheses is a recognized complication, the aetiology of which can vary widely, from mechanical issues with the prostheses themselves to anatomical and physiological issues associated with the reconstructed pharynx.

We report a new technique of using Dysport® in the management of intractable central leakage due to premature and forceful closure of the upper oesophageal sphincter during swallowing. This resulted in the pooling of fluids around the posterior flange of the prosthesis. This, along with the increased pressure from the muscle contraction, led to central leakage, as identified on videofluoroscopy. An injection of Dysport paralysed the upper oesophageal sphincter, preventing pooling of fluids around the prosthesis and the forcing open of the valve. The effect was to eliminate the leakage, and the patient did not require further injections over the following 22 months.

A case of piercing of the tympanic membrane, resulting in unusual consequences, is described. This is the first reported case of the long process of a dislocated incus resulting in trauma to the horizontal portion of a dehiscent facial nerve. Simultaneous depression of the stapes footplate resulted in a perilymph leak, but with delayed presentation.