Quality of life issues in head and neck cancer have been portrayed increasingly in the medical literature in recent decades. Reports vary in sample size and study design but the majority are cross-sectional and suffer from inherent bias. Many of the patients’ complaints in cancer of the head and neck manifest close linkage to problems related to the oral cavity. Frequent specific problems are trismus, pain, xerostomia, and speech and swallowing disorders. Although quality of life is multifactorial and subjective, some improvement may be achieved by recognizing and addressing problems during the course of treatment. More longitudinal long-term studies are indicated in order to better define quality of life along the time axis.

Abstract Traditionally major ear surgery in children has been regarded as an in-patient procedure. Evidence from the USA for adults, however, concludes that it is both safe and effective to perform many major ear procedures as day cases. We have been carrying out major ear operations on children as day cases routinely for six years in a dedicated children’s day unit and examined our data to find out whether it was both safe and feasible to perform major ear surgery in children on a day-case basis. As our main outcome measure we used the rate of unplanned admissions.

We found that the unplanned admission rate for surgery, excluding mastoid surgery, was 6.7 per cent and that procedures such as myringoplasty, ossiculoplasty, bilateral pinnaplasty, meatoplasty and tympanotomy with excision of cholesteatoma, were eminently suitable for day surgery.

Because otoacoustic emissions (OAEs) are transmitted from the cochlea to the ear canal via the middle ear, the transmission properties of the middle ear directly influence OAEs’ characteristics. In general, middle-ear effusion (MEE) reduces measured emission amplitudes and sometimes eliminates the response entirely. The purpose of this study was to establish the relationship between the conduction of the middle ear and OAEs’ properties and to elucidate the effect of middle-ear effusion on detecting OAEs’. Spontaneous otoacoustic emissions (SOAEs), transiently evoked otoacoustic emissions (TEOAEs) and distortion product otoacoustic emissions (DPOAEs) were recorded from 44 normal ears and 32 ears with middle-ear effusion. DPOAEs were collected in two basic forms consisting of distortion product audiograms (DP grams) and input-output (I-O) functions, elicited by two primary tones F1 and F2 and varying geometric mean frequencies between 1–6 kHz. The results of air and bone conduction hearing levels in pure tone audiogram were also analysed. In 21 ears out of 32 otitis media with effusion (OME) ears, SOAEs were absent. In the 28 ears with middle-ear effusion, the response and wave reproducibility were diminished, and in the 17 ears with middle-ear effusion, the DP gram was diminished or eliminated. In particular, I-O function curves at 3 kH and 4 kHz were diminished by the primary tones of 45 and 55 dB under the condition of MEE. The SOAEs, TEOAEs and DPOAEs (DP gram and I-O function curve) are highly reliable and useful tests for monitoring changes in middle-ear condition in children with OME and in predicting the course of OME.

Understanding the relationship between the anatomy of the fallopian canal and a variety of ear diseases is necessary. In this study, our purpose was to identify the incidence of facial nerve dehiscence in patients undergoing surgery for a variety of chronic ear diseases.

The operative records of 219 patients were reviewed retrospectively for dehiscence of the facial canal. The diagnoses were cholesteatoma (n = 49), tympanosclerosis (n = 51), adhesive otitis media (n = 38), and chronic otitis media (n = 81). Only 17 of 219 who underwent tympanoplasty without mastoidectomy were excluded from the calculations.

Dehiscence of the facial canal was encountered in 18 (8.9 per cent) of 202 patients. The dehiscence rate was highest with cholesteatoma, followed by adhesive otis media, chronic otis media and tympanosclerosis (p<0.01). The canal dehiscence was mainly seen in the tympanic segment and second genu, and was rare in the mastoid segment. Labyrinthine fistula was the most common pathology that coexisted with the dehiscence. It was encountered in two (11.1 per cent) of 18 patients. In conclusion, the likelihood of dehiscent bone covering the tympanic segment of the fallopian canal is significantly higher in cholesteatoma than the other chronic ear diseases. The surgeon can feel somewhat more confident while performing surgery for tympanosclerosis as far as the dehiscence in the fallopian canal is concerned.

Recent reports indicate that the cochlear nerve may be absent in some cases of congenital sensorineural hearing loss. The aim of this prospective study was to determine the incidence of cochlear nerve anomaly in cochlear implant candidates with congenital hearing loss using magnetic resonance imaging (MRI). Twenty-seven patients with congenital profound bilateral sensorineural hearing loss who were being evaluated for the cochlear implant procedure were studied.

These patients had high-resolution computerized tomography (CT), through the petrous bone in axial sections. MRI examinations consisted of T1 and turbo spin echo (TSE) T2-weighted 3 mm axial images, and additional 3D Fourier Transform T2-weighted TSE sequences obtained on three different planes (axial, perpendicular and parallel to the internal auditory canal (IAC) i.e. oblique sagittal and coronal, respectively) for the purpose of cochlear nerve demonstration. Results showed that all of the 14 patients with normal CT of the temporal bone, had four distinct nerves in the distal part of the IAC on TSE-MRI. Thirteen patients demonstrated various bony malformations of the cochleovestibular system on CT. MRI revealed the absence of the cochleovestibular nerve in four patients where the IAC was very narrow or completely absent on CT. One patient with severe Mondini malformation who had an enlarged IAC demonstrated an isolated absent cochlear nerve.

Consanguineous marriage is a tradition which is commonly practised among Asian, African, and Latin American communities whether they are living in their own countries or settled in Europe or the USA.

These communities, in addition to their custom of interrelated marriage, have large families and are a rapidly growing population. The siblings of consanguineous marriages have a significantly higher incidence of autosomal recessive diseases including hearing impairment.

Two epidemiological surveys were carried out 10 years apart. There were 6 421 subjects from Riyadh City and 9 540 from all other parts of the Kingdom of Saudi Arabia. A random sample was examined otologically and a questionnaire was filled in that included age, sex, family relation, number of siblings, etc. ENT examination and audiological assessment were performed. Consanguinity was found among 22 per cent as first cousins and 23 per cent as second cousins in the first survey. In the second survey 19 per cent were first cousins and 28 per cent second cousins. The rate of consanguinity was 45 per cent in the first survey and 47 per cent in the second. The prevalence of hereditary sensorineural hearing loss (SNHL) was 66.07 per cent and 36.6 per cent in the first and second survey respectively.

The incidence of hereditary hearing impairment is very high in developing countries compared to developed countries. Prevention is essential to reduce the incidence of genetic hearing loss. Consanguinity should be discouraged through health education of the public about the adverse effect of interrelated marriage. Genetic counselling, premarital and antenatal screening are to be applied whenever possible, at least for those at risk of developing genetic diseases including hearing impairment.

We present the results of a confidential telephone survey of ENT units in England on the disinfection of flexible fibre-optic nasendoscopes out-of-hours. The on-call residents of 124 units were contacted and questioned. In 35.1 per cent of units surveyed, the on-call resident was primarily responsible for cleaning the scopes after use. Only 46 per cent of these junior doctors had access to a chemical sterilant to allow for high-level disinfection of these scopes. Provision for disinfection of scopes was poorer in teaching hospitals and in units that served inner city populations. Only 12.1 per cent of Senior House Officers (SHOs) received any training in disinfection techniques and only 25.5 per cent of units kept a register of patients nasendoscoped out-of-hours for purposes of contact tracing.

An anatomical study of 50 fresh adult human cadavers was performed in order to verify prevalence of Galen’s anastomosis (GA) and to evaluate whether factors such as gender, ethnicity, side of the neck, and individual stature may interfere with GA prevalence. The results were analysed using the Chi-square test, Student t-test, and F-Snedecor test. GA was observed in 87 of 100 dissections. There was no statistically significant difference regarding GA prevalence between groups separated by ethnicity (p = 0.853), gender (p = 0.198), side of the neck (p = 0.766), or individual height (p = 0.199). Therefore, the GA was a frequent anatomical finding, and this result was not influenced by any studied factor. Comparing our data with previous studies, we also concluded that the GA seems to play an important role in the innervation of the larynx, even though its function remains unclear. Also, it is reasonable to consider GA a constant anatomical constituent.

Pharyngo-laryngo-oesophagectomy and gastric pull-up (PLOGP) is a complex and relatively uncommon procedure. The aim of this study is to analyse the results of PLOGP in patients with post-cricoid and cervical oesophageal squamous cell carcinomas.

This study was a retrospective review of 26 patients (11 males + 15 females, mean age 63.5 years) who underwent PLOGP from 1988 to 1997. Eighteen (69 per cent) patients were staged as T3 and eight (31 per cent) T4. Eighteen (69 per cent) patients had N0, seven (27 per cent) N1 and one (four per cent) N2 disease. Multiple primary tumours were recorded in three (11.5 per cent) patients. Four (15 per cent) patients had pre-operative radiotherapy with poor response and two (eight per cent) required emergency tracheotomy prior to surgery. Feeding jejunostomy was performed on 19 (73 per cent) and neck lymph node dissection in eight (31 per cent) patients.

The mean duration of surgery was five hours (range 3.5 to 7.5) with a mean blood loss of 840 ml (range 160 to 1800), a mean stay in ICU of 4.2 days and hospital stay ranged from nine to 84 days (mean 34). Three (11.5 per cent) patients died (pneumonia – one, congestive heart failure – one pulmonary embolus – one) in the early post-operative period. Eight (31 per cent) patients remain alive from 30 to 136 months (mean 58 months). Two (eight per cent) patients died with no evidence of disease. Thirteen (50 per cent) patients died of their disease between two to 51 months (mean 17.3 months) post-operatively. Kaplan-Meier survival estimates for one year was 65 per cent, for three years 35 per cent and for five years 26 per cent (see Figure 1). Median survival in the whole series was 18 months.

Post-operative speech was with an electrolarynx in 16 (62 per cent). One patient (four per cent) used gastric speech and one patient (four per cent) used a Blom-Singer valve effectively. Five (19 per cent) patients had no speech post-operatively. All patients maintained oral feeding. Gastric transposition constitutes a safe and reliable method of restoring the continuity of the upper digestive tract following pharyngo-laryngo-oesophagectomy.

Second primary tumours occur frequently in patients with a history of head and neck malignancies. Delays in making an early and correct diagnosis can seriously affect the therapy management and survival.

This was a retrospective study of 120 patients with a history of head and neck cancer, presenting with a second primary tumour. Current follow-up strategies and the use of routine sonographic imaging of the head and neck regions were evaluated, and the impact that tumour chronology, the tumour site and the various treatment modalities have on the survival were assessed. Forty-two per cent of patients developed a metachronous second malignancy more than five years after diagnosis of the index tumour. The accuracy of colour-duplex sonography in detection of second primaries in the head and neck was 82.3 per cent. First and second primary tumours located in the larynx were observed to have the highest five-year survival rate. Patients who developed metachronous tumours had a five-year survival rate of 68.9 per cent for the index tumours, and a 26 per cent five-year survival rate with the occurrence of a second neoplasm. With synchronous tumours a mean survival time of 18 months and a five-year survival rate of 11.9 per cent was found (p < 0.0001). Where clinically appropriate an aggressive treatment strategy was employed and yielded the most favourable results with a five-year survival rate of 66.8 per cent and 35.9 per cent for index tumours and second primary malignancies, respectively.

Since more than 40 per cent of the metachronous second primaries in patients with a history of head and neck malignancy occur beyond the five-year follow-up period, an extended protocol with individually adjusted close monitoring of high-risk patients seems appropriate. Colour-duplex sonography is a valuable screening investigation for the early detection of second primary tumours. The treatment of a second primary is often less successful than for the same malignancy occurring primarily. The prognosis of synchronous tumours is significantly lower when compared to malignancies of a metachronous nature, despite some encouraging individual results. Only the early implementation of aggressive treatment methods for second primaries is successful in terms of survival.

Knowledge of the factors that inform the career choice of medical students may help plan the workforce for medical specialities. To determine which factors inform the career choice of medical students we carried out a survey of medical students at the start of their educational block in Otolaryngology. Of 202 questionnaires handed out 169 were returned (84 per cent). Students were asked to rank factors according to their importance in their career choice. The single most important factor was career progression. Other factors include on-call commitment, teachers as role models, and the interest for a particular subject. At the present time progression from senior house officer grade to specialist registrar grade in Otolaryngology is delayed. If this issue is not addressed the influx of applicants into Otolaryngology training programmes will be reduced, limiting the pool from which candidates can be chosen for a career in Otolaryngology.

The tongue base and vallecula are common anatomical sites for impaction of inadvertently swallowed fish bones. Many techniques for their removal have been described but this apparently simple procedure can still pose a surgical challenge. We describe a previously unreported technique using rigid endoscopy with the 4 mm 30 degree Hopkins’ rod as a visual aid for transoral removal of the impacted bone. The technique has proved to be very well tolerated by the patient and more acceptable in terms of morbidity, time and resources than either flexible endoscopy or rigid endoscopy under general anaesthetic.

Ramsay Hunt’s hypothesis that herpes zoster oticus results from reactivation of the varicella zoster virus (VZV) in the geniculate ganglion is supported by the detection of viral genome in archival temporal bones of normals and Ramsay Hunt patients by the polymerase chain reaction. Ramsay Hunt syndrome is characterized by the presence of cochleovestibular symptoms in association with facial paralysis. VZV has also been demonstrated in the spiral and/or vestibular ganglion. Two cases are reported in which cochleovestibular symptoms outweighed the facial nerve symptoms, presumably representing VZV reactivation in the spiral and/or vestibular ganglion. From these observations and the known dormancy of VZV in non-neuronal satellite cells, it is argued that the cochleovestibular symptoms in Ramsay Hunt syndrome may result from VZV transmission across the nerves inside the internal auditory canal and that prompt treatment with an antiviral-corticosteroid combination might be justified in the management of any acute non-hydropic cochleovestibular syndrome.

Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant disorder characterized by dermal, mucosal, and visceral telangiectases as well as pulmonary and cerebral arteriovenous malformations. Recurrent epistaxis occurs in the majority of patients, and by the very nature of the thin walled vessels involved it is often refractory to conventional forms of treatment. We present the case of an 82-year-old lady with intractable epistaxis secondary to HHT, that was successfully controlled by the application of fibrin glue.

Clear cell carcinoma of the salivary glands is a rare tumour that represents less than one per cent of all salivary tumours. They are divided into a biphasic, epithelial-myoepithelial carcinoma and a monophasic pattern which may be myoepithelial or ductal in origin. The latter is accompanied by prominent fibrohyaline stroma and has been described recently as hyalinizing clear cell carcinoma (HCCC).

Most of the HCCC occur in the oral cavity, and are associated with minor salivary glands, unlike the biphasic pattern which is more common in the major salivary glands. In the oral cavity, the commonest site is the palate followed by the lips and the buccal mucosa. Its occurrence in the oropharynx and the larynx is extremely rare.