This article reviews the contemporary literature for septic cavernous sinus thrombosis (CST) with a focus on anticoagulation. Modern emphasis is placed on suspecting and treating this condition early, which is aided by recognizing clinical features attributable to sepsis, orbital venous congestion, and involvement of cranial nerves within each cavernous sinus. Established treatments include high dose broad-spectrum parenteral antibiotics, and selective surgery for concurrent suppurations. The role of anticoagulation is contentious because its efficacy is undetermined and it may cause or exacerbate concurrent intracranial haemorrhage in patients with septic CST. Moreover, prospective trials of anticoagulation may never be performed due to the rarity of this condition. Nevertheless, retrospective reviews of published reports indicate that haemorrhage caused by anticoagulation is rare, and that early adjunctive anticoagulation is beneficial in these patients if commenced after excluding the haemorrhagic sequelae of CST radiologically.

Most otolaryngologists treat patients with chondrodermatitis nodularis (CDN) by wedge excision. Although the results of this technique are generally good, it can leave the patient with an asymmetric, deformed ear.

In the dermatological literature, a relatively straightforward technique has been described for the treatment of CDN by smoothing only the underlying cartilage. This is based on the assumption that CDN is caused by pressure necrosis of protuberant cartilage, and thus is primarily not a skin disease. Reports on this technique claim excellent cosmetic results with only a small chance of recurrence.

In the present study we analyse the application of this technique to 34 patients with 37 CDN lesions. All patients were symptom-free with a minimum follow-up of three months according to their medical reports.

Seventeen patients with 19 lesions were interviewed later by telephone. In a mean follow-up of 30.7 months, 34 of these patients remained symptom-free and only one required revision surgery. The authors recommend this safe and simple technique to other physicians who treat patients with CDN.

Prominent ears are the most frequent congenital deformity in the head and neck area. Otoplasty has undergone important developments and numerous techniques have been employed to address the anatomical defects, namely the lack of antihelix and the overdevelopment of the concha. We present a cartilage-sparing technique involving scapha – conchal sutures insertion to recreate the antihelix, conchal setback and cartilage weakening. No cartilage is excised. Prior to creating the antihelix, the medial surface of the cartilage is superficially scored. Occasionally a tangential excision of the posterior prominence of the cartilage prior to the placement of set back sutures is employed for an excessively large conchal bowl. A series of 86 consecutive patients underwent otoplasty with this technique. According to our experience the described technique gives good and predictable long-term results with a natural-appearing ear. Significant complications are rare. In case of loss of correction, revisional surgery is straightforward on the intact pinna cartilage.

A bacteriological study on 161 consecutive out-patients presenting with otorrhoea was performed prospectively at a local teaching hospital in Taiwan between August 2000 and June 2001. A total of 177 isolates were recovered. Staphylococcus aureus was found in 77 (43.5 per cent) isolates, and non-Staphylococcus aureus in 100 (56.5 per cent) isolates. Pseudomas sp was found to be the most common pathogen (28.8 per cent) in the non-Staphylococcus aureus group. Staphylococcus aureus had become more common than Pseudomonas aeruginosa in acute otitis externa, granular myringitis, and chronic otitis media in Taiwan. Methicillin-resistant Staphylococcus aureus (MRSA) was also an increasing problem in all three disease entities. The prevalence of community-acquired MRSA infections in discharging ears was found to be 13.7 per cent (22/161). MRSAs were highly susceptible to vancomycin, teicoplanin, fusidic acid, and minocycline. More studies should be done to determine the susceptibility of MRSA to ofloxacin in the future.

Paediatric revision myringoplasty has received little attention. This study addressed the issue exclusively and reviewed the short- and long-term results of surgery in children between the ages of five and 15. Twenty-six out of 38 operated ears (68.4 per cent) were initially intact. The causes of immediate failure in decreasing order were: infection with graft necrosis, complete no-take of the graft and poor anterior adaptation of the graft. Age, size and site of perforation and surgeon’s experience did not significantly affect the initial outcome of surgery. Six ears developed delayed re-perforations, thus decreasing the overall success rate to 52.6 per cent. The latter were attributable to either episodes of acute otitis media or to insidious atrophy of the tympanic membrane. Notably, none developed post-operative sensorineural hearing loss. It is concluded that the results of paediatric revision myringoplasty are rather disappointing, yet arguments encouraging its practice are favourably presented.

A patient presented to the authors with unilateral sensorineural hearing loss after falling asleep with his ear tightly pressed against a window of a moving train. This study set out to determine whether a train could generate sound levels of sufficient intensity to cause such a hearing loss. A sound level meter was used to measure the sound levels produced at the window of a moving train. Further measurements were made with a rubber attachment on the microphone, that simulated the effect of the ear stuck to the window. The sound levels were found to be amplified by the attachment but not to levels that could cause a hearing loss over a short period. In a second experiment eight healthy volunteers all perceived an increase in sound levels when their ears were pressed against a train window.

It seems unlikely that sleeping with an ear against a train window can cause hearing loss, but it cannot be ruled out.

This series was undertaken to investigate the incidence of associated polyps and the recurrence rates of inverted papillomas with, or without, malignancies, as well as the treatment outcomes of the recurred cases.

A retrospective study evaluating the pathology, associated polyps, types of operation, recurrence rate after original operation, and surgical outcomes of recurred cases was conducted upon 96 patients diagnosed with inverted papilloma.

The overall malignancy rate was 11.5 per cent with synchronous tumours accounting for 9.4 per cent and metachronous for 2.1 per cent. Inflammatory polyps were found in association with inverted papilloma in 21.9 per cent. In cases without malignancies, the recurrence rate after the original conservative procedure was 33.9 per cent, compared to 14.3 per cent after a medial maxillectomy. In cases with malignancies, the recurrence rate after the original surgical procedure was 22.2 per cent.

Our study indicates that more aggressive and bolder surgical resection of inverted papilloma should be undertaken as a primary treatment method, or as a treatment for recurrent cases to reduce the recurrence rate of inverted papilloma with, or without, malignancy.

The traditional lateral rhinotomy incision described originally by Moure in 1902 has proved a versatile approach to the mid-facial skeleton. It is not, however, without its complications, particularly poor cosmesis due to depression of the nasofacial groove. In one series 10 per cent of patients developed wound complications. We present our modification of the lateral rhinotomy incision, that takes account of the nasal aesthetic subunits by placing the incision between the dorsal and side wall nasal subunits with extension inferiorly along the alar groove.

From November 1994 to February 2001, a retrospective review of case notes showed that 20 patients underwent modified lateral rhinotomy incision for a variety of pathology. Ten cases were for transitional papilloma, nine for malignant disease and one for chronic osteitis of the maxilla and ethmoids post-trauma. Follow up ranged from two weeks to five years. In five cases we were able to preserve the bony piriform aperture without compromising the excision or exposure. We believe that preservation of the bony piriform aperture will further enhance the overall cosmesis and nasal function. No complaints related to the incision were recorded.

Our experience with the modified lateral rhinotomy incision has been very satisfactory. It provides good exposure, a low complication rate and excellent cosmetic outcome without undue technical difficulty. It is our preferred incision for all surgery on the mid-facial skeleton and anterior skull base.

The objective of this study was to evaluate the safety, efficacy and acceptability to patients of day-case septorhinoplasty. Twenty-nine patients undergoing elective septorhinoplasty in a dedicated teaching hospital day-case unit were asked to complete day surgery questionnaires (DSQ) at six weeks post-operatively. Details of surgery performed, demographic data, readmission rates and complications were collected prospectively. No major complications were recorded. One patient had to be admitted for overnight observation following post-operative bleeding. The DSQ showed that the great majority of patients were satisfied from the day-case setting (satisfaction score 81). This preliminary study showed that day surgery septorhinoplasty was acceptable to the patient and was associated with a very low readmission rate. We believe that in carefully selected young healthy patients it is an acceptable alternative to an in-patient procedure.

Forty children (age group four to 12 years) undergoing adenoidectomy and/or tonsillectomy were subjected to pre- and post-operative polysomnography. Thorough clinical evaluation and X-ray soft tissue nasopharynx lateral view was carried out for all the patients. The tonsils were clinically graded from grade I to IV, whereas the adenoids were measured radiographically (using three different measurements) in all children. Thirty out of 40 (75 per cent) children presented with predominant obstructive symptoms, out of whom 22 (73.3 per cent) were found to have obstructive sleep apnoea (OSA), i.e. apnoea index > five per hour. The remaining 10 (25 per cent) had predominantly inflammatory symptoms on presentation and out of these two (20 per cent) were found to have OSA. Relative adenoid size expressed as a ratio between the distance from the point of maximum thickness of adenoids along a line drawn along a straight part of the basiocciput and distance from the posterior nasal spine to the antero-inferior edge of the spheno-basioccipital synchondrosis, was found to have a highly significant correlation with the grade of OSA. In our study, all patients with this ratio greater than 0.64 were found to have OSA. No correlation between tonsil size and grade of OSA was found. There was a highly significant improvement in polysomnographic scores following surgery in all patients.

Moderate to severe obstructive sleep apnoea is usually associated with multiple levels of pharyngeal airway collapse, including tongue base obstruction. A new technique has recently been introduced that improves the nocturnal retro-lingual airway. This study was a prospective, non-randomized single-institution evaluation of a recently introduced surgical technique. Nineteen consecutive patients with previously untreated moderate to severe obstructive sleep apnoea underwent tongue suspension using the Respose™ system and concomitant palatopharyngoplasty (multilevel pharyngeal surgery). The patient demographics and treatment outcomes were prospectively collected and retrospectively analysed.

There were 16 men and three women, with a mean (±SD) age of 44.9 years (±14.2) and a mean pre-operative apnoea-hypopnoea index (AHI) of 42.8 ± 24.8. Twelve of the 19 patients (63.2 per cent) have had post-operative polysomnography; eight of these 12 (67 per cent) met the standard criteria for surgical response. Among these eight patients, the AHI improved from 32.4 to 14.4 (p < 0.01); the individual scores fell by a mean of 51.7 per cent. The apnoea index improved from 7.4 to 0.9 (p < 0.01), with the individual scores falling by a mean of 81.4 per cent. There was anatomic and radiographic evidence of multilevel upper airway enlargement. Notably, the body mass index remained essentially unchanged (31.5 ± 7.2 to 31.2 ± 7.6, p > 0.5). Subjectively, the mean Epworth sleepiness scale score fell from 11.0 ± 5.4 to 5.4 ± 3.8 (p < 0.005). Four patients suffered transient velopharyngeal insufficiency, and two patients complained of limited anterior excursion of the tongue. There were no serious, long-term complications.

The tongue suspension procedure represents a minimally invasive technique for improving the nocturnal retro-lingual airway in patients with obstructive sleep apnoea. It is easily performed by otolaryngologists, distinguishing it from other established techniques designed to address tongue base obstruction.

In cases of thyroid surgery that require a drain post-operatively, the authors suggest the subcutaneous tunnelling of the drain to exit in the bra-strap line. This simple but effective technique hides the potentially unsightly resultant scars that may be of concern to women wearing clothes that expose the upper chest and lower neck. The bra-strap line can be easily found in the patient and the authors have found no additional complications with exiting the drain at this site.

The results of long-term follow-up after surgical treatment of two patients with intractable benign paroxysmal positional vertigo are reported. Argon laser irradiation of the blue-lined posterior and lateral semicircular canals in one patient, and of only the posterior canal in the other was performed seven and six years ago, respectively. Argon laser irradiation was carried out 10 times in succession three mm along the canal to occlude it. The power applied each time was 1.5.W on the dial of the laser device for 0.5.sec. Relief of vertigo was noted on the second post-irradiation day. There has been no recurrence of vertigo in these patients.

Petrous apicitis as a potentially fatal complication of suppurative otitis media presents in a variety of forms. Gradenigo’s triad of abducens paralysis, deep facial pain due to trigeminal involvement and acute suppurative otitis media rarely occurs. The conflicting symptoms reported in the literature usually result in the delayed recognition of the condition with potentially disastrous consequences. The VIth nerve palsy is considered to be the least reliable sign as it is least often present. We present a case in which it was the sole presenting symptom.

The authors present a case report of a retired furniture worker who initially presented with a mucin-secreting adenocarinoma of the right ethmoid sinus. He underwent surgical resection, leaving the nasal septum intact, and topical treatment with 5-fluorouracil. He remained disease free. Three years after his initial presentation he was found to have a left nasal polyp on routine examination. This subsequently proved to be a second primary adenocarcinoma. A review of the literature has not shown any other cases of a second primary adenocarcinoma of the ethmoid sinuses.

Laryngomalacia is the most common paediatric airway problem presenting as stridor in the neonate. This congenital anomaly is thought to be caused by inward inspiratory collapse of the supraglottic larynx due to a prolapsed, tall and tubular epiglottis with flaccid aryepiglottic folds. The natural history of this condition usually results in spontaneous resolution by the second year of life. Although acquired cases of adult laryngomalacia have been reported, a search of the literature has yet to show any cases of idiopathic laryngomalacia. We present two cases of idiopathic acquired laryngomalacia in adults.

Lipoid proteinosis is a rare disease that presents with hyaline deposits in many tissues. It involves predominantly the skin and upper aerodigestive tract, presenting with small yellowish papules and hoarseness. It may involve the central nervous system and cause intracerebral calcifications. Laryngeal lesions may resemble singer’s nodule or chronic laryngitis. The pathogenesis of the disease is not clear although several studies suggest a defective collagen production and/or lysosomal storage disease. In this article two cases with skin and larynx involvement are reported.

Schwannoma arising from the posterior pharyngeal wall is extremely rare. We report a 24-year-old female patient who had suffered from dysphagia and discomfort for two months. The tumour was excised completely via the intraoral approach. No recurrence was found after the follow-up period of one year. To our knowledge, only four cases of schwannomas from the posterior pharyngeal wall have been reported, and this patient is the fifth.

Hypohidrotic ectodermal dysplasia (HED) is a rare condition characterized by abnormalities to ectodermal derived tissues although other organs or systems are frequently involved. Patients with HED can have a number of symptoms that may lead them to present to the otolaryngologist. We present a case of a 37-year-old female with HED who initially presented with nasal obstruction but then very rapidly developed stridor due to a tracheal squamous cell carcinoma. We suggest a possible association between HED and carcinoma of the upper respiratory tract that has not previously been reported.