With the exception of distant metastasis, the presence of cervical lymph node metastasis is the single most adverse independent prognostic factor in head and neck squamous cell carcinoma. Surgical removal of metastatic cervical lymph nodes had been attempted during the late nineteenth century, with varying techniques and poor results. A systematic approach to en bloc removal of cervical lymph node disease, described in detail by Jawdyński at the end of the nineteenth century and popularized and illustrated by Crile in the early twentieth century, provided consistent and more effective treatment and forms the basis of our current techniques. The concepts of radical neck dissection, employed extensively by Martin, were followed with almost religious consistency by most head and neck surgeons until the late twentieth century, when the principles of ‘functional’ neck dissection, developed by Suárez and popularized by Bocca, Gavilán, Ballantyne, Byers and others, led to the acceptance of modified radical neck dissection as treatment for lymph node disease in various stages. More recently, selective neck dissection, involving removal of nodes confined to the levels at greatest risk of metastasis from primary tumours at various sites, has become accepted practice for elective and, in some instances, therapeutic treatment of the neck. In the future, sentinel lymph node biopsy and the use of molecular pathological analyses may be employed to predict the presence of occult cervical disease, thus directing therapy to patients at greatest risk and sparing those without regional metastasis.

Pulsatile tinnitus is an uncommon otological symptom. Objective pulsatile tinnitus has numerous causes, including benign intracranial hypertension, glomus tumours and atherosclerotic carotid artery disease. History and physical examination can give important information as to the underlying diagnosis. Radiographic evaluation is essential in all patients with pulsatile tinnitus. Many patients have a treatable underlying aetiology. Early diagnosis and appropriate intervention may save patients from unnecessary morbidity.

The pathogenesis of Ménière's disease is associated with a disorder of ionic homeostasis, with the pathologic correlate being endolymphatic hydrops. Despite uncertainty as to its particular mode of action, it is accepted wisdom that intra-tympanic gentamicin has a definite therapeutic role in the control of symptoms in patients who fail to respond to medical therapy. This study reports an evaluation of the efficacy of intra-tympanic gentamicin in the treatment of Ménière's disease and also presents a simple, reliable, safe method of administering gentamicin for this purpose.

A retrospective review of 56 patients undergoing intra-tympanic gentamicin treatment for Ménière's disease was conducted. Response to treatment was analysed using a patient survey and examination of pure-tone averages. An overall significant improvement in vertigo symptoms of 81.3 per cent was found. There was a 21.4 per cent rate of significant hearing loss, defined as greater than 10 dB, with an average loss in this group of 18.5 dB. A single dose of gentamicin applied directly to the round window resulted in a high rate of control of vertigo, with acceptably low rates of hearing loss.

The aim of this study was to investigate otoacoustic emissions in young adults who had a history of otitis media (OM) in childhood and to assess whether a history of OM had an irreversible effect on hearing. We studied 116 cases between 15 and 25 years of age, divided into three groups. Each subject underwent a single examination comprising otoscopy, pure-tone audiometry (PTA), tympanometry, and transient evoked otoacoustic emission (TEOAE) and distortion product otoacoustic emission (DPOAE) testing. Subjects in the first and second groups had normal audiometric hearing thresholds and type A tympanograms. The only difference between the first and second group was the presence or absence of a history of OM. The third group consisted of patients diagnosed as having active OM; these patients had poorer hearing thresholds and type B or C tympanograms. After statistical analysis of TEOAE and DPOAE results (one-way analysis of variance test), significant differences were noted between groups. Otoacoustic emission levels were, unsurprisingly, lowest in the third group, as expected. However, the most striking result in the study was that significantly fewer otoacoustic emissions were detected in subjects with a history of OM than in subjects without a history of OM. These findings suggest that OM in childhood may cause minor but irreversible damage to the middle ear or cochlea. Otoacoustic emissions testing can be used to detect this sub-clinical damage.

The use of steroids during rhinoplasty to reduce post-operative periorbital oedema and ecchymosis has been advocated. A number of randomized controlled trials have demonstrated the benefit of steroids in rhinoplasty. The aim of this study was to determine current UK practice in the use of steroids during rhinoplasty performed by otolaryngologists.

A postal survey of consultant otolaryngologists in the UK was conducted. We received 203 responses, with 115 consultants performing 12 or more rhinoplasties per year. Only 28 consultants (24 per cent) used steroids routinely in patients undergoing rhinoplasty and of these 11 used a protocol, although this was unpublished. Dexamethasone was the most common steroid used (82 per cent), being administered as a single intravenous dose of 8 mg in the majority of cases (54 per cent). There was no correlation between the use of steroids and the number of rhinoplasties performed by individual consultants.

Despite the evidence supporting the use of steroids to reduce post-operative sequelae following rhinoplasty, only a minority of consultants in the UK appear to use them as part of their practice.

Objective: To establish an olfactory test in the Hong Kong Chinese population. Study design: Prospective analysis of the results of a combined olfactory test (COT) for patients with olfactory dysfunction and for normal subjects attending a secondary and tertiary ear, nose and throat centre.

Method: Our COT was based on and modified from the Connecticut Chemosensory Research Centre test. It consisted of an odour identification test involving nine substances and a threshold test using a series of threefold dilutions of 1-butanol. From September 1998 to June 2002, 188 Hong Kong Chinese patients with olfactory dysfunction and subjects with normal olfaction were prospectively recruited. The subjects were categorized into normal, hyposmic and anosmic groups. The olfactory function of the main group of subjects (n = 153) was assessed with the COT by a blinded observer and also quantified with a visual analogue scale; the results were analysed to validate the discriminative ability of the COT. Another subgroup of subjects (n = 35) was tested with the COT twice with a two-week interval to evaluate test–retest reliability.

Results: There were 42 normal, 68 hyposmic and 43 anosmic subjects within the main group (total n = 153). The identification scores, threshold scores and combined olfactory scores were statistically significantly different between the anosmic, hyposmic and normal groups of subjects (p < 0.001). The combined olfactory score correlated with the visual analogue score and the correlation coefficient was 0.56 (p < 0.01). The mean time spent on each COT was 8.6 minutes (standard deviation = 3.4 minutes). The test–retest reliability of the COT was satisfactory, with a one-way model intraclass correlation coefficient of 0.87 (n = 35).

Conclusion: The satisfactory discriminative ability and test–retest reliability of the COT have been demonstrated in this study. The COT is a feasible method for assessing sense of smell in the Hong Kong Chinese population.

Aims: Acute or subacute haemorrhage is one of the most frightening complications in patients suffering from advanced head and neck cancer. Few articles report experience with superselective endovascular therapy for this purpose. Is endovascular therapy underestimated in the field of palliative head and neck cancer therapy? This study set out to investigate this question.

Patients and methods: A review was undertaken of the clinical courses of seven patients (six men, one woman) suffering from incurable, advanced head and neck cancer (four pharyngeal, two laryngeal, one neck) and treated with superselective endovascular strategies as an emergency procedure for acute bleeding.

Results: All patients were successfully treated without evidence of neurological complication. Patients reached a median survival of 20 weeks (range eight–168 weeks). Following endovascular treatment all patients were discharged from the hospital within several days. Three patients survived almost free of symptoms for several weeks and were able to stay at home with their families until their death.

Conclusion: We conclude that in the field of palliative care, superselective endovascular therapy deserves to be considered alongside standard treatment options for the management of acute haemorrhage from advanced head and neck cancer.

Objectives: To explore the interpretation of words commonly used to describe lumps. Specific words were explored to assess their understandability and implication of threat to the patient.

Methods: A cross-sectional, questionnaire-based study was undertaken. Age, gender, level of education, employment and socio-economic group were determined. The questionnaire explored the following words: malignant, tumour, carcinoma, lymphoma, sarcoma, lipoma, lymph node, nodule, ganglion, benign, cyst and gland. Participants comprised 204 consecutive adult patients attending the ENT out-patient clinic at a Bristol teaching hospital.

Results: Patients found ‘malignant’ and ‘tumour’ the most threatening words and were most unsure of the meaning of ‘sarcoma’ and ‘lipoma’. Nineteen per cent (n = 37) thought a ‘benign’ lump was a cancer. Results did not significantly differ between demographic groups.

Conclusions: A significant misunderstanding of some words commonly used to describe lumps was found. This study provides important guidance on which terms to use and which to avoid in consultations with patients.

Objective: To investigate the efficacy of medical antituberculous treatment in patients with tuberculous cervical lymphadenitis (TCL).

Methods: In the period 1996–2002, 73 TCL patients were reviewed and the results of clinical and laboratory testing were documented. The efficacy of a four-drug chemotherapy regimen was investigated.

Results: Purified protein derivatives (PPD) skin test results were positive in 58 (79 per cent) patients. Chest X-rays revealed changes consistent with tuberculosis in nine (12.3 per cent) patients. The mean duration of medical treatment was 10.04 months. In follow-up evaluation, 14 (20 per cent) patients were considered suspicious for resistant TCL and total excision of all nodes was performed. Histopathology confirmed TB in only 10 of these cases.

Conclusion: The high incidence of residual disease in our study indicates that medical treatment (at least nine months of four combined antituberculous drugs) did not seem to be effective. If lymphadenopathy persists, total surgical excision of lymph nodes should be the treatment of choice.

Introduction: Surgical trainees now receive less operating experience with the reduction in junior doctor hours.

Design: We designed a simple, portable, versatile ‘surgical skills box’ which allowed surgical trainees to practise vascular anastomosis, suturing, tonsil ties, hand ties and grommet insertion.

Discussion: With surgical trainees now receiving reduced operating experience it is more important than ever for them to practise their surgical skills outside the operating theatre environment.

The results of vestibular investigations in a patient with confirmed lateral medullary syndrome are presented. This patient showed a unilateral weakness on caloric testing which has not been reported previously in a patient with lateral medullary syndrome. The case for the possibility of a ‘central’ canal paresis on caloric testing is presented.

The parathyroid glands are small, inconspicuous, and variable in number, colour and position. Their identification is vital for excision of hyper-functioning glands and for preservation of normally functioning ones in patients undergoing thyroidectomy.

Intravenous infusion of methylene blue at a dose of 7.5 mg/kg is commonly used to aid visualization of the parathyroid glands intra-operatively. Methylene blue is generally considered benign, and there are only two cases published in the literature reporting toxicity following intravenous infusion – such toxicity is a diagnosis of exclusion.

We report a case of methylene blue toxicity resulting in expressive aphasia, confusion and disinhibition following infusion for parathyroid adenoma localization. The patient made a complete recovery over 48 hours. Methaemoglobinaemia was excluded as a cause. We suggest that the mechanism of toxicity was a direct effect of methylene blue, although an adverse interaction with serotonin re-uptake inhibitors could not be excluded.

In keeping with the UK National Poisons Information Service recommendations, we have altered our practice and now use methylene blue at a dose not exceeding 4 mg/kg. This has not affected our success rate for identification of parathyroid glands. We report this case to highlight the rare occurrence of methylene blue toxicity when used at a dose of 7.5 mg/kg.

Angiofibromas rarely localize in extranasopharyngeal sites. The most common site for extranasopharyngeal angiofibromas is the maxillary sinus. The ethmoid and sphenoid sinuses, nasal septum, middle and inferior turbinates, conjunctiva, molar and retromolar region, and larynx are other sites where extranasopharyngeal angiofibromas have been reported. Only one case of buccal extranasopharyngeal angiofibroma has been reported to date. We present a case of buccal extranasopharyngeal angiofibroma that was excised completely following embolization and we also review the literature.

Bronchogenic cysts are rare, benign, congenital lesions that occur as a result of aberrant development of the tracheobronchial tree during embryogenesis. They usually present during the first decade of life and are encountered predominantly within the mediastinum or the lung parenchyma. In a few instances, they appear within the neck mimicking a neoplasm and, depending on their size and site, may also cause acute upper respiratory obstruction. We describe a case of two cervical bronchogenic cysts adjacent to the larynx in a child who presented with a hoarse voice.

Congenital epulis or gingival granular cell tumour is a rare lesion occurring in the newborn, affecting females eight times more than males and arising more commonly from the maxillary than the mandibular alveolar ridge. We report the case of a five-day-old girl who presented to us with a large mass arising from the gingival mucosa of the mandible, causing feeding difficulty. Immediate surgical excision was followed by an uneventful recovery. The case is reported to make clinicians aware of this uncommon but easily treatable condition.

Laryngeal tuberculosis is a rare entity and the disease related to laryngeal cancer is extremely rare. We describe a case of laryngeal tuberculosis in a 74-year-old man with a history of radiotherapy for laryngeal carcinoma four months earlier. Laryngoscopy demonstrated a white mass on the right vocal fold at the site carcinoma had previously occupied. Recurrence of the cancer was suspected, but the biopsy result showed histological features of tuberculosis. We discuss the derangement of the host's mucosal barrier by the malignancy as a contributing factor in secondary tuberculous infection. Tubercular bacilli may be reactivated due to the immunosuppression associated with the therapy.

The sarcomatoid variant is a rare subtype of salivary duct carcinoma that comprises epithelial and sarcomatoid components. The authors present the first reported case of sarcomatoid salivary duct carcinoma occurring in the larynx, which was successfully treated by partial laryngectomy with ipsilateral neck dissection, with no evidence of recurrence after five years.

Microscopic analysis revealed a composite epithelial and sarcomatoid tumour. The epithelial component was characterized by papillary proliferation of glandular and ductal structures lined with multilayered epithelial tumour cells. The sarcomatoid component was characterized by pleomorphic spindle cells with cytologic atypia, accompanied by small lymphoid cells, extensive proliferation of blood vessels and focal myxoid changes.

To the best of our knowledge, only one case of sarcomatoid salivary duct carcinoma outside a major salivary gland has been reported previously in the literature, and this is the first report of sarcomatoid salivary duct carcinoma arising from the larynx.