To investigate whether multiple-use Co-phenylcaine Forte® spray was more cost-effective than single-use vials.

A literature review was conducted to determine the risk of cross-contamination associated with multiple-use topical nasal anaesthetic spray. The costs of multiple-use Co-phenylcaine Forte and single-use co-phenylcaine were compared, and potential savings were calculated. The cost of procuring these drugs from other sources was also examined.

Switching to multiple-use Co-phenylcaine Forte spray would lead to at least 40 per cent savings if bought from our local retailer. Potential savings of more than 70 per cent could be made if the drugs were procured from sources other than our local distributor.

Multiple-use Co-phenylcaine Forte spray is safe to use and more cost-effective than single-use vials. This paper illustrates how money can be saved within the National Health Service through changes in drug procurement. Similar cost savings to those calculated for our department could be made in other ENT departments nationally, depending on their annual consumption of co-phenylcaine.

To review the aetiology, investigation, diagnosis, treatment and clinical outcome of children with recurrent croup.

Retrospective case note review of all children with recurrent croup referred to the otolaryngology service at our hospital from November 2002 to March 2011.

Ninety children with recurrent croup were identified. Twenty-five children (28 per cent) had anatomical airway abnormalities, of which 16 (18 per cent) demonstrated degrees of subglottic stenosis. Twenty-three children (26 per cent) had positive microlaryngobronchoscopy findings suggestive of reflux. Eleven children were treated for gastroesophageal reflux disease, 10 (91 per cent) of whom responded well to anti-reflux medication (p = 0.006). No cause was identified for 41 (45 per cent) of the children; this was the group most likely to continue having episodes of croup at follow up. One death occurred in this group.

Airway anomalies are common in children that present with recurrent croup. Laryngobronchoscopy allows identification of the cause of croup and enables a more accurate prognosis. In the current study, laryngobronchoscopy findings that indicated reflux were predictive of benefit from anti-reflux medications, whereas the clinical presentation of reflux was not. Routine measurement of immunoglobulin E and complement proteins did not appear to be helpful.

Cross-sectional imaging can be used to trace the course of the vagus nerve and its laryngeal branches to detect many of the causes of vocal fold paralysis. The most frequent aetiologies are surgical injury and tumoural involvement of the recurrent laryngeal nerve anywhere along its course.

This review article focuses on the uncommon and rare causes of vocal fold paralysis that have been detected or diagnosed on cross-sectional imaging.

Uncommon causes included a tortuous oesophagus, tracheal diverticulum, cervical osteophytes and cardiovocal syndrome. These examples are presented with clinical case histories and radiological appearances, and are discussed in the context of the current literature.

The use of the stapes coupling technique, employed in the Vibrant Soundbridge system, is technically less demanding than the vibroplasty technique, and is more likely to generate a positive outcome without significantly changing residual hearing or resulting in medical or surgical complication.

We report a patient with repeated left ossiculoplasty failure, who was successfully implanted with a Vibrant Soundbridge.

We believe that the stapes coupling technique can provide natural stimulation to the inner ear, resulting in a better perceived sound quality.

To determine the success rate of initial probing in children with congenital nasolacrimal duct obstruction at different ages, using nasal endoscopy.

Fifty eyes of 38 consecutive children with congenital nasolacrimal duct obstruction underwent endoscopic nasolacrimal duct probing under general anaesthesia. Patients were followed up for at least three months. Probing success was defined as complete remission of symptoms and a normal fluorescein dye disappearance test result.

The age range of patients was 17–109 months. The success rates of probing were: 100 per cent (29 out of 29) for cases of stenosis at the lower nasolacrimal duct, 100 per cent (7 out of 7) for functional epiphora cases and 92.86 per cent (13 out of 14) for nasolacrimal atresia cases. Overall, there was only one child for whom the probing treatment for nasolacrimal duct obstruction was not successful; this child had Down's syndrome and a more complex developmental abnormality of the nasolacrimal duct. Age and site of obstruction were not found to significantly affect the outcome of probing.

Probing of the nasolacrimal system using an endoscopic approach allows direct visualisation of the nasolacrimal duct. This can facilitate diagnosis of the anomaly and significantly increase the procedure success rate.

To report a case of sigmoid sinus dehiscence presenting with pulsatile tinnitus and treated successfully with resurfacing.

This patient presented with pulsatile tinnitus due to sigmoid sinus dehiscence. This was successfully treated using only soft tissue resurfacing.

Sigmoid sinus dehiscence is a rare but treatable cause of pulsatile tinnitus. It can occur in the absence of a diverticulum, and is not necessarily limited to the transverse sigmoid junction. When resurfacing, care must be taken not to significantly alter the extraluminal diameter of the sigmoid in a dominant sinus, as this raises the risk of post-operative hydrocephalus.

Congenital lymphatic malformations are a challenging clinical problem. There is currently no universally accepted treatment for the management of microcystic disease. We describe the novel use of an existing technology (radiofrequency ablation, also termed Coblation) for the debulking of paediatric microcystic lymphatic malformations involving the upper aerodigestive tract.

Five children with microcystic or mixed-type lymphatic malformations were included in this retrospective case series.

Each child had a satisfactory outcome following radiofrequency debulking, with improved oral intake and airway symptoms. No serious complications were reported. These findings constitute level IV evidence.

We recommend radiofrequency ablation as a safe, viable alternative to existing techniques for the treatment of paediatric microcystic lymphatic malformations of the upper aerodigestive tract. Radiofrequency ablation achieves effective debulking of microcysts whilst avoiding excessive bleeding and thermal damage to surrounding tissues. This paper constitutes the first report of successful treatment of airway obstruction due to paediatric laryngopharyngeal microcystic disease, using radiofrequency ablation.

Asian patients with laryngeal cancer have been reported to have a high prevalence of thyroid involvement. This study aimed to investigate the prevalence of thyroid invasion in Iranian patients with laryngeal cancer.

Hospital records for all patients with a definite diagnosis of laryngeal cancer between 1996 and 2009 (351 patients) were reviewed, and the prevalence of thyroid invasion was established based on the pathology report at the time of surgery.

Thyroid invasion was found in 16 patients (4.55 percent), and was limited to one thyroid lobe in two-thirds of cases. All instances of thyroid invasion occurred in patients with stage III (81.25 percent) or IV (18.75 percent) cancer. No case of metastasis was reported. The glottic region was identified as the tumour origin in most cases of thyroid invasion (56.25 percent).

Most cases of thyroid invasion by laryngeal cancer occurred in cancer stage III, at grades G1 and G2, among male patients, and arose from tumours of the glottic region.

There is ongoing debate surrounding the roles of surgery and adjuvant radiotherapy in the management of primary and recurrent Merkel cell carcinoma of the head and neck. This study assessed the influence of local excision, margin status, adjuvant radiotherapy and chemotherapy on locoregional recurrence and survival.

A retrospective review of 54 consecutive cases of head and neck Merkel cell carcinoma at a single institution.

Median disease-specific survival time was 120 months. Forty-four per cent of patients developed locoregional recurrence. Combined treatment with surgery and locoregional radiotherapy improved disease-specific survival. Radiotherapy was associated with longer time to recurrence and regional recurrence. Irradiation of the regional nodes improved regional control, irrespective of clinical status. Margin-negative excision was not associated with improved local control. Combined modality treatment of recurrent disease resulted in a four-fold improvement of local control, but small numbers prevented this trend from reaching statistical significance.

Surgical excision of the primary disease and clinically involved regional nodes, plus adjuvant radiotherapy to the surgical bed and regional nodes are recommended for all patients with Merkel cell carcinoma of the head and neck, irrespective of clinical status. Recurrent disease should be aggressively treated with combined modality treatment.

To investigate the risk of contamination of lidocaine hydrochloride 5 per cent weight/volume and phenylephrine hydrochloride 0.5 per cent weight/volume topical solution, both in patients (in vivo) and in the laboratory setting (in vitro).

This paper reports a prospective study involving 10 samples of the lidocaine hydrochloride and phenylephrine hydrochloride topical anaesthetic spray. The samples were assessed for microbiological contamination after a single use on patients in a controlled laboratory environment. Additional samples were assessed for baseline contamination and later assessed for contamination in an in vitro setting.

In the in vivo setting, 2 of the 10 samples were positive for cultures from both the pump and the bottles. However, in the in vitro setting, the pump and the contents of the bottles were contaminated after a single use when the sterile solution was sprayed from distances of 1 and 2 cm.

The lidocaine hydrochloride and phenylephrine hydrochloride topical solution assembly was contaminated in both in vivo and in vitro settings after a single use.

Chondrodermatitis nodularis chronica helicis is a common benign condition of the pinna. It presents as a painful, well demarcated nodule on the pinna that may be associated with surrounding erythema or an overlying crust.

This paper describes techniques for the excision of chondrodermatitis nodularis chronica helicis on both the helix and anti-helix, and reconstruction of the defect.

Both methods give an excellent cosmetic result and can be performed under local anaesthetic. Excising and smoothing down the cartilage decreases the likelihood of recurrence as a smooth contour to the ear is achieved.

Tonsillectomy is a common operation performed in children and young adults. Pain and post-operation haemorrhage are its most common complications. This study was designed to evaluate the efficacy of topical antibiotics in reducing throat pain after tonsillectomy in adult patients.

A double-blind, placebo-controlled, randomised clinical trial was conducted, enrolling 30 patients older than 18 years who were scheduled to undergo tonsillectomy. Patients were randomly assigned to receive either clindamycin or normal saline (as placebo). Throat pain severity was evaluated using a visual analogue scale.

All patients in both groups had experienced a reduction in pain by the seventh day after surgery. There was no statistically significant difference in the extent of visual analogue scale pain score reduction, comparing the placebo and clindamycin groups throughout the study course (p = 0.424).

Topical clindamycin was not demonstrated to be more effective than normal saline in the reduction of throat pain following tonsillectomy in adults.

Gaucher's disease is a rare autosomal recessive lysosomal storage disease. We describe a unique case of middle-ear involvement presenting with hearing loss.

A five-year-old boy with known Gaucher's disease presented with bilateral hearing impairment and conductive hearing loss on pure tone audiometry with flat tympanometry traces.

Exploratory Tympanomastoidectomy revealed inflammatory material filling the mastoid and the middle ear. Histological analysis confirmed Gaucher cell infiltrates.

This is the first detailed report in the english language literature of Gaucher's disease affecting the middle ear and the mastoid. We discuss the disease process and suggest future management options.

The head and neck region is the second most frequent anatomical site of extranodal lymphomas. These tumours affect many individuals worldwide, justifying epidemiological studies in different countries. This study evaluated the characteristics, treatments and prognostic factors for non-Hodgkin's lymphoma of the head and neck in Chinese patients.

The clinical manifestations, clinicopathological characteristics, multidisciplinary treatment and prognostic factors for 102 patients with extranodal non-Hodgkin's lymphoma of the head and neck were analysed retrospectively.

The tonsil was the most commonly involved primary site, followed by the nasal cavity. The most common histological subtype was diffuse large B-cell lymphoma, followed by natural killer T-cell lymphoma. Patients receiving a combination of rituximab and chemotherapy did better than those receiving chemotherapy alone. Prognosis was significantly associated with both International Prognostic Index and histological subtype; the former was especially strongly associated with poor survival.

In this group of Chinese patients, diffuse large B-cell lymphoma was the most common pathological subtype, but the incidence of T-cell lymphomas was higher than that reported in the USA. Combined rituximab and chemotherapy led to better outcomes than chemotherapy alone. Prognosis depended on both International Prognostic Index and histological subtype.

Patients with enlarged lymph nodes present to a number of different specialties and diagnosis is often made following a biopsy.

This study aimed to establish department waiting times for cervical lymph node biopsy, and compare these to the cancer services guidelines.

A retrospective audit was carried out to record patient waiting times (defined as the number of days from referral to biopsy) between May and December 2010. A proforma for referral was introduced. In addition, appointments for biopsies were arranged by a co-ordinator. A prospective re-audit was carried out from March to September 2011.

The first audit showed that national guidelines were not met; there was a median waiting time of 74 days (interquartile range, 47–113). Re-audit demonstrated a significant reduction in waiting times using the proforma; the median waiting time had decreased to 18 days (interquartile range, 9–22).

A proforma for lymph node biopsy and a designated co-ordinator streamlined the service, significantly reducing waiting times. Together, these can aid referral for meeting guidelines and improve patient care.

Direct skin involvement of nodal metastasis from mucosal head and neck squamous cell carcinoma has traditionally been considered a poor prognostic indicator.

This retrospective review identified eight patients (five with mucosal upper aerodigestive and three with occult primary squamous cell carcinoma) who presented between 2000 and 2007 with direct skin involvement of nodal metastasis.

Five patients were treated with extended radical and three with extended modified radical neck dissection. Closure was achieved directly (four cases), with local (two) or pedicled (two) flaps. Surgery was always followed by radiotherapy (pan-mucosal or to the primary site). The five-year recurrence-free and disease-specific survival rates were 100 per cent.

It is exceptionally rare to encounter direct skin involvement of metastatic lymph nodes from mucosal head and neck squamous cell carcinoma without evidence of involvement of other anatomical structures. Surgical intervention is possible and combined modality treatment with curative intent is essential, as most patients can have a favourable outcome.

Petrous apex aspergillosis is an uncommon and dangerous condition, with only four previously reported cases. As with other forms of petrous apicitis, the clinical symptoms are often non-specific and this contributes to diagnostic delay. This paper presents the first reported case of Aspergillus petrous apicitis associated with an intracranial or nasopharyngeal abscess.

A 72-year-old man with chronic otorrhoea developed neuralgic headaches and progressive lower cranial nerve palsies despite antibiotic therapy. Imaging revealed petrous apicitis, a temporal lobe abscess and nasopharyngeal abscess. Analysis of biopsy tissue indicated invasive aspergillosis. The patient recovered on a protracted course of voriconazole in addition to medium-term antibiotic therapy.

Invasive fungal disease should be considered early in the course of skull base osteomyelitis that is clinically unresponsive to empirical broad spectrum antibiotics. This paper highlights the role of tissue biopsy in diagnosis, and the efficacy of voriconazole therapy without the need for radical surgery.

To introduce the application of confocal endomicroscopy during microlaryngoscopy, to enable intra-operative evaluation of human laryngeal epithelium.

A rigid endoscope was connected to the scanner head of a Heidelberg Retina Tomograph II confocal laser scanning system via an adapter. The endoscope was gently placed on the surface of a vocal fold through a laryngoscope during microlaryngoscopy.

The application of confocal endomicroscopy using a rigid endoscope enabled technical improvements (i.e. improved image quality, automatic volume scan, and reduced tissue pressure due to the presence of a perforation plate with central hole at the end of the endoscope) which permitted greater sensitivity and improved handling. Confocal endomicroscopy provided good quality, in vivo, en-face images and enabled an assessment of laryngeal epithelium volume.

This method enables the surgeon to monitor epithelial changes in pre-malignant lesions. The combination of confocal endomicroscopy together with optical coherence tomography (as a complementary technique that provides optical cross-sections) should be further explored in a formal clinicopathological study.