Aim: To establish the diagnostic accuracy and adequacy of fine needle aspiration cytology (FNAC) within a regional cancer network, and to determine what service improvements may be required to allow successful implementation of an FNAC-based, ‘one-stop’ head and neck clinic, as proposed by the current National Institute for Clinical Excellence guidelines.

Materials and methods: The Sussex cancer network serves a population of 1 200 000 and contains five hospitals within three acute trusts. In 2004, an audit was undertaken retrospectively to examine the diagnostic adequacy and accuracy of head and neck FNAC across the network. Comparisons were then made with the results of subsequent relevant surgery. For the purposes of the audit, FNAC was subdivided into three main groups: salivary gland, thyroid gland and neck node. As part of the data analysis, we also noted the clinical source of the FNAC and whether it was performed blind or under image guidance.

Results: In 2004, 712 FNAC procedures were undertaken in 647 patients, 276 of whom underwent subsequent surgery. Fine needle aspiration cytology was non-diagnostic in 52 per cent of patients in the neck node group, in 50 per cent in the salivary gland group and in 30 per cent in the thyroid group. With these non-diagnostic results removed, statistical analysis was performed on data from those patients who had undergone both FNAC and subsequent surgery. This gave a sensitivity of 89 per cent and a specificity of 57 per cent in the neck node group, a sensitivity of 64 per cent and specificity of 100 per cent in the salivary gland group, and a sensitivity of 62 per cent and specificity of 86 per cent in the thyroid group. Diagnostic problems with FNAC were noted, particularly in the differentiation of reactive nodal hyperplasia from lymphoma and in diagnosing follicular thyroid lesions. Ultrasound guidance was used in 50 per cent of the thyroid FNAC procedures but in only a minority of patients in the neck node and salivary gland groups.

Conclusion: This audit demonstrated widespread diagnostic difficulties associated with head and neck FNAC in a large patient sample. It is likely that these problems will be mirrored in other cancer networks. In order for one-stop head and neck clinics to succeed, the non-diagnostic rate of FNAC in particular must be minimised. There are strategies to enable this, depending on local resources, including increased access to cytologists or cytology technicians, diagnostic ultrasound, image guidance for FNAC and the use of ultrasound-guided core biopsy.

Background: Nonattendance for appointments is an impediment to otolaryngology patient care worldwide. In a previous study of children attending an otolaryngology clinic, we observed that attendance was determined by the waiting time for an appointment and the timing of the appointment within the day. However, the factors that affect nonattendance in adults have not been well studied.

Objective: We aimed to investigate factors associated with nonattendance in adults visiting an otolaryngology clinic.

Methods: Nonattendance was observed for a period of one year in adult patients visiting an ambulatory otolaryngology clinic. The following parameters were also noted: age, gender, treating physician, waiting time and timing of the appointment. The chi-square test was used to analyse differences between categorical variables. The t-test was used to analyse differences between continuous variables. Logistic regression was used for multivariate analyses.

Results: The study assessed 8071 visits to the otolaryngology clinic. The overall proportion of nonattendance was 27.7 per cent. A multivariate logistic regression model demonstrated that nonattendance was significantly associated with the following factors: female gender, younger age, long waiting time for an appointment, timing of the appointment within the day and the treating physician.

Conclusion: In adult otolaryngology patients, nonattendance was associated with patient-related factors and healthcare systems related factors alike. It is suggested that managed overbooking could be carefully introduced into otolaryngology patient scheduling.

More than 200 techniques have been described for correction of prominent ears, indicating that there is no single, widely accepted procedure that has been adopted by most surgeons. This article presents a simplified surgical method for correction of prominent ears. One hundred and twenty-eight otoplasties were performed on 70 patients using the described technique. The main modification of the technique was the use of a diamond burr drill to thin the cartilage posteriorly. Good aesthetic results were obtained in most patients.

Background: Bacterial biofilms identified in various medical devices used in otorhinolaryngology, including tympanostomy tubes, voice prostheses, and cochlear implants, can directly colonise mucosal tissues. The upper airways seem to be at high risk for this type of colonisation. Chronic and/or recurrent upper airway infections may be related to the complex structural and biochemical (quorum sensing) organisation of the biofilm which interferes with the activity of antibiotics (including those with proven in vitro efficacy), thus promoting the establishment of a chronic infection eradicable only by surgical treatment. Biofilm formation plays a role in upper respiratory infections: it not only explains the resistance of these infections to antibiotic therapy but it also represents an important element that contributes to the maintenance of a chronic inflammatory reaction.

Objectives: To document the presence of biofilms in surgical tissue specimens from patients with recurrent infection diseases, and identify their possible role in the chronicity of these infectious processes.

Method: We examined 32 surgical specimens from the upper respiratory tract (tonsils, adenoids, mucosa from the ethmoid and maxillary sinuses) of 28 patients (20 adults, eight children) with upper airway infections that had persisted despite repeated treatment with anti-inflammatory agents and antibiotics with demonstrated in vitro efficacy. Tissues were cultured using conventional methods and subjected to scanning electron microscopy for detection of biofilm formation.

Results: Over 80 per cent (26/32; 81.3 per cent) of the tissue specimens were culture-positive. Bacterial biofilms (associated in most cases with coccoid bacteria) were observed in 65.6 per cent of the tissue samples.

Aim: To compare voice performance following Bioplastique™ injection with that following Isshiki thyroplasty.

Measures: A 12 item, self-reported voice performance questionnaire was completed and observer-rated perceptual voice analysis scores were also measured, before and after Bioplastique injection, for 14 patients. Results were compared with our previously reported outcomes for 28 thyroplasty patients.

Results: Only 14 of 30 patients had complete datasets. For these patients, the mean pre-operative voice performance questionnaire score improved significantly, from 40.3 to 18.9 (p=0.002, Wilcoxon test). All perceptual analysis parameters showed significant improvement. These results compare favourably with the thyroplasty cohort (mean voice performance questionnaire score: pre-operative 35; post-operative 18; p<0.001). One Bioplastique patient developed contralateral paresis, requiring partial removal of the material 18 months later. Two thyroplasty patients experienced complications and three required revision.

Conclusions: Both Bioplastique injection and Isshiki thyroplasty resulted in a significant improvement in both subjective and perceptual voice performance. Our data suggest that the effect size of the two interventions is approximately similar (in nonrandomised cohorts of surviving patients). As in many similar studies, the incomplete follow-up data reflect severe comorbidity. Bioplastique injection is a quicker procedure associated with fewer complications, and thus appears superior to framework surgery in patients with limited life expectancy.

The aim of this study was to prospectively evaluate post-operative cessation of bleeding and late recurrence of epistaxis in a cohort of patients treated by endoscopic ligation of the sphenopalatine artery. Participants comprised patients undergoing sphenopalatine artery ligation for posterior epistaxis at three east Scotland hospitals. Main outcome measures were recurrence of epistaxis in the immediate post-operative period and at long-term follow up (minimum nine months). Forty-three patients (30 men and 13 women) underwent 45 procedures; two patients underwent bilateral ligation. Two patients suffered recurrence as in-patients. Two patients experienced subsequent epistaxis requiring medical treatment. Two further patients suffered minor late epistaxis not requiring treatment. Success in preventing significant recurrence was 93 per cent. All recurrences requiring intervention occurred within one month of surgery. None of the patients in this series reported nasal complications. We found sphenopalatine artery ligation to be an effective means of achieving long-term control of posterior epistaxis.

Concerns that a largely anecdotal increase in post tonsillectomy haemorrhage rates was related to the introduction of disposable instruments have prompted much investigation. The result has been, rather, to highlight other variables influencing this risk, but especially to insist on the following:

1. 1 Training in traditional ‘cold’ techniques.

2. 2 Regular departmental audit of haemorrhage rates.

3. 3 Presentation of such data to patients to ensure informed consent.

This audit demonstrates the pitfalls in interpretation of crude data, unadjusted for case-mix, in predicting individual patient risk and in national ranking of unit performance.

The importance of an adequate meatoplasty is often emphasised in mastoid surgery. However, bigger is not always better, as an excessively widened external meatus can be cosmetically unacceptable, provide little extra benefit for cleaning, be an obstacle to the good fitting of hearing aids and expose the mastoid cavity to exaggerated caloric effect.

The problems created by an overly large meatus can occasionally be difficult to manage, prompting consideration of reduction of the meatus. We describe the use of a pedicled, post-auricular skin flap to achieve reduction of an excessively large meatus.

Objective: With improvement in economic and social conditions and the use of effective anti-tubercular therapy, the developed nations, and most developing nations, have enjoyed a decline in tuberculosis for several decades. It is now seen that extra-pulmonary presentations form a major proportion of new cases, especially since the advent of the acquired immunodeficiency syndrome epidemic. Therefore, it is important that otolaryngologists are aware of tuberculosis in the head and neck region and its varied manifestations. We report the increased incidence of isolated head and neck tuberculosis, its various presentations and clinical manifestations over a 10-year period.

Materials and methods: A 10-year (1995–2004), retrospective study was undertaken by the department of otolaryngology and head and neck surgery, Kasturba Medical College, and its allied hospitals, Mangalore, South India, involving a group of 165 patients with head and neck tuberculosis. Each patient underwent a detailed clinical examination and a battery of investigations. Most patients were treated with anti-tubercular therapy alone; others required surgical intervention followed by Anti-tubercular therapy (ATT). In addition, those with human immunodeficiency virus infection or malignancy were treated with anti-retroviral therapy and radiotherapy, respectively.

Results: Of the 165 cases, 121 (73.3 per cent) had isolated tubercular lymphadenitis, 24 (14.5 per cent) had laryngeal tuberculosis, four (2.4 per cent) had tubercular otitis media, three (1.8 per cent) had tuberculosis of the cervical spine, three (1.8 per cent) had tuberculosis of the parotid, eight (5 per cent) had tuberculosis of the oral cavity, one had tuberculosis of the temporo-mandibular joint and one had tuberculosis of the nose. Fine needle aspiration cytology was highly effective in the diagnosis of tubercular lymphadenitis (92 per cent) but not so for other sites. The purified protein derivative (PPD) test was positive in only 20 per cent of cases. Pus for culture and sensitivity was positive only in caries of the spine and mandibular tuberculosis. Excision biopsy and histopathological examination were required to make a diagnosis in tuberculosis of the oral and nasal cavities, salivary glands, ear, temporo-mandibular joint, and mandible. There were 40 cases (24.2 per cent) with coexisting pulmonary tuberculosis and five cases (3 per cent) with coexisting malignancy. Of the 65 patients who were tested, 30 per cent were found to have coexisting human immunodeficiency virus infection.

Conclusion: In addition to cervical lymphadenitis, tuberculosis in the head and neck region can produce isolated disease in the oral cavity, ear, salivary glands, temporo-mandibular joint, nose and larynx. Seventy-five per cent of our head and neck tuberculosis patients did not have pulmonary involvement. Fine needle aspiration cytology was highly effective in the diagnosis of nodal tuberculosis, but histopathological examination was required to make the diagnosis in other head and neck sites. The PPD test was not effective as a diagnostic tool. If the otolaryngologist maintains a high index of suspicion, an early diagnosis can be made with the help of simple investigations. Successful outcome depends upon appropriate chemotherapy and timely surgical intervention when necessary.

In this study, we aimed to precisely define the patterns of allelic loss at the FRA3B site in endemic nasopharyngeal carcinoma and to determine whether an association exists between allelic loss, clinicopathological features and Epstein–Barr virus infection.

We examined the loss of heterozygosity in 40 cases of nasopharyngeal carcinoma from an endemic area in southern China, using eight high dense, polymorphic, microsatellite markers within or flanking the FRA3B site.

Loss of heterozygosity at the FRA3B region was shown in 31 (77.5 per cent) primary tumours. Loss of heterozygosity was found most frequently at the D3S1300 (55.6 per cent) and D3S2757 (50.0 per cent) loci. The common area of deletion was located between the D3S4103 and D3S4260 loci. In nasopharyngeal carcinoma, loss of heterozygosity at the FRA3B/fragile histidine triad locus correlated with the following clinicopathological parameters: tumour T-stage, lymph node status, clinical stage, tumour differentiation and serum antibody titres of immunoglobulin (Ig) A against Epstein–Barr virus capsid antigen. Significantly frequent loss of heterozygosity was observed in nasopharyngeal carcinoma with tumour stages T3 and T4, lymph node metastasis and advanced tumour–node–metastasis staging (III and IV). Very frequent loss of heterozygosity was also observed to correlate with World Health Organization type III nasopharyngeal carcinoma histopathology. We also found that nasopharyngeal carcinoma patients with high titres of IgA against Epstein–Barr virus capsid antigen showed very frequent loss of heterozygosity.

Allelic loss at the FRA3B site occurs significantly more commonly in endemic nasopharyngeal carcinoma patients. This suggests that the region between D3S4103 and D3S4260 may represent a preferential molecular target in nasopharyngeal carcinogenesis.

A postal survey of 500 general practitioners (GPs) in south-west England was undertaken to evaluate the levels of undergraduate and postgraduate otolaryngology training and/or experience received by GPs in that area. Most GPs had received two weeks of undergraduate training in ENT, which had involved no formal assessment. Three-quarters of GPs considered this inadequate. A quarter of GPs had completed a hospital post in ENT prior to entering general practice, most of which lasted three months. Sixty-one per cent of GPs had received some formal postgraduate training in ENT, in the form of courses, lectures or hospital training sessions. Almost half of the GPs considered this inadequate. Seventy-five per cent of GPs stated they would like further training in ENT. Subjective estimates of referral rates to hospital ENT specialist clinics varied considerably.

This study illustrates the variability and level of dissatisfaction regarding ENT training amongst GPs at both undergraduate and postgraduate levels.

Parotid abscess is an uncommon complication of suppurative infection of the parotid gland parenchyma, commonly bacterial or viral. Ductal ectasis, primary parenchymal involvement, or infection of the intraparotid or periparotid lymph nodes can result in abscess formation. Parotid abscess may arise from ductal ectasis, primary parenchymal involvement, or infection of the subcapsular lymph nodes.

The operative records for all the patients who underwent surgeries in the Department of Otorhinolaryngology, Head and Neck Surgery of the National University Hospital, Kuala Lumpur, Malaysia between January 2001 and December 2005 were retrospectively reviewed. Our case series comprises 15 patients, with 10 males and five females with a median age at presentation of 51 years old. Diabetes mellitus is a significant comorbid factor, with six patients being diabetics. Among the diabetics, two patients presented with facial nerve palsy and one of them also died due to overwhelming septicaemia. Here, we discuss the presenting symptoms, predisposing factors, investigations, microbiology and complications of this condition.

Background: Brushing cytology is a well established diagnostic procedure used by gynaecologists, physicians and surgeons to obtain representative samples from lesions. Our aim was to evaluate its reliability in ulcerative and tumour-like conditions arising in the skin of the head and neck.

Methods: Over 28 months, 86 patients with suspected cutaneous malignant lesions underwent a cytological examination with a cytobrush within the otolaryngology department.

Results: Cytological analysis identified 63 out of 64 histologically documented malignant tumours (60 primary basal cell and squamous cell carcinomas and three metastatic adenocarcinomas), and 21 out of 22 benign lesions. There was one false positive and one false negative result.

Conclusions: Brushing cytology of suspected cutaneous malignant lesions is a rapid and reliable diagnostic method which helps the clinician to decide on appropriate planning and treatment. The technique can be performed as an out-patient procedure, and smear preparation can be done in the laboratory, even at a peripheral hospital.

A new image-guided microscope using augmented reality overlays has been developed. Unlike other systems, the novelty of our design consists in mounting a precise mini and low-cost tracker directly on the microscope to track the motion of the surgical tools and the patient. Correctly scaled cut-views of the pre-operative computed tomography (CT) stack can be displayed on the overlay, orthogonal to the optical view or even including the direction of a clinical tool. Moreover, the system can manage three-dimensional models for tumours or bone structures and allows interaction with them using virtual tools, showing trajectories and distances. The mean error of the overlay was 0.7 mm. Clinical accuracy has shown results of 1.1–1.8 mm.

Objective: To review the results of surgical management of chronic parotid sialadenitis refractory to medical therapy, with particular respect to long-term symptom resolution and development of post-operative complications.

Methods: A retrospective review of parotidectomies performed for chronic intractable parotid sialadenitis. Information was collected about presentation, pre-operative investigations, surgical treatment, post-operative complications and outcome.

Results: 36 parotidectomies were performed for chronic sialadenitis between 1991 and 2002. Age at presentation was 56±9.6 years, with median symptom duration of 2.3 years. For patients with non-specific presentations, magnetic resonance imaging (MRI) was the most useful pre-operative investigation. Superficial parotidectomy with duct preservation was the main treatment with a 94 per cent success rate, and near-total parotidectomy was reserved for patients with extensive deep-lobe involvement. Duct ligation significantly increased the risk of transient facial palsy. There was a 56 per cent and 22 per cent incidence of temporary facial paresis and Frey's syndrome, respectively.

Conclusions: Controversies exist regarding the optimal pre-operative investigation and surgical treatment of chronic parotid sialadenitis. We advocate magnetic resonance image (MRI) scanning for patients with non-specific symptoms of sialadenitis, and sialography in the presence of reasonable clinical suspicion. We propose superficial parotidectomy without parotid duct ligation as the standard of care, with near-total parotidectomy reserved for extensive deep-lobe disease.

Objective: Analysis of the correlation between telomerase and the expression of its related proteins may provide insight into the molecular mechanism of nasopharyngeal carcinogenesis. We investigated the effect of short hair pin ribonucleic acid (RNA) specific for human telomerase reverse transcriptase messenger RNA on the expression of the proteins c-myc (the transcription factor c-myc is a shortlived nuclear phospho-protein involved in cell proliferation and differentiation, belongs to the myc family), proliferating cell nuclear antigen and Caspase-3 in nasopharyngeal carcinoma cells.

Methods: Short hairpin RNA expression vectors targeting the messenger RNA of human telomerase reverse transcriptase were constructed. Cells were treated with the short hairpin RNA expression vectors targeting human telomerase reverse transcriptase or vectors that included mismatched short hairpin RNA, and telomerase activity was measured by telomeric repeat amplification enzyme-linked immunosorbent assay. Cell viability was examined using the 3-(4,5-dimethyl thizol-2-yl) 2,5-diphenyl tetrazolium bromide assay. The expression of the three proteins (c-myc, proliferating cell nuclear antigen and Caspase-3) was determined by Western blotting.

Results: Short hairpin RNA specific for human telomerase reverse transcriptase messenger RNA significantly inhibited telomerase activity. In addition, the expression of and proliferating cell nuclear antigen were both inhibited, while the expression of Caspase-3 was up-regulated.

Conclusions: Our results suggest that short hairpin RNA directed against human telomerase reverse transcriptase inhibits cell viability by regulating telomerase activity and its related proteins expression in nasopharyngeal carcinoma cells. Therefore, RNA interference technology may be a promising strategy for the treatment of nasopharyngeal cancer.

Objective: We report an extremely rare case of family clustering of cholesteatoma.

Method: Case reports and a review of the world literature concerning cholesteatoma and heredity are presented.

Results: The family consists of parents and seven siblings of whom the mother and three sons have been surgically treated for cholesteatoma. All cholesteatomas in the family are acquired and all have a history of otitis media. Cholesteatomas occur with an incidence of 5/100 000 in Greenland, corresponding to two to three new cholesteatoma patients per year among the 57 000 inhabitants of Greenland. The family is very exceptional and interesting for further research concerning heredity in the pathogenesis of acquired cholesteatoma.

Conclusion: To our knowledge this is the first report in the world literature of family clustering of acquired cholesteatoma. This case indicates that hereditary factors interplay with other factors in the pathogenesis of cholesteatoma.