Cervical lymphadenectomy of level II encompasses lymph nodes associated with the upper internal jugular vein and the spinal accessory nerve (SAN). Removal of tissue superior to the SAN (submuscular recess-(SMR)) was recently shown to be unwarranted in selected cases of squamous-cell cancer. Thirtyfive patients with non-squamous-cell cancer (SCC) of the head and neck treated with cervical lymphadenectomy were prospectively evaluated. Thirty-seven neck dissection specimens were histologically analysed for the number of lymph nodes involved with cancer. At the time of surgery, level II was separated into the supraspinal accessory nerve component (IIa) and the component anterior to the SAN (IIb).

Neck dissections were most commonly performed for cancer of the thyroid gland (19) followed in frequency by the parotid gland (seven), skin: melanoma (five), basal-cell cancer (two), and other sites (four). Twenty-five neck dissections were modified-selective procedures and 12 were either radical or modified radical neck dissection. Twenty-nine necks were clinically N+ and eight N0. Histological staging was pathologically N+ in 32 neck dissection specimens. Level IIb contained an average of 12 nodes and the IIa component contained a mean of 5.0 nodes. Level II contained metastatic disease in 28 of 32 histologically node-positive specimens (87 per cent). Level IIa was involved with cancer in six cases (16 per cent), five of which were pre-operatively staged as clinically N+. All cases (100 per cent) with level IIa involvement had level IIb positive nodes. Three of the level IIa positive cases were cancer of the parotid gland comprising 43 per cent of this sub-group of patients.

Incidence of involvement of SMR in non-SCC cases is not uncommon. The additional time required and morbidity associated with dissection of the supraspinal accessory nerve component of level II are probably justified when performing neck dissection in cancer of the thyroid gland. The SMR should be excised in cancer of the parotid gland. Large-scale prospective controlled studies with long-term follow-up periods are necessary to support resection of level IIb only.

Diffuse infiltration of the meninges by metastatic carcinoma (meningeal carcinomastosis) is a potential complication of systemic malignancy. It may present with a variety of neurological symptoms as any aspect of the neuraxis can be affected. Often there is a history of pre-existing malignancy.

The authors describe a case with an initial presentation of sudden onset profound bilateral sensorineural hearing loss. The underlying pathology was found to be an occult breast carcinoma, a previously unreported finding.

The role of cerebrospinal fluid cytology and radio-imaging in diagnosis is discussed. All previously reported cases of sudden hearing loss and meningeal carcinomatosis are reviewed.

Nasal bleeding is one of the commonest emergencies that place medical staff at risk of blood contamination during management. A sizeable proportion of incidents have been reported where blood splashes in the facial area caused such contamination, and the exposed conjunctivae are potential sites for transmission of human immunodeficiency viruses (HIV). We present a simple self-made device named the ‘Double Bag’, which is highly effective in preventing blood spraying during the management of epistaxis. It was designed to be used while treating epistaxis or removing nasal packing after surgery, when transient bleeding is expected.

We describe a simple and easily adjustable method of retracting skin flaps during head and neck surgery. It involves the use of a modified fish hook and rubber band. The retractor is easily applied and adjusted, and inexpensive to manufacture.

Mite infestation of the ear is an unusual clinical problem that is easily cured with simple measures and recurrent infestation has not been reported till date. We present here a patient who developed recurrent infestation of otherwise healthy mastoid cavities with the storage mite Caloglyphus berlesei, secondary to occupational exposure. This kind of recurrent mite infestation of the ear has not been described before.

Although some form of commercial instrument mounting arm is available, a paucity of information in the literature may cause problems in selecting the most appropriate model for an ENT department wishing to trial their invention for use in the clinic or operating theatre.

The instrument mounting arm described here is based on existing designs used by hobbyists and model makers for many years but the main benefit of this innovation is its multi-purpose use in the operating theatre and cost effectiveness since it is made of aluminum alloy. It is compact, stable and easily adjustable and can incorporate an endoscope holder or an operating end piece to mount various ENT instruments that offers considerable advantages to the unassisted operator.

Second primary malignancies pose a significant clinical challenge to the head and neck oncologist. The prognosis for these patients is poor and therefore early detection of these tumours is essential. There are considerable differences in the reported cohorts of patients and the biological behaviour of these tumours throughout the world literature. This is particularly marked when there is considerable demographic variation present.

The behaviour of second primary malignancies in 425 Irish patients with head and neck cancer was reviewed retrospectively. The overall incidence of second cancers was 8.5 per cent. There were a higher proportion of oral cancer patients 47 per cent, the second cancers overall presented with a more advanced T stage, and the overall five-year survival was much lower than that of the index tumour.

We describe a modification of an instrument readily available on a standard basic ENT instrument set that can be utilized for the cessation of troublesome haemorrhage following curettage adenoidectomy.

The clinical notes of all new patients with T1 squamous cell carcinoma of the glottis seen in one head and neck cancer unit between 1989 and 1996 were reviewed. Fifty-three patients were treated with radical radiotherapy and of these 42 (79.2 per cent) had no loco-regional recurrence, after a median follow-up of seven years. Eleven (20.8 per cent) developed local recurrence and were treated with salvage surgery. Fourteen of the 53 (26.4 per cent) tumours involved the anterior commissure and eight of these 14 (57.1 per cent) developed recurrence, whereas only three of the 19 (15.8 per cent) tumours arising from the anterior half of the fold but not involving the anterior commissure had recurrence. None of the remaining tumours recurred. This difference is statistically significant (p<0.001). Anterior commissure involvement is a predictor of poor response to radiotherapy. This may be the result of understaging as none of the cases had computed tomography (CT) scans performed. Technical radiotherapy factors may also be important, although in all cases of anterior commissure involvement steps were taken to ensure adequate radiation dose to this region.

Facial schwannoma is a relatively rare but well documented lesion, presenting either as a mass or with facial nerve symptoms. In this report, an extensive facial schwannoma, extending from the brain stem to the periphery with minimal facial nerve symptoms and normal facial function is presented.

Wegener’s granulomatosis is a systemic disease characterized by a granulomatous lesion that can affect any organ throughout the body.

This case-report illustrates the problem posed by a patient presenting with bilateral serous otitis media with marked sensorineural hearing loss, facial nerve paralysis and an atypical serological picture. The importance of early diagnosis and the protocol for the management of a patient with an uncertain diagnosis is discussed. Due to atypical presentations, only a high index of suspicion will ensure an early diagnosis.

An extremely rare case of bilateral antrochoanal polyp in an otherwise fit 12-year-old girl is reported. The antrochoanal polyps were removed by bilateral Caldwell-Luc operation. Histopathological examination showed them to be of benign inflammatory nature.

Mitochondrial DNA (mtDNA) defects are responsible for symptom complexes that are characteristically heterogeneous but are typically represented by muscle weakness and neurological deficits. One common feature of mitochondrial disease is deafness. This report details the assessment and outcome of a patient with a previously undescribed mtDNA rearrangement who underwent cochlear implantation. The patient shows a marked improvement in sentence recognition tests and recognition of environmental sounds. Patients with profound sensorineural hearing loss due to mtDNA defects should be considered as candidates for cochlear implantation when they no longer benefit from conventional hearing aids.

A minimum dataset for recording of findings during myringotomy and ventilation tube insertion for cases of otitis media with effusion is presented. With increasing pressures on surgeons to audit existing practices and hence improve standards of health care, it is appropriate to produce such a set of guidelines for a surgery that is frequently performed world-wide. We believe that the data presented is not too exhaustive and can be readily incorporated into the operative notes.

Abstract Several studies have indicated that a number of different mitochondrial DNA (mtDNA) mutations may be responsible for human pathologies. Sensorineural Hearing Loss (SNHL) may be associated with known syndromes (syndromal SNHL) or represent the only manifestation of mitochondrial damage (non-syndromal hearing loss). Moreover, mtDNA alterations may be responsible for aminoglycoside-induced deafness.

We describe a patient harbouring a single sporadic mtDNA deletion, who presented with sudden adult-onset bilateral, although non-simultaneous SNHL, that was partially responsive to corticosteroids. Increased values of rest, and exercise, blood lactic acid were decisive for diagnosis, prompting muscle biopsy that revealed the mtDNA deletion. The case underscores the importance of investigating a mitochondrial disease in cases of SNHL of unknown origin and points out the importance of an increased blood level of lactic acid as a screening test.

We describe a method for performing secondary tracheo-oesophageal puncture in patients who have undergone total laryngectomy. The technique is straightforward and easy. It uses a minimum of readily available equipment with a simple modification to a standard pharyngoscope.

A case is presented of an entirely intracanalicular meningioma in a 48-year-old woman that was excised via a conventional translabyrinthine approach to the internal auditory canal (IAC). Pre-operative magnetic resonance imaging (MRI) suggested that the tumour was a vestibular schwannoma (VS). Histological examination confirmed the intra-operative impression that the tumour was a meningioma. Although VS is by far the commonest intracanalicular tumour, the differential diagnosis includes meningioma. MRI is unable to distinguish between these two entities when the tumour is located entirely in the internal auditory canal.

Relapsing polychondritis is a rare condition characterized by inflammation and subsequent degeneration of cartilages. Deformity of the pinna, nasal saddling and stridor due to involvement of the cartilages of the respiratory tract may lead to patients being referred to the otolaryngologist for initial assessment and further management. Recent observations have suggested that relapsing polychondritis may occur as a paraneoplastic phenomenon in cases of myelodysplasia. The case of a patient with relapsing polychondritis, myelodysplastic syndrome and a monoclonal gammopathy is presented. The authors highlight the apparent existence of this association and encourage otolaryngologists to consider such possible links when cases of relapsing polychondritis present to the outpatients department.

Endoscopic endonasal dacryocystorhinostomy (EDCR) has established itself as a popular means of relieving post-saccal obstruction of the naso-lacrimal ducts. Soft tissue stenosis of the rhinostomy is a significant cause of long-term failure. We describe the technique of using a standard otological T-tube as a cheap and easy self-retaining stent to ensure a patent rhinostomy following EDCR.