To investigate reasons for prolonged hospitalisation of children with tracheostomies once they are medically fit for discharge.

Retrospective, cross-sectional study of 101 children undergoing tracheostomy between 2000 and 2010.

Of the study patients, 44.6 per cent did not spend any time in hospital once medically fit, 19.8 per cent spent up to two weeks, 12.9 per cent spent between two weeks and one month, and 22.8 per cent spent over one month. Of the 56 cases with delayed discharge, the majority (22 children, 39.3 per cent) were delayed due to time taken obtaining parental competencies in tracheostomy management. A number of external factors were identified in these delays: parental substance abuse; single parenting; concerns about parenting ability, and English not being the parents' first language.

Paediatric tracheostomy may lead to prolonged hospitalisation, but this is often influenced by social factors. Better use of dedicated specialist paediatric tracheostomy nurses may reduce unnecessary hospitalisation.

To investigate voice function following Han's uvulopalatopharyngoplasty.

Acoustic and articulatory function was examined by acoustic analysis and by formant frequency and bandwidth analysis, before and after Han's uvulopalatopharyngoplasty, in 56 patients with obstructive sleep apnoea hypopnoea syndrome.

These patients' normalised noise energy was higher than normal, and improved post-operatively. Their pre-operative F1, F2, and F3 formant frequencies and B1 and B2 formant bandwidths were significantly lower than those of normal controls; however, one month after surgery their F1 and F2 frequencies were markedly higher.

The acoustic and articulatory characteristics of obstructive sleep apnoea hypopnoea syndrome patients differed from those of normal subjects. After Han's uvulopalatopharyngoplasty, obstructive factors in the oropharynx were relieved, allowing oropharyngeal cavity expansion and a gradual increase in formant frequency to within the normal range. Patients' vocal quality improved and their resonator and articulator functions were protected and enhanced.

Limited information is available on mucosa-associated lymphoid tissue lymphomas arising in the head and neck.

A retrospective analysis was conducted of 20 patients who were histologically diagnosed with mucosa-associated lymphoid tissue lymphoma and treated at our institution between January 1990 and December 2009.

Treatment consisted of surgical resection alone in two patients (10 per cent), surgical resection with consecutive radiotherapy in one (5 per cent), and radiotherapy alone in eight (40 per cent). Three patients (15 per cent) were treated with systemic chemotherapy, and three (15 per cent) received chemoradiotherapy. Three patients (15 per cent) were informed of the diagnosis but not treated for their condition.

All of the 20 patients were still alive after a mean follow-up period of 50.8 months. Local treatment for mucosa-associated lymphoid tissue lymphoma of the head and neck should be the first choice in early-stage disease. However, prolonged follow up is important to determine these patients' long-term response to treatment.

We report an interesting case of a right temporal pre-auricular arteriovenous fistula (cirsoid aneurysm) causing intractable tinnitus successfully managed by transarterial n-butyl cyanoacrylate glue embolisation.

A 52-year-old female presented with a one-year history of tinnitus and pulsatile swelling in the right pre-auricular region. A colour Doppler ultrasound test and magnetic resonance angiography revealed a high-flow scalp arteriovenous fistula with a feeder vessel from the distal superficial temporal artery, which drained into the corresponding, dilated, tortuous vein. The patient underwent diagnostic digital subtraction angiography. This was followed by transarterial embolisation of the fistula using a 50 per cent mixture of n-butyl cyanoacrylate glue and Lipiodol®, with manual distal venous occlusion. A successful outcome was achieved with instant relief of symptoms.

Cirsoid aneurysms of the facial region, an uncommon cause of tinnitus, can be effectively managed by endovascular embolisation. This treatment obviates the need for surgery, which is associated with an increased risk of complications such as scarring, deformity and bleeding.

Paediatric tonsillectomy is a common ENT operation. The use of day-case surgery is increasing, in order to improve efficiency in healthcare.

A prospective audit spiral was carried out from January 2006 to December 2008 for all children undergoing day-case tonsillectomy at Huddersfield Royal Infirmary.

There was a haemorrhage rate of 2.6 per cent over three years. The most common complication was nausea and vomiting, seen in 5.3 per cent of patients.

For a well selected group of children, day-case tonsillectomy in a district hospital setting is a safe and efficient alternative to an in-patient stay. A dedicated day-case team, good anaesthetic technique, adequate post-operative analgesia and on-site paediatric in-patient facilities are essential.

Intranasal medication is commonly used for nasal disease. However, there are no clear specifications for intranasal medication delivery after functional endoscopic sinus surgery.

A three-dimensional model of the nasal cavity was constructed from computed tomography scans of an adult Chinese male who had previously undergone functional endoscopic sinus surgery in the right nasal cavity. Computational fluid dynamic simulations modelled airflow and particle deposition, based on discrete phase models.

In the right nasal cavity, more particles passed through the upper dorsal region, around the surgical area, and streamed into the right maxillary sinus region. In the left cavity, particles were distributed more regularly and uniformly in the ventral region around the inferior turbinate. A lower inspiratory airflow rate and smaller initial particle velocity assisted particle deposition within the right maxillary sinus cavity. In the right nasal cavity, the optimal particle diameter was approximately 10−5 m for maxillary sinus cavity deposition and 3 × 10−6 m for bottom region deposition. In the right nasal cavity, altered back head tilt angles enhanced particle deposition in the top region of the surgical area, and altered right side head tilt angles helped enhance maxillary sinus cavity deposition.

This model indicates that a moderate inspiratory airflow rate and a particle diameter of approximately 10−5 m should improve intranasal medication deposition into the maxillary sinus cavity following functional endoscopic sinus surgery.

An increasing number of transnasal endoscopic surgical procedures are being performed, and these procedures are now also utilised in the management of malignant sinonasal tumours. This study aimed to evaluate the outcome of endoscopic resection of sinonasal malignancies, with or without chemotherapy and radiotherapy.

Between 2000 and 2009, six patients with sinonasal malignancies (diagnosed on pre-operative biopsy) underwent endoscopic resection at our hospital. The histopathological diagnoses varied and included squamous cell carcinoma, olfactory neuroblastoma, chordoma, extramedullary plasmacytoma and haemangiopericytoma.

Surgical resection was combined with chemotherapy and/or radiotherapy in four cases. The mean follow-up period was 43 months. One patient suffered local recurrence of chordoma, 84 months after the first operation, but this was successfully treated with proton beam radiotherapy.

These results suggest that endoscopic resection may be a valid alternative to conventional resection in selected cases of malignant sinonasal tumour.

To investigate the clinicopathological and prognostic significance of the expression of cathepsin L and its inhibitor headpin, in oral squamous cell carcinoma.

Immunohistochemical studies were performed on 56 oral squamous cell carcinoma samples. We evaluated the relationship between cathepsin L and headpin expression versus patients' clinicopathological factors and survival.

The group that was positive for cathepsin L expression tended to have positive metastatic neck lymph nodes and a poorer prognosis. Headpin expression was not related to metastasis or prognosis. Well differentiated squamous cell carcinoma had higher levels of headpin expression compared with poorly differentiated squamous cell carcinoma.

Cathepsin L expression is related to the invasive and metastatic potential of oral squamous cell carcinoma.

Flexible nasoendoscope is an important tool in otorhinolaryngology practice. The endoscope needs to be decontaminated prior to use in the next patient. The 2005 ENT-UK guidance for cleaning fibre-optic laryngoscopes stated that the ideal disinfecting agent and process should be effective and have low capital and maintenance costs.

To compare the efficacy and cost-effectiveness of chlorine dioxide wipes versus automated washer, for decontamination of flexible nasendoscopes.

A sequential cohort, in vitro study was performed to test the efficacy of chlorine dioxide wipes and automated washer. Costs were also calculated.

After deliberate bacterial contamination of the nasendoscope and subsequent decontamination, swab samples from the endoscope showed Staphylococcus epidermidis growth in 2 per cent (1/50 swabs) of the chlorine dioxide wipe group and in 28 per cent (14/50 swabs) of the automated washer group (p = 0.00). Based on a projected 10-year cost calculation, the automated washer was cheaper.

Further studies are required to test whether these results are replicable. A similar study should be performed using real patients, to check the significance of improper decontamination.

(1) To study the prevalence and characteristics of large endolymphatic sac internal compartments on thin-section T2- and T2*-weighted magnetic resonance imaging, and to relate these to other large endolymphatic sac magnetic resonance imaging features, and (2) to correlate the compartment imaging features, endolymphatic sac size and labyrinthine anomalies with the patients' clinical and audiological data.

Magnetic resonance imaging studies for 38 patients with large endolymphatic sac anomalies were retrospectively reviewed in a tertiary referral centre. Endolymphatic sac compartment presence, morphology and imaging signal were assessed. Endolymphatic sac size and labyrinthine anomalies were also recorded. Endolymphatic sac compartments and other imaging features were correlated with clinical and audiological data.

Compartments were present in 57 per cent of the imaged endolymphatic sacs, but their presence alone did not correlate with other imaging features or clinical data. The endolymphatic sac : internal auditory meatus signal ratio was associated with a history of sudden or fluctuating hearing loss. Hearing loss correlated with opercular and extraosseous endolymphatic sac size measurements. A larger midpoint intraosseous endolymphatic sac size was associated with clear fluid loss at cochlear implantation.

The magnetic resonance imaging characteristics of large endolymphatic sac compartments have been defined. The endolymphatic sac size and distal compartment signal should be recorded, as these provide prognostic information and assist the planning of appropriate interventions.

To evaluate the haemostatic efficacy and safety of the LigaSure vessel sealing system in major head and neck cancer surgery.

This two-year, prospective study included 34 patients who underwent major head and neck cancer surgery at a university hospital. The LigaSure Precise handpiece and LigaSure 8 vessel sealing system were utilised as the primary means of haemostasis, except when sealing vessels larger than 7 mm in diameter. Surgical outcomes were evaluated. In addition, in each patient the diameter of the largest vein and artery sealed (all were >2 mm) was measured before sealing.

In all cases except one (33/34 patients), a sutureless technique was performed. Post-operative bleeding was observed in two cases. Thirty veins and 22 arteries were measured. The mean diameter of the largest sealed vein was 3.8 mm, while that of the largest sealed artery was 2.7 mm.

Our experience indicates that the surgical technique described is safe and effective. The main advantages of the LigaSure system are that it simplifies the procedure and eliminates the need for clips and suture ligations.

Supracricoid laryngectomy with cricohyoidoepiglottopexy is an organ-preserving procedure used to treat laryngeal cancer. However, the post-operative neoglottis tends to be variable in form and difficult to predict.

We retrospectively analysed three-dimensional images reconstructed from multidetector-row computed tomography data for 21 patients, assessing arytenoid motion and minimum neoglottic gap cross-sectional area.

While mean transverse and coronal motion was similar for bilateral and unilateral arytenoids, movement along the sagittal axis was greater for unilateral than bilateral arytenoids. The neoglottic gap during respiration was wider in patients with bilateral arytenoids, but both groups had a similar neoglottic gap during phonation.

Anterior shifting of the unilateral arytenoid plays an important role in compensating for the inability to achieve neoglottic closure. These two results demonstrate that the unilateral arytenoid alone is capable of achieving sufficient neoglottic narrowing to compensate for the resected arytenoid. Three-dimensional analysis was useful to evaluate the physiological status of the neoglottis after supracricoid laryngectomy with cricohyoidoepiglottopexy.

Endoscopic, transnasal management of pituitary gland neoplasms is a widely accepted alternative to the traditional microscopic approach. This study aimed to determine outcomes and complication rates for the largest UK series of endoscopic, trans-sphenoidal hypophysectomies reported to date.

We performed a retrospective analysis of 136 primary resections and 35 revision cases performed at a tertiary referral centre.

Total tumour resection was confirmed in over 85 per cent of primary and revision cases, with biochemical remission in 60 per cent. The incidence of complications such as epistaxis, sphenoid sinus problems, endocrine insufficiency, visual disturbance, post-operative haemorrhage, cranial nerve injury and mortality was significantly lower, compared with similar series using the microscopic approach.

Despite its steep ‘learning curve’, our series demonstrates that the endoscopic approach not only allows superior anatomical visualisation and therefore facilitates full oncological resection of tumours, but also reduces the incidence of peri-operative complications.

Thyroid cancers infiltrating the upper aerodigestive tract are not uncommon. The management of these cases can be demanding, with a high level of surgical skill required to achieve adequate primary resection and reconstruction.

This study was a single institution series of seven patients, managed over two years, who underwent tracheal resection for advanced thyroid cancer. All patients were older than 45 years (range, 45–65 years) and were predominantly male (six of seven). All patients presented to us with a swelling in the neck. Fine needle aspiration cytology detected thyroid cancer in all patients. None of the patients required a tracheostomy prior to surgery; however, they all had varying levels of airway compromise. One patient had lung metastasis at presentation. In all patients, the airway was successfully secured with fibre-optic assisted intubation prior to surgery. All patients underwent a total thyroidectomy with tracheal resection and anastomosis. Montgomery's suprahyoid release was utilised to achieve adequate laryngeal drop. None of the patients required a tracheostomy in the post-operative period. All patients received adjuvant therapy with either radioiodine ablation and/or radiotherapy.

Tracheal resection and primary reconstruction is a feasible surgical procedure for patients with thyroid cancer infiltrating the upper aerodigestive tract, with good clinical outcomes. However, the morbidity of the procedure mandates careful case selection, airway management and meticulous surgical technique.

Amiodarone can induce severe hyperthyroidism that justifies its withdrawal and the introduction of antithyroid drugs. Continuing amiodarone use, failure to control hyperthyroidism and poor clinical progress may require thyroidectomy. This study aimed to evaluate patients’ post-operative development and mid-term outcome after thyroidectomy for amiodarone-associated thyrotoxicosis.

Prospective case series.

Tertiary care centre.

We prospectively collected cases of amiodarone-associated thyrotoxicosis requiring thyroidectomy due to failure of antithyroid treatment, despite amiodarone discontinuation. Post-thyroidectomy complications were compared immediately, 30 days and one year post-operatively, and also for scheduled versus emergency surgery cases.

Of 11 total cases, nine scheduled thyroidectomy cases had no morbidity after elective surgery. Two cases required emergency surgery for multiple organ failure and cardiac problems. Immediate post-operative complications (mostly haemodynamic) occurred in both cases (emergency vs routine surgery, p = 0.018).

In such cases, pre-operative medical treatment is vital to limit peri- and post-operative complications, but surgery should not be delayed if the haemodynamic status deteriorates. Surgery, with careful anaesthesia, is the cornerstone of the treatment.

Several studies have reported the use of peritonsillar infiltrations of local anaesthetics and/or locally active analgesic drugs for the relief of post-tonsillectomy pain, with variable results in terms of quality and duration of analgesia. We aimed to compare the effects of peritonsillar infiltration of lidocaine versus tramadol versus placebo on post-tonsillectomy pain.

Sixty patients over the age of 10 years undergoing bilateral elective tonsillectomy under general anaesthesia were randomised into three groups. The first group received peritonsillar infiltration of tramadol, the second 2 per cent lidocaine and the third normal saline. In all groups, peritonsillar infiltration was carried out after tonsillectomy but prior to tracheal extubation. Post-operative comparisons were made to assess the quality of pain control and the patients' analgesic requirements.

Peritonsillar infiltration of tramadol provided an analgesic effect comparable to that of lidocaine in the first 6 hours post-operation, as reflected by visual analogue scale pain scores and opioid requirements, which were lower compared with the placebo group.

Peritonsillar infiltration of tramadol provided pain control in the first 6 hours post-tonsillectomy which was comparable to that of lidocaine.

To evaluate modern diagnostic and therapeutic management of juvenile recurrent parotitis, and to show the benefits of operative sialoendoscopy on the basis of our experience in 14 patients and the results of others.

Ultrasonography is sensitive in detecting the pathological features of juvenile recurrent parotitis. Interventional sialoendoscopy is a safe and effective method of treating the disease. In our case series, after a mean follow-up time of 30 months only 5 patients experienced recurrence of symptoms, with a mean symptom-free period of 20 months.

The use of modern, minimally invasive diagnostic tools such as colour Doppler ultrasonography, magnetic resonance sialography and sialoendoscopy represents a new frontier in the management of juvenile recurrent parotitis. Operative sialoendoscopy also has the important therapeutic benefit of reducing the number of recurrences of acute episodes of parotitis, thus giving patients a better quality of life until puberty.

To compare the key functional results (regarding swallowing and voice rehabilitation) in patients treated by pharyngo-laryngectomy with flap reconstruction, versus standard, wide-field, total laryngectomy.

We studied 97 patients who had undergone total laryngectomy and pharyngo-laryngectomy with flap reconstruction. The main outcome measures were swallowing (i.e. solid food, soft diet, fluid or enteral feeding) and fluent voice development.

There were 79 men and 18 women, with follow up of one to 19 years. Voice (p = 0.037) and swallowing (p = 0.041) results were significantly worse after circumferential pharyngo-laryngectomy than after non-circumferential pharyngo-laryngectomy. There was no significant difference in voice (p = 0.23) or swallowing (p = 0.655) results, comparing total laryngectomy and non-circumferential pharyngo-laryngectomy. The presence of a post-operative fistula significantly influenced voice (p = 0.001) and swallowing (p = 0.009) outcomes.

The additional measures involved in pharyngo-laryngectomy do not confer any functional disadvantage, compared with total laryngectomy, but only if the procedure is non-circumferential. Functional results of circumferential pharyngo-laryngectomy are worse than those of both non-circumferential pharyngo-laryngectomy and total laryngectomy. If oncologically possible and safe, it is better to keep a pharyngo-laryngectomy non-circumferential.

Most human immunodeficiency virus positive patients now have a longer life expectancy, with the advent of highly active antiretroviral therapy. However, they are now at increased risk of developing a malignancy during their lives.

To investigate the age at which oral squamous cell carcinoma presents in patients infected with human immunodeficiency virus.

Prospective, clinicohistopathological audit of patients infected with human immunodeficiency virus.

Of 200 human immunodeficiency virus positive patients, 16 (8 per cent) presented with oral squamous cell carcinoma (nine women and seven men; age range 18–43 years, mean age 31.7 years). The majority of patients (62.5 per cent) had stage III and IV disease (tumour-node-metastasis staging). There was a predilection for poorly differentiated oral squamous cell carcinoma (using Broder's histopathological classification).

Oral squamous cell carcinoma associated with human immunodeficiency virus infection appears to present at a relatively young age.