Metastatic cutaneous squamous cell carcinoma is the most common parotid malignancy in Australasia. Prognostic indicators are not clearly defined and the extent of surgical resection required is controversial.

A retrospective analysis was conducted of 63 patients who underwent surgery for metastatic cutaneous squamous cell carcinoma of the parotid gland at a tertiary hospital over a 10-year period.

The five-year overall survival rate was 53 per cent, the disease-specific survival rate was 78 per cent and the locoregional control rate was 72 per cent. Immunosuppression and no adjuvant radiotherapy were associated with a significant reduction in disease-specific survival. None of the factors analysed had a significant effect on locoregional control rates.

More extensive surgery, including lateral temporal bone resection, may improve local control rates in cases of more advanced disease. The reduced survival of immunocompromised patients must be considered when planning their management.

This study aimed to determine the effect of the subperiosteal tight pocket technique versus the bone recess with suture fixation technique on the revision cochlear implantation rate and complications.

This retrospective study included 1514 patients who underwent cochlear implantation by 2 senior surgeons between October 2002 and January 2016. Revision cases were identified and analysed.

In all, 52 patients (3.34 per cent) underwent revision cochlear implantation. The revision rate was 7.18 per cent in the subperiosteal tight pocket group versus 2.37 per cent in the bone recess with suture fixation group (p < 0.001). Device failure was the most common reason for revision surgery in both groups. There was a significant difference in the device failure rate between the bone recess with suture fixation group (2.11 per cent) and subperiosteal tight pocket group (6.88 per cent) (p < 0.001).

Accurate fixation of the cochlear implant receiver/stimulator is crucial for successful cochlear implantation. As the bone recess with suture fixation technique is associated with a lower revision rate and a similar complication rate as the subperiosteal tight pocket technique, it should be the preferred fixation technique for cochlear implantation.

Identifying the nerve of origin in head and neck schwannomas is a diagnostic challenge. Surgical management leads to a risk of permanent deficit. Accurate identification of the nerve would improve operative planning and patient counselling.

Three patients with head and neck schwannomas underwent a diagnostic procedure hypothesised to identify the nerve of origin. The masses were infiltrated with 1 per cent lidocaine solution, and the patients were observed for neurological deficits.

All three patients experienced temporary loss of nerve function after lidocaine injection. Facial nerve palsy, voice changes with documented unilateral same-side vocal fold paralysis, and numbness in the distribution of the maxillary nerve (V2), respectively, led to a likely identification of the nerve of origin.

Injection of lidocaine into a schwannoma is a safe, in-office procedure that produces a temporary nerve deficit, which may enable accurate identification of the nerve of origin of a schwannoma. Identifying the nerve of origin enhances operative planning and patient counselling.

The use of lasers in cholesteatoma surgery is common and well accepted. The most commonly used laser fibres are straight and non-adjustable; these have several limitations. This paper describes the use of an alternative laser fibre.

This ‘How I Do It’ paper describes and illustrates the use of an alternative curved adjustable fibre-optic diode laser in microscopic cholesteatoma surgery.

The curved, adjustable laser fibre allows accurate and atraumatic disease removal when the use of a straight laser fibre may be less effective or accurate. It reduces potential damage to delicate structures without the need for extra drilling or bone removal.

It is suggested that the curved adjustable laser fibre is superior to the traditional straight fibre for cholesteatoma surgery.

This study associated Human Papillomavirus (HPV) infection and other clinical parameters with five-year survival of oral squamous cell carcinoma patients at a tertiary care hospital in Karachi, Pakistan.

A total of 140 patients diagnosed with oral squamous cell carcinoma were enlisted. HPV status and subtypes were established through polymerase chain reaction performed in a previously published study. Clinical data including five-year survival were obtained through institutional medical records.

Ninety-five patients (67.9 per cent) were positive for HPV. Of these, 85 patients were HPV 16 positive while 2 patients were HPV 18 positive. The mean survival time for HPV positive patients was 44.3 months, whereas survival time for HPV negative patients was 46.9 months. Univariate analysis showed that HPV status in oral squamous cell carcinoma was not a statistically significant factor in determining five-year survival rate (p = 0.386).

There is a high prevalence of HPV positive oral squamous cell carcinoma in Pakistan; however, there is no difference in the five-year survival rate when compared to HPV negative oral squamous cell carcinoma.

Carotid artery aneurysm is a potentially fatal complication of skull base osteomyelitis. It is important to know the warning signs for this complication, as early diagnosis is of great importance. This report aimed to determine whether the pattern of cranial nerve involvement may predict the occurrence of aneurysm involving the internal carotid artery in skull base osteomyelitis.

Two diabetic patients with skull base osteomyelitis were incidentally diagnosed with pseudo-aneurysm of the petrous internal carotid artery on follow-up magnetic resonance imaging. They presented with lower cranial nerve palsy; however, facial nerve function was almost preserved in both cases. Computed tomography angiography confirmed aneurysms at the junction of the horizontal and vertical segments of the petrous carotid artery.

Internal carotid artery trapping was conducted using coil embolisation. Post-coiling magnetic resonance imaging demonstrated no procedure-related complications. Regular follow up has demonstrated that patients’ symptoms are improving.

One should be mindful of this potentially fatal complication in skull base osteomyelitis patients with lower cranial nerve palsies, with or without facial nerve involvement, especially in the presence of intracranial thromboembolic events or Horner's syndrome.

This study aimed to estimate the cost-effectiveness of Coblation compared with cold steel tonsillectomy in adult and paediatric patients in the UK.

Decision analysis was undertaken by combining published clinical outcomes with resource utilisation estimates derived from a panel of clinicians.

Using a cold steel procedure instead of Coblation is expected to generate an incremental cost of more than £2000 for each additional avoided haemorrhage, and the probability of cold steel being cost-effective was approximately 0.50. Therefore, the cost-effectiveness of the two techniques was comparable. When the published clinical outcomes were replaced with clinicians’ estimates of current practice, Coblation was found to improve outcome for less cost, and the probability of Coblation being cost-effective was at least 0.70.

A best-case scenario suggests Coblation affords the National Health Service a cost-effective intervention for tonsillectomy in adult and paediatric patients compared with cold steel procedures. A worst-case scenario suggests Coblation affords the National Health Service an equivalent cost-effective intervention for adult and paediatric patients.

Flexible laryngoscopy is a commonly performed procedure in otolaryngology. Although this procedure is not considered painful, many patients describe it as uncomfortable. This study investigated the role of visual distraction as a form of pain relief during flexible laryngoscopy.

The study included patients undergoing flexible laryngoscopy at the University Hospital Southampton. Patients were self-allocated to one of four groups: with or without co-phenylcaine anaesthetic spray; and with and without visual distraction. Visual distraction involved the patient watching the procedure concurrently with the clinician, via a video monitor. Pre- and post-procedural discomfort was assessed using a visual analogue scale.

The use of topical anaesthetic spray was not associated with significantly reduced discomfort scores (p > 0.05). Discomfort scores were significantly reduced in the visual distraction groups (p = 0.04), irrespective of the use of topical anaesthetic spray.

This small study showed that visual distraction should be considered as a simple and cost-effective alternative to local anaesthetic for flexible laryngoscopy.

Eosinophils are the principal effector cells involved in the pathogenesis of allergic rhinitis. Cell numbers increase in non-allergic rhinitis patients with eosinophilia, aspirin hypersensitivity and nasal polyposis, as well as in allergic rhinitis patients. Exfoliative nasal cytology can be used in the differential diagnosis of allergic rhinitis.

To evaluate nasal eosinophilia in nasal smears of patients with mild, persistent and intermittent allergic rhinitis.

The study comprised 60 patients with allergic rhinitis and 20 healthy volunteers. The patients were divided into intermittent and persistent allergic rhinitis groups. Nasal smear status, eosinophil numbers and Total Nasal Symptom Scores were compared.

Nasal smear results were pathological in 40 of 60 allergic rhinitis patients, which was significantly higher than the rate in controls. The mean nasal eosinophilia score was significantly higher in the intermittent allergic rhinitis than in the persistent allergic rhinitis group (p = 0.029). There was a positive correlation between nasal eosinophilia score and Total Nasal Symptom Score (r = 0.652; p < 0.05) in persistent allergic rhinitis and intermittent allergic rhinitis patients.

The nasal smear test is inexpensive, objective and simple to perform, and should be part of the diagnostic investigation.

In endoscopic cricopharyngeal myotomy, surgeons sometimes have concerns about performing an adequate incision with only a narrow intra-cavital view from one direction. In order to overcome these issues, fluoroscopic radiography was used during endoscopic cricopharyngeal myotomy.

Peri-operative fluoroscopic radiography was utilised to check the position of the diverticuloscope, and to confirm the extent of the incision during surgery. A balloon catheter was used to determine whether the cricopharyngeal muscle was sufficiently resected. Blood loss, peri-operative complications, and functional oral swallowing scale and penetration aspiration scale scores were evaluated.

In 12 out of 15 patients, intra-operative fluoroscopic radiography showed the diverticuloscope positioned in the post-cricoid area, and the cricopharyngeal muscle was raised and the surgery completed without adverse effect. Swallowing functions improved following surgery.

Intra-operative fluoroscopy might improve endoscopic cricopharyngeal myotomy by allowing surgeons to confirm the extent of resection, and by reducing peri-operative morbidity and complication rates.

Positron emission tomography-computed tomography with fluorine-18 fluorodeoxy-D-glucose has a major role in the investigation of head and neck cancers. Fluorine-18 fluorodeoxy-D-glucose is not a tumour-specific tracer and can also accumulate in benign pathology. Therefore, positron emission tomography-computed tomography scan interpretation difficulties are common in the head and neck, which can produce false-positive results. This study aimed to investigate patients detected as having abnormal vocal fold uptake on fluorine-18 fluorodeoxy-D-glucose positron emission tomography-computed tomography.

Positron emission tomography-computed tomography scans were identified over a 15-month period where reports contained evidence of unilateral vocal fold uptake or vocal fold pathology. Patients’ notes and laryngoscopy results were analysed.

Forty-six patients were identified as having abnormal vocal fold uptake on positron emission tomography-computed tomography. Twenty-three patients underwent positron emission tomography-computed tomography and flexible laryngoscopy: 61 per cent of patients had true-positive positron emission tomography-computed tomography scans and 39 per cent had false-positive scan results.

Most patients referred to ENT for abnormal findings on positron emission tomography-computed tomography scans had true-positive findings. Asymmetrical fluorine-18 fluorodeoxy-D-glucose uptake should raise suspicion of vocal fold pathology, accepting a false-positive rate of approximately 40 per cent.

Medialisation thyroplasty is considered the ‘gold standard’ treatment for unilateral vocal fold paralysis, enabling improvement of voice and swallowing function, and preventing life-threatening aspiration events. The most commonly used laryngeal implants induce some degree of local tissue inflammatory response, and carry the risk of immediate or delayed implant extrusion.

This paper describes a novel approach for medialisation thyroplasty. Specifically, it utilises a ribbon of autologous tensor fascia lata harvested at the time of surgery. This is layered within the paraglottic space in a manner similar to Gore-Tex thyroplasty.

Thus far, this method has been accomplished in two patients with unilateral vocal fold paralysis, who also received prior radiotherapy to the head and neck.

Given the increased risk of post-operative wound breakdown and infection in irradiated patients, it is suggested that this new approach will lead to improved outcomes, and a decrease in complications such as extrusion or wound infection, particularly in this patient population.

Appropriate selection of tongue cancer patients considering surgery is critical in ensuring optimal outcomes. The American College of Surgeons' National Surgical Quality Improvement Program (‘ACS-NSQIP’) risk calculator was developed to assess patients' 30-day post-operative risk, providing surgeons with information to guide decision making.

A retrospective review of 30-day actual mortality and morbidity of tongue cancer patients was undertaken to investigate the validity of this tool for South Australian patients treated from 2005 to 2015.

One hundred and twenty patients had undergone glossectomy. Predicted length of stay using the risk calculator was significantly different from actual length of stay. Predicted mortality and other complications were found to be similar to actual outcomes.

The American College of Surgeons' National Surgical Quality Improvement Program risk calculator was found to be effective in predicting post-operative complication rates in South Australian tongue cancer patients. However, significant discrepancies in predicted and actual length of stay may limit its use in this population.

To report a novel management strategy for mixed hearing loss in advanced otosclerosis.

A 50-year-old male was referred to St Thomas’ Hearing Implant Centre with otosclerosis; he was no longer able to wear conventional hearing aids because of recurrent otitis externa. The patient underwent short process incus vibroplasty (using the Med-El Vibrant Soundbridge device), followed at a suitable interval (six weeks) by stapes surgery. The main outcome measures were: pure tone audiometry, functional gain and monosyllabic word recognition scores.

Post-operative pure tone audiometry showed a reduction of the mean air–bone gap from 55 dB HL to 20 dB HL. The residual mixed hearing loss was rehabilitated with the Vibrant Soundbridge, with an average device gain of 32 dB. The monosyllabic word recognition scores in quiet at 65 dB improved from 37 to 100 per cent when using the Vibrant Soundbridge at six months after switch-on of the device.

Stapedotomy in conjunction with incus short process vibroplasty (i.e. inner-ear vibroplasty) is a safe and promising procedure for managing advanced otosclerosis with mixed hearing loss in selected patients.

Re-stenosis and a consequent need for revision surgery are the most common problems in the follow-up period following endoscopic modification of the Lothrop procedure.

This paper reports a new technique for reconstructing and resurfacing of the posterior frontal recess bone for prevention of re-stenosis.

A 46-year-old man presented with a frontal sinus osteoma, and treatment featured an endoscopic modification of the Lothrop procedure. A vascularised, posteriorly based, septal mucosal flap was used in reconstruction. There have been no reported issues over 24 months of follow up.

The use of a nasoseptal flap seems feasible to reduce scarring and recurrence of (common) frontal recess stenosis after a Draf III operation.

Elderly patients have been consistently shown to receive suboptimal therapy for cancers of the head and neck. This study was performed to determine the peri-operative outcomes of these patients and compare them with those of younger patients.

In this retrospective analysis, 115 patients aged 70 years or more undergoing major surgery for head and neck cancers were matched with 115 patients aged 50–60 years, and univariate analysis was performed.

Elderly patients had a reduced performance status (p < 0.001) and more co-morbid illnesses (p = 0.007), but a comparable intra-operative course. They had a longer median hospital stay (p = 0.016), longer intensive care unit stay (p = 0.04), longer median tracheostomy dependence (p = 0.04) and were more often discharged with feeding tubes (p < 0.001). They also had a higher incidence of post-operative non-fatal cardiac events (p = 0.045).

Elderly patients with good performance status should receive curative-intent surgery. Although hospital stay and tube dependence are longer, morbidity and mortality are comparable with younger patients.

To evaluate for the first time the prevalence of human papillomavirus in oropharyngeal squamous cell carcinoma in a Middle-Eastern population, and to determine associations between human papillomavirus profiles and clinicopathological characteristics.

A retrospective chart review was conducted of all patients treated for oropharyngeal squamous cell carcinoma at the Hotel Dieu de France University Hospital (Beirut, Lebanon) between January 2010 and 2016. Existing formalin-fixed paraffin-embedded tumour samples were analysed. Human papillomavirus DNA viral load and p16 expression were evaluated using polymerase chain reaction and immunohistochemistry respectively.

Thirty patients (mean age of 60 years) were included. Twenty-seven per cent of patients were p16-positive/human papillomavirus DNA positive, 53 per cent were p16-negative/human papillomavirus DNA negative and 20 per cent were p16-positive/human papillomavirus DNA negative. Human papillomavirus 16 was the most frequent subtype (75 per cent). Smoking and alcohol consumption were significantly lower in the human papillomavirus positive group compared to the human papillomavirus negative group (p = 0.049 and 0.004, respectively).

Human papillomavirus rate was lower than reported rates in Western populations. Possible explanations include differences in social and cultural behaviours.

To compare functional and oncological treatment outcomes among patients with supraglottic laryngeal cancers who underwent transoral robotic supraglottic laryngectomy and open supraglottic laryngectomy.

A retrospective chart review was conducted of 17 patients treated by transoral robotic supraglottic laryngectomy and 20 patients treated by open supraglottic laryngectomy.

No tracheostomy or prolonged intubation was needed in the transoral robotic surgery group. Furthermore, that group had a shorter oral feeding time, hospitalisation and recovery period. There was no difference between groups in terms of complications. There were no differences in overall survival time and disease-specific survival time between groups.

Transoral robotic supraglottic laryngectomy for supraglottic laryngeal cancer is an oncologically safe and functional procedure with better results when compared to conventional open surgery.

The study primarily aimed to calculate the orientation of the cochlea pre-operatively, using high-resolution computed tomography of the temporal bone, and predict the ease of electrode insertion.

Pre-operatively, high-resolution computed tomography scans were conducted on children scheduled for cochlear implantation, and two angles, α and β, were calculated. The values of α and β were then correlated with intra-operative difficulty in insertion of the electrode array.

Ninety-six children were included in the study. Of the seven patients who had an α angle of less than 50 degrees, the surgeon experienced difficulties in electrode insertion. However, there were four patients with an α angle of more than 50 degrees for whom the surgeon also experienced difficulties in electrode insertion. In all these patients, the β angle was more than 20 degrees.

Calculation of cochlear orientation and its angle with the surgical axis (α and β) can aid the planning of surgery, particularly with regard to the cochleostomy site and preservation of residual hearing.

Dissociation between caloric and head impulse test results in patients with vestibular disorders has been well documented since the introduction of video head impulse testing. Prior to the introduction of video head impulse testing, vestibular diagnostic services relied mainly on caloric testing, and it is now known that the caloric testing shows more positive results than video head impulse testing. A dissipation model was proposed to explain this dissociation.

This paper presents two cases in which caloric testing indicated an absent or significantly reduced response on the horizontal semicircular canal plane but video head impulse testing showed near-normal or normal vestibulo-ocular reflex gain on the same plane.

This report supports the dissipation theory and questions the functional relevance of canal paresis values calculated from caloric test results.