To evaluate the significance of advanced post-operative haemostasis investigation in cases of recurrent, severe post-tonsillectomy bleeding.

Of the 120 patients treated at our tertiary centre between 2006 and 2010 due to post-tonsillectomy haemorrhage, 22 with recurrent, severe episodes of bleeding underwent further, advanced haemostasis investigation.

Underlying haemorrhagic disease was not diagnosed in any case. Isolated abnormal clotting factor levels were identified in two patients. Decreased fibrinogen concentration due to dilutional coagulopathy was found in nine cases (40.9 per cent).

Recurrent, severe post-tonsillectomy haemorrhage is rarely related to undiagnosed haemostatic disorders. Thus, advanced haemostasis studies have little therapeutic relevance. However, repetitive post-tonsillectomy bleeding may be related to decreased fibrinogen levels due to dilutional coagulopathy. Therefore, fibrinogen concentration should be tested, and dilutional coagulopathy treated promptly.

To report a rare case of tuberculous otitis media, and to highlight barriers to clinical and microbiological diagnosis.

Case report and literature review.

Tuberculous otitis media is a rare cause of chronic ear infection in the UK. Its symptoms may mimic a range of other otological conditions, including otitis media, chronic suppurative otitis media, cholesteatoma and necrotising otitis media.

This case report highlights the challenges of obtaining a clinical diagnosis of tuberculous otitis media, and emphasises the fact that screening for acid-fast bacilli is not sufficient, in isolation, to rule out mycobacterial infection.

We report a rare case of fibro-hyaline anterior extensions of the bony nasal pyramid.

The clinical, radiological, intra-operative and histological findings are presented.

A 34-year-old man presented with bilateral nasal obstruction due to enlarged lateral walls of the nasal vestibule. Radiology showed normal bony structures. Surgery revealed three histologically identical, non-malignant, fibrous masses, one in the nasal septum and one in each of the vestibular walls. The latter were attached to the bony pyramid, protruding anteriorly and converging medially.

The location and symmetry of the fibro-hyaline projections indicated that they constituted a malformation mimicking congenital bony nasal pyriform aperture stenosis. Histological analysis showed that the masses were not neoplastic.

We report a case of cholesterol granuloma of the petrous apex which was surgically treated via an endoscopic trans-sphenoidal approach.

Case report and review of the literature concerning cholesterol granulomas of the petrous apex and their management.

The lesion was approached endoscopically via a bilateral sphenoidotomy with removal of the vomer. A large cholesterol granuloma was evacuated and marsupialised. The patient made an uneventful recovery.

Trans-sphenoidal access to the petrous apex represents an alternative route for the drainage and ventilation of cholesterol granulomas. This approach is the technique of choice when the cholesterol granuloma abuts the posterior wall of the sphenoid sinus. The trans-sphenoid approach, unlike other lateral approaches to the petrous apex, spares cochlear and vestibular function and allows post-operative endoscopic follow up.

To evaluate the effect of primary, cross-over, zigzag neopharyngeal construction on tracheoesophageal voice, compared with pharyngoesophageal myotomy, following total laryngectomy with partial pharyngectomy.

Prospective clinical trial.

Otolaryngology department, Tanta University Hospital (tertiary referral centre), Egypt.

Over five years, 30 patients underwent total laryngectomy with partial pharyngectomy to manage stage III or IV laryngeal cancer, followed by primary tracheoesophageal puncture for voice restoration. For neopharyngeal construction, 15 patients underwent pharyngoesophageal myotomy (group one) and 15 cross-over, zigzag neopharyngoplasty (group two). Acoustic parameters of tracheoesophageal voice were compared.

Most acoustic parameters were almost equivalent for the two groups, although significant differences were seen for loud intensity, dynamic range, shimmer, loud fundamental frequency, loud jitter, fluency and speaking rate. One post-operative pharyngocutaneous fistula (6.6 per cent) occurred in each group, and resolved with conservative measures.

The cross-over neopharyngoplasty modification of hypopharyngeal closure may help avoid pharyngoesophageal spasm and assist maintenance of effective voice amplitude, fundamental frequencies, temporal measures and perceptual values.

To report the results of transoral laser microsurgery for the treatment of early glottic cancer at our institution.

Cohort study. Retrospective review of charts of patients diagnosed with tumour stage 1 or 2 (early stage; no nodes or metastases), previously untreated, primary glottic cancer, treated with transoral laser microsurgery at the Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada. The minimum follow-up period was two years.

Tertiary care head and neck cancer centre.

Fifty-three patients treated between January 2002 and November 2007.

Kaplan–Meier survival analysis for disease-free survival, overall survival and laryngectomy-free survival, at five years.

The group comprised 46 men and seven women, with a mean age of 66 years (range 30–84 years). Mean follow up was 40 months (range 12–89 months). There were four cases of complications (7.5 per cent). Kaplan–Meier survival analysis revealed a five-year disease-free survival (including salvage) of 96.2 per cent, a five-year overall survival (all causes) of 88.8 per cent and a five-year laryngectomy-free survival of 98.1 per cent.

Transoral laser microsurgery is a safe and effective initial treatment for early laryngeal cancer, and has high rates of laryngeal preservation and disease-free survival.

To study the role of mitomycin C in reducing keloid recurrence.

Prospective, randomised, controlled trial.

Tertiary care referral centre.

Case series of 20 patients presenting with 26 pinna swellings, mostly following ear piercing.

We used the technique of surgical shave excision combined with topical application of mitomycin C and secondary wound healing, in all 26 pinnae.

Patients were followed up six to 24 months post-operatively. No recurrences were noted during this period.

Keloids are fibrotic lesions resulting from abnormal wound healing. The uncontrolled proliferation of normal tissue healing processes results in scarring that enlarges well beyond the original wound margins. Successful treatment of keloids remains a challenge because this disease process has a high propensity for recurrence. Various therapies have previously been reported, and success rates are highly variable. We believe that shave excision followed by topical mitomycin C application is a promising treatment option for the management of pinna keloids.

Laryngotracheal stenosis is currently one of the most common complications associated with nasal and orotracheal intubation and tracheotomy. Once established, tracheal stenosis can be a complex and difficult problem to manage.

We retrospectively analysed 2004–2010 data for 12 male patients with postintubation cervical tracheal stenosis (grade III–IV) treated in the otolaryngology department, Mansoura University Hospitals. All patients had a tracheostomy at presentation, and all underwent tracheal resection with primary cricotracheal anastomosis and suprahyoid release.

Grade III stenosis was present in five patients (41.7 per cent) and grade IV stenosis in seven patients (58.3 per cent). The length of trachea resected ranged from 2 to 4 cm, representing one to four tracheal rings. In all 12 patients, the procedure allowed successful tracheotomy decannulation. Minor complications comprised surgical emphysema (n = 2) and wound infection (n = 1), and were managed conservatively. Major complications consisted of restenosis (n = 3), managed in two patients by repeated dilatation; one patient was lost to follow up.

Segmental tracheal resection with cricotracheal anastomosis was successful in 11/12 (92 per cent) patients with severe cervical tracheal stenosis. The strategy for treatment of airway stenosis is now well established and success rates are high, with minimal or no sequelae.

No consensus exists on optimal treatment for Graves’ disease once anti-thyroid medication fails to induce remission. Total thyroidectomy is a more cost-effective treatment than radioactive iodine or life-long anti-thyroid medication, but hypocalcaemia is an important complication, leading to longer hospital admissions and increased prescription costs. This study aimed to compare the relative risk of hypocalcaemia requiring medical treatment for patients with Graves’ disease.

Prospective cohort study of patients undergoing total thyroidectomy for Graves’ disease and for multinodular goitre, calculating serum calcium levels 24-hours post-operatively and prescription rates.

Mean corrected calcium concentrations 24 hours post-operatively were 2.05 mmol/l for Graves’ disease patients and 2.14 mmol/l for multinodular goitre patients (p = 0.003). Biochemical hypocalcaemia developed in 92 per cent (n = 34) of Graves’ disease patients and 71 per cent (n = 43) of multinodular goitre patients (p = 0.012). Graves’ disease patients were more likely to be prescribed calcium supplementation pre-discharge (p = 0.037).

Total thyroidectomy for Graves’ disease carries an increased risk of hypocalcaemia at 24 hours, and of calcium supplementation pre-discharge. Graves’ disease patients should be informed of the increased risk of hypocalcaemia associated with total thyroidectomy, and this risk must be factored into future cost-effectiveness analysis.

To assess the effect of chlorhexidine gluconate and benzydamine hydrochloride mouth spray, used in conjunction with antibiotic treatment, on the intensity of clinical signs and quality of life of patients with group A streptococcal tonsillopharyngitis.

Patients (n = 147) with streptococcal tonsillopharyngitis were recruited and randomly allocated to either the treatment group (penicillin plus chlorhexidine and benzydamine; n = 72) or control group (penicillin plus placebo; n = 75). Blinded assessments were conducted before and after 10 days' treatment, using an intensity rating scale for clinical sign severity, a visual analogue scale for subjective health state, the Short Form 36 Health Questionnaire for quality of life, and a customised questionnaire for side effects.

The treatment group showed a statistically significant reduction in the intensity of clinical signs, compared with the control group. On treatment day 7, there was no significant difference in quality of life between the treatment and control groups. The treatment drugs were well tolerated, and no serious adverse events were observed.

Chlorhexidine gluconate and benzydamine hydrochloride mouth spray, added to standard antibiotic treatment, significantly alleviate the intensity of clinical signs in patients with streptococcal pharyngitis. Further research is needed using larger sample sizes or alternative control groups.

To describe our technique of endaural meatoplasty for mastoid surgery, and to publish an online video demonstration.

After the endaural incision, a skin incision is accurately marked over the anterior conchal bowl, identified by pushing the anti-helix anteriorly. This should meet the line of the endaural incision superiorly and extend inferiorly to the lower anterior edge of the conchal cartilage. After performing the incision, a segment of conchal cartilage is removed. The soft tissue meatoplasty is facilitated by resecting a triangular segment of skin and underlying soft tissue medial to the conchal incision (on which it is based). The free edges are closed with absorbable sutures after the (attico)mastoidectomy.

We have used this method on 64 patients over the past two years. Satisfactory functional and cosmetic outcomes were achieved in all.

Our technique is simple, easy to learn, quick and effective in helping to achieve our goal of a dry mastoid cavity with an adequate meatoplasty.

Vascular rings are congenital vascular anomalies of the aortic arch complex which cause compression of the trachea and/or oesophagus. A variety of investigations may lead to diagnosis of these anomalies, including bronchoscopy and computed tomography. During the latter, image acquisition and processing use the multi-detector row technique and new reconstruction algorithms, producing high-resolution images which can be visualised as complex, three-dimensional renditions.

This study aimed to assess and compare the roles of bronchoscopy and multi-detector row computed tomography in the diagnosis of congenital vascular ring.

We included infants and children below the age of 16 years who presented with congenital vascular ring. All patients underwent rigid bronchoscopy under general anaesthesia, with spontaneous respiration. All computed tomography scans were obtained using a 16 multi-detector row computed tomography system, followed by data reconstruction on a three-dimensional workstation.

Ten patients with congenital vascular ring were identified (six boys and four girls). Fifty per cent of cases presented within the first year of life. Double aortic arch was the most common anomaly (40 per cent). Bronchoscopy detected external tracheal compression in nine cases (90 per cent). Associated airway lesions were detected endoscopically in three cases. In contrast, multi-detector row computed tomography detected the vascular ring in all cases, with accurate detection of the compressing vessel; however, it did not detect any associated airway lesions.

Bronchoscopy and radiological evaluation are essential for the diagnosis and pre-operative evaluation of congenital vascular ring. Multi-detector row computed tomography can provide more information about the nature of the disease, and can facilitate better communication between clinicians, compared with conventional computed tomography.

The incidence of acquired laryngeal stenosis is increasing. This retrospective study aimed to assess the long term results of circumferential resection with end-to-end tracheal anastomosis for isolated post-intubation stenosis of the cervical trachea, and to review the relevant literature.

Twelve male and two female patients (aged 16–30 years, mean age 24 years) treated between February 2003 and December 2008 were included. Hospital and office records were reviewed and relevant surgical details recorded.

Indications for tracheal resection anastomosis were post-intubation stenosis (78.57 per cent) and trauma (21.42 per cent). One to five tracheal rings were resected (i.e. 1–2.5 cm of cervical trachea). Tracheal anastomosis was considered successful if the patient remained asymptomatic for 24 months of close follow up (involving regular flexible bronchoscopy and neck X-ray). The anastomotic success rate was 92.85 per cent.

Tracheal resection and end-to-end anastomosis is relatively safe and reliable for definitive treatment of benign tracheal stenosis in appropriate patients. Local application of mitomycin C prevents granulation and aids long term airway patency.

To propose radiofrequency coblation as a potential treatment modality for mild to moderate epistaxis in patients with hereditary haemorrhagic telangiectasia.

Case reports and review of the world literature concerning coblation and other treatment modalities for epistaxis in patients with hereditary haemorrhagic telangiectasia.

Effective epistaxis control was achieved in four out of five cases of hereditary haemorrhagic telangiectasia. In the fifth case, we struggled to achieve haemostasis due to disease severity.

Radiofrequency coblation is a novel technique, which was found to be a safe, effective, quick and well tolerated treatment option for epistaxis management in patients with hereditary haemorrhagic telangiectasia.

Traditionally, small laryngeal clefts may be closed endoscopically, while larger clefts necessitate an open anterior approach. We report the presentation, evaluation and outcome following endoscopic surgical repair of a series of laryngeal clefts.

Retrospective study of children treated in a tertiary referral centre between 2003 and 2008. The presenting symptoms, patient demographics, cleft type, surgical outcome and complications were evaluated.

Seven children underwent primary endoscopic repair of their laryngeal clefts (four Benjamin-Inglis type III clefts and three type II clefts). Presenting symptoms included stridor, cough and cyanosis with feeds, swallowing problems, weak cry, and recurrent lower respiratory tract infection. Treatment was ultimately successful in six of the seven children; treatment was ongoing for the remaining child, who underwent subsequent revision surgery via an open approach. Two children went on to require a second endoscopic repair, and two underwent an open repair of a residual defect. One child required a tracheostomy for failed extubation in the post-operative period.

Endoscopic repair is a safe, useful technique in the management of laryngeal clefts. Laryngeal clefts must be excluded in a child presenting with persistent aerodigestive tract symptoms, as described here.

(1) To evaluate the efficacy of modified arytenoid adduction in the management of patients with symptomatic cancer-related unilateral vocal fold paralysis, and (2) to assess the impact of this treatment on patients' quality of life.

Forty-two patients with cancer-related unilateral vocal fold paralysis underwent modified arytenoid adduction between February 2001 and December 2008. Of these, 37 patients were enrolled in this retrospective study (one patient died of primary disease and four were lost to follow up). Laryngostroboscopy was performed to evaluate vocal fold orientation and mobility. Pre- and post-operative assessment of subjective and objective voice, aerodynamic parameters, and quality of life were also undertaken, and aspiration was subjectively rated.

Laryngostroboscopic findings indicated a significant post-operative improvement in vocal fold posterior glottal closure and vertical gap. Significant improvements in voice quality, aerodynamic parameters and quality of life were noted three months post-operatively in all patients (p < 0.01). The overall success rate for swallowing rehabilitation was 94.6 per cent (35/37). Subjective aspiration ratings decreased significantly post-operatively, compared with pre-operative values (p < 0.01). No major complication occurred in any patient, except for dyspnoea in one patient.

Modified arytenoid adduction is an effective and reliable medialisation technique which can restore satisfactory voice quality, prevent aspiration and lead to a better quality of life for patients with cancer-related unilateral vocal fold paralysis.

We report a case of successful cochlear implantation in a patient with petrous bone cholesteatoma in the only hearing ear.

A 63-year-old man presented with a four-year history of right-sided, progressive hearing loss in his only hearing ear. Computed tomography and magnetic resonance imaging revealed a right supralabyrinthine petrous bone cholesteatoma, with erosion of the superior semicircular canal and the roof of the internal auditory canal. Due to the high risk of post-operative right-sided deafness, we decided first to perform left cochlear implantation. Five months later, the patient had a 40 per cent score for open-set two-syllable word recognition and an 85 per cent score for sentence recognition. Given these good performances, we decided to eradicate the cholesteatoma via a translabyrinthine approach, with insertion of a second cochlear implant, as a single-stage procedure. A successful outcome was achieved.

Cochlear implantation can be an effective method of hearing rehabilitation in patients with petrous bone cholesteatoma, following total eradication of disease, if the cochlea remains intact. To our best knowledge, this is the first English language report of cochlear implantation in a patient with petrous bone cholesteatoma.

We report a rare case of epistaxis resulting from a ruptured internal carotid artery aneurysm, and present a successful treatment method.

A 72-year-old woman was admitted following recurrent massive epistaxis. There was no history of trauma or surgery. Radiographic imaging demonstrated a large internal carotid artery aneurysm. An attempt was made to occlude the aneurysm with endovascular coils. Despite this, the patient went on to have further epistaxis. Endovascular ablation of the feeding internal carotid artery led to complete resolution.

This case demonstrates that spontaneous epistaxis from intra-cavernous carotid artery aneurysms can be managed using endovascular techniques. To our knowledge, we report the first use of interventional radiological techniques to assess the collateral circulation to the brain and subsequently undertake endovascular ablation of the internal carotid artery.

We report a patient who underwent cochlear implantation in an ear with long-term deafness, after an acoustic neuroma had been removed surgically from the other, hitherto good ear and the cochlear nerve had subsequently been resected to relieve severe tinnitus.

Case report.

The patient could not tolerate the cochlear implant, because of a moderate headache due to the stimulation level necessary for environmental sound discrimination.

Cochlear implantation in patients with long-term deafness should be considered carefully, even if deafness is monaural.