Introduction: Once fitted with hearing aids, much reliance is placed on patients' own ability to manage their devices effectively. There has, however, been little research to assess how patients' own confidence compares with their actual ability to manage their hearing aids. This study compares patients' perceptions of their ability to insert their hearing aids with their observed ability to insert the devices satisfactorily.

Method: Eighty-five patients provided a rating of their level of confidence in fitting their hearing aid, using a visual analogue score (VAS). This was then compared with their observed level of ability, assessed by an audiologist, also using a VAS (both scores 0–100 mm).

Results: We found a weak to moderate correlation between the subjective and objective scores (Pearson r = 0.4912).

Conclusions: From these results, we would advise caution when accepting a patient's perceived level of ability as the only indicator of their true ability to insert their hearing aid. This also has important implications for follow-up services that rely only on telephone conversations with patients after a first fitting.

Two studies were performed to determine whether topical phenol is a safe and well tolerated local anaesthetic for grommet insertion. Study 1 was a retrospective examination of audiological outcomes and complications. Data were obtained regarding 71 procedures in 57 patients. One late infection and nine early extrusions were noted. No statistically significant changes between pre- and post-operative bone conduction thresholds were found. Study 2 was a prospective analysis of patients' perceptions of the procedure. Data from 17 patient questionnaires were analysed as follows: pain rating – not painful, three patients; slightly painful, 14 patients. Overall experience rating – pleasant, four patients; slightly unpleasant, 10; unpleasant, three. All patients stated that they would undergo the procedure again. In conclusion, we found no evidence of phenol-induced hearing loss. The complication rate was within normal limits and patients were satisfied with the procedure. Grommet insertion using phenol as a local anaesthetic is safe and acceptable to patients.

Introduction: Small cell neuroendocrine carcinoma (SNEC) of the sinonasal tract is a rare disease.

Objective: Report a descriptive study of a relatively large cohort of SNEC of the nasal cavity and paranasal sinuses.

Method: The medical records of 21 patients presenting with nasal and paranasal SNEC to various French hospitals, from 1989 to 2003, were analysed to determine the clinical features and current treatment of the disease.

Results: Patient data were obtained from eight French hospitals. Twelve of the patients were male and nine were female, with a mean age at presentation of 55 years (range: 27 to 79 years). Patients' staging for nasal cavity malignancy was: T1, four; T2, three; T3, one; T4, 13; N0, 18; N2, three; M0, 20; and M1, one. None of the patients suffered from SNEC of the sinonasal tract with ectopic hormone production. Immunohistochemistry proved useful for diagnosis in 20 cases. Twelve cases were positive for cytokeratin, 14 for chromogranin, eight for neuron-specific enolase and 11 for neuron-specific synaptophysin. One patient had an adenocarcinoma and an inverted papilloma associated with neuroendocrine carcinoma. Patients underwent surgery (11 cases), radiotherapy (14 cases) and chemotherapy (12 cases). Recurrence occurred in 10 cases. Five patients had visceral metastases or cervical lymph node involvement. Nine of the patients died within four years of onset of the disease.

Conclusion: Small cell neuroendocrine carcinoma of the sinonasal tract is an uncommon neoplasm with aggressive clinical behaviour. Recurrence is frequent and the prognosis is poor. However, the current treatment of these neuroendocrine neoplasms varies widely.

Three patients with extensive keratosis obturans were treated during a 12-month period. One presented with an idiopathic sensorineural hearing loss and was found to have keratosis obturans in the contralateral, asymptomatic ear. The disease process had resulted in a horizontal semicircular canal fistula in what was now, effectively, the only hearing ear. The second patient had an extensive dehiscence of the tegmen tympani. The third presented with a facial palsy. An automastoidectomy cavity was present, with circumferential skeletonization of the descending facial nerve over a length of 1.5 cm and dehiscence of the temporomandibular joint and jugular bulb. All three patients were successfully treated by surgical formalization of their automastoidectomy cavities. They appeared to represent cases of keratosis obturans rather than external auditory canal cholesteatoma, on the basis of previously published reports.

These complications and patterns of bone erosion have not previously been described in keratosis obturans. The third patient is believed to have the most extensive case of keratosis obturans yet described.

We investigated the motion of the single ossicle found in the middle ears of four different species of birds. In the avian middle ear, the off centre attachment of the extracolumella to the tympanic membrane and the flexion of the joint between the extracolumella and columella results in rocking of the footplate rather than direct excursion in and out of the vestibule. We postulate that this is a protective mechanism to avoid excessive displacement of the footplate into the vestibule during changes in middle-ear pressure and that it is analogous to the ossicular ‘decoupling’ observed in the human middle ear in the same circumstances.

The use of steroids during rhinoplasty to reduce post-operative periorbital oedema and ecchymosis has been advocated. A number of randomized controlled trials have demonstrated the benefit of steroids in rhinoplasty. The aim of this study was to determine current UK practice in the use of steroids during rhinoplasty performed by otolaryngologists.

A postal survey of consultant otolaryngologists in the UK was conducted. We received 203 responses, with 115 consultants performing 12 or more rhinoplasties per year. Only 28 consultants (24 per cent) used steroids routinely in patients undergoing rhinoplasty and of these 11 used a protocol, although this was unpublished. Dexamethasone was the most common steroid used (82 per cent), being administered as a single intravenous dose of 8 mg in the majority of cases (54 per cent). There was no correlation between the use of steroids and the number of rhinoplasties performed by individual consultants.

Despite the evidence supporting the use of steroids to reduce post-operative sequelae following rhinoplasty, only a minority of consultants in the UK appear to use them as part of their practice.

Objective: To study the role of mitomycin C in reducing adhesion formation following endoscopic sinus surgery.

Study design: Prospective, randomized, controlled trial.

Setting: Tertiary care referral centre.

Patients: Thirty patients were selected suffering long-term problems with bilateral chronic rhinosinusitis, with no relief obtained from medical therapy. Patients requiring revision sinus surgery or having acute upper respiratory tract infection were excluded.

Interventions: Diagnostic nasal endoscopies and non-contrast computerized tomography of nose and paranasal sinuses were undertaken and, following confirmation of the diagnosis, functional endoscopic sinus surgery (FESS) was carried out bilaterally using the Messerklinger technique. On completion of the surgery, a cotton wick soaked in mitomycin C was placed in one or other side of the nose in the middle meatus. Follow up was for three months and patients were assessed for subjective and objective improvement in their symptoms.

Results: Post-operatively, of the 11 (36.6 per cent) patients complaining of persistent nasal obstruction, nine had complaints limited to the control side only (p=0.005). Out of the nine (30 per cent) patients complaining of recurrent nasal discharge, eight had complaints on the control side and only one reported discharge from both sides (p=0.006).

Conclusion: Mitomycin C may be topically applied in post-operative FESS cases to reduce adhesion formation and hence the need for revision surgery.

Background: The study aimed to evaluate the clinical application of CO2 laser myringotomy in children with otitis media with effusion (OME) under topical anaesthesia in an office setting.

Methods: Laser myringotomy was performed with the CO2 laser Otoscan (OtoLAM) in 54 children (73 ears) with OME. The procedure on the tympanic membrane was performed under topical anaesthesia using Bonain's solution or 10 per cent Xylocaine (lidocaine) solution for 30 minutes before surgery. A circular perforation was created with a power of 15 W, single pulse duration of 200 msec and a scanned area of 1.9 mm in diameter.

Results: The mean healing time was 2.51 weeks (range 1–5 weeks). Effusion content was not a predictive prognostic factor for perforation healing time. Perforation location over anterior inferior or posterior inferior quadrants was not a predictive factor for perforation healing time. Xylocaine was the more effective anaesthestic. The OME resolution rate was 73 per cent.

Conclusion: Laser myringotomy provides intermediate duration middle-ear ventilation. It could be beneficial in selected children with OME.

We present our experience and also review the world literature on the management of retrosternal goitres (RSGs). There is now irrefutable evidence that almost all RSGs will continue to grow and eventually cause airway compression. We describe the diagnosis, investigation and surgical approach to the management of this condition.

Objectives: To evaluate patients' quality of life after receiving intratympanic gentamicin as treatment for Ménière's disease.

Design: Retrospective study using the Glasgow benefit inventory scale (GBI) questionnaire.

Participants: Patients diagnosed with Ménière's disease, according to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) diagnostic criteria (refractory to medical management), who were treated with intratympanic gentamicin injection.

Materials and methods: This retrospective study included all patients diagnosed with Ménière's disease (according to AAO-HNS criteria; refractory to medical management) undergoing gentamicin labyrinthectomy in our unit over the preceding three years. Other causes of hearing loss were ruled out as all patients underwent magnetic resonance imaging, electronystagmography and sway magnetometry. Patients underwent gentamicin infiltration at a concentration of 2 ml of 30 mg/ml and were reviewed six weeks later and received a repeat injection if no benefit was evident. Six months after their last follow up, they were sent a GBI questionnaire. Twenty-one questionnaires were posted, and the response rate was 81 per cent.

Results: As per the responses received, the total benefit of intratympanic gentamicin injection was found to be +30.3. The three components of GBI were analysed separately; it was found that general benefit was greatest (+33.3), followed by physical benefit (+28.1) and social benefit (+21.6).

Conclusion: This study suggests that gentamicin definitely improves quality of life in patients with Ménière's disease and should be the first line of treatment if medical management fails.

Objectives: The aim of this study was to assess the impact on implant survival, abutment skin reaction and patient satisfaction in patients implanted with a bone-anchored hearing aid (BAHA), following the introduction of a multidisciplinary team (MDT) in 1997.

Design and methods: Part prospective and retrospective analysis. Implant survival and cause of failures were recorded along with abutment skin reaction (graded as none, mild, moderate and severe, according to the amount of wound care required). Patient satisfaction and quality of life were assessed using a questionnaire enquiring about several aspects of the use and benefits of their BAHA.

Setting and participants: Eighty patients treated at the Bradford Royal Infirmary between 1991 and 2005. The unit is a recognized tertiary referral centre.

Results and conclusions: Twelve out of 80 implants failed, giving an overall failure rate of 15 per cent. Kaplan–Meier survival curves show a steady decrease in implant survival. The MDT had a positive effect on implant survival and adverse skin reactions, with a higher proportion of patients experiencing no reaction after its introduction. There was a 92.5 per cent response rate to the questionnaire. Overall patient satisfaction was high, both before and after the introduction of the MDT.

Objective: To determine whether bipolar dissection tonsillectomy is associated with a higher post-operative haemorrhage rate than cold dissection tonsillectomy.

Design: Prospective, randomized, controlled trial.

Setting: Otolaryngology department of a teaching hospital.

Participants: Two hundred and forty-five patients undergoing elective tonsillectomy between July 2002 and November 2004.

Interventions: Patients were randomly assigned to either bipolar dissection or cold dissection (with bipolar haemostasis).

Main outcome measures: Post-operative haemorrhage rates, management (conservative or surgical) and blood transfusion requirements were recorded. The grade of surgeon and history of quinsy were also recorded.

Results: One hundred and forty-one patients (58 per cent) were randomized to the bipolar dissection and 104 (42 per cent) to the cold dissection groups. Seventeen patients (12.1 per cent) in the bipolar dissection group and eight patients (7.7 per cent) in the cold dissection group suffered haemorrhage (p = 1.0; degrees of freedom (Df) 0.0; 95 per cent confidence intervals (CI) −0.1 to 0.0). The haemorrhage rates for procedures conducted by senior house officers, specialist registrars and consultants were 11.4 per cent, 10.3 per cent and 5.0 per cent, respectively. Two patients required surgical intervention, both from the bipolar dissection group. No patients required blood transfusion. A history of quinsy was not associated with an increased haemorrhage rate.

Conclusion: The difference in haemorrhage rates between groups and surgeon grades did not reach statistical significance. Nonetheless the trend towards a greater incidence of haemorrhage in the bipolar group and in procedures conducted by more junior surgeons during the trial raised concerns. The results of the National Prospective Tonsillectomy Audit and our interim results have led us to abandon the trial and disallow the use of bipolar dissection in tonsillectomies performed by junior staff members.

Objective: To establish an olfactory test in the Hong Kong Chinese population. Study design: Prospective analysis of the results of a combined olfactory test (COT) for patients with olfactory dysfunction and for normal subjects attending a secondary and tertiary ear, nose and throat centre.

Method: Our COT was based on and modified from the Connecticut Chemosensory Research Centre test. It consisted of an odour identification test involving nine substances and a threshold test using a series of threefold dilutions of 1-butanol. From September 1998 to June 2002, 188 Hong Kong Chinese patients with olfactory dysfunction and subjects with normal olfaction were prospectively recruited. The subjects were categorized into normal, hyposmic and anosmic groups. The olfactory function of the main group of subjects (n = 153) was assessed with the COT by a blinded observer and also quantified with a visual analogue scale; the results were analysed to validate the discriminative ability of the COT. Another subgroup of subjects (n = 35) was tested with the COT twice with a two-week interval to evaluate test–retest reliability.

Results: There were 42 normal, 68 hyposmic and 43 anosmic subjects within the main group (total n = 153). The identification scores, threshold scores and combined olfactory scores were statistically significantly different between the anosmic, hyposmic and normal groups of subjects (p < 0.001). The combined olfactory score correlated with the visual analogue score and the correlation coefficient was 0.56 (p < 0.01). The mean time spent on each COT was 8.6 minutes (standard deviation = 3.4 minutes). The test–retest reliability of the COT was satisfactory, with a one-way model intraclass correlation coefficient of 0.87 (n = 35).

Conclusion: The satisfactory discriminative ability and test–retest reliability of the COT have been demonstrated in this study. The COT is a feasible method for assessing sense of smell in the Hong Kong Chinese population.

Background: A prospective audit of specialist registrars' (SRs') training in tympanomastoid surgery for chronic otitis media within the Anglia Regional Training Scheme is described. This audit recorded the surgical activity of the trainees and their contribution to operative procedures, and assessed the results of the procedures. This type of systematic approach to the audit of surgical training is important in light of the current shortened training programmes and increased accountability of trainers.

Objectives: The study aimed to establish the levels of exposure to, supervision of and outcome of ear operations for chronic otitis media performed by ENT trainees in the East Anglia region.

Method: A prospective, region-wide, minimum otology dataset-based proforma audit was undertaken, with compulsory SR participation. Proformas were completed at the time of operation (form one) and at a minimum interval of nine months post-operatively (form two). Data on form one included hospital, supervising consultant, name and training year of SR, contribution of SR (based on England Royal College of Surgeons guidelines interpreted by the SR), pre-operative audiology average (air conduction/bone conduction over 0.5, 1, 2 and 4 kHz), the pathology and the state of the ear at the time of surgery, and a breakdown of the procedure(s) undertaken. Form two recorded data relevant to form one as well as information regarding patient satisfaction and the operative result obtained, graded as ‘gold’ (no disease, dry ear and hearing average < 25 dB), ‘silver’ (two of these three) and ‘bronze’ (one of these three). All completed forms were analysed using Microsoft Access software.;>   Results: Completed copies of 409 form ones and 156 form twos were analysed. With advancing years, SRs' contributions to procedures increased without significant effect on the graded outcome, which appeared to be independent of SR year of training. Different regional hospitals were compared. Data collected also provided an otology training portfolio for SRs, forming part of their registrar in-training assessment (RITA).

Conclusion: The East Anglia SR audit of SRs' training in tympanomastoid surgery for chronic otitis media was a powerful training tool. It demonstrated the safe progression of SR training in supervised ear surgery, with SRs' results being comparable to those for consultant-performed procedures.

Objectives: To investigate posterior external ear canal wall reconstruction with a composite cartilage titanium mesh graft in canal wall down tympanoplasty and revision surgery for open mastoids.

Study design: Retrospective case review.

Setting: Tertiary referral centre.

Methods: As a preliminary study, 15 selected patients underwent reconstruction of a posterior ear canal wall defect with titanium mesh. Large defects of the posterior external auditory canal wall, resulting from canal wall down tympanoplasty or present in revision surgery, were eliminated by reconstruction using a titanium mesh. The mesh was covered with conchal cartilage and attached to the cortical mastoid bone using 3-mm titanium screws.

Results: All patients maintained a normal contour of the external ear canal, without depression, extrusion or infection. There were no failures, based on short-term post-operative controls. However, two procedures had to be revised due to incomplete coverage of the titanium mesh.

Conclusions: This study shows that reconstruction of the posterior ear canal wall with a composite cartilage titanium mesh is a valuable method for preserving the morphology of the external auditory canal in selected cases. Problems occurring in canal wall down tympanomastoidectomy and radical cavities may therefore be avoided. However, long-term results have yet to be evaluated.

Objective: We report our technique and results for endoscopy-aided CO2 laser therapy for the treatment of intractable granular myringitis, as an out-patient office procedure.

Materials and methods: A total of 21 patients (14 women and seven men; mean age 32.6 years) were retrospectively reviewed, all of whom suffered from intractable granular myringitis and had undergone endoscopy-aided laser treatment. Granulation tissue was vaporized for one to two seconds with a CO2 laser (spot size 0.5–1 mm with a power setting of 5–10 W in continuous mode). The mean follow-up period was 11 months.

Results: Eighteen of the 21 patients (85 per cent) were cured after a single treatment. Three patients with the diffuse form of the disease required repeat laser treatments coupled with self-irrigation with a diluted vinegar solution. We noted no perforations of patients' tympanic membranes after laser vaporization. We also observed no recurrences over follow-up periods ranging from three months to 2.6 years. Our laser procedure produced no adverse effect on hearing thresholds, nor were any other complications observed.

Conclusion: Our results suggest that endoscopy-aided CO2 laser ablation is a reliable and minimally invasive method associated with low rates of recurrence and a low incidence of complications. It can be conducted as an office procedure.

Objective: To analyse the cause of failing voice production by a sound-producing voice prosthesis (SPVP).

Methods: The functioning of a prototype SPVP is described in a female laryngectomee before and after its sound-producing mechanism was impeded by tracheal phlegm. This assessment included: perceptual voice evaluation of read-aloud prose by an expert listener; inspection of the malfunctioning SPVP; and aero-acoustical in vivo registrations using a computer-based data acquisition system.

Results: Sound-producing voice prosthesis speech is higher pitched, stronger, contains less aperiodic noise and requires a lower airflow rate than the patient's regular tracheoesophageal (TE) shunt speech. Tracheal phlegm caused malfunction of the vibrating silicone lip of the SPVP by causing it to stick to its stainless steel container in an opened position, thereby reducing the SPVP to no more than a regular TE shunt valve from a functional point of view. Tracheal phonatory pressure and dynamic vocal intensity range were not affected by the functional status of the SPVP.

Conclusions: To exploit the advantages an SPVP could offer female laryngectomees with an atonic or severely hypotonic pharyngoesophageal segment, the sound-producing mechanism of the SPVP needs to be less vulnerable to tracheal phlegm.

Objectives: To investigate the topography of E-cadherin and its possible correlation with the histological phenotype of salivary gland tumours.

Material and methods: Archival formalin-fixed, paraffin-embedded sections of 54 benign and 56 malignant tumours and 24 samples of normal and inflamed salivary gland tissue were studied immunohistochemically using an Envision/horseraddish peroxidase (HRP) technique.

Results: In normal and inflamed salivary gland samples, E-cadherin was expressed at the membrane of acinar, myoepithelial and ductal cells located at cell–cell contact points. Reduction and/or absence of E-cadherin was only observed in pleomorphic adenoma at the peripheral cells of the duct-like or island structures, or in the cells exhibiting plasmacytoid or stromal differentiation. Neoplastic epithelium in Warthin's tumours and in myoepithelial and oncocytic adenomas was strongly positive. Furthermore, a weak to moderate loss of expression which was related to tissue tumour subtype was seen in malignant tumours such as: adenoid cystic carcinomas; polymorphous low-grade adenocarcinomas; acinic cell carcinomas; and mucoepidermoid low-grade, epithelial-myoepithelial, lymphoepithelial and squamous low-grade carcinomas. Moderate to extreme loss or alternative cytoplasmic non-functional expression were observed in cases of salivary ductal carcinoma, carcinosarcoma, myoepithelial carcinoma, oncocytic adenocarcinoma, unspecified adenocarcinoma and squamous high-grade carcinomas.

Conclusion: This study suggests a direct association of E-cadherin expression with neoplastic histologic phenotype, which is lost in the more undifferentiated and invasive epithelial salivary gland tumours.

Objective: To investigate the influence of hyperglycaemia on deep neck infection (DNI) and the differences between the diabetic and non-diabetic form of DNI.

Study design and setting: Retrospective review of 131 patients with DNI treated between 1993 and 2002 at Shin Kong Memorial Hospital, Taipei, Taiwan.

Results: Deep neck infection was significantly more prevalent in patients with diabetes mellitus (DM) over 60 years of age than in non-DM subjects of a similar age (p = 0.004). In the DM group, Klebsiella pneumoniae was the most common aerobic pathogen and tended to involve more than two anatomical spaces (p < 0.0001). Seventeen out of 18 patients (94.4 per cent) displayed an elevated (≥7 per cent) glycosylated haemoglobin level. The DM group had a significantly higher complication rate, longer hospital stay and tracheotomy rate than the non-DM group.

Conclusions: Diabetic DNI differs from non-diabetic DNI in several aspects and is associated with a higher morbidity. A greater than normal haemoglobin A1c level was commonly observed.

Objective: To establish the frequency of occurrence of delayed facial nerve paralysis following tympano-mastoid surgery in our department and to determine the aetiological factors and long term prognosis.

Setting: Tertiary care academic centre.

Materials and methods: A retrospective review of all patients who had undergone tympano-mastoid surgery in our department over the previous five years was carried out. A total of 219 patients were included in the study. Only two patients were identified as having delayed onset facial nerve palsy over this period of time. The patients' medical records were reviewed and the patients clinically assessed.

Results: The frequency of delayed onset facial nerve palsy following tympano-mastoid surgery in our series was 0.91 per cent. Facial weakness set in on day eight and day 14 in the two patients. Serological investigations in both patients revealed raised titres of immunoglobulin (Ig) M and IgG to varicella-zoster virus, confirming the presence of varicella-zoster infection. In our experience, the combined use of prednisone and acyclovir was an effective form of treatment for both patients, whose facial nerve function fully recovered within six months of onset.

Conclusion: The incidence of delayed facial nerve palsy following tympano-mastoid surgery is low. It can occur up to two weeks after the surgery. Our two cases confirm viral reactivation to be an important aetiological factor in the development of delayed onset facial nerve palsy. The overall prognosis for delayed facial nerve palsy following tympano-mastoid surgery appears to be good.