The development of hypertrophic mucosa and granulation tissue around a tracheo-oesophageal fistula voice prosthesis is a commonly encountered problem occurring in 15–20 per cent of patients. Upsizing of the voice prosthesis as well as cautery (silver nitrate and electocautery) are used to counteract this problem to a varying degree of success. The use of the CO2 laser has been mentioned by some authors but details of the method and results have not been published. We report the successful use of the KTP laser for removing such granulations whilst retaining the valve and discuss the reasons why this method should be considered.

Invasive aspergillosis, one of the common paranasal sinus fungal infections, often secondarily involves the orbit. We report six such cases with orbital extension, all occurring in apparently immunocompetent hosts, to specifically address the difficult diagnostic and therapeutic issues involved. Limited biopsy procedures were often inconclusive, necessitating wide surgical excision to establish the histopathological diagnosis. Conservative orbital debridement proved adequate for cases with disease limited to the infero-medial compartment of the orbit, but resulted in residual progressive disease in the two of the four cases with retro-orbital and apical extension. Orbital exenteration in this latter group, however, proved successful in controlling disease. The present report emphasizes the importance of near-complete extirpation and adjuvant chemotherapy in ensuring a favourable outcome in invasive Aspergillus infections. Orbital exenteration appears justified for posterior orbital disease, regardless of the functional status of the eye, but is inappropriate for anterior orbital disease.

In this retrospective study, the computed tomography (CT) archives of paranasal sinus examinations were reviewed and three cases of antroliths are presented. The archivesof paranasal sinus CT studies of 1957 patients (1023 females, 934 males, mean age 36.5 years) were surveyed. CT studies were performed using 3 mm collimation and interval in the coronal, axial or both coronal and axial planes.

Three out of 1957 patients demonstrated antroliths, all in the left maxillary sinus. Associated sinusitis was detected in all three patients. Only one patient was operated. The chemical analysis of the antrolith revealed it to be a calcium oxalate stone. All the relevant literatureis reviewed and only 25 other cases of true antrolithiasis were encountered. The clinical and radiological features of antroliths,as well as differential diagnosis were discussed.

Antrolithiasis should be considered in any case of sinusitis, that does not respond to appropriate medical therapy.

This is a report of a patient with an air-bone gap, thought 10 years ago to be a conductive hearing loss due to otosclerosis and treated with a stapedectomy. It now transpires that the patient actually had a conductive hearing gain due to superior semicircular canal dehiscence. In retrospect for as long as he could remember the patient had experienced cochlear hypersensitivity to bone-conducted sounds so that he could hear his own heart beat and joints move, as well as a tuning fork placed at his ankle. He also had vestibular hypersensitivity to air-conducted sounds with sound-induced eye movements (Tullio phenomenon), pressure-induced nystagmus and low-threshold, high-amplitude vestibular-evoked myogenic potentials. Furthermore some of his acoustic reflexes were preserved even after stapedectomy and two revisions. This case shows that if acoustic reflexes are preserved in a patient with an air-bone gap then the patient needs to be checked for sound- and pressure-induced nystagmus and needs to have vestibular-evoked myogenic potential testing. If there is sound- or pressure-induced nystagmus and if the vestibular-evoked myogenic potentials are also preserved, the problem is most likely in the floor of the middle fossa and not in the middle ear, and the patient needs a high-resolution spiral computed tomography (CT) of the temporal bones to show this.

A secondary tracheo-oesophageal puncture is required for voice restoration post-laryngectomy either for reasons of closure of the primary fistula or as a planned secondary procedure. A method of doing this safely is described using an endotracheal tube and a flexible nasopharyngoscope in especially difficult cases.

Bleeding is a dangerous complication of thyroid surgery. We describe a new technique of vessel and tissue sealing and bleeding control using an electrothermal sealer. The technique has some potential advantages over the current methods used for this purpose.

Laryngopharyngeal reflux (LPR), which is defined as the backflow of gastric contents into the upper aerodigestive tract, is a relatively common disorder. However, its diagnosis still poses many problems. Twenty-four-hour double-probe pH monitoring is currently the diagnostic test of choice, but it has many disadvantages. Thus, an empiric trial of antireflux therapy has been suggested as an alternative method for diagnosis. The purpose of this article is to evaluate the validity of this alternative method in the management of LPR. The study group consisted of 36 patients with symptoms and physical findings suggesting LPR. The control subjects were 23 healthy adults. Twenty-four-hour double-probe pH monitoring was performed both in the study group and the control group, and the results were compared. In addition, the symptoms and physical findings in the study group was scored by the modified reflux symptom index (MRSI) and reflux finding score (RFS) at four intervals: before the start of therapy and at the second, fourth and sixth months of the therapy. The results of the 24-hour double-probe pH monitoring showed no significant difference between the study and the control groups (p>0.05). In the study group, the MRSI before the therapy was 13.6±4.4. This index improved significantly to 4.3±1.9 at the second month; to 1.5±0.6 at the fourth month, and to 0.5±0.2 at the sixth month of the therapy (p<0.05). The RFS before the start of the therapy was 14.8±3.8; and it improved significantly to 7.7±3.8 at the second month; to 4.5±2.3 at the fourth month, and to 1.4±0.9 at the sixth month of the therapy (p<0.05). The significant improvement in the MRSI and the RFS during the course of proton pump inhibitor therapy relates the patients’ symptoms and physical findings to LPR. This implies the validity of the method, not only in the treatment of LPR, but in the diagnosis of this disorder, as well. Unfortunately, 24-hour double-probe pH monitoring has failed to differentiate LPR patients from healthy individuals.

Most patients with squamous cancer of the head and neck treated at Groote Schuur Hospital are from a poor socio-economic background with a high prevalence of tuberculosis (TB), human immunodeficiency virus (HIV) and other infections that may cause cervical lymphadenopathy resulting in overstaging of the neck.

A retrospective review of 186 patients requiring therapeutic and elective neck dissection was undertaken and the sensitivity and specificity of clinical and intra-operative staging of the neck determined.

Results showed overall sensitivity of staging at 80.1 per cent. Specificity was 52.2 per cent. Staging of the N1, N2b and N2c necks had positive predictive values of 53.2, 65.8 and 68.2 per cent respectively. Occult nodal metastases were present in 32 per cent elective neck dissections (END)s. Specificity of intra-operative staging of the N0 neck was 33.3 per cent and sensitivity was 72.4 per cent.

Conclusions were that our indications for elective neck dissection are appropriate. The high false positive rates for staging of the N1, N2b and N2c necks, necessitate a change in management strategy.

Exposure to carbon monoxide is a well-recognized cause of morbidity and mortality. Both acute accidental poisoning and chronic exposure are associated with a range of adverse health effects. We report two cases of carbon monoxide poisoning with the associated phenomenon of sensorineural hearing loss. Although hearing loss as a result of acute carbon monoxide exposure has previously been described, here we emphasize the need to consider chronic exposure to carbon monoxide as a potentially reversible cause of sensorineural hearing loss if diagnosed and treated early.

The use of an adenoid curette of appropriate size is recommended in operative textbooks for adequate adenoid removal and avoidance of potential injury to the eustachian tubes. The aim of this study is to calculate the right size of adenoid curettes to be used for children of different ages. The inter-tubal space (ITS) between the torus tubarius on both sides is the narrowest passage for adenoid curettage, and is identified in this study as the nasopharyngeal dimension to be considered in selecting the size of the adenoid curette. This prospective study is carried out on a series of 72 adenoidectomy cases aged from three to nine years at the Hearing and Speech Institute in Cairo, Egypt. The inter-tubal dimension (ITD) is measured for each child at the end of adenoidectomy and the results are recorded against the patient’s age. The ITD ranged from 17–21 mm in our series with no significant difference between males and females. There is an increase in ITD with age with a sharp increase at ages five and seven years. Accordingly, the patients are divided into three age groups and recommendations for appropriate adenoid curette sizes ranging from 18 to 21 mm are given for each group.

Voice disorders can cause problems for patients emotionally, physically, economically and functionally. Neither subjective nor objective voice examinations are able to evaluate such factors adequately. For this study, a retrospective analysis of 79 dysphonic cases was conducted using the voice handicap index (VHI) to gather comprehensive data across a variety of voice disorders. Of the 79 cases, 41 involved glottic insufficiency, 26 involved vocal polyps or mass, and 12 involved functional voice disorders. Cases were assessed with the VHI using physical (P), functional (F), emotional (E) parameters and a total (T) of the three. P, F, E and T variables were entered into a statistical programme and analysed using one-way analysis of variance (ANOVA). Mean ±SE values for P, F, E and T, respectively, in glottic insufficiency cases were 31.61 ± 1.10, 26.49 ± 1.43, 26.06 ± 1.54, and 84.20 ± 4.21. Mean ±SE values for P, F, E and T, respectively, in vocal mass cases were 30.69 ± 1.73, 25.23 ± 1.90, 23.96 ± 1.82, and 79.88 ± 5.08. The mean ±SE values of P, F, E and T,respectively, in functional voice disorders were 20.92 ± 2.06, 18.33 ± 1.82, 16.83 ± 1.86, and 56.08 ± 5.23. We found the mean glottic insufficiency was significantly greater than functional voice disorders for each measure. There were significant differences between vocal mass and functional voice disorders means for P and T. Glottic insufficiency and vocal mass means were not significantly different for any measure. Problems in the physical realm were identified as the most severe amongst all patients. Glottic insufficiency patients were found to suffer the most in every VHI value. Although VHI is a relatively new method by which to measure discomfort in voice-disordered patients, it provides a mechanism for patients to define their discomfort and for therapists to better target recovery programmes to patient’s needs.

Nasogastric intubation is often difficult in patients with upper aero-digestive tract tumours. We present a new method for replacing obstructed fine-bore nasogastric tubes. This method eliminates the need for specialized equipment and skills, minimizes the risk of tracheal intubation and oesophageal trauma, and is better tolerated by patients.

Alterations of cell cycle proteins contribute to the development and biological behaviour of malignant tumours. We evaluated the distribution and prognostic significance of immunohistochemically detected proteins p53, p21, Rb, and cyclin D1 in 101 laryngeal and hypopharyngeal squamous cell carcinomas (SCC) and adjacent epithelial hyperplastic lesions (EHL). Protein expression was correlated with tumour grade and stage.

Varying patterns of protein expression were found in SCC. A significant correlation (p <0.05) was found between Rb expression and tumour grade. Different grades of EHL exhibited randomly distributed p53 and cyclin D1 positive cell clusters with no association to the pattern of their expression in SCC.

Our study demonstrated derailment of cell cycle regulation in almost all cases of SCC of the larynx and hypopharynx. However, only cyclin D1 expression had an independent prognostic value for cancer-specific survival. The results also suggest that Rb gene inactivation, although rare, might be more important in the development of SCC than previously thought.

Warts are common lesions. The prevalence and incidence of squamous papilloma of the nasal vestibulum are not known, and it is not certain how often human papilloma viruses are involved. Numerous medical or surgical treatment modalities have been reported in the literature with variable, sometimes unsatisfactory results. Imiquimod cream is a topically applied immunomodulator. It is used for warts and other skin tumours on different locations of the body. We report results of six patients treated with imiquimod five per cent cream for nasal squamous papilloma.

Petrosal cholesteatomas are rare lesions, which may be congenital or acquired in nature. We report an exceptional case occurring in a seven-year old girl who presented with a unilateral conductive hearing loss, despite normal tympanic membrane appearance. Early diagnosis was facilitated by computed tomography (CT) scanning. Although this case satisfied the criteria for congenital cholesteatoma, it is likely that the petrous apex was secondarily involved. Complete cholesteatoma removal was accomplished using a transtemporal supralabyrinthine approach, which allowed for hearing preservation, while avoiding the morbidity associated with a craniotomy. The present case constitutes the youngest case of petrosal cholesteatoma reported. We suggest that a lower threshold for the use of CT scanning in unilateral conductive hearing loss may allow for the earlier detection of more cases of petrosal cholesteatomas, as well as facilitating their removal using more limited approaches associated with less morbidity.

One method for restoring the anterior floor of mouth defects resulting from T1 and especially T2 cancer excision involves the creation of a myomucosal island flap from the dorsal median portion of the tongue and transferring it as a transit flap to the floor of the mouth.

We are not the first to advocate this method. In this paper we present a previously unreported, slightly modified technique utilizing this tongue flap. The modification consists of a 90° twisting of the flap to achieve a more appropriate adaptation to the defect. In the case ofspreading carcinoma from the floor of the mouth to the central portion of the tongue, a similarparamedian one-sided tongue flap was created instead of a central island tongue flap. Our present experience consists of a small series of 12 patients. The procedures were successful in all patients. No remarkable disturbances of speech or deglutition were observed in any of the patients. There were two complications: one haematoma and one partial necrosis of the tip of the tongue. In our opinion, the reconstruction of the anterior floor of mouth defects using a central island tongue flap has not gained the popularity it deserves.

Management of patients with carcinoma of the larynx should systematically include an appropriate treatment of lymph nodes according to the TNM stage. One of the most controversial points of the treatment in these patients is the management of the clinically negative neck (N0). A retrospective study of 295 patients with laryngeal carcinoma and N0 neck undergoing treatment in our centre between 1983 and 1993 is presented. We observed a significant decrease in the survival of clinically N0 patients with histologically affected lymphnodes. Lymphadenopathy was more frequently detected in patients with supraglottic tumours (38 per cent) when compared to glottic tumours (16 per cent). In our experience, routine bilateral and unilateral dissection of N0 necks in all supraglottic tumours and in T3–T4 glottic tumours, respectively, is the most beneficial approach for patients in terms of survival.

Mucous membrane pemphigoid (MMP) is a sub-epithelial blistering disease that primarily involves mucosal surfaces but may also involve the skin. Clinically, it appears as vesiculobullous lesions of the oral cavity and eyes, but other tissues such as the nasopharyngeal and laryngeal mucosa can also be affected. Ultimately, scarring and airway stenosis may occur. The condition should be managed by a multidisciplinary team led by a dermatologist. Immunosuppressive therapy forms the mainstay of treatment, with surgery having both a diagnostic role and a use in the treatment of complications such as airway obstruction. There must be a low threshold of suspicion for laryngeal involvement in this group of patients, so that prompt action can be taken. Once laryngeal stenosis has occurred repeated endoscopic laser excision of scar tissue can be used to maintain an adequate airway. Adjuvant use of mitomycin-C can be used beneficially in the treatment of laryngeal complications of MMP.

Back and neck pain is an established occupational disease for many professions. No previous studies have shown the association of back and neck pain with ENT surgery. Our objective was to determine the prevalence of neck and back pain in ENT consultants in the United Kingdom and which sub-specialities were most at risk. A national survey from 325 ENT consultants in the UK revealed that 72 per cent had either back pain or neck pain or even both. Of those with pain 53 per cent attributed their symptoms directly to ENT surgery. Highest figures were received from otologists, related to microscope work and prolonged sitting. The importance of these findings has demonstrated the lack of awareness and adequate training to prevent long-term disability in ENT surgeons.

Paragangliomas are rare benign neoplasms arising from the neural crest-derived paraganglia of the autonomic nervous system. In the larynx three different localizations of paraganglia are known. Most laryngeal paragangliomas arise from the supraglottic paraganglia. A review of the literature shows that the treatment of choice for laryngeal paragangliomas is surgical excision. Since the implementation of CO2 laser surgery into laryngology in 1972, no reports of endoscopic laser surgical excisions of laryngeal paragangliomas have been published so far. We present the case of a 66-year-old female patient who suffered from a large (4 × 4 × 3 cm) left supraglottic paraganglioma. The tumour was completely excised utilizing the CO2 laser. Histopathology and immunohistochemistry of the tissue presented the typical findings of a laryngeal paraganglioma. The pre- and post-operative management as well as the treatment strategies are discussed. To our knowledge the present case demonstrates for the first time a complete transoral CO2 laser surgical resection of an advanced laryngeal paraganglioma.