Hearing impairment is a major public health problem in Nepal. The present service delivery, however, is mainly hospital based and is limited to large towns. Those people residing in rural areas lack many basic needs including ear care services. The collaborative community volunteer-based ear care pilot programme implemented in Banke, Nepal aims to reach out to those rural areas by establishing sustainable primary ear care services, empowering and utilizing local resources. The focus of the programme is to promote multi-sector improvement in sanitation, nutrition, immunization, breast-feeding and timely care and support to ear patients to help prevent hearing impairment mainly from the sequelae of otitis media.

The outcome of otitis media with effusion (OME) in children is generally good. However, it is less clear in adults. All adult patients who had a ventilation tube inserted for OME at the Ipswich Hospital between 1996 and 1997 were studied. Of 53 patients studied, 28 had had a previous history of ventilation tube insertion. Furthermore, at 15–27 months following ventilation tube insertion, the ventilation tube had already extruded in 31 patients and the OME had already recurred in 19 of these. Endoscopic examination revealed that many patients still had evidence of inflammation at the lateral nasal wall (26.4 per cent) and at the eustachian tube orifice (51 per cent). There is also a strong history of atopy in the studied group and the skin prick test was positive in 57 per cent of the patients. This study shows that many patients with adult-onset OME have underlying pathology that could lead to recurrence of OME following ventilation tube extrusion.

Twenty-two cases of perforated tympanic membrane due to fungal otitis externa were observed over a five-year period.

The diagnosis of fungal otitis externa was made on clinical grounds due to the obvious presence of fungal bloom in the external ear canal. Some perforations were noted at the first treatment after the fungal debris had been removed from the external ear canal using a microscope. Other perforations were observed to develop over a few days. Initially, a discrete area of the tympanic membrane appeared white and opaque. As time progressed the white area disintegrated, forming a perforation. Once the otitis externa had resolved most perforations healed spontaneously. Two that were observed to develop during treatment required a myringoplasty. Another one closed significantly but a tiny persistent perforation required cauterization with trichloracetic acid to encourage it to close over completely. The only residual hearing loss was in a case with almost total disintegration of the tympanic membrane requiring a myringoplasty.

Treatment of fungal otitis externa for the patients in this series was aural toilet using suction under a microscope and insertion of a gauze wick saturated in a combination of hydrocortisone, clotrimazole, framycetin and gramicidin.

Telomerase maintains the length of telomeres in immortal cells and is also often associated with cell proliferation. Cholesteatoma epithelium is characterized by a dysregulation with hyperproliferative growth. The study evaluated the telomerase activity in cholesteatoma and normal retro-auricular skin to discover the relationship between telomerase expression and clinical findings. Twenty-two samples of cholesteatoma and 15 samples of retro-auricular skin were obtained from patients undergoing middle-ear surgery. The telomerase activity was detected by the telomerase repeat amplification protocol (TRAP) assay method. Seventeen of the 22 (77.3 per cent) cholesteatoma cases expressed telomerase activity, whereas none of the 15 retro-auricular normal skin (0 per cent) detected telomerase activity. There was no significant difference between telomerase expressions and clinical findings, including hearing level, duration of disease, and the degree of extension (p>0.05). The high expression of telomerase in cholesteatoma suggests that the activation of telomerase may be related to the proliferative nature of cholesteatoma.

We present our experience using conchal composite grafts in major and minor nasal reconstruction. We believe that composite grafts have an important and under-utilized role as an adjunct to the paramedian forehead flap on total and subtotal nasal reconstruction, as well as in providing an internal lining and support in stenosis of the nasal vestibule. The use of a composite conchal graft as an inner lining and support is often preferential to a septal composite or hinge flap that often results in a septal perforation with its associated morbidity.

We recognize that a composite conchal graft used for reconstruction of the alar margin provides a suboptimal result after several months. This is because it is not always possible to replace a whole aesthetic subunit and whilst the site the graft is harvested from often allows the correct contour to be chosen, the quality of skin is often different and this can be seen after several weeks when any post-operative oedema has settled.

Use of rigid direct larygnoscopy (RDL) in the investigation of stridor in children is well recognized. This study presents awake flexible fibre-optic laryngoscopy (FFL) as the first line in investigation of children, under six months of age, who present with stridor without any associated respiratory distress. Using the per oral approach the procedures were conducted either in the out-patient department or in the ward. No anaesthesia, local or general, nor sedation was used. Of the 20 cases included in the study, in 16 (80 per cent) cases a working diagnosis was reached on awake FFL. Eleven had laryngomalacia, two subglottic stenosis, one glottic web and two were normal. Only four (20 per cent) cases needed RDL to reach a definitive diagnosis. There were no problems with the maintenance of the airway during the procedure. It is particularly useful in the diagnosis of functional abnormalities of the larynx, such as laryngomalacia and vocal fold palsies. Awake FFL using the per oral approach is a safe and reliable technique for reaching a working diagnosis in approximately 80 per cent of cases.

We present the ongoing results of the series of 53 consecutive patients who underwent laser-assisted uvulopalatoplasty (LAUP) for snoring at the Kent and Canterbury Hospital. Twenty-nine patients (55 per cent) were completely satisfied with their surgery 18 to 24 months following LAUP when previously questioned via telephone questionnaire.

We have followed up the 29 patients with a previously successful result at between 70 and 79 months following surgery. They underwent an average of 1.6 procedures. Twelve patients (22 per cent) continue to be completely satisfied at this late stage, and a further 12 (22 per cent) have some ongoing improvement in their snoring. Only three patients have indicated that a previously successful result has failed since the previous survey.

The failure rate of LAUP in the treatment of snoring is seen predominantly in the first two years following surgery, but some long-term subjective recurrence of snoring does occur.

The ability of superglue (a cyanoacrylate adhesive) to bond strongly and quickly to skin presents considerable problems when it is inserted into the ear. A case of a patient who inadvertently self-administered Bostik superglue into her left external auditory meatus is reported. The superglue was removed successfully, in the form of a cast, with warm three per cent hydrogen peroxide without damaging the meatus or the typanic membrane. The use of hydrogen peroxide to remove superglue from the ear has not been described previously.

The first report of a patient with gross Paget’s disease and progressive hearing loss who successfully underwent hearing rehabilitation with an osseo-integrated hearing aid is presented. The otological manifestations of Paget’s disease and the principles of osseo-integration are discussed. The use of a bone-anchored hearing aid (BAHA) in selected patients with Paget’s disease can provide useful amplification and hearing rehabilitation.

Diffuse infiltration of the meninges by metastatic carcinoma (meningeal carcinomastosis) is a potential complication of systemic malignancy. It may present with a variety of neurological symptoms as any aspect of the neuraxis can be affected. Often there is a history of pre-existing malignancy.

The authors describe a case with an initial presentation of sudden onset profound bilateral sensorineural hearing loss. The underlying pathology was found to be an occult breast carcinoma, a previously unreported finding.

The role of cerebrospinal fluid cytology and radio-imaging in diagnosis is discussed. All previously reported cases of sudden hearing loss and meningeal carcinomatosis are reviewed.

Ecstasy is a substance of abuse commonly associated with the dance scene and taken by many young people. A brief history of Ecstasy and its side-effects is given. A case of ototoxicity is presented, as an additional side-effect to the long list of complications caused by Ecstasy.

We present a case of peri-orbital surgical emphysema following functional endoscopic sinus surgery (FESS), due to extubation with simultaneous manual inhalation with a closed expiratory valve. This complication has not been previously reported in association with general anaesthetic and FESS. Patients undergoing FESS are advised against nose blowing. However, we recommend that the anaesthetist working with a surgeon who performs FESS should also be warned not to use manual inhalation with a closed expiratory valve while extubating, as this can cause peri-orbital surgical emphysema.

We describe a case of a quadriplegic brain-damaged man with severe upper airway obstruction. A diagnosis of tardive dystonia affecting the vocal folds was made and confirmed by flexible nasopharyngoscopy. Emergency tracheotomy was required. The tardive movement disorder resolved with discontinuation of thioridazine. This case serves to heighten awareness of potentially serious airway complications associated with the use of anti-psychotics and anti-emetics particularly in those with organic brain disease.

Myobacterium malmoense is a non-tuberculous mycobacterium that most commonly causes pulmonary infection, particularly in patients with underlying pulmonary disease or immunodeficiency. We describe a case of Mycobacterium malmoense infection of the larynx in a previously well middle-aged woman, which has previously not been reported. The case highlights the importance of considering atypical mycobacterial infection in the differential diagnosis of laryngeal lesions.

We report the first case of oro-facial granulomatosis (OFG) presenting in pregnancy with laryngeal manifestations.

Metastatic malignant melanoma of the larynx is considered to be extremely rare by most authors. This paper describes a 78-year-old patient, previously treated for cutaneous malignant melanoma and intestinal fibrosarcoma, who presented with stridor due to a metastatic melanoma in the larynx. It was a pedunculated lesion and surgical excision of the lesion was accomplished with a tonsillar snare. This paper further discusses the evolving history, diagnosis and treatment of this metastatic tumour, and reviews the literature regarding previously reported cases.

A case of chronic, fluctuating plasma cell gingivostomatitis that progressed despite chemotherapy and surgery is reported. This is the first case reported of treatment with radiation therapy, and one of the few cases reported where the infiltrate has reached the larynx. After receiving low dose radiation therapy, via a conformal technique encompassing the respiratory mucosal lining from the base of tongue to carina, there has been symptomatic improvement.

Primary mucosal malignant melanomas are rare. They appear late in life and their prognosis is grave. Although there is no consensus on therapy, wide surgical resection followed by radiotherapy, chemotherapy and immunotherapy are treatment modalities. In this report we present a case of widespread primary mucosal malignant melanoma located in the pharynx. After immunotherapy (four cycles of interleukin-2 and interferon-alpha) and chemotherapy (four cycles of cisplatin and dacarbazine) has been applied as primary therapy for suppression of the mass, transoral total pharyngeal resection was performed. After surgery three cycles of immunotherapy and three cycles of chemotherapy were administered followed by radiotherapy (total dose of 6600 cGy). An additional three cycles of immunotherapy and chemotherapy were administered. Although no local recurrence was observed during the 14 months of follow-up after the completion of radiotherapy, cranial and lung metastasis were detected in the 12th month.

Malignant tracheal stenosis presents a considerable challenge to the head and neck surgeon. The use of intraluminal stents has been previously described, but current literature notes a paucity of supportive physiological data. We describe the use of a self-expanding metallic Wallstent in the palliation of a case of papillary thyroid carcinoma. This is accompanied by significant improvement in quantitative pulmonary function.