Objective: Determination of early prognostic factors in patients with recurrent respiratory papillomatosis is extremely important, so the major goal of our prospective, multicentre study was to evaluate (1) the feasibility of various factors to determine prognosis of the clinical course,as well as (2) the response to interferon-alpha therapy in recurrent respiratory papillomatosis.

Methods: Forty-two patients with recurrent respiratory papillomatosis were treated with interferon-alpha (3 MU/m2 three times per week; mean therapy duration was 2.7 ± 1.8 years)in 1983–1994 and followed-up until 2003. Human papilloma virus (HPV) type, recurrent respiratory papillomatosis severity and 2′,5′-oligoadenylate synthetase activity were determined by standard methods and analysed for correlation with the results of long-term clinical outcome.

Results and conclusion: Patients with HPV type 11, a severity score >4, a high number of surgical procedures prior to interferon-alpha therapy and a high basal 2′,5′-oligoadenylate synthetase activity should be considered at high risk of an aggressive clinical course, often with spread to lower airway passages, malignant transformation and death. Human papilloma virus type, score for recurrent respiratory papillomatosis severity, number of surgical procedures and 2′,5′-oligoadenylate synthetase activity showed significant association with response to interferon-alpha therapy and the long-term clinical course, so these factors have value in predicting prognosis in recurrent respiratory papillomatosis.

The origin and behaviour of keratinizing stratified squamous epithelium, anessential component of cholesteatoma occurring in the middle-ear cavity, has puzzled otologistsfor decades. In this experimental study in 16 cats, central (n = 23) and peripheral (n = 9) tympanic membrane perforations were observed for up to 63 days before sacrifice. The tympanic membranes with bony rim were excised, decalcified and embedded in Epon 812. Sections werestained with toluidine blue and examined using a light microscope. The perforation had been sealed by meatal epithelium exhibiting pronounced hyperplasia and keratin formation, lying on abedof granulation tissue. Subtotal central perforations healed within 14 days, forming a bowl-shaped tympanic membrane and leaving parts of the handle of the malleus (with meatal epithelium) protruding freely into the middle-ear cavity. Stratified squamous epithelium, morphologicallyidentical with that of external ear canal epidermis, could be observed on the malleus even 63 days after operation. This meatal epithelium was non-keratinizing, non-invasive, and showed no destructive properties typical of acquired cholesteatoma. During certain circumstances, the cellcycle of hyperplastic epidermal epithelium within the middle-ear cavity can evidently be arrested and inactivated by a local defence mechanism.

This cadaver study assessed the value of navigation in cochlear implant surgery. Cochlear implantation was simulated on a cadaver using a Stryker-Leibinger navigation system and a Nucleus 24 Contour implant. A conventional surgical strategy consisting of mastoidectomy, posterior tympanotomy, and cochleostomy was performed. The navigated surgical procedure was evaluated for accuracy, reliability, reproducibility, and practicability. The technology of computer-assisted surgery is applicable in cochlear implantation and beneficial in as much as the navigation-controlled implantation constitutes a non-invasive instrument of quality management. Nevertheless, in order to keep the point accuracy below one millimeter, a referencing methodusing concealed bordering anatomical structures may be further needed to perform the cochleostomy reliably under the guidance of a navigation system. More reproducible reference systems are needed if navigated lateral skull base surgery is to be fully relied upon.

Necrotizing fasciitis of the head and neck is an uncommon, progressive, destructive soft tissue infection of mixed aerobic and anaerobic organisms, having high mortality if left untreated (22 to 100 per cent). This study makes an attempt to analyse various factors and management methods determining the overall prognosis.

A retrospective analysis of all cases of necrotizing fasciitis involving the head and neck, with exclusion of those involving the eyelid and the scalp, was undertaken. Various parameters such as demography, aetiology, complications, management and outcome were studied.

Males outnumbered the females with the latter having a greater risk of involvement after 60 years. Odontogenic infection was the primary source of infection. Anaerobes were cultured in seven out of 17 cases, with six others showing mixed Gram positive and Gram negative organisms. Anaemia was the most commonly associated illness, with diabetes affecting four out of 17 cases.Aggressive surgical debridement with triple antibiotic therapy was used in the management of necrotizing fasciitis with an overall mortality of 11.8 per cent. Patients having late referral, anaemia and one or other complication had increased duration of total hospital stay.

Better results can be obtained with proper control of infection by early diagnosis, aggressive surgical debridement and triple antibiotic therapy, along with timely control of complications and associated illnesses.

Although it is widely believed that management of the airway is difficult in surgery for retrosternal goitre, a review of the literature, revealing management of 1969 patients with retrosternal goitre, provided scant evidence of difficult intubation or post-operative tracheomalacia resulting in tracheal collapse. This was reflected in our own series of 18 thyroidectomies for retrosternal goitre performed at our hospitals.

Treating laryngopharyngeal reflux is the most accepted treatment for laryngeal granulomas. However, response to this treatment is prolonged and in some cases persistent. The authors hypothesize that this is due to the continuous trauma to the mucoperichondrium fromadduction of the vocal folds thus preventing regeneration of healthy mucosa.

A prospective study was performed on six patients with laryngeal granulomas failing prolonged laryngopharyngeal reflux treatment, speech therapy, and surgical excisions. Botulinum toxin Awas injected into the affected thyroarytenoid to reduce adduction trauma. Video-stroboscopy wasused to assess response.

A 50 per cent reduction in the size of the granulomas was noted within two weeks with a complete and permanent response within two to eight weeks in five out of six patients. One patient had an obstructing pyogenic granuloma that required excision and recurred after excision but responded to a repeated injection.

The addition of a single injection of botulinum toxin A to the standard treatment expeditiously eliminated persistent and recurrent laryngeal granulomas.

Wegener’s granulomatosis is a multisystemic disease characterized by foci of necrotizing vasculitis and granuloma formation. Subglottic stenosis may occur either asa presenting feature or a late-stage manifestation of the disease, but will occur in approximately 10–20 per cent of cases.

We present a series of seven cases of Wegener’s granulomatosis with subglottic stenosis and discuss our management of this condition. Where there is active disease, tracheostomy is the first-line surgical treatment of respiratory obstruction, as an adjunct to full medical therapy.More aggressive or elaborate surgical treatments should be reserved for non-active cases in which patients have not required medical treatment for one year.

This study was designed: to evaluate the vocal function in the patients with supracricoid laryngectomy (SCL) compared with normal subjects; to determine the factors affecting voice (such as number of arytenoid(s) preserved and movement of larynx and tongue base); and to determine the correlations between videolaryngostroboscopy, acoustic and perceptual parameters.

Ten patients who underwent SCL with cricohyoidopexy for primary laryngeal squamous cell carcinoma were included into the study. Vocal function was investigated by means or videolaryngostroboscopy. Voice quality was assessed by means of objective acoustic analysis and subjective perceptual ratings by trained raters.

Aberrant, incompetent, and rough mucosal wave was observed in the anterior and superior surfaces of arytenoids(s), the inferior part of tongue base and the lateral walls of the hypopharynx. The acoustic parameters were found to be significantly different from those of normal subjects. The values of perceptual scores were approximately within 50 per cent of normal range. The number of arytenoids spared did not affect acoustic or perceptual measurements. A rough, breathy, unpleasant but intelligible and acceptable voice could be obtained after SCL with cricohyoidopexy.

Objectives: Pre-admission clinics are traditionally run jointly by nurses and doctors. Within an adult ENT pre-admission clinic, we wished to assess what doctors added tonurses’ pre-clerking, to determine whether doctors were actually needed in the clinic.

Methods: Prospective study,looking at how often doctors, seeing patients after ward-based nurses, changed or added to clerking or tests as organized by nurses.

Results: Out of 184 patients, doctors changed or added to nurses’ clerking or planned investigations in 47 patients (26 per cent), making 64 different changes. The commonest reasonsfor changes were ordering blood tests (22 changes), chest X-rays (eight), cancelling due to hypertension (seven), altering drug history (five) and requesting electrocardiograms (five changes).

Conclusion: Most changes made by doctors could be eliminated by designing a pre-admission clinic protocol that could easily be used by nurses. We recommend that all ENT departments consider implementing nurse-led pre-admission clinics.

Background: Concha bullosa, an extensively pneumatized middle turbinate, may obstruct the paranasal sinuses. Messerklinger’s partial lateral turbinectomy is commonly used to debulk the concha bullosa, leaving a raw surface with the potential for adhesions.

Materials and methods: A modified technique of partial lateral turbinectomy is described. A posterior pedicled mucosal flap covers the inferior raw surface of the medial lamella of the middle turbinate. Three-month follow up of a consecutive series is compared with concurrent controls.

Results: Two (7 per cent) of 28 posterior pedicled flap and four (21 per cent) of 19 traditional partial lateral turbinectomies developed mild middle meatal adhesions (p = 0.011). Posterior pedicled flap reduced the need for post-operative cleaning of the middle meatus.

Conclusion: The posterior pedicled mucosal flap is a simple modification to partial lateral turbinectomy that covers the raw surface facing the lateral nasal wall, significantly reducing adhesions and speeding recovery.

Cochlear implantation is usually a safe procedure but, as in most surgical interventions, it can carry some risk of complications. These can be divided into major and minor that, in turn, in turn can present early or late. This case report highlights a potential late, major complication of cochlear implantation namely extrusion, which was averted by prompt intervention. The patient presented with a three months’ history of otalgia some six yearsafter successful implantation. The posterior half of the tympanic membrane was found to be retracted on the electrode, which appeared to be on the point of extruding through the drum. A tragal cartilage myringoplasty was performed to separate the electrode from the medial surface of the tympanic membrane. There was immediate and lasting relief of the otalgia, the electrode was well protected and performance with the device was unchanged.

The authors recommend reinforcing an atrophic tympanic membrane at the time of the cochlearimplantation by a cartilage graft to avoid this potentially serious complication. The case alsohighlights the need for regular otoscopy for all implanted patients.

Ectopic lingual thyroid glands may occasionally undergo massive hypertrophyand be a source of airway obstruction. Securing the airway prior to surgery in such cases may be difficult. In the present paper, we report on two cases of obstructive ectopic lingual thyroids which were successfully managed endoscopically using CO2 laser. The use of CO2 laser for removal of ectopic lingual thyroid tissue offers advantages over traditionalsurgical techniques. In our opinion, removal of an appropriate amount of gland to secure an adequate airway is all that is required in most cases.

Paget’s disease of bone is a common disorder of unresolved etiology characterized by excessive bone resorption followed by excessive bone formation. If the skull isaffected this may result in hearing loss and eventually develop into profound deafness. To date, no cases of cochlear implantation in patients with Paget’s disease have been reported.

The authors present a case of radiographically confirmed Paget’s disease of the skull in a 77-year-old man with a 20-year history of progressive bilateral sensorineural hearing losswho underwent cochlear implantation. A successful insertion of the Nucleus 24 Contour electrodearray was achieved without surgical and postoperative complications.

At the 10 months’ postoperative evaluation, the patient had gained useful open-set speech perception. In quiet conditions, his performance scores on the word and sentence recognition tests were 100 and 98 per cent, respectively. In the presence of noise (at +10 dB. signal-to-noise ratio), his performance scores on the word and sentence recognition tests were 96 and 94per cent, respectively.

Adult hypopharyngeal haemangioma is an uncommon neoplasm. We present three cases of adult hypopharyngeal haemangioma which were successfully treated with a neodymium: yttrium–aluminium–garnet (Nd: YAG) laser in our hospital between 2000 and 2003. The patients in this series experienced no untoward events from the use of the laser. Excessive bleeding and airway problems were not encountered. Postoperative pain was minimal. Excellent long-term function and a full resolution of symptoms can be obtained using Nd: YAG laser. The laser provides a bloodless field and complete healing of the hypopharynx, without stenosis or scar formation.

Narghile (water-pipe) smoking requires the generation of significant negative intrapharyngeal pressure, which may be transmitted to the middle ear through the Eustachian tube. A total of 80 ears from regular narghile smokers were examined otoscopically and by tympanometry. Seventy ears from heavy cigarette smokers were similarly examined and served as a control group. There was a highly significant increase in the prevalence of atticretractions (P < 0.01) in the narghile smokers. The tympanometric changes were not significantly different between the two groups (P > 0.05).

Patients diagnosed with malignancy often undergo combined positron emissiontomography (PET) and computerized tomography (CT) to investigate possible metastases. This report presents a case in which, in the investigation of suspected pulmonary malignancy, combined PET and CT images suggested a malignant lesion at the level of the vocal fold. Biopsy of the lesion, however, confirmed the clinical diagnosis of a Teflon granuloma. The case highlights the potential for a false positive report during scanning of patients who have had vocal fold injection.

Lower oesophageal foreign body meat bolus obstruction is potentially life-threatening. We report a case in a 94–year–old woman in which conservative measures and flexible oesophagoscopy were unsuccessful. Rigid oesophagoscopy was considered technically difficult and so clearance by interventional radiology was attempted. Through the mouth a radiologically guided balloon catheter was introduced. It was passed beyond the bolus to dilate the site of obstruction, before being withdrawn and inflated above the bolus, pushing it into the stomach. Although successful in this case, the technique is previously unreported and so its complication rate is unknown. It is therefore presented only to be considered when other treatments are neither effective nor possible.

This study investigated the usefulness of three-dimensional computed tomography (3DCT) in the evaluation of bony defects caused by cholesteatoma. Fifteen patients with chronic otitis media with cholesteatoma who showed bony destruction or suspicious destruction in two-dimensional CT were examined using 3DCT. The CT data were transferred to a workstation witha real-time image processor. We used three-dimensional reconstruction software enabling image processing. In all patients, 3DCT clearly delineated the destruction of bony structures by cholesteatoma. The 3DCT-generated images provided spatial relationships, which were not easily appreciated on two-dimensional CT. Intraoperative bony destruction findings correlated with 3DCT findings. From these results, 3DCT could be useful to evaluate the invasiveness of cholesteatoma to the cranial base. It could also be helpful in planning reconstruction during surgery.