Computer-based medical simulation has recently been adopted as a new method of medical education. This paper reviews the uses of medical simulation within the ENT specialty, and reports how such simulation is used in Al-Ahsa College of Medicine, Saudi Arabia.

We review our use of a simulation laboratory in ENT training. Students are taught ENT anatomy using physical models, ear diseases using physical models, and ENT examination by watching video recordings, and are taught the principles of common ENT surgery using a computerised mannequin (for laryngoscopy and bronchoscopy). A haptic temporal bone surgery simulator is used for mastoidectomy and functional endoscopic sinus surgery training, and a mannequin for cricothyrotomy and tracheotomy training.

The use of such simulation methods has greatly improved our students' perception and comprehension.

To assess the outcome of conservative management of vestibular schwannoma.

Observational study.

Tertiary referral centre.

Four hundred and thirty-six patients with vestibular schwannoma (490 tumours), including 327 sporadic tumours and 163 tumours in 109 patients with neurofibromatosis type two.

The relationship of tumour growth to tumour size at presentation, and to certain demographic features.

The initial tumour size was significantly larger in the neurofibromatosis type two group (11 mm) than in the sporadic vestibular schwannoma group (5.1 mm). In both groups, 68 per cent of tumours did not grow during follow up (mean 3.6 years; range one to 14 years). The mean growth rate was 1.1 mm/year (range 0–15 mm/year) for sporadic tumours and 1.7 mm/year (range 0–18 mm/year) for neurofibromatosis type two tumours. The tumour growth rate correlated positively with tumour size in the sporadic tumour group, and correlated negatively with age in the neurofibromatosis type two group.

Two-thirds of vestibular schwannomas did not grow. Radiological surveillance is an acceptable approach in carefully selected patients. Once a sporadic vestibular schwannoma reaches 2 cm in intracranial diameter, it is likely to continue growing. We do not recommend conservative management for sporadic tumours with an intracranial diameter of 1.5 cm or more. Vestibular schwannoma management is more complex in patients with neurofibromatosis type two.

(1) To compare audiometric parameters in patients with vestibular schwannoma and in those with asymmetric hearing loss from other causes; and (2) to assess proposed screening criteria by comparing published protocols.

Audiometric data from 199 vestibular schwannoma patients and 225 non-tumour patients were compared. Eight screening protocols were tested on these 424 patients.

Vestibular schwannoma and non-tumour patients with little or no hearing loss in the unaffected ear were inseparable; however, vestibular schwannoma patients with hearing loss in the unaffected ear had greater audiometric asymmetry, compared with non-tumour patients with the same pattern of hearing loss. The sensitivity of screening protocols varied from 73 to 100 per cent; parallelism was observed between sensitivity and screening rate.

As regards vestibular schwannoma screening protocols, the best compromise between sensitivity and screening rate was offered by a criterion comprising either: (1) ≥20 dB asymmetry at two neighbouring frequencies, or unilateral tinnitus, or (2) ≥15 dB asymmetry at two frequencies between 2 and 8 kHz.

To study the changes in facial nerve function, morphology and neurotrophic factor 3 expression in response to three types of nerve injury.

Changes in facial nerve function (in terms of blink reflex, vibrissae movement and position of nasal tip) were assessed in 45 rats in response to three types of nerve injury: partial section of the extratemporal segment (group one); partial section of the facial canal segment (group two); and complete transection of the facial canal segment (group three). All facial nerves were then dissected out from the sacrificed animals, on the first, seventh or 21st post-operative day, and the injured segment bisected for subsequent analysis. Morphological change and neurotrophic factor 3 expression in these facial nerve segments were evaluated by means of improved trichrome staining and immunohistochemical analysis, respectively.

Facial nerve function was more severely damaged and recovery was slower in group two compared with group one, although the facial nerve injury had been identical at the two sites involved. In group three (complete facial canal transection), scattered degenerative fibres were observed at the transection site on the seventh post-operative day. The number of degenerated fibres, assessed on the seventh post-operative day, was markedly increased in group two compared with group one. On the seventh post-operative day, axonal expression of neurotrophic factor 3 was strongly positive, whereas expression in Schwann cells was only weakly positive.

The facial palsy of the group two rats was more severe than that of group one rats, although their facial nerve function had partly recovered on the 21st post-operative day. Fibre degeneration was not only dispersed throughout the injury site but also occurred throughout the length of the nerve. Neurotrophic factor 3 immunoreactivity increased in facial nerve fibres after partial transection.

The prognosis for cases of idiopathic facial palsy is usually good. However, some cases develop disabling sequelae, such as synkinesis or severe facial hemispasm, despite targeted medical treatment.

The authors try to achieve that electromyography is useful to identify patients with severe palsy and an unfavourable prognosis. These patients would probably benefit from facial nerve decompression.

The otolaryngology – head and neck surgery department of Pitié-Salpêtrière Hospital, Paris, a tertiary referral centre.

Thirteen cases undergoing surgery between January 1997 and March 2007.

We describe the electromyographic findings that led to surgery. All patients underwent surgery via a subpetrous approach, within four months of the onset of palsy. Decompression involved the first and second portions of the nerve and the geniculate ganglion.

Recovery to House–Brackmann grade III was obtained in all cases at one year follow up.

These results compared favourably with previous reports. A new therapeutic procedure may allow improved results.

Granular myringitis is a poorly understood disease which causes considerable discomfort and concern to affected individuals. Some cases may progress to inflammatory obliteration of the deep ear canal. Treatment options are diverse, and no single accepted treatment modality exists. Local application of 5-fluorouracil has recently been trialled in the treatment of chronic otitis media, with promising results.

To investigate the efficacy and safety of topical 5-fluorouracil in cases of granular myringitis.

Sixty patients with granular myringitis were enrolled in this controlled, double-blinded study. Patients were divided randomly into two equal groups. Patients in the study group (n = 30) received three successive applications of topical 5-fluorouracil 5 per cent cream, with two-week intervals between treatments. Patients in the control group (n = 30) received only local petroleum jelly cream packing at the same intervals. Follow-up appointments were scheduled every two weeks for the first three months; patients were then seen again after two years for evaluation of any persistent disease. Outcome measures were: (1) after three months, symptomatic response to treatment (i.e. quantity of aural discharge as reported by patient) and change in the amount of granulation tissue (as assessed by the physician via endoscopic examination); and (2) persistent disease after two years.

There was a highly statistically significant difference in the studied outcomes, comparing the study and control groups.

Local application of 5-fluorouracil is a new treatment method for granular myringitis. In this study, it proved safe and efficacious, with no serious local reactions or complications.

This study sought to establish the prevalence of vestibular disorders, migraine and definite migrainous vertigo in patients with psychiatric disorders who were referred for treatment of dizziness, without a lifetime history of vertigo.

Retrospective study.

Out-patients in a university hospital.

Fifty-two dizzy patients with panic disorders and agoraphobia, 30 with panic disorders without agoraphobia, and 20 with depressive disorders underwent otoneurological screening with bithermal caloric stimulation. The prevalence of migraine and migrainous vertigo was assessed. The level of dizziness was evaluated using the Dizziness Handicap Inventory.

Dizzy patients with panic disorders and agoraphobia had a significantly p = 0.05 regarding the prevalence of peripheral vestibular abnormalities in the group of subjects with PD and agoraphobia and in those with depressive disorders. Migraine was equally represented in the three groups, but panic disorder patients had a higher prevalence of migrainous vertigo definite migrainous vertigo. Almost all patients with a peripheral vestibular disorder had a final diagnosis of definite migrainous vertigo according to Neuhauser criteria. These patients had higher Dizziness Handicap Inventory scores. The Dizziness Handicap Inventory total score was higher in the subgroup of patients with panic disorders with agoraphobia also presenting unilateral reduced caloric responses or definite migrainous vertigo, compared with the subgroup of remaining subjects with panic disorders with agoraphobia (p < 0.001).

Our data support the hypothesis that, in patients with panic disorders (and especially those with additional agoraphobia), dizziness may be linked to malfunction of the vestibular system. However, the data are not inconsistent with the hypothesis that migrainous vertigo is the most common pathophysiological mechanism for vestibular disorders.

This study aimed to investigate the utility of three-dimensional reconstructions of paranasal sinus computed tomography data in depicting the anatomy of the frontal sinus drainage pathway.

Twenty-nine patients underwent imaging of the sinuses for various clinical indications. Variations in frontal sinus recess anatomy were determined from 0.75-mm thick coronal, axial and sagittal computed tomography images. Three-dimensional, reformatted images were generated from manually segmented volumes of interest. Observations were made on the variation and usefulness of these reconstructions.

Three-dimensional, reformatted images of segmented volumes aided delineation of the spatial relationships of the frontal sinus, frontal sinus drainage pathway, infundibular and meatal direction of drainage, agger nasi cells, ethmoid bulla cells, supraorbital cells, and suprabullar cells.

Three-dimensional, reformatted images of frontonasal anatomy enable improved understanding of the frontal sinus drainage pathway anatomy and of the spatial relationships between ethmoid air cells in this region. Such images may provide a useful adjunct to surgical planning and education.

To test the association between clinical allergic sensitisation to pollens and the profile and load of those pollens, in Ankara, Turkey.

Forty-three patients with seasonal allergic rhinitis were included. Clinical sensitisation to various pollens was compared with 10-year counts of the same pollens. The ratios of sensitisation to various pollen groups, and the association between clinical sensitisation and pollen load, were investigated.

Grass pollen allergy was the leading cause of seasonal allergic rhinitis, followed by tree pollen allergy. In Ankara, the most common type of airborne tree pollen was salicacea; however, the commonest clinical tree pollen allergies were due to the betulaceae and fagaceae families.

Higher concentrations of airborne pollens may not always result in a higher prevalence of clinical allergy to those pollens.

To investigate the frequency and management of epistaxis in schools.

A postal survey of schools.

One hundred and fifty-seven questionnaires were posted out to 41 secondary schools (students aged 11–18 years) and to 116 primary schools (students aged four to 11 years). One hundred and twelve completed questionnaires were returned, 32 from secondary schools and 80 from primary schools. Most schools stated that they encountered a nose bleed once per month. The commonest method of treating a nose bleed was to pinch the top of the nose (an ineffective method), although pinching the bottom of the nose was almost as common. Only a minority of primary and secondary schools (37.5 and 25 per cent, respectively) had a policy for dealing with nose bleeds. Despite many respondents reportedly using an ineffective method, only two stated that they did not feel confident in dealing with nose bleeds.

Nose bleeds in school students are common, and management frequently deviates from recommended guidelines.

We modified and abbreviated a pre-existing research questionnaire, the Tonsil and Adenoid Health Status Instrument, to make it suitable for rapid completion as a disease-specific, health-related quality of life research tool for children with tonsil and adenoid disease in the UK. We determined the main psychometric properties of the resulting 14-item Paediatric Throat Disorders Outcome Test.

Pre- and post-operative questionnaires were completed by the parents of children with throat disorders referred to two large hospitals. We included children with recurrent tonsillitis and with obstructive sleep apnoea. A separate cohort of healthy children of comparable age range was also studied.

The test's internal consistency and responsiveness were analysed and its construct validity documented via known-group differences.

A total of 126 completed questionnaires were received from the hospital referral group. The children's mean age was 6.5 years (range one to 16). The 40 unaffected children were well matched in age to the study population (mean 6.1 years, range two to 15). Cronbach's α coefficient for the pre-operative assessment total score was 0.84. The test–retest reliability coefficient for the total score was 0.98, indicating very high reproducibility. The 14-item Paediatric Throat Disorders Outcome Test discriminated well between children known to suffer with throat problems and a group of healthy controls (p < 0.0001; t = 24.016). Six months after surgical intervention, parentally reported questionnaire scores had improved (i.e. were lower) (p < 0.0001; t = 7.01). The standard effect size (i.e. change in mean divided by baseline standard deviation) for children for whom post-operative questionnaires were completed was 1.53; this is very large.

The 14-item Paediatric Throat Disorders Outcome Test is an appropriate, disease-specific, parent-reported outcome measure for children with throat disorders, for which we have demonstrated internal consistency, reliability, responsiveness to change and two forms of construct validity.

Laryngeal and hypopharyngeal cancer is a multifactorial disease caused by various carcinogens such as tobacco, alcohol and viruses. Likewise, oxidative stress is known to cause aberrations in the cell membrane and DNA, leading to cancer. We conducted this prospective study in order to evaluate the level of oxidative stress in laryngeal and hypopharyngeal cancer patients.

Fifty patients with laryngeal and hypopharyngeal cancer and 40 control subjects were selected. Serum malondialdehyde concentrations and ferric reducing antioxidant power were assessed, in order to evaluate oxidative stress. Results were analysed by Student's t-test.

Malondialdehyde levels were significantly higher and ferric reducing antioxidant power lower in the cancer patients, compared with the controls, indicating higher oxidative stress in the former. There was no statistically significant difference in malondialdehyde concentration or ferric reducing antioxidant power, comparing patients with versus without neck secondaries, and patients with early stage versus late stage tumours.

Oxidative stress may have a role to play in the initiation of laryngeal and hypopharyngeal cancers, especially in patients with other risk factors such as tobacco and alcohol use.

It is well known that laryngeal squamous cell carcinoma is strongly related to tobacco and alcohol consumption. Accumulating evidence suggests that alterations of detoxification enzymes, such as glutathione S-transferases and N-acetyltransferases, influence the risk of cancers associated with tobacco smoke and alcohol.

This was a retrospective case–control study. The study group consisted of 88 Greek patients with laryngeal squamous cell carcinoma; there were also 102 control subjects. Frequencies of the genotypes GSTT1, GSTM1, GSTM3 and NAT2 were evaluated by polymerase chain reaction restriction fragment polymorphism.

The distribution of overall genotypes was 55.68 per cent rapid acetylator and 44.32 per cent slow acetylator in patients, and 36.27 per cent rapid acetylator and 63.72 per cent slow acetylator in controls. The odds ratio for rapid acetylator status in cases versus controls was 2.207 (95 per cent confidence interval 1.23–3.95, p = 0.0087).

This study demonstrated a significant relationship between rapid acetylator genotypes and laryngeal squamous cell carcinoma in a Greek population.

This study determined readability scores for sequential letters written to general practitioners and copied to patients, following ENT consultations at the Royal United Hospital in Bath. Intervention involved educating clinicians in techniques to improve readability.

A total of 295 letters from eight clinicians were assessed in the pre-intervention phase. The mean Flesch reading ease score was 61.8 (standard deviation 8.7) and the mean Flesch–Kincaid reading grade was 9.0 (standard deviation 1.7). Re-audit analysed a further 301 letters. There was no significant change in the readability of the letters post-intervention.

It may not be feasible to present medical information intended for general practitioners in a way that is readable to most of the UK adult population.

We present a novel, previously undescribed technique of obtaining a biopsy from an inaccessible parapharyngeal space mass.

A modified endo-cavitary ultrasound probe was utilised to obtain an intra-oral, image-guided core biopsy of a parapharyngeal tumour. The parapharyngeal mass was not accessible to percutaneous ultrasound-guided biopsy due to its anatomical location.

To our knowledge, this is the first such modification of the conventional endo-cavitary probe technique described in the literature. The technique permits accurate, well controlled biopsy of lesions located high in the parapharyngeal space, under general anaesthesia.

Superior semicircular canal dehiscence affects the auditory and vestibular systems due to a partial defect in the canal's bony wall. In most cases, sound- and pressure-induced vertigo are present, and are sometimes accompanied by pulse-synchronous tinnitus.

We describe a 50-year-old man with superior semicircular canal dehiscence whose only complaints were head rotation induced tinnitus and autophony. Head rotation in the plane of the right semicircular canal with an angular velocity exceeding 600°/second repeatedly induced a ‘cricket’ sound in the patient's right ear. High resolution temporal bone computed tomography changes, and an elevated umbo velocity, supported the diagnosis of superior semicircular canal dehiscence.

In addition to pulse-synchronous or continuous tinnitus, head rotation induced tinnitus can be the only presenting symptom of superior semicircular canal dehiscence without vestibular complaints. We suggest that, in our patient, the bony defect of the superior semicircular canal (‘third window’) might have enhanced the flow of inner ear fluid, possibly producing tinnitus.

We report an extremely rare case of recurrent laryngeal nerve paralysis due to subclinical Lyme borreliosis.

Case report presenting a 15-year-old girl referred with hoarseness and soft voice.

Right-sided recurrent laryngeal nerve paralysis was observed using videolaryngoscopy. Imaging was used to exclude intracranial, cervical and intrathoracic embryological lesions, vascular malformations and tumours. Laboratory and electrophysiological investigations were used to exclude inflammatory and paraneoplastic processes, endocrinopathy and metabolic disorders. Serological testing was positive for Lyme disease. Parenteral ceftriaxone therapy was commenced. The patient's nerve paralysis showed complete recovery on the seventh day of antibiotic treatment; this was confirmed by videolaryngoscopy.

Recurrent laryngeal nerve paralysis is an extremely rare complication of neuroborreliosis associated with Lyme disease. In patients with recurrent laryngeal nerve paralysis in whom the clinical history is uncertain and the usual diagnostic methods give negative results, screening with anti-borrelia immunoglobulin M is suggested.

To present an interesting cause of pre-auricular swelling.

We report the case of a 39-year-old woman who presented to the ENT department as an emergency with swelling in the left pre-auricular region. The patient had recently travelled to Central America, where the botfly is endemic. On examination, there was a raised, indurated area with a central orifice. A botfly larva was suspected. The larva was suffocated with paraffin paste, allowing removal without remnants being retained.

Suffocation of botfly larvae is favoured to surgical removal, due to the possibility of larval remnants being retained and acting as a nidus for infection. The increasing frequency of exotic travel means doctors need to be more aware of tropical medicine.