A long-standing diffuse chronic otitis externa can lead to itching. Resultant scratching may then lead to irreversible skin changes with canal stenosis by scar tissue. The poor ventilation and increased humidity gives rise to bacterial and fungal growths leading to breakdown of the skin defences and worsening itching. This vicious itching–scratch cycle or downward spiral often fails to respond to medical treatment. For these cases a simple conchal flap meatoplasty may improve ventilation of the external auditory canal and may lead to a self cleaning ear. We reviewed 84 patients who had undergone conchal flap meatoplasty in Calderdale and Huddersfield NHS Trust Hospitals from April 1993 to June 2002. A long-term follow up of conchal flap meatoplasty in chronic otitis externa showed no records of complications or further otitis in 93.2 per cent of cases. Thus surgical intervention plays an important role in the treatment of otitis externa not responding to treatment.

We studied the transmission of heat to the vestibule during revision stapes surgery with a piston in situ, using a CO2 laser, in an in vitro model. A type K thermocouple was placed around the medial end of stainless steel and fluoroplastic wire pistons in a ‘vestibule’ filled with saline. The effect of laser hits on fluoroplastic wire and stainless steel stapes prostheses was investigated. The effect of introducing a vein graft to seal the stapedotomy was also examined. Greater temperature rises occurred with stainless steel than with fluoroplastic wire pistons. The addition of the vein graft reduced heat transmission.

Application of the CO2 laser to fluoroplastic wire pistons, using the power settings suggested by the manufacturer, is not likely to damage the inner-ear structures. Application of 6 W laser energy to stainless steel pistons can potentially disturb the inner-ear function.

Background: Patients are traditionally advised to refrain from exposing their ears to water after most otological procedures. However, recent evidence suggests that water does not adversely affect the outcome for children with tympanostomy tubes. The evidence behind the potential harmful effects of water on the outcome of other otological procedures is scarce.

Objective: The study was done to determine the current practice of otolaryngology consultants in the UK on the advice given to patients regarding swimming, diving and bathing in soapy water after myringotomy and tympanostomy tube insertion, mastoidectomy and myringoplasty.

Method: Questionnaire based survey mailed to 382 members (consultants only) of the British Association of Otolaryngologists – Head & Neck Surgeons in the UK.

Results: A total of 195 responses were received (reply rate 51 per cent). In all, 95.6 per cent of the respondents allowed their patients to swim after insertion of tympanostomy tubes, with 32.9 per cent insisting on the use of earplugs until extrusion of the tympanostomy tubes. However, 61.6 per cent of the respondents restricted diving in these patients. In comparison, the respondents were more conservative with water precautions following myringoplasty and mastoidectomy. More than half the respondents recommended earplugs for bathing after all three operations.

Conclusion: This study reveals current national practice among UK otolaryngologists. There is no general consensus in post-operative advice following otolaryngological procedures, indicating a need for national guidelines.

Aim: Nasal and paranasal sinus involvement is common in lepromatous leprosy and is of considerable epidemiological significance. The aim of this study was to investigate paranasal sinus abnormalities in treated lepromatous leprosy cases and to evaluate the findings in comparison with those of previous studies.

Materials and methods: Thirty-eight patients who had been treated for lepromatous leprosy were included. All patients had been treated with dapsone and rifampicine for six months, and followed with dapsone, rifampicine and clofamizine for a minimum of two years. All patients received a clinical examination, a coronal computed tomography (CT) examination of the paranasal sinuses and ethmoidal sinus endoscopy, in order to investigate the involvement of the paranasal sinuses in the leprosy. Ethmoidal sinus biopsies were taken in 18 of the 21 cases of ethmoidal sinus involvement noted on CT scan.

Results: Twenty-three patients had sino-nasal symptoms. Endoscopic examination showed different pathologies in 21 of these patients. Abnormalities in the paranasal CT images were observed in 27 patients. The ethmoidal, maxillary, frontal and sphenoid sinuses were affected in 21, 18, three and two patients, respectively. Various degrees of nasal septum perforation were noted in 18 cases. In six of the 18 patients biopsied, the biopsy specimen showed involvement by lepromatous leprosy.

Conclusion: These findings suggest that although these lepromatous leprosy patients had been treated, persistent infection was still commonly encountered. Paranasal sinus CT examination is a useful method for the evaluation of patient response to treatment and follow up; however, a CT scan alone cannot determine whether the leprosy is active.

Background: Submucosal resection is accompanied by significant post-operative pain and discomfort. The aim of this randomized, double-blinded clinical trial was to study the efficacy of a local block anaesthetic, delivered after induction of general anaesthesia, in reducing post-operative pain.

Methods: Patients aged 16 years and over who were scheduled for elective submucosal resection were randomly assigned to receive either standardized general anaesthesia, general anaesthesia with local anaesthetic infiltration or general anaesthesia with placebo infiltration. Haemodynamic stability, intra-operative blood loss, post-operative pain (over a seven day follow-up period), analgesics consumption, hospital stay, and the patient's and surgeon's levels of satisfaction were assessed.

Results: We found significantly lower results for pack removal pain score, volume of intra-operative blood loss, number of patients suffering from headache, altered dental sensation or nasal pain, number of patients who consumed analgesics, and length of hospital stay, comparing the infiltration group with the general anaesthesia and placebo groups (p<0.05).

Conclusion: This clinical trial showed that infiltration with the local anaesthetics fentanyl and clonidine substantially reduced post-operative pain and shortened patients' hospital stay.

Bilateral vocal fold immobility in children is a challenging problem because a balance between good airway and voice quality has to be achieved. Surgery to improve the airway is often postponed or avoided because of fear of losing the voice. In this study our results of laser arytenoidectomy in children are described. This was a retrospective case notes review at a tertiary level paediatric ENT department. The six patients in this case series ranged from nine to 16 years old at the time of laser arytenoidectomy. Post-operative airway and voice quality were assessed. All children in the series had an adequate post-operative airway. Four of these patients had tracheostomies pre-operatively and achieved decannulation. All six patients rated their post-operative voice as better than pre-operatively. This is principally due to increased loudness associated with increased airflow through the larynx, particularly after tracheostomy decannulation. It is recommended that special care should be taken not to disturb the anterior two thirds of the vocal fold during the surgery in order to achieve a good post-operative voice outcome.

This paper describes a new application for radiofrequency ablation in head and neck surgery. Two patients with extensive laryngeal papillomata were successfully treated using this technology. The technique is described in detail, highlighting the main benefits of this approach as compared with existing techniques. These advantages include limited damage to underlying tissues and a bloodless field.

Background: Patients do not respond to treatment in a predictable manner. Individual preconceptions determine help seeking, compliance and treatment outcome, yet clinicians rarely explore these issues. The illness perception approach sees the patient as an active participant in the healthcare process.

Aims: The aim of this study was to investigate the illness perceptions of people with dysphonia. The subsidiary aims were to correlate the Illness Perception Questionnaire with any psychological distress identified and a self-report measure of dysphonia, and to consider any potential implications for patient management.

Design: Prospective, cross-sectional observation.

Setting: Primary and secondary care, two general and four community hospitals.

Participants: Fifty adult patients with dysphonia due to benign disease completed three self-administered questionnaires, which investigated their illness perceptions, psychological distress and perceptions of the impact of the presenting ‘illness’.

Measures: The dysphonia was categorised as being due to functional (n=40) or organic (n=10) causes. All the voices were rated by an expert listener according to the GRBAS (grade, roughness, breathiness, aesthenia, strain) scale. Participants completed the Illness Perception Questionnaire, the Vocal Performance Questionnaire and the Hospital Anxiety and Depression scale.

Results: Patients showed a wide variation in perception of causation. They had no strong perceptions about the causes, consequences or duration of the presenting dysphonia. Functional dysphonics reported greater consequences, lower perceived control and increased anxiety when compared to patients with organic dysphonia. In terms of cure/control, all patients expected treatment to be helpful but this expectancy reduced as time increased. Anxiety was more associated with functional dysphonia, however, only 17 per cent of the subjects in this group showed clinically significant levels of signs of psychological distress.

Conclusions: Lay illness representations often diverge from the clinician's understanding of the presenting problem and strongly influence treatment behaviour. Early exploration of illness perceptions may enhance health behaviour and maximise the impact of intervention.

Objective: To compare the complication rates of parotidectomy operations on benign histology performed by ENT and non-ENT surgeons.

Study design and setting: A seven-year (1994–2000) retrospective case notes review of patients undergoing parotidectomy in a United Kingdom district general hospital was performed. Patients with malignant histology were excluded.

Participants: Patients were identified from the hospital computer database. One hundred and fifty-nine patients underwent parotidectomy for both benign and malignant conditions over the seven-year period. One hundred and thirty-seven (86 per cent) patients had parotidectomy for benign conditions and were included in this study.

Main outcome measures: The presence or absence of facial palsy and other associated complications following parotidectomy surgery in both groups.

Results: The temporary facial palsy rates for ENT and non-ENT surgeons were 56 per cent and 57 per cent, respectively. The permanent facial palsy rates for ENT and non-ENT surgeons were 2 per cent and 7 per cent, respectively. Differences in facial palsy were not statistically significant. The difference in other complication rates such as Frey's syndrome, haematoma, salivary fistula, and neuroma were also not statistically significant.

Conclusion: Our complication rates were comparable with published results. There was no significant difference in the observed rate of post-operative facial nerve palsy and other known complications following parotid surgery performed by ENT and non-ENT surgeons.

The aim of this study was to evaluate spinal accessory nerve function after functional neck dissection (FND) and radical neck dissection (RND) by monitoring the nerve with electromyographic (EMG) examinations. A prospective, double-blind, clinical study was undertaken in 21 patients (42 neck side dissections) operated on for head and neck malignant diseases, separated into two groups: 10 neck sides in the RND group and 32 neck sides in the FND group. Electromyographic examinations were performed pre-operatively and post-operatively in the third week and third and ninth months. Additionally, a questionnaire, modified from the neck dissection impairment index, was applied to all the patients in order to assess shoulder function in the ninth post-operative month.

All patients had maximum EMG scores pre-operatively. Following the operation, motor amplitudes decreased in both groups. At the third post-operative month, amplitudes decreased to their lowest values. As expected, the decreases in amplitude and EMG score were more prominent in the RND group. Following reinnervation, the amplitudes of the trapezius motor response increased in the FND group but never reached pre-operative values (during the time of follow up). The FND group scores for pain, neck and shoulder stiffness, and disability in heavy object lifting, light object lifting and reaching overhead were significantly lower than those of the RND group.

In FND, one aims to preserve anatomically the spinal accessory nerve, and it is presumed to be intact after the procedure. However, using EMG nerve function monitoring, our study revealed that profound spinal nerve injury was detected immediately after FND surgery, which tended to improve over subsequent months but had not regained its original function by the end of the ninth post-operative month.

Head and neck cancer care was analysed in 2167 unselected patients for management compliance and outcome. Median age was 55 years, with a male to female ratio of 5.5[ratio ]1. Major sites were oropharynx (32.4 per cent), larynx (19.8 per cent), oral (16.6 per cent) and hypopharynx (12.9 per cent). Stage-wise distribution was I–II=8.9 per cent, III=20.6 per cent and IV=60.3 per cent and unstaged=10.2 per cent. Squamous cell carcinoma was the dominant histology for 90.9 per cent. Clinic-based cancer-directed treatment decisions were made for 1905 patients: curative intent in 53 per cent, palliative in 35 per cent and for the remaining 262 (12 per cent) supportive care. Overall, 1209 (56 per cent) patients complied with the prescribed treatments; 62 per cent, 54 per cent, and 35 per cent of curative, palliative and supportive care intent groups, respectively. Modalities were radiotherapy alone (64.6 per cent), combined surgery with irradiation (17.6 per cent), and chemoradiotherapy (11.2 per cent). Median follow-up periods were 17.5 and three months in curative and palliative groups respectively. Overall, 712 (33 per cent) cases received curative therapy, with three-year disease-specific survival of 49 per cent. Patient compliance was a major obstacle. The comparison of this series with the USA, Canada and Norway showed wide disparities in stage of presentation and survival.

Objective: To determine levels of confidence in the management of surgical airway emergencies by junior ENT staff.

Design: Telephone survey.

Participants: 100 Senior House Officers (SHOs) from 100 hospitals in the UK, providing 24 hour first on-call emergency ENT cover.

Method: A list of questions was put to participants. The effects of different variables on confidence with airway emergencies and what SHOs considered to be adequate training were compared.

Results: Most SHOs provided cover for the management of surgical airway emergencies. Many of the participants were not confident to handle airway emergencies or felt that their training was inadequate. As expected, the amount of previous experience in ENT and the ability to perform advanced airway procedures gave SHOs greater confidence, but attendance at airway courses did not.

Conclusion: Confidence in the management of airway problems is variable and does not correlate well with perceived adequacy of training. We suggest that systems of training in airway management are improved. Training issues may be better approached at an individual level, where deficiencies can be addressed.

More than 200 techniques have been described for correction of prominent ears, indicating that there is no single, widely accepted procedure that has been adopted by most surgeons. This article presents a simplified surgical method for correction of prominent ears. One hundred and twenty-eight otoplasties were performed on 70 patients using the described technique. The main modification of the technique was the use of a diamond burr drill to thin the cartilage posteriorly. Good aesthetic results were obtained in most patients.

Objective: We report an extremely rare case of family clustering of cholesteatoma.

Method: Case reports and a review of the world literature concerning cholesteatoma and heredity are presented.

Results: The family consists of parents and seven siblings of whom the mother and three sons have been surgically treated for cholesteatoma. All cholesteatomas in the family are acquired and all have a history of otitis media. Cholesteatomas occur with an incidence of 5/100 000 in Greenland, corresponding to two to three new cholesteatoma patients per year among the 57 000 inhabitants of Greenland. The family is very exceptional and interesting for further research concerning heredity in the pathogenesis of acquired cholesteatoma.

Conclusion: To our knowledge this is the first report in the world literature of family clustering of acquired cholesteatoma. This case indicates that hereditary factors interplay with other factors in the pathogenesis of cholesteatoma.

Angiosarcomas rarely arise from schwannomas, but we describe here a case of angiosarcoma that arose from a remnant of a benign vestibular schwannoma that had been removed 10 years earlier. The patient was a 66-year-old man with no sign of neurofibromatosis. Although we attempted surgical resection, we could not totally remove the tumour. The patient died nine months after diagnosis, primarily as result of an abscess in the cerebellum and base of the skull. The histological diagnosis was confirmed by the immunohistochemical findings of positivity for CD34 antigen and S-100 protein in the resected tumour.

A review of the literature revealed four other cases of angiosarcoma with schwannoma, all of which arose from an extracranial nerve. The present case is the first report of an angiosarcoma with schwannoma arising from an intracranial locus.

Ameloblastoma is an odontogenic neoplasm of enamel organ type tissue which does not undergo transformation to the point of enamel formation. We present the second case in the English literature of maxillary ameloblastoma that presented with nasal obstruction and rhinorrhoea, and the first to be excised using a combined maxillotomy and endoscopic ethmoidectomy. The patient had no previous dental history. The unusual presenting symptoms, as well as the highly destructive nature of these lesions when arising in the maxilla, make them worthy of consideration in the differential diagnosis of nasal and maxillary masses. We discuss the clinical features, pathology and management of these lesions and review the literature.

The translabyrinthine approach is one of the favoured access routes for removal of vestibular schwannomas; however, total hearing loss in the operated ear is a predictable consequence. Here, we report a case in which a patient maintained serviceable hearing almost six years after classic translabyrinthine surgery. Possible explanations for the hearing preservation are discussed, as well as the feasibility of a modified translabyrinthine approach in attempting preservation of hearing following vestibular schwannoma surgery.

Dehiscence of the semicircular canal is an uncommon condition and has been reported to involve the roof of the superior semicircular canal. We describe a case with dehiscence of four semicircular canals and in areas not involving the roof of the superior semicircular canal. Features that assist the diagnosis of this condition are reviewed, along with the current literature.

Objective: To demonstrate the feasibility and complexities of cochlear implantation in the setting of bilateral temporal bone osteoradionecrosis.

Study design: Case report.

Setting: Tertiary care referral centre.

Case description: A 66-year-old woman with bilateral temporal bone osteoradionecrosis and profound hearing loss, following treatment for tonsillar cancer, underwent cochlear implantation. Prior canal wall down mastoidectomy and subsequent temporal bone resection with free flap reconstruction had been performed on the implanted ear. The contralateral ear received a canal wall down mastoidectomy. A completely dehiscent mastoid segment of the facial nerve and extensive fibrosis were evident in the implanted ear. Only minimal fibrous reaction was found within the cochlea, allowing for full electrode insertion. At three months, speech recognition testing documented a consonant-nucleus-consonant (CNC) word score of 54 per cent.

Conclusions: This report demonstrates the feasibility of cochlear implantation after temporal bone surgery and free flap reconstruction in the setting of diffuse osteoradionecrosis. The patient's excellent open-set speech understanding using the cochlear implant implies that radiation did not severely damage the central auditory pathways. Thus, some patients with radiation-induced hearing loss may be appropriate cochlear implant candidates. Special attention should be paid to surgical planning, as complications related to wound healing, electrode insertion and facial nerve injury may be more likely.

Two patients who received supracricoid laryngectomy with cricohyoidoepiglottopexy to treat laryngeal cancers, underwent intra-operative electromyography analysis. After the lesion was removed and the electrodes were inserted into the remaining intrinsic laryngeal muscles, the depth of anaesthesia was carefully reduced. Gentle tactile stimulations were applied to the pharynx to trigger the reflex movement of the remaining arytenoids. Recordings were made when reflex movement was achieved.

Case one: Electromyography (EMG) of the remaining arytenoid demonstrated clear phase differences indicating reciprocal activities between the adductor group (lateral cricoarytenoid muscle, interarytenoid muscle) and the abductor muscle (posterior cricoarytenoid muscle). Case two: EMG of the remaining arytenoid demonstrated reciprocal activities between the interarytenoid muscle and the posterior cricoarytenoid muscle. Activity of the lateral cricoarytenoid muscle was not evident because the muscle was excised during removal of the paraglottic space. Mobility of the arytenoid was attributed to interaction between the interarytenoid muscle and posterior cricoarytenoid muscle. Reciprocal interaction between the interarytenoid muscle and posterior cricoarytenoid muscle alone is also capable of maintaining post-operative laryngeal functions after supracricoid laryngectomy with cricohyoidoepiglottopexy.