Following laryngectomy, a distinct population of patients fails to achieve successful tracheoesophageal voice. These patients' voices range from strained and effortful to none at all. Such patients may present with severe hypertonicity or spasm of the pharyngoesophageal segment. Botulinum toxin has been used to chemically denervate the pharyngeal musculature, and is an alternative to invasive surgical procedures. The aim of this article is to review the evidence for using botulinum toxin to achieve an improvement in post-laryngectomy voice.

A Medline literature review (1966 to January 2009) and a search of the Cochrane database were performed. Foreign language articles and those not pertaining to post-laryngectomy voice restoration were excluded.

Nine articles reporting a total of 134 patients were identified. Although there were differences in the outcome measures used, objective improvement in voice production occurred in between 70 and 100 per cent of cases.

Botulinum toxin can be used as a safe and cost-effective treatment in patients with confirmed pharyngoesophageal segment hypertonicity and/or spasm following laryngectomy, to obtain an improvement in voice quality.

To investigate the ventilation and drainage mechanism of the middle ear.

Prospective.

We observed 304 (of 337) middle ears with tympanic membrane perforation or myringotomy (102 normal, 90 with otitis media with effusion and 112 with chronic otitis media); 912 observations were recorded overall. Perforations were covered with solution, creating a fluid film, and inspected for gas bubbling at rest, and for outward and inward movement of the fluid film during swallowing. We also noted the inflammatory condition of the ear (i.e. dry, wet or purulent) and the perforation size.

Ears sometimes reacted differently in various sessions. Due to these differences, reactions were classified as ‘types’ of reactions rather than ‘ears’. We refer to 449 ‘types’ of 304 ears. Spontaneous gas bubbling at rest (indicating gas production) was observed in 98 per cent of normal types, 68 per cent of otitis media with effusion types and 65 per cent of chronic otitis media types. Evacuation towards the eustachian tube was observed in 47 per cent, no movement in 46 per cent and outward movement in 9 per cent. During swallowing, inward movement of the fluid film was observed in 74 per cent of normal types, 41 per cent of otitis media with effusion types and 32 per cent of chronic otitis media types.

We found no support for the theory that the eustachian tube supplies air to the middle ear during swallowing. The normal middle ear produces gas which is evacuated by the Eustachian tube. In ears with otitis media, this mechanism appears to be impaired.

To determine whether epithelial migration in the atelectatic tympanic membrane (secondary to any pathology) occurs in a similar fashion to that in the normal (non-pathological) tympanic membrane, by calculating and comparing the epithelial migration rate and pattern.

Prospective, non-randomised, case–control study. This study was a pilot study. We included patients with an atelectatic pars tensa region of the tympanic membrane and a healthy contralateral tympanic membrane (the latter used as the control).

Otorhinolaryngology out-patient clinic. The study was conducted from January 2006 to January 2008.

A total of 40 patients (80 ears) were included based on their otoscopic appearance and tympanography findings. All patients' ears were examined under an operating microscope. A dot of methylene blue dye was applied in the immediate vicinity of the umbo of the atelectatic tympanic membrane, and in the same position on the tympanic membrane of the control ear. Patients were then followed up weekly until the dye dot had migrated to reach the annulus.

Direction and rate of epithelial migration.

In the atelectatic tympanic membranes, epithelial migration proceeded from the centre of the retraction pocket toward the annulus in a lateral, radiating manner. Thirty-three (82.5 per cent) of the 40 patients showed a similar migratory pattern in both the study and control ears. Sixty per cent of the retracted tympanic membranes showed no migration in the first week after methylene blue staining. After the first week, the migration rate was nearly constant from the umbo towards the periphery, in both the study and control ears. The mean daily epithelial migration rate in the study and control ears was 62.6 and 64.7 µm/day, respectively; however, this difference was statistically insignificant (p = 0.202, independent samples t-test).

There is no difference in the epithelial migration rate or pattern, comparing atelectatic tympanic membranes and normal tympanic membranes. However, there may be a significant difference in the epithelial migration rate with increased grades of tympanic membrane atelectasis.

To evaluate the results of vestibular evoked myogenic potential testing in patients with idiopathic sudden hearing loss, and to correlate these results with the findings of caloric testing, the clinical appearance of vertigo and the influence of age.

Eighty-six patients with unilateral idiopathic sudden hearing loss and 35 healthy controls underwent a standard protocol of neurotological evaluation. Vestibular evoked myogenic potential responses were measured and compared with caloric responses.

On the affected side, 30.2 per cent of patients showed abnormal vestibular evoked myogenic potential responses, while 52.3 per cent had abnormal caloric responses. A statistically significant relationship was found between the results of these two tests. A statistically significant relationship was also found between the type of vestibular lesion and the occurrence of vertigo. Advancing age correlated statistically with more extensive labyrinthic lesions.

A combination of vestibular evoked myogenic potential and electronystagmography testing indicated the existence of vestibular involvement in many patients with idiopathic sudden hearing loss. Both tests are necessary in order to obtain a more thorough and in-depth knowledge of the pathophysiology of idiopathic sudden hearing loss.

This study aimed to determine whether magnetic resonance imaging has a role in the evaluation of the sphenoid sinus and internal carotid artery. In addition, we aimed to establish reference measurements for the minimal distance between the internal carotid arteries.

The sphenoid sinuses and neighbouring internal carotid arteries of 90 patients were evaluated using sagittal T1-weighted and axial and coronal T2-weighted magnetic resonance images.

Sphenoid sinus pneumatisation was categorised as occipitosphenoidal (0 per cent), conchal (3.3 per cent), presellar (14.4 per cent) or sellar (82.2 per cent). The internal carotid artery protruded into the sphenoid sinus in 32.8 per cent, with a septum in 9.4 per cent. The incidence of sellar-type sphenoid sinus pneumatisation was higher in patients with protrusion of the internal carotid artery into the sphenoid sinus (p < 0.001). The incidence of presellar pneumatisation was higher in patients without internal carotid artery protrusion (p < 0.001). The minimal distance between the internal carotid arteries varied between 9.04 and 24.26 mm (mean, 15.94 mm).

Magnetic resonance imaging can provide useful information about the sphenoid sinus and internal carotid artery, prior to endoscopic sphenoidotomy and trans-sphenoidal hypophysectomy.

This study aimed to compare an experienced ENT treatment room nurse's ability to assess nasal injuries with that of junior doctors.

One hundred consecutive patients with nasal injuries were assessed prospectively in two phases, followed by a telephone survey.

Comparison of nasal injury assessment, advice, and outcomes regarding cosmesis, airway obstruction and patient satisfaction.

In the first phase, there was almost perfect agreement between doctor and nurse assessments regarding the management of nasal fractures (p < 0.0001). There was no deterioration in outcomes in the nurse assessment only patient group with regards to cosmesis and airway obstruction. Ninety-four per cent of patients were satisfied with nurse-only assessment.

Our study showed that an experienced treatment room nurse was as effective as experienced junior doctors in assessing and advising patients with nasal injuries. Following this study, the nurse involved began to independently assess patients with nasal injuries attending the unit.

Patients suspected of having cervical tuberculous lymphadenitis are diagnosed using investigations such as fine needle aspiration cytology and the polymerase chain reaction for Mycobacterium tuberculosis. However, these investigations are intended for primary tuberculosis infection. The majority of cervical tuberculous lymphadenitis cases in the elderly are thought to be caused by reactivation.

The aims of this study were (1) to examine the efficacy of fine needle aspiration cytology, polymerase chain reaction and blood tests in the diagnosis of cervical tuberculous lymphadenitis caused by reactivation, and (2) to clarify any differences when compared with primarily infected cervical tuberculous lymphadenitis cases.

Thirty-three elderly patients with neck lumps underwent excisional biopsy from 2003 to 2008. The efficacy of fine needle aspiration cytology was examined by comparing the results of excisional biopsy with those of fine needle aspiration cytology performed at the initial medical examination for cases of suspected tuberculous disease. Furthermore, the leucocyte count and C-reactive protein concentration were compared for cases of cervical tuberculous lymphadenitis versus cases of malignant lymphoma.

Although nine cases were diagnosed with cervical tuberculous lymphadenitis using excisional biopsy, only one of these had been suspected based on fine needle aspiration cytology results. Three cases with tuberculous lymphadenitis were suspected of having malignant lymphoma on initial examination. There was no significant difference in the leucocyte count and C-reactive protein concentration, comparing cases of tuberculous lymphadenitis versus malignant lymphoma.

Unlike the primary infection often seen in endemic areas, the diagnosis of early stage tuberculous lymphadenitis of the swelling type caused by reactivation in elderly people is difficult to confirm unless excisional biopsy is performed. In elderly patients with neck lumps, cervical tuberculous lymphadenitis should be included in the differential diagnosis.

Although modern endoscopic laser techniques aim to avoid a permanent tracheostomy by augmenting the glottic aperture in cases of bilateral vocal fold palsy, loss of tissue from the posterior glottis risks compromising voice quality and swallowing function. The objective of this study was to describe our experience with bilateral transverse posterior cordotomy.

This was a retrospective analysis of functional outcomes in a series of consecutive patients undergoing a simple modification of the classical laser cordectomy procedure, which avoids tissue loss. The procedure was confined to the complete release of the vocal ligament from the arytenoid cartilage on both sides, while avoiding any significant loss of mucosa or cartilage.

Post-operative voice quality and quality of life were rated as good by most patients, which makes bilateral transverse cordotomy an attractive treatment option for bilateral vocal fold paralysis.

Bilateral transverse cordotomy is a reliable treatment option for patients with bilateral vocal fold paralysis, and aims to avoid the morbidity associated with a permanent tracheostomy.

To investigate whether information about the size of an oral tumour influences the multi-disciplinary team's judgement about the quality of life of head and neck cancer patients.

Using a between-group design, two groups of health care professionals rated a hypothetical patient on 20 outcome variables. The patient description was identical for both groups, except for the tumour size.

Comparison of variable ratings revealed only three significant differences between the groups' predictions and no consistency within conditions, suggesting that the participants held few common assumptions about the impact of tumour size on a range of patient experiences.

The lack of agreement amongst the health care professionals suggests that, where humane judgements are used in treatment decisions for head and neck cancer patients, these may be random and inconsistent. Consequently, patients should have a direct input into treatment decisions, via formalised quality of life data.

The surgical treatment of intractable aspiration usually requires sacrifice of the patient's natural voice to prevent food entering the airway. Biller described a tubed supraglottic laryngoplasty to control aspiration while allowing patients to phonate with their larynx. Our preliminary experience with this technique in Chinese patients has been disappointing, as tension in the mucosa on wound closure led to wound dehiscence. Our objective was to modify Biller's technique in order to achieve a better outcome.

We modified Biller's technique by trimming the epiglottic cartilage and by inserting a tibial periosteal graft to reinforce closure of the mucosa, creating an arrangement resembling a Chinese steam boat.

Three Chinese patients underwent the modified Biller's technique. No wound dehiscence occurred, the surgery controlled aspiration, and the patients were able to phonate with their own larynx. All patients resumed oral feeding, and previously placed gastrostomy tubes were removed.

The ‘steam-boat’ supraglottic laryngoplasty is a viable surgical alternative to total laryngectomy or tracheal diversion for controlling intractable aspiration, and preserves a phonating larynx.

This paper evaluates the feasibility of transoral, endoscopic resection of macroscopically localised, low grade, subglottic chondrosarcoma.

Retrospective case study including patients diagnosed with low grade, subglottic laryngeal chondrosarcoma. Tumours were resected endoscopically via direct laryngoscopy with microlaryngeal technique, under jet ventilation. The post-operative course, vocal fold function, airway patency and oncological results were evaluated.

Two male patients aged 49 and 60 years underwent endoscopic, translaryngeal, en bloc resection of low grade chondrosarcoma of the cricoid cartilage. Extubation was performed immediately after surgery. Neither patient required tracheostomy or developed subglottic stenosis. No tumour recurrence was noted after an average follow up of 10.5 months. Voice quality was stable and dyspnoea improved.

Transoral, endoscopic resection of low grade, subglottic chondrosarcoma is a viable technique with good functional outcomes. Extensive resection of subglottic disease is possible, which may afford patients an alternative to total laryngectomy.

After excision of a preauricular sinus, a head bandage compressive dressing is usually used to reduce dead space and to decrease the risk of recurrence. However, such use of a head bandage may cause various problems. We assessed a new method of compressive dressing, using suture transfixion of silicone sheets to the former sinus tract, following preauricular sinus excision.

This retrospective study reviewed the medical records of patients undergoing preauricular sinus excision in a tertiary referral centre over a five-year period. After excision of the preauricular sinus, patients underwent suture transfixion of silicone sheets. Post-operative outcomes were analysed.

The new dressing method was performed on 50 ears of 37 patients. The post-operative incidence of recurrence and haematoma formation was 4 and 2 per cent, respectively. Other problems possibly caused by head bandaging, such as headache, facial flushing, and nausea and/or vomiting, were not observed.

Compressive dressing by suture transfixion of silicone sheets is safe and effective following preauricular sinus excision.

We present an extremely rare case of a 44-year-old woman with right gustatory otorrhoea and otalgia.

The patient had been initially treated for otitis externa after Pseudomonas aeruginosa was grown from a microbiological swab. The otorrhoea fluid was collected and tested positive for amylase. Sialography and computed tomography imaging of the temporal bone confirmed a sialo-aural fistula from the right parotid gland to the bony external acoustic meatus. The defect was consistent with a patent foramen of Huschke. The fistula was identified surgically via a superficial parotidectomy approach, after contrast injection of Bonney's blue dye into the parotid duct, and then ligated and divided. The patient had immediate and sustained resolution of her otorrhoea.

Sialo-aural fistulae are extremely rare, and usually arise as a complication of surgery or as an acquired disease process. To date, only four cases have been reported. This case demonstrates the use of sensitive investigation involving sialography and computed tomography, as well as successful surgical management, with complete resolution of symptoms.

We report a patient with a 20-year history of apparently idiopathic airways stenoses, who presented with an antineutrophil cytoplasmic antibody (ANCA) associated, acute, systemic vasculitis with necrotising glomerulonephritis, subsequently diagnosed as Wegener's granulomatosis.

We present a case report and a review of the world literature on airway stenosis in Wegener's granulomatosis.

To our knowledge, this is the first report of Wegener's granulomatosis manifesting as local airway disease for such a prolonged period, before transforming into a systemic vasculitis.

This case highlights the need for physicians to be alert to the possibility of Wegener's granulomatosis as a cause of apparently idiopathic airway stenosis, and to be aware that systemic disease may occur in very long-standing, limited Wegener's granulomatosis.

A 29-year-old man presented with sudden onset of severe pain in his throat, difficulty breathing and a hoarse voice, following an episode of vomiting.

Initial laboratory tests were normal. The patient underwent fibre-optic nasendoscopy, which demonstrated a haematoma in the piriform fossa. Lateral neck radiography and subsequent computed tomography scanning confirmed a 2 cm, loculated, gas-containing collection at the level of the vallecula in the right posterolateral wall, extending to the false vocal folds and communicating between the right parapharyngeal space and the right carotid sheath. Water-soluble contrast swallow confirmed the diagnosis.

Contained oesophageal perforation.

Conservative treatment was adopted involving nil orally, intravenous antibiotics and nasogastric feeding. The patient made an uneventful recovery.

We report an extremely rare case of distant metastasis to the rectus femoris muscle from a laryngeal squamous cell carcinoma.

We present a case report and a review of the world literature concerning distant skeletal muscle metastasis from head and neck squamous cell carcinoma.

The patient showed no evidence of distant muscular recurrence at follow up after 21 months; however, two years later he died from brain and suprarenal metastases.

This report describes the first case of haematogenous distant metastasis to the left rectus femoris muscle from a laryngeal squamous cell carcinoma, without evidence of cervical lymph node metastases. To the best of our knowledge, this is the second reported case of muscular distant metastasis without cervical lymph node involvement. Although the prognosis associated with skeletal muscle metastasis is considered to be poor, surgical excision may be indicated for an isolated muscular metastasis.

We report a rare presentation of ancient schwannoma of the oesophagus, management of which required tracheal resection.

A 40-year-old woman was referred to our hospital with a six-year history of progressively worsening stridor. She had undergone laser excision of a tracheal tumour thrice in the past. Fibre-optic bronchoscopy showed a tumour arising from the posterior wall of the trachea. Computed tomography scanning showed evidence of extension along the retrotracheal plane. The patient required tracheal resection and anastomosis due to significant involvement of the posterior tracheal wall. The mass was seen to be arising from the oesophagus, and was able to be enucleated from the oesophageal wall. Histopathology was typical of an ancient schwannoma.

This case emphasises the need to consider oesophageal schwannomas in the differential diagnosis of posterior tracheal tumours; it also highlights the need for careful pre-operative assessment in the management of these tumours in order to avoid complications.