This article describes the principles which enable a bent septum to be corrected without the loss of tip or supratip support. These principles centre on the need for two points of fixation in order to provide adequate stability for the septal cartilage. These points include the maxillary spine, the vertical plate of the ethmoid bone (at least 4 mm in continuity with the septal cartilage), the vomer, the maxillary crest or suspension from the upper lateral cartilages. A columella pocket offers additional support but cannot be regarded as a primary anchoring point. An adequate height from the maxillary spine to the tip (approximately 28 mm) and dorsal length (24 mm) of cartilage are also needed to support the nasal dorsum. The main strategy for correcting a septal bend which is apparent externally, or a supratip depression is described and centres on the use of cartilage grafts to disguise any assymmetry.

Thirty-four ears with conductive hearing loss due to otosclerosis were operated upon using the laser stapedotomy technique. Audiological results were compared with the results of 316 non-laser stapedotomies. The post-operative air-bone gap, calculated as the difference between the postoperative air and bone conduction levels, was smaller with the laser stapedotomy group. Also, the bone conduction showed significant improvement with the use of laser.

Significant sensorineural hearing loss was not found in any of the laser-treated patients. According to our results, we concluded that laser is of benefit in stapes surgery for improving the hearing results and minimizing the inner ear trauma.

Factors affecting auditory improvement after stapes surgery were investigated retrospectively on a study group of 106 otosclerotic ears (86 subjects). While the closure of the air-bone (A-B) gap after surgery was good at 2 kHz and 4 kHz, it was poor at 8 kHz and at frequencies lower than 1 kHz. Under 1 kHz, the lower the frequency, the worse the A-B gap after surgery. Stapedotomy and partial stapedectomy showed better post-operative hearing gain at 4 kHz than total stapedectomy. Total stapedectomy scored significantly better at 250 Hz and 500 Hz than stapedotomy. There was a close relationship between the pre-operative and post-operative A-B gap at frequencies under 1 kHz. The smaller the pre-operative A-B gap, the better the closure of the post-operative A-B gap at frequencies under 1 kHz. The smaller the pre-operative A-B gap, the better the closure of the post-operative A-B gap at these frequencies. It was speculated that otosclerotic ears with a larger pre-operative airbone gap might have another lesion in the middle ear other than the oval window.

A retrospective study, which highlights some of the aspects of nasopharyngeal carcinoma (NPC) as seen in a large hospital for 20 years in Jordan, was performed. Collected data showed that NPC accounted for one per cent of all malignant tumours during the period. The present series showed an age range from six to 89 years old with a mean of 39.5 years. There was a bimodal peak at presentation at 16 to 20 and 46 to 50 years. A high incidence of childhood NPC was also noticed (two per cent of all childhood malignant tumours). The difficulty in early diagnosis urges for better awareness of the tumour especially among general practitioners. The tumour is still detected at an advanced stage with 34 per cent metastasis most frequently to bone. The study stresses the importance of full ENT examination in cases of persistent middle ear disease, recurrent or persistent nasal symptoms or headache, or neck swelling; and routine bone scanning for all cases with NPC. There is a need for prospective studies of the causal relationship of NPC to environmental factors including Epstein-Barr (EB) virus as well as occupational and domestic hazards.

Intubation granuloma of the larynx is an iatrogenic disease which is induced by endotracheal intubation. It has basically been managed by conservative medical treatment with observation. Surgical excision can be considered as a last resort due to the high recurrence rate which subjects the patients to repeated anaesthesia. The purpose of this study is to evaluate the therapeutic effect of topical steroid in intubation granuloma, comparing the results of conservative medical treatment with, or without, surgery (Group I, 14 patients) and inhalant therapy with topical budesonide (Group II, 20 patients).

In Group I, complete disappearance of granuloma occurred in six cases within a year (42.8 per cent) with conservative therapy only. Microlaryngeal surgery was performed on the eight cases of persisting granuloma after conservative therapy for a year, resulting in two cases of recurrence. In Group II, the granuloma disappeared completely in 85 per cent within six months and in 95 per cent within 12 months without any remarkable side-effects. We concluded that intubation granuloma of the larynx could be treated with topical inhalant steroid as the first choice of therapy rather than other medical treatment or surgical intervention.

Total laryngectomy for advanced carcinoma of the larynx is effective but functionally disabling. In an effort at laryngeal preservation, 33 patients of stage III/IV carcinoma larynx were treated between 1987 and 1991 with induction chemotherapy followed by definitive radiation. Two chemotherapy protocols were administered. Group I patients received one to three cycles of cisplatin 100 mg/m2 (day 1), bleomycin 15 U/m2 (day 1), and 5-fluorouracil 1000 mg/m2/day (day 2 to 5) at three weekly intervals. This was then followed by radiotherapy. Group II received one to six weekly injections of single agent methotrexate 50 mg/m2 with or without leucocovorin rescue followed by radiotherapy. Any recurrence was salvaged by surgery.

Midway through the study, Group II protocol was discontinued as the initial results were not comparable with Group I or standard treatment. The Group I protocol, however, yielded an initial locoregional control rate of 83.3 per cent With the addition of surgical salvage the locoregional control rate was 94.4 per cent and the control rate with laryngeal preservation was 88.8 per cent. The Kaplan-Meier probability of two years and five years disease-free survival was 81.9 per cent and 61.4 per cent respectively. For disease-free survival with laryngeal preservation the corresponding figures for two years and five years were 58.3 per cent and 41.7 per cent.

The control group of 51 patients treated with radical surgery followed by radiotherapy yielded survival figures at two years and five years of 64.3 per cent and 57.2 per cent. The difference in the survival of Group I and the control group was not statistically significant (p value = 0.280). These initial results indicate that for stage III and for surgically resectable stage IV laryngeal carcinomas, a protocol of induction combination chemotherapy consisting of cisplatin, bleomycin and 5-fluorouracil followed by radiotherapy and combined with surgical salvage whenever required, can lead to comparable cure rates. In addition, a large proportion of patients are spared the morbidity of a total laryngectomy.

Injury to the vagus nerve or one of its branches during carotid endarterectomy (CEA) can result in vocal fold paralysis (VFP). This study assessed prospectively 73 patients undergoing CEA. A total of 76 procedures were performed in these patients over a one-year period. All patients underwent preoperative and post-operative assessment of vocal fold mobility by indirect laryngoscopy and/or flexible nasendoscopy. All patients had normal vocal fold mobility pre-operatively. Eight patients (10 per cent) complained of hoarseness after surgery and in three patients (four per cent) examination confirmed an ipsilateral VFP. This persists in all three patients at six-month follow-up. Vocal fold assessment is important in patients undergoing CEA, particularly when performing second side surgery. We recommend that patients should be informed of the risk of VFP following CEA when obtaining consent.

Tracheostomy in infants and children has been the subject of controversy in the medical literature, but decannulation in the paediatric patient is even more controversial. Various approaches and techniques have been used for decannulation, however in spite of all efforts it continues to be a problem. The objective of our study was to assess the role of polysomnography (PSG) in predicting readiness for decannulation. All subjects (n = 31) of the study were less than 12 years of age, and tracheostomized for periods of at least six months to ensure a minimum period of dependence on the tube. All had clinical, radiological and endoscopic clearance before PSG was performed. Twenty-one out of 22 patients with favourable PSG data were successfully decannulated. Attempts to decannulate all the nine patients with unfavourable PSG failed. The conclusion of the study was that PSG is a useful adjunct to the many methods of evaluating readiness for decannulation in children with long-term tracheostomy tubes.

The TNM staging system is helpful but not enough to determine prognosis of the patients with squamous cell carcinoma of the oral tongue. T -stage alone is not suggestive for prediction of occult nodal metastases. For this reason, histopathological examination of 70 patients with squamous cell carcinoma of the oral tongue was done retrospectively. The histological differentiation, tumour thickness, perineural and lymphovascular space invasions, the amount of lymphocyte infiltration and pattern of tumour invasion were examined. Immunohistochemical examination was used to determine p53 immunoreactivity as well. The effect of these histopathological parameters and p53 immunoreactivity on nodal metastases and locoregional recurrence were analyzed using the chi-squared test. In terms of nodal metastases the only statistically significant difference between the two groups was tumour thickness, either <9 mm or >9 mm (p<0.05, χ2 = 17.182). Tumour thickness, perineural invasion, lymphovascular space invasion, the amount of lymphocyte infiltration all correlated statistically with locoregional recurrence (p<0.05, χ2 = 6.293 for tumour thickness; p<0.06, p = 0.054 for perineural invasion; p<0.05, χ2 = 8.689 for lymphovascular space invasion; p<0.05, χ2 = 5.320 for lymphocyte infiltration). The immunoreactivity of p53 correlated significantly with larger primary tumour size (p<0.05, χ2 = 5.440), lymph node metastases (p<0.05, χ2 = 4.093) and with pathological tumour stage (p<0.05, χ2 = 5.713). These results reveal that the above-mentioned histological parameters and p53 determination could be used for handling a specimen from an anterior tongue squamous cell carcinoma.

Malignant (invasive) otitis externa is an infection involving the external ear canal, often in elderly diabetic patients, which carries a high morbidity and mortality. It may involve widespread areas of soft tissue around the skull base, and in more advanced cases, may give rise to osteomyelitis and cranial neuropathy. We describe two patients who were treated for malignant otitis externa complicated by destructive osteomyelitis of the temporomandibular joint (TMJ). For both patients, diagnosis was made using magnetic resonance imaging (MRI), and repeat scans were employed during follow-up. Improved scan appearances mirrored improvements in clinical condition in both cases.

Seven cases of profound hearing impairment following either unilateral or bilateral temporal bone fracture are presented who were implanted with the Nucleus 22 channel or Ineraid devices. Six patients suffered bilateral temporal bone fractures. One patient had prior congenital unilateral profound hearing impairment. This patient suffered a unilateral temporal bone fracture. Six patients became regular users of their implants. One gained little benefit and became a non-user. Two of the regular users experienced facial nerve stimulation, which could not be programmed out. In these two cases the implant was removed and the contralateral ear successfully implanted. Implant-aided audiometry demonstrated a hearing threshold of 40–50 dB at nine months after switch-on. The reliability of computed tomography (CT) scanning in predicting cochlear patency in cases of temporal bone fracture will be discussed. The benefit of complimentary imaging with magnetic resonance (MR) is highlighted.

We present our experience using the Clarion® magnetless multichannel cochlear implant with a woman profoundly deafened following bilateral acoustic neuromata as a consequence of neurofibromatosis 2 (NF2). The right neuroma had been previously removed without an attempt at neural preservation. On the left, however, a posterior fossa approach had been taken with the aim of preserving hearing. Although the left cochlear nerve appeared to be undamaged at the end of the operation, no hearing thresholds could be elicited on post-operative audiometry, because of damage either to the cochlear nerve or to the blood supply to the cochlea. Round window electrical stimulation subsequently produced a perception of sound, confirming that the cochlear nerve was capable of functioning and that a cochlear implant would be effective. Because she would need regular magnetic resonance imaging (MRI) to monitor existing and future NF2 lesions, it was decided to use a magnetless Clarion® implant, which has been shown to be MRI compatible. We report our experience of using the device in this case and discuss some of the issues related to the provision of cochlear implants to patients with NF2.

Dysplastic gangliocytoma or Lhermitte-Duclos disease (LDD) is a hamartomatous malformation of the cerebellar hemisphere that usually presents with signs of increased intracranial pressure or symptoms of cerebellar dysfunction. In this paper, we report a case of LDD presenting with tinnitus, and postulate a probable mechanism for this unusual presentation.

Schwannomas, arising from the Schwann cells of the nerve sheath, occur very rarely in the sino-nasal tract and histological diagnosis can, sometimes, be difficult. We describe a case of schwannoma of the sphenoidal sinus occurring in a 71-year-old man, who underwent complete excision of the tumour endoscopically. To our knowledge, this is the third case of sphenoid sinus schwannoma reported in the English literature.

Congenital posterior laryngeal clefts are rare anomalies, being first described by Richter in 1792, and first operated upon successfully by Pettersson in 1955. Most clefts present within the first few months of life, with only a few cases being documented as presenting in adulthood. We present the case of a 50-year-old lady presenting with a previously undiagnosed posterior laryngeal cleft with an associated tracheoesophageal fistula. The defect was graded as 2 on the Benjamin and Inglis classification system of posterior laryngeal clefts. Following a literature review, we believe that our patient is the oldest to present with this congenital defect.

Development of vocal fold paralysis in the presence of thyroid disease is strongly indicative of thyroid cancer, and requires surgical exploration. At the same time, vocal fold paralysis does not relieve the surgeon of his obligation to identify and preserve the recurrent laryngeal nerves, since the cause of the paralysis may be a benign disease, with a fair chance of functional recovery after surgery. We hereby report a case of recurrent laryngeal nerve palsy secondary to a multinodular goitre.

Plummer-Vinson (Paterson, Brown-Kelly) syndrome refers to the association of iron-deficiency anaemia with dysphagia secondary to a post-cricoid web. Only seven cases of Plummer-Vinson syndrome in children and adolescents between the ages of 14 and 19 have been reported in the world literature. We report a case of the syndrome occurring in a child of 14 years and provide a short review of the present knowledge concerning the symptom complex.

A 49-year-old woman treated with increasing dosage of propylthiouracil (PTU) in order to control hyperthyroidism, developed progressive necrotic ulcers in the oral cavity, oropharynx and rhinopharynx and vasculitic ulcers on both auricular pinnae after a few days. The PTU treatment was immediately discontinued and the mucosal and skin manifestations resolved promptly. Laboratory findings, including anti-neutrophil cytoplasmic antibodies (ANCA), suggested allergic vasculitis. This is to our knowledge the first reported case of oral manifestations of PTU-induced allergic vasculitis.

Pneumocranium and spontaneous pneumocephalus are very rare disorders. We report a case in which the patient had suffered for some time from neck pain and neurological symptoms which originated from an extensively pneumatized cranium. The symptoms and the abnormal bone pneumatization disappeared after normalization of a high middle-ear pressure. The history and the findings suggest that the pathological pneumatization was caused by the patient's habit of frequently performing Valsalva's manoeuvre, in combination with the Eustachian tube functioning as a valve.

Pleomorphic adenoma is the commonest benign tumour of the major salivary glands. It can also occur in minor salivary glands, mainly in the oral cavity, but also in other sites in the head and neck both within and outwith the upper aerodigestive tract. We present a rare case of pleomorphic adenoma of the nasal septum with consideration of the clinical management and a review of the literature.