We report an extremely rare case of thyroid hemiagenesis with ectopic lingual thyroid.

Case report and review of the world literature concerning thyroid hemiagenesis with ectopic lingual thyroid and heredity.

Ectopic thyroid is an uncommon embryological aberration characterised by the presence of thyroid tissue in a site other than its usual, pretracheal location. The lingual thyroid is the most common manifestation of benign ectopic thyroid tissue, but is still a rare clinical entity. Thyroid hemiagenesis is also a very rare abnormality, in which one thyroid lobe fails to develop. We report a case of left thyroid hemiagenesis and goitre in the right lobe in a 26-year-old woman with an ectopic lingual thyroid.

To our knowledge, this is the first report in the world literature of thyroid hemiagenesis with ectopic lingual thyroid.

All nasal polyps originate from the mucosa of the nasal cavity or the paranasal sinuses. Most polyps originate from contact areas of the uncinate process, the middle turbinate or the ethmoid infundibulum. Polyps originating from the mucosa of the nasal septum are rare.

We present a 77-year-old man with nasal polyps originating from the superior aspect of the nasal septum. These lesions had the typical histological appearance of nasal polyps.

Nasal polyps are inflammatory growths of the nasal or paranasal mucosa. Nasal polyps commonly present clinically with nasal obstruction, sinusitis and anosmia. Most polyps originate from the lateral walls of the nasal passage. Isolated septal polyps are rare but can cause symptoms such as nasal obstruction and olfactory disorders.

The aim of this study was to document the occurrence of a cavernous haemangioma of the external auditory canal, and to review the literature on this pathology.

We report the clinical presentation, imaging studies, surgical procedure and histological findings for a cavernous haemangioma of the external auditory canal.

This patient represents the fourth reported case of cavernous haemangioma affecting only the external auditory canal. A cavernous haemangioma of the external auditory canal, not affecting the tympanic membrane, was surgically removed, without post-operative complications.

Cavernous haemangioma of the external auditory canal is a rare otological pathology. Computed tomography imaging is important in order to precisely define and localise the site and size of the lesion. Histological examination is necessary for the correct diagnosis of the pathology.

We report a rare case of giant petrous carotid aneurysm.

Case report and a review of the literature regarding treatment options for such aneurysms.

A 30-year-old man presented with epistaxis, headaches and visual disturbance. Definitive diagnosis was achieved by non-invasive imaging techniques, including magnetic resonance angiography and carotid angiography. Carotid angiography demonstrated a giant petrous carotid aneurysm effacing the petrous apex. The aneurysm was obliterated by internal carotid artery ligation, following successful tolerance of the balloon occlusion test. However, despite internal carotid artery ligation, this patient continued to have minor episodes of epistaxis.

Some aneurysms are too large to be treated with endovascular occlusion techniques; in such cases, ligation of the parent vessel is indicated. However, our patient continued to experience persistent, mild epistaxis despite internal carotid artery ligation, as a result of the reperfusion phenomenon.

To evaluate the reliability of transcranial magnetic stimulation in eliciting admittance changes due to activation of middle-ear muscles.

Admittance changes induced by transcranial magnetic stimulation at the inion were evaluated in eight normal subjects, two subjects with prelingual deafness and 22 patients suffering from other otological disorders characterised by absence of acoustic reflex.

Responses showed a predominant negative peak in normal ears. Two small positive components, one preceding and the other following the negative deflection, were less consistently elicited. Only a positive wave was detected in otosclerotic subjects. Patients with tympanic membrane perforation or previous tympanoplasty with ossicular discontinuity did not show any response.

Transcranial magnetic stimulation is able to activate both stapedius and tensor tympani muscles. In conjunction with admittance audiometry, it may represent a method of exploring the mechanics of the middle ear when acoustic reflex testing is not reliable. It can be helpful in the confirmation of stapes fixation when a severe to profound hearing loss is present.

Ménière's disease is a diagnosis requiring expert clinical judgment. There are several differences between the American Academy of Otolaryngology Head and Neck Surgery diagnostic guidelines and Prosper Ménière's original description of the disease.

Six hundred and fifty patients attending a specialist balance clinic had their clinical profiles fully analysed according to each set of diagnostic criteria.

Application of the American Academy of Otolaryngology Head and Neck Surgery guidelines resulted in the diagnosis of three times more patients than did use of Ménière's diagnostic criteria. Treatment options for patients in both groups were similar. It is unlikely that the application of different diagnostic criteria would have an effect on the treatment of individual patients.

The American Academy of Otolaryngology Head and Neck Surgery guidelines are more sensitive and less specific in diagnosing Ménière's disease than Prosper Ménière's original description. Standardised criteria should be applied across published series, in order to make results accurate, comparable and useful in the long term. We would recommend the introduction of a stricter diagnostic category for definite Ménière's disease.

Dizziness is a common presenting complaint in primary healthcare. One differential diagnosis is Ménière's disease. The UK National Health Service ‘Prodigy’ guidelines have been produced to help healthcare professionals to diagnose and manage Ménière's disease. The aim of this audit was to consider how Ménière's disease is managed in general practice, and to assess how well general practitioners adhere to the Prodigy guidelines.

We identified general practices near the Torbay region of south Devon which had a ‘TQ’ postcode. There were 41 practices, staffed by a total of 203 general practitioners. We wrote to each general practitioner, asking them to fill in a questionnaire regarding Ménière's disease. Our practice response rate was 68 per cent and our individual rate 43 per cent.

The mean correct answer rate was >50 per cent. The respondents achieved this despite few being aware of any formal guidelines, and none being aware of the Prodigy guidelines.

Detailed knowledge of Ménière's disease was uncommon, and formal guidelines were not frequently consulted.

Repeated exposure to excessive noise will eventually lead to an irreversible increase in hearing thresholds. In theory, the damage reflects both the intensity of the noise and the duration of exposure. This is not linear with respect to duration of exposure; rather, the worker may experience a disproportionate loss in the early years of exposure.

A prospective study surveying workers of the production section (i.e. most noise-exposed area) of a bottling factory was carried out in December 2003 and in December 2005. A self-administered questionnaire was used to extract information about worker's demographic characteristics, drug intake, and medical and occupational history, as well as information on the use of hearing protection devices. Noise mapping of the various departments of the factory was carried out. Otological examination, tympanometry and audiometry were also carried out on selected subjects.

Eighty-four workers, 76 (90.5 per cent) men and eight (9.5 per cent) women, were studied. Their mean age was 33.0 ± 7.6 years in 2003 and 35.0 ± 7.6 years in 2005. The recorded noise levels in the factory production section ranged between 91.5 and 98.7 dBA. The prevalence of sensorineural hearing loss among workers was noted to be 64.9 and 86.9 per cent for test one (2003) and test two (2005), respectively. The degree of hearing deterioration within the two years of this study was 1.0–3.2 dB for the right ear and 1.6–3.4 dB for the left ear. This deterioration was at discrete frequencies. More than half (53.6 per cent) of the workers did not have a hearing protection device. Of the 46.4 per cent who did, only 38.5 per cent claimed to have used it regularly.

These findings showed that there was a high prevalence of mild sensorineural hearing loss and significant hearing deterioration among workers, due to exposure to excessive noise over a two-year period. The study demonstrates the practical importance of serial audiometry for noise-exposed workers as a means of monitoring hearing deterioration. It is necessary to enforce existing occupational health laws in our industries in order to prevent noise-induced hearing loss, since it is eminently preventable.

The aim of this study was to investigate the differences between pre- and post-operative hearing thresholds, measured by high frequency audiometry, in patients undergoing open heart surgery.

Pre- and post-operative audiometric assessments were performed in 20 patients undergoing open heart surgery. Pure tone audiometry testing was performed at 500, 1000, 2000, 3000, 4000, 6000, 8000, 10 000, 12 000 and 14 000 Hz. We also evaluated: patients' clinical parameters (i.e. age, sex, diabetes mellitus, hypertension, hypercholesterolaemia, history of myocardial infarction, and whether undergoing coronary artery bypass surgery or valve surgery); various operative details (operative temperatures, cardiopulmonary bypass time and cross-clamp time); and post-operative clinical progress and its effect on hearing loss.

Patients' pre- and post-operative pure tone audiometric results were significantly different at some frequencies (p < 0.05). In addition, there was a significant impact of hypertension, hypercholesterolaemia, history of myocardial infarction and cross-clamp time.

This study shows that open heart surgery using cardiopulmonary bypass can lead to significant post-operative changes in hearing levels at some frequencies. Some additional patient parameters may influence this process. It seems possible that the risk of such hearing loss could be reduced; further studies may be able to define the significance of patients' concomitant disorders.

To analyse current trends in our population with respect to the presentation, diagnosis and management of tubercular and chronic pyogenic osteomyelitis of the cranio-facial bones.

Retrospective study.

Tertiary healthcare centre.

The study population comprised 14 patients with tubercular and chronic pyogenic osteomyelitis who were managed in the otorhinolaryngology department between May 2002 and December 2005.

Odontogenic infections, sinus infections and aural infections were the most commonly identified aetiological factors. Most of the patients presented with swelling, pain and discharging sinus. The diagnosis was established on the basis of clinical evaluation, radiological investigations and histopathological analysis, with six cases diagnosed with tubercular osteomyelitis and eight cases with chronic pyogenic osteomyelitis. All the patients were initially commenced on oral antibiotics, which were continued for two weeks in all cases with chronic pyogenic osteomyelitis. All the patients with pyogenic osteomyelitis underwent surgical management, with one patient requiring repeated surgical interventions. All the patients with tubercular osteomyelitis received anti-tubercular chemotherapy, with complete cure.

Osteomyelitis of the cranio-facial bones is an uncommon entity which requires a high index of clinical suspicion along with radiological and histopathological investigations in order to establish the diagnosis. Tubercular osteomyelitis is clinically and radiologically indistinguishable from pyogenic osteomyelitis, and the two conditions can be differentiated only on the basis of histopathological evaluation of involved tissue.

Olfaction studies in the institution of Department of Otorhinolaryngology at Leicester Royal Infirmary have detected a previously unreported, variable phenomenon – ‘superosmia’ – in which subjects' olfaction threshold concentrations are up to 100 000 smaller than the average value.

The aim of this report is to define and quantify this phenomenon.

Two hundred and thirty subjects, who had been screened for active nasal pathology (age range 20–60 years), underwent individual olfactory threshold tests for phenylethyl alcohol or eucalyptol, using a computer-driven olfactometer in a controlled laboratory setting. Some tests were single tests and others were repeated on a small cohort.

Two per cent of subjects demonstrated the superosmic phenomenon on single testing, and 10 per cent demonstrated this phenomenon on variable occasions during repeated testing. The superosmic phenomenon was defined by: (1) confident olfactory perception of a threshold at least equal to if not greater than three threshold levels below the subject's average threshold; (2) repeated perception of the odour at this level for at least 10 responses (1:1024 probability of chance finding); and (3) (where time permitted) a sudden, rapid loss of superosmia.

Superosmia is a distinct phenomenon, the stimulus or mechanism of which is currently the subject of further research. The enhancement of olfactory ability may be possible through activation of an accessory pathway or modulation of the existing olfactory apparatus.

To assess the significance of Streptococcus milleri in acute rhinosinusitis with complications.

A retrospective case note review was undertaken of in-patients at both the Red Cross Children's Hopital and the Groote Schuur Hospital (for adults), Cape Town, South Africa, between 1999 and 2003, with a diagnosis of acute rhinosinusitis with complications. The following were documented: age, gender, complications, organisms cultured and their sensitivity, type and number of operations, and length of hospital stay.

Seventy-one case notes were reviewed, for 30 female and 41 male patients, representing 38 adults and 33 children. Streptococcus milleri was the most commonly implicated organism (52.1 per cent; 37/71). Patients from whom this organism was isolated tended to require more than one operative procedure, and had a protracted hospital stay.

Blood-tinged post-nasal drip is a rare manifestation of paranasal sinus disease. Although the presence of such a symptom would intuitively prompt suspicion of malignancy, no previously published study has addressed this issue.

One hundred and ninety-three patients with paranasal sinus lesions, who had undergone endoscopic sinus surgery for treatment or biopsy, were prospectively recruited. Their clinical information was collected and analysed.

In patients without blood-tinged post-nasal drip, 177/181 (97.8 per cent) had chronic paranasal sinusitis and fungal sinusitis. However, in patients who presented with this symptom, six of 12 (50 per cent) were diagnosed with other conditions. The difference was statistically significant (Fisher's exact test, two tails, p < 0.001). In patients with blood-tinged post-nasal drip, diagnoses other than chronic paranasal sinusitis and fungal sinusitis were found more frequently in older males.

The chance of diagnoses other than the usual sinusitis increased significantly in patients with paranasal sinus diseases who presented with blood-tinged post-nasal drip, especially in older males.

To describe the incidence trends, clinical presentation, management and outcome of acute epiglottitis in a Danish population after the introduction of Haemophilus influenzae type b vaccine.

Retrospective review of the health records of all patients discharged with a diagnosis of acute epiglottitis from the otolaryngology department, Roskilde County Hospital, Denmark, from 1996 to 2005.

One infant and 34 adults were identified. The incidence of acute epiglottitis in children was 0.02 cases/100 000/year. Before introduction of the H influenzae type b vaccination (1983–1992), the mean national incidence of acute epiglottitis was 4.9 cases/100 000/year. The incidence of acute epiglottitis in adults was constant, with a mean value of 1.9 cases/100 000/year. Twenty-nine per cent of the patients required an artificial airway, and respiratory distress was found to be associated with airway intervention (p = 0.010). All patients recovered completely.

In the H influenzae type b vaccine era, acute epiglottitis in children has almost disappeared. The incidence in the adult population has been constant. A discriminate approach to airway management seems safe in adults.

This study evaluated the role of botulinum toxin type A in the treatment of refractory laryngeal granulomas.

Retrospective clinical review at a tertiary care hospital. Seven patients with vocal process granulomas underwent percutaneous injection of botulinum toxin into both vocal folds, performed in an office setting. Total doses ranged from 10 to 25 U, divided between both vocal folds.

All patients experienced resolution of their granulomas over two to seven weeks. No patient developed aspiration pneumonia. All patients experienced hoarseness secondary to the injections, but voice quality returned to baseline in all patients as the toxin was degraded.

Botulinum toxin is safe and effective therapy in resolving vocal process granulomas in patients refractory to traditional therapy. The optimal treatment dose remains to be determined.

Percutaneous botulinum toxin injection is helpful in resolving laryngeal granulomas.

(1) To examine the vocal symptoms and acoustic changes perceived in the short period immediately after laryngeal mask airway, and (2) to compare these findings in patients using laryngeal mask airway and endotracheal tube.

A total of 27 patients were enrolled. They were evaluated pre-operatively and then at 2 and 24 hours post-operatively. Patients were divided into two subgroups, laryngeal mask airway and endotracheal tube. Patients were asked about the presence or absence of the following: hoarseness, vocal fatigue, loss of voice, throat-clearing sensation, globus pharyngeus and throat pain. Patients then underwent acoustic analysis of their voice, measuring the average fundamental frequency, relative average perturbation, shimmer, noise to harmony ratio, voice turbulence index, habitual pitch and maximum phonation time.

In the laryngeal mask airway group, there was an increase in the incidence of all vocal symptoms two hours post-operatively, except for globus pharyngeus. The increase was statistically significant for vocal fatigue, loss of voice and throat pain. All the symptoms had reverted back to a normal baseline level by 24 hours. There was a decrease in the maximum phonation time and habitual pitch, with an increase in all the perturbation parameters, two hours post-operatively. At 24 hours, an increase was still present for shimmer, noise to harmony ratio and voice turbulence index. The maximum phonation time and habitual pitch reverted back to normal values.

In the endotracheal tube group, there was a significant increase two hours post-operatively in the incidence of hoarseness, loss of voice and throat pain. At 24 hours, all the symptoms reverted to baseline, except for vocal fatigue and throat pain. Two hours post-operatively, there was a significant decrease in maximum phonation time and an increase in all other parameters (however, the latter was significant only for relative average perturbation and noise to harmony ratio). At 24 hours, there was a significant increase in the maximum phonation time and a persistent (but statistically insignificant) increase in the average fundamental frequency, habitual pitch, noise to harmony ratio and voice turbulence index.

At two hours, there was more loss of voice and vocal fatigue in the laryngeal mask airway group, compared with the endotracheal tube group. At 24 hours, these symptoms were comparable in both groups. Comparing changes in acoustic parameters to baseline values in both groups, there were no statistically significant changes.

Shortly after reversal of anaesthesia, laryngeal symptoms following laryngeal mask airway are no less significant than those experienced following endotracheal tube anaesthesia. Both methods can be regarded as nontraumatic, in view of the lack of significant vocal symptoms and acoustic changes 24 hours after anaesthesia.

Embryological remnants of third or fourth branchial pouches are a rare but important cause of recurrent neck abscesses in children. They are characterised by an internal opening in the piriform fossa. Traditional management involves surgical excision of the entire tract. We present our experience with the use of monopolar diathermy applied to the internal sinus opening as a treatment modality for this condition.

A retrospective, case report review was performed.

Four cases of piriform fossa sinus were treated with monopolar diathermy to the sinus opening via an endoscopic approach. The first three cases were treated in this way for recurrence, following external tract excision, while the fourth case had simultaneous excision of the tract and diathermy to the piriform fossa opening. There were no serious complications and no recurrence within a follow-up period ranging from nine to 27 months.

Obliteration of the internal opening of these sinuses by endoscopic diathermy is a safe and effective management option for this condition, either as an alternative to or as an adjunct to external surgical excision of the tract.

To assess the value of lateral soft tissue neck X-rays in patients presenting with upper aero-digestive tract foreign bodies.

Retrospective study.

(1) Patients referred to the ENT team, via either the accident and emergency department or their general practitioner; (2) a history of a non-aspirated, upper airway, aero-digestive tract foreign body; and (3) a lateral soft tissue neck X-ray taken on admission.

A total of 62 patients met the inclusion criteria. Twenty-four patients (38.7 per cent) had positive findings on lateral soft tissue neck X-ray. ‘Soft’ signs, such as widened pre-vertebral shadow and loss of lordosis, were seen in all 24 patients, and foreign bodies were visualised in six patients. Overall, lateral soft tissue neck X-rays were helpful in the management of 32 patients (51.6 per cent). Rather worryingly, doctors in the accident and emergency and ENT departments missed 79.2 and 66.6 per cent of the positive findings, respectively.

A lateral soft tissue neck X-ray is a helpful tool in the management of patients presenting with upper aero-digestive tract foreign bodies. Junior doctors need better radiology training.

This study was performed to assess the efficacy and safety profile of combination treatment with S-1 and cisplatin in patients with locally advanced squamous cell carcinoma of the head and neck.

Eligibility criteria comprised: histologically confirmed squamous cell carcinoma of the head and neck; stage three or four disease with no evidence of distant metastasis; evaluable lesions; adequate organ function; age 20–80 years; and a performance status of two or less. Cisplatin was infused over one hour on day one (75 mg/m2) and S-1 was administered orally for 14 consecutive days (days two to 15). The dosages of S-1 were calculated according to the patients' body surface area: 50 mg twice a day (body surface area <1.5 m2) or 60 mg twice a day (body surface area >1.5 m2). Each course was repeated every three weeks. After two courses, tumour response was evaluated by computed tomography and laryngoscopy. If a response was evident (either complete or partial), the patient received one more course of chemotherapy, before undergoing radical treatment such as radiotherapy or surgery.

All 30 patients were assessable for toxicity, and 29 patients for treatment response. The overall response was 89.7 per cent (complete response: nine; partial response: 17). The two-year estimated overall survival rate was 79.2 per cent. Adverse reactions occurred 128 times during 81 courses in the 30 cases. The most common grade three to four adverse event was neutropenia, which occurred in eight patients. Cases of non-haematological grade three or four toxicity included nausea and vomiting in four patients, stomatitis in two and diarrhoea in one.

S-1 plus cisplatin combination chemotherapy is effective against locally advanced squamous cell carcinoma of the head and neck, with only mild toxicity.