The use of suction drains following thyroid and parathyroid surgery is controversial. Although there have been several prospective and retrospective studies carried out on this subject, no paper had sufficient power to provide a suitable answer to whether or not drains should be used routinely. We present the first formal meta-analysis of the data from eight randomized controlled trials on this subject. The result of the meta-analysis showed that there is no difference in complication rates between patients in whom drains have been used routinely and those in whom they have not.

A medical, as opposed to a surgical, specialty which was to be entrusted with the investigation, care and management of patients with hearing and balance disorders was established in the UK in 1975. This medical specialty was termed ‘audiological medicine’ and its specialists, ‘audiological physicians’. The relationship of the audiological physician to the ear, nose and throat surgeon is analogous to that between the neurologist and the neurosurgeon, or to that between the cardiologist and the cardiac surgeon. The audiological physician’s role needs to be distinguished also from that of the audiologist. An audiologist is a scientist (or technician). (In the UK, science is firmly established as an integral and autonomous discipline within British health-care systems.) The role and scope of the audiological physician is clarified. Audiological physicians are concerned primarily with patients suffering from disorders of auditory communication, equilibrium and spatial disorientation, i.e. ‘deaf and dizzy’ patients.

The objective of this prospective study was to report on the prevalence of hearing impairment in the neonatal unit population. From 15 February 2000 to 15 March 2000 and from 15 February 2001 to 15 May 2001, 401 neonates were screened using transient evoked otoacoustic emissions (TEOAE) followed by second-stage screening of those infants who failed the initial test. Eight (2 per cent) infants failed one ear and 23 (5.74 per cent) infants failed both ears, adding up to 7.74 per cent planned for second-stage screening. Five out of 22 infants who came for the follow up failed the screening, resulting in a prevalence of hearing impairment of 1 per cent (95 per cent confidence interval [95% CI]: 0.0–2.0). Craniofacial malformations, very low birth weight, ototoxic medication, stigmata/syndromes associated with hearing loss and hyperbilirubinaemia at the level of exchange tranfusion were identified to be independent significant risk factors for hearing impairment, while poor Apgar scores and mechanical ventilation of more than five days were not. In conclusion, hearing screening in high-risk neonates revealed a total of 1 per cent with hearing loss. The changes in the risk profile indicate improved perinatal handling in a neonatal population at risk for hearing disorders.

Both experimental and clinical studies have demonstrated that carbon dioxide laser is suitable for stapedotomy. The aim of this study was to investigate morphological, electrophysiological and functional changes in the inner ear after irradiation with CO2 laser set with different energy parameters.

A cochleostomy in the basal cochlear turn of guinea pig cochleae was performed with CO2 laser of 1, 2 and 3 w, respectively. The cochleae were removed three weeks after laser irradiation. The auditory evoked brainstem response (ABR) was measured before and after laser application and immediately before removal of the cochlea. Immunohistochemical methods were used to examine inducible nitric oxide synthase (iNOS/NOSII) and heat-shock protein 70(Hsp70) concentrations in the cochlea after laser application. The organ of Corti was studied by scanning electron microscopy.

Worse hearing loss was observed in animals receiving higher-power CO2 laser. These findings correlated with more intense injury of the cochlear ultrastructure and with positiveexpression of iNOS and Hsp70 in spiral ganglion cells, nerve fibres, supporting cells of the organ of Corti and cells of the spiral ligament.

The CO2 laser as a noncontact procedure is shown to be effective and safe if the total amount of energy is kept within the limits applied in this study. Nitric oxide and stressproteins play important roles in the traumatic mechanism of the inner ear, which are related tohearing loss and injury of the ultrastructure of the inner ear.

The aim of this study was to investigate the usefulness of a three-dimensional (3D) reconstruction of computed tomography (CT) images in determining the anatomy and topographic relationship between various important structures. Using 40 ears from 20 patients with various otological diseases, a 3D reconstruction based on the image data from spiral high-resolution CT was performed by segmentation, volume-rendering and surface-rendering algorithms on a personal computer. The 3D display of the middle and inner ear structures was demonstrated in detail. Computer-assisted measurements, many of which could not be easily measured in vivo, of the reconstructed structures provided accurate anatomic details that improved the surgeon’s understanding of spatial relationships. A 3D reconstruction of temporal bone CT might be useful for education and increasing understanding of the anatomical structures of the temporal bone. However, it will be necessary to confirm the correlation between the 3D reconstructed images and histological sections through a validation study.

Insertion of ventilation tubes is regarded as a simple, effective and safe treatment for recurrent otitis media or prolonged middle-ear effusions. We conducted a prospective observational study of 112 children to ascertain what early post-operative complications were experienced. Our findings were consistent with previously published figures for post-surgical otorrhoea and obstruction rates, at 13.5 per cent and 4 per cent (by ear), respectively, using intra-operative administration of antibiotic/steroid ear drops. We identified unique characteristics of differing ethnic groups with regard to findings at surgery and post-operative outcomes. There was a tendency for grommets placed in the left ear to be extruded early and Maori andPacific Islanders were significantly more likely to have a non-functioning tube (blocked or extruded) in the early post-operative period. Overall, one in four children developed a post-operative complication (otorrhoea or non-functioning tube) suggesting that early and close follow up may allow timely identification and intervention where required.

The aim of the present study is to evaluate the effect of swallowing type (dry versus wet) on the outcome of a nine-step inflation/deflation tympanometric Eustachian tubefunction (ETF) test in healthy adults.

Fourteen normal healthy volunteers, between 19 and 28 years of age, were included in the study. The nine-step test was performed in two different test procedures: (1) test with dry swallows (dry test procedure) and (2) test with liquid swallows (wet test procedure). If the equilibration of middle-ear (ME) pressure was successful in all the steps of the nine-step test, ETF was considered ‘Good’. Otherwise, the test was considered ‘Poor’, and the test was repeated at a second session.

In the dry test procedure, ETF was ‘Good’ in 21 ears at the first session and in 24 ears after the second session (p > 0.05). However, in the wet test procedure, ETF was ‘Good’ in 13 ears at the first session and in 21 ears after the second session (p < 0.05).

At the first session, ETF was ’Good’ in 21 and 13 ears in the dry and wet test procedures, respectively. The difference was statistically significant (p < 0.05). However, after the second session, the overall number of ears with ‘Good’ tubal function was almost the same in both test procedures (24 ears at dry test procedures versus 21 ears at wet test procedures;p > 0.05).

Dry swallowing seems to be more effective for the equilibration of ME pressure. Thus, a single-session dependent evaluation of ETF may be efficient for the dry test procedure of the nine-step test. Swallowing with water may be easier for subjects, but a repetition of the test at a second session may be necessary when the test result is ‘Poor’.

Objective: To describe endoscopic management of frontal sinus cerebrospinal fluid (CSF) leaks.

Study design: Retrospective.

Methods: We reviewed all frontal sinus CSF leaks treated using an endoscopic approach at ourinstitutions from 1998 to 2003. CSF leaks originated immediately adjacent to or within the frontal recess or frontal sinus proper for inclusion in the study. Data collected included demographics, presenting signs and symptoms, site and size of skull-base defect, surgical approach, repair technique, and clinical follow up.

Results: Seven frontal sinus CSF leaks in six patients were repaired endoscopically. Average age of presentation was 45 years (range 25–65 years). Aetiology was idiopathic (three), congenital (one), accidental trauma (one), and surgical trauma (two). All patients presented with CSF rhinorrhea; two patients presented with meningitis. Four defects originated in the frontal recess, while two others involved the posterior table and frontal sinus outflow tract. Four patients had associated encephaloceles. We performed endoscopic repair in all six patients withone patient requiring an adjuvant osteoplastic flap without obliteration. All repairs were successful at the first attempt with a mean follow up of 13 months. All frontal sinuses remained patent on both post-operative endoscopic and radiographic exam.

Conclusions: Endoscopic repair of frontal sinus CSF leaks and encephaloceles can be an effective method if meticulous attention is directed toward preservation of the frontal sinus outflow tract, thus avoiding an osteoplastic flap and obliteration. The major limiting factor for an endoscopic approach is extreme extension superiorly or laterally within the posterior table beyond the reach of current instrumentation.

Objective: In children cerebrospinal fluid (CSF) otorhinorrhoea can be due to congenital inner-ear malformations. Cochlear dysplasia associated with a defect in the stapes footplate is usually the cause of the CSF leak. Repair of the CSF leak in these cases is usually done by packing the vestibule with muscle or fascia. This traditional method of repair has a 30 to 60 per cent failure rate.

Material and methods: CSF otorhinorrhoea due to congenital inner-ear anomalies in four patients was repaired using multiple-layer packing of the vestibule with glue, muscle and fascia, reinforced by a pedicle temporalis muscle graft. Intra-operatively, continous lumbar drainage wasperformed.

Results: Repair of the CSF leak was successful in four cases and no recurrence was noticed. Inner-ear magnetic resonance imaging (MRI) using three-dimensional fast-spin echo (3D FSE) T2-weighted imaging (T2WI) and 3D steady-state free precession (FIESTA) sequences was found to be a very helpful, noninvasive investigation to localize the site and route of the CSF leak.

Conclusions: Children presenting with recurrent meningitis and CSF rhinorrhoea should be investigated for congenital inner-ear anomalies. In these cases CSF fistulae should be repaired using fibrin or cyanoacrylate glue and intra-operative continuous lumbar drainage; 3D FSE T2WI and 3D FIESTA MRI sequences of the inner ear are helpful.

Waardenburg syndrome is an autosomal-dominant trait resulting from mutations occurring in different genes. It is often characterized by varying degrees of: congenital hearing loss; dystopia canthorum; synophrys; broad nasal root; depigmentation of hair (white forelock), skin or both; and heterochromic or hypochromic irides.

A retrospective case study was done to assess speech perception, speech production, general intelligence and educational setting in six profoundly hearing-impaired children with Waardenburg syndrome (four with type I, one with type II and one with type III) ranging in age from two years to 14 years, seven months (mean = six years, six months). None of the patients had malformation of the cochlea and were implanted using Nucleus 22/24 and Med-el combi40+. Five out of the six cases were of average intelligence and one had a borderline intelligence quotient. The follow-up period ranged from one year, 10 months to six years, six months (mean = three years, six months) after implantation. The evaluation of auditory perception in patients was accomplished using the Persian Auditory Perception Test for the Hearing-Impaired, a Persian Spondee wordstest and the Categories of Auditory Performance Index. The Speech Intelligibility Rating test was used to evaluate speech production ability. All the patients’ speech perception and speech intelligibility capabilities improved considerably after receiving the implants, and they were able to be placed in regular educational settings. Patients used their cochlear-implant devices whenever awake, implying that they benefitted from the devices. We suggest that any further expansion of cochlear-implantation criteria in children include those with Waardenburg syndrome.

Objective: To investigate the previously documented inverse association between ambient temperature and presentation rates for patients with epistaxis and seasonal variation of emergency presentation rates for patients with epistaxis.

Study design: A retrospective analysis of all consecutive emergency patients with epistaxis presenting to hospital from the community over a five-year period, 1997–2002 (1830 days), including those who required admission to hospital with epistaxis over the same period. Patients in whom there was a clear aetiology for the epistaxis (traumatic, recurrent, iatrogenic, coagulopathic and hypertensive) were excluded.

Setting: A tertiary referral centre in south-west London serving a population in excess of 2.8 million.

Method: A retrospective analysis of all patients presenting or admitted to St George’s Hospital with epistaxis over a five-year period. Daily ambient temperature readings from London Heathrow airport were recorded for the same period. Presentations were correlated with monthly temperature variations and the month itself. Statistical analysis with Pearson’s correlation coefficient was performed.

Results: 1373 patients with epistaxis presented to our department, of whom 386 (28.1 per cent) were admitted to hospital. No correlation is seen between ambient temperature and presentation rate for patients with epistaxis. No seasonal preponderance is noted for presentation rate (Pearson r = 0.160, p = 0.221) in this series.

Conclusion: To our knowledge, this is the largest study to date examining ambient temperature association and epistaxis, and the first to investigate presentation rate in place of admission rate. We feel that the exclusion of all patients with epistaxis not admitted to hospital introduces a bias. In this series, there is no correlation between ambient temperature, seasonal preponderance, presentation rate or admission rate for patients with epistaxis. This is contrary to previously reported findings. We do not support the view that there is a relationship between epistaxis and temperature or seasonal variation. This contradicts the current belief that incidence of epistaxis displays seasonality, and has implications for the allocation of resources for healthcare provision within ENT departments.

Foley’s catheter is used for post-nasal packing in severe epistaxis. Various methods have been described for securing the catheter in position, all of which can be associated with patient discomfort, risk of alar necrosis or unsightliness. We describe a new method to secure the Foley’s catheter without these problems. The ribbon gauze used for anterior nasal packing is tied over the catheter in multiple knots to secure it in place. This has been successfully tried on over 50 patients.

We present a method to cauterize an actively bleeding source in anterior epistaxis. In our experience, this method is efficient, provides full control of the bleeding, and ensures precise cautery of the bleeding source with minimal usage of chemical cautery sticks.

With increasing use of expandable metallic stents to manage patients with a variety of endobronchial pathologies, some will have a subsequent need for tracheostomy insertion. We describe a successful technique to insert a tracheostomy using rigid and fibre-optic bronchoscopy in a patient who had an 8 cm expandable metallic tracheal stent deployed previously on account of tracheomalacia.

Sarcoidosis often presents with signs and symptoms within the head and neck. In this region, it most commonly affects the nose, larynx, parotid and cervical lymph nodes. Within the ear, it usually causes sensorineural hearing loss of varying severity. We report a patient in whom sarcoidosis involved the middle ear and presented with a conductive hearing loss. Granulomata were found in the middle ear during an exploratory tympanotomy. The granulomatous process had caused necrosis of the long process of incus and was also encasing the chorda tympani nerve. Histological examination confirmed the diagnosis.

Internal jugular vein thrombosis from non-otological causes is not well documented in the otolaryngology literature. The authors report a case of left internal jugular vein thrombosis due to severe ovarian hyperstimulation syndrome. Causes, investigations and treatment of internal jugular vein thrombosis from non-otological causes are discussed.

We present a case report of an aggressive natural killer T cell lymphoma in a police officer who presented with combined features of orbital cellulitis and mid-facial destruction. However, his initial diagnosis was confused with other disease conditions that had overlapping features. This emphasizes the significance of clinical alertness and adequate tissue sampling; this can have a great impact on early diagnosis and treatment.

Acute tonsillitis is a common condition and usually runs a benign course. However life-threatening complications do still occur, even in this postantibiotic era. Infection can spread downwards into the mediastinum through the anatomic cervical spaces, causing widespread cellulitis, necrosis, abscess formation and sepsis. We present a case of descending mediastinitis in an 18-year-old woman, arising from her first episode of tonsillitis and treated successfully by surgical drainage. We believe that an awareness of this complication, early diagnosis using computed tomography scanning, and prompt, adequate surgical drainage will reduce morbidity and mortality.

We present the case of a previously healthy 59-year-old man who was under treatment for scleritis and episcleritis when he developed a parotid-gland swelling and pus-producing sinus. On surgical exploration, the features were those of a parotid abscess, but the lesion not only failed to heal post-operatively but increased in size very significantly. There was also severe necrotizing keratitis of the eyes. Due to clinical suspicion and a positive antineutrophil cytoplasmic antibodies test, Wegener’s granulomatosis was diagnosed and the patient successfully treated with cyclophosphamide and steroids. Previously, a number of cases of Wegener’s granulomatosis causing salivary-gland swelling have been reported in the literature; this is the first case in which the disease has masqueraded as a parotid abscess.