Examination of the upper aerodigestive tract is an important part of ENT practice. The use of both flexible and rigid nasendoscopes is the most common way of achieving this in the out-patient setting. However, these procedures can cause pain or discomfort for the patient, and topical preparations have been used in an attempt to reduce this.

The variability in current practice amongst those performing nasendoscopy may suggest an uncertainty as to what constitutes best practice for this procedure. A systematic review of the literature was undertaken in an attempt to clarify this.

A literature search of the Cochrane ENT group trials register, the Cochrane central register of controlled trials (CENTRAL), CINAHL (1982–2007), MEDLINE (1950–2007) and EMBASE (1974–2007) was performed. Reference lists of selected studies were scanned for additional research material.

Eighteen studies relevant to this review were identified. The evidence suggests that local anaesthetic is not beneficial when performing flexible nasendoscopy, neither alone nor in combination with a vasoconstrictor. Water is better than lubricant for flexible endoscope passage and gives a superior optical outcome. Further research is required on the use of endosheaths for flexible and rigid nasendoscopy.

Previously, we have mapped the DFNA52 (Online Mendelian Inheritance in Man (OMIM) 607683) locus, using an 8.8-cM interval on the human chromosome 5q31.1-q32, in a large, consanguineous Chinese family with congenital sensorineural hearing loss. In order to identify the responsible pathogenic mutation within the DFNA52 locus, we set out to identify candidate disease genes within that region and to sequentially analyse these candidate genes.

Using bioinformatics analysis, 52 candidate disease genes were identified based on gene expression data, deafness phenotype, and findings from a mouse model and from the literature (including two mouse deafness genes NEUROG1 and SMAD5). Mutation detection was performed for the 52 candidate genes, in patients from the pedigree.

In these patients, we found no disease-causing mutations in the coding and splice site regions of these genes, which segregated with the disease. However, 108 single nucleotide polymorphisms were identified, of which 15 were novel. Eleven of these 108 single nucleotide polymorphisms altered the encoded amino acid.

Although we identified a number of nucleotide changes in the affected patients, by analysis of coding and splice site regions of the genes, none of these changes are likely to be pathogenic mutations segregating with the disease. The result implies that the genes studied are unlikely to be a cause of DFNA52-linked sensorineural hearing loss.

To characterise the hearing loss, and the frequency of the mitochondrial deoxyribonucleic acid 12S ribosomal ribonucleic acid A1555G mutation, in a large pedigree of aminoglycoside-induced deafness.

Hearing loss was clinically assessed. Blood samples were collected from 27 family members (19 matrilinear and eight non-matrilinear) and leukocyte deoxyribonucleic acid was extracted. Mitochondrial deoxyribonucleic acid fragments, spanning the 1555 location, were amplified by polymerase chain reaction. Polymerase chain reaction products were analysed by restriction fragment length polymorphism and deoxyribonucleic acid sequencing.

We detected the A1555G mutation in all 19 matrilinear relatives. Of these 19, two exhibited congenital deafness, four had no hearing deficits and the remaining 13 suffered mild to profound hearing loss.

We confirmed that the A1555G mutation is a ‘hot spot’ associated with non-syndromic, inherited hearing loss. This mutation may play a vital role in the pathogenesis of hearing impairment, and can result in various grades of deafness.

To compare hearing results in patients undergoing myringostapediopexy or myringolenticulopexy in canal wall down mastoidectomy.

Case series of one surgeon. A retrospective review of 83 consecutive mastoid cavity operations for primary cholesteatoma. Only those patients who had undergone either myringostapediopexy or myringolenticulopexy were included.

District general hospital.

Forty-two procedures were performed in 40 patients. The mean age was 42 years old. The average follow up was 5.9 years.

Seventeen patients underwent myringolenticulopexy (the incus head was excised, leaving the lenticular process attached to the stapes prior to graft placement) and 25 underwent myringostapediopexy (type III tympanoplasty).

Audiometry three to six months after surgery, and status of mastoid cavity after a minimum follow up of one year.

Comparison of post-operative hearing results for the two groups showed a statistically significant hearing advantage for myringolenticulopexy (p = 0.029). In the myringolenticulopexy group, 92 per cent achieved a post-operative air–bone gap of less than 30 dB, compared with 62 per cent in the myringostapediopexy group. The mean post-operative air–bone gaps in the two groups were 17.5 and 24.7 dB, respectively.

When surgically feasible, the technique of myringolenticulopexy is a useful method of preserving serviceable hearing in single-stage mastoid cavity surgery.

To assess contralateral suppression of transiently evoked otoacoustic emissions in patients with fibromyalgia syndrome and normal hearing.

Twenty-four female patients with fibromyalgia syndrome and 24 healthy female controls with normal hearing were assessed using pure tone audiometry and transiently evoked otoacoustic emissions.

All patients with fibromyalgia syndrome and all controls had normal hearing on pure tone audiometry. In the patients with fibromyalgia syndrome, the mean transiently evoked otoacoustic emission amplitude was 15.5 ± 4.8 dB. The mean transiently evoked otoacoustic emission amplitudes after contralateral suppression was 15.5 ± 4.9 dB. There was no statistically significant difference between the transiently evoked otoacoustic emission amplitudes measured before and after contralateral suppression (p > 0.05). In the controls, the mean transiently evoked otoacoustic emission amplitude was 12 ± 5 dB. The mean transiently evoked otoacoustic emission amplitudes after contralateral suppression was 11 ± 4.7 dB. There was a statistically significant decrease in transiently evoked otoacoustic emission amplitudes after contralateral suppression (p < 0.01).

The mechanisms related to contralateral suppression of transiently evoked otoacoustic emissions seem dysfunctional in fibromyalgia syndrome. This dysfunction may be at the brain stem level, where the medial superior olivary complex is located, or at the synapses of medial superior olivary complex fibres with the outer hair cells in the cochlea. Demonstration of lack of contralateral suppression of transiently evoked otoacoustic emissions can be used as a diagnostic tool in patients with fibromyalgia syndrome.

(1) To assess the subjective tinnitus perception of patients with audiologically proven hearing loss presenting to a tinnitus clinic, both before and after hearing aid provision; (2) to investigate subjective tinnitus perception in patients with unilateral and bilateral hearing loss; and (3) to assess the impact on tinnitus perception, if any, of a digital hearing aid programme in patients provided with hearing aids.

Prospective data collection for patients attending a tinnitus clinic over a 25-year period (1980–2004).

University teaching hospital otolaryngology department.

A total of 2153 consecutive patients attending a consultant-delivered specialist tinnitus clinic.

A visual analogue scale was used to assess the degree of tinnitus perception improvement, if any, comparing before versus after unilateral or bilateral aiding (in those with audiometrically proven hearing loss). A further assessment compared the effect of digital hearing aid programme introduction on symptomatic tinnitus perception in patients provided with unilateral or bilateral aids.

A total of 1440 patients were given hearing aids (826 unilateral and 614 bilateral). There was little difference in tinnitus perception, comparing overall aiding results in unilaterally or bilaterally aided patients. Overall, 554 (67 per cent) of unilaterally aided patients and 424 (69 per cent) of bilaterally aided patients reported some improvement in their tinnitus perception following aiding. There was a statistically significant improvement in tinnitus perception, comparing analogue aids with digital hearing aids, following introduction of a digital hearing aid programme in 2000, in both unilaterally (p < 0.001) and bilaterally (p < 0.001) aided patients.

Provision of hearing aids in patients with audiometrically demonstrable hearing loss can play a very important part in tinnitus control. The additional improvement in tinnitus control observed following introduction of programmable digital aids had a summative effect in the management of these patients.

Deafness is the hidden disability of childhood, and leads to poor educational and employment prospects. There is little published information on deafness in Pakistan. Profound hearing impairment is more prevalent in countries where consanguineous marriages are common, such as Pakistan. This study aimed to assess causes of childhood deafness and association with parental consanguinity, within deaf and hearing children in the Peshawar district of Pukhtoonkhwa Province, Pakistan.

One hundred and forty deaf children were identified from two schools for deaf children within the Peshawar district. These children were assessed via audiology, otoscopic examination, case note review and parental history, in order to attempt to ascertain the cause of their deafness. Two hundred and twenty-one attendees at a local immunisation clinic (taken as representative of the local childhood population) were also screened for hearing impairment. Parents of both groups of children were assessed by interview and questionnaire in order to ascertain the mother and father's family relationship (i.e. whether cousins or unrelated).

Of the 140 deaf school pupils, 92.1 per cent were profoundly hearing impaired and 7.9 per cent were severely hearing impaired. All these children had bilateral sensorineural hearing loss. A possible cause of deafness was identified in only six of these children. Parental consanguinity (i.e. first or second cousins) was established for 86.4 per cent of deaf school pupils and 59.7 per cent of immunisation clinic attendees. None of the control children were identified as having a hearing problem.

The prevalence of parental consanguinity was significantly higher in deaf children compared with non-hearing impaired children. However, the study also confirmed a high rate of consanguinity within the general Peshawar community. In this setting, prevention of consanguineous unions is the only means of reducing levels of congenital hearing impairment. The current levels of hearing disability represent both a prominent public health problem and an important, potentially preventable childhood disability.

This study is the first attempt to link quantified phenylthiocarbamide bitter taste recognition threshold with susceptibility to motion sickness.

The study was conducted on a sample of 291 teenage Rajput children (146 males and 145 females; age range 13–19 years) from the Sirmour district of Himachal Pradesh, India. Phenylthiocarbamide taste sensitivity was measured by administering a serial dilution of a freshly prepared phenylthiocarbamide solution, following the method of Harris and Kalmus. Motion sickness susceptibility was assessed retrospectively via interview.

About 40 per cent of the subjects had experienced motion sickness in the past. The mean and standard deviation of phenylthiocarbamide taste thresholds in non-tasters and tasters were 0.83 ± 0.87 and 7.98 ± 1.86, respectively. A bimodal distribution test (D/S) index of 5.24 confirmed bimodality of phenylthiocarbamide taste threshold distribution. The Mann–Whitney U test rejected the null hypothesis of μ1 = μ2 and thus confirmed the existence of differences in the distributions of phenylthiocarbamide taste threshold between individuals susceptible and not susceptible to motion sickness. Individuals susceptible to motion sickness had lower mean and median taste thresholds, indicating higher phenylthiocarbamide taste sensitivity, compared with non-susceptible individuals. The frequency of non-tasters was about 10 per cent in both motion sickness susceptible and non-susceptible individuals. The simple division of phenylthiocarbamide tasting ability into tasters and non-tasters was a less sensitive criterion with which to measure the association of this ability with motion sickness susceptibility. However, further differentiation of tasters into weak threshold, medium threshold and super threshold (‘supersensitive’) tasters clearly revealed a highly significantly increased risk of motion sickness in super threshold tasters (i.e. threshold solution number ≥12). The ratio of motion sickness susceptible individuals to non-susceptible individuals was 1:1.7 for non-tasters (threshold solution numbers zero to three) and weak and medium tasters (threshold solution numbers four to 11), but the trend was reversed for super threshold tasters (threshold solution numbers 12 and 13), in whom the ratio was 2:1.

Individuals exhibiting greater phenylthiocarbamide taste acuity (i.e. supersensitive tasters) had a higher susceptibility to motion sickness than did non-, weak and medium phenylthiocarbamide tasters, as measured in terms of their taste thresholds (i.e. threshold solution numbers zero to 11).

To identify the nature of Woodruff's plexus, which has been frequently mentioned in the rhinological literature but has never been properly characterised.

A study using 21 cadaveric specimens, combining microdissection of the mucosa of the posterior part of the inferior meatus, Spalteholz ‘clearing’ of specimens injected with latex ink, and histological analysis of sections of the inferior meatal mucosa.

Microdissection revealed a superficial plexus of thin walled vessels in the inferior meatus, which were also seen in cleared, injected specimens. Histological sections showed these vessels to be large, thin walled veins with very little muscle or fibrous tissue, within a thin mucosa relatively devoid of other structures.

Woodruff's plexus is a venous plexus in the posterior part of the inferior meatus.

This is the first time Woodruff's plexus has been properly characterised. Whilst the significance of the plexus itself is uncertain, its long overdue identification as a venous plexus provides a platform for further study and discussion.

To investigate the prevalence in adults of pharyngeal and laryngeal symptoms associated with the use of inhaled corticosteroids.

Prospective, observational and based on a structured, specifically designed postal questionnaire.

University Hospital Aintree, Liverpool, UK.

The questionnaire was distributed to 190 patients on the basis of current inhaled corticosteroid use. Recruitment was from the databases of two local general practices. Individuals were classified as mild, moderate or severe asthmatics, using the guidelines of the British Thoracic Society.

Demographic data, including smoking history, were recorded. The number, type, strength, dosing regime and duration of individual inhaler use were recorded. Specific pharyngeal and laryngeal side effects were enquired about. Co-morbidities and preventive measures were also recorded. Results were analysed using univariate and multivariate statistical tests.

There was a 75.8 per cent response rate (144/190 questionnaires); 63 (43.8 per cent) of respondents were male and 81 (56.2 per cent) were female. The majority of our patients were either mild or moderate asthmatics. Longer use of an inhaled corticosteroid predisposed to weak voice (p = 0.0016), hoarseness (p = 0.0001) and throat irritation (p = 0.008). Hoarseness, throat irritation, sore throat and cough were observed much more frequently than anticipated. Severe asthmatics were more likely to use a spacer device compliantly (p = 0.0487; odds ratio 1.53). Side effects were more prevalent as asthma severity worsened (p = 0.0049; odds ratio 1.87).

Inhaled corticosteroids cause sore throats, throat irritation, hoarseness and cough. Further research in this area is required in order to elucidate the mechanism of inflammation. Only then can effective preventive measures be introduced and implemented.

To determine the long-term outcome for children treated for recurrent epistaxis, and to compare the efficacy of antiseptic cream treatment and nasal cautery.

Retrospective analytical cohort study of 88 children treated for recurrent epistaxis in 2001.

Five-year data on chlorhexidine–neomycin cream usage, nasal cautery, current epistaxis frequency and emergency room attendance was collected by telephone interview and case record review.

During their first clinic visit, 51 per cent of the children had been treated with cautery and cream and 35 per cent with cream alone; 14 per cent had received no treatment. Five years later, 65 per cent of these children were still having ongoing epistaxis. Those who had undergone cautery and received cream had the highest ongoing bleeding rate (77 per cent).

The majority of children treated at our clinic for recurrent epistaxis had ongoing bleeding five years later. Despite the proven short-term efficacy of chlorhexidine–neomycin cream, few patients receive further courses of cream or are referred back to the clinic.

We aimed to devise a method whereby every surgeon performing gold eyelid implantation could have easy and quick access to the implant. Furthermore, we aimed to develop a means of creating an implant of the exact weight required for complete eyelid closure.

A prospective study was performed from 1997 to 2005 in a tertiary research hospital, involving 50 subjects requiring gold upper eyelid implantation and using the technique in question.

Only patients with a minimum follow up of one year were included in the study group. Symptoms improved in 96 per cent of subjects, who were able to dispense with eyedrops and eye ointments. Visual acuity improved in 92 per cent of patients. There were two extrusions amongst the early cases.

Customised gold eyelid implantation offers an alternative in regions where commercial implants are not easily obtained.

A reliable grading system allows the clinician to classify disease severity, monitor progress and evaluate treatment efficacy. There is no currently accepted grading system for vocal process granuloma of the larynx.

To evaluate the reliability of a new grading system for vocal process granuloma.

All vocal process granuloma images from a digital laryngeal image library were abstracted. Granulomas were graded on a one to four system, as follows: grade one, sessile, non-ulcerative granuloma limited to vocal process; grade two, pedunculated or ulcerated granuloma limited to vocal process; grade three, granuloma extending past vocal process but not crossing midline of airway in fully abducted position; and grade four, granuloma extending past vocal process and past the midline of the airway in the fully abducted position. The granulomas were additionally graded A if unilateral and B if bilateral. Two laryngologists and two otolaryngology residents rated the granulomas on two separate occasions. Intra- and inter-observer reliability was evaluated with the kappa (κ) test statistic.

Thirty-five vocal process granulomas were identified. The percentage intra-observer agreement for the two laryngologists was 97 and 100 per cent (κ = 0.94 and 1.00, respectively). The percentage inter-observer agreement between the two laryngologists was 91 per cent (κ = 0.83). The percentage intra-observer agreement for the two residents was 89 and 91 per cent (κ = 0.83 and 0.77, respectively). The percentage inter-observer agreement between the two residents was 83 per cent (κ = 0.67).

The proposed grading system for vocal process granuloma displayed excellent intra- and inter-observer reliability among residents and experienced laryngologists.

This paper outlines our use of cricothyroid cannulation in those patients undergoing head and neck surgery in whom a ‘difficult airway’ is anticipated. Audit results are presented.

Prospective data collection for all patients undergoing cricothyroid cannulation for management of head and neck neoplasms, over a two-year period.

Thirty-nine cricothyroid cannulae were sited in 32 patients. All patients with laryngeal tumours underwent the procedure while awake, prior to the anticipated difficult intubation, and the cannulae were removed within six hours. Most cannulations performed under general anaesthetic were for anticipated ‘dangerous extubations’ in patients with oral cavity tumours, and these cannulae remained in place for 24 hours. Tracheostomy was possibly avoided in six patients. No complications were identified.

Cricothyroid cannulation can be a simple, safe, reliable technique which is a useful adjunct in the management of patients with a potentially difficult airway.

To measure patient-reported quality of life before and after botulinum toxin A treatment of post-parotidectomy Frey's syndrome (gustatory sweating).

A questionnaire concerning functional, social and emotional aspects of Frey's syndrome (14 questions, with responses on a zero to three point scale) was administered to 17 patients (13 women and four men) before and one month after intradermal injection of botulinum toxin A. Parotidectomy had been performed one to 19 years previously, for benign (n = 10) or malignant (n = 7) tumours, with gustatory sweating occurring a median of 15 months after surgery (range: one month to 14 years). Pre- and post-treatment quality of life scores were compared using Wilcoxon's test (p < 0.05).

Patients' reported functional quality of life improved significantly (p = 0.0004). Their social and emotional scores were not significantly modified (p = 0.155 and 0.142, respectively). Seven patients (41 per cent) found the injections painful, but all patients said that the effects were beneficial, that they would undergo new injections if necessary and that they would recommend this treatment to other patients. The benefit lasted over 1.5 years for 60 per cent of patients. No correlation was found between duration of the effect and the extent of parotidectomy (p = 0.067).

Botulinum toxin A significantly improved patients' functional quality of life, without significant improvement in their social or emotional quality of life, according to our questionnaire results. The duration of the effect was longer than the reported physiological effect of botulinum toxin A on acetylcholine receptors.

To assess elective surgery consent practices amongst senior house officers from a selection of UK ENT departments, and to compare results with those obtained in a similar survey in 2002.

A telephone survey of senior house officers in 40 UK ENT departments was carried out to assess departmental consent policies and knowledge of complications of common ENT operations.

Over 80 per cent of the senior house officers surveyed remained responsible for obtaining consent for routine surgery. Since 2002, there had been a significant increase in the proportion of departments which: used the Department of Health model consent form; provided patient information leaflets; and had an established informed consent protocol. Senior house officers' knowledge of specific complications remained poor.

There has been a small change in the practice of obtaining informed consent, in accordance with General Medical Council guidelines. Many senior house officers continue to perform this duty, however, and the majority are poorly trained.

We describe in detail the technique of in vivo endolaryngeal ultrasound during microlaryngoscopy, offering a number of practical suggestions which may be of use, especially to the otolaryngologist.

Endosonography is a non-invasive imaging technology usually applied for the assessment of local tumour growth and regional lymph node metastases in the digestive tract.

Due to a penetrating depth of up to 25 mm and a high tissue resolution, endosonography also qualifies for use in the larynx. The technique may have a potentially important role in the intra- and post-operative investigation of laryngeal lesions bigger than 3 mm.