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.

Symptomatic salivary stones in the middle or proximal parotid duct have previously been treated by gland excision, which is associated with a 3–7 per cent risk to the facial nerve. Minimally invasive approaches to the management of salivary duct calculi have been devised over the past decade. Fluoroscopically guided basket retrieval, lithotripsy and intra-oral stone removal under general anaesthesia have found favour with most surgeons. Endoscopically controlled intracorporeal shock wave lithotripsy using the pneumoblastic lithotripter has been replaced by electrohydraulic lithotripsy (used in sialolith treatment).

The electrokinetic lithotripter is normally used for the treatment of lower ureteric stones, and has the benefit of minimal concomitant tissue damage. We have extended its use to the treatment of parotid duct calculi. We present initial results for its use in the treatment of a proximal parotid duct stone.

Application of the shock wave to the stone under direct vision avoided injury to the duct or to any local structure. The patient made an uneventful recovery and was asymptomatic after 18 months' follow up.

Continuous, endoscopically monitored electrokinetic lithotripsy with good irrigation gives a well illuminated field and absolute delivery of energy to the target. It avoids the side effects caused by impact of the shock wave on the parotid duct and adjacent anatomical structures, thereby making it a safer procedure.

Large substernal goitres present a challenge to the otolaryngologist due to their size and location. Predicting which patients will require sternotomy can enable planning of surgery in a specialist centre, with the assistance of a thoracic surgeon. Our aim for this study was to establish clinical and radiological predictors which would aid the otolaryngologist in the pre-operative planning of such cases.

A retrospective medical record review was conducted for all patients undergoing thyroidectomy for substernal goitre who required sternotomy in our institution over a 10-year period.

During the study period, 140 patients with substernal goitres underwent thyroidectomy. Three patients (2 per cent) required sternotomy. These cases are described.

Radiological evidence of extension of a substernal goitre to the aortic knuckle, or loss of tissue planes on computed tomography, should raise suspicion that the patient may require sternotomy for safe delivery of the gland. The otolaryngologist should plan surgery for these patients in a specialist centre, with the help of a thoracic surgeon.

We question the need for packing of the ear canal after ear surgery. For several years, it had not been the first author's standard practice to use post-operative ear packing. During this period, few problems or complications had been encountered.

Tertiary referral, academic, paediatric hospital.

A retrospective review of all children who had undergone major ear surgery in our unit over the last year was carried out. These cases represented a full range of otological procedures. Post-operative complications and infections in the first six post-operative weeks were recorded.

A total of 135 ears were operated upon in 107 patients ranging in age from 11 months to 19 years (mean 9.5 years). During this time period, eight children (7.5 per cent) developed a post-operative ear infection. No cases of tympanic or meatal granulations, problems with the tympanomeatal flap, or meatal stenosis were encountered. All infections were successfully managed with topical antibiotics.

We conclude that packing after ear surgery may be safely abandoned. This would not only save valuable operating time, but would also obviate the need for pack removal, always a source of discomfort and anxiety. This is especially important in children, who may subsequently require a further general anaesthesia in order to remove the pack.

Airway fires pose a risk during laser microlaryngoscopy, and neurosurgical cotton patties, used to prevent tissue injury from stray laser beams, are a potential ignition source. Using a configuration approximating clinical practice, we experimentally assessed the relative impact of changing different ‘fire triad’ components on the occurrence of airway fires, in order to better inform patient care.

The relative effects of wet vs dry neurosurgical patties, oxygen concentration and laser power setting on the patty ignition time were studied in a cadaveric porcine model. Data were analysed using t-test and two-way analysis of variance.

Dry patties ignited after 2.3 ± 1.2 seconds (average ± standard deviation) of continuous 5 W laser fire at 50 per cent oxygen concentration, compared with 63.9 ± 27.8 seconds for wet patties under the same laser and oxygen settings (p < 0.0001). There was a statistically significant reduction in the time to patty ignition when laser power settings were increased from 5 to 7.5 W, but no further reductions occurred when the power was further increased to 10 W (p < 0.05; Tukey test for multiple comparisons; two-way analysis of variance). There was no significant reduction in the time to ignition between oxygen concentrations of 50 and 75 per cent, but the time to ignition fell significantly when the oxygen concentration was further increased to 100 per cent.

We suggest that surgical patties should always be soaked and should be used for relatively short periods, in order to prevent drying. If at all possible clinically, prolonged laser use at high power settings and ventilation with 100 per cent oxygen should be avoided.

To develop and characterise an experimental model of recurrent laryngeal nerve injury for the study of viral gene therapy.

Twenty rats underwent unilateral recurrent laryngeal nerve injury. After vocal fold mobility was observed, larynges were serially sectioned, and immunohistochemical techniques were employed to stain for neurofilament and motor endplates in order for a blinded investigator to determine the percentage of nerve–endplate contact, as a histological indicator of an intact neuromuscular connection.

All animal procedures resulted in complete, ipsilateral vocal fold paralysis that recovered by three weeks. The mean nerve–endplate contact percentage was 11.6 per cent at one week, 53.9 per cent at two weeks, 88.6 per cent at three weeks, 81.7 per cent at four weeks and 86.6 per cent at five weeks. The differences between results at week one and week three were statistically significant (p < 0.01). The mean nerve–endplate contact percentage on the control side was 86.8 per cent.

There was a dramatic, measurable decrease in nerve–endplate contact percentage following crush injury to the recurrent laryngeal nerve. Spontaneous recovery was observed by three weeks post-injury. This model will be used to investigate the potential therapeutic role of viral gene therapy for the treatment of recurrent laryngeal nerve injury.

Dizziness is a common and often complex complaint. Between nine and 13 per cent of patients seen in general practice are referred to a variety of specialist clinics. The diagnoses and outcomes of these referrals are seldom reported.

To determine the proportion of patients referred to an otology led vertigo clinic in whom an otological cause for vertigo could be identified.

Prospective cohort study of consecutive new clinic attendees over one year.

Otology led vertigo clinic in an urban teaching hospital in England. Patients' details including age, sex, referring clinician, investigations, diagnoses, treatment and final outcome were recorded in an anonymised database.

91 new patients, 31 men and 60 women with a mean age of 52.6 years (range 16–81) were seen. General practitioners referred 87 per cent of the patients. Twenty-seven patients underwent further investigations including imaging, electronystagmography and other audiological tests. A labyrinthine disorder accounted for 50 per cent of the diagnoses. Ménière's disease or a variant was diagnosed in 20 patients (21 per cent). Fifty-six patients (61 per cent) reported resolution of or improvement in their symptoms. Thirty-one patients (34 per cent) were asymptomatic and free of abnormal findings on initial attendance and were discharged from hospital care.

Forty-six patients (50.6 per cent, 95 per cent confidence interval, 40.4–60.6 per cent) had vertigo due to an otological disorder. The selection of an otolaryngology based vertigo clinic by the general practitioner for initial referral seems appropriate.

To investigate the methods of surgical closure used by Australian ENT and head and neck surgeons after undertaking total laryngectomy surgery.

In order to audit surgical variation, 56 short questionnaires were sent to all Australian ENT and head and neck surgeons who were registered members of the Australia and New Zealand Head and Neck Society. Twenty-eight questionnaires (50 per cent) were completed and returned.

Respondents reported using a variety of different reconstructive methods after total laryngectomy surgery. Specifically, there were differences in the type and levels of pharyngeal closure employed and the suturing techniques used.

Currently, there is no scientific evidence to direct surgeons to the optimal pharyngeal reconstruction technique(s) ensuring for good swallowing results post-laryngectomy. An analysis of the effect of surgical reconstruction technique on laryngectomees' post-operative swallowing ability is needed, in order to provide evidence to determine optimal surgical techniques.

Chronic nonspecific pharyngitis is a chronic inflammation of the pharynx. It is found worldwide, and treatment is difficult. The underlying aetiopathogenesis is still controversial. The aim of this study was to investigate Helicobacter pylori seroprevalence in chronic nonspecific pharyngitis patients without other possible causative factors for chronic pharyngeal irritation and without H pylori gastric mucosal infection.

Forty-one patients with symptoms of chronic nonspecific pharyngitis and 30 healthy control subjects were enrolled in this prospective, controlled, clinical study. In both study and control groups, selected patients were shown to have gastric mucosa uninfected by H pylori, as demonstrated by the 14C-urea breath test. Comprehensive otorhinolaryngological examination did not elicit any factor contributing to the chronic pharyngeal complaint. Serum H pylori immunoglobulin G antibody titres were assayed using serum enzyme-linked immunosorbent assay. The difference between the study and control groups was analysed by the chi-square test (the likelihood ratio was used).

Thirty-two of the 41 patients (78 per cent) and 14 of the 30 control subjects (46.7 per cent) were found to be H pylori positive. Patients with chronic nonspecific pharyngitis were found to have a significantly higher rate of H pylori seropositivity than the control group (p = 0.016).

These data may be important in developing future treatment strategies for chronic nonspecific pharyngitis.

To assess the effectiveness and determine the compliance to a local protocol for requesting magnetic resonance imaging scans to screen for the presence of cerebellopontine angle lesions.

A combined retrospective study of all patients who had magnetic resonance imaging scans requested six months prior to and one year following introduction of the protocol and assessment of the true positive and false negative rate of the protocol by assessment of its sensitivity in cases referred from outside the department.

Comparison of the number of scans in each period showed a reduction in annualised rate of 142 to 46. The incidence of positive scans was the same in both periods, increasing the true positive rate from 1.4 to 4.3 per cent. The false negative rate was 1.1 per cent.

The Charing Cross protocol has a good compliance rate within the department, has reduced the cost of screening for cerebellopontine angle lesions and has an acceptable true positive and false negative rate.

To determine olfactory adaptation and clearance times for healthy individuals, and to assess the effect of common variables upon these parameters.

Fourteen healthy volunteers were recruited for a series of tests. Their initial olfactory threshold levels for phenethyl alcohol were determined. After olfactory exposure to a saturated solution of phenethyl alcohol (i.e. olfactory adaptation), the time taken for subjects to return to their initial olfactory threshold was then recorded (i.e. olfactory clearance). Visual analogue scale scores for subjective variables were also recorded.

The 14 subjects performed 120 tests in total. Despite consistent linear trends within individuals, olfactory clearance times varied widely within and between individuals. The mean olfactory clearance time for phenethyl alcohol was 170 seconds (range 81–750). Univariate analysis showed a relationship between olfactory clearance times and age (p = 0.031), symptoms (p = 0.029) and mood (p = 0.048).

When testing a person's sense of smell in a clinical setting, recent exposure to similar smells should be noted, and a period of 15 minutes needs to be allowed before retesting if using phenethyl alcohol. Other variables need not be controlled, but greater clearance time may be needed for older patients.

To evaluate the efficacy of endoscopic exposure and excision for juvenile nasopharyngeal angiofibroma.

Prospective analysis of the outcomes of endoscopic removal of the angiofibroma at a tertiary care centre, using endoscopic and radiological parameters.

Twenty-eight consecutive patients with angiofibroma were included. These patients underwent endonasal endoscopic excision of the lesion, following pre-operative computed tomography and digital subtraction angiography. Post-operative endoscopy and radiology were performed at six weeks to detect any residual lesion, and thereafter at six-monthly intervals to detect recurrence.

Twenty-one patients (75 per cent) were new cases and seven patients (25 per cent) had recurrent tumour. Pre-operative embolisation was performed in 21 patients (75 per cent). An endoscopic endonasal approach was used to access the pterygopalatine fossa. The average blood loss was 228 ml. Residual lesion was noted in one patient (initially with recurrent stage II C pathology). The remaining 27 patients (initially with stage I, II A and II B pathology) were free of residual pathology or recurrence after a minimum follow-up period of 12 months.

Endoscopic exposure and excision of angiofibroma was found to be effective.

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.

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.

Allergic rhinitis has traditionally been classified into seasonal and perennial rhinitis. However, many subjects with dual sensitisation do not fit neatly into either category. Recently, the Allergic Rhinitis and its Impact on Asthma workshop has proposed a new allergic rhinitis classification, into intermittent and persistent forms. The purpose of the present study was to investigate whether the symptomatic and secretory responsiveness of allergic rhinitis sufferers correlated well with the Allergic Rhinitis and its Impact on Asthma classification, compared with the traditional classification.

Experimental study.

Forty subjects with allergic rhinitis and 13 normal controls underwent a unilateral nasal bradykinin challenge protocol. Symptom scores were recorded and secretion weights measured bilaterally using filter paper disks. The symptomatic and secretory responses of allergic subjects were analysed according to both the traditional and the Allergic Rhinitis and its Impact on Asthma classifications, and the two systems were compared.

For both classification systems, the two groups of allergic subjects were clearly demarcated by secretory responses. However, after classification according to the traditional system, there was a lack of clear demarcation between the groups as regards symptomatic response, whereas clear demarcation of symptomatic responses was seen after using the Allergic Rhinitis and its Impact on Asthma classification.

In allergic rhinitis subjects, the degree of nasal responsiveness was closely related to their Allergic Rhinitis and its Impact on Asthma classification. Furthermore, this classification was not compromised by the inclusion of subjects with dual sensitisation. Thus, the Allergic Rhinitis and its Impact on Asthma classification may have advantages for future research studies on allergic rhinitis.

The consequences of vocal fold paralysis include voice change, airway problems and difficulty swallowing. Medialisation procedures using injected material have been used for many decades, with varying outcomes, mainly secondary to lifespan, tissue reaction or migration. Newer materials have recently become clinically available which are easier to manage and supposedly less likely to elicit foreign body reaction.

Case report.

We report a case of foreign body reaction and possible migration of polymethylsiloxane gel (Bioplastique™), one such material, after vocal fold injection. To our knowledge, this is the second such case described.

This case highlights the fact that the risk of foreign body reaction and migration is still present for this material, albeit low. We also highlight the fact that, although this material can cause foreign body reactions and may possibly migrate, it is removable by microlaryngoscopy via the microflap technique, with vocal improvement.