Rhinoscleroma is a chronic, infectious, granulomatous disease that may present with mass lesions in the respiratory tract anywhere from the nose to the trachea. The nose is involved in 95–100 per cent of cases. There are three stages of the disease: catarrhal-atrophic, granulomatous (also known as hypertrophic) and sclerotic. The diagnosis is made either by positive Klebsiella rhinoscleromatis culture or from the classic histological findings of Mikulicz cells and transformed plasma cells with Russell bodies. Rhinoscleroma is endemic to areas of Africa, South-East Asia, Mexico, Central and South America, and Central and Eastern Europe, and it has been associated with low socioeconomic status. In the past, rhinoscleroma was infrequent in the US population but, with current trends in migration, the incidence of rhinoscleroma may be on the rise. There is often a delay in diagnosis in non-endemic areas such as the US due to unfamiliarity with the disease, the stage-dependent clinical and histological manifestations of disease, and the fact that only 50–60 per cent of cultures are positive for K rhinoscleromatis. Such late diagnosis leads to increased morbidity in the form of nasal and airway obstruction and nasal deformity from erosive processes. Rhinoscleroma is difficult to cure and prone to recur. Currently, the recommended treatment consists of a combination of surgical debridement and long-term antibiotic therapy. We present a case report of a culture-positive diagnosis of rhinoscleroma, and we review the existing literature.

Objectives: To describe the use of the great auricular nerve as a 'road map' for locating the accessory nerve in the anterior and posterior triangle, in comparison with other methods described in the literature.

Design: A review of the literature using Medline and Embase searches was performed. Illustrative photographs were taken from consenting, elective patients.

Results: Various methods have been described, using different anatomical landmarks. We describe a new method, based on the fact that the great auricular nerve runs, with relation to the edges of the sternocleidomastoid muscle, 1 cm superior to the accessory nerve anteriorly and 1 cm inferior posteriorly.

Conclusions: This is a reliable and safe method, used by the senior authors in their extensive work as head and neck and skull base surgeons. It allows the accessory nerve to be located in both the anterior and posterior triangle. This avoids the inherent dangers of following the nerve's tortuous course through the sternocleidomastoid.

Objective: The aim of this study was to compare the subjective tracheoesophageal pressure symptoms associated with substernal goitres with objective cross-sectional radiographic measurements.

Design: Patients with substernal goitre were questioned regarding tracheoesophageal compression symptoms and these data were analysed for correlation with radiographic and intra-operative findings.

Results: Twenty-six patients were included. Patients with airway symptoms including dyspnoea, stridor and coughing were more likely to have significant tracheal narrowing on pre-operative computed tomography (CT) imaging. There was also a significant correlation between the perceived severity of lump sensation in the throat and the presence of tracheal and oesophageal displacement and retrotracheal extension of the thyroid mass.

Conclusion: Pre-operative CT measurements of tracheal and oesophageal displacement, retrotracheal extension and the degree of tracheal compression correlate well with the presence and severity of tracheoesophageal pressure symptoms. None of the radiographic findings that are exclusive to substernal goitre (percentage of substernal mass, goitre size at the level of the thoracic inlet, ratio of goitre size to the vertebral body at the thoracic inlet and retrosternal isthmus size) had any correlation with clinical symptoms in this study.

Considerable inter- and intra-individual anatomical differences can be observed during neck dissections. In this case report, we describe an unusual relationship of the accessory nerve to the internal jugular vein.

Dehiscence of the semicircular canal is an uncommon condition and has been reported to involve the roof of the superior semicircular canal. We describe a case with dehiscence of four semicircular canals and in areas not involving the roof of the superior semicircular canal. Features that assist the diagnosis of this condition are reviewed, along with the current literature.

We present a case of acute, unilateral facial nerve paralysis in a patient who had received a low voltage electrical current. This is an extremely rare cause of this neurological condition. The patient regained complete neurological function approximately three months after the incident. Unilateral facial nerve paralysis most commonly occurs due to infection or blunt or penetrating trauma; it has not been previously reported as a result of low voltage electrical injury.

We present a case of acute disseminated encephalomyelitis after mastoid surgery in an 11-year-old child. The aim of this paper is to increase awareness about a previously unreported and an unusual neurological complication of cholesteatoma and mastoid surgery.

We present the case of a 71-year-old man with anaplastic thyroid cancer. On presentation, his thyroid function was normal, but he subsequently developed sudden, rapid thyrotoxicosis. Thyrotoxicosis in anaplastic thyroid carcinoma is very rare, but in all previously reported cases the patient was thyrotoxic at presentation. Our case is unusual as our patient presented euthyroid, and thyrotoxicosis developed subsequently. We challenge current ideas regarding the biochemical pathophysiology of rapid thyrotoxicosis in anaplastic thyroid carcinoma and provide an alternative explanation.

Aims: To analyse the epidemiology, presentation and diagnosis of head and neck tuberculosis (TB).

Methods: We conducted a 10-year retrospective study of all cases of tuberculosis of the head and neck region occurring in Bradford, UK.

Results: Of a total of 1315 cases of TB, 128 presented with head and neck TB (12 per cent of which (15/128) were in children). Cervical lymph nodes were most commonly involved (87 per cent, 111/128), other sites being: salivary glands (five cases); larynx, oral cavity, eyes and ears (two cases each); and skin, thyroid, nasopharynx and retropharyngeal space (one case each). Patients' ethnic origins were Asian (89 per cent, 114/128), Caucasian (10 per cent, 13/128) and African (one case). Only 26 per cent (33/128) had constitutional symptoms, and 20 per cent (25/128) had a coexistent site of TB. Only 39 per cent (40/105) of surgical specimens were sent for culture.

Conclusions: Isolated head and neck TB is not uncommon. Atypical presentations render diagnosis challenging, so awareness aids early diagnosis. Mycobacterial cultures should be performed, where possible, for diagnosis.

Chondrodermatitis nodularis chronica helicis is a well-recognised painful condition of the pinna. There have been several modes of treatment described for this condition. Although the most common mode of treatment is surgery,1,2 several conservative approaches have also been tried.

We report the case of a 67-year-old man with a left pharyngeal tumour, whose peripheral blood showed granulocytosis (white blood cell count, 58 300/μl) and a high serum granulocyte colony stimulating factor titre (184 pg/ml). The tumour showed pleomorphic proliferation of atypical spindle cells in a myxomatous stroma, revealing a sarcomatous pattern. The spindle-shaped neoplastic cells had irregularly shaped nuclei, a thick nuclear membrane, prominent eosinophilic nucleoli and abundant cytoplasm. They strongly expressed wide-spectrum keratin, cytokeratins (CAM5.2, MNF116), vimentin and vascular endothelial growth factor. A few neoplastic cells expressed granulocyte colony stimulating factor. A spindle cell carcinoma was diagnosed. This may be the first documented case of a granulocyte colony stimulating factor producing cancer arising in the pharynx. The patient died four months after the initial symptoms appeared.

This article describes the technique of ultrasound-guided core-needle biopsy in the head and neck, and also warns of its risks. In contrast to fine-needle aspiration, this minimally invasive procedure has the advantage of supplying a histological specimen rather than a cytological smear. Therefore, it could be used as an additional diagnostic tool in the investigation of head and neck lesions, and can be carried out within the out-patients clinic.

Objectives: To demonstrate the importance of detailed clinical analysis in the differential diagnosis of unilateral vocal fold paralysis, and to provide an update on current knowledge and treatment of myasthenia gravis.

Case report: A female patient presented with left unilateral vocal fold immobility. Diagnostic investigation revealed a 10 mm thyroid adenoma, but no other abnormality likely to cause unilateral vocal fold paralysis. Follow-up flexible endoscopy at three months showed laryngeal remobilisation with persistent left vocal fold bowing and vertical asymmetry of the vocal folds on phonation. Over the following months, voice quality varied between normal and breathy, with the breathy periods lasting from three days to one month. Laryngeal electromyography (EMG) showed a slight bilateral paradoxical activation of both posterior crico-arytenoid muscles on phonation. Magnetic resonance imaging of the brain and brainstem was normal. A diagnostic test for myasthenia gravis with intravenous edrophonium bromide (Tensilon®) lead to an immediate improvement in voice quality. The patient was subsequently treated with pyridostigmine bromide, with complete resolution of dysphonia.

Conclusions: Myasthenia gravis affecting the larynx may mimic unilateral vocal fold paresis or paralysis. A personal or family history of auto-immune disease, fluctuating symptoms, motor deficits in cranial nerve territories, and normal or subnormal laryngeal EMG results should lead the physician to reconsider a diagnosis of idiopathic unilateral vocal fold paralysis and to perform specific testing.

Introduction: Pre-operative endoscopic assessment of the distal extension of hypopharyngeal cancer is essential for proper surgical extirpation. This assessment is frequently not feasible in advanced, obstructing tumours.

Aims: To study the role of a proposed new diagnostic technique: intra-operative open oesophagoscopy, in distal assessment of advanced hypopharyngeal cancer.

Materials and methods: A clinicopathological study, including 35 consecutive patients with obstructing hypopharyngeal cancer.

Results: Intra-operative open oesophagoscopy revealed inferior submucosal tumour extension in 19 out of 22 cases proven histopathologically, with a sensitivity, specificity and accuracy of 86, 100 and 91 per cent, respectively. Oesophageal skip lesions were detected in two cases. Intra-operative open oesophagoscopy findings surpassed data obtained from pre-operative radiological investigations and influenced the extent of resection performed. Accordingly, 19 patients had a total laryngopharyngectomy for local disease control, while 16 patients needed an additional total oesophagectomy. Histopathologically negative inferior resection margins were obtained in all cases.

Conclusions: Intra-operative open oesophagoscopy was found to be a reliable diagnostic modality for distal assessment of obstructing hypopharyngeal cancer in cases in which pre-operative distal endoscopic examination was not feasible.

Sinusitis and its associated facial pain are frequently seen by ENT surgeons. However, it is important to have a high index of suspicion in cases with atypical symptoms, particularly those with unexplained, unilateral, severe facial pain, and to consider an internal carotid artery dissection. This important diagnosis accounts for almost 20 per cent of all strokes in the young, and anti-coagulation can help to prevent thrombosis and embolism. Two cases are presented for illustration.

Exposure to otolaryngology is currently minimal in the UK undergraduate medical curriculum. This may lead to difficulties in attracting graduates into higher ENT surgical training and in ensuring a reasonable standard of ENT knowledge amongst primary care practitioners.

A recent innovation, of which many ENT units may be unaware, is the introduction to the undergraduate curriculum of ‘student-selected components’. Like the traditional elective, this allows students to undertake an attachment to a speciality and department of their choice. Units which do not regularly teach medical students but which have a welcoming and enthusiastic approach to undergraduate training may well be ideal hosts.

This paper introduces the concepts underlying student-selected components, outlines the preparation required and offers a template for such an attachment, for which ENT is ideally suited.