Background: Orbital cellulitis has important complications. Despite this, there are few studies in the literature of large groups of cases of this condition.

Methods: We performed a retrospective case analysis of all patients admitted with periorbital and orbital cellulitis between 2002 and 2004.

Results: A total of 27 cases were included in the study. Of these, 25 had undergone a computed tomography scan, 19 of which had revealed significant sinus disease; 10 had had a microbiology result, with the most common organism being Streptococcus milleri; 20 had had a white cell count taken, with raised results in only 10; 12 had undergone surgery; and 25 had made a good recovery. One case had been found to be squamous cell carcinoma of the nasal cavity.

Conclusions: In this study, sinus disease was the commonest cause of orbital cellulitis, with the commonest organism being Streptococcus milleri. Only 50 per cent of cases with proven disease had had a raised white cell count; this is therefore not a very sensitive test.

Following systematic skull imaging of hundred and sixty seven individuals attending a medical referral centre for the deaf in Brussels, Belgium, fifteen patients (9 per cent) aged between two and 25 years were diagnosed with dilatation of the vestibular aqueduct. Careful audiological study, with a baseline assessment then longitudinal follow up, indicated mild to profound deafness with a progressive course (i.e. an average loss of 3.3 dB per year) and frequent dizziness. Sequencing of PDS was performed in all individuals. Alterations of this gene (either homozygous, heterozygous or compound heterozygous base changes) were found in 53 per cent of patients with a large vestibular aqueduct. Four new mutations (two missense, a splice site and a four base pair insertion) were described. We were unable to confirm a correlation between homozygosity, heterozygosity and a Pendred or deafness-only phenotype.

Background: The aim of this study was to describe the authors' minimally invasive procedure developed to significantly decrease excessive salivation in children suffering from chronic neurological diseases, using botulinum toxin A.

Objective: Ultrasound-guided, intraglandular injection of botulinum toxin blocks the parasympathetic innervation of salivary glands, resulting in a temporary decrease in saliva production and improved quality of life, lasting about three to four months.

Materials and methods: Prior to introducing the method into clinical practice, animal experiments were conducted in order to verify the lack of histological changes three months following botulinum toxin administration. Twenty-one children were included in the clinical study, with ages ranging from two and a half to 14 years.

Results: The animal studies did not reveal any histological changes three months after botulinum toxin administration. Although botulinum toxin A proved to be ineffective in a single case, the majority of the other 20 patients responded well, with a highly significant reduction of their symptoms. The parents of 18 responder children requested repeated treatment with botulinum toxin A. However, two families refused to be further involved in the study, despite good results. The protein content of saliva, regulated by sympathetic innervation, was not affected by the treatment.

Conclusion: This minimally invasive method, applied repeatedly three to four times a year, may be a viable alternative to surgical procedures such as submandibular duct relocation, duct ligature or nervus tympanicus neurectomy.

The aim of our study was to evaluate the functional results of stapes surgery and to compare the effectiveness of small fenestra stapedotomy with that of total stapedectomy in improving hearing in patients affected by otosclerosis.

Three hundred and fifty-seven consecutive ears, in 265 patients affected by otosclerosis, underwent surgery. All cases underwent either primary small fenestra stapedotomy (group A, 196/357, 54.91 per cent) or stapedectomy (group B, 161/357, 45.09 per cent). After surgery, 256/357 (71.71 per cent) cases showed a 0–20 dB gap. There were no significant differences in hearing results between the two groups at either early or late post-operative assessment. The mean post-operative pure tone average and air–bone gap results were slightly greater for group B than for group A, at both early and late post-operative assessments, but these differences were not statistically significant. Therefore, in group A, the mean pure tone average at 4 kHz significantly improved, from 56.60 to 47.66 dB at early post-operative assessment and to 52.98 dB at late post-operative assessment.

Our study suggests that the technique of microtomy of the oval window is able to improve hearing results especially at high frequencies.

Objective: To determine if there is a relationship between a foreign body in the external auditory canal and undiagnosed otitis media with effusion or significant eustachian tube dysfunction in children.

Study design and setting: This is a prospective, uncontrolled analysis of 37 consecutive children with a foreign body in the external auditory canal (group I) and 37 children with non-ENT complaints as a control (group II), seen over two years in the ENT unit of a district general hospital. All the children underwent removal of the foreign body, examination of both ears by a senior ENT surgeon followed by tympanometry within seven to 10 days.

Result: Thirty-seven children with a foreign body in the external auditory canal (group I) were analysed and a similar number of children with non-ENT problems (group II) were taken as a control. The age range for both groups was two years to 10 years with a median age of six years. Of the 37 children, 25 (68 per cent) in group I had an abnormal view of the tympanic membrane compared to only five (14 per cent) in group II (p < 0.04 – chi-squared test). In group I 20 children (54 per cent) and in group II three children (8 per cent) had abnormal middle-ear compliance (either type B or type C2) (p < 0.05 – chi-squared test). Nineteen (51 per cent) children in group I had a history of previous ear symptoms such as irritation, otalgia, blockage or deafness more than once in the past six months, and none had in the control group (p < 0.03 – chi-squared test).

Conclusion: There is clinical and statistical evidence to suggest that children may insert a foreign body in the ear as a result of irritation/pressure sensation secondary to otitis media with effusion or significant eustachian tube dysfunction. Therefore, we recommend that all children with a history of a foreign body in the ear should be screened in an ENT clinic.

Aims: To evaluate the risk of hypocalcaemia (transient or permanent) after total thyroidectomy for bilateral, benign, multinodular goitre, the frequency and impact of unintentional parathyroidectomy, and the value of parathyroid gland autotransplantation during thyroid surgery.

Materials and methods: This was a retrospective study of 351 surgical patients who had undergone total thyroidectomy for bilateral, benign, multinodular goitre over a seven-year period. The primary endpoint was serum calcium concentration immediately post-operatively and during follow up. Normal serum calcium concentration was defined as 2 mmol/l. Parathyroid data were collected during surgery and histological examination.

Results: In 62 per cent of cases, no hypocalcaemia had been observed after surgery. In 35 per cent of cases, transient hypocalcaemia had been observed after surgery. In 3 per cent of cases, chronic hypocalcaemia had been present six months after surgery. Permanent hypoparathyroidism had been diagnosed two years after surgery in 1.4 per cent of cases. Unintentional parathyroidectomy had been detected in 5.2 per cent of cases. Parathyroid gland autotransplantation had been performed in 7 per cent of cases during surgery.

Conclusion: Permanent hypoparathyroidism is rare, although transient hypoparathyroidism occurs relatively frequently. Unintentional parathyroidectomy and parathyroid gland autotransplantation do not affect serum calcium levels.

Objective: to assess the usefulness of delayed post-contrast computed tomography (CT) examination for the detection of residual or recurrent cholesteatoma after canal wall up tympanoplasty.

Study design and setting: This prospective, non-randomized study, set within an academic medical centre, included 17 consecutive patients who had undergone canal wall up tympanoplasty for cholesteatoma, with possible recurrence. Pre-contrast CT scans and delayed post-contrast images were compared with second look surgical findings.

Results: A residual or recurrent cholesteatoma was found in eight of the 17 patients at revision surgery and was correctly diagnosed on post-contrast CT images in six patients (75 per cent). In the two misdiagnosed cases, cholesteatoma pearls smaller than 2.5 mm were not seen on post-contrast CT. The sensitivity of the imaging test was 75 per cent, the specificity was 60.1 per cent, the positive predictive value was 88.1 per cent and the negative predictive value was 81.8 per cent.

Conclusion: Computed tomography with delayed post-contrast images is a sensitive imaging modality for the detection of residual cholesteatoma. If proven reliable, this method of non-invasive imaging could spare the patient unnecessary revision surgery.

Background: Testing of olfactory thresholds in the clinic is becoming more common, with commercially produced tests now available. The effect of common potential variables in the clinic setting on these results is unclear. If many variables must be controlled, tests become more complex and a universally accepted olfactory test becomes less likely.

Objectives: The aim of this study was to determine which potential variables the clinician needs to consider when testing olfaction in the out-patient clinic.

Methods: The study was conducted in a clinic setting at a university hospital, using 103 normal volunteers, comprising staff members and patients and relatives from the ENT clinic waiting room. The subjects recruited had no active rhinological complaints, were not taking any medications and were aged between 16 and 70 years. An olfactory threshold was established for each subject for the odour eucalyptol. Gender, smoking status, age, peak nasal inspiratory flow, ambient temperature and relative humidity were all recorded.

Results: For eucalyptol, the distribution of values for olfactory thresholds in the normal population lies around the concentration 10−3 log vol/vol. There was no significant effect of smoking status, tester, ambient temperature or humidity on the thresholds obtained.

Conclusions: The above variables do not have a significant effect on olfactory thresholds elicited in the clinic. The clinician therefore need not attempt to control these factors when testing olfaction in the out-patient setting. These findings bring the implementation of a universal, reliable and easily administered measurement of olfaction a step closer.

Aim: To evaluate the effectiveness of an information leaflet in improving patient understanding of the procedure and complications of septoplasty.

Design: The baseline knowledge of a group of patients who had attended a pre-assessment clinic prior to septoplasty was assessed. The procedure and its complications were then verbally explained. The patients' knowledge was then re-assessed on the morning of surgery and any improvements noted. In the second arm of the study, an information leaflet was introduced at the time of verbal instruction and any differences in improvement in knowledge were assessed.

Results: Data from the two groups were analysed using an analysis of covariance with differences in baseline (pre-instruction) knowledge controlled. Additional improvements in mean recall score following leaflet distribution were highly statistically significant when compared with mean recall in the control group (p<0.001).

Conclusion: The use of information leaflets increases patients' knowledge about a surgical procedure and its potential complications.

Even though endoscopic removal of inverted papillomas has gained popularity, many studies advocate supplementary external approaches. The impact of including the current surgical staging system into the pre-operative clinical and radiological assessment has not been systematically evaluated. We present our experience with total endoscopic management of inverted papillomas and compare the accuracy of the pre-operative predicted extent of surgery, with the actually performed surgery.

From 1997 to 2005 data from 51 patients with inverted papillomas were prospectively collected and subsequently reviewed. All have been operated on endoscopically without an external approach.

The overall recurrence rate was 3.9 per cent. Pre-operative prediction of extent of surgery was accurate in 26 of 51 (51 per cent). The main reasons for the inaccurate pre-operative prediction were the variable sizes and locations of the inverted papilloma bases, particularly in the maxillary sinus and the frontal recess. Our results encourage us to recommend endoscopic management as the standard treatment of benign inverted papillomas.

The sino-nasal assessment questionnaire is a system used for scoring the symptoms of chronic rhinosinusitis. However, the range of scores for this questionnaire in the healthy adult population is unknown. We aimed to establish this by recruiting 100 healthy volunteers and comparing their sino-nasal assessment questionnaire scores with those of 100 individuals who had undergone sinus surgery for rhinosinusitis. The difference in mean scores in the symptomatic group (44.62) and the asymptomatic group (8.46) was statistically significant. However, there was substantial overlap between the scores of the two groups. Factors such as age, gender and smoking did not have a statistically significant impact on the eventual score in the asymptomatic group. We believe that symptom scores can only be used effectively when the range in the asymptomatic population is known. This is so that disease severity can be gauged in the context of the normal population and post-operative improvements can be forecast.

Although cochlear implantation is considered a safe method of rehabilitation for profoundly deaf individuals, a number of these patients suffer complications after surgery. To evaluate post-operative complications after cochlear implantation, a retrospective chart review was performed for 112 patients who had undergone implantation in the Maastricht Academic Hospital. Minor complications were defined as those that could be overcome by medical or audiological management. These occurred in 36 patients (32 per cent) and all were managed successfully. Major complications were defined as device extrusion and those requiring further surgery, and these were identified in four patients (3.6 per cent). These complications included wound infection and device failure mediated by middle-ear pathology. In cases of chronic otitis media, we recommend performance of cochlear implantation as a staged procedure. In order to reduce the post-operative incidence of acute otitis media, we recommend adenoidectomy, placement of ventilation tubes and early antibiotic treatment.

Background: Patients do not respond to treatment in a predictable manner. Individual preconceptions determine help seeking, compliance and treatment outcome, yet clinicians rarely explore these issues. The illness perception approach sees the patient as an active participant in the healthcare process.

Aims: The aim of this study was to investigate the illness perceptions of people with dysphonia. The subsidiary aims were to correlate the Illness Perception Questionnaire with any psychological distress identified and a self-report measure of dysphonia, and to consider any potential implications for patient management.

Design: Prospective, cross-sectional observation.

Setting: Primary and secondary care, two general and four community hospitals.

Participants: Fifty adult patients with dysphonia due to benign disease completed three self-administered questionnaires, which investigated their illness perceptions, psychological distress and perceptions of the impact of the presenting ‘illness’.

Measures: The dysphonia was categorised as being due to functional (n=40) or organic (n=10) causes. All the voices were rated by an expert listener according to the GRBAS (grade, roughness, breathiness, aesthenia, strain) scale. Participants completed the Illness Perception Questionnaire, the Vocal Performance Questionnaire and the Hospital Anxiety and Depression scale.

Results: Patients showed a wide variation in perception of causation. They had no strong perceptions about the causes, consequences or duration of the presenting dysphonia. Functional dysphonics reported greater consequences, lower perceived control and increased anxiety when compared to patients with organic dysphonia. In terms of cure/control, all patients expected treatment to be helpful but this expectancy reduced as time increased. Anxiety was more associated with functional dysphonia, however, only 17 per cent of the subjects in this group showed clinically significant levels of signs of psychological distress.

Conclusions: Lay illness representations often diverge from the clinician's understanding of the presenting problem and strongly influence treatment behaviour. Early exploration of illness perceptions may enhance health behaviour and maximise the impact of intervention.

The aim of this study was to evaluate the hearing results of ossiculoplasty in canal wall down tympanoplasty in one stage middle-ear cholesteatoma surgery.

We carried out a retrospective review of a consecutive series of 142 cases which had undergone type two or three canal wall down tympanoplasty with ossicular reconstruction, between January 1995 and December 2002, due to chronic otitis media with cholesteatoma.

Pre-operative audiometric testing revealed a mean air conduction pure tone average (PTA) of 50.97 dB and a mean bone conduction PTA of 22.14 dB. The mean post-operative result for air conduction PTA was 37.62 and for bone conduction PTA was 23.37 dB. The mean pre- and post-operative air–bone gaps (ABGs) were 28.83 and 13.94 dB, respectively, with a gain of 14.89 dB. Almost 62.67 per cent of patients closed their ABGs to within 20 dB.

Our functional results are comparable with those of other authors. In the present study, we show that hearing improvement is possible following cholesteatoma surgery with canal wall down tympanoplasty and ossicular chain reconstruction.

Objective: To compare the complication rates of parotidectomy operations on benign histology performed by ENT and non-ENT surgeons.

Study design and setting: A seven-year (1994–2000) retrospective case notes review of patients undergoing parotidectomy in a United Kingdom district general hospital was performed. Patients with malignant histology were excluded.

Participants: Patients were identified from the hospital computer database. One hundred and fifty-nine patients underwent parotidectomy for both benign and malignant conditions over the seven-year period. One hundred and thirty-seven (86 per cent) patients had parotidectomy for benign conditions and were included in this study.

Main outcome measures: The presence or absence of facial palsy and other associated complications following parotidectomy surgery in both groups.

Results: The temporary facial palsy rates for ENT and non-ENT surgeons were 56 per cent and 57 per cent, respectively. The permanent facial palsy rates for ENT and non-ENT surgeons were 2 per cent and 7 per cent, respectively. Differences in facial palsy were not statistically significant. The difference in other complication rates such as Frey's syndrome, haematoma, salivary fistula, and neuroma were also not statistically significant.

Conclusion: Our complication rates were comparable with published results. There was no significant difference in the observed rate of post-operative facial nerve palsy and other known complications following parotid surgery performed by ENT and non-ENT surgeons.

Background: We have previously found by lateral cephalometry an association between nasopharyngeal anatomy and the risk of acute otitis media (AOM). We evaluate here the association of nasopharyngeal dimensions in magnetic resonance imaging (MRI) with the occurrence of AOM in otherwise healthy children.

Methods: Sixty-one healthy children (mean age 5.7 years, range 3.9–6.9) were recruited from child care centres. The parents filled in a questionnaire on the child's history of ear infections and adenoidectomy. MRI was performed with a 4 mm slice thickness during an upper respiratory infection. Five dimensions and two angles expressing the structure of the bony nasopharynx were measured in sagittal images.

Results: The dimension from the caudal edge of the septum to the midpoint of the sella, reflecting the height of the nasopharynx, was on average 2.2 mm smaller in the children who had had AOM attacks during the last 12 months than those without attacks (95% confidence interval (CI) 0.9 to 3.4, p=0.001) and the nasal base angle was on average 2.1 degrees smaller (95% CI 0.7 to 3.5, p=0.004). These differences remained significant after adjustment for age, sex and previous adenoidectomy in the logistic modelling. A history of adenoidectomy did not have any effect on the dimensions.

Conclusions: The nasopharynx was smaller in the children with AOM attacks during the last year. The value of this finding for predicting susceptibility to recurrent AOM and directing preventive procedures should be evaluated.

Introduction: The globus sensation is a constant feeling of a lump in the throat and may be associated with thyroid enlargement. A two year prospective study was set up to ascertain the relationship between thyroid pathology and globus symptoms.

Materials and methods: All patients undergoing thyroid surgery over a two year period were included. Patients were questioned pre- and post-operatively. Globus symptom scores were recorded using a visual analogue scale. The size, weight and histological features of the removed specimens were correlated and statistical analysis performed.

Results: Two hundred patients were included in the study; 58 were symptomatic for globus pharyngeus pre-operatively, and 80 per cent of these patients' symptoms resolved post-operatively (p≤0.0001). Patients with histological features of inflammation showed the greatest improvement (p≤0.0001).

Conclusion: As many as one-third of patients with a thyroid mass will complain of a globus-like symptom. Patients undergoing thyroid surgery, who are symptomatic for globus pharyngeus, can expect that their symptoms will improve following surgery.