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.

Bilateral submandibular duct transposition is one of several surgical methods described to control sialorrhoea in the paediatric patient. The purpose of this study is to assess the effect of submandibular duct repositioning surgery on the quality of life of children using the Glasgow Benefit Inventory outcome measure. Consecutive children who underwent submandibular duct repositioning surgery were invited to participate in the study. The parents or guardians of children who gave consent were interviewed. The carer's opinion of the change in salivation, responses to the items in the Glasgow Benefit Inventory score and report of the complications were recorded.

Nine children aged two and a half to 16 years were studied. The mean follow-up time was four years. The mean Glasgow Benefit Inventory score of +33 related to the procedure demonstrates that submandibular duct repositioning leads to a substantial measurable improvement in the quality of life (QoL) of the drooling child.

Aims: To report on the use of holmium yttrium aluminium garnet (YAG) laser in the treatment of acquired posterior choanal atresia following radiotherapy in patients with nasopharyngeal carcinoma.

Materials and methods: Five patients with acquired bilateral choanal atresia and two with unilateral choanal atresia in the posterior choanae were identified following treatment of nasopharyngeal carcinoma by external radiotherapy, from July 1998 to April 1999. The mean age was 44.6 years (range, 22–65 years). Two patients had stage two and five had stage three disease according to Ho's classification. All patients received 66 Gy of external irradiation delivered to the nasopharynx and a mean dose of 61 Gy (39.8–72 Gy) to the neck. Five patients received an additional external boost of 20 Gy and two received 14 Gy delivered to the parapharyngeal region. Two other patients also received intracavitatory brachytherapy of 18 Gy delivered to the nasopharynx. One patient had concurrent chemotherapy by cisplatinum during external radiotherapy. The mean onset of nasal symptoms was 17 months (range, 2–38 months) following irradiation. All patients were treated by transnasal endoscopic holmium YAG laser resection. Merocel® epistaxis packing and a modified nasopharyngeal tube were used to stent the nasal airway for two weeks post-operatively.

Results: The mean follow up was 26.8 months (range, 20–32 months) after surgery. All patients were symptom free on follow up. Five patients (71 per cent) retained full patency in the posterior choanae. Two patients (28 per cent) had bilateral mild restenosis in the postnasal space, not requiring revision surgery. The surgical fields were almost bloodless. No adverse post-operative complications occurred, except for delayed nasal septal perforation in one patient and unilateral exposure of the septal cartilage in another; no further treatment was required in either patient.

Conclusion: Acquired posterior choanal atresia is an unusual complication following radiotherapy, and it can occur early after treatment. It can be successfully treated by transnasal endoscopic holmium YAG laser resection of the scar tissue, with minimal bleeding. A two week period of Merocel® nasal packing and nasopharyngeal tube stenting was sufficient to prevent severe restenosis in the posterior choanae; nasal breathing through the tube lumen was possible during this time.

The suitability of performing laser inferior turbinectomy under local anaesthesia in an out-patient setting was assessed, regarding its effectiveness and patients' toleration of the procedure. Prospective data collection was undertaken from 129 patients undergoing laser inferior turbinectomy over four years. Patients were assessed, pre-operatively, operatively and at two weeks and three months post-operatively, for pain, complications and symptoms, using the sino-nasal assessment questionnaire.

All patients had hypertrophied inferior turbinates. Ninety-eight patients complained of nasal obstruction and 67 had the procedure as part of treatment for snoring. One hundred and twenty-one of the patients had treatment to both inferior turbinates. There were no cases of intra-operative haemorrhage. The average pre-operative sino-nasal assessment questionnaire score was 18.22, which improved to 10.68 at the three month post-operative assessment (p<0.001). Five patients had significant intra-operative pain.

This study shows that laser inferior turbinectomy under local anaesthesia is well tolerated and that good results can be achieved when performing the procedure in the out-patient department.

Internal jugular vein ectasia (dilatation of the internal jugular vein) is a rare clinical entity, often undiagnosed. Usually it presents as an asymptomatic, soft, compressible neck swelling that increases in size on Valsalva's manoeuvre. Our report describes right internal jugular vein ectasia in a 15-year-old girl who presented to us with intractable paroxysmal cough. The entity was suspected on ultrasound imaging and confirmed by computed tomography scan and Doppler. Ligation and excision of the dilated vein almost immediately cured her cough. The probable reason for the cough was the pressure exerted by the dilated vein on the vagus nerve.

Background: Balance function is known to change with age during infancy and childhood. However, the relative contributions of the three primary inputs to position sense are not fully understood.

Methods: In this paper we report the computerised dynamic posturography findings in a group of 60 healthy children from the age of five to 17.

Results: The results confirm that there is a progressive improvement in balance function with age. The EquiTest system that was used gave indications of the relative contributions of the three principal contributors to overall balance function and showed that somatosensory function was intact throughout the age range tested and that there are significant increases in vestibular function with age and visual contribution with height. The technique used was found to be reliable and repeatable in this paediatric sample.

Conclusions: It is hoped that a better understanding of the normal age related development of balance will be helpful in dealing with children presenting with disequilibrium and vertigo.

Design: a cross-sectional study.

Participants: One hundred and ninety-nine patients with Wegener's granulomatosis belonging to a patient self-help group.

Main outcome measures: Mode of initial presentation; diagnosis timescales and delay; rhinologic involvement; and treatment.

Results: Sixty-three per cent of patients initially presented with ENT-related symptoms. Ninety-two per cent faced a delay in their diagnosis of more than one month, a pattern which has not improved over the last few decades and which compares unfavourably with North American figures. Rhinologic and otologic symptoms are a common occurrence in up to 85 and 50 per cent of Wegener's granulomatosis patients, respectively, attracting varying degrees of targeted treatment.

Conclusions: As sinonasal and other ENT symptoms are so common at the presentation of Wegener's granulomatosis, it is clear that the otolaryngologist has an important role in its diagnosis and treatment. There are long delays in the diagnosis and possible under-treatment of the ENT symptoms of this condition, highlighting the need for greater awareness, particularly in the ENT community.

The management of paediatric airway emergencies is part of ENT practice. The most common conditions are acute viral laryngotracheobronchitis (croup), acute epiglottitis and bacterial tracheitis. Management of these conditions is significantly different and accurate diagnosis is crucial. We performed a retrospective analysis of all acute airway admissions to the paediatric intensive care unit (PICU) at the Royal Belfast Hospital for Sick Children from 1990 to 2003. The results showed a gradual decrease in the number of admissions due to croup. Acute epiglottitis admissions decreased markedly after 1992 but rose again in 2000, with a peak in 2002. Bacterial tracheitis is now the most common paediatric airway emergency requiring PICU admission and its incidence has been steadily increasing since 1990, peaking in 2003. The total number of admissions showed little change over the 14-year period audited. The significant shift in the nature of these conditions and these findings confirm the ongoing requirement for caution in dealing with a suspected airway emergency.

Aims: To evaluate the results of chemotherapy alone in patients with invasive squamous cell carcinoma of the larynx who have achieved a complete clinical response after an induction chemotherapy protocol.

Methods: A comparison of results in a group of complete responders managed with a chemotherapy alone protocol, matched with those of an incomplete responder group managed with conventional modalities.

Results: The survival rate of the complete responder group was significantly higher than that of the incomplete responder group. No statistically significant difference was noted between the two groups in terms of local failure and nodal recurrence.

Conclusion: Our results confirm the fact that chemotherapy alone is a viable option in selected patients with carcinoma of the larynx who have achieved a complete clinical response after an induction chemotherapy protocol. This therapeutic approach allows surgery and/or radiation therapy to be reserved for the management of metachronous second primary tumours.

Objectives: The aims of this study were: (1) to establish current UK practice with respect to ‘group and save’ of serum for paediatric tonsillectomy; and (2) to determine the need to group and save serum prior to routine paediatric tonsillectomy.

Methods: Members of the British Association of Otorhinolaryngologists – Head and Neck Surgeons were surveyed by e-mail. A prospective study (November 1999 to August 2002) of all children undergoing tonsillectomy or adenotonsillectomy was undertaken. Outcome measures included reactionary and secondary post-tonsillectomy haemorrhage rates, blood transfusion requirements and ‘return to theatre’ rates.

Results: We surveyed 464 association members. The response rate was 52 per cent (n=242). Twenty-five respondents (10.3 per cent) indicated that they undertook group and save prior to tonsillectomy or adenotonsillectomy in children. Two hundred and seventeen (89.7 per cent) indicated that they did not. Of those who did group and save for children, 20 respondents (80 per cent) did so routinely. The remaining five respondents (20 per cent) did so only for children weighing less than 15 kg (n=4) or less than 10 kg (n=1). During the study period, 325 children underwent tonsillectomy or adenotonsillectomy. The reactionary haemorrhage rate was 0.6 per cent (n=2) and the secondary haemorrhage rate 5.5 per cent (n=18). The two cases of reactionary haemorrhage were returned to theatre immediately for control of haemostasis. All secondary haemorrhages were managed conservatively. No child required blood transfusion during the study period.

Conclusion: Routine group and save of serum for children undergoing elective tonsillectomy or adenotonsillectomy seems unnecessary. We recommend that it be undertaken only in special circumstances.

The Pakistan cochlear implant programme was started in Lahore in August 2000. It was initially established with the technical support of the Manchester cochlear implant team. There are no government resources available for cochlear implantation in Pakistan and the cost of cochlear implantation is met by the candidates and their families. Up till December 2005, 52 individuals have been implanted. Forty-four (84.6 per cent) of these patients were children and eight (15.4 per cent) patients were adults. Congenital deafness (94 per cent) is the main aetiological factor in children. Seventy-six per cent of these children were born to blood related parents. All patients received a Med-El Combi 40+  device. The listening progress profile, the meaningful auditory integration scale and the meaningful use of speech scale were used to assess the auditory performance in children. Thirty-nine children achieved an average listening progress profile score of 37.7 after 12 months of implantation. The overall rate of major and minor complications was 11.5 per cent. Failure rate for the device itself has been 3.8 per cent. In addition to considering these preliminary outcomes and funding issues, the problems of setting up a cochlear implant programme in a developing country are discussed.

Introduction: Inverted papillomas are relatively rare, benign epithelial tumours of the nasal cavity which generate considerable interest because they are locally aggressive, have a tendency to recur and are associated with malignancy.

Aims: To review our experience of the management of inverted papillomas, and to review the literature in order to evaluate recurrence rates, rates of synchronous and metachronous carcinoma, and outcomes of treatment, both endoscopic and conventional.

Methods: We retrospectively reviewed all cases of inverted papilloma that presented to our unit, a tertiary referral centre, over a 20-year period from 1985 to 2005. A Medline review of the literature was performed to identify published case series of inverted papillomas. We undertook a critical analysis of the literature.

Results: We treated 65 patients with inverted papilloma over the 20-year period, with a mean follow up of five years (range one to 20 years). Fifty-eight patients initially underwent nasal biopsy, often with polypectomy. Thirty-six had endoscopic surgery, with five (14 per cent) suffering recurrence, whilst 16 had a lateral rhinotomy and medial maxillectomy, of which four (25 per cent) suffered a recurrence. Seven septal inverted papillomas required local resection, with no subsequent recurrences. There were seven (11 per cent) synchronous and two metachronous malignancies.

Sixty-three case series with adequate data were identified from the literature. There were 163 (7.1 per cent) cases of synchronous carcinoma, out of 2297 cases. Metachronous carcinomas were reported in 74 out of 2047 cases, representing a transformation rate of 3.6 per cent. However, the true population base for these figures is uncertain, given that many series were reported from tertiary centres, where recurrent and problematic cases are likely to be over-represented. The recurrence rates were 12.8 per cent for endoscopic procedures, 17.0 per cent for lateral rhinotomy with medial maxillectomy, and 34.2 per cent for limited resections such as nasal polypectomy and Caldwell–Luc approaches. No significant association between atypia or dysplasia and recurrence or malignant transformation was found. The mean time taken to develop a metachronous carcinoma was 52 months (range six to 180 months). The estimated malignant potential for recurrent disease was up to 11 per cent.

Conclusion: Patients with inverted papilloma should undergo thorough surgery to remove all mucosal disease, most probably by the endoscopic, endonasal route when complete resection is possible. Cases demonstrating atypia or dysplasia may be treated by the endoscopic route. Recurrent disease and metachronous carcinoma can develop after a prolonged period of time. Long-term follow up is recommended to detect recurrence, as disease can become quite extensive before it becomes symptomatic.

Abnormalities of the first branchial cleft are rare. They may present with a cutaneous defect in the neck, parotid region, external auditory meatus or peri-auricular area, or with inflammatory or infective lesions at these sites.

A retrospective case note review of the patients treated by the senior author is presented. This group consisted of 18 patients and represents the largest published UK series to date. Eleven patients (65 per cent) had undergone incomplete surgery prior to referral.

Over half the patients had a clinically apparent lesion in relation to the external auditory meatus. There was a variable relationship between the tract and the facial nerve, which was identified at surgery in 15 cases.

These findings are consistent with those of previously published series. Clinicians should keep this diagnosis in mind when assessing patients with infected lesions in the neck and parotid area. Surgeons should be familiar with parotid surgery, in children where appropriate, and be prepared to expose the facial nerve before embarking on the surgical management of these lesions.

Head and neck squamous cell carcinoma (HNSCC) is an aggressive epithelial malignancy. It is the most common neoplasm arising in the upper aerodigestive tract.

Interleukin (IL) 12 and IL-18 are cytokines which have a major anti-tumour activity via stimulation of a T-helper type 1 (Th1) immune response. Interleukin 10, a potent antagonist of IL-12, is a cytokine which possesses immunosuppressive activity mainly produced via T-helper type 2 (Th2) cells. Studies of other types of cancer have shown that the level of IL-12 in serum or tissues is suppressed and/or the IL-10 level is increased, suggesting that there is an impaired cell-mediated anti-tumour response.

The aim of this study was to measure pre-operative serum cytokine concentrations in HNSCC patients in order to detect any changes in IL-10, IL-12 and IL-18, compared with non-tumour controls. The relationship between cytokine levels and standard clinicopathological features, including tumour site, tumour stage and presence of nodal metastasis, was also examined.

Fifty-seven patients with primary HNSCC were prospectively recruited, together with 40 non-tumour control patients with a similar age and sex distribution. Serum cytokine levels were measured using commercial quantitative enzyme-linked immunosorbent assay.

The HNSCC patients had significantly lower IL-12 levels (median; interquartile range) than controls (42.8 pg/ml, 26.2–61.6 vs 52.3 pg/ml, 37.5–113.7; p=0.018). Also, patients were more likely to have detectable IL-10 levels than were controls, as IL-10 was positive in 27/55 patients but in only 9/39 controls (p=0.011). Furthermore, IL-10 detectability varied according to primary site, being more commonly observed in hypopharyngeal and laryngeal tumours, and IL-10 was more likely to be detected with advanced tumour stage (T3 and T4). No differences in IL-18 levels were observed between patients and controls (p=0.169).

These results suggest (in agreement with studies on other solid malignancies) that HNSCC causes a significant change in the serum levels of specific Th1 and Th2 cytokines, producing an in vivo environment that is unlikely to promote an effective cell-mediated anti-tumour response.

Objectives: To assess the myringoplasty graft take rate, comparing two methods of post-operative ear packing: bismuth iodoform paraffin paste (BIPP) gauze versus tri-adcortyl ointment (TAO).

Methods: A retrospective study of patients who had undergone myringoplasty at our department within a three-year period was undertaken. Data, including age, site and size of perforation, grade of surgeon, surgical approach, use of post-operative ear dressings, complications, and audiometric outcome, were collected from the patient notes and analysed. The overall success rate of the operation (with success being defined as an intact tympanic membrane at six months) was noted.

Results: One hundred and seventy myringoplasties were performed over the study period, but data were complete on 154 patients and these constituted the study population. Age ranged from nine to 71 years (mean age 34 years) and the mean follow-up period was seven months. Consultants performed 62 per cent of the operations, with an 85 per cent success rate, whereas trainees performed the remaining 38 per cent, with a success rate of 73 per cent (p=0.059). The overall success rate was 80 per cent; 79 per cent for BIPP and 83 per cent for TAO (p=0.55), and 87 per cent for small perforations and 75 per cent for subtotal perforations (p=0.22). There was audiometric improvement in 74 per cent of cases.

Conclusion: We found no significant difference in outcome between patients packed with TAO and BIPP. Packing with TAO is therefore a suitable alternative to BIPP gauze ear dressing following myringoplasty.

Introduction: Chronic, persistent cough is a common clinical problem, the cause of which sometimes remains unidentifiable.

Aims: To study a potential association between Helicobacter pylori infection and chronic, persistent cough.

Materials and methods: A clinical observational study with symptom analysis, including 162 patients whose main presenting complaint was chronic, persistent cough of unidentifiable cause (study group) and 42 patients with chronic, non-specific laryngopharyngeal manifestations not including chronic cough (control group).

Results: Active H pylori infection was present in 86.4 per cent (140/162) of patients in the chronic cough group, as opposed to 45.2 per cent (19/42) of the control group, as confirmed by detection of H pylori antigen in stool specimens. This difference was statistically significant (p<0.001). There was a significant improvement of the chronic cough of 75.4 per cent (98/130) of patients after successful H pylori eradication using appropriate medical therapy (p<0.001).

Conclusions: Helicobacter pylori infection may lead to laryngopharyngeal irritation, with several clinical manifestations including chronic, persistent cough. However, the exact mechanism of this requires further research.

The aim of this study was to evaluate spinal accessory nerve function after functional neck dissection (FND) and radical neck dissection (RND) by monitoring the nerve with electromyographic (EMG) examinations. A prospective, double-blind, clinical study was undertaken in 21 patients (42 neck side dissections) operated on for head and neck malignant diseases, separated into two groups: 10 neck sides in the RND group and 32 neck sides in the FND group. Electromyographic examinations were performed pre-operatively and post-operatively in the third week and third and ninth months. Additionally, a questionnaire, modified from the neck dissection impairment index, was applied to all the patients in order to assess shoulder function in the ninth post-operative month.

All patients had maximum EMG scores pre-operatively. Following the operation, motor amplitudes decreased in both groups. At the third post-operative month, amplitudes decreased to their lowest values. As expected, the decreases in amplitude and EMG score were more prominent in the RND group. Following reinnervation, the amplitudes of the trapezius motor response increased in the FND group but never reached pre-operative values (during the time of follow up). The FND group scores for pain, neck and shoulder stiffness, and disability in heavy object lifting, light object lifting and reaching overhead were significantly lower than those of the RND group.

In FND, one aims to preserve anatomically the spinal accessory nerve, and it is presumed to be intact after the procedure. However, using EMG nerve function monitoring, our study revealed that profound spinal nerve injury was detected immediately after FND surgery, which tended to improve over subsequent months but had not regained its original function by the end of the ninth post-operative month.