Endoscopic epiglottectomy is usually performed using a surgical laser. Epiglottectomy may be indicated for the treatment of benign or malignant lesions and for the relief of airway obstruction caused by a floppy epiglottis. We present four patients who had endoscopic partial epiglottectomy using monopolar diathermy to treat a floppy epiglottis. All the four patients were male in their sixth and seventh decades with snoring and/or obstructive sleep apnoea syndrome (OSAS) due partly or wholly to a floppy epiglottis. Diathermy epiglottectomy is easily carried out using the laryngoscope, laryngeal instruments and curved rotating microdissection monopolar scissors (used in laparoscopic surgery). This was found to be safe and effective with minimal morbidity. It requires no elaborate preparation and could be performed in hospitals that have no laser facilities. It may be performed in conjunction with other procedures e.g. uvulopalatopharyngoplasty (UPPP) if necessary.

Over the past 20 years, use of tracheo-oesophageal puncture (TEP) speech after total laryngectomy has resulted in reported success rates of 90-93 per cent worldwide. Despite this, data collected from major acute hospitals in Victoria, Australia indicated that, of 38 patients who underwent total laryngectomy in 1997, only 10 (26 per cent) were using TEP speech as their primary mode of communication at 12 months post-operatively. This paper describes how a quantitative research methodology was used to investigate why so few patients in Victoria were successfully using TEP speech as their chosen mode of rehabilitation after total laryngectomy. Patients, speech pathologists and ENT surgeons were interviewed. Their thoughts and beliefs regarding speech rehabilitation were mapped, and themes were identified, coded and analysed. This paper describes and discusses the results of this research and its possible implications for future patient management, through establishing a model for ‘ideal’ speech rehabilitation.

Pre-admission clinics are becoming increasingly popular for surgical specialties with a quick turnover as they aid waiting list management and reduce non-attender rates for surgery. As paediatric patients have a high rate of non-attendance, we performed a retrospective audit of otolaryngology paediatric pre-admission assessment clinic notes for June to October 1998 (n = 363). The attendance rate for the clinic was 97 per cent. Of the children who attended the clinic, 90 per cent had their operation as planned, complications occurred in 2.9 per cent. The operation date was delayed in 20 patients, in 11 patients no cause for the delay was given in the case notes. As a result of this audit, the Senior House Officer sees the patient on the day of admission rather than in the pre-admission clinic, which is staffed by nurses.

The feasibility of paediatric day-case tonsillectomy (PDCT) depends on its safety and acceptance by parents and patients. The purpose of our retrospective study of paediatric day-case tonsillectomy was to review the role of the home care team (HCT) in improving the safety and acceptance of the procedure.

Between January 1997 and June 1999, 352 consecutive children underwent day-case tonsillectomy. The notes and HCT assessment sheets were reviewed for telephone calls made by HCT or by parents, home visit by HCT, types of complication and their outcome.

The primary haemorrhage rate was 0.6 per cent. The effective day-case rate was 97 per cent. The unplanned admission rate was three per cent. The HCT visited about 25 per cent of patients at home. We conclude that paediatric day-case tonsillectomy is associated with high morbidity and considerable parental anxiety that can be dealt with by timely reassurance, support and advice by a dedicated HCT.

This study assessed the ability of otolaryngologists to diagnose and grade reflux disease at rigid endoscopy. Twenty-one out of 25 senior otolaryngologists who were questioned by means of a telephone survey said that if they find evidence of reflux disease at rigid endoscopy of the oesophagus and larynx, their practice is to place the patient on a proton pump inhibitor for six weeks without requesting pH and manometry studies, and without referral to a gastroenterologist. Over a two year period, 21 patients were diagnosed as having reflux disease at rigid endoscopy. This was based on the finding of fluid and erythema in the aerodigestive tract and upper oesophagus. Subsequent oesophageal pH and manometry was performed. Nine out of 21 patients were confirmed as refluxers. This demonstrated an accuracy of less than 50 per cent when using these findings to diagnose gastro-oesophageal reflux at rigid endoscopy.

The objective of this study was to determine the presence of oestrogen and/or progesterone receptors in laryngeal pyogenic granulomas and the impact of these receptors on recurrence of pyogenic granulomas.

Twenty-two consecutive patients who underwent microlaryngoscopy and removal of pyogenic granulomas were studied retrospectively. The indications for surgery were airway compromise, failure of medical therapy and suspicion of malignancy. Twelve of these patients’ granulomas were analysed for oestrogen and progesterone receptors.

Charts were analysed for age, sex, location of the lesion, history of trauma, intubation or gastroesophageal reflux disease (GORD), airway symptoms and recurrence. Oestrogen/progesterone receptors were analysed following deparaffinization of specimens and immunostaining with prediluted anti-oestrogen receptor monoclonal antibody and anti-progesterone receptor monoclonal antibody.

No sample expressed oestrogen or progesterone receptors. There were too few recurrences to detect if lack of these receptors played any role in determining outcome in this group. Most of the patients had a history of GORD, intubation or laryngeal surgery. There were 12 recurrences in four patients. All of the recurrences improved on prolonged courses of omeprazole.

Pyogenic granulomas do not possess oestrogen or progesterone receptors and are unlikely to respond to hormonal therapy. Patients who have, or are being operated on for, laryngeal pyogenic granulomas should be placed on proton pump inhibitors to decrease the likelihood of recurrence.

A new established pilot husky voice clinic with agreed referral protocols for patients at risk of developing laryngeal malignancy was audited. Thirty-four patients were seen, 41.2 per cent having abnormal findings on flexible nasendoscopy, 29.4 per cent requiring rigid endoscopy, 38.1 per cent were discharged after the initial visit. One case of early laryngeal cancer was picked up during this period from this group of patients. The data for the remaining population in Portsmouth was examined, and a further eight cases of laryngeal cancer were diagnosed in keeping with national incidences. A rapid access clinic with agreed protocols that referring practitioners adhered to, was useful for diagnosing laryngeal cancer and should meet the requirements of the government’s 14-day rule.

The pain experienced at home and the burden this places on primary care resources is considerable following tonsillectomy in children. This was audited by postal questionnaire in 52 patients (36 responders). We found a significant proportion of patients experiencing moderately severe to severe pain and a high rate of consultation with general practitioners (50 per cent) for pain-related issues. These findings lead to changes in practice which included the provision of five days discharge medication (paracetamol/ibuprofen in non-asthmatics; paracetamol/dihydrocodeine in asthmatics) and improved written discharge advice. On re-auditing a year later in 100 patients (56 responders), we found reduced rates of consultation with general practitioners (27 per cent). However, the proportion of children experiencing moderately severe to severe pain was not reduced probably because most children were given the recommended analgesia during the first audit. We also found that paracetamol and ibuprofen was superior to paracetamol and dihydrocodeine for analgesia (p <0.05). Suggestions for further improvements are discussed.

Benign positional vertigo is a common condition which may be easily treated with the canalith repositioning procedure. This procedure may be difficult for patients to understand and for medical staff to learn. This paper describes a model of the vestibular apparatus which may be used to demonstrate the procedure.

We report the use of a self-retaining aural speculum that provides an excellent view of the middle ear through a small endural incision. We have found this instrument of value in tympanoplasty and stapes surgery in particular.

Lateral saccular cysts have been diagnosed in 17 patients. Definitive diagnosis was made by computed tomography (CT) that showed a fluid-filled cystic swelling of the saccule with no air fluid level in all patients. Fifty-three per cent of cysts were bulging through the thyrohyoid membrane. They were hugely enlarged in 18 per cent, moderately enlarged in 24 per cent, and slightly enlarged in 12 per cent of patients. One patient (six per cent) showed bilateral cysts. Lateral saccular cysts were primary in origin in 82 per cent of patients and secondary to prolonged intubation, hemilaryngectomy, and laryngoscleroma in 18 per cent of patients. Surgical excision via a lateral cervical approach was performed in eight patients, whereas endoscopic CO2 laser vestibulectomy was performed in nine patients.

Endoscopic vestibulectomy with CO2 laser proved to be an efficient and safe procedure for excision of small and medium-sized cysts with a diameter equal to or less than 3 cm in the greatest dimension. The external approach appears more efficient than laser vestibulectomy in excision of huge cysts, as 22 per cent of patients undergoing laser surgery showed a recurrence.

A survey was undertaken of the practice of all Otorhinolaryngologists in England and Wales looking both at practice in general and at management of individual patients, including a patient satisfaction questionnaire, under the auspices of the Clinical Effectiveness Unit at the Royal College of Surgeons. Postal questionnaires enquired about practice in general and management in particular of 20 sequential patients per consultant. Parent questionnaires were sent six weeks and one year post-operatively. Ninety consultants took part and 1503 individaul patient proformas were returned. Results showed that these consultants are managing children with otitis media with effusion (OME) in a manner very close to the recommendations of the Effective Healthcare Bulletin (1992) and consistent with the recent Clinical Effectiveness Statement of the BAOHNS, and that the intervention is popular with parents.

Many surgical landmarks have been suggested to help the surgeon identify the facial nerve when performing parotid gland surgery. There is no conclusive evidence that any one landmark is better than the rest. In this study distances from the most frequently used surgical landmarks to the main trunk of the facial nerve were measured in 30 halves of cadaver heads. Two ENT surgeons assessed the best landmark in each case. The tympanomastoid suture was nearest to the main trunk and was therefore considered the most reliable landmark. Its average distance to the main trunk of the facial nerve was 2.7 mm. This result was consistent with the subjective best score given by two ENT surgeons.

An immunohistochemical study of both p27 and proliferating cell nuclear antigen (PCNA) was performed on 102 cases of laryngeal squamous cell carcinomas (LSCCs), and large variations in p27 expression were found among the tumours. Reduced expression of p27 was revealed in 54 (52.9 per cent) cases and correlated with tumour size, lymph node metastasis, and clinical stage, but did not correlate with age, sex, tumour site, or tumour grade. A significant positive correlation was found between the percentage of loss of p27 expression and the PCNA index (r = 0.844, p < 0.0001). Reduced expression of p27 was significantly correlated with both reducing disease-free and overall survival by univariate analysis. By multivariate analysis, reduced expression of p27, tumour grade, tumour size, lymph node metastasis as well as clinical stage were independent prognostic factors for overall survival of LSCCs. These findings indicate that reduced expression of p27 may be correlated with the malignant biological behaviour of LSCCs.

The anti-tumour effect of the angiogenic inhibitor TNP470, σ-(chloro-acetyl-carbamoyl) fumagillol, a synthetic analogue of fumagillin, was studied in vitro and in vivo using KB cells, one of the human head and neck carcinoma cell lines that produce interleukin(IL)-8. In the in vitro study, the combination treatment of TNP470 and anti-IL-8 antibody significantly reduced the proliferation of KB cells. In the in vivo studies, TNP470 administration by any route (intratumoral: it, intraperitoneal: ip, intravenous: iv) reduced the tumour volume significantly, compared to the control group. Among the groups administered TNP470, the anti-tumour effect was strongest in the it group. Furthermore, the concurrent treatment of anti-IL-8 antibody and TNP470 also maximally reduced the tumour volume. The combination therapy of TNP470 and anti-IL-8 antibody was very effective. These results suggest that combination therapy of TNP470 and anti-IL-8 antibody could be beneficial for solid tumours, such as head and neck cancer.

Between 1 April 1996 and 30 June 1997, 1003 ear, nose and throat (ENT) outpatients and 340 inpatients diagnosed as having pulmonary tuberculosis were analysed for ENT manifestations of tuberculosis to determine the relationship to sputum positivity, whether any high risk factors exist for the ENT manifestations as compared to other pulmonary tuberculosis patients, and the response to anti-tubercular treatment. The commonest ENT manifestation was found to be laryngitis (seven cases), which was more common in pulmonary tuberculosis patients (five out of seven), all except one of whom were sputum negative. All of these patients were defaulters from anti-tuberculosis treatment or relapse cases, and vocal cords were the commonest site of involvement. One case of tuberculous tonsillitis and one case of tuberculous mastoiditis were also noted. The practical implications of an awareness of ENT tuberculosis is a benefit of anti-tubercular therapy and hence conservative management usually suffices.

Oncological and functional results were assessed in 47 type C and/or D jugular paraganglioma operated on between 1984 and 1998 using the classical infratemporal fossa type A approach (mean follow-up = 66 months). In 24 instances, however, the facial nerve was not re-routed. Total resection was achieved in 33 cases (70 per cent). In 25 patients available for follow-up this resulted in a 92 per cent cure rate while two patients (eight per cent) developed recurrences that are being followed-up clinically and radiologically. Sub-total resection, leaving infracentimetric tumour remnants after being coagulated, was achieved in 14 cases (30 per cent). In 11 patients available for follow-up, only three cases developed tumour regrowth (27 per cent) that was controlled by salvage irradiation or surgery while in the other cases tumour remnants remained stable (73 per cent). Symptomatic post-operative lower cranial nerve impairment was observed in 23 per cent. When results were analysed depending on whether the facial nerve had been re-routed (n = 18) or not (n = 24), the incidence of facial paralysis HB grade III or more at one year was 33 per cent and eight per cent, respectively. Total resection was achieved in 56 per cent when the facial nerve was re-routed versus 75 per cent when it was not, the difference being due to a higher incidence of large tumours in the first group.

The present study suggests that: 1) surgical resection of jugular paraganglioma provides overall satisfactory results, i.e. a 86 per cent rate of either cure or tumour remnant stabilization, but carries a significant risk of iatrogeny; 2) complete tumour removal should not be attempted, especially in patients over 60 years of age with no pre-operative neurological deficits, since leaving infracentimetric tumour remnants has no major detrimental effect on the final outcome; 3) facial nerve transposition carries a significant risk of cosmetic sequelae while it does not provide significant advantages in terms of tumour resection and long-term oncological control.

Topical vasoconstriction using four to 10 per cent cocaine is widely used for nasal surgery. A number of techniques are being used with equally satisfactory results. Here we describe a novel method of topical application of cocaine for nasal surgery. The method is simple, cheap and effective.

The first report of a patient with gross Paget’s disease and progressive hearing loss who successfully underwent hearing rehabilitation with an osseo-integrated hearing aid is presented. The otological manifestations of Paget’s disease and the principles of osseo-integration are discussed. The use of a bone-anchored hearing aid (BAHA) in selected patients with Paget’s disease can provide useful amplification and hearing rehabilitation.

Tooth protection during suspension microlaryngeal surgery is a challenge when teeth are damaged or missing. We present an effective, disposable and cheap tooth guard for microlaryngeal surgical procedures using Turbocast™. The tooth guard transits the laryngoscope’s pressure directly to the hard palate leaving the teeth uninvolved and free of any pressure.