Paediatric obstructive sleep apnoea is a common clinical condition managed by most ENT clinicians. However, despite the plethora of publications on the subject, there is wide variability, in the literature and in practice, on key aspects such as diagnostic criteria, the impact of co-morbidities and the indications for surgical correction.

A systematic review is presented, addressing four key questions from the available literature: (1) what is the evidence base for any definition of paediatric obstructive sleep apnoea?; (2) does it cause serious systemic illness?; (3) what co-morbidities influence the severity of paediatric obstructive sleep apnoea?; and (4) is there a medical answer?

There is a considerable lack of evidence regarding most of these fundamental questions. Notably, screening measures show low specificity and can be insensitive to mild obstructive sleep apnoea. There is a surprising lack of clarity in the definition (let alone estimate of severity) of sleep-disordered breathing, relying on what may be arbitrary test thresholds. Areas of potential research might include investigation of the mechanisms through which obstructive sleep apnoea causes co-morbidities, whether neurocognitive, behavioural, metabolic or cardiovascular, and the role of non-surgical management.

This review aimed to critically analyse data pertaining to the clinical presentation and treatment of neuroendocrine carcinomas of the larynx.

A PubMed search was performed using the term ‘neuroendocrine carcinoma’. English-language articles on neuroendocrine carcinoma of the larynx were reviewed in detail.

While many historical classifications have been proposed, in contemporary practice these tumours are sub-classified into four subtypes: carcinoid, atypical carcinoid, small cell neuroendocrine carcinoma and large cell neuroendocrine carcinoma. These tumours exhibit a wide range of biological behaviour, ranging from the extremely aggressive nature of small and large cell neuroendocrine carcinomas, which usually have a fatal prognosis, to the less aggressive course of carcinoid tumours. In small and large cell neuroendocrine carcinomas, a combination of irradiation and chemotherapy is indicated, while carcinoid and atypical carcinoid tumour management entails conservation surgery.

A systematic review was conducted to investigate the effectiveness of fibroblast growth factor-2 on the regeneration of tympanic membrane perforation.

The PubMed database was searched for relevant studies. Experimental studies, human randomised controlled trials, prospective single-arm studies and retrospective studies reporting acute and chronic tympanic membrane perforations in relation to two healing outcomes (success rate and closure time), were selected.

All 11 clinical studies investigating the effect of fibroblast growth factor-2 on traumatic tympanic membrane perforations in humans reported a success rate of 89.3–100 per cent, with a closure time of around 2 weeks. Three studies of fibroblast growth factor-2 combined with Gelfoam showed that the success rate of chronic tympanic membrane perforation was 83–98.1 per cent in the fibroblast growth factor-2 group, but 10 per cent in the gelatine sponge groups.

Fibroblast growth factor-2 with or without biological material patching promotes regeneration in cases of acute and chronic tympanic membrane perforation, and is safe and efficient. However, the best dosage, application time and administration pathway of fibroblast growth factor-2 are still to be elucidated.

One hundred years ago, millions of British and Allied troops were fighting in the trenches of the Great War. With a tenth of soldiers losing their lives, hearing loss seemed a low priority; however, vast numbers of troops sustained significant hearing loss.

A review was conducted of literature published between 1914 and 1925.

Soldiers were exposed to up to 185 dB of sustained noise from new, high-energy weapons, which caused ‘labyrinthine concussion’. Traumatic injuries, non-organic hearing loss and malingering were also common. One source estimated that 2.4 per cent of the army was disabled by hearing loss. However, many British doctors viewed this ‘soldier's deafness’ as a temporary affliction, resulting in soldiers being labelled as malingerers or ‘hysterical’.

Today, one can recognise that a scant evidence base and misconceptions influenced the mismanagement of hearing loss by otolaryngologists in World War I. However, noise-induced hearing loss is still very much a feature of armed conflict.

This paper highlights the importance of reporting air–bone gap closure in stapes surgery according to the American Academy of Otolaryngology – Head and Neck Surgery guidelines and reviews compliance in recent years.

A retrospective case series was conducted and the outcomes were reviewed. Closure of the air–bone gap was calculated in 204 adult patients using the aforementioned guidelines. Results were recalculated ignoring the Carhart phenomenon to determine any significant difference. Adherence to guidelines was also reported as a secondary outcome.

Ignoring the Carhart phenomenon resulted in 75 per cent over-reporting of successful air–bone gap closure (p < 0.001). Over-reporting occurred in 5.9 per cent of papers, and in 11.8 per cent it was difficult to determine how the results were reached.

Despite the existence of clear guidelines, stapes surgery outcomes are still being over-reported as successful. This can lead to incorrect information being provided to patients during the consent process and makes comparative studies difficult.

Without the release of histamines, patients with rhinosinusitis may not benefit from antihistamines. Additionally, anticholinergic effects may do more harm than good. This study aimed to investigate the effectiveness of antihistamines in treating rhinosinusitis.

An electronic search was performed. Randomised controlled trials comparing antihistamines with either placebo or other treatments for patients with rhinosinusitis were selected.

Two studies (184 patients) met the inclusion criteria. Loratadine decreased nasal obstruction in allergic rhinitis patients with acute rhinosinusitis (mean difference = −0.58; confidence interval = −0.85 to −0.31, p < 0.01), but had no benefit on total symptom score (mean difference = −1.25; confidence interval = −2.77 to 0.27, p = 0.11), or rhinorrhoea symptoms (mean difference = −0.06; confidence interval = −0.37 to 0.25, p = 0.71).

There is limited evidence to support the use of antihistamines in treating rhinosinusitis. The number of included studies in this systematic review is limited. Antihistamines may relieve nasal obstruction in allergic rhinitis patients with acute rhinosinusitis.

Despite the plethora of publications on the subject of paediatric obstructive sleep apnoea, there seems to be wide variability in the literature and in practice, regarding recourse to surgery, the operation chosen, the benefits gained and post-operative management. This may reflect a lack of high-level evidence.

A systematic review of four significant controversies in paediatric ENT was conducted from the available literature: tonsillectomy versus tonsillotomy, focusing on the evidence base for each; anaesthetic considerations in paediatric obstructive sleep apnoea surgery; the objective evidence for the benefits of surgical treatment for obstructive sleep apnoea; and the medical treatment options for residual obstructive sleep apnoea after surgical treatment.

There are many gaps in the evidence base for the surgical correction of obstructive sleep apnoea. There is emerging evidence favouring subtotal tonsillectomy. There is continuing uncertainty around the prediction of the level of post-operative care that any individual child might require. The long-term benefit of surgical correction is a particularly fertile ground for further research.

Hereditary haemorrhagic telangiectasia is an autosomal dominant condition, characterised by mucocutaneous telangiectasia, aneurysm and arteriovenous malformations. Thalidomide has been used as a therapeutic strategy for refractory epistaxis in hereditary haemorrhagic telangiectasia patients. This review set out to examine the evidence for using thalidomide in the management of refractory epistaxis in hereditary haemorrhagic telangiectasia patients.

A systematic search of the available literature was performed using Medline, Embase, Cochrane Library and NHS Evidence databases, from inception to December 2017. The search terms used included: hereditary haemorrhagic telangiectasia (HHT), Osler-Weber-Rendu syndrome, epistaxis, haemorrhage and thalidomide.

All studies using thalidomide therapy showed a reduction in the frequency and duration of epistaxis, as early as four weeks post-therapy. In addition, thalidomide therapy was shown to increase median haemoglobin levels and reduce blood transfusion dependence.

Current available evidence suggests that low-dose thalidomide is effective in transiently reducing epistaxis frequency and duration. Further studies are required to establish a treatment regimen to prevent side effects.

Pharyngocutaneous fistula is a cause of significant morbidity following laryngectomy. Routine use of salivary bypass tubes during laryngectomy has been proposed to reduce the incidence of fistulae and neopharyngeal strictures.

Following a systematic search of Embase, Medline and Cochrane databases (1946 – current), included articles were assessed for bias according to the Cochrane Handbook for Systematic Reviews of Interventions.

Three case–control trials showed reduced pharyngocutaneous fistula rates with the use of salivary bypass tubes; six case series reported widely varied fistula rates. With regards to stricture rates, the largest case–control trial found no improvement with salivary bypass tube use. No fatal adverse events were observed among the 204 patients who received a salivary bypass tube.

Low-level evidence suggests salivary bypass tubes may reduce the incidence of fistula in high-risk patient groups. A robust randomised controlled trial, or large, multicentre cohort studies, are needed to further examine this intervention.

Nasal irrigation is commonly performed in patients with chronic rhinosinusitis after functional endoscopic sinus surgery. This study systematically assessed the clinical efficacy of nasal irrigation from the medical literature.

The PubMed, Embase and Cochrane Central Register of Controlled Trials databases were searched using a comprehensive strategy, limited to English-language articles, published from October 1971 to March 2017, and comprising human subjects.

A total of 824 trials were identified, 5 of which, involving 331 participants, were included in this systematic review. After selection, only three trials were eligible for inclusion in a meta-analysis. Nasal irrigation using normal saline and various solutions was found to be effective in reducing symptom scores and endoscopic scores for chronic rhinosinusitis patients after functional endoscopic sinus surgery. Comparison of outcome measures, such as eosinophil count reduction, revealed that various solutions are more effective than normal saline alone; however, no statistical significance was found in terms of reduced symptom or endoscopic scores.

Based on the current limited evidence, nasal irrigation is an effective therapy for chronic rhinosinusitis patients after functional endoscopic sinus surgery. However, when comparing various solutions with normal saline, no significant difference was found in symptom scores or endoscopic scores.

Intranasal splints have long been utilised as a post-operative adjunct in septoplasty, intended to reduce the risk of adhesions and haematoma formation, and to maintain alignment during healing.

A Medline literature review of the history and evolution of intranasal splint materials and designs was performed. Advantages and disadvantages of various splints are discussed.

Intranasal splints fashioned from X-ray film were first reported in 1955. Since then, a variety of materials have been utilised, including polyethylene coffee cup lids, samarium cobalt magnets and dental utility wax. Most contemporary splints are produced from silicon rubber or polytetrafluoroethylene (Teflon). Designs have varied in thickness, flexibility, shape, absorption and the inclusion of built-in airway tubes. Future directions in splint materials and designs are discussed.

Intranasal splints have steadily evolved since 1955, with numerous novel innovations. Despite their simplicity, they play an important role in nasal surgery and will continue to evolve over time.

Cholesteatoma is widely considered to be more aggressive in children than adults, yet few studies have directly compared the operative findings and surgical outcomes between these two groups. This study aimed to assess differences between childhood and adult cholesteatoma.

The operative caseload of a single consultant surgeon was reviewed between January 2006 and May 2017 using the online Common Otology Audit database. Extracted data were categorised according to patient age (children, aged below 16 years, and adults, aged 16 years or over) and compared.

This study included data from 71 operations on children and 281 operations on adults, performed for cholesteatoma. Childhood cholesteatoma demonstrated significantly more extension (into the sinus tympani, mastoid antrum and mastoid air cells) and ossicular erosion (of the malleus, incus and stapes superstructure) compared to adults. No significant differences were seen in revision rates, post-operative complications or hearing gain.

Childhood cholesteatoma was more extensive and destructive compared to adults, representing a more aggressive disease in this cohort.

Sinonasal malignant melanoma is a relatively rare malignancy with poor prognosis, and effective treatments remain elusive. This analysis aimed to explore whether post-operative radiotherapy conferred any survival advantages in patients with this disease when compared with surgery alone.

Published studies were identified by searching four electronic databases. The endpoints evaluated were: rates of overall survival, disease-free survival and local control.

Twenty-eight studies including 1392 patients were identified. The results indicated that post-operative radiotherapy led to a significantly better three-year overall survival rate (p = 0.02), and suggested a borderline significant benefit for five-year overall survival (p = 0.05), when compared with surgery alone. However, no statistical advantage was found for disease-free survival, local control or one-year overall survival.

This meta-analysis indicated that adjuvant radiotherapy prolonged survival, but showed no benefit for disease-free survival or local control.

The cause of Ménière's disease remains enigmatic after 156 years. Schuknecht's rupture and potassium intoxication theory of attacks was based on histological studies.

This paper aimed to: present the most contemporary evidence indicating that ruptures do not usually occur, and discuss the possibility that detached saccular otoconia are the main cause of Ménière's disease; and to establish an unequivocal definition of the age of Ménière's disease onset.

The paper reviews the electrophysiological basis of the Gibson–Arenberg drainage theory used to explain vertigo attacks. The current, limited knowledge of the likely fate of detached saccular otoconia is discussed.

Electrophysiological studies during attacks do not support endolymph ruptures, but rather endolymph flowing in one direction and then in the opposite direction. Age of onset for Ménière's disease parallels that for benign paroxysmal positional vertigo.

The similarity of age of onset spectrum for Ménière's disease and benign paroxysmal positional vertigo raises the possibility that the two conditions have the same fundamental cause.

Cervical metastases in papillary thyroid carcinoma are associated with increased recurrence. However, their effect on survival remains controversial. This study evaluated literature on the prognostic value of lymph node ratio for loco-regional recurrence and survival in metastatic papillary thyroid carcinoma.

The PubMed database was systematically searched using the terms ‘papillary thyroid carcinoma’ and ‘lymph node ratio’. Articles addressing the association between lymph node ratio and loco-regional recurrence or survival were identified.

Nine retrospective studies were included, comprising 12 400 post-thyroidectomy and neck dissection papillary thyroid carcinoma patients (median age, 48.6 years; 76 per cent females). Lymph node ratio was associated with worse recurrence-free survival in 60 and 75 per cent of studies investigating the effect of central compartment metastases and both central and lateral compartment metastases on recurrence-free survival, respectively. One large population-based study showed an association between lymph node ratio and disease-specific mortality in N1 nodal disease, but failed to maintain the same association when N1b patients were excluded.

Regional lymph node ratio is an independent predictor for loco-regional recurrence in pathologically staged N1 patients with papillary thyroid carcinoma. Patients with a high lymph node ratio should be closely followed up.

Mules and other equine species have been used in warfare for thousands of years to transport goods and supplies. Mules are known for ‘braying’, which is disadvantageous in warfare operations. This article explores the fascinating development of surgical techniques to stop military mules from braying, with particular emphasis on the key role played by the otolaryngologist Arthur James Moffett in devoicing the mules of the second Chindit expedition of World War II.

The PubMed database (1900–2017) and Google search engine were used to identify articles related to devoicing mules in the medical and veterinary literature, along with information and images on the Chindit expedition.

This paper reviews the surgical techniques aimed at treating braying in mules, ranging from ventriculectomy and arytenoidectomy to Moffett's approach of vocal cordectomy.

Moffett's technique of vocal cordectomy provided a quick, reproducible and safe solution for devoicing mules. It proved to be advantageous on the battlefield and demonstrated his achievements outside the field of medicine.

Advanced hypopharyngeal carcinoma has a dismal prognosis. The optimal treatment for these patients remains under debate. This systematic review aimed to compare survival following surgical and non-surgical treatments.

A systematic review was conducted of randomised studies, with a descriptive analysis of retrospective observational studies.

Two randomised trials and 11 observational studies were included in the review. A meta-analysis of randomised trials reported a hazard ratio of 0.89 for overall survival in favour of surgical treatment (p = 0.44). Neither treatment was favoured in terms of overall survival. Observational studies did not report a survival advantage with either treatment. The five-year larynx preservation rates for non-surgically treated patients were between 38 and 58 percent.

Chemoradiotherapy offers similar survivorship compared to surgery in advanced disease, while also making larynx preservation feasible. It can be used as a treatment in all patients as an alternative to surgery.

Smoking is purported to increase the risk of peritonsillar abscess formation, but prospective data are needed to confirm this hypothesis. This prospective study aimed to identify this correlation.

Fifty-four patients with peritonsillar abscess were prospectively asked about their smoking behaviour using a questionnaire that was designed and approved by the Robert Koch Institute (Berlin, Germany) to analyse smoking behaviour in epidemiological studies. Afterwards, a consecutive control group (without peritonsillar abscess), matched in terms of age and gender, was surveyed using the same questionnaire. A classification of smoker, former smoker and non-smoker was made, and the numbers of pack-years were calculated and compared.

Statistical analysis of both groups revealed a significant correlation between peritonsillar abscess and smoking experience (p = 0.025). Moreover, there were significantly fewer non-smokers in the non-peritonsillar abscess group (p = 0.04). The number of pack-years was higher in the peritonsillar abscess group (p = 0.037).

There is a statistically significant association between peritonsillar abscess and smoking.

This study evaluated the relationship between radiation and Eustachian tube dysfunction, and examined the radiation dose required to induce otitis media with effusion.

The function of 36 Eustachian tubes in 18 patients with head and neck cancer were examined sonotubometrically before, during, and 1, 2 and 3 months after, intensity-modulated radiotherapy. Patients with an increase of 5 dB or less in sound pressure level (dB) during swallowing were categorised as being in the dysfunction group. Additionally, radiation dose distributions were assessed in all Eustachian tubes using three dose–volume histogram parameters.

Twenty-two of 25 normally functioning Eustachian tubes before radiotherapy (88.0 per cent) shifted to the dysfunction group after therapy. All ears that developed otitis media with effusion belonged to the dysfunction group. The radiation dose threshold evaluation revealed that ears with otitis media with effusion received significantly higher doses to the Eustachian tubes.

The results indicate a relationship between radiation dose and Eustachian tube dysfunction and otitis media with effusion.

A variety of paediatric tracheostomy tubes are available. This article reviews the tubes in current use at Great Ormond Street Hospital for Children and Evelina London Children's Hospital.

This paper outlines our current preferences, and the particular indications for different tracheostomy tubes, speaking valves and other attachments.

Our preferred types of tubes have undergone significant design changes. This paper also reports further experience with certain tubes that may be useful in particular circumstances. An updated sizing chart is included for reference purposes.

The choice of a paediatric tracheostomy tube remains largely determined by individual clinical requirements. Although we still favour a small range of tubes for use in the majority of our patients, there are circumstances in which other varieties are indicated.