A vascular ring refers to encirclement of the trachea and oesophagus by an abnormal combination of derivatives of the aortic arch system. These malformations can cause variable degrees of compression of the oesophagus, trachea or both. Symptoms can range from no effect to severe stridor, dyspnoea and/or dysphagia.

This study presents a case series of six patients treated over a six-year period (2003–2009), illustrating the features of four different types of vascular ring; these types are discussed in detail. The clinical presentation, radiology, and microlaryngoscopy and bronchoscopy findings are also discussed.

The management of children with vascular rings requires a high index of clinical suspicion to ensure prompt diagnosis. As many of these children present with airway symptoms, the paediatric otolaryngologist plays a key role in identifying and assessing their anatomical anomalies.

In an emergency, the non-availability of a conventional paediatric tracheostomy tube is a therapeutic challenge for the attending surgeon.

To describe a simple alternative to a paediatric tracheostomy tube for use in an emergency situation.

Case report of a 14-year-old boy who developed tracheomalacia following partial cricotracheal resection for subglottic stenosis. As a suitably sized tracheostomy tube (with a long narrow segment) was not available, an endotracheal tube was modified and used successfully. Details of the modification, and a relevant literature review, are also discussed.

In the paediatric age group, when an appropriately sized tracheostomy tube is not available, a modified endotracheal tube is a simple temporary alternative; this may be especially useful in an emergency.

To determine the differences in myelination between the human recurrent laryngeal nerve and superior laryngeal nerve.

Fifteen confirmed laryngeal nerve specimens were harvested from five cadavers. Cross-sections were examined under a photomicroscope and morphometric analysis performed.

There was a significantly greater number of myelinated fibres than unmyelinated fibres, in both the recurrent laryngeal nerve (p = 0.018) and the superior laryngeal nerve (p = 0.012). There was a significantly greater number of myelinated fibres in the superior laryngeal nerve, compared with the recurrent laryngeal nerve (p = 0.028). However, there was no significant difference in the number of unmyelinated fibres, comparing the two nerves (p = 0.116).

These findings support those of previous studies, and provide further evidence against the historical plexus theory of laryngeal nerve morphology. The differences in the degree of myelination, both within and between the human laryngeal nerves, may have clinical consequence regarding recovery of function following nerve injury.

To establish the features of Mycobacterium tuberculosis infection in the head and neck region, and to determine which investigations have the greatest diagnostic accuracy.

Region-based, retrospective cohort study.

The study included 148 patients with tuberculosis of the head and neck treated in the Greater Glasgow and Clyde region between 2000 and 2007.

The following diagnostic sensitivities were calculated: 53 per cent for fine needle aspiration, 95 per cent for core biopsy and 91 per cent for lymph node excision biopsy. There was a statistically significant difference between the sensitivity results for fine needle aspiration versus core biopsy (p = 0.0003) and fine needle aspiration versus excision biopsy (p < 0.0001). There was no statistically significant difference between the sensitivity results for core biopsy and excision biopsy.

Core biopsy has equivalent diagnostic accuracy to excision biopsy in the investigation of head and neck tuberculosis. We suggest that core biopsy should be used in preference to lymph node excision, as it can be performed under local anaesthetic outside the operating theatre. A proposed algorithm for diagnostic management is included.

We undertook collagen injection laryngoplasty to achieve arytenoid augmentation in patients with dysphagia and persistent aspiration following partial laryngectomy, and we evaluated the efficacy of arytenoid augmentation in aiding neoglottic closure and ensuring airway safety.

Two patients with persistent swallowing impairment after partial laryngectomy were studied. Swallowing was evaluated using fibre-optic endoscopy, and modified barium swallow study. Collagen was then injected into the arytenoid mucosa to achieve neoglottic competence.

The patients were followed up for up to two years. Both patients showed a marked improvement in neoglottic competence, as evaluated by fibre-optic and flexible endoscopy at three-month and one-year follow-up appointments.

Arytenoid augmentation by injection laryngoplasty can be considered a safe and effective surgical tool for the treatment of dysphagia with persistent aspiration following partial laryngectomy.

To determine the sensitivity and specificity of intensive empirical treatment with pantoprazole in diagnosing laryngopharyngeal reflux in adults.

This was a prospective, double-blind study.

Fifty-five patients with either a Reflux Symptom Index of more than 13 or a Reflux Finding Score of more than 7 were enrolled. All patients underwent 24-hour, double-probe pH monitoring before commencing pantoprazole 40 mg twice daily; both investigators and patients were blinded to pH monitoring results. The Reflux Symptom Index and Reflux Finding Score were reassessed during the second, third and fourth month of follow up.

The sensitivity of empirical pantoprazole treatment in diagnosing laryngopharyngeal reflux was 92.5 per cent. The specificity was 14.2 per cent, the positive predictive value 86 per cent and the negative predictive value 25 per cent. There was significant reduction in the total Reflux Symptom Index and Reflux Finding Score after the second, third and fourth month of treatment. There was no correlation between laryngopharyngeal reflux and body mass index.

Our results suggest that intensive empirical treatment with proton pump inhibitors is effective in diagnosing laryngopharyngeal reflux.

To identify the cause of operative failure in patients who have undergone parathyroid surgery for primary hyperparathyroidism.

Retrospective case review.

Patients who had undergone a primary procedure for primary hyperparathyroidism between July 2003 and December 2007. Cases with incomplete post-operative serum calcium data were excluded.

Operative failure was defined as failure to achieve normalisation of serum adjusted calcium levels post-operatively.

A total of 220 primary procedures were conducted over 4.5 years. Data were not available for 16 patients. Thirteen procedures (6.4 per cent) were considered failures, and these cases were individually reviewed and classified according to the reason for failure.

Establishing the cause of failure following surgery for primary hyperparathyroidism can be a complex task. In some instances, diagnostic uncertainty remains despite detailed biochemical and radiological assessment. This paper outlines our approach to maximising the cure rate at primary surgery.

To investigate the incidence of metastasis to the submandibular gland in patients with head and neck squamous cell carcinoma.

We retrospectively evaluated histological reports of neck dissections for upper respiratory tract carcinoma (performed 2002–2009), recording: primary tumour site, tumour–node–metastasis stage, level Ib involvement, previous radiotherapy, perineural invasion, lymphovascular invasion, extracapsular spread, and the presence of malignant disease in the submandibular gland.

We evaluated 107 cases. The most common primary site was the oral cavity (49 per cent) followed by the supraglottis (21 per cent), glottis (14 per cent), oropharynx (9 per cent) and hypopharynx (6 per cent). Forty-eight per cent of patients had advanced local disease, with 21 per cent at tumour stage 3 and 27 per cent at tumour stage 4. Fifty-six per cent had cervical lymph node metastasis, and 8 per cent received pre-operative radiotherapy. Forty-eight per cent had perineural invasion, 46 per cent lymphovascular spread, 27 per cent extracapsular spread and 8 per cent level Ib metastasis. Only one patient had submandibular gland involvement, due to direct spread (a case with prior radiotherapy and macroscopic submandibular gland involvement evident peri-operatively).

Submandibular gland metastasis from head and neck primary squamous cell carcinoma is extremely rare. Preservation of the ipsilateral submandibular gland during neck dissection is oncologically safe, except in patients with prior surgery or radiotherapy, or a primary tumour in close relation to the gland.

To investigate the characteristics of the laryngeal mucosal microvascular network in suspected laryngeal cancer patients, using narrow band imaging, and to evaluate the value of narrow band imaging endoscopy in the early diagnosis of laryngeal precancerous and cancerous lesions.

Eighty-five consecutive patients with suspected precancerous or cancerous laryngeal lesions were enrolled in the study. Endoscopic narrow band imaging findings were classified into five types (I to V) according to the features of the mucosal intraepithelial papillary capillary loops assessed.

A total of 104 lesions (45 malignancies and 59 nonmalignancies) was detected under white light and narrow band imaging modes. The sensitivity and specificity of narrow band imaging in detecting malignant lesions were 88.9 and 93.2 per cent, respectively. The intraepithelial papillary capillary loop classification, as determined by narrow band imaging, was closely associated with the laryngeal lesions' histological findings. Type I to IV lesions were considered nonmalignant and type V lesions malignant. For type Va lesions, the sensitivity and specificity of narrow band imaging in detecting severe dysplasia or carcinoma in situ were 100 and 79.5 per cent, respectively. In patients with type Vb and Vc lesions, the sensitivity and specificity of narrow band imaging in detecting invasive carcinoma were 83.8 and 100 per cent, respectively.

Narrow band imaging is a promising approach enabling in vivo differentiation of nonmalignant from malignant laryngeal lesions by evaluating the morphology of mucosal capillaries. These results suggest endoscopic narrow band imaging may be useful in the early detection of laryngeal cancer and precancerous lesions.

To present a case of, and to review the literature concerning, osteoblastoma of the nasal cavity, and to demonstrate the importance of considering this rare entity when assessing patients presenting with a nasal septum lesion.

Benign osteoblastoma is a rare tumour, constituting 1 per cent of all bone tumours. Most cases occur in the long bones. Osteoblastoma involving the nasal cavity is rare, with only 10 reported cases in the English-language literature. Most nasal cavity cases originate from the ethmoid sinus and spread to involve the nasal cavity. There are only four reported cases of osteoblastoma originating from the bones of the nasal cavity. We report a case of osteoblastoma originating from the bony nasal septum in a 45-year-old man with a history of recurrent, right-sided epistaxis and nasal obstruction.

This is the second report in the English-language literature of osteoblastoma originating from the bony nasal septum.

Metastasis to regional lymph nodes via lymphatic microvessels plays a key role in cancer progression, and is an important prognostic factor in many cancers. Recent evidence suggests that tumour lymphangiogenesis promotes lymphatic metastasis.

To investigate whether tumour lymphatic microvessel density correlates with clinicopathological factors and serves as a prognostic indicator of supraglottic laryngeal carcinoma progression.

The lymphatics of 84 supraglottic laryngeal carcinoma cases were investigated by immunohistochemical staining for podoplanin (also termed D2-40). The relationships between (intra- and peritumoural) lymphatic microvessel density, clinicopathological parameters and clinical prognosis were analysed.

There was a significant relationship between high intratumoural lymphatic microvessel density and aggressive tumour node stage (p < 0.0001), distant metastasis (p = 0.037) and poor prognosis (p = 0.011), and between high peritumoural lymphatic microvessel density and node stage (p = 0.004) and poor prognosis (p = 0.029). Patients with high lymphatic microvessel density also had significantly worse disease-free survival (p = 0.003) and overall survival (p = 0.005). Intratumoural lymphatic microvessel density was found to be an independent prognostic factor for overall survival (p = 0.008) and disease-free survival (p = 0.005) (multivariate analysis).

Lymphatic microvessel density (detected by podoplanin immunohistochemistry), especially intratumoural density, may be an independent predictor of lymphatic tumour spread and survival in supraglottic laryngeal carcinoma patients, and may be useful to guide decisions regarding additional surgery.

Infantile haemangiomas enter a rapid proliferative phase within months of birth, before slowly involuting. Those with the potential for disfigurement or morbidity require intervention. Propranolol has emerged as an effective new treatment modality, with the potential to become the first-line treatment of choice.

Four children with haemangiomas of the head and neck were treated with propranolol at a tertiary referral centre. The size of the haemangioma and the symptoms resulting from airway compromise were monitored.

Three of the four children showed a dramatic response to treatment with propranolol. However, one child responded initially but was readmitted with stridor secondary to new haemangioma proliferation.

We report a cautionary case in which a subglottic haemangioma developed contemporaneously with propranolol treatment, requiring surgical intervention. This finding highlights the need for regular follow up of treatment response, and the need for monitoring for treatment side effects.

Following the onset of facial palsy, physiotherapists routinely inspect the inside of the patient's mouth and cheek for complications such as ulceration or trauma. In several patients with complete facial nerve palsy, it was noticed that when the cheek was stretched there was subsequent spasm of the muscles of facial expression. This also occurred in patients whose facial nerve had been transected.

We present four patients in whom this response was demonstrated. We consider the mechanism of this response and its relevance in the management of patients with facial paralysis.

Following severe or complete denervation, contraction of the facial muscles following mechanical stretch provides evidence of preservation of activity in the facial muscle's excitation–contraction apparatus. Further research will investigate the clinical significance of this sign and whether it can be used as an early predicator of the development of synkinesis, as well as its relevance to facial nerve grafting and repair.

To evaluate the clinical course and pathological characteristics of basaloid head and neck squamous cell carcinoma.

Retrospective study of 18 cases of basaloid head and neck squamous cell carcinoma. Epidemiological, clinical and histological data were analysed and the Kaplan–Meier test used to estimate survival rates.

The majority of lesions were at an advanced stage. These lesions were primarily localised in the larynx, hypopharynx and oropharynx. Routine pre-therapeutic assessment of squamous cell carcinoma was performed. Pathological diagnosis was difficult, although immunostaining was extremely useful. Positive staining for KL1, MNF 116 and 34βE12 and negative immunostaining for chromogranin and synaptophysin were also important factors in obtaining a definitive diagnosis. In the majority of cases, treatment involved surgery and radiotherapy. The five-year survival rate was 5 per cent.

Basaloid squamous cell carcinoma is an uncommon head and neck lesion, with a challenging histological diagnosis. These lesions must be carefully monitored due to their aggressive course, and require multimodality treatment.

To review outcomes and complications in a series of adults undergoing a frontal osteoplastic flap procedure without obliteration, for endoscopically inaccessible sinus disease.

Retrospective case note review of patients treated at Glasgow Royal Infirmary between January 2004 and October 2008.

Ten patients were identified (age range 19–81 years, mean age 46.3 years). No major intra- or post-operative complications occurred. There were three minor complications: superficial discharging wound, forehead swelling and haematoma.

The frontal osteoplastic flap still has a role in frontal sinus surgery. With minor technical modifications, this procedure may be performed with minimal complication and morbidity for patients with endoscopically inaccessible frontal sinus disease.

Patients with nasopharyngeal carcinoma may have residual cervical lymphadenopathy after definitive treatment of the primary tumour and regional cervical nodal disease. Whether such lymphadenopathy truly represents persistent disease is unclear. There are few published studies addressing this clinical problem.

We retrospectively and systematically reviewed the clinical records of 12 patients with nasopharyngeal carcinoma who had presented to a tertiary academic hospital, over an 11-year period, with suspected persistent cervical nodal disease after definitive radiotherapy or concurrent chemoradiotherapy. Findings on fine needle aspiration cytology and computed tomography scanning were correlated with final histopathological results.

The incidence of negative neck dissection was 41.7 per cent. The positive and negative predictive values of fine needle aspiration cytology in identifying disease were 100 and 42.9 per cent, respectively. Computed tomography scanning had a positive predictive value of 58.3 per cent in identifying disease.

In patients treated definitively for nasopharyngeal carcinoma, residual cervical lymphadenopathy may not represent persistent disease. Head and neck surgeons involved in the management of these patients should bear in mind the current limitations of fine needle aspiration cytology and computed tomography in confirming the diagnosis pre-operatively. Salvage neck dissection may over-treat some of these patients.

We present a case report and systematic review of acute mastoiditis caused by metastatic lung cancer.

A 62-year-old woman developed acute mastoiditis as a complication of otitis media. Cortical mastoidectomy revealed deposits of metastatic non-small cell lung carcinoma around the sigmoid sinus. The patient had previously received treatment for lung cancer, but was thought to be in remission.

A literature review confirmed that this is the first reported case of mastoiditis caused by metastatic lung cancer. Only four similar case reports were identified: two caused by breast carcinoma, one by renal cell carcinoma and one by cholangiocarcinoma. Post-mortem histopathological studies suggest that temporal bone metastasis occurs in 22 per cent of oncology cases.

This is the first reported case of mastoiditis caused by metastatic lung cancer. Metastasis to the temporal bone is not uncommon, but rarely causes mastoiditis.

In some cases of epistaxis, anterior packing and/or electrocoagulation are not sufficient and suturing is needed. However, standard suturing techniques are sometimes ineffective. This paper reports the use of a new kind of trans-septal mattress suture, based on regional vascular anatomy, in this clinical context.

Four adult patients with haemorrhage in Little's area underwent standard suturing, but bleeding persisted. These patients were successfully treated with trans-septal mattress suturing, using four punctures around the haemorrhage site.

No relapses or complications were observed over a six-month follow-up period.

In cases of persistent bleeding from Little's area, suturing should surround the bleeding area. The described suturing method is simple, efficacious and cheap.

Various techniques are used to maintain retraction of the skin flap during open-approach rhinoplasty.

This report aims to present the use of maxillofacial retractors in open-approach rhinoplasty, a previously undescribed technique.

Use of these retractors provides excellent exposure of the lower lateral cartilages for surgery of the nasal tip, as well as access for surgery on the upper lateral cartilages. This technique allows the surgeon and assistant to proceed with surgery without needing to maintain retraction with a hand-held instrument.